Every finding on record at The Laurels of Forest Glenn

Based on record reviews and interviews with facility staff and the Pharmacist, the facility failed to have effective systems in place for the return of discontinued narcotic medications to prevent the diversion of controlled medications (Percocet 5/325 milligrams 4 tablets and six (6) 1/2 tablets of Oxycodone 5 milligrams) for 2 of 2 discharged residents reviewed for pharmacy services (Resident #106 and Resident #107). The findings included:a. Resident #106 was admitted into the facility on [DATE] and was discharged home on [DATE].Resident #106 Physician orders revealed an order dated [DATE] for Percocet 5/325 mg (milligrams) one tablet by mouth every 12 hours as needed for hip or knee pain for 10 days. On [DATE] the facility received 20 tablets of Percocet 5/325 mg from the pharmacy for Resident #106. A review of Resident #106's Medication Administration record for [DATE] and [DATE] revealed he was administered 16 tablets of Percocet 5/325 milligrams. The facility was unable to locate Resident #106's Declining Inventory Narcotic Sheet and Controlled Substance Return form for review. b. Resident #107 was admitted into the facility on [DATE] and He was discharged home on [DATE].Resident #107's Physician Orders revealed an order dated [DATE] for Oxycodone 5 mg give 1/2 tablet every 6 hours as needed for moderate pain for 3 days. On [DATE] the facility received ten (10) 1/2 tablets of Oxycodone 5milligrams from the pharmacy for Resident #107. A review of Resident 107's Medication Administration Record for [DATE] indicated four (4) of the 1/2 tablets of Oxycodone 5 milligrams were administered. The facility was unable to locate Resident #107's Declining Inventory Narcotic Sheet and Controlled Substance Return form for review. The Investigation Report (5-day) dated [DATE] completed by the Director of Nursing indicated that on [DATE] the facility became aware of two missing cards of narcotic pain medication (Percocet 5/325 mg and Oxycodone 5 mg) for two residents (Resident #106 and Resident #107). An investigation was initiated by the facility immediately and on [DATE] Nurse #2 admitted to taking the medications out of the building. Nurse #2 was immediately terminated by the facility and the appropriate State agencies along with law-enforcement were notified of the diversion. An interview with the Director of Nursing (DON) on [DATE] at 10:30 AM revealed she was notified by Nurse #1 on [DATE] at approximately 10:54 PM concerning a discrepancy with the narcotic count. The DON asked Nurse #1 to remain in the facility until she arrived. The DON indicated that 4 tablets of Percocet 5/325 mg were missing for Resident #106 and six (6) 1/2 tablets of Oxycodone 5mg were missing for Resident #107 when she arrived at the facility. The DON indicated Nurse #1 stated in her interview on [DATE] she had placed Resident #106 and Resident #107's discontinued narcotic medications in an unsealed pharmacy return bag in the narcotic box on the medication cart, so the medication would remain in the narcotic count. Nurse #1 explained she then placed the completed Controlled Substance Return to the Pharmacy form in the back of the narcotic book. On [DATE] Nurse #1 realized the narcotic medications she had placed in the narcotic box on [DATE] were not returned to the pharmacy due to the medications not being in the unsealed pharmacy return bag that she had placed in the narcotic drawer on [DATE] and called the DON. The Director of Nursing further revealed when she arrived at the facility, took Nurse #1's statement and then conducted a thorough search was completed on all medication carts and medication storage rooms on [DATE] (after midnight), however she was unable to find the missing Oxycodone 5 milligram 1/2 tablets or the Percocet 5/325 milligrams tablets. The DON stated on [DATE] she contacted nurses scheduled from [DATE] through [DATE] to inform them of the discrepancy and requested a formal written statement. She also informed the nurses that a urine drug screen was to be completed. The DON revealed that she received a text message from Nurse #2 on [DATE] that she had taken the medication. The DON stated that Nurse #2 was immediately terminated and the Administrator was notified along with all the appropriate state authorities. The DON further revealed that after Nurse #1 had filled out the Controlled Substance Return to the Pharmacy form she should have immediately faxed the form to the pharmacy so a ticket could be made for the medications to be picked up, however this step was omitted by Nurse #1. The DON explained the process for discontinued narcotic medications was the medication was removed from the cart and placed into a sealed plastic pharmacy return bag which had a number on it immediately after the order to discontinue a narcotic medication was received. A pharmacy Controlled Substance Return form was completed and faxed to the pharmacy after placing the medication in the sealed plastic pharmacy return bag so the return could be scheduled. Once the form was completed and faxed the sealed pharmacy return bag was placed in the locked narcotic drawer of the medication cart. The form was then placed in the back of the narcotic book so the medication would continue to be counted until it was picked up by the pharmacy. A review of the daily assignment sheets revealed Nurse #1's revealed she worked 7:00 PM to 7:00 AM on [DATE], and [DATE]. A telephone interview was attempted with Nurse #1, who no longer works at the facility, a voicemail message was left however Nurse #1 did not respond. A review of the daily assignment sheets revealed Nurse #2's working scheduled revealed she worked 7:00 AM to 7:00 PM on [DATE], [DATE], and [DATE]. A telephone interview was attempted with Nurse #2, and a voicemail was left but she did not respond. An interview with the Pharmacist on [DATE] at 1:48 PM indicated the facility had contacted the pharmacy regarding the narcotic discrepancies and missing medication on [DATE] for Resident #106 and Resident #107. The Pharmacist further revealed the medication had not been returned to the pharmacy.An interview with the Administrator on [DATE] at 2:30 PM revealed that he expected the nursing staff to follow the facility procedure for returning narcotic medications to the pharmacy.The facility provided the following corrective action plan with a date of [DATE].Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice:On [DATE], Nurse #1 prepared the controlled substances for Resident #106 and Resident #107 for return to the pharmacy and placed the return bag in the narcotic return box. The narcotic declining inventory sheets remained in the narcotic record book to ensure the medications would continue to be counted during each shift change. The completed Controlled Substance Return to Pharmacy form was placed in the back of the narcotic record book. Nurse #1 inadvertently failed to send the medications back to the pharmacy and did not return to work until [DATE]. On [DATE] at approximately 10:54 p.m., upon realizing the medications had not been returned, Nurse #1 immediately notified the Director of Nursing (DON) of missing controlled substances for Resident #1, who was discharged home on [DATE], and Resident #2, a current resident whose narcotic dose was changed on [DATE]. Resident #106 was missing four (4) tablets of Percocet 5/325 mg, and Resident #107 was missing six (6) 1/2 tablets of Oxycodone 5 mg. The Nurse #1 on duty remained at the facility until the Director of Nursing arrived. The Director of Nursing reviewed staffing assignments from [DATE] through [DATE] to identify all licensed nurses who had possession of the narcotic keys for the medication cart during the applicable timeframe. Each nurse who had worked the medication cart during [DATE] through [DATE] was contacted by the Director of Nursing on [DATE], interviewed, and instructed to report to the facility for reasonable suspicion drug screeningUpon discovery of the missing narcotics on [DATE], the Director of Nursing reviewed Resident #106's Medication Administration Record (MAR) and narcotic declining inventory sheets to ensure the resident had not missed any prescribed doses prior to discharge. No negative findings were identified.On [DATE], the Director of Nursing conducted a thorough search of all medication carts, medication rooms, and designated narcotic storage areas but was unable to locate the missing medications.On [DATE], the Director of Nursing contacted the pharmacy and spoke to the Control Pharmacist to verify whether the narcotics had been returned. The pharmacy confirmed they had no record of receiving the medications.On [DATE], the Director of Nursing interviewed Resident #107 regarding pain management and medication administration. Resident #107 voiced no concerns and reported pain was adequately managed. The Director of Nursing attempted to reconcile Resident #107's Medication Administration Record with the narcotic declining inventory sheet; however, the declining inventory sheet could not be located.At approximately 11:27 a.m. on [DATE], Nurse #2 admitted responsibility for the missing narcotics via text message to the Director of Nursing.The Nursing Home Administrator notified local law enforcement, the DEA, and the State Bureau of Investigation on [DATE] at 12:25 p.m. and submitted the initial report to the North Carolina Health Care Personnel Registry (HCPR) on [DATE] at 2:13 p.m.On [DATE], the Director of Nursing contacted the pharmacy to ensure the narcotics for Resident #1 and Resident #2 were not billed to either resident or their insurance providers. The pharmacy confirmed the facility would be billed directly for the replacement medications.On [DATE], the Director of Nursing terminated Nurse #2 verbally via the phone. On [DATE], the Unit Manager completed a pain assessment for Resident #107 to ensure pain remained adequately controlled. No negative findings were identified.On [DATE], the Director of Nursing reported Nurse #2 to the North Carolina Board of Nursing via telephone and completed the employer complaint form on the NC BON website. Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On [DATE], the Director of Nursing reviewed licensed nursing assignments from [DATE] through [DATE] to identify all residents who received care from Nurse #2 during the identified timeframe.On [DATE] the Director of Nursing reviewed each identified resident's Medication Administration Record and narcotic declining inventory sheets for discrepancies. No negative findings were identified.All alert and oriented residents identified were interviewed on [DATE] by the Director of Nursing regarding concerns related to medication administration or pain management. No concerns were identified.On [DATE] the Director of Nursing assessed all identified residents who were unable to reliably communicate for signs and symptoms of unrelieved pain. No negative findings were noted.Additionally, on [DATE], the Director of Nursing reviewed nursing progress notes for these residents from [DATE] through [DATE] for documentation of uncontrolled pain, missed medications, or other concerns. No negative findings were identified.On [DATE] the Director of Nursing audited resident who were discharged in past 7 days narcotics had been returned to the pharmacy. No concerns were identified. On [DATE], the Director of Nursing audited orders for narcotics that had been discontinued from [DATE] to [DATE] to ensure they had been sent back to the pharmacy. No concerns were identified Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur:On [DATE], all licensed nurses who had possession of the narcotic keys for the affected medication cart received one-on-one education by the Director of Nursing regarding the facility's Inventory Control of Controlled Substances policy. One licensed nurse who was unavailable received the required education prior to working on [DATE].Education emphasized that all controlled substances, including medications awaiting return to the pharmacy, must remain on the declining inventory record and be counted at every shift change and whenever narcotic keys are transferred. Narcotics awaiting return to the pharmacy may not be bundled with inventory sheets and placed unsecured in the narcotic drawer. Once prepared for return, controlled substances must immediately be placed in the designated sealed return bag and secured in the approved narcotic return storage area until retrieved by the pharmacy courier.All licensed nurses employed by the facility as of [DATE] received this education. No licensed nurse will be permitted to work until the required education has been completed. On [DATE] the Nursing Home Administrator notified the Director of Nursing to ensure this education will be provided to any newly hired license nurse in orientation. This education will be provided by the Assistant Director of Nursing during orientation for all newly hired licensed nurses. Indicate how the facility plans to monitor its performance to ensure the solutions are sustained:An Ad Hoc QAPI meeting was held on [DATE] with the Nursing Home Administrator, Director of Nursing, Regional Clinical Coordinator, and the interdisciplinary team (IDT). The incident, root cause, and corrective action plan were reviewed and approved. The root cause was the deficient practice resulted from the intentional diversion of controlled substances by Nurse #2, combined with the absence of a standardized verification process to confirm that narcotics prepared for return to the pharmacy were immediately secured, reconciled, and accounted for until pharmacy pickup. Beginning [DATE], the Director of Nursing and/or Unit Managers will conduct random audits of narcotic declining inventory sheets and perform visual inspections of controlled substances stored on one medication cart each audit day, five times per week for 4 weeks, then 3 times per week for 4 weeks and then weekly for 4 weeks to verify compliance with the facility's Inventory Control of Controlled Substances policy. Audits will include residents with active narcotic orders as well as residents whose narcotic medications have been discontinued, changed, or are awaiting return to the pharmacy.Any identified variances will be addressed immediately through corrective action, including additional staff education, counseling, or disciplinary action as appropriate by the Director of Nursing. The Nursing Home Administrator reviewed the corrective action plan with the facility Medical Director on [DATE]Audit results will be presented to the QAPI Committee by the Director of Nursing monthly for three (3) months for review, evaluation of effectiveness, and recommendation of additional interventions as indicated.Alleged Date of Compliance: [DATE]Onsite validation of the corrective action plan was completed on [DATE]. Interviews with nursing staff confirmed they received in-service training on how to return narcotics to the pharmacy including where to store narcotics while waiting for the pharmacy to pick up the narcotics, when and how to complete narcotic counts. A review of the audit tool was conducted including a review of the resident questionnaires for all alert and oriented residents completed and the audit tool to determine pain on non-alert residents. A review of the audit was completed by Director of Nursing to ensure there were no other narcotic discrepancies from other discharged residents.The corrective action plans compliance date of [DATE] was validated.

Based on observation and staff interviews, the facility failed to post the daily nurse staffing information for 1 of 4 days of the survey (7/12/26).The findings included:During the initial tour on Sunday, 7/12/26 at 10:15 AM the daily nurse staffing information posted on the table by the Administrator's office was observed to be dated Friday, 7/10/26.During an interview on 7/14/26 at 2:07 PM the Staffing Coordinator revealed she prepared the daily nurse staffing information for the weekend (Saturday and Sunday) and placed them in the holder behind Friday's posting. The posting was to be changed by the Manager on Duty or the Nursing Supervisor on Saturday and Sunday. The Staffing Coordinator further indicated that on Monday, 7/13/26 she exchanged the staffing information and noted the one posted was dated for Friday, 7/10/26. The Staffing Coordinator stated that the Manager on Duty had not arrived at the facility prior to the survey team's entry.An interview conducted on 7/15/26 at 2:15 PM with the Nurse Supervisor who worked on 7/12/26 from 7:00AM to 7:00 PM indicated she did not know who was responsible for changing the daily nurse staffing information on the weekend.An interview with the Administrator on 7/14/26 at 2:30 PM indicated he expected the daily nurse staffing information to be changed daily in the morning. He further revealed that either the Nursing Supervisor or the Manager on Duty should have ensured daily nurse staffing information were posted for the correct day on the weekends.

Based on record review, and staff and Medical Director interviews, the facility failed to provide services in a safe manner when the Certified Occupational Therapy Assistant (COTA) utilized a rollator (a four wheeled walker with a seat) during a therapy session which had been deemed unsafe for Resident #313. During a therapy session with COTA #1 on 11/9/24 Resident #313 stood up from the locked rollator, unlocked brakes, and while turning herself around to walk forward, she fell to her left against the counter/lower kitchen cabinets and slid down to the floor. Resident #313 was sent to the emergency department (ED) on 11/9/24 for evaluation after reporting pain in her left shoulder and hip. A computerized tomography (CT) scan of the pelvis revealed a nondisplaced left greater trochanter fracture (break at the top of the thigh bone near the hip). Orthopedics was consulted and recommended nonoperative management and Resident #313 was admitted for inpatient care for further evaluation and pain management due to uncontrolled pain. Resident #313 was discharged from the hospital back to the facility on [DATE] with orders that included weight bearing as tolerated, ambulation with rolling walker, scheduled Tylenol for pain, lidocaine patch to left hip topically one time a day for pain, oxycodone (opioid pain medication) every 6 hours as needed for pain and rehabilitation services at a skilled nursing facility. The deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #313). The findings included: Resident #313 was admitted to the facility on [DATE]. Her diagnoses included diabetes, chronic obstructive pulmonary disease and generalized muscle weakness. An OT evaluation dated 10/30/24 included a section titled functional skills assessment - mobility during activities of daily living (ADLs) that indicated wheelchair mobility was stand by assist, wheelchair management was standby assist and other functional mobility during ADLs was moderate assistance. A review of Resident #313's medical records revealed a physical therapy treatment encounter note completed on 11/11/24 with a date of service of 10/31/24. The summary of skill section indicated skilled interventions focused on gait training using a rollator as per Resident's request during her meeting with Director of Rehabilitation. Resident #313 wanted therapist to train her to ambulate with a rollator so she could carry her oxygen tank in the basket as she was adamant about going home. Gait training with Rollator for 15 feet x 2 with minimum/moderate assist on level surface. Resident unable to keep up with rollator speed despite instructions to use rollator brakes. Resident also stated that she could stop and sit on the rollator seat if she gets tired. Therapist demonstrated safe transfer technique from ambulating to sitting (rollator seat). Resident lost her balance while in the process of turning in preparation to sit on her rollator (after she locked rollator brakes). Therapist explained safety concerns with her using a rollator. Resident verbalized understanding. A physical therapy treatment encounter note completed on 11/11/24 with a date of service of 11/1/24 included a summary of skills that indicated skilled intervention focused on gait training with Rollator for 10 feet + 16 feet with minimum/moderate assist on level surface. Resident #313 noted to lose balance after left foot catching on floor. Therapist explained safety concerns regarding use of rollator. Resident verbalized understanding. A physical therapy treatment encounter note dated 11/9/24 at 11:38 AM included a summary of skills that indicated gait training with a two-wheel walker and wheelchair follow for oxygen transport. 8 bouts of 20 to 30 feet gait training with contact guard assist with min verbal cues position to assistive device with fatigue and change in direction. With fatigue, increased distance from assistive device and increased instability. Cues for position to surface prior to turn to sit for appropriate targeting and to limit retro (backward)walking. Educated Resident and nursing staff related to ongoing falls risk and need for assist with standing and ambulation for falls prevention at this time. A physical therapy discharge summary dated 11/11/24 included a summary since evaluation/start of care section that indicated Resident #313 progress and response to treatment was that Resident had made substantial functional gains in response to skilled interventions including ambulating with front wheel walker to minimum assistance/contact guard assist. Functional outcomes indicated the assistive device was a front wheeled walker. During an interview on 5/7/25 at 12:07 PM, the Director of Rehabilitation indicated she was a physical therapist (PT). The Director of Rehabilitation stated that Resident #313's level of function was a front wheel walker, and a wheelchair as indicated on Resident #313's physical therapy discharge summary dated 11/11/24 as well as documented on the physical therapy treatment encounter note dated 11/9/24. The Director of Rehabilitation verbalized that she had informed Resident #313 on 10/30/24 during a meeting for potential discharge that the rollator with four wheels was not safe for her. She further stated that Resident #313 required standby assistance from sit to stand position and with functional transfers. The Director of Rehabilitation verbalized that she would not have told COTA #1 to train Resident #313 on the rollator because she was not her immediate supervisor. Resident #313's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as cognitively intact and required partial to moderate assistance with rolling in bed, sitting to standing, transfers, walking 10 feet and walking 50 feet with two turns. Resident #313 was also coded for a walker and wheelchair for mobility devices. A review of Resident #313's medical records revealed an occupational therapy treatment encounter note dated 11/9/24 written by Certified Occupational Therapy Assistant (COTA) #1. The note indicated a plan was made with Resident #313 to address simple meal preparation in the therapy kitchen as Resident still reported intent to return home alone this week. Resident reported that she was told by a therapist that she would need to go home with oxygen and that she would be safest with a rolling walker (RW) and would be unsafe with a rollator, because it'll get away from me. Resident was asked what her revised plan would be, as Resident had repeatedly stated, her plan was to go home using a rollator in the home, despite having a RW, and that the size of her living area would not support a wheelchair (WC). Resident stated once again that she would still be using a rollator at home, despite therapist education, stating, Well that's their opinion. Resident asked therapist if she could demonstrate the way she intended to use her rollator at home in her kitchen. Resident was educated in management of rollator brakes, ambulating with standby assistance (SBA), then sitting on seat of therapy rollator, using it as a WC to propel around from kitchen cabinets to refrigerator to stove, removing items from bottom cabinet seated on rollator. Resident educated on proper use of rollator as a walking aid, not to be used as a WC due safety concerns. Resident then stood up from the locked rollator, unlocked brakes, while turning herself and rollator around to walk forward, she fell to her left against the counter/lower kitchen cabinets and slid down to the floor. Therapist provided Resident with a pillow for her head and alerted nursing staff who came to evaluate the Resident and lift the Resident from the floor into the WC. Resident then agreed that the use of a rollator for her was not a good option. Resident had a small skin tear and stated that she needed to go to the hospital due to pain in her left shoulder and hip. An interview was conducted with COTA #1 on 5/8/25 at 8:38 AM. She indicated that she was aware that Resident #313's safest level of function was a front wheel walker (FWW) also known as a rolling walker and a wheelchair (WC) and not a rollator which had 4 wheels. COTA #1 stated that Resident #313 had told her that when she discharged home, she was going to use a rollator and she informed the Resident that it was not safe, and the Resident stated that was the opinion of the therapist. COTA #1 verbalized she asked Resident #313 to show her how she intended to use the rollator when she went home. COTA #1 pushed Resident #313 from her room to the therapy room so that she could demonstrate how she would use the rollator. She stated that her intention was not to make the rollator use a full training session but to show Resident #313 that it was not safe for her. She stated that her goal was to get Resident #313 away from using the rollator and to agree to use the front wheel walker and WC which were safe for her and that Resident #313 realized that the rollator was not safe for her after she fell . COTA #1 stated she did not ask the OT or anyone else if she should train Resident #313 to use the rollator because she was not planning to make it a full training session. She stated that she did not realize that the Resident was going to use the rollator as a wheelchair. COTA #1 stated that after she wheeled Resident #313 to the therapy room she placed the rollator in front of the Resident. Resident #313 stood up from the wheelchair and walked to the rollator that was in front of her and she sat on the rollator and COTA #1 informed the Resident not to use the rollator as a wheelchair. COTA #1 stated she then turned to the cabinet and in that process Resident #313 stood up from the rollator, unlocked the rollator and was turning herself to move when she fell against the cabinet. She informed nursing staff who came to assess the Resident and transfer the Resident to the wheelchair. An interview was conducted on 5/8/25 at 9:38 AM with the facility Occupational Therapist (OT). The OT indicated she had evaluated Resident #313 on 10/30/24 and the short-term goals included toileting transfers, lower body bathing, and lower body dressing. The long-term goals included lower body dressing, bathing and toileting with modified independence and simple meal preparation with modified independence in order to return home safely. The OT explained that the OT completed the evaluation and came up with goals which the COTA implemented. She stated that she trusted the COTA's clinical judgement to determine what is safe for a resident and if the COTA wanted to try a device, she would expect the COTA to communicate with her. She stated COTA #1 did not communicate to her that she was going to train Resident #313 to use the rollator and that it was a weekend and she was not at the facility on that day. The OT verbalized that the recommended safety level for Resident #313 was the front wheel walker, and that she had not told COTA #1 at any point to train Resident #313 to use the rollator. The OT stated that the rollator was not safe for Resident #313 because the rollator had four wheels and could roll away faster than a front wheel walker which had only 2 wheels. She further stated physical therapy had determined that the rollator was not safe for Resident #313. A nursing note dated 11/9/24 indicated at around 1:30 pm Resident #313 fell on her stomach, while walking with the rollator in the therapy room witnessed by occupational therapy staff. Resident #313 complained of pain to the left hip and left shoulder. Tylenol was given as ordered, provider was made aware with new orders given for x-ray to left hip and left shoulder and Responsible Party (RP) was made aware. A nursing note dated 11/9/24 indicated Resident #313 was sent to the emergency department (ED) at around 3:55 PM for further evaluation. During an interview with Nurse #1 on 5/12/25 at 2:00 PM, she indicated she was assigned to care for Resident #313 on 11/9/25 on day shift. She stated that she was notified by a staff member that Resident #313 had fallen while working with therapy staff. She went to the therapy room and found Resident # 313 lying on the floor facing down and she was complaining of pain to her left side. Nurse #1 stated that they transferred Resident #313 with the assistance of 4 staff members to the wheelchair and she notified the provider who gave an order for x-rays, but the x-rays were not completed because Resident # 313 requested to be sent to the ED and Nurse # 1 notified the provider and the Resident was sent to the ED. Nurse #1 verbalized that nursing staff utilized the wheelchair for Resident #313 and she had treatment sessions with physical therapy where they were walking with her but she could not tell exactly what kind of walker she was using for ambulation when working with therapy. ED progress notes dated 11/9/24 indicated Resident #313 was seen at the ED after a fall while walking at a skilled nursing facility and complained of pain. A computerized tomography (CT) scan of the pelvis revealed a nondisplaced left greater trochanter fracture. Consultation with orthopedics recommended nonoperative management and Resident #313 was admitted for inpatient care for further evaluation and pain management due to uncontrolled pain. Prior to inpatient admission Resident #313 was started on as needed pain medicine Toradol and fentanyl at the ED. Upon admission for in patient care she was started on scheduled Tylenol, as need oxycodone, lidocaine patch to the left hip and as needed Robaxin (muscle relaxant). Resident #313 was discharged from the hospital back to the facility on [DATE] with orders that included weight bearing as tolerated, ambulation with rolling walker, scheduled Tylenol 500 milligram 4 times a day for pain, lidocaine patch to left hip topically one time a day for pain, oxycodone 5 mg every 6 hours as needed for pain and rehabilitation services at a skilled nursing facility. Her discharge diagnoses included closed trochanter fracture of the left femur with routine healing and hip pain. An interview was conducted on 5/9/25 at 10:42 PM with the facility Medical Director (MD). The MD stated that COTA #1 should not have used the rollator with Resident # 313 because it was not part of OT's treatment plan and it had been determined unsafe. He also stated that if it was for demonstrative purposes, then it should have been done in a safe manner. During an interview on 5/9/25 at 12:07 PM with the Director of Nursing (DON), she stated that COTA #1 should have verified with OT if she should use the rollator with Resident #313 if it had been deemed unsafe for the Resident. During an interview with the facility Administrator on 5/9/25 at 12:30 PM, he indicated that his expectation was for the COTA to work with the Resident at a safe functional level for the Resident.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of hospice care for 2 of 21 residents reviewed for MDS accuracy (Resident #17 and Resident #87). Findings include: 1. Resident #17 was admitted to the facility on [DATE]. Her diagnoses included senile degeneration of the brain, chronic diastolic heart failure, and chronic respiratory failure with hypoxia. Resident #17's care plan had a care focus area created 9/2/24 that indicated Resident #17 was receiving hospice services. A physician order dated 8/26/24 indicated Resident #17 was a hospice recipient since 8/24/24. Resident #17's quarterly MDS dated [DATE] did not indicate Resident #17 was receiving hospice care. During an interview with the MDS Nurse on 5/9/25 at 9:08 AM, she stated that Resident #17 was receiving hospice services, and it should have been coded on the quarterly MDS. The MDS Nurse further stated that it was an oversight. An interview was conducted on 5/9/25 at 11:41 AM with the Director of Nursing (DON). The DON stated that Resident #17's MDS should have been coded correctly to reflect the Resident's status. She indicated Resident #17's quarterly MDS should have included hospice care since she was receiving hospice services. During an interview on 5/9/25 at 12:19 PM, the facility Administrator verbalized he expected Resident #17's MDS to be coded correctly to include hospice care. 2. Resident #87 was admitted to the facility on [DATE]. Her diagnoses included dementia, and hypertensive heart disease. Resident #87's care plan had a care focus area created 12/24/24 that indicated Resident #87 was receiving hospice services. A physician order dated 12/23/24 indicated Resident #87 was a hospice recipient since 12/21/24. Resident #87's quarterly MDS dated [DATE] did not indicate Resident #87 was receiving hospice care. During an interview with the MDS Nurse on 5/9/25 at 9:08 AM, she stated that Resident #87 was receiving hospice services, and it should have been coded on the quarterly MDS. The MDS Nurse further stated that it was an oversight. An interview was conducted on 5/9/25 at 11:41 AM with the Director of Nursing (DON). The DON stated that Resident #87's MDS should have been coded correctly to reflect the Resident's status. She indicated Resident #87's quarterly MDS should have included hospice care since she was receiving hospice services. During an interview on 5/9/25 at 12:19 PM, the facility Administrator verbalized he expected Resident #87's MDS to be coded correctly to include hospice care.

Based on observations and staff interviews, the facility failed to discard an opened canned drink in 100-hall nourishment room refrigerator and label and date food items stored in the 200-hall nourishment room refrigerator for 2 of 2 nourishment room refrigerators (100-hall and 200-hall nourishment room refrigerators). Findings included: Observation of the nourishment room refrigerators with the facility's Dietary Manager (DM) on 5/8/25 revealed the following: a. An open energy drink can with some liquid in it and a straw was observed in the 100-hall nourishment refrigerator at 12:34 PM. The energy drink can was not labeled or dated. The DM discarded the energy drink. b. Two pizza boxes, one with 1/4 pizza and the other one with half a pizza were observed in the 200-hall nourishment refrigerator at 12:40 PM. The pizza boxes were not labeled or dated. The Dietary Manager, who was present during the observations, stated that nursing staff were supposed to ensure the food items were labeled and dated before being placed in the refrigerator. An interview was conducted on 5/8/25 at 12:42 PM with the Director of Nursing (DON) when she came into the 200-hallway nourishment room and placed the food items in the trash can. The DON stated that nursing staff should have labeled and dated the food items before placing them in the fridge. The DON further stated the energy drink should not have been placed in the refrigerator after it was opened. An interview was conducted with the facility Administrator on 5/9/25 at 12:29 PM. The Administrator stated that his expectation was for all foods to be labeled and dated before being placed in the nourishment room refrigerators and opened drinks should not have been placed in the refrigerator.

Based on observations and staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP) and Paramedic #1 interviews and record review, when the facility moved the resident's bed against the wall to prevent her from getting out of the bed, they failed to identify this as a restraint, failed to complete a restraint assessment, failed to obtain a physician order and failed to obtain the RP's consent for the use of a restraint. When the resident fell out of the bed she was wedged between the bed and the wall. Resident #1 was assessed by facility staff and found to not have a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This was for 1 of 3 residents reviewed for restraints (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1 was found wedged between the bed and the wall after being restrained. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: Resident #1 was admitted on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, anxiety, unspecified psychosis and dementia. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #1 was assessed for severe cognitive impairment, she exhibited no behaviors, required partial staff assistance rolling from side to side, no impairments to bilateral upper and lower extremities, a weight of 275 pounds, and no use of restraints. Resident #1 was care planned on [DATE] as a risk for falls related to her decreased range of motion and pain. The care plan included the intervention of assist bars (narrow type of side rail attached to the side of a resident's bed approximately at shoulder level that is used to assist a resident with getting out of the bed or repositioning more easily. Assist bars are made to also swing outward to assist with a transfer from the bed to another surface as well but are not full weight bearing. They are not capable of movement up or down and are stationary). The care plan did not include the new intervention of pushing her bed against the wall to prevent her from getting out of bed. Review of Resident #1's [DATE] Physician orders included an order dated [DATE] for Oxygen at 2 liters per minute as needed for shortness of breath, Risperdal (antipsychotic) 0.25 milligrams (mg) at bedtime for psychosis and an order dated [DATE] for bilateral assist bars up on both sides of the bed to increase bed mobility. There was also an order dated [DATE] for Hydroxyzine (antihistamine) 25 mg every 8 hours as needed for restlessness/anxiety. Review of a progress note written by Nurse #1 dated [DATE] at 2:41 AM, read Resident #1 was yelling, wanting to get out of bed, calling out to her roommate for help. This behavior went on for about 2 to 3 hours. When asked what she needed help for, she replied, I don't know, will continue to monitor. A telephone Interview was completed on [DATE] at 1:25 PM with Nurse #1. Nurse #1 stated he worked with Resident #1 from 7:00 PM on [DATE] through 7:00 AM on [DATE] when she was experiencing behaviors during the [DATE] night shift around 2:40 AM. He stated her behaviors were yelling out, calling her roommate's name keeping her awake, repeatedly trying to get up out of the bed and asking for her son. Nurse #1 stated the staff could not sit the rest of the 11:00 PM-7:00 AM shift with her so he decided to move Resident #1's bed from its regular position in the center of the room to having the right side of the bed up against the wall. He stated he did this to keep Resident #1 from getting out of the bed. Nurse #1 stated he did not obtain a physician order, complete a restraint assessment or get a consent from her RP. Nurse #1 stated he did not do the things associated with implementing a restraint because a bed against the wall was not a restraint. Nurse #1 confirmed that according to the [DATE] Medication Administration Record (MAR), on [DATE] second shift starting from when he came in at 7:00 PM and third shift on [DATE], he did not administer Resident #1's prescribed as needed Hydroxyzine (antihistamine) for anxiety and restlessness. He was unable to recall if the bed had bilateral assist bars, why he didn't administer her prescribed Hydroxyzine or call the Physician for an antianxiety medication. Nurse #1's only explanation was that he did not think of it. A telephone interview was completed on [DATE] at 3:10 PM with Nursing Assistant (NA) #8. He confirmed working on [DATE] and [DATE] on third shift with Resident #1 and Nurse #1. NA #8 stated in the middle of the night of the ,d+[DATE] shift of [DATE], Resident #1 was yelling, bothering her roommate, keeping other residents awake and repeatedly attempting to get out of her bed. He stated Nurse #1 decided to move Resident #1's bed from the center of her room up against the wall so the right side of her bed was blocked by the wall. NA #8 stated this was done to keep Resident #1 from trying to get up out of her bed because she tended to throw her legs off the bed to the right side in an effort to get up. He stated he was not aware that in doing that, Nurse #1 had restrained Resident #1 because he thought that it was ok to do that because the facility did it for other residents. NA #8 stated he thought Resident #1's bed did have bilateral assist bars that made her bed not flush against the wall but rather it stuck out maybe an inch. A telephone interview was completed on [DATE] at 3:02 PM with Nurse #4. She stated she worked 7:00 AM to 7:00 PM on [DATE] with Resident #1. Nurse #4 stated Nurse #1 reported to her that morning that Resident #1 was up most of the night, yelling out and trying to get out of the bed. She stated Nurse #1 reported he moved Resident #1's bed against the wall during his shift to keep her from falling out of the bed. Nurse #4 stated she was aware that for the use of a restraint, there had to be permission from the Director of Nursing (DON) and the RP and the care planned had to be revised. She stated she didn't think of Resident #1 bed position change as restraint at the time. Nurse #4 stated Medication Aide (MA) #1 worked with Resident #1 on first shift on [DATE]. An interview was completed on [DATE] at 244 PM with MA #1. He stated he was assigned Resident #1 on [DATE] and [DATE] on first shift. MA #1 stated Resident #1 was known to have anxiety, agitation and restlessness that was difficult to redirect and that her providers were aware. MA #1 stated Resident #1 would disrobe, attempt to get out of her bed unassisted and had fallen at the facility before. He stated Nurse #4 reported to him on [DATE] that her bed was moved on night shift to prevent her from trying to get up out of the bed and falling. He stated at other facilities he worked at, that would have been a restraint but he did not think it was considered a restraint at this facility. A telephone interview was completed on [DATE] at 1:57 PM with NA #9. She stated she worked [DATE] 7:00 AM to 7:00 PM with Resident #1. She stated she noticed Resident #1's bed had been moved up against the wall and that MA #1 told her that the weekend staff did it to keep her from getting out of the bed. NA #9 stated Resident #1 was anxious and she removed her oxygen on multiple occasions but this was not unusual. MA #1 recommended getting her up to the reclining chair which settled her down. NA #9 stated Resident #1 stayed up in her reclining chair from lunch time till right after dinner then she assisted her to bed. She stated at this time Resident #1 began yelling, screaming, swinging at her and her bed was still up against the wall. She stated the MA #1 gave her a Hydroxyzine at 4:45 PM and that he could not give her anything else because it was too early. NA #9 stated Resident #1 eventually settled down enough that she felt it was safe to leave the room. A telephone interview was completed on [DATE] at 7:25 PM with NA #10 who worked with Resident #1 on [DATE] from 7:00 PM to 11:00 PM. She stated she immediately noticed that her bed had been moved up against the wall and assumed it was because of her attempts to get up out of the bed. She recalled Resident #1 as being emotional and confused on her shift. NA #10 stated she was not aware that Resident #1's bed against the wall was considered a restraint since she could exit the other side of her bed if she wanted to. A telephone interview was completed on [DATE] at 2:14 PM with Nurse #3. She confirmed working with Resident #1 on [DATE] from 3:00 PM to 7:00 PM and on [DATE] from 7:00 AM to 7:00 PM. She stated MA #1 reported to her the Resident #1 had been experiencing anxiety of late and there were two occasions the week before when her RP was contacted and came to sit with her. Nurse #3 stated there had been communication left in the psychiatric providers notebook and in the Physician's notebook regarding her increased anxiety but so far only Hydroxyzine had been ordered as needed. She stated Resident #1 received psychiatric services and talk therapy but there had been no significant changes and that her confusion and behaviors seemed to worsen later in the afternoons. Nurse #3 stated she noticed that Resident #1's bed had been moved but it never occurred to her that it could be considered a restraint until Resident #1 fell in between the bed and the wall and ended up dying. Nurse #3 stated the bed against the wall created a dangerous situation for Resident #1 given her cognitive status with her increased anxiety and behaviors. A telephone interview was completed on [DATE] at 7:55 AM with NA #12. She stated she worked 11:00 PM on [DATE] to 7:00 AM on [DATE]. She stated she noticed Resident #1's bed had been moved. She stated Resident #1 was known to try to get out of the get, crawl out of the bed, disrobe, yell and strike at staff. NA #12 stated she was not aware that having her bed pushed up against the wall was considered a restraint. She confirmed restraint training but could not recall when she last received that training. A telephone interview was completed on [DATE] at 7:30 PM with NA #11. She stated she worked on [DATE] from 7:00 AM to 3:00 PM with Resident #1 and noticed that her bed had been moved up against the wall. She stated Resident #1 seemed to experience increased anxiety while in the bed and rested better in the reclining chair. NA #9 stated that was where she typically let Resident #1 nap on the days she was assigned to her. She stated that moving the bed against the wall was not considered a restraint as far as she knew. Review of psychiatric NP note dated [DATE] read the reason for her visit was due to staff request regarding anxiety, insomnia and psychosis. Staff reported the Resident #1 had been confused and yelling out to be put to bed or taken out of the bed. The note read Hydroxyzine was prescribed by the MD on [DATE]. A telephone interview was completed on [DATE] at 10:37 AM with the psychiatric NP. She stated when she saw Resident #1 on [DATE] it was because it was at the request of the staff. They documented the reason as anxiety and restlessness. She stated when she reviewed Resident #1's medical record, she noted that that the MD had already prescribed a medication for her anxiety (Hydroxyzine). The psychiatric NP stated she reviewed Resident #1's nursing notes and read that after the Hydroxyzine was administered, the nurses documented that it was effective. She stated this was why she did not to prescribe anything else for her anxiety or restlessness. When questioned if she interviewed any of the floor staff about Resident #1's anxiety or recent behaviors, she stated she only reviewed the electronic medical record. A telephone interview was completed on [DATE] at 7:00 PM with Nurse #5. She stated she worked on [DATE] from 7:00 PM to 7:00 AM with Resident #1. She recalled Resident #1 often yelling out help me' and she was difficult to redirect. Resident #1 would want to get up out of the bed then she would want to get back in the bed. She stated she assumed the bed was positioned against the wall because she often tried to get out of the bed unassisted. Nurse #5 stated Resident #1's bed was a bariatric bed that also had bilateral assist bars to help with bed mobility. A telephone interview was completed on [DATE] at 12:41 PM with NA #13. She confirmed she worked [DATE] from 3:00 PM to 11:00 PM with Resident #1. She stated Resident #1 seemed to rest better sitting up in her reclining chair and when she was placed in the bed, she would attempt to get out of the bed and exhibit more behaviors. NA #13 stated when she left at 11:00 PM, Resident #1 was sleeping in her reclining chair. She stated she noticed that Resident #1's bed had been moved against the wall with maybe one to two inches in between the wall and the bed due to assist bars. NA #13 stated the assist bars on her bed did not move up or down but were affixed to the bed frame. An interview was completed on [DATE] at 1:00 with NA #1. She recalled working first shift on [DATE] with Resident #1. NA #1 stated she asked NA #2 to assist her to put Resident #1 back to bed using the mechanical lift and assist with giving her a bath. She stated after the bath, Resident #1 was tired and stated she wanted to take a nap. An interview was completed on [DATE] at 1:16 PM with NA #2. She stated she helped NA #1 transfer Resident #1 using the mechanical lift into the bed on [DATE] at approximately 1:30 PM and they gave her a bath and completed her personal care. NA #2 stated Resident #1 was known to try to get out of the bed and she was unsafe to do so. She also said Resident #1 was known to display agitation and anxiety at times and was extremely difficult to redirect. NA #2 stated that also was the first day she had observed Resident #1's bed pushed up against the wall. She stated she did not consider that a restraint because Resident #1 could still get out of her bed on the other side. NA #2 stated Resident #1 was known to try to get out of the bed and she was unsafe to do so. She also said Resident #1 was known to display agitation and anxiety at times and was extremely difficult to redirect. NA #2 stated that also was the first day she had observed Resident #1's bed pushed up against the wall. She stated there were bilateral assist bars on Resident #1's bed that left about one to two inches of room between her bed and the wall. A review of an incident report dated [DATE] at 4:38 PM read Resident #1's RP opened her door and called out for assistance. An aide screamed out for additional staff assistance. Resident #1 was seen lying on her right side face down next to the right side of her bed on the floor. Resident #1 was turned over while her RP moved the bed and furniture out of the way. Resident #1's vital signs and blood sugar were requested along with a request for someone to call Emergency Medical Services (EMS) and to announce a code blue (full code for presumed cardiac arrest). CPR was started and taken over by EMS while the RP was present in the room. A telephone interview was completed on [DATE] at 2:11 PM with NA #3. She stated she was scheduled to work from 3:00 PM to 11:00 PM with Resident #1 on [DATE] but she was late for work and walked by her room around 3:20 PM and saw her sleeping in her bed. NA #3 stated she then gave another resident a shower and returned to check on Resident #1 sometime between 3:30 PM and 3:45 PM. It was at this time she observed Resident #1's door to her room closed so she assumed her RP was in the room visiting. NA #3 stated she was aware that Resident #1's bed had been pushed up against the wall so she could not get out of the bed on the right side because she tended to throw her legs over to the right side of the bed when trying to get up. NA #3 stated she would not have considered Resident #1's bed against the wall an accident hazard. A telephone interview was completed on [DATE] at 2:51 PM with MA #2. She stated she was working on [DATE] from 7:00 AM to 7:00 PM with Resident #1. She stated she heard NA #4 calling out for help saying Resident #1 was on the floor. She stated she responded to the room and saw her face down in between the bed and the wall. MA #2 stated the bed had been moved and UM #1 and Nurse #2 were working on her. She stated she had not questioned Resident #1's bed being up against the wall because she assumed the interdisciplinary team (IDT) team had put it in place as a fall intervention. A telephone interview was completed on [DATE] at 1:30 PM with Resident #1's RP. He stated he arrived on [DATE] at 4:03 PM and stopped at the nurses station to talk to UM #1 then proceeded down the hall to Resident #1's room. The RP stated when he observed the door to her room closed, he assumed staff were inside providing care and would be coming out shortly. He stated within a few minutes of standing in the hallway outside Resident #1's door, he thought heard her call out his name but he didn't think much of it since he assumed staff were in the room with her. He said he was chatting with a few other residents in the hallway when he decided he had waited too long for staff to be in the room assisting Resident #1.The RP stated it was around 4:15 PM when he decided to knock on the door and gently open the door to peek inside. He stated that was when he saw the bottom of Resident #1's right foot on top of her mattress and could not see the rest of her body. He stated he knew something was wrong so he stuck his head outside her room and asked staff to get help. He stated he then attempted to pull the bed away from the wall to see Resident #1. He said the bed must have been locked because it was difficult to move but he got the end of the bed pulled out and the head of the bed out slightly enough to see that Resident #1 was not responsive and her color didn't look right. The RP stated he called for help and then staff entered the room and took over. He stated they turned her over and started CPR until EMS arrived but they were unable to revive her. When asked approximately how much space did he think was between the bed and the wall when he found her, he stated just a few inches. The RP stated Resident #1's bed had never seen her bed up against the wall before and Resident #1 had bilateral assist bars on her bed. An interview was completed on [DATE] at 9:45 AM with UM #1. She stated Resident #1 had a history of throwing her feet over the side of the bed trying to get up unassisted. UM #1 stated it was reported to her Monday ([DATE]) by Nurse #2 that Resident #1 had experienced increased anxiety and behaviors over the weekend. Resident #1 was yelling, calling out for her roommate to assist her and trying to get up out of the bed unassisted. Nurse #2 stated that Nurse #1 reported to her that he moved her bed from the center of her room to be flush against the wall with the headboard against the wall near the hallway door. UM #1 stated she did not question the bed being moved nor did she consider the bed against the wall as a restraint. When questioned regarding the rationale for the bed being moved up against the wall, UM #1 stated it was to keep her from getting out of the bed and falling. When asked if that could be the definition of a restraint, UM #1 stated yes. UM #1 stated on [DATE] at approximately 4:15 PM, she heard NA #4 calling for help needed in Resident #1's room. NA #4 stated the RP found Resident #1 on the floor between the bed and the wall. She summoned Nurse #2 to assist and asked staff to retrieve the crash cart (a cart that contains all the supplies and equipment need in the event of a cardiopulmonary arrest) requiring CPR and call 911. UM #1 stated upon entry to the room, the RP was standing at the foot of the bed and had pulled to foot of the bed away from the wall to allow them to get between the bed and the wall and turn her over to assess. UM #1 stated Resident #1 was blue, warm to the touch, absent of any pulses or respirations so CPR was initiated. A telephone interview was completed on [DATE] at 1:10 PM with NA #4. She stated she was walking down the hallway when Resident #1's RP opened her door and stated he needed help because Resident #1 was on the floor. She stated she could not see Resident #1 from the doorway. She stated once she entered the room and walked over to the end of the bed, she could see Resident #1 lying on the floor in between the bed and the wall. She stated the RP had already pulled out the foot of the bed some but stated she assisted him in pulling out the bed more to allow for staff to roll her and perform CPR. NA #4 stated she did not know how much space was between the bed and the wall prior to her fall. She stated once CPR was initiated, she exited the room. An interview was completed on [DATE] at 2:30 PM with NA #6. She confirmed she was working second shift on [DATE] but was not assigned Resident #1. She stated Resident #1 was known to display agitation, disrobe and continuously trying to get out of her bed. NA #6 recalled Resident #1's door being closed thinking her RP was in the room for a visit. She stated she was not aware that he wasn't in the room until he found her on the floor between the bed and the wall. NA #6 stated since this incident with Resident #1, she understood better how putting a bed against a wall could be a restraint. She also confirmed that Resident#1's bed had bilateral assist bars. A telephone interview was completed on [DATE] at 3:00 with Nurse #2. She stated she worked [DATE] 7:00 AM to 7:00 PM on another cart but she responded to Resident #1's room with UM #1. Nurse #2 stated when she arrived in the room, Resident #1 was lying on the floor in between her bed and the wall. She stated the bed had already been pulled out enough so that she and UM #1 could roll her over and begin CPR. Nurse #2 stated Resident #1 was known to try to get out of the bed unassisted but she did not have the cognition nor the ability to walk and would end up falling. She stated she did not think she had assist bars on her bed at the time of the fall. A telephone interview was completed on [DATE] at 4:07 PM with NA #5. She stated she was working second shift on [DATE] and she was in another residents room when she heard the RP say outside Resident #1's door that she was on the floor. She stated she entered the room to see Resident #1 on the floor in between the right side of her bed and the wall and the RP was pulling the bed out some to allow for the staff to help Resident #1. That's when UM #1 and Nurse #2 entered and rolled Resident #1 over and we saw she was not breathing and blue so they began CPR then she exited the room. A telephone interview was completed on [DATE] at 12:59 PM with NP #1. She stated she was not notified that Resident #1's bed was being used as a restraint and would have not ordered it due to the risk associated with Resident #1's known behaviors of attempting get out of her bed unassisted and the risk of injuries and possible entrapment. On [DATE] at 3:40 PM, in the presence of the DON, ADON and the Regional Clinical Coordinator, UM #1 provided a description of what occurred on [DATE] involving Resident #1's fall. This description was done in an empty room with a non-bariatric bed that was placed against the wall in the same position as Resident #1's bed would have been in on [DATE]. UM #1 described entering the room and noting the foot of the bed had been pulled away from the wall approximately 18 to 20 inches at the foot and approximately 8 inches at the head when she observed Resident #1 with the right side of her body lying on the floor while the left side of her body lying against the base board of the floor slightly leaning into the wall. She described her as nonresponsive. UM #1 stated somebody moved the bed out of the way further and they rolled Resident #1 onto her back and noted she was not breathing and had no pulse. An interview was completed on [DATE] at 10:48 AM with the ADON. She stated she was not aware that Resident #1's bed had been repositioned against the wall on the 11:00 PM to 7:00 AM shift [DATE]. A telephone interview was completed on [DATE] at 2:12 PM with Paramedic #1 who responded to the code at the facility on Resident #1 on [DATE]. He recalled that when he arrived at Resident #1's room, the facility staff were in the process of performing CPR. He stated staff reported that Resident #1 was found on the right side of the bed near the wall but that she had not fallen off of the bed. He stated Resident #1 never regained a pulse and only a brief rhythm change was seen before asystole (no heart beat) again. He said the code was called at 5:00 PM. An interview was completed on [DATE] at 9:30 AM with the DON. She stated at approximately 4:05 PM on [DATE], the RP came to the facility for a visit but stopped at the nurses station to talk to Unit Manager (UM) #1 then he walked down the hall to Resident #1's room and noted the door closed. He stated he assumed staff were in the room providing personal care. The DON stated he was waiting in the hallway chatting with other residents until he eventually knocked on the door and stuck his head in. The DON stated that was when the RP reported seeing Resident #1 on the floor in between in the bed and the wall with her right foot still propped up on the bed. The DON stated he stuck his head out of the room and yelled for help. NA #4 was walking down the hallway and ran to get the nurses and NA #5 was in another room but responded to the room. The DON stated next UM #1 and Nurse #2 arrived in the room where the RP had pulled the foot end of the bed out to allow the nurses to roll Resident #1 over to assess her and initiate CPR. The DON stated EMS and the police were notified. She stated when EMS arrived, they assumed care of Resident #1 and pronounced her deceased at 5:00 PM. The DON stated she was not aware that Resident #1's bed had been moved up against the wall until [DATE]. The DON stated her investigation included staff statements at the time of the incident and review of the incident report. She stated at no time did the facility consider moving Resident #1's bed up against the wall as a restraint. The DON stated prior to any device being used to prevent a resident's movement in any manner, it had to be assessed for safety, a Physician order had to be obtained and a written consent obtained from the RP. A telephone interview was completed on [DATE] at 11:07 AM with the MD. He stated Resident #1 being found on the floor in between her bed and the wall, it would not mean that it caused her death. He stated she could have had a pulmonary embolism (a sudden blockage in the pulmonary arteries) or died due to her poor cardiac status. The MD stated her death was not likely the result of suffocation or strangulation in conjunction with her weight of 280 pounds. He stated Resident #1's bed being placed against the wall and subsequent fall did not result in her death because she could have easily gotten out of the bed on the left side as well. The Administrator was notified of Immediate Jeopardy on [DATE] at 11:55 AM. The facility provided the following credible allegation of immediate jeopardy removal with a competition date of [DATE]: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The deficient practice resulted when the facility failed to have licensed nurses and nurse aides that were able to demonstrate competency in skills and techniques to address Resident # 1's behavior and attempts to get out of bed. Staff restrained Resident #1's movement by pushing the bed against the wall on [DATE]. This staff nor other staff who subsequently provided care for Resident #1 recognized the restraint of the resident's movements could create a life-threatening hazard. Resident #1 was found unconscious and wedged between the wall and the bed. Resident #1 expired on [DATE]. Based on the investigation and the root cause analysis completed by the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Coordinator (RCC) for Laurel Health Care Company on [DATE], it was noted that the lack of staff education related to the restraint management policy, incidents and accidents policy and the abuse policy to include injuries of unknown origin is what led to the incident forementioned. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The facility implemented the immediate actions to ensure that policies and systems were in place to investigate, implement effective interventions, document, ensure training and competencies for all nursing staff who would place a resident's bed against the wall to prevent future accidents and or injuries. No revisions to the restraint management policy were required. On [DATE] the LNHA, DON and the RCC for Laurel Health Care completed a root cause analysis of the incident related to Resident #1. The resulting interventions from the root cause analysis were: The LNHA and the DON received education from the RCC on [DATE] regarding the restraint management policy, incidents and accidents policy and the abuse policy to include injuries of unknown origin. The education was provided, in person, verbally with opportunity for discussion and /or clarification, and contained the definition of a restraint, the required evaluation prior to application of a restraint, identification of the risks of using the restraint, physician order for the bed against the wall prior to initiation of the restraint and that a bed placed against the wall as a behavior management intervention is considered a restraint with alternative behavior management interventions. The facility nursing staff (to include LPN, RN, Med Aides, and CNAs) currently working in the facility received education from the DON or the Assistant Director of Nursing verbally, in person, with opportunity for discussion and /or clarification, regarding the restraint management policy, incidents and accidents policy and the abuse policy, to include injuries of unknown origin, on [DATE] and contained the definition of a restraint, the required evaluation prior to application of a restraint, identification of the risks of using the restraint, physician order for the bed against the wall to be completed prior to initiation of the restraint, that a bed placed against the wall, as a behavior management intervention, is considered a restraint and alternative behavior management interventions that is not a restraint. The remaining facility nursing staff will receive this education from the DON prior to returning to work at the facility. This education will also be provided to new nursing staff during orientation. All staff currently working in the facility received education from the DON or the Assistant Director of Nursing verbally, in person, with opportunity for discussion and /or clarification, abuse policy, to include injuries of unknown origin, on [DATE]. The remaining facility staff will receive this education from the DON prior to returning to work at the facility. This education will also be provided to new facility staff during orientation. The DON or Assistant Director of Nursing (ADON) completed an audit of residents with their bed against the wall for a physician order, physical device evaluation, current signed consent and care plan on [DATE]. The DON completed an audit of residents with behaviors of attempting to get out of bed, to identify residents that have the bed placed against the wall as a behavior management intervention and none were observed on [DATE]. The facility alleges the immediate jeopardy was removed on [DATE]. An onsite validation of the immediate jeopardy removal plan was completed on [DATE]. Staff were interviewed to validate in-servic[TRUNCATED]

Based on record review, observations and interviews with staff, Responsible Party (RP), Bed Supplier Manager, Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Examiner (ME) #1 the facility failed to keep Resident #1 free from accident hazards by placing her bed against the wall and trying to restrict her from getting out of bed and implement fall interventions ensuring Resident #1's bed remained in the lowest position. Resident #1 fell out of the right side of her bed in between her bed and the wall where there was approximately two to three inches of space. Resident #1 was discovered by her RP in between the wall and the bed lying face down with the left side of her body slightly leaning against the base board on the wall keeping her from being completely flat on the floor. Resident #1 was assessed by facility staff and found not to have a pulse or respirations so cardiopulmonary resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This deficient practice was for 1 of 3 residents reviewed for accidents (Resident #1). Immediate jeopardy began on [DATE] when Resident #1 was discovered wedged between the wall and the bed face down without pulse and respiration. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level grid of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective and all staff have been in-serviced. The findings included: Resident #1 was admitted on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, psychosis and dementia. Resident #1 was care planned on [DATE] as a full code and for a risk for falls related to her decreased range of motion and pain. The care plan included the intervention of assist bars to her bed as of [DATE] and the intervention to keep her bed in the lowest position was added on [DATE]. Resident #1's [DATE] Physician orders included an order dated [DATE] for Oxygen at 2 liters per minute as needed for shortness of breath. Risperdal (antipsychotic medication) 0.25 milligrams (mg) at bedtime for psychosis and an order dated [DATE] for bilateral assist bars up on both sides of the bed to increase bed mobility. A Physical Device assessment dated [DATE] read Resident #1 was re-evaluated and approved for bilateral assist bars to increase her bed mobility on readmission. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #1 had severe cognitive impairment, required partial staff assistance rolling from side to side, a weight of 275 pounds, no restraints and coded. A progress note written by Nurse #1 dated [DATE] at 2:41 AM read, Resident #1 was yelling, wanting to get out of bed, calling out to her roommate for help. This behavior went on for about 2 to 3 hours. When asked what she needed help for, she replied, I don't know, will continue to monitor. A telephone Interview was completed on [DATE] at 1:25 PM with Nurse #1. Nurse #1 stated he was assigned Resident #1 on [DATE] from 7:00 PM to 7:00 AM on [DATE] when she was experiencing extreme behaviors that night. He stated her behaviors were yelling out, calling her roommate's name, keeping her awake, repeatedly trying to get up out of the bed and asking for her son. Nurse #1 stated the staff could not sit with her for the rest of the shift, so he decided to move Resident #1's bed from its regular position in the center of the room to the right side of the bed up against the wall. He stated he did this to keep Resident #1 from getting out of bed and he did not consider it as a potential accident hazard. Nurse #1 stated he could not recall if Resident #1 had an assist bar to the right side of her bed against the wall but recalled one assist bar to the left side of her bed. A telephone interview was completed on [DATE] at 3:10 PM with NA #8. He confirmed working on [DATE] and [DATE] on third shift with Resident #1. NA #8 stated on [DATE] night shift, Resident #1 was yelling, bothering her roommate, keeping other residents awake and repeatedly attempting to get out of her bed. He stated Nurse #1 decided to move Resident #1's bed from the center of her room to up against the wall so the right side of her bed was blocked by the wall. NA #8 stated this was done to keep Resident #1 from trying to get up out of her bed because she tended to throw her legs over the bed to the right side to get up. He stated he thought it was okay to do because the facility does it for other residents. NA #8 stated Resident #1 had bilateral assist bars to her bed. A telephone interview was completed on [DATE] at 3:02 PM with Nurse #4. She stated she worked 7:00 AM to 7:00 PM on [DATE] with Resident #1. Nurse #4 stated Nurse #1 reported to her that morning that Resident #1 was up most of the night, yelling out and trying to get out of the bed. She stated Nurse #1 reported he moved Resident #1's bed up against the wall during his shift to keep her from falling out of the bed and she did not consider it unusual since there were other residents with their beds against the wall. An interview was completed on [DATE] at 1:00 with NA #1. She recalled working first shift on [DATE] with Resident #1. She stated after lunch, Resident #1 was sitting up in her reclining chair in the hallway around 1:30 PM. NA #1 stated Resident #1 seemed to rest better in her reclining chair. NA #1 stated things were slow so she asked NA #2 to assist her to put Resident #1 back to bed using the mechanical lift and assist with giving her a bath. She stated after the bath, Resident #1 was tired and stated she wanted to take a nap. NA #1 stated she did not recall if she left the bed in the lowest position or not but did recall Resident #1's bed having bilateral assist bars attached to her bed. An interview was completed on [DATE] at 1:16 PM with NA #2. She stated she helped NA #1 transfer Resident #1 using the mechanical lift into the bed on [DATE] at approximately around 1:30 PM. NA #2 stated the head of her bed (HOB) was raised to approximately 30 degrees and Resident #1 was going to take a nap. NA #2 stated Resident #1 was known to try to get out of the bed and she was unsafe to do so. She also said Resident #1 was known to display agitation and anxiety at times and was extremely difficult to redirect. NA #2 stated that this was the first day she had observed Resident #1's bed pushed up against the wall. She stated Resident #1's bed was not left in the lowest position based on her recollection since it was raised to provide care and moved away from the wall while care was provided. NA #2 did recall placing the bed back against the wall and locking the brakes prior to leaving the room. She stated there were bilateral assist bars on Resident #1's bed that left about ,d+[DATE] inches of room between her bed and the wall and she did not consider the bed against the wall an accident hazard. A telephone interview was completed on [DATE] at 2:51 PM with MA #2. She stated she was working on [DATE] from 7:00 AM to 7:00 PM with Resident #1. She stated she heard NA #4 calling out for help saying Resident #1 was on the floor. She stated she responded to the room and saw her face down in between the bed and the wall. MA #2 stated UM #1 and Nurse #2 were working on her. MA #2 stated the bed was not in a low position when she was in the room earlier. She stated she did not question Resident #1's bed being up against the wall because she assumed the interdisciplinary team (IDT) team had put it in place as a fall intervention. A telephone interview was completed on [DATE] at 2:11 PM with NA #3. She stated she was scheduled to work from 3:00 PM to 11:00 PM with Resident #1 on [DATE] but she was late for work and walked by her room around 3:20 PM and saw her sleeping in her bed. She stated she did not think Resident #1's bed was in the lowest position. NA #3 stated she then gave another resident a shower and returned to check on Resident #1 sometime between 3:30 PM and 3:45 PM. It was at this time she observed Resident #1's door to her room closed so she assumed her RP was in the room visiting. NA #3 stated she was aware that Resident #1's bed had been pushed up against the wall so she could not get out of the bed on the right side because she tended to throw her legs over to the right side of the bed when trying to get up. NA #3 stated she would not have considered Resident #1's bed against the wall an accident hazard. A telephone interview was completed on [DATE] at 1:30 PM with Resident #1's RP. He stated he arrived on [DATE] at 4:03 PM and stopped at the nurse station to talk to UM #1 then proceeded down the hall to Resident #1's room. The RP stated when he observed the door to her room closed, he assumed staff were inside providing care and would be coming out shortly. He stated within a few minutes of standing in the hallway outside Resident #1's door, he thought he heard her call out his name, but he didn't think much of it since he assumed staff were in the room with her. He said he leaned against the handrail opposite Resident #1's door chatting with a few other residents when he decided he had waited too long for staff to be in the room assisting Resident #1. The RP stated it was around 4:15 PM when he decided to knock on the door and gently open the door to peek inside. He stated that when he saw the bottom of Resident #1's right foot on top of her mattress and could not see the rest of her body. He stated he knew something was wrong, so he stuck his head outside her room and asked staff to get help. He stated he then attempted to pull the bed away from the wall to see Resident #1. He said the wheels must have been locked because it was difficult to move but he got the end of the bed pulled out and the head of the bed out slightly enough to see that Resident #1 was not responsive and her color didn't look right. The RP stated staff entered the room and took over. He stated they turned her over and started CPR until EMS arrived, but they were unable to revive her. When asked approximately how much space did he think was between the bed and the wall when he found her, he stated just a few inches. The RP stated Resident #1's bed was not in the lowest position when he found her and that he had never seen her bed up against the wall before. He stated Resident #1 had bilateral assist bars on her bed. A telephone interview was completed on [DATE] at 1:10 PM with NA #4. She stated she was walking down the hallway when Resident #1's RP opened her door and stated he needed help because Resident #1 was on the floor. She stated she could not see Resident #1 from the doorway. She stated once she entered the room and walked over to the end of the bed, she could see Resident #1 lying on the floor in between the bed and the wall. She stated the RP had already pulled out the foot of the bed some, but she assisted him in pulling out the bed more to allow for staff to roll her and perform CPR. NA #4 stated she did not know how much space was between the bed and the wall prior to her fall but there was maybe three to four inches between the wall and the foot of the bed when she saw Resident #1 on the floor. She also recalled the bed was not in its lowest position. An interview was completed on [DATE] at 2:30 PM with NA #6. She confirmed she was working from 3:00 PM to 11:00 PM on [DATE] but was not assigned Resident #1. She stated Resident #1 was known to display agitation, disrobe and continuously tried to get out of her bed. She said her bed was supposed to be in the lowest position when she was in it. NA #6 recalled Resident #1's door being closed thinking her RP was in the room for a visit. She stated she was not aware that he wasn't in her room until he found her on the floor between the bed and the wall. An interview was completed on [DATE] at 9:45 AM with UM #1. She stated Resident #1 had a history of throwing her feet over the side of the bed trying to get up unassisted. UM #1 stated it was reported to her on [DATE] by Nurse #4 that Resident #1 had experienced increased anxiety on the previous night shift on [DATE] and that Resident #1 was yelling, calling out for her roommate to assist her and trying to get up out of the bed unassisted. Nurse #4 stated that Nurse #1 reported to her that he moved her bed from the center of her room to be flush against the wall with the headboard against the wall near the hallway door. UM #1 stated she did not question the bed being moved nor did she consider the bed against the wall as an accident hazard. When questioned as to the rationale for the bed being moved up against the wall, UM #1 stated it was to keep her from trying to get out of the bed and falling. UM #1 stated on [DATE] at approximately 4:15 PM, she heard NA #4 calling for help to Resident #1's room. NA #4 stated the RP found Resident #1 on the floor between the bed and the wall. She summoned Nurse #2 to retrieve the crash cart (a cart that contains all the supplies and equipment needed in the event of a cardiopulmonary arrest). UM #1 stated upon entry to the room, the RP was standing at the foot of the bed and had pulled the foot of the bed away from the wall to allow them to get between the bed and the wall and turn her over to assess Resident #1. She stated the bed was not in the lowest position at the time she entered the room, and she could not recall if there was an assist bar on the side of the bed (right) that was against the wall. UM #1 stated Resident #1 was blue, warm to the touch, absent of any pulses or respirations so CPR was initiated. A telephone interview was completed on [DATE] at 3:00 with Nurse #2. She stated she worked [DATE] from 7:00 AM to 7:00 PM on another cart but she responded to Resident #1's room with UM #1. Nurse #2 stated when she arrived in the room, Resident #1 was lying on the floor in between her bed and the wall. She stated the bed had already been pulled out enough so that she and UM #1 could roll her over and begin CPR. She stated the staff kept her bed in the lowest position, but it was the regular position at the time of this fall. A review of an incident report dated [DATE] at 4:38 PM read, Resident #1's Responsible Party (RP) opened her door and called out for assistance. An aide screamed out for additional staff assistance. Resident #1 was seen lying on her right-side face down next to the right side of her bed on the floor. Resident #1 was turned over while her RP moved the bed and furniture out of the way. Resident #1's vital signs and blood sugar were requested along with a request for someone to call emergency medical services (EMS) and to announce a code blue (full code for presumed cardiac arrest). Cardiopulmonary Resuscitation (CPR) started and taken over by EMS while the RP was present in the room the entire time. A telephone interview was completed on [DATE] at 2:23 PM with the Maintenance Director. He stated Resident #1's bariatric bed was a rental so he could not make any alterations or repairs to the bed and when it was picked up on [DATE], it had bilateral assist bars in place. A telephone interview was completed on [DATE] at 3:18 PM with the Bed Supplier Manager. He stated when Resident #1's bariatric bed was picked up on [DATE], the bed was received in good condition and returned with assist bars attached to the bed. On [DATE] at 3:40 PM, in the presence of the DON, ADON and the Regional Clinical Coordinator, UM #1 provided a description of what occurred on [DATE] involving Resident #1's fall. This description was done in an empty room with a non-bariatric bed that was placed against the wall in the same position as Resident #1's bed would have been in on [DATE]. UM #1 described entering the room and noting the foot of the bed had been pulled away from the wall approximately 18 to 20 inches at the foot and approximately 8 inches at the head when she observed Resident #1 with the right side of her body lying on the floor while the left side of her body lying against the base board of the floor slightly leaning into the wall. She described her as nonresponsive. UM #1 stated somebody moved the bed out of the way further and they rolled Resident #1 onto her back and noted she was not breathing and had no pulse. An interview was completed on [DATE] at 9:30 AM with the Director of Nursing (DON). She stated that NA #3 reported that after she completed the other resident's shower she went back to Resident #1's room and noticed her door was closed. NA #3 stated this was between 3:30 PM or 3:45 PM. The DON stated NA #3 assumed Resident #1's RP was in the room for a visit. The DON stated at approximately 4:05 PM, the RP came to the facility for a visit but stopped at the nurse's station to talk to Unit Manager (UM) #1 first. She stated he then walked down the hall to Resident #1's room and noted the door closed assuming staff were in the room providing personal care. The DON stated he was waiting in the hallway chatting with other residents until he eventually knocked on the door and stuck his head in. The DON stated that was when the RP reported seeing Resident #1 on the floor in between the bed and the wall with her right foot still propped up on the bed. The DON stated he stuck his head out of the room and yelled for help. NA #4 was walking down the hallway to get the nurses and NA #5 was in another room but responded to the room. The DON stated next UM #1 and Nurse #2 arrived in the room with the crash cart. The RP pulled the foot end of the bed out to allow the nurses to roll Resident #1 over to assess her and initiate CPR. The DON stated Emergency Medical Services (EMS) and the police were all notified. She stated when EMS arrived, they assumed care of Resident #1 and pronounced her deceased at 5:00 PM. She stated when Police Officer #1 arrived, he never entered the room but rather, once the code was over, Police Officer #1 spoke with the RP at that time. The DON stated she was not aware that Resident #1's bed had been moved up against the wall. The DON stated her investigation included staff statements at the time of the incident and review of the incident report. She stated that was the extent of the facility's investigation and at no time did the facility consider moving Resident #1's bed up against the wall as an accident hazard. The DON stated she did not investigate whether her assist bars were involved in the events surrounding Resident #1's fall and subsequent outcome. An interview was completed on [DATE] at 5:00 PM with Police Officer #1. He stated when he arrived at the facility, staff reported to him that Resident #1's RP discovered her on the floor face down with the right leg still partially on the mattress. Police Officer #1 stated after he spoke with the RP in the hallway after the code ended, he contacted Medical Examiner #1 and reported that there were no suspicious circumstances involved in Resident #1's death and he did not feel an autopsy was warranted. A telephone interview was completed on [DATE] at 2:35 PM with Medical Examiner #1. She recalled Police Officer #1 contacting her on [DATE] regarding Resident #1. She read from her report that Police Officer #1 stated to her that Resident #1 was found unresponsive in her bed and not on the floor. She read he reported there was nothing suspicious and her death appeared to be from natural causes. The Medical Examiner stated had she known about the actual details of how Resident #1 was found, it would have been up to the RP if he would have wanted an autopsy. A telephone interview was completed on [DATE] at 2:12 PM with Paramedic #1 who responded to the code at the facility on Resident #1 on [DATE]. He recalled that when he arrived at Resident #1's room, the facility staff were in the process of performing CPR. He stated staff reported that Resident #1 was found on the right side of the bed near the wall, but the facility staff did not report that she had fallen. He stated Resident #1 never regained a pulse and only a brief rhythm change was seen before asystole (no heart beats) again. He stated the code was called at 5:00 PM. A telephone interview was completed on [DATE] at 12:59 PM with NP #1. She stated she not aware that Resident #1's bed had been moved to up against the wall and likely would not have approved it because of fears of her known behaviors of attempting to get out of her bed unassisted along with the risk of injuries and possible entrapment. A telephone interview was completed on [DATE] at 11:07 AM with the MD. He stated Resident #1 being found on the floor in between her bed and the wall, it would not mean that it caused her death. He stated she could have had a pulmonary embolism (a sudden blockage in the pulmonary arteries) or due to her poor cardiac status. The MD stated her death was not likely the result of suffocation or strangulation. He stated Resident #1's bed being placed against the wall and subsequent fall did not result in her death because she could have easily gotten out of the bed on the left side as well. The Administrator was notified of the immediate jeopardy on [DATE] at 11:55 AM. The facility provided the following credible allegation of immediate jeopardy removal with a competition date of [DATE]: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The deficient practice resulted when the facility failed to have licensed nurses and nurse aides that were able to demonstrate competency in skills and techniques to address Resident # 1's behavior and attempts to get out of bed. Staff restrained Resident #1's movement by pushing the bed against the wall on [DATE]. This staff nor other staff who subsequently provided care for Resident #1 recognized the restraint of the resident's movements could create a life-threatening hazard. Resident #1 was found unconscious and wedged between the wall and the bed. Resident #1 expired on [DATE]. An incident and accident report form was completed by the licensed nurse at the time of the incident. An investigation of the incident was initiated by the Director of Nursing on [DATE] Other residents that may be at risk for the same deficient practice include those residents with behaviors identified with attempts to get out of bed unsafely. The Director of Nursing (DON) and nurse managers evaluated like residents on 6.21.24, residents that are fall risk and attempting to get out of bed unassisted, to ensure no other beds were pushed against the wall, creating a safety hazard. There were no other residents with these behaviors that had beds pushed against the wall. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Based on the investigation and the root cause analysis completed by the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Coordinator (RCC) on [DATE], it was determined that the lack of staff knowledge related to the potential safety hazard contributed to the deficient practice, as well as the licensed nurse not using alternative methods of addressing the residents behavior of self exiting the bed unsafely. The Director of Nursing and Nurse Managers implemented education to licensed nurses and certified nurses assistants on the fall management, restraint management, and behavior management policies, with a focus on the potential creation of safety hazard of pushing a bed against the wall, and the potential of the bed against the wall being a restraint on 6.21.24. Additionally, there is a focus on Behavioral Interventions to utilize for residents displaying behaviors of attempts to self exit beds unsafely. Any nursing staff not educated will receive this education prior to their next scheduled shift and will be included in the orientation of new nursing staff. The LNHA and the DON received education from the RCC on [DATE]. The education was provided, in person, verbally with opportunity for discussion and /or clarification regarding the incident and accident management policy and procedure, general investigation guidelines for incident investigations, how to develop a root cause analysis, and the implementation of effective interventions for incidents. Additionally, the DON and LNHA received education from the RCC on the behavioral management policy with an emphasis on behavioral interventions at that time. The facility alleges the immediate jeopardy was removed on [DATE]. Onsite validation of the immediate jeopardy removal plan was completed on [DATE]. Staff were interviewed to validate in-services were completed on the fall management, restraint management and behavior management to include the potential safety hazard of pushing a bed against the wall. The in-service included a focus on behavioral interventions for residents displaying behaviors of attempting to self-exit the bed unsafely was confirmed to be completed. A review of the education completed by the Licensed Nursing Home Administrator (LNHA) and DON regarding the incident and accident management policy, general investigations and behavioral management policy were confirmed to be completed. The immediate jeopardy removal date of [DATE] was validated.

Based on record review, observations and interviews with staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Examiner (ME) #1, psychiatric NP and the Bed Supplier Manager, the facility failed to demonstrate competency by not recognizing that putting the bed against the wall for a severely cognitively impaired resident with anxiety, agitation and restlessness was a restraint and an accident hazard. Nurse #1 positioned Resident #1's right side of her bed up against a wall to prevent her from getting out of the bed. Resident #1 fell out of the right side of her bed in between the bed and the wall where she was discovered by her RP on the floor with the left side of her body slightly leaning against the base board keeping her from being completely flat on the floor. She was found to not have a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This was for 1 (Resident #1) of 3 residents reviewed for restraints. Immediate Jeopardy began [DATE] when Resident # 1 was found on the floor wedged between the bed and the wall after being restrained and staff did not identify the position of the bed as a restraint or accident hazard. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: This tag is cross referenced to: F604: Based on observations, staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP) and Paramedic #1 interviews and record review, when the facility moved the resident's bed against the wall to prevent her from getting out of the bed, they failed to identify this as a restraint, failed to complete a restraint assessment, failed to obtain a physician order and failed to obtain the RP's consent for the use of a restraint. When the resident fell out of the bed she was wedged between the bed and the wall Resident #1 was assessed by facility staff and found to not have a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This was for 1 of 3 residents reviewed for restraints (Resident #1). F689: Based on record review, observations and interviews with staff, Responsible Party (RP), Bed Supplier Manager, Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Examiner (ME) #1 the facility failed to keep Resident #1 free from accident hazards by placing her bed against the wall and trying to restrict her from getting out of bed and implement fall interventions ensuring Resident #1's bed remained in the lowest position. Resident #1 fell out of the right side of her bed in between her bed and the wall where there was approximately two to three inches of space. Resident #1 was discovered by her RP in between the wall and the bed lying face down with the left side of her body slightly leaning against the base board on the wall keeping her from being completely flat on the floor. Resident #1 was assessed by facility staff and found not to have a pulse or respirations so cardiopulmonary resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This deficient practice was for 1 of 3 residents reviewed for accidents (Resident #1). Review of the facility's electronic training records indicated the most recent restraint training was on [DATE] for the following staff: Nurse #1, Nursing Assistant (NA) #8, Nurse #4, Medication Aide (MA) #1, NA #9, NA #10, Nurse #3, NA #12, Nurse #5, NA #13, NA #2, NA #3, MA #2, UM #1 and Nurse #2. NA #11 received her training on [DATE] and review of NA #1's New Employee Facility General Orientation Checklist dated [DATE] did not include any specific training on restraints. An interview was completed on [DATE] at 1:12 PM with the Director of Nursing (DON). She stated the facility did not currently have a Staff Development Coordinator (SDC) so she had been filling in with general orientation and ensuring certifications were not expired. She stated the facility utilized an electronic education system that was programmed for different training subjects to be due for the staff at certain times of the year and the previous restraint training was [DATE]. The DON stated the training included a review of the risk associated with implementing a restraint, the different types of restraints, the facility's effort to create a restraint free environment, alternatives to restraints and the risk associated with the use of side rails. She stated it was not up to the floor nurses to initiate restraints but rather to the nursing management team after an assessment, obtaining a Physician order and written consent from the resident's RP. She stated the annual training for 2024 was already set up. She stated it was clear that the staff needed re-education and clarification on the definition of restraints and accident hazards. She stated she had all the staff completed retraining on again on [DATE] but clearly, there was still work to be done. She stated NA #1 was a new hire on [DATE] and apparently the New Employee Facility General Orientation Checklist that was completed with NA #1 didn't have anything on it regarding restraints and she was unable to find any kind of orientation competency checklist. The Administrator was notified of Immediate Jeopardy on [DATE] at 11:55 AM. The facility provided the following credible allegation of immediate jeopardy removal with a date of [DATE]: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The deficient practice resulted when the facility failed to have licensed nurses and nurse aides that were able to demonstrate competency in skills and techniques to address Resident # 1's behavior and attempts to get out of bed. Staff restrained Resident #1's movement by pushing the bed against the wall on [DATE]. This staff nor other staff who subsequently provided care for Resident #1 recognized the restraint of the resident's movements could create a life-threatening hazard. Resident #1 was found unconscious and wedged between the wall and the bed. Resident #1 expired on [DATE]. Other residents in the facility that have a behavior of trying to get out of bed were reviewed and there were no other residents noted that the staff had pushed the bed against the wall to keep the residents in bed. This was completed on [DATE] by the Director of Nursing. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Nurse # 1 received 1:1 education on [DATE] by Director of Nursing on the restraint and abuse policy and procedure with a focus on a bed against the wall needing to be evaluated as well as options to address residents that are attempting to get out bed. On [DATE], the Director of Nursing was provided education on the restraint and abuse policy with a focus on a bed against the wall potentially being a restraint, as well as addressing resident's attempting to get out of bed and options to address this behavior, by the Regional Clinical Coordinator. The education was provided, in person, verbally with opportunity for discussion and/or clarification. On [DATE], the Director of Nursing and the Nurse Managers initiated education on the restraint, abuse, and behavioral policy for licensed nurses and aides with an emphasis on the potential of pushing a bed against the wall being a restraint. The education was provided, in person, verbally with opportunity for discussion and/or clarification. Licensed nurses and nursing assistants will continue to receive this education prior to their next scheduled shift until all have been educated. This education will also be provided to new nursing staff during orientation. The Director of Nursing, Assistant Director of Nursing and Nurse Managers have conducted observational audits of residents in bed, with a focus on whether the bed is pushed against the wall. This was completed on [DATE]. The Director of Nursing, Assistant Director of Nursing and Nurse Managers have conducted staff interviews of five current nursing employees for validation of ability to identify that placing the bed against the wall as a behavior management intervention is a restraint and the required actions to complete prior to initiation of placing a bed against the wall. This was completed on [DATE]. The facility alleges credible allegation of immediate jeopardy removal [DATE]. The LNHA is responsible to implement the plan. An onsite validation of the immediate jeopardy removal plan was completed on [DATE]. A review of Nurse #1's education on the restraint and abuse policy was confirmed to be completed. A review of the DON's education on the restraint and abuse policy and addressing resident's attempts to get out of bed was confirmed as completed. Staff were interviewed to validate in-services were completed on restraint, abuse and behavioral policy to include pushing a bed against the wall was a restraint. This education will also be provided to new nursing staff during orientation. A review of the audits of residents in bed with a bed against the wall were confirmed to be completed. The Immediate Jeopardy removal was validated as removed on [DATE].

Based on record review, observation, and staff interviews, the facility failed to ensure medications were not left unattended on top of the medication cart (100 Hall medication cart) and failed to dispose or discard out of date medications stored in 2 of 5 medication carts (100 Hall middle A/B medication cart). The findings included: 1a. On 4/03/24 a continuous observation from 9:50 AM through 9:55 AM was conducted during a medication pass. Nurse #2 was observed to have left 2 medicine cups of prepared medication unattended on top of the 100-hall medication cart. Nurse #2 was observed to have covered each medication cup with a plastic cup. Nurse #2 was then observed to have left the medication cart and proceeded down the 100 hallway toward the 100-hall nursing desk looking for a vital signs monitor to take a resident's blood pressure. Nurse #2 went to a resident's room, donned on personal protective equipment, then entered a resident room to check a resident's blood pressure. At 9:55 AM Nurse #2 returned to the medication cart. Two residents, one from room [ROOM NUMBER] and another from room [ROOM NUMBER], (semi-private rooms) were in the hall near the medication cart during the period when the nurse left the medication cups unattended. The two residents had cognitive loss and were up in their wheelchairs self-mobilizing around the hall. 1b. On 4/03/24 a continuous observation from 1:44 PM through 1:49 PM during a medication pass, Nurse #2 was observed to have left a medicine cup of prepared medication unattended on top of the 100-hall medication cart. Nurse #2 was observed to have covered the medication cup with a plastic cup. Nurse #2 went to the medication room and returned at 1:49 PM to the medication cart. Two residents, room [ROOM NUMBER] and room [ROOM NUMBER] were observed to have been in the hallway near the medication cart. The two residents had cognitive loss and were in their wheelchairs self-mobilizing around the hall. An interview with Nurse #2 on 4/3/24 at 1:56 PM revealed the nurse acknowledged she left the medications cups unattended on top of 100 hall medication cart during both observations. Nurse #2 stated she normally doesn't go that far away from the medications cart but explained she was in a rush. 2a. An observation was conducted on 4/4/24 at 2:43 PM of middle A/B medication cart with Nurse #3. A vial of multidose lidocaine hydrochloride injection 1% (used as a local injectable anesthetic) was found open in the medication cart and was not dated when opened. 2b. The manufacturer's recommendations for Ipratropium-albuterol stated to keep the medication in the container it came in, and to keep the packaging tightly closed. Keep the unused vials of nebulizer solution in the foil pouch until they were used. Once removed from the foil pouch, the individual vials should be used within one week. An observation was conducted on 4/4/24 at 2:43 PM of middle A/B medication cart. Ipratropium-albuterol 0.5-3 milligrams (mg)/3 (used for chronic obstructive pulmonary disease) vials were observed in the medication cart. The individual vials were found outside of the foil in two different boxes in the medication cart with no date. An interview with Nurse #3 on 4/4/24 at 2:45PM revealed nursing staff should be checking the medication cart and remove all non-dated medications. Nurse #3 also stated that the vial of multidose lidocaine hydrochloride and vials of Ipratropium-albuterol 0.5-3mg/3 should have been removed and returned to the pharmacy. An interview with the Nurse Supervisor on 4/4/24 at 2:48 PM revealed the vial of multidose lidocaine hydrochloride should have been dated and the vials of Ipratropium-albuterol 0.5-3mg/3 should have been inside of the foil packaging. An interview with the Director of Nursing (DON) on 4/4/24 at 3:20 PM revealed that all medication when pulled from the medication cart should be secured, and not left unattended. Nursing staff should check all medication rooms and medication carts for any expired medications on a weekly basis and remove multidose vials with no dates and remove Ipratropium-albuterol 0.5-3mg/3 when out of the foil packaging. Medication rooms and medication carts were inspected for proper medication storage monthly by the pharmacy staff.

Based on observations, record review and staff interview the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 6/21/21 recertification and complaint investigation. This was for 1 recited deficiency on the current recertification and complaint survey of 2/23/24 in the area of label/store drugs and biologicals (F761). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F671- Label/store drugs and biologicals: Based on record review, observation and staff interviews, the facility failed to ensure that medication were securely stored in a locked medication cart and not left unattended that was inaccessible by residents and failed to dispose or discard out of date medications in 2 of 5 medication carts. During the 6/21/21 recertification and complaint investigation survey the facility failed to discard insulin medications in accordance with the manufacturer's instruction for 1 medication cart (100 hall) out of 4 medication carts observed for medication storage.

Based on observations, record review, staff interviews, and Medical Director interview, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for accidents (Resident #1). On [DATE] Resident #1 was positioned on her left side with the bed raised to waist height by Nurse Aide (NA) #1 to perform incontinence care and bathing. NA #1 left the resident unattended on her left side to obtain supplies on the other side of the bed, and Resident #1 fell from the bed onto her right side on the floor and sustained a laceration to her head and a skin tear to her right elbow. Resident #1 was transferred to the emergency room for evaluation where she received a computerized tomography (CT) head and cervical spine imaging which was notable for small hemorrhagic contusions (bleeding inside the brain) to bilateral temporal lobes (area of the brain behind the ears). No surgical intervention was recommended, and Resident #1 continued to decline despite fluids, nutrition, and supportive care measures. Resident #1 was placed on hospice care and according to the death certificate expired on [DATE] with the cause of death identified as blunt force trauma to the head related to a fall from bed. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included stroke, hemiplegia (paralysis of one side of the body), and post-polio syndrome (viral infection on nervous system with decreased muscular function and acute weakness). A physician order dated [DATE] for aspirin 325 milligrams one time a day. Resident #1's care plan initiated on [DATE] revealed she was at risk for fall related injury and falls related to stroke with right sided weakness and altered cognition with interventions which included to keep the environment as safe as possible to and keep the bed in the appropriate position. Review of the Resident Care Guide (A nurse aide's guide for providing care to a resident) (no date) revealed Resident #1 required extensive assistance for bed mobility which included rolling from side to side. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, she required substantial maximum assistance (staff does more than half of the effort, lifts and holds limbs) with turning and repositioning and she was dependent on staff for toileting and bathing. Resident #1 was coded for a feeding tube and antiplatelet medication use during the 7-day lookback period. During a telephone interview on [DATE] at 12:41 pm Nurse Aide (NA) #1 revealed she was assigned to Resident #1 on the morning of the fall. NA #1 stated she prepared Resident #1 for incontinence care and bathing, she had positioned Resident #1 on her left side slightly past center of the bed but not on the edge of the bed, and Resident #1 had both hands on her one-quarter side bed rail (a rail attached to the bed frame and used to assist resident with positioning) on the left side of the bed. NA #1 stated Resident #1 had weakness on one side of her body, but she was unable to remember which side. NA #1 reported she forgot to obtain the personal care wipes from the bedside table on the other side of the bed, so she left Resident #1 on her left side with the bed elevated at about waist height and walked around the foot of the bed to retrieve the personal care wipes. NA #1 stated when she walked back around the foot of the bed towards Resident #1, she witnessed Resident #1 start falling forward from the bed. NA #1 stated she tried to grab Resident #1's right hip in an attempt to stop the fall, but she was unable to stop Resident #1's fall from the bed. NA #1 stated she should have lowered Resident #1's bed before she walked around the bed to get the personal care wipes, but she was near the bed and did not think Resident #1 would fall. The fall incident report initiated on [DATE] at 6:08 am and completed by Nurse #1 revealed Resident #1 was observed on the floor with active bleeding from the right side of her head and a skin tear to her right elbow. Resident #1 was unable to report pain, pressure was applied by Nurse #1 to the right side of the head until emergency medical technicians (EMTs) arrived and transported Resident #1 to the emergency department. The physician and Resident #1's Responsible Party (RP) were notified of the fall and emergent transfer for evaluation. An interview was conducted on [DATE] at 1:13 pm with Nurse #1 who was assigned to Resident #1 at the time of the fall on [DATE]. Nurse #1 stated she was notified by NA #1 that Resident #1 had rolled off the bed when she was in the room to provide care. Nurse #1 stated she entered the room and observed Resident #1 to be on the floor between the bed and the window with her feeding tube line wrapped around her waist. Nurse #1 stated Resident #1 had a large amount of blood from the right side of her head, but she was able to respond to her name. Nurse #1 stated she stayed with her, applied pressure to the wound and tried to keep Resident #1 comfortable until the EMTs arrived. Review of the hospital record dated [DATE] revealed Resident #1 presented as a trauma consultation status post fall from bed with nausea and vomiting, atrial fibrillation (irregular heart beat), and an abrasion and hematoma (localized bleeding outside the blood vessels) to right occipital lobe (very back of the skull) upon arrival to the emergency department. A computed tomography (CT) scan of the head was completed which revealed Resident #1 had a small hemorrhagic contusion (bleeding inside the brain) to the left and right temporal lobes (area of the brain behind the ears), a small left-sided subdural (pool of blood between the brain and the outermost covering) hemorrhage, and trace right-sided subdural hemorrhage. No surgical intervention was recommended. Resident #1 continued to decline despite fluids, nutrition, and supportive care measures. Resident #1 was placed on hospice services and expired on [DATE]. The Certificate of Death revealed Resident #1 expired on [DATE] and the immediate cause of death was determined to be blunt force trauma to the head related to a fall from bed that occurred on [DATE]. A telephone interview was conducted on [DATE] at 8:15 am with the Rehabilitation Director who revealed Resident #1 received therapy services which included physical, occupational, and speech at the facility. The Rehabilitation Director stated Resident #1 had right sided weakness with a score of 0 out of 5 on the manual muscle testing grading system which indicated no visible or palpable contraction (flaccidity) of the right upper extremity. The Rehabilitation Director stated Resident #1 had no significant functional improvement identified throughout her admission and remained dependent upon staff for activities of daily living. A telephone interview was conducted on [DATE] at 7:37 pm with the Medical Director who revealed Resident #1 had right sided weakness from her history of stroke and general muscle weakness from history of post-polio syndrome. He stated he was unable to recall if Resident #1 had purposeful function of her right upper extremity to perform tasks. He stated Resident #1 did participate in therapy services at the facility. The Medical Director stated he was notified of Resident #1's fall and transfer to the emergency department. An interview was conducted on [DATE] at 5:11 pm with the Director of Nursing (DON) who revealed NA #1 should have prepared all needed supplies prior to positioning Resident #1 on her side to provide care. The DON stated NA #1 failed to position Resident #1 in a safe position on the bed and place the bed in a low position before she walked to the other side to the bed to obtain the supplies. An interview was conducted with the Administrator on [DATE] at 2:45 pm who revealed NA #1 was responsible to follow the policies and procedures regarding positioning and turning of residents and performing a bed bath properly to ensure Resident safety. The Administrator was notified of immediate jeopardy on [DATE] at 2:27 pm. The facility provided the following corrective action plan with a completion date of [DATE]: 1. How corrective action will be accomplished for resident(s) found to have been affected: On [DATE] the DON completed a root cause analysis and Nurse Aide (NA) #1 did not follow policy and procedure for transfer and bed bath. One on one education was provided to NA #1 by the DON on [DATE] which included turning and repositioning of residents, bed bath policy which included gather and prepare necessary equipment and supplies, turning resident toward staff or obtain coworker to be on other side of resident. 2. How corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: A review of the facility incident reports for the past thirty (30) day period was conducted by the interdisciplinary team (IDT) on [DATE] to identify any similar situations that may have occurred, no findings were identified. All residents who must be turned and positioned could be affected. Residents were identified by the Unit Managers who utilized the Minimum Data Set (MDS) CMS-802 (a list of resident census and condition), and a review of resident care plans was completed on [DATE]. A review of all falls for the past 30-day period was completed on [DATE] by the IDT, which consisted of the Social Worker, Unit Managers, MDS Coordinator, Assistant Director of Nursing, and the DON to identify any incident that resulted in a fall could have been caused by a transfer/bed bath provision of care. No findings were noted. A review of the grievances was completed by the Assistant Director of Nursing on [DATE] with no complaints of improper transfer and bed bath provision of care policy. 3. What measure will be put in place or systemic changes made to ensure that the identified issues does not occur in the future: All nursing staff were to be re-educated on turning and positioning in bed and bed bath. The education was completed on [DATE] by the Assistant Director of Nursing and the Director of Nursing. Policy and Procedures presented: Bed Bath, which included but not limited to, gather, and prepare the necessary equipment and supplies, always turn resident towards you or obtain a coworker to stay on the opposite side of the bed, and return the bed to original position after completing provision of care. Turning and positioning a resident in bed, which included but not limited to, obtain positioning devices as needed, have resident flex arms across their chest if able, flex the resident's knees and roll toward you utilizing a pillow or positioning wedge to maintain the resident in the side lying position, and support with pillows as needed. The facility does not utilize agency staff. All new staff will be educated by the Assistant Director of Nursing during orientation and prior to working on the floor for turning and positioning and bed bath education with a skill checkoff list to document the education was completed. The education is tracked by the Assistant Director of Nursing. 4. Indicate how the facility plans to monitor its performance to make sure the solutions are achieved and sustained: The Administrator and Director of Nursing met to complete an Ad Hoc meeting on deficient practice and steps to correct deficient practice on [DATE]. Facility care audits will be completed on different shifts and different days of the week. The facility will observe 3 residents daily for 5 days, then 3 residents weekly for 4 weeks, then 3 residents monthly for 2 months. Audits will include bed bath procedure, turning and positioning procedures, including turning the resident towards staff member. Monthly reporting to the Quality Assurance Performance Improvement committee (QAPI) will occur to gauge the effectiveness of interventions and to determine when substantial compliance has been obtained and maintained. The audit process with stop at the time on the recommendation of the QAPI committee. The QAPI committee members include the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Director of Maintenance, Director of Environmental Services, Food Services Director, Activities Director, and the Medical Director. The Director of Nursing is responsible for implementation and obtaining compliance for the plan. Alleged date of compliance: [DATE] Onsite validation was completed on [DATE] through record review, staff interviews, and observations of resident care including incontinence care and turning and repositioning. Staff were interviewed to validate the in-service was completed on turning and positioning residents in bed, proper procedure to perform resident bed bath with emphasis on resident safety and to have all supplies before care was started. A review was completed of the resident care audits, and of the [DATE] Quality Assurance and Performance Improvement (QAPI) meeting minutes. The facility's corrective action plan was validated to be completed as of [DATE].

Based on observations, record review, staff interviews, and Medical Director interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the [DATE] recertification and complaint investigation. This was for 1 recited deficiency on the current complaint investigation survey of [DATE] in the area of Provide Supervision to Prevent Accidents (F689). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F689 Based on observations, record review, staff interviews, and Medical Director interview, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for accidents (Resident #1). On [DATE] Resident #1 was positioned on her left side with the bed raised to waist height by Nurse Aide (NA) #1 to perform incontinence care and bathing. NA #1 left the resident unattended on her left side to obtain supplies on the other side of the bed, and Resident #1 fell from the bed onto her right side on the floor and sustained a laceration to her head and a skin tear to her right elbow. Resident #1 was transferred to the emergency room for evaluation where she received a computerized tomography (CT) head and cervical spine imaging which was notable for small hemorrhagic contusions (bleeding inside the brain) to bilateral temporal lobes (area of the brain behind the ears). No surgical intervention was recommended, and Resident #1 continued to decline despite fluids, nutrition, and supportive care measures. Resident #1 was placed on hospice care and according to the death certificate expired on [DATE] with the cause of death identified as blunt force trauma to the head related to a fall from bed. During the [DATE] recertification and complaint investigation survey the facility failed to secure a resident's wheelchair to the transportation van securement system per manufacturer instructions and failed to apply a lap and shoulder restraint across a resident per manufacturer instructions which resulted in three falls on the transportation van. A telephone interview was conducted on [DATE] at 8:30 am with the Administrator who revealed the facility continued to monitor all incident events for root cause analysis for the residents of the facility from the previous recertification survey. The Administrator stated Resident #1's fall was determined to be an isolated incident based on the root cause analysis, auditing, and record review that was completed by the Director of Nursing and the nursing management team.

Based on record review, staff interview, and physician interview the facility failed to obtain a urine specimen for analysis and culture/sensitivity. This was for one of one (Resident # 1) sampled resident identified to have urinary symptoms. The findings included: Resident # 1 resided at the facility from 3/14/23 to 4/19/23. Resident # 1's diagnoses in part included recent history of small bowel obstruction with lysis of adhesions, atrial fibrillation, sick sinus syndrome, severe protein malnutrition, and history of breast cancer. Resident # 1's admission Minimum Data Set assessment, dated 3/21/23, coded Resident # 1 as cognitively intact. The resident was assessed to be incontinent of bowel and bladder and needed extensive assistance with her hygiene needs. The resident was not assessed to have any behavioral problems. Resident # 1's care plan, dated 3/14/23, noted Resident # 1 was incontinent and directed staff to assess for any signs of a urinary tract infection. The care plan noted signs could include altered mental status, increased temperature and failure to eat. On 4/10/23 at 1:26 PM Physician # 1 noted she was seeing Resident # 1 for an acute visit due to increased confusion, being verbally aggressive, and displaying behaviors. Physician # 1 also noted Resident # 1 had increased urination and issues. The physician noted a UA C&S (urinalysis with culture and sensitivity) would be obtained. On 4/10/23 a physician's order was entered into Resident # 1's electronic record for a UA C&S and confirmed by Nurse # 1. The order was never discontinued prior to Resident # 1's discharge date of [DATE]. There was never a urine lab result that corresponded to the 4/10/23 order. On 4/11/23 the psychiatric Nurse Practitioner (NP) saw Resident # 1 due to behaviors. The psychiatric NP noted the urine test, which had been ordered by the primary physician the previous day, was still pending. On 4/13/23 the primary care NP (NP # 1) saw Resident # 1 and noted she discussed discharge planning with the resident and the resident was alert and able to communicate that day. The resident had no complaints. The primary care NP made no mention of the pending urine specimen result. On 4/14/23 an order was entered into Resident # 1's electronic record for a stat (right away) UA C&S to rule out UTI (urinary tract infection). On 4/15/23 at 8:25 PM Nurse # 2 noted the following. Resident # 1 continued to be confused and combative with care at times. She was having a hard time following commands and participating in therapy. The urinalysis results showed the resident had 3 + bacteria in her urine. The culture and sensitivity were still pending. The resident's vitals were stable, and she was afebrile. The nurse further noted she spoke to NP # 1 and there were no new orders at that time. Review of the record revealed no culture and sensitivity results were ever obtained from the 4/14/23 specimen. Only the urinalysis was reported from the 4/14/23 specimen. On 4/17/23 orders were given to start Intravenous (IV) fluids for the resident. Nursing notes reflected the IV fluids were started on 4/17/23 at 1:55 PM. Additionally, another order was given for a urine culture and sensitivity to be done on 4/17/23. This was noted to be obtained on 4/17/23 at 1:55 PM. On 4/17/23 at 7:53 PM Nurse # 2 noted Resident # 1 was lethargic, difficult to arouse, and had poor oral intake. She had worsened over the week-end (4/15 and 4/16/23) and was having a low grade temperature. Nurse # 2 noted the urine culture was still pending. Nurse # 2 noted she informed Physician # 1 of Resident # 1's worsening status and an order was given for the antibiotic, Rocephin, intramuscularly for three days pending the results of the urine culture. According to Resident # 1's April 2023 Medication Administration Record, Resident # 1 received two doses of Rocephin prior to her discharge. These doses were administered on the evenings of 4/17/23 and 4/18/23. On 4/18/23 at 11:29 PM NP # 1 saw Resident # 1 and noted the following. Resident # 1 would give slow responses. She was not eating well, and the urine culture results were still pending. Physician # 1 had started Rocephin the previous day due to the urine lab results not being finalized. The NP noted she would continue IV fluids. On 4/19/23 at 11:16 PM NP # 1 noted Resident # 1 gave slow responses. She had been hydrated with IV fluids and an x-ray had ruled out pneumonia. The NP noted the urine culture and sensitivity were pending and the resident was on prophylactic antibiotic treatment while awaiting results. The NP also noted she talked to the family who requested that Resident # 1 be sent to the hospital. According to the facility record, Resident # 1 was transferred to the hospital on 4/19/23 at 12:05 PM. The urine specimen which had been collected on 4/17/23 had a result report date of 4/20/23 at 2:50 PM. The report noted the urine had grown greater than 100,000 colonies of Escherichia coli and the bacteria was sensitive to Rocephin (the antibiotic on which the resident had been started). Review of hospital records revealed the hospital continued treatment for Resident # 1's urinary tract infection upon hospital admission, and the resident's continued lethargy was found to be related to another medical issue other than the urinary tract infection. Nurse # 1 and the Director of Nursing were interviewed on 5/17/23 at 12:15 PM and reported the following. There was no result for the 4/10/23 UA C&S. When Physician # 1 had given the 4/10/23 order, Nurse # 1 had confirmed the lab in the computer system. The facility system was as follows so that follow up could be done to make sure the urine lab was obtained. When the order was obtained, it should have been entered under lab in the orders. That way it would populate on the MAR (medication administration record) so the nurses would know the lab was due. The order also had to be automatically entered into the lab computer system. At midnight, the night shift nurses would print off an expiring log lists of labs that would need to be drawn or picked up by the lab technician when the lab technician arrived at the facility every night around 4:00 AM. If a urine lab order was on the list and the specimen had not yet been obtained and placed in the refrigerator for pick up, then the night shift nurse knew they were supposed to obtain it. For some reason, this had not occurred for Resident # 1. Nurse # 1 stated she had also entered the orders for the 4/14/23 UA & C&S into the computer. She thought she had entered everything correctly for both the urinalysis and the culture, but she could not recall for sure, and the system showed only the UA had been ordered. Nurse # 4 was interviewed on 5/17/23 at 10:40 AM and reported the following. She (Nurse # 4) was told by Nurse # 1 to obtain a urine specimen from Resident # 1 on 4/14/23 because it had not been obtained prior to that. She performed an in and out catheterization to do so and the urine did not look like urine when it came out. It looked like a different substance. She had not been the one to put the order into to the lab system on 4/14/23, but later found out the culture had not been ordered in the system and therefore not done. Nurse # 3 was interviewed on 5/17/23 at 10:58 AM and reported the following. She had worked on 4/11/23 from 7 AM to 7 PM. She had been told in nurse's report on 4/11/23 that Resident # 1 had been combative and agitated the previous day. That was not Resident # 1's baseline. It had not been called to Nurse # 3's attention that a urine specimen still needed to be obtained on 4/11/23 or she could have easily gotten one that day because Resident # 1 seemed more at her baseline and was cooperative. On 4/11/23, Nurse # 3 had not noted anything alarming. In the last few days prior to Resident # 1's hospital discharge, Resident # 1 changed and was sleeping all the time. She recalled one day in report a night nurse mentioning Resident # 1's 4/14/23 urine specimen culture was still pending, and it seemed to her as if it should have been back. She looked in the computer system and found the culture had never been put in the lab system to be performed. Therefore, she catheterized Resident # 1 again on 4/17/23 to get the culture. Physician # 1 was interviewed on 5/17/23 at 4:40 PM revealing the following. It was her understanding that on the initial day of the urine specimen order (4/10/23), Resident # 1 had been noncooperative and combative and the specimen could not be obtained that day. It was her intent the nurses try to continue to get it. When it was not obtained and the resident seemed to worsen a broad- spectrum antibiotic was started, which worked for the urinary tract infection. The lack of obtaining the specimen as ordered had not contributed to Resident # 1's worsening or caused her any harm. Her continued lethargy had been found to be caused by another medical issue when she was hospitalized , and her urinary tract infection had already started to respond to the Rocephin started at the facility.

Based on physician interview, resident interview, record review, observations, staff interviews, and Medical Director interview, the facility failed to secure a resident's wheelchair to the transportation van securement system per manufacturer instructions and failed to apply a lap and shoulder restraint across a resident per manufacturer instructions for 1 of 4 residents reviewed for accidents (Resident #26). Residents #26 had three falls on the transportation van. On March 31, 2022 the resident fell backwards in her wheelchair in the transportation van. The Resident had complaints of neck pain, back pain, and a skin tear on her left forearm. On June 30, 2022 the Resident fell from the wheelchair in the transportation van. On July 21, 2022 the Resident fell backwards in her wheelchair in the transportation van. An observation on 12/8/2022 revealed staff were unable to identify the recommended location per manufacturer's instructions, to apply retractors from a 4-point wheelchair securement system to a resident's wheelchair during transportation on the facility's van. The facility failed to complete a thorough investigation and implement interventions after Resident #26 had a fall while on the transportation van on March 31, 2022, June 30, 2022, and July 21, 2022. In addition, the facility failed to have a policy and procedure for the 4-point wheelchair securement system located inside the facility's transportation van or a policy and procedure for the application of a safety lap and shoulder belt for residents during transit on the facility transportation van. Immediate jeopardy began on 3/31/2022 when the facility failed to secure Resident #26's wheelchair to the floor securement system of the transportation van and the facility administration did not complete a root cause analysis so that effective interventions could be implemented to protect Resident # 26 and all residents during transport. This resulted in 2 additional avoidable accidents for Resident # 26. Immediate jeopardy was removed on 12/9/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a E which is no actual harm with the potential for more than minimal harm that is not immediate jeopardy to complete staff education and ensure monitoring systems put in place are effective. Findings included: Review of a facility's policy titled Transportation dated 11/2016 did not include information about using the van's 4-point wheelchair securement system located inside the van to secure a resident's wheelchair when transporting residents to appointments away from the facility or address the application of a safety lap and shoulder belt. Review of 4-point wheelchair securement system's use and care manual dated 2014 found on the manufacture's website included the following information: * J-Hooks must be attached to a sold wheelchair frame (no spokes or moveable components * Compliant shoulder and pelvic belt restraint must go across occupant's shoulder and pelvis (lap). Resident #26 was admitted to the facility on [DATE] with cumulative diagnoses that included abnormal posture and bilateral amputation. Resident #26's care plan in place on 3/31/2022 included an area of focus Resident #26 was at risk for fall related injury, at risk for acute/chronic pain, and had a potential for fluctuations in mood related to depression, anxiety, and psychosis. Interventions included ensure the environments was as safe as possible, anticipate residents need for pain relief, notify doctor if interventions are unsuccessful, administer medications as ordered, observe for ineffectiveness, and notify physician, consult with behavioral health as needed. Resident #26's quarterly MDS dated [DATE] indicated resident was cognitively intact. Resident #26 required the assistance of one staff with transfers and was unable to walk. a. An incident report dated 3/31/2022 and completed by Nurse #1, read on 3/31/2022 at 11:40 A.M. Resident #26's wheelchair flipped back on the transportation van. The report indicated Resident #26 had a skin tear. The immediate interventions included Resident #26's appointment was rescheduled, and therapy was to check Resident #26 for wheelchair positioning. Nurse's progress note written by Nurse #1 dated 3/31/2022 showed Resident #26 flipped her wheelchair back while on transportation van. Resident #26 had complaints of neck pain, back pain, and a small skin tear noted to her left arm. Nurse Practitioner (NP) note dated 3/31/2022 showed Resident #26 was evaluated by the NP after she fell backwards while on the transportation bus and hit her back on the floor. Resident #26 had complaints of left forearm pain, neck pain, and back pain. The note indicated Resident #26 had a small bruise noted on her wrist and a skin tear on her arm. Physician order dated 3/31/2022 showed an xray ordered for the left forearm, cervical spine, and lumbar to sacral spine. Review of the xray results for the forearm and spine dated 3/31/2022 showed Resident #26 had no acute fractures. Review of a post fall evaluation report created by Nurse #1 dated 3/31/2022 showed environmental factors (circle or write in): fell backwards in wheelchair on transportation van was written in. The description of the position the resident was observed in at the time of the incident read unknown did not observe guest. The type of assistance resident received at the time of the fall was documented as buckled down on transportation van. The re-creation of fall read guest had multiple items in back of wheelchair. The report indicated the cause of the fall was environmental factors/items out of reach. New interventions included Resident #26 was scheduled to follow up with physical therapy for wheelchair positioning. An interview was conducted on 12/7/2022 at 2:00 P.M. with Nurse #1. Nurse #1 indicated she was familiar with Resident #26. Resident #26 was a double amputate and had a lot of anxiety. Nurse #1 indicated during one of her shifts, Resident #26 had a fall on the transportation van, but due to the length of time since the incident, Nurse #1 was unable to provide a month Resident #26's fall occurred. Nurse #1 indicated she was told by transportation staff, the van had pulled away from the facility and Resident #26's wheelchair had flipped backwards. Nurse #1 responded to the van to assess Resident #26. When Nurse #1 walked onto the van, the back of the wheelchair was laying on the van floor and Resident #26 was lying on her back in the wheelchair facing the van roof. During the interview, Nurse #1 indicated Resident #26 had retractors secured to the wheelchair and to the best of her knowledge Resident #26 had a seatbelt in place. Nurse #1 stated she did not recall any items under the wheelchair or around the back of the van. She further indicated she did not recall Resident#26 to voice any concerns of pain. Review of Resident #26's Medication Administration Records (MAR) for March 2022 showed Resident #26's received oxycodone tablet 5 milligram (mg) ordered for severe pain on 3/31/2022 at 4:13 P.M. for a pain level of 4 on a 0-10 pain scale where 0 is no pain and 10 is the highest pain level. Review of Resident #26's MAR for April 2022 showed Resident's #26 received oxycodone tablet 5mg for severe pain one time a day from 4/3/2022 - 4/15/2022 for a pain level that ranged from 3-9 on a pain level scale. Resident #26's received two doses of oxycodone on 4/3/2022 and 4/9/2022. Attempts were made to interview the Nurse Practitioner who assessed Resident #26 on 3/31/2022 were unsuccessful. An interview was conducted on 12/8/2022 at 12:48 P.M. with the Medical Director. During the interview, the Medical Director reviewed Resident #26's electronic medical record. The Medical Doctor indicated Resident #26 was evaluated by the Nurse Practitioner on 3/31/2022 after she had a fall in the transportation van. Resident #26 had complaints of back and neck pain. The NP ordered and reviewed xrays of Resident #26's arm, neck, and back. The xrays indicated Resident #26 had no fractures. The Medical Director indicated Resident #26 had degenerative changes to her back Review of a therapy evaluation and plan of treatment note dated 7/22/2022 showed Resident #24's last dates of therapy were 10/12021 - 1/8/2022. An interview was conducted on 12/7/2022 at 11:50 A.M. with the Director of Nursing (DON). During the interview, the DON indicated she did not recall this incident due to the length of time since the event happened. She indicated Resident #26 was a double amputee and maybe her positioning contributed to her fall. The DON indicated an investigation would have been completed after the fall. The DON was unable to provide additional written information related to this incident. An interview was conducted on 12/7/2022 at 11:36 A.M. with the Administrator. During the interview, the Administrator indicated she did not recall the details of Resident #26's fall on the transportation van on 3/31/2022. The Administrator reviewed the incident report and indicated it appeared Resident #26 was retrieving items from a bag on the back of her wheelchair and the wheelchair flipped backwards. During the interview, the Administrator indicated Resident #26 was a bilateral amputee, which caused her center of gravity to be different when she sat in the wheelchair. The Administrator indicated physical therapy had worked with Resident #26 on positioning while she was in the wheelchair. b. An incident report dated 6/30/2022 and completed by Nurse #2 showed on 6/30/2022 at 4:00 P.M., Resident #26 had a fall from a wheelchair on the transportation van. The report read Resident #26 had no injuries. The immediate interventions included range of motion, skin assessment, pain assessment, position secured in wheelchair, and make sure all seatbelts are fastened. Nurse's progress note written by Nurse #2 and dated 6/30/2022 read Resident #26 observed sitting on floor of transportation van. Van driver stated she didn't have all the seatbelts secured to Resident #26. Review of a post fall evaluated report created by Nurse #2 and dated 6/30/2022 showed Resident #26's seatbelt was not buckled securely, and resident slid to floor. Factors observed at the time of the fall had equipment malfunction and environmental factors checked. The description of the guest was described as sitting on buttocks in transportation van. New interventions included ensure safety device in van is secure while in transit. The report included signatures under the section titled IDT Signatures. One signature was the signature of the Director of Nursing. An interview was conducted on 12/8/2022 at 1:08 P.M. with Nurse #2. She indicated she was familiar with Resident #26 and to her knowledge Resident #26 only had falls when she was transported in the facility's transportation van. During the interview, Nurse #2 indicated she was only involved in one of Resident #26's falls. She heard a page overhead that stated Resident #26 had fallen while on the transportation van. Nurse #2 went out to the van to assess Resident #26. She observed Resident #26 sitting on the van floor and her wheelchair was still sitting up. During the interview, Nurse #2 indicated to the best of her knowledge, she was told Resident #26 fell forwards when the driver started to drive the van out of the facility's parking lot. Nurse #2 was unable to recall if Resident #26's wheelchair was secured with retractors to the van's floor. Nurse #2 indicated Resident #26 was not wearing a seatbelt. Attempts were made to interview Transportation Driver #2 who worked as the transportation driver from March 2022 through September 2022 were unsuccessful. An interview was conducted on 12/8/2022 at 9:45 A.M. with the DON. During the interview, the DON confirmed she did not recall this incident. c. An incident report dated 7/21/2022 created by Nurse #3 showed on 7/21/2022 at 9:30 A.M. Resident #26 had a witnessed fall on the transportation van during transportation. Resident #26 had no injuries during this fall. There were no immediate interventions listed on the report. Nurse's progress note written by Nurse #3 and dated 7/21/2022 read Resident #26 observed laying on her back still strapped to wheelchair inside transportation vehicle. Review of a post fall evaluation report dated 7/21/2022 listed no factors observed at the time of the fall. The description provided described Resident #26's as lying flat on her back and the fall was a witnessed fall to the floor. New interventions included add anti-roll back brakes on Resident #26's wheelchair and refer to physical therapy. An interview was conducted on 12/8/2022 at 10:13 A.M. with Nurse #3. Nurse #3 assessed Resident #26 after her fall on 7/21/2022. During the interview, Nurse #3 indicated it was reported to him when the van was leaving the parking lot and moving forwards when Resident #26's wheelchair rolled backwards and flipped. Nurse #3 indicated when he arrived on the van, he observed Resident #26 lying on her back, still in her wheelchair. The wheelchair appeared to have tipped over backwards and the back of the chair had come to rest on the floor of the van. Nurse #3 indicated he assisted additional staff to upright Resident #26's wheelchair. Resident #26 had no injuries and went to her scheduled appointment. Review of an occupational therapy note dated 7/22/2022 showed the reason Resident #26 was referred to therapy was due to a fall from wheelchair during transportation to appointment. The listed goals included demonstrate improvement in trunk control/sitting balance and demonstrate good upright midline posture in wheelchair for 1-2 hours with appropriate system including anti tippers. The evaluation report showed Resident #24's last dates of therapy were 10/12021 - 1/8/2022. An interview was conducted on 12/7/2022 at 12:21 P.M. with the Rehabilitation Service Director. During the interview, the Director indicated Resident had been referred to therapy after a fall a few months ago. The Director stated Resident #26 was a bilateral amputee and therapy worked with her to build her core strength and upper muscles. During the interview, the Director further indicated Resident #26 had a regular wheelchair and the therapy department had maintenance install anti tippers to her wheelchair. The Director indicated she was unable to recall the date of Resident #26's fall. An interview was conducted on 12/7/2022 at 9:12 with Resident #26. Resident #26 indicated she did not recall her wheelchair falling in the transportation van and was unable to provide any additional information. An interview was conducted on 12/7/2022 at 2:49 P.M. with the Transportation Driver #1, who was out on medical leave from March 2022 through September 2022. The Transportation Driver indicated when he was hired at the facility, he shadowed the previous transportation driver for thirty days and was showed by the previous driver how to secure residents into the transportation van for transportation to outside appointments. The Transportation Driver indicated the transportation van was equipment a 4-point wheelchair securement system that used retractors and this was the same system installed on the transportation van used during the time of each of Resident #26's falls. During the interview, Transportation Driver #1 indicated he had heard Resident #26 had a fall with Transportation Driver #2, but he was not at the facility during the times of the falls. An interview was conducted on 12/8/2022 at 11:46 A.M. with Nurse Aide (NA) #1. During the interview, NA #1 indicated she was present on the transportation van when Resident #26 had a fall. NA #1 was unable to recall the date of the incident. She indicated Transportation Driver #2 secured Resident #26's wheelchair in the facility van. When the van started to pull out of the parking lot, Resident #26 and her wheelchair tipped over backwards. Resident #26 had no observed injuries. During the interview, NA #1 indicated a staff showed Transportation Driver #2 where to clip the safety straps to Resident #26's wheelchair to prevent the wheelchair from tipping backwards and Resident #26 continued to her scheduled appointment. NA #1 stated she sat behind Resident #26's wheelchair as Transportation Driver #2 drove and Resident #26's wheelchair did not tip over a second time that day. NA #1 was unsure which staff assisted Transportation Driver #2 with repositioning Resident #26's wheelchair after she fell backwards. An interview was conducted on 12/8/2022 at 12:39 P.M. with NA #2. NA #2 indicated she was responsible to ride on the van and assisted as needed to secure residents into the transportation van when traveling to appointments away from the facility. During the interview, NA #2 stated she assisted with loading residents onto the transportation van when the residents had appointments away from the facility. She stated Transportation Driver #2 showed her where to hook the safety straps that attached from the van floor to the resident's wheelchair. NA #2 indicated she was told each of the straps were hooked on the outside wheel of the wheelchair. An observation was completed on 12/8/2022 at 12:52 P.M. with NA #2. NA #2 used a resident's wheelchair and pointed to the location on the wheelchair she hooked the safety straps to if she had secured the resident on the transportation van for transport. NA #2 pointed to the outside wheel and verbalized that is where she would place the safety strap An interview was conducted with the Director of Nursing (DON) on 12/9/2022 at 2:03 P.M. During the interview, the DON was made aware during an interview NA #2 was asked to demonstrate on a resident's wheelchair where the retractor straps would be attached if a resident needed to be secured on the transportation van in the transportation van. NA #2 indicated the J hooks would be clipped to the outside wheel on the wheelchair. The DON indicated the retractor straps were not to be clipped to the wheelchair wheel and further indicated the new policy created indicated the transportation drive was responsible for securing a resident in the transportation van. An interview was conducted on 12/8/2022 at 9:15 A.M. with a Physical Therapist (PT) #1. PT #1 indicated he had showed Transportation Driver #2 how to use the retractors to secure Resident #26 onto the transportation van after she had a fall. PT #1 was unable to provide an exact date of this incident. He did state it was about three months ago. During the interview, PT #1 indicated he was unsure how Resident #26's wheelchair fell backwards and further indicated he was unsure how Resident #26's wheelchair was secured when she fell backwards. He indicated Resident #26 was a double amputee and had a greater risk of falling forwards compared to falling backwards because there was no support in front of her body compared to the support of the back of the wheelchair. An interview was conducted on 12/8/2022 at 9:00 A.M. with the Assistant Director of Nursing (ADON). During the interview, the ADON indicated she was only aware Resident #26 had one fall and was unaware of additional falls. The ADON indicated when Resident #26 had a fall in the transportation van, PT #1 provided Transportation Driver #2 with training on how to secure a wheelchair for transportation on the facility transportation van. The ADON indicated PT #1 was responsible to train staff on the transportation van following an incident. During the interview, the ADON indicated she was present on the van with Transportation Driver #2 and PT #1 for the training on how to secure Resident #26's wheelchair on the transportation van. The ADON further indicated when the safety retractors were used on the transportation van, a resident should not fall, and she is unsure what caused Resident #26 to flip her wheelchair backwards. An interview was conducted on 12/7/2022 at 11:50 A.M. with the Director of Nursing (DON). During the interview, the DON indicated it was her responsibility to investigate each fall Resident #26 had in the transportation van. During the interview, the DON indicated she only recalled Resident #26 to have one fall in July. The DON indicated she was unsure how the wheelchair flipped over during transportation on the van and stated physical therapy was consulted to assess Resident #26. The DON further indicated physical therapy also provided Transportation Driver #2 with additional training on how to secure Resident #26's wheelchair in the transportation van when traveling to appointments. Review of the incident report dated 3/31/2022, 6/30/2022, and 7/21/2022 showed the DON's signature. The post fall evaluation dated 3/31/2022 and 6/30/2022 revealed the DON signed under IDT signatures. A follow-up interview on 12/8/2022 at 2:27 P.M. with the DON indicated a clinical meeting was held each business day after Resident #26's falls. During these meetings the fall incident was discussed, and the interdisciplinary team worked to implement appropriate interventions. During the interview, the DON indicated the lack of training for the transportation staff in securing Resident #26 in the transportation van was not identified. On 12/7/2022 at 5:49 P.M., the facility's Administrator and Director of Nursing were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 12/9/2022. The allegation of immediate jeopardy removal indicated: Credible Allegation of IJ removal The Laurels of Forest [NAME] o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The alleged jeopardous deficient practice resulted when resident #26's wheelchair tipped backwards while in the facility transport van. Resident # 26 was assessed by practitioner on 04.01.22. Resident #26 had a skin tear as a result of the incident which is healed. X-rays of the left lateral forearm, cervical and lumbar spine and all were without acute fracture. An incident and accident report form was completed by licensed nurse at the time of the incident. An investigation of the incident was completed by the licensed nursing home administrator on 12.07.22 Resident #26 had an incident on 06.30.22 in which she slid from wheelchair while in transport van. She was evaluated by licensed nurse and was without injury noted. An incident and accident report form was completed at the time of the incident by the licensed nurse. The licensed nursing home administrator and the Director of Nursing were aware of the incident that occurred on 06.30.22 when the incident report was signed by both on 07.05.22. Investigation of this incident was completed 12.08.22 by licensed nursing home administrator when this alleged deficient practice was identified in the Immediate Jeopardy Citation. Resident # 26 had an incident when wheelchair tipped backward on transport van on 07.21.22 without any injury noted. She was seen 07.21.22 by practitioner with no new orders received and no injuries noted. An incident and accident report form was completed at the time of the incident by the licensed nurse. An investigation of this incident was completed on 12.08.22 by licensed nursing home administrator. The licensed nursing home administrator and the Director of Nursing were aware of the incident that occurred on 07.21.22 when the incident report was signed by the director of nursing on 07.22.22 and the licensed nursing administrator signed on 11.01.22. Investigation of this incident was completed 12.08.22 by licensed nursing home administrator when this alleged deficient practice was identified in the Immediate Jeopardy Citation. Care plan was reviewed 12.8.22 by the MDS nurse with interventions to ensure proper wheelchair positioning and securement while in the transport van. Resident remains at her baseline. The investigation of the incidents of 03.31.22, 06.30.22 and 07.21.22 have been completed using the Incident and Accident Investigation Form by the licensed nursing home administrator (LNHA) on 12.07.22 and 12.8.22. Identification of other residents in the facility that may be affected due to the alleged noncompliance was completed by the LNHA on 12.8.22 via review of the transportation log and Incident and Accident log and there have been no other residents that have been affected by the alleged noncompliance. Identified resident # 26 had two additional incidents in the transport van on 6.30.22 and 7.21.22 Resident did not have injuries related to the additional two incidents. Future residents requiring transportation with facility van have the potential to be affected by the alleged noncompliance and therefore the following has occurred to prevent this. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Action taken to alter the process to prevent recurrence (systemic corrective action): The facility LNHA and Director of Nursing received education on Root Cause Analysis and completion of facility incident and accident investigations by the Director of Clinical Service for Laurel Health Care Company on 12.07.22 The LNHA and DON are the only staff that are responsible for the completion of investigations of incidents and accidents. On September 15, 2022, the facility implemented the risk management incident and accident portion of the electronic medical record. The administrator and director of nursing log into the electronic medical record system and review the risk management console for any new incident and accident reports daily. The incident and accident reports are then reviewed by licensed nursing home administrator and the director of nursing during morning meeting. The facility administrator, the facility Director of Nursing, and the Director of Clinical Services (DCS) for Laurel Health Care, on 12.07.22, completed a root cause analysis (RCA) of the incident dated 03.31.22, 06.30.22 and 07.21.22 regarding resident #26. The RCA determined that lack of facility policy and procedure on the transport of residents in the facility van as well as lack of competency training of the van transport driver resulted in the incident occurring. The Root Cause Analysis included interventions to prevent further occurrences and have been implemented and completed on 12.08.22, including: A policy and procedure for transport of a resident in facility van was developed and approved on 12.8.22 by the LNHA and the Director of Clinical Services for Laurel Health Care. A job description with required training and competencies was developed by the LNHA and DCS on 12.7.22 and reviewed with the transport van driver. Additionally, the LNHA and DON developed a job description for the van transport driver, and he has reviewed and signed the job description which includes stated education and competency on 12.07.22. The only staff required to be educated on the policy and procedure for transport of resident in a facility van are the LNHA, DON and the van transport driver. All completed on 12.08.22. The facility has only one transport driver. The transport driver reviewed the Q'Straint QRT Max Training video on 12.07.22 The transport driver also received verbal education with return competency demonstration on the securing of wheelchair into the transport van by the Director of Rehab Services on 12.07.22. There is only one van transport driver. If he is not available for transport for any situation, the facility will utilize an outside transportation company for resident transports. The facility has a contract with an outside transportation company for transportation and the medical records clerk would schedule the transportation. If the transport van driver leaves the company for any reason, the newly hired transport van driver would receive the same education and competency evaluations as well as job description prior to starting. The licensed nursing home administrator or the Director of Nursing are responsible for ensuring the job description and training has been completed, and the therapy director is responsible to complete the competency. Date of IJ removal: 12/9/2022 The facility's credible allegation of Immediate Jeopardy removal was validated on 12/9/2022. The validation was evidenced by staff interviews, record reviews, and review of competency training logs. The interventions included creating a policy on transportation of a resident in facility van, a new job description for the transportation driver, verified the transportation drive watched the Qstraint (van's 4-point wheelchair securement system) video, verified the transportation driver completed a return demonstration with the physical therapy director on the steps to complete to secure a resident wheelchair to the floor of the van as well as properly securing the resident in the wheelchair, the facility provided a copy of a signed contract with an outside company for non-emergency transportation of residents, and an observation of the transportation driving securing a resident in the transportation van after he completed his competency training. The Administrator was notified the removal of the immediate jeopardy had a removal date of 12/9/2022 and was validated on 12/9/2022. The LNHA is responsible to implement the plan.

Based on record review and staff interviews, the facility's administration failed to provide effective leadership and oversight of processes and procedures to ensure a policy was in effect per manufacturer's instructions on the securement of a resident in the facility transportation van who required the use of a 4-point wheelchair securement system. In addition, the facility failed to assure transportation drivers were competent to operate the 4-point wheelchair securement system in the transportation van for 3 of 3 staff members (Transportation Driver #1, Transportation Driver #2, and Nurse Aide (NA) #2) and 1 of 4 residents (Resident #26) The facility's failure resulted in Resident #26 to have falls in the transportation van on 3/31/22, 6/30/22, and 7/21/22. The facility failed to thoroughly investigate each fall or provide evidence of surveillance and oversight for the transportation system within the facility. This practice had the high likelihood for serious injury and adverse outcomes to all residents transported by the facility. Immediate jeopardy began on 3/31/22 when a resident fell in the facility transportation van as result of not being secured according to manufacturer's recommendations as a result of staff not being trained. Immediate jeopardy was removed on 12/9/22 when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: This tag is crossed referenced to F689: F689 Based on physician interview, resident interview, record review, observations, staff interviews, and Medical Director interview, the facility failed to secure a resident's wheelchair to the transportation van securement system per manufacturer instructions and failed to apply a lap and shoulder restraint across a resident per manufacturer instructions for 1 of 4 residents reviewed for accidents (Resident #26). Residents #26 had three falls on the transportation van. On March 31, 2022 the resident fell backwards in her wheelchair in the transportation van. The Resident had complaints of neck pain, back pain, and a skin tear on her left forearm. On June 30, 2022 the Resident fell from the wheelchair in the transportation van. On July 21, 2022 the Resident fell backwards in her wheelchair in the transportation van. An observation on 12/8/22 revealed staff were unable to identify the recommended location per manufacturer's instructions, to apply retractors from a 4-point wheelchair securement system to a resident's wheelchair during transportation on the facility's van. The facility failed to complete a thorough investigation and implement interventions after Resident #26 had a fall while on the transportation van on 3/31/22, 6/30/22, and 7/21/22. In addition, the facility failed to have a policy and procedure for the 4-point wheelchair securement system located inside the facility's transportation van or a policy which addressed the application of a safety lap and shoulder belt for residents during transit on the facility transportation van. An interview was conducted on 12/8/2022 at 2:27 P.M. with the Director of Nursing (DON). During the interview, the DON indicated the clinical management team discussed resident accidents reported on a 24-hour report and put interventions into place. The DON indicated the root cause for Resident #26's falls on 3/31/22, 6/30/22, and 7/21/22 were not identified during the investigation and interventions to prevent additional falls were not put into place. The DON further indicated she was unaware a policy for the safe transportation of residents on the facility transportation van had not been created and staff had not completed training on the use of the 4-point wheelchair securement system prior to transporting residents. During the interview, the DON stated she was unaware a training program for the transportation drivers was not in place and further indicated she expected staff to be trained on how to transfer, transport, and make sure the residents were secured during transit on the transportation van. An interview was conducted on 12/9/2022 at 2:35 P.M. with the Administrator. During the interview the Administrator stated the incident and accident policy indicated it was her responsibility to complete a full investigation to include a general timeline of events, staff/resident interviews, summary of investigation, identify the root cause for the incident, and create interventions to prevent additional accidents. The Administrator offered no explanation why the van accidents had not been thoroughly investigated. On 12/8/22 at 4:35 P.M., the facility's Administrator and Director of Nursing were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 12/9/22. The allegation of immediate jeopardy removal indicated: Credible Allegation of IJ removal The Laurels of Forest [NAME] F 835 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; The alleged jeopardous deficient practice resulted when resident #26's wheelchair tipped backwards while in the facility transport van. Resident # 26 was assessed by practitioner on 4/1/22. Resident #26 had a skin tear as a result of the incident which is healed. X-rays of the left lateral forearm, cervical and lumbar spine and all were without acute fracture. An incident and accident report form was completed by licensed nurse at the time of the incident. An investigation of the incident was completed by the licensed nursing home administrator on 12/7/22. Resident #26 had an incident on 6/30/22 in which she slid from wheelchair while in transport van. She was evaluated by licensed nurse and was without injury noted. An incident and accident report form was completed at the time of the incident by the licensed nurse. The licensed nursing home administrator and the Director of Nursing were aware of the incident that occurred on 6/30/22 when the incident report was signed by both on 07/05/22. Investigation of this incident was completed 12/8/22 by licensed nursing home administrator when this alleged deficient practice was identified in the Immediate Jeopardy Citation. Resident # 26 had an incident when wheelchair tipped backward on transport van on 7/21/22 without any injury noted. She was seen 7/1/22 by practitioner with no new orders received and no injuries noted. An incident and accident report form was completed at the time of the incident by the licensed nurse. An investigation of this incident was completed on 12/8/22 by licensed nursing home administrator. The licensed nursing home administrator and the Director of Nursing were aware of the incident that occurred on 7/21/22 when the incident report was signed by the director of nursing on 7/22/22 and the licensed nursing administrator signed on 11/1/22. Investigation of this incident was completed 12/8/22 by licensed nursing home administrator when this alleged deficient practice was identified in the Immediate Jeopardy Citation. The investigation of the incidents of 3/31/22, 6/30/22, and 7/21/22 have been completed using the Incident and Accident Investigation Form by the licensed nursing home administrator (LNHA) on 12/7/22 and 12/8/22. Identification of other residents in the facility that may be affected due to the alleged noncompliance was completed by the LNHA on 12/8/22 via review of the transportation log and Incident and Accident log and there have been no other residents that have been affected by the alleged noncompliance. Identified resident # 26 had two additional incidents in the transport van on 6/30/22 and 7/21/22. Resident did not have injuries related to the additional two incidents. Future residents requiring transportation with facility van have the potential to be affected by the alleged noncompliance and therefore the following has occurred to prevent this. Based on the investigation and the root cause analysis completed by the LNHA, DON and Director of Clinical Resources (DCR) for Laurel Health Care Company on 12/7/22, it was determined that the lack of policies relative to resident transportation in facility van, lack of staff education and competency for the transport van driver is what led to each of the incidents forementioned. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The facility implemented the immediate actions to ensure policies and systems were in place to investigate, implement effective interventions, document, ensure training and competencies for all staff who provide resident with transportation to outside appointments to prevent future accidents/injuries. 1) On 12/7/22 the licensed nursing home administrator, the director of nursing, and the director of clinical services for Laurel Health Care completed a root cause analysis of the incidents related resident # 26's incidents. a.The resulting interventions from the root cause analysis were: i. The development of a policy and procedure for Resident Transportation with Facility Van was on 12/8/22 by the licensed nursing home administrator and the Director of Clinical Services. ii. A job description for the transportation van driver was developed on 12/7/22 by the licensed nursing home administrator and the director of clinical services, which included training requirements and competencies to be completed initially and annually thereafter. This was reviewed and signed by the transport driver and competency completed on 12/8/22. iii. Licensed nursing home administrator received education from the Director of Clinical Services on 12/7/22 regarding the incident and accident management policy and procedure, general investigation guidelines for incident investigations, how to develop a root cause analysis, and the implementation of effective interventions for incidents. iv. The licensed nursing home administrator or director of rehab services will provide surveillance of the securement of residents in the facility transport van weekly and as needed by direct observation. Date of IJ removal: 12/9/22 The facility's credible allegation of Immediate Jeopardy removal was validated on 12/9/22. The validation was evidenced by staff interviews, record reviews, and review of competency training logs. The interventions included creating a policy on transportation of a resident in facility van, a new job description for the transportation driver, verified the transportation drive watched the Qstraint (van's 4-point wheelchair securement system) video, verified the transportation driver completed a return demonstration with the physical therapy director on the steps to complete to secure a resident wheelchair to the floor of the van as well as properly securing the resident in the wheelchair, the facility provided a copy of a signed contract with an outside company for non-emergency transportation of residents, and an observation of the transportation driving securing a resident in the transportation van after he completed his competency training. An interview was conducted with the Administrator indicated she received education from the Director of Clinical Services on 12/7/22 about the incident and accident management policy and procedure.

Based on observation, family interview, staff interview and record review the facility failed to provide effective oversight to ensure COVID-19 testing supplies were available for testing symptomatic residents and put transmission based precautions in place upon the identification of COVID-19 symptoms for 5 (Resident #3, Resident #12, Resident #13, Resident #14, and Resident #15) of 5 sampled residents. Findings included: A. Cross refer to F886: Based on observation, staff interview, family interview, and record review the facility failed to provide COVID-19 testing upon the appearance of symptoms for 5 (Residents #3, #12, #13, #14, #15) of 5 sampled residents who tested positive for COVID-19 during a facility COVID-19 outbreak. This occurred during a coronavirus pandemic. B. Cross refer to F880: Based on staff interview and record review the facility failed to implement isolation and transmission based precautions upon the appearance of symptoms for 5 (Residents #3, #12, #13, #14, #15) of 5 sampled residents who tested positive for COVID-19 during a facility COVID-19 outbreak. This occurred during a coronavirus pandemic.

Based on staff interview and record review the facility failed to implement isolation and transmission based precautions upon the appearance of symptoms for 5 (Residents #3, #12, #13, #14, #15) of 5 sampled residents who tested positive for COVID-19 during a facility COVID-19 outbreak. This occurred during a coronavirus pandemic. Findings included: Documentation in the facility Coronavirus (COVID-19) testing policy, dated as last reviewed on 2/16/2022, stated in part, If a guest/resident presents with a fever or symptoms consistent with COVID-19, place guest/resident in Transmission Based Precautions and test for [CONDITION(S)]-CoV. The policy also stated, All recommended Covid-19 PPE (personal protective equipment) should be worn during care of guests/residents under observation or in Transmission Based Precautions, which includes use of an N95 or higher-level respirator (or surgical if a respirator is not available), eye protection (ie. goggles or a face shield that covers the front and sides of the face), gloves and gown. Documentation in NHSN vaccination summary data for the week of 1/3/2022 to 1/9/2022 revealed 85.33% of all staff were fully vaccinated, 7.33% were partially vaccinated, and 7.33 % were unvaccinated. The documentation in the NHSN vaccination summary dated for the week of 1/3/2022 to 1/9/2022 also revealed 85.83% of the residents were fully vaccinated, 2.5% were partially vaccinated, and 11.67% were unvaccinated. 1. Documentation in the vaccine administration section of the medical record revealed, Resident #3 was up-to-date with all recommended COVID-19 vaccines. Resident #3 resided in a semi-private room at the facility. Documentation in the medical record of Resident #3 written by Nurse #2 in an electronic MAR - shift level administration note dated 1/10/2022 at 12:27 AM stated, Cough, ADON (Assistant Director of Nursing) aware, resident will be tested this AM on [first] shift when supplies [available]. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 stated she was not able to test the residents due to a lack of reagent, and therefore the residents were not placed on transmission-based precautions or isolated during her shift. She called and informed the ADON when she realized she could not test the residents and passed along in shift change report to Nurse #3 the residents who needed to be tested . Nurse #3, the nurse who took the nursing shift change report from Nurse #2 on 1/10/2022, was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #3 did not recall any other information about events that occurred after she was notified some of the residents had symptoms and needed to be tested . An interview was conducted with the ADON on 2/17/2022 at 12:50 PM. The ADON stated she was not called by Nurse #2 on 1/9/2022 or 1/10/2022. The ADON revealed it was not communicated to her some of the residents were having symptoms of COVID-19 so that proper testing and isolation of the residents could be initiated. The ADON revealed NA #3 was assigned to test the residents for COVID-19 every Monday. If the testing was completed and residents tested positive, they would have been put on isolation precautions. Documentation in a social service note dated 1/10/2022 at 5:55 PM revealed Resident #3 tested positive for COVID-19 on a rapid test and a voice mail was left with a family member for notification of the results. Documentation in a social service progress note dated 1/11/2022 at 8:28 AM revealed a family member of Resident #3 was notified of the positive COVID-19 rapid test, an explanation given an additional test would be given, and if the second test was positive Resident #3 would be moved to the COVID-19 unit. Documentation in an additional social service note dated 1/11/2022 at 3:16 PM revealed a family member was notified Resident #3 was to remain in her current room because her room was at that time a part of the COVID-19 unit. An interview was conducted with the facility Administrator on 2/18/2022 at 9:58 AM. The facility Administrator explained COVID-19 testing of the residents was initiated on 1/10/2022 after 4:00 PM and was started on the 200 Hall area. Resident #3 and her roommate both tested positive for COVID-19 on the same day at the same time. The Health Department was contacted, and the facility received confirmation to put the residents who tested positive with the rapid test under transmission-based precautions. The COVID-19 unit was expanded at that time to include the room for which Resident #3 and her roommate resided. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken with the testing and isolation of the symptomatic residents, but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON stated Nurse #2 should have called her and notified her if several of the residents were showing symptoms of COVID-19. DON confirmed she did not receive a call from Nurse #2 on 1/10/2022. An interview was conducted with the DON and Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility Administration was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The DON noted that no other symptoms of COVID-19 were documented for Resident #3 on 1/10/2022 or 1/11/2022. The DON indicated the reason the residents were not placed on transmission-based precautions was because of a communication problem. The DON stated she and her staff were aware residents who were symptomatic needed to be tested right away and placed on transmission-based precautions, but she nor the ADON ever received a phone call from Nurse #2 alerting them that residents were symptomatic and needed testing. If they had been notified, they could have provided for the immediate testing because the supplies were in the facility and then the residents who showed positive would have been isolated and place on transmission-based precautions. According to the DON, nurses could have called her or the ADON at any time and neither of them had a record of any phone calls from Nurse #2. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 2. Documentation in the vaccine administration section of the medical record revealed, Resident #14 was up-to-date with all recommended COVID-19 vaccines. Resident #14 resided in a semi-private room in the facility but did not have a roommate. Documentation in the medical record of Resident #14 written by Nurse #2 in an electronic MAR (medication administration record) shift level administration note dated 1/10/2022 at 12:28 AM stated, cough, sore throat, low fever, ADON (Assistant Director of Nursing) aware, resident to be tested this AM on 1rst shift when supplies [available]. Documentation in the vital signs section of the medical record revealed Resident #14 had a low-grade fever of 99.3 degrees Fahrenheit on 1/10/2022 at 10:42 PM. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 stated she was not able to test the residents due to a lack of reagent, and therefore the residents were not placed on transmission-based precautions or isolated during her shift. She called and informed the ADON when she realized she could not test the residents and passed along in shift change report to Nurse #3 the residents who needed to be tested . Nurse #3, the nurse who took the nursing shift change report from Nurse #2 on 1/10/2022, was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #3 did not recall any other information about events that occurred after she was notified some of the residents had symptoms and needed to be tested . Documentation in a social service progress note dated 1/10/2022 at 5:53 PM revealed Resident #14 tested positive for COVID-19 and a voicemail was left for the guardian. Documentation in a nurse practitioner progress note dated 1/11/2022 at 3:03 PM revealed Resident #14 was seen for an acute visit for COVID-19 positive test but was not showing any symptoms. Documentation in a nursing note on 1/11/2022 at 4:10 PM revealed Resident #14 was moved to the COVID-19 unit that evening. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken with the testing and isolation of the symptomatic residents, but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON stated Nurse #2 should have called her and notified her if several of the residents were showing symptoms of COVID-19. DON confirmed she did not receive a call from Nurse #2 on 1/10/2022. An interview was conducted with the DON and Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility Administration was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The DON noted that no other symptoms of COVID-19 were documented for Resident #3 on 1/10/2022 or 1/11/2022. The DON indicated the reason the residents were not placed on transmission-based precautions was because of a communication problem. The DON stated she and her staff were aware residents who were symptomatic needed to be tested right away and placed on transmission-based precautions, but she nor the ADON ever received a phone call from Nurse #2 alerting them that residents were symptomatic and needed testing. If they had been notified, they could have provided for the immediate testing because the supplies were in the facility and then the residents who showed positive would have been isolated and place on transmission-based precautions. According to the DON, nurses could have called her or the ADON at any time and neither of them had a record of any phone calls from Nurse #2. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 3. Documentation in the vaccine administration section of the medical record revealed, Resident #15 was up-to-date with all recommended COVID-19 vaccinations. Resident #15 resided in a private room in the facility. Documentation in the medical record of Resident #15 written by Nurse #2 in an electronic MAR (Medication Administration Record) - shift level administration note dated 1/10/2022 at 12:39 AM stated, Cough, sore throat, ADON (Assistant Director of Nursing) aware, resident will be tested this AM on first shift when [COVID-19] supplies available. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 stated she was not able to test the residents due to a lack of reagent, and therefore the residents were not placed on transmission-based precautions or isolated during her shift. She called and informed the ADON when she realized she could not test the residents and passed along in shift change report to Nurse #3 the residents who needed to be tested . Nurse #3, the nurse who took the nursing shift change report from Nurse #2 on 1/10/2022, was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #3 did not recall any other information about events that occurred after she was notified some of the residents had symptoms and needed to be tested . Documentation in a social service note dated 1/11/2022 at 11:40 AM revealed Resident #15 tested positive for COVID-19. Documentation in a Nurse Practitioner note dated 1/11/2022 at 11:58 AM stated in part, I am seeing this patient following her rapid test positive COVID-19 test. Patient is fully vaccinated. She [complains of] mild scratchy throat but no other symptoms. Documentation in the nursing notes dated 1/11/2022 at 6:00 PM revealed Resident #15 was transferred to the COVID-19 unit that evening. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken with the testing and isolation of the symptomatic residents, but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON stated Nurse #2 should have called her and notified her if several of the residents were showing symptoms of COVID-19. DON confirmed she did not receive a call from Nurse #2 on 1/10/2022. An interview was conducted with the DON and Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility Administration was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The DON noted that no other symptoms of COVID-19 were documented for Resident #3 on 1/10/2022 or 1/11/2022. The DON indicated the reason the residents were not placed on transmission-based precautions was because of a communication problem. The DON stated she and her staff were aware residents who were symptomatic needed to be tested right away and placed on transmission-based precautions, but she nor the ADON ever received a phone call from Nurse #2 alerting them that residents were symptomatic and needed testing. If they had been notified, they could have provided for the immediate testing because the supplies were in the facility and then the residents who showed positive would have been isolated and place on transmission-based precautions. According to the DON, nurses could have called her or the ADON at any time and neither of them had a record of any phone calls from Nurse #2. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 4. Documentation in the vaccine administration section of the medical record revealed, Resident #12 was up-to-date with all recommended COVID-19 vaccinations. Resident #12 resided in a semiprivate room in the facility. Documentation in the medical record of Resident #12 written by Nurse #2 in an electronic MAR (Medication Administration Record) - shift level administration note dated 1/10/2022 at 12:26 AM stated, Resident has cough, ADON (Assistant Director of Nursing) aware, resident to be tested this AM when supplies [available]. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 stated she was not able to test the residents due to a lack of reagent, and therefore the residents were not placed on transmission-based precautions or isolated during her shift. She called and informed the ADON when she realized she could not test the residents and passed along in shift change report to Nurse #3 the residents who needed to be tested . Nurse #3, the nurse who took the nursing shift change report from Nurse #2 on 1/10/2022, was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #3 did not recall any other information about events that occurred after she was notified some of the residents had symptoms and needed to be tested . The documentation in the point of care [MEDICATION(S)] testing log dated 1/10/2022 at 4:55 PM revealed Resident #12 tested positive for COVID-19 at 5:10 PM. Documentation in a social service progress note dated 1/10/2022 at 5:33 PM revealed Resident #12 was to be moved to the COVID-19 unit after testing positive for COVID-19. An interview was conducted with the facility Administrator on 2/18/2022 at 9:58 AM. The facility Administrator explained COVID-19 testing of the residents was initiated on 1/10/2022 after 4:00 PM and was started on the 200 Hall area. Resident #12 and her roommate both tested positive for COVID-19 on the same day at the same time. The Health Department was contacted, and the facility received confirmation to put the residents who tested positive with the rapid test under transmission-based precautions. The COVID-19 unit was expanded at that time to include the room for which Resident #12 and her roommate resided. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken with the testing and isolation of the symptomatic residents, but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON stated Nurse #2 should have called her and notified her if several of the residents were showing symptoms of COVID-19. DON confirmed she did not receive a call from Nurse #2 on 1/10/2022. An interview was conducted with the DON and Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility Administration was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The DON noted that no other symptoms of COVID-19 were documented for Resident #3 on 1/10/2022 or 1/11/2022. The DON indicated the reason the residents were not placed on transmission-based precautions was because of a communication problem. The DON stated she and her staff were aware residents who were symptomatic needed to be tested right away and placed on transmission-based precautions, but she nor the ADON ever received a phone call from Nurse #2 alerting them that residents were symptomatic and needed testing. If they had been notified, they could have provided for the immediate testing because the supplies were in the facility and then the residents who showed positive would have been isolated and place on transmission-based precautions. According to the DON, nurses could have called her or the ADON at any time and neither of them had a record of any phone calls from Nurse #2. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 5. Documentation in the vaccine administration section of the medical record revealed, Resident #13 was up-to-date with all recommended COVID-19 vaccinations. Resident #13 resided in a semiprivate room at the facility with another resident who was fully vaccinated and boosted and was never diagnosed with COVID-19 while at the facility. Documentation in the medical record of Resident #13 written by Nurse #2 in an electronic MAR (Medication Administration Record) - shift level administration note dated 1/10/2022 at 12:31 AM stated, cough, fatigue, ADON (Assistant Director of Nursing) aware, resident to be tested this AM on 1rst shift when [COVID-19] supplies available. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 stated she was not able to test the residents due to a lack of reagent, and therefore the residents were not placed on transmission-based precautions or isolated during her shift. She called and informed the ADON when she realized she could not test the residents and passed along in shift change report to Nurse #3 the residents who needed to be tested . Nurse #3, the nurse who took the nursing shift change report from Nurse #2 on 1/10/2022, was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #3 did not recall any other information about events that occurred after she was notified some of the residents had symptoms and needed to be tested . The documentation in the point of care [MEDICATION(S)] testing log dated 1/10/2022 at 4:23 PM revealed Resident #13 tested positive for COVID-19 at 4:43 PM. Documentation in a social service note dated 1/10/2022 at 5:50 PM revealed Resident #13 tested positive for COVID-19 and was being moved to the COVID-19 unit. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken with the testing and isolation of the symptomatic residents, but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON stated Nurse #2 should have called her and notified her if several of the residents were showing symptoms of COVID-19. DON confirmed she did not receive a call from Nurse #2 on 1/10/2022. An interview was conducted with the DON and Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility Administration was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administr

Based on observation, staff interview, family interview, and record review the facility failed to provide COVID-19 testing upon the appearance of symptoms for 5 (Residents #3, #12, #13, #14, #15) of 5 sampled residents who tested positive for COVID-19 during a facility COVID-19 outbreak. This occurred during a coronavirus pandemic. Findings included: The facility Coronavirus (COVID-19) Testing policy and procedure, dated as last reviewed on 2/16/2022, was reviewed. Documentation in the policy stated in part, Guests/residents who have signs and symptoms of COVID-19, regardless of vaccination status, must be tested immediately. While results are pending, guests/residents with signs and symptoms should be placed on transmission-based precautions in accordance with CDC guidance. Once test results are obtained, the facility must take the appropriate actions based on the results. The documentation in the policy additionally stated, A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a guest/resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. Documentation in NHSN vaccination summary data for the week of 1/3/2022 to 1/9/2022 revealed 85.33% of all staff were fully vaccinated, 7.33% were partially vaccinated, and 7.33 % were unvaccinated. The documentation in the NHSN vaccination summary dated for the week of 1/3/2022 to 1/9/2022 also revealed 85.83% of the residents were fully vaccinated, 2.5% were partially vaccinated, and 11.67% were unvaccinated. 1. Resident #3 was coded on her admission Minimum Data Set assessment, dated 12/30/2021, as cognitively intact with no moods or behaviors. Documentation in the vaccine administration section of the medical record revealed Resident #3 was up-to-date with all recommended COVID-19 vaccinations. Resident #3 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is used to relieve chest congestion. Documentation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse # 4, who obtained the order for [MEDICATION(S)] from the physician for Resident #3, was interviewed on 2/18/2022 at 2:37 PM. Nurse #4 revealed she obtained the order for Resident #3 because Nurse #2, requested in report at change of shift on 1/9/2022 she contacted the physician for cough medicine because Resident #3 had a cough. Nurse #4 stated she did not know if Resident #3 had a cough on 1/9/2022 and only contacted the physician at the request of Nurse #2. There was no documentation in the medical record on 1/8/2022 or 1/9/2022 indicating Resident #3 was coughing or had congestion. Documentation in the medical record of Resident #3 written by Nurse #2 in an electronic MAR - shift level administration note dated 1/10/2022 at 12:27 AM stated, Cough, ADON (Assistant Director of Nursing) aware, resident will be tested this AM on [first] shift when supplies [available]. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 indicated she went up to the front of the building to the coffee shop to get the testing supplies to test the residents she identified as having COVID-19 symptoms. Nurse #2 explained at the front of the building she found testing swabs and cards but no reagent solution to conduct the testing. Nurse #2 stated she called the ADON and was told both she and the DON (Director of Nursing) could not come to the building. Nurse #2 revealed she was directed by the ADON to tell Nurse #3 when she came in at 7:00 AM to have the residents with symptoms of COVID-19 to be tested when the reagent solution was obtained. Nurse #2 confirmed she gave a list of the residents with COVID-19 symptoms to Nurse #3 in report at 7:00 AM and told Nurse #3 the residents needed to be tested for COVID-19 when the reagent solution was available in the morning. Nurse #3 was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #2 stated she did not recall if the COVID-19 testing was done or who did the testing on that day. Nurse #2 surmised NA #3 did the COVID-19 testing on that day because it was her job to test all the residents every Monday. An interview was conducted with the ADON on 2/17/2022 at 12:50 PM. The ADON revealed the facility kept a COVID-19 testing log which documented the time and date and result for each resident in the facility. The ADON revealed the testing log for Resident #3 could not be located. The ADON stated she was not called by Nurse #2 on 1/9/2022 or 1/10/2022. Documentation in a social service note dated 1/10/2022 at 5:55 PM revealed Resident #3 tested positive for COVID-19 on a rapid test and a family member was notified. An interview was conducted with a family member of Resident #3 on 2/18/2022 at 10:21 AM. The family member stated she visited Resident #3 on 1/8/2022 along with other visitors. The family member stated Resident #3 said to her and the other visitors during the visit to not get too close to her because she had a cough and congestion and might have COVID-19. The family member stated Resident #3 indicated she had informed the facility nursing staff of her symptoms. Documentation in a nurse practitioner note dated 1/13/2022 at 2:11 PM revealed under the assessment and plan portion of the note, a chest x-ray revealed Resident #3 had pneumonia. The nurse practitioner started Resident #3 on [MEDICATION(S)] 500 milligrams daily for 7 days and [MEDICATION(S)] 1 mg daily for 10 days. [MEDICATION(S)] is prescribed to treat bacterial infections and [MEDICATION(S)] was found to have benefits for recovering COVID-19 patients. An observation was made on 2/18/2022 at 11:30 AM in the front of the building in the coffee shop of the COVID-19 testing supplies available to the nurses. Seventeen boxes of COVID-19 testing supplies were stacked on top of each other. Documentation on the outside of the COVID-19 testing boxes stated, Rapid test for the qualitative detection of COVID-19 [MEDICATION(S)] in nasal swab specimens. The Documentation on the box revealed each box was to contain, 40 [Brand Name] COVID-19 Ag cards, 40 nasal swabs, 1 positive control swab, 1 reagent bottle, 1 product insert, and 1 procedure card. Observations were made of each COVID-19 testing supply box and each box contained a varying amount of the supplies that were listed to be in the box. None of the boxes contained a reagent bottle. Documentation on the procedure card revealed the reagent bottle was required for the testing process. An interview was conducted with NA #3 on 2/18/2022 at 11:49 AM. NA #3 confirmed she performed COVID-19 testing of the residents in the facility every other Monday. NA #3 confirmed she was working on Monday, 1/10/2022. NA #3 stated there were only two places she knew where to obtain COVID-19 testing supplies in the facility, in the coffee shop and at the front desk with the receptionist. An interview was conducted with the Receptionist/Administrative Assistant on 2/18/2022 at 12:02 PM in her office. One box of COVID-19 testing supplies including a reagent solution bottle was observed at the time of the interview in the office of the receptionist. The Receptionist/Administrative Assistant revealed a box of COVID-19 testing supplies are kept in her office should anyone arrive at the front door and need to be tested for COVID-19 after screening for COVID-19. The Receptionist/Administrative Assistant stated testing supplies are kept in the coffee shop and the front desk area as well as the speech therapy office. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON confirmed the COVID-19 testing log for Resident #3 could not be found. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON explained the testing supplies in the coffee shop in the boxes without reagent were kept so that supplies were not wasted, and additional reagent solution was ordered so the supplies could be used. The DON explained the facility routinely kept a box of testing supplies with reagent in the coffee shop, but it was removed upon the arrival of the survey team. The DON further explained the nursing staff also had access to the box of testing supplies at the receptionist area until 11:30 PM, when the screener leaves for the day. The DON stated if the testing supplies were locked up at the receptionist desk and Nurse #2 could not find reagent solution, she should have called her directly so the testing supplies could have been made available to her immediately, because the facility had more reagent available. The DON stated that she had staff members who could have come to the building immediately, retrieved the reagent solution for Nurse #2, and the testing could have been immediately completed if Nurse #2 had called her. An observation was made at the time of the interview of additional COVID-19 testing supplies that were kept locked in the speech therapy room. The DON confirmed the nursing staff do not have access to the COVID-19 testing supplies in the speech therapy room, but they are stored there if needed. An interview was conducted with the DON and the Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents to include Resident #3 were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The DON noted that no other symptoms of COVID-19 were documented for Resident #3 on 1/10/2022 or 1/11/2022. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 2. Documentation in the vaccine administration section of the medical record revealed, Resident #14 was up-to-date with all recommended COVID-19 vaccinations. Documentation in the medical record of Resident #14 written by Nurse #2 in an electronic MAR (medication administration record) shift level administration note dated 1/10/2022 at 12:28 AM stated, cough, sore throat, low fever, ADON (Assistant Director of Nursing) aware, resident to be tested this AM on 1rst shift when supplies [available]. Documentation in the vital signs section of the medical record revealed Resident #14 had a low-grade fever of 99.3 degrees Fahrenheit on 1/10/2022 at 10:42 PM. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 indicated she went up to the front of the building to the coffee shop to get the testing supplies to test the residents she identified as having COVID-19 symptoms. Nurse #2 explained at the front of the building she found testing swabs and cards but no reagent solution to conduct the testing. Nurse #2 stated she called the ADON and was told both she and the Director of Nursing (DON) could not come to the building. Nurse #2 revealed she was directed by the ADON to tell Nurse #3 when she came in at 7:00 AM to have the residents with symptoms of COVID-19 to be tested when the reagent solution was obtained. Nurse #2 confirmed she gave a list of the residents with COVID-19 symptoms to Nurse #3 in report at 7:00 AM and told Nurse #3 the residents needed to be tested for COVID-19 when the reagent solution was available in the morning. Nurse #3 was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #2 stated she did not recall if the COVID-19 testing was done or who did the testing on that day. Nurse #2 surmised NA #3 did the COVID-19 testing on that day because it was her job to test all the residents every Monday. Documentation in a social service progress note dated 1/10/2022 at 5:53 PM revealed Resident #14 tested positive for COVID-19. Documentation in a nurse practitioner progress note dated 1/11/2022 at 3:03 PM revealed Resident #14 was seen for an acute visit for COVID-19 positive test but was not showing any symptoms. An observation was made on 2/18/2022 at 11:30 AM in the front of the building in the coffee shop of the COVID-19 testing supplies available to the nurses. Seventeen boxes of COVID-19 testing supplies were stacked on top of each other. Documentation on the outside of the COVID-19 testing boxes stated, Rapid test for the qualitative detection of COVID-19 [MEDICATION(S)] in nasal swab specimens. The Documentation on the box revealed each box was to contain, 40 [Brand Name] COVID-19 Ag cards, 40 nasal swabs, 1 positive control swab, 1 reagent bottle, 1 product insert, and 1 procedure card. Observations were made of each COVID-19 testing supply box and each box contained a varying amount of the supplies that were listed to be in the box. None of the boxes contained a reagent bottle. Documentation on the procedure card revealed the reagent bottle was required for the testing process. An interview was conducted with NA #3 on 2/18/2022 at 11:49 AM. NA #3 confirmed she performed COVID-19 testing of the residents in the facility every other Monday. NA #3 confirmed she was working on Monday, 1/10/2022. NA #3 stated there were only two places she knew where to obtain COVID-19 testing supplies in the facility, in the coffee shop and at the front desk with the receptionist. An interview was conducted with the Receptionist/Administrative Assistant on 2/18/2022 at 12:02 PM in her office. One box of COVID-19 testing supplies including a reagent solution bottle was observed at the time of the interview in the office of the receptionist. The Receptionist/Administrative Assistant revealed a box of COVID-19 testing supplies are kept in her office should anyone arrive at the front door and need to be tested for COVID-19 after screening for COVID-19. The Receptionist/Administrative Assistant stated testing supplies are kept in the coffee shop and the front desk area as well as the speech therapy office. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON confirmed the COVID-19 testing log for Resident #3 could not be found. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON explained the testing supplies in the coffee shop in the boxes without reagent were kept so that supplies were not wasted, and additional reagent solution was ordered so the supplies could be used. The DON explained the facility routinely kept a box of testing supplies with reagent in the coffee shop, but it was removed upon the arrival of the survey team. The DON further explained the nursing staff also had access to the box of testing supplies at the receptionist area until 11:30 PM, when the screener leaves for the day. The DON stated if the testing supplies were locked up at the receptionist desk and Nurse #2 could not find reagent solution, she should have called her directly so the testing supplies could have been made available to her immediately, because the facility had more reagent available. The DON stated that she had staff members who could have come to the building immediately, retrieved the reagent solution for Nurse #2, and the testing could have been immediately completed if Nurse #2 had called her. An observation was made at the time of the interview of additional COVID-19 testing supplies that were kept locked in the speech therapy room. The DON confirmed the nursing staff do not have access to the COVID-19 testing supplies in the speech therapy room, but they are stored there if needed. An interview was conducted with the Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 3. Documentation in the vaccine administration section of the medical record revealed, Resident #15 was up-to-date with all recommended COVID-19 vaccinations. Documentation in the medical record of Resident #15 written by Nurse #2 in an electronic MAR (Medication Administration Record) - shift level administration note dated 1/10/2022 at 12:39 AM stated, Cough, sore throat, ADON (Assistant Director of Nursing) aware, resident will be tested this AM on first shift when [COVID-19] supplies available. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 indicated she went up to the front of the building to the coffee shop to get the testing supplies to test the residents she identified as having COVID-19 symptoms. Nurse #2 explained at the front of the building she found testing swabs and cards but no reagent solution to conduct the testing. Nurse #2 stated she called the ADON and was told both she and the Director of Nursing (DON) could not come to the building. Nurse #2 revealed she was directed by the ADON to tell Nurse #3 when she came in at 7:00 AM to have the residents with symptoms of COVID-19 to be tested when the reagent solution was obtained. Nurse #2 confirmed she gave a list of the residents with COVID-19 symptoms to Nurse #3 in report at 7:00 AM and told Nurse #3 the residents needed to be tested for COVID-19 when the reagent solution was available in the morning. Nurse #3 was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #2 stated she did not recall if the COVID-19 testing was done or who did the testing on that day. Nurse #2 surmised NA #3 did the COVID-19 testing on that day because it was her job to test all the residents every Monday. Documentation in a social service note dated 1/11/2022 at 11:40 AM revealed Resident #15 tested positive for COVID-19. Documentation in a Nurse Practitioner note dated 1/11/2022 at 11:58 AM stated in part, I am seeing this patient following her rapid test positive COVID-19 test. Patient is fully vaccinated. She [complains of] mild scratchy throat but no other symptoms. An observation was made on 2/18/2022 at 11:30 AM in the front of the building in the coffee shop of the COVID-19 testing supplies available to the nurses. Seventeen boxes of COVID-19 testing supplies were stacked on top of each other. Documentation on the outside of the COVID-19 testing boxes stated, Rapid test for the qualitative detection of COVID-19 [MEDICATION(S)] in nasal swab specimens. The Documentation on the box revealed each box was to contain, 40 [Brand Name] COVID-19 Ag cards, 40 nasal swabs, 1 positive control swab, 1 reagent bottle, 1 product insert, and 1 procedure card. Observations were made of each COVID-19 testing supply box and each box contained a varying amount of the supplies that were listed to be in the box. None of the boxes contained a reagent bottle. Documentation on the procedure card revealed the reagent bottle was required for the testing process. An interview was conducted with NA #3 on 2/18/2022 at 11:49 AM. NA #3 confirmed she performed COVID-19 testing of the residents in the facility every other Monday. NA #3 confirmed she was working on Monday, 1/10/2022. NA #3 stated there were only two places she knew where to obtain COVID-19 testing supplies in the facility, in the coffee shop and at the front desk with the receptionist. An interview was conducted with the Receptionist/Administrative Assistant on 2/18/2022 at 12:02 PM in her office. One box of COVID-19 testing supplies including a reagent solution bottle was observed at the time of the interview in the office of the receptionist. The Receptionist/Administrative Assistant revealed a box of COVID-19 testing supplies are kept in her office should anyone arrive at the front door and need to be tested for COVID-19 after screening for COVID-19. The Receptionist/Administrative Assistant stated testing supplies are kept in the coffee shop and the front desk area as well as the speech therapy office. An interview was conducted with the Director of Nursing (DON) on 2/18/2022 at 12:08 PM. The DON confirmed the COVID-19 testing log for Resident #3 could not be found. The DON revealed NA #3 was working on the floor as a nursing assistant on the morning of 1/10/2022 and did not start the COVID-19 testing of the residents until after her shift ended at 3:00 PM. The DON confirmed it was noted on the 24-hour report on the morning of 1/10/2022, Resident #3 had a cough and needed to be tested for COVID-19. The DON did not know why this was not discussed in morning meeting so action could be taken but she surmised the daily meeting going over the 24-hour report was not held until later in the day. The DON explained the testing supplies in the coffee shop in the boxes without reagent were kept so that supplies were not wasted, and additional reagent solution was ordered so the supplies could be used. The DON explained the facility routinely kept a box of testing supplies with reagent in the coffee shop, but it was removed upon the arrival of the survey team. The DON further explained the nursing staff also had access to the box of testing supplies at the receptionist area until 11:30 PM, when the screener leaves for the day. The DON stated if the testing supplies were locked up at the receptionist desk and Nurse #2 could not find reagent solution, she should have called her directly so the testing supplies could have been made available to her immediately, because the facility had more reagent available. The DON stated that she had staff members who could have come to the building immediately, retrieved the reagent solution for Nurse #2, and the testing could have been immediately completed if Nurse #2 had called her. An observation was made at the time of the interview of additional COVID-19 testing supplies that were kept locked in the speech therapy room. The DON confirmed the nursing staff do not have access to the COVID-19 testing supplies in the speech therapy room, but they are stored there if needed. An interview was conducted with the DON and the Administrator on 2/18/2022 at 2:00 PM. The Administrator confirmed NA #3 was working caring for residents from 7:00 AM to 3:00 PM on 1/10/2022 and did not start testing residents for COVID-19 until after 3:00 PM. The Administrator stated the facility was in the middle of a COVID-19 outbreak so any of the residents who were not tested on [DATE] were tested the following day on 1/11/2022, because the facility was not aware of any other symptoms in any other residents at that time. The Administrator added that some of the residents who tested positive were receiving therapy services and none of the therapists documented any signs or symptoms of COVID-19 in the residents on 1/10/2022. On 1/10/2022 some of the residents were testing positive for COVID-19 so the health department was contacted. The Administrator stated the facility was directed by the health department to isolate the residents on the COVID-19 unit based on the rapid test for COVID-19 and not to wait for the PCR (polymerase chain reaction test) results because it was taking 6 to 10 days to get results. The PCR test is a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the COVID-19 virus. The rapid COVID-19 test, also called the [MEDICATION(S)] test detects proteins from the virus which causes COVID-19. The rapid test is considered most accurate in those individuals who are experiencing symptoms of COVID-19. The Administrator reiterated that all the residents were asymptomatic on 1/10/2022 and after the nurse practitioner saw the residents who tested positive on 1/10/2022, all were asymptomatic except for one. 4. Documentation in the vaccine administration section of the medical record revealed, Resident #12 was up-to-date with all recommended COVID-19 vaccinations. Documentation in the medical record of Resident #12 written by Nurse #2 in an electronic MAR (Medication Administration Record) - shift level administration note dated 1/10/2022 at 12:26 AM stated, Resident has cough, ADON (Assistant Director of Nursing) aware, resident to be tested this AM when supplies [available]. The documentation also revealed the note was to, show on shift report and show on 24-hour report. Nurse #2 was interviewed on 2/17/2022 at 7:17 PM. Nurse #2 revealed she worked weekends at the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 explained on the evening of 1/9/2022 into the morning of 1/10/2022 she was doing her respiratory assessments of the residents on her hall. Upon assessment Nurse #2 discovered several of the residents, whose names she could not recall at the time of the interview, had symptoms of COVID-19 and concluded the whole hall should be tested for COVID-19. Nurse #2 indicated she went up to the front of the building to the coffee shop to get the testing supplies to test the residents she identified as having COVID-19 symptoms. Nurse #2 explained at the front of the building she found testing swabs and cards but no reagent solution to conduct the testing. Nurse #2 stated she called the ADON and was told both she and the Director of Nursing (DON) could not come to the building. Nurse #2 revealed she was directed by the ADON to tell Nurse #3 when she came in at 7:00 AM to have the residents with symptoms of COVID-19 to be tested when the reagent solution was obtained. Nurse #2 confirmed she gave a list of the residents with COVID-19 symptoms to Nurse #3 in report at 7:00 AM and told Nurse #3 the residents needed to be tested for COVID-19 when the reagent solution was available in the morning. Nurse #3 was interviewed on 2/18/2022 at 9:18 AM. Nurse #3 stated she remembered the conversation with Nurse #2 but did not remember what day the conversation happened. Nurse #3 revealed she recalled receiving a list of residents from Nurse #2 who needed to be tested for COVID-19 on the first shift because no reagent solution was available to perform the testing. Nurse #2 stated she did not recall if the COVID-19 testing was done or who did the testing on that day. Nurse #2 surmised NA #3 did the COVID-19 testing on that day because it was her job to test all the residents every Monday. The documentation in the point of care [MEDICATION(S)] testing log dated 1/10/2022 at 4:55 PM revealed Resident #12 tested

Based on record review, staff interview, and Nurse Practitioner interview for one (Resident # 1) of three sampled residents reviewed for professional standards, the facility failed to assess a resident's vital signs when he experienced a change in condition. The findings included: Record review revealed Resident # 1 resided at the facility from 9/24/21 until his discharge to the hospital on 10/8/21. According to records, prior to the resident's facility residency he had been hospitalized for fevers and joint pain which the physician felt was possibly related to polyarticular gout. Additionally, the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's admission minimum data set assessment, dated 9/30/21, coded the resident as cognitively intact and as needing supervision with his dressing and toileting. He was independent for his bathing needs. According to the record, on 10/4/21 the resident was diagnosed with COVID, evaluated by the physician per a virtual visit in conjunction with a nurse, and found to have clear lung sounds. He was started on a COVID-19 protocol which included the anticoagulant medication [MEDICATION(S)] 2.5 mg (milligrams) twice per day for 30 days. Other medications, which were included on the protocol, were Z-Pac, [MEDICATION(S)], and [MEDICATION(S)]. According to the record, the resident was evaluated by either the NP or the physician on the dates of 10/4/21, 10/5/21, 10/6/21 and 10/7/21. On the 10/7/21 assessment, the physician noted the resident was doing well on the COVID protocol. His lungs were clear to auscultation. On 10/8/21 at 7:58 AM the resident's vital signs were documented to be: Blood pressure: 135/59; temperature- 97.6; Pulse 82; and respirations 18. There were no further vital signs after this time. On 10/8/21 at 11:40 AM Nurse # 1 documented the following. Resident has what appeared to be two episodes of a [CONDITION(S)] and the second one was followed by him throwing up some coffee ground emesis. NP was made aware and gave me the ok to send him out. I've spoken with his daughter numerous times this AM and she's aware of what's going on and agrees he should be sent out. I am sending him to (hospital name), waiting on EMS to come get him, report has been called to the ER as well. Nurse # 1 was interviewed on 11/30/21 at 4:20 PM and reported the following. On the AM of 10/8/21 she was called into the room by the resident's NA (nurse aide) who felt like the resident was not acting like himself. When she got to the room, the resident was sitting on the side of the bed where the NA had been assisting him to get dressed. He was not responding and his whole body was shaking. To the nurse, it resembled [CONDITION(S)] activity and it only lasted a few seconds. She called his name and they laid him down. He became alert and had not realized what had happened. That morning, the resident also had some brown, dark, coffee ground emesis two different times. She talked to the NP twice about the resident and had reported both the shaking and the emesis. The nurse recalled the episodes of emesis and the shaking episode occurred all within an approximate 45- minute time frame. When she talked to the NP the second time, she let the NP know she felt the resident needed to be sent out and orders were received to do so. She could not recall obtaining the resident's vital signs or his oxygen level after he was noted to have the shaking and emesis. She did not recall he was short of breath or in need of oxygen. Review of EMS documentation revealed EMS arrived in the resident's room on 10/8/21 at 11:52 AM. EMS documented they found the resident sitting in a wheelchair appearing weak with coffee ground emesis in a towel nearby. They also documented ABCs without compromise. (Airway-breathing-circulation). His lungs were clear to auscultation with diminished bases. His mental status was documented to be his norm. Initial EMS Vital signs and Oximetry readings indicated the resident's respirations were abnormally high and his oxygen level was abnormally low but eventually rose with oxygen. Initial readings were: 11:59- B/P 93/38; pulse 57; respirations 40 and oxygen level 85% on room air 12:04- B/P 91/38; pulse 54; respirations 39 and oxygen level 84% on oxygen 12:09- B/P 88/41; pulse 58; respirations 39 and oxygen level 59% on oxygen 12:14-pulse 56; respirations 32; and oxygen level 94% on oxygen One of the EMS responders was interviewed on 12/9/21 at 9:00 AM and reported the following. The resident's pulse oximetry at their time of arrival indicated the resident was in need of oxygen when they arrived. Review of hospital records revealed the resident was admitted and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The DON and Nurse Practitioner were interviewed on 12/9/21 at 9:24 AM via phone. The DON reported that it was her expectation that nurses obtain vital signs and oximetry readings when there is a change of condition. The NP also reported that this would be an expectation with any change in condition. The NP validated that the nurse had talked to her twice on the morning of 10/8/21 within a short time frame. She saw the resident as he was being transferred out. He did not appear in distress. The NP stated residents with COVID can experience a change in their breathing very quickly and the facility has standing orders to administer oxygen at 2 to 4 liters to maintain residents' oxygen saturation levels greater than 90%.

Based on resident and staff interviews and facility record review the facility failed to seal a hole in the kitchen floor to reduce possible food harborage for roaches. Findings included: A facility exterminator invoice was reviewed on 10/23/21. The invoice dated 10/7/21 stated, Service complete. Light American roach activity in the 100 hallways. Please seal hole in floor in kitchen area to help reduce possible food harborage for roaches. Interview with an alert an oriented resident on 10/23/21 at 5:09 PM revealed that he sees cockroaches at night sometimes. The resident stated he saw a roach the previous night and did not like bugs. He stated that the exterminator had come out to spray but did not believe he did a good job. Interview with an alert and oriented resident on 10/23/21 at 5:14 PM revealed that they had a problem with big roaches recently and that he had seen one that day. Interview with an alert and oriented resident on 10/23/21 at 5:27 PM revealed that she saw a big bug crawling near her closet the other day. During observation of the kitchen area at 6:00 PM dietary staff pointed to a hole in the lower side of the wall as the area the exterminator may have been referencing. The staff were not positive if that was hole. The area was the approximate size of a tile that was forming the baseboard at the lower wall. Interview with an alert and oriented resident at 6:06 PM on 10/23/21 revealed that he saw a roach, or a water bug the previous night. He stated that he believed the bugs were coming in around the air conditioner. Interview with the Assistant Director of Nurses (ADON) at 6:13 PM on 10/23/21 revealed that they had a problem with roaches especially during the rainy season and after the exterminator came by, she would see the roach ' s dead on the floors. She stated she did have resident complaints about roaches and explained to the residents that they were treating them (roaches). Interview with nurse #1 at 6:26 PM on 10/23/21 revealed that she occasionally saw a bug on wall that looked like a cock roach, but she though was more of a big pimento bug. Interview with maintenance staff on 10/24/21 revealed that he had not sealed the hole in the kitchen referenced by the exterminator. He stated it was only in his second week at the facility and he was not made aware of the issue until yesterday (10/23/21). Interview with nurse #2 on 10/24/21 at 8:03 PM revealed that she had seen some roaches in the last couple of weeks, maybe 1 or two. She had not had any resident reports of roaches. She stated that she saw the roaches more after the exterminator came. The nurse stated that the roaches are not bad, but they are at the facility.

Based on record review, observation and staff interview, the facility failed to ensure that a cognitively impaired resident did not wander outside unsupervised for 1 of 3 sampled residents identified as a wanderer (Resident #1). On 3/3/14, Resident #1 was found outside in the front courtyard on the ground with laceration on her forehead and with the outside temperature of less than 20 degrees Fahrenheit (F). Immediate jeopardy began on 3/3/14 when Resident # 1 wandered outside unsupervised. The immediate jeopardy was identified on 3/6/14. Immediate jeopardy was removed on 3/7/14 at 11:35 AM when the facility provided an acceptable credible allegation of compliance. The facility will remain at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place and 100% of employee training. The findings included: The facility's policy on missing guest dated 5/13 was reviewed. The policy read in part " the missing guest plan will be implemented if a guest is presumed to have left the facility unaccompanied or to be missing from his/her usual location. Resident missing from the designated area of facility, the employee who identifies that a guest is missing must immediately notify all working staff of the missing guest by announcing on the public address system Code W, unit__ or __ wing, repeat twice. Upon hearing the announcement of Code W, all available staff will report to the nurse's stations. The charge nurse of the missing resident will notify the charge nurse of each nurse ' s station of the name of the missing guest and implement the action plan checklist. All nursing units will initiate a census guest count and report the unit census number to the charge nurse implementing the action plan. The nursing supervisor or charge nurse will assign appropriate staff to look for the guest. All interior areas of the building including closets, guest bathrooms and shower room will be searched. Facility grounds including outdoor buildings will also be searched. " Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had memory and decision making problems. The assessment also indicated that Resident #1 had wandering behavior which occurred daily, needed supervision with ambulation in room and corridor and needed limited assistance with transfer. The elopement assessment was conducted on admission (2010) and there was no current assessment completed. The social service progress notes were reviewed. The notes dated 1/20/14 indicated that " guest continue on a daily basis to wander aimlessly throughout the facility, most of the times with dolls in her arms looking for her family. This occurs more late in the afternoon and evening. Guest does have a wander guard in place. " The care plan dated 1/30/14 was reviewed. The care plan problem was " at risk for elopement related to wandering, " the goal was " will not leave facility unattended x (times) 90 days. " The approaches included " redirect away from exit doors as needed, redirect to activities as able, approach in a slow, calming manner when redirecting away from doors, observe whereabouts frequently, ensure the wander guard is on each shift and working daily. " The nurse's notes were reviewed. The nurse's notes were written by Nurse #3. The notes dated 3/3/14 at 11:30 PM revealed " noted guest missing from her room. Informed all staff guest was missing. All staff looking for guest. " At 11:45 PM, the notes indicated " found guest lying on her back in courtyard. Noted cuts on her face and left side of head and guest's glasses are broken. Her blood pressure 110/70, respiration 28, temperature (axilla) 96 degrees F and pulse 70. Guest is moaning. Wrapped in blankets. " At 11:55 PM, the notes read that responsible party (RP) was notified and the guest left via emergency medical service (EMS). The EMS records dated 3/3/14 were reviewed. The records indicated that the 911 call was received from the facility on 3/3/14 at 11:50 PM and the EMS staff members were on the scene at 11:58 PM. On assessment, Resident #1 was lying outside, supine and covered in blood. Resident #1 was cool to touch, responsive to voice and was snoring. She has a 2 inch open laceration to her right forehead, which was the source of the blood on her face and clothing and some lateral skin tears in her right temple. She was shivering. Her temperature was too low for the thermometer to register. The hospital records were reviewed. The emergency room (ER) records dated 3/4/14 revealed that Resident #1 had a temperature of 87.9 degrees on 3/4/14 at 12:48 AM and was noted to have a 3 centimeter (cm) laceration that was deep, ragged and macerated on the right forehead. The laceration was repaired with 7 sutures. The admitting [DIAGNOSES REDACTED]. " The notes further indicated that on arrival, Resident #1 was wearing an elastic long pants, bra, white socks and pink top. The history and physical notes dated 3/4/14 revealed that Resident #1 was brought in by EMS after " being found down outside. " She was brought into the ER and was noted to be hypothermic with a temperature of 87.9 degrees. She has a laceration on her right temple with fresh blood pooling in her orbit and abrasion on her right calf. She had bruising on her arms bilaterally. The report of the computerized tomography (CT) of the face dated 3/4/14 revealed non displaced fractures of the right maxillary sinus and right scalp laceration. On 3/5/14 at 1:50 PM, tour of the courtyards was conducted with the administrative staff #1. The facility had two courtyards, front and back courtyards. The front courtyard had exit/entrance doors to the front lobby and the rehabilitation (rehab) gym. The back courtyard had exit/entrance doors to the activity office and dining room. These doors did not have the wander guard system installed. Administrative staff #1 stated that these doors were always locked when staff left for the day. On 3/5/14 at 1:55 PM, administrative staff #1 had shared his investigation regarding the incident with Resident #1 on 3/3/14. He stated that he had investigated the incident by interviewing the staff and obtaining their written statements. He stated that the temperature outside was 18 degrees F when he looked at his cell phone that night. He added that there was a sheet of ice on the concrete (walkway) of the courtyard. He indicated that he didn't know which door Resident #1 exited to the courtyard, the front lobby or rehab gym door. He also stated that he didn't know who unlocked the rehab gym door that night. He suspected that Resident #1 was in the rehab gym because of the condition in the gym, papers every where, the phone was hanging off the desk and the copier had been messed up. On 3/5/14 at 2:40 PM, administrative staff #2 was interviewed. He stated that he had to lock all doors to the courtyard everyday before he left the facility except the rehab gym and activity office doors. The activity staff and rehab staff were supposed to lock their doors when they left for the day. He stated that he didn't know why the front lobby door was unlocked that night. On 3/5/14 at 2:58 PM, Nurse #2 (3-11 shift nurse on 200 hall) was interviewed. She indicated that she had stayed late that night to finish her documentation. She stated around 11:40 PM, she heard Nurse #3 (11-7 shift nurse assigned to Resident #1) asking " anybody seen (name of Resident #1)? " She also indicated that earlier in the shift around 11:05 PM, she had seen NA # 2 (11-7 shift NA assigned to Resident #1) looking for Resident #1 on the 200 hall. She stood up and seen staff members standing at the nurse's station. She said " you all are supposed to be looking for that woman (referring to Resident #1). She proceeded to look in the dining room, and then towards the 100 hall, going to the staff break room, checking the rooms and bath rooms of the lower end of 100 hall, back to the 100 hall nurse ' s station and then checked the room and bathroom of the upper end of the 100 hall. Then she turned towards the lobby. The front courtyard has a glass wall, she looked outside and saw something lying on the ground. She opened the door and saw Resident #1 on the ground. It was around 11:45 PM. Resident #1 was on her back, her arm/hands on her chest, her clothing were dark/bloody and her right side of face was covered with blood. She had laceration on her forehead. Her glasses were smashed, no more lenses, her shoes next her and she was mumbling. She applied compression to the laceration to stop the bleeding. It was very cold outside. She immediately yelled to call 911 and for blankets. Nurse #2 stated that 911 arrived in 5 minutes and took over. Nurse #2 further stated that she didn't check the rehab room because the door was always locked at night. She added that Resident #1 was independent with transfer and ambulation and she always expressed wanting to go home. She also stated that Resident #1 was on the 200 hall that night walking up and down the hall. The telephone interview statement from Nurse # 2 dated 3/4/14 at 1:45 AM was reviewed. The statement revealed that Nurse #2 had noticed NA # 2 looking for Resident #1. Nurse #2 joined the searched, went to the front lobby of the building, went out the courtyard and she saw something on the ground. It was Resident #1 lying on the concrete. She was moaning a little bit but was not responding. It was dark, her face and right eye were covered with blood and a dent on the side of head. She creamed for help and NA # 2 appeared. On 3/5/14 at 4:39 PM, NA #1 (3-11 shift NA assigned to Resident #1) #1 was interviewed. She stated that she was assigned to Resident #1 for the first time on 3/3/14. She worked as a floater on different halls for 3-11 shift. She indicated that she knew Resident #1 as a wanderer, walking up and down the hall holding her baby dolls and was confused. She indicated that on 3/3/14, she put Resident #1 to bed around 9:30 and 10:00 PM. She changed her clothes to a long sleeve pink gown. She would not take her pants off, a regular (polyester) pair of pants. She added that before she left the room, Resident #1 was up walking again. She had socks and sandals on when she was up walking. She added that Resident #1 was independent with transfer and would not stay in bed. She was pacing up and down the halls and wanted to go home. She also stated that they were supposed to make rounds with the incoming shift to see all the residents assigned to them but that was not happening because at times the incoming shift staff came in late. The written statement from NA#1 dated 3/5/14 was reviewed. NA #1 indicated that Resident #1 was walking all over the building on her shift. She put her pink gown on, took her shoes off and put her to bed. Before she could get out of her room, Resident #1 was up walking again saying she had to go to take care of her mother. She revealed that she had left the facility at 11:00 PM. She indicated that she did not give report to the oncoming NA the night of 3/3/14. On 3/5/14 at 4:55 PM, rehab staffs #1 & #2 were interviewed. The rehab staff #1 and #2 stated that they always made sure the rehab door to the hallway was always locked when the last person left for the day. Rehab staff #1 added that at times after office hours, non rehab staff entered the front courtyard through the front lobby door, went though the rehab gym and unlocked the door to the hallway. He further stated that this was the short cut way from the entrance door to the nurses' stations. The rehab staff #1 further indicated that administrative staff #4 had witnessed that the rehab door was locked at 6:15 PM of 3/3/14. On 3/6/14 at 6:25 AM, Nurse #1 was interviewed. She stated that she was assigned 11-7 shift on 200 hall the night of 3/3/14. She indicated that at 11:00 PM, NA #2 came to 200 hall and asked if anyone had seen Resident #1. She responded " no. " NA #2 went back to 100 hall and few minutes later he came back and said that Resident #1 was still missing. Nurse #1 stated that she had observed Resident #1 on the 200 hall earlier that night. While NAs #3, #4 (11-7 shift NAs assigned on 200 hall) and I were searching on 200 hall, Nurse #2 went to search in the front lobby. After a few minutes later, she heard Nurse #2 yelling to call 911. She called 911. When she saw Resident #1, she was already covered with blankets, her face was bloody, she has difficulty breathing, the walkway was icy and slippery and was very cold. She stated that for missing resident, code W should have been paged but it was not. The written statement from Nurse #1 dated 3/5/14 was reviewed. The statement indicated that NA # 2 was on the 200 hall looking for Resident #1. He returned to the 200 hall around 11:20 PM and the staff started to search all rooms on the 200 hall. Shortly after 11:40 PM, someone yelled that Resident #1 was outside and to call 911. On 3/6/14 at 6:48 AM, NA #5 was interviewed. She stated that she worked 10:30 PM -6:30 PM the night of 3/3/14 on 100 hall. She indicated that she came in early at 8:30 PM that night because the road was bad and it was icy. She stated that she saw Resident #1 at 10:45 PM on the hall ambulating with a pink gown, sandals and socks on. She stated that once in a while Resident #1 was still up late at night. She was independent with transfer. She added that she was not aware that Resident #1 was missing because she was in the bathroom with other resident. She revealed that she didn't hear the page for code W. The written statement from NA #5 dated 2/4/14 was reviewed. The statement indicated that NA #5 had seen Resident #1 coming up the hall to the nurse's station (desk) and turned towards the 200 hall at 10:45 PM. On 3/6/14 at 6:50 AM, administrative staff #3 was interviewed. She assumed that the code W was not paged because of the time of the night, the staff didn't want to wake up other residents. She added that the expectation was the staff should have paged through the intercom the code W because it was the policy. On 3/6/14 at 6:53 PM, NA #6 (11-7 shift NA on 200 hall) was interviewed. She stated that she came in late that night (11:15 PM) of 3/3/14 because the road was icy. She added that the staffs were already searching for Resident #1 when she came in. She started searching the laundry room, every rooms and cafeteria. And then she heard that Resident #1 was found outside the courtyard. She added that she didn't look at the administrative offices because the doors were usually locked at night. She also stated that the policy for missing resident was to announce code W and everybody should be searching. She didn't know if the code was announced because she came in late. She added that Resident #1 was ambulatory and she has to hold on to the rail when walking. The written statement from NA#6 (undated) was reviewed. The statement revealed that NA #6 came in at 11:20 PM the night of 3/3/14 and the staffs were in the process of looking for Resident #1. On 3/6/14 at 7:16 AM, Nurse # 3 (11-7 shift nurse assigned to Resident #1 on 3/3/14) was interviewed. She stated that she came in late that night (11:09 PM) because the road was icy. She then received the report from the outgoing nurse and she was told that Resident #1 had been wandering that night but that was normal for her. She indicated that at 11:30 PM, NA #2 had asked if Resident #1 was at the hospital and she responded " no. " She started searching for Resident #1. She didn't check the rehab gym because the door was always locked at night. She revealed that Resident #1 was independent with transfer in and out of bed, walked slow and she had to hold on to the railing. Nurse #3 stated that anybody could call code W and she didn't recall hearing the code and she didn't think to call the code because she was busy searching for the resident. She revealed that when she saw Resident #1 on the courtyard ground, she was moaning and was cool to touch. She assessed her and her temperature was 96 degrees axillary. The pavement on the courtyard was slippery and icy. The written statement from Nurse # 3 dated 3/4/14 revealed that at 11:20 PM, NA #2 reported that Resident #1 was missing. She looked in every room on 100 hall, went to 200 hall and she reported that Resident #1 was missing. The statement further indicated that all nurses and NAs went around the facility looking for Resident #1. At 11:40 PM, Nurse #2 found Resident #1 in the courtyard. The resident was cold and she was covered with blankets. Cuts were noted on her face and head. Her head was wrapped with towel. 3/6/14 at 8:28 AM, administrative staff #4 was interviewed. She stated that at around 6:15 PM on 3/3/14, she tried to open the rehab gym door to go to the front lobby to make coffee but the door was locked. On 3/6/14 and 9:34 AM, Nurse # 4 (3-11 shift nurse assigned to Resident #1) was interviewed. She stated that Resident #1 was observed sleeping in her room at 9:30 PM and she had not seen her again. She gave report to Nurse #3 just after 11:00 PM and was at the nurse's station finishing her documentation. She left the facility between 11:20-11:25 PM and she was not informed that Resident #1 was missing. The written statement of Nurse #4 was reviewed. She stated that she saw Resident #1 in bed asleep at 9:30 PM. She gave report to the oncoming nurse at approximately 11:05 PM and she left the facility approximately 11:25 PM. On 3/6/14 at 10:04 AM, NA # 2 was interviewed. He indicated that he did not receive any reports from the outgoing shift. He stated that he came in at 11:00 PM, gathered his supplies and started his rounds from room 134. He provided incontinent care in room 134 and proceeded down the hall to room 126. He noticed that Resident #1 was not in her bed or bathroom, and then he went to the nurse ' s station and asked Nurse # 3 if she had seen Resident #1 and she responded " no. " He went to the dining room and then to 200 hall. He asked the NAs and Nurse #1 on 200 hall if they had seen Resident #1 and they responded " no. " He went to check every rooms and bathrooms on the 200 hall by himself and went back to the 200 hall nurse's station. He told Nurse # 2 that he could not find Resident #1. He heard Nurse #2 saying everybody needed to be looking for the resident at around 11:40 PM. NA # 2 revealed that he had checked the lower end of the 100 hall but not the upper end. He also stated that he didn't check the gym or the activity office doors. He further stated that he was not aware that he had to call for the code W when a resident was missing but he just had the training on the policy of missing resident after the incident. The recorded statement from NA #2 dated 3/3/14 was reviewed. NA #2 stated that he made his round at 11:00 PM. He started at room 134 and went down to room 126. He didn't notice Resident #1, so he went to notify Nurse # 3 that Resident #1 was not in bed. He proceeded to 200 hall thru the main dining room. He asked Nurse #1 if she had seen Resident #1 and she responded that she didn't see her. He started searching in the laundry room and worked down the 200 hall checking the rooms and bathrooms. All NAs were looking for the resident. Nurse #2 came running out of the first courtyard asking for blankets and for someone to call 911. She helped put blankets on Resident #1. Resident #1 was unresponsive when he saw her. The Administrator was notified of the Immediate Jeopardy on 3/6/14 at 12:30 PM. The facility presented an acceptable credible allegation of compliance on 3/7/14 at 11:35 AM which included: March 3, 2014, at approximately 11:20pm Resident #1 was noted missing and was found in the front enclosed courtyard at 11:40pm. March 3, 2014, at approximately 11:40pm staff stabilized Resident #1, covered with blankets, and called 911. March 3, 2014, at 11:40 pm the 11pm-7am charge nurses conducted a full facility head count. The head count was complete and all residents were accounted for. The 24 hour census record for March 4, 2014, has documented the presence of all residents in the facility at midnight. The entire facility was engaged in the search for Resident#1. There were multiple charge nurses on duty at the time of the incident. One charge nurse was assessing Resident#1, another charge nurse called 911 and prepared paperwork for EMS, and another charge nurse did the facility head count of the facility. March 4, 2014, at 12:05 am, resident was sent to the emergency room via 911. March 4, 2014, 1:00 am the Administrator made full rounds of the facility and checked all exit doors. All doors were locked and alarm doors were functioning. March 4, 2014 at 1:00 am: While making rounds in the facility the Administrator and 100 Hall Unit Manager noticed that the left therapy gym door was unlocked. Administrator and 100 Hall Unit Manager immediately locked the therapy gym door. Administrator and 100 Hall Unit Manager continued to monitor the Therapy doors and the inner court yard doors from the main lobby were monitored every 30 minutes by the Administrator until the maintenance supervisor arrived to apply temporary locks. March 4, 2014, an audit of all safety devices was conducted to ensure all devices were present and functional. This audit was compared to the care plans and physician orders. This audit was completed by 4:00 am by the 100 hall unit manager. March 4, 2014 the facilities elopement binder (the facility maintains a notebook of information for residents who are at risk for exit seeking behaviors. The information includes a resident photo, name, demographics, physician, contact information, and basic medical diagnosis) was reviewed and was determined to be correct and up-to-date. This review was completed by 4:00 am by 100 hall unit manager. March 4, 2014, at 7:00 am temporary locks were installed by facility maintenance supervisor to all inner courtyard doors and were secured. March 4, 2014, at 12:30 pm the therapy staff 21 of 22 was in-serviced on Guest Safety and Securing the Gym. Remaining therapy staff will be inserviced prior to starting their next shift. March 4, 2014, at 12:30 pm 38 of 40 non-licensed staff (i.e. dietary, housekeeping, laundry, etc.) were in-serviced on facility ' s Missing Guest Policy. Remaining non licensed staff will be in-serviced prior to starting their next shift. March 5, 2014 at 2:00 pm Secure Care locking system was installed and is functional on the inner courtyard doors. This system will lock the door when a resident with a wander guard bracelet approaches the door. In addition they are programmed to lock automatically 1t 7:00 pm until 9:00 am. March 4th, 5th and 6th, 2014, In-serving was being conducted on facility ' s Missing Guest Policy. (By midnight 42 of 63 NAs and Nurses were re in-serviced by the DON and ADON). By March 6th Nursing staff 104 of 116 had been in-serviced. Remaining nursing staff will be in-serviced prior to starting their next shift. March 6, 2014, Additional Secure Care locks were installed on additional doors in the facility and this installation was completed at 4:00 pm. These doors are electronically monitored to ensure they are closed and functioning properly. Malfunctions alert the nurses via a panel and buzzer at the 200 hall nurses unit. March 6, 2014, The maintenance supervisor physically tested the function of the doors using a test bracelet or device and they were properly functioning, this audit was recorded I the maintenance log. March 6 and 7, the facility conducted a missing resident drill on each shift. Validation of credible allegation was conducted on 3/7/14. Observations of all exit doors and doors to the courtyards were conducted and revealed that they had secure locks installed. All doors were tested with the use of a wander guard device and all doors locked when the device was brought near the doors. Observations of residents with wander guard bracelets revealed bracelets were appropriately placed on the residents and/or on wheelchairs. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on the policy of missing guest. The therapy staff members were also inserviced on making sure their doors were locked at night. The location of the book containing the names of residents who wore the wander guard bracelet was in place and was current.

Based on record review, resident and staff interviews, the facility restrained 1 of 3 residents (Resident #169) without medical necessity. The findings included: Resident #169 was admitted to the facility on [DATE], and then re-admitted on [DATE]. Her cumulative [DIAGNOSES REDACTED]. On the annual Minimum Data Set ((MDS) dated [DATE], she was assessed as being severely cognitively impaired, with no limitations to her range of motion, nor a history of falls. A chart review was conducted and revealed in the nurse's notes on 5/19/12 that a lap buddy device was ordered for Resident #169 per family request. The admission MDS did not list the lap buddy as a restraint. A physician's telephone order on 6/19/12 stated to discontinue the lap buddy and to use a lap tray for wheelchair safety and positioning. A Physician's Report of Consultation, 6/19/12, did not address any treatment through the use of a lap tray, for positioning in either the [DIAGNOSES REDACTED]. On Resident 169's most recent quarterly MDS, dated [DATE], she was remained cognitively impaired, needing extensive assistance with transfers, walking and locomotion. Her balance was listed as unsteady and she had limitations on both sides of her lower extremities. Resident #169 was receiving restorative nursing exercises for her range of motion skills. She had not experienced any falls. The lap tray was not listed on the MDS as a restraint. Her most recent Fall Risk Assessment, dated November 2012 had reduced her from a high risk fall with a score of 11 to a non-high risk with a score of 9, due to improvements with her mental status. The assessor stated that she went from intermittent confusion to disoriented x3 at all times. Further, she required the use of an assistive device and used a walker and a wheelchair. A care plan was developed for Resident #169 on 11/26/12 noted that she had developed a tendency to get out of her chair or bed unattended. The goal was listed as keeping her free from injury during the next 90 days review period. Approaches to be used included supervising and assisting her with transfers as well as using a lap tray for positioning. The chart revealed that between 5/17/12 until 11/4/12, Resident #169 received supports from occupation and physical therapies. In an interview with the occupational therapist #1 (OT) on 1/24/13 at 2:48 pm, she stated that she used to provide services to Resident #169 but had to stop because her cognition impairments, and because she had reached her full potential. She shared that Resident #169 did not require any support to sit still. However, she noted that she would easily lose her balance once she became distracted with another task, such as trying to pick something up from off the floor. Further, she didn't think that Resident #169 could sit unsupervised because of her cognitive deficits and poor safety awareness. She required visual supervision, not to prevent her toppling over, but to cue her due to her cognition. The MDS nurse was interviewed on 1/25/13 at 9:35 am. She stated that Resident #169's lap tray was considered an enabler not a restraint, because she had the tendency to lean forward. The Enabler Assessment, dated 6/9/12 had stated that Resident #169 couldn't attempt to stand, whereas notes in the therapy summaries stated that she could use a walker to ambulate and could stand during ADL (activities of daily living) care. The chart also contained a Pre-Restraint Intervention Evaluation completed by the Unit Nurse on 6/19/12 stating that Resident #169 as unable to maintain body alignment and couldn't understand safety during standing or transfers. The Unit Nurse was interviewed on 1/25/13 at 9:55 am about other least restrictive devices explored for Resident #169 before the use of a lap buddy and lap tray. She clarified that Resident #169 didn't lean forward in her chair, but actually scooted herself to the edge of the chair, attempting to stand up. She shared that she has been known to slouch down in her wheelchair, even with the lap tray in place, trying to be free of it. The Unit Nurse acknowledged that the restraint was in place solely at the request of a family member. In a Psychiatric Follow Up Note, 11/30/12, it was written that staff reported that Resident #169 had became agitated in the evening, trying to knock her tray off of her wheelchair and was combative. Taking a medication to relieve her agitation was noted to be helpful. The Nurse's notes on 12/11/12 at 2:15 pm recorded that Resident #169 had refused to stay in wheelchair, attempting to remove the lap tray 3 times. She was given medication to reduce her agitation, which was prescribed for as needed purposes. During an interview with Nurse #2 on 1/24/13 at 3:19 pm, she stated that when the lap tray was applied to Resident #169's wheelchair, it needed to be fastened well, if not she would try to remove it or slide underneath it. She stated that she made a point to visually supervise Resident #169 whenever she was on the hall in her wheelchair, often removing the tray. NA #3 was interviewed on 1/24/12 at 5:20 pm. She demonstrated how she used to apply the lap tray to Resident #169's wheelchair, before she fractured her hip on 1/9/13. She stated that there were two Velcro straps on the sides of the device that were used to wrap several times around the arms of the chair. A long belt was snapped in place behind the chair, however, she had witnessed Resident #169 unwrap the straps, slide the snapped belt to the front, where she could then unhook it. She shared that if Resident #169 wasn't successful, unhooking the belt, she would either loosen the side straps enough to lift the lap tray over her head or she would have it lose enough to slide underneath the tray, trying to get out of the chair. She was always able to redirect her. NA #3 commented that Resident #169 did not like the device and would say to her, "Why y'all tying me up like that, you're treating me like a dog." Resident #169 was present during the demonstration and acknowledged that she did not like the lap tray. OT #2 and the Physical Therapy Assistant came to the room to transfer Resident #169 out of her bed on 1/25/13 at 10:40 am. Resident #169 was sitting up in the bed, demonstrating good trunk control. She was alert, oriented and in a pleasant mood. She was able to follow short simple commands and was able to scoot herself to the edge of the bed then allowed the therapist to place a gait belt around her waist to help her stand. She held onto her rolling walker to support, then was able to pivot and turn, with many instructions, until she was able to sit down in her wheelchair. The therapist stated that Resident #169's cognition remained the biggest factor in getting her to do things safely. The OT #2 shared that he has come down the hall before to see Resident #169 trying to get up from her wheelchair, before she was injured. He even recalled seeing her, unfasten the Velcro straps on her lap tray and lift the tray, attempting to stand. Both of the therapists said that the presence of the tray helps to agitate her. When in therapy, the device was not used, since she was supervised by staff.

Based on observation, record review and staff interviews, the facility failed to supervise 1 of 3 cognitively impaired residents with a history of falls and who required extensive assistance with toilet use. The findings included: Resident #169 was admitted to the facility on [DATE], and then re-admitted on [DATE]. Her cumulative [DIAGNOSES REDACTED]. On the annual Minimum Data Set ((MDS) dated [DATE], she was assessed as being severely cognitively impaired, with no limitations to her range of motion, nor a history of falls. On Resident 169's most recent quarterly MDS, dated [DATE], she was still assessed as being cognitively impaired, needing extensive assistance with transfers, walking, locomotion and toilet use. Her balance was listed as unsteady and she had limitations on both sides of her lower extremities. Resident #169 was receiving restorative nursing exercises for her range of motion skills. She had not experienced any falls. Her most recent Fall Risk Assessment, dated November 2012 had reduced her from a high risk fall with a score of 11 to a non-high risk with a score of 9, due to improvements with her mental status. The assessor stated that she went from intermittent confusion to disoriented x3 at all times. Further, she required the use of an assistive device and used a walker and a wheelchair. Resident #169's chart was reviewed and revealed the following information. An undated Nursing Care Card stated that she was a fall risk and should have a pad alarm to the bed used for safety equipment. She needed the assistance of 1 and received therapeutic supports. She remained oriented to person. In an interview with the Unit Nurse on 1/24/13 at 3:36 pm, she stated that the care guard was developed at the time of admission and was based on the hospital summary and the initial nursing admission assessment. Then the care cards are amended as new needs present themselves. Staff can find the care card in the closet of each resident or at the nurse's station in a book. A care plan was developed for Resident #169 on 6/6/12 identifying Falls as a problem area due to her unsteady gait, impaired mobility and Dementia. On 11/26/12 it was noted that she had also developed a tendency to get out of her chair or bed unattended. The goal was listed as keeping her free from injury during the next 90 days review period. Approaches to be used included supervising and assisting her with transfers. In addition, on 5/30/12 another problem area to be care planned for Resident #169 reflected her cognitive deficits. She was noted to have short and long term memory problems. Approaches to be used included encourage her to converse during care and provide prompting, cues and/or reminders as needed. Also, staff should attempt to minimize distractions. The chart revealed that between 5/17/12 until 11/4/12, Resident #169 received supports from occupation and physical therapies. In an interview with the occupational therapist #1 (OT) on 1/24/13 at 2:48 pm, she stated that she used to provide services to Resident #169 but had to stop because her cognition impairments, and because she had reached her full potential. She shared that Resident #169 was able to sit on a toilet well and depending on how she felt, would determine if she could maintain her balance. She mentioned that Resident #169 did not require any support to sit still on a toilet up to 5 minutes. However, she noted that she would easily lose her balance once she became distracted with another task, such as trying to pick something up from off the floor. The OT #1 stated that determining the supports to assist Resident #169 with transfers varied on if she needed one person (minimum) or two persons (moderate) depending on what she could understand at the time. She didn ' t think that Resident #169 could sit on the toilet for a minute unsupervised because of her cognitive deficits and poor safety awareness. She required visual supervision, not to prevent her toppling over, but to cue her due to her cognition. On 1/9/13 at 7:45 am, the nurse's notes documented a fall that Resident #169 sustained in her bathroom. She was found lying down on her right side on the bathroom floor. She complained of left hip pain, no bruises were noted. At 8:14 am, she was transported by ambulance to the hospital for treatment and evaluation. The Incident Report, 1/9/13 further stated that Resident #169 was known to remove her alarm. Nurse Aide #1 had assisted her to the bathroom then went into the room to get clothes out of her closet. She was found on the bathroom floor by NA#1 a few minutes later. Nurse Aide #1 was interviewed on 1/23/13 at 2:38 pm. She stated that Resident #169 was her regular assignment since her admission and she was familiar with her needs. She described her as someone who was able to verbalize but who had dementia, often speaking about past events. She recalled that on 1/9/13, Resident #169 was not having a good morning. She was using foul language and had torn her brief off, throwing it on the floor. Immediately, NA #1 said she knew that Resident #169 would not be cooperative and she went to get assistance from NA #2 to transfer her out of bed to the bathroom. Once NA #2 entered the room, they placed Resident #169 in a wheelchair and took her to the bathroom and placed her on the toilet. NA #2 then left the room, leaving NA #1 with Resident #169. NA #1 said that she was expecting Resident #169 to have a bowel movement, because she began passing gas, so she left her sitting on the toilet, to give her privacy, leaving the two bathroom doors open. She shared that as she left her on the toilet, she continued to converse with her, which was her practice to keep her engaged and focused on task. She stated that she stayed inside of her room but walked over to the closet, which was along the same wall as the bathroom. She began to remove clothes from the closet and personal hygiene supplies, when she noticed that Resident #169 was no longer talking so she went to check on her in the bathroom and found her on the floor. She stated that she fell on her left side and was lying along the wall. She commented that Resident #169 had a habit of reaching down to pick things off of the floor. When she approached Resident #169 and touched her, she screamed out in pain. NA #1 said that she had witnessed the family members of Resident #169 leave her on the toilet unsupervised and there was never a problem, however, after she fell , she was counseled by the Director of Nursing (DON) to gather her supplies first, before transferring a resident, to prevent leaving her unattended in the bathroom. On 1/24/13 at 11:10 am, NA #2 was interviewed. She stated that she assisted NA#1 transfer Resident #169 from her bed to the wheelchair on 1/9/13. She stated that she provided restorative exercises to Resident #169 and was familiar with her abilities. She shared that on that particular morning, Resident #169 was uncooperative, confused and wouldn't follow directions. She had thrown her legs over the bed, attempting to get out without assistance, when she entered the room. NA #2 stated that Resident #169 had good posture. The Director of Nursing was interviewed on 1/24/13 at 11:33 am. She stated that there are some residents in the facility who do not need to be supervise entirely while they are in the bathroom and to her knowledge, Resident #169 did not require that kind of supervision. She stated that she re-educated NA #1 not to leave Resident #169 unsupervised in the bathroom after the accident, despite what might be witnessed from family members providing care to her. The Hospital Transfer Summary, 1/14/13 was reviewed. It recorded that Resident #169 was admitted to the hospital for a hip fracture.

Based on record review, observation, staff and family interview, the facility failed to administer the [MEDICATION NAME] (loop diuretic) for 11 days to a resident with a [DIAGNOSES REDACTED].#211) of 3 sampled residents reviewed. The finding includes: Resident #211 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #211's cognitive status was impaired. Review of the nurse's notes dated 11/13/12 indicated that Resident #211 was admitted at 3:00 PM. The nursing admission assessment revealed that the resident was admitted with no [MEDICAL CONDITION]. The physician notes on the medical history and physical dated 11/15/12 indicated that Resident #211 had no [MEDICAL CONDITION]. The nurse's notes dated 11/24/12 at 10:36 PM revealed that Resident #211 was yelling and stated that he could not breathe. The oxygen saturation was 88% on room air. The resident was encouraged to relax and oxygen at 2 liters/per minute was applied. The oxygen saturation went up to 92%. The notes further indicated that the physician was called and with orders including chest x-ray due to shortness of breath. The impression on the chest x-ray report dated 11/25/12 read " large right pleural effusion without frank evidence of [MEDICAL CONDITION] " . On 11/25/12 at 12:10 PM, the nurse's notes indicated that the physician was informed of the chest x-ray report with orders for [MEDICATION NAME] 2 mgs (milligrams) by mouth twice a day and [MEDICATION NAME] (antibiotic) 750 mgs by mouth daily for 7 days. On 11/26/12 at 1:50 PM, Resident #211 was observed up in wheelchair in his room. His legs/feet were swollen and a water blister was noted on his right leg. On 11/26/12 at 1:54 PM, a family member was interviewed. The family member indicated that the resident's legs were swollen and with a big water blister on his right leg because he was not getting his [MEDICATION NAME] medication from admission until 11/25/12. The family member stated that the resident was on [MEDICATION NAME] because of his chronic [MEDICAL CONDITION]. On 11/26/12 at 2:00 PM, the nurse's notes revealed that Resident #211's bilateral lower legs were [MEDICAL CONDITION] with some weeping noted. There was also an intact blister measuring 2 x 2 cm (centimeter) noted. Review of the discharge physician medication reconciliation order from the hospital dated 11/13/12 revealed an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/27/12 at 11:50 AM, Unit Manager #1 was interviewed. She stated that she transcribed the medications listed on the FL2 because she did not see the hospital medication reconciliation form. On 11/27/12 at 12:05 PM, administrative staff #1 was interviewed. She stated that normally when there is a new admit resident, the medications were checked against the discharge summary, medication reconciliation form, FL2, or whatever form was available. She acknowledged that the [MEDICATION NAME] for Resident #211 was a transcription error on their part. On 11/28/12 at 1:55 PM, UM # 2 was interviewed. She stated that when a resident was admitted , the UM will receive different forms (FL2, discharge summary and medication reconciliation) from the admission coordinator. Then, the UM would compare the medications listed on the different forms and when there were discrepancies, the hospital was called to clarify the orders. On 11/28/12 at 2:03 PM, administrative staff #2 was interviewed. The administrative staff stated that when there was a new admit resident, the hospital/facility sends him a copy of the discharged medication orders via fax. Then, the orders were given to the UM immediately or as soon as possible. The administrative staff was unable to remember the name of the UM but acknowledged that the medication reconciliation form was faxed on 11/13/12 at 11:36 AM to the facility (date/time printed on the form) before Resident #211 was admitted to the facility.