Every finding on record at The Rosewood Health Center

Based on observations, record review, and staff interviews, the facility failed to provide a dignified dining experience when 1.) Nurse #3 stood up while providing assistance with eating to a resident (Resident #27), and 2.) staff did not ensure all residents seated at that table were served their meals at the same time when Resident #25 was served her meal more than 10 minutes after the remaining residents seated at the same table for 2 of 3 residents reviewed for dignity. A reasonable person expects to be treated with dignity while dining. Findings included:1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of dementia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was severely cognitively impaired and the resident required set up, clean up and needs supervision (oversight, encouragement, or cueing) assistance with eating. A continuous observation occurred on 7/14/26 from 12:17 pm through 12:39 pm of the lunch meal in the resident's dining room. Nurse #3 was observed providing assistance with eating to Resident #27 while standing next to the resident. Observation revealed a chair was available behind Nurse #3 at a table to her left. On 7/15/26 at 3:46 pm, interview with Nurse #3 revealed the facility's process was to sit down when providing feeding assistance to a resident. Nurse #3 indicated the facility provided education on feeding assistance during the yearly skills fair, on-line education modules, and as needed. Nurse #3 stated she was aware she must provide the residents with dignity and respect by sitting down when assisting with feeding. Nurse #3 indicated Resident #27 would sometimes try to feed himself if he's having a good day and Nurse #3 was trying to get him to feed himself by offering food to him.An attempt was made to interview Resident #27 but due to her cognitive status this could not be completed.Interview with the Director of Nursing (DON) on 07/15/26 at 4:01 pm revealed any staff providing feeding assistance to a resident were educated on the facility's policy and requirements to sit down while feeding to ensure all residents are treated with dignity and respect per regulation. The DON stated she was uncertain why Nurse #3 did not sit down when assisting Resident # 27. 2. Resident #25 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired and required set up and clean up assistance with eating.A continuous observation occurred on 7/15/26 from 12:08 pm through 12:25 pm. The observation revealed Resident #25 was seated at a table with three other residents. The Dietary Assistant #1 was observed delivering the lunch meal to the three other residents at the table starting at 12:08 pm through 12:11 pm. The other three residents were observed eating their meal while Resident #25 waited to be served. Resident #25's lunch meal was not served until 12:25 pm. An attempt was made to interview Resident #25 but due to her cognitive status this could not be completed.Interview with the Dietary Manager on 07/15/26 at 1:02 pm revealed the usual practice should be to deliver their meal trays at the same time to provide residents with dignity and respect. The Dietary Manager also stated meal delivery was different from the facility's normal practice on the day of observation because the residents were served their meal trays one at a time to ensure the correct tray had been given to the resident. The Dietary Manager stated the process was to serve one table at a time, so all residents were eating at the same time. The Dietary Manager could not give a reason as to why meal delivery was different from the facility's normal process. The dietary staff were provided education via education modules on dignity and respect including sitting while assisting the resident eat. Dietary Assistant #1 who served Resident #25 completed education regarding aiding a resident with eating via an in-service during the annual skills fair on 12/10/25. Interview with the Director of Nursing (DON) on 07/15/26 at 4:04 pm revealed that any staff delivering meal trays to the residents must ensure meals are delivered to the entire table to maintain dignity and respect.

Based on record review, observation, and staff interviews, the facility failed to protect Residents private healthcare information (PHI) by leaving confidential medical information unattended, visible, and accessible to others on top of medication carts for 2 of 3 medication carts observed (100 hall medication cart and 400 hall medication cart).The findings included: a. On 07/16/2026 a continuous observation occurred from 8:12 AM to 8:25 AM of the medication cart on the 100-hall. The medication cart was left unattended with an empty medication blister packet face up exposing a resident's name, date of birth , medication name, medication dose, and medication frequency, an empty laxative bottle with a resident's label which exposed the resident's name and date of birth , and the facility's 24 hour report that was face up with many residents' PHI visible. During the time the medication cart was left unattended there were two residents sitting within 2 feet of the medication cart, and a Nurse Aide (NA) walked by the medication cart. During an interview on 7/16/2026 at 8:27 AM with Nurse #1, she explained when walking away from her medication cart, the top of the medication cart should not contain any visible resident information. Nurse #1 confirmed she had left a medication blister pack, a laxative bottle and the 24-hour report sheet all with resident information visible on top of her medication cart when she was not present at her medication cart. Nurse #1 acknowledged she did not ensure resident information was not visible to others. b. On 07/16/2026 a continuous observation occurred from 8:33 AM to 8:40 AM of the medication cart on the 400-hall. The medication cart was left unattended with a label from medication blister packet exposing a resident's name, date of birth , medication name, medication dose, and medication frequency, on top of the medication cart. During this time a housekeeper and dietary staff walked by. During an interview on 7/16/2026 at 8:40 AM with Nurse #2, she confirmed there was a label from the medication blister pack with resident information visible left on top of her medication cart. The nurse stated she would usually take the labels off the empty medication blister packets and shred them. Nurse #2 acknowledged she did not ensure resident information was not visible to others. An interview on 7/16/2026 at 10:42 AM with the Director of Nursing (DON) revealed the Nurses should not have walked away and left resident information visible for anyone walking by to see it. She indicated all resident PHI should be put away to protect resident's privacy whenever the medication cart was left unattended.

Based on record review, observation and staff interviews, the facility failed to secure medications and lock the medication cart for 1 of 3 medication carts observed for medication administration (100 Hall medication cart).The findings included:On 07/16/2026 at 8:25 AM, Nurse #1 placed the medication cart against the wall to the side of a resident's doorway. Nurse #1 then prepared medications to be administered to a resident. Nurse #1 removed 8 medication blister packets from the medication cart drawer, placed them on the top of the medication cart, and dispensed the medications into a medication cup for the resident. Nurse #1 then walked away from the medication cart and entered the resident room without securing the 8 medication blister packets that were on top of the medication cart and left the medication cart unlocked. The medication cart was out of sight from inside the resident's room. The medication cart lock system was electronic with a keypad that revealed a green flashing light when the medication cart was unlocked. When Nurse #1 walked away from the medication cart the flashing green light indicated it was not locked. The medications that were left unattended were as follows: allopurinol (blocks uric acid), aspirin, carvedilol (high blood pressure), docusate sodium, lisinopril (high blood pressure), memantine (Dementia), multivitamin, and pantoprazole sodium (acid reflux). During the time that Nurse #1 was not present at the medication cart, a housekeeper and an Occupational Therapist walked past the unlocked medication cart and the medications that were left on top of the cart. There were no residents in the area. During an interview on 7/16/2026 at 8:27 AM with Nurse #1, she explained that before leaving the medication cart, nurses were to make sure all medications were in the cart and that the medication cart was locked. Nurse #1 stated she usually placed the medications back in the cart and locked the medication cart before leaving it. The Nurse acknowledged she did not ensure the 8 medication blister packets were secured and the medication cart was locked when she went to administer the medications. Nurse #1 stated she didn't follow the process because she was being observed during the survey.An interview with the Director of Nursing (DON) took place on 7/16/2026 at 3:32 PM. The DON stated all nurses were to ensure medication carts were locked when unattended. The DON stated when doing a medication pass, nurses should bring the cart into the resident doorway, so the medication cart was in line of sight. The DON stated the Nurse was to place the medication blister packs back in the medication cart drawer once the medications were prepared and lock the medication cart. The DON stated she felt Nurse #1 was nervous and that was why the process was not followed.

Based on record review and staff interviews, the facility failed to ensure the daily nurse staffing posting had the correct census for 15 of 23 days reviewed for (6/1/26 through 6/8/26) and (7/1/26 through 7/15/26). The findings included:A review of the facility's Daily Nurse staff posting from 6/1/26 through 6/8/26 and 7/1/26 through 7/15/26 revealed the following: Daily Nurse Staffing Information dated 6/1/26 revealed a resident census of 45. Review of the facilities detailed census report dated 6/1/26 revealed a resident census of 43.Daily Nurse Staffing Information dated 6/4/26 revealed a resident census of 46. Review of the facilities detailed census report dated 6/4/26 revealed a resident census of 45.Daily Nurse Staffing Information dated 6/5/26 revealed a resident census of 46. Review of the facilities detailed census report dated 6/5/26 revealed a resident census of 45.Daily Nurse Staffing Information dated 6/6/26 revealed a resident census of 46. Review of the facilities detailed census report dated 6/6/26 revealed a resident census of 48.Daily Nurse Staffing Information dated 6/7/26 revealed a resident census of 46. Review of the facilities detailed census report dated 6/7/26 revealed a resident census of 48.Daily Nurse Staffing Information dated 6/8/26 revealed a resident census of 48. Review of the facilities detailed census report dated 6/8/26 revealed a resident census of 47.Daily Nurse Staffing Information dated 7/1/26 revealed a resident census of 44. Review of the facilities detailed census report dated 7/1/26 revealed a resident census of 43.Daily Nurse Staffing Information dated 7/2/26 revealed a resident census of 44. Review of the facilities detailed census report dated 7/2/26 revealed a resident census of 43.Daily Nurse Staffing Information dated 7/3/26 revealed a resident census of 43. Review of the facilities detailed census report dated 7/3/26 revealed a resident census of 42.Daily Nurse Staffing Information dated 7/4/26 revealed a resident census of 44. Review of the facilities detailed census report dated 7/4/26 revealed a resident census of 42.Daily Nurse Staffing Information dated 7/6/26 revealed a resident census of 44. Review of the facilities detailed census report dated 7/6/26 revealed a resident census of 45.Daily Nurse Staffing Information dated 7/9/26 revealed a resident census of 45. Review of the facilities detailed census report dated 7/9/26 revealed a resident census of 44.Daily Nurse Staffing Information dated 7/12/26 revealed a resident census of 45. Review of the facilities detailed census report dated 7/12/26 revealed a resident census of 46.Daily Nurse Staffing Information dated 7/13/26 revealed a resident census of 45. Review of the facilities detailed census report dated 7/13/26 revealed a resident census of 46.Daily Nurse Staffing Information dated 7/15/26 revealed a resident census of 46. Review of the facilities detailed census report dated 7/15/26 revealed a resident census of 45.An interview was conducted with the Director of Nursing (DON) on 7/16/26 at 11:27 a.m. The DON explained that the Social Worker (SW) would send the resident census that was created the previous day at midnight to a member of the leadership team. The DON also explained that a bed hold could sometimes cause a discrepancy in the resident census on the Daily Nurse Staffing Information. The overnight nurse was responsible for posting the Daily Nurse Staffing Information including the resident census. Any changes that needed to be made to the Daily Nurse Staffing Information were to be completed by the Medical Records Coordinator.An interview with the Social Worker on 7/16/26 at 1:27 p.m. revealed she was responsible for completing a daily report which included resident bed hold information. She was unsure if the report she sent to the Administrator and DON was included in the resident census on the Daily Nurse Staffing Information. An interview with the Medical Records Coordinator on 7/16/26 at 12:08 p.m. revealed the night shift nurse was responsible for posting the Daily Nurse Staffing Information. The Medical Records Coordinator further revealed if the night shift nurse did not post the Daily Nurse Staffing Information, she would post it. She explained she would make any changes to the resident census but rarely ever had to. During a follow-up interview with the Medical Records Coordinator on 7/16/26 at 3:39 p.m. she revealed before today's date she had not been updating the daily resident census on the Daily Nurse Staffing Information. An interview with Administrator on 07/16/2026 1:37 p.m. revealed he was not sure of the process of updating the resident census on the Daily Nurse Staffing Information when there were admissions or discharges. During interview with night shift Nurse #4 on 7/16/2026 at 2:46 p.m., she revealed she completed and posted the Daily Nurse Staffing Information according to the midnight census. She stated she obtained the resident census by counting all residents in each hallway.

Based on record review, and staff and physician interviews, the facility failed to administer medications as prescribed by the physician for resulting in significant medication error for 1 of 5 residents reviewed for unnecessary medications (Resident #25). The findings included: 1. Resident #25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included hypertension (HTN), history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, paroxysmal atrial fibrillation and nonrheumatic aortic (valve) stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and peripheral vascular disease. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was moderately cognitively impaired and had a diagnosis of hypertension. The annual MDS 5/29/25 was still in progress. Physician order dated 2/4/25 revealed administer Resident #25, Hydralazine HCI oral tablet 50 milligrams (mg). Give 50 mg by mouth every 8 hours as needed (PRN) for HTN give for systolic blood pressure (SBP) greater (>) than 160. Hydralazine is a medication used to treat high blood pressure and heart failure. Review of physician order dated 2/4/25 dated hydralazine HCI oral tablet 50 mg by mouth three times a day. a. Resident #25's blood pressure (BP) was reviewed in the electronic medical record which revealed a SBP of 169 on 3/22/25. Resident #25's blood pressure was taken by Nurse #3. Review of the Medication Administration Record (MAR) for the Month of March 2025 revealed the MAR was left blank on 3/22/25. Nursing progress notes for the month of March 2025 did not indicate if Resident#25 was administered the PRN hydralazine or not on 3/22/25. The nursing notes did not reveal Resident #25's blood pressure was rechecked for a SBP > or < 160. Interview with Nurse #3 on 6/4/25 at 1:26 pm revealed Resident #25 had heart medication that was PRN if his SBP was more than 160. She indicated if his blood pressure was 169 on 3/22/25 she should have provided the PRN medication. If there was no nursing note, it could have been because she rechecked the BP and it was lower. She further stated she could have also gotten busy and not completed a nursing note to state it had lowered. Nurse #3 revealed she would have also notified the oncoming nurse to monitor Resident #25 and recheck his BP due to fluctuations. b. Resident #25's blood pressure for 4/10/25 was reviewed in the electronic medical record. The blood pressure log revealed a SBP of 164 taken by Nurse #8. Review of the MAR for the month of April 2025 was left blank for 4/10/25. Nursing progress notes for the month of April 2025 did not indicate if Resident#25 was administered the PRN hydralazine or not on 4/10/25. The notes did not indicate Resident #25's BP was rechecked for a SBP > or < 160. Nurse #8 was out of the country and unavailable for interview. c. Resident #25's blood pressure was reviewed in the electronic medical record. The BP log revealed a SBP of 163 on 5/2/25 BP taken by Nurse #4, SBP of 162 on 5/8/25 taken by Nurse #5, SBP of 190 on 5/22/25 taken by Nurse #6 and SBP of 175 on 5/23/25 BP taken by Nurse #7. Review of the MAR for the month of May 2025 revealed it was left blank on 5/2/25, 5/8/25, 5/22/25 and 5/23/25. Nursing progress notes for the month of May 2025 did not indicate if Resident #25 was administered the PRN hydralazine on 5/2/25, 5/8/25, 5/22/25 and 5/23/25. The nursing progress notes did not indicate if Resident #25's BP was rechecked for a SBP > or < 160. Interview and observation of the MAR with Nurse #4 on 6/4/25 at 9:45 am revealed she passed medications to Resident #25 on 5/2/25. Nurse #4 stated there was nothing in the electronic system that would prompt the nurse to look at BP if it was higher than 160. Resident #25's BP would fluctuate easily so she would typically recheck the blood pressure herself. Resident #25 was on a standard dose of hydralazine 50 mg that he took three times a day which worked with Resident #25's BP. She further indicated if she had rechecked Resident #25's blood pressure she would have included it in a progress note. Nurse #4 indicated it would depend on the time she took the resident's blood pressure if she would have provided the PRN medication. Interview with Nurse #5 on 6/4/25 at 1:16 pm revealed she recalled working with Resident #25 on a couple of occasions. She stated when a nurse gave a resident a PRN medication, it should automatically generate a nurse's note. If she had not given the PRN there wouldn't be a nursing note. Nurse #5 stated she gave the medication, but she may have forgotten to sign the MAR. Interview with Nurse #6 on 6/4/25 at 7:55 pm revealed she was currently on shift and reviewing the MAR for Resident #25 for 5/22/25. She stated Resident #25's SPB was higher than 160 and she should have followed the physician order and administered Resident #25's PRN Hydralazine HCI. She stated she should have rechecked it to be sure and then given the PRN if the BP was still running high, and also report the high blood pressure to the resident's physician. She did not recall Resident #25 having any complications due to his SBP reading 195. An interview was attempted with Nurse #7. She was unavailable for an interview. Interview with the Director of Nursing (DON) on 6/4/25 at 10:11 am revealed she expected the nursing staff to follow physician orders as written. Upon observation of the MAR for the months of March 2025, April 2025 and May 2025, the DON stated the order for Hydralazine HCL PRN was not discontinued and should have been given when Resident #25's SBP was higher than 160. Interview with Resident #25's Physician on 6/4/25 at 11:50 am revealed he would expect the facility to administer medications as he prescribed. If the medication was not administered as written he would further expect the nursing staff to document the reason why the medication was not provided. He further stated a systolic blood pressure of 195 could lead to a stroke or possible heart attack. Had he been contacted regarding Resident #25 a systolic blood pressure that was greater than 160 he would have advised the nurse to administer the PRN hydralazine he prescribed.

Based on record review, observations, and staff interviews, the facility failed to discard the expired medications stored for use in 1 of 5 medication carts (300 Hall Medication Cart) reviewed for medication storage. The findings included: An observation of the 300- hall medication cart with Nurse #2 on 6/5/25 at 9:48 AM revealed three 16-ounce Children's Acetaminophen Oral Solution with an expiration date of 9/24/2024 on the pharmacy label and one, one-pint bottle of Chlorhexidine Gluconate 0.12% Oral Rinse was opened with no expiration date on the bottle or label. Nurse #2 was interviewed at the time of the observation and revealed she was not aware of the expired bottles of medication and the medication bottle with no expiration date. Nurse #2 stated expired medications or medications without an expiration date should not be in the medication cart. She further stated the expired medications and medication without an expiration date would be discarded. An interview was conducted with the Director of Nursing (DON) on 6/5/25 at 11:38 AM. The DON stated a pharmacy technician would perform medication cart audits monthly for expired medications. She also stated the night nurses were expected to check the medication cart for expired medications weekly. The DON revealed there was not a designated day of the week when nurses were expected to check the medication cart for expired medication. She further revealed expired medications were discarded in a drug buster (a product that facilitates the safe and eco-friendly disposal of unused or expired medications). The DON indicated there should be no expired medications in the medication carts and was not sure how the expired medications were missed and left in the cart. Lastly, she stated everyone was accountable for ensuring no expired medications were left in the medication cart. The Administrator was interviewed on 6/5/2025 at 11:45 AM. He stated medication carts were checked for expired medications weekly on night shift. He stated there was no designated day of the week for medication carts to be checked. The Administrator noted the pharmacy representative would audit the medication carts monthly for expired medications. He revealed expired medications were returned to the pharmacy or were disposed of in a secure medication disposal device. The Administrator further stated no expired medication should be in the medication carts. He noted there was a night shift audit failure since the pharmacy had not yet done the monthly audit.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan that included interventions for high-risk medications for 1 of 5 residents (Resident # 25) reviewed for unnecessary medications. The findings included: 1. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included hypertension and paroxysmal atrial fibrillation and nonrheumatic aortic (valve) stenosis. Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was moderately cognitively intact, was prescribed an anticoagulant (blood thinning medication) and had a diagnosis of hypertension (HTN) and paroxysmal atrial fibrillation. a. Physician order dated 2/4/25 revealed Resident #25 was prescribed Eliquis (anticoagulant) oral tablet 5 milligrams (mg) two times a day for atrial fibrillation. Medical record review revealed Resident # 25 had no care plan with interventions for the use of Eliquis. Review of Resident #25 medication administration record (MAR) for the months of March 2025, April 2025 and May 2025 revealed Resident #25 was administered Eliquis 5 mg 2 times a day. b. The Physician order dated 2/4/25 revealed administer Resident #25 Hydralazine HCI oral tablet 50 mg 3 times a day for hypertension. Further review of the physician orders revealed hydralazine HCI oral tablet 50 mg. Give 50 mg by mouth every 8 hours as needed (PRN) for HTN give for systolic blood pressure (SBP) greater (>) than 160. Review of the MAR for the months of March 2025, April 2025 and May 2025 revealed Resident #25 was administered Hydralazine HCI tablet 50 mg three times a day for hypertension. Review of the medical record revealed there was no care plan for hypertension with the use of Hydralazine HCI oral tablet 50 mg 3 times a day or the use of Hydralazine HCL PRN if SBP > 160. The interview with the MDS Coordinator on 6/4/25 at 9:31 am revealed he would develop an individualized care plan for high-risk medications to include Resident #25's use of an anticoagulant. He further indicated the facility had a change in electronic medical records provider in February 2025. Resident #25 did not have a care plan for the use of an anticoagulant, and he must have missed creating the goals and interventions when transferring care plans to the new electronic medical record. An interview with the Director of Nursing on 6/4/25 at 10:11 am revealed Resident #25's use of an anticoagulant should have been care planned. The care plan should include monitoring for high-risk medications and interventions.

Based on record review and staff interviews the facility failed to develop a documented water management plan that included an assessment to identify were Legionella and other waterborne pathogens could grow and spread and what control measures were in place. This had the potential to affect all residents in the facility. Findings included: A review of the infection prevention and control program policy dated October 2018 revealed no documented water management plan. During an interview with the Maintenance Director on 2/10/23 at 11:44 am it was revealed the facility did not have a plan in place to assess and or monitor for Legionella and other opportunistic waterborne pathogens. He stated he checked the water temperatures and was not aware of the regulation to have a water mangagment plan in place. An interview was conducted on 2/10/23 at 11:54 am with the Administrator and he indicated he was not aware there was not a plan in place for a water management plan. An interview was conducted with the Invention Preventionist on 2/10/23 at 12:28 pm and she indicated they had not had any case of a resident with legionellosis.

Based on record review and resident and staff interviews, the facility failed to safely transfer a resident off the bus via the lift and failed to have a licensed health care professional assess the patient before standing the resident up after a fall for 1 of 3 sampled residents (Resident #13) reviewed for supervision to prevent accidents. Resident #13 fell back into the bus while attempting to transfer onto the lift and she sustained a bruise to her left upper arm and increased back pain as a result of the fall. Immediate jeopardy began on 3/19/18 when Resident #13, fell on the bus after attempting to transfer onto the lift. Resident #13 was assisted up by Driver #1 and sustained bruise to the left upper arm and back pain as a result of this fall. Immediate jeopardy was removed on 5/3/18, when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D' (no harm with the potential for more than minimal hard that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: The operational manual dated 3/2010 for the Braun century 2 series lift stated that for standees: lift operating instructions apply to wheelchair passengers and standees. Standees should stand in the center of the platform (fully inside the yellow boundaries) and grip both handrails (if able) when on platform. Resident #13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #13 annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident was cognitively intact. The resident had no moods or behaviors and required supervision with the assistance of one person for bed mobility, transfers, walking in the room, eating, toilet use, personal hygiene and locomotion. The resident required limited assistance with dressing. The resident was steady at all times when moving from the seated to standing positon, walking, turning around, with surface to surface transfers and moving on and off the toilet. The resident used a walker and was always continent of bowel and bladder. The resident had not had a fall since admission. A care plan last updated 3/19/18 for falls revealed that resident #13 would be placed in a transport wheelchair to get on bus lift and assisted to a seat on the bus. An incident report dated 3/19/18 stated that the incident occurred on 3/19/18 at 7:00 PM. The report revealed that the resident had a fall due to equipment failure. Resident #13's vitals were taken. Per the incident report, the event occurred outside the premises at the clubhouse and was a self-reported fall. The incident report stated that the resident was being assisted to get off the bus according to the member. The incident report also stated the resident was getting off the bus lift ramp. The resident did not have any cognitive impairment. The note on the incident report stated that resident #13 was standing on the bus lift ramp and the lift ramp, instead of going down, went up and threw the member backward and she ended up on the floor and hit her back. No injury was noted at the time of the assessment or pain. The root cause analysis revealed that contributing factors included environmental factors. A skin assessment was completed and no injury was noted at the time of fall but a bruise was noted 2 hours later to the left upper arm. The Director of Nursing (DON) was notified on 3/20/18 at 7:00 AM. The physician was notified on 3/19/18 at 9:00 PM and power of attorney was notified on 3/19/18 at 9:00 PM. The incident report also stated the resident was out for an event at the clubhouse and had an accident on the bus. The interventions according to the incident report included (1. Any ambulatory member will be placed in transport wheelchair to get in a lift and put in a seat on bus. 2.) There was ongoing training of staff in transportation department. The incident report also revealed that Resident's #13 X-rays were negative. A nursing note dated 3/19/18 revealed that a bruise noticed on member's left upper arm and may be caused by the fall member had when she went over to the clubhouse for War World II lecture. According to member, when she was getting off the bus, the lift platform ramps moved upward instead of downward and caused member to fall. Fall on her back and back assessed, no bruises noted and member states: I known I had a fall but my body does not feel like I had one for now but if I feel the pain at night I will call for medicine. Member declines pain to her left upper arm. Will monitor member through the night if pain occurs then will notify medical doctor for X-rays if needed. Family notified also. Member had 400 milliliters (ml) of fluid and total of the day was 860 ml. Member is currently sleeping with call bell at fingertip and will continue monitor. A skin check dated 3/19/18 revealed that the resident had a bruise to her left upper arm that was reddened and measured 10 centimeters (cm) x 7.5 cm. Review of the resident's Medication Administration Record [REDACTED]. Resident #13 also received 50 milligrams of [MEDICATION NAME] (a medication for pain) on 3/20/18 at 12:17 PM for back pain, which included signs of bracing and grimacing with a pain level of 10. An X-ray report dated 3/20/18 revealed that the resident had an X-ray of her lumbar spine and revealed that the resident had a Levoscoliotic alignment (a spine abnormality) of the lumbar (lower) vertebrae. The lumbar vertebral bodies showed [MEDICAL CONDITION] osteophyte spurring (boney projections). There was also an osteoporotic compression involving the L2 vertebrae. The age of the compression is old or undetermined. Another set of X-rays dated 3/26/18 showed an age-indeterminate compression deformity of the lumbar [MEDICATION NAME] spine. The conclusion revealed a compression deformity. The resident was interviewed on 04/30/18 at 10:49 AM. She stated they were not sure if she broke her vertebral or if it was an old fracture. She stated that she had a fall from the bus. She stated that her back was fine now and that it was just a human error. She stated that on 3/19/18, the controller pressed the wrong button on the standing lift and flipped her backwards off. She stated the facility gave her Physical Therapy. Nurse #1 (nurse on 3/19 from 3:00 PM to 11:00 PM) was interviewed on 4/20/18 at 3:40 PM. She stated residents were going to the clubhouse for a meeting on World War II. She stated that resident #13 told her that she was on the ramp and the ramp went backwards instead of down and threw her back inside of the bus. She stated the resident stated she was standing on the ramp with the walker. She stated the receptionist called the nursing home and asked for a nurse to come over. When she went there, Resident #13 was sitting in the lobby in a chair at the clubhouse with the receptionist. The nurse stated that she started range of motion and a pain assessment. She stated that she asked the resident if she was in pain and the resident was able to move. She offered to take the resident back (to the nursing home) but the resident stated that she was ok and denied pain. The resident went to the World War II event and when she came back, the nurse stated that she did another full assessment on the resident after the event. The resident got back to the facility around 8:45 PM and the event happened around 7:00 PM. She stated that when she got to the clubhouse, that the bus had already left. She stated she was not sure who was on the bus. She stated she was also not sure who helped the resident up but the receptionist was the one providing her with the information. She stated that she never saw the driver of the bus. The nurse added that they did order an X-ray a day after the event because the resident's family stated that resident #13 may have stated that she was not having pain because she wanted to go to the World War II activity. The day the event occurred, Resident #13 did not have pain but the next 2 days, the resident was complaining of pain in her back. The nurse stated that she was not working the day the resident starting having pain but had heard this. An X-ray was ordered and came back negative. Nurse #1 also stated that the receptionist did not see the event or how the resident got off the bus. The resident only told her that the lift had thrown her back. She reported the incident to the nurse manager, DON, family and physician and completed an incident report and nursing note. She stated that Resident #13 was alert and oriented to time, person, place, time and situation. The resident did have a vision deficiency but could ambulate short distances. She stated that for residents who can stand, it is usual for residents to stand in order to use the lift. She stated that the clubhouse was located inside the community right when you enter the gait. The Director of Transportation was interviewed on 5/1/18 at 8:53 AM via phone. He stated that on 3/19/18, Driver #1 was driving from 4:00 PM to 9:00 PM. He said that he heard that resident #13 was on the bus lift and the lift jerked when the resident was on it. He stated that he didn't think that the resident fell but that it just scared the resident. He stated that the incident was reported to him the next day because it occurred in the evening when it happened. The staff member was working less now because of this event. Driver #1 was interviewed on 5/1/18 at 10:00 AM. He stated he was the driver and he had picked the resident up at the nursing home and was getting ready to drop her off and let the lift down. He stated that after the event they (staff) called the nursing home and the resident was ok. He stated that the lift was for residents in wheelchairs and would lifted residents up and down to get on the bus. The resident said she could not use the stairs and the only way to get her on and off the bus was to use the lift. He stated the resident would walk on the lift, be lifted and then walk onto the bus. He stated that she was getting on the lift and was heading to the lift area when she fell backwards inside the bus. He stated that he helped her up and asked her if she was ok. He added that no other residents were on the bus at that time. He stated that the resident was heading towards the lift and her walker was on the lift but she was not yet on it. He stated that there was a controller to the lift that controlled the lift. The controller could move the lift up, down, flat, and unfold. He stated that the lift was flat when the resident was going to walk on it. He stated that he had the controller in his hand when her walker was on it. He stated that after she fell , he ran in the bus and asked her if she was ok and she said that she was ok. He stated that he lifted her up after she fell and the resident grabbed her walker and continued to walk on the lift. At that point, the resident was placed back on the lift, lifted down and went to the World War II event. He stated he stuck around till the nursing home came but he stated that he wasn't sure who came. He added that it took the nursing home about 5 to 10 minutes to get there. After they said everything was fine, he stated that he left. He stated that the nursing home's golf cart was noted to come to the clubhouse but he stated that he did not talk to any staff from the nursing home and didn't go inside the clubhouse after the incident. The resident just walked in the clubhouse and kept insisting that she was fine and didn't want the nursing home to get involved. He stated that Nursing Assistant #1 was on the bus and insisted that the resident be checked out. He stated that he reported the event to the Director of Transportation the next day because it happened at night. He stated the event happened around 7:25 PM. He stated that he was to contact someone about any kind of fall and that he contacted his director. The Director of Transportation was interviewed again on 5/1/18 at 10:03 AM. He stated that the driver would put residents on the lift. There was a transport chair and any resident transported would sit in the transport chair and the lift would be lowered to the ground. Then the driver would get on the lift behind the resident. If a resident had a walker, then the walker would be placed on the bus. Then they would put the walker outside of the bus and would lift the member down in the transport chair with the lift and help the resident to the walker. He stated that staff undergo training on the lift when they start here. He said that he didn't think this resident actually fell but heard the lift shook or something. It was not reported to him how the resident was being transported during the incident. If a resident fell then they would have to fill out an incident report and the driver would call him. They would also have to get a nurse from the nursing home to assess the resident if a resident had a fall as they are not allowed to touch the resident. The Administrator stated on 5/1/18 at 2:17 PM that he talked to Resident #13 the day after the event and received a PERS (personal emergency response system) email about the incident. The Corporate Consultant was interviewed on 5/1/18 at 2:17 PM. He stated he thought the resident, driver and other staff members all had a different story. He stated the resident had a history of [REDACTED]. The Activities Director was interviewed on 5/1/18 at 3:26 PM. She stated that resident #13 and another resident went to the World War II presentation. She stated that she was not here when the resident left for the activity. The bus would have picked up the residents around 7:00 PM or 7:15 PM and the event was about an hour and a half long. The Administrator was interviewed on 5/1/18 at 4:05 PM. He stated he talked to the resident after the incident and thought they had completed some in-services and would look for them. He stated they also got an X-ray of resident #13 from a nursing standpoint. The Administrator was interviewed on 5/1/18 at 4:47 PM. He stated he interviewed the resident the day after the event and she stated that she was coming back from an activity. He stated that the resident stated that the bus lift was in the up position and she was standing on it when getting off the bus. The resident stated she fell on the bus. He stated that he didn't ask her about pain. He stated that they provided the buses with transport chairs now as they didn't have them before. The administrator stated that he had made a timeline of events that happened for the incident today. The receptionist was interviewed on 5/1/18 at 4:56 PM. She stated that there was World War II lecture and the resident came to the clubhouse around 7:00 PM. The receptionist stated that she was inside the clubhouse building. When the resident got off the tram (she was referring to the bus) another resident stated that the resident fell backwards and hit her head. She stated that the resident walked in the clubhouse and she called the nursing home. The nurse from the nursing home came up and did a complete assessment on the resident. She stated that she could not remember the name of the resident that reported the fall to her. The resident told her that when the door opened and the lift was going down, the lift went up instead of down and she fell . She stated that she sat with the resident for about half an hour and around 7:45 PM, the resident went to the lecture. She stated that the resident was walking with her walker. She stated that she would have not known that the resident had a fall unless she was told by the other resident. The driver came in the clubhouse after he was done with his rounds and she told him that resident #13 had reported to her that the lift went up instead of down, which caused her to fall. The driver stated that he did not recall this. She stated there was also a nursing aid that was caring for another resident on the bus. She added that the nurse did a thorough job of assessing the resident and no pain was noted. An observation (Driver, Administrator, Corporate consultant, human resources staff were all present) was made on 5/1/18 at 5:15 PM of the mini bus (The bus involved in the incident). The bus was E-350 Superduty Ford. A metal piece (ramp) from the lift on the bus was observed to unfold from an upright to a horizontal position when the unfold button was pressed when the lift was in the up position and parallel to the bus. The metal flap (ramp) was then observed to fold up and the lift went back down to the ground (for residents to exit onto the bus). The down button was pressed and held and the lift dissented down to the ground then the unfold button was pressed as the metal ramp would unfold again. The lift appeared to be functioning properly according to the manufacturer's instructions. The lift also had a belt with a latch across it and there was 2 handles on each side of the lift. The lift was controlled via a small electronic hand held remote that the driver used, which was functioning properly. Driver #1 stated on 5/1/18 at 5:15 PM that he would unfold the lift, then the resident would get on the lift and the lift would go down and that he would control the lift via the remote. He stated that he would tell the resident to come on the lift and this resident was standing with the walker. He stated that the only thing the residents have to hold onto is the walker when they get on the lift. He stated resident #13 was coming on the lift and when he turned around and saw her go backwards and saw her on the floor of the bus. He stated he got on the bus and the resident said she was fine and he helped her up. He stated that the resident did not want to go back to the nursing home. The resident then walked back on the lift and was brought back down to the ground with the lift. He stated that there was no issue with the lift going in the wrong direction (up or down) when she fell . He stated that he thought the resident was standing on the 1st metal panel of the lift (the ramp) and the walker was on the lift (he pointed to the middle part of the lift) He stated now they use the wheelchair for residents who have walker and would strap them in the wheelchair, secure them with the seatbelt and that a staff member would ride with the resident on the lift. The Corporate Consultant was interviewed on 5/1/18 at 5:15 PM. He stated they heard there was a nursing assistant present and saw the event. He stated that now the bus had a wheelchair in place for residents that used walkers that it was implemented about a month ago. The Director of Transportation was interviewed again on 5/1/18 at 5:15 PM. He stated that the drivers were in-service on proper use of the lift. He stated that he had documentation of this. He stated there was no incident report filled out for this incident and there should have been but the resident was assessed by the nursing home after the incident, which may have been why an incident report not been completed. The Human Resources staff member was interviewed on 5/1/18 at 5:15 PM. She stated upon hire and annually that safety training was completed for the drivers. Nursing Assistant #1 was interviewed on 5/2/18 at 10:18 AM. She stated that she was caring for another resident when she was on the bus. She stated that she was standing next to the driver's door outside with the resident she was caring for and resident #13 was waiting for the bus lift inside the bus when she heard something (she demonstrated a loud thump on the table). She stated that she ran inside the bus. Resident #13 was sitting on her buttock and was holding the walker in her hands. The resident's head was not on the ground and the resident was just sitting on the floor of the bus. The resident did not scream or make a noise. The lift was in the up position as it was going to lift the resident down. She stated that the resident could walk. She stated that she didn't hear noises or anything from the lift before the resident fell . The resident had a regular walker with wheels on it. The driver came on the bus too and the resident got up. She stated she was not sure how the resident got up but she thinks it was combination of the resident getting up on her own and help from the driver. Then the resident got back on the lift and it took her down. Then the resident walked on her own into the entry of the clubhouse. The NA stated that she got off the bus and told the resident that she had to be checked out by the nursing home. She stated that she followed the resident inside the clubhouse and she told the receptionist about what had happened to the resident. The resident did sit down with the receptionist and the receptionist called the nursing home. She stated that she told the receptionist to call the nursing home because Resident #13 needed to be checked out. She stated that she didn't hear a jerking sound or anything from the lift. The driver helped the resident back on the lift and resident #13 stood on the lift to get off the bus. She thought there was a way the resident was secure on the lift but couldn't exactly describe it. After the resident was walking towards the clubhouse, the driver starting helping the other residents that were on the bus. The resident was insisting that she was fine and that she was going to dinner. The resident did not say anything to her about why she fell . An observation of the Mini bus was made on 5/1/18 at 10:55 AM with the Administrator, Corporate Consultant and Director for Transportation. The lift in the bus was observed to go up, down, fold and unfold when the corresponding buttons on the remote were pressed. The buttons on the hand held remote had to be held down continuously in order for the lift to operate when moving up, down, folding and unfolding. The lift did not move when the buttons were not pressed. A safety feature was observed for the lift when the lift was in the up position and the director of transportation was standing on the ramp part of the lift. The lift alarmed when the buttons were pressed on the hand held remote and the lift would not move up or down when the director of transportation was standing on the ramp part of the lift. The Director of Transportation was interviewed on 5/2/18 at 10:55 AM. He stated when the lift buttons are pressed and held, the lift would go up and down but when you stop pushing the buttons on the remote, the lift would not move. He stated that all the buttons worked on the hand held remote. He stated that the ramp of the lift will go up when the down button on the remote is pressed. The lift has a safety function when you are standing on the yellow ramp that keeps the lift from going up or down and will alarm. He stated that there was no way for the lift to go down if the resident was standing on the ramp due to this safety feature. He stated there was no way the lift could have moved if the resident was standing on it as it would have alarmed and locked up. He stated that the belt was used to secure residents that were standing but residents were not allowed to stand on the lift anymore. He stated that he was notified in a fine amount of time (the next day) about the incident and that he inspected the lift the next day and tested it. He stated that he did not find any problems with the lift. The Corporate Consultant was interviewed on 5/2/18 at 10:55 AM. He stated he thought that they had provided everything (information) they were able to provide. He also added that he thought the resident lost her balance and fell backward and was not on the lift. NA #1 (NA that was a witness to the incident) was interviewed again on 5/2/18 at 11:36 AM. She stated she was standing outside beside the passenger's door near the front of the bus just before the entry door of the bus. She stated that the resident was inside the bus and was not on the ramp or on the lift. She stated that she could see the resident from the window and from the door opening of the bus because there wasn't many seats on the bus and she was tall. The Medical Director was interviewed on 5/2/18 at 11:51 AM. He stated that the resident was methodical and brilliant. He stated that the resident took very good care of herself. The resident could not see and had many retinal hemorrhages. He stated the resident was very smart and very alert and oriented. He stated that he was notified promptly about the fall the resident had. He thought that if the resident was having pain after the fall that they would have checked her out. He thought her X-ray showed an L1 partial compression and he had seen her on Thursday. He stated the resident did not have a lot of pain when he saw her and was doing pretty well. He thought the resident was not going to need any kind of procedure for the compression of the spine. He stated that sometimes residents with a compression of the spine would get X-rays completed to see if the compression happened over time or if it was acute. He stated that they did a second set of X-rays to see if the compression was evolving and it wasn't. The second set of X-rays of the spine didn't show that there was an acute process. The resident had [MEDICAL CONDITION], type 1 diabetes, was elderly and had many risk factors could have caused her compression of the spine. He could not recall if the resident had pain medication ordered after the fall. He stated that he did not recall a formal meeting about the incident but had discussed it with staff at the nursing home. He stated he thinks he was notified about falls really promptly. He stated he does not remember recently that the resident had any acute pain. A service manager for the lift company was interviewed on 5/2/18 at 1:47 PM. He stated the lift was made for wheelchairs but people could stand on it too. He stated that you were not supposed to stand on the lift with a wheelchair but could stand on it with a walker. There was lift belt and handles that should be held onto. The lift belt attached to the lift but would not a snug around the resident. The resident was interviewed again on 5/2/18 at 2:37 PM. She stated that she was totally blind in her right eye due to a hemorrhage [AGE] years ago. She stated that she was independent with getting around with the walker but the only thing that she cannot do it put her compression stocking on and the aids helps her. She stated she was standing with the walker and the breaks on the walker were locked. She stated that she was standing on the ramp part of the lift, where you get on, and her walker was also on the ramp part of the lift and she was thrown back. She stated that she was holding onto the walker and it fell back on her as she was holding it. She bruised her left upper arm and her back had a spot where it was bruised. She stated that she had back pain for a short time after the fall; maybe for a couple of weeks. She stated that the driver helped her stand and then got on the lift to get her off the bus then she walked inside the clubhouse. She stated that the nurse from the nursing home came and checked her out. She stated that her blood sugar was not low and she sat in the clubhouse for an hour then watched the World War II lecture. She stated she took some Tylenol (a medication for pain) before she went to bed that night. She stated that she had previously broken her sacrum in 2014. She stated that the last time she rode on the bus, she took the steps to get in the bus and her walker was taken inside the bus. Nurse #1 was interviewed on 5/2/18 at 3:18 PM. She stated that the resident told her that the ramp of the lift threw her back so she put Equipment malfunction on the incident report because she didn't see another option. She stated that she did check the resident's blood sugar when she assessed the resident at the clubhouse. Resident #13 denied pain after the assessment. She stated that when Resident #13 got back from the event, the resident told her that she was not having pain but that her mind remembers what happened. She stated that the resident came back around 8:45 PM to 11:00 PM and the resident could get Tylenol as needed at night. Nurse #1 was interviewed on 5/2/18 at 3:44 PM. She stated that she did not put in the incident report but that resident's #13 blood sugar was 142 when she assessed her at the clubhouse. The administrator was interviewed on 5/4/18 at 1:50 PM. He stated he would expect for any member to be seated on the lift and was properly secured to the chair and to the lift with the appropriate seat belts. He stated that members that can ambulate safety would use the stairs. The NA would not be operating the controls on the lift. If a resident had a fall then he would want non- clinical members to comfort the resident but not to touch or relocate the member and make sure the member was assessed by a clinical staff member. The Director of Transportation should be notified, the nursing home, the director of nursing and himself. In addition, a PERS (Personal Emergency Response System) email should be sent to all department heads. The facility would do a root cause analysis and the status of the resident fall should be assessed and new interventions should be put in place. He stated that they would follow their protocol for incidences and notify the resident's family. The administrator was notified of Immediate Jeopardy on 5/2/18 at 4:12 PM. On 5/4/18 at 9:31 AM, the facility provided the following credible allegation of Immediate Jeopardy removal. On 03/19/2018 the bus driver transferred three members to the club house utilizing the community 14 passenger mini bus. Around 7:15 PM, Resident #13 was preparing to get off the bus to go to the club house to attend an activity. Resident was able to ambulate with a walker, however needed supervision during ambulation. According to the member statement, Resident #13 got on the lift with her walker. The resident reported that she was standing on the bus lift ramp and the lift ramp, instead of going down, it went up and threw the resident backward and she ended up on the floor and hit her back. The driver helped the resident to stand up, and walk to the lift with her walker. Then, the driver used the lift to get the resident off the bus before being assessed by nursing professionals to rule out injuries. 1. The root cause analysis: The resident was holding onto the walker instead of the handrails on the lift. The bus driver did not instruct the resident to utilize the yellow hand rails per manufacturer's guidelines. Also the bus driver did not instruct the resident to utilize the safety belt that was present on the lift. The nurse responded to a Personal Emergency Response Call involving Resident #13 and evaluated resident. No suspicious injuries were observed or documented at the time of her initial evaluation and resident requested to continue towards venue. A bruise on the left arm was observed five hours later. Member is at risk for easily bruising and bleeding due to eliquis use. During the investigation it was determined that the bus driver training (Per manufacturer's instructions) and comprehension was inadequately documented, however it was observed and verbally reported by the Driver responsible for leading training as complete to ensure resident safety during transition from bus to ground on 02/07/2018. The instructions included proper use of handrails and safety belt to ensure member safety. All new employees receive new hire training prior to working with residents. Despite being adequately trained during general new hire orientation on 02/06/2018 on Cypress Safety and Security, the bus driver did not follow community protocols on 03/19/2018 by moving a member prior to nurse evaluation/assessment. The driver has received comprehensive retraining on 03/20/2018 for transferring residents utilizing the transport chair. o The facility did not conduct a thorough investigation to determine root cause of the resident fall and root cause of why the employee moved the resident before waiting for the nurse to arrive to evaluate resident. Due to the incident occurring on the mini bus and t (TRUNCATED)

Based on record review, observations and staff interviews, the facility's administration failed to conduct an investigation and determine the root cause analysis for a fall for 1 of 3 residents reviewed for accidents. (Resident #13). The failure of administration to address these concerns led to the inability to implement effective interventions to prevent a reoccurrence. Immediate jeopardy began on 3/19/18 when Resident #13 fell and an investigation and root cause analysis was not conducted after the fall. Immediate jeopardy was removed on 5/3/18, when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D' (no harm with the potential for more than minimal hard that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: This tag is cross referenced to 689: Based on record review and resident and staff interviews, the facility failed to safely transfer a resident off the bus via the lift and failed to have a licensed health care professional assess the patient before standing the resident up after a fall for 1 of 3 sampled residents (Resident #13) reviewed for supervision to prevent accidents. Resident #13 fell back into the bus while attempting to transfer onto the lift and she sustained a bruise to her left upper arm and increased back pain as a result of the fall. The Director of Nursing stated on 5/4/18 at 12:19 PM that the nurse would call her for any incident with injury and that she would start an investigation. If it happened over the weekday, the inter-disciplinary team would do a thorough investigation and would focus on the root cause analysis. The Administrator was interviewed on 5/4/18 at 1:50 PM. He stated that the facility would do a root cause analysis and the status of the resident's fall should be assessed and new interventions should be put in place. He stated that they would follow their protocol for incidences and notify the resident's family. The Administrator was notified of Immediate Jeopardy on 5/2/18 at 4:12 PM. On 5/4/18 at 9:31 AM, the facility provided the following credible allegation of Immediate Jeopardy removal. 1. On 03/19/2018 the bus driver transferred three members to the club house utilizing the community 14 passenger mini bus. Around 7:15 PM, Resident #13 was preparing to get off the bus to go to the club house to attend an activity. Resident #13 was able to ambulate with a walker, however needed supervision during ambulation. According to the member statement, Resident #13 got on the lift with her walker. The resident reported that she was standing on the bus lift ramp and the lift ramp, instead of going down, it went up and threw the resident backward and she ended up on the floor and hit her back. The driver helped the resident to stand up, and walk to the lift with her walker. Then, the driver used the lift to get the resident off the bus before being evaluated by nursing professionals to rule out injuries. The root cause analysis: The resident was holding onto the walker instead of the handrails on the lift. The bus driver did not instruct the resident to utilize the yellow hand rails per manufacturer's guidelines. Also the bus driver did not instruct the resident to utilize the safety belt that was present on the lift. The LPN responded to a Personal Emergency Response Call involving Resident #13 and evaluated resident. No suspicious injuries were observed or documented at the time of her initial evaluation and resident requested to continue towards venue. A bruise on the left arm was observed five hours later. Member is at risk for easily bruising and bleeding due to eliquis use. During the investigation it was determined that the bus driver training (Per manufacturer's instructions) and comprehension was inadequately documented however it was observed and verbally reported by the Driver responsible for leading training as complete to ensure resident safety during transition from bus to ground on 02/07/2018. The instructions included proper use of handrails and safety belt to ensure member safety. All new employees receive new hire training prior to working with residents. Despite being adequately trained during general new hire orientation on 02/06/2018 on Cypress Safety and Security, the bus driver did not follow community protocols on 03/19/2018 by moving a member prior to nurse evaluation. The driver has received comprehensive retraining on 03/20/2018 for transferring residents utilizing the transport chair. The facility did not conduct a thorough investigation to determine root cause of the resident fall and root cause of why the employee moved the resident before waiting for the nurse to arrive to evaluate resident. Due to the incident occurring on the mini bus and the bus transfer protocol being changed on 03/20/2018 administration wrongly assumed that the root cause had been determined and therefore failed to follow facility investigative protocol. On 5/2/18 a thorough investigation of the incident which occurred on 03/19/2018 was conducted by the Executive Director, Administrator, Director of Clinical Operations, Nurse Consultants and Director of Survey Compliance which included interviews with the driver, resident #13, and additional witnesses and staff. The Rosewood Health Center had Life Care Services (LCS) corporate resources, to include the Director of Operations Management, Nurse Consultant and Director of Survey Compliance, conduct a review on 05/02/2018 about the standard investigative processes at the Rosewood Health center at the Cypress of Raleigh and identified opportunities for process improvement. We found that event investigation needs to be consistently completed regardless of the location of the incident. Any instances of a Rosewood member accident will be consistently investigated in order to determine root cause. The changes made will ensure that we will consistently conduct a root cause analysis as a part of our investigative process. Those were the missed steps that occurred in the investigative process. Administration prematurely determined corrective action without doing a root cause analysis. 2. It is the practice of the Rosewood Health Center to investigate all member related accidents. All incidents/accidents involving transport will initiate an investigation immediately. The Administrator and Rosewood Nursing Administration were counseled 05/02/2018 by the Director of Operations Management. Life Care Services is the management company for The Cypress of Raleigh and The Rosewood Health Center. On 05/02/2018 Administrator and Nursing Administration were re-inserviced on event investigation, which included root cause analysis, by Life Care Services corporate resources to include the Director of Operations Management, Nurse Consultant and Director of Survey Compliance on Event Investigation. Rosewood leadership including the Director of Clinical Operations, MDS Nurse, Executive Director, Administrator and Nursing Supervisors will participate in a mandatory in-service conducted by LCS Nurse Consultant on 05/03/2018 on proper completion and review of Fall Scene Investigation report. Anyone unable to attend the mandatory in-service will not be allowed to work until they have completed mandatory in-servicing. 3. Administrator or designee will review all incident/accident reports to ensure forms are fully completed and a thorough root cause analysis is also completed. Executive Director of the community will provide oversight of the Administrator to ensure that incidents are being investigated. The Executive Director will audit incident/accident reports for 60 days. Any incomplete incident/accident reports will be investigated. Quarterly (x 2) audit results will be reviewed and discussed during QAPI. Trends and patterns will be tracked amongst the QAPI Committee for feedback and/or recommendations. 4. The Administrator will be responsible for implementing this credible allegation of removal on 5/3/18. The credible allegation was verified on 5/4/18 at 2:00 PM as evidence by administration interviews regarding in-servicing on incident/accident notification, protocols for falls, investigating accidents/incidents and determining the root cause analysis of a fall. Review of on- going in service records revealed that staff present would receive training who did not receive in servicing prior to working.

Based on observations, record review, and staff interviews, the facility failed to store medications as specified by the manufacturer in 1 of 3 medication carts (200 Hall medication cart). The findings included: 1) An observation of the 200 Hall medication cart on 3/22/17 at 12:10 PM revealed an opened bottle of prednisolone acetate 1% ophthalmic suspension eye drops (a steroid medication) was stored in the manufacturer's box lying down on its side in a drawer of the medication cart. The eye drops were labeled for use by Resident #52. A handwritten notation on the bottle of the eye drops indicated it had been opened on 1/8/17. The pharmacy label placed on the outside of the box covered the manufacturer's storage instructions. However, the storage instructions printed directly on the eye drop bottle stored inside the box was visible and read in part, Store in upright position. A review of Resident #52's March 2017 physician orders [REDACTED]. An interview was conducted on 3/22/17 at 12:18 PM with Nurse #1. Nurse #1 was assigned to the 200 Hall medication cart. Upon inquiry, Nurse #1 reported she was not aware of the manufacturer's storage instructions which specified this medication needed to be stored upright. The nurse stated she would need to find another place on the cart to store the medication. An interview was conducted on 3/23/17 at 9:15 AM with the facility's Director of Nursing (DON). The manufacturer's storage instructions for the prednisolone acetate 1% ophthalmic suspension eye drops were discussed. The DON stated she had not been aware of this storage requirement. A follow-up interview was conducted on 3/23/17 at 3:00 PM with the DON. Upon inquiry, the DON stated she expected medications to be stored correctly. 2) An observation of the 200 Hall medication cart on 3/22/17 at 12:10 PM revealed a QVAR aerosol inhaler (an inhaled corticosteroid) 40 micrograms (mcg) per actuation was stored in the manufacturer's box lying down on its side in a drawer of the medication cart. The inhaler was labeled for use by Resident #9 and dispensed from the pharmacy on 1/14/17. Manufacturer storage instructions printed on the box containing the QVAR inhaler read, in part: Store in upright orientation. A review of Resident #9's March 2017 physician orders [REDACTED]. An interview was conducted on 3/22/17 at 12:18 PM with Nurse #1. Nurse #1 was assigned to the 200 Hall medication cart. Upon inquiry, Nurse #1 reported she was not aware of the manufacturer's storage instructions which specified this medication needed to be stored upright. The nurse stated she would need to find another place on the cart to store the medication. An interview was conducted on 3/23/17 at 9:15 AM with the facility ' s Director of Nursing (DON). The manufacturer's storage instructions for the QVAR inhaler were discussed at that time. The DON stated she was not aware of the QVAR inhaler needing to be stored upright and had contacted the facility's pharmacy to inquire more about it. A review of the full prescribing information for QVAR Inhalation Aerosol (revised July 2014) included information on How Supplied/Storage and Handling (Section 16). Section 16.2 on the Storage and Handling of the QVAR aerosol inhaler read in part: Store QVAR Inhalation Aerosol when not being used, so that the product rests on the concave end of the canister with plastic actuator on top. A review of a document from the facility's contracted pharmacy entitled, Recommended Minimum Medication Storage Parameters (last revised 9/29/16) was completed. The document listed Storage Recommendations for a QVAR inhaler which read, in part: .Store the inhaler resting on the concave end of the canister with the plastic actuator on top . A follow-up interview was conducted on 3/23/17 at 3:00 PM with the DON. Upon inquiry, the DON stated she expected medications to be stored correctly. 3) An observation of the 200 Hall medication cart on 3/22/17 at 12:10 PM revealed a QVAR aerosol inhaler (an inhaled corticosteroid) 40 micrograms (mcg) per actuation was stored in a plastic bag lying down on its side in a drawer of the medication cart. This was the second QVAR inhaler stored on the medication cart and labeled for use by Resident #9. The QVAR inhaler was dispensed from the pharmacy on 3/17/17. A pharmacy auxiliary label placed on the plastic bag containing the QVAR inhaler read: Store upright, mouthpiece up. A review of Resident #9's March 2017 physician orders [REDACTED]. An interview was conducted on 3/22/17 at 12:18 PM with Nurse #1. Nurse #1 was assigned to the 200 Hall medication cart. Upon inquiry, Nurse #1 reported she was not aware of the manufacturer's storage instructions which specified this medication needed to be stored upright. The nurse stated she would need to find another place on the cart to store the medication. An interview was conducted on 3/23/17 at 9:15 AM with the facility's Director of Nursing (DON). The manufacturer's storage instructions for the QVAR inhaler were discussed at that time. The DON stated she was not aware of the QVAR inhaler needing to be stored upright and had contacted the facility's pharmacy to inquire more about it. A review of the full prescribing information for QVAR Inhalation Aerosol (revised July 2014) included information on How Supplied/Storage and Handling (Section 16). Section 16.2 on the Storage and Handling of the QVAR aerosol inhaler read in part: Store QVAR Inhalation Aerosol when not being used, so that the product rests on the concave end of the canister with plastic actuator on top. A review of a document from the facility's contracted pharmacy entitled, Recommended Minimum Medication Storage Parameters (last revised 9/29/16) was completed. The document listed Storage Recommendations for a QVAR inhaler which read, in part: .Store the inhaler resting on the concave end of the canister with the plastic actuator on top . A follow-up interview was conducted on 3/23/17 at 3:00 PM with the DON. Upon inquiry, the DON stated she expected medications to be stored correctly.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect the use of an anticoagulant medication administered during the 7-day look back period for 1 of 5 sampled residents (Resident #1) reviewed for unnecessary medications. The findings included: Resident #1 was admitted to the facility on [DATE] with re-entry from the hospital on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] was completed. Section N (Medications) of the MDS did not indicate the resident received an anticoagulant medication at any time during the 7-day look back period. A review of the resident's Medication Administration Record [REDACTED]. An interview was conducted on 3/23/17 at 1:53 PM with the facility's interim MDS Nurse. Upon inquiry, the MDS Nurse reviewed Resident #1's electronic medical record. Upon review of Section N on Resident #1's annual MDS assessment dated [DATE], the MDS nurse reported the assessment should have indicated this resident received an anticoagulant (Xarelto) 7 out of 7 days during the assessment period. The nurse stated the MDS would require modification and reported she would take care of it. An interview was conducted on 3/23/17 at 2:00 PM with the facility's Director of Nursing (DON). During the interview, the coding of medications on Resident #1's MDS was discussed with the DON. When asked, the DON indicated she would expect the MDS assessment to be coded correctly.

Based on record review and observations, the facility failed to post the correct census for 3 of 3 days during the recertification survey. Findings included: The daily staffing hours posting was observed on 3/21/17 during the initial tour at 10:16 AM. The staff hours posting dated 3/21/17 stated the facility's total census was 35 and included the facility's name and hours of the registered nurses, licensed practical nurse, nursing assistants and clinical leader/registered nurse supervisor hours. On 3/21/17 at 10:20 AM, the facility provided a copy of the census for the facility on 3/21/17. The facility's census sheet revealed there were 32 residents on 3/21/17. The unit manager was interviewed on 3/21/17 at 3:28 PM. She stated the Nurse on B hall completed the staff posting and it was updated every shift. The census was based on the number of residents. She stated there were 35 residents. An Interview with the administrator on 3/22/17 at 9:22 AM revealed the census was 32. The daily staffing hours posting was observed on 3/22/17 at 4:00 PM. The staff hours posting dated 3/22/17 stated the facility's total census was 35. The Director of Nursing was interviewed on 3/23/17 at 2:45 PM. She stated the nurse on B hall would fill out the staff posting sheet. She stated the facility's census included 32 residents that were in certified beds for the entire week. The daily staffing hours posting was observed on 3/23/17 at 2:50 PM. The staff hours posting dated 3/23/17 stated the facility's total census was 35. The Director of Nursing was interviewed again on 3/23/17 at 3:11 PM. She stated she would expect for the correct census to be recorded on the posted staffing sheet at the beginning of each shift.