Every finding on record at Trinity Place

Based on record review and staff interviews, the facility failed to provide a bed hold notice to the resident and their representative when transferred to the hospital for 2 of 2 residents reviewed for hospitalization (Resident #23 and Resident #73).The findings included: 1. Resident #23 was admitted to the facility 11/18/23 with diagnoses including diabetes and heart failure. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #23 to be severely cognitively impaired. A. Review of the medical record for Resident #23 revealed a nursing note that documented on 8/13/25 she experienced a change in condition, and she was sent to the hospital for evaluation and treatment. Review of the medical record for Resident #23 revealed no evidence a bed hold notice had been provided to Resident #23 or her representative. A nursing note dated 8/16/25 documented Resident #23 returned to the facility after admission to the hospital for treatment of gastrointestinal bleeding. B. Review of the medical record for Resident #23 revealed a nursing note dated 9/23/25 that documented on 9/23/25 she experienced a change in condition, and she was sent to the hospital for evaluation and treatment. Review of the medical record for Resident #23 revealed no evidence a bed hold notice had been provided to Resident #23 or her representative.A nursing note documented Resident #23 was readmitted to the facility on [DATE] from the hospital for treatment of acute kidney failure and a urinary tract infection.An interview was conducted with Nurse #1 on 11/20/25 at 10:22 AM. Nurse #1 reported she was the charge nurse for the unit, and she reported she assisted with printing materials for a resident when they were sent to the hospital. Nurse #1 explained she did not send a bed hold notice with the residents when they were transferred to the hospital because that was the admission Coordinator's responsibility. The admission Coordinator was interviewed on 11/20/25 at 11:31 AM. The admission Coordinator reported she did not send a bed hold notice with residents when they were transferred to the hospital. The admission Coordinator explained that if the facility had a shortage of beds and they needed a bed while a resident was in the hospital, she would call and discuss with the resident representative, but the facility did not charge to hold a bed when a resident was hospitalized .An interview was conducted with the Administrator on 11/20/25 at 2:11 PM. The Administrator reported that a bed hold notice should be provided to all residents and their representatives when the resident is hospitalized . 2. Resident #73 was admitted to the facility on [DATE] with diagnoses including heart disease and atrial fibrillation. The admission Brief Interview for Mental Status completed on 8/26/25 assessed Resident #73 to be moderately cognitively impaired. A nursing note dated 8/31/25 documented Resident #73 was transferred to the hospital for evaluation and treatment after a change in condition. Review of the medical record for Resident #73 revealed no evidence a bed hold notice had been provided to Resident #73 or his representative. An interview was conducted with Nurse #1 on 11/20/25 at 10:22 AM. Nurse #1 reported she was the charge nurse for the unit, and she reported she assisted with printing materials for a resident when they were sent to the hospital. Nurse #1 explained she did not send a bed hold notice with the residents when they were transferred to the hospital because that was the admission Coordinator's responsibility. The admission Coordinator was interviewed on 11/20/25 at 11:31 AM. The admission Coordinator reported she did not send a bed hold notice with residents when they were transferred to the hospital. The admission Coordinator explained that if the facility had a shortage of beds and they needed a bed while a resident was in the hospital, she would call and discuss with the resident representative, but the facility did not charge to hold a bed when a resident was hospitalized .An interview was conducted with the Administrator on 11/20/25 at 2:11 PM. The Administrator reported that a bed hold notice should be provided to all residents and their representatives when the resident is hospitalized .

Based on record review, observation, and interviews with staff and a resident, the facility failed to provide a safe transfer. The resident was transferred manually by stand pivot (A technique for moving where a resident stands with assistance and pivots on their feet then sits. This technique requires the ability to bear most of their body weight.) and supported under her arm pits by Nursing Assistant (NA) #1. During transfer the resident's right knee had a popping sound and the resident reported immediate pain. The resident was transferred to the hospital for an evaluation and x-ray determined the resident had a non-displaced fracture (the bone fractured but did not move out of place) of the proximal tibia-fibula (fracture of the shin and calf bone just below the knee). The resident had a knee immobilizer placed. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with the diagnosis of stroke.The care plan dated 7/24/25 for Resident #1 documented she had an activity of daily living deficit. Transfers were total lift (mechanical lift). The quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a severely impaired cognition. Her functional limitations were impaired upper body on one side and lower body no impairment. The resident required maximal assistance to roll and up to sit in her bed and lying to sitting and sitting to stand was not applicable. The resident was dependent during transfer. The resident had no pain and was not receiving therapy. On 9/10/25 at 1:40 pm NA #1 was interviewed. NA #1 stated she was assigned to Resident #1 on 9/2/15 evening shift. The resident required mechanical lift for transfer. NA# 1 requested NA #2 assist with the transfer of the resident using mechanical lift. The resident was sitting in a reclining wheelchair, and the sling was out of place. The NA moved the sling underneath the resident. When the resident was lifted, she was slipping out of the sling. The resident was then manually transferred, both NAs lifted and transferred the resident from her chair. NA #1 felt it was safer to manually transfer the resident to prevent a fall out of the sling. NA #1 went on to further state she placed the resident's arms over her shoulders for the transfer. The nurse was not informed the sling was in the wrong position and the resident was manually transferred. The resident complained her right leg was hurting after the transfer and the nurse was informed immediately. This type of transfer had not happened before the incident. On 9/10/25 at 1:20 pm an interview was conducted with NA #2. NA #2 stated she walked into Resident #1's room to assist NA #1 as the second person for the mechanical lift. The lift pad was up the resident's back and not underneath her. NA #1 stated to NA #2 how she was unable to reposition the sling. NA #1 had thought it would not be safe to use the lift pad/sling in its position; the resident could fall. NA #1 decided to transfer the resident without the lift. NA #1 used the stand pivot method with the resident's arms over the NAs shoulders and was holding her by her pants for support. NA #2 stated she observed the transfer and could not see the resident's legs. NA #2 stated we heard a pop as the transfer was done. NA #2 stated she would move the sling if not in the proper place before attempting to use the mechanical lift. NA #2 further stated she would never transfer a resident by standing when they needed a lift. The resident had not said anything about the type of transfer. The resident stated my knee, my knee it hurt during the stand pivot transfer. The resident was successfully transferred without falling. NA #2 indicated she made a concerned facial expression to NA #1 during transfer and NA #1 stated she had done this before transfer successfully but had not mentioned which resident. NA #2 stated she had not observed NA #1 manually transfer a resident that required a mechanical lift before. Nurses' note dated 9/3/25 written by Nurse #1 documented on 9/2/2025 at 10:25 pm NA #1 reported that while putting Resident #1 to bed with the lift, they heard a popping sound from her right knee. The knee appeared to be rotated to the right, and the resident complained of pain. On 9/10/25 at 1:32 pm an interview was conducted with Nurse #1. Nurse #1 stated she was at the nurses' station evening shift 9/2/25 when NA #1 and NA #2 informed Nurse #1 they had to rearrange the sling for the mechanical lift to transfer Resident #1 into her bed. The NAs thought the resident's bottom was going to come through the sling and rushed to put her in bed and heard something pop. Nurse #1 indicated she was informed by both NAs that the resident was on the sling for transfer. The sling was under the resident when her leg was assessed in her bed. The resident stated she heard a pop in her right leg, and it hurt. Nurse #1 further stated the resident had not mentioned anything about the transfer, and she was not asked. Tylenol was administered for pain, and the NP was notified. Nurses' note dated 9/2/25 at 9:15 pm written by Nurse #2 documented a discharge summary note that Resident #1 was sent to the hospital for evaluation of her right knee pain after transfer via Emergency Medical Services. The resident rated her pain at 10 out of 10 (10 worst pain and 1 minor pain). The resident's vital signs were stable.On 9/10/25 at 2:29 pm Nurse #2 was interviewed. Nurse #2 stated NA #1 and NA #2 came to the nurses' station 9/2/25 evening shift to inform nursing that while transferring Resident #1 with the mechanical lift, her bottom was sliding out of the sling. The NAs hurried and heard a pop of the resident's knee. It was not reported the resident had hit the lift during transfer. Nurse #2 was requested to evaluate Resident #1's knee. The resident was in her bed, and her knee was rotated out to the right. Nurse #2 had not seen the sling underneath the resident while in the bed. The resident stated the knee popped and it hurt. Resident #1 did not say anything about the type of transfer. The medical staff was notified and directed staff to send the resident to the hospital. The resident's pain was a 10 out of 10. Tylenol was the only medication ordered for pain and was administered. The NAs had not reported that the resident was transferred by stand pivot. Nurse #2 stated the resident had osteoporosis and prior history of fracture and the resident was not able to stand.Resident #1's hospital record documented she was seen in the emergency room on 9/2/25 for pain in her right knee. The x-ray report documented she had a non-displaced fracture of the proximal tibia-fibula. The resident had not required surgery. Orthopedic follow up outpatient was planned. The resident had a history of hip fracture and osteoporosis. The resident had a knee immobilizer placed. Resident #1 had an order dated 9/3/25 for Oxycodone 5-325 milligrams every 6 hours as needed for pain started at the facility.The Nurse Practitioner (NP) note dated 9/3/25 documented that the resident was sent to the emergency room (ER) for right knee pain. The resident was evaluated after her ER visit on 9/3/25. ER imaging diagnosed closed fracture of the right tibia-fibula nondisplaced. She returned with a knee immobilizer. During exam today she verbalized pain. ER orthopedic consultation concluded due to age avoiding an operation would be beneficial. The resident was discharged back to the facility with outpatient follow-up and nonoperative management. Nurses' note dated 9/3/25 at 1:00 pm written by Nurse #3 documented the facility received a call from the orthopedic office. The physician informed staff the resident would not need to be seen until one week. An appointment was made for 9/11/25.On 9/10/25 at 1:10 pm an interview was conducted with Nurse #3. Nurse #3 stated she was not present at the time of Resident #1's transfer 9/2/25 evening shift but was on shift the next morning. Nurse #3 stated NA #2 reported a lift was not used to transfer the Resident #1. NA #2 watched a stand pivot transfer of Resident #1 by NA #1. NA #2 had not said anything to NA #1 about not using a mechanical lift. The resident required transfer by mechanical lift. Nurse #3 indicated if a NA had a problem with transfer they were required to find a nurse. Resident #1 had a fractured end of her tibia-fibula and was wearing a whole leg immobilizer. The resident was being medicated for pain and was comfortable when not moving. Resident #1 was having pain with movement and care. The resident had grimacing and facial expression when moved. On 9/10/25 at 3:10 an interview was conducted with the Administrator. The Administrator stated she was aware of the incident with Resident #1 where NA #1 reported she tried to transfer the resident using the mechanical lift and was unable due to discomfort. NA #1 reported she decided to transfer Resident #1 by standing and supporting the resident. NA #1 informed the Administrator she heard a pop during transfer, and the resident had knee pain. The Administrator stated the resident was not able to stand; she was transferred with a mechanical lift. The resident was sent to the Emergency Department and an investigation was completed. The Administrator stated all nursing staff was required to complete education on safe transfer.The facility provided the following corrective action plan: 1) How will the corrective action be accomplished for those residents affected?At approximately 8:00 p.m. on 9/2/2025, Nurse Aide NA #1 and NA #2 attempted to transfer Resident #1 with a total mechanical lift, but during the transfer, Resident #1 indicated discomfort due to the position of the lift sling. NA #1 and NA #2 attempted to reposition the lift sling but could not get it to a different position since it was under Resident #1 in her reclining wheelchair. Since Resident #1 was expressing discomfort with the total mechanical lift transfer, NA #1 decided that a manual transfer by herself would be the best way to transfer Resident #1 to avoid discomfort. Resident #1 was transferred from the reclining wheelchair chair into her bed by NA #1. NA#1 initiated the transfer out of the reclining wheelchair NA #1 stood the resident by having placed her arms over the NA's shoulders and holding the back of her pants. During the transfer from the reclining wheelchair to the bed, the nurse aides heard a pop, after which the resident indicated right leg pain. NA #2 and NA #1 reported to Nurse #2 immediately. Nurse #2 called the residents daughter and left a message at 8:27 p.m. Nurse #2 used the medical director's standing orders, which state that in the event of an emergency, a resident should be sent to the emergency department; the medical director's triage line also states if calling with an emergency dial 911. Emergency Medical Services transported the resident to the Emergency Department at 9:15 p.m. An X-ray of the right knee revealed a fracture of the proximal tibia-fibula. Resident #1 returned to the facility on 9/3/2025 with orders for a mobilizer. On 9/3/25, the director of nursing began an investigation. Mechanical lift slings that are used for transfers are inspected by the nurse aide using the sling prior to each use. They are inspected per manufacturers recommendations to include: if any fraying or visible wear and tear, do not use, follow care instructions on wash tag and if illegible, do not use. Nurse Aide #1 and Nurse Aide #2 found no issues with the lift sling that was used with Resident #1 on 9/2/25. There was no issue with the lift sling; the resident expressed discomfort with the position of the lift sling and the nurse aides thought trying to reposition the sling in Resident #1's chair could cause further discomfort which led to the transfer without the lift. 2) How will corrective action be accomplished for those residents who have the potential to be affected?On 9/3/25, a root cause analysis was completed by the Administrator and the Director of Nursing. It was determined that the nurse aides did not notify a nurse when they felt they could not follow the resident's transfer status due to resident discomfort, so the nurse could assist with repositioning of the sling or provide other assistance. On 9/3/25, the Director of Nursing and Minimum Data Set nurse audited electronic health records for all residents requiring 2+ person assist transfers or higher. This audit included every resident who required more than one person to transfer. No issues noted and no residents reported concerns. Every resident requiring more than one person for transfers was assessed by the Director of Nursing, Staff Development Coordinator, and the MDS Nurse. No injuries were observed or reported. The audit included evaluation if any nursing staff had not followed the care plan and used the appropriate transfer status. On 9/3/25, the MDS nurse reviewed all special transfer instructions in the electronic health record. Special transfer instructions are what identify the transfer status for each resident in their chart. The transfer instructions were compared to care plans for all current residents to ensure consistency, and no discrepancies were noted. 3) What measures will be put into place to ensure that the deficient practice will not occur?Staff education for all nurses and nurse aides was conducted by broadcast text and in-person by the Staff Development Coordinator on 9/3/25, covering procedures for following transfer status according to care plans, on Lutheran Services Carolinas' transfer policy, on safe lift and transfer techniques including the requirement to get a nurse if there is any concern about following the resident's transfer status, and the abuse and neglect policy. Nursing staff received instruction on reporting instances of improper resident transfer, as well as how to reposition lift slings when necessary for residents seated in chairs. Nursing staff who have not completed the training on 9/3/25 will be educated prior to their next working shift by the Director of Nursing and/or Staff Development Coordinator. The Staff Development Coordinator is responsible for tracking all education, and education for all staff was initiated 9-3-25. No staff will work without receiving the education. New hires will be educated during new hire orientation by the Staff Development Coordinator. 4. How does the facility plan to monitor its performance to make sure that solutions are sustained? The charge nurses will conduct observations of five randomly selected resident transfers each week for eight weeks, commencing on 9/4/2025, and subsequently five resident transfers will be observed each month for an additional three months. These audits will include Residents transfer status, transfer performed correctly, ordered equipment used, lift sling inspection and staff member observed. These Audits will be completed on all shifts, including first shift, second shift and third shift. Audit findings will be presented by the Staff Development Coordinator and evaluated for effectiveness at the monthly QAPI meetings, and modifications will be implemented as needed to maintain compliance. The facility determined on 9/3/2025 that a corrective action plan was necessary. This plan became effective 9/3/2025 and no staff worked without education after 9/3/2025. The decision was made to monitor with a plan of correction on 9/3/25.The Administrator will be responsible for ensuring completion of the corrective action plan. Completion date for the corrective action plan: 9/4/25 Validation of the corrective action plan was completed on 9/12/25. Documentation reviewed of education sent out by broadcast text with confirmation that it was read and in person by signed roster for all current nursing employees that all mechanical lift transfers must be done with 2 staff, lift slings should be readjusted for appropriate positioning, manually transfer residents only in an emergency, and to report any staff that does not follow the policy. The Abuse and Neglect policy was also part of the required education. Documentation reviewed of skills fair observation that began on 9/11/25 of transfers including mechanical lift for all nursing staff which was ongoing. Staff could not return to work until the observation was completed.A review of the documented audits revealed the audits began on 9/3/25 for all residents that required a mechanical lift transfer. As part of the audit, residents that were oriented were interviewed. No other resident that required a mechanical lift transfer had a manual transfer identified.On 9/10/25 the Administrator and Director of Nursing were interviewed. Both stated audits of observed transfers had begun the week of 9/8/25.Interviews were completed with 4 NAs and 3 licensed nurses. All 7 staff interviewed participated in abuse and resident transfer education including the use of the mechanical lift. On 9/10/25 at 1:03 pm an observation of NA #3 and NA #4 transfer Resident #4 by mechanical lift from her wheelchair to her bed revealed no concerns with technique and safety. Resident #4 was interviewed and stated she had never been transferred without the lift and had no concerns. The corrective action plan's completion date of 9/4/25 was validated.

Based on observations, record review, staff interviews and review of the manufacturers guidelines the facility failed to discard an expired multi dose oral inhaler, and expired nebulizer solutions, and record an opened date on a nebulizer solution on 2 of 3 medication carts and failed to discard an expired influenza vaccine and nebulizer solution in 1 of 2 medication rooms reviewed for medication storage. Findings included. Review of the manufactures guidelines revealed Trelegy multi dose oral inhalers should be discarded 6 weeks after opening. Ipratropium Bromide 0.2% nebulizer solution and Levalbuterol 1.25 milligram (mg) nebulizer solution should be discarded 2 weeks after opening the foil pouch. An observation of the B hall medication cart on 06/08/23 at 10:00 AM revealed a Trelegy oral inhaler with an opened date of 03/27/23. The label on the inhaler instructed to discard 6 weeks after opening. Ipratropium Bromide 0.2% nebulizer solution was observed in an opened foil pouch with no opened date. During an interview with Medications Aide #1 on 06/08/23 at 10:00 AM she stated expiration dates should be checked prior to administering the medications. She stated she was not aware the Trelegy oral inhaler, or the Ipratropium Bromide nebulizer solution were expired because she had not administered those medications. She stated the nurses were responsible for checking the medication carts for expired medications. An observation of the C hall medication cart on 06/08/23 at 10:30 AM revealed an Ipratropium Bromide 0.2% nebulizer solution with an opened date of 03/20/23. Levalbuterol 1.25 mg nebulizer solution with an opened date of 05/07/23. The instructions on the foil pouch of the Ipratropium Bromide nebulizer solution and the Levalbuterol nebulizer solution read to discard 2 weeks after opening. During an interview with Nurse #1 on 06/08/23 at 10:30 AM she stated she was not aware the Ipratropium Bromide or the Levalbuterol solution was expired. She stated Medication Aide #2 was working on the medication cart today and Nurse #1 had not checked the cart yet for expired medications. She stated the nurse, or the medication aides were responsible for checking expiration dates prior to administering the medications. She stated the night shift nurses also checked the medication carts on Friday nights for expired medications. She stated it was an oversight. An observation of the B/C hall medication storage room on 06/08/23 at 10:45 AM revealed Levalbuterol 1.25 mg nebulizer solution in a foil pouch with an opened date of 05/15/23. Ipratropium Bromide 0.2% nebulizer solution was observed with no opened date. The instructions on the foil pouch of the Ipratropium Bromide solution and the Levalbuterol solution read to discard 2 weeks after opening. An observation of the B/C hall medication storage room refrigerator on 06/08/23 at 10:45 AM revealed an opened vial of Influenza vaccine with an expiration date of 05/25/23. During an interview on 06/08/23 at 1:00 PM the Director of Nursing stated the nurses and medication aides should be checking the carts for expired medications. She stated they had a process in place to check for expired medications which included checking the medication expiration date prior to administration, night shift checked all carts once a week on Friday, and the Consultant Pharmacist also checked for expired medications monthly. She stated the expired medications should not have been on the medication cart or in the medication storage rooms. She stated education would be provided to nursing staff.

Based on record review and staff and physician interview, the facility failed to provide pressure ulcer treatment for 1 of 1 resident (Resident #61) reviewed for pressure ulcers. The findings included: Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61 had a significant change Minimum Data Set (MDS) dated [DATE] which revealed she was moderately cognitively impaired with a Stage 4 facility acquired pressure ulcer. She required extensive assistance with bed mobility, toileting and eating. Resident #61 was incontinent of bowel and bladder. The care plan updated on 11/24/21 indicated Resident #61 had a Stage 4 wound to the coccyx and the goal was to heal without signs or symptoms of complications or infection in three months. One of the interventions was to provide treatment as ordered. Resident #61 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Records revealed there was no documentation of the application of [MEDICATION(S)] [MEDICATION(S)] to the buttocks on: 11/17/21 11/20/21 11/21/21 11/24/21 11/27/21 11/30/21 12/11/21 12/12/21 Resident #61 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily every morning until healed. Review of the November Treatment Administration Record revealed no documentation of treatment to the coccyx on: 11/13/21 11/14/21 11/15/21 11/20/21 11/21/21 11/24/21 11/27/21 Review of the medical record revealed Wound Care Physician measurements of coccyx wound were as follows: 11/9/21 0.6x0.5x0.6 centimeters (cm.) (length x width x depth) 11/30/21 0.9x0.9x0.5 cm. (length x width x depth) Resident #61 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December Treatment Administration Record revealed there was no documentation of the treatment to the coccyx and right buttock areas on 12/8/21 12/11/21 12/12/21 Review of the medical record revealed Wound Care Physician measurements of coccyx wound were as follows 12/7/21 1.1 cm x 1.1 cm x 0.8 cm (length x width x depth) 12/14/21 0.9 cm x 0.9 cm x 0.5 cm (length x width x depth) During an interview on 12/15/21 at 10:37 AM, Treatment Aide ll stated she worked Monday through Friday and was responsible for treatments. She stated she was reassigned to the floor to provide patient care at times and then the floor nurses were responsible for completing wound care. During an interview on 12/15/21 at 11:16 AM, the Wound Care Nurse stated she worked Monday through Friday. She stated the Treatment Aide ll provided wound care Monday through Friday. On the weekends and in the absence of an assigned treatment nurse, the nurse on the floor provided the wound care. She stated she rounded weekly with the Wound Care Physician. She further stated she did not review the Treatment Administration Records to ensure treatments were completed. Record review of the facility Daily Assignment Sheets revealed the following assignment for treatments: 11/20/21: Nurse #2 11/21/21: no assigned nurse 11/24/21: no assigned nurse 11/27/21: no assigned nurse 12/8/21: floor nurses' complete own treatments 12/11/21: no assigned nurse 12/12/21: no assigned nurse During an interview via phone on 12/15/21 at 3:18PM, Nurse #1, indicated she was aware of her responsibility to administer the wound treatments to her assigned residents including Resident #61 in the absence of Treatment Aide ll or designated treatment nurse. She had not completed the assigned wound care for Resident #61 on dates listed below and was unable to verbalize why: 11/13/21 11/14/21 11/15/21 11/20/21 11/21/21 11/24/21 11/27/21 11/30/21 12/8/21 12/11/21 12/12/21 During an interview on 12/16/21 at 10:33 AM, Nurse #2 indicated initially on 11/20/21 she was assigned to do all treatments but one of the nurses went home early, and the schedule was changed. She was reassigned to a medication cart and resident assignment. Nurse #2 indicated she had not completed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview via phone on 12/16/21 at 9:53 AM the Wound Care Physician revealed wound care was ordered daily for Resident #61 and should be followed as written. She indicated she visits the facility briefly each week. She indicated wound healing could be impacted by not changing the dressing daily as ordered. During an interview on 12/16/21 at 1:00 PM, the Director of Nursing indicated that the nurses were aware to complete wound care in the absence of a wound care aide or nurse. She stated she was not aware of any problems with completing daily wound treatments and she does not review Treatment Administration Records.

Based on record review, resident and staff interviews, the facility failed to protect a resident's right to be free from mistreatment by a staff member (Nursing Assistant #3) due to being rough while provide care and making disrespectful comments to 1 of 1 resident reviewed for mistreatment (Resident#49). The Findings included: Resident #49 was admitted to the facility on [DATE]with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annal Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact. A review of the email correspondence included in the facilities investigation dated 8/24/21 at 10:46 AM from the Facility Supervisor nurse to the Staff Development Coordinator (SDC) read: [Resident #49] told [Nurse #1] today [8/24/21] that last night [Nursing Assistant (NA) #3] was rough with [Resident #49]. She also explains that [NA #3] kept complaining that her back was hurting. [Resident #49] states that [NA #3] would grab her legs and when they got into the bathroom had to be asked to help her on the toilet. [Resident #49] told [Nurse #1] that when she was getting back to bed [NA #3] had grabbed her legs so hard that she was yelling to let go because of the pain. [Resident #49] then stated that [NA #3] told her 'I did not put them bruises on your legs, I know that is what you white women try to say about us black women'. An email from the Staff Development Coordinator (SDC) on 8/24/21 at 11:20 AM to the Facility Supervisor read; does she have any bruises. The email response at 8/24/21 at 12:07 PM back from the Facility supervisor to the SDC read: [Nurse #1] says she does but they were there previously. A review of Resident #49's skin evaluations revealed the following skin assessments: August 20,2021 8:07 PM - skin is warm, dry, fragile. Discoloration noted to both lower extremities (BLE). Some bruising noted to both upper extremities (BUE). No new areas noted. August 25th, 2021- 8:06 AM pressure reducing matters in place to help prevent skin breakdown. August 27th, 2021- 8:30 PM - Skin is warm, dry, fragile. Discoloration noted to BLE. Skin tear to back side of right hand. Some bruising noted to BUE. No new areas noted. There was no skin evaluation documented after the facility became aware of the incident with Resident #49 and NA #3 on August 24, 2021. A review of the Social Workers (SW) interview with Resident #49 included in the facilities investigation dated 8/24/21 read in part; [Resident #49] felt like [NA #3] was upset about something because she stated to [Resident #49] 'I don't have time to mess with you,' the NA then grabbed Resident #49's calves and squeezed them while she was helping her get up. [Resident #49] screamed because it hurt, and she asked the NA to please not do that, it hurt. When [Resident #49] was being put back to bed, the NA squeezed her calves again. [Resident #49] stated that NA #3 said 'I know what you white women will say to us black women put bruises on you'. [Resident #49] stated she did not know why NA #3 said that. An interview and observation were completed with Resident #49 on 12/14/21 at 9:01 AM. An observation of Resident #49's both lower extremities revealed her legs are very small and skin was red and blotchy. Resident #49 stated a staff member was very rough with her one night back in the fall when she needed to use the bathroom. Resident #49 stated that she had pressed her call light and NA #3 came in and had asked me what I needed, and huffed and said lordy, lordy then grabbed my legs and snatched them around. Resident #49 mentioned that NA #3 stated to her I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. Resident #49 stated I really felt mad when that happened. Resident #49 stated that she told NA #3 that she was nothing but a racist because of what she said to me. Resident #49 stated that her comments still bother me and every time I think about how uncalled for it was. I get along with everyone and I don't know why she (NA #3) was so mean, I guess I am not made to be in nursing homes. An interview was completed with the Social Worker (SW) on 12/14/21 at 2:54 PM who stated she recalled that NA #3 (on 8/24/21) went into Resident #49's room and grabbed her legs and when NA #3 went to put her back to bed grabbed her legs again. The SW stated that Resident #49 told her she that NA #3 made a comment to Resident #49 that 'you white women get together and say black people put bruises on her'. The SW was asked did you ask Resident #49 how this made her feel and the SW responded, well, she did not like it of course. The SW stated regarding the comment 'I don't have time to mess with you' NA #3 should not have said that. An interview was completed with the SDC and the Facility Supervisor on 12/14/21 at 3:10 PM. The Facility Supervisor stated that she did go in and speak with Resident #49 and did look at her legs but did not chart it. The Facility Supervisor stated that Resident #49 had stated that the NA #3 did grab her legs and her legs had hurt from what happened. The Facility Supervisor stated she did have scattered bruising but like the Nurse #1 stated the bruising was already there The Facility Supervisor stated that Resident #49 stated her legs hurt from what happened. An interview was completed on 12/15/21 at 2:53 PM with NA #5 who was asked how she assists Resident #49 to get up out of bed. NA #5 stated she would first get her walker and put this by the bed and then would put her one arm under her thighs and the other around her shoulder and rotate her. NA #4 stated that you do have to be careful of her calf areas as they can be sensitive. An interview was completed on 12/15/21 at 2:53 PM with NA #6 who was asked how she assists Resident #49 to get up out of bed. NA #6 stated that Resident #49 does hurt a lot and you have to be very careful with her and one must turn her legs straight out and help her sit up. Once she would sit up you cannot rush her as she needs to get her balance. When you grab her [Resident #49's] legs you just lightly pull on her legs to the side and move her by her hips, if you pull to hard you will really hurt her and stated, Resident #49 will always let you know. An interview was completed on 12/15/21 at 5:13 PM with Nurse #4 who was working third shift on 8/23/21 from 11:00 PM to 7:00 AM who was asked if she had heard any yelling from Resident #49's room that evening. Nurse #4 stated, I did not hear her [Resident #49] scream. An interview was completed on 12/15/21 at 8:53 PM with NA #3 who stated that it is very hard to get Resident #49 out of bed as you need to hold her walker and hold her at the same time. NA #3 stated that Resident #49 was concerned about the bruises on her legs and NA #3 stated the bruises were not that bad and was trying to re-direct Resident #49 instead of focusing on her legs. NA #3 was asked if she had grabbed Resident #49's calves and NA #3 stated that she did not remember and stated that you have to put your hands underneath her calves and bring her legs around to the side of the bed and physically pull her legs and you have to put some energy into it and put pressure on her legs. NA#3 was asked if she was too rough with Resident #49, and she stated she did not think she had been too rough with Resident #49 but there was a lot of pushing and pulling and nothing was intentional. NA #3 stated it had been a rough night. NA #3 stated she did not remember her screaming in pain and was not rushing her. NA #3 stated she knew Resident #49's legs are sensitive, and Resident #49 told NA #3 to go slower. NA #3 stated that she did tell her to come on that her back was about to give out. NA #3 was read the statement interview from the SW and Resident #49 which indicated NA #3 stated to Resident #49 'I don't have time to mess with you' 'I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. NA #3 stated that she did not say those things to Resident #49 and would never put anybody down. NA #3 stated she had not been asked to write any statements about what happened but stated; I wish they would have, as I cannot remember the details of what happened now.

Based on record review and staff and family interviews the facility failed to provide effective oversight to ensure abuse allegations made by 2 of 3 residents, Resident #113 and Resident #49, were assessed, investigated, and reported according to the facility's Abuse Investigation and Reporting for Senior Services Policy. Findings included: This tag is cross referenced to: F607- Based on record review and family and staff interviews facility staff failed to follow the facility's Abuse Investigation and Reporting for Senior Services Policy when they failed to promptly report allegations of abuse for 2 of 3 residents, Residents #113, and Resident #49, reviewed for abuse. Resident #113 reported allegations of abuse to a staff member who did not report the allegation to facility management, which resulted in the accused staff member not being removed from the facility and an investigation being delayed. Resident #49 also reported allegation of abuse to staff, and they failed to report the allegation to the Division of Health Service Regulation and failed to assess Resident #49 and investigated the allegation. The Administrator was interviewed on 12/16/2021 at 2:21 pm and stated the staff should report any allegation of abuse to their supervisor immediately and then the supervisor should report the allegation to the Director of Nursing and Administrator. The Administrator stated the staff are educated on abuse at least once a year and whenever an incident occurs.

Based on record review and staff interviews, the facility failed to develop and implement comprehensive care plans for 2 of 2 residents (Resident #42, Resident #59) reviewed for care plans. The findings included: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only for transfer, dressing, toilet use and personal hygiene and the assistance of 1 person. For eating she required supervision only with meal set up assistance. She needed limited assistance from staff for bed mobility with the assistance of 1 person. Locomotion occurred only 1-2 times with 1 person assist on the unit. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted and indicated several areas of decline. The functional status section of the MDS reported the resident required supervision only with eating and one person physical assist. She required extensive assist of 2 staff with bed mobility, extensive assist with 1 person assist for transfer, dressing, toilet use and personal hygiene A review of Resident #42's care plan initiated on 05/25/21 and most recently revised on 10/29/21 indicated a care area for Help with my ADL's. The care area only addressed oral hygiene and refusal of care for her ADL's. An interview was conducted with MDS Nurse #1 on 12/15/21 at 9:45 AM regarding the care plan not reflecting the ADL decline in the functional areas. She stated she did not know what the staff would see on Resident #42's care plan as she had a different view. She stated the ADL information displayed in her view. A follow-up interview was done with MDS Nurse #1 on 12/15/21 at 12:03 PM. She stated the nurses were not able to view the ADL functional need information on Resident #42's care plan and she did not know why. The MDS nurse noted that usually the care plan had more information than just oral care such as transfers, bathing and mobility in the care plan. An interview was done on 12/16/21 at 1:05 PM with the Administrator regarding Resident #42's ADL decline and her care plan. She stated the care plan should be all inclusive and everyone should be able to see the care areas and interventions. 2. Resident # 59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) dated [DATE] included that Resident # 59 had severe cognitive impairment and required supervision of 1 staff with meals. Resident # 59 weighed 109 pounds and was not on a physician prescribed weight loss regimen. Review of a nutritional progress note dated 11/17/2021 at 12:07 PM included that Resident # 59 had a significant weight loss. She received a regular diet and a nutritional supplement two times a day. Resident # 59 was recorded to consume an average of 49% of meals. On 12/16/2021 the care plans for resident # 59 were reviewed and had been updated on 09/16/2021 and on 11/23/2021. The nutritional status and weight loss of resident # 59 was not included in the comprehensive care plans. MDS # 1 was interviewed on 12/16/2021 at 11:00 AM. MDS nurse #1 reviewed the current care plans for Resident # 59 and stated that she did not see nutritional or weight loss care plans for Resident # 59 and that there should be care plans to address those areas. The facility administrator was interviewed on 12/16/2021 at 1:22 PM and she stated that she expected care plans to be implemented and revised to reflect the status of the resident.

Based on staff and resident interviews and record reviews the facility failed to complete significant change Minimum Data Sets (MDSs) for 2 of 2 residents reviewed for a change in status (Resident # 39 and resident # 42). Findings included: 1.Resident # 39 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS dated [DATE] revealed that Resident # 39 had moderate cognitive impairment and required extensive assist of at least 2 staff for bed mobility ,transfers and toileting. Resident # 39 required supervision to limited assist of 1 staff to eat, was always incontinent of bladder and bowel and had no pain. A quarterly MDS dated [DATE] for Resident # 39 included that Resident # 39 had significant cognitive impairment, felt down, depressed, or hopeless on at least 1day of the review period and 12 to 14 days of feeling bad about herself. Resident # 39 required extensive assist of 1 staff to eat and was frequently incontinent of bladder and bowel. Resident # 39 had no pain. A review of a quarterly MDS dated [DATE] included that Resident # 39 required supervision and set up to eat and she had frequent pain that limited her day-to-day activities. An interview conducted with MDS nurse # 1 on 12/16/2021 at 11:00 AM. MDS nurse #1 stated that a significant change MDS was required if a resident had 2 areas of decline or improvement in resident status as determined by the interdisciplinary team that consisted of MDS nurse #1 and MDS nurse #2. MDS nurse # 1 stated that there had been a difference in MDS coding for Resident # 39 but that she was not certain the MDS was coded correctly. The administrator was interviewed on 12/16/2021 at 1:22 PM. The administrator stated that she expected that significant change MDSs be completed as stated in the regulation and the Resident Assessment Manual (RAI). 2. Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only for transfer, dressing, toilet use and personal hygiene and the assistance of 1 person. For eating she required supervision only with meal set up assistance. She needed limited assistance from staff for bed mobility with the assistance of 1 person. Locomotion occurred only 1-2 times with 1 person assist on the unit. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only with eating and one person physical assist. She required extensive assist of 2 staff with bed mobility, extensive assist with 1 person assist for transfer, dressing, toilet use and personal hygiene An interview was conducted with MDS Nurse #1 on 12/15/21 at 9:45 AM regarding the decline in the functional status on Resident #42's Quarterly assessments from 08/04/21 to 10/27/21. The MDS nurse stated the resident had not changed much and did not indicate a need for a significant change assessment to be completed. She stated they looked at the Activities of Daily Living (ADL's), but they can fluctuate and if they need a significant difference in care and had 2 or more differences in care, they might do one. An interview was done on 12/15/21 at 10:33 AM with Nurse #5 regarding Resident #42. He stated the resident used to be very independent and after one of her falls, she now required a lot more assistance. An interview was done on 12/15/21 at 11:11 AM with PT #1 that completed the requested rehabilitation evaluation after some falls. He stated he evaluated her post falls on 09/15/21 and she had she absolutely refused to participate. He noted she would not stand when asked or actively participate and had become more non-compliant since completing therapy in June 2021. Record review indicated Resident #42 had 7 falls since admission including 08/31/21 and 11/14/21. Record review of X-rays from 9/17 indicated a pelvis fracture. A follow-up interview was done on 12/16/21 at 12:03 PM with MDS Nurse #1 and she was asked why a significant change assessment was not done with 2 or more changes, and with several functional area declines. She stated the final decision if a significant change needed to be done was made by the Interdisciplinary Team, which consisted of the 2 MDS nurses. An interview was done on 12/16/21 at 1:05 PM with the Administrator. She stated if there were changes on the MDS assessment in 2 or more areas and the changes were for a prolonged time, a significant change should be done.

Based on record review and family and staff interviews facility staff failed to follow the facility's Abuse Investigation and Reporting for Senior Services Policy when they failed to promptly report allegations of abuse for 2 of 3 residents, Residents #113, and Resident #49, reviewed for abuse. Resident #113 reported allegations of abuse to a staff member who did not report the allegation to facility management, which resulted in the accused staff member not being removed from the facility and an investigation being delayed. Resident #49 also reported allegation of abuse to staff, and they failed to report the allegation to the Division of Health Service Regulation and failed to assess Resident #49 and investigated the allegation. The findings included: 1. A review of the Abuse Investigation and Reporting for Senior Services revised on 3/5/2021 revealed facility staff should report observed or suspected incidents of abuse to his/her department manager as soon as he is aware of an incident or potential incident. The nursing supervisor or department manager must notify the administrator and the director of nursing immediately. The administrator or designee is responsible for ensuring the thorough investigation of the allegation. While the investigation is pending, the accused individual employed by the facility will be suspended, pending the results of the investigation. Resident #113 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #113's Annual Minimum Data Set assessment dated [DATE] indicated she was moderately cognitively impaired and required extensive assistance with bed mobility and set up assistance with her meal trays. A review of an abuse investigation dated 5/14/2021 revealed Resident #113's Family Member called the facility to report Resident #113 had told him, while she was visiting with the Family Member in his home, Nurse Aide #1 had slammed her dinner tray down on her over bed table several weeks ago, causing pain in her legs, and had threatened to do it again. The Family Member asked Resident #113 if the incident was an accident and she stated Nurse Aide #1 had meant to do it and she was afraid of him. During an interview with Nurse Aide #1 on 12/15/2021 at 3:58 pm he stated Resident #113 told him he had hit her with the over the bed table, but he could not remember the date it happened. He stated he told Nurse #4 when the incident occurred that Resident #113 had accused him of hitting her with the over the bed table and he was reassigned to another resident and did not take care of Resident #113 again. Nurse Aide #1 stated he was not suspended when he reported the incident to Nurse #4, and he continued to work that night. Nurse Aide #1 stated about 2 weeks after the incident the Staff Development Coordinator called him and suspended him pending an allegation and then three days later the Director of Nursing called him and told him to come to work early and she interviewed me before I went back to work. During an interview with Nurse #4 on 12/15/2021 at 5:13 pm she stated Nurse Aide #1 did not report Resident #113's allegation to her when it occurred on 4/30/2021. Nurse #4 stated Resident #113 told her Nurse Aide #1 intentionally slammed the over bed table on her knees on 5/7/2021, a week after the incident happened. Nurse #4 stated she immediately went to Nurse Aide #4, who was working at the time, and asked him what happened, and he told her it was an accident. Nurse #4 stated Nurse Aide #1 stated the over the bed table dropped and hit her knees and he looked at her knees but did not see any injury. Nurse #4 stated she reported the incident to the Charge Nurse on 5/7/2021 when Resident #113 reported the allegation to her. An interview was conducted with the Charge Nurse on 12/15/2021 at 5:38 pm and she stated she did not remember Nurse #4 reporting an allegation of abuse involving Resident #113 and was not aware of the incident. On 12/16/2021 at 1:05 pm an interview was conducted with the Director of Nursing and she stated she was not aware of Resident #113 reporting the allegation of abuse until the Family Member called the Staff Development Coordinator on 5/14/2021 and reported the allegation. The Director of Nursing stated she was not working when the allegation was reported, and the Staff Development Coordinator had suspended Nurse Aide #1 and obtained the statements from the staff. The Staff Development Coordinator was interviewed on 12/16/2021 at 2:07 pm and stated he was not aware of the abuse allegation regarding Resident #113 until 5/14/2021 when the Family Member called him to report Resident #113 told him that Nurse Aide #1 intentionally slammed the over the bed table on her legs several weeks ago. He stated he had immediately made the Administrator aware of the allegation and suspended Nurse Aide #1 until the investigation was completed. The Staff Development Coordinator stated the staff receive abuse education at least annually and any time there is an allegation of abuse. During an interview with the Administrator on 12/16/2021 at 2:21 pm she stated she was not aware Resident #113 had reported the allegation of abuse to Nurse #4 before it was reported by the Family Member to the Staff Development Coordinator on 5/14/2021. The Administrator stated Nurse #4 should have reported Resident #113's allegation of abuse regarding Nurse Aide #1 slamming the over the bed table down on her legs intentionally to her immediately. The Administrator stated Nurse Aide #1 should have reported to Nurse #1 and the Charge Nurse when the resident told him her hurt her legs with the over the bed table. The Administrator stated the staff should follow the facility's policy for Abuse Investigation and Reporting for Senior Services and report any allegations of abuse immediately. 2. Resident #49 was admitted to the facility on [DATE]with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annal Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact. A review of a policy titled: Abuse Investigations and Reporting for Senior Services revision date 3/5/21 read in part: Identification and Investigation: 2. The administrator or designee is responsible for ensuring the thorough investigation of the allegation. 3. Upon receiving a report of physical abuse, the nursing supervisor (or designee) shall immediately examine the resident. Finding of the examination must be recorded in the resident's record. 5. The director of nursing or designee will begin the abuse investigation which will consist of: Completing the Division of Health Service Regulation (DHSR) required reporting from the (initial allegation report) Interviewing the person(s) reporting the incident Interviewing staff members (on all shifts) that have had contact with the resident during the period of this alleged incident Reviewing all circumstances and events leading up to the incident 6. Witness reports will be made in writing, signed and dated. Witness reports will be maintained with all written reports. The director of social work or designee will monitor the resident's feeling concerning the incident, as well as the resident's reaction to his/her involvement in the investigation. Reporting: For certified nursing facilities and skilled nursing facilities, all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than two hours after the allegation is made A review of the facility's reportable incidents revealed no reportable investigations were completed related to the allegation of staff to resident abuse for Resident #49. The facility completed an investigation which included the following: Social Worker's (SW) interview with the resident, email correspondence between the Facility supervisor and the SDC, a signed statement from the Administrator and a Employee Coaching/Disciplinary Action Report. There were not signed statements from any staff. A review of the email correspondence included in the facilities investigation dated 8/24/21 at 10:46 AM from the Facility Supervisor nurse to the Staff Development Coordinator (SDC) read: [Resident #49] told [Nurse #1] today [8/24/21] that last night [Nursing Assistant (NA) #3] was rough with [Resident #49]. She also explains that [NA #3] kept complaining that her back was hurting. [Resident #49] states that [NA #3] had grabbed her legs and then they got into the bathroom had to be asked to help her on the toilet. [Resident #49] told [Nurse #1] that when she was getting back to bed [NA #3] had grabbed her legs so hard that she was yelling to let go because of the pain. [Resident #49] then stated that [NA #3] told her 'I did not put them bruises on your legs, I know that is what you white women try to say about us black women'. An email from the Staff Development Coordinator (SDC) on 8/24/21 at 11:20 AM to the Facility Supervisor read; does she have any bruises. The email response at 8/24/21 at 12:07 PM back from the Facility supervisor to the SDC read: [Nurse #1] says she does but they were there previously. A review of Resident #49's skin evaluations revealed the following skin assessments: August 20,2021 8:07 PM - skin is warm, dry, fragile. Discoloration noted to both lower extremities (BLE). Some bruising noted to both upper extremities (BUE). No new areas noted. August 25th, 2021- 8:06 AM pressure reducing matters in place to help prevent skin breakdown. August 27th, 2021- 8:30 PM - Skin is warm, dry, fragile. Discoloration noted to BLE. Skin tear to back side of right hand. Some bruising noted to BUE. No new areas noted. There was no skin evaluation documented after the facility became aware of the incident with Resident #49 and NA #3 on August 24, 2021. A review of the Social Workers (SW) interview with Resident #49 included in the facilities investigation dated 8/24/21 read in part; [Resident #49] felt like [NA #3] was upset about something because she stated to [Resident #49] 'I don't have time to mess with you', the NA then grabbed Resident #49's calves and squeezed them while she was helping her get up. [Resident #49] screamed because it hurt, and she asked the NA to please not do that, it hurt. When [Resident #49] was being put back to bed, the NA squeezed her calves again. [Resident #49] stated that NA #3 said 'I know what you white women will say to us black women put bruises on you'. [Resident #49] stated she did not know why NA #3 said that. A signed statement from the Administrator dated 8/24/21 read in part; After reviewing interviews conducted by the social worker on 8/24/21, with [Resident #49] and other residents on that assignment and reviewing recent body assessments of [Resident #49], I concluded that abuse did not take place. The encounter with the third shift [NA #3] and [Resident #49] was inappropriate but the behavior did not meet the definition of abuse defined by the Centers for Medicaid Services (CMS). Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'(42 CFR 488.301). However, this encounter did not meet the facility's expectation with the standard set-in place for customer service and professionalism. These expectations clearly stated in the LSC (Lutheran Services Carolina) WAY policy. Teammate [NA #3] was removed from this resident's [Resident #49] assignment. An interview and observation were completed with Resident #49 on 12/14/21 at 9:01 AM who stated that a staff member was very rough with her one night back in the fall when she needed to use the bathroom. Resident #49 stated that she had pressed her call light and NA #3 came in and had asked me what I needed, and huffed and said 'lordy, lordy' then grabbed my legs and snatched them around. She grabbed my legs below the knee and was very rough and squeezed them, she left fingerprints. Resident #49 stated she had used the walker to walk to the bathroom and when NA #3 had put Resident #49 back to bed she threw her back into bed and was very rough. Resident #49 described that her right calf was the worst because of the pain. Resident #49 stated that NA #3 said to her I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. Resident #49 stated I really felt mad when that happened. I told NA #3 that she was nothing but a racist because of what she said to me. Resident #49 stated I was not bleeding it just really hurt. Resident #49 stated that NA #3 is no longer able to come into my room. An observation of Resident #49's BLE revealed her legs are very small and skin was red and blotchy. A follow up interview was completed with Resident #49 on 12/15/21 at 5:30 PM who stated that her comments still bother me and every time I think about how uncalled for it was. I get along with everyone and I don't know why she (NA #3) was so mean, I guess I am not made to be in nursing homes. An interview was completed with the Social Worker (SW) on 12/14/21 at 2:54 PM who was asked if she had asked Resident #49 how this made her feel and the SW responded, well, she did not like it of course, but was not asked. The SW stated I do not know why it was not reported. An interview was completed with the SDC and the Facility Supervisor on 12/14/21 at 3:10 PM The Facility Supervisor stated the SDC notified the Administrator, and she did not direct a 24-hour report to be completed. The Facility Supervisor stated that she did go in and speak with Resident #49 and did look at her legs but did not chart it. The Facility Supervisor stated that Resident #49 had stated that the NA #3 did grab her legs and she did have scattered bruising but like the Nurse #1 stated the bruising was already there. The Facility Supervisor stated that Resident #49 stated her legs hurt from what happened. The SDC and the Facility Supervisor was asked if NA #3 was suspended. The SDC stated that she did not work the next night as she had called out, and by then the investigation was completed and we did not need to suspend her. She was removed from performing care to Resident #49. An interview was completed with the Administrator on 12/15/21 at 9:16 AM who stated that the facility became aware of the allegation of staff to resident abuse for Resident #49 at 10:45 AM on 8/24/21 and started the investigation. The Administrator was asked what the allegation was about, and the Administrator stated it was an allegation of an unpleasant encounter and Resident #49 was upset about the encounter and the facility wanted to follow up. The Administrator stated the facility did not report this allegation to the state as it did not meet the definition of abuse per the regulation. The Administrator stated that Resident's #49 does have frequent pain and when she if they are moving her legs, she would be in chronic pain regardless of if she had complained of pain. The Administrator stated, Do I think the encounter should have gone differently absolutely, but I don't think the criteria of abuse was met. The Administrator was asked why they did an investigation and the Administrator stated that we do an investigation with any conduct that does not meet our customers expectations. An telephone interview was competed with Resident #49's responsible party (RP) on 12/15/21 at 10:45 AM who stated they had visited Resident #49 that morning on 8/24/21. The RP stated they did remember some racial comments that were made. The RP was asked if they remember any way Resident #49 was treated physically and the RP responded, I do remember [Resident #49] saying that [NA #3] squeezed her legs but did not recall if she had any marks. The RP stated that my mom is not one to get upset but would get mad if she thought something was wrong. The RP stated Resident #49 has on-going skin issues and if the aides would accidentally bump it on a wheelchair or something it causes her discomfort. An interview was completed on 12/15/21 at 5:13 PM with Nurse #4 who was working third shift on 8/23/21 from 11:00 PM to 7:00 AM and was asked if she was interviewed about the incident with Resident #49 and NA #3. Nurse #4 stated that no one had interviewed her about the incident. An interview was completed on 12/15/21 at 8:53 PM with NA #3 who stated she did not think she had been too rough with Resident #49 but there was a lot of pushing and pulling and you have to guide her legs and put pressure on them. NA #3 stated she did not remember her screaming in pain and was not rushing her. NA #3 stated she knew Resident #49's legs are sensitive, and Resident #49 told NA #3 to go slower. NA #3 stated that she did tell her to come on that her back was about to give out. NA #3 stated that she did not recall Resident #49 screaming out in pain. NA #3 was read the statement interview from the SW and Resident #49 which indicated NA #3 stated to Resident #49 'I don't have time to mess with you' 'I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. NA #3 stated that she did not say those things to Resident #49. NA #3 stated she had not been asked to write any statements about what happened but stated; I wish they would have, as I cannot remember the details of what happened now. An interview was completed with the DON on 12/16/21 at 10:11 AM who was asked what the process was for reporting abuse allegations. The DON stated that if the resident said it was on purpose, they would report it and if there was full intent, we would do an investigation. The DON stated that any allegation of abuse should be reported to the state. The DON stated that she did remember that there was an incident with NA #3 and Resident #49 during a transfer and stated that she felt that the NA had moved too quickly for the resident and did not think that NA #3 would do anything intentional. The DON stated that Resident #49 likes to be moved slowly and she will tense up and complain of pain. The DON stated that she thought she had been on vacation during the incident and that is all she could remember. A follow up interview was completed with the Administrator on 12/16/21 at 2:26 PM who stated that once the interviews were completed with Resident #49 and NA #3 it seemed to be more of a customer service situation, and it was not reported. The Administrator stated that during an investigation the facility would get interviews and written statements from staff but was not sure if they had gotten one from NA #3. The Administrator stated the night nurse should have been interviewed and a skin assessment should have been completed.

Based on record review and staff interviews the facility failed to ensure a staff member was medically cleared when exhibiting symptoms of COVID-19 ([MEDICAL CONDITION] of 2019) while working in the facility for 1 of 3 COVID-19 positive staff members reviewed. Findings included: The facility's policy, Coronavirus Disease 2019 (COVID-19) Plan and Protocol, dated 12/2/2020 stated, Anyone who enters the facility for any reason (with the exception of EMS personnel) will be screened for an increased temperature, symptoms of respiratory disease, recent travel to locations with high levels of COVID-19 infections, and potential exposure to someone who has or is being isolated for [MEDICAL CONDITION]. Any person who is questionable for any reason will be denied entrance to the facility. A review of the Team Member/Visitor Log for 11/30/2020 at 8:34 am revealed the Activity Director had responded no she did not have a cough when screened when entering the building. The Team Member/Visitor Log for 12/1/2020 at 7:56 am was reviewed and the Activity Director had responded no she did not have a cough when screened when entering the building. A review of the Team Member/Visitor Log for 12/2/2020 at 8:36 am the Activity Director had responded no she did not have a cough when screened when entering the building. During a phone interview with the Activity Director (AD) on 12/15/2020 at 11:18 am she stated she was tested on [DATE] for COVID-19 and when her results came back on 12/3/2020 she tested positive for COVID-19. The AD stated she told the Director of Nursing (DON) on 11/30/2020 she had a cough and she thought the cough was from seasonal allergies. The AD stated she had an intermittent cough when she worked on 11/30/2020, 12/1/2020, and 12/2/2020. The AD stated she had worked outside the facility putting up Christmas lights on 11/30/2020, 12/1/2020 and 12/2/2020 but she had come into the facility and went into her office. She stated she did not remember being in proximity (less than 6 feet) to any residents on 11/30/2020, 12/1/2020, or 12/2/2020 but she had been near two staff members, Activity Aide #1 and Activity Aide #2. An interview was conducted with the Director of Nursing (DON) on 12/15/2020 at 11:52 am she stated the staff were all tested on [DATE] and they received the positive results of the AD on 12/2/2020 in the evening and the AD was notified of the results by the Infection Control Nurse on 12/3/2020 before reporting to work in the facility. The DON stated the AD did tell her on 11/30/2020 she had a cough, but she thought the cough was from seasonal allergies. She stated she did not send the AD home because she had a history of [REDACTED]. The DON stated the AD had worked outside the facility on 11/30/2020 putting up Christmas lights and decorations but came into the facility to go into her office. The Director of Nursing stated they did have rapid tests, but the AD was not tested because she had seasonal allergies. Activity Assistant #1 was interviewed on 12/15/2020 at 2:14 pm and stated she worked on 11/30/2020 with the AD and had been outside most of the day putting up Christmas lights and decorations. Activity Assistant #1 stated they had come into the building and went into the activity office. The Activity Assistant #1 stated she had not seen the AD near any of the residents on 11/30/2020, 12/1/2020, or 12/2/2020. Activity Assistant #1 stated she had been in the office with the Activity Director, and she was tested on [DATE] and her test was negative when they received the results on 12/3/2020. During an interview with Activity Assistant #2 on 12/16/2020 at 2:50 pm and he stated he had been outside on 11/30/2020, 12/1/2020 and 12/2/2020 putting up Christmas lights and decorations for a drive by light show the facility was doing for the Christmas holiday. He stated he had not been around the Activity Director on 11/30/2020, 12/1/2020 or 12/2/2020, and had not witnessed her being around any of the other staff or residents. The Administrator was interviewed on 12/17/2020 at 9:30 am and stated she was aware the Activity Director worked on 11/30/2020, 12/1/2020 and 12/2/2020 after telling the Director of Nursing she had a cough. The Administrator stated the Director of Nursing had allowed the Activity Director to work because the cough was chronic, and the Activity Director had reported she had the cough since 2018. The Administrator stated since the Activity Director had a history of [REDACTED]. The Administrator stated the facility does have rapid COVID-19 tests but they had not felt the Activity Director's chronic cough rose to that level of need and had not done a rapid test on 11/30/2020 when the Activity Director reported her cough to the Director of Nursing

Based on observations, staff and resident interviews and record reviews, the facility failed to administer continuous oxygen at the Physician ordered flow rate for Resident #54 and Resident #64. The facility also failed to store a nebulizer mask in a sealed bag when not in use for Resident #22. This was for 3 of 4 residents reviewed for respiratory care. The findings included: 1. Resident #54 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #54's annual Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment and she exhibited no behaviors. She was coded for the use of oxygen. Resident #54's care plan dated 7/30/19 indicated a potential for altered respiratory status with the intervention administration of oxygen as ordered. Review of Resident #54's (MONTH) 2019 Physician orders [REDACTED]. Review of Resident #54's Medication/Treatment Administration Record for (MONTH) 2019 indicated staff were to ensure her oxygen was being administer continuously at 2L/M. Licensed nurses initials documented indicated Resident #54 oxygen was administered as ordered with the exception on one omission on 8/11/19 third shift. Nurse #1 initialed off on first shift for 8/19/19, 8/20/19 and 8/21/19. Observations on 8/19/19 at 9:45 AM and again at 3:45 PM revealed Resident #54's continuous oxygen was running at 4L/M via oxygen concentrator. In an observation on 8/20/19 at 10:20 AM, Resident #54 was observed in her room sitting up in her wheelchair. Her oxygen was running a 2L/M via a portable oxygen tank. In an observation on 8/20/19 at 4:10 PM, Resident #54 was observed lying in bed. Her oxygen was running at 4L/M via oxygen concentrator. In an observation on 8/21/19 at 8:55 AM, Resident #54 was observed lying in bed. Her oxygen was running at 4L/M via oxygen concentrator. In an interview on 8/21/19 at 9:10 AM, Nursing Assistant (NA) #1 stated aides were not allowed to adjust oxygen flow rates on either the oxygen concentrators or the portable oxygen tanks. NA #1 stated only a nurse could do that. In an interview on 8/21/19 at 9:41 AM, the Physician stated it was his expectation that Resident #54's oxygen be administrated continuously at 2L/M as ordered. In an observation on 8/21/19 at 10:08 AM, Resident #54's oxygen was running at the ordered rate of 2L/M via oxygen concentrator. Interviews conducted at this time with Nurse #2 stated she was not assigned Resident #54 and she was not aware of her ordered oxygen flow rate. Nurse #1 stated he was assigned Resident #54 and he checked her oxygen concentrator rate shortly before 10:00 AM but stated he did not adjust the flow rate from 4L/M down to 2L/M as ordered. The Director of Nursing (DON) stated it was possible the Nurse Supervisor #1 may have made a round and adjusted Resident #54's oxygen to the ordered rate of 2L/M. In an interview with Nurse Supervisor #1 and the DON on 8/21/19 at 10:15 AM, Nurse Supervisor #1 stated she earlier completed a round on residents prescribed oxygen. She stated during her round, she only assessed oxygen tubing and humidification bottles to ensure they did not need changing. She stated she did not assess oxygen flow rates. The DON stated aides were not allowed to adjust any prescribed oxygen flow rates. She stated apparently someone adjusted Resident #54's oxygen rate and it was her expectation that Resident #54's oxygen be administered at the prescribed flow rate of 2L/M as ordered. In an interview on 8/21/19 at 10:47 AM, the Administrator stated it was her expectation that Resident #54's prescribed oxygen be administered at order flow rate of 2L/M ordered rate. 2. Resident #22 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #22's care plan dated 3/18/19 indicated a potential for altered respiratory status with the intervention administration of medications as ordered. Review of Resident #22's quarterly Minimum Data Set ((MDS) dated [DATE] indicated he was cognitively intact and exhibited no behaviors. Review of Resident #22's (MONTH) 2019 Physician orders [REDACTED]. Review of Resident 22's Medication/Treatment Administration Record for (MONTH) 2019 licensed nurses initials indicated administration his nebulizer treatments three times daily as ordered. An interview was conducted with Resident #22 on 8/19/19 at 9:47 AM. He stated he received nebulizer treatments three times a day. Observed on Resident #22's nightstand was his nebulizer machine with his nebulizer mask placed in a holder section of the machine. There was no observed sealed bag on the nebulizer mask. In an observation on 8/20/19 at 11:00 AM, Resident #22's nebulizer machine was on his night stand with his nebulizer mask placed in a holder section of the machine. There was no observed sealed bag on the nebulizer mask. In an observation on 8/20/19 at 4:09 PM, Resident #22's nebulizer machine was on his night stand with his nebulizer mask lying across the top of the night stand with other items. There was no observed sealed bag on the nebulizer mask. In an observation on 8/21/19 at 8:55 AM, Resident #22's nebulizer machine was on his night stand with his nebulizer mask placed in a holder section of the machine. There was no observed sealed bag on the nebulizer mask. In an interview on 8/21/19 at 9:41 AM, the Physician stated it was his expectation that Resident #22's nebulizer mask be stored in a sealed bag to prevent contamination and infections. In an observation with the Director of Nursing (DON) and Nurse #1 on 8/21/19 at 10:17 AM, Resident #22's nebulizer machine was on his night stand with his nebulizer mask placed in a holder section of the machine. There was no observed sealed bag on the nebulizer mask. Nurse #1 confirmed the nebulizer mask should be stored in a sealed bag when not in use to control germs. The DON stated it was her expectation that Resident #22's nebulizer mask be stored in a sealed bag when not in use to prevent contamination and infections. In an interview on 8/21/19 at 10:47 AM, the Administrator stated it was her expectation that Resident #22's nebulizer mask be stored in a sealed bag when not in use to prevent contamination and infections. 3. Resident #64 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] revealed the resident had severe cognitive deficits. The staff provided extensive to total assistance for all personal care to include eating. The MDS indicated oxygen therapy was utilized. Resident #64 had a care plan dated 8/11/19 with goals and interventions for respiratory problems. A physician order [REDACTED]. On 8/19/19 at 3:30pm an observation was made of Resident #64 which revealed the oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. On 8/20/19 at 10:26 am an observation was made of Resident #64 lying in her bed. The oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed at horizontal, eye level. On 8/21/19 at 9:00am an observation was made of Resident #64 which revealed the oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed at horizontal, eye level. An interview was conducted with Nurse #1 on 8/21/19 at 9:00 am who stated the oxygen regulator on the concentrator was set at 3 liters when standing over the machine, looking down. Nurse #1 stated when he observed the regulator horizontally at eye level, he could see the flow was set at 2.5 liters. Nurse #1 adjusted the flow to administer 3 liters of oxygen. On 8/21/19 at 9:55 am an interview occurred with the Medical Director who stated it was his expectation for the oxygen to be delivered at the ordered rate for Resident #64. During an interview with the Director of Nursing on 8/21/19 at 10:15 am, she indicated it was her expectation for oxygen to be delivered at the ordered rate.

Based on record review and staff interviews, the facility ' s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification/complaint survey of 8/23/18. This was for 1 deficiency originally cited 8/23/18 and was subsequently recited on the current recertification survey of 8/22/19. The recited deficiency was in the area of Minimum Data Set accuracy (medication). The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: The tag is cross referenced to: F-641 Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of bowel and bladder (Resident #69) and medication (Resident #59) for 2 of 17 sampled residents. During the prior survey of 8/23/18 Based on record review, observation, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of active [DIAGNOSES REDACTED].#18), falls (Resident #72), and dental status (Resident #2) for 3 of 27 residents reviewed. On 8/22/19 at 11:30 am an interview was conducted with the Administrator who indicated the root cause for the repeat tag was human error.

Based on record review, observation, and staff and resident interview, the facility failed to develop a resident care plan in the areas of medication refusal and [MEDICAL TREATMENT] fistula management (Residents #15 and #26) and failed to implement the resident care plan in the area of [MEDICAL CONDITION] (Resident #169) for 3 of 17 residents reviewed. Findings included: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s care plan last updated on 7/5/19 revealed problem for potential adverse consequences from antidepressant. There was no mention of medication refusal. The resident ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired. The resident required 1 staff physical assistance for most activities of daily living. The active [DIAGNOSES REDACTED]. A review of the resident ' s 3/1/19 to 8/22/19 nurses ' notes and Medication Administration Record [REDACTED]. The resident ' s physician note dated 4/17/19 revealed she was compliant with the health care team. The resident was working with the behavioral team and her dementia was advancing with decline. On 8/20/19 at 3:00 pm an interview was conducted with Nurse Supervisor #2 who stated she was aware that the resident refused her medication occasionally and that the physician was aware. The nurse was not aware that medication refusal was not care planned. An interview was conducted with the physician on 9/21/19 at 9:45 am who stated he was notified that the resident periodically refused her meds due to dementia/behaviors. The physician stated he was notified and had no concerns. An interview was conducted on 9/22/19 at 10:30 with the Director of Nursing who indicated she expected the resident ' s care plan to meet the needs of each individual resident. 2. Resident #169 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented the resident was severely cognitively impaired. The resident required one-person physical assist for all activities of daily living. The active [DIAGNOSES REDACTED]. The resident received oxygen therapy. The resident ' s care plan dated 8/5/19 revealed a problem for [MEDICAL CONDITION] and approach to notify the physician as needed and to assess for [MEDICAL CONDITION]. The care plan was noted to be updated on 8/19/19 and the approaches were removed, and a new problem was added for diuretic with an approach to assess [MEDICAL CONDITION], determine the severity and to review the resident ' s labs. Nurses ' note dated 8/16/19 at 10:16 pm documented no [MEDICAL CONDITION] (lower extremities). Nurses ' note dated 8/17/19 documented no [MEDICAL CONDITION] (lower extremities). Nurses ' note had no other documentation of [MEDICAL CONDITION] assessment identified in the record from 8/17/19 to 8/21/19. On 8/19/19 at 10:30 am an observation was done of the resident and bilateral lower leg (foot and calf) [MEDICAL CONDITION] of the right leg +1 and left leg +2 was noted. The resident was wearing socks and sneakers. TED hose were not present at this time. The resident was wearing a nasal cannula with oxygen flowing at 1.5 liters from an oxygen concentrator. The resident appeared tired and was breathing a little deeper when talking. On 8/19/19 at 10:30 am an interview was conducted with the Resident who stated that her [MEDICAL CONDITION] had increased in her feet and legs over the past couple of days. The resident commented the nurse saw her legs this morning when she gave her the medication. On 8/20/19 at 4:30 pm an observation was done of the resident dressed and sitting in her wheel chair. Her lower leg [MEDICAL CONDITION] was the same and TED hose were not present. An interview on 8/20/19 at 4:30 pm was conducted and the resident stated that she did not have shortness of breath but that she had increased weakness. The resident commented that the nurse was aware of her [MEDICAL CONDITION]. An observation was done on 8/21/19 at 11:10 am of the resident and Nurse Supervisor #1 observed that the resident was on 3 liters, which was an increase. A review of the physician communication book was done and there was no communication that the resident had increased [MEDICAL CONDITION] or need for increased oxygen flow rate. The resident ' s nurses ' note revealed night shift 8/20/19 documented +1 [MEDICAL CONDITION]. On 8/21/19 at 11:20 am an interview was conducted with the resident ' s physician who stated he was not informed that the resident had increased [MEDICAL CONDITION], weakness and an increase in oxygen flow rate this morning. The resident was not on his schedule to be seen today. On 8/21/19 at 11:22 am an observation was done of the Physician assess the resident. The physician commented that the resident ' s [MEDICAL CONDITION] was up. Nurse #2 was interviewed on 8/21/19 at 11:24 am and stated that she that noted the resident ' s [MEDICAL CONDITION] and the resident was moved up from 2 liters to 3 liters of oxygen this morning because her pulse oximetry was in the 80's and I had not documented yet. Nurse #2 commented that she had not informed the physician today (care planned). On 8/22/19 at 10:30 am an interview was conducted wit the DON who stated she expected staff to follow (implement) the care plan. 3. Resident #15 was admitted on [DATE] with End Stage [MEDICAL CONDITION]. Review of Resident #15's annual Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with no exhibited behaviors. He was coded for [MEDICAL TREATMENT]. Review of Resident #15's care plan dated 6/26/19 read he required [MEDICAL TREATMENT] with an arteriovenous (AV) fistula. (An AV fistula is an abnormal connection between an artery and a vein designed to make a blood vessel wider and stronger to handle the needles that allow blood flow out and return from the [MEDICAL TREATMENT] machine). Interventions included observation for signs of infection, assessment for patency by palpitation for a trill (rumbling sensation when touched) and bruit ( a rumbling sound heard with a stethoscope). The care plan made no mention of the interventions or precautions regarding blood pressures and lab work should not be done on the AV fistula arm. Review of the undated Aide Guidelines for Daily Care did not include any instructions related to the care or precautions associated with Resident #15's AV fistula. In an interview on 8/21/19 at 2:52 PM, Resident #15 was in his room sitting up in his wheel chair. Observed was his AV fistula to his left forearm. He stated the staff only check his blood pressure in his right arm and his lab work was done usually at [MEDICAL TREATMENT] but if anyone tried to draw blood from his left arm, he knew to tell them no since he had an AV fistula in his left arm. In an interview on 8/21/19 at 2:56 PM, Nursing Assistant (NA) #2 stated she was instructed that Resident #15 could not have his blood pressure taken in his left arm because of the AV fistula. She confirmed that no special precaution was on his Guidelines for Daily Care but was aware of the precaution. In an interview on 8/21/19 at 3:10 PM, Nurse #1 stated Resident #15 was not allowed any blood pressures or lab work to his left arm because of his AV fistula. In an interview on 8/22/19 at 11:10 AM, the Director of Nursing (DON) stated Resident #15 was the first [MEDICAL TREATMENT] resident in many years. MDS Nurse #2 stated she was not familiar with specific precautions associated with a [MEDICAL TREATMENT] access. The DON and MDS Nurse #2 stated it was their expectation that the precautions of no blood pressures or lab work to Resident #15's left arm should be care planned and added to his Guidelines for Daily Care.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of bowel and bladder (Resident #69) and medication (Resident #59) for 2 of 17 sampled residents. The findings included: 1) Resident #69 was admitted to the facility on [DATE] and was discharged home on[DATE]. His [DIAGNOSES REDACTED]. The admission MDS dated [DATE] revealed the resident was cognitively intact. The resident was coded as Not Rated (resident had an ostomy or did not have a bowel movement for the entire 7 days) for bowel incontinence, but not marked with an ostomy present. During an interview with the MDS Nurse #1 on 8/22/19 at 11:05am, she confirmed the resident had a [MEDICAL CONDITION] and it was not marked on the MDS assessment. She stated it was an error. An interview was conducted on 8/22/19 at 11:15am with the Director of Nursing. She indicated it was her expectation for the MDS to be coded accurately. 2. Resident #59 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s quarterly MDS dated [DATE] documented the resident had a moderate cognitive deficit. The resident required limited assistance for transfer and toileting and extensive assistance for bathing. The resident ' s active [DIAGNOSES REDACTED]. The resident was coded as having received medication for 7 days of an anti-anxiety. The resident ' s documented Medication Administration Record [REDACTED]. A review of the resident ' s physician orders [REDACTED]. The documented care plan updated on 5/9/19 addressed depression and anti-depressant side effects. There was no mention of anxiety. On 8/22/19 at 10:30 am an interview was conducted with MDS Nurse #1 who stated that the resident ' s quarterly MDS dated [DATE] coded for 7 days of anti-anxiety medication received was an error and would be corrected. An anti-depressant medication was mistaken for an anti-anxiety medication. On 8/22/19 at 11:30 am an interview was conducted with the Administrator who stated she expected the MDS coding to be accurate.

Based on record review, observation, and staff, resident, and Physician interview, the facility failed to assess the resident ' s [MEDICAL CONDITION], place TED hose as ordered, and identify development of [MEDICAL CONDITION] for 1 of 4 residents reviewed for respiratory (Resident #169). Findings included: Resident #169 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] documented the resident was severely cognitively impaired. The resident required one-person physical assist for all activities of daily living. The active [DIAGNOSES REDACTED]. The resident received oxygen therapy. The resident ' s care plan dated 8/5/19 revealed a problem for [MEDICAL CONDITION] and approach to notify the physician as needed and to assess for [MEDICAL CONDITION]. The care plan was noted to be updated on 8/19/19 and the approaches were removed, and a new problem was added for diuretic with an approach to assess [MEDICAL CONDITION], determine the severity and to review the resident ' s labs. The resident ' s nurses' note dated 8/3/19 to 8/6/19 documented no [MEDICAL CONDITION] present. Nurses ' note dated 8/7/19 [MEDICAL CONDITION] was present (amount not documented). [NAME] hose were ordered. Nurses ' note dated 8/8/19 documented +1 [MEDICAL CONDITION] [MEDICAL CONDITION] to lower extremities. Signed by Nurse #2. Nurses ' note dated 8/8/19 at 4 pm documented the resident oxygen desaturated to 83% (order to stay aboe 90%) with use of accessory muscles. Oxygen 3 liters applied with an increase to 95% by Nursing Supervisor #1. At 6:36 pm the chest x-ray resulted [MEDICAL CONDITION] congestion. Forty milligrams of [MEDICATION NAME] (diuretic) was provided now (in addition to the daily [MEDICATION NAME] dose). Nurses ' note documented by Nursing Supervisor #2 documented on 8/11/19 revealed the resident had +1 [MEDICAL CONDITION] (lower extremities). Nurses note dated 8/13/19 documented non-[MEDICAL CONDITION] (amount not provided). Nurses ' note dated 8/15/19 documented 2 liters oxygen per minute with 93% oxygen saturation and no shortness of breath (no [MEDICAL CONDITION] documentation). Nurses ' note dated 8/16/19 at 10:16 pm documented no [MEDICAL CONDITION] (lower extremities). Nurses ' note dated 8/17/19 documented no [MEDICAL CONDITION] (lower extremities). Nurses ' note had no other documentation of [MEDICAL CONDITION] assessment identified in the record from 8/17/19 to 8/21/19. On 8/19/19 at 10:30 am an observation was done of the resident and bilateral lower leg (foot, ankle and calf) [MEDICAL CONDITION] of the right leg +1 and left leg +2 was noted. The resident was wearing socks and sneakers. [NAME] hose (compression hose to help return edeam to the circulator system) were not present at this time. The resident was wearing a nasal cannula with oxygen flowing at 1.5 liters from an oxygen concentrator. The resident appeared tired and was breathing a little deeper when talking. On 8/19/19 at 10:30 am an interview was conducted with the resident who stated that her [MEDICAL CONDITION] had increased in her feet and legs over the past couple of days. The resident denied shortness of breath or increased weakness. The resident stated she needed her oxygen but was not sure the liter flow rate. The resident commented the nurse saw her (leg [MEDICAL CONDITION]) this morning when she gave her the medication. On 8/20/19 at 4:30 pm an observation was done of the resident dressed and sitting in her wheel chair. Her lower leg [MEDICAL CONDITION] was the same and [NAME] hose were not present. The resident had her nasal cannula in place and the oxygen was flowing at 1.5 liters from the oxygen concentrator. The resident required deeper breathes while talking and mild supraclavicular retraction. An interview on 8/20/19 at 4:30 pm was conducted and the resident stated that she did not have shortness of breath but that she had increased weakness. The resident commented that the nurse was aware of her [MEDICAL CONDITION] today. An observation was done on 8/21/19 at 11:10 am of the resident trying to get up on her own from the wheel chair. The resident was calling help me, I need to get to the bathroom. Help was summoned from Nurse Supervisor #1 who observed that the resident was on 3 liters and was not sure of the flow rate and asked for Nurse #2 (assigned nurse) to assist. Nurse Supervisor #1 commented that she was not comfortable taking the resident to the bathroom on 3 liters. Nurse #2 was not available so other staff assisted. Nurse Supervisor #1 checked the pulse oximetry which was 97% and lowered the resident to 2 liters. A review of the physician communication book was done and there was no communication that the resident had increased [MEDICAL CONDITION] or need for increased oxygen. The resident ' s nurses ' note revealed night shift 8/20/19 documented +1 [MEDICAL CONDITION]. On 8/21/19 at 11:20 am an interview was conducted with the resident ' s physician who stated he was not informed that the resident had increased [MEDICAL CONDITION], weakness and a need for increased oxygen this morning or [MEDICAL CONDITION] earlier in the week. The physician further stated he was not informed by the nurse or had written communication in the physician book (housed at the nurses' station). The physician stated he would want to be notified of the resident ' s change in condition. The resident was not on his schedule to be seen today. On 8/21/19 at 11:22 am an observation was done of the Physician assess the resident. The physician commented that the resident ' s [MEDICAL CONDITION] was up. Nurse #2 arrived and stood at the doorway. Nurse #2 was interviewed at 11:24 am and stated that she that noted the resident ' s [MEDICAL CONDITION] and the resident was moved up from 2 liters to 3 liters this morning because her oxygen pulse oximetry was in the 80's and I had not documented this yet. Nurse #2 stated that she had not informed the physician of the resident ' s change. Observation of Nurse #2 at time of interview while standing in the resident ' s doorway noted she did not inform the physician of the resident's change while he was present. The resident ' s drop in pulse oximetry reading, increase in oxygen administration, and [MEDICAL CONDITION] information was relayed to the physician by the Surveyor. Nurse Supervisor #1 remained with the resident during the physician's assessment and then assisted the resident to the bathroom. Upon return from the bathroom the resident was short of breath using accessory muscles, breathing deeper when speaking, and waiting in between words. The resident nodded her head yes when asked if she was short of breath. Nurse Supervisor #1 moved the resident from her room to the nurses ' station for closer observation. Nurse #2 was interviewed 8/21/19 at 11:40 am who stated that she did not inform the physician of the resident's lower pulse oximetry (80s) and need for increase in oxygen flow rate this morning. She commented that she was assigned to the resident yesterday and noted the [MEDICAL CONDITION] (lower extremities). Nurse #2 acknowledged that the resident was usually on 2 liters of oxygen but increased the oxygen to 3 liters to address the resident's drop in pulse oximetry to the 80's this morning. Nurse #2 was aware that the resident was to wear TED hose on in the am and off in the pm for the [MEDICAL CONDITION]. She passed medications this morning when the resident was in the bed and did not assess for TED hose. The hose were currently not in place. Nurse #2 commented that the Nursing Assistants were required to place the hose when they get the resident out of bed and must not have done that. Nurse #2 was asked about the hose from yesterday that were not observed to be in place and signed for on the Medication Administration Record. She responded that she would notify the physician of increased [MEDICAL CONDITION] and a drop in oxygen pulse oximetry level but had not informed the physician of the resident's change this morning. The Administrator was informed on 8/21/19 at 11:55 am of the resident's [MEDICAL CONDITION], TED hose, change in assessment and interview with Nurse #2. Administrator stated that it would be addressed and that her behavior was not the expectation. Physician order [REDACTED]. Chest x-ray was reported on 8/21/19 and faxed to the facility at 6:55 pm. Results were right basilar infiltrate with right pleural effusion, a new development since x-ray of 8/8/19. Nurses' note dated 8/21/19 family notified of x-ray results. Three extra doses of [MEDICATION NAME] 20 milligrams ordered each day and follow up with the infacility provider. Nurses ' note dated 8/22/19 7:28 am resident ' s pulse oximetry was 90%. Physician ' s Assistant visited and no new orders. Pitting [MEDICAL CONDITION] +2 left foot and +1 right foot while legs were elevated. On 9/22/19 at 10:30 am an interview was conducted with the Director of Nursing who stated she expected staff to assess and report any resident changes in condition and place [NAME] hose as ordered.

Based on record review, observations, family and staff interviews, the facility failed to report to the local law enforcement within two hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility 7/13/17 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) coded as a quarterly assessment and dated 11/15/18 assessed Resident #1 to have severe cognitive impairment with behaviors of physical aggression towards others and rejection of care. He required extensive to total assistance of one or more staff members for bed mobility, transfers, meals, and all Activities of Daily Living (ADL's). Resident #1 was always incontinent of bowel and bladder. A review was made of the 24-hour Initial Allegation Report that revealed the facility was made aware of an allegation of abuse 1/2/19 at 2:45pm. A staff member reported that a Nurse Assistant (NA) had pinched the resident's breast and pulled his pubic hair during care on several occasions, however the incident date was unknown. It was documented that the local law enforcement was notified 1/3/19 at 1:22pm. No concerns were identified with the 5-day working report. An interview was completed with the Administrator on 1/17/19 at 8:55am, who stated that she called the local law enforcement 1/3/19 and spoke with an officer. She explained that the officer did not come to the facility and had informed her that since the alleged perpetrator was no longer on the premises and the resident was not oriented and able to provide a statement, the family would have to call the Police if there were any further concerns. On 1/17/19 at 11:20am, an interview was completed with the Administrator. She explained that she contacted the local law enforcement within 24 hours because she was gathering all the details and statements to provide to them. She added that if she had a specific date for the alleged abuse she would have notified the local law enforcement agency sooner.

Based on record review, staff interview, and observation, the facility failed to provide supervision to prevent a resident with severe cognitive impairment who displayed wandering behaviors from exiting the facility unsupervised for 1 of 1 residents (Resident #30) reviewed for wandering behaviors. Resident #30 was found unsupervised outside of the facility by a visitor and returned inside the facility by staff with no injuries. Immediate Jeopardy began on 6/13/18 when Resident #30 was observed in his wheelchair outside of the facility without supervision at approximately 11:00 PM. Immediate Jeopardy was removed on 8/23/18 when the facility provided and implemented an acceptable credible allegation of removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review indicated Resident #30 resided in the rehabilitation (rehab) unit of the facility. An elopement risk assessment dated [DATE] indicated Resident #30 was not at risk for elopement. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 ' s cognition was severely impaired. He was coded with no wandering behaviors. He required the extensive assistance of 2 or more staff with bed mobility and transfers. Resident #30 was assessed as requiring the assistance of 1 staff for locomotion on and off the unit and these activities were indicated to happen only once or twice during the 7-day review period. He had impairment on 1 side of his lower extremities and utilized a wheelchair. A Nurse Practitioner (NP) note dated 5/4/18 indicated Resident #30 was wheelchair bound but was able to self-propel independently. He was noted with cognitive deficits that made it difficult to obtain reliable information. A nursing note dated 5/14/18 indicated Resident #30 self-propelled through the halls in his wheelchair. A plan of care for Resident #30 indicated the initiation of a problem area, I am an: identified wanderer on 5/14/18. This care plan indicated Resident #30 had a [DIAGNOSES REDACTED]. There were no approaches and/or interventions for this problem area. The goals for Resident #30 were to wander within the facility where his safety could be maintained and monitored, have no injuries, make no attempts to leave the facility, and accept redirection. A physician's order [REDACTED].#30 ' s left leg. A fall risk assessment dated [DATE] indicated Resident #30 was at high risk for falls. His risk factors included intermittent confusion, self-propelled wheelchair, and inability to retrain due to cognitive deficits. A nursing note dated 6/11/18 indicated Resident #30 was confused, mobile in wheelchair, and out of his room around the nursing station when he had no visitors. A physician ' s note dated 6/13/18 indicated Resident #30 had cognitive impairment, memory deficits, and impaired decision-making skills. He was noted to require frequent monitoring to prevent falls with potential injuries or fractures. An acute condition note dated 6/14/18 at 2:05 PM completed by Unit Manager #2 (UM) indicated Resident #30 was observed outside at 11:04 PM (on 6/13/18) by outgoing staff. No injuries were noted. Resident #30 reportedly stated he just wanted to go outside for a while. A late entry incident note for 6/13/18 was completed on 6/15/18 by UM #2. This late entry note specified, Resident #30 was noted with an unsupervised exit from the building on 6/13/18 at 11:00 PM. Resident #30 was noted with poor cognition and was independently mobile in his wheelchair. He had no apparent injuries. The immediate action was placement of a staff member with Resident #30 for one on one (1:1) supervision for the remainder of the shift. Resident #30 ' s care plan related to wandering continued to include no approaches and/or interventions for this problem area after his unsupervised exit from the facility on 6/13/18. A physician's order [REDACTED].#30 ' s wheelchair. An NP Note dated 6/15/18 indicated staff reported Resident #30 wandered at night and wore a wander guard. He was noted to sleep during day and was up and restless at night. A behavior note and mood note dated 6/26/18 indicated Resident #30 was in the therapy room in his wheelchair trying to get out of the double doors to go outside. He was noted to be pushing on one door and then the other. The note indicated Resident #30 was mobile in his wheelchair, he was confused, and he had not wanted to sit in his room alone. A review of the staff schedules from 6/14/18 through 6/26/18 indicated 1:1 supervision was provided for Resident #30 during the third shift (11:00 PM - 7:00 AM). On 6/27/18 Resident #30 was moved from the rehab unit (F hall that connected to the E hall) to the long-term care unit (A, B, C, and D halls) on the opposite side of the building. An elopement risk assessment dated [DATE] for Resident #30 indicated he may be at risk for elopement. A review of the nursing notes indicated Resident #30 continued to self-propel his wheelchair from the long-term care unit to the rehab unit on 6/29/18, 7/9/18, 7/19/18, 7/22/18, 7/25/18, 8/7/18, and 8/9/18. As of 8/21/18 at 1:30 PM Resident #30 ' s care plan related to wandering continued to include no approaches and/or interventions for this problem area. Resident #30 ' s NA guidelines for daily care, undated, was reviewed on 8/21/18. This form indicated Resident #30 had a [DIAGNOSES REDACTED]. He was noted with a wander guard. A review of the weather conditions per Weather Underground ' s website (www.wanderground.com) for Albemarle ' s weather history indicated the temperature on 6/13/18 at 11:00 PM was 74 degrees Fahrenheit and there was no precipitation. An interview with the Business Office Manager (BOM) on 8/22/18 at 9:15 AM revealed the facility had video surveillance of the rehab hall. This video was available for only a 72-hour period and then it was overwritten. The BOM indicated she reviewed the video and completed a written timeline on 6/14/18 and 6/15/18 for the time period leading up to Resident #30 ' s unsupervised exit from the facility on 6/13/18. This timeline was reviewed with the BOM. She stated that the video camera on the rehab hall gave a view of the hallway. She explained that the rehab hall exit door was in a short corridor off the hall and that it was outside of the video camera ' s range. She stated that the video showed NA #10 turn the corner toward the exit door located off the rehab hall around 11:00 PM and within 20 seconds of this, Resident #30 was seen self-propelling his wheelchair around the same corner. The timeline indicated there was a period of 4 minutes and 31 seconds from the time Resident #30 turned that corner to the time that NA #1 was seen bringing Resident #30 back inside through the rehab hall exit door. The BOM explained that this exit door on the rehab hall was not equipped for wander guard security. She stated that this door was secured by a numerical security code that was entered into a keypad. She indicated that staff members who worked on the rehab unit and facility visitors had been entering and exiting through that door as it was a shorter walk from the parking lot. A written statement, dated 6/25/18, completed by NA #10 was reviewed. She indicated she was not on duty on 6/13/18 at the time of Resident #30 ' s unsupervised exit from the facility. She wrote that she had been in the facility to visit another staff member that evening. She reported that around 11:00 PM on 6/13/18 as she was preparing to exit the facility through the rehab hall ' s exit door she saw Resident #30 seated in his wheelchair near the corridor that led to the exit door. NA #10 indicated she had not redirected him away from vicinity of the exit door. She reported she exited the door and ensured it was closed prior to walking to her car. She indicated she had not seen Resident #30 outside of the facility. An interview was conducted with NA #10 on 8/21/18 at 4:50 PM. She confirmed her written statement, dated 6/25/18, related to the events on 6/13/18 prior to Resident #30 ' s unsupervised exit from the facility. She reported Resident #30 was a known wanderer, he self-propelled throughout the facility in his wheelchair, he was regularly up during the night, and he was alert to himself with confusion. She stated that she saw Resident #30 near the rehab hall ' s exit door when she was leaving the facility, but she had not redirected him as she was not on duty. She indicated she entered the numerical code to unlock the door, proceeded out of the door, and then shut the door behind her. NA #10 reported there was always a delay on the locking mechanism of the door, so it had not locked as soon as it was shut. An observation was conducted of the rehab hall exit door with NA #10 on 8/21/18 at 5:00 PM. A sign was observed on the door that stated, Use Front Door to Enter and Exit Building. The door was observed opening and closing multiple times. A numerical code was entered into the keypad, the door unlocked, and remained unlocked for about ten seconds prior to the lock engaging. It was observed that if the door was not closed prior to the end of the ten seconds that an audible alarm sounded in the nurse ' s station. NA #10 indicated the alarm had to be manually turned off by staff or it continued to sound. An interview with the Maintenance Director as well as an observation of the rehab hall exit door in his presence was conducted on 8/22/18 at 6:24 PM. He confirmed the rehab hall exit door had a 10 second delay from the time the numerical code was entered on the keypad to the time the door lock re-engaged. He also confirmed if the door was not closed by the end of the 10 seconds that an audible alarm sounded in the nurse ' s station. He stated this audible alarm had to manually be shut off from the nurse ' s station. A written statement, undated, completed by NA #1 was reviewed. NA #1 was working on the long-term care unit on 6/13/18 during the second shift. She indicated she punched out on the time clock shortly after 11:00 PM and when she was leaving the building through the main entrance she was notified of Resident #30 ' s presence outside. She indicated she hurried over to Resident #30 and that he was found in his wheelchair in the grass area outside of the rehab unit. Resident #30 had not informed her how he got outside. NA #1 pushed Resident #30 back inside and she alerted staff on the rehab unit that he had been outside. A phone interview was conducted with NA #1 on 8/22/18 at 8:24 AM. She confirmed her written statement related to Resident #30 ' s unsupervised exit from the facility on 6/13/18. She stated that a facility visitor, her name was unknown to NA #1, saw her as she was leaving the building and told her a resident was outside. She stated Resident #30 had not answered her when she asked him what he was doing outside. She indicated she pushed Resident #30 to the rehab unit ' s exit door, punched in the numerical code because the door was locked, and took the resident back inside. She reported she informed the staff on his unit that he had been outside. NA #1 stated that although she had never worked with Resident #30 she was aware he was a wanderer as she had seen him self-propel his wheelchair throughout the facility. The facility visitor was unable to be reached for interview during the survey as there was no contact information available. An interview was conducted with UM #2 on 8/21/18 at 1:45 PM. He confirmed he had written the acute condition note and the late entry incident note related to Resident #30 ' s unsupervised exit from the facility on 6/13/18. He stated he was not present at the facility when the incident occurred but had been asked by the previous Director of Nursing (DON) to document the incident. He reported that at the time of the incident, staff and visitors were using that exit door to enter and exit the facility because it was closer to the parking lot. He indicated that since the incident no one was supposed to enter and exit through the rehab hall exit door. He confirmed Resident #30 was cognitively impaired, a known wanderer, and was able to self-propel in his wheelchair. He stated that Resident #30 continued to come over to the rehab unit after his room was moved to the long-term care unit. UM #2 was asked what interventions were utilized to address Resident #30 ' s known wandering and exit seeking behaviors. He reported that Resident #30 had a wanderguard that was monitored for function and placement by nursing staff. He indicated when Resident #30 was having exit seeking behaviors that staff tried to redirect him toward an area near the nurse ' s station so it was easier to keep an eye on him. A written statement, dated 6/14/18, completed by Nurse #2 was reviewed. Nurse #2 was assigned to Resident #30 during the second shift (3:00 PM - 11:00 PM) on the date he exited the facility unsupervised (6/13/18). Her statement indicated she was in another resident ' s room when NA #7 informed her Resident #30 was outside. She indicated by the time she completed care for the other resident and returned to the nurse ' s station she saw NA #1 pushing Resident #30 in his wheelchair inside of the facility. She indicated 1:1 supervision was initiated as a precaution and the DON was notified by phone. An interview was conducted with Nurse #2 on 8/21/18 at 3:20 PM. She confirmed she was assigned to Resident #30 on the second shift on 6/13/18. She verified her written statement related to his unsupervised exit from the facility and additionally revealed staff had not known that Resident #30 was missing until the facility visitor alerted NA #1 of his presence outside on 6/13/18. She reported she assessed Resident #30 after NA #1 returned him inside and she identified no apparent injuries. She indicated he was oriented to self only and when asked how he got out of the building he had pointed toward the main entrance of the facility. Nurse #1 stated that because Resident #30 pointed toward the main entrance that staff initially believed he had exited through that entrance. She stated his wander guard was checked for proper function and placement and it was in working condition. She indicated an additional wander guard was placed on Resident #30 ' s wheelchair because at that time, staff believed there must have been a problem with the wander guard system if he was able to exit through the main entrance. Nurse #1 stated that 1:1 supervision was initiated for Resident #30 during the third shift (11:00 PM - 7:00 AM) beginning on 6/13/18. She revealed the investigation of the incident showed Resident #30 had exited out of the rehab hall exit door which was not equipped for the wander guard. This interview with Nurse #2 continued. She verified that Resident #30 was a known wanderer, was able to self-propel in his wheelchair, and was cognitively impaired. She stated Resident #30 really wanted to go home and he was an exit seeker. She confirmed UM #2 ' s statement that Resident #30 continued to self-propel to the rehab unit after his room was moved to the long-term care unit. She additionally confirmed that since the incident no one was permitted to enter and exit the facility through the rehab hall exit door. Nurse #2 was asked what interventions were utilized to address Resident #30 ' s known wandering and exit seeking behaviors. She indicated that Resident #30 had a wander guard and that he was able to wander through the facility as he chose. She stated that when he was exhibiting exit seeking behaviors staff tried to keep him by the nurse ' s station for easier monitoring. She reported if he was showing increased anxiety or agitation with the exit seeking behaviors that staff ensured his basic needs were met. She explained that this meant he was offered things such as toileting, food and/or drink, and a pain assessment to make sure he was comfortable. A phone interview was conducted with NA #7 on 8/21/18 at 4:27 PM. She stated she had worked on the rehab unit on 6/13/18 for the second shift. She stated she had punched out of work for the evening and was headed out of the building when a facility visitor alerted her and NA #1 that a resident was outside. She revealed she had not known Resident #30 was missing prior to this facility visitor ' s report. She indicated NA #1 went to Resident #30 and she informed Nurse #2 that he was found outside. She reported that she was not assigned to Resident #30 on 6/13/18. She stated she believed NA #2 was assigned to Resident #30. A written statement, undated, completed by NA #2 was reviewed. NA #2 was assigned to Resident #30 during the second shift on the date he exited the facility unsupervised (6/13/18). The statement indicated Resident #30 requested to get out of bed around 10:30 PM. She stated she assisted him up and into his wheelchair and pushed him down the hall in front of the nurse ' s station. She noted that she closed the double doors that separated the rehab unit from the long-care unit to keep (Resident #30) from going down onto the other halls because of shift change and I needed to keep an eye out on him. NA #2 noted around 11:00 PM NA #1 saw Resident #30 outside of the exit door of the rehab hall. NA #1 brought Resident #30 back inside. A phone interview was conducted with NA #2 on 8/22/18 at 12:53 PM. NA #2 stated she was no longer employed at the facility. She confirmed that she was assigned to Resident #30 for the second shift on 6/13/18. She verified her written statement related to his unsupervised exit from the facility on 6/13/18 and additionally revealed she had not known Resident #30 was missing until she saw NA #1 bring him back inside. She reported Resident #30 was a known wanderer, he self-propelled throughout the facility in his wheelchair, he was regularly up during the night, and he was alert to himself with confusion. NA #2 was asked what interventions she had utilized to address Resident #30 ' s known wandering behaviors. She stated that if Resident #30 was having his normal wandering that she just tried to keep an eye on him. She indicated if he seemed agitated or anxious in addition to the wandering that she tried to redirect to an area near the nurse ' s station so it was easier to watch him. A written statement, undated, completed by Nurse #3 was reviewed. She indicated she was working the third shift on Resident #30 ' s unit on the date he exited the building unsupervised (6/13/18). She wrote that prior to receiving her report at the beginning of her shift, NA #1 brought Resident #30 into the facility and informed staff he was found outside. Nurse #3 noted that 1:1 supervision was initiated that night. Resident #30 was noted to be wandering through the hallways continuing to go to the rehab door and pulling at the door handles while on 1:1 supervision. A phone interview was conducted with Nurse #3 on 8/22/18 at 5:00 PM. She confirmed her written statement related to Resident #30 ' s unsupervised exit from the facility on 6/13/18 and additionally revealed she had not known Resident #30 was missing until NA #1 brought him back into the facility. She stated that she provided 1:1 supervision for Resident #30 during the third shift on 6/13/18 through 6/14/18. She indicated that NA #5 stayed over from the second shift and performed the medication cart duties for her during the third shift as she was also a medication technician. Nurse #3 confirmed Resident #30 was cognitively impaired, a known wanderer, and was able to self-propel in his wheelchair. She additionally confirmed that Resident #30 continued to self-propel his wheelchair to the rehab unit after his room was moved to the long-term care unit. A phone interview was conducted with NA #5 on 8/22/18 at 2:20 PM. She confirmed she stayed over from the second shift on 6/13/18 to work the third shift on the medication cart so Nurse #3 was able to provide 1:1 supervision for Resident #30. A phone interview was conducted with NA #3 on 8/22/18 at 9:33 AM. She stated that she was working the third shift on the date Resident #30 had an unsupervised exit from the facility (6/13/18). She indicated she was splitting the rehab unit with NA #4 that night. She reported she believed she saw Resident #30 in his wheelchair by the nurse ' s station when she came into the facility that night, but she was not certain as it was shift change and there many people in that area. NA #3 revealed she had not known Resident #30 was missing until NA #1 brought him back into the facility. She stated it was normal behavior for Resident #30 to be awake at that time of night. She indicated Resident #30 was cognitively impaired and he wandered daily by self-propelling his wheelchair throughout he facility. A phone interview was conducted with NA # 4 on 8/22/18 at 9:41 AM. She stated that she was working the third shift on the date Resident #30 had an unsupervised exit from the facility (6/13/18). She indicated she was splitting the rehab unit with NA #3 that night. She stated she had not seen Resident #30 that night and had not known he was missing until NA #1 brought him back inside. She indicated Resident #30 was cognitively impaired and he wandered daily by self-propelling his wheelchair throughout he facility. An interview was conducted with NA #6 on 8/21/18 at 2:20 PM. She stated that she normally worked on the long-term care unit. She reported she had not worked with Resident #30, but she was familiar with him. She indicated he was cognitively impaired and he wandered daily by self-propelling his wheelchair throughout he facility. She reported he went over the rehab unit on most days as he previously resided there. NA #6 stated she was not aware Resident #30 had an unsupervised exit from the facility when he resided on the rehab unit. An interview was conducted with Nurse #4 on 8/21/18 at 2:25 PM. He stated he was a nurse on the long-term care unit. He indicated that Resident #30 was cognitively impaired, was a known wanderer, and self-propelled his wheelchair. He reported Resident #30 self-propelled to the rehab unit daily. Nurse #4 stated he was not aware Resident #30 had an unsupervised exit from the facility when he resided on the rehab unit. An email written by the Administrator dated 6/14/18 at 2:55 PM was sent to the Medical Records Coordinator, the facility ward clerks, and the facility care plan team. This email indicated that Resident #30 had an unsupervised exit from the facility at 11:00 PM and was found outside at 11:04 PM. The email stated, patient will continue one to one observation until he is placed in a locked unit, patient will have a wander guard placed on the wheelchair in addition to his person, patient will be asked if he wants to go outside and will be allowed to sit outside with supervision, system will continue to be checked daily to assure it is working properly. A documentation of a staff inservice, undated and untitled began with the statement, Due to some recent events that have taken place, there will be some changes effective immediately. This training read: 1. When a hall alarm is ringing, someone must check the door and announce on their walkie (portable multi-way radio used for communication)- (specific hall) is clear, before resetting the alarm. 2. All staff should have an assigned walkie with them while clocked in for their shift(s). 3. Staff will no longer use the E or F Hall doors to exit the building at the end of their shift. All staff will use the front door to exit. 4. Front entrance will be locked at 7:00pm or after front office staff are done for the day. Staff and family can exit the facility, however you must be buzzed in to return. 5. No (NAs) shall remain in the nursing station. If you are taking a 5 (minute) break to cool off, that is acceptable. There are always things that need to be done for the residents. Please see your charge nurse if you have any questions. 6. When leaving your assigned area, please notify your charge nurse if you have any questions. 7. When leaving the facility for any reason, you must clock out and sign out so in case of emergency, your supervisor can account for your location . There were 28 staff signatures on the inservice sign in sheet. The inservice had not mentioned Resident #30 ' s unsupervised exit from the facility. An interview was conducted with the Administrator on 8/21/18 at 3:25 PM. She stated that based on the facility ' s investigation and video surveillance evidence, Resident #30 had exited the facility from a door on the rehab hall (F hall) of the facility and was outside of the building for approximately 4 minutes around 11:00 PM on 6/13/18. She confirmed staff had not known he was missing until a facility visitor alerted NA #1 and NA #7. She indicated it was believed Resident #30 got out of the rehab hall exit door after NA #10 and prior to the door lock re-engaging. The Administrator verified that previously, staff on the rehab unit and visitors had been utilizing this door to enter and exit the facility by using the numerical code to unlock the door. She stated that after the 6/13/18 incident a sign was placed on the rehab hall exit door that indicated it was not to be used to enter or exit the building. She revealed the numerical code had not been changed after the 6/13/18 incident. The Administrator stated that following the incident (6/13/18) she was off for a few days and had not returned to the facility until 6/18/18. She reported that on 6/18/18 she and the previous DON checked the rehab hall ' s exit door and observed it to be working properly. The staff inservice, undated, and the sign in sheet with 28 staff signatures were reviewed with the Administrator. She was asked who was responsible for providing the inservice and if all staff received the inservice. She indicated the previous DON and the Staff Development Coordinator were responsible for the education. The Administrator revealed the 28 signatures had not accounted for all staff at the facility. She stated her expectation was for all full-time, part-time, as needed (PRN), and contracted staff to receive the inservice as all of these employees had access to the rehab hall exit door. She verified the rehab department employees were contracted staff and that the rehab hall exit door was located right next to the rehab department. She additionally verified that there was no evidence the rehab department ' s contracted staff had received the inservice. This interview with the Administrator continued. The email dated 6/14/18 at 2:55 PM related to Resident #30 ' s unsupervised exit from the facility on 6/13/18 was reviewed with the Administrator. She confirmed this email was sent to the Medical Records Coordinator, the facility ward clerks, and the facility care plan team. The care plan team was noted to include the DON, MDS Nurse, Care Coordinator, Social Worker, Dietary Manager, and Life Enrichment Director. The interventions noted on the email (patient will continue one to one observation until he is placed in a locked unit, patient will have a wanderguard placed on the wheelchair in addition to his person, patient will be asked if he wants to go outside and will be allowed to sit outside with supervision, and system will continue to be checked daily to assure it is working properly) were reviewed with the Administrator. She reported that at the time of email, it was believed that Resident #30 had gotten out of the building through the main entrance. She stated this was why an additional wander guard was placed on his wheelchair. She indicated that as part of the facility ' s normal protocol, all wander guards in use were checked for function and placement on each shift daily and that this protocol continued. She reported that initially, the facility felt that Resident #30 needed a locked unit to ensure his safety and the plan was to place him on 1:1 supervision until that occurred. She indicated this was re-evaluated and Resident #30 was instead moved to the long-term care unit on 6/27/18 so he was further away from the rehab hall exit doors. She confirmed the 1:1 supervision was only in place during the third shift and that it ended when Resident #30 was moved to the long-term care unit (6/27/18). The Administrator was asked why 1:1 supervision was provided only during the third shift as the 6/14/18 email indicated Resident #30 was going to be on 1:1 supervision until he moved. She was unable to explain why 1:1 supervision was only provided to Resident #30 during the third shift. The staff interviews and nursing notes that indicated Resident #30 continued to self-propel his wheelchair to the rehab unit after his move to the long-term care unit were reviewed with the Administrator. She was asked if any increased monitoring was in place for Resident #30 since his move to the long-term care unit as the move had not kept him from going to the rehab unit. She confirmed there had been no increased monitoring for Resident #30 since 6/27/18 when he was moved to the long-term care unit. The Staff Development Coordinator (SDC) was out of the country and unavailable for interview. A phone interview was conducted with the previous DON on 8/22/18 at 10:14 AM. She confirmed she was the DON on 6/13/18 when Resident #30 had an unsupervised exit from the facility. She confirmed that the findings of the investigation indicated Resident #30 exited the building unsupervised through the rehab hall exit door at approximately 11:00 PM on 6/13/18. Resident #30 was outside for around 4 minutes prior to staff being alerted by a facility visitor of his presence outside. She verified staff had not known Resident #30 was missing until the facility visitor alerted them. The previous DON was asked about the interventions implemented following Resident #30 ' s unsupervised exit from the facility. She stated that during the third shift on 6/13/18 Resident #30 ' s wander guard was checked for function and placement and an additional wander guard was placed on his wheelchair. She indicated Resident #30 was placed on either 1:1 supervision or 15 minute checks, she was unable to recall which intervention, during the third shift. She stated this increased monitoring continued for several days, but she was unable to recall how long. She confirmed there was no increased monitoring during the first or second shifts. The previous DON indicated that all residents with wander guards had their devices checked for function and placement each shift daily and that this process was completed during the third shift on 6/13/18 following the incident. This interview with the previous DON continued. She was asked about the inservice, undated, and the sign in sheet with 28 staff signatures. She reported she thought the SDC provided the inservice to all nursing staff. She confirmed the 28 signatures had not accounted for all staff at the facility. She stated that she recalled all department heads were notified of Resident #30 ' s unsupervised exit from the facility during a meeting, but she was unable to recall the date of the meeting. There was no evidence that all staff (full-time, part-time, as needed, and contracted staff) were informed of Resident #30 ' s unsupervised exit from the building on 6/13/18 or that they had received the inservice. An interview was cond (TRUNCATED)

Based on observations, staff interviews and record review, the facility failed to specify the medical symptom to be treated with the use of a physical restraint and facility failed to assess for the least restrictive physical restraint for 3 (Resident #55, Resident #53 and Resident #8) of 3 residents reviewed for physical restraints. The findings included: 1. Resident #55 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #55's cumulative physician orders [REDACTED]. Release every two hours, at meals and PRN (as needed). The order did not include the medical symptom to be treated with the use of the restraint. There was no documented evidence of an assessment for the least restrictive physical restraint. Review of a progress note dated 4/24/18 read Resident #55 had been without his thigh restraint for the past four days and tolerated well. The thigh restraint was discontinued. Review of a Care Conference Note dated 4/24/18 read restraints were discontinued since no longer needed. Review of an incident report dated 4/25/18 at 11:55 PM read Resident #55 was lowered to the floor by staff. He had been sitting in his Broda Chair in the parlor near the nurses' station. He stood and attempted to ambulate. He sustained one skin tear. Review of an incident report dated 4/26/18 at 3:14 PM read Resident #55 was observed on the floor in front of his Broda Chair near the parlor area. He sustained a skin tear. He was placed in his Broda Chair in the reclining position. Review of Resident #55's cumulative physician orders [REDACTED]. There was no documented evidence of medical symptom for the thigh restraint or assessment for the least restrictive physical restraint. Resident #55 was care planned for the use of a thigh restraint on 4/30/18. Interventions included trial restraint free periods, thigh restraint when up in the Broda Chair, release during care, at meals and approximately every two hours. Review of Resident #55's quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment and he was coded for rejection of care. Resident #55 was coded for extensive assistance with transfers, locomotion, toileting and non-ambulatory. He was coded with no impairments to his lower extremities, unsteady with walking, turning around and surface to surface transfers. Resident #55 was coded for a trunk restraint. In an observation on 8/21/18 at 1:43PM, Resident #55 was sitting asleep in his Broda Chair with a thigh restraint around his lower abdomen and extending in down in between his legs and buckled in the back of his chair preventing him from standing. Nursing Assistant (NA) #11 stated he has had the thigh restraint for as long as she was aware. NA #11 stated it was to be unbuckled during meals and with incontinence care as needed. In an interview on 8/21/18 at 2:00 PM, the Facility Care Coordinator (FCC) stated she completed the MDS and care plan for Resident #55. She stated it was the responsibility of the staff nurse or Unit Manager to call and obtain physician orders [REDACTED]. She stated she was not aware that an assessment was needed to determine the least restrictive physical device prior to initiating the restraint. FCC stated she documented a progress note quarterly about the continued need for the thigh restraint but did not complete an assessment to determine if Resident #55 was ordered the least restrictive physical restraint. Review of a Progress Note dated 8/21/18 read thigh restraint was to be continued but there was no documentation regarding the medical symptom to be treated with the use of a physical restraint or assessment until 8/21/18 at 7:22 PM In an interview on 8/22/18 at 2:00 PM, NA #8 stated Resident #55 does not attempt to stand unassisted from his Broda Chair. She stated he sleeps most of the time. In an interview on 8/22/18 at 2:52 PM, the Medical Director stated he was not aware that the use of restraints required a medical symptom for the use of a physical restraint. He stated physical restraints were used to prevent falls. In an observation on 8/23/18 at 8:29 AM, Resident #55 was sitting at the table with his thigh restraint unbuckled. Staff were prompting him to eat. In an interview on 8/23/18 at 8:30 AM, Unit Manager (UM) #1 stated restraint reductions had failed in the past and that Resident #55 continued to try and get up unassisted. He stated Resident #55 was unpredictable and would sleep for days then be awake for days. UM #1 stated restraints were implemented by the Interdisciplinary Team (IDT) after the Physician gave the order. He stated he was not aware of the need for a medical symptom to use physical restraints. He stated it was the responsibility of the FCC to complete the assessment for the least restrictive physical restraint. In a second interview on 8/23/18 at 10:09 AM, the FCC stated she completed Resident #55's an assessment for the least restrictive physical restraint for Resident #55 on 8/22/18. In an interview on 8/23/18 at 2:39 PM, the Administrator stated it was her expectation that the facility obtained a medical symptom for the physical restraint and assess for the least restrictive physical restraint. 2. Resident #53 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of an incident report dated 2/9/18 at 10:50 PM revealed, Resident #53 was lying on the floor in another resident's room. She was in her wheel chair prior to the fall. She complained of left hip pain. She was sent to the hospital and diagnosed with [REDACTED]. She had disabled her chair alarm and removed her self-releasing seat belt. She was discharged back to the facility on [DATE]. Resident #53 was seen by Occupational Therapy starting on 2/16/18 and was discharged from services on 3/9/18 having reached her maximum potential. She was discharged using a Broda Chair (high-back wheel chair with tilt-in space capability). Review of Resident #53's cumulative physician orders [REDACTED]. Release every two hours, during meals and PRN (as needed). The order did not include the medical symptom to be treated with the use of a physical restraint and no documented evidence of an assessment for the least restrictive physical restraint. Review of Resident #53's cumulative orders indicated an order dated 7/16/18 for a Seat Belt to her Broda chair at all times for safety. (This was not a self-releasing seat belt). Release every two hours, during meals and PRN. The order did not include the medical symptom to be treated with the use of a physical restraint and no documented evidence of an assessment for the least restrictive physical restraint until 8/21/18 at 8:20 PM. Review of Resident #53's last revised care plan dated 7/16/18 read she had a seat belt. Interventions included trial restraint free periods, monitor for proper use of the seat belt, release during care, at meals and approximately every two hours. Review of the undated CNA Guideline for Daily Care reflected the use of a seat belt restraint when up in the Broda Chair. Resident #53's quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment and she was coded for rejection of care. Resident #53 was coded for extensive assistance with transfers, locomotion, toileting and non-ambulatory. She was coded with no impairments to his lower extremities and unsteady with surface to surface transfers. Resident #53 was coded for a trunk restraint. In an observation on 8/20/18 2:20 PM, Resident #53 was sitting up the Broda Chair in the parlor near the nurses' station. She was observed with a padded seat belt around her abdomen. The seat belt was buckled in the back of the chair. In an interview on 8/21/18 at 2:00 PM, the Facility Care Coordinator (FCC) stated she completed the MDS and care plan for Resident #53. She stated she was not aware that an assessment was needed to determine the least restrictive physical device prior to initiating the restraint. FCC stated she documented a progress note quarterly about the continued need for the seat belt restraint but did not complete an assessment to determine if Resident #53 was ordered the least restrictive physical restraint. In an interview on 8/22/18 at 8:41 AM, Nursing Assistant (NA) #12 stated Resident #53 no longer attempts to get up from her bed or Broda Chair unassisted. In an observation on 8/22/18 at 8:45 AM, Resident #53 was asleep in bed with NA #13 attempting to feed her breakfast. NA #13 stated Resident #53 still attempted to get up unassisted and the seat belt was removed at meals and if she was sleeping and staff were around to watch her. She stated she had not observed Resident #53 attempting to slid under or climb over the seat belt on her Broda Chair. In an interview on 8/22/18 at 2:00, NA #8 stated Resident #53 does attempt to stand while in the Broda Chair if her seat belt was not buckled but that she is easily redirected. In an interview on 8/22/18 at 2:52 PM, the Medical Director stated he was not aware that the use of restraints required a medical symptom for use of a physical restraint. He stated physical restraints were used to prevent falls. In an interview on 8/23/18 at 8:30 AM, Unit Manager #1 stated Resident #53 would sleep during the day then be awake for days. He stated restraint reductions had failed in the past and that Resident #53 continued to try and get up unassisted. UM #1 stated restraints were implemented by the Interdisciplinary Team (IDT) after the Physician gave the order. He stated he was not aware of the need for a medical symptom to use physical restraints. He stated it was the responsibility of the FCC to complete the assessment for the least restrictive physical restraint. In a second interview on 8/23/18 at 10:09 AM, the FCC stated she completed Resident #53's an assessment for the least restrictive physical restraint on 8/22/18. In an interview on 8/23/18 at 2:39 PM, the Administrator stated it was her expectation that the facility obtained a medical symptom for the physical restraint and assess for the least restrictive physical restraint. 3. Resident # 8 was originally admitted to the facility on [DATE] and was readmitted on [DATE], 6/1/81 and 8/5/18. He had multiple [DIAGNOSES REDACTED]. Review of Resident #8's readmission physician orders [REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #8 had severe cognitive impairment, had a fall prior to admission and had no restraints. Resident #8's care plan dated 8/13/18 was reviewed. There was no comprehensive care plan developed for restraints. On 8/20/18 at 2:19 PM, Resident #8 was observed up in wheelchair in his room. He was observed wearing a Velcro type lap belt. When asked to remove the lap belt, Resident #8 was unable to remove the belt on command. On 8/21/18 at 1:50 PM, Resident #8 was observed up in wheelchair in his room wearing a Velcro type lap belt. The facility's Care Coordinator was observed asking the resident to remove the belt and the resident was unable to undo it. On 8/21/18 at 1:55 PM, Nurse Aide (NA) #9, assigned to Resident #8, was interviewed. She stated Resident #8 had the lap belt since he was readmitted from the hospital this (MONTH) (YEAR). NA #9 indicated that the resident was high risk for falls. On 8/21/18 at 2:15 PM, Nurse #1, assigned to Resident #8 was interviewed. She stated that Resident #8 had the lap belt since he was readmitted from the hospital in (MONTH) (YEAR). Nurse #1 stated that the resident was confused and was high risk for falls. On 8/21/18 at 2:20 PM, the Unit Manager (UM) #2 was interviewed. He stated that Resident #8 had the lap belt since (MONTH) (YEAR) after his fall. The UM confirmed that there was no restraint assessment nor least restrictive device tried before the lap belt was restarted in (MONTH) (YEAR). He added that the resident's family member wanted the lap belt used for resident's safety. On 8/22/18 at 4:10 PM, the MDS Nurse was interviewed. She stated that she was responsible for the restraint assessment. She indicated that a restraint assessment should have been completed prior to the use of the lap belt. The MDS Nurse stated that she was not aware that Resident #8 was using a lap belt until 8/21/18 and therefore there was no restraint assessment completed. The MDS Nurse revealed she had discontinued the lap belt on 8/21/18 because there was no indication or medical symptom that warrant the use of the lap belt. On 8/23/18 at 2:28 PM, the Administrator was interviewed. She stated that she expected the staff to follow the facility's policy on restraints. The policy indicated that the resident should be assessed for the need of the restraint prior to the use of the restraint.

Based on record review and staff interviews, the facility failed to accurately code the admission Minimum Data Set (MDS) and quarterly MDS for 1 (Resident #15) of 1 reviewed for hospice services and failed to accurately code the quarterly MDS for 1 (Resident #30) of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident #15 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #15's admission orders [REDACTED]. Review of Resident #15's admission MDS dated [DATE] indicated a prognosis of less than 6 months but she was not coded as receiving hospice services. Review of Resident #15's quarterly MDS dated [DATE] indicated a prognosis of less than 6 months but she was not coded as receiving hospices services. Review of Resident #15's care plan last revised on 7/29/18 read she was care planned for hospice services on 5/11/18. In an interview on 8/21/18 at 2:42 PM, with the Facility Care Coordinator (FCC) stated she was responsible for Long Term Care MDS and care plans. FCC confirmed the error in the hospice coding for Resident #15 on the resident's admission MDS dated [DATE] and quarterly MDS dated [DATE]. She stated she added the hospice care plan on 5/11/18. In an interview on 8/23/18 at 2:31 PM, the Administrator stated it was her expectation that the admission MDS dated [DATE] and the quarterly MDS dated [DATE] would have been coded accurately. She further stated it was her expectation that when the error was noted, a correction MDS should have been submitted. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30's cognition was severely impaired and he had an active [DIAGNOSES REDACTED].#30 had received injections (of any type) on 6 of 7 days and insulin injections on 6 of 7 days during the MDS review period (6/28/18 through 7/4/18). Section N of Resident #30 ' s 7/4/18 MDS was completed by the Facility Care Coordinator (FCC). A review of the Medication Administration Records (MARs) for Resident #30 during the 7/4/18 MDS review period (6/28/18 through 7/4/18) indicated he received Humalog (insulin) injection on 5 of 7 days (6/28, 6/29, 6/30, 7/2, and 7/3). This MAR indicated [REDACTED]. An interview was conducted with the FCC on 8/21/18 at 1:30 PM. Section N of the MDS dated [DATE] for Resident #30 that indicated he had received injections (of any type) on 6 of 7 days and insulin injections on 6 of 7 days during the MDS review period was reviewed with the FCC. The MARs that indicated Resident #30 had received Humalog injections on 5 of 7 days and no other injections during the 7/4/18 MDS review period was reviewed with the FCC. She reviewed the record and confirmed this 7/4/18 MDS for Resident #30 was coded incorrectly for insulin injections. The FCC revealed she had made an error. An interview was conducted with the Administrator on 8/23/18 at 2:31 PM. She indicated she expected the MDS to be coded accurately.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan with interventions and/or approaches to address the known wandering behaviors for 1 of 1 residents (Resident #30) reviewed for wandering behaviors. The findings included: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 ' s cognition was severely impaired. He was coded with no wandering behaviors. A Nurse Practitioner (NP) note dated 5/4/18 indicated Resident #30 was wheelchair bound but was able to self-propel independently. A nursing note dated 5/14/18 indicated Resident #30 self-propelled through the halls in his wheelchair. A plan of care for Resident #30 indicated the initiation of a problem area, I am an: identified wanderer on 5/14/18. This care plan indicated Resident #30 had a [DIAGNOSES REDACTED]. There were no approaches/interventions to address this problem area. The goals for Resident #30 were to wander within the facility where his safety could be maintained and monitored, have no injuries, make no attempts to leave the facility, and accept redirection. A physician's order [REDACTED]. A nursing note dated 6/11/18 indicated Resident #30 was confused, mobile in wheelchair, and out of his room around the nursing station when he had no visitors. An acute condition note dated 6/14/18 at 2:05 PM completed by Unit Manager (UM) #2 indicated Resident #30 was observed outside at 11:04 PM (6/13/18) by outgoing staff. A late entry incident note for 6/13/18 was completed on 6/15/18 by UM #2. This late entry incident note indicated Resident #30 had an unsupervised exit from the building on 6/13/18 at 11:00 PM. Resident #30 was noted as independently mobile in wheelchair and with poor cognition. He had no injuries. Resident #30 ' s care plan related to wandering continued to include no approaches/interventions to address this problem area after his unsupervised exit from the facility on 6/13/18 at 11:00 PM. An NP Note dated 6/15/18 indicated staff reported Resident #30 wandered at night and wore a wander guard. He was noted to sleep during day and was up and restless at night. A behavior note and mood note dated 6/26/18 indicated during the first shift (7:00 AM – 3:00 PM) Resident #30 was in the therapy room in his wheelchair trying to get out of the double doors to go outside. He was noted to be pushing on one door and then the other. The note indicated Resident #30 was mobile in his wheelchair, he was confused, and he had not wanted to sit in his room alone. The quarterly MDS assessment dated [DATE] indicated Resident #30 ' s cognition was severely impaired. He was assessed with [REDACTED]. Resident #30 ' s care plan related to wandering was noted as reviewed on 7/9/18. The problem area remained unchanged, I am: an identified wanderer. This care plan indicated Resident #30 had a [DIAGNOSES REDACTED]. There continued to be no approaches and/or interventions to address this problem area. The goals for Resident #30 remained unchanged: wander within the facility where his safety could be maintained and monitored, have no injuries, make no attempts to leave the facility, and accept redirection. A behavior note entered as a late entry note on 7/26/18 indicated on 7/25/18 during the second shift (3:00 PM – 11:00 PM) Resident #30 was exit seeking. He was noted to self-propel back and forth between the exit doors on the rehabilitation hall (F hall). Resident #30 ' s care plan related to wandering was noted as reviewed on 8/6/18. The problem area remained unchanged, I am: an identified wanderer. This care plan indicated Resident #30 had a [DIAGNOSES REDACTED]. There continued to be no approaches and/or interventions to address this problem area. The goals for Resident #30 remained unchanged: wander within the facility where his safety could be maintained and monitored, have no injuries, make no attempts to leave the facility, and accept redirection. A behavior note dated 8/9/18 indicated Resident #30 was exit seeking. Resident #30 ' s NA guidelines for daily care, undated, was reviewed on 8/21/18. This form indicated Resident #30 had a [DIAGNOSES REDACTED]. He was noted with a wander guard. As of 8/21/18 at 1:30 PM Resident #30 ' s care plan related to wandering continued to include no approaches/interventions to address this problem area. An interview was conducted with UM #2 on 8/21/18 at 1:45 PM. He confirmed he had written the acute condition note and the late entry incident note related to Resident #30 ' s unsupervised exit from the facility on 6/13/18. He stated Resident #30 was cognitively impaired and was able to self-propel in his wheelchair. He indicated Resident #30 wandered throughout the facility daily. An interview was conducted with Nurse #2 on 8/21/18 at 3:20 PM. She indicated Resident #30 was a known wanderer, was able to self-propel in his wheelchair, and was cognitively impaired. She stated Resident #30 really wanted to go home and he was an exit seeker. An interview was conducted with Nurse #4 on 8/21/18 at 2:25 PM. He indicated Resident #30 was cognitively impaired, was a known wanderer, and self-propelled his wheelchair all over the facility. An interview was conducted with NA #6 on 8/21/18 at 2:20 PM. She indicated Resident #30 was cognitively impaired and he wandered daily by self-propelling his wheelchair throughout he facility. A phone interview was conducted with NA # 4 on 8/22/18 at 9:41 AM. She indicated Resident #30 was cognitively impaired and he wandered daily by self-propelling his wheelchair throughout he facility. An interview was conducted with the Facility Care Coordinator (FCC) on 8/21/18 at 1:58 PM. She indicated she was aware Resident #30 had an unsupervised exit from the facility on 6/13/18. She was asked who was responsible for the development of comprehensive care plans related to wandering behaviors. She stated the Social Worker (SW) was responsible for all behavior related care plans. The care plan related to wandering for Resident #30 that was initiated on 5/14/18 and reviewed on 7/9/18 and 8/6/18 and included no approaches/interventions was reviewed with the FCC. She confirmed that this care plan was not comprehensive as it had not included approaches/interventions to address his wandering behaviors. An interview was conducted with the SW on 8/21/18 at 4:35 PM. She indicated she was aware Resident #30 had an unsupervised exit from the facility on 6/13/18. She confirmed she was responsible for the completion of care plans related to wandering behaviors. The care plan related to wandering for Resident #30 that was initiated on 5/14/18 and reviewed on 7/9/18 and 8/6/18 and included no approaches/interventions was reviewed with the SW. She was unable to explain why there were no approaches/interventions on the care plan to address Resident #30 ' s wandering. The SW stated that approaches/interventions should have been added to Resident #30 ' s care plan to address his wandering behaviors when the care plan was initiated on 5/14/18. She indicated that following Resident #30 ' s unsupervised exit from the facility on 6/13/18 his care plan should have been reviewed to ensure appropriate approaches/interventions were in place. The SW was again unable to explain why it had not been identified during the reviews of Resident #30 ' s care plan on 7/9/18 and 8/6/18 that there were no approaches/interventions to address the problem area of wandering. An interview was conducted with the Administrator on 8/23/18 at 2:30 PM. The Administrator indicated that she expected all residents to have comprehensive care plans that included approaches/interventions utilized to meet the goals of identified problem areas. She stated that her expectation was for Resident #30 ' s care plan related to wandering to have included approaches/interventions at the time of its initiation on 5/14/18. She indicated that following Resident #30 ' s unsupervised exit from the facility on 6/13/18 she expected his care plan related to wandering to be reviewed to ensure appropriate approaches/interventions were in place. The Administrator additionally indicated that she expected it to be identified during the care plan reviews on 7/9/18 and 8/6/18 that there were no approaches/interventions to address Resident #30 ' s wandering behaviors.

Based on observation, staff interview, and record review, the facility failed to implement the plan of care interventions to prevent injury for a resident at high risk for falls. Resident #31 sustained a fall that resulted in a left femur (hip) fracture for 1 of 4 residents reviewed for accidents. The findings included: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had moderate cognitive impairment. He required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #31 was not steady on his feet and was only able to stabilize with staff assistance. He utilized a wheelchair and a walker. He was indicated to be frequently incontinent of bladder and always incontinent of bowel. Resident #31 had 1 fall since his admission to the facility. This fall resulted in no injury. Resident #31 had 1 fall prior to his admission to the facility and within the past month that resulted in a related fracture. The Care Area Assessment (CAA) related to falls for the 9/18/16 MDS admission assessment indicated Resident #31 had one fall since his admission to facility. The fall occurred on 9/18/16 at 12:45 AM when Resident #31 fell out of bed. This fall was indicated to result in no injury. Resident #31 was assessed with [REDACTED]. He was noted with a decline in functional status, muscle weakness, impulsivity or poor safety awareness, cognitive impairment, dementia, fatigue, and incontinence. Resident #31 was admitted to the facility following a recent hospitalization stay due to a right femur fracture that had been repaired. The plan of care for Resident #31 initiated on 9/29/16 indicated he was at risk for falls. The interventions initiated on 9/29/16 included, in part, call bell within reach and provide proper footwear. Interventions initiated on 9/30/16 indicated antiroll-backs to wheelchair as ordered and floor mat. An intervention initiated on 10/27/16 indicated a pool noodle (used to create a raised boundary at the outer edge of the bed) was to be placed under the cover when Resident #31 was in bed. The goal of this fall risk plan of care, initiated 9/29/16 and reviewed 6/2/17, read I don ' t want to be seriously injured if I fall. An acute condition note indicated Resident #31 had an unobserved fall in his bathroom on 4/21/17 at 7:30 PM. No injuries were noted. The fall risk assessment dated [DATE] indicated Resident #31 was at high risk for falls. An acute condition note indicated Resident #31 had an unobserved fall in his bedroom on 5/23/17 at 4:30 AM. No injuries were noted. The fall risk assessment dated [DATE] indicated Resident #31 was at high risk for falls. The 5/24/17 quarterly MDS assessment indicated Resident #31 had moderate cognitive impairment. He required limited assistance of 1 staff with bed mobility, transfers, walking in corridor, dressing, toileting, and personal hygiene. Resident #31 had limitations with range of motion on one side of his lower extremities, he was not steady on his feet, and was only able to stabilize with staff assistance. Resident #31 had 2 or more falls with no injury since his previous MDS assessment (quarterly dated 2/22/17). An acute condition note indicated Resident #31 was observed on the floor by Nursing Assistant (NA #2) on 6/19/17 at 5:30 AM. NA #2 heard Resident #31 fall, she went to his room, observed him lying on his back, and she then alerted the nurse. Resident #31 was noted to have regular socks on both feet (not non-skid socks). The nurse assessed Resident #31. He was noted with blood around the left side of his head behind his ear and a small raised hematoma (solid swelling of clotted blood) about the size of a dime. Resident #31 was unable to move his left leg and he complained of pain in the left hip area. The physician was notified and Resident #31 sent to the ER for evaluation. The medical record revealed Resident #31 was admitted to the hospital on [DATE] for a left femur fracture. Resident #31 was readmitted to the facility on [DATE]. The plan of care for Resident #31 related to his risk for falls was updated on 7/11/17 with the same interventions that were in place prior to the 6/19/17 fall that resulted in a left femur fracture. The interventions included, in part, provide proper footwear and a pool noodle under the cover when Resident #31 was in bed. On 7/12/17 the NA Care Guide was reviewed. Resident #31 was indicated to require staff assistance of 1+ for transfers, he was on a toileting program, and used a low bed. It was noted that all residents were to be wearing shoes or gripper socks when out of bed unless care planned otherwise. There were no other fall risk interventions indicated on Resident #31 ' s NA Care Guide. Resident #31 was observed sleeping in bed in his room on 7/13/17 at 7:15 AM. There was no pool noodle under the covers on Resident #31 ' s bed. An interview was conducted with NA #2 on 7/13/17 at 7:20 AM. She indicated she was familiar with Resident #31 and she had worked with him regularly on the third shift (11:00 PM to 7:00 AM). She reported he was at high risk for falls. She stated she was informed of fall risk interventions by reviewing the NA Care Guide and by talking to staff. NA #2 indicated if a new intervention was put into place she was informed by the nurse verbally. She reported she had not reviewed Resident #31 ' s plan of care. She stated the fall risk interventions that were in place for Resident #31 were to check on him every 2 hours, fall mat on the floor when in bed, and non-skid footwear. The plan of care for Resident #31 that indicated a noodle was to be placed under the cover when he was in bed was reviewed with NA #2. She stated she had not known this was an intervention for Resident #31. She revealed she had not utilized a pool noodle as an intervention for Resident #31 when she worked with him. The interview with NA #2 continued on 7/13/17 at 7:25 AM. The documentation from Resident #31 ' s 6/19/17 fall in which he sustained a femur fracture was reviewed with NA #2. She verified she was the NA assigned to Resident #31 at the time of the fall. She confirmed the information provided in the documentation that Resident #31 had regular socks on at the time of the 6/19/17 fall. NA #2 stated Resident #31 sometimes took his non-skid socks off during the night if he was hot. She indicated she had not regularly checked to see if he was wearing his non-skid socks throughout the night. NA #2 was asked if Resident #31 was capable of removing his non-skid socks and replacing them with regular socks. She stated she was unsure because sometimes he needed assistance getting dressed and other times he didn ' t. NA #2 revealed the intervention of a pool noodle under the covers when Resident #31 was in bed was not implemented at the time of the 6/19/17 fall. An interview was conducted with the Director of Nursing (DON) on 7/12/17 at 10:10 am. The documentation from Resident #31 ' s 6/19/17 fall in which he sustained a femur fracture was reviewed with the DON. She reported proper footwear meant non-skid socks when the resident was in bed and non-skid shoes when the resident was out of bed. The DON stated the NA assigned to the resident was responsible for checking his footwear. The 7/13/17 observation of Resident #31 in bed with no pool noodle under the covers at 7:25 AM was reviewed with the DON. The interview with NA #2 that revealed the pool noodle was not in use at the time of 6/19/17 fall was reviewed with the DON. She stated her expectation was for the fall risk interventions to be in place at all times. An interview was conducted with MDS Nurse #1 on 7/13/17 at 10:50 AM. She indicated she was responsible for creating and revising the plans of care with fall risk interventions. She stated the fall risk interventions on the care plan were supposed to be on the NA Care Guide. The care plan interventions for Resident #31 ' s risk for falls were reviewed with MDS Nurse #1. The NA Care Guide for Resident #31 that had not matched the fall risk interventions in his care plan were reviewed with MDS Nurse #1. The NA Care Guide had not included the interventions of a floor mat or a pool noodle under the cover when Resident #31 was in bed. MDS Nurse #1 reported she thought when a fall risk intervention was added to the care plan that the electronic medical records system automatically added the intervention to the NA Care Guide. She indicated that based on the discrepancies with Resident #31 ' s care plan and NA Care Guide, that she was incorrect. MDS Nurse #1 revealed there had not been monitoring in place to ensure the fall risk interventions in the care plan were on the NA Care Guide. She additionally revealed there had not been any monitoring in place to ensure the fall risk interventions in the care plan were implemented.

Based on observation, family interview, staff interview, and record review, the facility failed to implement the fall risk interventions for 1 of 4 residents (Resident #31) at high risk for falls resulting in the resident sustaining a left femur (hip) fracture. The facility also failed to provide adequate supervision to prevent repeated falls for a resident with a history of falls for 1 of 4 residents (Resident #64) reviewed for accidents. The findings included: 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had moderate cognitive impairment. He required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #31 was not steady on his feet and was only able to stabilize with staff assistance. He utilized a wheelchair and a walker. He was indicated to be frequently incontinent of bladder and always incontinent of bowel. Resident #31 had 1 fall since his admission to the facility. This fall resulted in no injury. Resident #31 had 1 fall prior to his admission to the facility and within the past month that resulted in a related fracture. He was indicated to be receiving Physical Therapy (PT) and Occupational Therapy (OT) with a start date of 9/12/16. The Care Area Assessment (CAA) related to falls for the 9/18/16 MDS admission assessment indicated Resident #31 had one fall since his admission to facility. The fall occurred on 9/18/16 at 12:45 AM when Resident #31 fell out of bed. This fall was indicated to result in no injury. Resident #31 was assessed with [REDACTED]. He was noted with a decline in functional status, muscle weakness, impulsivity or poor safety awareness, cognitive impairment, dementia, fatigue, and incontinence. He was admitted to the facility following a recent hospitalization stay due to a right hip fracture that had been repaired. The plan of care for Resident #31 initiated on 9/29/16 indicated he was at risk for falls. The interventions initiated on 9/29/16 included, in part, call bell within reach and provide proper footwear. Interventions initiated on 9/30/16 indicated antiroll-backs to wheelchair as ordered and floor mat. An intervention initiated on 10/27/16 indicated a pool noodle (used to create a raised boundary at the outer edge of the bed) was to be placed under the cover when Resident #31 was in bed. An acute condition note indicated Resident #31 was observed on the floor in his bathroom on 4/21/17 at 7:30 PM. The call light in Resident #31 ' s bathroom was on. He was assessed with [REDACTED].#31 indicated he was standing in front of the toilet and his feet started sliding. Resident #31 was assisted to bed, his bed was then placed in the lowest position, and his call light was put within his reach. Resident #31 was asked by staff not to get up on his own and to use the call light for assistance. He was noted to be wearing non-slip shoes, his room and bathroom were uncluttered, and the bathroom light was on. The fall report related to Resident #31 ' s 4/21/17 fall indicated the bathroom call light had been utilized, but the call light in his bedroom was in reach of the bed and had not been utilized. Resident #31 was indicated to have been wearing proper footwear. The floor in Resident #31 ' s bathroom was noted to be slick (no urine or water was noted on the floor). Resident #31 ' s known behaviors were a history of falls and getting up without assistance. Interventions in place/added for Resident #31 were low bed, noodle on his bed, clean/dry floor .the floor was noted slick when the (staff) entered the room, they started to slide on the floor, the floor was mopped after (Resident #31) was assisted to bed. The fall risk assessment dated [DATE] indicated Resident #31 was at high risk for falls. Resident #31 was taught how to use the call light. The facility indicated the fall risk intervention added was a clean/dry floor, as Resident #31 ' s bathroom floor where he had fallen was noted slick when staff found the resident. He was indicated to have had 1 or more falls in the past 6 months. Resident #31 required assistance with toileting. He was assessed with [REDACTED]. An acute condition note indicated Resident #31 was observed on the floor of his bedroom with his back against the bed on 5/23/17 at 4:30 AM. The floor was noted to be clean and clear, bed in the lowest position, and the wheelchair was close to the bed. Resident #31 was wearing white cotton socks and bedroom slippers. He was assessed with [REDACTED].#31 indicated he had tried to get up to put his shoes on and he slid down to the floor. Neurological checks were initiated and no concerns were identified. Resident #31 was instructed on the use of his call light. The fall report related to Resident #31 ' s 5/23/17 fall indicated he had not utilized his call light. Resident #31 had fallen in his room, he was indicated to be attempting to put his shoes on and he slid to the floor. His call light was noted to be in reach and he was wearing proper footwear. His known behavior was getting up without assistance. Interventions in place/added for Resident #31 were low bed. The fall risk assessment dated [DATE] indicated Resident #31 was at high risk for falls. Resident #31 was instructed on use of the call light. The intervention added was increased lighting (leaving night light on). He was indicated to have had 1 or more falls in the past 6 months. Resident #31 was assessed with [REDACTED].>The 5/24/17 quarterly MDS assessment indicated Resident #31 had moderate cognitive impairment. He had no behaviors and no rejection of care. He required limited assistance of 1 staff with bed mobility, transfers, walking in corridor, dressing, toileting, and personal hygiene. Resident #31 had limitations with range of motion on one side of his lower extremities, he was not steady on his feet and was only able to stabilize with staff assistance. He utilized a wheelchair and a walker. He was indicated to always be continent of bladder and occasionally incontinent of bowel. Resident #31 had 2 or more falls with no injury since his previous MDS assessment (quarterly dated 2/22/17). He was indicated to be receiving PT with a start date of 5/9/17. He was also indicated to have received restorative nursing services for active range of motion and walking. An acute condition note indicated Resident #31 was observed on the floor by Nursing Assistant (NA #2) on 6/19/17 at 5:30 AM. NA #2 heard Resident #31 fall, she went to his room, observed him lying on his back, and she then alerted the nurse. Resident #31 was noted to have regular socks on both feet (not non-skid socks). The nurse assessed Resident #31. He was noted with blood around the left side of his head behind his ear and a small raised hematoma (solid swelling of clotted blood) about the size of a dime. Resident #31 was unable to move left leg and he complained of pain in the left hip area. Resident #31 ' s room was clean, uncluttered, the floor was dry, and the call light was clipped to the side of the bed (within reach of Resident #31 when he was in bed). The physician was notified and Resident #31 sent to the ER for evaluation. The fall report related to Resident #31 ' s 6/19/17 fall indicated he had not utilized his call light and he was not wearing proper footwear. Resident #31 was instructed on use of the call light, but he was noted to be unable to retain knowledge at that time due to pain. His known behaviors were a history of falls and getting up without assistance. Interventions in place/added for Resident #31 were low bed, encourage to wear proper footwear. The fall risk assessment dated [DATE] indicated Resident #31 was at high risk for falls. The interventions added were noted to be low bed and proper footwear. He was indicated to have had 1 or more falls in the past 6 months. Resident #31 required assistance with toileting. He was assessed with [REDACTED]. The medical record revealed Resident #31 was admitted to the hospital on [DATE] for a left femur fracture. Resident #31 was readmitted to the facility on [DATE]. The plan of care for Resident #31 related to his risk for falls was updated on 7/11/17 with the same interventions that were in place prior to the 6/19/17 fall that resulted in a femur fracture. The interventions included, in part, call bell within reach, provide proper footwear, antiroll-backs to wheelchair as ordered, floor mat, and a pool noodle under the cover when Resident #31 was in bed. On 7/12/17 the NA Care Guide was reviewed. Resident #31 was indicated to require staff assistance of 1+ for transfers, he was on a toileting program, and used a low bed. It was noted that all residents were to be wearing shoes or gripper socks when out of bed unless care planned otherwise. There were no other fall risk interventions indicated on Resident #31 ' s care guide. Resident #31 was observed sleeping in bed in his room on 7/13/17 at 7:15 AM. There was no pool noodle under the covers on Resident #31 ' s bed. An interview was conducted with NA #2 on 7/13/17 at 7:20 AM. She indicated she was familiar with Resident #31 and she had worked with him regularly on the third shift (11:00 PM to 7:00 AM). She reported he was a high risk for falls. She stated she was informed of fall risk interventions by reviewing the NA Care Guide and by talking to staff. NA #2 indicated if a new intervention was put into place she was informed by the nurse verbally. She reported she had not reviewed Resident #31 ' s plan of care. She stated the fall risk interventions that were in place for Resident #31 were to check on him every 2 hours, fall mat on the floor when in bed, and non-skid footwear. The plan of care for Resident #31 that indicated a noodle was to be placed under the cover when he was in bed was reviewed with NA #2. She stated she had not known this was an intervention for Resident #31. She revealed she had not utilized a pool noodle as an intervention for Resident #31 when she worked with him. The interview with NA #2 continued on 7/13/17 at 7:25 AM. The documentation from Resident #31 ' s 6/19/17 fall in which he sustained a femur fracture was reviewed with NA #2. She verified she was the NA assigned to Resident #31 at the time of the fall. She confirmed the information provided in the documentation that Resident #31 had regular socks on at the time of the 6/19/17 fall. NA #2 stated Resident #31 sometimes took his non-skid socks off during the night if he was hot. She explained that Resident #31 had a history of [REDACTED]. She reported she checked on him about every 2 hours to ensure he was still in bed, but she had not regularly checked to see if he was wearing his non-skid socks throughout the night. NA #2 was asked if Resident #31 was capable of removing his non-skid socks and replacing them with regular socks. She stated she was unsure because sometimes he needed assistance getting dressed and other times he didn ' t. NA #2 revealed the intervention of a pool noodle under the covers when Resident #31 was in bed was not implemented at the time of the 6/19/17 fall. An interview was conducted with the Director of Nursing (DON) on 7/12/17 at 10:10 am. The documentation from Resident #31 ' s 6/19/17 fall in which he sustained a femur fracture was reviewed with the DON. She reported proper footwear meant non-skid socks when the resident was in bed and non-skid shoes when the resident was out of bed. The DON stated the NA assigned to the resident was responsible for checking his footwear. The 7/13/17 observation of Resident #31 in bed with no pool noodle under the covers at 7:25 AM was reviewed with the DON. The interview with NA #2 that revealed the pool noodle was not in use at the time of 6/19/17 fall was reviewed with the DON. She stated her expectation was for the fall risk interventions to be in place at all times. 2. Resident #64 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #64 had severe cognitive impairment and he needed extensive assistance with transfer. The assessment also indicated that he had a fall with injury in the last 6 months prior to admission to facility. The assessment further indicated that Resident #64 was frequently incontinent of bowel and bladder and he was unsteady when moving on and off toilet, moving from seated to standing and when transferring between bed, chair or wheelchair. Resident #64's care plan dated 6/8/17 was reviewed. One of the care plan problems was at risk for falls due to unsteady gait and recent falls. The goal was resident will not be seriously injured if he falls. The approaches included encourage to ask for assistance, bed alarm as needed, scheduled toileting, toilet upon awakening, after meals, at bedtime and as needed. The incident reports for Resident #64 were reviewed. The reports indicated that he had 6 falls since admission (5/25/17) to facility. On 6/1/17 at 8:03 PM, Resident #64 was found sitting on the floor in the bathroom. The interventions added were the room was rearranged, wheelchair and bedside table were placed at friendlier angle and lighting was increased on hallway. On 6/6/17 at 10:28 AM, Resident #64 was found sitting on the floor in front of the recliner. His clothes were wet with urine and he stated that he was going to the bathroom. The intervention added was personal alarm. On 6/15/17 at 9:05 AM, Resident #64 was observed on the floor in the doorway of the bathroom door. The interventions added were low bed, fall mat and bed alarm. On 6/24/17 at 7:20 PM, Resident #64 was found sitting on the bathroom floor. The intervention added was to toilet after meals. On 6/28/17 at 10:28 AM, Resident #64 was found lying on his left side in the bathroom. Skin tear to his left wrist was noted. The interventions added were spoke with therapy and explained that we do not leave the resident in room during the day and to keep him with others at activities and toilet him very often. On 7/10/17 at 10:20 AM, Resident #64 was found on the floor. He sat down on floor on the way back from the toilet. Interventions added were increased lighting and foot wear provided. Resident #64 was observed on 7/12/17 at 3:46 PM. He was up in wheelchair in his room. A family member was in the room with the resident. NA #1 came in the room and was interviewed. NA #1 stated that he was assigned to Resident #64. He indicated that the resident was on toileting program and he toileted him every 2 hours. A family member was interviewed on 7/12/17 at 3:47 PM. The family member stated that she/he came to visit Resident #64 every day from 2 PM until 6-6:30 PM. She/he stated that she/he had not observed the staff taking Resident #64 to the bathroom during her/his visits. An interview was conducted with the Director of Nursing (DON) on 7/12/17 at 4:05 PM. The DON stated that she was aware that Resident #64's falls happened in the bathroom. She expected his care plan to be individualized and to toilet him more often than after every meal and at bedtime and not to leave resident in his room during the day and to provide more supervision. She also expected the staff to ensure a urinal was kept at bedside when he was in bed. Resident #64 was observed in bed on 7/13/17 at 7:10 AM. There was no urinal observed at the resident's bedside. NA #2, assigned to Resident #64 on 3rd shift was interviewed on 7/13/17 at 7:30 AM. She stated that the resident was incontinent of bowel and bladder and he was wearing a disposable brief. NA #2 further indicated that the resident was unsteady and he tried to get up and to walk to the bathroom. She indicated that the resident was not on any toileting schedule at night. She further stated that she checked the resident every 2 hours for incontinence and he was wet most of the time. She further stated that she offered the resident a urinal but didn't keep the urinal at bedside.

Based on record review, observation and staff interview, the facility ' s Quality Assurance and Assessment (QAA) committee failed to maintain implemented procedures and to monitor these interventions that the committee put into place in July 2016. This was for recited deficiencies that were originally cited in July 2016 recertification and complaint investigation survey and subsequently recited on the facility's recertification and complaint investigation survey on July 13, 2017. The deficiencies were in the areas of accidents F323 and kitchen sanitation F371. The continued failure of the facility during the two federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross referred to: F323 (Accidents) -Based on observation, family interview, staff interview, and record review, the facility failed to implement the fall risk interventions for 1 of 4 residents (Resident #31) at high risk for falls resulting in the resident sustaining a left femur (hip) fracture. The facility also failed to provide adequate supervision to prevent repeated falls for a resident with a history of falls for 1 of 4 residents (Resident #64) reviewed for accidents. During the recertification and complaint investigation survey of July 2016, the facility was cited accidents for failure to safeguard a resident from entrapment between the side rail and the air mattress. F371 (Kitchen Sanitation) - Based on observation and staff interviews the facility failed to clean food service equipment, cookware, meal delivery carts and kitchen fans. The facility allowed lettuce to contact an unsanitized towel and counter surface that had not been properly sanitized exposing food to possible contaminants for 21 of 21 residents who received specialized diets. The facility failed to maintain a thoroughly clean floor under five of nine appliances. During the recertification and complaint investigation survey of July 2016, the facility was cited kitchen sanitation for failure to consistently monitor and maintain a refrigerator temperature of 41 degrees Fahrenheit (F) or below. The QA Nurse was interviewed on 7/13/17 at 10:15 AM. The QA Nurse stated that she was aware that accidents and kitchen sanitation were cited during the recertification survey of July 2016. She indicated that the facility had been monitoring the use of side rails on admission. She also indicated that she had been monitoring the temperature of the nourishment refrigerators. The QA Nurse stated that the areas that were recited were different from last year. She added that the committee would create a new system to address falls. The Administrator was interviewed on 7/13/17 at 10:35 AM. She stated that she started working at the facility as administrator 2 weeks ago. She was aware that accidents and kitchen sanitation were cited during the recertification survey of July 2016. She also indicated that she would take over as head of the QA committee.

Based on observation, medical record review, facility policy review, physician, nurse practitioner and staff interviews, the facility failed to safeguard a resident from entrapment between the side rail and the air mattress. On 7/10/16 at 9:40PM, Resident #62 fell between the air mattress and the bed rail causing her head to become wedged between the rail and the air mattress. Immediate jeopardy began on 7/10/16 and was removed on 7/14/16 at 3:50PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective and all staff have been in-serviced. A manufacturer's user guide for the (name) mattress was reviewed. The manufacturer ' s guide stated the air mattress in the mattress replacement is continually monitored and a visual and audible alarm activates in the event mattress pressure becomes too low. There were no manufacturer's instructions noted for the use of the air mattress with an assist rail. Resident #62 was admitted to the facility 10/3/12 and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. On 7/12/16, a review of Resident #62's medical record was conducted. Information provided by the facility revealed Resident #62 had been using the same air mattress since 5/30/2014 and the assist rails that had been on the bed were put on 7/27/2015. A review of a facility assessment for the use of side rails dated 6/15/16 stated Resident #62's mental function fluctuated with periods of confusion at night. She was non-ambulatory and no falls were noted in the last 6 months. An assist rail was used by Resident #62 for bed mobility. The use of the assist rail was not coded on the MDS as a restraint. A Quarterly Minimum (MDS) data set [DATE] indicated Resident #62 was moderately impaired in cognition. She required extensive assistance of two people for bed mobility. Functional limitation in range of motion was limited on one side upper and one side lower extremity. Medical record review conducted on 7/12/16 revealed Resident #62 also had times when she moved about in bed independently without staff assistance. A Care Plan dated 11/17/15 and last revised on 7/12/16 stated Resident #62 was at a risk for falls due to her history of falls. Approaches included, in part, to instruct Resident #62 on safety. Staff would observe, record and report all unsafe conditions and situations. Resident #62 had a low bed and a floor mat beside the bed. Encourage her to ask for assistance. The use of floor mats on both sides of the bed when Resident #62 was in bed was added to the approaches on 7/12/16. A review of falls for Resident #62 over the past two years revealed the following falls recorded: 3/19/14 (nursing note stated fell from wheelchair), 9/7/15 (observed on floor and did not call for assistance when trying to get up) and 7/11/16 (wedged in between mattress and side rail). A nursing note dated 7/11/16 at 2:28AM stated observed on mat next to bed. Resident observed laying on stomach with neck stuck in between bed rail and bed, body straight out half on bed, half off bed, legs straight out touching the floor mat, arms at side. Bed was in low position. Floor mat was down. Upon resident being put back to bed, full assessment and skin assessment was completed. Signs and symptoms of pain were presented when the anterior left side of neck was palpated. No swelling, redness or bruising was noted. The Physician on call was called and new orders were received. The time of incident was documented as follows: 7/10/16 at 9:40PM. The equipment involved was documented as bed rails. An x-ray of the cervical spine dated 7/10/16 indicated the following: Impression linear lucency within the anterior aspect of the C4 vertebral body, consistent with a fracture. A nursing note dated 7/11/16 at 2:43 AM stated the on-call physician was notified of the results. The on-call physician stated for the in house physician to see resident in the morning and for resident to see orthopedic physician. An observation of Resident #62 was conducted on 7/11/16 at 12:40PM. Resident #62 was lying in her bed. She had an alternating air mattress in place. There were 2 assist rails on either side of the bed near the head of the bed. The air mattress was soft to touch. There was a small gap between the air mattress and the side rail. Area was not measured at that time. On 7/11/16 at 1:45PM, Resident #62 was seen by the Nurse Practitioner and orders were given to send Resident #62 to the hospital emergency room for evaluation and for a computerized tomography (CT) scan of the cervical spine. A CT scan of the cervical spine without contrast dated 7/11/16 stated the following: Findings: Normal alignment. No evidence of fracture. There is multilevel cervical spondylosis (neck arthritis) with posterior disc osteophyte (bone spur) complexes and bilateral facet hypertrophy (degeneration and enlargement of joints). Impression: cervical spondylosis without evidence of cervical fracture or malalignment. A review of Resident #62's medical record revealed neurological checks were done from the time of the incident through 7/11/16 at 11:30PM and all were normal. On 7/11/16 at 4:55PM, an interview was conducted with the Administrator who stated she was not aware of the accident involving Resident #62 until the morning meeting on Monday 7/11/16. She stated Resident #62 had rolled in her bed, had a hand rail on the side of the bed and got positioned between the mattress on the bed and the handrail. Resident #62 had some pain in her neck; the facility obtained an order for [REDACTED]. The on call physician was called and he stated to have the nurse practitioner see Resident #62 today (7/11/16). She said her expectation was the following: if a resident has a fall with major injury, call the physician and family; if the resident was sent out to the hospital, she expected them to call the on call nurse or Director of Nursing. If it was an injury of unknown origin, to call the Administrator also. She stated the charge nurse removed the hand rails on that resident's bed on 7/11/16 sometime after lunch on 7/11/16. On 7/11/16 at 5:09PM, an interview was held with Nurse #3 who was the nurse who completed the accident investigations for falls. She stated she only knew what was in the medical record that Resident #62 fell yesterday at 9:40PM. In looking at the nursing notes, her head was pinned between the rail and the mattress. She stated they had taken the side rails off Resident #62 ' s bed sometime after lunch on 7/11/16 due to the nursing documentation about the way Resident #62 had her head in the rails. She stated Resident 62 was trying to turn over in the bed and rolled off the bed. She could turn over by herself. Nurse #3 stated the same rails were on all the beds. Nurse #3 said Resident #62 had a regular pressure reducing standard mattress and she did not know if it was an air mattress. She stated all falls are investigated within the first day. The daily condition sheets were brought into morning meeting and reviewed go over them, anything out of the ordinary like falls starts the investigation that day. Nurse #3 stated she had not come to the morning meeting and had not had a chance to speak to anyone yet about the accident. She stated Resident #62 could not walk and, if her legs were going off the bed, her body weight would carry her lower body but her head could still be in the bed rails even if the bed was low to the floor. On 7/11/16 at 5:40PM, an interview was conducted with the Director of Nursing. She stated she got in the facility around 11:30AM on 7/11/16. She could not remember exactly when she was made aware of the accident involving Resident #62. She stated Nurse #4 was going to let the Nurse Practitioner see Resident #62 because the on call physician stated for the Nurse Practitioner to see her on 7/11/16. The Director of Nursing stated she spoke to Nurse #1 who was present at the time of the accident and Nurse #1 told her she was called to the room by other nursing staff due to the positioning of Resident #62 who was positioned between the bed and the rails and her head was in the railing so they immediately moved Resident #62 because they had to. She stated Nurse #1 told her she called the on-call doctor and explained what happened and the on-call doctor stated Resident #62 should be all right and ordered a cervical spine x-ray. The results of the x-ray were obtained around midnight. Nurse #1 called the on call physician and he said to just let the Nurse Practitioner see her in the morning. The Director of Nursing stated she expected nursing staff to call her if a resident was sent out to the hospital. She stated they should have called her if it was a side rail injury. If she had received a call, she would have told them to send Resident #62 to the hospital anyway. She said she would have removed the side rails at the time of the accident. On 7/11/16 at 6:05PM, an interview was conducted with Nurse #2 who stated she and another nursing assistant (NA#1) were coming back up the hall on B hall and were spot-checking the rooms. As they came up the hall, they saw that the bedspread and sheet were hanging off the foot of Resident #62's bed. Resident #62 was able to get her legs off the bed so they went in to check her because the curtain was pulled and they could not see her from the hallway. Resident #62 had her head wedged in between the side rail and the bed itself. She had one hand on the side rail. Her knees were actually on the floor. She talked to nursing staff and said she slid out of bed. She still had her oxygen cannula on and was facing the headboard. Her head was wedged at the eye area. Nurse #2 stated Resident #62 could not physically move herself. On 7/11/16 at 6:15PM, an interview was conducted with NA#1, the nursing assistant who was assigned to Resident #62 on 7/10/16 when the accident occurred. She stated she last saw Resident #62 on 7/10/16 between 8:15-8:30PM. NA#1 said she was going to see her nurse to tell her about one of her residents when she looked in Resident #62's room and saw the bed covers on the floor. She said she was by herself when she went in the room and immediately called for Nurse #2 to come in the room. NA#1 said she could not see the resident at all from the outside of the room. Her backside was exposed her head was facing down with her head between the rail and the mattress. Resident #62 was calling for help in a low toned voice. NA#1 stated Resident #62 did not complain about any pain on any part of her body. On 7/11/16 at 6:23PM, an interview was conducted with Nurse #1 who was in charge of Resident #62 on 7/10/16. She said she was working on the hall and had just finished up medication pass. Resident #62 had received a bedtime snack between 8:30-9:00PM. Nurse #1 stated one of the nursing assistants went into Resident #62's room around 9:40-9:45PM. Nurse #1 was called to the room. Resident #62's bed was in the lowest position and her floor mat was in place on the floor. Resident #62 had her head in between the rail and the air mattress with the left side of her face was on the rail and the right side of her face was pressed against the side of the air mattress. Her face wasn't on the mattress. There was an open space under her chin. Her whole head and neck was in between and she was looking down-neck was down. Her feet were stretched out on the floor mat and her knees were almost on the floor mat. Resident #62 had her eyes open and she did not speak. She was breathing normally but Nurse #1 felt it was an unsafe position for her to be in and she, along with two other staff members (Nurse #2 and NA#1), log rolled her back onto the bed. Resident #62 was not in pain or hurting when she was moved back onto the bed. Nurse #1 said she asked Resident #62 if anything hurt and initially Resident #62 did not say anything. Nurse #1 asked her about her neck, head, ears and she said it hurt when Nurse #1 pressed on the left side of her neck and if it wasn't touched, it did not hurt. Nurse #1 stated neurological checks were initiated, vital signs were done and Resident #62 squeezed Nurse #1's hands and moved her feet on command. Resident #62 had no redness, bruising or swelling only pain when Nurse #1 touched her neck. Nurse #1 called the on-call doctor and he ordered a spinal x-ray and he said it could be done in the morning. The mobile x-ray personnel were in the building so the x-ray was obtained that night and the results from the x-ray came in around 1:00AM. Nurse #1 called the on-call physician immediately and he said to let the physician see her in the morning and get an appointment for orthopedic consult. Nurse #1 said she wasn't concerned about the rail as she repositioned Resident #62 better in the bed and not as close to the floor mat area. She stated she felt it was safe at the time and the resident was in no danger. Nurse #1 stated she did not call the on-call person for the facility because the on-call doctor stated Resident #62 would be all right. On 7/11/16 at 7:07PM, an interview was conducted with NA#2 who was a nursing assistant who also worked 7/10/16 on the evening shift. He stated he was on B hall charting and Nurse #1 and #2 were at their medication carts. He stated he was called to the room and Resident #62 was halfway on the floor and her head was wedged between the bed rail and the mattress and her knees were on the mat. The bed was in the lowest position. She was alert. He stated that he, NA#1 and Nurse #1 scooted Resident #62 back on the bed. On 7/11/16 at 7:20PM, an interview was conducted with the Administrator. The Administrator stated they did not have a process in place for checking the gap between the side rails and the air mattress. She stated the housekeeper checked the air mattress for correct size and function of the air mattress when she put it on the bed. No one checked for the gap between the side rails and the air mattress. An observation of Resident #62 was conducted 7/12/16 at 7:45AM. Resident #62 was lying in bed with the head of the bed slightly elevated. She was lying on an alternating air mattress. The setting of the mattress was checked and revealed 2 green lights were lit which indicated soft . The bed was in the lowest position and the mat was on the floor. There were no side rails on the bed at the time of the observation. On 7/12/16 at 8:36AM, an interview was conducted with the Minimum Data Set (MDS) coordinator who stated she removed the bed rails on Resident #62's bed around 1:00PM on 7/11/16. She stated Resident #62 had one of the newer beds and the bed rails were not loose on either side of the bed. She removed the rails by pushing a button that was on the bottom of the rail. Regarding the air mattress and monitoring of the pressure in the air mattress, she stated the air mattress had an alarm that sounded whenever the pressure was too low or there was a problem with the mattress. On 7/12/16 at 9:30AM, an observation of the bed rails and air mattress of Resident #62 was conducted with the Maintenance director. At that time, the bed rails are affixed to the bed by putting the base of the rail into a round opening at the base of the bed frame. Both of the rails were able to be moved slightly outward. Per the Maintenance supervisor, there was no way to tighten the rails more to decrease the movement of the rails. The Maintenance director measured the open gap between the bed rail and the mattress. The right side rail had a gap between the rail and the air mattress of 1 ½ inches when measured without any pressure to the rail. With pressure to the rail to make the rail go outward until the point of resistance, the gap measured 2 ½ inches. With the rail at its most outward position and pressure to the side of the air mattress, the gap measured 4 ½ inches between the rail and the aide of the air mattress. The left side rail had a gap between the rail and the air mattress of ¾ inches when measured without any pressure to the rail. With pressure to the rail to make the rail go outward until the point of resistance, the gap measured 1 1/8 inches. The bed rails were then removed from the bed of Resident #62. On 7/12/16 at 9:30AM, the gap between the side rails and a regular mattress was measured with the left side measuring 1 ¼ inches and the right side measured 1/3/4 inches with the rails moved to the point of resistance. On 7/12/16 at 9:30AM, Resident #62 was observed moving her lower legs and she stated I've got to get my legs out. Resident #62 was observed to bend her legs and moved her legs to the side of the bed and she was trying to get her legs off the bed. Nursing staff arrived and assisted her with repositioning. On 7/12/16 at 10:38AM, an interview was conducted with the Nurse Practitioner. Resident #62's physician was also present during the interview. The Nurse Practitioner stated she examined resident #62. She stated Resident #62 had limited communication and she had some tenderness when the Nurse Practitioner palpated the back of her neck. Resident #62 had a history of [REDACTED]. Orthopedics could not see her for 2 weeks. The Nurse Practitioner stated she was not comfortable with waiting 2 weeks and ordered her to go the hospital to get a computerized tomography (CT) scan done as a precautionary measure and that was the fastest way to get a CT done. She said she looked at the mobile x-ray results and there was a question as to an actual fracture or not. On 7/12/16 at 10:56AM, an interview was conducted with Resident #62's physician who stated, based on his knowledge of the resident, her family, her medical frailty, if he had received the call regarding the mobile x-ray results, he would have sent her to the hospital at that time as a precautionary measure. On 7/13/16 at 11:40AM, an interview was conducted with the sales representative for the air mattress that was used on Resident #62's bed. He stated the air mattress on the bed was of a standard size. He stated, to his knowledge, there were no alerts or recommendations on the use of the air mattress with any type of side rail. On 7/14/16 at 11:19AM, an interview was conducted with the on-call physician. He stated the nursing staff did appropriate actions and followed his orders. He stated Resident #62 needed additional x-rays with MRI (Magnetic Resonance Imaging) and/or a CT scan at an x-ray suite at the hospital. The physician stated the resident would not have been served by being sent out to the emergency room . He stated the resident needed further care but it was not an emergency situation. He said if there was a fracture, Resident #62 was safer at the nursing home than on a skinny gurney at the emergency room . He chose to keep her at the nursing home and be seen by the provider at the nursing home. He said it was not necessary to use a vertebral collar and the collar could cause more harm than good. A soft c-collar would not stabilize the neck and was only a neck warmer . On 7/14/16 at 11:23AM, an interview was conducted with the Nurse Practitioner. She stated she came to the facility around 12:15 or 12:30PM. She stated it was about one hour after that (1:30PM) when she was informed about Resident #62's incident. She stated she was told that Resident #62 had an incident on 7/10/16 and her positioning, that the on-call physician was called, given the x-ray results to review. She said she reviewed the x-ray results and examined the resident around 1:45PM and ordered her to go to the hospital for a CT scan. When she did an assessment, she asked resident #62 if she had any pain and she didn ' t answer her. The Nurse Practitioner stated she did not feel any abnormalities. She said she told the nursing staff to put a neck roll around her neck, call EMS (Emergency Medical Services) to send her to the hospital and get a CT scan done. The Nurse Practitioner stated if she had been notified by the facility the first thing on the morning of 7/11/16 and the x-ray results had been read to her, she would have ordered a CT scan. If that could not be obtained within an hour, she would have ordered for the facility to send Resident #62 to the emergency room via ambulance. On 7/12/16 at 6:22PM, the Administrator and Director of Nursing were informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 7/14/16 at 2:19PM. The allegation of compliance indicated: Credible Allegation of Compliance: 1. Resident #62 was immediately assessed for injury at time of incident on 7/10/16 at 9:40 pm. No markings, indentations or bruising were noted upon assessment by a licensed nurse. The licensed nurse did note pain during palpitation of Resident #62's neck. Resident #62 was noted to not be in any distress, neurological checks were completed with no abnormalities, and Resident #62 was able to have a conversation with staff regarding the situation. Physician was notified on 7/10/16 at around 10:30-11:00 pm and an order was received for an x-ray, which was obtained at 12:26 am on 7/11/16. Mobile X-Ray completed a spine cervical x-ray. The findings of the x-ray were Linear lucency within the anterior aspect of the C4 vertebral body, consistent with a fracture. Correlate with studies such as CT. Physician notified of results on 7/11/16 at approximately 1:00 am. Nurse Practitioner assessed resident on 7/11/16 at 2:00 pm and ordered further assessment at emergency room (ER); Resident #62 sent out at 2:43 pm on 7/11/16. Computerized Tomography (CT) scan obtained at hospital with no injury from incident noted. Resident #62 returned from the emergency room around 7:00 pm. 2. Side rails were removed from Resident #62's bed on 7/11/16 at 1:07 pm. Bed repositioned to allow placement of bed mats on each side of bed on 7/11/16 around 6:30 pm by the Second Shift Supervisor . Resident re-assessed for need for assist rails by the Director of Nursing (DON) on 7/11/16 at approximately 11:30 am. Care plan updated to reflect no further need for side rails on Monday, 7/11/16 at 4:19 pm, by Minimum Data Set (MDS) Nurse. 3. To identify potential safety risks for all other residents, the beds, mattresses, and side rails in the facility were measured to ensure that there was not any give and that any compression of the mattress would not allow enough space for a resident to become entrapped. This process began on 7-12-16 at 12:00 pm and will be completed on 7-13-16 by midnight by the Maintenance Director, Maintenance Assistant, Director of Clinical Reimbursement, Care Coordinator, MDS Nurse, Environmental Services Director, Housekeeper, Medical Records Director, and Billing Office Manager. These checks will be completed using a bed safety checklist. In addition, on 7-12-16, the Administrator and the Director of Nursing checked every bed in the facility and assessed any gaps in beds that could potentially be dangerous for residents. 4. Residents who have air mattresses were assessed for need for assist rails on 7/12/16 by the Director of Nursing, MDS Coordinator, and Staff Development Coordinator; the rails of two residents, in addition to resident #62, were removed when it was determined that the rails were not needed. The Care Plans for these residents were updated by the MDS Coordinator. 5. Effective 7/13/16, every resident with an air mattress will have a monitoring signoff regarding their air mattress on the Treatment Administration Record (TAR) so that it will be checked daily, every shift, to ensure that it is inflated properly, by the Nurse or Medication Aide. 6. Staff education began on 7/11/16 and will be completed by 7/14/16 by 12:00 pm via in-person or on the phone by Staff Development Coordinator, Director of Nursing, and the MDS Nurse. Staff that are on vacation or unable to be reached will be trained prior to their next working shift. The education will be conducted by the Director of Nursing, Staff Development Coordinator, MDS Nurse, Administrator, and the Clinical Reimbursement Nurse and will include the following: a. Written protocol, created on 7/12/16, for immediately reporting serious incidents, including any incident involving a bed rail, elopement, abuse, neglect, serious injury, resident altercation, or anything deemed unusual by a licensed nurse, to Administrator and DON. All staff that are non-licensed will be in-serviced that any incidents should immediately be reported to the charge nurse. b. Licensed and non-licensed staff will be educated on Bed Safety and Side Rails policy; Accidents and Incidents-Residents policy. (These are existing corporate policies) c. Licensed Nurses and Medication Aides will be in-serviced that air mattress documentation will now be on the Treatment Administration Record and they will be required to check them every shift, every day. d. All facility staff will be in-serviced on the potential risk of injury if there is a gap between the mattress and the assist rails and the importance of reporting any gap of concern to the charge nurse immediately. e. All nursing staff will be in-serviced on proper use and inflation of air mattresses per manufacturer guidelines (manufacturer representative also trained nursing staff on 7-13-16 on the air mattress). f. Licensed Nurses will be in-serviced about assessing for need of side rails immediately after an incident occurs involving a side rail. The Charge Nurse or RN on duty will complete the assessment. The credible allegation was verified 7/14/16 at 3:50PM as evidenced by staff interviews on the policy and procedures for immediately reporting serious accidents to include any accident involving a bed rail, the Bed Rail and Side Rails policy to include notification of accidents with side rails, Air mattress documentation and when/ where that would be documented, proper use and inflation of the air mattress, immediate notification to the charge nurse if an air mattress is alarming , reporting any gap between the side rail and mattress that is of concern to the nursing staff and assessment for the need for side rails. A total of 13 nursing staff had not received the in-service bit Administrative staff stated the remainder of staff would receive the in-service prior to working on the floor. All residents with air mattresses and side rails were observed with the side rails removed for 3 residents and no gaps of concern noted on the remaining 2 residents. All residents with air mattresses and side rails had care plans regarding their use and documentation was noted on the Treatment Administration Record. The bed safety check list was reviewed and audits done and completed for 80 residents on 7/13/16. In-service records were reviewed with the following dates noted: Side rails and bed safety, resident accident/ incidents reporting--7/13 When to contact the administrator and DON (nursing)--7/11-7/14/16 Contacting the charge nurse (Nursing assistants)--7/13/16 Air mattress documentation (licensed and med aide) 7/13--7/14/16 How to check the air mattress for all nursing staff--7/14/16