Every finding on record at Treyburn Rehabilitation Center

Based on record review and staff interviews, the facility failed to follow a pharmacy recommendation to discontinue a medication for 1 of 5 residents reviewed for unnecessary medication (Resident #100). Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes and neuropathy.The quarterly Minimum Data Set, dated [DATE] for Resident #100 documented he had an intact cognition. The monthly medication pharmacy review dated 5/21/26 for Resident #100 revealed a documented recommendation to discontinue the Zinc Sulfate 220 milligrams each day. The pharmacist documented that the resident's skin was intact, and the zinc was no longer needed. The recommendation was signed and approved by the Nurse Practitioner (NP) dated 6/1/26.A review of Resident #100's medication orders revealed there was not an order to discontinue Zinc Sulfate 220 milligrams each day. A review of Resident #100's Medication Administration Record (MAR) revealed the resident had documented nursing initials for administration of Zinc Sulfate 220 milligrams each day from 6/1/26 through 6/24/26. On 6/24/26 at 2:10 pm an interview was conducted with the Director of Nursing (DON). The DON stated the pharmacist's recommendation to discontinue the Zinc that was signed/approved by the NP 6/1/26 for Resident #100 was not provided to nursing by the NP. The DON explained that the NP was required to provide any signed recommendation to nursing for the order change. The DON stated the NP gave the Zinc pharmacy order change to be scanned into the resident's chart and not to nursing. The DON was not aware of Resident #100's order to discontinue the Zinc until today (6/24/26) when discussed. The DON further commented that the medication was signed for by nursing staff with initials on the MAR which indicated the Zinc medication was administered from 6/1/26 to 6/24/26. The NP that signed the pharmacy recommendation to discontinue Resident #100's Zinc was no longer working at the facility and was unable to be reached.On 6/25/26 at 1:30 pm the Administrator was interviewed. The Administrator stated he was not aware that Resident #100's pharmacy recommendation to discontinue the Zinc and signed/approved by the NP was not provided to nursing to process the order.

Based on observation, record review and interviews with staff and resident, the facility failed to get the resident out of bed for 3 consecutive days which caused the resident to feel frustrated because he was stuck in bed. The deficient practice affected 1 of 2 residents reviewed for choices (Resident #100).Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes and neuropathy.The quarterly Minimum Data Set, dated [DATE] for Resident #100 documented he had an intact cognition. The resident was dependent for all activities of daily living including transfers.The care plan last updated on 5/14/26 with his assessment documented Resident #100 required assistance with all his activities of daily living. Transfer was by mechanical lift by 2 staff. On 6/23/2026 at 10:18 am Resident #100 was observed and interviewed. The Resident stated he was not assisted out of bed on 6/19/26, 6/20/26, and 6/21/26 and indicated he asked Nursing Assistant (NA) #3 to get him up as usual every morning on 6/19/26, 6/20/26, and 6/21/26. The resident commented that NA #3 had informed him each of the three days that there was no staff to get him out of bed. The resident stated he was frustrated that he was stuck in bed and not having enough staff was not an excuse to not get me out of bed and it was not my fault there was no staff. The resident again stated, that was not my problem. The resident further commented he liked to get out of bed by breakfast time, and he was usually back to his bed for care and dinner in the evening. The resident indicated he was also not assisted out of bed for those 3 days by the evening shift (3:00 pm to 11:30 pm) on 6/19/26 through 6/21/26. Resident #100 recalled he was assisted out of bed on 6/22/26 in the afternoon by the evening shift. On 6/23/26 at 10:40 am NA #3 was interviewed and confirmed she was assigned to Hall 200 where Resident #100 resided on day shift (7:00 am to 3:30 pm) on 6/19/26, 6/20/26, and 6/21/26. NA #3 stated she cared for the resident frequently and was aware that he liked to be out of bed early every morning. NA #3 indicated there were NA staff call outs each of the three days and no replacements when she asked the assigned Nurse #7 about staffing. NA #3 stated the nursing staff decided that the residents would remain in bed so staff would be able to provide care. NA #3 explained there was not enough time to get the residents out of bed and back to bed for care. NA #3 further commented that Resident #100 required mechanical lift by 2 staff and she was the only NA on her hall on 6/19/26 and 6/20. NA #3 confirmed Resident #100 had requested her to get him out of bed each of the 3 days, and he could not be accommodated because there was not the 2 required staff to transfer. NA #3 stated on Saturday 6/20/26 there were 4 NAs for the entire building on day shift and 5 NAs for the entire building on Sunday 6/21/26. NA #3 stated that she had 24 residents to provide care for her assignment on Friday and Saturday. The interview further revealed NA #3 was assigned to the resident on 6/23/26 and she assisted him into his wheelchair right after breakfast. Nurse #7 was assigned to Resident #100 on day shift on 6/19/26 and 6/20/26 and was unable to be contacted for interview. On 6/23/26 at 11:10 am an interview was conducted with Nurse #6 who was assigned to Resident #100 on Sunday 6/21/26 day shift 7:00 am to 3:30 pm. Nurse #6 indicated he was informed by staff that there were 4 NAs in the building 6/19/26 and 6/20/26 for day shift and nursing decided to keep the residents in their beds so staff would be able to provide care. On Sunday, 6/21/26 there were staff call outs and the residents that requested to go to church were gotten up. Otherwise, the remaining residents were left in bed to be able to provide care with the staffing. Nurse #6 further commented that he was informed there was no staff to replace the call outs. On 6/24/26 at 2:10 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was aware there were NA call outs on 6/19/26 through 6/21/26 day shift. The DON was not aware that residents were kept in bed so staff would be able to provide care and that Resident #100 requested to get out of bed and staff was unable to accommodate him.On 6/25/26 at 1:30 pm the Administrator was interviewed. The Administrator stated he was not aware there were nursing staff call outs on 6/19/26 through 6/21/26 and some residents remained in bed during the day for staff to provide care. The Administrator commented that he knew Resident #100 well and the resident would surely make his choice known as he was usually out of bed every day and liked to participate in activities.

Based on record review, staff, Responsible Party, Cancer Clinic Supervisor, Physician, and Oncologist interviews the facility failed to ensure that Resident #93 with metastatic prostate cancer received the medically necessary recommended six-month oncology follow-up appointment for 1 of 1 sampled resident reviewed for medically necessary oncology follow-up services.The findings included:Resident #93 was admitted to the facility on [DATE] with diagnoses that included communication deficit, dementia, and metastatic prostate cancer involving the lymph nodes.The quarterly Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #93 was severely cognitively impaired and had a diagnosis of cancer.Review of the cancer clinic visit dated 6/13/25 revealed Resident #93's documented diagnoses were prostate cancer with intrapelvic lymph node involvement. The recommendations included Resident #93's continuation of maintenance injection therapy and follow-up every six months to monitor the resident's condition, review laboratory studies, including prostate-specific antigen (PSA: blood test used to screen for prostate cancer) levels. Resident #93 received Lupron (hormone therapy used to treat prostate cancer) 45 milligrams (mg) and tolerated the injection well. The next injection is recommended due on or after 11/21/25. Review of the facility appointment record revealed oncology appointments had been scheduled on 12/16/25, 2/3/26 and 2/17/26 with the cancer clinic and Resident #93 did not go to the scheduled appointments. Review of Resident #93's medical record provided by the facility revealed there was no documented evidence that facility staff notified the resident's family regarding the appointment cancellation or the transportation options available for those appointments.A telephone interview was conducted on 6/26/26 at 2:58 PM with the Cancer Clinic Supervisor who stated Resident #93 was last seen in the clinic on 6/13/25. The Cancer Clinic Supervisor stated the clinic received communication from the facility on 12/16/25 that Resident #93 cancelled his scheduled appointment, on 2/3/26 it was documented in the patient portal that the facility cancelled Resident #93's scheduled appointment. The appointment was rescheduled for 2/17/26 and the resident did not show up for appointment. The Cancer Clinic nurse called the facility 2/17/26 to ask if Resident# 93 would be attending the appointment and was told by the facility that the family had cancelled the appointment. The Cancer Clinic Supervisor stated, the nurse at the cancer clinic received communication from the family on 2/18/26 through Resident #93's patient portal that the family had not cancelled the appointment. The family reported the facility was refusing to bring the resident to his appointments and the family could not provide transportation. The facility was canceling these appointments and communicating that they were canceling them on behalf of the family member when that was not in line with what the family wanted. The nurse encouraged the family to contact the facility to reschedule the appointment and if the family needed the clinic nurse to help with getting outside transportation arranged, they would assist. The family did not call back to the clinic after the 2/18/26 conversation about rescheduling the appointment.A telephone interview was conducted on 6/24/26 at 3:05 PM with Resident #93's Responsible Party (RP) who stated the family's primary concern was that Resident #93's recommended oncology follow- up appointments had not been maintained. The RP stated the family had been informed from the clinic on multiple occasions that appointments were cancelled because the family was unable to accompany Resident #93 to the appointments. However, the RP reported that the family expected the facility to transport the resident to the appointment regardless of whether a family member could accompany the resident or not. The RP stated she believed the facility cancelled the appointments because staff were unavailable to accompany Resident #93 to the scheduled appointments. The RP reported that Resident #93's last appointment occurred on 6/13/25, at which time the oncologist indicated the resident was responding well to the prescribed maintenance injections and recommended continued follow-up care. The RP stated the family became increasingly concerned after multiple oncology appointments were missed, she specifically recalled Resident #93 had an appointment scheduled for 2/17/26, and Resident #93 was not transported to the appointment. The RP indicated she had accessed Resident #93's patient portal and found documentation that stated the appointment had been cancelled at the family's request. The RP asserted that neither she nor any other family member requested cancellation of the appointment and disputed the accuracy of that notation by calling the clinic directly and informing them that the family had not cancelled the appointment. The RP indicated the family was concerned that the resident had not been receiving the prescribed maintenance injection for prostate cancer and was uncertain about the current status of Resident #93's condition because the recommended oncology appointment had not occurred. The RP stated the family's expectation was that the facility would schedule, coordinate, and maintain medically necessary oncology appointments on the resident's behalf, including arranging transportation and staff accompaniment when needed, rather than canceling appointments based on staff availability or because family members were unable to attend.An interview was conducted on 6/24/26 at 9:00 AM with the Scheduler who was responsible for scheduling and coordinating residents outside medical appointments, including Resident #93's oncology follow up appointments. The Scheduler explained that when an appointment was scheduled, she notified the resident and the RP of the date, time and location of the appointment and offered the RP the opportunity to accompany the resident to the appointment or meet them at the provider's office. If the RP was unable to attend, the appointment was maintained, and the facility arranged transportation and staff to accompany the resident to ensure the resident received the recommended medical care. The Scheduler acknowledged that she did not have documentation of her conversation with the Resident #93's RP about the cancellation or any requested changes to the appointment.An interview in conjunction with a record review was conducted with the Director of Nursing on 6/25/26 at 11:00 AM and confirmed Resident #93 did not receive the recommended oncology follow up within the time frame established by the treating Oncologist.A follow-up interview was conducted on 6/25/26 at 1:00 PM with the Director of Nursing who stated it was the responsibility of the Unit Manager and nursing staff to review documentation received from outside providers for follow-up appointments, laboratory testing, treatments or other recommendations. The Director of Nursing further stated the Unit Manager and nursing staff were responsible for putting the documentation in the physician communication book. The Director of Nursing acknowledged the recommended follow-up appointment was an oversight, and the facility did not have a specific tracking system in place to ensure appointments were done and recommendations for follow-up appointments from outside providers were consistently monitored and completed as scheduled.An interview was conducted on 6/25/26 at 1:28 PM with the Unit Manager who stated she was unaware that Resident # 93's Oncologist had recommended a six-month follow-up evaluation and maintenance injections for his prostate cancer. The Unit Manager indicated she did not review the recommendations from his last appointment. The Unit Manager stated she was responsible for ensuring that recommended follow-up appointments were documented in the medical record and that appropriate coordination occurred to facilitate those appointments. The Unit Manager stated she did not receive notification from the Charge Nurse or the Scheduler of the appointment for Resident #93. The Unit Manager explained that the facility process was for the Resident and or the family to notify the Charge Nurse when they returned from an appointment so that follow-up appointments could be scheduled. The Charge Nurse then communicated the appointment information to the Scheduler, who was responsible for arranging the transportation and the staff to accompany the resident to the appointment. Following the appointment, nursing staff were expected to obtain and review the specialist recommendations, including any orders for additional treatment, laboratory testing, diagnostic studies, or follow up appointments, and communicate those recommendations to the attending Physician and to a Nurse Practitioner for implementation. The Unit Manager stated that once an appointment was scheduled the Scheduler then contacted the Resident and/or the Responsible Party to provide the appointment date, time, location and offer the Responsible Party the opportunity to accompany the Resident or meet the Resident at the provider's office. The Unit Manager stated that if the Responsible Party was unable to attend, the appointment should remain scheduled, and the facility should arrange transportation to ensure the resident received the recommended medical care. The Unit Manager stated that if an appointment was cancelled or rescheduled by the Resident or Responsible Party, staff should document the cancellation in the medical record, including who requested the cancellation, the reason for the cancellation and the action taken to reschedule the appointment. The Unit Manager stated that unless there was a legitimate reason to cancel or reschedule the appointment should be maintained regardless of whether the resident's family could attend or not.An interview and record review was conducted on 6/25/26 at 2:35 PM with the Regional Nurse Consultant who stated that the residents recommended oncology follow up appointment should have been completed in accordance with the treating specialist recommendations. The Regional Nurse Consultant stated the facility was responsible for coordinating medically necessary specialty appointments and ensuring continuity of the residents' care. The Regional Nurse Consultant further stated that all communication with the residents' Responsible Party regarding cancellation or rescheduling of appointments should be documented in the Resident's medical record. She indicated the documentation should clearly identify the date of the communication, the individual involved, the reason for any cancellation or rescheduling and follow up action taken by the facility. Additionally, the Regional Nurse Consultant stated that when a medically necessary appointment was cancelled or rescheduled, the facility should document the communication held with the specialty provider, confirm the status of the appointment and or ensure a new appointment was scheduled as appropriate. She acknowledged that based on her review of Resident #93's medical record, the documentation supporting communication with the RP and coordination of Resident #93's oncology follow up appointment was incomplete.An interview was conducted on 6/25/26 at 12:45 PM with the facility Physician who stated he was unaware the Oncologist had recommended a six-month follow-up appointment until he was informed by the Director of Nursing on 6/25/26 after learning the appointment had not occurred. The Physician stated that regardless of whether the family cancelled the appointment or was unable to attend the facility should have coordinated the medically necessary oncology appointment on the resident's behalf. The Physician further stated the absence of symptoms did not rule out disease progression and that updated PSA testing and oncology evaluation were necessary to determine the resident's current cancer status.A telephone interview was conducted on 6/29/26 at 2:04 PM with Resident #93's treating Oncologists who stated Resident #93 had a long-standing history of metastatic prostate cancer involving the lymph nodes and had responded to maintenance therapy prior to admission. The Oncologist stated routine follow up every six months was necessary to monitor disease progression, review prostate specific antigen (PSA) results, evaluate treatment effectiveness, and determine whether changes in therapy were warranted. The Oncologist reported he had been informed the appointment on 2/17/26 was cancelled by the family but could not verify that information. The Oncologist further stated that because the recommended follow-up did not occur, he was unable to determine whether Resident #93's cancer had remained stable or progressed. Updated laboratory testing and clinical assessment will be necessary to evaluate Resident #93's current condition. Although, Resident #93 had not demonstrated a confirmed adverse outcome, the oncologist stated the resident still needed to be monitored.

Based on record review and interviews with staff and residents, the facility failed to protect the right of a resident (Resident # 2) to be free of abuse when another resident (Resident # 3), who was experiencing an increase in agitated behaviors while diagnosed with a urinary tract infection, hit Resident # 2 in the head with a reacher. (A reacher is a metal assistive device used to grab items that are out of reach). This was for one of three residents reviewed for abuse and neglect. The findings included: Record review revealed Resident # 3 resided at the facility from 10/29/19 until his final discharge on 12/3/24. Although not inclusive of all diagnoses, Resident # 3 had a history of hip fracture, vascular dementia, and insomnia. Review of Resident # 3's 10/9/24 quarterly Minimum Data Set (MDS) assessment revealed Resident # 3 was moderately cognitively impaired. He was not assessed to have behavioral problems during the assessment period. The resident was coded as using a wheelchair for mobility. On 11/19/24 at 2:59 PM Nurse # 3 documented in a nursing entry the following information. Resident # 3 was yelling and attempting to be combative with staff. He was seen by the PA (Physician's Assistant) who ordered a urinalysis and urine culture. On 11/19/24 PA # 1 documented she was seeing Resident # 3 for increased confusion. PA # 1 noted Resident # 3 thought he was in [NAME], England and a urine specimen would be obtained. On 11/19/24 Resident # 3 was also seen by the Psychiatric PA who documented the following information. Resident # 3 had a history of intermittent confusion. The Psychiatric PA further documented, Was seen today exhibiting aggressive behaviors, increased agitation, and anxiety. He was observed in his wheelchair in the hallway attempting to strike other residents and staff members with his grabber. His behaviors escalated to the point where he was obstructing the hallway, not allowing others to pass. According to the treatment nurse, these behaviors began in the morning during Medpass. Patient mentioned to the nurse about an imminent call from the 'Russians' and urged him to administer his medications quickly as they would be 'shooting at him soon.' After this interaction, he retreated to his room quietly until after lunch, when his behaviors began to escalate again. Throughout the day, patient was seen self-propelling his wheelchair up and down the hallways, appearing very agitated and difficult to redirect. His anxiety, agitation, and aggressiveness continued to escalate to the point where he threw a computer on the floor and was swinging his grabber around. Despite staff's attempts to redirect and de-escalate the situation, patient remained agitated. Patient was eventually guided back to his room where attempts were made to calm him down. He was offered snacks, food, and drinks as a distraction and to help de-escalate the situation. The medical team was made aware of his condition and ordered a urinalysis to check for a urinary tract infection. A one time dose of Ativan was ordered but not used. The Psychiatric PA noted the resident's behaviors could be secondary to worsening dementia or due to a possible urinary tract infection or other type of infection. According to physician orders, a urinalysis and culture were ordered on 11/19/24. On 11/20/24 the resident was ordered to have an increase in his Trazodone (used for depression and insomnia). His dose was increased from 25 milligrams to 50 milligrams at bedtime. On 11/20/24 Nurse # 4 noted at 11:47 PM that Resident # 3 was alert and oriented times three, had experienced a calm evening, and there had been no behaviors. On 11/21/24 PA # 1 documented she saw Resident # 3 for improvement of behaviors and that the resident had slept well. PA # 1 also documented the resident was still confused and reported to her he was looking to catch a flight to the local airport. On 11/22/24 at 8:25 AM Nurse # 5 documented the resident was alert and had slept throughout the night. According to orders the resident was begun on an antibiotic for treatment for a urinary tract infection on 11/22/24 when his urine culture result revealed the resident's urine grew E-coli. On 11/24/24 at 11:28 PM Nurse # 1 documented the resident was on an antibiotic for a urinary tract infection and had hit another resident with a reacher. The other resident had sustained a scratch to his left ear. The Nurse Practitioner was called and orders were obtained to send Resident # 3 to the emergency room According to hospital records, following the incident, Resident # 3 was sent to the hospital and hospitalized from 11/24/24 until 12/2/24. A review of Resident # 3's hospital discharge summary, dated 12/2/24, revealed he had been diagnosed with metabolic encephalopathy, a urinary tract infection, and hyperactive delirium. The hospital discharge summary included information that the resident's delirium improved with treatment for his urinary tract infection. (Delirium is an acute state of mental confusion and disorientation that develops rapidly and usually lasts for a short period. Symptoms can include delusions and agitation.) Nurse # 1 was interviewed on 2/5/25 at 1:11 PM and reported the following information. She had not witnessed the incident when Resident # 3 hit another resident. Nurse # 2 had told her about the incident. Prior to the incident, she did not recall any specific incidents during which Resident # 3 had hit another resident. Review of the facility's investigation into the incident revealed the incident had occurred on 11/24/24 at 9:05 PM and the resident who had been hit with the reacher was Resident # 2. The facility's investigation also included documentation that another Resident (Resident #7) had witnessed the incident. A review of Resident # 2's record revealed Resident # 2's 11/14/24 quarterly Minimum Data Set assessment coded Resident # 2 as cognitively intact and independent in his wheelchair mobility. Resident # 2 was interviewed on 2/5/25 at 8:45 AM and reported the following information. On the date of the incident he (Resident # 2) had been minding his own business and talking to Resident # 7 when for some unknown reason another resident used a grabber and hit him in the head. Resident # 2 reported it had caused a cut on his head but did not bother me too much. Resident # 2 also reported he had to defend himself and therefore he slapped back at the resident who had hit him. Resident # 2 reported Resident # 7 had seen the incident. A review of Resident # 7's record revealed Resident # 7's MDS assessments, dated 10/23/24 and 1/23/25, coded Resident # 7 as cognitively intact. Resident # 7 was interviewed on 2/5/25 at 1:25 PM and reported the following information. On the date of the incident, Resident # 2 had been in her room talking to her. There was another resident who came into her room while Resident # 2 was talking to her. She did not know this other resident's name. The intruding resident had a reacher and said, I am going to hit you with this. She replied, Please do not do that. At that point, Resident # 2 stated he wanted to get out of the room and started to back his wheelchair out of her room. The intruding resident then took the reacher and hit Resident # 2 on the ear and side of his head with the reacher. It made Resident # 2's head bleed where it cut him. She did not recall with certainty if Resident # 2 hit back at Resident # 3 or not. A review of Resident # 2's record revealed an entry by Nurse # 2 dated 11/24/24 at 10:58 PM which read, performed head to toe assessment after an incident with another resident, scratch found on left ear. Resident is alert and oriented X 4. No c/o (complaints) of pain or discomfort. 149/71 (blood pressure), 97.4 (temperature), 17 (respirations), 74 (pulse), 98% room air (oxygen saturation). Level of pain at 0. Nurse # 2 was not available for interview during the survey. On 11/25/24 at 1:40 PM the facility's Wound Nurse documented she assessed Resident #2's ear and observed a scab to the ear with no drainage noted. The Wound nurse further noted Resident # 2 had no complaints of pain at the time. Interview with the Administrator on 2/5/25 at 9:10 AM and again on 2/5/25 at 1:39 PM revealed the following information. Resident # 3 did not have a history of hitting other residents prior to the incident with Resident # 2. He had been diagnosed with a urinary tract infection, was on an oral antibiotic, and was experiencing an acute increase in confusion when the incident occurred. He seemed to be having flashbacks about war and his military service which were distressing to him. It was her understanding that her staff did not see the actual incident but heard the commotion and responded to separate the two residents. They had been trying to monitor and treat the resident when the incident occurred. She thought Resident #2 had slapped back at the reacher to protect himself and may have brushed Resident # 3's hand but he did not hurt Resident # 3. Resident 2's cut was not serious and was cleaned and cared for without any further long term problem. While Resident # 3 was hospitalized they initiated intravenous antibiotics in lieu of the oral antibiotic and this helped resolve his delirium and urinary tract infection. According to the Administrator, the facility had taken steps through their quality assurance program and implemented a corrective action plan. On 2/6/25 the Administrator provided the following corrective action plan. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 11/24/2024 Resident #3 (BIMS 12) struck Resident #2 (BIMS 15) with Reacher. Resident #3 and Resident #2 were immediately separated by staff. Skin check was performed by Nurse #2 on Resident #2 and noted to have a scratch on his left ear. Skin check was performed by Nurse #1 on Resident #3 with no negative findings. Provider notification for both Resident #3 and Resident #2 was completed by Nurse #1. Orders obtained and processed by Nurse #1 to send Resident #3 to the Emergency Department for further evaluation. Nurse #1 notified Resident #3's representative. Nurse #1 notified the Administrator who initiated the investigation. On 11/24/2024 the administrator submitted initial report to Department of Health and Human Services (DHHS) on 11/24//2024 at approximately 10pm. On 11/24/2024 the administrator notified [NAME] Police Department and Adult Protective Services on 11/24/2024 at 9:30pm. Resident #2 was seen by the in-house provider on 11/25/2024 with new orders for triple antibiotic cream to be applied topically daily for 5 days. The Director of Nursing/Designee completed interviews on 11/25/24 with Resident #2 and Resident #7, Resident #2 was visiting at time of incident. Interviews stated that Resident #3 was in hallway behind Resident #2 and when Resident #2 turned around to exit room Resident #3 lifted reacher and struck Resident #2. Nurse #1 was interviewed by the Director of Nursing/Designee on 11/24/2024 and did not witness the incident. Administrator along with the Interdisciplinary Team members (Director of Nursing, Infection Prevention Control Officer, Staff Development Coordinator, Rehab Program Manager and Social Services Manager) held an Adhoc Meeting on 11/26/2024 to initiate Performance Improvement Plan. The Administrator submitted the Initial Report to DHHS on 11/24/2024 and 5- day investigation to DHHS on 11/28/24. Resident #3 was admitted to the hospital with altered mental status. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: Social Services Manager completed interviews on 11/25/2024 with Residents with a BIMS 13 or greater to ensure they felt safe in the Center, with no negative findings. Skin checks were initiated on 11/24/24 by Nursing Staff and Wound Care Nurse #1 on Residents with a BIMS 12 or less, skin checks completed by 11/28/24 with no negative findings. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Staff Development Coordinator / designee educated all Center staff on Abuse and Neglect Prohibition and Caring for Residents with Behaviors and Communication. Education included identifying types of abuse, resident to resident altercations, and identifying behaviors, expressions, and triggers that may lead to abuse. Additionally, the training included how to effectively communicate, approach, and deescalate behaviors. Education completed 11/28/24. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Beginning on 11/26/24, the Director of Nursing /designee will review during daily clinical morning meeting for changes in condition, new or worsening behaviors, resident altercations and altered mental status x 6 weeks. The decision was made to begin monitoring on 11/26/24 when the Performance Improvement Plan was reviewed by the Interdisciplinary Team. Beginning on 11/26/24, Data obtained during the audit process will be analyzed for patterns and trends and reported to The Quality Assessment and Assurance (QA & A/QAPI) Committee by the Director of Nursing monthly x 1 or until substantial compliance is obtained. At that time, the QA & A/QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Date of Compliance: 11/29/24 The facility's corrective action plan was validated by the following: Beginning on 2/4/25 at 9:50 AM a tour of the facility was conducted and multiple residents and family members were interviewed. These interviews revealed residents were not being mistreated or abused in any way. During onsite observations conducted on 2/4/25 and 2/5/25, staff members were observed monitoring and responding to confused residents. The facility presented documented evidence of their inservice training and audits as outlined in their corrective action plan. Interviews with staff confirmed education was completed per the corrective action plan. The facility's corrective action date of 11/29/24 was validated on 2/6/25.

Based on record review and interviews with staff, resident, Responsible Party (RP, ) Nurse Practitioner, Physician Assistants, and Physicians the facility failed to effectively communicate amongst their staff and with the medical providers and family and to ensure assessment and treatment occurred for a resident who was showing signs of a change in condition and whose family had initially requested the resident be transferred to the hospital but agreed with facility treatment based on the understanding the resident would receive appropriate evaluation and treatment at the nursing home. The resident's status deteriorated while still at the facility, and she was transferred to the hospital where she was emergently intubated (a tube is placed down an individual's throat, and they are placed on a machine to help them breathe) and admitted to the intensive care unit with a principal problem of sepsis with acute organ dysfunction. (Sepsis is a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction. The body's reaction causes damage to its own tissues and organs, and it can lead to shock, multiple organ failure and sometimes death). This was for one (Resident # 6) of three sampled residents reviewed for professional standards of practice. Immediate jeopardy began on 5/28/24 when due to poor communication over several shifts the facility failed to identify the seriousness of the changes in Resident #6's condition, complete thorough assessments or identify the urgent need for medical attention. Immediate jeopardy was removed on 6/13/24 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 6 was admitted to the facility on [DATE]. The resident had diagnoses which included occipital stroke, lewy body dementia, diabetes, hypothyroidism, hypertension, Parkinson's disease, depression, history of deep vein thrombosis/pulmonary embolism (blood clots). The resident's admission Minimum Data Set assessment, dated 3/5/24, revealed the resident had moderate impairment of her cognitive abilities. Additionally, she was assessed to require set up to eat, needed substantial to maximum assistance with her hygiene and turning in bed, and required total assistance with her toileting and bathing needs. She was also assessed to be totally incontinent of both bowel and bladder. Review of orders revealed the resident was a full code while the resident resided at the facility. On 3/1/24 Resident # 6 was ordered to receive speech therapy services for cognitive communication deficits. According to a Speech Therapy discharge summary, dated 3/26/24, the resident's swallowing function had also been assessed and she had no signs of esophageal dysphagia (difficulty swallowing). Review of progress notes revealed Resident # 6 was seen on 5/6/24 by Nurse Practitioner (NP) # 1 who noted the visit was per the family/resident requests due to nausea. The NP noted that the resident denied any other issues at the time. The NP further noted she changed the resident's timing of some of her medications, and also prescribed Zofran as needed if further nausea occurred. (Zofran is a medication used to treat nausea). Review of progress notes revealed Resident # 6 was seen again by Nurse Practitioner# 1 on 5/8/24. The Nurse Practitioner noted the resident denied any issues with pain, bowel or bladder or sleep at the current time. Interview with NP # 1 on 6/10/24 at 2:33 PM revealed it was her impression when she saw Resident # 6 on 5/6/24 and 5/8/24 that the resident's nausea was not chronic and could possibly be related to medication timing. She had adjusted the timing of some of the resident's medications. When she saw the resident on 5/8/24 the resident did not complain of further nausea. Review of Resident # 6's May 2024 Medication Administration Record (MAR) revealed between the dates of 5/6/24 and 5/27/24, Resident # 6 received the Zofran once. This was on 5/12/24 at 8:27 PM. Review of nursing progress notes and electronic medication administration (EMAR) notes for the dates of 5/27/24 and 5/28/24 revealed the following information: On 5/27/24 at 8:49 AM Nurse # 1 administered Ondansetron (Zofran) 4 mg per a PRN (as needed) order for nausea and vomiting according to a MAR administrative note. On 5/27/24 at 12:27 PM Nurse # 1 documented in a nursing note Resident # 6's vital signs registered blood pressure 129/72; temperature 98; pulse 93; respirations 16. The nurse further documented the resident had no complaints of pain. On 5/27/24 at 12:38 PM Nurse # 1 documented in a MAR administrative note the Ondansetron (Zofran) had been effective. On 5/27/24 at 8:02 PM Nurse # 5 documented in a nursing note the following vital signs: blood pressure 129/72; temperature 97.8; pulse 93; respirations 16; and the resident was without pain. The following information noting a change in condition appeared in Resident # 6's nursing notes and was entered by Nurse # 1 with an effective date of 5/28/24 at 9:20 AM. Nurse # 1 had attempted to give morning medications and the resident showed signs of difficulty swallowing. The resident did not want to eat anything. The resident had no complaints of nausea and no emesis. The resident's provider ordered a KUB (kidney, ureter, and bladder x-ray), IV (intravenous) fluids, CBC (complete blood count) and CMP (complete metabolic panel) to be drawn with a gastrointestinal consult to also be done. Nurse # 1 further recorded Resident # 1's vital signs as blood pressure-131/74 taken at 9:43 AM; pulse100 taken at 9:43 AM; temperature-97.8 taken at 9:44 AM; and respirations 16 taken at 9:43 AM. The resident's oxygen saturation registered 98% on room air. The following orders were entered into the computer on 5/28/24: Stat KUB Stat CBC and CMP Start peripheral IV of NACL .45% (Sodium Chloride) at 90 cc (cubic centimeters)/ hour for 1000 cc. The following information appeared as effective date of 5/28/24 at 9:35 AM in Resident # 6's nursing notes. The DON (Director of Nursing) documented a Late entry. She had started an IV in the resident's left arm. After the DON's nursing note, the following information appeared as effective date of 5/28/24 at 9:45 AM in Resident # 6' s electronic record. Nurse # 1 wrote, Writer received orders to send patient out to the ER from {Name of Physician Assistant #1] Orders were put on hold by DON to do work on patient in house. DON/Unit Manager received new orders from NP. Orders given to writer are place peripheral IV, IV fluids, KUB, CMP and CBC, and GI consultation. Orders followed. DON and another nurse attempted to place peripheral IV and it was unsuccessful. IV team called by unit manager. IV team gave a call back with an ETA (estimated arrival time) of 9:00 PM. NP was called and writer was given orders to hold fluids until IV team arrives to place the IV. Stat KUB and stat labs were done around 3:00 PM. Plan of care ongoing. Following Nurse # 1's entry for 5/28/24 at 9:45 AM the next nursing entry appeared as effective date of 5/28/24 at 10:39 AM in the resident's electronic record. It was entered by Unit Manager # 2 and read, Writer approached by assigned nurse in regard to resident experiencing n/v (nausea/vomiting). Writer approached NP in the building asking her to assess resident, NP gave orders to treat in house due to resident being stable at the time of assessment. Resident able to respond to writer's commands. No pain nor any s/sx (signs/symptoms) of distress at the time. New orders for IV fluids, Stat orders for a KUB, CBC, CMP. Orders were completed. Resident's fluids hanged and ran for about an hour until IV was infiltrated (IV fluids going into the surrounding tissue instead of the vein). IV team was called and stated they would be in the building around 9:00 PM. Assigned nurse asked if we could do a hypodermoclysis (IV fluids are administered underneath the skin). NP stated that waiting for the IV team would be fine. Following Unit Manager# 2's nursing entry for 5/28/24 at 10:39 AM the next nursing entry appeared as effective date of 5/28/24 at 1:30 PM in the resident's electronic record. It was entered by Nurse # 1 and read, Correction: IV placement on left AC successful, IV fluids given. Order .45 Normal Saline 90 cc/hr (hour) X 1 L bag. IV fluids ran for 1 hr (hour). Writer assessed patient with unit manager. IV infiltration noted. IV fluids stopped. NP notified. IV team called to place IV. Unit Manager contacted IV team. IV team called back with an ETA (estimated time of arrival) of 9 PM. NP notified and orders given to hold IV fluids until IV placement. Plan of care ongoing. An entry in the electronic record appeared as a Medication Administration Record note with an effective date of 5/28/24 at 2:34 PM. It was entered by Nurse # 1. Nurse # 1 noted the IV team was being awaited. The NP was notified, and a verbal order was given to hold the IV fluids. The next nursing entry appeared with an effective date of 5/28/24 at 3:35 PM in the resident's electronic record. It was entered by Nurse # 1 and indicated the resident had experienced nausea the morning of 5/28/24. Nurse # 1 wrote, Writer was doing her walking rounds and patient stated that she was nausea. Patient vital signs was obtained by writer, BS (bowel sounds) present X 4. Patient was given PRN Zofran. Writer assessed patient 30 minutes later. Patient stated that the medication helped. Breakfast was given to the patient and patient stated that she did not want to eat. Patient stated that she no longer felt nausea, but she did not want to eat. NP notified of patients COC (change of condition). Orders given for KUB, peripheral IV fluids, CBC and CMP, and a GI consultation. Orders followed as ordered. IV attempted by [DON] and it was unsuccessful. Attempt was made by another nurse, and it was unsuccessful. IV team has been called with an ETA of 9:00 PM. Hold orders given by NP until peripheral IV is placed. Patient has no c/o pain or discomfort. Plan of care ongoing. Review of physician orders revealed there was no order to hold the IV. Following Nurse # 1's entry for 5/28/24 at 3:35 PM, the next nursing note in the progress notes were EMAR medication notes entered by Nurse # 3 at 4:24 PM and 5:43 PM noting they were awaiting the IV team and the NP had been notified with orders to hold the fluids. Following the EMAR medication notes by Nurse # 3, the next note in the progress notes was by Nurse # 3 with an effective date of 5/28/24 at 6:39 PM. The note read Writer walked into the resident's room around 6 PM. Found out resident not responding, sweating all over her extremities, VS taken RR elevated Oxygen 2L administered via nasal canula. 6:10 PM writer called on call PA [Name PA # 2}. Order received to send her out via 911. Emergency Medical Services (EMS) team arrived 1825 (military time for 6:25 PM). Resident left to the [regional hospital] via stretcher by {name of county] EMS team around1838 (military time for 6:38PM). Daughter present in the room with EMS team when they arrived. Nurse Manager notified. In a change of condition nursing note on 5/28/24 at 6:44 PM, Nurse # 3 also recorded the following vital signs with times the vitals were taken (The blood pressure reading, pulse, and respirations were the first noted in Resident # 6's record since 9:43 AM on 5/28/24). Blood pressure -92/52 at 6:03 PM Pulse -94-at 6:03 PM Respirations-25-at 6:03 PM Temperature-96.1 -at 6:03 PM Oxygen level 90% on oxygen- at 6:03 PM Blood glucose 154-taken at 4:39 PM Review of EMS records revealed EMS was called on 5/28/24 at 6:17 PM and arrived at 6:31 PM. EMS noted the following information. The local fire department staff were already on the scene. The resident was receiving oxygen. The resident's eyes were open. She was unconscious and had a right sided gaze. The resident responded to pain. At 6:35 EMS recorded Resident # 6's vital signs as blood pressure 92/68; pulse 96; respirations 28; and oxygen level 77%. She was transported to the hospital. In route to the hospital, EMS documented they were not able to get a continual reading on the resident's oxygen level and they assisted the resident to breathe. The paramedic, who had responded on 5/28/24, was interviewed on 6/13/24 at 1:20 PM and reported when they arrived the fire department first responders were already on the scene. The resident had oxygen being administered at that time. Her oxygen saturation levels were low. The fire department had the paperwork from staff. He (the paramedic) obtained information from the family. The staff did not give them a report. It would have been helpful to have a report from staff because the paramedics were the ones who were responsible for transferring the resident to the hospital. He had to assist the resident with breathing on the way to the hospital by squeezing a bag that inserts oxygen into the resident's nose and mouth with each squeeze of the bag because her oxygen levels could not be raised and maintained. Attempts were made to talk to the fire department responders during the complaint survey. As of 6/14/24 at 11:33 AM, the fire department first responder could not be interviewed. Review of hospital Emergency Department (ED) records and Intensive Care Unit admitting records, dated 5/28/24, revealed upon arrival to the ED, Resident# 6 was emergently intubated (a tube is inserted in a resident's throat, and they are placed on a machine to help them breath). She appeared critically ill and would not follow commands. The resident had multiple lab abnormalities which included although were not limited to the following: A potassium level of 7.3 (normal 3.5 to 5.0-- a potassium level of 7.3 is considered dangerously high and can cause heart problems); a white blood count of 27.2 (normal 3.2 to 8.8); a blood urea nitrogen level of 62 (normal 7-20); a creatinine of 4.7 (normal 0.4 to 1.0). She was admitted to the intensive care unit with the principle primary problem documented as Sepsis with acute organ dysfunction. Although not all inclusive, other active problems included hypotension (low blood pressure) related to hypovolemia (abnormally low extracellular fluid in the body which can occur from a loss of both salt and water) and acute kidney injury (sudden loss of the kidneys ability to filter the blood). The resident was given IV fluids in the emergency room . Unit Manager # 2 was interviewed on 6/7/24 at 2:01 PM and reported the following information. Resident # 6 routinely would say the food was not good and would refuse to eat. On 5/25/24 (Saturday), while not at work she had received a cell phone text message from Resident # 6's RP (Responsible Party) with several questions. One of the questions was, What is being done about her not eating and if she does take a few bites, she throws up? The RP had also texted the Unit Manager not to respond till after the holiday weekend to her questions. When the Unit Manager received the text, she called the RP on the same day she received it. The RP had indicated there was no urgency to address her concern at that point because of the holiday weekend. The RP had told her it could wait to be discussed until after the holiday weekend and did not elaborate further about the resident not eating and vomiting. She (Unit Manager # 2) tried calling the facility staff on 5/25/24 but none of the nurses were able to pick up when she called. She (Unit Manager # 2) was the on-call Nurse Manager for the facility that weekend and had not received any reports of problems. The nurses were usually very good to call her for acutely ill residents. She planned to follow up when she returned to work on 5/28/24. Nurse Practitioner # 1 was interviewed on 6/10/24 at 2:33 PM and reported the following information. She was the NP covering the facility's concerns on 5/27/24. She had been in the facility on 5/27/24 and there was nothing in the physician's communication book that indicated Resident #6 needed to be seen. The resident's baseline was that she could answer yes and no questions and nod her head, but she did not normally carry on a full conversation to explain how she was feeling when the NP had previously visited her. NA (Nurse Aide # 10) had cared for Resident # 6 from 7:00 AM to 3:00 PM on 5/27/24 (Monday). NA # 10 was interviewed on 6/10/24 at 1:40 PM and reported the following information. Resident # 6 did not eat her food for breakfast or lunch on 5/27/24 (Monday). She did drink a little milk for breakfast and drank some tea for lunch. She did not recall further problems. NA # 11 had cared for Resident # 6 from 3 PM to 7 PM on 5/27/24 (Monday). NA # 11 was interviewed on 6/7/24 at 4:56 PM and reported the following information. The resident did not eat any of her food for the evening dinner meal on 5/27/24 (Monday). She drank about 120 cc of fluids (cubic centimeters). NA # 11 reported the resident did not like the food and she did not recall any further problems with the resident. Nurse # 5 had cared for Resident # 6 from 3:00 to 11:00 PM on 5/27/24 (Monday). Nurse # 5 was interviewed on 6/7/24 at 1:33 PM and reported the following information. Nothing out of the ordinary occurred that shift that the Nurse could recall. She did not recall the resident having problems with swallowing. Nurse # 9 had cared for Resident # 6 from 11 PM on 5/27/24 until 7:00 AM on 5/28/24 (Tuesday). Nurse #9 was interviewed on 6/8/24 at 1:06 PM and reported the following. She (Nurse #9) recalled the 3:00 to 11:00 PM nurse (Nurse #5) had difficulty getting Resident # 6 to swallow her medications. The 3:00 to 11:00 PM nurse still had the medications when she (Nurse # 9) arrived to work at 11:00 PM on 5/27/24. The 3:00 to 11:00 PM nurse decided to crush the medications in order to get the resident to swallow them. Nurse # 9 reported she did not recall Resident # 6 having problems on her shift. Nurse # 1 had cared for Resident # 6 on 5/27/24 (Monday) and 5/28/24(Tuesday) during the 7:00 AM to 3:00 PM shifts. Nurse # 1 was interviewed on 6/7/24 at 10:38 AM and reported the following information. On 5/27/24 (Monday) the resident had not eaten her breakfast or lunch. She had also been nauseated. She (Nurse # 1) administered Zofran (Ondansetron) per a PRN order to do so. The Zofran was effective and the resident never vomited. She was only nauseated. The resident never ate 100% so that was not new for the resident, but the nausea was new on 5/27/24. On 5/28/24 (Tuesday), she noted further differences in the resident. On 5/28/24 (Tuesday), before the night shift nurse (Nurse #9) left, the night shift nurse told her (Nurse # 1) that Resident # 6 had trouble swallowing her pills during the night. The night shift nurse had to administer them in applesauce. This was a change for the resident. She (Nurse # 1) also noticed a change in Resident # 6's swallowing. The resident could not swallow her pills on the morning of 5/28/24. She swallowed liquid but the pills would not go down her throat. Resident # 6 also had been nauseated again on the morning of 5/28/24. She again gave the resident PRN Zofran on 5/28/24. The resident did not vomit. She called the resident's RP (Responsible Party) and informed her of the new swallowing problem and not eating. The RP indicated the resident had problems over the weekend but did not explain what problems the RP had noticed. Nurse # 1 did not know about problems over the weekend. The RP wanted the resident sent to the ER for evaluation. After talking to the RP, Nurse # 1 called the PA (PA # 1) and obtained an order to send the resident to the hospital. She started to prepare the paperwork before entering the order into the computer because she knew she could do the order entry after calling 911 and having EMS papers ready. The DON (Director of Nursing) passed by her while she was preparing to send Resident # 6 to the hospital, and she (Nurse # 1) informed the DON that Resident # 6 was being sent to the hospital. The DON asked if she had educated the family about services they could provide in the facility. The DON wanted Unit Manager # 2 to communicate with the family and ask if the resident's RP would be agreeable to letting them try to treat the resident in the facility. Therefore, Nurse # 1 continued to do her med pass. She did not call the RP back. As she was doing the medication pass, Unit Manager # 2 approached her and let her know that she had obtained orders for Resident # 6 which included stat labs, a KUB, and an IV. Unit Manger # 2 told her (Nurse # 1) that the PA wanted the orders done. She (Nurse # 1) started processing the orders. She accompanied the DON and another nurse to start the IV. The resident looked dry and they had a hard time finding a vein to start the IV. One unsuccessful attempt was made and then the DON was able to place the IV. This was around 12:00 PM when the IV was started. Also, during the day, she (Nurse # 1) assisted Nurse Aide # 2 to turn and position the resident. The resident had complained of back pain and wanted to be only on her right side. She would not lay on her left. Positioning seemed to help this, and she did not require pain medication. Therefore, she (Nurse # 1) thought the pain had originated from how the resident was lying in bed. In approximately an hour after the IV was started, the IV had infiltrated. Unit Manager # 2 called the IV team, and the facility was notified that it would be around 9 PM before they could be at the facility. She (Nurse # 1) called the PA to update her about the delay in the IV and asked if they could hold the IV order due to the infiltration until the IV team could arrive. The PA agreed. She did not know how much the resident had drunk that day and she did not recall if she had mentioned to the PA that the resident had not eaten that day when she asked for the hold order. She also did not tell the PA that the resident was hurting in her back. After she had obtained the order to hold the IV, Unit Manger # 2 told her (Nurse # 1) that the DON wanted them to ask the PA if they could do hypodermoclysis (the administration of IV fluids beneath the skin). She (Nurse # 1) informed Unit Manger # 2 she had already called the PA, and the PA said it was okay to hold the IV until the IV team came to start it. The nurse further reported that during the day the resident would respond to questions. It was her baseline not to volunteer information. The staff had to ask her questions in order to determine how she was doing. During the day, the resident had no garbled speech and when asked if she was okay, she would say yes. She had taken the resident's vital signs in the morning and knew Resident #6's heart rate was 100. She had not taken a complete set of vital signs before leaving at the end of her shift. When she left at the end of the 7:00 AM to 3:00 PM shift, she had not noted any further changes. Nurse # 1 was further interviewed about the two differences in the medical record written by her; one indicating the resident did not have nausea on 5/28/24 and the other note indicating the resident did. Nurse # 1 validated the resident had nausea both days. She had written a second note to clarify the events that had happened and the entry noting she had nausea on 5/28/24 was correct. Nurse # 1 indicated it had been a very busy day and that may have contributed to some of the differences in the charting about the nausea. NA # 2 had cared for Resident # 6 on 5/28/24 (Tuesday) from 7 AM to 3 PM. NA # 2 was interviewed on 6/7/24 at 12:42 PM and reported the following information. On Tuesday (5/28/24) the resident did not eat any food for breakfast or lunch. For breakfast she drank her orange juice. For lunch she drank 1 1/2 glasses of lemonade. She just did not want to eat. They kept water by her bedside. When she (NA # 2) turned the resident, the resident complained of pain in her back. She did not want to be on her right side. During the interview with Unit Manager # 2 on 6/7/24 at 2:01 PM the Unit Manger further reported the following information regarding 5/28/24. On Tuesday (5/28/24) she returned to work for the first time after having received the RP's text message on 5/25/24. The DON mentioned to her that Resident # 6's RP wanted her sent out to the hospital. She had talked to Nurse # 1 and Nurse # 1 did not mention to her that the resident's heart rate was 100 or that the resident had trouble swallowing. Nurse # 1 did tell her (Unit Manager # 2) that the resident had some nausea and vomiting that morning but did not mention her having any problems with nausea the previous day which required medication. She (Unit Manager # 2) and the DON went to see the resident on Tuesday morning (5/28/24). They did not do a hands-on physical assessment of the resident. By looking at her, the resident appeared alert, she was not sluggish, nor in pain. Her breathing was not labored. She called and talked to the RP around 10:10 AM per her cell phone records. The RP conveyed she was worried about the resident. Unit Manager # 2 made her aware the facility could do labs, IV fluids, and tests and asked if she would want her treated at the facility instead of sending her to the hospital. She made it clear it was the RP's decision. The RP did not mention any problems the resident had over the weekend during the phone call. The RP was agreeable to have the resident treated at the facility. She (Unit Manager # 2) went to talk to PA # 1 who was in the facility at that point. Orders were given for stat labs, a KUB, and an IV to be started. She talked to Nurse # 1, gave Nurse# 1 the orders, and helped call and arrange for the lab/tests to be done. The DON went with Nurse # 1 to start the IV. She (Unit Manager # 2) thought this was before lunch when the IV was started. About an hour after the IV was started the IV was observed to be infiltrated and Nurse # 1 stopped the IV. The facility used a contracted provider to start IVs when needed. The DON texted Unit Manager # 2 to contact the IV team for Resident # 6. At first the IV team indicated they were coming right away and then they called back to say it would be around 9 PM. The DON asked Unit Manager # 2 to ask the provider if they could do hypodermoclysis. She told Nurse # 1 to ask the provider this question. Nurse # 1 said she had already spoken to the provider and obtained an order to hold the IV until the IV team arrived. She left work that day around 3:00 PM, checked on the resident before leaving, and the resident was still the same. On 5/28/24 her phone showed a text message at 2:37 PM from Resident # 6's RP saying she was checking on the resident and wanting to know if there was anything else that she (the RP) needed to do. She (Unit Manager # 2) saw the text message at 5:35 PM and called the RP back. She informed the RP at that time that the resident's IV had infiltrated. Prior to 5:35 PM, she had not spoken to the RP about the IV infiltrating or about the anticipated delay in getting it restarted. When she spoke to the RP, the RP indicated another family member (Family member # 1) had already been to see the resident that afternoon, the resident was not doing well, and she was headed to the facility at that time. According to her phone records, she (Unit Manager # 2) received a text from Resident # 6's RP at 6:18 PM saying that the resident looked terrible, and they were calling 911. The DON was interviewed on 6/7/24 at 4:22 PM and reported the following information. Prior to Resident # 6 being sent out to the hospital she had been aware the resident did not like the facility's food and did not want to eat. On the morning of 5/28/24, Nurse # 1 was wanting the resident sent out to the hospital. At the time, the DON had not been aware the resident had not eaten any food on 5/27/24 (Monday). She had asked Nurse # 1 if there was any other acute symptoms, and Nurse # 1 had indicated there was not. She had asked Unit Manager # 2 to call Resident # 6's RP about in house treatment. At the time she had requested Unit Manager to do this, she (the DON) was not under the impression there was anything further wrong with the resident other than her not eating much. She had started the IV on Resident # 6 and the resident did not look like she was in distress. She looked in on the resident around 1:00 PM and the resident appeared fine. When the IV infiltrated, she had asked Unit Manager # 2 to call the IV team. She also asked the Unit Manager to find out if the provider would want them to do hypodermoclysis and she was told by her staff that the provider said it was okay to wait until the IV team arrived. After leaving work, she received a call from Unit Manager # 2 saying that they had sent the resident to the hospital. NA # 1 had cared for Resident # 6 on 5/28/24 (Tuesday) from 3:00 PM to 11:00 PM. NA # 1 was interviewed on 6/7/24 at 3:41 PM and reported the following information. She had cared for Resident # 6 another time previously but did not routinely care for her. When she arrived on 5/28/24 (Tuesday) for her evening shift, Resident # 6 was having a test completed. The resident did not seem off compared to how she had been the other time she had cared for her. The resident responded when she first checked on her. After the test, she provided incontinent care for the resident. Her urine had a strong odor and seemed off settling. The resident did not complain of pain. She responded during the incontinent care. Prior to the evening dinner time meal, she had checked on Resident # 6 again and her head was tilted back. Her eyes appeared dazed as she focused on the Nurse Aide and the resident was not responding the same. Her speech was slurred when the Nurse Aide tried to talk to the resident, and it was not clear what the resident was saying. She had talked to Nurse # 3 about this, and he acknowledged he knew the resident was not feeling well and she was off that day. This was around 4 something when she talked to Nurse # 3. The dinner trays came out around 5:30 to 6 PM. Another Nurse Aide took the tray in the room. She (NA # 1) knew the resident was not going to be able to eat. She went back to Nurse # 3 who at that time was on his way to call 911 and was focused on sending her out. Resident # 6's former roommate (Resident # 12) was interviewed on 6/7/24 at 5:40 PM. (A review of Resident #12's Quarterly MDS assessment, dated 5/13/24, revealed the resident was cognitively intact). During the interview, Resident # 12 recalled rooming with her former roommate for about a week and being concerned that Resident # 6 did not eat many meals in a row. Resident # 12 reported the following information. On the last day Resident # 6 had been at the facility, one of Resident# 6's family members visited in the afternoon. It was at that time that she (Resident # 12) noticed a difference in Resident # 6. Normally Resident # 6 would not initiate conversation on her own accord but she would respond when someone spoke to her. When the family member entered on the afternoon of 5/28/24, Resident # 6 spoke when the family member first came into the room and then stopped speaking to him. The family member was concerned and called the RP asking her to come to the facility. Resident # 12 reported she recalled the family member stating he had an appointment at 4:30 PM to attend and she thought the timing of the family member's visit would have been before that time. The phlebotomist, who drew Resident # 6's blood work on 5/28/24, was interviewed on 6/10/24 at 12:49 PM and reported she had drawn Resident # 6's blood work at 4:15 PM. The phlebotomist further reported the resident was able to state her name and date of birth at the time the blood was drawn. The phlebotomist reported that if she had observed that the resident seemed in some sort of medical distress, she would have gotten a facility staff member when she drew the blood. NA # 12 was the Nurse Aide who took Resident # 6's evening dinner tray to he [TRUNCATED]

Based on record review and interviews with staff, Responsible Party (RP) and Physicians the facility failed to immediately notify the responsible party when Resident # 6's intravenous fluids (IV) infiltrated (IV fluids going into the surrounding tissue instead of the vein), and the fluids were placed on hold. At the time of infiltration, the resident had already been identified to have new swallowing problems, nausea, and no food intake for multiple consecutive meals. Resident # 6's family reported she would have requested the resident be sent to the hospital if she had known about any delay with the IV fluids. After the IV infiltration, the resident was transferred hours later to the hospital and admitted to the Intensive Care Unit for a principal diagnosis of sepsis. (Sepsis is a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction. The body's reaction causes damage to its own tissues and organs, and it can lead to shock, multiple organ failure and sometimes death). This was for one (Resident # 6) of three residents reviewed for change in condition. Immediate jeopardy began on 5/28/24 when Resident #6's RP agreed to treat the Resident at the facility after a change in condition and was not notified when the IV fluids infiltrated and were placed on hold. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 6 was admitted to the facility on [DATE]. The resident had diagnoses which included occipital stroke, Lewy body dementia, diabetes, hypothyroidism, hypertension, Parkinson's disease, depression, history of deep vein thrombosis/pulmonary embolism (blood clots). The resident's admission Minimum Data Set assessment, dated 3/5/24, revealed the resident had moderate impairment of her cognitive abilities. Review of orders revealed the resident was a full code while the resident resided at the facility. Review of nursing progress notes and electronic medication administration notes for the dates of 5/27/24 and 5/28/24 revealed the following information: On 5/27/24 at 8:49 AM Nurse # 1 administered Ondansetron (Zofran) 4 mg per a PRN (as needed) order for nausea and vomiting according to a MAR administrative note. On 5/27/24 at 12:38 PM Nurse # 1 documented in a MAR administrative note the Ondansetron (Zofran) had been effective. The following information noting a change in condition appeared in Resident # 6's nursing notes and was entered by Nurse # 1 with an effective date of 5/28/24 at 9:20 AM. Nurse # 1 had attempted to give morning medications and the resident showed signs of difficulty swallowing. The resident did not want to eat anything. The resident's provider had given orders which included IV fluids to be administered. The following information appeared as effective date of 5/28/24 at 9:35 AM in Resident # 6's nursing notes. The Director of Nursing (DON) documented a Late entry that she had started an IV in the resident's arm. After the DON's nursing note, the following information appeared as effective date of 5/28/24 at 9:45 AM in Resident # 6' s electronic record. Nurse # 1 wrote that the DON and another nurse attempted to place a peripheral IV and it was unsuccessful. The facility's IV team was called by the unit manager. The IV team gave a call back with an ETA (estimated arrival time) of 9:00 PM. The provider was called and gave orders to hold the IV. Following Nurse # 1's entry for 5/28/24 at 9:45 AM the next nursing entry appeared as effective date of 5/28/24 at 10:39 AM in the resident's electronic record. It was entered by Unit Manager # 2 and included information that the resident's IV was started and ran about an hour until it infiltrated. The IV team was called and stated they would be in the building around 9:00 PM. The provider had said that waiting on the IV team to start the IV would be fine. There was no documentation that the RP was notified of this change in treatment plan to hold the IV fluids until 9:00 PM. Following Unit Manager# 2's nursing entry for 5/28/24 at 10:39 AM the next nursing entry appeared as effective date of 5/28/24 at 1:30 PM in the resident's electronic record. It was entered by Nurse # 1 and read as a correction to the nurse's previous entry. The nurse noted the IV had been started but had infiltrated and was stopped. The estimated arrival time for the facility's IV team to arrive and start the IV was at 9:00 PM. There was no documentation the RP was notified. Nurse # 3 entered a nursing note in the progress notes with an effective date of 5/28/24 at 6:39 PM. The note read Writer walked into the resident's room around 6 PM. Found out resident not responding, sweating all over her extremities, VS (vital signs) taken RR (respiratory rate) elevated Oxygen 2L administered via nasal canula. 6:10 PM writer called on call PA [Name PA # 2}. Order received to send her out via 911. EMS team arrived 1825 (Military time for 6:25 PM). Resident left to the [regional hospital] via stretcher by {name of county] EMS team around 1838 (Military time for 6:38 PM) {RP} present in the room with Emergency Medical Services (EMS) team when they arrived. Nurse Manager notified. Review of EMS records revealed EMS was called on 5/28/24 at 6:17 PM and arrived at 6:31 PM. EMS noted the following information. The local fire department staff were already on the scene. The resident was receiving oxygen. The resident's eyes were open. She was unconscious and had a right sided gaze. The resident responded to pain. At 6:35 EMS recorded Resident # 6's vital signs as blood pressure 92/68; pulse 96; respirations 28; and oxygen level 77%. She was transported to the hospital. In route to the hospital, EMS documented they were not able to get a continual reading on the resident's oxygen level and they assisted the resident to breathe. The paramedics also placed a saline lock (a portal of entry to the vein) for IV access. Review of hospital Emergency Department (ED) records and Intensive Care Unit admitting records, dated 5/28/24, revealed upon arrival to the ED, Resident# 6 was emergently intubated (a tube is inserted in a resident's throat, and they are placed on a machine to help them breath). She appeared critically ill and would not follow commands. The resident had multiple lab abnormalities which included although were not limited to the following: A potassium level of 7.3 (normal 3.5 to 5.0-- a potassium level of 7.3 is considered dangerously high and can cause heart problems); a white blood count of 27.2 (normal 3.2 to 8.8); a blood urea nitrogen level of 62 (normal 7-20); a creatinine of 4.7 (normal 0.4 to 1.0). She was admitted to the intensive care unit with the principle primary problem documented as Sepsis with acute organ dysfunction. Although not all inclusive, other active problems included hypotension (low blood pressure) related to hypovolemia (abnormally low extracellular fluid in the body which can occur from a loss of both salt and water) and acute kidney injury (sudden loss of the kidneys ability to filter the blood). The resident was given IV fluids in the emergency room . Nurse # 1 had cared for Resident # 6 on 5/27/24 (Monday) and 5/28/24 (Tuesday) during the 7:00 AM to 3:00 PM shifts. Nurse # 1 was interviewed on 6/7/24 at 10:38 AM and reported the following information. The resident was experiencing a change in condition. She had symptoms of nausea, not eating, and not able to swallow as she usually did. She had spoken to Resident #6's RP on 5/28/24 and the RP wanted the resident sent to the hospital. This was the initial plan. After Unit Manager # 2 talked to the RP and the PA, then the plan was changed to treat the resident in the facility. Part of the treatment plan included orders for the resident to have an IV. She (Nurse # 1) observed the resident appeared dry when the DON started the IV. After about one hour, the IV infiltrated and it was stopped. She had called the PA and obtained an order to hold the IV. She was aware the IV team was coming to the facility around 9:00 PM to restart the IV. She had not called the RP about the IV infiltrating or about any delay in getting it restarted Unit Manager # 2 was interviewed on 6/7/24 at 2:01 PM. The Unit Manger reported the following information regarding 5/28/24. She had talked to Resident # 6's RP on the morning of 5/28/24 and made her aware that the facility could provide treatment at the facility. The RP agreed. Orders were obtained for treatment. One of the orders included starting an IV. About an hour after the IV was started the IV was observed to be infiltrated and Nurse # 1 stopped the IV. The facility used a contracted provider to start IVs when needed. At first the IV team indicated they were coming right away and then they called back to say it would be around 9:00 PM. She had not called and talked to the RP about the delay in IV administration before leaving work that day around 3:00 PM. On 5/28/24 her phone showed a text message from 2:37 PM from Resident # 6's RP saying she was checking on the resident and wanting to know if there was anything else that she (the RP) needed to do. She (Unit Manager # 2) saw the text message at 5:35 PM and called the RP back. She informed the RP at that time that the resident's IV had infiltrated and about the delay in the IV fluids. Prior to 5:35 PM, she had not spoken to the RP about the IV infiltrating or about the anticipated delay in getting it restarted. Resident# 6's RP was interviewed on 6/10/24 at 8:26 AM and reported the following information. When she talked to Unit Manager # 2 on the morning of 5/28/24 the Unit Manager had asked her why she would want Resident # 6 sent to the ED (Emergency Department) where the resident would sit for hours when the facility could do tests and treatment there. It was her (the RP's) understanding that Resident # 6 would be seen by the provider, receive IV fluids, diagnostic tests, and monitoring at the facility. That was why she agreed because the Unit Manager had said to trust her that these things could be done. She did not hear about a delay in providing IV fluids until she talked to Unit Manager # 2 at 5:35 PM. If she had known they were having to wait on an IV placement, she would have told the staff to go ahead and send Resident # 6 to the hospital. The RP commented, Who wouldn't have? The chief operating officer of the company which provides IV placement services to the facility was interviewed on 6/10/24 at 1:03 PM and reported the following. They had received the first call from the facility on 5/28/24 at 1:40 PM requesting placement for Resident # 6's IV. The Emergency Department physician was interviewed on 6/3/24 at 1:00 PM and reported the following. When Resident # 6 had arrived at the hospital she was very septic and had to be emergently intubated. She was hypothermic with unstable vital signs. Even with medical treatment, the resident continued to worsen. It was his opinion that if the resident had been transferred to the hospital even four hours earlier, she would not have been as sick. The facility's Medical Director was interviewed on 6/10/24 at 4:41 PM and reported the following information. Residents who become septic can become worse very quickly. According to the medical director, retrospectively, sometimes it can be seen that a few hours in treatment may have made a difference with a resident but that is not always initially apparent with residents when they first develop symptoms which progress to severe illness. On 6/14/24 at 11:33 AM the facility Administrator was informed of Immediate Jeopardy. The facility provided the following credible allegation of immediate jeopardy removal with a completion date of 6/13/24. 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility must ensure the family is immediately notified when there is a change in treatment plans for a resident experiencing a change in condition. On 5/28/2024 1) staff were aware the resident had experienced two consecutive days in which she had experienced nausea; 2) the resident had not eaten any food for four consecutive meals (all meals on 5/27/24 and breakfast on 5/28/24) 3) The resident had new swallowing problems 4) The staff had been made aware on 5/25/24 the resident's family noticed she would take a few bites and she would throw up 5) the resident's heart rate was on the upper end of normal registering 100 and 6) Resident # 6's family was wanting her sent to the hospital on the morning of 5/28/24. On the morning of 5/28/24 the PA was in the facility and left orders for the resident to be treated at the facility without physically evaluating the resident. According to the family, the family was in agreement with the resident receiving treatment at the facility with the understanding that the resident would be seen by the provider, be monitored and receive diagnostic tests and treatment which included IV fluids. On 5/28/24 the facility became aware the IV had infiltrated and there would be a delay in starting it again. The family was not notified at that time and reported if they had been notified, they would have wanted the resident sent on to the hospital. The resident was later sent out hours later to the hospital and required assistance breathing by EMS in route to the hospital. She required intubating at the hospital ER. According to the ER physician, it was his opinion that if the resident had been sent out four hours earlier, she would not have been as sick. On 6/4/2024, current residents records were reviewed by the Director of Nursing for the past 30 days for notification to physician and resident/responsible party of change in condition and treatment change during change in condition. Audit completed on 6/12/2024. 2) 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: On 6/4/2024, education was initiated to licensed nursing staff by the Director of Nursing/designee on notification to provider and resident/responsible party for change in treatment during change of condition. Education was completed by 6/8/2024. On 6/4/2024, education was initiated to certified nursing assistants by the Director of Nursing/designee regarding the ability to identify a change in condition in residents and reporting those changes to the nurse that includes but not limited to having a decreased appetite, consistent refusal of therapeutic diet, nausea, decreased intake of fluids, and/or general malaise, etc. Education for licensed and unlicensed staff was completed by 6/8/2024. The Director of Nursing was responsible for ensuring all licensed and unlicensed staff received the education. Newly hired licensed, unlicensed and agency staff will receive this education during orientation. The Director of Nursing will be responsible for ensuring that this education is completed. Effective 6/8/2024, the Administrator and Director of Nursing will be ultimately responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of Immediate Jeopardy Removal: 6/13/2024 On 6/19/24, the facility's credible allegation for immediate jeopardy was validated. Review of the facility's corrective action plan revealed 100% licensed nursing staff education regarding notification to the provider and resident and/or responsible party (RP) for any changes of condition, as well as 100% unlicensed nursing staff education regarding reporting changes in resident condition to the nurse. Education was completed by 6/12/24. 100% audit of resident medical records was completed to ensure that notification of changes in condition was completed in the past 30 days as applicable. The audits began on 6/4/24 and were ongoing. Staff interviews confirmed education was received on notification of the nurse or provider and resident and/or RP for any changes in condition. The facility's immediate jeopardy removal date of 6/13/24 was validated.

Based on record review and staff interviews, the facility failed to investigate the root cause of the repeated falls and provide supervision to prevent more falls from occurring. One of these falls required hospital intervention with sutures for lacerations to the nose and forehead and another fall the same day required hospital intervention with additional sutures to the back of the head. This resident did not return to the facility after the last fall with injury. This deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #8). The findings included: Resident #8 was admitted [DATE] with metabolic encephalopathy(any brain disturbance of the brain's function), history of multiple falls at home, osteoarthritis of the knees, intervertebral disc degeneration and macular degeneration. Review of Resident #8's comprehensive care plan included a care area risk for falls with an initiation date of 4/5/24. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #8 had moderate cognitive impairment, required supervision with transfers and bed mobility, was continent of bladder and bowel and coded for falls prior to admission. Review of an incident report dated 4/14/23 at 9:15 PM read Resident #8 was found with her left knee on the floor. She stated she was trying to transfer to her chair and lost her balance. She denied pain of discomfort. The intervention was frequent rounding. Nurse #8 completed this report. Review of an interdisciplinary team (IDT) note dated 4/18/24 at 11:09 AM read Resident #8 was discussed in the weekly IDT meeting because she triggered for falls. Resident #8 had a fall on 4/14/24. She was observed on floor in room on her left knee. Resident stated she was trying to sit in her chair and lost her balance. There were no injuries noted. The intervention in place was for frequent rounding at night. The Physician and Responsible Party were aware, the care plan was updated and continued with the current plan of care. Unit Manager (UM) #1 completed this note. Review of an incident report dated 4/18/24 at 10:21 AM read Resident #8's spouse came out of the room yelling for help. Resident #8 was found on the floor trying to get up. She stated she was trying to go to the bathroom when she lost her balance and fell . There were no injuries. The spouse stated he was assisting her when she fell . Resident #8 was reminded to use her call bell and her spouse was reminded to let staff assist Resident #8. Nurse #7 completed this report. A telephone interview was completed on 6/4/24 at 3:07 PM with Nursing Assistant (NA) #7 who was assigned Resident #8 on 4/18/24 at the time of her fall at 10:21 AM. She stated Resident #8 was her usual self. She did not display any increase in restlessness or agitation. NA #7 stated her spouse stayed with her most of the day every day and he was assisting her to the bathroom when she lost her balance and fell . Review of another incident report dated 4/18/24 at 9:30 PM read Resident #8 was found sitting on the floor in front of the bed. There were no injuries. She stated she was trying to sit on her bed and missed the bed. The intervention was to offer out of the room activities when she appeared restless. Nurse #8 completed this report. A telephone interview was completed on 6/12/24 at 1:20 PM with Nurse #8. She recalled Resident #8 and stated she did not appear restless or agitated on second shift on 4/18/24. She stated Resident #8 was in her room watching television and while she went to administer some medications, she returned and noted Resident #8 sitting on the floor beside her bed. Nurse #8 stated she had to get a close eye on Resident #8 because she was difficult to redirect. She stated there were two aides working with her that evening which was the normal assignment. A telephone call was attempted on 6/4/24 at 2:50 PM with Nursing Assistant (NA) #4 assigned Resident #8 on 4/18/24 at the time of the fall at 9:30 PM Her cell phone mailbox was full. There were no additional contact numbers per the facility. A telephone interview was completed on 6/12/24 at 11:25 AM with NA #9 who also worked second shift on 4/18/24. She stated she started working at the facility the second week of April and only did a couple of shifts on the rehabilitation hall. She stated she did not recall Resident #8. Review of Resident #8's electronic medical record included a situation, background, assessment and recommendation (SBAR) note dated 4/19/24 at 2:55 AM read Resident #8 was found on the floor on the 100 hallway. She sustained lacerations to her face and the bridge of her nose. She was transferred to the hospital for sutures. There was also an electronic transfer form completed that read she was transferred to the emergency department at 3:22 AM. Nurse #6 completed this SBAR and transfer form. This fall did not appear on the facility's incident list for resident falls in April 2024. A telephone interview was completed on 6/4/24 at 11:11 AM with Nurse #6. She stated she had been working at the facility for approximately a month and was still in orientation. She stated she was working with Resident #8 on the night of 4/19/24 when she fell in the hallway. Nurse #6 stated Nurse #8 reported to her that Resident #8 had been restless and was found sitting on the floor bedside her bed on her shift. Nurse #6 stated the night of 4/19/24, Resident #8 was up in a wheelchair self-propelling up and down the halls looking for her spouse when she observed Resident #8 on the floor. Nurse #6 stated there were two aides that night. She stated one aide may have been in a resident room and the other aide may have taken her lunch break. When questioned about the lack of an incident report completion, she stated she must have forgotten to complete it but Nurse #7 was her relief and she made him aware that she had sent Resident #8 out to the hospital due to a fall earlier on her shift. A telephone call was attempted on 6/4/24 at 2:52 PM with NA #5 assigned Resident #8 on 4/19/24 at the time of the fall at 2:55 AM. Her cell phone mailbox was full. There were no additional contact numbers per the facility. A telephone interview was completed on 6/12/24 at 3:20 PM with NA #8 who worked third shift on 4/19/24. She stated she started out helping at station 1 where Resident #8's room was but she was moved to station 2 to work shortly after coming into work. She stated she did recall Nurse #8 talking about Resident #8 requiring close observation at the beginning of the shift. Review of Resident #8's progress notes did not include a nursing note regarding her return to the facility from the hospital department on 4/19/24 after receiving sutures to her nose and forehead however, emergency department records indicated she was discharged back to the facility at approximately 8:00 AM. Review of the electronic medical record included another transfer form dated 4/19/24 at 11:40 AM that read Resident #8 was transferred back to the hospital for another fall. Nurse #7 completed the transfer form. This fall did not appear in the progress notes or on the facility's incident list for resident falls in April 2024. An interview was completed on 6/4/24 at 11:30 AM with Nurse #7. He confirmed he was assigned Resident #8 on 4/19/24 when she fell again at approximately 11:00 AM-12:00 PM. Nurse #7 stated when he came in at the beginning of his shift on 4/19/24, Nurse #6 reported that she was out at the hospital for treatment due to a fall she sustained at 2:55 AM. Nurse #7 recalled Resident #8 returning from the hospital early on 4/19/24 with sutures to her forehead and the bridge of her nose. He stated he was passing medications on the 100 hall with his medication cart positioned in between rooms [ROOM NUMBERS] since Resident #8. He stated he did this so he could keep a close watch on her. He stated he left his medication cart to administer some medications when Resident #8 apparently got her walker and walked into the hallway and apparently fell backwards striking the back of her head at approximately 11:00 AM. Nurse #7 stated he applied pressure to the back of her head and emergency medical services (EMS) was notified. He stated it was a really busy day so he did not have time to complete a note or incident report. An observation with Nurse #7 of the 100 hall was completed on 6/5/24 at 11:04 AM. rooms [ROOM NUMBERS] were on the left side of the hall and room [ROOM NUMBER] was on the right side of the hall. Nurse #7 stated he placed the medication cart in between rooms [ROOM NUMBERS] with his back to room [ROOM NUMBER]. He stated he had to keep his medication cart parked there because he needed the outlet for his laptop on the medication cart. He stated he was still able to keep a close eye on Resident #8 but she was able to get up and ambulate into the hall so quickly, that he did not see her actually fall. A telephone interview was completed on 6/4/24 at 2:55 PM with NA #6 who was assigned Resident #8 on 4/19/24 at the time of the fall around 11:00 AM. She stated she was unable to recall Resident #8 or anything about her falls. Review of emergency department records dated 4/19/24 at 1:45 PM read Resident #8 sustained another unwitnessed fall at the facility where she fell backwards striking the back of her head. There was no loss of consciousness. A cervical collar was put in place. There was a new laceration to the back of her head requiring sutures and a renal mass suspicious of cancer was identified on the scans. She was discharged to a memory care unit. A telephone interview was attempted with the Medical Director on 6/3/24 at 1:10 PM. He stated he did not recall Resident #8. An interview was completed on 6/4/24 at 11:25 AM with UM #1. She stated the facility had a weekly IDT meeting usually led by the Director of Nursing (DON). She stated all unit managers, the dietary manager, therapy director and the MDS Nurse all attend the weekly meetings. She stated all falls were discussed daily from the day before in each morning clinical meeting to ensure an effective intervention was put in place. She stated Resident #8's two falls on 4/18/24 would have been discussed in the morning clinical meeting on 4/19/24 but stated she was not certain if the clinical team would have discussed Resident #8's two falls with injuries that occurred on 4/19/24 since there was no incident report generated. An interview was completed on 6/5/24 at 9:50 AM with the DON. She stated she started at the facility in January of 2024. She stated she worked with the staff on documentation but offered no explanation for the lack of information documented on Resident #8. She also stated Resident #8 needed close supervision but the facility could not provide one-on-one supervision. The DON stated the facility needed to improve on their investigative process to determine any patterns or root cause behind reported falls.

Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by not obtaining a Physician order to hold Intravenous fluids, incomplete oral intake records and inaccurate medication administration times on 5/28/24 that did not match the times Nurse #8 reported administering the medications for Resident #6. This was for 1 of 12 residents reviewed for complete and accurate medical records. The findings included: 13289 Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by not obtaining a Physician order to hold Intravenous fluids, incomplete oral intake records and inaccurate medication administration times on 5/28/24 that did not match the times Nurse #8 reported administering the medications for Resident #6. This was for of 1 of 12 residents reviewed for complete and accurate medical records. The findings included: 1a. Resident # 6 was admitted to the facility on [DATE]. Nurse # 1 documented a nursing note on 5/28/24 at 1:30 PM noting Resident # 6's IV (intravenous) fluids had infiltrated, and the Nurse Practitioner was notified and gave an order for the IV fluids to be placed on hold until IV placement was obtained. A review of Resident # 6's electronic record on 6/7/24 revealed the record was incomplete. There was no order entered into the resident's record to hold the IV. It was confirmed with the regional clinical director on 6/7/24 at 7:00 PM that there was no order in Resident # 6's record to hold the IV. 1b. A review of Resident # 6's electronic record on 6/7/24 revealed Resident # 6's meal consumption sheets were incomplete. Although not all inclusive, some examples included no meal intake recorded for the supper meal for the dates of 5/18/24, 5/19/24, and 5/26/24. Additionally, the meal consumption sheet showed that Resident # 6 consumed 51 to 75 % of her supper meal on 5/27/24. During an interview with Nurse Aide # 11, who cared for Resident # 6 on the evening of 5/27/24, NA # 11 reported the resident had not eaten any of her supper meal. The area on the meal consumption sheet which would have accurately reflected this was blank. 1c. Review of a medication administration audit report, which was generated from Resident # 6's electronic record on the date of 6/7/24 at 9:31 AM, revealed the report included scheduled medications and orders for Resident # 6 for the date of 5/28/24. The report also included the documented administration times which had been entered into Resident # 6's electronic record for medications and her blood sugar check on 5/28/24. According to the report, Nurse # 3 had documented on 5/28/24 at 4:40 PM he had completed a blood sugar check on Resident # 6. Further review of the report revealed Nurse # 3 documented he administered multiple medications to Resident # 6 over an hour after he had performed the resident's blood sugar check. Although not all inclusive, some examples are as follows. Nurse # 3 documented that he administered carbidopa-levodopa, atorvastatin, metformin, and duloxetine at 5:45 PM on 5/28/24. Nurse # 3 was interviewed on 6/10/24 at 12:38 PM and reported he gave medications to Resident # 6 at the same time he did the resident's blood sugar reading on 5/28/24. He did not know why the administration times in Resident # 6's record reflected her medications were given over an hour later, and the administration times should have been closer or at the time he did her blood sugar check. According to the nurse, that would have been an accurate reflection of what he had done.

Based on observations, record review and interviews the facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in reach-in refrigerator and maintain the kitchen equipment and bin holding scoops and ladles clean. The facility failed to label, and date opened dietary supplements and thickened liquids, and discard expired food from 2 of 2 nourishment refrigerator (Nourishment refrigerator in Kitchenette #2 and Kitchenette #1). These practices had the potential to affect food served to the residents. Finding included: 1. An observation of the walk-in refrigerator on [DATE] at 9:17 AM revealed an aluminum pan containing multiple individual cups of yogurt and nutritional supplements on ice. Observation revealed ten, 4-ounce cups of yogurt with an expiration date [DATE]. During an interview with the Dietary Manager on [DATE] at 9:20 AM, she indicated the aluminum pan contained yogurt and supplements for lunch meal. She stated the expired dates for the yogurt cups were overlooked. She indicated the expired yogurt cups would be discarded. 2. An observation of the reach-in refrigerator on [DATE] at 9:30 AM revealed two opened 46 fluid ounce of nectar thick water cartons. There was no label indicating the open date or use by date on them. Review of the manufacturing recommendations on the carton revealed the product could be refrigerated for 10 days in the refrigerator after opening. The Dietary Manager during an interview on [DATE] at 9:30 AM, indicated all opened food/ nutrition supplements or thickened liquids should be labeled with an open date. The dietary manager stated that the thickened liquid cartons may have been opened during the weekend. 3. Review of the cleaning schedule for February, Week 3 revealed the following: Deep fryer - Drain oil, scrub, and de-grease outside and inside door panels. Rinse and discard used oil. The document was marked X as cleaned on Sunday, Wednesday, Thursday, Friday, and Saturday. The document did not indicate the frequency of cleaning (daily, bi-weekly, weekly, bi-monthly, or monthly). A. Observation of the deep fryer on [DATE] at 9:37 AM revealed the fryer had dried food crumbs on the top panel of the equipment. There were light brown food particles floating in the oil. A large brown greasy stain was observed on the back splash of the equipment. During an interview with the Dietary Manager on [DATE] at 9:37 AM, she stated the staff would be cleaning the equipment that day. She further stated the Assistant Dietary Manager was responsible for cleaning the equipment and would be completing the task that day. During an interview on [DATE] at 1:51 PM, the Assistant Dietary Manager stated that he was responsible for cleaning the deep fryer and usually cleaned the deep fryer on Monday and Wednesday. He indicated the oil in the fryer was drained when fish was fried. He stated the Friday menu had chicken tenders and Catch of the day (fish fry). The oil was not drained, and equipment was not cleaned after that meal. B. Observation of the plastic bin containing scoops, ladles and serving spoon during tray line observation on [DATE] at 11:50 AM revealed dirt and dried food particles in the bin. The dietary manager stated this bin was constantly used by staff during tray line and does have some dried food particles on the base. 4. Review of the Food from Outside Sources Use and Storage policy revealed perishable foods should be discarded after 72 hours of the date placed in the refrigerator. Review of the manufacturer's recommendations for nutritional supplement Ready Care 2.0 read, in part Shelf Life: 9 months from date of manufacture. Refrigerate after opening and use within 72 hours. A. Observation of the nourishment refrigerator #2 (Kitchenette #2) on [DATE] at 9:40 AM, revealed a white plastic bag dated [DATE], containing a takeout container with food in it, a wet brown bag with 3 take out containers dated [DATE], a small, opened snack tray containing slices of apples and pretzels with use by date [DATE]. The apple slices had some brown colored fluid on them. The refrigerator also contained four 32 fluid ounce Nutritional Supplements that were opened. There was no label indicating the open date or use by date on them. During an interview on [DATE] at 9:40 AM, the Dietary Manager indicated she conducted daily checks in the morning and discarded expired food. She further indicated that she had completed the daily check of the nourishment refrigerator that morning and had not noticed these bags of takeout food. The Dietary Manager indicated the nursing staff were responsible to label any opened nutrition supplement or thickened liquid carton with an open date. B. Observation of the nourishment refrigerator #1 (Kitchenette #1) on [DATE] at 9:45 AM revealed a plastic bag containing takeout food dated [DATE]. The refrigerator also contained two opened 46 fluid ounce nectar thick water cartons with no open date on them and, two opened nutritional supplements dated [DATE]. During an interview with the Dietary Manger on [DATE] at 9:45 AM, she indicated the nursing staff were responsible to label all opened nutritional supplements with an open date. During an interview on [DATE] at 2:58 PM, the Director of Nursing (DON) stated the nurses should label all opened nutrition supplements with an open date. DON indicated nutritional supplements use on the medication cart should be discarded within 24 hours of opening. Any thickened liquid when opened should be discarded within 72 hours of opening. The DON indicated all perishable food brought by families for residents should be discarded within 72 hours if the resident does not consume them. The DON stated the dietary department was responsible to ensure these foods were discarded within 72 hours.

Based on observations, record reviews, resident and staff interviews, the facility's Quality's Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification and complaint survey conducted on [DATE]. This was for recited deficiencies in the areas of Food Procurement/Prepare/serve-Sanitary (F812) and Care Plan Timing and Revision(F657). These deficiencies were recited during an annual recertification and complaint survey conducted on [DATE]. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This tag is cross-referenced to: F812: Based on observations, record review and interviews the facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in reach-in refrigerator and failed to maintain the kitchen equipment clean. The facility failed to label, and date opened dietary supplements and thickened liquids, failed discard expired food and failed to maintain the refrigerator clean for 2 of 2 nourishment refrigerator. These have the possibility to affect all residents. During the complaint/recertification survey dated [DATE], the facility failed to label and date food stored in the walk-in refrigerator, discard foods with expired use by date in the walk-in refrigerator and reach in refrigerator. The facility failed to discard expired food in 2 of 2 nourishment refrigerators reviewed for food storage (Nursing station #1 and Nursing station #2). The facility failed to ensure the plate warmer and the nourishment refrigerator #2 (near nursing station #2) were maintained clean. The Dietary Manager failed to change gloves and perform hand hygiene in between tasks when observed during meal preparation. F657- Based on record reviews, resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 41). During the complaint/recertification survey [DATE], the facility failed to conduct care plan meetings with residents or resident representatives for 1 of 19 sampled residents reviewed for care plans. An Interview with the administrator and the Regional Director (RD), conducted on [DATE] at 2:30pm, revealed the administrator had been in the position since [DATE], and he stated he was still learning about all the procedures involved in the survey process. The RD stated that he continued to train the administrator in policy and procedures that relate to QAPI and follow-up of the Plan of Correction (POC) post survey. The RD further explained the QAPI/Quality Assurance (QA) Manual was being updated and improvement performance was being monitored and evaluated for better outcomes. The administrator further stated it was his responsibility to make sure process and follow-ups continued and the planned outcome was met. The RD revealed that since the last survey changes had been made to the process of the MDS scheduling and admission assessments.

Based on records review, and staff interviews, the facility failed to have Advance Directives (code status) in the residents' records for 1 of 1 resident reviewed for Advance Directives (Resident #41). Findings included: Resident #41 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #41 was assessed as severely cognitively impaired. Resident #41's comprehensive care plan dated 1/4/24 did not contain information regarding code status or Advance Directives. At the time of physician's orders review on 2/26/24, there was no active order for code status in Resident #41's medical record in neither the Electronic Health Record (EHR) nor hard copy chart. An interview was conducted with Nurse #1 on 2/27/24 at 12:15 PM. Nurse #1 stated the code status was usually displayed in EHR, next to the resident's picture, in the physician's orders or hard copy chart for Advance Directives. Nurse #1 confirmed that there was no documentation to indicate the code status for Resident #41. During an interview on 2/27/24 at 12:40 PM, the Director of Nursing (DON) stated the residents Advance Directives were entered by the social worker in the EHR and in the resident's hard copy chart. The DON further stated Nurses looked for a resident's code status under the resident profile, displayed next to the resident's picture in the EHR. In addition, the staff could look up the code status in the physician orders or in resident's hard copy chart. The DON reviewed Resident #41's medical records, including EHR, hard copy the crash cart and confirmed that there was no information regarding the resident's code status. DON stated the Social Worker (SW) and /or Social Worker Assistant were responsible for ensuring the resident's code status was reviewed with the resident and /or resident's representative and entered in the resident's chart. During an interview on 2/27/24 at 12:50 PM, the Social Worker assistant stated when any resident was newly admitted to the facility, the resident's code status was indicated in the discharge summary. During the baseline line/ initial care plan meeting the code status was discussed with the resident and/or resident's representative and the new code status was entered in the EHR near the resident's profile. The physician was given a copy of the resident's code status to be signed, and the order was entered in the resident's chart. She stated, if the resident / resident representative had opted for Do Not Resuscitate (DNR), then she would place a copy of the code status in the Code status book near the nursing station. The Social Worker assistant stated if any resident was Full Code, then there was no documentation placed in the Code status book. She indicated Nurses could see the code status in the EHR near the resident profile, in the hard copy chart and in the code status book. During an interview on 2/28/24 at 1:15 PM, Nurse Practitioner #1 stated that the staff would discuss with the resident and/or resident representative about Advance Directives and code status. This information was notified to her, and the order was signed. The staff would then enter the information in the resident's record. During an interview on 2/29/24 at 9:58 AM, the Administrator stated the resident's code status should be entered in the resident's electronic medical record and hard copy chart at admission. Resident #41 should have a code status order and should be care planned based on his code status.

Based on record review, resident, and staff interviews, the facility failed to complete a thorough investigation for an allegation of physical abuse for 1 of 3 residents (Resident # 68) investigated for abuse. The findings included: Review of the abuse neglect policy dated 1/3/24, read in part: revealed the facility protocol included an investigation checklist which included a review of the staff schedule, interview(s) of employees directly involved and witness(es) who observed or had knowledge of the alleged incident or injury and complete statements of the event, interview the resident, other residents, visitors, vendors, and complete witness(es) statements of the event. Resident # 68 was admitted to the facility on [DATE]. The quarterly Minimum Data Set(MDS) dated [DATE], revealed Resident #68's cognition was intact. The facility 24- hour incident report dated 10/3/23 at 11:00 AM, revealed the facility was made aware by Resident #68 that Nurse Aide #2 had pulled her hair and stuck a finger in her ear. The 5-day summary of investigation completed by the Administrator on 10/9/23 revealed oral statements were obtained from Resident #68 and Nurse Aide #2. There was no evidence a written statement was obtained from Resident #68 or Nurse Aide #1 and no evidence of interviews or written statements with witness(es) who observed or had knowledge of the alleged incident or injury or interviews with other residents who may have had contact with the Nurse Aide #2. Nurse Aide #2 was suspended for 3 days and later terminated for poor customer service. The facility did not substantiate the allegation. An interview was conducted with Resident #68 on 02/26/24 11:48 AM. Resident #68 reported she was interviewed by the Administrator and the Director of Nursing, and she told them was not harmed by the aide and felt bad they let the aide go because she was a good aide. A telephone interview was conducted on 2/27/24 at 7:20 AM. Nurse Aide #2 stated she was unaware of the allegation until she was called into the office on 10/3/23 by the Administrator and Director of Nursing, who informed her that Resident #68 had reported Nurse Aide #2 had pulled her hair and stuck a finger in Resident #68's ear and the resident felt abused. Nurse Aide #2 stated Nurse #2 was present during interaction with Resident #68. Nurse Aide #2 stated she was interviewed by the Administrator or the Director of Nursing but she had not be asked to write a statement about the allegation. An interview was conducted on 2/26/24 at 2:41 PM in conjunction with a record review with the Administrator who completed the 5 -day investigation summary dated 10/9/23. He revealed he and the former Director of Nursing obtained oral statements from Resident #68 and Nurse Aide #2 but did not have written statements from Resident #68 or Nurse Aide #2 documenting the allegation. He further stated the facility process would include interviews with witness(es) who observed or had knowledge of the alleged incident or injury, and interviews with other residents who may have had contact with the alleged Nurse Aide #2.The Administrator acknowledged the investigation process had not been followed or completed per the facility protocol when he did not obtain the written statements from Resident #68, Nurse [NAME] #2, or interview Nurse #2. The Administrator stated it was an oversight. An interview was conducted on 2/27/24 at 8:17 AM, Nurse #2 stated she had worked with Nurse Aide #2 on the day of the alleged incident. Nurse #2 stated she did not witness the alleged abuse. She had become aware of the allegation after Nurse Aide #2 had been terminated. Nurse #2 stated any allegation of abuse, the process would have been, each person that was involved would have written a statement, shift nurses would have been interviewed, resident interview, resident assessment etc. Nurse #2 stated she was not asked to write a statement or asked any questions regarding the alleged staff interaction with Resident #68. A telephone interview was conducted on 2/28/24 at 8:29. The former Director of Nursing stated that standard procedures for abuse investigation was to obtain written statements of all individuals involved, to include residents, staff, nursing would perform head to toe assessments, resident would be asked abuse interview questions She stated she could not recall if other staff that were present were interviewed. The former Director of Nursing stated she did not recall if statements were obtained from the Unit Supervisor or the staff working on the unit with the resident or the accused nurse aide (NA #2). NA #2 was not terminated based on the abuse allegation, but for poor customer services related to previous incidents.

Based on record review, and staff interview the facility failed to conduct a baseline care plan within 72 hours of admission for 2 of 2 residents reviewed for base line care plan. (Resident #91 and Resident #252). Findings included: 1. Resident #91 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was admitted on [DATE]. The resident was assessed as cognitively intact. Review of the discharge return anticipated MDS dated [DATE] revealed the resident was discharged to hospital. The resident was readmitted to the facility on [DATE]. Review of the Social Worker (SW) note dated 2/26/24 indicated the interdisciplinary team completed a 72-hour meeting for readmission. The code status and resident discharge plan to return home were discussed. During an interview on 2/26/24 at 10:42 AM, Resident #91 stated she does not recollect having a base line care plan meeting and a summary of baseline care plan provided to her. Resident further stated she returned from the hospital 4 days ago. During an interview on 2/28/24 at 9:54 AM, the Social Worker (SW) stated the Baseline care plan for all newly admitted residents was completed within 72 hours of admission. The SW indicated during the baseline care plan meeting the team discussed with resident and their representatives, their discharge goals, rehab, dietary and nursing goals. The SW further stated base line care plan summary was not provided to residents and/or resident's representatives. She indicated she documented the details of the meeting conducted in the resident's electronic medical record (EHR). The SW stated they had missed the baseline care plan meeting during the initial admission and had conducted a baseline care plan meeting on 2/26/24 upon readmission. 2. Resident # 252 was admitted to the facility on [DATE]. Review of the 5 days Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. During an interview on 2/26/24 at 10:59 AM, Resident #252 stated she did not have any care plan meeting since her admission. She stated she did not receive any summary of her baseline care plan. During an interview on 2/28/24 at 10:22 AM, the Social Worker (SW) stated the baseline care plan meeting with newly admitted residents and/or resident representatives was conducted within 72 hours of admission. She indicated the interdisciplinary team were meeting with the resident and resident representative today (2/28/24). The SW stated the Admission assistant was responsible to schedule the baseline care plan meeting with resident representative per their preference. During an interview on 2/28/24 at 10:43 AM, Admission assistant stated she usually schedules the baseline care plan meeting within 72 hours of admission with the resident and/ or resident's family. She indicated she had missed scheduling a baseline care plan meeting for Resident #252 within 72 hours of admission. The meeting was set up for today (2/28/24). During an interview on 2/28/24 at 11:00 AM, The [NAME] President of Operations stated baseline care plan meeting should be conducted with the resident and/or resident representative within 48 hours of resident's admission. A summary of the initial baseline care plan should be signed by the resident and /or resident representative and a copy should be provided to them.

Based on record reviews, resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 41). The findings included: Resident #41 was readmitted on [DATE] with diagnoses in part, end stage renal disease, dependence on renal dialysis, and dementia. A record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed as severely cognitively impaired and was dependent on staff for most of the activity of daily living. Review of the resident's comprehensive care plan revealed it was reviewed by staff on 1/4/24 but there was no indication that the resident and/or resident's representative participated in the care plan meeting or in the development of Resident #41's plan of care. During an interview on 2/26/24 at 12:31 PM, Resident #41 indicated he or his family had not participated in his care plan meeting and did not receive any invitation to participate in the care plan meeting. During an interview on 2/28/24 at 9:59 AM, the Social Worker (SW), stated Resident #41 was admitted on [DATE] and a baseline care plan meeting with resident's representative was completed on 12/27/23. The SW further stated the resident was cognitively impairment and was unable to participate in baseline care plan meeting. The SW indicated that comprehensive care plan meetings were not conducted with resident and/or resident representative. She stated the baseline care plan meetings were conducted within 3 days of admission with resident/and or resident representatives in very detail by all team members. She further indicated the Social Services completed their assessment and the resident's discharge planning, code status, financial details, therapy, and other issues were discussed in detail during the baseline care plan meeting. The SW stated she was not aware that a care plan meeting should be conducted after the comprehensive care plan was completed by the interdisciplinary team. The SW indicated the SW assistant was responsible for sending out care plan meeting letters and documented the care plan meeting in detail in residents' charts. SW confirmed only baseline care plan meeting was conducted at the time of admission and no comprehensive care plan meetings were conducted with residents and/or residents' representatives. During an interview on 2/28/24 at 10:19 AM, the Social Worker assistant stated she received a monthly calendar from the MDS nurse that indicated the quarterly, annual, and significant change MDS completion dates. She further stated that based on this calendar a letter was sent out to residents/resident representatives and a care plan meeting was scheduled. She indicated she maintained the attendance log as to who participated in the meeting. She further indicated She did not schedule the comprehensive care plan meeting for Resident #41 because it was not indicated in the monthly calendar sent to her. During an interview on 2/28/24 at 10:28 AM, the MDS Nurse coordinator stated a monthly calendar which includes the Assessment Reference Date (ARD) for quarterly, annual, and significant change MDS was given to the Social Services. The MDS Nurse coordinator stated the Social Services conducted a baseline care plan meeting with residents and their representatives and during that meeting, the comprehensive care plan meeting was scheduled with the residents and/or resident representatives. MDS Nurse Coordinator restated that the calendar sent to the Social Services did not include the comprehensive assessment ARD as it was thought that the Social Services department would had scheduled meetings for comprehensive care planning during their 72-hour care plan meeting. During an interview on 2/28/24 at 10:37 AM, the [NAME] President of Operations stated the expectation was that care plan meetings and notifications were sent to residents and/or resident representatives per the state/ federal regulations. The [NAME] President of Operations stated the care plan should be reviewed and revised by the interdisciplinary team after each assessment, including comprehensive assessments. He further stated residents and/or resident's representatives should be involved in the care plan meeting and make decisions about their care.

Based on record review, resident interview, staff interview, Psychiatric Nurse Practitioner, and Psychologist interview the facility failed to assure the providers of psychiatric services were aware of altercations and behaviors for residents for whom the psychiatric providers were treating. This was for three (Residents # 5, # 6, an #8) of three residents reviewed for behavioral problems. The findings included. 1. Review of Resident # 5's record revealed Resident # 5 was admitted to the facility on [DATE]. The resident had a diagnosis of depression and a diagnosis of cognitive social or emotional deficit following a stroke. Resident # 5's annual Minimum Data Set Assessment (MDS), dated [DATE], coded Resident # 5 as cognitively intact and as independent in his locomotion within the facility. Resident # 5 was not coded to have behavior problems during the MDS assessment period. Resident # 5's care plan noted Resident # 5 had behaviors related to inappropriate sexual advances and sexually inappropriate language towards others. This had been added to the care plan on 10/13/22 and remained part of Resident # 5's care plan. An intervention for Resident # 5's sexual behavior was to provide a psychological evaluation as needed. Review of Resident # 5's psychotherapy notes revealed Resident # 5 was seen on 6/2/23. The clinical psychologist noted no mention of sexual behaviors in her notes. She noted Resident # 5 had the following symptoms: Anhedonia (the inability to feel pleasure), anxiety, fatigue, grief/loss, life dissatisfaction, poor decision making, ruminating thoughts, sadness, and worry. She further noted his next treatment plan was due 8/5/23. Review of Resident # 5's social work notes for the month of July 2023 and August 2023 revealed no notation of behavioral issues. On 7/15/23 at 3:26 PM Nurse # 1 entered a nursing note into Resident # 5's record noting Resident # 5 had been in an altercation with another resident, and Resident # 5 was placed on every 15 minute checks by staff. Nurse # 1 was interviewed on 8/10/23 at 10:00 AM and reported the following. When the 7/15/23 incident occurred no staff member had witnessed the incident. Resident # 6 had been the other resident involved in the altercation. She had heard Resident # 6 yell. When she entered the room, Resident # 6 had reported to her that Resident # 5 had hit her. She assessed Resident # 6 and found no injuries. Resident # 5 denied he had hit Resident # 6. Instead, Resident # 5 stated that Resident # 6 had run her wheelchair into him. Resident # 5 stated he had wanted to hit Resident # 6 but had not done so. Resident # 8 had been present at the time and reported Resident # 5 had hit Resident # 6. The facility social worker assistant was interviewed on 8/10/23 at 12:00 PM and again on 8/11/23 at 12: 29 PM and reported the following. She was familiar with both Resident # 5 and Resident # 6. Both had behavioral issues. Resident # 5's behavioral issue involved making sexual comments to staff. She had never known Resident # 5 to make the comments to residents. His behavior had improved since he had resided at the facility. Review of the facility's Psychiatric Nurse Practitioner's (NP) notes revealed Resident # 5 was seen on 7/19/23. The Psychiatric NP noted the following. She was seeing Resident # 5 for a visit related to chronic problems with insomnia and sexual behavior. Staff had reported no problems with his mood, sleep and appetite. His sexual behavior was noted to be managed with an antidepressant. There was no mention in the Psychiatric NP's notes about the altercation that had occurred on 7/15/23. Resident # 5 was interviewed on 8/10/23 at 1:35 PM and reported the following. He did not recall the details of any specific altercation with another resident, and he stated he had never hit anyone. He did at times make sexual jokes but meant no harm by them, and only said them to people who he thought might not be upset by his remarks. Resident # 6 was interviewed on 8/9/23 at 4:45 PM and reported the following. On the date of the 7/15/23 incident, Resident # 5 kept saying sexual remarks to her while they were in the television room, and she told him to go away. Resident # 5 then hit her. During the interview with Nurse # 1 on 8/10/23 at 10:00 AM, Nurse # 1 reported neither Resident # 6 nor the witnessing resident (Resident # 8) had said anything about sexual advances by Resident # 5. The Psychiatric NP was interviewed on 8/11/23 at 2:20 PM and reported the following. She saw Resident # 5 routinely every month. When she visited the staff always told her Resident # 5 had verbal sexual behaviors towards staff but not to residents. She had started Resident # 5 on an antidepressant to help decrease his Libido. She did not think Resident # 5 meant to hurt anyone from his remarks. She had seen Resident # 5 on 7/19/23 and none of the facility staff had mentioned the 7/15/23 altercation that had occurred between Resident # 5 and Resident # 6. Their practice had a triage line that was available to the facility 24 hours per day and at any point if an altercation occurred or details about behaviors needed to be discussed, the facility could call and talk to someone through their practice. The clinical psychologist, who provided psychotherapy to Resident # 5 and Resident # 6, was interviewed on 8/11/23 at 3:15 PM and reported the following. She routinely saw both Resident # 5 and Resident # 6. She was in the facility every other Friday and talks to the staff. She would like to know about any altercations and behaviors that her residents have, but she was never informed about any altercation between Resident # 5 and Resident # 6 that occurred in July 2023. The clinical psychologist stated details about behaviors and altercations are important for her know. The interim Administrator and the Director of Nursing were interviewed together on 8/10/23 at 11:15 AM and reported the following. Both Resident # 5 and Resident # 6 were interviewed about the altercation which had occurred on 7/15/23, and both were not consistent in their details of the altercation. No staff member or resident had mentioned to them that Resident # 5 made sexual comments to other residents. 2. Review of Resident # 6's record revealed Resident # 6 was admitted to the facility on [DATE] and had a diagnosis of depression. Resident # 6's quarterly MDS assessment, dated 6/14/23, coded Resident # 6 as cognitively intact. Resident # 6 was assessed to have verbal behaviors one to three days during the MDS assessment period. Resident # 6 was also coded to need supervision/cueing for independent locomotion in the facility within the assessment period. Resident # 6's care plan noted Resident # 6 received medication to treat depression. This was added to the care plan on 2/20/23 and remained part of Resident # 6's current care plan. Staff were directed on the care plan to monitor Resident # 6 for behaviors such as sadness, irritability, anger, and attention seeking behaviors. On 7/15/23 at 3:20 PM Nurse # 1 entered a nursing note into Resident # 6's record that the resident had been involved in an altercation. Nurse # 1 noted she had heard Resident # 6 scream and when she responded, Resident # 6 alleged she had been hit by another resident. Review of a facility's 7/17/23 investigation into the altercation, which occurred on 7/15/23, revealed Resident # 6 alleged that Resident # 5 had hit her. On 7/19/23 the Psychiatric NP noted she saw Resident # 6 for a chronic mood disorder and insomnia. The Psychiatric NP noted there were no concerns from staff, and there was no notation about the altercation that had occurred on 7/15/23. On 8/8/23 Resident # 6's care plan was updated to reflect she had been in an altercation with another resident. On 8/9/23 another problem was created on Resident # 6's care plan noting the resident exhibited manipulative and persuasive behaviors. This problem was noted on the care plan to have been initiated on 7/18/23 as applicable to Resident # 6. Resident # 6 was interviewed on 8/9/23 at 4:45 PM and reported the following. On the date of the 7/15/23 incident, Resident # 5 kept saying sexual remarks to her while they were in the television room, and she told him to go away. While Resident # 5 was seated in his wheelchair behind her, Resident # 5 then pulled her (Resident # 6's) wheelchair back towards him and hit her in the arm, chest, and head. The nurse came in after she was hit. The nurse asked them what happened, and Resident # 5 lied and said that she (Resident # 6) had pushed her wheelchair into him. Resident # 6 stated that was not true, and she had not pushed her wheelchair into Resident # 5. During the interview with Nurse # 1 on 8/10/23 at 10:00 AM, Nurse # 1 reported neither Resident # 6 nor the witnessing resident (Resident # 8) had said anything about sexual advances by Resident # 5 and no staff member had witnessed the incident. The facility social worker assistant was interviewed on 8/10/23 at 12:00 PM and again on 8/11/23 at 12: 29 PM and reported the following specific behaviors Resident # 6 demonstrated. Resident # 6 had verbal and manipulative behaviors. She would try to ask staff and residents for cigarettes and when she did not get her way, she would go off cursing down the hall. She was not fond of anyone and her words were not always kind to other residents. The previous week, she (the SW assistant) had heard Resident # 6 mimic a cognitively impaired resident who was asking repetitively about where her room was. Resident # 6 had also befriended Resident # 8, who was alert and oriented, and the SW Assistant felt as if Resident # 6 could get Resident # 8 to agree with Resident # 6 even if something was not true. The Psychiatric NP was interviewed on 8/11/23 at 2:20 PM and reported the following. She saw Resident # 6 routinely every month. She had seen Resident # 6 on 7/19/23 and none of the facility staff had mentioned the 7/15/23 altercation that had occurred between Resident # 6 and Resident # 5. She was not aware it had occurred. Also, none of the staff had mentioned to her any details about unkind words Resident # 6 was saying to other residents or that another resident was copying Resident # 6's opinions about things. She visited every month and would want to know about altercations and behavior details. Their practice had a triage line that was available to the facility 24 hours per day and at any point if an altercation occurred or details about behaviors needed to be discussed, the facility could call and talk to someone through their practice. The clinical psychologist, who provided psychotherapy to Resident # 5 and Resident # 6, was interviewed on 8/11/23 at 3:15 PM and reported the following. She routinely saw both Resident # 5 and Resident # 6. She was in the facility every other Friday and talks to the staff. She would like to know about any altercations and behaviors that her residents have, but she was never informed about any altercation between Resident # 5 and Resident # 6 that occurred in July 2023. The clinical psychologist stated details about behaviors and altercations are important for her know. The interim Administrator and the Director of Nursing were interviewed together on 8/10/23 at 11:15 AM and reported the following. Both Resident # 5 and Resident # 6 were interviewed about the altercation which had occurred on 7/15/23, and both were not consistent in their details of the altercation. The DON further reported that she was aware Resident # 6 did not always portray the truth in what she said, and the DON had witnessed this herself. 3. Resident # 8 was admitted to the facility on [DATE]. The resident's diagnoses included depression and a history of substance abuse. Resident # 8's Minimum Data Set assessment, dated 6/1/23, coded Resident # 8 as cognitively intact and without behaviors during the assessment period. Resident # 8's care plan revealed Resident # 8 received medication for depression. This was initially added to Resident # 8's care plan on 8/4/22 and remained part of Resident # 8's current care plan. Staff were directed on the care plan to monitor Resident # 8 for behaviors, which included attention seeking behaviors. Staff were also directed on the care plan to refer Resident # 8 for mental health services as needed. On 8/2/23 Resident # 8 was seen by the Psychiatric Nurse Practitioner. The psychiatric NP noted she was seeing Resident # 8 for depression and insomnia, which were chronic conditions for which she had been seeing Resident # 8. The Psychiatric NP noted that staff reported no new behavioral issues or concerns. The Psychiatric NP did not note any behavioral issues regarding manipulation or fabrication. On 8/9/23 another problem was created on Resident # 8's care plan to reflect Resident # 8 had manipulative and persuasive behaviors and would fabricate information. The care plan reflected this problem had been initiated on 7/18/23. Nurse # 2 was interviewed on 8/11/23 at 12:05 PM regarding Resident # 8's behaviors and reported if Resident # 8 wanting something, then she would work to get it. Nurse # 2 reported the following example regarding Resident # 8's behavior. Within the last month another resident (Resident # 10) had a soda drink which Resident # 8 wanted. Resident # 8 lied to a NA (Nurse Aide) and told the NA that Resident # 10's soda drink was hers while thinking she would then get the drink for herself. A second NA then approached during the interaction, spoke up and let the first NA know that she (the second NA) had gotten the drink for Resident # 10 and that Resident # 8 was not being honest in order to take the soda drink from Resident # 10. The facility social worker assistant was interviewed on 8/10/23 at 12:00 PM and again on 8/11/23 at 12: 29 PM and reported the following. Resident # 8 had been befriended by another resident (Resident # 6), who also had manipulative behavior. Since they had formed a friendship, Resident # 8 copied Resident # 6's opinions. The social worker gave the following example. Resident # 8 used to be friends with another resident in the facility (Resident # 9). Resident # 6 did not get along or like Resident # 9. Therefore, Resident # 8 no longer counted or treated Resident # 9 as a friend either. The Psychiatric NP was interviewed on 8/11/23 at 2:20 PM and reported she was not aware Resident # 8 was copying another resident's opinions for her own or had manipulative behavior. She stated details were significant in the treatment of behavioral issues and she had been unaware of Resident # 8's recent behaviors towards other residents. The Director of Nursing was interviewed on 8/10/23 at 11:15 AM and reported the following. The DON reported that she was aware Resident # 8 did not always portray the truth in what she said, and the DON had witnessed this herself.

Based on record review, resident interview, and staff interview the facility failed to implement their abuse policy to 1) assure an abuse allegation was reported to facility administration immediately in order that administration take further actions per their policy and 2) to assure the investigation was thorough enough to identify and talk with a witness who had been present. This was for one (Resident # 6) of four residents reviewed for abuse. The findings included: The facility's abuse policy, last revised on 8/30/2022, included the following information. The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but no later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. Resident # 6 was admitted to the facility on [DATE]. Resident # 6's quarterly MDS assessment, dated 6/14/23, coded Resident # 6 as cognitively intact. Resident # 6 was assessed to have verbal behaviors one to three days during the MDS assessment period. Resident # 6 was also coded to need supervision for locomotion in the facility. Resident # 6's care plan, revised on 8/8/23, noted Resident # 6 exhibited manipulative and persuasive behaviors. On 7/15/23 at 3:20 PM Nurse # 1 entered a nursing note into Resident # 6's record noting the following. Resident had altercation with another resident in T.V room. Staff heard resident screaming, upon arrival, resident states resident hit her. Other resident removed from room. Resident assess for injuries. No injuries noted. RP/MD (responsible party/medical doctor) notified. Other resident on 15 min monitoring. Will continue to monitor. According to the facility's investigation into the incident, Resident # 5 had been the resident who had allegedly hit Resident # 6. Review of Resident # 5's record revealed Resident # 5 was admitted to the facility on [DATE]. Resident # 5's annual Minimum Data Set Assessment (MDS), dated [DATE], coded Resident # 5 as cognitively intact and as independent in his locomotion within the facility. Resident # 5 was not coded to have behavior problems during the MDS assessment period. Resident # 5's care plan, updated on 8/8/23, noted Resident # 5 had behaviors related to inappropriate sexual advances and sexually inappropriate language towards others. This had been added to the care plan on 10/13/22 and remained part of Resident # 5's care plan. On 7/15/23 at 3:26 PM Nurse # 1 entered a nursing note into Resident # 5's record noting Resident # 5 had been in an altercation and Resident # 5 was placed on every 15 minute checks by staff. Review of the facility's investigation into the incident revealed the 7/15/23 incident was reported to the state agency on 7/17/23, which was two days after the incident occurred. The investigation summary noted, Resident (Resident # 6) claims to have been hit by another resident. It was not witnessed and residents in question kept changing their account of incident. No injuries noted on either resident. Resident # 6 was interviewed on 8/9/23 at 4:45 PM and reported the following. On the date of the 7/15/23 incident, Resident # 5 kept saying sexual remarks to her while they were in the television room, and she told him to go away. While Resident # 5 was seated in his wheelchair behind her, Resident # 5 then pulled her (Resident # 6's) wheelchair back towards him and hit her in the arm, chest, and head. At the time Resident # 8 was present in the room also and saw what happened. The nurse came in after she was hit. The nurse asked them what happened, and Resident # 5 lied and said that she (Resident # 6) had pushed her wheelchair into him. Resident # 6 stated that was not true, and she had not pushed her wheelchair into Resident # 5. Resident # 6 reported she was not hurt, but it did make her sore where she had been hit. Resident # 5 was interviewed on 8/10/23 at 1:35 PM and reported the following. He did not recall the details of any specific altercation with another resident and stated he had never hit anyone. He did at times make sexual jokes but meant no harm by them, and only said them to people who he thought might not be upset by his remarks. Nurse # 1 was interviewed on 8/10/23 at 10:00 AM and reported the following. When the 7/15/23 incident occurred no staff member had witnessed the incident. She heard Resident # 6 yell out. When she entered Resident # 5 was not at the back of Resident # 6's wheelchair. Resident # 5 was facing towards Resident # 6 from a diagonal position. Resident # 6 reported to her that Resident # 5 had hit her. Resident # 5 reported to her that Resident # 6 had pushed her wheelchair into his knees, and he wanted to hit her but had not done so. At the time Resident # 8 was present. She (Nurse # 1) asked Resident # 8 what happened, and Resident # 8 stated Resident # 5 had hit Resident # 6. Nurse # 1 reported the incident occurred on a weekend, and she tried to call the Director of Nursing (DON) but could not get in touch with her. At the time of the incident, Resident # 6 did not report any problems with Resident # 5 making sexual remarks to her. She placed Resident # 5 on every 15 minute checks and called the responsible parties and physician. A review of Resident # 8's record revealed an annual MDS assessment of 6/1/23 noting Resident # 8 was cognitively intact. Resident # 8's care plan, updated on 8/9/23, revealed Resident # 8 exhibited manipulative behaviors and would fabricate information. The facility social worker assistant was interviewed on 8/10/23 at 12:00 PM and reported Resident # 5, Resident # 6, and Resident # 8 all have behavioral issues. To her knowledge, Resident # 5 used to exhibit sexual behavior to staff only and not towards residents, but his behaviors had improved. Resident # 6 and Resident # 8 were close friends, and she thought Resident # 8 would say anything that Resident # 6 wanted her to say although it might not be true. The Social Worker Assistant provided examples of both Resident # 6's and Resident # 8's behaviors. The Director of Nursing and interim Administrator were interviewed on 8/10/23 at 11:15 AM and reported the following. The DON was reviewing clinical records on 7/17/23 and found the notation about the 7/15/23 incident. This was the first time she or the interim Administrator knew about the incident. Her staff had not reported it before then. She always carried and answered her phone at all times when she was at or away from the facility. The staff could have reached her on the weekend. Both Resident # 5 and Resident # 6 were interviewed during the facility's investigation and were inconsistent in what they reported. Resident # 6 had not reported any problems with Resident # 5 making sexual remarks to her. During their investigation, they had not been made aware Resident # 8 had witnessed the incident and therefore had not talked to her and given any consideration to her details of what happened. On 8/11/23 at 5:45 PM the facility's corporate [NAME] President (VP) was interviewed. According to the VP, the facility's investigation should have identified there was a witness on 7/15/23 and the witness should have been interviewed during the facility's investigation.

Based on observations, record reviews and interviews the facility failed to have sufficient dietary staff with competencies to carry out meal preparation and food service tasks for 101 of 103 residents who received meal trays. The findings included: During an interview on 3/27/23 at 10:15 AM, the dietary manager stated he was not having sufficient staff as some of the dietary staff had quit. The dietary manager stated there was no cook in the morning as a result was responsible for cooking breakfast and lunch for the residents. He further stated he had only two dietary aides who assisted him with cleaning and other kitchen jobs. He stated the plate warmers needed to be cleaned over the weekend and there was no adequate staff to complete the cleaning task. During an interview on 3/27/23 at 10:40 AM, dietary aide #1 stated there was usually one cook and 2 dietary aides in the morning. She further stated that the cook was not coming in for few days and the dietary manager was working as the cook. She indicated she had yet to complete cleaning of the carts before she could clean other kitchen equipment. During a continuous observation of meal preparation and tray line on 3/28/23 from 11:25 AM to 12:00 PM, the dietary manager was observed cooking resident's meals. There was no alternate menu prepared and available for the residents on the tray line. During an interview on 3/28/23 at 2:40 PM, the dietary manager stated that the dietary department needed staff. The department had no cook, and he was working as a cook. He stated he did not have adequate time to complete cooking of the alternate entree and hence was not served at lunch. He further stated he was responsible for cleaning the nourishment refrigerators but hadn't been having time due to lack of staffing. He stated there were 2 dietary aides and himself in the morning. One dietary aide usually comes around 12 PM and a cook comes in the afternoon to complete the evening cooking. A review of the dietary staff schedule revealed on 3/27/23 there was one person assigned as cook and two dietary aide for the morning shift. There was one cook and two aide for the evening shift. Observation revealed on 3/27/23 the dietary manager was the cook on duty for the morning shift and there were 2 dietary aides on the morning shift. Review of the dietary staff schedule revealed on 3/28/23, revealed there was no one assigned as a cook. There were 2 dietary aide assigned for morning shift. There was one cook and two aide for the evening shift. Observation on 3/28/23 revealed the dietary manager was the cook on duty for the morning shift and there were 2 dietary aides on the morning shift. One cook and 2 dietary aides were observed in the evening shift. Review of the dietary staff schedule from 3/16/23 - 3/29/23 revealed on 3/16/23 and 3/17/23 there was only one dietary aide for evening shift; On 3/20/23 and 3/21/23 there was no cook assigned on morning shift. On 3/24/23 there was only one dietary aide assigned in the evening shift. On 3/25/23 there was no cook assigned to the morning and in the evening shift. There was only one dietary aide assigned on 3/26/23 for both morning and evening shift. During an interview with the Dietary manager on 3/28/23 at 2:20 PM, he indicated the dietary department did not have adequate staff and he stepped in as a cook when there was no cook or any call outs. Review of the food temperature chart logs from 2/1/23 to 3/27/23 revealed 20 daily food temperature chart log sheets that did not contain at least one meal food temperatures entered in them. During an interview with the dietary manager stated he was aware the evening cooks were not entering the food temperatures of menu items after cooking and prior to plating. He indicated he had requested the staff to enter them multiple times. During an interview on 3/29/23 at 4:51 PM, the Administrator stated four (4) dietary staff had quit few weeks ago. The facility was actively recruiting since, and multiple interviews had been conducted. The jobs had also been offered to few based on their background checks, however they were no show. The Administrator stated the dietary manager's primary function has been a cook until the facility has adequate dietary staff.

Based on observations, test tray evaluation, resident interviews (Resident #314, Resident #18, Resident #76), and staff interviews, the facility failed to serve nutritive, appealing, and palatable foods to residents. Findings included: Resident #314 was admitted to the facility 3/17/23. The admission Minimum Data Set (MDS) assessment dated [DATE] was in progress. Review of the nursing note dated 3/18/23 revealed the resident was alert and oriented and could make her needs known. Resident #314 was interviewed on 3/27/23 at 1:52 PM. Resident #314 reported that the food served on the tray was bland and sometimes served cold. There was no salt or spices added to the food. Resident #18 was admitted to the facility 3/1/23. The admission MDS dated [DATE] assessed Resident #18 to be cognitively impaired. During an observation and interview on 3/27/23 at 12:16 PM. Resident #18 was observed not eating her meal tray and complaining that the food was tasteless and over cooked. Resident #76 was admitted to the facility 3/10/23. The admission MDS dated [DATE] assessed Resident #76 to be cognitively intact. Resident #76 was interviewed on 3/27/23 at 3:00 PM. Resident #76 reported that the food was not palatable, over cooked, and bland. During a continuous observation of meal preparation and tray line on 3/28/23 from 11:25 AM to 12:00 PM, the dietary manager was cooking resident's meals. During the tray line observation, the menu vegetable (cauliflower, squash, and brussels sprouts) that was on the steam table appeared to be mushy and without any seasoning. The starch (cheddar mashed potatoes) appeared to be running. The dietary manager who was plating resident's food stated the vegetable on the steam table was for mechanically altered diets and hence was well cooked. He further stated that no seasoning were added to the vegetables as it was served on therapeutic diet tray and these diets should not be served any salt. A two-test tray was requested on 3/28/23 at 12:00 PM. One was a regular diet tray, and another was a mechanically altered diet tray. These were the last tray after all the residents were served their lunch meal. The test tray was sampled with the dietitian on 3/28/23 at 1:30 PM. The regular diet tray had oven fried chicken, cheddar mashed potatoes and mixed vegetables. The mixed vegetables were served in the bowl and placed on the plate with chicken and mashed potatoes The plate was covered by a dome. The consistency was the mashed potatoes was runny and not scooped. The mixed vegetables very extremely salty to taste. The dietitian also tasted the test tray and agreed the vegetables were too salty and mashed potatoes were not correct consistency. She stated the cook should be following the recipe. The mechanically altered tray had mashed potatoes, mechanically altered meat (appeared like semi shredded chicken with a lot of gravy) and vegetables (cauliflower, squash, and brussels sprouts). The vegetables were served in a bowl and placed on the plated. The plate was covered with a dome. The mashed potatoes was runny, the mechanically altered meat had a lot of gravy and the food was running off the plate. The color of the plate was not appealing and appetizing. The vegetables were overcooked and had no salt or any seasoning in them. The dietitian also tasted the test tray. The dietitian stated she felt the mechanically altered tray was not appealing and the food was running out of the plate. She agreed the mashed potatoes and the meat were too runny and vegetables had no seasoning and was very bland. It was not an appealing or palatable plate. During an interview on 3/28/23 at 2:50 PM, the dietary manager indicated the standard recipes were followed when food were cooked for the residents. However, when seasoning or salt was added to the mechanically altered vegetables, he received complaints that the food was very salty. He indicated it was due to this reason, he has not been adding any seasoning to the vegetables. He indicated he did not report to the dietitian when he received complaints about the food being salty when seasonings were added. During an interview on 3/28/23 at 3:05 PM, the dietitian stated the recipes were available for the dietary cooks. The recipes indicate how a therapeutic diet should be prepared and cooked. The recipes also indicate the ingredients to be used, including the type and amount of seasonings needed for the menu item. The dietitian stated the dietary cooks should follow standard recipes that were printed from the nutritional software system. During an interview on 3/29/23 at 5:04 PM, the Administrator stated the expectation was the food served to the residents was nutritious, appealing, and palatable. The cook and dietary staff cooking residents' food should be following standard recipes. The Administrator indicated the dietary Manager had access to standard recipes and these were also available online.

Based on record review, observations and staff interviews, the facility failed to date opened medications in 3 of 5 medication administration carts (100, 200 and 500 halls.) and failed to remove expired medications stored in 1 of 5 medication administration carts (100 hall.) Findings Included: 1. On 3/27/23 at 10:05 AM, an observation of the medication administration cart on 200 hall with Nurse #11 revealed one opened and undated multi-dose Insulin Levemir Flex Pen Injector. A review of the manufacturer's literature indicated to discard the insulin multi-dose pen-injector 42 days after opening. On 3/27/23 at 10:10 AM, during an interview, Nurse #11 indicated that the nurses, who worked on the medication carts, were responsible for putting the date of opening on insulin multi-dose injectors. The nurse indicated that she had not checked the date of opening on insulin pen-injectors in her medication administration cart at the beginning of her shift. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. The nurse did not administer undated insulin this shift. 2. On 3/27/23 at 10:20 AM, an observation of the medication administration cart on the 100 hall with Nurse #12 revealed two opened Geri-Mox Antacid Liquid 12 fluid ounces, expired on February 2023. On 3/27/23 at 10:25 AM, during an interview, Nurse #12 indicated that the nurses, who worked on the medication carts, were responsible to check all the medications in her medication administration cart for expiration date and remove expired medications. The nurse indicated that she checked expiration date on medications at the beginning of her shift but missed expired Geri-Mox Antacids. The nurse did not administer expired medication this shift. On 3/28/23 at 8:05 AM, an observation of the medication administration cart on 500 hall with Nurse #1 revealed one opened and undated multi-dose Insulin Lantus Pen Injector. A review of the manufacturer's literature indicated to discard the insulin multi-dose pen-injector 28 days after opening. 3. On 3/28/23 at 8:15 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible for putting the date of opening on insulin pens-injectors. The nurse indicated that she checked the date of opening on medications in her cart but did not see the opened insulin injector without date at the beginning of her shift. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. The nurse did not administer undated insulin this shift. On 3/28/23 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for putting the date of opening on insulin pens-injectors, check all the medications in medication administration carts for expiration date and remove expired medications every shift. The DON stated that weekly, the pharmacy staff checked the expiration dates and removed expired medications. She expected that no expired items be left in the medication carts.

Based on resident and staff interviews and review of resident council minutes, the facility failed to address and resolve ongoing grievances about the quality, preference and palatability of food reported at resident council meetings by 5 of 5 residents who regularly attended the resident council meetings for 4 consecutive months ((12/7/22, 1/18/23, 2/8/23 and 3/8/23). (Resident #11, #32, #38, #46 and #58). The findings included: Review of resident council minutes dated 12/7/22 read in part: breakfast trays are late in mornings and food being served cold; the DM spoke with residents to assure them dietary was working on the issues. The Dietary Manager and Administrator were present. Review of the resident council minutes dated 1/18/23 read in part: the dietary manager was present at the meeting and there was no follow-up on the concerns from the previous month. Review of the resident council minutes dated 2/8/23 read in part: the residents stated they were tired of eating the same foods and would like fresh fruit daily. There was no evidence of resolution from the previous month. Review of the resident council minutes dated 3/8/23 read in part: the residents discussed food choices and there was no evidence resolution to dietary concern. Review of the resident council minutes did not reflect all the concerns identified by the residents as reported monthly. The president of resident council confirmed the minutes did not reflect all the concerns discussed monthly. I would suggest separating each month into its own paragraph. Make sure to include the concern and lack of response. Resident council meeting was held on 03/29/23 11:06 AM, there were five residents identified as alert and oriented who participated in the meeting. The members of the group reported they were regular attendees and had reported on-going food concerns during the resident council meetings as well as to management. The residents reported they had ongoing concerns with the meal of the day not being served and food items on the meal cards not available or served. In addition, the residents also reported the food preferences, likes/dislikes were not listed on the meal card and staff had no clue of what they like or not and what needs to be the substitute. The residents further stated the food was being served cold. In addition, the five members of the resident council reported administration and the previous dietary manager stated they would resolve their food concerns, but they were unaware of what action was taken to resolve the issues. The residents stated the food continued to be served cold and there were no changes in the quality of the food or the selection of food choices. The residents added there had been no individual discussions held with them by dietary or administration about the changes or resolution to their food concerns. The residents also stated that despite all the conversations held in resident council meetings discussion regarding food concerns, things have not improved. The residents further stated the registered dietician (RD) never came to talk to them, they were told one exist and we have never seen them or talk to them. They have no idea who the person was, and the dietary manager staff change so much, we have no idea what was happening with the food. The resident's stated they did not feel as though management was addressing their concerns with the food concerns. In addition, the residents further stated staff did not offer to reheat the food and when asked it took longer for the food to return. The meats were either half cooked, tough or not cooked enough. Resident #58 and #46 stated most meals you could not recognize, the oatmeal, grits and eggs were so hard it would stick to the spoon. In the same interview, the five residents reported food issues had been an on-going issue for more than 4 months and nothing was done to correct the problem. The consensus of the group was the food does not come to them hot enough and it may be soggy or dry depending on what was served for the day. Residents #46, #58 and #11 reported they have asked their family members to bring them preferred food items, so they had something to eat when the food was bad. Resident # 45 and #58 reported the food was nasty and they were tired of receiving the same breakfast and meals in general. All residents reported they were unaware of what the meal of the day was because there were no menus posted and no alternate to choose from. In addition, the residents reported they would receive random selection of foods thrown together that would include a lot of starch, no vegetables or meat, or a starch and small portion of whatever was available. Meals were late daily, cold food served at least three to four times a week. examples of poor food quality were, tough/burnt bacon, stiff/hard grits/oatmeal, mushy/soggy vegetables, too many starch foods, meats/dry tough, no fresh fruit offered/provided, eggs rubbery/overcooked, received dislikes or missing desired food items. An interview was conducted on 3/29/23 at 12:00 PM, the Activity Director stated the residents, had reported concerns in the group about the meals being served cold, receiving the same foods, no flavor/taste, preferences not being honored, meal delivered late, food missing on trays, quality, and palatability of food. The AD further stated the food concerns were given to the dietary manager after each meeting, but she was not sure what happen to resolve the concern. The Dietary manager (DM) was present for some of the meetings when food concerns were presented by the group. She reported the grievance the forms were given to each of the department heads for their response. She added the dietary staff were aware of the individual and group concerns via the form. She stated dietary staff have not directly resolved the concerns for the past several months as there were repeated food concerns by different residents during the meetings. An interview was conducted on 3/29/23 at 4:39 PM, the Administrator presented the resident council minutes that were incomplete of the resident concerns and resolutions of the identified concerns. The Administrator stated the group concerns should be submitted to the department heads after each meeting. The department head was responsible for resolutions by the next resident council meeting or sooner depending on the concern presented from meeting. The Administrator stated the expectation would be for the department heads to meet/discuss with resident/individuals the concern and resolve the concern to the resident satisfaction. An interview was conducted on 3/30/23 at 8:57 AM, with the Dietary Manager (DM) and the Administrator. The DM stated he attended a few of the resident council meetings and resolved the concerns for the residents in the group. The Administrator confirmed all the concerns were not documented in the resident council minutes to reflect the improvements that had been done. There was no evidence presented to reflect any resolution to any of the resident concerns for the past 4 months. There were no defined concerns from the group discussion the DM resolved. The DM stated he had attended the resident council meeting and was aware of the food concerns regarding temperatures, taste, and quality. The DM reported food temperatures were done daily and were accurate, but once the food left the kitchen, he did not ask residents directly about the food temperatures.DM did not follow-up with resident about any other concerns i.e., preference/likes/dislikes, food quality or variety etc.

Based on observation, record review, staff interviews, Nurse practitioner interview and Wound Physician interview, the facility failed to prevent an avoidable pressure ulcer to the right mid inner forearm and right heel that resulted in hospitalization [MEDICAL CONDITION] for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and was fully dependent on staff to accomplish activities of daily living. Resident #1 had contractures to bilateral lower extremities, bilateral hands and right arm. Review of Resident #1 care plan dated 6/3/20 revealed Resident #1 was at risk for impaired skin related to impaired mobility and incontinence with a goal to remain free from skin breakdown. Interventions included: apply barrier cream to skin after each incontinent episode paying attention to bony prominences, keep bed linen clean, dry and free of wrinkles, meds/treatment per doctor's order, required pressure relieving mattress on bed and pressure reducing cushion in wheel chair, turn and reposition on rounds and as needed. Review of Resident # 1 progress note dated 8/31/20 revealed that Resident #1 had a new wound to right forearm and right hand. Review of Resident #1 medical records revealed head to toe weekly skin assessment dated [DATE] that indicated Resident # 1 skin was impaired. Further review of weekly skin assessment revealed no documentation of Resident # 1 skin condition for the week of 8/17/20 and 8/24/20. Review of Resident #1 medical record revealed pressure ulcer risk evaluation dated 10/13/20 that indicated Resident #1 was high risk for skin breakdown, the pressure ulcer risk evaluation prior to that was dated 8/28/19 and indicated Resident #1 was at mild risk for skin Breakdown. Review of Resident #1 Occupational Therapy treatment encounter note dated 8/31/20 revealed Resident #1 had an odorous wound on the volar aspect of forearm. Review of specialty physician wound evaluation and management summary dated 9/1/20 revealed Resident #1 had a stage 4 pressure wound to the right arm. The wound size was (L x W x D) 3.0 x 2.5 x 1.0 cm with moderate serous exudate, 50 % necrotic tissue and 50% granulation tissue. The physician wound evaluation summary also revealed Resident #1 had a stage 2 pressure ulcer of the right heel that measured (L x W x D) 0.3 x 0.5 x 0.1 cm. Review of Hospital Admission History and Physical dated 9/18/20 revealed Resident #1 was seen at the emergency room for a chronic wound of the right inner arm. The doctor's assessment revealed: Presents with large stage IV pressure ulcer of flexor surface of right forearm in the setting of her chronic contracture. Also with [MEDICAL CONDITION], meets criteria [MEDICAL CONDITION] (leukocytosis and tachypnea). She received antibiotics ([MEDICATION NAME]/[MEDICATION NAME] x1), intravenous fluids, and was admitted to General Medicine for further management. Resident #1 was observed on 10/13/20 at 2:00 PM lying in bed with eyes closed, had oxygen nasal cannula on and was nonverbal. The Wound Physician and Wound Care Nurse were doing wound care. Measurements of Resident #1 wounds by Wound Physician were: 1. Right mid inner forearm: 8 x 5 x 1.3, undermining at 12 o'clock, 70% necrosis and 30% granulation. 2. Right heel: 3.5 x 3.5, blackened. Interview with Nursing Assistant #1 (NA #1) on 10/14/20 at 1:47 PM revealed she had cared for Resident #1 prior to discovery of pressure ulcer to right forearm. The interview further revealed NA#1 did not observe Resident #1 forearm skin when bathing and dressing her and therefore did not see the wound. The interview also revealed that no padding was used on Resident #1 right forearm. Interview with NA #2 on 10/13/20 at 12:53 PM revealed Resident #1 right arm skin was not observed during bathing and dressing and the wound was missed. NA #2 stated she was the one who had bathed and dressed Resident #1 and did not see the wound. She also stated she was informed of the wound by one of the therapists and would have informed the nurse if she had seen the wound. She further stated she was not instructed by anyone to use a pillow or pad the arm. Interview with Occupational Therapist (OT) on 10/13/20 at 12:23 PM revealed she was the one who had found Resident #1 right forearm wound. OT stated Resident #1 had had upper body contractures for almost a year with a lot of [DIAGNOSES REDACTED]. The interview revealed OT started working with Resident #1 on 08/24/20 for bilateral thumb range of motion. She stated that as soon as she moved Resident #1 right arm, she noticed a foul smell and her glove became wet, she pulled the resident right sleeve up and found a stage 4 wound to the mid inner forearm. She stated she informed the nurse unit manager and OT supervisor about the wound. She also stated the pressure ulcer might have been prevented if the skin was assessed everyday and arm repositioned. Interview with Nurse #1 on 10/14/20 at 1:12 PM revealed she had cared for Resident #1 prior to the discovery of Resident #1 right forearm wound. Nurse #1 stated nurses were to complete a head to toe assessment of resident skin and document it on a weekly basis. She stated she had examined Resident #1 skin and did not see any skin impairment but may have forgotten to document it. Interview with Nurse #2 on 10/14/20 at 9:02 AM revealed he was aware of requirement for residents' weekly skin assessment and documentation. He stated nurses were to assess and document resident weekly skin assessment when the reminder came up on the computer. He also stated Nursing assistants would notify nurses if they noticed any new skin impairment while bathing and dressing resident. He further stated nobody saw Resident #1 wound until OT found it. Interview with Nurse #3 on 10/14/20 at 12:12 PM revealed she was the Unit Manager. The interview revealed she was notified of Resident #1 right forearm wound by OT on 08/31/20. The Unit manager stated nurses were to complete a head to toe assessment of resident skin weekly and document their findings even if the resident did not have any skin breakdown. This interview also revealed that Resident #1 head to toe skin evaluation was not documented for the week of 8/17/20 and 8/24/20. The Unit manager stated she could not locate the missing documentation since she was not working at the facility at that time. Interview with Nurse Practitioner (NP) on 10/14/20 at 9:30 AM revealed she was informed of Resident #1 right forearm wound by the Unit Manager. She stated she found an unstageable silver dollar size wound with yellow slough on Resident #1 right forearm. The interview also revealed she asked staff to pad Resident #1 right arm and to consult Wound Physician to see Resident #1. Interview with Wound Physician on 10/13/20 at 1:22 PM revealed he was consulted by the Facility to assess Resident #1 wounds. The Wound Physician stated Resident #1 had severe contractures, was elderly and thin. He stated it was possible for Resident #1 wound to present as a stage 4 pressure ulcer because of the resident comorbidities that included diabetes and contractures. He stated padding might have helped to relieve pressure. An interview was conducted with the Director of Nursing (DON) on 10/13/20 at 12:15 PM. She stated nurses were to complete a pressure ulcer risk evaluation for all residents quarterly and more often if the resident condition warranted it. She also stated pressure ulcers could be minimized, during care if noticed. She further stated it was unfortunate that Resident #1 developed a pressure ulcer in a non-bony prominence area. A second Interview was conducted with the DON on 10/16/20 at 1:20 PM. She stated nurses were to complete resident weekly head to toe assessment and document it as per Facility Policy and Procedure for Pressure Ulcer and Skin Care Management.

Based on medical record review, staff, resident and family interview the facility failed to assess and treat 1 of 1 resident's with falls resulting in injury Resident #1. Findings included: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set assessment 5/8/18 revealed that the resident's short and long term memory were ok. She was coded as needing limited one person assistance for bed mobility, limited assistance with set up help only for transfer and supervision with one person assistance for toileting. Review of nurses note 5/18/18 8:30 AM stated, Found resident on floor. Assisted to bedside commode then to bed. Resident reports severe pain to right leg and that she hit her head. Notified Dr. and resident's daughter. Nurses note 5/18/18 9:11 AM stated, At approximately 8:20 found resident on floor near doorway. Complaints of right leg pain and headache. MD notified, daughter notified, Orders obtained. Electronic medical record note 5/18/18 at 14:06 stated, Resident fell this morning and has had change in mental status she did not want medication. Medical record review of the Medication Administration Record [REDACTED]. Review of the facility investigation revealed a signed statement by the nurse on duty (no date) on 5/18/18 which stated, At 8:20 nursing assistant (NA) stated that she heard a thud. We both entered the resident's (Resident #1) room (door was closed) and found resident on the floor, lying on her right side. Resident stated that she had hit her head and she was going to the bathroom. She also complained of pain to right thigh. NA and I lifted resident off of floor and to the bedside commode. After resident finished voiding we assisted her to bed. Resident would not straighten her right leg to be able to assess the leg lengths. Neurovascular checks to right leg were within normal limits; pedal pulses were good and resident could wiggle her toes. At 0835 Dr. was paged. Call was returned and orders for right hip x-rays were received. Approximately 0840 the daughter, __________ was called and notified that resident fell and orders for x-rays were given. The note further stated that at approximately 12:30 family member arrived and was concerned about the residents change in mental status and wanted resident to be evaluated by a physician. At approximately 1305 emergency services transported the resident to the hospital. Review of hospital records dated 5/19/18 stated, Reports she fell today when she was half-asleep getting out of bed and fell on the floor. She had tripped over something. Hospital records stated the resident had a comminuted intertrochanteric [MEDICAL CONDITION] with major fragments fixed in near anatomic alignment. Review of a statement written by the nursing assistant 5/22/18 stated, On Friday (MONTH) 18 while picking up the breakfast trays I, (name), heard a loud thump and then proceeded to check my patients for a fall. When I opened the door to room ___the patient was laying on her right side by the door. I went and got the nurse (name). Nurse then asked the patient was she hurt; and if she hit her head. The patient responded with her right leg felt broke and yes she hit her head. She then asked her what she was trying to do when she fell . The patient responded with I was trying to go the bathroom. The patient then said she still had to use the bathroom. Nurse asked if she could stand and the patient said no. We then go the bed side commode and placed it behind the patient, then stood her and moved the commode underneath her and sit her down on it. When the patient finished using the bathroom we then placed her walker behind her, then stood her, moved the commode, then moved the walker underneath her, then we sat her on the walker, rolled the patient to the bed then helped transfer her to the bed. After we straightened her in bed Nurse left to go and call the doctor and the family of the patient. I then proceeded to check her vitals. Review of the facility investigation revealed a notarized statement from the physician 5/24/18 which stated, On (MONTH) 18, (YEAR) at approximately 8:20 am, the resident (#1) experienced an incident and accident which resulted in a fall and sustained an injury. This injury included a fracture resulting in complaints of pain. During interview with a family member on 5/30/18 at 5:02 PM she reported that the facility called her at 8:15 AM and told her that her that the resident fell and they would have mobile x-ray come over. She stated she arrived at 1:00 PM and her Mom had been laying there for 5 hours or so. The family member stated that the resident looked passed out. During interview with Resident #1 on 5/30/18 at 7:02 PM she stated that her daughter told her she was laying there for 5 hours. She said she did not remember and that she hit her head. She said the next thing she knew she was at the hospital and they told her she had a broken hip. Interview with a nurse on 5/30/18 at 8:56 PM revealed that around 8 AM about 10 minutes after she and the nursing assistant left the resident's room they heard a thud. The resident was on the floor. The resident reported that she was going to the bathroom. The resident complained of pain at that time. The nurse stated they helped the resident up to use the bedside commode and she would not straighten her leg. The nurse said she checked the resident's neurovascular vital signs, checking capillary refill and that the resident was able to move her foot. When she returned to the resident's room around 10 AM, she was asleep and the nurse did not feel like she needed to wake her up to give her pain medication. The nurse said she called and got an order for [REDACTED]. The nurse stated that the resident said she hit her head but she did not see or feel any kind of bump. She did neuro checks by asking her orientation questions. Interview with the Director of Nurses (DON) at 9 PM on 5/30/18 revealed that the nurse was terminated because she felt like the nurse did not do her job the way she should have. She stated the nurse should have assessed the resident and noticed her hip was out of line. She never should have moved her. She should have called emergency services. Per the DON the nurse's statement said she didn't assess the resident. She stated that both she and the administrator were in the facility and were never notified of the fall or complaints of pain. Interview on 5/31/18 at 1:51 PM with the nursing assistant on duty at the time of the incident revealed that she was doing breakfast trays when she heard a thud. She checked Resident #1's room and she was at the door on the floor with the [DEVICE] attached to her leg. The resident said she was going to the bathroom. The nurse said can you stand and the resident said no, my leg is broken. We stood her and I slid the bedside commode under her because she said she had to go to the bathroom. She said her leg was hurting. She said she had never had a broken bone in her life. After she finished using the commode the resident was assisted back to bed. The nurse asked her if she hit her head and the resident said yes. The NA stated that she did the resident's vital signs after she was back in bed. She stated she left the room to go get vital sign equipment. The NA further stated that the resident was so confused she didn't know the [DEVICE] was on. She had been confused for a couple of mornings; just out of it. She reported that she thought the resident was checked for a urinary tract infection a few days ago. The NA said the resident was hard to wake up that morning. The NA said that the resident did not ring the bell that morning. She said she tried to get her up to eat but she was out of it. She went back in Resident #1's room to put her back on the commode again and the resident was in pain. She kept ring the bell because she was in pain and said her leg was broken. She stated the resident was out of it and confused. She said she told the nurse the resident was in pain. Review of the facility's plan of correction revealed the following: The nurse who was responsible for the care for the care of the resident at the time of the fall was in-serviced and suspended pending investigation on 5/18/18. After investigation, the nurse's employment was terminated on (MONTH) 24, (YEAR) and the nurse was reported to the North Carolina Board of Nursing on (MONTH) 24, (YEAR). The nursing assistant that assisted with moving the resident was in-serviced and disciplined upon her return to work on 5/22/18. The resident was sent to the hospital on [DATE] and has not returned to the facility, thus, no other corrective action can be taken for this resident. A root cause analysis was completed and it was determined (the nurse) singularly acted and violated the standards of care regarding assessment and documentation after a fall, assessment of pain and timely pain intervention, and movement of a resident after a fall with injury. Any resident with a fall has the potential to be affected by this practice. Incidents 30 days back from the fall were reviewed to determine if assessments and documentation were complete, complaints of pain were appropriately addressed, if suspicion of significant injury was reported to Senior Staff, and if transport to the hospital was reported to senior staff. Licensed nurses were in-serviced regarding assessment and documentation after a fall, Senior Staff notification of incidents with suspicion of significant injury, not moving a resident unless absolutely necessary if a fractured is suspected, and pain assessment and timely intervention for pain. The Certified Nursing Assistants were in-serviced regarding reporting signs and symptoms of pain and following up with nurse and/or Senior Staff if no intervention from nurse or if signs and symptoms of pain persist. Their in-service also included what to do if a nurse request a CAN (certified nursing assistant) to help move a resident after a fall and the CNA suspects significant injury. As a systemic change, the unit manager/supervisor will check the progress notes throughout their shift to see if there are any indications of incidents. If there is an indication of a fall, the unit manager/supervisor will review the documentation to ensure the assessment is complete and document, if a pain assessment had been completed and treated as necessary, and if there is any indication of significant injury. If there is indication of significant injury, it will be determined if a Senior Staff member was notified, and will follow up with the nurse as necessary. Ongoing monitoring will be performed by the Director of Nursing or designee utilizing the fall audit tool to ensure continued compliance. The auditing will occur daily until 100% compliance is maintained for two consecutive months. All results will be brought to the Quality Assurance Committee for review and recommendations. The Director of Nursing is responsible for implementing the plan of correction and will be in compliance by (MONTH) 24, (YEAR). The in-service topics and the staff sign in sheets were reviewed on (MONTH) 30, (YEAR). A review of the facility fall audit look back and ongoing monitoring sheets with documented review of falls which occurred after (MONTH) 24th was also reviewed.

Based on observation, record review and interviews with the resident, facility staff, and the physician, the facility failed to prevent neglect by transferring a resident from the bed to the wheelchair with a mechanical lift knowing that the mechanical lift was not functioning properly and was not safe to use. The mechanical lift's leg positioning device did not lock in place resulting in the lift tilting, the resident being dropped suddenly in the wheelchair and the overhead beam on the lift striking the resident's head. The facility staff continued to use the malfunctioning lift after the incident. This was evident for one of three residents reviewed for neglect (Resident #106). Immediate Jeopardy (IJ) began on 02/02/18, when Resident #106 was transferred from the bed to the chair with a malfunctioning lift. The lift tilted resulting in the resident being dropped suddenly into the wheelchair and the overhead beam on the lift striking the resident's head. The immediate jeopardy was removed on 03/16/18 when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to prevent neglect. The findings included: The manufacturer's User Manual for (brand name of lift) provided a Maintenance Safety Inspection Checklist on pages 40-42 that detailed 10 areas for monthly institutional inspection or adjustment. Included was ensuring the shifter handle locks (the) adjustable base whenever engaged. The User Manual advised lift operators on page 21 that If the shifter handle is NOT positioning completely into its mounting slot, DO NOT use the patient lift .Otherwise, injury and/or damage may occur. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact. Resident #106 was occasionally incontinent and required extensive assistance for bed mobility and toileting. Two persons were needed for transfers. The current care plan (most recently reviewed on 12/04/17) had entries for complications following left hip replacement, falls risk and deficits related to the performance of activities of daily living. The care plan included the use of a mechanical lift for resident transfers. A nursing progress note dated 02/02/18 by Nurse #7 recorded that Resident #106 was being transferred from bed to chair and was struck on the forehead at approximately 9:45 a.m. Vital signs were obtained, neurological checks instituted, and the physician notified. In an interview on 03/15/18 at 3:20 p.m., Resident #106 stated she was scared to death when the mechanical lift did not work correctly on 02/02/18. She said both nurse aides were behind the wheelchair when the top bar fell toward her. She indicated the bar gave her a knot on her head. The resident was unclear in her description of the incident. She was concerned that the impact of being dropped into the wheelchair had opened up her left hip incision line which started to ooze over the following days. In an interview on 03/19/18 at 4:45 p.m., the facility Medical Director indicated her familiarity with Resident #106 and the hospitalization s related to her left hip replacement. She stated that, based on her review of the clinical documentation, there was no indication that the incident with the mechanical lift contributed to the seepage/drainage from the left hip area that eventually led to her hospitalization four days after the incident. In an interview on 03/16/18 at 10:42 a.m., Nurse Aide #4 and Nurse Aide #5 provided a demonstration of what had happened on 02/02/18 during Resident #106's transfer. The DON was present during the interview. The mechanical lift used for the demonstration was present on the 300 Hall and was the same lift used on 02/02/18 for Resident #106. The machine was permanently assigned for use on the 100 and 300 Halls. When needed, the lift was transferred to the other side of the building for temporary use and then returned to the unit. During the demonstration, Nurse Aide #4 indicated that she was operating the lift on 02/02/18 with Nurse Aide #5 guiding the lift pad holding the resident. The wheelchair was positioned between the two legs of the lift with the open seat facing one of the legs. During the lowering of the Resident #106 into the chair, they described the machine suddenly dropping and depositing the resident in the wheelchair. She was not seated squarely in the wheelchair but did not land on the floor. She was dropped from a height of approximately one foot into the chair. The aides stated that the resident was screaming during the incident. When asked for clarification, Nurse Aide #4 confirmed that as the mechanical lift tilted to the left, both wheels of the leg on the right side of the lift lifted off the ground. The overhead beam of the lift holding the attached swivel bar and sling struck Resident #106 on the top of her forehead. Both aides indicated that they were able to grab the bar as it was happening to prevent a major injury to the resident. Nurse Aide #5 stated that she reported the injury and equipment malfunction to the charge nurse immediately, and Nurse Aide #4 stated she placed a sign on the machine and removed it from the unit to the back service hall. During the interview 03/16/18 at 10:42 a.m., Nurse Aide #4 shared that the mechanical lift was still prone to malfunctioning up to the time of this interview. Using the tall shifter handle connected to the base of the machine, she showed that the locking mechanism did not engage correctly. The shifter handle repositioned the legs of the machine as designed to do but did not lock them into place. When the shifter handle was moved to the left and up, the legs closed in a parallel position. When the shifter handle was moved to the right and up, the legs opened out at an angle to provide a more stable foundation when weight was lifted in the air. The shifter handle on this machine, however, did not engage in the up position and fell back to neutral, preventing proper locking of the legs in both the open and closed positions. Nurse Aides #4 and #5 both offered this as the reason the legs did not lock and the lift tilted during the resident's transfer on 02/02/18. Nurse Aide #4 moved the mechanical lift in the short part of the hall to demonstrate that the legs did not stay locked when rolled across the floor. She stated that she did not trust the machine after the incident with Resident #106 and now when using it, she placed one leg on the base with most of her body weight on it to provide extra stability. When asked about training, both aides confirmed that they had a skills assessment on using mechanical lifts on hire and then received refresher training annually from the facility. In an interview on 03/19/18 at 11:50 a.m., Nurse Aide #6 stated she has been working on the 100 and 300 Halls for over a year. She confirmed that the lift that malfunctioned during the incident of 02/02/18 was the same one that had been used on the unit since her assignment. The lift continued to be used for Resident #106 who has resided on the 300 Hall since admission to the facility last summer. In an interview on 03/16/18 at 10:33 a.m., Nurse #7 recounted her assessment of Resident #106 following the incident on 02/02/18. The resident was lying in bed complaining of pain. There was a red mark on her forehead without laceration, bleeding or bruising. Nurse #7 informed the Unit Supervisor and the DON of the incident. She did not do anything with the mechanical lift at the time. A progress note dated 02/06/18 by Nurse #7 noted that Resident #106 was transported to MD (medical doctor) appointment at approximately 9 a.m., informed by SW (social worker) that patient was transferred to hospital from MD appointment. The resident was later diagnosed with [REDACTED]. In an interview on 03/16/18 at 11:20 a.m., the Maintenance Director inspected the mechanical lift used for Resident #106's transfer and that continued to be used on the 100 and 300 Halls until its removal on 03/16/18 at 11:15 a.m. He acknowledged that the base mechanism was too loose to keep the shifter handle engaged in locking the legs in either the open or closed position. He was unable to provide any written documentation that the mechanical lift had been repaired after the transfer incident on 02/02/18 and stated that neither he nor his assistant remember working on the machine at that time. He stated that the Maintenance department did routine monthly preventative maintenance checks on equipment and he provided a completed checklist dated 02/06/18. The facility's five-page Preventative Maintenance Monthly Checklist for the year (YEAR) included 20 areas for monitoring. One recommended check was listed under Medical Equipment Management: Check all patient lifting equipment, (mechanical lift) and (sit to stand) lifts for defects. Checkmarks indicated that this check was performed in (MONTH) and February. The Maintenance Director further stated he used the general facility checklist rather than a checklist designed specifically for that lift model. The Maintenance Director confirmed that the model used on the 100 and 300 Halls was the only model of that lift in the building. During the interview, the Maintenance Director stated that he did not notice a need for any adjustments to the machine when he inspected it on 02/06/18. He also inspected the lift recently on 03/12/18 when he had it in the shop for repair of the scale component for weighing residents. He did not examine the base of the machine. He stated that, in addition to his monthly monitoring of facility equipment, he relied on nurse aides and other staff members to report concerns or problems with the mechanical lifts. The Maintenance Director moved the machine from the back service hall to the shop area. On 03/16/18 at 5:15 p.m. an inspection of the lift machine was performed after return from the shop. The machine was stored behind the locked door of the Restorative room. Operation of the shifter handle verified that appropriate adjustments had been made. The mechanism holding the shifter handle was tighter, and the handle did not slip out of position when engaged. In an interview on 03/19/18 at 9:30 a.m., the Maintenance Director indicated that the lift had since been removed from the building. In an interview on 03/19/18 at 3:16 p.m., the Director of Nursing (DON) stated she assessed Resident #106's injury after the incident on 02/02/18. The resident was anxious and weeping when interviewed. The DON also stated she had instructed Nurse Aide #4 to place a tag on the mechanical lift identifying it as needing repair and to remove it from the unit to the back service hall. The DON stated that she did not see the lift later that day on the unit but could not confirm that the matter had come to the attention of Maintenance for follow-up. She shared that at the time she was more concerned about the possible malfunctioning of the lift than the aides' proper operation of it. She stated that one of the aides had many years of experience operating mechanical lifts. She was not aware of the aides' concern about the stability of the machine before the interview and demonstration on 03/16/18. She acknowledged that the mechanical lift used to transfer Resident #106 was still in use on the 100 and 300 Halls until that morning and had not been working properly. The DON acknowledged in the interview that staff members were continuing to use a mechanical lift with identified safety hazards to transfer residents, endangering those who relied on safe operation during transfer and exposing residents to potential trauma. Her expectation was that staff members tag malfunctioning equipment for repair and remove it immediately from resident care areas to prevent further use. The Administrator and Director of Nursing were informed of the immediate jeopardy on 03/16/18 at 4:21 p.m. On 03/16/18 at 9:41 p.m., the facility provided the following credible allegation of IJ removal: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: A resident was being transferred from bed to wheelchair utilizing a mechanical lift with two CNAs (certified nurse aides) present who followed policy and procedure during the transfer. The lift legs retracted related to the handle that locks the legs was loose, and did not fully engage to the locked position, causing the bar to swing and the resident to be hit in the head with the bar from the lift. The facility failed to protect residents from neglect by failing to remove a lift from service. Root cause is the facility did not follow policy and procedure regarding removing the lift from service and filling out a maintenance request due to lack of training in the process regarding reporting and removing equipment from service when faulty equipment is noted. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: 1. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The (brand name) lift in question was removed from service and repaired by the Maintenance Director on 3/16/18 and will remain out of service until it has been evaluated by an outside technician and deemed safe for use. Preventative maintenance has been increased from monthly to at least weekly inspections, to be done according to the manufacturer's recommendations, of the lifts to identify and fix any part that has started to loosen. There was no injury to Resident #106 thus no other corrective action could be taken for this resident. The resident was assessed by the licensed nurse, there was no redness, swelling, laceration, or bruising. The resident did not report any pain and no pain medication was administered. Neuro checks were implemented per facility policy with no negative outcomes. The resident did go to the hospital after an appointment four days after the event secondary to infection of her hip replacement prostheses which was not related to the event. 2. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: The incident reports for last six months were reviewed by the Director of Nursing on 3/16/18 to determine if there were any other incidents related to the mechanical lifts. No other incidents were identified. The Maintenance Director examined all mechanical lifts in the facility on 3/16/18 to ensure the lifts are functioning properly. Any lift needing repair was addressed and removed from service. There was one other mechanical lift and two sit and stand lifts. One of the sit and stand lifts was identified with slight wear of one wheel. It has been removed from service until the wheel is replaced. Wearing of the wheels will be monitored by weekly preventative maintenance inspections so they can be replaced as necessary. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: A. An ad hoc QAPI (quality assurance and performance improvement) committee meeting was held on 3/16/18 with Interim Administrator, ADON (assistant director of nursing), Rehab Manager, Unit Managers, Vice President of Operations and the Regional Clinical Director in attendance. Medical Director attended via telephone. The agenda included determining the root cause of the event, what process would be used to identify other residents that may have been affected, determining what education needed to be completed, the content of that education, and who would be responsible for completing the education. The means for validation of the training was discussed and how the facility was going to monitor the processes and system changes to ensure the event does not reoccur. The goal of the meeting was to determine the root cause of why the event occurred, develop a plan for correcting any identified issues, develop a plan for monitoring to ensure the event does not reoccur. The outcome was a definitive plan was put in place to abate and prevent reoccurrence of the event. B. Licensed and non-licensed staff re-education regarding Abuse/Neglect prohibition and policy was conducted by the Director of Nursing, the Unit Managers, the MDS Nurses and the Staff Development Coordinator starting 3/16/18 and will continue until all staff are educated. No staff will be able to work after 3/16/18 until they receive the education. The education consisted of the definition of neglect meaning Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It also emphasized that it is neglect to discover faulty equipment and not report it, and it is neglectful to knowingly use equipment that is faulty or malfunctioning. It was explained that it is the employee's responsibility to tag and remove the equipment from service themselves. Unexplained injuries or injuries that are inconsistent with a person's medical condition may indicate abuse. The education presented will be revised or updated based on updated research or feedback from audits. Newly hired employees will be educated regarding Abuse and Neglect Prohibition upon hire. The Director of Nursing and the Maintenance Director were in-serviced by the Regional Clinical Nurse regarding the process of investigating and reporting neglect that includes: - Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse and neglect is at risk for occurring. - The facility will conduct an investigation of any incidents or accidents. - The importance of reporting equipment failure and removing the equipment from service to alleviate the potential for injury. A. The Director of Nursing was in-serviced by an outside consultant pertaining to the facility and accident program with an emphasis on who and when to complete investigations and Root Cause Analysis on 3/16/18. B. The procedure for the Incident/Accident Management Investigation process was revised on 3/16/18 to include: - Initiate an investigation. The DON/designee is responsible for making sure an investigation is completed. Administrator/ DON will ensure all investigation items are in order, complete, and maintained. A complete investigation will include interviews and witness statements, medical record review and a Root Cause Analysis. - Preventative maintenance will be completed weekly per manufacturer's recommendations to ensure the lifts are in working order. Preventative Maintenance Documentation Form for the mechanical lift was revised to include tracking for individual lifts and specific items regarding the lift to be checked per manufacturer recommendations. The title of the person responsible for implementing the acceptable plan of correction: Administrator The credible allegation of IJ removal was validated on 03/19/18 at 6:30 p.m. The facility's history for abuse and neglect training was reviewed. The most recent training was initiated on 03/16/18 and was ongoing. Staff members were trained on policy and procedures for reporting, investigating and documenting abuse and neglect. The facility's mechanical lifts were checked to ensure they were working according to manufacturer's specifications. Staff members were given refresher training on the proper use of the lift with return demonstrations. Two persons managed the lift with one operating the mechanical component and the other in front for support and positioning of the resident. Staff members checked for proper positioning and safety of the lift pad, positioning of the resident's body in the lift pad and functioning of the equipment. Staff members performed safety checks before, during and after the lifts procedure. The mechanical lift involved in the incident was removed from the unit and placed out of service. New mechanical lifts were ordered and the broken lift was removed from service. Staff members were trained 03/16/18 on the need to document and report and malfunctioning equipment and to complete a Maintenance Request Form. The training record was reviewed and several staff members were interviewed regarding the reporting and documenting process for incidents and accidents. The facility ordered new mechanical lifts. In-service training on the use of lifts for resident transfer as well as proper functioning was provided with return demonstration by staff members. Training included reporting practices for malfunctioning or broken lifts and equipment. Staff members were instructed to remove the equipment from the unit and place an orange out-of-service sign with their name, date and time the equipment or lifts were removed. Mechanical lifts were to be placed in the back service area. The Maintenance Department was expected to check the service area daily to ensure items to be repaired were serviced and the repair was documented when it was completed. Orange out-of-service signs were present in the Maintenance Books available at each of the two nursing stations.

Based on observation, record review and interviews with the resident, facility staff, and the physician, the facility failed to safely transfer a resident from the bed to the wheelchair by using a malfunctioning mechanical lift. The mechanical lift's leg positioning device did not lock in place resulting in the lift tilting, the resident being dropped suddenly in the wheelchair and the overhead beam on the lift striking the resident's head. The facility staff continued to use the malfunctioning lift after the incident. This was evident for one of three residents reviewed for accidents (Resident #106). Immediate Jeopardy (IJ) began on 02/02/18, when Resident #106 was transferred from the bed to the wheelchair with a malfunctioning lift. The lift tilted resulting in the resident being dropped suddenly into the wheelchair and the overhead beam on the lift striking the resident's head. The Immediate Jeopardy was removed on 03/16/18 when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to prevent accidents. The findings included: The manufacturer's User Manual provided a Maintenance Safety Inspection Checklist on pages 40-42 that detailed 10 areas for monthly institutional inspection or adjustment. Included was ensuring the shifter handle locks (the) adjustable base whenever engaged. The User Manual advised lift operators on page 21 that If the shifter handle is NOT positioning completely into its mounting slot, DO NOT use the patient lift .Otherwise, injury and/or damage may occur. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact. Resident #106 was occasionally incontinent and required extensive assistance for bed mobility and toileting. Two persons were needed for resident transfers. The current care plan (most recently reviewed on 12/04/17) had entries for complications following left hip replacement, falls risk and deficits related to the performance of activities of daily living. The care plan included the use of a mechanical lift for transfers. A nursing progress note dated 02/02/18 by Nurse #7 recorded that Resident #106 was being transferred from bed to chair and was struck on the forehead at approximately 9:45 a.m. Vital signs were obtained, neurological checks instituted, and the physician notified. The Director of Nursing (DON) provided the incident report with the names of the two nurse aides (Nurse Aide #4 and Nurse Aide #5) who were operating the mechanical lift at the time along with their written statements. When asked, the DON stated that no written investigation of the incident had been completed by management. The witness statements provided a brief description. Nurse Aide #4 wrote .the (brand name) lift spreader bar closed and the (brand name) lift was tilted back and the lift hit her (the resident) in the face. Nurse Aide #5 wrote .we adjusted the (resident's) leg while lowering her in the chair and the lift just closed in on her and hit her forehead. In an interview on 03/15/18 at 3:20 p.m., Resident #106 stated she was scared to death when the mechanical lift didn't work correctly on 02/02/18. She said both aides were behind the wheelchair when the top bar fell toward her. She indicated the bar gave her a knot on her head and it brushed against her thigh giving her a bruise. The resident was unclear in her description of the incident. She was concerned the incident had opened up her left hip incision line which started to ooze in the following days. She was readmitted to the hospital on [DATE] and diagnosed with [REDACTED]. In an interview on 03/19/18 at 4:45 p.m., the facility Medical Director indicated her familiarity with Resident #106 and the hospitalization s related to her left hip replacement. She did not recall being contacted about the head injury which occurred on 02/02/18. She stated that, based on her review of the clinical documentation, there was no indication that the incident with the mechanical lift contributed to the seepage/drainage from the left hip area that eventually led to her hospitalization four days after the incident. If staff members or the resident had any concerns about disruption to the incision line after the impact of her landing in the chair, she was not aware of it. In an interview on 03/16/18 at 10:42 a.m., Nurse Aide #4 and Nurse Aide #5 provided a demonstration of what had happened during Resident #106's transfer on 02/02/18. The DON was present during the interview. The mechanical lift used for the demonstration was present on the 300 Hall and was the same lift used on 02/02/18 for Resident #106. The machine was permanently assigned for use on the 100 and 300 Halls. When needed, the lift was transferred to the other side of the building for temporary use and then returned to the unit. During the demonstration Nurse Aide #4 indicated that she was operating the lift on 02/02/18 with Nurse Aide #5 guiding the lift pad holding the resident. The wheelchair was positioned between the two legs of the lift with the open seat facing one of the legs. During the lowering of Resident #106 into the chair, they described the machine suddenly dropping and depositing the resident in the wheelchair. She was not seated squarely in the chair but did not land on the floor. She was dropped from a height of approximately one foot into the chair. The aides stated that the resident was screaming during the incident. When asked for clarification, Nurse Aide #4 confirmed that both wheels of the leg on the right side of the machine lifted from the ground as the mechanical lift tilted to the left. The overhead beam of the lift holding the attached swivel bar and sling struck Resident #106 on the top of her forehead. They stated they were able to grab the bar as it was happening to prevent a major injury to the resident. Neither aide saw the beam hit the resident's thigh as the resident claimed, and she did not complain of hip pain at the time of the incident. Nurse Aide #5 stated that she reported the injury and equipment malfunction to the charge nurse immediately, and Nurse Aide #4 stated she placed a sign on the machine and removed it from the unit. During the interview, Nurse Aide #4 shared that the mechanical lift was still prone to malfunctioning. Using the tall shifter handle connected to the base of the machine, she showed that the locking mechanism did not engage correctly. The shifter handle repositioned the legs of the machine as designed to do but did not lock them into place. When the shifter handle was moved to the left and up, the legs closed in a parallel position. When the shifter handle was moved to the right and up, the legs opened out at an angle to provide a more stable foundation when weight was lifted in the air. The shifter handle on this machine, however, did not engage in the up position and fell back to neutral, preventing proper locking of the legs in both the open and closed positions. Nurse Aides #4 and #5 both offered this as the reason the legs did not lock and the lift tilted during the resident's transfer on 02/02/18. Nurse Aide #4 moved the mechanical lift in the short part of the hall to demonstrate that the legs did not stay locked when rolled across the floor. She stated that she did not trust the machine after the incident with Resident #106 and now when using it, she placed one foot on the base with most of her body weight shifted on it to provide extra stability. When asked about training, both aides confirmed that they had a skills assessment on using mechanical lifts on hire and then received refresher training annually from the facility. The malfunctioning lift was moved to the back service hall behind closed doors after the nurse aides' demonstration by the Maintenance Director and Corporate Vice President of Operations in order to prevent staff members from using it. In an interview on 03/19/18 at 11:50 a.m., Nurse Aide #6 stated she has been working on the 100 and 300 Halls for over a year. She confirmed that the lift that malfunctioned during the incident of 02/02/18 was the same one that had been used on the unit since her assignment. The lift continued to be used for Resident #106 who has resided on the 300 Hall since admission to the facility last summer. In an interview on 03/16/18 at 10:33 a.m., Nurse #7 recounted her assessment of Resident #106 following the incident on 02/02/18. The resident was lying in bed complaining of pain. There was a red mark on her forehead without laceration, bleeding or bruising. The resident had not mentioned any injury to the thigh or hip. She informed the Unit Supervisor and the DON of the incident. Nurse #7 did not do anything with the mechanical lift at the time. A review of the medical records revealed no documentation of hip or thigh injury or bruising from the transfer procedure. A nursing progress note dated 02/05/18 by the Wound Treatment Nurse stated that she evaluated Resident #106 for a clear fluid-filled area 6.8 x 1.8 c.m. (centimeters) along surgical incision line of left thigh lateral aspect, surrounding tissue intact, warm to touch compared to right leg and [MEDICAL CONDITION] . A progress note the following day by Nurse #7 noted that Resident #106 was transported to MD (medical doctor) appointment at approximately 9 a.m., informed by SW (social worker) that patient was transferred to hospital from MD appointment. In an interview on 03/16/18 at 11:20 a.m., the Maintenance Director inspected the mechanical lift used for Resident #106's transfer and that continued to be used on the 100 and 300 Halls until its removal on 03/16/18 at 11:15 a.m. He acknowledged that the base mechanism was too loose to keep the shifter handle engaged in locking the legs in either the open or closed position. He was unable to provide any written documentation that the mechanical lift had been repaired after the transfer incident on 02/02/18 and stated that neither he nor his assistant remember working on the machine at that time. He stated that the Maintenance department did routine monthly preventative maintenance checks on equipment, and he provided a completed checklist dated 02/06/18. The facility's five-page Preventative Maintenance Monthly Checklist for the year (YEAR) included 20 areas for monitoring. One recommended check was listed under Medical Equipment Management: Check all patient lifting equipment, (brand name mechanical lift) and (brand name sit-to-stand) lifts for defects. Checkmarks indicated that this check was performed in (MONTH) and February. The Maintenance Director further stated that he used the general facility checklist rather than a checklist designed specifically for that model of lift. The Maintenance Director confirmed that the model used on the 100 and 300 Halls was the only model of that lift in the building. During the interview, the Maintenance Director stated that he did not notice a need for any adjustments to the machine when he inspected it on 02/06/18. He also inspected the lift recently on 03/12/18 when he had it in the shop for repair of the scale component for weighing residents. He did not examine the base of the machine. The Maintenance Director then moved the machine from the back service hall to the shop area. On 03/16/18 at 5:15 p.m. an inspection of the lift machine was performed after return from the shop. The machine was stored behind the locked door of the Restorative room. Operation of the shifter handle verified that appropriate adjustments had been made. The mechanism holding the shifter handle was tighter, and the handle did not slip out of position when engaged. In an interview on 03/19/18 at 9:30 a.m., the Maintenance Director indicated that the lift had since been removed from the building. In an interview on 03/19/18 at 3:16 p.m., the DON stated she assessed Resident #106's injury after the incident on 02/02/18. She had instructed Nurse Aide #4 to place a tag on the mechanical lift identifying it as needing repair and to remove it from the unit to the back service hall. The DON stated that she did not see the lift later that day on the unit but could not confirm that the matter had come to the attention of Maintenance for follow-up. She shared that at the time she was more concerned about the possible malfunctioning of the lift than the aides' proper operation of it. She stated that one of the nurse aides had many years of experience operating mechanical lifts. She was not aware of the aides' concern about the stability of the machine before the interview and demonstration on 03/16/18. She acknowledged that the mechanical lift used to transfer Resident #106, and still in use on the 100 and 300 Halls until that morning, had not been working properly, placing residents at risk for injury due to the potential for accidents. The Administrator and Director of Nursing were informed of the immediate jeopardy on 03/16/18 at 4:21 p.m. On 03/16/18 at 9:41 p.m., the facility provided the following credible allegation of IJ removal: A resident was being transferred from bed to wheelchair utilizing a mechanical lift with two CNAs (Certified Nurse Aides) present who followed policy and procedure during the transfer. The lift legs retracted related to the handle that locks the legs was loose, and did not fully engage to the locked position, causing the bar to swing and the resident to be hit in the head with the bar from the lift. The facility failed to protect residents from neglect by failing to remove a lift from service. Root cause is the facility did not follow policy and procedure regarding removing the lift from service and filling out a maintenance request due to lack of training in the process regarding reporting and removing equipment from service when faulty equipment is noted. The procedure for implementing the acceptable corrective action for the specific deficiency cited: 1. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The (brand name) lift in question was removed from service and repaired by the Maintenance Director on 3/16/18 and will remain out of service until it has been evaluated by an outside technician and deemed safe for use. Preventative maintenance of the lifts has been increased from monthly to at least weekly inspections, and will be completed per manufacturer's recommendations, to identify and fix any part that has started to loosen. There was no injury to Resident #106 thus no other corrective action could be taken for this resident. The resident was assessed by the licensed nurse, there was no redness, swelling, laceration, or bruising. The resident did not report any pain and no pain medication was administered. Neuro checks were implemented per facility policy with no negative outcomes. The resident did go to the hospital after an appointment four days after the event secondary to infection of her hip replacement prostheses which was not related to the event. 2. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: The incident reports for the last six months were reviewed by the Director of Nursing on 3/16/18 to determine if there were any other incidents related to the mechanical lifts. No other incidents were identified. The Maintenance Director examined all mechanical lifts in the facility on 3/16/18 to ensure the lifts are functioning properly. Any lift needing repair was addressed and removed from service. There was one other (brand name) lift and two (brand name sit-to-stand) lifts. One of the (brand name sit-to-stand) lifts was identified with slight wear of one wheel. It has been removed from service until the wheel is replaced. Wearing of the wheels will be monitored by weekly preventative maintenance inspections so they can be replaced as necessary. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: A. An ad hoc QAPI (quality assurance and performance improvement) committee meeting was held on 3/16/18 with Interim Administrator, ADON (assistant director of nursing), Rehab Manager, Unit Managers, Vice President of Operations and the Regional Clinical Director in attendance. Medical Director attended via telephone. The agenda included determining the root cause of the event, what process would be used to identify other residents that may have been affected, determining what education needed to be completed, the content of that education, and who would be responsible for completing the education. The means for validation of the training was discussed and how the facility was going to monitor the processes and system changes to ensure the event does not reoccur. The goal of the meeting was to determine the root cause of why the event occurred, develop a plan for correcting any identified issues, develop a plan for monitoring to ensure the event does not reoccur. The outcome was a definitive plan was put in place to abate and prevent reoccurrence of the event. B. CNAs and licensed nurses were educated by the Director of Nursing, the Unit Managers, the MDS Nurses and the Staff Development Coordinator regarding transfers utilizing mechanical lifts with return demonstration starting 3/12/18 and will continue until 100% CNAs and licensed nurses are educated. The in-service included inspecting the lifts and slings prior to use, operation of the lift with return demonstration, reporting and not using the equipment if any faults/issues are noted, the employee is responsible for tagging and immediately removing the equipment from service and placing in the service hall, and completing the maintenance request. C. All facility staff regardless of position or title education regarding process for reporting and removing malfunctioning equipment and completion of the Maintenance Request Form. The in-service emphasized it is the staff members responsibility to tag and remove the equipment from service by placing it in the service hallway and not using the equipment until it has been cleared by the maintenance staff for use. D. Incidents will be reviewed in the weekly focus meeting to ensure the incident had been investigated, a root cause analysis is completed, and interventions are put in place to prevent reoccurrence. The title of the person responsible for implementing the acceptable plan of correction: Administrator The credible allegation of IJ removal was validated on 03/19/18 at 6:30 p.m. All mechanical lifts were inspected. Staff members were observed while demonstrating proper use of mechanical lifts. Two persons managed the lift with one operating the mechanical component and the other in front for support and positioning of the resident. Staff members checked for proper positioning and safety of the lift pad, positioning of the resident's body in the lift pad and proper functioning of the equipment. Staff members performed safety checks before, during and after the lift procedure. Staff members reported they were provided in-service training on resident transfers with use of a lift on 03/12/18 through the weekend of 03/17/18. The mechanical lift involved in the incident was removed from the unit and placed out of service. The Maintenance Department was provided in-service training on expected maintenance checks and procedures for equipment with manufacturer instructions on the proper use and maintenance checks for different types of mechanical lifts. Lift inspections were added to the maintenance checklist to ensure they were being inspected more frequently. The Preventive Maintenance Documentation Form for mechanical lifts was revised to include tracking for individual lifts. The Preventive Maintenance Documentation Form for mechanical lifts present in each nursing station's Maintenance Book was reviewed. Staff members were trained 03/16/18 on the need to document and report and malfunctioning equipment and to complete a Maintenance Request Form. The training record was reviewed and several staff members were interviewed regarding the reporting and documenting process for incidents and accidents. The facility ordered new mechanical lifts. In-service training on the use of lifts for resident transfer as well as proper functioning was provided with return demonstration by staff members. Training included reporting practices for malfunctioning or broken lifts and equipment. Staff members were instructed to remove the equipment from the unit and place an orange out-of-service sign with their name, date and time the equipment or lifts were removed. Mechanical lifts were to be placed in the back service area. The Maintenance Department was expected to check the service area daily to ensure items to be repaired were serviced and the repair was documented when it was completed. Orange out-of-service signs were present in the Maintenance Books available at each of the two nursing stations.

Based on observation, record review and interviews with the resident and facility staff, the facility failed to keep a mechanical lift working properly to ensure a resident was safely transferred from the bed to a wheelchair. The mechanical lift's leg positioning device did not lock in place resulting in the lift tilting, the resident being dropped suddenly in the chair and the overhead beam on the lift striking the resident's head. The facility staff continued to use the malfunctioning lift after the incident. This was evident for one of three residents reviewed for accidents (Resident #106). Immediate Jeopardy (IJ) began on 02/02/18, when Resident #106 was transferred from the bed to the wheelchair with a malfunctioning lift. The lift tilted resulting in the resident dropping suddenly into the wheelchair and the overhead beam on the lift striking the resident's head. The Immediate Jeopardy was removed on 03/16/18 when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to ensure equipment are maintained and working properly before use to transfer residents. The findings included: The manufacturer's User Manual for (brand name of lift) provided a Maintenance Safety Inspection Checklist on pages 40-42 that detailed 10 areas for monthly institutional inspection or adjustment. Included was ensuring the shifter handle locks (the) adjustable base whenever engaged. The User Manual advised lift operators on page 21 that If the shifter handle is NOT positioning completely into its mounting slot, DO NOT use the patient lift .Otherwise, injury and/or damage may occur. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact. Resident #106 was occasionally incontinent and required extensive assistance for bed mobility and toileting. Two persons were needed for resident transfers. The current care plan (most recently reviewed on 12/04/17) had entries for complications following left hip replacement, falls risk and deficits related to the performance of activities of daily living. The care plan included the use of a mechanical lift for resident transfers. A nursing progress note dated 02/02/18 by Nurse #7 recorded that Resident #106 was being transferred from bed to chair and was struck on the forehead at approximately 9:45 a.m. Vital signs were obtained, neurological checks instituted, and the physician notified. The Director of Nursing (DON) provided the incident report with the names of the two nurse aides (Nurse Aide #4 and Nurse Aide #5) who were operating the mechanical lift at the time along with their written statements. When asked, the DON stated that no written investigation of the incident had been completed by management. Witness statements provided a brief description. Nurse Aide #4 wrote .the (brand name) lift spreader bar closed and the (brand name) lift was tilted back and the lift hit her (the resident) in the face. Nurse Aide #5 wrote .we adjusted the (resident's) leg while lowering her in the chair and the lift just closed in on her and hit her forehead. In an interview on 03/15/18 at 3:20 p.m., Resident #106 stated she was scared to death when the mechanical lift did not work correctly on 02/02/18. She said both nurse aides were behind the wheelchair when the top bar fell toward her. She indicated the bar gave her a knot on her head. The resident was unclear in her description of the incident. In an interview on 03/16/18 at 10:33 a.m., Nurse #7 recounted her assessment of Resident #106 on 02/02/18 following the incident. The resident was lying in bed complaining of pain. There was a red mark on her forehead without laceration, bleeding or bruising. Nurse #7 informed the Unit Supervisor and the DON of the incident. She did not do anything with the mechanical lift at the time. A progress note dated 02/06/18 by Nurse #7 noted that Resident #106 was transported to MD (medical doctor) appointment at approximately 9 a.m., informed by SW (social worker) that patient was transferred to hospital from MD appointment. The resident was later diagnosed with [REDACTED]. In an interview on 03/16/18 at 10:42 a.m., Nurse Aide #4 and Nurse Aide #5 provided a demonstration of what had happened during Resident #106's transfer. The DON was present during the interview. The mechanical lift used for the demonstration was present on the 300 Hall and was the same lift used on 02/02/18 for Resident #106. The machine was permanently assigned for use on the 100 and 300 Halls. When needed, the lift was transferred to the other side of the building for temporary use and then returned to the unit. During the demonstration Nurse Aide #4 indicated that she was operating the lift on 02/02/18 with Nurse Aide #5 guiding the lift pad holding the resident. The wheelchair was positioned between the two legs of the lift with the open seat facing one of the legs. During the lowering of Resident #106 into the chair, they described the machine suddenly dropping and depositing the resident in the wheelchair. She was not seated squarely in the wheelchair but did not land on the floor. She was dropped from a height of approximately one foot into the chair. The aides stated that the resident was screaming during the incident. When asked for clarification, Nurse Aide #4 confirmed that both wheels of the leg on the right side of the machine lifted from the ground as the mechanical lift tilted to the left. The overhead beam of the lift holding the attached swivel bar and sling struck Resident #106 on the top of her forehead. Nurse Aide #5 stated that she reported the injury and equipment malfunction to the charge nurse immediately, and Nurse Aide #4 stated she placed a sign on the machine and removed it from the unit. During the interview Nurse Aide #4 shared that the mechanical lift was still prone to malfunctioning. Using the tall shifter handle connected to the base of the machine, she showed that the locking mechanism did not engage correctly. The shifter handle repositioned the legs of the machine as designed to do but did not lock them into place. When the shifter handle was moved to the left and up, the legs closed in a parallel position. When the shifter handle was moved to the right and up, the legs opened out at an angle to provide a more stable foundation when weight was lifted in the air. The shifter handle on this machine, however, did not engage in the up position and fell back to neutral, preventing proper locking of the legs in both the open and closed positions. Nurse Aides #4 and #5 both cited this as the reason the legs did not lock and the lift tilted during the resident's transfer on 02/02/18. The aides were aware that the locking mechanism bolt became loose over time, and that it had been sent to the maintenance shop on other occasions. During this transfer on 02/02/18, apparently the bolt was loose enough to prevent locking of the lift legs, causing injury to the resident when her weight was mid-air and the machine tilted. Nurse Aide #4 moved the mechanical lift in the short part of the hall to demonstrate that the legs did not stay locked when rolled across the floor. She stated that she did not trust the machine after the incident with Resident #106 and now when using it, she placed one foot on the base with most of her body weight shifted on it to provide extra stability. When asked about training, both aides confirmed that they had a skills assessment on using mechanical lifts on hire and then received refresher training annually from the facility. The malfunctioning lift was moved to the back service hall behind closed doors after the nurse aides' demonstration by the Maintenance Director and Corporate Vice President of Operations in order to prevent staff members from using it. In a later interview on 03/16/18 at 3:15 p.m., Nurse Aide #4 stated that she has been constantly complaining about the machine used on the 100 and 300 Halls. When asked for clarification, she indicated that this was over the course of months and involved both face-to-face communication and written communication in the Maintenance Book at the nurses' station. She further stated that at one point she had physically shown the lift to the DON and the former Administrator while expressing her concerns. (The former Administrator left his position at the facility on 02/14/18.) In an interview on 03/19/18 at 11:50 a.m., Nurse Aide #6 stated she has been working on the 100 and 300 Halls for over a year. She confirmed that the lift that malfunctioned during the incident of 02/02/18 was the same one that had been used on the unit since her assignment. The lift continued to be used for Resident #106 who has resided on the 300 Hall since admission to the facility last summer. She estimated the lift had been like that for over a year. She indicated that both she and Nurse Aide #4 have written it in the Maintenance Book requesting repairs. She stated that staff members in the Therapy Department had reported concerns about this particular lift as well as staff members assigned to the 200, 400 and 500 Halls. In an interview on 03/19/18 at 12:50 p.m., the Rehabilitation Manager shared that some therapy staff members were aware of the mechanical lift used on the 100 and 300 Halls being repaired and returned to the unit, but that none of the staff she spoke with had personally submitted a Maintenance request form. In an interview on 03/16/18 at 11:20 a.m., the Maintenance Director inspected the mechanical lift used for Resident #106's transfer and that continued to be used on the 100 and 300 Halls until its removal from use on 03/16/18 at 11:15 a.m. He acknowledged that the base mechanism was too loose to keep the shifter handle engaged in locking the legs in either the open or closed position. He was unable to provide any written documentation that the mechanical lift had been repaired after the transfer incident on 02/02/18 and stated that neither he nor his assistant remember working on the machine at the time. He stated that the Maintenance department did routine monthly preventative maintenance checks on equipment, and he provided a completed checklist dated 02/06/18. The facility's five-page Preventative Maintenance Monthly Checklist for the year (YEAR) included 20 areas for monitoring. One recommended check was listed under Medical Equipment Management: Check all patient lifting equipment, (brand name mechanical lift) and (brand name sit-to-stand) lifts for defects. Checkmarks indicated that this check was performed in (MONTH) and February. The Maintenance Director further stated that he used the general facility checklist rather than a checklist designed specifically for that model of lift. The Maintenance Director confirmed that the model used on the 100 and 300 Halls was the only model of that lift in the building. During the interview, the Maintenance Director stated that he did not notice a need for any adjustments to the machine when he inspected it on 02/06/18. He also inspected the lift recently on 03/12/18 when he had it in the shop for repair of the scale component for weighing residents. He did not examine the base of the machine. He stated that, in addition to his monthly monitoring of facility equipment, he relied on nurse aides and other staff members to report concerns or problems with the mechanical lifts. The Maintenance Director then moved the machine from the back service hall to the shop area. On 03/16/18 at 5:15 p.m. an inspection of the lift machine was performed after return from the shop. The machine was stored behind the locked door of the Restorative room. Operation of the shifter handle verified that appropriate adjustments had been made. The mechanism holding the shifter handle was tighter, and the handle did not slip out of position when engaged. In an interview on 03/19/18 at 9:30 a.m., the Maintenance Director indicated that the lift had since been removed from the building. In an interview on 03/19/18 at 4:00 p.m., Regional Consultant #1 confirmed that the facility had no written policy and procedure on faulty or broken resident-care equipment. In an interview on 03/19/18 at 3:16 p.m., the DON stated she assessed Resident #106's injury after the incident on 02/02/18. She also stated she had instructed Nurse Aide #4 to place a tag on the mechanical lift identifying it as needing repair and to remove it from the unit to the back service hall. The DON stated that she did not see the lift later that day on the unit but could not confirm that the matter had come to the attention of Maintenance for follow-up. She shared that at the time she was more concerned about the possible malfunctioning of the lift than the aides' proper operation of it. She stated that one of the aides had many years of experience operating mechanical lifts. She was not aware of the aides' concern about the stability of the machine before the interview and demonstration on 03/16/18. She acknowledged that the mechanical lift used to transfer Resident #106, and still in use on the 100 and 300 Halls until that morning, had not been working properly, placing residents at risk for injury from potential accidents. She stated she was not aware of staff members' ongoing concerns with the functioning of the lift. There had been issues with the battery pack in the machine, and she said she referred those to Maintenance. She did not remember either her or the Administrator being shown the faulty locking mechanism. The DON acknowledged in the interview that staff members were continuing to use a mechanical lift with identified safety hazards to transfer residents, endangering those who relied on safe operation during transfer and exposing residents to potential trauma. Her expectation was that staff members tag malfunctioning equipment for repair and remove it immediately from resident- care areas to prevent further use. The Administrator and Director of Nursing were informed of the immediate jeopardy on 03/16/18 at 4:21 p.m. On 03/16/18 at 9:41 p.m., the facility provided the following credible allegation of IJ removal: A resident was being transferred from bed to wheelchair utilizing a (brand name) lift with two CNAs (Certified Nurse Aides) present who followed policy and procedure during the transfer. The lift legs retracted related to the handle that locks the legs was loose, and did not fully engage to the locked position, causing the bar to swing and the resident to be hit in the head with the bar from the lift. The facility failed to protect residents from neglect by failing to remove a lift from service. Root cause is the facility did not follow the policy and procedure regarding preventative maintenance, there was a lack in processes of review to ensure preventative maintenance was completed, and it was determined the preventative maintenance log did not specify which lift or which part of the lift was checked per the manufacturer's recommendations. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: 1. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The (brand name) lift in question was removed from service and repaired by the Maintenance Director on 3/16/18 and will remain out of service until it has been evaluated by an outside technician and deemed safe for use. Preventative maintenance has been increased from monthly to at least weekly inspections, to be done according to the manufacturer's recommendations, of the lifts to identify and fix any part that has started to loosen. There was no injury to Resident #106 thus no other corrective action could be taken for this resident. The resident was assessed by the licensed nurse, there was no redness, swelling, laceration, or bruising. The resident did not report any pain and no pain medication was administered. Neuro checks were implemented per facility policy with no negative outcomes. The resident did go to the hospital after an appointment four days after the event secondary to infection of her hip replacement prostheses which was not related to the event. 2. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: The Maintenance Director examined all mechanical lifts in the facility on 3/16/18 to ensure the lifts are functioning properly. Any lift needing repair was addressed and removed from service. There was one other (brand name) lift and two (brand name sit-to-stand) lifts. One of the (brand name sit-to-stand) lifts was identified with slight wear of one wheel. It has been removed from service until the wheel is replaced. Wearing of the wheels will be monitored by weekly preventative maintenance inspections so they can be replaced as necessary. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: A. An ad hoc QAPI (quality assurance and performance improvement) committee meeting was held on 3/16/18 with Interim Administrator, ADON (assistant director of nursing), Rehab Manager, Unit Managers, Vice President of Operations and the Regional Clinical Director in attendance. Medical Director attended via telephone. The agenda included determining the root cause of the event, what process would be used to identify other residents that may have been affected, determining what education needed to be completed, the content of that education, and who would be responsible for completing the education. The means for validation of the training was discussed and how the facility was going to monitor the processes and system changes to ensure the event does not reoccur. The goal of the meeting was to determine the root cause of why the event occurred, develop a plan for correcting any identified issues, and develop a plan for monitoring to ensure the event does not reoccur. The outcome was a definitive plan was put in place to abate and prevent reoccurrence of the event. B. Education of the Maintenance Director regarding the Preventative Maintenance Policy and Procedure by the Regional Vice President of Operations on 3/16/18. C. All facility staff regardless of position or title education regarding process for reporting and removing malfunctioning equipment and completion of the Maintenance Request Form. The in-service emphasized it is the staff members responsibility to tag and remove the equipment from service by placing it in the service hallway and not using the equipment until it has been cleared by the maintenance staff for use. D. Preventative Maintenance Documentation Form for the mechanical lift was revised to include tracking for individual lifts and specific items regarding the lift to be checked per manufacturer recommendations. Preventative maintenance of other equipment utilized in the facility will be reviewed by the Director of Operations to ensure the equipment is reviewed per manufacturer's recommendations. The monitoring procedure to ensure the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: To remain in compliance and under the direction of the Administrator or designee, beginning 3/16/18: A. Preventative maintenance related to (brand name) lifts will be completed by the Maintenance Director or designee per manufacturer's recommendations. B. The Administrator or designee will review Preventative Maintenance Log to ensure preventative maintenance is being completed as scheduled weekly until 100% compliance is maintained for 2 consecutive months. The title of the person responsible for implementing the acceptable plan of correction: Administrator The credible allegation of IJ removal was validated on 03/19/18 at 6:30 p.m. All mechanical lifts were inspected. Staff members were observed while demonstrating proper use of mechanical lifts. Two persons managed the lift with one operating the mechanical component and the other in front for support and positioning of the resident. Staff members checked for proper positioning and safety of the lift pad, positioning of the resident's body in the lift pad and functioning of the equipment. Staff members performed safety checks before, during and after the lifts procedure. Staff members reported they were provided in-service training on resident transfers with use of a lift on 03/12/18 through the weekend of 03/17/18. The mechanical lift involved in the incident was removed from the unit and placed out of service. The Maintenance Department was provided in-service training on expected maintenance checks and procedures for equipment with manufacturer instructions on the proper use and maintenance checks for different types of mechanical lifts. Lift inspections were added to the maintenance checklist to ensure they were being inspected more frequently. The Preventive Maintenance Documentation Form for mechanical lifts was revised to include tracking for individual lifts. The Preventive Maintenance Documentation Form for mechanical lifts present in each nursing station maintenance book was reviewed. Staff members were trained 03/16/18 on the need to document and report and malfunctioning equipment and to complete a Maintenance Request Form. The training record was reviewed and several staff members were interviewed regarding the reporting and documenting process for incidents and accidents. The facility ordered new mechanical lifts. In-service training on the use of lifts for resident transfer as well as proper functioning was provided with return demonstration by staff members. Training included reporting practices for malfunctioning or broken lifts and equipment. Staff members were instructed to remove the equipment from the unit and place an orange out-of-service sign with their name, date and time the equipment or lifts were removed. Mechanical lifts were to be placed in the back service area. The Maintenance Department was expected to check the service area daily to ensure items to be repaired were serviced and the repair was documented when it was completed. Orange out-of-service signs were present in the Maintenance Books available at each of the two nursing stations.

Based on observations, record review, and staff interviews, the facility failed to a place a fall floor mat on the floor beside the bed and failed to safely position a resident while bathing for 1 of 3 sampled residents (Resident #2) known to be at risk for falls. Findings included: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) completed on 2/24/11 indicated the resident required extensive assistance of one with bed mobility, transfer, toilet and hygiene. The resident was totally dependent on staff for one person physical assist with bathing. There was no occurrence of balance during transitions and walking. The resident was indicated as having no impairment to the upper extremities and impaired on both sides of the lower extremities. Additionally, the resident was indicated not steady, only able to stabilize with human assistance for surface to surface transfer (between bed and chair or wheelchair). The resident was indicated with a history of a fall with no injury or pain. The MDS also indicated the resident cognitive pattern was severely impaired with a score of " 00. " The Care Area Assessment Summary completed on 1/3/11 indicated the resident required approaches to minimize the risk for injury and falls. The care plan indicated on 4/10/08 as a fall risk intervention the floor was to be padded next to the bed. On 4/1/09 the care plan indicated continue with the floor as padded next to the bed. On 5/5/09 the care plan indicated continue with the mats " Mat effective. " On 4/12/10 the care plan indicated changed with annual (not specified what the change included). The care plan revealed on 3/3/11 the staff was in-serviced related to the winged mat. The Resident Care Information Sheet-care guide (undated), located at the nurses ' station indicated special instructions that included " Mats by bed, winged mat, two persons assist with bed mobility, wheel chair and transfers; fall risk, non-weight bearing (status [REDACTED]. " Record review revealed from 2/10/11-2/17/11 the resident was hospitalized due to a family member called 911. The resident was not sent to the hospital prior to the 911 call by the nursing facility; due to a physician's order [REDACTED]. Past medical history and [DIAGNOSES REDACTED]. The facility ' s readmission assessment revealed on 2/17/11 the resident complained of no pain, and there were no signs/symptoms of pain. The admission assessment also indicated an assessed fall risk score of 11, which indicated a high risk for potential falls. The side rail evaluation completed on 2/17/11 revealed the resident was non- ambulatory and non-weight bearing. Therefore, the resident was assessed as needed no side rails. Facility record revealed on 3/3/11 at 7:30 AM the resident rolled out of the bed without injury. The bed was documented in the low position. Further review of the facility records revealed Nurse #1 indicated upon entry into the room the floor mat was not in place on the floor, the bed was in the lowest position and the resident was located on the floor, positioned on the side. Facility documentation indicated the resident was assessed by Nurse #1 and no injuries or pain were noted. The resident was assisted back into the bed by the staff. Facility record revealed on 3/3/11 the staff was in-serviced on all shifts to ensure the bed alarms were attached, beds were positioned in the lowest position and the floor mats were placed bedside the residents ' beds that were identified at risk for falls. Facility record revealed a family member requested an x-ray to be completed while the resident was evaluated at the hospital, for a head laceration that occurred on 3/15/11 while at the nursing facility. The family member observed the resident slightly wincing with movement of the left hip. Results of the hospital x-ray report dated 3/15/11 read, " Two views of the left hip: There is a fracture of the left femoral neck. The possibility of an underlining pathologic etiology could not be completely excluded but the appearance is more suggestive of a subacute fracture with various deformity. " Further review of the hospital record revealed the injury likely occurred 2-3 weeks prior to 3/15/11. On 3/22/11 at 1:10 PM, the resident was positioned in a low bed without side rails. Floor mats were positioned on the floor on both sides of the bed and the call bell was located in reach. The resident was unable to engage in a conversation and responded to simple questions, as indicated by " Yes, no, or a moan. " There was a laceration scar above the resident ' s right eyebrow. Interview on 3/22/11 at 5:15 PM with NA #4 revealed she bathed, turned/repositioned, and transferred the resident from the bed to the broda chair independently during morning care. When asked where she would look to find out if there was any changes or updates on how to care for the resident, NA #4 stated she would ask the charge nurse. Interview on 3/23/11 at 12:40 PM with Nurse #1 revealed on 3/3/11 at approximately 7:30 AM she entered into the resident ' s room after summoned by NA#1 and observed the resident lying on the floor, positioned on the left side (beside the left side of the bed) facing the door. She indicated there was no floor mat on the floor. Nurse #1 further indicated, the floor mat was positioned up against the wall, and was not located where it should have been, on the floor under the resident. Nurse #1 elaborated, she suspected the nurse aides probably forgot to place the floor mat back in the proper place (on the floor beside the bed) after rounds were completed. Nurse #1 concluded the resident was assessed and complained of no pain and the bed alarm was intact and alarming. Interview on 3/23/11 at 2:10 PM with NA #1 revealed, on 3/3/11 at the start of her shift (1st shift) she heard an alarm sounding on the unit. NA #1 indicated upon getting to the resident door, she observed the resident lying on the floor on the left side of the bed facing the door, but could not recall what side (side of the body) the resident was positioned on. NA #1 further indicated, she could not remember if the floor mat was positioned on the floor. NA #1 indicated she immediately screamed for Nurse #1. NA #1 elaborated the resident was assessed by Nurse #1. Thereafter, the resident was rolled onto a sheet while lying on the floor by Nurse #1 and lifted from the floor, back into the bed while on the sheet, with two persons at the top (head) and two persons at the bottom (feet). NA #1 stated she did not recall if the resident complained of pain. NA #1 concluded no shift report or walking round was completed with the off-going nurse aide. She indicated she usually consulted with her charge nurse for any needed updates in residents ' condition, as part of her normal routine. Interview on 3/23/11 at 3:35 PM with Nurse #2 revealed approximately 5-6 months ago she recalled the resident attempted to get out of the bed/wheelchair unassisted and the bed/chair alarms would sound. However, she had not noticed any recent attempts to get up unassisted, since her physical condition declined. Interview on 3/23/11 at 3:50 PM with NA #2 (assigned 3rd shift NA morning of fall) indicated she did not recall moving the floor mat from either side of the bed during her shift. She indicated she usually clocked out between 7:00-7:05 AM and did not recall doing a walking round, or shift report with the oncoming nurse aide. Interview with Nurse #3 (Unit Manager) on 3/23/11 at 4:20 PM revealed the floor mats were implemented greater than 5 months ago for falls, to be placed on both sides of the bed. She further indicated the floor mats were still an active part of the care plan and should have been in place on the floor, beside the bed, on the day of the fall. Interview on 3/24/11 at 6:05AM with Nurse #4 (assigned 3rd shift nurse morning of fall) indicated she did not recall moving the floor mat during her shift. Nurse #4 concluded the mat should have been positioned on the floor on both sides of the bed at all times. Interview on 3/24/11at 6:10 AM with NA #2 revealed she had cared for the resident independently to present and was not notified the resident required two staff assist at all times. NA #2 indicated Nurse #4 informed her on 3/23/11 the resident required two person physical assist. Interview on 3/24/11 at 6:27 AM with Nurse #5 (Nursing supervisor) revealed he informed staff to ensure the residents ' floor mats were in place and any other fall prevention device was intact and functioning (alarms). Interview on 3/24/11 at 11:25 AM with the Director of Nursing (DON) revealed she compared the hospital x-ray report completed on 3/15/11 to the facility ' s x-ray report completed on 3/19/11. The DON further indicated she requested a re-read of the facility ' s x-ray report completed on 3/19/11 by the contracted x-ray company on 3/23/11. She indicated she requested a re-read to rule out any pathological factor that would have contributed to the fracture. Review of the facility ' s re-read x-ray report completed 3/23/11 at 5:32 PM indicated significant findings of two-views of the left hip that showed a subcapital fracture of the left femur, with no other fractures identified. An addendum impression note to the initial facility ' s x-ray report completed on 3/19/11 indicated " Generalized osteopenia of the left hip, left femur, and visualized portion of bony pelvis probably on the basis of osteoporosis. " Interview on 3/24/11 at 7:40 PM with the Staff Development Coordinator (SDC) revealed she expected the staff to know the residents ' care needs at the start of the shift. This involved upon arrival on the unit, checking to ensure floor mats, bed alarms, call bells and other safety devices were in intact or properly place. Interview on 3/24/11 at 8:15 PM with the Director of Nursing revealed she expected the floor mats to be positioned beside the bed for any resident whose care plan indicated as an intervention/approach. The DON also indicated she expected the nurses/nurse aides to do walking rounds and shift report, upon arrival on the unit. The DON concluded the facility had started an action plan (after survey entry) of re-educating the staff on all shifts. Record review revealed on 3/15/11 at approximately10:30 AM Nurse #1 documented the nurse aide was bathing the resident in bed and rolled the resident onto her side and the resident rolled into the night stand and hit her head, causing a laceration. First aide was administered and the resident was transported to the hospital for sutures. Record review dated 3/15/11 at 10:35 PM revealed the resident returned from the hospital to the nursing facility with sutures to the forehead, with a change in mobility/transfer status to two person ' s physical assist. The hospital report dated 3/15/11 indicated the resident had a soft tissue scalp laceration to the right forehead with no underlining fracture. Facility record revealed on 3/15/11 the staff was in-serviced regarding turning/repositioning, handling fragile residents, and the staff was informed to use two person physical assist, at all times when providing care. The bedside table was removed to prevent any further injuries. On 3/22/11 at 1:10 PM, the bedside table was not positioned next to the bed. The night stand was positioned on the right side of the bed against the wall, one arm length or greater away from the resident ' s bed. Interview on 3/22/11 at 5:15 PM with NA #4 revealed she bathed, turned/repositioned, and transferred the resident from the bed to the broda chair independently, during morning care. Interview on 3/23/11 at 2:40 PM with Nurse #1 (assigned nurse on duty day of laceration) revealed the bed was in a high position when care was provided to the resident. She further indicated when NA #3 pulled the pad under the resident close to her, the resident flopped over and hit her head on the bed-side table. Nurse #1 concluded the resident was assessed and complained of no pain and was transported to the hospital. Interview on 3/23/11 at 3:50 PM with NA #2 revealed she turned/repositioned and provided incontinent care independently on third shift on 3/23/11. NA #2 further indicated she used the pad underneath the resident, to turn the resident to one side and then back to the other side, without help from another nursing staff. Interview on 3/23/11 at 4:20 PM with Nurse #3 (Unit manager) revealed two aides were required at all times when physical care was provided to the resident. Nurse #3 also indicated care was to be provided per the revised resident care guide (located in the nurse aides flow book at the nurses ' station), implemented the same day after the laceration occurred. Interview on 3/24/11at 6:10 AM with NA #2 revealed she had cared for the resident independently since 3/15/11 (date of laceration) to date and was not notified that two persons were required at all times, when care was provided. NA #2 indicated Nurse #4 informed her on 3/23/11 the resident required two person physical assist. Interview on 3/24/11 at 6:27 AM with Nurse #5 (Nursing Supervisor) revealed to date, one person turned/repositioned, and provided incontinent care for the resident. Nurse #5 elaborated this was how the staff cared for the resident on 3rd shift and he had not been informed to do otherwise. He also indicated he did not recall attending an in-service related to two person physical assist. Nurse #5 indicated he had no idea the resident care guide posted at the nurses ' station had been revised. He concluded the revised resident care guide did not indicate a date, wherein, changes were implemented. Interview on 3/24/11 at 7:10 AM with NA #3 revealed on 3/15/11 the resident appeared weaker than usual. She further indicated after she finished providing genital care and pericare, she was positioned on the side of the bed with her back facing the door. NA #3 then pulled the draw sheet underneath the resident toward her and the resident body went forward to the edge (side) of the bed and her forehead head hit the edge of the night stand, located at the head of the bed. NA #3 further indicated the bed was positioned very close to the night stand, at the time she turned the resident. She also indicated the bed was positioned (elevated) at a comfortable height for her to turn, reposition and bathe the resident. NA #3 concluded she informed Nurse #3 (Unit Manager) the resident may require two people assist, on the day of the incident (after occurrence). Interview on 3/24/11 at 7:40 PM with the SDC revealed she expected the staff to assess the environment (resident room) to ensure the resident was safe and prevent injury. The SDC also indicated she expected the staff, after he or she assessed the environment, to get assistance from another nursing staff, if there was any indicative change in the resident ' s condition or get guidance from the charge nurse. Interview on 3/24/11 at 8:15 PM with the DON revealed she expected the staff to assess the environment (resident room) to ensure, any accidental causing agent was removed before care was provided. The DON further indicated she expected the staff to use pillows during turning and repositioning as a protector between the resident and anything that could contribute to an injury. The DON concluded the facility had started an action plan (after the survey entry) of re-educating the staff on all shifts.