Every finding on record at White Oak Manor-Shelby

Based on observations, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #1) with right side weakness and vascular dementia with incontinence care. The resident fell off the side of the bed onto the floor. The resident complained of mild pain to her right knee and right arm and was provided her as needed pain medication and an order was received for in-house x-rays of the right side. Resident #1's right wrist began to show some mild swelling, and she continued to complain of pain, scheduled pain medication was administered, and she was transferred to the hospital for treatment. A hospital x-ray (imaging test for body's internal structures) revealed Resident #1 had suffered a fractured right wrist and right knee during the fall. Resident #1 was admitted to the hospital on [DATE] for further treatment and discharged back to the facility on 2/09/26. Resident #1 stated that she believed this was the worst fall she had suffered. The deficient practice occurred for 1 of 3 residents for the prevention of accidents (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included stroke, hemiplegia (paralysis) and hemiparesis (partial weakness) affecting the right dominant side and vascular dementia. Review of bed rail assessment dated [DATE] revealed Resident #1 was assessed for use of bilateral half side rails. Resident #1 demonstrated appropriate use of bed rails as an enabler to assist with positioning, mobility, and support in bed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, had been assessed as being dependent on staff for all activities of daily living, mobility, transfers, and was frequently incontinent of bladder and bowel. Review of revised care plan dated 1/02/26 revealed Resident #1 required assistance with all activities of daily living related to history of stroke with right side hemiplegia and vitamin deficiencies. Interventions included give verbal cues to help prompt and bilateral half side rails to bed to enhance mobility and safety. Review of Resident #1's MAR dated 1/31/26 revealed order for Percocet 10-325 milligrams (mg) (medication used to manage moderate to severe, acute, short-term pain) one (1) tablet by mouth 4 times daily (12:30 AM, 6:30 AM, 12:30 PM, 6:30 PM) for pain was administered by Nurse #1 at 6:30 AM with a reported pain level of 6. A telephone interview with Nurse Aide (NA) #1 on 3/11/26 at 3:35 PM revealed she had worked 3rd shift starting at 11:00 PM on 1/30/26 until 7:00 AM on 1/31/26 and was assigned to Resident #1. She stated that around 6:50 AM on the morning of 1/31/26 she had gone in to assist Resident #1 with her personal care. She revealed she had been standing on the side of the bed closest to door and was attempting to fix Resident #1's bed pad so she rolled her away from her towards the window assuming Resident #1 would grab and hold onto the half side rail like she normally did. NA #1 stated she believed while Resident #1's left leg was rolling over her right leg that her hand slipped off the side rail causing her legs to keep going and her falling onto the floor. She revealed she tried to grab and stop Resident #1 from falling but it happened so fast she was unable to stop her. She stated while Resident #1 was lying on the floor she checked on her to make sure she was okay and not bleeding or unconscious and then she immediately went and notified Nurse #1 and Nurse #2. NA #1 revealed both nurses came and assessed Resident #1 and she did not have any signs of injury and was only complaining of some pain to her right knee where she had a small abrasion present. She stated she and Nurse #1 assisted Resident #1 using the total lift off the floor and onto her bed and while Nurse #1 continued with her assessment she finished with her personal care. NA #1 revealed the fall was an accident and that Resident #1 had always been a one person assist for personal care due to her ability to use her side rails to help with turning but she should have also made sure Resident #1's hand was firmly secured on the side rail before rolling her. Review of nursing progress note dated 1/31/26 written by Nurse #1 revealed Resident #1 was observed lying partially on right abdomen area with face towards floor and right arm beneath torso. NA #1 verbalized she was turning Resident #1 and Resident #1 did not hold onto half side rails. NA #1 stated while Resident #1 was turning she kept going and rolled off the bed. Noted abrasion to Resident #1's right knee with no bleeding at site observed. No swelling was noted at this time. Resident #1 was able to follow commands and move extremities within her normal limits. She was able to perform active range of motion (ROM) per self to bilateral lower extremities with no deformities of extremities observed. No outward turning or difference in leg lengths observed during observation. Bed height was approximately 3 feet. Resident #1 was able to assist staff with turning to position for use of total lift. Resident #1 complained of pain to right knee upon movement but stated it would be alright; she did not mean to fall and did not hold onto side rail. Telephone call made to on call, notified of Resident #1's fall and received order to obtain x-ray of right knee related to complaint of discomfort. Initiated neurological checks. Resident #1 was encouraged to use side rails for safety purposes. Responsible person (RP) was notified. Review of nursing progress note dated 1/31/26 written by Nurse #1 revealed NA #2 came out of Resident #1's room and verbalized that it had looked like her right wrist was swelling a little bit. Nurse #1 went into Resident #1's room and noted swelling with no redness or warmth to right wrist area. Resident #1 was observed moving right arm at wrist joint. When asked to squeeze Nurse #1's hand, noted with weakness and facial grimacing. When asked about pain, Resident #1 stated it hurt a little bit, but it would be ok. On-call nurse practitioner (NP) was notified and added right wrist, right arm and right shoulder to x-ray order. Resident #1 declined cool compress to area. An interview with Nurse #1 on 3/11/26 at 1:45 PM revealed she worked at the facility every Friday, Saturday, Sunday on 3rd shift (6:45 PM- 7:15 AM) and had been assigned to Resident #1 the evening of 1/30/26 though the morning of 1/31/26. She stated on the morning of 1/31/26 around 6:55 AM while giving the report to Nurse #2, NA #1 had come up to the nurse's desk and stated while she had been providing Resident #1's care she had rolled off the bed and into the floor. Nurse #1 went to Resident #1's room and observed her bed was at a waist high position, half side rails were raised, she was lying on the floor beside her bed, facing the window, with her arm underneath her. She stated she immediately began assessing Resident #1 for any injuries and Resident #1 stated that she was fine and to get her up out of the floor, no complaints of pain at that time, or issues with her ROM. She revealed when she rolled Resident #1 over, she complained of knee pain and small abrasion was noted to the right knee but there were no complaints of pain to wrist and no swelling noted at that time. Nurse #1 stated she and NA #1 utilized the total lift and assisted Resident #1 back into her bed and finished with her assessment. She revealed Resident #1 was able to use her hands to grip and denied any pain. Nurse #2 notified Resident #1's RP of the fall and contacted the on-call NP and received orders for x-rays and fall protocol for neuro checks were initiated. Nurse #1 stated as she was getting ready to leave the facility she heard NA #2 inform Nurse #2 that Resident #1's wrist was starting to swell so on her way to the time clock she checked in on Resident #1 and verified to Nurse #2 that Resident #1's right wrist was starting to show some mild swelling and then Nurse #1 clocked out and left. Nurse #1 stated that when she asked NA #1 what happened she stated that she was turning Resident #1 during care and Resident #1 was not able to get a hold of the side rail and her legs kept going over and she fell onto the floor. She revealed Resident #1 told her the same thing that her hand had slipped while trying to grab onto the side rail and she fell into the floor. She stated Resident #1 was a one person assist during care and while turning and repositioning due to her ability to utilize her side rails and assist with her care. Review of Resident #1's medication administration record (MAR) dated 1/31/26 revealed an order for Acetaminophen 325 mg (medication used for temporary relief of mild to moderate pain) 2 tablets by mouth every 6 hours as needed for pain was administered by Nurse #2 at 7:30 AM. An interview with NA #2 on 3/11/26 at 1:35 PM revealed she had worked 1st shift (7 AM- 3 PM) at the facility for the past year and had been assigned to work with Resident #1 on Saturday 1/31/26. She stated on the morning of 1/31/26 she had arrived at the facility around 6:55 AM and Nurse #2 informed her that Resident #1 had fallen onto the floor. She revealed she went straight to Resident #1's room and observed Resident #1's bed was at waist level, her bilateral half side rails were raised, Resident #1 was lying on the floor beside her bed and Nurse #1 and NA #1 were assisting her off of the floor using the total lift. NA #2 stated she assisted Nurse #1 and NA #1 with getting Resident #1 back into her bed and Resident #1 was moaning some when moved or touched, she had a scrape on her right knee, but she did not observe any swelling to her knee or her wrist during that time. She revealed to her knowledge, the on-call physician had been notified and ordered x-ray to right knee and her as needed pain medication had been provided. NA #2 stated she had performed checks on Resident #1 about every 30 minutes and during one of her checks she noticed her right wrist was showing some mild swelling, so she informed Nurse #2 about the swelling and then went to provide care to her other residents. She revealed when she went into Resident #1's room for her 30-minute check, Resident #1 was upset and had been talking on the phone with her son and stated her son wanted her sent out and had called emergency medical services (EMS). NA #2 revealed when she asked NA #1 how Resident #1 had fallen, NA #1 stated that she had been rolling her to provide her care and was going to fix her bed pad under her and Resident #1's hand slipped when trying to grab the bed rail and her legs just kept going and she fell onto the floor. NA #2 stated when she asked Resident #1 how she fell, she also stated that her hand slipped off the bed rail and she just kept going into the floor. NA #1 stated Resident #1 was a one person assist while providing care in bed due to her ability to use her bed rails and assist with her turning and repositioning. Review of nursing progress note dated 1/31/26 written by Nurse #2 revealed she was receiving report from Nurse #1 when NA #1 notified both nurses that Resident #1 had fallen out of bed. Upon assessment, Resident #1 was on the floor, lying on her right side, beside her bed. Resident #1 denied hitting her head and verbally voiced that she had pain in her right knee. Nurse #2 left room to call Resident #1's responsible person (RP) and notify him of fall. Review of nursing progress note dated 1/31/26 written by Nurse #2 revealed Resident #1 received scheduled pain medication, related to complaints of pain due to fall. Resident #1 voiced pain related to right knee and right wrist at this time. Review of Resident #1's MAR dated 1/31/26 revealed order for scheduled Percocet 10-325 mg one tablet by mouth 4 times daily (12:30 AM, 6:30 AM, 12:30 PM, 6:30 PM) for pain was administered by Nurse #2 at 11:30 AM with a reported pain level of 10. A telephone interview with Nurse #2 on 3/11/26 at 2:45 PM revealed she worked at the facility every Saturday and Sunday on 1st shift (6:45 AM- 7 PM) and had been assigned to Resident #1 on the morning of 1/31/26. She stated while she was receiving the morning report from Nurse #1, NA #1 came to the nurse's desk and stated Resident #1 had fallen out of her bed onto the floor. She revealed when she entered Resident #1's room she observed the bed in waist high position, half side rails were raised, and Resident #1 was lying on the floor beside her bed, facing the window with her right arm under her body. She stated that while Nurse #1 assessed Resident #1 she left the room and attempted to call Resident #1's RP to notify him of fall. Nurse #2 revealed Nurse #1 contacted the on-call physician and received the order for the in-house x-ray on the right side. She stated Resident #1 had received her scheduled pain medication just prior to her fall and then she administered her as needed pain medication. She revealed later that morning NA #2 informed her that Resident #1's wrist was looking a little swollen, so she called Nurse #3 to come and assess Resident #1's wrist. Resident #1 then requested her scheduled pain medication and Nurse #2 administered her scheduled pain medications around 11:00 AM. Nurse #2 stated not long after she had administered Resident #1's scheduled pain medications EMS arrived at the facility stating Resident #1's son had called asking for Resident #1 to be taken to the hospital and she left for the hospital. She revealed she did ask NA #1 how Resident #1 had fallen out of bed and NA #1 stated that she assumed Resident #1 had a hold of her bed rails but apparently her hand had slipped off so when she rolled her over away from her to provide her care her legs just kept going and she fell onto the floor. She stated when she spoke with Resident #1 about the fall, she stated that NA #1 was rolling her onto her side to provide her care and fix her bed pad and when she went to grab onto her bed rail her hand slipped but her legs kept going causing her to fall into the floor. Review of nursing progress note dated 1/31/26 written by Nurse #3 revealed emergency medical services (EMS) arrived at the facility for Resident #1. They had been called by Resident #1's son. Nurse #3 had spoken with Resident #1 around 10:45 AM and she had complaints of pain. Nurse #3 assessed Resident #1 and noticed slight swelling to the right wrist. Resident #1 was able to move her wrist and did not complain of pain with movement. Resident #1 also had a small amount of swelling to right knee to which she had chronic pain. Nurse #3 had told Resident #1 it was about time for her scheduled pain medication and they were waiting for x-ray to come and complete her x-rays. Resident #1 stated she would try her scheduled pain medication first and see if that helped. Resident #1 did not inform Nurse #3 about any pain after the scheduled pain medication was given. RP and on-call NP notified. A telephone interview with Nurse #3 on 3/11/26 at 2:52 PM revealed she was the weekend nurse supervisor on 1st shift (7AM-7 PM) and was working on Sunday 1/31/26 when Resident #1 suffered a fall. She stated on 1/31/26 around 10:45 AM she was notified by Nurse #2 that earlier that morning around 6:55 AM Resident #1 had suffered a fall from her bed while receiving care and that her wrist was now showing some signs of mild swelling and pain, on-call physician had been notified, and x-ray of right side had been ordered. Nurse #3 revealed she went into Resident #1's room and observed mild swelling to her right wrist. She completed some range of motion assessments with Resident #1's arms and legs and she appeared at baseline (able to move arms, hands, legs) with no complaints. She stated Resident #1 only complained of normal pain in her arms and bottoms of legs. Nurse #3 revealed she contacted the on-call physician to inform of the mild swelling to the right wrist and ensured the order for x-rays to right side included her right hand and wrist. She stated she informed Resident #1 of the ordered x-rays and discussed receiving her scheduled pain medication now and if those did not work and her pain continued then they would send her out to the hospital. Nurse #3 revealed Resident #1 agreed and her scheduled pain medication was administered. She stated before she could go back to assess Resident #1 and see if the pain medication she was administered had helped, her son had called EMS, and they were at the facility to take her to the hospital. Nurse #3 revealed she did not ask Resident #1 about the fall but did speak with Nurse #1 and Nurse #2 who informed her that while NA #1 was rolling Resident #1 onto her right side to provide care, NA #1 assumed Resident #1 had a hold of her half rail on the side of her bed but Resident #1's hand slipped off the rail so when NA #1 was rolling her leg just kept going and Resident #1 fell into the floor. Review of hospital admission summary dated [DATE] revealed Resident #1 presented for evaluation after a fall. Resident #1 experienced a fall that morning, landing on her hip and legs, did not lose consciousness and reported no head injury. Resident #1 stated she attempted to grab side rail but missed it which resulted in her fall. She was able to sit up independently and reported pain in her right arm and hand and pain in her knee extending down her left side. She reported she had received pain medications for pain management, but they had not provided relief. X-rays were ordered for the right and left side. Review of hospital Discharge summary dated [DATE] revealed Resident #1was admitted following a fall resulting in bilateral leg pain and right arm pain. Imaging revealed a left femoral neck fracture (break to the upper thigh bone, just below the hip ball, also known as hip fracture) probable right patellar fracture (break in kneecap) with knee effusion (swelling or blood in the joint) and prepatellar soft tissue swelling (inflammation of the fluid-filled sac in front of kneecap), and acute distal radial (larger thumb-side forearm bone) and ulnar (smaller pinky side bone) fractures of right wrist. Orthopedic consultation was obtained and advised Resident #1 did not have a left femoral neck fracture. Recommended knee immobilizer for patella fracture and a splint for the right radius/ulnar fracture and orthopedic follow-up. Nursing facility reported she wore 2 to 3 liters of oxygen at baseline. Recommend outpatient follow-up with primary care physician and orthopedics. Review of nursing progress note dated 2/09/26 revealed Resident #1 had returned to facility from hospital via emergency medical services (EMS). Soft cast to right upper extremity. Immobilizer to right lower extremity. No signs of distress noted, continue to monitor, and care would be ongoing. An interview with the Director of Therapy on 3/11/26 at 3:21 PM revealed he was familiar with Resident #1 and provided her therapy services off and on since her admission. He stated Resident #1 was more than capable of utilizing her half side rails to include being able to grab and hold onto the rails to assist with her bed mobility, turning, and repositioning. He revealed due to Resident #1's ability to utilize her half side rails to assist with her care she would only require 1-person assistance while providing her care. The Director of Therapy stated that although Resident #1 was able to grab and hold-on to the side rail to assist with her mobility she would still need to be assisted by staff in making sure her hand was secured onto the bed rail prior to her being turned or repositioned. An interview with the Director of Nursing (DON) on 3/11/26 at 4:42 PM revealed she was familiar with Resident #1 and the fall that occurred on 1/31/26. She stated on 1/31/26 she believed she was notified Nurse #3 that while NA #1 was rolling Resident #1 away from her towards Resident #1's right side to provide her care, Resident #1 hand was not on or had slipped off the side rail while her legs continued to roll over and caused her to suffer a fall onto the floor. She revealed to her knowledge Resident #1 did not at first show any signs of pain or swelling, the on-call physician was notified and ordered x-rays of the right side. She stated a few hours later after the fall, Resident #1's right wrist began to show signs of swelling, so nursing notified the on-call physician again and x-ray orders were modified to include the right wrist and as needed pain medications were provided. The DON stated Resident #1 had been administered her scheduled pain medication prior to her fall, as needed pain medication right after her fall, and then her scheduled pain medications were given early to assist with her pain. She revealed Resident #1's son called EMS and requested that she be taken to the hospital instead of waiting on the in-house x-rays to be completed. She also revealed Resident #1 did suffer a fractured right knee and right wrist because of the fall and had to wear a knee immobilizer and wrist splint as treatment. The DON stated during her interview with NA #1 about the fall, NA #1 told her she had raised the bed waist level, bilateral half side rails were raised, and she was standing on the side of the bed closest to the door and was rolling Resident #1 away from her towards the window so that she could provide her care and fix her bed pad. She revealed NA #1 stated that she assumed Resident #1 had grabbed the side rail when she started rolling her left leg over her right and believed Resident #1's hand must have slipped off the side rail and her legs continued going over side of bed resulting in her fall. She stated when she interviewed Resident #1, she told her the same thing and stated that her hand slipped off the side rail and her legs just kept going and fell onto the floor. The DON stated NA #1 should have assured Resident #1's safety by making sure her hand was secured onto the side rail before beginning her care or fixing the bed pad. An interview with the Nurse Practitioner (NP) on 3/12/26 at 11:00 AM revealed she was familiar with Resident #1 and was made aware of her fall on 1/31/26. She stated Resident #1 was able to demonstrate and utilize her half side rails by grabbing and holding onto them for bed mobility, turning, and repositioning. She revealed staff should assist Resident #1 in making sure her hand was securely placed onto the side rail prior to turning her and that staff should follow their facility protocol in assuring residents' safety and appropriate use of side rails during care and notify nursing of any changes. NP stated in her opinion no one should ever suffer a break from a fall but Resident #1 did suffer from demineralization (reduction of mineral content in bones leading to weakened structures) and had a history of Vitamin D deficiency (insufficient levels of nutrient) which would make her more likely to suffer a fracture or break during a fall than someone who did not suffer from those issues. She revealed to her knowledge nursing staff followed protocol, notified the on-call physician who ordered x-rays of the right side. She stated typically if a resident suffers a fall but there were no immediate signs of a fracture or displaced bones then they would order x-rays in-house prior to sending them out to hospital and since Resident #1 had a scheduled and as needed pain medication the on-call physician would not have ordered another pain medication. The facility provided the following Corrective Action Plan: Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices.On 1/31/26 Nurse Aide (NA) #1 was providing incontinent care and repositioning Resident #1 in bed. During care Resident #1 had two half siderails in place, and while NA#1 was turning Resident #1 away from her, Resident #1 rolled out of bed to the floor. NA #1 did not instruct or ensure Resident #1 had reached over and used the half side rail during the turning action. Resident #1 was assessed by Nurse #1 and Nurse #2 after the fall, then the on-call provider was contacted by Nurse #1, and x-ray orders were received in-house. Resident representative was notified of the fall by Nurse #2, and order for x-rays was obtained. Resident #1 was then assessed by Nurse #3 related to complaints of pain; pain medication was then administered. Then Resident #1 was later transferred to local hospital for further evaluation and treatment. X-rays were obtained at local hospital, it was noted that Resident #1 had sustained right knee fracture, right wrist fracture. Resident #1 was then admitted to the hospital for further treatment. Treatment for the left knee fracture was an immobilizer and a splint for the right wrist fracture that Resident #1 was to wear at all times until seen by orthopedics and orders changed.Resident #1 was readmitted to facility on 2/9/26 and her care plan was updated and reviewed on 2/9/26 and then again on 2/12/26 for her quarterly assessment. This was completed by the Interdisciplinary Team (IDT) team, which included Administrator, Director of Nursing, Social Services, Activities, and the Nurse Assessment Coordinator. Address how the facility will identify other residents having the potential to be affected by the same deficient practiceDirector of Nursing (DON) and or designees began audits on 2/3/26 through 2/04/26 to ensure all residents were receiving incontinent care and activities of daily living (ADL) care in bed safely, mobility statuses were up to date, turning and repositioning instructions were being followed, and assistive devices were being used properly. To determine safe ADL and incontinent care residents transfer and repositioning statuses were audited to ensure the lift status was accurate along with proper staff needed for turning/repositioning. There were 36 residents identified with an overdue lift assessment in the facility, these were updated/corrected on 2/3/26 and 2/4/26 by the safety nurse. Any updated/changed assessments were updated on the resident's door sticker outside of the room per facility policy for staff communication. An audit was completed by the Director of Nursing for any overdue safe resident handling assessments on 2/3/26. This audit assesses the residents' transfer status and repositioning/ADL care while in bed, this assesses how much staff is needed in the room to ensure safe ADL care and repositioning while in bed. Any overdue assessments were completed/updated on 2/3/26 through 2/4/26 by the Safety Nurse. Door stickers were updated by the safety nurse on the day the assessment was completed on 2/3/26 through 2/4/26 with any revised safe handling assessment to ensure proper communication with staff. The Director of Nursing reviewed the overdue assessments due to all others in the building being up to date and accurate at the time of the audit.The incident/accident log was reviewed by the Director of Nursing, and this incident was the only fall identified from the bed where staff were present and involved turning and repositioning. The incident/accident log was reviewed from August of 2025 to current. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recurDirector of Nursing investigated the fall on 2/3/26 with staff involved and collected witness statements. On the same day the Director of Nursing, Administrator and Regional nurse consultant spoke and decided to implement a plan of correction. Resident audits and Nursing staff education started on 2/3/26 and was completed by 2/9/26. Education included proper/bed safety, not leaving residents unattended during incontinent or ADL care while in bed, that any safety devices ordered for the resident are used during incontinence/ADL care to ensure safety, and proper number of staff are utilized while providing care including turning and repositioning in bed. Education was provided by the Director of Nursing (DON) or designee to all nursing staff, including nurses and nurse aides. The training focused on safe care practices in bed. Staff were reminded not to leave residents unattended during incontinent care or ADLs. They were also instructed on proper use of safety devices, such as side rails, and to make sure residents use or hold them during care when ordered. In addition, staff were reminded to use the correct number of caregivers when providing care and to follow turning and repositioning protocols. The education that was provided on the turning and repositioning protocol included staff reading the door sticker outside of the door at each resident's room to identify their lift status and the number of staff needed for turning/repositioning. The letter R on the door designates the number of staff needed for repositioning. Staff were instructed to follow the turning and repositioning policy and that they are to follow the number of staff and lift status posted outside the door to ensure safety during resident transferring and ADL care/repositioning. Education was completed on 2/9/26, the sticker on the outside of the door is per the facility's policy and allows any staff member entering the room to know the residents' lift status and how many staff are needed for assisting with turning/repositioning. The restorative/safety registered nurse or designee in her absence was responsible for updating the assessments along with updating the sticker on the door. Upon returning to the facility Resident #1 was assessed to need two staff members to assist with turning/repositioning and the door sticker was updated to reflect the assessment changes.Proper bed height was determined to be about waist level of the staff member providing the care, this was included in the staff education, education started on 2/3/26 and was completed on 2/9/26 and was completed by the Director of Nursing/Designee. All employees were able to verbalize understanding of education provided back to the educator via in person or over the phone. This ensures the bed is at the appropriate level for back safety and safety of the residents while in bed receiving care. Verbal education via phone was completed with nursing staff that were not in the facility by the Director of Nursing/Designee. Staff educated in-person and via phone were able to verbalize understanding of above education topics. Education was completed by 2/9/26. Newly hired nursing staff will receive this education during their job specific orientation prior to performing resident care. Education will be provided by the Director of Nursing or designee. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.A monitoring tool for resident safety during ADL/incontinent care while in bed was started on 2/3/26 with four resident observations completed weekly for twelve weeks by the DON or designees. The audit being performed by the Director of Nursing and or Designee monitors safe bed height, proper staff is in the room during care, and if side rails are ordered/assessed for the resident they are being used properly. These audits will take place on all three shifts including weekends.Falls are reviewed each morning in our daily quality improvement stand-up meeting, and no further falls have involved staff being present in the room at the time of incident nor have the falls involved turning and repositioning.Plan of Correction and weekly monitoring findings are discussed in regular weekly quality assurance and performance improvement (QAPI) meetings starting on 2/6/26 and continuing for twelve weeks. There have been no further falls with injury related to bed mobility or safety since this incident on 1/31/26. Date of Compliance: 2/10/2026 On 3/12/26, the facility's corrective action plan effective 2/10/26 was validated by the following: Observations of resident's ability to use assistive devices during care including side rails, staff turning and repositioning, and resident beds being in a safe position while in use with no issues or concerns noted. Nursing staff interviews revealed they had received education on providing incontinent care to residents safely prior to providing care, making sure all assistive devices (side rails) for residents were being used appropriately and safely, turning and repositioning to include making sure residents are being turned safely, correct number of staff required to provide assistance was being utilized, notification of changes with mobility or ability to use side rails safely, fall protocol being followed to include notifying superv

Based on observations, staff interviews, and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints (Resident #8), infections (Resident #15), and falls with major injury (Resident #35). This deficient practice was identified for 3 of 5 sampled residents.The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included epilepsy (seizure disorder). Review of Resident #8’s quarterly MDS assessment dated [DATE] revealed Resident #8 was cognitively intact and used restraints (bedrails) on a daily basis. Review of the Bed Rail assessment dated [DATE] completed by the Safety Nurse revealed Resident #8 utilized two upper bed rails for positioning and mobility. An observation and interview were conducted with Resident #8 on 08/27/2025 at 12:35 PM. Resident #8 was observed in his room sitting up in his chair beside his bed. Resident #8’s hands were contracted with bilateral palm guards in place. Resident #8’s bed had no side rails in use. Resident #8 stated he was not able to help staff turn and position him in bed and he did not need the rails on his bed. An interview was conducted with the Nurse Assessment Coordinator on 08/27/2025 at 1:50 PM. The Nurse Assessment Coordinator stated that Resident #8’s MDS was coded inaccurately and that she had made a mistake when completing Resident #8’s MDS assessment. The Nurse Assessment Coordinator explained that she did not mean to click “restraints” used daily. The Nurse Assessment Coordinator further explained that she was new to the MDS role and was still learning the MDS process. An interview was conducted with the Safety Nurse on 08/27/2025 at 2:10 PM. The Safety Nurse stated that Resident #8 had previously used two upper rails for positioning and bed mobility but Resident #8’s last bed rail assessment revealed he was unable to use the side rails for any type of repositioning or support. An interview was conducted with the DON on 08/27/2025 at 2:30 PM. The DON stated that she expected all MDS assessments be completed accurately based on the resident’s clinical status. An interview was conducted with the Administrator on 08/27/2025 at 2:46 PM. The Administrator stated that she expected the MDS to be reflective of the resident’s clinical condition and completed accurately. 2. Resident #15 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and latent tuberculosis (TB). Review of the Electronic Medical Record revealed Resident #15 had received no treatment for TB since she was admitted to the facility on [DATE]. Review of Resident #15’s quarterly MDS assessment dated [DATE] revealed Resident #15 was cognitively intact and was coded for active TB. An observation and interview were conducted with Resident #15 on 08/27/2025 at 10:04 AM. Resident #15 was observed in her room sitting up in her wheelchair. Resident #15 was alert and oriented and stated that she did not have TB, but she had smoked for many years and had lung disease. An interview was conducted with the Nurse Assessment Coordinator on 08/27/2025 at 10:07 AM. The Nurse Assessment Coordinator stated that Resident #15’s MDS entry for TB was made in error. The Nurse Assessment Coordinator explained that she did not mean to select “tuberculosis”. The Nurse Assessment Coordinator further explained that she was new to the MDS role and was still learning the MDS process. An interview was conducted with the Administrator on 08/27/2025 at 10:28 AM. The Administrator stated the Nurse Assessment Coordinator was new to the role and miscoded the TB on Resident #15’s MDS. The Administrator also stated that she expected the MDS to accurately reflect the resident’s clinical assessment including active diagnoses. An interview was conducted with the Nurse Practitioner (NP) on 08/28/2025 at 11:31 AM. The NP stated that Resident #15 had latent TB, not active TB. The NP further explained that Resident #15 had not received any treatment for TB and had no respiratory issues. 3. Resident #35 was initially admitted to the facility on [DATE] and was readmitted to facility on 12/31/24. Resident #35’s diagnoses included unspecified dementia, generalized muscle weakness, and unsteadiness on feet. Resident #35’s progress note dated 03/18/25 at 8:26 AM revealed Resident #35 had an assisted fall when lowered to the ground during transfer from toilet to wheelchair. Swelling and bruising were immediately noted to Resident #35’s left pinky finger after the fall. An x-ray of Resident #35’s left hand was ordered at that time. Resident #35’s physician orders dated 03/18/25 revealed the following orders: 1. Refer to orthopedics (physicians who treat bone fractures) for proximal (fracture is closer to hand than the fingertip) 5th finger comminuted (a fracture where bone breaks into three or more fragments) fracture. 2. Wrap left hand with ACE (all cotton elastic) wrap daily to support left pinky due to broken finger until follow-up with orthopedics. A review of Resident #35’s quarterly MDS assessment dated [DATE] revealed Resident #35 was coded to have sustained no falls with major injury. An interview with the MDS Coordinator on 08/28/25 at 10:59 AM revealed that Resident #35’s quarterly MDS assessment had been completed on 06/10/25 but was not correctly coded for fall with major injury after the fall on 03/18/25 which resulted in a finger fracture. The MDS Coordinator stated the miscoding was an error due to an oversight. An interview with the DON on 08/28/25 at 10:13 AM revealed that she expected the resident’s MDS assessments would be accurate and reflect the resident's care needs. An interview with the Administrator on 08/28/25 at 11:29 AM revealed that it was important that MDS assessments were completed accurately.

Based on record review, observation, resident and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan for 1 of 6 residents whose comprehensive care plans were reviewed (Resident #30). Findings included:Resident #30 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes and constipation.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact, had no reports of constipation on look back period, and had no pressure or vascular ulcers on admission.A review of Resident #30's comprehensive care plan initiated 6/02/25 and last revised 8/06/25 did not reveal a care plan for wounds to left foot or constipation.Physician's orders for Resident #30 revealed the following orders: A current order initiated on 5/30/25 for polyethylene glycol (a laxative) 17 grams twice daily. A current order initialed on 05/30/25 for Senna (a laxative) 8.6 mg tablet, take 2 tablets by mouth twice daily. An order dated 06/20/25 for daily treatment of left great toe wound. A current order initiated on 06/21/25 for lactulose (a laxative) 45 milliliters daily. An order dated 08/04/25 for daily treatment of left foot wound. A review of Resident #30's Gastroenterologist consult for constipation dated 08/14/25 revealed recommendations were for metoclopramide to assist with clearing stool from Resident #30's colon. A physician order was entered on 8/16/25 for metoclopramide (a medication that increases intestinal movement) 5 mg daily.An interview with the MDS Coordinator on 08/28/25 at 10:59 AM revealed that Resident #30's comprehensive care plan should have been updated when Resident #30 developed two separate wounds on his left foot which required daily treatment. The MDS Coordinator stated a care plan for constipation should have been initiated when Resident #30 was admitted due to constipation. The MDS Coordinator would be notified of resident changes in the daily team meeting. The MDS Coordinator stated the lack of care plan initiation was an error due to an oversight.An interview with the Director of Nursing (DON) on 08/28/25 at 11:13 AM revealed that she expected the resident's care plans to be accurate and reflect the resident's care needs. If a resident's condition changes, a new care plan should be initiated by the MDS Coordinator.An interview with the Administrator on 08/28/25 at 11:29 AM revealed that it was important that care plans were completed accurately. The Administrator stated the care plan should reflect the clinical condition of the residents, including constipation and wounds.

Based on record review, staff and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when Resident #1, who had a history of falls, slid out of a standard wheelchair onto the floor. The standard wheelchair was not the wheelchair Resident #1 was care planned to use when out of bed. Resident #1 later complained of pain and an x-ray revealed a femur fracture. Resident #1 was transferred to the hospital and diagnosed with a femur and knee fracture. The deficient practice occurred for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1).Resident #1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, Parkinson's, type 2 diabetes mellitus, acute congestive heart failure, low back pain, other chronic pain, vitamin D deficiency, hypomagnesemia, major depressive disorder, unspecified atrial fibrillation, anxiety disorder, pain unspecified.Review of Resident #1's medical record revealed Resident #1 had received hospice services that started on 1/27/2025 related to end stage Parkinson's disease. On 2/18/2025 documentation revealed hospice services would not cover Resident #1's intravenous antibiotic therapy, and Resident #1's family agreed to revoke hospice services. Palliative services were requested by Resident #1's family on 2/21/2025, and a referral for Palliative services was sent on 2/24/2025. Review of Resident #1 physician's orders revealed active orders that read: Eliquis 5 milligram (mg) tablet one tablet by mouth every 12 hours for atrial fibrillation. Tramadol 50mg one tablet by mouth three times daily for chronic pain. Acetaminophen 325 mg tablet two tablets by mouth every 4 hours as needed for chronic pain.Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and indicated Resident #1 had impairment with range of motion for bilateral lower extremities, used a wheelchair for mobility, used a mechanical lift for transfers, required partial/moderate assist with rolling left and right in bed, and was dependent on staff for all other activities of daily living and mobility, and indicated Resident #1 received anticoagulant (blood thinner) medication. Review of Resident #1's comprehensive care plan last reviewed 6/25/2025 revealed Resident #1 was care planned at risk for falls due to narcotic use and dependence with mobility and history of falls with major injury with interventions that included: High back wheel chair with foam wedge cushion, elevating leg rests, and drop leg pad, when out of bed, assess transfer status as needed. Review of a progress note written by Nurse #1 on 7/1/2025 at 5:50 PM revealed Nurse #1 was called to Resident #1's room on 7/1/2025 at 2:45 PM by Nursing Assistant (NA) #1 and found Resident #1 lying on the floor in front of her wheelchair. NA #1 reported Resident #1 was sliding out of the wheelchair and NA#1 assisted Resident #1 to the floor. Resident #1 was assessed; range of motion was completed without complaint of pain. Resident #1 was transferred from the floor to the bed using the mechanical lift. Nurse #1 completed a skin audit and found no injuries. Family and provider were notified, and Resident #1 had no further complaints.During an interview on 7/16/2025 at 10:48 AM NA #1 stated on 7/1/2025 she worked from 7:00 AM to 3:00 PM and cared for Resident #1. NA #1 was told Resident #1 needed to be up in the wheelchair to go to a hair appointment. NA #1 stated she didn't normally work with Resident #1, and there were three chairs in Resident #1's room, a recliner and two wheelchairs. NA #1 stated NA #2 told her which wheelchair to use and it was the one that did not have a high back or attachments on the leg rests. NA #1 and NA#2 transferred Resident #1 into the standard wheelchair. NA #1 stated the hairdresser took Resident #1 to the beauty shop and brought Resident #1 back to her room when the hair appointment was finished. NA #1 stated she saw Resident #1 was back in her room around 2:35 PM, and Resident #1 requested to be put back in bed. NA #1 prepared Resident #1 to be transferred back to bed with the mechanical lift. NA #1 stated she brought the mechanical lift into Resident #1's room, positioned Resident #1 in the wheelchair next to the wall, locked the wheelchair and adjusted the footrests to the sides of the wheelchair and waited for another staff to assist with the transfer. NA #1 stated she noticed Resident #1 had started to slide out of the wheelchair. NA #1 stated she attempted to keep Resident #1 from sliding out of the wheelchair but was unable to reposition Resident #1 back into the wheelchair, and NA #1 assisted Resident #1 to the floor. NA #1 stated Resident #1's legs did not go behind her or under the wheelchair. NA#1 stated Resident #1's right leg went down straight in front of Resident #1 and her left leg bent out to the side. NA #1 stated it did not look out of place, and that Resident #1's left leg normally had a slight bend out and did not ever completely straighten out. NA #1 stated she called for a nurse to assess Resident #1. NA #1 stated Resident #1 was assessed by the nurses and no injury was noted. NA #1 stated after the nurse assessed Resident #1, she moved Resident #1's left leg to what appeared to be a more comfortable position before Resident #1 was transferred back to bed and Resident #1 had no complaint of pain. NA #1 stated Resident #1 complained of back pain while on the floor and after Resident #1 was transferred back to bed she voiced back pain that alternated with complaints of leg pain but was not consistent. NA #1 stated she did not see any injury, redness or swelling on Resident #1's legs.During an interview on 7/16/2025 at 11:08 AM Nurse #1 stated she entered Resident #1's room on 7/1/2025 at 2:45 PM and saw Resident #1 lying on her back on the floor. Resident #1 was assessed for injury, range of motion was within normal limits, no injury, bruising or swelling, and nothing out of the ordinary was noted during assessment. Nurse #1 stated after assessment Resident #1 was transferred back to bed using a mechanical lift, and another assessment was completed that revealed no injury. Nurse #1 stated Resident #1 frequently complained of back pain and voiced back pain after transfer so as needed (PRN) acetaminophen was administered. Nurse #1 stated if she had noted any swelling, or signs of injury she would have reported it to the provider immediately. Nurse #1 in a follow up interview on 7/21/2025 at 3:21 PM, stated the PRN acetaminophen administered to Resident #1 on 7/1/2025 at 3:09 PM was given for general discomfort, which was charted as pain, but due to the time the medication was documented in the electronic MAR, it was later in the shift the comment resident care was entered to explain the late documentation.Review of Resident #1's July Medication Administration Record (MAR) revealed: Resident #1 received PRN acetaminophen on 7/1/2025 at 3:09 PM for pain at a level of 8 out of 10, and it was documented with a comment of: resident care and follow up was documented as somewhat effective. Resident #1 received PRN acetaminophen on 7/1/2025 at 8:41 PM for leg pain at a level of 7 out of 10, and it was documented at follow up as somewhat effective. Resident #1 received a scheduled tramadol 50mg three times daily as ordered on 7/1/2025.During an interview on 7/16/2025 at 11:45 AM NA #2 stated on 7/1/2025 she worked 7:00 AM- 7:00 PM, and she assisted NA #1 while Resident #1 was transferred from bed to wheelchair. NA #2 stated Resident #1 used a standard wheelchair, not the high back wheelchair for hair appointments, because Residents #1's family and hairdresser said they were unable to complete the hair appointment when Resident #1 was in the high back wheelchair. NA#2 stated she was not present when Resident #1 slid from the wheelchair.During a telephone interview on 7/21/2025 at 4:10 PM NA #7 verified she had worked 3:00 PM to 11:00 PM on 7/1/2025 and cared for Resident #1. NA #7 stated Resident #1 had voiced pain in her leg, NA #7 reported it to the nurse. NA #7 did not recall any bruising, swelling or increased complaints of pain with movement.During a telephone interview on 7/22/2025 at 9:58 AM NA #8 verified she had worked 11:00 PM - 7:00 AM on 7/1/2025 and cared for Resident #1. NA #8 stated she did not recall the specific report she received. NA #8 stated Nurse #3 assisted her while she provided care to Resident #1. NA #8 stated Resident #1 voiced pain during care but was asleep prior to and after care was provided. NA #8 stated no bruising or swelling was noted to Resident #1's lower extremities, but care was provided very gently due to pain with movement. NA #8 stated Resident #1 had a lot of stiffness normally around her knees, which caused her legs to appear bent, but NA #8 did not recall any signs of injury.Review of a nursing progress note written by Nurse #3, revealed Resident #1 had vocalized pain throughout Nurse #3's shift. Nurse #3 wrote when her shift started at 7:00 PM on 7/1/2025 she received report Resident #1 had fallen during the day. Nurse #3 documented Resident #1 had episodes of yelling throughout the shift and had voiced pain in left leg near buttock and vocalized pain when staff provided incontinence care. Resident #1 received PRN acetaminophen, and staff attempted to position Resident #1 in a more comfortable position. Nurse #3 completed a Situation, Background, Assessment, and Recommendation (SBAR) form (a structured communication framework used primarily in healthcare settings to facilitate prompt and appropriate communication among professionals) so the provider would see Resident #1 in the morning. During a telephone interview on 7/21/2025 at 4:00 PM Nurse #3 verified she worked from 7:00 PM to 7:00 AM on 7/1/2025 and was assigned to Resident #1. Nurse #3 stated she received a report at the start of her shift at 7:00 PM, that Resident #1 had a fall- slid out of her wheelchair- assisted by staff earlier that day, and had no injuries. Nurse #3 stated Resident #1 yelled out related to her confusion and dementia at baseline. Nurse #3 stated on 7/1/2025 Resident #3 voiced pain in her leg when turned by staff, Nurse #3 assisted NA #8 as Resident #1 was turned, cleaned, changed and repositioned in bed. Nurse #3 stated she saw no bruising, swelling or signs of injury on Resident #1, or she would have called the on-call provider immediately. Nurse #3 stated she administered PRN acetaminophen to Resident #1 at 8:44 PM for leg pain, and it was somewhat effective. Nurse #3 stated after the PRN was administered Resident #3 was quieter and rested. Nurse #3 stated Resident #3 voiced leg pain when turned early in the morning of 7/2/2025. Nurse #3 stated she administered PRN acetaminophen at 3:11 AM on 7/2/2025 to Resident #1 for leg pain after she was turned and repositioned, and Resident #1 went back to sleep. Nurse #3 stated the acetaminophen appeared to be effective since Resident #1 went back to sleep. Nurse #3 stated she had not noted any sign of an obvious injury based on her assessment, but thought Resident #1 was sore from her fall. Nurse #3 stated she completed an SBAR so the Nurse Practitioner (NP) would assess Resident #1 in the morning, to see in an x-ray was needed. Resident #1 received PRN acetaminophen on 7/2/2025 at 3:11 AM for a pain level of 7 out of 10, and it was documented effective. Resident #1 received a scheduled tramadol 50mg three times daily as ordered on 7/2/2025.Review of Resident #1's medical record revealed an order dated 7/2/2025 for a STAT (needed immediately) left hip, femur, pelvis and lumbar spine x-ray, entered by Nurse #1 at 9:54 AM.During a telephone interview on 7/22/2025 at 11:25 AM Nurse #4 verified on 7/2/2025 she worked 7:00 AM to 7:00 PM and Resident #1 was assigned to one of the halls she worked. Nurse #4 stated she had assessed Resident #1's leg on the morning of 7/2/2025 and had not seen any bruising swelling or signs of injury. Nurse #4 stated Resident #1 had appeared at her baseline. Nurse #4 stated she was only involved with sending Resident #1 to the hospital after x-ray results were received. Nurse #4 stated she thought the order for the x-ray had been obtained by another nurse, and Nurse #1 or the DON had helped with Resident #1. Nurse #4 stated she did recall the NP had assessed Resident #1 on the morning of 7/2/2025. Review of a nursing progress note written by the Director of Nursing (DON) on 7/2/2025 at 1:06 PM revealed x-rays were obtained on Resident #1 related to complaints of left hip pain after a fall on 7/1/2025. The provider reviewed x-ray results which noted a left femur fracture. Resident #1's family was notified and requested transfer to the hospital and the Nurse Practitioner (NP) agreed. 911 was called and Resident #1 was transferred to the hospital.Review of Resident #1's hospital records from 7/2/2025 through 7/8/2025 revealed Resident #1's left lower leg had swelling and tenderness. X-ray results revealed left distal femoral (thigh bone) fracture, the fracture extended into or was in close proximity to the knee replacement, and a fracture in a bone of the left knee joint. Resident #1's left leg was placed in a brace. An orthopedic surgery consult recommended conservative management with continued use of immobilizer to left leg, and non-weight bearing status on left lower extremity with follow up with orthopedic surgery in the outpatient setting after discharge. Resident #1 had a Palliative care consultation, and by family request was discharged to a hospice facility on 7/7/2025. During an interview on 7/16/2025 at 1:27 PM the Nurse Practitioner (NP) stated Resident #1 used a mechanical lift for transfers. The NP stated she had only seen Resident #1 in the recliner or bed; it had been a while since the NP had seen Resident #1 in a wheelchair. NP was aware Resident #1 used a wheelchair for hair appointments and when Resident #1 went out of the facility. The NP stated she was not aware of which wheelchair Resident #1 was supposed to use, that she left that to therapy and nursing. The NP stated she was notified on 7/2/2025 that Resident #1 had slid out of the wheelchair on 7/1/2025. The NP stated when she was notified Resident #1 had complained of pain in her legs she had ordered STAT x-rays. The NP stated if Resident #1 had a care plan to use a specific wheelchair when out of bed, that is the wheelchair that should be used. The NP stated if Resident #1 needed another wheelchair for hair appointments, then the NP would expect it to be discussed with therapy and care planned for use. During a follow up telephone interview on 7/21/2025 at 4:17 PM the NP stated she did not work on 7/1/2025, but on- call providers are available. The NP stated Resident #1 had dementia and some yelling behaviors at baseline, but if Resident #1 had complained of consistent pain that was not relieved by medication, she would have expected the on-call provider to be notified. The NP stated the SBAR was an appropriate communication for her to receive when she returned on 7/2/2025, if there was no sign of injury and pain medication was effective.During an interview on 7/16/2025 at 2:25 PM the Occupational Therapist (OT) stated Resident #1 had been assessed and approved for the high back wheelchair with wedge cushion, elevated footrests and leg drop pad, no other wheelchair. The OT stated she did not see any referrals for evaluation of another wheelchair for Resident #1. The OT stated she was unaware Resident #1 had used a different wheelchair for hair appointments. The OT stated an evaluation of the wheelchair should have been completed to ensure it met Resident #1's needs. During an interview on 7/16/2025 at 2:45 PM the MDS Nurse stated if Resident #1 required a different chair for hair appointments, it should have been added to the care plan.During a telephone interview on 7/16/2025 at 3:45 PM NA #3 stated it had been awhile since he had taken Resident #1 to a hair appointment but he recalled part of the high back wheelchair could be removed for the hair dresser to complete the appointment, or the high back chair could be leaned back and the hair dresser had equipment used to wash Resident #1's hair.During a telephone interview on 7/16/2025 at 3:55 PM NA #4 stated she thought Resident #1's high back chair had a piece that could be removed for hair appointments.During an interview on 7/16/2025 at 4:05 PM the Social Worker stated Resident #1's family had a hairdresser, that did not work for the facility, that came in to do Resident #1's hair. The Social Worker stated the hairdresser had reported she was unable to complete Resident #1's hair appointment when Resident #1 was in her normal wheelchair and a regular wheelchair was used when Resident #1 went to the beauty shop. The Social Worker stated she thought a regular wheelchair was used so Resident #1's hair could be washed in the sink. The Social Worker stated she thought nursing had assessed Resident #1 using a standard chair for the beauty shop, and a standard chair had been used for Resident #1's hair appointments for quite a long time. The Social Worker was unsure of exactly how long a standard chair had been used for Resident #1 in the beauty shop.During an interview on 7/16/2025 at 4:33 PM the Director of Nursing (DON) stated Resident #1 only used the standard wheelchair for hair appointments at the beauty shop because Resident #1's family and hairdresser had told them Resident #1's hair could not be completed in Resident #1's regular chair. The DON stated she did not recall exactly how long Resident #1 had used the standard wheelchair for hair appointments but had stated it had been used for a couple years. The DON stated she could not verify Resident #1 was not assessed to use the standard wheelchair for hair appointments but verified there was no documentation of an assessment or orders for therapy referral. The DON stated since Resident #1 had a care plan for a specific chair when out of bed, and that wheelchair was not being used for hair appointments, there should have been an assessment and documentation regarding the wheelchair used for hair appointments.During an interview on 7/16/2025 at 5:31 PM the Administrator stated she was notified Resident #1 had slid out of her wheelchair onto the floor. The Administrator stated at the time she was notified of the fall she was not aware Resident #1 had used a standard wheelchair, and not Resident #1's care planned wheelchair. The Administrator stated she was then told the hairdresser had asked for Resident #1 to be in a lower back chair. The Administrator stated she asked the DON, after the fact, if Resident #1 had looked appropriate in the standard wheelchair and that the DON had stated Resident #1's positioning was appropriate in the standard wheelchair. The Administrator stated if a resident had to use a wheelchair that was not the care planned wheelchair, she expected there to be assessment and documentation regarding the use of a different wheelchair.

Based on record review, Resident Representative, and staff interviews, the facility failed to provide dignity for a cognitively impaired resident who waited for incontinence care to be provided. Resident #1 was severely cognitively impaired and Resident Representative stated that Resident #1 would have felt awful and embarrassed when left in wet brief without incontinence care. This deficient practice affected 1 of 3 resident sampled for dignity and respect (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, cystitis with hematuria (inflammation of the bladder with bleeding), and overactive bladder. Resident #1 was discharged on 07/02/2025.An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired. MDS further indicated she required extensive assistance for toileting, bathing, and personal hygiene. Resident #1 was always incontinent of urine.A review of Resident #1's care plan revealed a plan initially dated 09/19/23 and revised 06/25/25 for urinary incontinence. Stated goal was Resident #1 would have no urinary discomfort. Interventions included administer medications and monitor for medication effectiveness, provide incontinence care, and monitor for bladder discomfort.A review of facility grievances revealed a grievance for Resident #1 dated 01/13/25. Grievance revealed the Resident Representative reported incontinence care was not provided for hours on 1st shift 01/11/25. Investigation was completed by previous Director of Nursing (DON) and Social Worker. Investigation notes indicated that NA #5 received disciplinary action for failing to provide care. Folow-up with Resident #1's Representative was completed by Social Worker at care plan meeting on 01/16/25. Follow-up stated that all questions were addressed, and no new concerns were identified. A care plan meeting was scheduled. Grievance was signed completed by the Administrator on 04/04/25.An interview statement with Resident #1's Representative dated 01/13/25 was completed by Social Worker. The statement revealed Resident #1's Representative had visited on 01/11/25 and at 1:00 PM, inquired to Nurse #2 about Resident #1's hematuria. When Nurse #2 asked NA #5 about Resident #1's urine that day, NA #5 responded to Nurse #2 and Resident Representative that she had not yet provided incontinence care to Resident #1 during her shift which began at 7:00 AM. Incontinence care was provided for Resident #1 by NA #5 and NA #1.An interview with the Resident Representative on 07/16/25 at 12:14 PM revealed concerns Resident #1's incontinence care was not performed 01/11/25. Resident Representative stated that NA #5 had not change Resident #1 during NA #5's shift until asked to do so at 1:00 PM. Resident Representative stated she was satisfied with the facility's resolution of grievance and reported no further concerns about Resident #1's incontinence care.A review of NA #5's personnel file revealed a hire date of 10/15/24. Documented counseling form dated 01/17/25 described the reason for counseling was employee failed to provide incontinent care to resident for an overly extended amount of time on 01/11/25.NA #5 was not available for interview.A telephone interview with NA #1 on 07/16/25 at 11:36 AM revealed that she could not recall the specific date of 01/11/25. NA #1 stated that she could not recall any specific concerns about Resident #1's care.A review of Nurse #2's written statement dated 01/12/25 revealed that Resident #1 was not changed on 7:00 AM to 3:00 PM shift until NA #5 was asked to change Resident #1.Interview with Nurse #2 on 07/16/25 at 2:24 PM who provided care for Resident #1 on 01/11/25. Nurse #2 stated that she could not specifically recall the 01/11/25 shift. Nurse #2 stated that although she could not recall that specific date, Nurse #2 had to remind NA #5 often to provide incontinence care to residents including Resident #1. Nurse #2 indicated she verbalized her concerns to previous Director of Nursing (DON) who no longer worked at the facility but could not recall specific date or time of report.A telephone interview on 07/16/25 at 4:16 PM with NA #6 revealed she worked on 01/11/25 from 3:00 to 11:00 PM and was assigned to care for Resident #1. She stated she was familiar with Resident #1's care. NA #6 stated that she would often follow behind NA #5 who worked from 7:00 AM to 3:00 PM. When NA #6 arrived after NA #5, Resident #1 was often in her bed and her bed sheets would be saturated in urine with a brown ring around Resident #1. NA #6 reported that NA #5 left at 3:00 PM on 01/11/25. NA #6 stated that she would make a point to check Resident #1 first on rounds because NA #5 would not change her. NA #6 had previously verbalized concerns to nurses when Resident #1 was left with wet brief by NA #5 but could not recall specific nurses or times. NA #6 indicated that she could not recall if Resident #1 was left with wet brief on 01/11/25 and could not recall any specific concerns that day.An interview with Social Worker on 07/16/25 at 4:33 PM revealed that the grievance investigation indicated Resident #1 was left wet with urine on 01/11/25. The Social Worker stated that she could not recall specific evidence related to the incident. The Resident Representative reported that Resident #1 was left wet with urine through the 7:00 AM to 3:00 PM shift until 1:00 PM. The Social Worker stated that NA #5 received disciplinary action for failure to provide incontinence care. The Resident Representative revealed no further concerns when Social Worker followed up.The previous DON was not available for interview.An interview with the current DON on 07/16/25 at 04:33 PM revealed that she was aware of Resident #1's Resident Representative report that Resident #1 did not receive incontinent care by NA #5 on 01/11/25. The current DON stated that she was Assistant Director of Nursing on 01/11/25 and provided the documented counseling to NA #5. The previous DON had investigated, and Nurse #2 validated that Resident #1 was left wet on 01/11/25. The current DON indicated that NA #5 had ongoing issues with time management and NA #5 was transferred to another hall and time management improved. DON stated incontinent care should be provided to residents every 2 hours.

Based on observations, record review, and staff interviews, the facility failed to establish policies and procedures for standard and transmission-based precautions and failed to implement Enhanced Barrier Precautions (EBP) when providing urinary catheter care for 1 of 3 staff members reviewed for infection control practices (Nurse Aide #1). The findings included: A review of the facility's Infection Control policies and procedures revealed no policy and procedure for Enhanced Barrier Precautions (EBP). Review of a care plan dated 9/12/2024 revealed Resident #1 had an indwelling catheter with interventions which included to utilize Enhanced Barrier Precautions (EBP) per facility protocol. An observation was conducted on 10/17/2024 at 3:35 pm. Resident #1 had an EBP sign which stated everyone should clean their hands before entering and after leaving the room. All healthcare personnel must wear gloves and gown for the following high-contact activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of a central line/urinary catheter/feeding tube/tracheostomy, and/or wound care (any skin opening requiring a dressing). A personal protective equipment (PPE) caddy was hanging outside of the door. Nurse Aide (NA) #1 was observed sanitizing her hands prior to entering Resident #1's room. NA #1 washed her hands, put on clean gloves, and proceeded to provide urinary catheter care. An interview was conducted on 10/17/2024 at 3:45 pm with NA #1. NA #1 stated she was trained on infection control when she was hired. NA #1 stated EBP were used when a resident had a common cold and sometimes for a wound. NA #1 stated that she had seen the EBP sign and caddy on the outside of Resident #1's door but was not sure why it was there. NA #1 stated Resident #1 did not have a wound and did not have any respiratory symptoms which is why she did not wear a gown when providing indwelling urinary catheter care. NA #1 was unaware that EBP was utilized for residents with an indwelling urinary catheter. NA #1 stated that she had received education about EBP. An interview was conducted on 10/17/2024 at 3:48 pm with Nurse #1. Nurse #1 stated EBP was utilized when a resident had an indwelling urinary catheter or a wound. Nurse #1 stated staff should wear a gown, mask, and gloves when providing direct care including indwelling urinary catheter care. Nurse #1 stated Resident #1 had an indwelling urinary catheter and a wound. Nurse #1 stated a mask, gown, and gloves should have been worn when providing indwelling urinary catheter care. An interview was conducted on 10/18/2024 at 8:32 am with the Assistant Director of Nursing (ADON). The ADON stated that she was also the Staff Development Coordinator (SDC) and the Infection Preventionist (IP). The ADON stated that during orientation, staff were educated about EBP. The ADON stated staff were taught to look for precaution signage on the outside of the resident's room and were to follow what the signage said. The ADON stated staff was taught to ask for clarification if they had any questions regarding EBP. The ADON stated she had not performed audits of donning/doffing PPE and would provide additional training for staff if there were any issues. The ADON stated gloves and a gown, should be worn when providing direct care to a resident with an indwelling urinary catheter or a wound. The ADON stated NA #1 should have worn a gown and gloves when she provided indwelling urinary catheter care for Resident #1. An interview was conducted on 10/18/2024 at 10:45 am with the Director of Nursing (DON). The DON stated EBP were new, and staff were educated when the facility began to implement EBP. The DON stated EBP were used for residents who had an indwelling urinary catheter, intravenous catheter (IV), wounds, or received tube feeding. The DON stated a gown, and gloves were to be worn when providing direct care to a resident on EBP. The DON stated there was a sign and PPE on the door if a resident was on EBP and the ADON was responsible for placing EBP signage. The DON stated a gown, and gloves should have been worn when staff provided indwelling urinary catheter care. The DON stated that there were no policies or procedures for EBP and stated that their corporate office had instructed them to go by Center for Disease Control (CDC) guidelines.

Based on staff interviews the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control Program. The deficient practice had the potential to affect 105 of 105 residents at the facility. The findings included: An Entrance Conference was conducted on 10/17/2024 at 8:40 am with the Administrator. The Administrator stated the Assistant Director of Nursing (ADON) was the Infection Preventionist (IP). An interview was conducted on 10/18/2024 at 8:30 am with the Administrator. The Administrator stated that the ADON had immediately stepped into the IP role after the previous IP left on 7/25/24. The Administrator stated the facility had not had a qualified IP since 7/25/2024. The Administrator stated she had signed the ADON up for the Statewide Program for Infection Control and Epidemiology (SPICE) training on 10/17/2024 after she realized that the ADON not being SPICE trained might be an issue. The Administrator stated there were only two SPICE training classes per year and she signed the ADON up to take the class that started on 11/4/2024. The Administrator stated that she had every intention of enrolling the ADON in SPICE training but had just not signed the ADON up. An interview was conducted on 10/18/2024 at 8:32 am with the ADON. The ADON stated she began the role of IP immediately after the previous IP left. The ADON stated that she had not received any training for her role as an IP. The ADON stated a consultant did not come to the facilityroutinely but whenever she had a question about something related to Infection Control, she would call and ask a corporate consultant. The ADON stated the Administrator signed her up on 10/17/2024 to take SPICE training and she would attend training on 11/4/2024 through 11/6/2024. The ADON stated that she had no primary training in epidemiology or infection prevention/control. An interview was conducted on 10/18/2024 at 10:05 am with the Director of Nursing (DON). The DON stated that after the previous IP left, the ADON stepped into the IP role. The DON stated she had taken SPICE training more than five years ago but did not have a copy of her certification and was not able to obtain a copy.

Based on observations, record review, resident, and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 3 residents (Resident #2) reviewed for activities of daily living (ADL). The findings included: Resident #2 was readmitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was moderately cognitively impaired, required maximum assistance for bathing and supervision for personal hygiene. A care plan dated 9/4/2024 revealed Resident #2 required assistance for all activities of daily living (ADL) related to weakness secondary to non-traumatic intracranial hemorrhage. An observation and interview were conducted on 10/17/2024 at 9:10 am of Resident #2. Resident #2 was observed with 1/4 inch long jagged fingernails on all ten fingers with a brown substance underneath all ten nails. Resident #2 stated the only time her nails were trimmed or cleaned, was when she went to activities. An observation was conducted on 10/17/2024 at 3:25 pm of Resident #2. Resident #2's fingernails remained 1/4 inch long, jagged, with a brown substance underneath all ten fingernails. An interview was conducted on 10/18/2024 at 11:19 am with Nurse Aide (NA) #2. NA #2 stated she worked first shift, 7:30 am to 3:00 pm, on 10/17/2024. NA #2 stated that she was not assigned Resident #2, however, she had assisted NA #3 with giving a bed bath. NA #2 stated that NAs were allowed to perform nail care, including cleaning and cutting, and stated that she had not provided fingernail care for Resident #2 because she was only assisting with bathing the resident. An interview was conducted on 10/18/2024 at 12:22 pm with NA #3. NA #3 stated that she worked first shift, 7:00 am to 3:00 pm, on 10/17/2024 and was assigned Resident #2. NA #3 stated she had only worked at the facility for a few weeks. NA #3 stated NA #2 assisted her in giving Resident #2 a bed bath on 10/17/2024. NA #3 stated she had not performed fingernail care for Resident #2 because she had not been taught/instructed to perform fingernail care since she started at the facility. An interview was conducted on 10/18/2024 at 12:04 pm with the Director of Nursing (DON). The DON stated that NAs were responsible for performing fingernail care for residents on an as needed basis. The DON stated that she was not aware that Resident #2 had 1/4 inch, jagged fingernails with a brown substance underneath. The DON stated her fingernails should have been cut and cleaned.

Based on record review, resident interview, and staff interviews the facility failed to safely transfer a resident when Nurse Aide (NA) #3 and NA #4 transferred Resident #240 resident from the bed to the wheelchair. During the transfer the resident reported pain and stated her knee had popped. Resident #240 was sent to the emergency room (ER) and x-ray results indicated a right horizontal fracture involving the superior patella (a break in the upper part of the kneecap) with large knee joint effusion. Resident #240 was discharged back to the facility the same day with an immobilizer and a follow up appointment with .This occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #240). The findings included: Resident #240 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #240 was moderately cognitively impaired and was dependent for transfer and required two people assist. Review of Resident #240's Kardex which explained the resident's transfer status indicated the resident was a two person assist with a gait belt since admission on 04/25/24. Review of Resident #240's physical therapy note dated 04/26/24 revealed Resident #240 was dependent for chair to bed and bed to chair transfers and required maximal assistance for sit to stand transfers. Interview conducted with the Director of Therapy on 05/22/24 at 10:10 AM revealed Resident #240 was admitted from the hospital as a two people assist with a gait belt and was assessed on 04/26/24 by therapy and was dependent for transfers. The Director of Therapy stated the resident was limited weight bearing and continued to require two people assist with a gait belt or a Hoyer lift. The Director of Therapy further revealed transferring Resident #240 without a gait belt was unsafe and nursing staff had been educated on how to properly transfer residents. A written statement completed by NA #3 on 05/03/24 revealed on 05/02/24 NA #3 and NA #4 entered Resident #240's room and the resident was sitting on the side of the bed with family wanting to assist the resident to the bedside commode. The statement further revealed Resident #240 was okay to be transferred from the bed to the wheelchair to be weighed. NA #3 indicated before Resident #240 sat in the wheelchair she plotted down, and her leg was under the wheelchair. The statement revealed NA #3 and NA #4 took Resident #240 to be weighed and then put her back in the bed. NA #3's written statement revealed Resident #240 stated her knee was hurting and they had received a footrest for the resident's wheelchair before going to be weighed. Interview conducted with NA #3 on 05/21/24 at 4:20 PM revealed on 05/02/24 she and NA #4 went into Resident #240's room to get the resident to be weighed. Resident #240 was sitting in the side of the bed with family present with the bedside commode nearby when they entered the room. NA #3 indicated the family left the room and they assisted the resident from the bed to the wheelchair to be taken to get her weight. NA #3 revealed she and NA #4 stood Resident #240 by the arms without a gait belt and started to turn the resident to be able to sit down but the resident lost her balance and fell back in the wheelchair. NA #3 stated Resident #240's right foot ended up behind and underneath the chair. NA #3 revealed Resident #240 started to scream in pain and stated that her knee popped. The NA indicated Nurse #4 was notified and assessed Resident #240 and instructed NA #3 to get a leg rest for the wheelchair to put the resident ' s right leg on. NA #3 revealed Resident #240 continued to complain of pain, but they were instructed by Nurse #4 to weigh the resident after she was assessed. NA #3 indicated Resident #240 was weighed and assisted back into bed by Nurse #4 and Nurse #3. NA #3 indicated Resident should have had a gait belt when transferred and they failed to do so because they were in a hurry. A phone interview conducted with Nurse Aide (NA) #4 on 05/21/24 at 1:50 PM revealed on 05/02/24 she and NA #3 were instructed by Nurse #4 to get Resident #240's weight. NA #4 further revealed the resident was sitting on the side of the bed with family present when they entered the room. NA #4 indicated the family left the room and NA #3 and NA #4 changed Resident #240's brief and transferred the resident from the bed to the wheelchair. NA #4 stated Resident #240 stood up assisted by both NAs and when the resident went to turn the resident fell back into the chair and Resident #240's right leg was bent back behind. NA #4 indicated Resident #240 stated my knee hurts bad, and something popped. Nurse #4 assessed the resident and placed Resident #240's right leg on a wheelchair leg rest and instructed for the NAs to weigh the resident after she was assessed. NA #4 indicated Resident #240 continued to complain of pain while being weighed. NA #4 revealed Nurse #4 and Nurse #3 put the resident back to bed. NA #4 stated she and NA #3 did not use a gait belt to transfer Resident #240 because they were in a hurry and should have because the resident was unable to hold her own weight and her Kardex required a two person transfer with a gait belt. A phone interview conducted with Nurse #4 on 05/22/24 at 8:55 AM revealed on 05/02/24 a NA reported Resident #240 was complaining of leg pain and heard a pop in her leg. Nurse #4 stated she observed Resident #240 in her wheelchair and was complaining of pain in both of her legs. Nurse #4 indicated she assessed Resident #240 but could not recall if she instructed NA #3 and NA #4 to obtain a footrest, the outcome of the assessment, or if she assessed the resident before or after she was weighed. Nurse #4 indicated she did not complete an incident report but did notify the Assistant Director of Nursing (ADON) due to being at shift change. Nurse #4 was unable to share any further details of what occurred on 05/02/24 with Resident #240. A written statement completed by Nurse #3 on 05/03/24 revealed on 05/02/24 Resident #240 stated that her right knee hurt, and the RR indicated it occurred during a transfer. The statement indicated the on call was notified and a STAT (immediate) x-ray was ordered, and a lidocaine patch was placed on the resident ' s knee for pain. Nurse #3's statement indicated the family requested for Resident #240 to be sent out to the ER and the on call provided an order for the resident to be sent out. Review of progress note dated 5/2/24 completed by Nurse #3 revealed Resident #240's resident representative (RR) reported the resident had complained of knee pain and that her knee popped when being transferred from the bed to the wheelchair. The on-call provider was contacted, and a STAT x-ray was ordered for Resident #240's right knee and the RR was notified. The note indicated Resident #240 received pain medication and a lidocaine patch that was applied to the knee for pain. Nurse #3 documented an estimated time of an hour and half later Resident #240's RR was concerned about the results and wanted the resident to be sent out to the hospital. The on-call was contacted again and an order was obtained to send out Resident #240 to the emergency room (ER) per RR request. A phone interview conducted with Nurse #3 on 05/22/24 at 8:30 AM revealed on 05/02/24 she arrived at the facility after the incident at shift change. Nurse #3 indicated Nurse #4 shared to monitor Resident #240's knee due to the resident stating her knee felt tight during a transfer. Nurse #3 recalled being on shift for about 45 minutes and Resident #240's RR asked her to assess Resident #240 right leg. Nurse #3 indicated Resident #240's right knee was swollen, and the resident had complained of pain. Nurse #3 further revealed she contacted and notified the on-call provider and a STAT order for an x-ray was put in. Nurse #3 revealed Resident #240's RR did not want to wait any longer and requested the resident go out to the hospital. Nurse #3 revealed on call was contacted again and the resident was sent to the ER per family request. Review of the ER report dated 05/02/24 revealed Resident #240 arrived from the facility with a right knee pain she sustained from the facility while being transferred from bed to a wheelchair. The note further revealed it was reported the resident heard a pop, and the family would like an x-ray to be completed. It was documented Resident #240 had history of osteopenia but no significant degenerative joint disease. Results of x-rays revealed an acute appearing horizontal fracture involving the superior patella (a break in the upper part of the kneecap) with large knee and joint effusion (fluid built up in between joints causing swelling). Resident #240 was discharged back to the facility on [DATE] with an immobilizer. The note indicated a referral was completed for the resident to follow up with an orthopedic provider. Review of the occurrence reported completed by Nurse #5 on 05/03/24 revealed Resident #240 went to the emergency room (ER) to have right knee evaluated which resulted in a non-displaced fracture to the right patella per report. The resident returned wearing an immobilizer and the Program of All-Inclusive Care for the Elderly (PACE) to schedule an ortho appointment. Recommended interventions revealed Resident #240 was to be changed to a total lift with two people assisting. A phone interview conducted with Resident #240 on 05/21/24 at 10:30 AM revealed she had dementia and sometimes got confused but recalled two staff members helping her get in her wheelchair from her bed. The resident stated when staff transferred her it happened fast and when she sat down in her wheelchair her knee hurt bad. The resident indicated staff pushed her out the room after it happened. A phone interview conducted with Resident #240's resident representative (RR) on 05/21/24 at 10:40 AM revealed family had visited the resident, and two staff members came into the resident ' s room to take her to get weighed. The RR further revealed he was out in the hall and heard Resident #240 yell oh, my leg. When Resident #240 exited her room, it was observed the resident's right leg was placed in a leg rest on the wheelchair with staff pushing her to be weighed. The RR indicated staff reported that the resident's leg was not straight when she sat down, and her leg went back behind the wheelchair. The RR indicated they observed Resident #240 to have facial expressions of being in pain. The resident continued to complain of pain while they took the resident to get weighed. The RR revealed after the staff weighed Resident #240, they put the resident into bed and a Nurse assessed the resident. The Nurse stated she would keep an eye on the resident's knee to make sure it was not swelling. Interview conducted with the Assistant Director of Nursing (ADON) on 05/21/24 at 2:15 PM revealed she was not in the facility on 05/02/24 at the time of the incident and Nurse #3 contacted her and told her that Resident #240 had complained of knee pain and the RR wanted the resident sent out to the ER. The ADON advised Nurse #3 to contact the on call and provide the information. The ADON indicated she was not aware that the injury could have been as a possible result of the transfer until Monday 05/06/24 after speaking to staff. The ADON stated when Resident #240 was transferred staff should have been aware if Resident #240 ' s legs and feet were straight, and the resident legs should have not been bent behind. Interview conducted with the Director of Nursing (DON) on 05/21/23 at 2:30 PM revealed she was not present at the facility at the time of the incident and was not aware of Resident #240 was sent out to the ER until 05/03/24 during morning meeting. The DON further revealed she was not aware the NAs did not use a gait belt during the transfer. The DON stated Resident #240 was a dependent two person assist with gait belt and a gait belt should have been used. The DON indicated if a gait belt was used and used properly the resident wouldn't have fallen in the wheelchair. The DON revealed no in service or education was conducted with staff after the incident because she was not aware the transfer was not done correctly.

Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure evening and weekend group activities were planned for the facility to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #17, #23, #43, and #75). The findings included: A review of the May 2024 activity calendar revealed group activities for the facility were only scheduled in the mornings and afternoons during the week, Monday through Friday. There were no activities scheduled for evenings or weekends at the facility except for a 10:30 AM church service on Saturday mornings. a. Resident #17 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #17 felt that it was very important to have activities that included inside and outside of the facility and doing things in an independent and group setting. The assessment further indicated Resident #17 was cognitively intact. An interview was conducted with Resident #17 on 5/22/24 at 10:10 AM during resident council meeting revealed there had not been scheduled evening and weekend group activities at the facility for the past 6 months. She stated the facility does offer a church service on Saturday mornings at 10:30 AM but nothing else and she would like to have some activities scheduled for the evenings and the weekends, so they had something to do other than watch television in their rooms or the dayroom. She revealed her family visits and takes her out of the facility often but not all residents have families that can do that and feels evening and weekend activities would help occupy resident time. Resident #17 also revealed not having evening and weekend activities caused her to feel bored and lonely. b. Resident #23 was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #23 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #23 was cognitively intact. An interview was conducted with Resident #23 on 5/22/24 at 10:10 AM during resident council meeting revealed she had been at the facility for several years and felt like in the past they had activities staff off and on that would come in and do activities in the evenings and weekends, but for the past 6 months at least they have had no scheduled evening and weekend activities. She stated the facility does offer a church service on Saturday mornings at 10:30 AM and usually only residents that can take themselves attend the service. She revealed she felt residents would benefit from having scheduled activities in the evenings and weekends because it would give the something to look forward to and that it gets sad and lonely in the evenings and on weekends especially if you don't have any visitors and nothing to do but watch television. When asked if she had discussed these concerns with the Activities Director, she said no because she didn't want to hurt her feelings but the other residents in resident council had discussed the issue. c. Resident #43 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #43 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #43 was cognitively intact. An interview was conducted with Resident #43 on 5/22/24 at 10:10 AM during resident council meeting revealed she enjoyed activities and for the past several months at least, there had been no activities scheduled for the evenings and weekends. She stated she often gets bored, lonely, and sometimes a little depressed especially when all she has to do in the evenings and on the weekends was watch television. d. Resident #75 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #75 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #75 was cognitively intact. An interview was conducted with Resident #75 on 5/22/24 at 10:10 AM during resident council meeting revealed for the past 6 months or longer the facility has not offered scheduled evening or weekend activities other than a church service on Saturday mornings. She stated she enjoys participating in activities because it gave her reason to get up out of bed and socialize with other residents and not having them in the evenings and on weekends, the time goes by slowly and she gets lonely, bored, and sometimes depressed. Resident #43 revealed she had not addressed her concerns with the Activities Director but had discussed them with other members of resident council and they also felt residents would benefit from having scheduled activities in the evenings and on the weekends. An interview with NA #1 on 5/22/24 at 10:00 AM revealed she had worked at the facility on both 1st and 2nd shift for the past several months and could not recall ever seeing any scheduled group activities during the evenings and on weekends. She stated some of the residents attend a church service on Saturday mornings but other than that they can watch television in their rooms or in the dayroom, read the paper, color, or do crossword puzzles if they are able. She revealed there are not enough nursing staff on nights and weekends to assist with activities, so residents basically have to find their own activities to do. An interview with NA #2 on 5/23/24 at 2:07 PM revealed she worked at the facility on both 1st and 2nd shift for the past couple of months and was not aware of any scheduled activities being offered in the evenings or weekends except for a church service on Saturday mornings. She stated most activities are scheduled during the mornings and afternoons through the week and then after that residents either have to watch television in their rooms or the dayroom or read if they are able. She revealed some of the residents have family that take them out for visits but most of them are stuck in the facility 24 hours a day and would benefit scheduled activities in the evenings and the weekends, so they have something to pass the time and feel bored and depressed. An interview with the Activities Director on 5/23/24 at 2:55 PM revealed she had been employed as the Activities Director at the facility for the past couple of years and typically worked Monday through Friday 8 AM to 5 PM. She stated she has a full-time activity assistant who works 1st shift Monday through Friday and 2 part-time assistants who also work 1st shift Monday through Friday. She revealed they have had activity assistants off and on who worked evenings but they have been hard to keep and the last one they had was in December 2023, so they have had no scheduled group activities in the evenings and on weekends since then. The Activities Director stated they do have activity packets with coloring sheets, word search puzzles, and some other different worksheets they give to nursing staff every Friday so they can be set out in the dayroom for residents to do over the weekends. She revealed they also have a church service on Saturday morning at 10:30 AM for residents who like to attend but other than that they have no other scheduled group activities during the evenings or on the weekends. She revealed she has had some residents complain about not having activities on the weekend or being bored on the weekends and she will try and set up an individual activity for them when she can. She stated she knew how important activities were to the residents and agreed they could benefit from having scheduled group activities in the evenings and on the weekends and could understand why residents could feel lonely, sad, or depressed and get bored with just watching television. The Activities Director revealed she would discuss with the Administrator possibly switching up some of the schedules or times for the activity assistants to help cover some evening and weekend activities until they could find someone to fill the position. An interview with the Administrator on 5/23/24 at 3:42 PM revealed the facility has had activity assistants, off and on, who would specifically work evenings and weekends but then they would leave and the last one they had left this past December. She stated they were currently in the process of trying to hire an activity assistant to work the evening and weekends and in the meantime would be discussing with the Activities Director about possibly changing up the times of when the other activity assistants were scheduled to see if they could cover some evening and weekend shifts until another assistant could be hired. She stated she understood scheduling resident activities for evenings and on the weekends was very important and she would try her best to accommodate those needs.

Based on record reviews, staff, Nurse Practitioner and Pharmacist interviews the facility failed to obtain a routine medication from the pharmacy for administration which caused a resident to miss 28 doses of the medication for 1 of 5 residents (Resident #46) reviewed for unnecessary medication. The findings included: Resident #46 was admitted to the facility originally on 11/15/21 with diagnoses that included hyperlipidemia. Resident #46 was readmitted into the facility on [DATE] following a hospitalization . The Minimum Data Set admission assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46's hospital discharge summary dated 03/28/24 revealed orders for Atorvastatin 40 mg by mouth every morning for high cholesterol. A physician order dated 03/29/24 revealed an order for Atorvastatin 40 mg by mouth once daily at bedtime. Resident #46's Medication Administration Record (MAR) dated April 2024 revealed an order for Atorvastatin 40 mg by mouth once daily at bedtime. The order was documented as not given on 14 of the 31 days during the month by Medication Aide #1. Resident #46's Medication Administration Record (MAR) dated May 2024 revealed an order for Atorvastatin 40 mg by mouth once daily at bedtime. The order was documented as not given on 14 of the 21 days during the month by Medication Aide #1. On 05/22/24 at 11:28 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated she was responsible for completing Resident #46's admission medication reconciliation and had entered the physician orders. The interview revealed when she entered Resident #46's Atorvastatin there was a pharmacy box in the computer system that she had not checked when completing the admission. She stated the order had not been sent to the pharmacy to fill the medication by mistake. On 05/22/24 at 9:00 AM an interview was conducted with Medication Aide #1. During the interview she stated she was typically the MA assigned to administer Resident #46's medication Monday through Friday. She stated the medication came to the facility prepackaged for each resident. The interview revealed since Resident #46 returned to the facility from the hospital she had not had Atorvastatin 40 mg to administer to the resident. She stated she had told the Staff Development Coordinator (SDC) she did not have the medication to give and the SDC told her she would call the Pharmacy. On 05/22/24 at 10:33 AM an observation was conducted with the Staff Development Coordinator (SDC) of the 100-hall medication cart. The SDC pulled from the cart Resident #46's prepackaged medication for the day. Atorvastatin 40 mg was not included in the medication for the resident. She stated she did recall MA #1 telling her they did not have the medication several weeks ago and she let Nurse #2 know to call the pharmacy. On 05/22/24 at 10:42 AM an interview was conducted with Nurse #2. During the interview she stated the SDC had come to her and stated they did not have the medication Atorvastatin 40 mg for Resident #46. She stated she called the pharmacy and spoke with someone on the phone who said they would refill the order and then hung up the phone. She stated she had not followed up to see if the medication had come to the facility. On 05/22/24 at 10:42 AM an interview was conducted with the Pharmacy Staff Member #1. During the interview she stated the pharmacy had never filled the order for Atorvastatin 40 mg because when the resident was readmitted into the facility the nurse completing the admission had not checked the box in the computer system to send the order to the pharmacy to be filled. She stated she could not see any reports in the system from the facility requesting a refill of the prescription. On 05/22/24 at 2:15 PM an interview was conducted with the Nurse Practitioner. The NP stated the facility should have ensured the resident had her medication as ordered. However, Atorvastatin 40 mg was not significant and would not be a medication that had to be tapered off. She stated the resident would have had no side effects from not receiving it since 03/28/24. On 05/22/24 at 4:42 PM an interview was conducted with the Pharmacist. The Pharmacist stated he did not feel Resident #46's would have had any side effects from not receiving Atorvastatin 40 mg. He stated the medication could be stopped abruptly and effects from not taking the medication would not be seen from missing one month or two months dose. The interview revealed the pharmacy had never received the order for the medication from the facility. On 05/23/24 at 9:30 AM an interview was conducted with the Director of Nursing (DON). The DON stated after reviewing the orders for Atorvastatin 40 mg in the computer system she realized the ADON had never checked the box to send the order for the medication to the pharmacy. She stated the medication had not been filled by pharmacy since 03/28/24 after Resident #46 returned from the hospital. She stated Medication Aide #1 should have come to her directly when she realized she had not been giving the resident the medication for over a month.

Based on observations, resident and staff interviews the facility failed to provide evening snacks to residents when requested for 4 of 4 residents (Resident #17, #23, #43, and #75) reviewed for frequency of snacks. This practice had the potential to affect other residents who requested or desired an evening snack. The findings included: a. Resident #17 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and heart failure. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was cognitively intact. An interview with Resident#17 during resident council meeting on 5/22/24 at 10:15 AM revealed since she had been at the facility she could not recall if she had ever received an evening snack or been offered an evening snack consistently. She stated sometimes when you ask for things from nursing staff, especially in the evenings, they will forget to bring it back to your room. She revealed sometimes her family would provide her with snacks, but she would like staff at the facility to offer her a snack in the evenings and she was not aware of snacks being available to her in the nourishment room. b. Resident #23 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and heart failure. A significant change MDS dated [DATE] indicated Resident #23 was cognitively intact. An interview with Resident #23 during resident council meeting on 5/22/24 at 10:15 AM revealed during her stay at the facility she might have been offered or received an evening snack on occasion but not on a consistent basis. Resident #23 revealed she would like to be offered and receive an evening snack because sometimes she does get hungry after dinner, but she didn't like to bother staff by asking them to get her things and she wasn't aware that snacks were available in the nourishment room for her to be able to get on her own. c. Resident #43 was admitted to the facility on [DATE] with diagnosis that included anemia and hypertension. An annual MDS dated [DATE] indicated Resident #43 was cognitively intact. An interview with Resident #43 during resident council meeting on 5/22/24 at 10:15 AM revealed during her stay at the facility she did not recall ever being offered or receiving an evening snack. She stated sometimes the dinner portions are small and she gets hungry later in the evening and would like to be offered an evening snack. She revealed she had no knowledge of the facility having a nourishment room with snacks and drinks for residents or where the nourishment room was even located. Resident #43 stated her family does provide her with snacks when she asks but she doesn't always want to ask them to bring her things and felt the facility should offer an evening snack. d. Resident #75 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and heart failure. An annual MDS dated [DATE] indicated Resident #75 was cognitively intact. An interview with Resident #75 during resident council meeting on 5/22/24 at 10:15 AM revealed since she had been at the facility she might have received an evening snack a couple of times but not on a consistent basis. She stated she did not always have the money to be able to purchase her own snacks and didn't want to have to ask her family to purchase her snacks all the time and she felt the facility should be able to provide her with an evening snack when requested. Resident #75 revealed when she has asked staff about receiving a drink or an evening snack, they would usually forget to come back with her snack, and she wasn't always able to get up and get her own snack from the nourishment room. An observation of nourishment room on 5/20/24 at 10:30 AM revealed the refrigerator to have sandwiches, drinks, and thickened liquid juices. There were bagged snacks, snack cakes, cookies, crackers, sugar free pudding, sugar free Jello, and sugar free cookies located in the cabinet of the room. An interview with Dietary Manager #1 on 5/20/24 at 10:00 AM revealed he had been employed at the facility for several months and part of dietary staff responsibilities were to make sure the nourishment room was stocked at all times with sandwiches, drinks, thickened liquid juices, snacks, and sugar free snacks. He revealed that dietary staff, including himself, checked the nourishment room during each shift and had been educated on making sure the nourishment room was stocked with snacks, sandwiches, and drinks to be available for residents and staff. Dietary Manager #1 stated nursing staff also had access to replenish snacks and drinks for the nourishment room if needed and the facility always had an overstock of snacks and drinks available. He revealed to his knowledge there had been no complaints of the nourishment room running out of snacks and drinks, but he was not aware if staff were offering residents evening snacks. An interview with NA #1 on 5/23/24 at 10:00 AM revealed she worked both 1st and 2nd shift and had never seen evening snacks being offered to residents, she had never offered evening snacks to residents, and had never been told to offer evening snacks to residents. She stated if a resident asked for a snack, then staff would get them one, but she wasn't sure if most residents were aware they could request a snack, that snacks were supposed to be offered, or where the nourishment room was even located to get their own snack. She revealed no issues with the nourishment room not having an ample supply of snacks, sandwiches, and drinks available for residents, she believed staff just were not aware that were supposed to be offering an evening snack to all residents. An interview with NA #2 on 5/23/24 at 2:07 PM revealed she worked both 1st and 2nd shift at the facility. She stated to her knowledge staff do not offer residents evening snacks but if a resident requested a snack, they would provide them with one. She stated she was not really sure why staff did not offer evening snacks; she had been working at the facility for several months and had never been told to offer evening snacks to residents and had never seen other staff offering evening snacks. She revealed it would make sense to offer residents an evening snack because not all residents are able to request an evening snack, and some require certain types of snacks or liquids based on their diets. NA #2 stated she did not recall residents complaining about not receiving an evening snack, but she was also not sure if most residents were aware staff should be offering an evening snack, could request an evening snack, or where the nourishment room with snacks and drinks available was located. An interview with NA #3 on 5/23/24 at 2:20 PM revealed she typically worked 1st shift at the facility but has worked 2nd shift on occasion and did not recall staff offering residents evening snacks. She stated during 1st shift she will offer afternoon snacks to her residents especially those that cannot request a snack or require a modified snack or liquid due to their dietary needs. She revealed she did not know if staff on 2nd shift were not aware they should be offering evening snacks or if they just chose not to because the nourishment room was always stocked with assorted snacks, sandwiches, and drinks. An interview with the Administrator on 5/23/24 at 3:42 PM revealed she expected there to always be snacks available and offered to residents. The Administrator further revealed dietary staff should be stocking enough snacks, sandwiches, and drinks for residents and nursing staff should have notified dietary staff, nursing supervisors, the DON or herself if there was an issue with not having evening snacks available for residents. The Administrator indicated nursing staff could have asked the Director of Nursing or Unit Managers for the codes to the nourishment rooms. She stated the facility orders an adequate amount of snacks each month to make sure residents have a variety of options for their snacks and there was no reason why residents should not be offered or receiving their evening snacks.

Based on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner when staff assisted a resident onto the commode and left the resident. This deficient practice was for 1 of 3 residents reviewed for dignity (Resident #3). Resident #3 required extensive 1 person assist with transfers and toileting, and due to the long wait, transferred himself back to his wheelchair causing feces to get onto his clothes and wheelchair which made him feel very upset and mad. The Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, osteoarthritis, and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 was cognitively intact, required substantial 1-person maximum assistance with toileting and transfers, with some incontinence of bladder and bowel. Resident #3 was assessed as requiring a wheelchair for mobility. No refusal of care was noted during the assessment reference period. A telephone interview with Resident #3's responsible person (RP) on 5/23/24 at 11:13 AM revealed the family arrived at the facility after lunch on 12/25/23 to take Resident #3 out for a visit and found him sitting outside the shower room door with his pants pulled up mid-thigh and bowel movement on him and his chair. She stated Resident #3 revealed a nursing assistant (NA) had taken him to use the commode in the shower room and left him there for what he thought was at least 40-45 minutes. She revealed Resident #3 stated that while he was on the commode he had a bowel movement, was not able to clean himself or pull his pants up all the way so he transferred himself off the commode into his wheelchair and was sitting outside of the shower room waiting for help. The RP stated the family assisted with pulling up Resident #3's pants and cleaning off the bowel movement enough to get him back to his room when the NA arrived with a fast-food bag in her hand apologizing for leaving Resident #3 on the commode. She revealed the NA then assisted Resident #3 back to the shower room to assist with cleaning him up and when she returned, she again apologized for leaving him on the commode stating she had gotten sidetracked and then had left the faciity on her lunch break. She stated Resident #3 was mad and appeared very upset and even a little bit embarrassed about the incident. She revealed she contacted the Social Work (SW) Director a couple of days later, on 12/27/23 and discussed the incident with her, filed a grievance, and the SW Director handled the matter from there and she received a letter in the mail stating the outcome. Resident #3 was interviewed in his room on 5/23/24 at 2:07 PM. During the interview he stated several months ago NA #2 took him to the restroom in the shower bathroom, assisted him to the commode and left the room. Resident#3 revealed he was uncomfortable and had a bowel movement and was not able to wipe himself or pull up his pants past mid-thigh, so he transferred himself back into his wheelchair and was sitting in the doorway of the shower room trying to get someone to assist him when the same NA #2 came back and looked surprised. When asked if he was exposed while sitting outside of the shower room due to only being able to pull up his pants to mid-thigh, Resident #3 stated no that his pants were still able to provide coverage and he did not feel he was exposed. The interview revealed Resident #3 had been sitting on the shower room commode for about 45 minutes. When asked how he knew it had been 45 minutes, Resident #3 stated he looked at the clock in his room prior to leaving and when he returned. He stated NA #2 apologized and said she had gotten busy and forgot she had placed him onto the commode. NA #2 took Resident #3 back to the shower room and got him cleaned up. He stated he could not recall if his family was in the building, but he had spoken with them about it afterwards. Resident #3 revealed he was upset and mad about the situation stating he doesn't like for staff to leave him because they won't come back and from now on, he doesn't let staff leave him while toileting. An interview was conducted with NA #2 on 5/23/24 at 2:15 PM. She stated she had been working 1st shift on 12/25/23 and had overheard Resident #3 ask NA #4 for assistance with going to the bathroom and NA #4 told Resident #3 she would assist him with toileting when she returned from her lunch break. NA #2 revealed she didn't want Resident #3 to have to wait that long, so she took him to the shower room, removed his brief, and assisted him onto the commode. She revealed while Resident #3 was toileting she realized there were no clean briefs in the shower room, so she left the shower room while Resident #3 was toileting to find clean briefs and was sidetracked by another resident's family asking for assistance. NA #2 stated after she finished assisting the other resident and their family, she also went on her lunch break with NA #4 and while they were at lunch talking, she realized that she had forgotten about Resident #3 and had left him on the commode in the shower room. She revealed that when she returned Resident #3 was in his room with his family, she assisted him back to the shower room and finished cleaning him up. NA #2 also revealed that from the time that she had assisted Resident #3 onto the commode, assisted the other resident and family, left for lunch, and realized that she had left him on the commode was at least 40-45 minutes. She revealed she did not recall reporting to the nursing supervisor about leaving Resident #3 on the commode and that she did not intentionally mean to leave Resident #3 on the commode and forget, it was a mistake and human error and would never happen again. Attempted to contact NA #4 on 5/23/24 who was no longer employed with the facility, and she did not return telephone calls. On 5/23/24 at 3:42 PM an interview was conducted with the Administrator and the DON. The DON revealed she was not made aware of the incident with Resident #3 being left on the commode in the shower room for a long period of time until the SW Director notified her of the grievance filed by his RP. The DON stated during her interviews with 1st shift staff who worked with Resident #3 on 12/25/23, she learned NA #2 and NA #4 had been involved. She revealed both NA #2 and NA #4 were very honest, forthcoming, and remorseful about the incident and she felt this was an isolated incident based on human error and there did not seem to be any malicious or ill intent to cause harm. The DON stated NA #2 was re-educated on resident care and notifying nursing supervisor of any incidents and prior to leaving for breaks and that NA #4 chose not to return to the facility prior to receiving re-education. The Administrator stated that staff should be performing patient care in a timely manner, as needed, and as requested and no resident should be left on a commode without supervision, especially residents that required assistance.

Based on record review and staff interviews the facility failed to develop comprehensive care plans in the areas of anticoagulant (blood thinning) medication use for 2 of 2 residents whose comprehensive care plans were reviewed (Resident #4 and Resident #31). Findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF). A review of Resident #4's medical record revealed a physician's order dated 09/07/2023 for apixaban (an anticoagulant medication) 5.0 milligrams (mg) twice daily for atrial fibrillation (an irregular, rapid heartbeat which causes poor blood flow). A review of Resident #4's comprehensive care plan last revised on 03/12/24 did not reveal any care plan focus area or interventions related to receiving an anticoagulant medication. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 received anticoagulant medication during the assessment period. A review of Resident #4's April and May 2024 Medication Administration Record revealed she received apixaban 5 mg twice daily as prescribed. On 05/22/2023 at 10:13 AM an interview with the MDS Nurse revealed Resident #4's care plan did not address anticoagulant medication. She explained the care plan should include the use of an anticoagulant medication. An interview was conducted with the Regional MDS Coordinator on 05/22/2024 at 10:30 AM. The Regional MDS Coordinator stated that the quarterly MDS was accurate, but the care plan did not address Resident #4's use of anticoagulant medication. She explained the care plan should capture an accurate clinical picture of the resident and include the management of anticoagulant medications. An interview was conducted on 05/22/2023 at 11:10 AM with the Director of Nursing (DON). The DON indicated anticoagulant medications were considered high-risk medications. She stated it should be addressed in Resident #4's comprehensive care plan so all staff caring for her would be aware she was at risk for side effects like bleeding or bruising. 2. Resident #31 was admitted to the facility on [DATE]. Her diagnoses included deep vein thrombosis (blood clot in lower leg) and embolism (blood clot in the lungs). A review of Resident #31's medical record revealed a physician's order dated 09/08/2023 for apixaban (an anticoagulant medication) 5 milligrams (mg) twice daily for deep vein thrombosis and embolism. A review of Resident #31's comprehensive care plan dated 09/14/2023 did not reveal any care plan focus area or interventions related to receiving an anticoagulant medication. A review of the quarterly MDS assessment dated [DATE] for Resident #31 revealed she had received anticoagulant medication during the assessment period. A review of Resident #31's April and May 2024 Medication Administration Record (MAR) revealed she received apixaban twice daily as prescribed. On 05/22/2023 at 10:13 AM an interview with the MDS Nurse revealed Resident #31's care plan did not address anticoagulant medication. She explained the care plan should include the use of an anticoagulant medication. An interview was conducted with the Regional MDS Coordinator on 05/22/2024 at 10:30 AM. The Regional MDS Coordinator stated that the quarterly MDS was accurate, but the care plan did not address Resident #31's use of anticoagulant medication. She explained the care plan should capture an accurate clinical picture of the resident and include the management of anticoagulant medications. An interview was conducted on 05/22/2023 at 11:10 AM with the Director of Nursing (DON). The DON indicated anticoagulant medications were considered high-risk medications. She stated it should be addressed in Resident #31's comprehensive care plan so all staff caring for her would be aware she was at risk for side effects like bleeding or bruising. An interview was conducted with the Administrator on 05/23/2024 at 9:16 AM. The Administrator stated she expected all resident care plans to be reflective of their clinical condition including the use of anticoagulant medications.

Based on record review, staff, Nurse Practitioner and Pharmacist interviews the facility failed to clarify orders for monitoring blood pressure and pulse for the administration of an antihypertensive medication.This occurred for 1 of 5 residents reviewed for unnecessary medication (Resident #46). The findings included: Resident #46 was admitted to the facility originally on 11/15/21 with diagnosis that included hypertension. Resident #46 was readmitted into the facility on [DATE] following a hospitalization . The Minimum Data Set admission assessment dated [DATE] revealed Resident #46 was cognitively intact. A hospital discharge summary dated 03/28/24 revealed orders for Carvedilol (blood pressure medication) 12.5 milligrams by mouth in the morning and evening. Montior heart rate and blood pressure (avoid medication if the heart rate is below 70 and blood pressure is below 120/80). A physician order dated 03/28/24 revealed an order for Carvedilol 12.5 mg 1 tablet by mouth twice a day. The order read to monitor Resident #46's blood pressure weekly and pulse daily. Resident #46's Medication Administration Record (MAR) dated April 2024 revealed the facility was monitoring the resident's pulse twice a day and blood pressure weekly. Resident #46's Medication Administration Record (MAR) dated May 2024 revealed the facility was monitoring the resident's pulse twice a day and blood pressure weekly. On 05/22/24 at 11:28 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated she was responsible for completing Resident #46's admission medication reconciliation and had entered the physician orders. She stated the facility had a standard protocol for monitoring blood pressure medication. The ADON stated the standard protocol was not written on paper, but it was, just what the facility went by. She stated if a resident was on a blood pressure medication regardless of if there were parameters or not coming from the hospital, they only monitored the residents' pulse daily and blood pressure weekly. The interview revealed she had not transcribed the order as written on the hospital discharge summary. The interview revealed she had not clarified the standard protocol with the Nurse Practitioner or Physician. On 05/22/24 at 2:15 PM an interview was conducted with the Nurse Practitioner. During the interview she stated typically for any blood pressure medication there would be parameters set to monitor the blood pressure prior to administration. She stated if the resident was getting the medication twice a day, then the blood pressure should be monitored twice daily and not just once a week. She stated from the review of Resident #46's vital signs her blood pressure remained elevated so there would have been no negative effects from the facility only monitoring once a week, but they should have followed the hospital discharge orders. On 05/22/24 at 4:42 PM an interview was conducted with the Pharmacist. During the interview he stated the order dated 03/28/24 was placed into the pharmacy system to hold the medication for a blood pressure less than 120/80 and heart rate less than 70. On 05/23/24 at 9:30 AM an interview was conducted with the Director of Nursing (DON). During the interview she stated the blood pressure parameters come from the pharmacy and they should have attached a parameter setting to the order. She stated it was a computer issue that the parameters had not transferred over onto the MAR for the nurses to see. The interview revealed the nursing staff should have clarified with the Nurse Practitioner or Medical Director to make sure they wanted to continue those parameters.

Based on observations, record review, Medical Director and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff pushed a resident with diabetes in her wheelchair without shoes, and when the resident asked the staff person to stop because her foot was hurting, the staff kept pushing the wheelchair and the resident sustained an open area to her great left toe and an abrasion to her left heel due to her foot being caught under the wheelchair footrest and being dragged during the transport. The left great toe had to be treated for one month before it healed. This was for 1 of 1 resident reviewed for neglect (Resident #6). Immediate Jeopardy began on 11/14/22 when Transport Driver #1 continued to transport Resident #6 in her wheelchair after she told him to stop pushing her down the hall because he was dragging her foot and it hurt. The immediate jeopardy was removed on 02/25/23 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, and coronary artery disease (CAD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was moderately cognitively impaired and was dependent upon two staff members for transfers. Resident #6 was documented as able to make herself clear and understood. She was documented to also have a clear comprehension and understood others. The assessment revealed Resident #1 had no skin conditions or needed special footcare during the assessment period. On 2/22/23 at 12:03 PM an interview was conducted with Resident #6. She stated a few months ago a transport driver came into the facility to pick her up and was dragging her feet up the hallway to the front lobby. Resident #6 stated, I was telling him to stop, I was telling him I was in pain, but he never said anything and kept pushing me forward. The interview revealed her foot was caught underneath the footrest of the wheelchair and he had dragged her left foot from her room to the front lobby of the facility. Resident #6 stated she just had socks on because shoes hurt her feet. She stated a staff member whom she did not know finally stopped him because her foot was bleeding. Resident #1 stated a nurse came and got her and dressed her foot before going out to her appointment. The interview revealed she told Nurse #3 and Nurse Aide #5 about the incident and that Transport driver #1 had dragged her foot underneath the pedal while she asked him to stop while Nurse #3 was dressing her foot. On 2/22/23 at 3:39 PM an interview was conducted with Nurse Aide (NA)#5. She stated on 11/14/22 she had gotten Resident #6 dressed and ready for an outside appointment. The interview revealed Resident #6 did not get out of the bed much per personal preference and did not want to wear shoes only socks. She stated she put regular socks on the resident because she did not see any gripper socks in her drawer. NA #5 stated it was approximately an hour after she had gotten Resident #6 dressed and in her wheelchair to the time she saw Nurse #3 bringing the resident back down the hallway and her foot was injured. NA #5 stated Resident #6 was saying the man from transport was rough with her when he was pushing her. Resident #6 stated she was in pain and NA #5 stated her left great toenail looked like it had been lifted or had a bubble underneath it. She stated Nurse #3 removed the residents sock and told her she was going to notify the Director of Nursing. NA #5 stated Resident #6 was very clear in stating it was the male transport driver who hurt her foot and that it happened when she was leaving the facility. NA #5 stated she did not tell anyone else about the incident because she knew Nurse #3 was handing the situation. On 2/23/23 at 8:50 AM an interview was conducted with Transport Driver #2. She stated she had been a full-time employee working for the facility but due to scheduling conflicts and the number of residents with appointments the facility also had to use a contract company for transports. During the interview she stated on 11/14/22 she had a cancellation and returned to the facility. She stated when she was coming into the front lobby of the facility, she saw the contract company Transport Driver #1 pushing Resident #6 towards the door. She stated she saw the resident's foot was bleeding badly and stopped Transport Driver #1. Resident #6 stated, he was dragging my foot, I told him to stop. Transport Driver #2 stated she asked the secretary to go and get Nurse #3 because the resident could not leave the facility in the condition, she was in. Transport Driver #2 stated Resident #6's foot was underneath the wheelchair and had been dragged by Transport Driver #1 when he pushed her to the lobby. The interview revealed Nurse #3 came to the front lobby and got Resident #6 to dress her foot. She stated Transport Driver #1 was impatient because it was delaying the transport. On 2/22/23 at 3:49 PM a voicemail message was left for the facility's previous secretary that was working during the time of the incident. A return phone call was not received. On 2/22/23 at 4:05 PM an interview was conducted with Transport Driver #1. He stated he worked for a contract company the facility used for transports. During the interview he stated he did not remember the incident with Resident #6 and was in the facility to transport one of the facilities residents to an appointment. The interview revealed he had continued to transport residents from the facility following the incident with Resident #6 on 11/14/22. Review of the facility initial allegation report dated 11/14/22 revealed on this date at 1:45 PM Resident #6 returned from an outside appointment with an open area on her left great toe measuring 2 centimeters (cm) by 2 cm. Nurse #3 cleaned the area with normal saline and covered it with a bandage. The Nurse Practitioner (NP) was notified along with the residents Responsible Party (RP). Resident #6 denied pain and was in no distress per the report. Resident #6 also obtained a closed abrasion to her left heel. Resident #6 stated to Nurse #3 she had bumped it on something but could not remember what. Interventions to reduce risk of further skin conditions included a high back wheelchair for mobility. On 2/22/23 at 3:16 PM an interview was conducted with Nurse #3. She stated Resident #6 was scheduled to go out of the facility to an appointment, so Nurse Aide #5 had gotten her ready, and she was waiting in her room. Nurse #3 stated Transport Driver #1 went to the resident's room and began pushing her to the front of the facility. She stated the Secretary came to her and said Resident #6's foot was bleeding. The interview revealed when she saw Resident #6, the resident stated to her that she must have hit her foot on something but did not know what. Nurse #3 stated the Transport Driver told her he did not know what had happened. Resident #6 was noted to be wearing regular non grip socks with no shoes at the time of the incident. Nurse #3 stated Resident #6 did not normally wear shoes because she didn't get out of the bed unless she went to an appointment. The interview further revealed she had shoes in her room. Nurse #3 stated she took Resident #6 back to her room, removed the sock exposing a 2 cm by 2 cm open area to her left great toe and an abrasion to her left heel. She cleaned the area and applied a dry dressing. Nurse #3 stated at the end of the sock there was bright red blood at the area of the residents left great toe. Resident #6 had footrests on her wheelchair along with a board (device used to prevent the residents foot from dropped off of the footrest), but the resident's foot had become lodged under the footrest. The interview revealed the staff had issues with Resident #6 sliding down in her wheelchair on previous occasions and after the incident Nurse #3 and Nurse Aide #5 had to pull Resident #6 up in her wheelchair because she had slid down causing her foot to drop off the footrest. She stated after she redressed the resident's foot, she pushed her back to the front lobby and Transport driver #1 took her to the scheduled appointment. The interview revealed she had made an error on the incident report by stating the incident occurred when the resident was out of the facility. Nurse #3 stated she filled out the incident report and placed it in the Director of Nursing's (DON) box, placed a note in the Nurse Practitioner's non emergent folder and notified the resident's Responsible Party following the incident. A verbal physician order dated 11/14/22 written by Nurse #3 at 3:45 PM read to, cleanse left great toe with normal saline, cover with a bandage. Cleanse open area to left great toe with normal saline and apply antibiotic ointment. Cover with a dry dressing daily. A physician order dated 11/15/22 written by Wound Nurse #1 at 9:40 AM revealed to discontinue the current treatment to the left great toe. Cleanse left great toe with normal saline daily. Apply antibiotic ointment, cover with a non-stick pad, wrap with gauze and secure with tape daily and as needed. Cleanse left heel with normal saline and apply antibiotic ointment. Cover with foam daily and as needed related to an abrasion. The facility weekly wound report dated 11/30/22 revealed Resident #6 had obtained an acquired abrasion due to trauma on the left great toe measuring 0.9 cm by 1.0 cm and on the left heel measuring 1.2 cm by 1.0 cm. The facility weekly wound report dated 12/14/22 revealed Resident #6 had obtained an acquired abrasion due to trauma on the left great toe measuring 0.5 cm by 0.5 cm and on the left heel measuring 0.5 cm by 0.5 cm. A physician order dated 12/14/22 written by Wound Nurse #1 at 1:15 PM revealed to discontinue current treatment to left great toe and left heel. Apply skin prep daily to the left great toe and heel for a duration of 7 days. The facility weekly wound report dated 12/21/22 revealed Resident #6 was not listed on the report for having a skin condition. The report revealed Resident #6 had been removed from the report due to the wound being healed. The facility weekly wound report dated 2/15/23 revealed Resident #6 was listed as having a new skin condition identified on 2/13/23. An observation was conducted on 2/23/23 at 8:56 AM of Resident #6's wound care with Wound Nurse #1. Resident #6 was observed to have a open area to the left great toe and third toe with a closed deep tissue injury to the base of the fifth toe. Wound Nurse #1 followed the physicians' orders for wound care along with following infection control protocol during the dressing change. No drainage was observed to the open areas. On 2/23/23 an interview was conducted with the Director of Nursing (DON). She stated she found out about the incident the day after it had occurred because they go over the incidents from the previous day during stand-up morning meeting. She stated she normally would not have been informed earlier unless it was a serious injury. The interview revealed she felt the incident was minor at the time. She stated during stand-up meeting they discussed switching the resident to a Geri-chair to keep her feet elevated and prevent her from scooting down in her wheelchair. The team decided to initiate a therapy evaluation however after discussing with Resident #6's Responsible Party (RP) she stated she did not want the resident in a Geri chair. Once therapy saw the resident, she was transitioned into a high back wheelchair in which she still uses. The DON stated it was her understanding Nurse #3 had to go to the front lobby and get Resident #6 because her foot was bleeding and provide wound care before she could leave for the appointment. The interview revealed she did not know if Resident #6 had been seen following the incident for wound care by the Physician. On 2/23/23 at 11:32 AM an interview was conducted with the Medical Director (MD). She stated she recalled being notified of the incident with the resident having a minor injury. She stated she knew the resident's wounds had improved after with healing. The MD stated it was Resident #6's left great toe and left heel in which a bandage had been applied with follow up wound care treatment by the nurses. She stated the wound from 11/14/22 had healed completely within a few weeks. On 2/22/23 at 4:10 PM an interview was conducted with the Transportation Company. During the interview they stated they had not received any notification of issues with a resident during transport for the date of 11/14/22. The Administrator was notified of immediate jeopardy on 02/23/23 at 4:30 PM. The Credible Allegation for noncompliance dated 11/14/22 for immediate jeopardy removal as follows. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The identified resident is Resident #1's and her right foot dropped off from the wheelchair foot footrest and became lodged under the foot footrest of the wheelchair or rubbed against the floor while being rolled down the hallway by the transporter on 11/14/22. Resident #1 alleges the transporter failed to stop pushing the resident in her wheelchair from her room in the facility to the facility lobby after she told him to stop because her foot was hurting. This caused her to have an abrasion to her right heel and an open area at the end of the left great toe that measured 2x2 cm. Licensed nurse was notified of the area and the resident's right foot was treated and she was able to go to her appointment. Other residents can potentially sustain a similar injury while being transported in a wheelchair. An audit was completed by nursing administration on 2/23/23 to ensure identified residents at risk for neglect are transported via the proper device (i.e. standard wheelchair, geriatric chair, high back wheelchair, stretcher) for their safety. An audit of residents that used wheelchair transport since November 2022 revealed no other incidents with residents being maneuvered in a wheelchair. This audit was completed on 2/23/23 by Administration and the Corporate Nurse Consultant. Another audit was completed by Nursing Administration on 2/23/23 to ensure residents are transported via the proper device (i.e. standard wheelchair, geriatric chair, high back wheelchair, stretcher) for their safety. A further audit consisting of resident interviews to determine if the facility staff and outside providers stop what they are doing while transporting residents in a wheelchair when asked to stop or if the resident is vocalizing that they are in pain. This audit was completed by the social services department on 2/24/23. Interviews with residents were conducted asking the question if they ask the staff member to stop is their request honored and is the staff paying attention to their request. The interviews were completed by the social services department on 2/24/23. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be completed. All facility staff including agency staff were re-educated on the neglect protocol that includes residents are free from abuse, neglect and exploitation, including the resident's right to be free from physical neglect. The nursing staff including agency staff will also be educated on ensuring that residents who are being transported in a wheelchair, that their body parts are stabilized including their feet on the foot footrests before being transported. The education also includes any staff transporting residents in a wheelchair to stop what they are doing when asked by the resident, no matter the circumstance. This education will be conducted by the Director of Nursing and Nursing Administration and completed by 2/24/23. All facility staff/ transporter including agency staff and the other outside transporters were educated on paying attention to the residents while transporting them in a wheelchair to include making sure the resident's body parts, such as their feet, are secured and not rubbing against the floor. This education also included stopping the wheelchair, if a resident complains of pain and notifying the facility licensed nursing staff in order to conduct an assessment and render treatment. This education was completed by the Director of Nursing and the transport company by 2/24/23. All facility staff/transporter including agency staff and the other transporters will be educated on paying attention to the residents while transporting them in a wheelchair to include making sure the resident's body parts, such as their feet, are secured and not rubbing against the floor. This education will be completed by the Director of Nursing and the transport company by 2/24/23. The wheelchair van transport company's transporters and the facility staff/transporter (on FMLA or vacation) that are not available for the education will not start working or care for residents until after the education is completed. Newly hired staff will receive this education as well prior to caring for residents. The Human Resources Director will inform the Director of Nursing of new hires, and the Director of Nursing will ensure the training is completed. The Human Resources Director was notified of this responsibility on 2/24/23 by the Administrator. The wheelchair transport company was given a copy of the education by the Director of Nursing to educate the transporters, and copies of the completion of this education will be given to the facility on [DATE]. Transporters will also be asked if they received this education by the facility prior to transporting residents in a wheelchair by Nursing Administration. If education was not completed, the education will be completed at that moment by the Nursing Administration prior to handling the residents' transport in a wheelchair. The Administrator and Director of Nursing are responsible for the ongoing compliance of F600. IJ Removal Date is 2/25/23. On 2/28/23, the facility's credible allegation for immediate jeopardy removal effective 2/25/23 was validated by the following: Staff interviews revealed they had received education on resident abuse and neglect, ensuring residents are stabilized in their wheelchair prior to transport and to observe residents who are being transported by outside staff to ensure they are being handled appropriately. Device audits were conducted on all residents to ensure they were being transported in the proper device such as a standard wheelchair, geriatric chair, or high back wheelchair for their safety. Interviews were conducted with alert and oriented residents who had been transported since November 2022 with no concerns identified. No additional transportation incidents were identified since November 2022. The facility's action plan was validated to be completed as of 2/25/23.

Based on record review, resident and staff interviews the facility failed to follow their neglect policy in the areas of reporting immediately to administration, conducting a thorough investigation and protecting residents. Transport driver #1 pushed Resident #6 from her room to the front lobby of the facility with her foot caught underneath the footrest of the wheelchair. Resident #6 stated to Transport driver #1 to stop however he kept pushing despite the resident being in pain resulting in an injury to the resident's foot. The incident was not immediately reported to Administration staff. The lack of reporting, investigating and protecting put all residents at risk for serious harm. This occurred for one of one resident reviewed for abuse (Resident #6). Immediate Jeopardy began on 11/14/22 an alleged perpetrator was allowed to continue to work without any corrective action. The immediate jeopardy was removed on 02/25/23 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Review of the facility's Abuse, neglect and Exploitation policy dated 10-1-22 revealed in part that the facility will Identify, correct, and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property was more likely to occur. The policy read to respond immediately to protect the alleged victim by removing them from the alleged perpetrator and to immediately report the allegation to administration. The facility will conduct a investigation into the allegation. Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, and coronary artery disease (CAD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was moderately cognitively impaired and was dependent upon two staff members for transfers. Resident #6 was documented as able to make herself clear and understood. She was documented to also have a clear comprehension and understood others. The assessment revealed Resident #1 had no skin conditions or needed special footcare during the assessment period. Review of the facility initial allegation report dated 11/14/22 revealed on this date at 1:45 PM Resident #6 returned from an outside appointment with an open area on her left great toe measuring 2 centimeters (cm) by 2 cm. Nurse #3 cleaned the area with normal saline and covered it with a band aid. The Nurse Practitioner (NP) was notified along with the residents Responsible Party (RP). Resident #6 denied pain and was in no distress per the report. Resident #6 also obtained a closed abrasion to her left heel. Resident #6 stated to Nurse #3 she had bumped it on something but could not remember what. Interventions to reduce risk of further skin conditions included a high back wheelchair for mobility. On 2/22/23 at 12:03 PM an interview was conducted with Resident #6. She stated a few months ago a transport driver came into the facility to pick her up and was dragging her feet up the hallway to the front lobby. Resident #6 stated, I was telling him to stop, I was telling him I was in pain, but he never said anything and kept pushing me forward. The interview revealed her foot was caught underneath the footrest of the wheelchair and he had dragged her left foot from her room to the front lobby of the facility. Resident #6 stated she just had socks on because shoes hurt her feet. She stated a staff member whom she did not know finally stopped him because her foot was bleeding. Resident #1 stated a nurse came and got her and dressed her foot before going out to her appointment. The interview revealed she told Nurse #3 and Nurse Aide #5 about the incident and that Transport Driver #1 had dragged her foot underneath the pedal while she asked him to stop while Nurse #3 was dressing her foot. On 2/22/23 at 3:39 PM an interview was conducted with Nurse Aide (NA)#5. She stated on 11/14/22 she had gotten Resident #6 dressed and ready for an outside appointment. The interview revealed Resident #6 did not get out of the bed much per personal preference and did not want to wear shoes only socks. She stated she put regular socks on the resident because she did not see any gripper socks in her drawer. NA #5 stated approximately an hour had lapsed from the time she got Resident #6 dressed and in her wheelchair to the time she saw Nurse #3 bringing the resident back down the hallway and her foot was injured. NA #5 stated Resident #6 was saying the man from transport was rough with her when he was pushing her. Resident #6 stated she was in pain and NA #5 stated her left great toenail looked like it had been lifted or had a bubble underneath it. She stated Nurse #3 removed the residents sock and told her she was going to notify the Director of Nursing. NA #5 stated Resident #6 was very clear in stating it was the male Transport Driver who hurt her foot and that it happened when she was leaving the facility. NA #5 stated she did not tell anyone else about the incident because she knew Nurse #3 was handing the situation. On 2/23/23 at 8:50 AM an interview was conducted with Transport Driver #2. She stated she had been a full-time employee working for the facility but due to scheduling conflicts and the number of residents with appointments the facility also had to use a contract company for transports. During the interview she stated on 11/14/22 she had a cancellation and returned to the facility. She stated when she was coming into the front lobby of the facility, she saw the contract company Transport Driver #1 pushing Resident #6 towards the door. She stated she saw the resident's foot was bleeding badly and stopped Transport Driver #1. Resident #6 stated, he was dragging my foot, I told him to stop. Transport Driver #2 stated she asked the Secretary to go and get Nurse #1 because the resident could not leave the facility in the condition, she was in. Transport Driver #2 stated Resident #6's foot was underneath the wheelchair and had been dragged by Transport Driver #1 when he pushed her to the lobby. The interview revealed Nurse #3 came to the front lobby and got Resident #6 to dress her foot. She stated Transport Driver #1 was impatient because it was delaying the transport. The interview revealed she did not tell Administration because she thought Nurse #3 was handling the situation. She stated she was never asked about the incident. On 2/22/23 at 3:16 PM an interview was conducted with Nurse #3. She stated Resident #6 was scheduled to go out of the facility to an appointment, Nurse Aide #5 had gotten her ready, and she was waiting in her room. Nurse #3 stated Transport Driver #1 went to the resident's room and began pushing her to the front of the facility. She stated the Secretary came to her and said Resident #6's foot was bleeding. The interview revealed when she saw Resident #6, the resident stated to her that she must have hit her foot on something but did not know what. Nurse #3 stated Transport Driver #1 told her he did not know what had happened. Resident #6 was noted to be wearing regular non grip socks with no shoes at the time of the incident. Nurse #3 stated Resident #6 did not normally wear shoes because she didn't get out of the bed unless she went to an appointment. The interview further revealed she had shoes in her room. Nurse #3 stated she took Resident #6 back to her room, removed the sock exposing a 2 centimeter (cm) by 2 cm open area to her left great toe and an abrasion to her left heel. She cleaned the area and applied a dry dressing. Nurse #3 stated at the end of the sock there was bright red blood at the area of the residents left great toe. Resident #6 had footrests on her wheelchair along with a board (device used to prevent the residents foot from dropped off of the footrest), but the resident's foot had become lodged under the footrest. The interview revealed the staff had issues with Resident #6 sliding down in her wheelchair on previous occasions and after the incident Nurse #3 and Nurse Aide #5 had to pull Resident #6 up in her wheelchair because she had slid down causing her foot to drop off the footrest. She stated after she redressed the resident's foot, she pushed her back to the front lobby and Transport Driver #1 took her to the scheduled appointment. The interview revealed she had made an error on the incident report by stating the incident occurred when the resident was out of the facility. Nurse #3 stated she filled out the incident report and placed it in the Director of Nursing's (DON) box, placed a note in the Nurse Practitioner's non emergent folder and notified the resident's Responsible Party following the incident. The interview revealed she had not obtained statements from the staff members involved. On 2/22/23 at 4:05 PM an interview was conducted with Transport Driver #1. He stated he worked for a contract company the facility used for transports. During the interview he stated he did not remember the incident with Resident #6 and was at the facility to transport a resident. The interview revealed he had continued to transport residents from the facility following the incident with Resident #6 on 11/14/22. On 2/22/23 at 4:10 PM an interview was conducted with the Transportation Company. During the interview they stated they had not received any notification of issues with a resident during transport for the date of 11/14/22. On 2/23/23 an interview was conducted with the Director of Nursing (DON). She stated she found out about the incident the day after it had occurred, on 11/15/22 because they go over the incidents from the previous day during stand-up morning meeting. She stated she normally would not have been informed earlier unless it was a serious injury. The interview revealed she felt the incident was minor at the time. She stated during stand-up meeting they discussed switching the resident to a geriatric chair to keep her feet elevated and prevent her from scooting down in her wheelchair. The team decided to initiate a therapy evaluation however after discussing with Resident #6's Responsible Party (RP) she stated she did not want the resident in a geriatric chair. She stated Resident #6's RP also requested she not be transported by the contract company again following the incident. The interview revealed looking back the facility should have removed the transportation driver from the facility to ensure protection of other residents. Once therapy saw the resident, she was transitioned into a high back wheelchair in which she still uses. The DON stated it was her understanding Nurse #3 had to go to the front lobby and get Resident #6 because her foot was bleeding and provide wound care before she could leave for the appointment. The interview revealed she did not know if Resident #6 had been seen following the incident for wound care by the Physician. She stated she did not obtain statements regarding the incident or interview Resident #6, further stating the nurses on the floor that file the incident report should be obtaining the statements from all staff members involved. The interview revealed the incident should have been investigated more since it resulted in an injury to Resident #6. The DON stated Transport Driver #1 should have stopped pushing the resident when he asked him to. The Administrator was notified of immediate jeopardy on 02/23/23 at 4:30 PM. The Credible Allegation for immediate jeopardy removal dated 11/14/22 was as follows: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The identified resident is Resident #1 and on 11/14/2 the resident's right foot dropped off the wheelchair foot pedal and became lodged or caught under the foot pedal of the wheelchair or rubbed against the floor while being rolled down the hallway by the transporter. Resident #1 alleges the transporter failed to stop pushing the resident in her wheelchair from her room in the facility to the facility lobby after she told him to stop because her foot was hurting. This caused her to have an abrasion to her right heel and an open area at the end of the left great toe that measured 2x2 cm. Licensed nurse was notified of the area and the resident's right foot was treated and she was able to go to her appointment. The facility failed to identify that this incident was an abuse situation and staff failed to report to administration immediately. The facility further failed to assess other residents, put protective measures in place, and conduct a thorough investigation. The facility also failed to provide corrective actions for the named transporter as identified as the perpetrator. The Director of Nursing interviewed resident #1 on 2/24/23 regarding the occurrence with the transporter pushing her in the wheelchair on 11/14/22. Resident # 1 was reassessed for transportation device on 11/14/22 and new order was implemented for geriatric chair, and further evaluation and preference from resident resulted in an order for a high back wheelchair with foam wedge cushion, elevating leg rests and drop leg pad. The wheelchair transport company was notified on 2/23/23 to inform the owner that the identified transporter will no longer be able to transport residents from facility. Interviews with residents were conducted asking the question if they ask the staff member to stop is their request honored and is the staff paying attention to their request. The interviews were completed by the Social Services department on 2/24/23. An audit of residents that used wheelchair transport since November 2022 by the wheelchair van transport company and by the facility staff/transporter revealed no other incidents with residents being maneuvered in a wheelchair. This audit was completed on 2/23/23 by administration and the corporate nurse consultant. Another audit was completed by Nursing Administration on 2/23/23 to ensure residents are transported via the proper device (i.e. standard wheelchair, geriatric chair, high back wheelchair, stretcher) for their safety. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be completed. All facility staff including agency staff were re-educated on the neglect protocol that includes how to identify what is a reportable, to report immediately to administration if they see neglect, how to assess other residents and put protective measure in place, to immediately remove and/or suspend the perpetrator, while facility is conducting a thorough investigation. This education consists of the following: how to identify what is reportable; to report immediately to administration if they see neglect; how to assess other residents and put protective measures in place; to immediately remove and/or suspend the perpetrator; facility conducting a thorough investigation; ensure that residents are protected during any care, services and situation; to stop what they are doing while providing care and services to a resident when asked by the resident to stop; to stop care and services, if a resident complains of pain and notify the facility licensed nursing staff in order for them to conduct an assessment and render treatment; and the overall need to pay attention to the residents while providing care and services that the resident ask to stop, that staff does stop. This education was completed by the Corporate Social Services Consultant for the Administrator on 2/23/23. Then it was completed by the Administrator for the Director of Nursing and Nursing Administration. All facility staff including agency staff were then educated by the Director of Nursing and Nursing Administration on 2/24/23. The wheelchair van transport company's transporters and the facility staff/transporter (on FMLA or vacation) that are not available for the education will not start working or care for residents until after the education is completed. Newly hired staff will receive this education as well prior to caring for residents. The Human Resources Director was notified on 2/24/23 by the Administrator to inform the Director of Nursing of new hires. The Director of Nursing will ensure the training is completed. The wheelchair transport company was given a copy of the education by the Director of Nursing to educate the transporters, and copies of the completion of this education will be given to the facility on [DATE]. Transporters will also be asked if they received this education by the facility prior to transporting residents in a wheelchair by Nursing Administration. If education was not completed, the education will be completed at that moment by the Nursing Administration prior to handling the residents' transport in a wheelchair. The Director of Nursing also re-educated the current licensed nurses including agency nurses on completing occurrence reports as soon possible after an incident occurs. Occurrence reports to be completed after the resident is assessed and appropriate treatment rendered. The education included the process of filling out an occurrence report that entails the following: generate occurrence report form; give description of the circumstances surrounding the occurrence; provide emergency care to the resident if needed; chart occurrence in the clinical record and enter it on acute board; notify the physician and resident representative; document all pertinent observations; obtain individual staff statements for current shift and at least two previous shifts for any/all occurrences not witnessed; investigate occurrence; and licensed nursing staff to complete report and submit completed occurrence report form to nursing administration as soon as possible during the specific shift. This education was completed on 2/24/23. The facility licensed nursing staff (on FMLA or vacation) that are not available for this education will not start working or care for residents until after the education is completed. The Director of Nursing will maintain a listing of staff that will need this education. Newly hired licensed nursing staff will receive this education as well prior to caring for residents. The Human Resources Director will notify the Director of Nursing of the new hires, and was notified of responsibility on 2/24/23 by the administrator. Occurrence reports are completed by the floor license nurse staff when an incident occurs. At that point, the licensed safety nurse will report daily, Monday through Friday during morning meetings. Then it is determined by the Director of Nursing and the Administrator if further investigation is needed. This will be conducted by Nursing Administration and reported to the administrator. During the weekends and off hours, the director of nursing and administrator are contacted by phone and the determination is made for investigation. All residents and resident representatives are provided information and education on the resident rights that include the right to be free from abuse and neglect by the admissions department on or prior to admission to the facility. All staff members including agency staff are provided information and education on resident rights that include the right to be free from abuse and neglect by the Social Services Department and/or staff development coordinator upon hire and at least yearly thereafter. All staff members including agency staff are responsible for the protection of residents and the immediate removal of any harm to residents. This education is provided by the Social Services Department and/or Staff Development Coordinator upon hire and at least yearly thereafter. The Administrator and Director of nursing received additional coaching and re-education of F610 by the corporate nurse consultant and the Corporate Social Services Consultant on 2/23/23. The Administrator and Director of Nursing are responsible for the ongoing compliance of F610. IJ Removal Date is 2/25/23. On 2/28/23, the facility's credible allegation for immediate jeopardy removal effective 2/25/23 was validated by the following: Staff interviews revealed they had received education on reporting resident abuse and neglect, ensuring residents are stabilized in their wheelchair prior to transport and to observe residents who are being transported by outside staff to ensure they are being handled appropriately. All staff were educated on notifying Administration if they see any resident in an abuse or neglect situation. Nursing staff received education which included the process of filling out an occurrence report. The facility's action plan was validated to be completed as of 2/25/23.

Based on record review, and interviews with staff, Nurse Practitioner (NP) and Medical Director (MD), the facility failed to provide wound care to an unstageable sacral pressure ulcer on 3 consecutive days, 12/08/22, 12/09/22, and 12/10/22 for 1 of 3 residents (Resident #154) reviewed for pressure ulcers. The findings included: Resident #154 was admitted to the facility on [DATE] and was discharged to the hospital on 12/11/22. Her admitting diagnoses included atrial fibrillation, hypertension, diabetes and end stage renal disease on dialysis. Resident #154's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors and required extensive to total assistance with all activities of daily living except eating in which she required set up only. The assessment also revealed Resident #154 had a pressure reducing device for her bed and chair and was at risk of developing pressure ulcers but had none on admission. The MDS further revealed the resident was currently receiving dialysis. Review of a pressure ulcer report dated 12/07/22 completed by the Treatment Nurse revealed Resident #154 had an unstageable wound to the sacrum that was classified as pressure ulcer with an odor and eschar. It was described as soft with normal surrounding skin and smooth and regular wound edges with no exudate (fluid that leaks out of blood vessels into nearby tissue). According to the report, the treatment plan was to cleanse with Dakin's solution (antiseptic used to cleanse wounds) and apply skin prep (liquid film that shields delicate and vulnerable skin). Review of a physician's order written 12/11/22 revealed an order written by the Treatment Nurse for Resident #154's sacral pressure ulcer to be cleansed with Dakin's solution, apply skin prep around the wound and cover with a foam dressing daily and prn related to pressure ulcer, turn, and reposition every 2 hours, and daily skin audit by the nurse. Review of Resident #154's Treatment Administration Record (TAR) revealed the sacral unstageable pressure ulcer wound dressing had only been done on 12/11/22 and daily wound care to the unstageable pressure wound was not done 12/08/22 through 12/10/22. Interview on 02/22/23 at 12:05 PM with the Treatment Nurse revealed Resident #154 had a decline in the condition of her skin. She stated on 12/07/22 she found the resident had an unstageable facility acquired pressure ulcer on her sacral area with an odor. The Treatment Nurse explained Resident #154's RP had visited the resident on 12/11/22 and observed the wound during her wound care on that date and after seeing the wound the RP requested the resident be sent out to the hospital for evaluation and treatment of the wound. Phone interview on 02/23/23 at 8:26 AM with Nurse #2 who cared for Resident #154 on 12/10/22 and 12/11/22 on 1st shift revealed she was a travel nurse and had worked at the facility for a few weeks but could not recall the resident or her wound. Interview on 02/23/23 at 11:48 AM with the Medical Director (MD) revealed she didn't look at all the wounds at the facility, but if the Treatment Nurse was monitoring an area that she thought was infected she would contact the MD to see the wound. The MD explained Resident #154 had a venting PEG tube, end stage renal disease, diabetes and atrial fibrillation as well as protein calorie malnutrition and it was possible the resident had a Kennedy ulcer. She further explained she had not seen the wound and could not be certain that was the type of wound the resident had when discharged . Phone interview on 02/24/23 at 11:29 with the Nurse Practitioner (NP) revealed Resident #154 was at the end of her life with multiple comorbidities including what she believed to be the development of a Kennedy ulcer. The NP stated the rapid development and deterioration of the wound was likely due to her gastric outlet obstruction, malnutrition and malabsorption and there was no way to avoid the breakdown of her skin. Follow up phone interview on 02/24/23 at 11:57 AM with the Medical Director (MD) revealed given Resident #154's protein malnutrition and other comorbidities there was nothing that could be done to prevent or avoid skin breakdown and ultimately pressure ulcers. Follow up interview on 02/24/23 at 1:08 PM with the Treatment Nurse revealed she had not written the order for wound care until 12/11/22 and it would not have flagged the nurses on the Treatment Administration Record (TAR) Resident #154 needed wound care. She stated she could not provide any documentation that indicated Resident #154 had wound care to her sacral wound on 12/08/22, 12/09/22, or 12/10/22 but said she had wound care on 12/11/22 as documented by Nurse #2.

Based on record reviews, observations, staff interviews, and resident interviews the facility failed to treat residents in a dignified manor when staff did not provide incontinence care and the resident heard staff talking about her being difficult to change (Resident #16), when staff rolled their eyes when a resident asked to be put to bed (Resident #79), when staff told a resident they were going on break before providing incontinence care (Resident #55) and when staff yelled at a resident for trying to get assistance with care and trying to get assistance with incontinence care for her roommate (Resident #73). The residents expressed feelings of being upset, uncomfortable, unclean, and felt the nursing home did not care about them. This affected 4 of 4 residents reviewed for dignity and respect (#16, #79, #55, and #73). The findings included: 1. Resident #16 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resdient#16 was cognitively intact and required extensive assistance with activities of daily living (ADL). The MDS noted Residetn #16 was always incontinent of urine and frequently incontinent of bowel movements. An observation and interview conducted on 06/15/21 at 2:30 PM revealed Resident #16 pointed towards Nurse Aide (NA) #7 and NA #8 stating she did not want to be in the facility anymore and was tired of staff being ugly. Resident #16 revealed she had not been changed since breakfast and was soaked through to her clothes. She stated the NAs were making comments about prior shift staff not changing her and stated she was a pain to change because they had to put her back in the bed. Resident #16 stated she was upset, angry and felt that staff does not care about her. An interview conducted with NA #8 on 06/15/21 at 4:25 PM revealed Resident #16 was found dripping wet because prior shift did not change her. She further revealed she was upset and should have not portrayed being aggravated in front of the resident. An interview conducted with NA #7 on 6/15/21 at 5:00 PM revealed Resident #16 was mad because she and NA #8 were talking about prior shift while caring for the resident and Resident #16 believed they were speaking about her. She further revealed she was frustrated with short staffing and should have been paying attention to Resident #16 during care. An interview conducted with the Director of Nursing (DON) on 06/18/21 at 5:00 PM revealed it was expected there to be no conversation about anything other than the resident when giving care and all residents should be treated with dignity and respect. An interview conducted with the Administrator on 06/18/21 at 6:15 PM revealed during one on one care staff should be focused on the resident and it was expected for all residents to feel comfortable with staff. 2. Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #79 was cognitively intact and required extensive assistance with activities of daily living (ADL). An observation conducted on 06/05/21 at 4:09 PM revealed Resident #79 sitting in her wheelchair outside of her room stating she was in a lot of pain and wanted to go back to bed. The Director of Nursing (DON) walked up to the Nurse Aide (NA) #7 and requested to put Resident #79 back into bed. It was further observed NA #7 rolled her eyes and Resident #79 starting crying and continued to apologize multiple times to NA #7 who did not acknowledge the resident. An interview conducted with Resident #79 on 06/16/21 at 9:15 AM revealed the resident was very upset on how NA #7 did not acknowledge her and continued to ignore her when she was apologizing for having to be put back to bed. She further revealed NA #7 always seemed mad about giving care and has been rude to Resident #79 on multiple occasions. An interview conducted with NA #7 on 06/15/21 at 5:00 PM revealed she was frustrated because three different residents were needing assistance at the same time. She further revealed she did not recall rolling her eyes but stated she should have acknowledged Resident #79 and not ignored her when apologizing for needing assistance. An interview conducted with the Director of Nursing (DON) on 06/18/21 at 5:00 PM revealed Resident #79 should have not been ignored and should have been acknowledged by NA #7. The DON further revealed all residents should be spoken to with respect and NA #7 would be completing sensitivity training. An interview was conducted with the Administrator on 06/18/21 at 6:15 PM revealed NA #7 should have acknowledged Resident #79, and residents were expected to be treated with dignity and respect by all facility staff. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her admission Minimum Data Set (MDS) dated [DATE] revealed Resident #55 had adequate hearing, was cognitively intact, required limited assistance of 2 staff with toileting and was frequently incontinent of urine and occasionally incontinent of bowel and wore briefs. Review of Resident #55's care plan dated 06/07/21 revealed she had a care plan in place for assistance with activities of daily living (ADL). The interventions included assist with bathing, dressing, personal hygiene, and incontinence care on rounds and as needed. An observation and interview on 06/14/21 at 1:23 PM with Resident #55 revealed she had waited last evening on 06/13/21 for an hour and 32 minutes (which she timed by the clock in her room) for assistance in getting her brief changed. Resident #55 stated when the Nurse Aide (NA) came in to change her she told the resident it was 8:00 PM and she had not sat down since coming on shift and she was taking her dinner break and the resident would have to wait to be changed until she was back from her break. Resident #55's roommate (Resident #73) agreed the NA said that to Resident #55. Resident #55 further stated the NA had been in 2 times while her light was on and turned it off and told Resident #55 she would be back when she finished with other residents she was assisting. Resident #55 said she could not recall the NA's name but stated she frequently worked on their hall. On 06/15/21 at 4:39 PM during a follow-up interview with Resident #55 and Resident #73, they identified the NA from 6/13/21 as NA#7. Resident #55 stated she was not only wet but had a bowel movement and it really upset her and made her feel dirty and like she didn't matter when the NA told her she was going to take a break before changing her brief. Resident #55 stated she was also concerned about the bowel movement getting into or on her sacral wound. On 06/15/21 at 5:00 PM an interview with NA #7 revealed she had been assigned to care for Resident #55 and Resident #73 on 06/13/21, 06/14/21 and 06/15/21 during the 3:00 PM to 11:00 PM shift. NA #7 said she did not recall telling Resident #55 she was going to take a break before providing her incontinence care. She stated she always took care of her residents and provided incontinence care when requested. NA #7 indicated she would never treat a resident disrespectfully. On 06/16/21 at 9:37 AM an interview with the Social Services Director (SSD) revealed she had spoken with Resident #55 and Resident #73 and they both had requested that NA #7 not be assigned to take care of them again because of the way she treated them. The SSD stated the residents did not feel like they had been abused by NA #7 but did not feel as though she cared about them and their needs. On 06/18/21 at 4:24 PM an interview with the Director of Nursing (DON) revealed she had not received any complaints about NA #7 and her not taking care of residents prior to this week. She stated NA #7 was usually soft spoken and quiet and did not complain. The DON further stated she expected NA #7 and all the NAs to provide care to residents requesting care prior to going on breaks and expected them to treat all the residents with dignity and respect. On 06/18/21 at 7:13 PM an interview with the Administrator revealed she expected all residents in the facility to be treated with dignity and respect by all the staff. 4. Resident #73 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had adequate hearing, was cognitively intact, and required extensive assistance of 1 staff member with bed mobility, transfers, walking in room, and toileting and required total assistance of 1 staff person for bathing. The MDS further revealed Resident #73 was always incontinent of urine and frequently incontinent of bowel and wore briefs. Review of Resident #73's care plan dated 05/25/21 revealed she had a care plan in place for assistance with activities of daily living (ADL) related to decreased mobility secondary to weakness. The interventions included assist with bathing, hygiene, dressing, grooming, turning, and repositioning, assist with toileting and incontinence care with rounds and as needed. The care plan indicated the resident's ADL participation and need for assistance fluctuates from day to day and time of day and per resident desire to participate. An observation and interview on 06/14/21 at 1:23 PM with Resident #73 revealed she had been yelled at by an NA for requesting assistance and stated the NA had told her you can just get up and do it yourself. The resident stated she did everything she could for herself but sometimes she needed assistance and when she asked the NA, she told her to do it herself. Resident #73 further stated the NA used a loud tone and acted like the resident was bothering her by her asking for assistance. Resident #73 expressed it made her feel like a child that was being scolded and like her needs were not important. Resident #73 indicated that was not the first time the NA had yelled at her and stated she yelled at her last evening when she was yelling for assistance for her roommate (Resident #55) who needed her brief changed. Resident #73 further indicated the NA came in the room and yelled at her and told her to stop yelling for help that the NAs were helping other residents and they would get to them when they got to them. Resident #73 disclosed her saying that made her feel like they were not important and that the NAs didn't care when they got to them. On 06/15/21 at 4:39 PM while in the room talking with Resident #73, NA #7 and NA #8 came in to provide incontinence care to Resident #55. After they left the room Resident #73 identified NA #7 as the NA who had yelled at her and told her to get up and do for herself. Resident #73 stated she would prefer NA #7 not take care of her anymore after today because of the way she had talked to her and treated Resident #55. On 06/15/21 at 5:00 PM an interview with NA #7 revealed she had been assigned to care for Resident #73 on 06/13/21, 06/14/21 and 06/15/21 on the 3:00 PM to 11:00 PM shift. NA #7 said she did not recall yelling at Resident #73 or telling her to do care for herself. She stated she always took care of her residents and would never yell at a resident. NA #7 indicated she would never treat a resident disrespectfully. On 06/18/21 at 4:24 PM an interview with the Director of Nursing (DON) revealed she had not received any complaints about NA #7 and her not taking care of residents prior to this week. She stated NA #7 was usually soft spoken and quiet and did not complain. The DON further stated she expected NA #7 and all the NAs to provide care to residents requesting care, not yell at residents and expected them to treat all the residents with dignity and respect. On 06/18/21 at 7:13 PM an interview with the Administrator revealed she expected all residents in the facility to be treated with dignity and respect by all the staff.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide sufficient nursing staff, resulting in missed showers for dependent residents, partial baths or bed baths being provided instead of preferred showers, nail care not being provided for dependent residents, residents not being assisted up out of bed as requested and incontinence care not being provided for 13 of 17 residents reviewed for dignity and respect, choices and activities of daily living (Residents #16, #79, #55, #73, #47, #53, #71, #35, #78, #70, #39, #40 and #294). The findings included: This tag is cross referred to: 1. F550: Resident Rights: Based on record reviews, observations, staff interviews, and resident interviews the facility failed to treat residents in a dignified manor when staff did not provide incontinence care and the resident heard staff talking about her being difficult to change (Resident #16), when staff rolled their eyes when a resident asked to be put to bed (Resident #79), when staff told a resident they were going on break before providing incontinence care (Resident #55) and when staff yelled at a resident for trying to get assistance with care and trying to get assistance with incontinence care for her roommate (Resident #73). The residents expressed feelings of being upset, uncomfortable, unclean, and felt the nursing home did not care about them. This affected 4 of 4 residents reviewed for dignity and respect (#16, #79, #55, and #73). 2. F561: Self Determination: Based on observations, record reviews, resident and staff interviews, the facility failed to provide a resident with her preferred number of showers a week and failed to get her up out of bed to her wheelchair (Resident #47), failed to provide a resident his preference of using his machine (cleaner and sanitizer) to clean his Continuous Positive Airway Pressure (CPAP) mask, tubing, humidifier and water chamber instead of staff cleaning the equipment and honor his wish for a new mattress without lumps and dips in it (Resident #53) and failed to honor a resident 's wish to get up out of bed and into her wheelchair every [MEDICATION(S)] breakfast (Resident #71) for 3 of 3 residents reviewed for choices. 3. F677: Activities of Daily Living for Dependent Residents: Based on record review, observations, resident and staff interviews, the facility failed to provide nail care to 6 of 10 residents (Resident #35, Resident #78, Resident #70, Resident #39, Resident #40 and Resident #294) reviewed for assistance with activities of daily living. On 06/15/21 at 4:41 PM an interview was conducted with NA #8. The NA stated she and the other NA working with her had to work together to get all the residents changed and put to bed because a lot of them required 2 staff assistance with care. On 06/15/21 at 5:08 PM an interview was conducted with NA #7. NA #7 stated she and the NA working with her were only able to complete 2 incontinence rounds on with the current staffing. On 06/15/21 at 10:54 PM an interview was conducted with Nurse #12. The Nurse stated there were 3 Nurses and 6 NAs in the building at present for 91 residents. Nurse #12 further stated from 11:00 PM to 7:00 AM there would only be 4 NAs in the building and said it was difficult especially on the back halls due to residents that required 2 staff for care. On 06/15/21 at 11:03 PM an interview was conducted with NA #10 and NA #11. NA #10 stated staffing was not good on her shift which was 11:00 PM to 7:00 AM. The NA stated she had residents on North, South and skilled and spent her time running from one hall to another and stated it was difficult to get care done for the residents when you were assigned to 22 residents. NA #10 and NA #11 explained they worked together to get at least 2 rounds of incontinence care done on the residents they were assigned and said it was not possible to do rounds every 2 hours as expected. On 06/16/21 at 10:27 AM an interview was conducted with NA #12. The NA stated although she had other duties, she had been working on the floor lately due to so many open positions for NAs and not being able to secure help through Agencies. NA #12 described staffing as being good some days and bad some days. She stated on days when there were only 5 NAs they would have 14 to 15 residents and were not able to get all the showers done, were not able to get incontinence care done every 2 hours and could not get all the linens changed for the residents. NA #12 further stated the residents that require 2 staff assistance were the most difficult to get done with bathing and incontinence care. On 06/16/21 at 10:37 AM an interview was conducted wit Nurse #6. The Nurse described staff as terrible especially at night. She stated some of the NAs leave at 5:00 AM and there was not enough NAs to provide care to the residents. On 06/16/21 at 10:58 AM an interview was conducted with NA #4. The NA stated staffing was not good and said when NAs were assigned 18 to 20 residents, they could not complete incontinence rounds every 2 hours, give showers as scheduled and get residents up. She further stated it was very frustrating for the NAs and was not fair to the residents. NA #4 described a day last week in which they had 16 residents each and it was all they could do to keep them clean and dry. NA #4 indicated they were constantly asked to work over shift to cover holes in the schedule from not enough help to care for the residents. On 06/16/21 at 11:47 AM an interview was conducted with the Nurse Schedule Coordinator (NSC). The NSC stated she did schedule at least a week out with assistance from the Director of Nursing (DON). The NSC explained for 1st shift she tried to staff shifts with the following for the current census of 88: · Day shift: (7:00 AM to 7:00 PM) 5 to 6 Nurses · 1st shift: (7:00 AM to 3:00 PM) 9 to 10 NAs · 2nd shift: (3:00 PM to 11:00 PM) 7 to 9 NAs · Night shift: (7:00 PM to 7:00 AM) 3 to 4 Nurses · 3rd shift: (11:00 PM to 7:00 AM) 5 to 6 NAs The NSC indicated there was usually a Nurse on call and said the Nurse usually had to come into work. She further indicated they were using one Agency to staff for Nurses and NAs and said they were using Agency daily. The NSC explained there was not enough staff employed by the facility to meet the staffing needs daily. She disclosed the facility was offering incentives to employees to work half and full shifts, weekends, weekdays and said they were getting a lot of participation with the incentives. According to the NSC, she has heard from the NAs they need more help and said 2nd shift was the most difficult shift to staff. The NSC advised staffing was based on the number of residents in the building, the acuity of the residents and the staffing pattern provided to her by administration. On 06/16/21 at 2:09 PM an interview was conducted with NA #1. NA #1 stated she had not been able to do resident nails due to her heavy load. NA #1 indicated there was not enough help on 1st shift to get showers done, get residents up and do incontinence care every 2 hours as expected and said it was not fair to the residents or the staff. On 06/16/21 at 2:39PM an interview was conducted with NA #5. The NA stated there was not enough help or time in the day to get everything done for the residents when they were assigned 12 to 16 residents. NA #5 indicated the only way she could get showers done was to skip all her breaks and could only get 2 incontinence rounds done on the residents. On 06/16/21 at 2:52 PM an interview was conducted with NA #2. The NA stated she had done a lot of double shifts at the facility. NA #2 further stated she could not do proper care when she had 18 to 20 residents. She indicated she was not able to get showers done and barely got 2 rounds of incontinence care done and said it was impossible to do incontinence rounds every 2 hours. On 06/18/21 at 4:35 PM an interview was conducted with the Director of Nursing (DON). The DON described their staffing patterns as the following: Nurse Aides: 7:00 AM to 3:00 PM - 1 NA for 10 residents 3:00 PM to 11:00 PM - 1 NA for 16 residents 11:00 PM to 7:00 AM - 1 NA for 22 residents The DON indicated staffing patterns were based on census and acuity of residents and said she worked closely with the Nurse Staffing Coordinator (NSC) to ensure adequate staffing for the resident needs. She further indicated they were offering referral and sign-on bonuses, recruiting from colleges, advertise online with job sites, and are doing moral boosters for the current employees. According to the DON additional help did not always compute to more being done for the residents but stated her expectation was for residents to receive the care deserved and requested. On 06/18/21 at 7:04 PM an interview was conducted with the Administrator. The Administrator stated they were trying to recruit Nurses and NAs and were offering sign on bonuses, incentives for working extra shifts, visiting colleges, and sending flyers to colleges. She further stated they had even tried to hire Medication Techs but stated they were competing with salaries at the hospital and other facilities. The Administrator indicated they were trying to hire but the geographical area was difficult to find help and the salaries were challenging. She explained despite the difficulties with staffing, her expectation was for staff to provide the care requested and deserved to the residents and to request assistance from other staff as needed.

Based on observations, record review, review of manufacturer's instructions, and staff and manufacturer representative interviews the facility failed to ensure all 4 of transport van's wheelchair tiedown retractors were secured to a wheelchair during a van transport for 1 of 1 resident reviewed for supervision to prevent accidents. Resident #112's wheelchair flipped backwards and he struck his head on the wheelchair lift platform. Resident #112's head started bleeding. The Transport Aide (TA) assisted Resident #112 into an upright position in his wheelchair and placed gauze on the laceration to Resident #1's head prior to the resident being assessed by a nurse or emergency medical technician (EMT) and returned to the facility. Resident #112 was later transported to the hospital and was diagnosed with [REDACTED]. Resident #112 was discharged from the hospital and was readmitted to the facility. Findings included: Review of the manufacturer's instructions for the securement system used by the facility's transport van to secure residents who are seated in wheelchairs during transport read in part, the following parts make a complete wheelchair/passenger securement system: 4 wheelchair tiedown retractors, 1 occupant lap belt, and 1 occupant shoulder belt and mounting hardware. Resident #112 was admitted to the facility 09/10/18 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #112 was cognitively intact and required extensive assistance with transfers. The facility's incident/accident report dated 04/05/19 indicated Resident #112 fell backwards in his wheelchair while being transported in the facility van. Resident #112 had a laceration to the top of his head and was sent to the hospital. Resident #112 denied pain. Nurse #1's note dated 04/05/19 at 4:40 PM indicated the following: At approximately 3:15 PM the TA and (Resident #112) entered the facility via wheelchair after returning from a dermatology appointment. Resident #112 had blood on his face, neck, and shirt. The Medication Nurse requested emergency assistance from the other nursing staff. Nurse #1 entered Resident #112's room noting blood on resident's face, neck, and shirt and the Medication Nurse was applying pressure to the top of resident's head. Resident #112 was alert and verbal. 911 was called. Nurse #1 assessed for head, neck, and spinal injury and denied pain to touch. Vital signs were obtained. Resident #112 was alert and oriented to person, place, time, and date. Neurological checks were within normal limits. Resident #112 denied losing consciousness. A laceration was noted to Resident #112's scalp and a discoloration was noted to his right knuckle. Nurse #1 asked Resident #112, What happened? Resident #112 replied, I was on the van and my wheelchair flipped backwards. I hit my head on the back door. Resident #112 reported wearing his seatbelt. Resident #112 stated, He (the TA) strapped me in, he always does. Emergency Medical Services (EMS) arrived and checked for head, neck, and spinal injury. Resident #112 was able to stand and pivot from his wheelchair to the stretcher. The Physician was notified and approved an order to send Resident #112 to the hospital. The Emergency Department (ED) report dated 04/05/19 revealed Resident #112 was examined after he fell out of a chair and struck his head. A laceration with bleeding was noted to the top of Resident #112's head. Resident #112 received a Computerized [NAME]ography (CT) scan (computer generated images of the bones, blood vessels, and soft tissues inside the body) of the head. Resident #112 was diagnosed with [REDACTED]. facet joints of the spine). Resident #112 received laceration repair, was given a cervical collar (neck brace), and returned to the facility. Resident #112 was unable to be interviewed because he was not in the facility at the time of the survey. A telephone interview conducted with Transportation Aide #1 on 08/26/19 at 2:44 PM confirmed he was driving the transport van on 04/05/19 when Resident #112 fell backward in the wheelchair during transport and had not been back to work since the incident. TA #1 initially stated he picked Resident #112 up at the dermatologist's office after an appointment and strapped Resident #112's wheelchair in with the 2 rear securement straps and 1 front securement strap. TA #1 then stated he may have been distracted by talking with Resident #112 and only used 3 of the 4 securement straps or that Resident #112 could have messed with a securement strap and caused it not to be secure. TA #1 stated he drove out of the Physician's office parking lot and after a few minutes heard a noise from the back of the van. TA #1 stated he turned around and saw the wheelchair had fallen backwards and landed on the wheelchair lift platform. TA #1 stated he pulled off the road and got Resident #112 upright in his wheelchair. TA #1 stated he saw Resident #112's head was bleeding and he placed gauze over the cut and drove back to the facility. When the van returned to the facility TA #1 got Resident #112 out of the van, brought him inside the facility, and told the nurses Resident #112 needed assistance. TA #1 stated he used all 4 securement straps for transport back to the facility after Resident #112's fall. TA #1 stated he was trained to use 4 points of securement for all transports involving a wheelchair. There were no other residents on the van at the time of Resident #112's fall. An interview with Nurse #1 on 08/26/19 at 4:49 PM revealed she was the Staff Development Coordinator (SDC) at the time of Resident #112's van accident. Nurse #1 stated the day of the van accident an employee came running into her office and said she was needed in Resident #112's room. Nurse #1 stated when she entered Resident #112's room he was bleeding from his head. She stated a nurse was holding pressure to Resident #112's head and she asked another nurse to call 911. EMS came, placed a neck collar on Resident #112, and transported him to the hospital. Nurse #1 stated she interviewed Resident #112 before EMS arrived and he told her he was strapped into the van but he was uncertain how many straps were used. An interview with the Maintenance Director on 08/26/19 at 3:39 PM revealed training for all staff driving the facility van involved watching a video made by the company which manufactured the securement straps, return demonstrations of wheelchair securement, a road test, and practice loading and unloading a resident. The Maintenance Director stated TA #1 did van transports and was a nurse aide (NA) before he became employed with the facility and TA #1's road test was done when he was originally signed off on driving the van. The Maintenance Director stated TA #1 was in-serviced on van operation and wheelchair transport on 12/09/16 and 05/22/17 for van safety. The Maintenance Director also stated he inspected the wheelchair securements used for transporting Resident #112 on 04/05/19 and found them to be in working order. The Maintenance Director stated 4 points of securement were to be used for all wheelchair transports and there was no situation when using 3 points of securement would be appropriate. An interview with the Director of Nursing (DON) was conducted on 08/26/19 at 4:56 PM. The DON confirmed there was an incident on 04/05/19 where Resident #112 fell backwards in his wheelchair while being transported from an appointment in the facility van. She stated an investigation was begun and TA #1 was suspended following the incident. As part of the investigation the DON, Staff Development Coordinator, Administrator, Maintenance Director, and TA #1 re-enacted the entire occurrence with Resident #112's wheelchair. The Corporate Safety Manager inspected the wheelchair securements and other devices in the facility van and all the devices were functioning properly. The Corporate Safety Manager in-serviced the Maintenance Director regarding use of wheelchair securement devices. The DON stated during a re-enactment of the incident attempts were made to move the wheelchair with 3 straps and the wheelchair became unsecured with continuous movement of an individual's feet. Foot rests were not in place on the wheelchair at the time of the incident and by movement of Resident #112's feet it was possible he could have loosened the securement strap or tapped the red release button on the securement device. Another possible cause of the wheelchair turning over backwards was the van went over railroad tracks during the transport on 04/05/19 and the J-hook could have become loosened or become detached during transport. A telephone interview with a representative from the manufacturer of the wheelchair securement device on 08/27/19 at 8:37 AM revealed all wheelchair securement devices were designed to be used with 4 points of securement. The representative stated if all 4 securement devices were used correctly it would be highly unlikely the wheelchair could tip backwards. The representative also stated it was highly unlikely the resident could have hit the red release button on the securement straps because it would require an extreme amount of force. An interview with the Administrator on 08/27/19 at 9:57 AM revealed the investigation was not able to determine the exact cause of the wheelchair falling backwards but contributing factors could have been driving over train tracks, stop and start traffic, or Resident #112 hitting the red release button on the wheelchair securement. The Administrator stated TA #1 should have pulled the van safely off the road, called 911, and not moved Resident #112. The Administrator provided a summary of the investigation and Quality Assurance/Process Improvement (QAPI) that was put into place following the incident on 04/05/19. The facility provided the following QAPI with the plan of correction date of 04/11/19. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. -The facility self-identified an opportunity with transportation services related to the training of transportation attendants regarding safety precautions, utilization of required safety restraints, and emergency management following an accident. -The Quality Improvement Plan dated 04/05/19 had a problem statement that read 3 out of 4 safety belt straps were used to secure a resident in his wheelchair in the van resulting in the wheelchair turning over backwards. The root causes of the incident were determined to be 3 out 4 safety belt straps were applied to secure a wheelchair in the van, no foot rests were applied to the wheelchair, the positioning of the J-hook above the bracket of the foot rest, and the location of the incident including travel over railroad tracks. Barriers were education of staff and a busy transport schedule. -The Maintenance Director was re-inserviced by the Corporate Safety Manager 04/05/19 on van safety and procedures with return demonstration and equipment check on the van. The Maintenance Director performed all safety procedures correctly on return demonstration. All equipment on the van was checked and was in working order. -Facility van drivers were re-inserviced on van safety and procedures by the Maintenance Director with return demonstration and included watching a video of proper placement of securement straps by the manufacturer of the securement straps. Education began 04/08/19 was completed 04/10/19. Facility van drivers performed all safety procedures correctly on return demonstration. -New retractable safety belts which secured the wheelchair to the floor of the van were ordered and replaced in the facility van by the Maintenance Director on 04/08/19. -Facility van drivers were in-serviced on what to do in case of an emergency/accident in the van by the Maintenance Director and the Assistant Director of Nursing on 04/08/19. Training was completed 04/10/19. All van drivers were able to correctly state pull over and call 911. -Facility van drivers were given road tests with return demonstration of safety procedures by the Maintenance Director on 04/11/19 and auditing is ongoing. -An audit of all approved van drivers performing transportation was done Monday through Friday for 2 weeks by the Maintenance Director. The audit began 04/11/19 and is ongoing. -An audit of 5 transports with demonstration was done weekly Monday through Friday for 4 weeks by the Maintenance Director beginning 05/20/19, then an audit of 2 transports with demonstration was done weekly Monday through Friday by the Maintenance Director beginning 06/24/19, then regular safety checks will be conducted monthly to all safety devices in the wheelchair van for 3 months by the Maintenance Director beginning 05/10/19, and van transports will be discussed daily Monday through Friday with morning QI meetings by the Maintenance Director and DON for issues and trends for 3 months beginning 04/11/19 and is ongoing. The QAPI was validated 08/27/19 and concluded the facility implemented an acceptable corrective action plan on 04/11/19 once all authorized drivers were trained. The facility provided documentation that included transport drivers training and re-education records, Departmental Manager safety training records, and facility audits. Review of the in-service records revealed staff were trained if an accident occurred during a resident transport not to move the resident until the resident was assessed by a licensed professional. Residents who were transported to outside appointments were interviewed and reported no concerns. Facility staff were interviewed and confirmed they received training on transportation safety that included how to properly secure a resident in a wheelchair and perform return demonstrations. Staff interviews also confirmed they were trained if an accident occurred during a resident transport to not move the resident until they have been assessed by a licensed professional.

Based on observations, record review and staff interviews, the facility failed to prevent one (1) of fifteen (15) sampled cognitively impaired residents, who were at risk for elopement, from exiting the facility. Resident #2 eloped from the facility on 3/2/12 while unsupervised and was found by staff walking in the middle of the roadway approximately 0.3 miles away from the facility. (Resident #2). Immediate Jeopardy began on 3/2/12 when Resident #2 eloped from the facility without staff's knowledge that she was outside unsupervised. Immediate Jeopardy was removed on 3/14/12 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings are: Resident #2 was admitted from home to the facility on [DATE]. [DIAGNOSES REDACTED].#2 as ambulatory, seeking an exit for the reason of wanting to go home, had been located just outside the door, i.e. porch, patio, and had easily altered exit desires. On 5/16/11 a watch mate bracelet was applied to her ankle. The facility was equipped with a watch mate alarm system on the front entrance. This system works via a watch mate bracelet which contains a transmitter which will lock the front door if the transmitter comes within several feet of the closed front door. If the front door is already opened, the transmitter will set off an alarm to alert staff that a watch mate bracelet has come within feet of the open door. Nursing notes revealed the following behaviors/events: *11/20/11 at 10:11 AM Resident #2 was packing clothes and stating she was going home. *12/22/11 at 11:17 AM Resident #2 was packing her clothing and personal items and stating she was going home. She became agitated when redirected. *1/16/12 at 2:31 PM the physician visited Resident #2 as responsible party had concerns about the resident packing her clothes and requested urinalysis. Physician denied request for urinalysis due to resident's denial of symptoms. *1/22/12 at 1:45 PM Resident #2 packed belongings in a pillow case and walked down hall with jacket and purse. She was redirected with no further episodes. The quarterly Minimum Data Set ((MDS) dated [DATE] coded her with severe cognitive impairment, being independent with ambulation and having no wandering behaviors. The care plan reviewed on 2/7/12 identified the problem that Resident #2 had a watch mate due to the potential for exit seeking due to confusion. The goal was for the resident to have no attempts to exit building during the next assessment. Interventions included to monitor placement of watch mate every shift; monitor resident every fifteen minutes to know of her whereabouts; encourage resident to come to out of room for activities for socialization and diversion; report increases in exit attempts to medical doctor as needed; monitor watch mate for proper functioning; and redirect resident if seen packing up her things to leave. Nursing notes dated 2/14/12 at 11:27 PM revealed Resident #2 was extremely confused, dressed in coat waiting and watching for someone. When questioned, her response was garbled. She was out of her room in the hall and was very anxious. Nursing notes dated 3/2/12 at 10:13 PM revealed that at 4:45 PM, Licensed Nurse (LN) #2 received a phone call that Resident #2 had exited the building. LN #2 approached the front of the building and noted the resident was being assisted inside the facility by staff members. The watch mate was in place and working properly. No acute distress was noted upon assessment. Notification to family and physician was made. Resident #2 was placed on one to one supervision. On 3/12/12 at 12:32 PM a phone interview was conducted with Nurse Aide (NA) #1. NA #1 stated she was off duty and running errands on 3/2/12 at approximately 4:40 - 4:45 PM when she heard cars honking their horns. She stated she saw Resident #2 in the middle of the road near railroad tracks and identified the street corner. NA #1 stated after a few minutes, she was able to convince Resident #2 to get into the car. NA #1 stated she called the facility as she was getting the resident into the car. She returned the resident to the facility. On 3/12/12 at 12:45 PM surveyors observed the location Resident #2 was found by NA #1 as approximately 0.3 miles away from the facility. The road in front of the facility being a 35 miles per hour zone and then changing to 20 miles per hour zone closer to the corner where Resident #2 was found by staff. On 3/12/12 at 1:52 PM the Administrator stated that she believed Resident #2 was let outside by a visitor. She confirmed no one knew Resident #2 was missing until NA #1 called the facility notifying staff she had found the resident. On 3/12/12 at 2:01 PM LN #2 stated she was Resident #2's floor nurse on 3/2/12, on the South unit. LN #2 stated Resident #2 had been active that day, visiting another resident on the Skilled unit and walking around the facility. She stated that approximately 4:30 PM on 3/2/12 Resident #2 had her purse in hand and stated she was going to eat and headed in the direction of the dining room. LN #2 stated although the resident frequently packed clothes, she did not pack or speak of leaving that day. LN #2 stated within the next twenty minutes she received word that Resident #2 was found out of the facility. LN #2 stated she did not know the resident was missing. LN #2 stated Resident #2 always wore a watch mate that alarmed the doors, which was checked daily for placement by nurses. She stated the quality assurance (QA) nurse checked the functioning of the watch mate. LN #2 stated she did not hear the front door alarm and further stated the front door alarm could not be heard on the South unit (where Resident #2 resided) but should ring on the North unit. LN #2 stated she determined via interviews with social service staff (SS) #1 that the alarm sounded. Social service staff had to deactivate the alarm via a code and looked but saw no residents outside. LN #2 then decided to inservice staff about ensuring that alarms are answered and staff thoroughly look for the cause of the alarm. LN #2 stated Resident #2 was placed on one to one supervision throughout the remainder of the shift. Interview with the Social Service Director (SSD) on 3/12/12 at 2:25 PM revealed she and SS#1 were in a meeting when they heard an alarm sounding. She stated she thought it was a bathroom door alarm from a resident's room on North unit that frequently goes off. She stated it went off for approximately 20 seconds when a male visitor stopped by her office and requested to be let out of the facility as the front door was locked. She stated it was at this time she realized it was the front door alarm that was sounding. She stated she had to use the code to stop the alarm and open the door. Once she opened the door, SSD stated she looked across the parking lot, right and left, on the porch and upon seeing no residents, SSD went back inside. She stated she left the facility for the day without further intervention. SSD stated Resident #2 packed things up almost every day but did not check doors in attempts to leave the facility. On 3/12/12 at 2:46 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated he was working back on the Skilled unit on 3/2/12. The ADON stated he was informed by LN #2 that Resident #2 was found down the street and that he should go help NA #1 who was with her. Per interview, when he got to the front door, NA #1 was already in the parking lot with Resident #2 so he assisted the resident inside. He stated the front door locked down as they neared it, indicating Resident #2's watch mate was working. The ADON stated he had not heard the front door alarm. He stated the front door alarms at the front door and on the North unit. He stated the front door alarm could not be heard on the Skilled unit where he was working. The ADON stated Resident #2 frequently packed her things and would talk about going home but he did not recall her every trying to leave the facility. On 3/12/12 at 3:12 PM interview with LN #3 revealed she was working on 3/2/12 and answered the phone on the South unit when an employee called to report Resident #2 was found down the street. LN #3 stated no one knew the resident was missing and she reported the phone call to LN #2. LN #3 stated she did not hear the front door alarm when working on the South unit. It could only be heard on the North unit. LN #3 stated Resident #2 walked around the facility often, verbalized a desire to go home but wore a watch mate for safety. Interview with NA #2 on 3/12/12 at 3:40 PM revealed he was working on the South unit during the second shift of 3/2/12. NA #2 stated he did not know Resident #2 was missing until she was brought back to the facility. NA #2 stated he did not hear the front door alarm and further stated the alarm did not sound on the South unit. Interview with NA #3, second shift staff, on 3/12/12 at 3:46 PM revealed she worked during second shift on 3/2/12. NA #3 stated she generally worked all halls. She recalled seeing Resident #2 around 4:30 PM and again around 4:45 PM when she was talking to LN #2. NA #3 was unaware Resident #2 was missing until she was returned to the unit. NA #3 stated she did not hear any door alarms and further stated the front door alarm could be heard on the North unit only. NA #4 was interviewed on 3/12/12 at 3:55 PM. She worked on the South unit during the second shift on 3/2/12. NA #4 stated she did not hear the front door alarm and was unaware Resident #2 was missing until someone called the facility. NA #4 was sent to the front to assist Resident #2 back to her room. NA #4 stated Resident #2 was disoriented, crying and more quiet than usual. During an interview on 3/12/12 at 4:10 PM LN #4 stated on 3/2/12 during second shift she saw Resident #2 approximately fifteen minutes prior to receiving the notification that she was found outside the facility. She stated no one knew the resident left the facility. LN #4 stated she did not hear the front door alarm, as she was working on the South unit, when the resident exited the building. On 3/12/12 at 2:57 PM an interview was conducted with the Quality Assurance (QA) nurse. She stated up until a month ago, the SSD was responsible for checking watch mate alarms. QA nurse stated the floor nurses check every shift for the presence of the watch mate bracelet. QA nurse stated she checked weekly that each watch mate bracelet was functioning. She stated each watch mate's battery had an expiration date that she monitored weekly. QA nurse also stated she checked the front door weekly to ensure the watch mate will lock the door and or alarm if the door was open when a resident wearing a watch mate was with in range. QA nurse stated maintenance staff check the front door alarms. QA nurse stated she was not sure how far the front door alarm could be heard when activated. She did not think it alarmed at the nursing stations. On 3/12/12 at 5:10 PM, observations were made of the front door/lobby area. The front door entering the facility was equipped with an alarm system for a watch mate bracelet. The front door led to a small lobby. From the lobby a person had to enter another unalarmed door to access the resident areas. The front door was checked with the Administrator using a watch mate and noted the front door locked when the watch mate came within 3-6 feet of the door. When the door was already opened and the watch mate came within the same range, a high pitched screeching alarm sounded. On 3/12/12 at 5:15 PM observations were made to determine if the watch mate alarm system was functioning properly and how far the alarm could be heard. The front door alarm could be heard approximately five resident rooms down the North hall. At the nursing station, the alarm was barely audible. There was no additional alarm or light at the North station to alert anyone that the front door alarm was sounding. The Director of Nursing (DON), who was also involved in this observation confirmed that the North unit was supposed to have an alarm that sounded to alert staff the watch mate alarm system on the front door activated. The DON confirmed this alarm was not working. On 3/13/12 at 8:24 AM, the Administrator stated maintenance determined the fuse was not working at the North station which was the only one of three nursing stations equipped with an alarm signaling the front door alarm was activated by a watch mate bracelet. Interview with the maintenance supervisor on 3/13/12 at 8:28 AM revealed he was not responsible for checking the door alarms unless a problem was reported. He further stated that was the QA nurse's responsibility to check to ensure the front door and North unit alarms were functional. The administrator was notified of the Immediate Jeopardy on 3/13/12 at 9:41 AM. The facility provided a credible allegation of compliance on 3/14/12 at 9:48 AM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: The Credible Allegation of Compliance: 1. CORRECTIVE ACTION FOR RESIDENT #2 ? Resident #2 assisted back into the facility on [DATE]. Res was unharmed. ? The following interventions were implemented on March 2, 2012: ? Resident's alarm device was immediately checked by RN working on the South Unit and the device was operational, secured the front door correctly, and alarm relay sounded on the North Unit. ? Resident was placed on 1:1 supervision during hours awake from March 2, 2012 until March 5, 2012. ? Inservice for Nursing Assistants and Nurses on the three Nursing units was immediately initiated on March 2, 2012 by RN Unit Coordinator. Title of Inservice: "Front Door Alarm" and presented by RN Unit Coordinator. Content of inservice was to address: door alarms sounding and immediately responding to the door alarm; if door alarm sounding and cannot determine why alarm is sounding, staff should walk outside and do a thorough search. ? RN Unit Coordinator completed the inservice on the South Unit and verbally communicated the new inservice to a Nurse on both the North and Skilled Units. The written inservices were given to a Nurse on each Unit by RN Unit Coordinator. The Nurses were then instructed to inservice the Nursing Assistants. The inservice material was then placed in each Unit's inservice books and the Nurses were informed to communicate the inservice to oncoming shifts. The information about the resident exiting and being on 1:1 observation was communicated on the 24-hour Nursing Report by RN Unit Coordinator. ? On March 5, 2012, the following interventions were implemented: ? Quality Assurance/Quality Improvement initiated for responding to secure door alarm by Administrator. This entailed development of a new procedure for what to do when responding to a secured door alarm for facility staff. The new procedure involves the person hearing the alarm is responsible for responding to the alarm and then determining why the alarm is sounding. If a determination cannot be made as to why the alarm is sounding, then another staff member or members should be immediately contacted to assist. One staff member shall do a thorough assessment of the outside area of the building while the other staff member(s) contacts each of the Nursing Units to begin an immediate count of the exit-seeking residents (those residents wearing a door alarm bracelet/anklet for exit-seeking behavior). The investigation may not stop until all the exit seeking residents have been accounted for. Staff inservicing for this new procedure was initiated on March 5, 2012. Inservicing completed by the Administrator, the Staff Development Coordinator, the Human Resource Manager and Department Heads. The inservice has been communicated by both 1:1 inservicing and reviewing written inservice material on the procedure. As of March 14th, 173 of 194 employees have been inserviced on the new procedure. The remaining 21 employees will receive inservicing prior to the start of their next shift. ? Sign at lobby door to alert visitors to not assist unfamiliar persons outside without first checking with staff was checked by the Administrator and was in place. ? Administrator placed additional and larger signage about not assisting unfamiliar persons outside without first checking with staff, as well as what to do if you are a visitor and note the alarm sounding (stay in place until a Staff member arrives) was added to both the front and backside of the swinging lobby door near the front entrance. ? On March 6, 2012, the following interventions were implemented: ? Social Service Director met with resident's two daughters to discuss resident's safety and possible transfer to a secure unit. ? On March 7, 2012, the following interventions were implemented: ? Deputy placed "Project Lifesaver" device on resident. ? On March 8, 2012, Maintenance Supervisor checked the front door and the door was functioning correctly and the sound relay to the North Unit was operational as noted by the Maintenance Supervisor, NHA, and Receptionist. ? On March 9, 2012, Maintenance Supervisor checked the front door and the door was functioning correctly and the sound relay to the North Unit was operational as noted by the Maintenance Supervisor, NHA, and Receptionist. ? On March 12, 2012, the front door alarm system was checked by the Administrator and QA Nurse and sounded and locked correctly. The North Unit sound relay did not sound at this time. The Administrator immediately called Maintenance Supervisor to check the relay. The Administrator monitored the door until corrective action was taken. Upon inspection, the fuse operating the North Unit sound relay was found to have been blown and was immediately replaced. The Administrator verified the North Unit sound relay functioned appropriately after the fuse was replaced. ? On March 13, 2012, the following interventions were implemented: ? Front door alarm system and the North Unit relay were checked in the am by Maintenance Supervisor and were noted to be fully functional. ? Resident was again placed on 1:1 supervision (there had been no further attempts to exit). At approximately 2pm, the resident was transferred to a secure unit at another facility. 2. CORRECTIVE ACTION FOR CURRENT RESIDENTS AT RISK: ? There are no other residents at the facility who are ambulatory and exhibit exit-seeking behaviors. All other residents who are identified as potential exit-seekers locomote via wheelchair. On March 5, 2012 the Quality Assurance Nurse checked and documented the checks of all door alarm bracelets/anklets to ensure devices were functional. The Quality Assurance Nurse is responsible for weekly checks of the door alarm bracelets/anklets and documenting these weekly. The Quality Assurance Nurse is also responsible for checking the door alarm system and documenting this weekly. The North Unit sound relay was fully functional after a blown fuse was replaced by maintenance on March 12, 2012. 3. INSERVICE ? Inservice initiated on new procedure for what to do when responding to a secured door alarm for facility staff. The new procedure involves the person hearing the alarm is responsible for responding to the alarm and then determining why the alarm is sounding. If a determination cannot be made as to why the alarm is sounding, then another staff member or members should be immediately contacted to assist. One staff member shall do a thorough assessment of the outside area of the building while the other staff member(s) contacts each of the Nursing Units to begin an immediate count of the exit-seeking residents (those residents wearing a door alarm bracelet/anklet for exit-seeking behavior). The investigation may not stop until all the exit seeking residents have been accounted for. Staff inservicing for this new procedure was initiated on March 5, 2012. Inservicing completed by the Administrator, the Staff Development Coordinator, the Human Resource Manager and Department Heads. The inservice has been communicated by both 1:1 inservicing and reviewing written inservice material on the procedure. As of March 14th, 173 of 194 employees have been inserviced on the new procedure. The remaining 21 employees will receive inservicing prior to the start of their next shift. The Staff Development Coordinator will be responsible for inservicing this procedure for all new hires during Orientation. 4. MONITORING: ? Developed new procedure for staff response to door alarm on March 5, 2012. The new procedure involves the person hearing the alarm is responsible for responding to the alarm and then determining why the alarm is sounding. If a determination cannot be made as to why the alarm is sounding, then another staff member or members should be immediately contacted to assist. One staff member shall do a thorough assessment of the outside area of the building while the other staff member(s) contacts each of the Nursing Units to begin an immediate count of the exit-seeking residents (those residents wearing a door alarm bracelet/anklet for exit-seeking behavior). The investigation may not stop until all the exit seeking residents have been accounted for. Whomever hears the door alarm is expected to respond immediately to that alarm and follow this procedure. Immediate Jeopardy was removed on 3/14/12 at 3:25 PM. Review of the 24 hour report,used for relaying information shift to shift, revealed Resident #2 was assigned a sitter from 3/2/12 through 3/5/12. Review of facility documentation revealed that each watch mate was being checked weekly for function and battery expiration dates and the front door alarm and North Nursing unit alarms were being checked weekly. All residents identified as having a watch mate were observed with a watch mate in place. Their pictures were located at each nursing station and the placement of the watch mate bracelets were documented in the QA book for safety devices. All facility doors were checked and found to be operational with alarms in working order. Signs were posted in the front door/lobby area instructing visitors not to allow residents out of the facility. Interviews with staff from all three shifts were completed confirming they had received inservice training on how to respond when they hear the door alarms.