Every finding on record at Tucker Operating Company LLC

Based on observations, resident representative and staff interviews, record review, and review of the facility policies titled, Incident and Accidents and Elopements and Wandering Residents, the facility failed to prevent the elopement of one of four sampled residents (R) (R1). The deficient practice had the potential to place R1 and other cognitively impaired residents at risk of compromised health and safety.Findings include:Review of the facility policy titled Incidents and Accidents revised 9/23/2025 documented under Policy: It is the policy of the facility for staff to report, investigate and review any accidents or incidents that occur, on facility property and may involve or allegedly involve a Resident. Under Definitions: An incident is defined as an occurrence or situation that is not consistent with the routine care of a Resident or with the operation of the organization. Under Compliance Guidelines: .5. The following incidents/accidents require an incident/accident report but are not limited to: Alleged abuse, Choking, Combative behavior, Drug diversion, Elopement, Entrapment and Falls. Review of the undated facility policy titled Elopements and Wandering Residents documented under Policy: This facility ensures that Residents who exhibit and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with the Resident Centered Care Plan addressing the unique factors contributing to wandering or elopement risk. Under Policy Explanation and Compliance Guidelines: 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.4. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.d. Adequate supervision will be provided to help prevent accidents or elopements. 5. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between facility and the police department. g. Appropriate reporting requirements to the State Survey agency should be conducted.Review of the History and Physical received by the facility before R1's admission and dated 9/18/2025 documented R1 had an altered mental status. R1 was provided with a seater (someone to watch the patient) at the hospital when he attempted to leave the hospital without medical advice and proper discharge.Review of R1's face sheet showed R1 was admitted with diagnoses of but not limited to cerebral infarction, end stage renal disease, cognitive communication deficit, unspecified dementia, and psychotic mood disturbance.Review of R1s admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated R1 had severe cognitive impairment.Review of R1's Comprehensive Care Plan (CCP) Initiated on 10/1/2025 documented R1 was at risk for wandering looking for his home. R1 was disoriented to place, had impaired safety awareness and wandered aimlessly. Care plan directed staff to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books.Review of R1s progress notes dated 10/1/2025 at 10:14 pm, Licensed Practical Nurse (LPN) CC documented on 10/1/2025 at approximately 5:30 pm to 6:00 pm. She observed R1 standing at North nurses' station, R1 requested to leave and stated, Am I able to go? I'm ready to go. LPN CC asked R1 to reveal his name and R1 mentioned his correct name. LPN CC informed R1 he could not leave and instructed him to return to his room. R1 acknowledged and turned around and walked back to his room.Review of a written statement signed and dated 10/2/2025, LPN DD documented at approximately 7:00 pm, the alarm sounded, she discovered the sound was coming from the North Hall close to the activity office. When she arrived at the door, she silenced the alarm. LPN DD documented she did not realize a Resident could have triggered the alarm. LPN DD further documented she was unaware R1 exited the facility until she returned to work to start her shift on 10/2/2025, DD worked the 7:00 am to 7:00 pm shift. LPN DD documented and concluded she had since been made aware of facility expectations, when an alarm had sounded and she was required to search the inside and outside of the facility and notify the police and the Administrator immediately.Review of R1s progress notes dated 10/2/2025 at 6:00 pm, LPN CC documented the following timeline in R1s progress notes:On 10/1/2025 at 7:00 pm - R1 LPN CC observed R1 standing outside his room, wearing personal clothing. At 8:00 pm - Certified Nurse Assistant (CNA) on North Hall reported R1 was missing. CNA stated she attempted to obtain weight from R1 but was unable to locate him. At 8:05 pm - R1s room checked and R1 was not in bed. At 8:15 pm - South Nurse's station notified to verify if R1 was on their unit. Staff reported they were unable to locate R1. Staff were informed of a potentially missing Resident. Code [NAME] (missing resident code) was announced, and all caregivers looked for R1. At 8:45 pm - Administration notified via phone call. Staff continued searching for R1 and at 10:30 pm - R1 was found seated outside the facility on a sidewalk. R1 was brought back into the building via wheelchair. Head-to-toe assessment completed; no skin injuries noted. R1 denied pain. R1 asked staff how staff knew his name and location and he stated he had never been at the facility before. R1 stated he was able to ambulate, without assistance. R1 appeared alert and oriented to people and time only.Review of the Elopement Risk assessment dated [DATE] at 5:40 pm, the facility documented the following responses on R1s assessment form: Does the Resident have a history of elopement or elopement while at home, facility documented - No. Does the Resident have a history of elopement or attempted leaving the facility without informing staff, Facility documented- No. Does the Resident wonder - facility documented- No.An interview on 10/8/2025 at 9:51 am with the Maintenance Director (MD) EE revealed R1 exited the building through the side door located on North Hall. He stated the alarm bell sounded and Registered Nurse (RN) DD turned the alarm off. RN EE revealed staff did not follow facility protocol. He expected staff to conduct a thorough search and account for all residents. RN EE stated on 10/1/2025 at approximately 10:30 pm, staff notified him, R1 had been located.During an interview on 10/8/2025 at 10:05 am, R2 revealed he was roommates with R1. He stated, on 10/1/2025 at approximately 6:00 pm he observed R1 outside the parking lot as he arrived at the facility to be admitted . He stated he was admitted on [DATE] at approximately 6:15 pm. R2 revealed he was surprised when staff wheeled R1 into his room at approximately 10:45 pm at night. R2 concluded that he wondered why R1 had been outside for that long without supervision. An interview on 10/8/2025 at 10:39 am, RN DD revealed on 10/1/2025 she worked from 7:00 am to 7:00 pm. She stated at approximately 6:40 pm, the alarm sounded and she went out to investigate. RN DD revealed she did not observe anything, she proceeded and turned the alarm system off. She stated at the time she did not realize a resident may have triggered the alarm and exited the building. She did not investigate the cause of the alarm; it was the end of her shift and was thinking about going home. She stated she should have thoroughly searched, reported to the administrator and accounted for all the residents. She concluded she had not done elopement drills and was unaware of what she was required to do at the time.During an interview on 10/8/2025 at 10:45 am, the Director of Nursing (DON) BB revealed R1 was a new admission. She explained on 10/1/2025, R1 left his room and exited the building through the North 1 Hall exit door. She explained when the alarm sounded, and RN DD looked and did not observe anything, and she turned the alarm off. According to the DON, RN DD thought everything was okay and went home after her shift ended. The DON further explained R1 was ambulatory. The DON stated staff should have conducted a head count and account for all the residents. The DON concluded staff did not follow facility policy and procedure.During an interview on 10/8/2025 at 11:59 am with the Administrator revealed on 10/1/2025 at approximately 8:20 pm, staff reported R1 was missing. She told staff to look everywhere inside and outside the building. The Administrator explained that facility staff were under the impression R1 was unable to walk and concentrated on searching the inside of the facility. The Administrator explained at approximately 10:15 pm that the facility owner located R1. The Administrator stated she attempted to call law enforcement and was on hold for 40 minutes and eventually hung up without making a police report.During an interview on 10/8/2025 at 12:45 pm, the Social Services Director (SSD) II revealed elopement assessments were due at admission. She stated she visited R1 the night after the incident occurred. She stated R1 could not recall he had exited the facility and was not aware of the date and time. She stated R1s family requested R1 to be transferred. During an interview on 10/8/2025 at 3:37 pm, the Cooperate Owner (CO) FF revealed he was in the area when the Administrator reported R1 was missing. He stated he drove around the facility and located R1 a quarter of a mile away from the facility at approximately 10:15 pm. He stated R1 was seated on the curbside of a road. Corporate Owner FF was unaware if local law enforcement were notified. Review of a written statement signed and dated 10/9/2025, CNA QQ documented she recalled she observed R1 on 10/1/2025 at approximately 7:00 pm, when the morning shift was leaving for the day. CNA QQ documented she asked if R1 was a visitor and staff stated R1 was a Resident. CNA QQ further documented she asked R1 if he needed anything and R1 stated he was okay. At approximately 8:40 pm, CNA QQ checked R1s room and was unable to locate him. CNA QQ informed the nurse and another CNA, and they started looking for R1. CNA QQ proceeded outside the building and searched the nearby apartments and was unable to locate R1, she returned to the facility after 10:00 pm and was informed R1 had been located. During an interview on 10/9/2025 at 9:12 am, CNA JJ revealed she worked on the Rehabilitation Unit. She stated she had not done training regarding elopement drills and explained the facility talked about elopement training on 10/2/2025. She explained prior to that the facility had not done any elopement drills or training.During an interview on 10/9/2025 at 9:55 am, RN OO explained that the facility had not done elopement drills and stated RN DD did not investigate the cause of the alarm as required and stated that a head count should have been completed and staff should have completed rounds and made sure all residents were accounted for.During an interview on 10/9/2025 at 10:55 am, the Administrator revealed she was the only one with access regarding video camera reviews. She said she did not review the video camera because she was too busy.During an interview on 10/9/2025 at 11:55 am, R1s Resident Representative (RR) revealed a facility nurse called her on 10/1/2025 between 7:00 pm - 8:00 pm and stated R1, her father, was missing. RR stated that staff told her the police had been notified. She stated facility staff later called her and informed her that R1 was located inside the building and explained to her that R1 never left the building. RR stated R1 had attempted to leave the hospital without medical advice and explained he had wandering tendencies. She stated facility staff did not ask the family if R1 had elopement tendencies prior to his admission.During an interview on 10/9/2025 at 12:29 pm, the Administrator revealed she did not notify the State since R1 was not harmed. The Administrator stated she started the inservice at night on 10/1/2025 and placed a wander guard on R1. She concluded the facility was unaware R1 had exit seeking behaviors and concluded staff did not go through R1s history and physical prior to admission and stated mistakes were made.

Based on observations, staff interviews, record review, and review of the facility policy titled, Elopements and Wandering Residents, the facility failed to report elopement within two hours to law enforcement and the State Agency for one of four sampled residents (R) (R1). Findings include:Review of the undated facility policy titled Elopements and Wandering Residents documented under Policy: This facility ensures that Residents who exhibit and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with the Resident Centered Care Plan addressing the unique factors contributing to wandering or elopement risk. Under Policy Explanation and Compliance Guidelines: 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.4. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.d. Adequate supervision will be provided to help prevent accidents or elopements. 5. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between facility and the police department. g. Appropriate reporting requirements to the State Survey agency should be conducted.Review of R1's face sheet showed R1 was admitted with diagnoses of but not limited to cerebral infarction, end stage renal disease, cognitive communication deficit, unspecified dementia, and psychotic mood disturbance.Review of R1s admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated R1 had severe cognitive impairment.Review of R1's Comprehensive Care Plan (CCP) Initiated on 10/1/2025 documented R1 was at risk for wandering looking for his home. R1 was disoriented to place, had impaired safety awareness and wandered aimlessly. Care plan directed staff to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books.During an interview on 10/8/2025 at 11:59 am with the Administrator revealed on 10/1/2025 at approximately 8:20 pm, staff reported R1 was missing. She told staff to look everywhere inside and outside the building. The Administrator explained that facility staff were under the impression R1 was unable to walk and concentrated on searching the inside of the facility. The Administrator explained at approximately 10:15 pm that the facility owner located R1. The Administrator stated she attempted to call law enforcement and was on hold for 40 minutes and eventually hung up without making a police report.During an interview on 10/9/2025 at 12:29 pm, the Administrator revealed she did not notify the State Agency since R1 was not harmed.

Based on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from debris and failed to ensure the lids of two of two garbage disposals were kept close when not in use to prevent pest and rodents. Findings include:A review of the facility's policy titled Disposal of Garbage Refuse revised October 2024 documented under Policy Explanation and Compliance Guidelines: .6.Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attraction are minimized.During the initial tour of the kitchen, accompanied by the Dietary Manager on 9/9/2025 at 8:54 am, it was revealed that there were two garbage dumpsters outside of the facility. Two of two garbage dumpsters had the left open while not in use. Further observation of the areas surrounding the garbage dumpster revealed food particles, trash, and debris on the ground surrounded by flies. Some of these items on the ground included milk cartons, food particles, and plastic cups,During an interview on 9/9/2025 at 8:55 am, the Dietary Manager stated the trash on the ground is likely due to the dumpster being picked up. After closer inspection of the dumpsters, they revealed their dumpsters had not been picked up as the dumpster was approximal two thirds filled.In an Interview 9/9/2025 at 8:55 am, the Dietary Manager revealed the staff should have closed the lids to the garbage after every use. The Dietary Manager continued that housekeeping was responsible for keeping the area surrounding the dumpsters clean.

Based on observations, resident and staff interviews, and review of the facility policy's titled, Safe and Comfortable Environment and Environmental Services Inspection, the facility failed to make necessary repairs as needed to maintain a homelike environment in rooms for nine of 64 sampled residents (R) (R39, R178, R47, R5, R65, R84, R93, R115 and R185) in a timely manner.Findings include: Review of the facility policy titled Safe and Comfortable Environment dated August 2023 documented under Policy: In accordance with Residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the Resident to use his or her personal belongings to the extent possible. This included ensuring that the Residents can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes Resident independence and does not pose a safety risk. The policy documented under Definitions: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the Residents' rooms, bathrooms, hallways, dining areas, lobbies, outdoor patio, therapy areas and activity areas. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the Resident to use those personal belongings that support a homelike environment. A determination of homelike should include the Resident's opinion of the living. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, completion of activities of daily living. The facility will report any unresolved environmental concerns to the Administrator. Review of the facility policy titled Environmental Services Inspection dated August 2023 and last revised October 2024 documented under Policy: the facility will regularly monitor environmental services to ensure the facility was maintained in a safe and sanitary manner on regularly basis. Facility environmental services will perform random and routine inspections, and all opportunities will be corrected immediately. 1. Review of R189s admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, indicating no cognitive impairment. Review of the grievance log dated 8/18/2024, R189 voiced concern that her room smelled like mold. The Maintenance Director (MD) checked the room and verified evidence of mold was present in the room and R189 was offered a room change. Review of R84s quarterly MDS assessment dated [DATE] documented a BIMS score of 14/15, indicating no cognitive impairment. During observation and interview on 9/9/2025 at 1:04 pm revealed R84s wall was scraped with visible dents marked with lines across the wall. R84's headboard concealed a large brown board attached to the wall with uneven patches of the dry wall. Large brown spots on the roof showed evidence the roof leaked in some parts of the ceiling. R84 stated the room was the same way when she first occupied the room. She revealed staff were supposed to complete the renovation in her room and stated she was not sure how much longer it was going to take the facility to fix and repair the wall. She stated there was a hole behind the wall and staff placed the brown board behind her headboard to conceal the hole. She stated her room needed to be fully remodeled. During an interview on 9/10/2025 at 2:30 pm, Registered Nurse (RN) CC revealed she had been working at the facility for over a month and stated Resident 84's room appeared unfinished and had been that way since she starting working at the facility. During an interview on 9/11/2025 at 12:05 pm, Administrator AA stated renovations had been going on for eight months and she stated R84s room would be updated and renovated as soon as possible. She stated the facility was currently updating and renovating the entire building. During an interview on 9/11/2025 at 12:10 pm, Corporate Officer FF stated the facility was working towards speeding up the renovations around the facility. During an interview on 9/15/2025 at 8:26 am, Maintenance Coordinator DD revealed the renovation had been going on for over a year. He revealed R84's room was not completely done; he explained the room will be updated as soon as possible. Maintainance Coordinator DD stated the facility had been renovating two rooms at a time. He revealed the facility replaced the entire roof and the leaks stopped. He stated mold was identified in certain rooms during the renovating process. The Maintenance Coordinator concluded it would take a while before all the rooms were completed. 2. An observation of Resident Room N-132 on 9/9/2025 at 11:30 am revealed the bathroom tile was rusted and soiled at the base of the wall. A ceiling tile at the entrance of the room was stained brown and yellow. The wall across from both beds was missing paint in several areas and had multiple holes in the wall. Both R56 and R178 were in the room sleeping at the time of the observation. An observation of Resident Room S-206 on 9/9/2025 at 11:35 am revealed an alcohol swab that was soiled red on the floor beside bed B. The floor had brown liquid spilled on it in several areas. The wall across from both beds was discolored black with multiple areas of missing paint and chunks of the wall. R34, who resided in the room, was at an activity at the time of the observation. An observation and interview of Resident Room S-209, R65's room, on 9/9/2025 at 11:41 am revealed the wall beside the window had a black substance and was cracked. The electrical receptacle beside bed B had a cover that was cracked and half missing. The ceiling tile above bed B was stained brown and yellow. The toilet seat was stained brown. R65 was in the room at the time of the observation. R65 revealed his room needed some updating and cleaning. An interview with the Director of Nursing (DON) on 9/9/2025 at 11:50 pm revealed she would have the rooms cleaned immediately. The DON stated, The rooms are being remodeled soon. 3. During an observation on 9/9/2025 at 2:29 pm, R132's over bed table was missing the trim on the sides and the particle board was visible on the long side of the table. During an observation on 9/15/2025 at 9:25 am, all four sides of R132's over bed table were missing the trim, and the particle board was exposed. During an interview on 9/15/2025 at 9:28 am, Certified Nursing Assistant (CNA) EE verified R132s overbed table was missing the trim and the particle board was exposed on all four sides. CNA EE said she didn't know how long it had been that way. During an interview on 9/15/2025 at 9:30 am, the South Registered Nurse Unit Manager verified said she didn't know how long the overbed table had four exposed sides and said she did not know how long the overbed table had exposed sides and said R132 could get hurt on the overbed table. During an interview on 9/15/2025 at 9:33 am, the DON verified R132s overbed table was in disrepair with all four sides missing the trim with exposed particle board. The DON said there was a maintenance system in place to check the overbed tables, but she did not know what it was. During an interview with the Maintenance Director on 9/15/2025 at 10:01 am revealed there was no process for checking overbed tables. He only checked overbed tables when they got a new admission or if they were remodeling a new room. The Maintenance Director said with all the sides of the overbed table with exposed particle board, R132 could get their arms cut and splinters.

Based on observations, staff interviews, record review, and review of the facility policy titled, Restraint Free Environment, the facility failed to provide freedom from restraints for one of five residents reviewed who used a Geri chair (a large, padded chair that is designed to help residents with limited mobility) out of 26 residents in the sample (Resident (R) 47).Findings include:Review of the facility policy titled Restraint Free Environment implemented August 2023, revealed under Policy: It is the policy of this facility that each resident shall attain or maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Medical Symptom refers to any indication or characteristic of a physical or psychological condition. Placing a resident in a chair that prevents the resident from rising independently. Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed. Under Compliance Guidelines: .2. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint.Review of the electronic medical record (EMR) revealed R47 was admitted with pertinent diagnosis including aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, history of falling, traumatic cerebral edema without loss of consciousness, focal traumatic brain injury without loss of consciousness, encephalopathy, and cerebrovascular disease.Review of the annual Minimum Data Set (MDS) assessment completed on 7/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R47 had no behaviors, and no falls since admission/entry or reentry or the prior assessment. Section (Restraints and Alarms) was coded as none, chair prevents rising- not used. Section GG (Functional Abilities and Goals) revealed R47 had impairment in his upper extremity range of motion (ROM) on one side. R47 was coded as does not use a wheelchair. The MDS was coded as R47 needs partial to moderate assistance for sit to stand. The functional assessment was coded as uses a manual wheelchair or scooter.Review of the care plan for R47 included the following: At risk for falls due to mobility and cognitive impairments with a fall on 6/29/2024, fall on 7/3/2024 and a fall on 2/2/2025.[R47] has behaviors and is non-compliant with using the call light, utilizing wheelchair, sits & crawls on floor in room, and is not easily redirected at times.Review of the Physician's orders revealed there was no order for a Geri chair. Review of the care plans revealed the use of a Geri chair was not included. The care plan did include the use of a wheelchair.Review of Physical Therapy Discharge Summary notes revealed dates of service were 4/2/2025 to 6/27/2025. [R47] was seen for seven day(s) during the 5/30/2025 - 6/27/2025 progress period. Patient will perform Supine to Sit with CGA (contact guard assistance)- Supine to sit up in bed requires Minimal/CGA (contact guard assistance) of one with 75% (percent) verbal cues and encouragement to follow through most of time. [R47] discontinued physical therapy on 6/27/2025 with the goal that [R47] will ambulate 25 feet with rolling walker including two turns with minimal assistance. Long term goal was [R47] will ambulate 150 feet with rolling walker including two turns with minimum to moderate assistance.During an observation on 9/9/2025 at 9:50 am, the South Unit Manager (UM) pointed out R47, who was seated at the nurse's station in a Geri chair with his feet elevated and the left side of the Geri chair was pushed against the wall. During an observation on 9/10/2025 at 2:00 pm, R47 was sitting at the nurses' station, reclined in a Geri chair with the left side of the Geri chair against the wall, trying to get out of chair using his arms to pull up on the arm rests. The footrest was extended preventing R47 from getting out of the Geri chair. During observations on 9/11/2025 at 8:53 am and at 10:37 am, R47 was still in bed. During an observation on 9/15/2025 at 9:25 am, R47 was observed at the nurse's station in a Geri chair with his feet elevated. The left side of Geri chair was placed against the wall. During an observation on 9/15/2025 at 10:20 am, R47 was across from the nurses' station with his eyes open and seated in a reclined Geri chair with the footrests up. The left side of the Geri chair was placed against the wall. During an observation on 9/16/2025 at 10:52 am, R47 was still in bed. During an interview on 9/9/2025 at 9:50 am, South UM said R47 was in a Geri chair because he falls.During an interview on 9/15/2025 at 10:23 am, Certified Nursing Assistant (CNA) HH said, [R47] has been in a Geri chair for a couple of months now. He used to be in a wheelchair, but he tends to stand up and fall. During an interview on 9/15/2025 at 10:25 am, Licensed Practical Nurse (LPN) II said R47 had an order for the Geri chair and looked through R47's physician orders but could not find an order for the Geri chair. During an interview on 9/15/2025 at 10:30 am, the Director of Rehabilitation said, When [R47] was discharged from therapy, he was using a high-backed wheelchair. I don't know why he's in a Geri chair now.During an interview on 9/15/2025 at 10:32 am, the Director of Nurses (DON) stated, I do not need an order to have a resident in a Geri chair with his feet up. Therapy evaluates residents and leaves the appropriate chair in the room for the CNAs to use. During an interview on 9/16/2025 at 9:31 am, the DON revealed they updated care plans for falls, wounds, change in function and behaviors, ADL (activities of daily living) care changes, ADL care needs, and therapy details were put on their own plan of care.During an interview on 9/16/2025 at 10:31 am, the DON said, A Geri chair is not a restraint.During an interview on 9/16/2025 at 10:37 am, the Registered Nurse (RN) Minimum Data Set Coordinator (MDS) said, Usually [R47 is in a high back wheelchair. If he uses a Geri chair, it should be on the care plan. We use Geri chairs for residents with no trunk control or if he is not in a high back wheelchair. [R47] should be in a wheelchair, needs extensive to minimal assistance required with transfers. He is definitely a fall risk; He can walk 10 feet with assistance. The MDS Coordinator revealed the last MDS dated [DATE] indicated [R47] did not use a cane, wheelchair, or walker, then later in the MDS it was coded that he was dependent in a wheelchair. The MDS Coordinator revealed it was a MDS coding mistake in data entry. The MDS Coordinator revealed transfer abilities and fall risks were not on the care plan [for R47]. He's sitting in a Geri chair instead. [R47] behavior care plan includes: uses a wheelchair and sits and crawls on the floor. There is nothing in the care plan about the use of a Geri chair. We should update the care plans as things change, like the use of a Geri chair.During an interview with the Director of Rehabilitation on 9/16/2025 at 10:49 am revealed R47 could get out of any chair, but he cannot get out of the Geri chair on command because he had dementia.

Based on record review, staff interview, and a review of the facility policy titled, Baseline Care Plan, the facility failed to fully develop and implement a baseline care plan within 48 hours of admission for one of 64 sampled residents (R) (R 178).Findings include:Review of the facility policy titled Baseline Care Plan dated 12/2/2022 revealed under Policy Explanation and Guidelines: 1. The baseline care plan will: a. Be developed with 48 hours of admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: .ii. Physician orders.Review of the electronic medical record (EMR) revealed R178 was admitted to the facility with diagnoses including but not limited to metabolic encephalopathy, urinary tract infection, anemia, dementia with unspecified severity with agitation, adjustment disorder with mixed anxiety and depressed mood, and personal history of suicidal behaviors.Review of the admission Physician's orders for R178 revealed an order for Quetiapine Fumarate (an antipsychotic-psychotropic medication) 25 milligrams to be given at bedtime upon admission to help with behaviors.Review of R178's baseline care plan revealed the baseline care plan was not completed until 9/9/2025. The baseline care plan did not include the use of psychotropic medications.An interview with the Director of Nursing (DON) on 9/16/2025 at 9:15 am revealed the baseline care plan for R178 was not completed within 48 hours of admission. The DON also verified R178 was taking psychotropic medication at the time of admission and should have been included in the baseline care plan.

Based on observations, staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to update/revise the care plan for three of 64 sampled residents (R) (R47, R113, and R4). This failure had the potential to result in nursing personnel providing inaccurate or inappropriate care for R47, R113, and R4.Findings include:Review of the facility policy titled Comprehensive Care Plans implemented March 2023, revised March 2023 revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the last annual Minimum Data Set (MDS) completed on 7/3/2025 revealed in Section P (Restraints and Alarms) was coded as none, chair prevents rising- not used. R47 was coded as does not use a wheelchair.Review of the care plans for R47 revealed the use of a Geri chair was not included. The care plan did include the use of a wheelchair.During an interview on 9/16/2025 at 10:37 am, the Registered Nurse (RN) Minimum Data Set Coordinator (MDS) said Usually [R47 is in a high back wheelchair. If he uses a Geri chair, it should be on the care plan. The MDS Coordinator said the last MDS dated [DATE] indicated [R47] did not use a cane, wheelchair, or walker, then later in the MDS it was coded that he was dependent in a wheelchair. The MDS Coordinator said it was a MDS coding mistake in data entry. The MDS Coordinator said transfer abilities and fall risks were not on the care plan [for R47]. He's sitting in a Geri chair instead. [R47] behavior care plan includes uses a wheelchair and sits and crawls on the floor. There is nothing in the care plan about the use of a Geri chair. We should update the care plans as things change, like the use of a Geri chair.2. Review of R113's care plan, with a revision date of 9/9/2025 did not document R113 was receiving rehabilitation services.During an interview on 9/15/2025 at 3:05 pm, MDS Coordinator, RN revealed R113 had Medicaid part B insurance, as such the MDS team did not get notification when the resident was on rehabilitation services. The MDS Coordinator RN continued that if there were any PT/OT (physical therapy/occupational therapy) services documented for the residents, it would be under the ADL (activities of daily living) section of the care plan. The MDS Coordinator RN confirmed there was nothing in R113's care plan for PT/OT.3. Review of R4's care plan, with a revision date of 9/10/2025, did not document R4 was receiving wound treatments.During an interview on 9/15/2025 at 3:05 pm, the MDS Coordinator RN confirmed that R4's wound care management was not captured on the care plan.In an interview on 9/16/2025 at 9:31 am, the DON revealed wound care should be captured on the care plan for R4.

Based on staff interview and review of the PBJ (Payroll Based Journal) Staffing Data Report, [NAME] Report 1705D for the First Quarter (Q1) of fiscal year 2024 (October 1-December 31), the facility failed to report accurate nurse staffing data to the Centers for Medicare and Medicaid (CMS) related to nursing staff coverage. The facility census was 113 residents. Findings include: Review of the PBJ Staffing Data Report, [NAME] Report 1750D for Q1 2024 (October 1 through December 31), revealed a One-Star Staffing rating indicating the facility failed to submit accurate and/or timely nurse staffing data to CMS. Interview on 6/5/2024 at 1:00 pm with the Administrator revealed she was not aware of the PBJ One-Star rating for Q1 2024. She stated since the new owners took over approximately last summer, they have made a concerted effort to increase the number of nursing staff, specifically registered nurses (RNs) and certified nursing assistants (CNAs) and have also added Certified Medication Aides (CMAs). She stated they have made other significant investments into the facility; however, sufficient and competent nurse staffing was a high priority.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for one of five residents (R) R50 related to the removal of facial hair. The sample size was 45 residents. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL's) dated 11/1/2023 under the section titled Policy revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Number one, Bathing, dressing, grooming, and oral care . Under the section titled Policy explanation and Compliance Guidelines, revealed Number three A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R50's Electronic Medical Record (EMR) revealed was admitted to the facility with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, ataxia, contracture of left hand, and lack of coordination. Review of R50's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated R50 was cognitively intact. Section GG (Functional Abilities and Goals) revealed that R50 required substantial/maximum assistance with personal hygiene which included the ability to comb hair, shave, apply makeup, wash/dry face and hands. Review of R50's care plan under Focus revealed, R50 required assistance with ADL's related to left sided hemiplegia, ataxia, contracture of left hand with the date initiated on 9/20/2021 and revision date of 9/27/2021. Under Goal revealed R50 will have ADL needs met daily with appropriate assistance, the date initiated was 9/20/2021 and last reviewed 6/2/2024. Under Interventions included but not limited to R50 needs (total) with one assist for personal hygiene, date initiated was 9/2021 and revised on 10/6/2021; staff to implement were listed as Certified Nursing Assistants (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN). Review of R50's ADL-Bathing task sheet from April 2024 and May 2024 revealed there was no documentation related to the removal or presence of facial hair. Observation and interview on 6/2/2024 at 2:35 pm, with R50 who was observed with long facial hair located on her chin. She acknowledged she had hair on her chin and stated she used to cut it with scissors but no longer had a pair of scissors. She revealed that staff had not removed or offered to shave the hair from her chin. She stated that the facial hair did not bother her, but she would like it to be removed. Observation and interview on 6/4/2024 at 8:57 am and at 1:45 pm, with R50 who was observed sitting up in a wheelchair continued to have long facial hair located on her chin. She stated the CNA's did offer showers or bed baths but did not offer to remove the facial hair from her chin. Observation and interview on 6/4/2024 at 1:55 pm LPN AA confirmed and verified R50 had facial hair located on her chin. She stated the facial hair should have been removed during AM (morning) care and proceeded to ask R50 how she would like for her to remove the facial hair from her chin and R50 responded, could just cut it with a pair of scissors. Interview on 6/4/2024 at 1:50 pm with LPN AA revealed that staff perform ADL rounds every morning before breakfast. She stated that facial hair should be removed for both male and female residents with their permission. She stated this should be written on the bath sheet when it is completed. She revealed that residents who need to be shaved are usually shaved on Sundays. She stated she shaves the male residents on the South Unit each week. She stated if a female resident has facial hair, then she would remove the facial hair either by shaving or plucking the hair out whichever the resident prefers. Interview on 6/4/2024 at 1:50 pm with the Director of Nursing (DON), she confirmed R50 had facial hair and she stated her expectations of staff was to remove facial hair while performing ADL care.

Based on observations, staff interviews, record review, and review of the facility's policy titled Accidents and Supervision, the facility failed to ensure hazardous chemicals were safely secured for two of three residents (R) (R6 and R21) reviewed for accidents. This deficient practice placed residents at risk for avoidable chemical incidents, injuries, and a diminished quality of life. The sample size was 45 residents. Findings include: Review of the facility's policy titled Accident and Supervision, undated, under the Policy Explanation and Compliance Guidelines: revealed, Number One (a) All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. Number One (b)The facility should make a reasonable effort to identify the hazards and risk factors for each resident. 1. Review of R6's Electronic Health Record (EHR) revealed the resident had diagnoses that included carpal tunnel, contracture of the left hand and wrist, and cerebral infarction. Review of R6's Annual Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition; Section E (Behaviors) revealed the resident did not exhibit any behavioral symptoms during the assessment period and Section GG (Functional Abilities and Goals) revealed the resident required the use of a wheelchair. Review of the Safety Data Sheet for [Name] ant and roach killer spray revealed the following: Number One, Hazard Identification: Causes serious eye damage, may cause an allergic skin reaction. Observations on 6/2/2024 at 2:30 pm, on 6/3/2024 at 11:39 am and on 6/4/2024 at 11:06 am of R6's room revealed one can of [Name] ant and roach killer spray inside a box placed in front of the Packaged Terminal Air Conditioner (PTAC) unit. 2. Review of R21's EHR revealed, the resident had diagnoses that included major mood disorder, contracture of the left hand and wrist, and anxiety. Review of R21's Annual MDS dated [DATE] revealed Section C (Cognitive Patterns), a BIMS score of 15 which indicated intact cognition. Section E (Behaviors) revealed the resident did not exhibit any behavioral symptoms during the assessment period and Section GG (Functional Abilities and Goals) revealed the resident required the use of a wheelchair. Review of the Safety Data Sheet for [Name] disinfectant spray revealed the following: Number One, Hazard Identification: Causes serious eye irritation, causes skin irritation. Observations on 6/3/2024 at 10:56 am, on 6/4/2024 at 10:17 am, and 6/4/2024 at 11:25 am of R21's room revealed, a can of [Name] disinfectant spray sitting on the resident's dresser. Observations and Interviews on 6/4/2024 at 11:25 am with the Administrator and the Director of Nursing (DON) confirmed and verified there was a can of [Name] ant and roach killer spray in a box placed in front of the PTAC unit in R6's room and a can of [Name] disinfectant spray on R21's dresser next to her bed. Interview with the Administrator and DON revealed staff complete room sweeps and that the Certified Nursing Assistants (CNA) were in the resident rooms' multiple times a day. The DON stated her expectation was that all staff complete room sweeps while in the resident rooms and that CNAs should report to the nurse any finding of chemicals in any residents' room. She revealed she expected the nurse to remove any chemicals found in a resident room, call the resident representative, and allow them to choose to pick up the item or allow the staff to discard the item found.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Accident and Supervision, Medication Storage, and Resident Self-Administration of Medication, the facility failed to store one bottle of over the counter (OTC) liquid indigestion medication in a locked medication storage area for one of 45 sampled residents (R) (R50). The deficient practice had the potential to place the resident at risk for medical complications, unauthorized persons access to medications, and a diminished quality of life. Findings include: Review of the facility's policy titled Accident and Supervision copyright date of 2023, under the section titled Policy revealed, The resident environment will remain as free of accident hazards as possible. Under the section titled Policy Explanation and Compliance Guidelines revealed, Number one (a) All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. Review of the facility's policy titled Medication Storage dated 8/1/2023, under the section titled Policy revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the section titled Policy Explanation and Compliance Guidelines revealed, Number one General Guidelines: (a) All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . (c) During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of the facility's policy titled Resident Self-Administration of Medication copyright date of 2023 under the section titled Policy revealed, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely. Under the section titled Policy Explanation and Compliance Guidelines revealed, Number eight All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. Review of R50's Electronic Medical Record (EMR) revealed R50's was admitted to the facility with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, ataxia, contracture of left hand, and lack of coordination. Review of R50's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 13, which indicated R50 was cognitively intact. Section GG (Functional Abilities and Goals) revealed, R50 required substantial/maximal assistance for activities of daily living (ADLs). Review of R50's care plan revealed R50 did not have a focus area related to self-administration of medications. Review of R50's physician's orders revealed there were no orders for OTC [Name] liquid indigestion medication nor were there orders to self-administer any medications. Review of R50's EMR revealed there was no evidence of a nursing assessment for self-administration of medication had been completed or located. Observations and interview on 6/2/2024 at 1:29 pm with R50 revealed one bottle of OTC [Name] liquid indigestion medication sitting on R50's nightstand. R50 revealed the medication did not belong to her. Observation on 6/4/2024 at 8:47 am R50's room revealed one bottle of OTC [Name] liquid indigestion medication sitting on R50's nightstand. During an observational round on 6/4/2024 at 11:15 am with the Director of Nursing (DON) and the Administrator revealed one bottle of OTC [Name] liquid indigestion medication sitting on R50's nightstand. They both confirmed the OTC [Name] liquid indigestion medication was sitting on R50's nightstand beside her bed. Interview on 6/4/2024 at 11:25 am with the DON and the Administrator revealed that they do not encourage residents to self-administer medications. The DON in the presence of the Administrator stated if a resident were persistent and wants to self-administer medications, they would first meet with the physician, and educate the resident of the pro/cons of self-administration of a medication. The DON stated if the physician agreed and the resident met all requirements, the facility would then provide a lock box to be kept in the resident's room. She stated the resident must be able to demonstrate how to open, lock/unlock the box, and self-administer the medication. She revealed the care plan would be updated to reflect the resident could self-administer medications and what medications they could self-administer. She confirmed that R50 was not allowed to self-administer medications and the care plan did not reflect R50 had been assessed to self-administer medications. The DON confirmed there was no physician order for OTC [Name] liquid indigestion medication. She stated her expectation of staff was that during everyday care of residents the CNA's should observe the resident rooms each time they enter and notify the nurse when medications are found in the room un-secured. She stated the nurses are expected to remove unsecured medications from resident's rooms and call the resident representative/family to determine how they (the family) would like for the staff to proceed whether the family pick up the medication or staff to discard the medication. She further stated the nurse should also notify the physician of medications found at the residents' bedside. She further stated the nurse should also notify the physician of the possibility of the resident taking the medication and the pharmacy would review the resident's medications for possible adverse interactions as well as staff monitoring the resident for any symptoms of adverse reactions/interactions. She stated this practice could result in a resident taking a medication that may adversely interact with their prescribed medications and/or even overdose on a medication.

Based on observations, record review, resident and staff interview, review of the facility's Admission Agreement and Employee Handbook and review of the policy titled Smoking Policy, the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff, by failing to enforce the facility's No Smoking Property guidelines in an area that has an active propane tank. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. The census was 118 residents. On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/18/2023 at 3:46 pm, the facility's Administrator was informed of a second Immediate Jeopardy (IJ). The individuals in attendance were the Director of Nursing (DON), Facility Owner and Operator and [NAME] President of Clinical Services. The noncompliance related to the Immediate Jeopardy was identified when Certified Nursing Assistant DD, Housekeeper EE and R1 were observed smoking on the facility's property at different times in the same area. A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the undated policy titled Smoking Policy revealed the purpose is to facilitate the health and safety of our residents, this facility is a no smoking facility. The policy is to ensure compliance with regulatory guidelines and safety protocols, the facility prohibits smoking in its facility. Procedure: 1. Residents: a. Each resident should be individually assessed and notified as to the facility's policy. d. Residents or staff may not provide other residents with cigarettes and may not light a cigarette for another resident. II. Designated areas: a. outdoor areas may be designated as smoking areas. c. designated areas will have signage to indicate that smoking is allowed; easy access to fire extinguishers; ash trays on noncombustible material in sufficient numbers; metal containers with self-closing cover devices into which ashtrays can be emptied shall be available to all areas where smoking is permitted. Review of the facility's Admission Agreement section titled Smoke Free Facility documented it is the policy of this facility to provide a safe and healthy environment for residents, visitors and employees. The facility has a facility-wide Smoke Free Facility Policy. Policy Explanation and Guidelines: 1. Residents who are admitted to the facility will be notified of this policy during the admission process and as needed. 2. Family members will be informed during the admission process and as needed, of the policy prohibiting smoking. Further review of the signed Admission Agreement revealed that R1 and her responsible party acknowledged the policy by signing and dating the agreement on 4/18/2023. Housekeeper EE was not indicated as R1's responsible party. Review of the facility's undated Employee Handbook section titled Smoking and Use of Tobacco documented the objective of providing the highest quality resident care requires that we maintain a clean, odor free, and healthy environment for our residents and their families and guests. As a result, smoking is not allowed in the Community. Employees may smoke, vapor, or use tobacco only in outdoor areas designated by their Administrator, and only during authorized break periods. During further review of the Tobacco-Free Workplace Policy Acknowledgement from the Employee Handbook revealed that Housekeeper EE signed the document on 3/1/2023. Observation on 10/10/2023 at 9:00 am upon initial entrance to the facility revealed signage on front door indicating This is a tobacco free facility and No smoking. This is a smoke free property and No smoking. Medical gases in use. Observation on 10/12/2023 at 2:20 pm, Certified Nursing Assistant (CNA) DD was observed outside on the facility property talking on the phone. She was standing across from a fenced structure that has an unmarked cylindrical tank. There was a sign attached to the wooden fence that indicated No Smoking. This is a Smoke Free Property. The area surrounding the wooden fence and cylindrical tank was overgrown with kudzu. During continued observation, CNA DD was observed lighting a cigarette and began to smoke while standing in a grassy area of overgrown kudzu, right behind a metal sign that indicated, Please Park on the Grass. Thank you. Observation on 10/12/2023 at 2:27 pm, CNA DD was observed putting out the cigarette on the back of the sign that indicated, Please Park on the Grass. Thank you, before walking back into the facility. On 10/12/2023 at 2:50 pm, Housekeeper EE and R1 were observed smoking in the facility parking overflow area. Resident 1 was seated in a wheelchair and Housekeeper EE was standing next to her, on R1's left side. There were dried leaves and brush were under and around where they were observed to be smoking. Resident 1 and Housekeeper EE were using a white cup sitting on the ground as an ashtray. Observation on 10/12/2023 at 3:00 pm revealed there was no evidence of approved smoking receptacles, fire extinguishers, or fire blankets located in the area where R1, Housekeeper EE and CNA DD were observed smoking. Observation on 10/12/2023 at 4:00 pm the Maintenance Director measured the distance from the tank to sign that indicated Please Park on the Grass and two large white barrels labeled Liquid Sour Bright. The distance measured to be approximately 65 feet. The Maintenance Director stated the white barrels were empty and used to barricade the parking overflow when the area gets muddy from inclement weather. Observation on 10/13/2023 at 9:00 am revealed the two large white barrels were no longer in the area where CNA DD, Housekeeper EE and R1 were observed to be smoking at on 10/12/2034. Observation on 10/18/2023 at 9:15 am revealed the Maintenance Director measuring the distance from the edge of the paved parking area to the grassy overgrown kudzu area in which staff and R1 were observed to be smoking measured approximately nine feet. Interview on 10/12/2023 at 3:54 pm the Administrator stated the facility has always been a nonsmoking facility. When questioned about what is considered the facility property, she replied according to her knowledge, the paved areas are considered facility property, and denied the grassy vacant lot adjacent to the facility as facility property. During further interview, she stated that facility staff have been parking in that grassy area until they are told otherwise by the city. She stated her expectation is no-one is to have any smoking items on them while in the facility, and stated staff are educated about this during their orientation/onboarding and the residents are informed during the admission process. Interview on 10/12/2023 at 4:00 pm the Maintenance Director stated that the unmarked cylindrical tank contained propane that is used for the facility's emergency generator. He confirmed that the tank was active with propane in the tank. Interview on 10/18/2023 at 9:11 am the Maintenance Director stated staff were told smoking was prohibited on the property and that there were no designated smoking areas on the property. Interview on 10/18/23 at 9:45 am with Social Services Director II, confirmed the facility is a smoke free property. She stated residents and their families are informed upon admission of the facility's No Smoking policy. An attempt to interview Housekeeper EE was made on 10/25/2023 at 2:45 pm and at 6:18 pm via telephone. Both phone calls went unanswered. Voice recording indicated that the voicemail had not been set up. A Google earth search revealed that 2165 Idlewood Road and 2179 Idlewood Road, were adjacent properties. Review of the Property Appraisal with a run date of 10/19/2023 revealed the parcel number for the facility and the vacant lot parcel number are under the same property ownership. The adjacent vacant lot used by the facility for staff parking is where CNA DD, Housekeeper EE, and R1 were observed smoking. An Acceptable Removal Plan was received on 10/25/2023. The removal plan included reassessing R2, placing tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for No Smoking-Smoke Free Facility and Tracheostomy Care. Through interviews with facility staff, observation of tracheostomy supplies, observations of residents with tracheostomy's, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/20/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.

Based on observations, record review, interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Smoling Policy, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its No Smoking Policy and failed to ensure that licensed nursing staff were knowledgeable and competent to act in emergency situations for decannulation of tracheostomy tubes. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. The census was 118 residents. Specifically 1. Facility Administrator and Director of Nursing failed to perform duties of their job descriptions that facilitated medical care to the residents of the facility. 2. Administration failed to enforce No Smoking Facility/Property by allowing staff and resident (R) R1 to smoke on facility property in close proximity to an active propane tank. Cross Refer F689 3. Facility administration failed to maintain emergency tracheostomy supplies in the event of accidental dislodgement of trach tube. Cross Refer F695 4. Administration failed to ensure that nursing staff are trained and competent to care for residents admitted with special needs such as emergency care for tracheostomy tube dislodgement. Cross Refer F940 5. Facility Administration failed to develop a care plan for smoking for R1 and failed to implement care plan interventions that addressed emergency care and supplies at bedside for R2 admitted with a tracheostomy. Cross Refer F656 On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/17/2023 at time 4:30 pm, the facility's Administrator was informed of an Immediate Jeopardy (IJ) situation when an observation of R2 revealed the resident had a tracheostomy, further observation revealed no emergency trach supplies were found at the bedside. On 10/18/2023 at 3:46 pm, the facility's Administrator was informed of a second Immediate Jeopardy (IJ). The individuals in attendance were the Director of Nursing (DON), Facility Owner and Operator and [NAME] President of Clinical Services. The noncompliance related to the Immediate Jeopardy was identified when Certified Nursing Assistant DD, Housekeeper EE and R1 were observed smoking on the facility's property at different times in the same area. A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the undated document titled Administrator Job Description, signed and dated 7/5/2022 by current Administrator, indicated the position purpose is to lead, guide, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Major duties and Responsibilities include: *Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators and establishes an ongoing system to monitor key indicators through the Quality Assurance and Performance Improvement process. *Evaluates outcomes to determine the need for action from leadership and/or management such as re-education or revisions related to the outcomes. *Ensures delivery of compassionate quality care and services across an interdisciplinary team approach evidenced by adequate and competent facility staff, employee turnover, general cleanliness, physical plant conditions, and optimal resident functioning-physically and psychosocially. * Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Makes himself/herself available to employees at all levels by practicing an open-door policy. *Conducts periodic observations of in-service education to ensure staff members delivering education are competent with the knowledge and skill set required to accomplish employee learning. *Promotes safe work practices, safety rules, and accident prevention procedures to prevent injury. Review of the undated document titled Director of Nursing Job Description, signed and dated 3/2023 by current Director of Nursing, indicated the position purpose is planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal regulations, standards, and established facility policies and procedures and as may be directed by the Administrator or Medical Director, to provide appropriate care and services to the residents. Major duties and Responsibilities include: *Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. *Participates in QAPI or facility assessment activities as needed, such as carrying out duties assigned as part of a performance improvement committee. *Performs rounds to observe residents and ensure nursing needs are being met. *Conducts observations of nursing care and supervises development of in-service education to ensure nursing staff is competent in current knowledge and skills. *Promotes safe work practices, safety rules, and accident prevention procedures to prevent injury and illness. 1. Review of the undated policy titled Attachment J-Smoking Policy revealed the purpose is to facilitate the health and safety of our residents, this facility is a no smoking facility. The policy is to ensure compliance with regulatory guidelines and safety protocols, the facility prohibits smoking in its facility. Procedure: 1. Residents: a. Each resident should be individually assessed and notified as to the facility's policy. d. Residents or staff may not provide other residents with cigarettes and may not light a cigarette for another resident. II. Designated areas: a. outdoor areas may be designated as smoking areas. c. designated areas will have signage to indicate that smoking is allowed; easy access to fire extinguishers; ash trays on noncombustible material in sufficient numbers; metal containers with self-closing cover devices into which ashtrays can be emptied shall be available to all areas where smoking is permitted. 111. Responsible Party: a. The Compliance Officer is responsible for this policy. Review of the clinical record revealed R1 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, cerebral vascular accident (CVA) with left hemiparesis, seizures, depression, and diabetes. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status coded as 14, indicating no cognitive impairment. Section J revealed that R1 did not smoke. Review of smoking assessment for R1 dated 7/17/2023 activity Does resident smoke? was marked as 'no'. Review of the facility Admission Agreement entered into agreement on 4/10/2023 and signed by R1 and her responsible party on 4/18/2023, agreeing to abide by the facility's smoke free facility policy. The Administrator signed the agreement on 4/18/2023. Review of the facility Tobacco-Free Workplace Policy Acknowledgement from the employee handbook, revealed employee understands the terms of the policy and that any violations of this smoking/tobacco policy will be subject to disciplinary action. Housekeeper EE signed the acknowledgement on 3/1/2023. Observation on 10/10/2023 at 9:00 am revealed signage on front door entrance indicating This is a tobacco free facility and No smoking. This is a smoke free property and No smoking. Medical gases in use. Observation on 10/12/2023 at 2:20 pm revealed Certified Nursing Assistant (CNA) DD was observed lighting a cigarette and began to smoke in the grass and overgrown kudzu area steps away from the paved parking lot. Observation on 10/12/2023 at 2:50 pm revealed Housekeeper EE and R1 were observed smoking in the same grass/kudzu area of the facility parking lot. RI was seated in a wheelchair and Housekeeper EE was standing beside her. Interview on 10/12/2023 at 3:54 pm the Administrator confirmed the facility is a smoke free property. She defined the facility property as the paved areas and denied the ownership of the overflow grass parking lot. During further interview, the Administrator stated residents and their families are educated about the nonsmoking policy during the admission process. She stated that employees are informed about the facility's nonsmoking policy during the onboarding process. 2. Review of the policy titled Tracheostomy Care copyright 2022, indicated the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: Number 3. Tracheostomy care will be provided according to physician orders, comprehensive assessment and individualized care plan as monitoring resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an Ambu bag easily accessible for immediate emergency care. Number 5. The facility will ensure staff responsible for providing tracheostomy care, including suctioning, are trained and competent according to professional standards of practice. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, hypertension, chronic respiratory failure, and tracheostomy, Review of the quarterly MDS dated [DATE] revealed a BIMS was not coded, indicating cognitive status was unable to be determined. Section O revealed that R2 had a tracheostomy. Observation on 10/11/2023 at 1:00 pm revealed in room [ROOM NUMBER] revealed a note on the wall above R2 bed with a transparent bag hanging from the wall. The sign had the words contains obturator, tracheostomy replacement kit and Ambu bag. Do Not Remove. Surveyor observed items in the bag at this time to note there was no obturator or replacement trach tubes in the transparent bag, only an Ambu bag was in the transparent bag. There was a suction machine and suction catheter sitting on bedside nightstand. Observation on 10/11/2023 at 1:15 pm Licensed Practical Nurse (LPN) EEE arrives with resident to his room for medication administration. The surveyor asked LPN EEE to locate the emergency trach supplies to use in the event trach became dislodged. She looked on the top of the nightstand, in all drawers of the nightstand, and in the closet, and was unable to locate any emergency supplies. At this time, LPN EEE removed the transparent bag and the sign from the wall and exited residents room. Interview on 10/11/2023 at 2:15 pm the DON stated the facility has plenty of tracheostomy supplies in stock, and she would make sure the supplies were at R2 bedside. 49690

Based on observations, record review, interviews, review of facility's Employee Handbook, Admission Packet, and policy titled Smoking Policy, the facility failed to ensure that there was a policy developed outlining the procedures of a non-smoking facility and smoke free property, including the potential outcomes when individuals smoke on the facility property. Specifically, two facility staff and one resident (R) R1 were allowed to smoke on the facility property near an active propane tank. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy.The census is 118 residents. On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/18/2023 at 3:46 pm, the facility's Administrator was informed of a second Immediate Jeopardy (IJ). The individuals in attendance were the Director of Nursing (DON), Facility Owner and Operator and [NAME] President of Clinical Services. The noncompliance related to the Immediate Jeopardy was identified when Certified Nursing Assistant DD, Housekeeper EE and R1 were observed smoking on the facility's property at different times in the same area. A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the undated policy titled Attachment J-Smoking Policy revealed the purpose is to facilitate the health and safety of our residents, this facility is a no smoking facility. The policy is to ensure compliance with regulatory guidelines and safety protocols, the facility prohibits smoking in its facility. Procedure: 11. Designated Areas: a. Outdoor areas may be designated as smoking areas. Designated areas will have i. signage to indicate the smoking is allowed. There are no designated smoking areas on the property grounds. 111. Responsible Party: a. The Compliance Officer is responsible for this policy. Review of the facility's undated Admission Agreement section titled Smoke Free Facility documented it is the policy of this facility to provide a safe and healthy environment for residents, visitors and employees. The facility has a facility-wide Smoke Free Facility Policy. Policy Explanation and Guidelines: 1. Residents who are admitted to the facility will be notified of this policy during the admission process and as needed. 2. Family members will be informed during the admission process and as needed, of the policy prohibiting smoking. Review of the facility's undated Employee Handbook section titled Smoking and Use of Tobacco documented the objective of providing the highest quality resident care requires that we maintain a clean, odor free, and healthy environment for our residents and their families and guests. As a result, smoking is not allowed in the Community. Employees may smoke, vapor, or use tobacco only in outdoor areas designated by their Administrator, and only during authorized break periods. Observation on 10/12/2023 at 2:20 pm, Certified Nursing Assistant (CNA) DD was observed smoking outside on the facility property, standing across from a fenced structure that has an unmarked cylindrical tank. There was a sign attached to the wooden fence that indicated No Smoking. This is a Smoke Free Property. Observation on 10/12/2023 at 2:50 pm, Housekeeper EE and R1 were observed smoking in the same area designated as No Smoking. This is a smoke Free Property. Interview on 10/12/2023 at 3:45 pm, Administrator stated that the non-smoking policy that the facility follows is found in the facility's Admissions Agreement and the Employee handbook and confirmed that is the only smoking policy available. An Acceptable Removal Plan was received on 10/25/2023. The removal plan included reassessing R2, placing tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for No Smoking-Smoke Free Facility and Tracheostomy Care. Through interviews with facility staff, observation of tracheostomy supplies, observations of residents with tracheostomy's, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/20/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.

Based on observations, record review, resident and staff interviews, and review of the policy titled Comprehensive Care Plan, the facility failed to implement the Comprehensive person-centered care plan for one resident (R) R2 with a tracheostomy (trach) by not having emergency trach supplies at the bedside in the event of decannulation. In addition, the facility failed to develop a Comprehensive person-centered care plan for smoking for one resident, R1. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. The sample size was 33 residents. On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/17/2023 at 4:30 pm, the facility's Administrator was informed of an Immediate Jeopardy (IJ) situation when an observation of R2 revealed the resident had a tracheostomy, further observation revealed no emergency trach supplies were found at the bedside. On 10/18/2023 at 3:46 pm, the facility's Administrator was informed of a second Immediate Jeopardy (IJ). The individuals in attendance were the Director of Nursing (DON), Facility Owner and Operator and [NAME] President of Clinical Services. The noncompliance related to the Immediate Jeopardy was identified when Certified Nursing Assistant DD, Housekeeper EE and R1 were observed smoking on the facility's property at different times in the same area. The facility is a Smoke Free Facility A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the policy titled Comprehensive Care Plan revised 3/2023, indicated the policy of this facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.' 1. Review of the undated policy titled Tracheostomy Care indicated the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. General considerations include b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an Ambu bag easily accessible for immediate emergency care. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, hypertension, chronic respiratory failure, and tracheostomy, Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was not coded, indicating cognitive status was unable to be determined. Section O revealed that R2 had a tracheostomy. Observation on 10/11/2023 at 1:00 pm revealed no emergency trach supplies (trach tube, obturator, hemostats) were located at the bedside of R2. Review of care plan revised 1/26/2023 for R2 indicated the resident has a tracheostomy. Interventions for care indicated Tube Out Procedures: Keep extra trach tube and obturator at bedside. If the tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, obtain medical help immediately. Review of Progress Note dated 5/9/2023 at 7:18 pm documented R2's trach was dislodged resulting in the resident being transferred to the emergency room and then to surgery to have the trach tube replaced. Review of Progress Note dated 10/10/2023 at 6:50 am documented R2 was observed on his bed with no apparent distress. Further review indicated while attempting to administer trach care, trach noted dislodged. Continued review of the Progress Note documentation on 10/10/2023 at 8:00 am revealed trach reinserted. On 10/11/2023 at 3:05 pm, an interview with Licensed Practical Nurse (LPN) EEE stated that she was unable to locate the trach supplies for R2. She stated that she gave the bag and the sign to LPN XX who took it to the Director of Nursing (DON) to find the supplies. On 10/11/2023 at 4:00 pm, an interview with the DON stated that her expectation is that trach supplies should be available at the bedside. She stated she would make sure the supplies were at R2 bedside. 2. Review of the clinical record revealed R1 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, cerebral vascular accident (CVA) with left hemiparesis, seizures, depression, and diabetes. Review of the Admission MDS dated [DATE] revealed BIMS coded as 14, indicating no cognitive impairment. Section J revealed that R1 did not smoke. Observation on 10/10/2023 at 2:10 pm revealed No Smoking. This is a Smoke Free Property. signs near the area of an active propane tank and on the facility front entrance door. Observation on 10/12/2023 at 2:50 pm of two individuals in the facility parking lot smoking, towards the side of the building. One was seated in a wheelchair and appeared to be R1, who was accompanied by a housekeeping staff member EE. Review of R1's smoking assessment dated [DATE], revealed no to the question, does resident smoke?' Review of R1's comprehensive care plan dated 5/1/2023 did not include a smoking care plan or interventions for smoking. On 10/18/2023 at 9:45 am, an interview with Social Service Director (SSD) II related to the smoking policy, stated that the facility is a Smoke Free Property. She stated that family and residents are made aware of this policy upon admission. She stated smoking assessments are part of the nursing assessment process, and no resident would have a smoking care plan, because the facility is Smoke Free. On 10/23/2023 at 2:10 pm, an interview with MDS LPN RR stated that MDS staff complete the baseline care plans for residents within 48 to 72 hours. She stated that they would not develop a smoking care plan for residents, because the facility is smoke-free. During further interview, she stated if the resident is signed out by a family member and goes to smoke, a care plan still would not be developed. If the resident smokes on the property, the Interdisciplinary Team (IDT) meets with the resident, provides additional education, and offers to get an order for nicotine patches from the MD. She stated that if the resident declines, then she would develop a care related to non-compliance. An Acceptable Removal Plan was received on 10/25/2023. The removal plan included reassessing R2, placing tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for No Smoking-Smoke Free Facility and Tracheostomy Care. Through interviews with facility staff, observation of tracheostomy supplies, observations of residents with tracheostomy's, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/20/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.

Based on observations, record review, staff interviews, and review of the policy titled Tracheostomy Care, the facility failed to provide respiratory/tracheostomy care by trained and competent nursing staff according to professional standards, failed to develop a policy/procedure for accidental dislodgement of trach tubes, and failed to have emergency tracheostomy supplies at the bedside for one resident (R2) of three residents receiving tracheostomy care. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/17/2023 at 4:30 pm, the facility's Administrator was informed of an Immediate Jeopardy situation when an observation of R2 revealed the resident had a tracheostomy, further observation revealed no emergency trach equipment was found at the bedside. A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the policy titled Tracheostomy Care copyright 2022, indicated the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: Number 3. Tracheostomy care will be provided according to physician orders, comprehensive assessment and individualized care plan as monitoring resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an Ambu bag easily accessible for immediate emergency care. Number 5. The facility will ensure staff responsible for providing tracheostomy care, including suctioning, are trained and competent according to professional standards of practice. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, hypertension, chronic respiratory failure, and tracheostomy, Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for mental Status (BIMS) was not coded, indicating cognitive status was unable to be determined. Section O revealed that R2 had a tracheostomy. Review of care plan revised 1/26/2023 for R2 indicated the resident has a tracheostomy. Interventions for care indicated Tube Out Procedures: Keep extra trach tube and obturator at bedside. If the tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Review of Health Status Note dated 5/9/2023 at 7:18 pm revealed resident pulled out his trach. Alert and oriented. Not in any distress sating [sic] at 96%. NP (Nurse Practitioner) notified. Sent out to the ER (emergency room ). Review of hospital record dated 5/13/2023 at 10:47 am documented patient presented to the Emergency Department (ED) with stridor and dyspnea after decannulated himself. After failure to re-insert tube in the ED, patient was taken to the Operating Room (OR) for replacement of his tracheostomy tube under anesthesia. Review of clinical record revealed Order Note dated 10/7/2023 at 9:26 am documented clinical staff spoke with the Nurse Practitioner (NP) regarding R2's trach. The trach is dislodged and not completely secured by sutures, the left side is secure by sutures and the right side is not secure. Resident was experiencing expiratory wheezing. The NP ordered to send R2 to the ED for respiratory distress, expiratory wheezing, and compromised tracheostomy. Review of the clinical record revealed a Move-In Note/New/Return note dated 10/7/2023 at 8:35 pm documented R2 returned to the facility via wheelchair from the hospital after trach dislodgement, requiring stoma dilation and placement of a 4-0 cuffless trach. Review of the clinical record revealed a Behavior Note dated 10/10/2023 at 6:50 am documented upon entering the room resident observed sitting on the side of the bed, no apparent distress noted. While attempting to administer trach care, trach noted dislodged, resident has behaviors of tampering with his trach. Review of the clinical record revealed a Behavior Note dated 10/10/2023 at 8:00 am documented trach reinserted. Observation on 10/11/2023 at 1:00 pm revealed in room [ROOM NUMBER] revealed a note on the wall above R2 bed with a transparent bag hanging from the wall. The sign had the words contains obturator, tracheostomy replacement kit and Ambu bag. Do Not Remove. Surveyor observed items in the bag at this time to note there was no obturator or replacement trach tubes in the transparent bag, only an Ambu bag was in the transparent bag. There was a suction machine and suction catheter sitting on bedside nightstand. Observation on 10/11/2023 at 1:00 pm, R2 was in the hallway in his wheelchair. Licensed Practical Nurse (LPN) Charge Nurse EEE instructed R2 to return to his room so he could get his medication. Observation of the room revealed a functioning suction machine in place on top of the bedside table with tubing connected to a suction tip. Sterile suction kits were lying next to the suction machine. On the wall, to the left was a semi-transparent bag hanging from the wall next to a sign, which indicated: Contains obturator, tracheostomy replacement kit and Ambu bag (device that provides breathing assistance). DO NOT REMOVE. Observation on 10/11/2023 at 1:15 pm LPN EEE was asked to locate the emergency tracheostomy supplies to use if R2 decannulated himself. She looked on the top of the chest of drawers, looked in all drawers in the chest, and looked in drawers in the bedside table. She was unable to locate any extra trach tubes, obturator, or hemostats. Licensed Practical Nurse removed the transparent bag with the Ambu bag off the wall with the sign and took them to the Unit Manager (UM). The UM took them to the DON. The DON assured the surveyor she would place the supplies at the bedside immediately. On 10/11/2023 at approximately 2:15 pm, the Administrator and the DON stated the supplies were at R2's bedside. The DON revealed they had plenty of trach supplies in the facility. Interview on 10/11/2023 at 2:30 pm, the Staff Development Coordinator (SDC) was asked about required education for licensed nursing staff, and she stated she assures staff have education regarding resident rights, behavior issues (especially regarding dementia) and infection control and early signs of sepsis. She stated she uses power point presentations and videos to teach in-services. She was asked if she teaches staff about caring for tracheostomies, and she indicated education is provided including suctioning and dressing changes. The SDC stated she didn't teach nurses about what to do if a patient decannulates his trach tube. Review of education documents provided by the SDC revealed two binders from 2022 and 2023 containing records of staff education. In addition, she provided a list of licensed staff who had completed programs via online education source utilized by the facility. Further review revealed only one licensed nurse completed two education programs on the care of residents with tracheostomies. There was no evidence of competency checks for emergency care for trach tube dislodgement. Interview on 10/31/2023 at 9:43 am, Medical Director BBB stated the standard of practice for a resident with a tracheostomy is to have extra trach tubes, either the same size or a size smaller, should be at the bedside for emergency care if the trach becomes dislodged. An Acceptable Removal Plan was received on 10/25/2023. The removal plan included reassessing R2, placing tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for No Smoking-Smoke Free Facility and Tracheostomy Care. Through interviews with facility staff, observation of tracheostomy supplies, observations of residents with tracheostomy's, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/20/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.

Based on record review, staff interviews, and review of the job description for the Director of Nursing, the facility failed to ensure clinical staff were trained and competent to provide emergency care for accidental trach dislodgement for one of three residents (R) R2 reviewed for tracheotomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance resulted in R2 trach becoming dislodged, and R2 required surgical intervention to reinsert tracheostomy tube. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. On 10/17/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 10/17/2023 at 4:30 pm, the facility's Administrator was informed of an Immediate Jeopardy situation when an observation of R2 revealed the resident had a tracheostomy, further observation revealed no emergency trach equipment was found at the bedside. A Credible Allegation of Compliance was received on 10/25/2023. Based on observations, resident and staff interviews, record review, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/20/2023. The facility remains out of compliance while the facility continues to develop and implement a Plan of Correction. (POC). Findings include: Review of the undated document titled Director of Nursing Job Description, signed and dated 3/2023 by current Director of Nursing, indicated the Major duties and Responsibilities include: *Conducts observations of nursing care and supervises development of in-service education to ensure nursing staff is competent in current knowledge and skills. *Promotes safe work practices, safety rules, and accident prevention procedures to prevent injury and illness. Review of education documents provided by the Staff Development Coordinator (SDC) revealed two binders from 2022 and 2023 containing records of staff education. In addition to the binders, she provided a list of licensed staff who had completed education programs via online education source utilized by the facility. Continued review revealed that only one licensed nurse completed two education programs on the care of residents with tracheostomies. There was no evidence of competency checks for any licensed staff regarding emergency care for trach tube dislodgement. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, hypertension, chronic respiratory failure, and tracheostomy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for mental Status (BIMS) was not coded, indicating cognitive status was unable to be determined. Section O revealed that R2 had a tracheostomy. Review of October 2023 Clinical Physician Orders for R2 revealed an order to change disposable inner cannula (resident is using 6 Shiley disposable) one time per day for tracheostomy care with a start date of 6/7/2023 and perform trach care every 12 hours, with start date of 5/15/2023. The orders did not include orders for emergency trach management, trach style (cuffed or uncuffed), suctioning trach, and/or changing the trach dressing or collar. Review of Progress Note documentation revealed on 5/9/2023 at 7:18 pm, revealed R2's trach was dislodged resulting in the resident being transferred to the emergency room and then admitted for surgery to have the trach tube replaced, R2 was discharged back to the facility on [DATE]. Interview on 10/11/2023 at 2:30 pm with the Staff Development Coordinator (SDC), revealed she provides education and training for licensed staff regarding tracheostomy care and suctioning, but stated she does not provide training regarding replacing a dislodged tracheostomy tube. An Acceptable Removal Plan was received on 10/25/2023. The removal plan included reassessing R2, placing tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for No Smoking-Smoke Free Facility and Tracheostomy Care. Through interviews with facility staff, observation of tracheostomy supplies, observations of residents with tracheostomy's, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/20/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.

Based on observations, record review, resident and staff interviews, and the Georgia Comprehensive Rules and Regulations, r. 410-10-.03, the facility failed to meet professional standards of quality by providing two non-pharmacist labeled prescription medications at time of discharge for one resident (R) R9 of three sampled residents. Findings include: Review of the Georgia Comprehensive Rules and Regulations, r. 410-10-.03 Definition of Unprofessional Conduct (Georgia Administrative Code). Department 410. Rules of Georgia Board of Nursing, Chapter 410-10. Standards of Practice and Unprofessional Conduct. https://rules.sos.ga.gov/[NAME]/410-10-.03 stated: (1) Nursing conduct failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not be limited to, the following: (2) Practice * Using inappropriate or unsafe judgment, technical skills or interpersonal behaviors providing nursing care. * Performing any nursing technique or procedure for which the nurse is unprepared by education or experience. Review of the Clinical Physician Orders dated 8/8/2023 through 10/16/2023 revealed R9 was ordered, among other medications, Carvedilol 6.25 milligrams (mgs) by mouth (PO) daily and Lantus SoloStar 15 Units subcutaneous (subQ) at bedtime. Review of Progress Note dated 10/16/2023 at 12:36 pm revealed 'resident being discharged on this date and education given to sister and resident on the mechanical lift, peri care and insulin administration. Caregiver demonstrated understanding in the process.' Observation on 10/16/2023 at 10:00 am, R9 was resting in bed, awake, alert, and stated he was excited about getting to go home. Resident 9 stated he was not able to get up on his own, but he knew there were arrangements made for someone to come in and assist him. He stated he was unable to administer his own insulin, but his brother would help give it to him. On 10/17/2023 at 2:30 pm, R9's responsible party (RP) came back to the facility and reported to surveyor she had taken R9 home yesterday. The RP stated she was sent home with the remainder of what medication R9 had in his bubble packs (medication dispensing system), but R9 was not sent home with his insulin and one other medication, nor enough of the other medications until he sees his Primary Care Provider (PCP). Resident 9's RP stated she came by today to ask Registered Nurse (RN) MM if she could obtain enough of the medications he was missing until R9 could see his PCP. She stated RN MM found an insulin pen and a bubble pack of one medication to provide R9 with what he was missing in the medications sent home with him. Interview on 10/17/2023 at 2:45 pm, the Director of Nursing (DON) and RN MM were questioned about the medications in the brown paper bag brought in by R9's RP, including an insulin pen and a bubble pack containing nine pills. The DON examined the medications. The DON observed that the medications for R9 were not labeled and stated they should not have been dispensed to the resident. Interview on 10/17/2023 at 2:50 pm, RN MM stated she obtained the Carvedilol from the box of disposed medications from residents who had been discharged . She also stated that she found an unused Insulin pen of Lantus, which she gave to R9's RP. RN MM stated she did not know it was illegal or inappropriate to dispense medication to a patient that was not prepared by a pharmacist. Interview on 10/18/2023 at 10:45 am with Pharmacist CCC, stated she is aware of the situation with the nurse dispensing unlabeled medications. She acknowledged this action is illegal. She stated she notified RN DDD, Nurse Pharmacy Consultant from the facility and he is aware of the situation. She referred the surveyor to discuss this issue with RN DDD. Interview on 10/18/2023 at 12:26 pm, RN DDD, Nurse Consultant for the facility pharmacy confirmed it was illegal and inappropriate for nurses to label and/or dispense medication and give it to patients. He stated he is aware of RN MM action and will be in touch with the DON to assist her in any way she requires.

Based on observations, record review, staff interviews, and review of the policy titled Comprehensive Care Plans, the facility failed to develop a baseline care plan for one newly admitted resident (R) (R#382) that included goals and interventions related to oxygen use, tracheostomy care, and gastrostomy tube feeding. The sample size was 43 residents. Findings include: Review of the undated facility policy titled Comprehensive Care Plans, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation: number 3.a. The comprehensive care plan will include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the Electronic Medical Record (EMR) for R#382 revealed he was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage, cerebral vascular accident (CVA), acute respiratory failure with hypoxia, and end-stage renal disease (ESRD). Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented Special Procedures to include dialysis, tracheostomy care, oxygen use, and tube feedings. Review of the December 2022 Order Summary Report revealed Physician Orders for: a. dialysis, Mondays-Wednesdays-Fridays b. oxygen by trach PRN (as needed) for SOB (shortness of breath) c. oxygen sat (saturation) q-shift (every shift) d. gastrostomy tube feedings (g-tube) Review of the EMR revealed there was not a baseline care plan completed that included the goals and interventions needed to provide person-centered care for a resident to address dialysis, tracheostomy, oxygen use, and g-tube feedings. Observation on 12/21/2022 at 1:43 p.m. revealed R#382 lying in his bed with eyes closed, wearing oxygen (O2) at six (6) liters per minute (LPM) tracheostomy (trach) collar through a trach tube. He was in no apparent distress. Observation on 12/22/2022 at 11:30 a.m. revealed head of bed elevated and tube feeding infusing via pump, per physician orders. Observation on 12/27/2022 at 12:42 p.m. of revealed resident lying in bed wearing O2 via trach collar. Trach site was clean and dressed properly. Interview on 12/27/2022 at 6:00 p.m. with the Director of Nursing (DON) confirmed there was no baseline care plan in place for R#382 to address his care for dialysis, tracheostomy, oxygen, and tube feeding. She stated she was not aware of the omissions and would update the care plan. 46579

Based on observations, facility documentation, resident and staff interviews, the facility failed to ensure that it maintained a clean and comfortable home-like environment for four residents (R), (R#37, R#31, R#51, R#62) related to dirty wheelchairs; and six resident rooms (217, 219, 220, 222, 224, 227) with dirty floors, dirty windowsills, damaged walls and doors, dirty equipment, and improper functioning air mattress. The facility census was 87 residents. Findings include: Review of a document provided by the facility titled Logbook Documentation-conduct wheelchair inspection, revealed to check wheelchairs for proper operation and check for cleanliness, and was as marked on dated 3/31/22, 1. Review of the electronic medical record (EMR) for R#37 revealed she was admitted to the facility 10/1/2018. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Observation on 12/20/2022 at 11:20 a.m. in R#37's room, resident was sitting in her wheelchair. The wheelchair was dirty with food crumbs, dirt, and layers of grime. Interview with resident at this time revealed her wheelchair had never been cleaned. Review of the EMR for R#31 revealed she was admitted to the facility on [DATE]. Review of the Annual MDS assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observation on 12/21/2022 at 2:30 p.m. in R#31 room revealed resident resting in her bed. Observation of the wheelchair at her bedside revealed it was dusty all over. She stated her wheelchair was dirty and asked if anybody was going to clean it. She stated she had never seen anyone clean her wheelchair. Observation on 12/22/2022 at 12:00 p.m. revealed R#31's wheelchair was still at her bedside, and remined dusty and dirty. Review of the EMR for R#51 revealed he was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. Observation on 12/21/2022 at 2:35 p.m. revealed R#51 was seated in his wheelchair in the hallway near the nurse's station. The wheelchair had dust on the back of the wheelchair and dirty wheels. During an interview at this time, R#51stated his wheelchair had never been cleaned since he was admitted , and stated it needed to be cleaned. He stated he hasn't seen anyone clean wheelchairs. Observation on 12/22/2022 at 12:05 p.m. R#51 seated in his wheelchair in hallway near South Unit nurse's station. He re-stated his wheelchair was dirty and had never been cleaned. Review of the EMR for R#62 revealed she was admitted to the facility on [DATE]. Review of the MDS PPS Interim Payment Assessment, dated 10/1/2022, documented a BIMS score of 12, indicating moderate cognitive impairment. Observation on 12/21/2022 at 2:40 p.m. revealed R#62 sitting in her wheelchair outside her room. The wheelchair had areas of the chair that were covered with dust, including the wheels. When asked if her wheelchair had ever been cleaned or washed, she stated she cannot remember staff ever cleaning her wheelchair. Observation on 12/22/2022 at 12:11 p.m. R#62 sitting in her wheelchair in the doorway of her room. Her wheelchair remained dirty. Interview on 12/22/2022 at 1:12 p.m. with the Maintenance Director, stated they use TELS electronic maintenance system which prompts his staff to perform certain tasks, including inspection/repair of wheelchairs. He stated there's no place to document the work completed. During further interview, he stated there was not a policy regarding washing the wheelchairs. He stated the housekeeping staff was responsible for washing the wheelchairs. Interview on 12/27/2022 at 6:15 p.m. with the Environmental Services Director, stated washing the wheelchairs was the responsibility of the Maintenance Department, although he assists the maintenance staff with that task. He stated he was not certain when the last time the wheelchairs were washed. During further interview, he stated he would meet with the Maintenance Director to determine the responsibility of cleaning the wheelchairs. 46579 2. Observation on 12/20/2022 at 11:10 a.m. in room [ROOM NUMBER], revealed the wall behind bed A had peeled and missing paint. The windowsill was dirty and had dead bugs in it. Interview with the resident at this time, stated the wall had been missing the paint for a very long time. Observation on 12/20/2022 at 11:30 a.m. in room [ROOM NUMBER], resident was laying to the left side edge of the bed. Interview at this time with R#11, revealed she has an air mattress on her bed. She stated that the air mattress has a dip in the middle, and it causes her to lay sideway in the bed. She stated the facility was supposed to get her a new mattress, but she hasn't gotten one yet. Observation on 12/20/2022 at 11:40 a.m. in room [ROOM NUMBER], revealed multiple dead bugs in the windowsill. Observation on 12/20/2022 at 11:52 a.m. in room [ROOM NUMBER], revealed multiple dead bugs in the windowsill. The floor in the bathroom had dirty buildup on it. There was a hole on the inside of the bathroom door. Observation on 12/20/2022 at 12:10 p.m. in room [ROOM NUMBER] revealed the windowsill was dirty. Observation on 12/20/2022 at 12:30 p.m. in room [ROOM NUMBER], the tube feeding pole and pump was dirty. The floor behind the head of the bed was dirty. On 12/22/2022 at 5:30 p.m., the Administrator and the Director of Nursing verified the environmental concerns identified during the survey.

Based on review of medical records and staff interviews it was determined that the facility failed to ensure a patient centered care plan with measurable goals and interventions was developed to prevent a reoccurrence of injury to R#37's lower extremities . The care plans reviewed were developed and or revised on 3/14/18 after R#37 sustained injury to her left ankle. On 5/14/18 R#37 sustained a second injury to her to right ankle, both injuries resulted in harm to R#37. Findings include: Record review revealed that R#37 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident R#37 sustained injury while being transferred in a wheelchair by staff on 2/27/18. Review on the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed in Section G0400 -Functional Limitation in Range of Motion lower extremity (hip, knee, ankle, foot) was coded 0 indicating no impairment. Due to the injury on 2/14/18 a Significant Change Minimum Data Set (MDS) assessment dated [DATE] was completed and revealed Section G0400- Functional Limitation in Range of Motion lower extremity (hip, knee, ankle, foot) 2 = impairment on both side. Review of the in-service education form dated 2/28/18 regarding pushing residents in wheelchairs included: when pushing residents in wheelchairs must have foot rest on chair. All residents in wheelchairs must have leg rest. If resident self-propel must let them self-propel (sic). If a resident chooses not to have leg rest and self-propel, they should not have a leg rest and self-propel, they should not be assisted by staff. (sic) The aforementioned information was not included on R#37's care plan. Review of the At risk for falls care plan with a problem onset date of 10/18/2016 revealed a revision date of 3/14/18 (two weeks) after R#37 sustained a fracture to the left foot. The interventions added included: Patient prefers one-foot rest to left side because she will propel with right foot. Ensure left foot rest is on and secured always. Review of the care plan developed with an onset date of 3/4/18 revealed, Patient sustained fracture to left ankle and is at risk potential (sic) injuries and/or fractures due to diagnosis (dx) [MEDICAL CONDITION] the interventions included: Provide gentle care when assisting with Activities of Daily living (ADL's) and mobility, observe for signs/symptoms (s/s) of fracture-swelling, tenderness, bruising, malformations, avoid activities which may increase risk of fracture, encourage adequate intake of meals, encourage use of appropriate foot wear and administer medication as ordered. The care plan did not include measurable goals and interventions to prevent a reoccurrence of the same type of injury. On 5/14/18 R#37 sustained a fracture to the right ankle when being pushed in a wheelchair by staff. Review of the care plan dated 5/16/18 included the following interventions: Pt needs both foot rest always when in wheelchair (w/c) due to recent Fx (fracture) of right ankle. Foot rest x 2 until weight bearing status changed and observe patient when in w/c to avoid using R (right) foot to propel w/c due to recent fracture. On 5/23/18 at 2:00 p.m., during an interview with the Minimum Date Set (MDS) Nurse regarding development and revisions of care plans, she said it is her responsibility to update the care plans, she continued saying the electronic charting system does not always function correctly, so care plans are sometimes updated by hand.

Based on observation, interviews and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents which resulted in actual harm to resident (R) #37. On 2/26/18, R#37 was being pushed in a wheelchair by an Occupational Therapist (OT) when R#37's left foot got caught on the front wheel of the wheelchair resulting in a [MEDICAL CONDITION] lateral malleolus Bimalleolar Ankle Fracture. A second incident occurred, on 5/15/18 when R #37 was being pushed to her room in a wheelchair by the facility transporter. Resident #37's right foot dropped and hit the floor which resulted in a [MEDICAL CONDITION] fibula on the right ankle. The facility failed to monitor and provide adequate supervision and assistive devices to ensure safety and prevent accidents. The sample size was 25. Finding Included: Record review revealed that R#37 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected Section C-Cognitive Pattern coded on a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R#37 has no cognitive impairment. During interview on 5/21/18 at 2:35 p.m. R#37 was sitting in a wheelchair next to the bed with a right and left leg rest attached to the chair. Her right foot was wrapped in a white cast like material and the left foot was held in place with a blue immobilizer. When asked what happened R#37 revealed that she had a fracture on the left and right leg. She further stated, in (MONTH) (YEAR), the therapist was pushing me back to my room in a wheelchair as I was holding my legs up when the left leg dropped and was caught under the wheelchair which caused a fracture. She continued and stated, I was returning from an appointment in (MONTH) (YEAR) for treatment of [REDACTED]. A review of the facility's Resident Incident Report dated 2/27/18 at 6:12 p.m. notes R#37 complained of pain to the left foot and [MEDICAL CONDITION] noted, stated that she was being pushed back from therapy and her foot got caught on the front wheel of the wheelchair bruising/ swelling and pain noted to left lower extremity. The physician and family were notified, and x-rays ordered to rule out fracture. Review of a form dated 2/27/18 at 6:12 p.m. and titled Department Notes revealed , x-ray ordered on today for left foot due to pain and swelling. Family called and informed. After receiving results of x-ray which stated no fracture to foot, but possible ankle fracture, order as given to x-ray left ankle. At 10:03 p.m. on 2/27/18 a radiology report of the left ankle recommended a CT (cat scan), results of an x-ray of the left ankle and foot revealed abnormal alignment of the ankle, joint and talus and possible posterior malleolus fracture. Review of the Medical Center radiology results dated 3/2/18 at 1:46 p.m. revealed the resident sustained [REDACTED]. The Post Discharge Patient form notes included; [DIAGNOSES REDACTED]. Review of a Rehab Event Report Worksheet dated 2/28/18 (two days after the incident) noted Event Nature left ankle injury during wheelchair transport. Event Adverse Effect Fracture ankle. Event details Therapist was pushing patient in wheelchair down hallway. Patient had legs extended, left foot dropped and inverted under wheelchair. Therapist found leg rest to remediate. No pain reported from patient and no signs of redness or injury noted. Documentation on the Orthopedics form dated 3/9/18 included, On 2/26/18 she was injured when staff failed to use foot rest on her wheelchair and her foot went under the chair and twisted while being pushed, presented to the Medical center for X-rays on (MONTH) 27,2018. The X-rays confirmed 2 fractures on either side of the ankle. Before the injury, she ambulates minimal to transfer. (sic) Review of the Orthopedics report dated 5/18/18 revealed the following, Ms._____ Presents today for a new issue of right ankle fracture. She was last seen by me on Monday 5/14/18 for her previously left ankle fracture. When she was in that day she was in a wheelchair with no foot rest on the right side. Later that day her foot was caught under her chair, the same mechanism that resulted in the left ankle fracture. She was taken to the ED on Tuesday due to ankle pain and swelling where she was diagnosed with [REDACTED]. On 5/15/18 at 4:53 p.m. a Radiology Report of the right tibia and fibula, revealed a [MEDICAL CONDITION] fibula, Suspicious for a [MEDICAL CONDITION] malleolus. It is documented on the report N.O (new order) to send to ER (emergency room ) for evaluation. Review of the Medical Centers Post Discharge note dated 5/15/18 included, presents with right ankle pain and she got caught under her wheelchair coming back from a doctor's appointment in their portion (sic) wheelchair without foot rest and right foot got caught on the wheelchair. She media(sic) started having pain which she rates 10/10. The discharge summary Patient Education included instructions for Nondisplaced Bimalleolar Ankle Fracture Treated with Immobilization. Review of R#37's clinical record included an addendum Departmental Notes dated 5/15/18 at 3:14 p.m. a nurse documented Patient arrived back to unit from out of facility appointment on 5/14/18 around 3PM, driver Mr.___verbalized patient had a C/O (complained of) her foot being bumped and had slight pain, writer went to assess patient while in her room post report and patient denied pain in area. Patient had C/O discomfort today during therapy and x-ray ordered per facility DON. (sic). During interview on 5/24/18 at 11:30 a.m. with the Director of Nursing (DON) regarding the incident on 5/14/18 the DON said, the resident was returning from a doctor's appointment the facility transporter was pushing the resident in her wheelchair taking the her back to her room. The DON revealed that R#37 only had a foot rest on the left side. DON revealed that R#37 was holding right foot up and the foot dropped and was ran over by the wheel of the wheelchair. She stated, staff was in-serviced on placing foot rest on the residents when pushing them in a wheelchair and that the Certified Nursing Assistant (CNA) OO was in-serviced on placing the foot on the wheelchairs prior to this incident. The DON revealed that on 2/26/18, R#37 was returning to her room from therapy being escorted in the wheelchair by the occupational therapist, the resident was holding her foot up while the therapist was pushing the wheelchair. The resident's foot dropped and was ran over by the wheel of the chair. Interview with CNA OO on 5/24/18 at 3:39 p.m. regarding transporting R#37 to the physician's appointment on 5/14/18, CNA OO said before leaving for the appointment he asked the resident to allow him to put the leg rest on the chair and the resident told him she would be fine without the leg rest. CNA OO said on 5/15/18 around 12:15-12:30 p.m. he was returning from a doctor's appointment with R#37 and he was pushing her in the wheelchair to the resident's room and the resident was holding her leg up. CNA OO said as he approached the resident's room, R#37 right foot fell , and the wheel of the wheelchair hit the residents leg. CNA OO stated he reported the incident to the charge nurse on the floor. CNA OO said he was suspended pending investigation and when he returned to work he was in serviced on placing the leg rest on residents that go out for appointments if they want them or not. CNA OO stated he had no in-service prior to the day he was providing transportation for R#37 from the doctor's appointment. Interview with CNA OO on 6/15/18 at 9:47 a.m. regarding the day he transported the R#37 to the Orthopedic appointment and he said all residents need to have the leg/foot rest on when being transported down the hall and if the resident refuse to put on the leg/foot rest the nurse must be notified. He stated that on the day of the Orthopedic appointment the resident did not want the leg/foot rest on. CNA OO revealed that he did not explain the importance of having the leg rest to the resident nor did he report that she did not want the leg rest as he was instructed to do in the in-service During interview with R#37's family on 6/15/18 at 11:30 a.m., the family member said on the day of the injury 5/14/18 she received a call from another family member that met R#37 at her Orthopedic appointment and it was said that R#37 had arrived at the appointment without a foot rest on the right side. The family stated she contacted the facility immediately and requested that the staff make sure that both foot rest are on the chair anytime R#37 is being moved to prevent another occurrence of having her foot ran over. The family member said a call was received on 5/15/18 at 5:00 p.m. from a nurse stating that the right leg had been fractured by a wheelchair running over the leg. During an interview with the Orthopedic physician on 6/15/18 at 1:30 p.m. regarding the foot rest on the wheelchair, she stated the patient arrived at her office on 5/14/18 without a foot rest and both she and her assistant spoke with the family and told them how important it was for her to have both footrest to prevent any further injuries. Review of the in-serviced education report dated 2/28/18 topics included; pushing residents in wheelchairs must have foot rest on chair. All residents in wheelchairs must have leg rest. If resident self-propel must let them self-propel. If a resident chooses not to have leg rest and self-propel, they should not have leg rest and self-propel they should not be assisted by staff. Review of the in-service sign in sheets dated 2/28/18 there are no signatures to verify that therapy staff or CNA OO had attended the in-service. Review of a document titled, In-Service/Education Attendance Sign in-log dated 3/15/18, CNA OO signed as attending however, the sheet did not include a topic or document what training was presented . Review of a form dated 5/17/18 titled Rehab-care Education/Training Attendance Roster revealed training was presented to Rehabilitation staff three months after R#37 sustained the first injury on 2/26/18. The training course topic included W/C (wheelchair) leg rest policy. During an interview on 6/15/18 at 10:20 a.m. with the DON regarding the wheelchair leg rest policy she said, the facility does not have a wheelchair leg rest policy. On 6/15/18 the Administrator was interviewed regarding the wheelchair leg rest policy and stated she would provide the policy to the surveyor. The surveyor did not receive a policy on wheelchair leg rest.

Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The facility failed to provide protective oversight including continued monitoring of Resident (R)#37's being transferred in a wheelchair to prevent a reoccurrence of injury. Resident #37 sustained a fractured left lateral malleolus Bimalleolar Ankle on 2/24/18 and a [MEDICAL CONDITION] ankle distal fibula on 5/14/18. The failure to monitor and provide adequate supervision and assistive devices to ensure safety and prevent accidents resulting in harm. The facility failed to ensure a patient centered care plan with measurable goals and interventions was developed to prevent a reoccurrence of injury to R#37's lower extremities The facility census was 107. Sample size 25. Findings Included: Record review revealed that R#37 was admitted to the facility on [DATE]. Current Diagnosis: [REDACTED]. right non-displaced Bimalleolar ankle fracture. Review the facility incident reports R#37 was being pushed in a wheel chair (w/c) on 2/26/18 by the Occupational Therapist (OT) when the resident's left foot was run over by the wheel of the w/c. This resulted in a right displaced [MEDICAL CONDITION] fibula. Review of an undated incident report which included the physician and family were notified on 5/15/18 noted, Resident #37 was being pushed to her room in a w/c on 5/14/18 by the facility transporter. Resident #37's right foot was ran over by the wheel of the w/c which resulted in a right non-displaced Bimalleolar ankle fracture. Review of an in-service education dated 2/28/18 regarding pushing residents in wheelchairs included: when pushing residents in wheelchairs must have foot rest on chair. All residents in wheelchairs must have leg rest. If resident self-propel must let them self-propel (sic). If a resident chooses not to have leg rest and self-propel, they should not have a leg rest and self-propel, they should not be assisted by staff. (sic) The aforementioned information regarding residents with wheelchairs was not included on R#37's care plan. In addition review of the in-service sign in sheets dated 2/28/18, provided by the facility, does not reflect Certified Nursing Assistant (CNA) OO (facility transporter) or the Occupational Therapist (OT) were present for the education. Review of the At risk for falls care plan revealed a revision date of 3/14/18 (two weeks) after R#37 sustained a fracture to the left foot. Review of the care plan dated as developed on 3/14/18 with a problem onset titled Patient sustained fracture to left ankle and is at risk potential (sic) injuries and/or fractures due to dx (diagnosis) [MEDICAL CONDITION]. The interventions included: Provide gentle care when assisting with Activities of Daily Living (ADL's) and mobility, observe for sign/symptoms (s/s) of fracture-swelling, tenderness, bruising, malformations, avoid activities which may increase risk of fracture, encourage adequate intake at meals, encourage use of appropriate foot wear and administer medication as ordered. Interview with the Administrator on 5/24/18 at 5:18 p.m. regarding R#37's incident's, she said the transporter attempted to put the second leg rest on and the resident refused, education was provided at a town hall meeting after the first education. Refer to F656 and F689 which exemplifies deficient practice.

Based on clinical record review, facility Resident Incident Report review, Personnel Consultation Form review, facility Bed Making Policy review, and staff interview, the facility failed to ensure a Certified Nursing Assistant (CNA) EE provided care in accordance with the facilities Policy and Procedures regarding bed making of an occupied bed during Activity of Daily Living (ADL) care for one (1) resident (#1), of the twenty-five (25) sampled. The failure resulted in actual harm to Resident #1 who had a fall and sustained a head injury. It was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1, Z and R#2, is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) began on [DATE], the date that R#1 sustained a, subdural hematoma, and expired on [DATE] and remains on-going. On [DATE] at 10:50 a.m. the Administrator and Director of Nursing (DON) were informed that it was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1 and is likely to cause, serious injury, harm, impairment, or death to residents. Review of the Census and Condition Report revealed a total of forty-seven (47) residents have been identified to need assistance of one (1) or two (2) staff for transfers; a total of fifty-eight (58) residents are totally dependent on staff for transfers, for a total of one-hundred-five (105) residents. The total resident census was one-hundred-twelve (112). Cross reference: 483.25 Free of Accidents/Hazards/Supervision Devices 483.75 {e} {8} Nurse Adie Demonstrates Competency/Care Needs Findings include: Review of the Nursing Note entry on [DATE], 11:15 a.m. for R#1 revealed: Licensed Practical Nurse (LPN) JJ was called to resident room by assigned CNA EE this shift. R#1 was laying on the right side on the floor next to the bed. During provision of care and change of the bed linens, CNA EE stated that she pulled on the bed sheet and the resident fell over the edge of the bed. R#1 was noted with an open area to the right side of forehead with hematoma. This note further revealed R#1 was alert and awake, screaming and crying. Pressure was applied to the area and ice bag, bleeding subsided, resident was transferred out of the facility to the hospital. Review of the Resident Incident Report for R#1 documented a fall on [DATE]: The resident fell out of bed during occupied bed making, further documented that the CNA EE stated that while reaching to the other side of the bed to take the old sheets off and to put the new sheets, R#1 started to slip and CNA EE tried to push body against resident, and grabbed her, but the resident slipped. Further review of this incident report revealed the root causes of this fall includes failure to follow procedural policy, and there should have been two (2) staff assisting resident with ADLs. Review of the Personnel Consultation Form , which referenced CNA EE and the fall involving Resident #1 on [DATE] documented: CNA EE caused resident to fall out of bed causing head injury by not using proper technique when caring for resident during turning and re-positioning. Review of the facility Policy and Procedure 190-Bedmaking, Occupied which includes but not limited to, #5: Raise the side rail as necessary, #6: Assist resident to turn on his/her side away from you towards far side of the bed, with side rail up. #8: Fan fold or roll soiled linen toward resident and tuck against his/her back, #14: Push all bottom linens to center of bed along resident's back, this will create a roll of linen next to the resident in the center of the bed, #15: Raise the side rail on your side of the bed, if necessary, and assist the resident to roll towards you, over the linen, #16: Go to the opposite side, #17: Remove soiled linen by rolling edges toward center with soiled side inward and place in hamper for soiled linens. Interview on [DATE] at 6:19 p.m. with the Director of Nursing (DON) revealed R#1 has been in and out of the hospital, she had a stroke and her health condition was in a downward spiral. The day of the incident [DATE] the resident was given a bath, and dressed in bed by one (1) assist which she required for positioning while in bed. The DON further stated, the staff was trying to make the resident bed, leaned over the resident to pull the sheet on opposite side of bed while resident leaning toward staff, she could not hold the resident, and caused resident to fall. Resident #1 sustained hematoma/laceration to forehead from the staff using improper technique during care. The DON then stated that the staff member was terminated for improper technique. The DON further revealed that for this fall with injury, R#1 was sent to the hospital for evaluation and treatment. During follow up with the hospital, the facility was informed that R#1 expired in the hospital. (However, per review of the hospital record review the resident expired on [DATE], at a hospice) According to our policy and procedure on occupied bed making, the staff did not follow our policy.

Based on observation, record review and staff interview, it was determined that the facility failed to follow the care plans to use two (2) staff persons during transfer and fall alarm for three (3) residents (R#1, Z and R#2) of the twenty-five (25) sampled residents. It was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1, Z and R#2, is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) began on [DATE], the date that R#1 sustained a, subdural hematoma, and expired on [DATE] and remains on-going. On [DATE] at 10:50 a.m. the Administrator and Director of Nursing (DON) were informed that it was determined that the noncompliance with one or more requirements of participation has caused actual harm to R# and is likely to cause, serious injury, harm, impairment, or death to a resident. Review of the Census and Condition Report revealed a total of forty-seven (47) residents have been identified to need assistance of one (1) or two (2) staff for transfers; a total of fifty-eight (58) residents are totally dependent on staff for transfers, for a total of one-hundred-five (105) residents. The total resident census was one-hundred-twelve (112). Cross reference: 483.25-F323 Free of Accidents/Hazards/Supervision Devices 483.75 {e} {8}-F469 Nurse Aide Demonstrates Competency/Care Needs Findings include: 1. Resident Z was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating that the resident had cognitive impairment, was non-ambulatory, was frequently incontinent of bowel and bladder, required total assistance of one staff person for toileting, required extensive assistance from two staff for bed mobility and transfer and had no falls since the last MDS assessment. Review of the care plan dated [DATE] revealed that the resident required assistance from staff for Activities of Daily Living (ADL) and was revised on [DATE] with an intervention for two (2) staff to transfer the resident. Further review of the care plan revealed that the resident was at risk for falls related to incontinence, impaired cognition, noncompliance with asking for help, and limited mobility with an intervention for staff to apply an alarm on the wheelchair. However, on [DATE] at 8:25 a.m., the resident was inappropriately transferred from the bed to the wheelchair by one (1)staff person. On [DATE] at 1:42 p.m., 2:01 p.m., 2:31 p.m. and 3:00 p.m., the resident was sitting in the wheelchair in their room with closed eyes, unsupervised and without an alarm on the wheelchair. Interview with the DON on [DATE] at 3:40 p.m. revealed that certified nursing staff were supposed to apply the alarm on the the wheelchair prior to leaving the resident unsupervised in their room as care planned. Continued interview with the DON revealed that two (2) nursing staff were supposed to transfer the resident as care planned. 2. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#2 revealed severe cognitive impairment, and was assessed as needing extensive assistance of two-plus (2+) staff for transfers. Review of the care plan developed on [DATE] noted a Problem/Need of Fragile skin: prone to skin tears and bruising. Further review of this care plan revealed an approach dated [DATE] of an actual skin tear. Review of an activity of daily living (ADL) care plan dated [DATE] and reviewed [DATE] revealed an approach for two (2) person assist with positioning and transfers, with the role(s) responsible listed as Certified Nursing Assistant (CNA) and Nursing. An interview conducted with CNA AA on [DATE] at 1:28 p.m. revealed that they knew how many staff it took to transfer a resident because it's displayed on their computer screens mounted in the hallways. Review of the transfer status in the CNA's computerized system for R#2 revealed that they were a 2+ person assist, which was verified during interview with CNA AA. Review of a Nursing Note dated [DATE] at 10:38 a.m. revealed that R#2, scraped the outer right leg on the wheelchair during an assisted transfer from the bed to the chair, and sustained a superficial skin tear. An interview conducted with CNA AA on [DATE] at 10:35 a.m. revealed that they were transferring R#2 from the bed to the wheelchair by themselves (assist of one) on [DATE], when R#2 hit their leg on the wheelchair where the footrest is attached to the wheelchair frame. During an interview conducted with the Director of Nursing (DON) on [DATE] at 9:20 a.m., revealed that the facility used guidance in the Lippincott Nursing Procedures (Fifth Edition) book for their transfer policy and procedure. Review of the Bed to Wheelchair section in this book revealed that for a patient with diminished or absent lower body sensation or one-sided weakness, transfers may require partial to full assistance, initially by at least two (2) persons. During an interview conducted with the DON on [DATE] at 11:20 a.m., who verified that CNA AA had transferred R#2 without assistance on [DATE] when the resident sustained [REDACTED]. During an interview and record review conducted with the DON on [DATE] at 1:25 p.m., and a printed ADL care sheet for R#2, it was verified that the approach and role displayed on the CNA's computer screen when they logged into the system, included 2+ assist for transfers.

Based on observation and staff interview the facility failed to ensure that extension cords and power strips were used and mounted properly to ensure a hazard free environment for three (3) residents (#1, B, and #109.) The resident sample size was thirty-three (33) and the census was one hundred nine (109). Observation on 09/21/15 at 1:50 p.m. and on 09/22/15 at 9:15 a.m. of resident #1's room revealed resident's radio and bed plugged into a power strip located on the floor and not mounted to the wall. Observation on 09/22/15 at 11:00 a.m. of resident B's room revealed an extension cord draped over the resident with her cellular phone charging cable. Interview on 09/22/15 at 11:00 a.m. with resident B revealed that her family brought in the extension cord from home and she had been using it to charge her cellular phone for the last several weeks. Observation on 09/22/2015 at 10:57 a.m. and 2:45 pm revealed resident's #109 care equipment plugged into a power strip located on the floor and not mounted to the wall. Interview on 09/22/15 at 11:45 a.m. with the Maintenance Director confirmed residents were using power strips that were not mounted properly.

Based on record review, Facility Resident Incident Report review, Personnel Consultation Form review, and staff interview, the facility failed to ensure that a Certified Nursing Assistant (CNA) demonstrated competency during Activity of Daily Living (ADL) care for one (1) resident (#1) of the twenty- five (25) sampled. It was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1, Z, R#2, is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) began on [DATE], the date that R#1 sustained a, subdural hematoma, and expired on [DATE] and remains on-going. On [DATE] at 10:50 a.m. the Administrator and Director of Nursing (DON) were informed that it was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1 and is likely to cause, serious injury, harm, impairment, or death to a resident. Review of the Census and Condition Report revealed a total of forty-seven (47) residents have been identified to need assistance of one (1) or two (2) staff for transfers; a total of fifty-eight (58) residents are totally dependent on staff for transfers, for a total of one-hundred-five (105) residents. The total resident census was one-hundred-twelve (112). Cross reference: 483.25 Free of Accidents/Hazards/Supervision Devices 483.20 {k} {3} {i} Services Provided Meet Professional Standards Findings include: The Minimum Data Set 3.0 referenced date [DATE] for A2100 Discharge Status 03. Acute hospital documented resident had a fall with major injury. Further documented resident is cognitively impaired with long and short term memory loss, and is total dependence with one assist for ADL's. Also documented [DIAGNOSES REDACTED]. The Comprehensive Care Plan for at risk for falls dated [DATE] due to unsteady gait, [MEDICAL CONDITION], cognitive impairment, periods of incontinence and visual deficits which places at risk for injury. Further documented interventions which includes but not limited to monitor for changes in my condition that may warrant increased supervision/assistance. Review of the Resident Incident Report for Resident #1 dated [DATE] documented that the resident fell out of bed during occupied bed making, and further documented that CNA EE stated that while reaching to the other side of the bed to take the old sheets off and to put the new sheets, Resident #1 started to slip and CNA EE tried to push her body against the resident and grabbed her, but the resident slipped. Further review of this incident report revealed the root causes of this fall includes failure to follow procedural policy, and there should have been two staff assisting resident with ADL care. Review of the Nurses Note entry on [DATE] at 11:15 a.m. for R#1 documented: Was called to resident room by assigned CNA EE this shift. Received resident laying on her right side on the floor next to the bed. During provision of care and change of bed sheets, CNA EE stated that she pulled on the bed sheet and the resident fell over the edge of the bed. R#1 was noted with an open area to the right side of forehead with hematoma. This note further documented R#1 was alert and awake, screaming and crying. Pressure applied to area and ice bag, bleeding subsided, resident was transferred out of the facility to the hospital. Further review of R#1 medical records noted a resident transfer form to the hospital referenced date of [DATE] for a fall with injury of laceration to left forehead/left eyebrow which required sutures. Review of the facility Policy and Procedure 190- Bedmaking, Occupied which includes but not limited to, #5: Raise the side rail as necessary, #6: Assist resident to turn on his/her side away from you towards far side of the bed, with side rail up. #8: Fan fold or roll soiled linen toward resident and tuck against his/her back, #14: Push all bottom linens to center of bed along resident's back, this will create a roll of linen next to the resident in the center of the bed, #15: Raise the side rail on your side of the bed, if necessary, and assist the resident to roll towards you, over the linen, #16: Go to the opposite side, #17: Remove soiled linen by rolling edges toward center with soiled side inward and place in hamper for soiled linens. Review of the personnel file for CNA EE documented on the Personnel Consultation Form dated [DATE] The CNA EE caused an injury to R#1 by not using proper technique when caring for, turning and repositioning. R#1 fell out of bed causing head injury. Further review of the Nurse Aide Registry indicated an expiration date of [DATE] for CNA EE. The review also indicated a GCIC background check was completed on CNA EE. The results were clear. Further review revealed a One on One In-service dated [DATE] on Expectation when showering residents . What occurred- resident in room [ROOM NUMBER] was left unattended in shower room and slid from chair to the floor. What should have occurred?-Employee should not have left resident unattended in shower room. HH should have remained with resident until shower was complete. In-service to prevent further occurrences: 1:1 per above. Interview on [DATE] at 6:00 p.m. with the Staff Coordinator, Registered Nurse (RN) revealed the skill check list for bed making is a corporate competency checklist, which every staff during orientation is taught during training and with a preceptor on how to make an occupied bed. CNA EE was trained and returned demonstrated on proper technique on how to make an occupied bed. The Staff Coordinator validated CNA EE received in service and demonstrated competency during return demonstration on proper technique and procedure for occupied bed making according to corporate competency checklist form with CNA EE signed signature. The staff coordinator further stated that all staff were in-serviced again on [DATE] for making an occupied bed using proper technique as per facility policy. Interview on [DATE] at 6:19 p.m. with the Director of Nursing (DON) stated that R#1 has been in and out of the hospital, she had a stroke and her health condition was in a downward spiral. The day of the incident [DATE] the Resident was given a bath, and dressed in bed by one assist which she required for positioning while in bed. The DON further stated, the staff was trying to make the resident bed, leaned over resident to pull the sheet on opposite side of bed while resident leaning toward staff, she could not hold resident, and caused resident to fall and sustained hematoma/laceration to forehead from the staff using improper technique during care. The DON then stated that the staff was terminated for improper technique. According to our policy and procedure on occupied bed making, the staff did not follow our policy.

Based on record review and staff interview, the facility failed to develop an individualized care plan with an intervention that included two (2) person physical assistance with bed mobility in accordance with the Minimum Data Set assessment - Section G - functional status for one (1) resident (R#1) of the twenty-five (25) sampled. The facility's failure resulted in actual harm to three (3) residents (R#1, Z and R#2). It was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1, Z and R#2, is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) began on [DATE], the date that R#1 sustained a, subdural hematoma, and expired on [DATE] and remains on-going. On [DATE] at 10:50 a.m. the Administrator and Director of Nursing (DON) were informed that it was determined that the noncompliance with one or more requirements of participation has caused actual harm to R#1 and is likely to cause, serious injury, harm, impairment, or death to residents. Review of the Census and Condition Report revealed a total of forty-seven (47) residents have been identified to need assistance of one (1) or two (2) staff for transfers; a total of fifty-eight (58) residents are totally dependent on staff for transfers, for a total of one-hundred-five (105) residents. The total resident census was one-hundred-twelve (112). Cross reference F323 Findings include: 1. Record review for Resident #1 revealed an admission date of [DATE]. An re-admission Minimum Data Set (MDS) assessment dated [DATE], a Quarterly MDS assessment dated [DATE], a Quarterly MDS assessment dated [DATE], a Quarterly MDS assessment dated [DATE] and a Significant Change MDS assessment dated [DATE] all coded in Section G- Functional Status that the resident required extensive assistance with two (2) person physical assist for bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed). Review of Section V- Care Area Assessment (CAA) of the comprehensive re-admission MDS assessment dated [DATE] and Significant Change MDS assessment dated [DATE] both documented the decision to address Activities of Daily Living (ADL) Functional /Rehab Potential and Falls in the care plan. Review of the Care Plan dated [DATE] identified R#1 required assistance with/or provision for ADLs with interventions that include but are not limited to, one (1) person assist with positioning and two (2) person assist with transfers. Review of the Care Plan dated [DATE] further identified the resident was at risk for falls due to unsteady gait, [MEDICAL CONDITION], cognitive impairment, periods of incontinence and visual deficits. Review of the approaches section dated on [DATE] revealed, resident was sent to emergency room (ER). Telephone interview conducted on [DATE] at 9:43 a.m. with the MDS Coordinator confirmed that the MDS assessments reflected that Resident #1 required extensive assistance with bed mobility of two (2) person physical assist and further, that the care plan intervention indicated one (1) person physical assist with positioning. Positioning would include any position either in or out of bed. The MDS Coordinator continued to state all care plans are developed in accordance with the MDS assessments and does not know why the care plan for R #1 was not in line with the care plan. In addition, the MDS Coordinator was unable to view the re-admission assessment dated [DATE] and stated it was not showing up in the system. However, all previous assessments were in the system.