Every finding on record at Whitestone a Masonic and Eastern Star Community

Based on record review, observations, and Medical Director, family member, and staff interviews, the facility failed to utilize a sit to stand lift per manufacturer's instructions which resulted in the sling slipping up and causing extensive bruising to Resident #399 under the resident's left arm, left side, and across her breast. Resident #399 was prescribed an anticoagulant (blood thinner) daily for atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart). The following day Resident #399 experienced a syncopal episode (temporary loss of consciousness due to a sudden, temporary drop in blood flow to the brain) and when assessed it was noted she had low blood pressure and an irregular pulse. Resident #399 was evaluated in the emergency department and the physician documented the syncope was likely related to dehydration and acute blood loss anemia and was possibly worsened by atrial fibrillation with rapid ventricular rate (RVR). She was hospitalized for six days and required one unit of packed red blood cells (PRBC) due to a low hemoglobin (Hgb) (a protein in red blood cells that carries oxygen from your lungs to the rest of your body). The facility also failed to investigate the cause of the bruising and failed to have the manufacturer's manual for the sit to stand mechanical lift utilized by the facility. This deficient practice was for 1 of 6 residents reviewed for supervision to prevent accidents (Resident #399). The findings included: The manual for the sit to stand mechanical lift the facility utilized during stand strength trailing with Resident #399 was not provided by the facility. Per the manufacture's website, manufactures guidelines for the sit to stand mechanical lift, dated 11/2014, read in part: - Intended to be used on a horizontal surface for raising to a standing position and short transfer of residents in hospitals, nursing homes or other health care facilities where the resident has been clinically assessed to correspond to the following categories: Sits in a wheelchair. Is able to partially bear weight on at least one leg. Has some trunk stability. Dependent on carer in most situations. Physically demanding for carer. Stimulation of remaining abilities is important. - The equipment must be used for its intended purpose only and is operated within the published limitations. -intended to be used with clip slings only -except for the ' Transfer Slings ' which also have loops for attachment of the leg flaps to the central lug situated on the resident support arms. - Warning: Use only the sit to stand designated parts to avoid injuries attributable to the use of inadequate parts. Unauthorized modifications or repairs may affect its safety. Resident #399 was admitted to the facility on [DATE] with diagnoses that included mechanical complications of internal fixation device of bone of left lower leg (a surgical implant, such as a screw, plate, or rod, used to stabilize and maintain the alignment of broken bones during the healing process), physical deconditioning, anemia, atrial fibrillation with rapid ventricular rate (RVR). and obesity. Review of Resident #399's orders for September 2024 revealed the following order: Rivaroxaban (anticoagulant- decreases the clotting ability of the blood), Oral Tablet 20 MG, give 20 mg by mouth in the evening related to atrial fibrillation, give with supper. Resident #399 received daily until 09/24/24. Resident #399's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. She was dependent on staff for all transfers by staff to sit to lying/lying to sitting and weighed 233 pounds. Resident #399 was also coded as receiving an anticoagulant. Resident #399's care plan, dated 07/09/24, included a focus that indicated she had the potential for injury related to mechanical lift use. No interventions were included. Another focus revealed Resident #399 was receiving anticoagulant medication. The interventions included for staff to obtain labs as ordered and report abnormal lab results to the physician, staff to monitor/document/report to physician any signs or symptoms of anticoagulant complications to include bruising, sudden changes in mental status, and significant or sudden changes in vital signs. Review of physical therapy (PT) note dated 09/04/24 at 5:16 PM, written by Physical Therapist #1 revealed she discussed trialing of the sit to stand lift to facilitate weight bearing through bilateral extremities and increase functional tolerance. Family member and Resident #399 agreeable to transfer training with the sit to stand lift. Physical Therapist #1 directed Resident #399 in static sitting at edge of bed (EOB) with maximal assistance initially to facilitate forward trunk lean but supported with bilateral upper extremity support on the sit to stand lift. Resident #399 directed in attempted standing with sit to stand lift times four trials with Resident #399 unable to clear buttocks from EOB due to pain to bilateral knees during each attempt. Review of Physical Therapy (PT) notes for Resident #399 dated 09/05/24, 09/09/24, 09/11/24, 09/12/24, 09/13/24, 09/17/24, and 09/18/24 revealed Physical Therapists #1 utilizing the sit to stand lift for stand strengthening. Review of physical therapy (PT) note dated 09/23/24, written by Physical Therapist #1 revealed Physical Therapist #1 instructed Resident #399 in supine (lying flat on back with face upwards) to sit with moderate assistance x 2 people. Physical Therapist #1 directed in static sitting at edge of bed requiring moderate assistance to correct posterior lean when supported. Physical Therapist #1 instructed Resident #399 to transfer from bed to wheelchair using the sit to stand mechanical lift followed by standing tolerance using the sit to stand mechanical lift and an additional support strap at her buttocks to achieve full upright posture. Resident # 399 tolerated 15 minutes and 17 seconds. An interview was conducted on 04/16/25 at 10:15 AM with the Community Rehabilitation Director. She verified Resident #399 was on the therapy case load for strengthening after a hospitalization for surgical ankle repair. She stated Resident #399 did have lower extremity impairments and her overall strength was diminished due to deconditioning and that the Nursing Assistants (NAs) used the mechanical lift for all transfers. The Community Rehabilitation Director indicated Resident #399 did not want to go to the therapy gym and that the therapist would do her treatments in her room. A follow up interview was conducted on 04/16/25 at 2:17 PM with the Community Rehabilitation Director. She explained residents were normally brought to the therapy gym for stand strengthening using the parallel bars and/or the standing frame. She stated Resident #399 did not want to go to the therapy gym and Physical Therapist #1 thought of using the sit to stand with an additional strap under her buttocks to aid in keeping her in the standing position for stand strengthening. The Community Rehabilitation Director verified there was no written therapy plan for utilizing the sit to stand lift for stand strengthening training for Resident #399. She verified the added strap was not recommended by the manufacturer's guidelines. She indicated Occupational Therapist (OT) #1 assisted Physical Therapist #1 with the treatment. The Community Rehabilitation Director also explained that she was made aware at the beginning of 09/2024 by Physical Therapist #1 that she was going to try utilizing the sit to stand lift for stand strength training on Resident #399, however she could not recall the specific date. She stated she trusted Physical Therapist #1 and supported her decision to use the sit to stand lift with the additional strap for stand strengthening training. The Community Rehabilitation Director indicated she personally would not use the sit to stand lift for stand strengthening, as it was intended to transfer residents, not for strengthening. She explained she was made aware by Physical Therapist #1 of the bruising to Resident #399's breasts, side, and under her arms caused by the sling sliding while Physical Therapist #1 utilized the sit to stand lift on 09/23/24 after Resident #399 was sent to the emergency roiagnom on [DATE]. Review of nursing note dated 09/24/24 at 12:44 PM written by Nurse # 2, revealed Resident #399 had an area of bruising noted on her left side, underneath her left arm, and breast area. The bruise was possibly caused by an apparatus used by physical therapy on 09/23/24. The area was examined by the Unit Manager and Nurse Practitioner (NP) #1 was notified. The area was also examined by Occupational Therapist #1. A phone interview was conducted on 04/16/25 at 8:17 PM with Nurse #2. She explained that Resident #399's family member came to her on 09/24/24 and told her Resident #399 was complaining of pain under her arms and on her left side. Nurse #2 stated upon assessment of the areas she noted extensive bruising under residents left arm, left side, and across her breast. The family member told Nurse #2 that staff had used the sit to stand lift for stand strengthening on 09/23/24 and that the sling slipped and that was what caused the extensive bruising. She indicated she immediately reported the bruising to the Clinical Care Coordinator and Nurse Practitioner #1 (NP) who went in to assess Resident #399. NP #1 gave no orders at that time other than to monitor Resident #399. She also stated Resident #399 did not get out of bed often and that her legs were on the bigger side which made it hard for her to use them. After the incident the PT department did not use the lift with her again. Nurse #2 indicated Resident #399 could not stand unassisted at all, and nursing assistants (NAs) used the mechanical lift for all transfers with Resident #399. Nurse #2 did not recall if she completed an incident report. Nurse Practitioner (NP) #1 did not document the assessment and was not available for interview. Review of physical therapy (PT) note dated 09/24/24, written by Physical Therapist #1 revealed Resident #399 with new bruising to left upper flank, possible due to pressure from sit to stand mechanical lift sling. Nursing requested PT to withhold sit to stand treatment training at this time. Resident #399 required maximal assistance to maintain unsupported sitting due to heavy posterior lean. Resident #399 sat on edge of bed less than 2 minutes prior to exhibiting unresponsive episode. Resident was left with OT to monitor while PT immediately notified nursing who came and assessed vital signs. Resident #399 was left with nursing and ultimately ended up getting sent to the emergency room . Attempts to reach Physical Therapist #1 by phone were not successful. Attempts to reach Occupational Therapist #1, who no longer worked at the facility, were not successful. Review of nursing note dated 09/24/24 at 9:35, written by Nurse #6 revealed Resident #399 had a syncopal episode while working with PT. Nurse Practitioner#1 and Unit Manager assessed resident at bedside. Stated blood pressure was soft, and pulse was elevated and irregular. Emergency medical services were called. Resident #399 was gray and had fine tremors noted while on stretcher. Attempts to reach Nurse #6 by phone were not successful. Record review revealed vital signs, dated 09/24/24 at 3:30 PM (time of syncope episode) was blood pressure 90/50, blood sugar 285, pulse irregular, and respirations 16. An interview was conducted on 04/17/25 at 8:35 AM with the Unit Manager. She stated she worked Monday through Friday, and no one had reported an incident on 09/23/24 related to the sit to stand lift and the sling sliding up on Resident #399. She was made aware of the bruising on 09/24/24 by Nurse #2 and upon observation of the area she noted very extensive bruising to Resident #399's left side, under her arms, and her breast. She did not fill out an incident report because Physical Therapist #1 indicated the incident with the sling slipping occurred with Physical Therapist #1, and she assumed they had reported it to the Director of Nursing. The Unit Manager verified she did assist Nurse Practitioner #1 with assessing Resident #399 when her blood pressure dropped after sitting up on the side of the bed with PT, and she passed out. She stated NP #1 gave the order to send Resident #399 to the emergency room for evaluation. She indicated Nursing Assistants (NAs) used the mechanical lift for all transfers with Resident #399. A phone interview was conducted on 04/15/25 at 11:42 AM with Resident #399's family member. He explained on 09/23/24 he observed staff utilizing the sit to stand lift to aid with stand strengthening with Resident #399, after 15 minutes of being in a semi standing position, the sling around her slipped up, and she complained that the sling was hurting her under her arms. He indicated the sling was wrapped around Resident #399's torso and it had 2 buckles that were fastened in the front under her breasts. The sling hooks were connected to the lift at the handles where the slots were located. The additional strap was hooked in the same area as the sling connections, and it went across her buttocks, there was a pillow between her buttocks and the strap. Resident #399 was then lowered back down to her bed. He stated when he arrived at the facility on 09/24/24 Resident #399 was complaining of pain under her arms and to her breast areas. The family member explained he looked at the areas and observed extensive bruising under her arms, her left side, and her breasts. He then stated he notified Nurse #2 to make her aware. He stated he took pictures of Resident #399 in the sit to stand lift, she had a pillow under her buttocks and the additional strap on top of the pillow. He also had pictures of the extensive bruising to her breasts, under her arms, and down her side. The family member provided copies of the pictures he had taken which were reviewed by this surveyor. Review of hospital discharge summary dated 09/30/24 revealed Resident #399 was brought to the emergency department on 09/24/24 after suffering a syncopal episode. At the time her blood pressure was 91/50. In the emergency department she was found to be tachycardic (high pulse) with heart rates 118-143 beats a minute. Resident #399's hospital course description included syncope was likely related to dehydration and acute blood loss anemia and possible worsened by atrial fibrillation with rapid ventricular rate (RVR). Extensive bruising/bleeding into the skin under left arm-acute blood loss anemia. Due to use of anticoagulant as well as lift at facility which appears to secure under the arms-holding anticoagulant for now. On 09/24/24 Resident #399's hemoglobin (Hgb) was 10.6 (normal range of Hgb 12.0-16.0), 09/25/24 Hgb 8.7, and on 09/26/24 Resident #399's Hgb dropped to 7.0 and required a blood transfusion of 1 unit of packed red blood cells (PRBC). Resident #399's Hgb was 8.2 on 9/27/24. It was noted Resident #399's Hgb was trending upward at the time of discharge and to continue to hold anticoagulant for now and recheck hemoglobin in 3-5 days. Permanent atrial fibrillation with acute RVR likely driven by volume depletion/acute blood loss and diagnoses with urinary tract infection. Disposition: Discharge back to skilled nursing facility (SNF) for rehabilitation stay. Hospital discharge orders included restarting previous medications with the following exceptions. Furosemide 20 milligram (mg) by mouth daily-start on 10/01/24 (note dosage change), rivaroxaban (anticoagulant) 20 mg by mouth daily with supper (start taking on 10/07/24), and recheck Hgb in 3-5 days. Review of Medical Director note dated 10/03/24 revealed Resident #399 was sent to the emergency roiagnom on [DATE] and discharged to our facility on 09/30/24 due to a syncopal episode (a temporary loss of consciousness, also known as fainting). Resident #399 was noted to have extensive bruising/bleeding into the skin under left arm, right arm with blood loss anemia. Resident #399 was transfused 1 unit of packed red blood cells (RBC), and her anticoagulant was held. During physical examination Resident #399 was awake and oriented, did not look in any distress. Vital signs: temperature 97.6, blood pressure 120/72, heart rate 70, respiratory rate 18, and saturation 96% on room air. Lungs clear, no wheeze or rales, abdomen soft, nontender, extremities with no pedal edema and neurologically no focal neurological sign. An interview was conducted on 04/17/25 at 8:45 AM with the Director of Nursing (DON). She verified therapy was using the sit to stand mechanical lift with Resident #399 for stand strengthening. She stated that Physical Therapist #1 was the only therapist that used the sit to stand lift for stand strengthening and Resident #399 was the only resident that received stand strengthening with the sit to stand mechanical lift. The DON explained that she was unaware of this prior to 09/24/24 and was informed the day Resident #399 was sent to the emergency room . She explained after Resident #399's transfer to the hospital, she was asking the nursing staff why Resident #399 was being sent out to the hospital. Physical Therapist #1 told her (DON) she utilized the sit to stand mechanical lift with an additional strap positioned under Resident #399's buttocks for stand strengthening on 09/23/24 and the sling strap slid up some causing her to lower Resident #399 back down to the bed. Physical Therapist #1 told the DON she was unaware that the sling caused any trauma until the husband brought it to the staff's attention on 09/24/24. The DON indicated it wasn't until the next day that a family member reported to nurse#2 that the resident had pain and bruising under her arms and side. The DON verified the added strap was not recommended by the manufacture's manual guidelines. Nursing Assistants (NAs) used the mechanical lift for all transfers with Resident #399. An interview was conducted on 04/17/25 at 8:45 AM with the Director of Nursing (DON). She stated she was made aware of the bruising to Resident #399's torso that was caused by the sling sliding after Resident #399 was sent to the emergency roiagnom on [DATE]. The DON indicated an incident report, and an investigation should have been completed. The DON provided a manufacturer's manual for a sit to stand mechanical lift utilized by the facility, the manual provided was the incorrect manual for the specific sit to stand mechanical lift that was utilized with Resident #399. An interview was conducted on 04/17/25 at 11:25 AM with the Medical Director. He stated he was not aware that therapy was utilizing the sit to stand lift for stand strengthening and he had never heard of anyone doing that. He indicated according to the hospital records Resident #399 had an episode of syncope after therapy had sat her up on the side of the bed and her blood pressure dropped. He explained that bruising could cause acute bleeding, dropping the hemoglobin (Hgb), if the bruising was bad enough, however, he did not think this was the case with Resident #399. He further explained that Resident #399's blood pressure ran on the lower side, and he believed when Psychical Therapist #1 sat her up on the side of the bed she had a period of orthostatic hypotension (a sudden drop in blood pressure when you sit up after lying down) which caused her to black out. The Medical Director then stated Resident #399's Hgb dropped because of the blood draws she was getting during the hospital stay.

Based on record review and interviews with the Pharmacy Consultant, Medical Director and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #42). This was for 1 of 5 residents whose medications were reviewed. The findings included: A review of Resident #42's medical record revealed a hospital Discharge summary dated [DATE] that included an order for Seroquel (an antipsychotic medication) 25 milligrams (mg) take a half tablet by mouth at bedtime. Resident #42 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke. A review of the physician orders for Resident #42 included the following: - An order dated 2/25/25 for Seroquel 25mg take half a tablet by mouth at bedtime for anxiety. This order was changed on 3/6/25. - An order dated 3/6/25 for Seroquel 25mg one tablet by mouth at bedtime for anxiety. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #42 was cognitively intact and received 7-days of an antipsychotic medication during the assessment period. A review of the February 2025, March 2025, and April 2025 Medication Administration Records (MARs) indicated Resident #42 received Seroquel at bedtime as ordered. The Director of Nursing (DON) was interviewed on 4/16/25 at 3:50 PM and reviewed Resident #42's active physician orders. She confirmed the diagnosis for Seroquel use was anxiety and stated that it was not an appropriate clinical indication. On 4/17/25 at 9:25 AM, an interview was conducted with Nurse #1, who entered the increase in dosage for Seroquel on 3/6/25. She stated she was unaware that a diagnosis of anxiety was not an appropriate clinical indication for the use of Seroquel. On 4/17/25 at 9:37 AM, an interview occurred with the Unit Manager who entered the admission orders on 2/25/25. She reviewed the order and stated she was aware that anxiety was not an appropriate clinical indication for the use of Seroquel. She further stated that she should have found an appropriate diagnosis in the hospital discharge summary or contacted the physician to get an appropriate diagnosis. She felt it was an oversight. A phone interview was conducted with the Pharmacy Consultant on 4/17/25 at 9:53 AM. She was able to review her monthly drug regimen reviews for Resident #42 and stated that on 3/2/25 she requested for the physician to provide a qualifying diagnosis for the Seroquel that was used at bedtime. An interview occurred with the Medical Director on 4/17/25 at 10:22 AM. He reviewed Resident #42's medical record and indicated when he was admitted to the facility on [DATE], the diagnosis of anxiety was chosen inadvertently. He stated he was aware that a diagnosis of anxiety was not an appropriate clinical indication for the use of Seroquel and stated that the order should have been clarified at the time of admission.

Based on record review and staff interviews, the facility failed to verify that 1 of 5 nurses, Nurse #4, had a valid, non-expired nursing license. The facility was responsible for ensuring that all nursing staff employed had current licenses. The findings included: Review of facility's workers directory on [DATE] and an interview with the Human Resource Manager on [DATE] at 2:32 PM revealed Nurse #4 was hired on [DATE] as a Licensed Practical Nurse (LPN) and was still employed by the facility. A review of Nurse #4's LPN license with the North Carolina Board of Nursing (NCBON) revealed her LPN license approval date was [DATE] with an expiration date of [DATE]. A phone interview was conducted on [DATE] at 11:38 AM with Nurse #4. She verified she had been working full time and worked the 300 hall at the facility. She stated the last day she worked at the facility was [DATE]. She explained she was not aware her license had expired until she received a letter from the state Board of Nursing. She further explained that she was not working from [DATE] through [DATE] because she had surgery along with chemotherapy and had not thought about the renewal of her nursing license. The facility had not notified her that her license had expired, and she did not recall receiving an email from the NCBON to remind her it was time to renew. She verified she had not worked since she found out her license had expired. Nurse #4 indicated she checked her personal email daily however did not recall seeing the email. An interview was conducted on [DATE] at 2:06 PM with the Director of Nursing (DON). She stated the facility did keep track of nurse licensures and notified the employee to renew 30 days prior to expiration date. She further stated the human resource department was responsible for notification. She explained she was not aware Nurse #4's license had expired until the employee herself had notified her in [DATE]. She immediately removed Nurse #4 from the schedule and told her to make them aware when her license was renewed. She stated she did not know what happened in this case and how it was missed. It was expected nursing licenses would be kept current. An interview was conducted on [DATE] at 2:32 PM with the Human Resource Director. She stated since 2021 the system they use for payroll keeps track of nursing license and date of expiration. She explained that the nurse license was uploaded into the system during the hiring process then 30 days prior to the expiration date the system would send an automatic email to the employee, DON, Staff Development Nurse (SDC), and the Administrator making them aware the employee license would be expiring in 30 days, and the employee would need to submit the new license to the human resource department. She stated she did not know what happened with Nurse #4's case. She stated the current DON had not been in her position long prior to the license expiring, however the DON was the former SDC Nurse. An interview was conducted on [DATE] at 1:55 PM with the Administrator. He stated the facility did not keep track of nursing licensures and that it was the employee's responsibility to keep up with it.

Based on observation, record review, and staff and emergency contact interviews, the facility failed to identify hearing aides were missing and investigate whether an appointment was needed to maintain hearing abilities for a resident with reported hearing difficulties for 1 of 1 resident reviewed for hearing (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, unspecified dementia, and sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment, and she was coded for moderate hearing difficulty and the use of hearing aids. The care plan revised on 4/13/22 and reviewed on 1/6/25 indicated Resident #16 had a care plan in place for having a communication/hearing impairment. The written interventions included providing the resident with hearing aids every day, placed in both ears daily. An observation was conducted on 4/14/25 at 11:35 AM with Resident #16. She did not have hearing aids in either ear. The resident was unable to respond to interview questions. One of Resident #16's emergency contacts was interviewed on 4/14/25 at 11:39 AM, and she stated Resident #16 entered the facility with two hearing aids, but they were lost at some point. She stated the facility replaced those hearing aids but then the hearing aids were lost again. The resident's contact stated she had weekly video call visits with Resident #16, and the hearing aids made it easier for the resident to understand their conversations when she wore them in the past. The contact stated she had spoken with the Administrator about the missing hearing aids in the past, but she was unsure if there was a plan to replace them. An interview was conducted on 4/16/25 at 1:49 PM with Nurse #2 who stated she had worked for the facility for six months and had never put hearing aids in for Resident #16. She stated she felt the resident usually understood her. On 4/17/25 at 9:25 AM, an interview was conducted with Nurse #3 who stated she had never seen or applied any hearing aids for Resident #16. Nurse #3 checked the medication storage room where she stated all hearing aids were cleaned and charged overnight for residents who used them but was unable to locate a storage pouch with Resident #16's name or label. She also checked the medication cart for the 300 hall where Resident #16 resided, but did not find any hearing aids stored in it. She also searched in Resident #16's room but did not locate any hearing aids. An interview was conducted with the Director of Nursing (DON) on 4/17/25 at 10:32 AM. She indicated she was unaware Resident #16's hearing aids were an issue until that day. She stated she would have the NAs search for the hearing aids and would contact the resident's family if they were not found. She stated the facility would replace the hearing aids if they were not found. The Administrator was interviewed on 4/17/25 at 12:08 PM, and he stated he was unaware Resident #16's hearing aids were missing until that day when the DON brought it to his attention. He stated he contacted the family to work on the replacement of the hearing aids. He further stated if the staff had been unable to locate Resident #16's hearing aids they should have brought it to the attention of the DON for a replacement.

Based on record review, and resident, staff, Medical Director, Pharmacy Consultant and Resident Representative interviews, the facility failed to ensure a resident was free of significant medication error when Resident #14 received 2 units of Humalog insulin (short acting insulin/antidiabetic medication). Humalog insulin was not prescribed to Resident #14. On 10/26/25 Resident #14 was given Humalog insulin medication prescribed to another resident. This deficient practice affected 1 of 1 resident reviewed for significant medication error. Findings included: Resident #14 was admitted to the facility on [DATE] with diagnosis that included hypertension, hyperlipidemia, major depressive disorder, dysphagia, left shoulder pain and macular degeneration. Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired, and did not receive any insulin. Review of medication related incident report dated 10/26/24 indicated that Nurse #5 had administered 2 units of Humalog Insulin to the wrong resident (Resident #14). Report also revealed that Nurse #5 had checked the blood glucose levels for Resident #14, and it was 195 and administered 2 units of Humalog Insulin to Resident #14. Report further indicated that Nurse #5 had given insulin to the wrong resident. Report also indicated that medical provider and resident representative were notified and that no harm occurred to Resident #14. Report also revealed that medical provider orders for Resident #14 was to have blood glucose levels checked once a day for three days. Multiple attempts made to reach Nurse #5 for an interview were unsuccessful. An interview conducted with Resident Representative (RR) on 04/15/25 at 12:50 pm, revealed that on 10/26/24 Resident #14 received insulin from Nurse #5. RR indicated that Resident #14 did not have an insulin order and did not have diabetes. RR also revealed that Nurse #5 did report to her (RR) the significant medication error. RR further stated that Nurse #5 acknowledged that he had given Resident # 14, 2 units of insulin at about 11:30 am. RR confirmed that Resident #14 did not have any adverse reactions and was not affected by the insulin. RR indicated that Nurse #5 was very forth coming and had notified medical provider. RR also confirmed that Resident #14 had a blood sugar level checked and her levels were never below normal. Interview with Director of Nursing (DON) was conducted on 4/16/25 at 11:00 am. DON indicated that on 10/26/24, Nurse #5 administered 2 units of Humalog insulin to Resident #14 . DON confirmed that Nurse #5 had administered the 2 units to the wrong resident (Resident #14) . DON further stated that Nurse #5 did not identify Resident #14 and thus made the medication error. DON further revealed that Nurse #5 did notify the medical provider, RR, and DON. DON indicated that new orders were received to check the blood glucose levels for Resident #14 once a day for three days. DON confirmed that Resident #14 did not have any negative outcomes or adverse reactions from receiving the insulin, and in fact Resident #14 blood glucose levels remained 150. DON indicated that Nurse #5 no longer worked at the facility, but did receive immediate education after medication error , together with all other nurses and medication aides who were currently working at the facility. Interview with Pharmacy Consultant was conducted on 4/16/25 at 12:30 pm. Pharmacy Consultant indicated that DON notified her of the medication error. Pharmacy Consultant indicated that she conducted random medication observation on several nurses over different shifts and units, multiple routes of administration to include subcutaneous (insulin injections) and no medication errors were observed. Interview with Medical Director was conducted on 4/17/25 at 11:31 am . Medical Director indicated that he was notified by Nurse #5 of medication error. Medical Director indicated that Resident #14 did not have any negative outcomes from receiving the 2 units of Humalog Insulin. Interview with the Administrator was conducted on 4/17/25 at 12:16 pm. The Administrator indicated that he would require each nurse and medication aide to administer medication to the right resident, per physician orders. The facility provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The physician was immediately notified, orders obtained to monitor blood sugars 1x that day, then at 6am for the next 2 days for Resident #14 . The resident had no ill effects from the medication. The nurse is no longer employed at facility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The DON reviewed all residents Medication Administration Record (MARs) on the nurse's (Nurse #5) assignment. No others had orders for blood glucose monitoring or insulin orders were on that assignment. The supervisor also reviewed other residents had no medication administration concerns. No other residents were affected. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education was provided from 10/26/24 through 10/28/24, to the licensed nurses and medication aides by the DON on the medication policy as well as education by pharmacy on proper medication administration. This policy consists of ensuring the triple check is completed and the correct resident is identified prior to medication administration methods including checking the residents' pictures, ensuring the room number matches the MAR and asking the residents name as well as asking other staff members for identification if not sure. Audit/review of medication administration is observed each am in morning meeting to monitor for actual/potential medication issues and new orders are reviewed for accuracy. Pharmacy notified on 10/28/24. Pharmacy visits the community monthly and completes medication observations with nurses (ensuring the correct resident is part of the monitoring process). The error was reviewed by the interdisciplinary team on 10/28/24, and this plan of correction was developed and implemented. Results of medication administration reviews/audits as well as pharmacy observation results are taken to monthly QAPI by the Director of Nursing starting 10/28/24. The Medical Director was notified by the Director of Nursing on 10/28/24. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Results of the reviews/audits will be reported to the QAPI committee monthly. Additional audits may be completed based upon the level of compliance. The review results/audits will be required by the Quality Assurance Committee until such time that consistent substantial compliance has been achieved as determined by the committee Allegation of compliance 10/29/24. The facility's corrective action plan was validated by the following: On 04/17/25 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses and medication aides on proper medication administration per medication policy and procedures. Review of the monitoring audits revealed they were completed as stated in the corrective action plan with no concerns identified. Interviews conducted with licensed nurses and medication aides aides revealed they had received education on proper medication administration. In addition, the plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses and certified nurse aides on proper medication administration. Medication Administration was observed as part of the recertification survey and no errors were noted.The compliance date of 10/29/24 for the corrective action plan was validated.

Based on record review and staff interviews, the facility failed to ensure a medical record was accurate regarding the Treatment Administration Record (TAR). This was for 1 of 1 resident in the area of hearing aid application (Resident #16) who was reviewed for medical record accuracy. Findings included: A review of the April 2025 Treatment Administration Record revealed documentation of Resident #16's right hearing aid being on every AM from 4/1/25 through 4/7/25, 4/11/25, 4/12/25, and 4/14/25. Further review of the April 2025 MAR revealed Nurse #2 had documented on the TAR the resident's hearing aid was on 4/1/25, 4/2/25, 4/4/25, 4/6/25, 4/11/25, and 4/14/25. On 4/16/25 at 1:49 PM an interview was conducted with Nurse #2 who stated she had worked for the facility for the past six months and had never seen Resident #16 with hearing aids. In a follow up phone interview with Nurse #2 on 4/17/25 at 10:13 AM, she stated if she had checked the box indicating the hearing aid was on then that was a mistake on her part. An interview with the Director of Nursing was held on 4/17/25 at 10:32 AM at which time she stated the staff should not document a task was completed if they had not done it. An interview with the Administrator was conducted on 4/17/25 at 12:08 PM who stated staff should not have checked boxes that they put hearing aids on for Resident #16 if they had not.

Based on observations, staff, facility contracted Phlebotomist, and physician interviews, and record review, the facility failed to develop and implement facility policies for infection control as recommended by the Centers for Disease Control and Prevention (CDC) guidelines; the facility failed to implement current infection control measures as recommended by the CDC when a facility contracted Phlebotomist and 3 of 3 staff members (Treatment Nurse, Nursing Assistant #1 and Nursing Assistant #2) failed to wear the required Personal Protective Equipment (PPE) when they entered into COVID-19 enhanced droplet isolation rooms; a facility contracted Phlebotomist and 3 of 3 staff members (Treatment Nurse, Nursing Assistant #1 and Nursing Assistant #2) failed to remove PPE when they exited COVID-19 enhanced droplet isolation rooms; 2 of 2 staff members (Nursing Assistant #1 and Nursing Assistant #2) failed to disinfect face shields when they exited COVID-19 rooms and provided care to residents who were not up to date on the COVID-19 vaccinations for the duration of their shift (Resident #189 and Resident #190). The COVID-19 outbreak began on 08/01/22 when a second resident tested positive for COVID-19 (Resident #34). There were 4 residents who were not up to date on the COVID-19 vaccination series residing at the facility. Two of the 4 residents (Resident #189 and Resident #190) resided on the hall as the residents with COVID-19. These system failures occurred during the COVID-19 pandemic, which caused a high likelihood of affecting all residents by placing them at an increased risk for developing and transmitting COVID-19. Immediate jeopardy began on 8/02/22 when facility staff and a facility contracted Phlebotomist were observed to be out of compliance with CDC recommendations regarding PPE use, removal of PPE, and disinfection of PPE when caring for residents with COVID-19 and facility administrative staff were unaware of the noncompliance with CDC recommendations regarding required PPE required for COVID-19 enhanced droplet isolation rooms. Immediate jeopardy was removed on 08/06/22 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility complete all staff training and ensure monitoring systems put into place are effective. The findings included: 1a. The CDC guidelines entitled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22 indicated the following statements: Health Care Professionals (HCP) caring for residents with suspected or confirmed COVID-19 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Symptomatic residents, regardless of vaccination status, should be cared for by HCP using a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown. Review of the facility policy entitled COVID 19 Surgical and N95 Respirator Masks Guidelines (undated) revealed A surgical mask when worn with shield, can be used to care for COVID positive residents. Review of the facility policy entitled Isolation - Initiating Transmission-Based Precautions revised August 2019 revealed When Transmission-Based Precautions are implemented, the Infection Preventionist clearly identifies the type of precaution, the anticipated duration, and the personal protective equipment (PPE) that must be used. The policy further indicated the Infection Preventionist Determines the appropriate notification on the room entrance door. The signage informs the staff of the type of CDC precautions(s), instruction for use of PPE, and/or instructions to see a nurse before entering the room. 1b. Resident #34 tested positive for COVID-19 on 08/01/22 and was placed on enhanced droplet isolation precautions in a private room. An observation on 08/02/22 at 9:49 AM of the sign posted on the door (no date available) of Resident #34 revealed staff were to wear N95 (if available), eye protection, and gown and gloves when entering the room. The sign did not indicate how to remove PPE when exiting an enhanced droplet isolation room. During a continuous observation on 08/02/22 from 2:13 PM to 2:15 PM, the facility's Treatment Nurse was observed to enter and exit Resident #34's room wearing gown, gloves, surgical mask, and reading glasses. When she exited, she did not remove or change her surgical mask. She then proceeded to walk down the hall in which other residents were walking. An interview with the Treatment Nurse on 08/02/22 at 2:16 PM revealed she was preforming a skin assessment on Resident #34. She stated she was told by the Director of Nursing (DON) she could wear a surgical mask as well as her personal glasses when she cared for a resident with COVID-19. 1c. Resident #35 tested positive for COVID-19 on 07/30/22 and was placed on enhanced droplet isolation precautions in a private room. An observation on 08/02/22 at 2:12 PM of the sign posted on the door (no date available) of Resident #35 revealed staff were to wear N95 (if available), eye protection, and gown and gloves when entering the room. The sign did not indicate how to remove PPE when exiting an enhanced droplet isolation room. During a continuous observation on 08/02/22 from 9:50 AM to 10:03 AM, Resident #35 was observed to be getting blood drawn by a facility contracted Phlebotomist. The Phlebotomist was wearing a N95 mask, gloves, and gown. She was not wearing eye protection. The resident was observed to not be wearing a mask and could be heard actively coughing and speaking. During the continuous observation, the Phlebotomist walked 3 feet out of the room twice wearing a gown and N95 mask and retrieved items in her bag which were located on the floor. After she finished, she exited the room with the gown, gloves, and N95 still on. She proceeded to remove the PPE and entered back into the room to discard the PPE, then she performed hand hygiene. The Phlebotomist stated in an interview on 08/02/22 at 10:04 AM she was not wearing eye protection because her glasses fell off while in Resident #35's room. She stated she wore eye protection when working with residents who were COVID-19 positive and removed the PPE before she exited the resident's room. She further stated she had 3 additional residents (Resident #27, Resident #29 and Resident #188) to visit after Resident #35. She stated these residents were not in COVID-19 isolation rooms. During a continuous observation 08/02/22 from 2:18 PM to 2:25 PM, Nursing Assistants (NA) #1 and NA #2, were observed to enter Resident #35's room wearing gloves, gown, surgical masks, and face shields. They proceeded to reposition Resident #35 in the bed. They were not wearing N95 masks when they entered the room. When they exited the room, they removed their gown and gloves and preformed hand hygiene. They then walked down the hall with the same surgical mask and face shield. Resident #189 was not up to date on the COVID-19 vaccination series. Resident #190 was not up to date on the COVDI-19 vaccination series. Resident #27, Resident #29, and Resident #188 were not in enhanced droplet precaution isolation rooms. Interview with NA #1 on 08/02/22 at 2:26 PM revealed she had just started working at the facility. She stated she had asked for a N95 mask but was told by the Infection Preventionist none were available. She stated she was educated on how to put on and take off PPE. She further stated she wanted to keep the face shield for the duration of the shift but did not indicate why she did not sanitize the face shield. An additional interview with NA #1 on 08/04/22 at 3:38 PM revealed her assignment included caring for Resident #34, Resident #35, Resident #189, Resident #190 on 08/02/22. She stated she provided direct personal care to these residents and indicated Resident #189, and Resident #190 were not in COVID-19 enhanced droplet precautions isolation rooms. An interview with NA #2 on 08/02/22 at 2:28 PM revealed she was educated on how to put on and take off PPE as well as to use a surgical mask when she worked with a resident with COVID-19. She stated she wanted to keep the face shield for the duration of the shift but did not indicate why she did not sanitize the face shield. An additional interview with NA #2 on 08/04/22 at 3:38 PM revealed she was assigned to another hall on 08/02/22 in which there were no COVID-19 enhanced droplet isolation rooms; however, assisted NA #1 with repositioning Resident #35 on 08/02/22. She further stated she provided direct personal care to Resident #35, Resident #189, Resident #190 on 08/03/22. During an interview with the Infection Preventionist on 08/04/22 at 12:22 PM revealed the facility used enhanced droplet precautions for resident diagnosed with COVID-19. She stated it was their policy for staff to wear surgical masks, face shields, gloves, and gowns when they provided care to residents with COVID-19. She stated it was acceptable to wear a surgical mask when staff cared for residents who were COVID-19 positive. She further stated only a few staff members had N95 masks because staff members must sign a medical release form and be fit tested for a N95 mask. She stated staff members could choose whether or not to wear a N95 mask, and N95 masks were available. She stated all PPE must be discarded before the staff exited a resident's room and face shields needed to be cleaned in between caring for residents with COVD-19. She further stated the Director of Nursing (DON) was responsible for the vaccination efforts in the facility. An additional interview with the Infection Preventionist on 08/04/22 at 3:49 PM revealed she was unaware of the CDC guidelines which stated a N95 mask were required when staff provided care to residents with COVID-19. Another interview with the DON on 08/05/22 at 10:07 revealed she did get updates from the CDC regarding COVID-19 but could not find the updated guidelines for N95 use. The DON stated in an interview on 08/04/22 at 4:16 PM the facility was following CDC guidelines when staff wore a surgical mask, face shield, gown and gloves when providing care to residents with COVID-19. She stated N95 masks were not required during the pandemic and did not know why N95 masks were being required now. She further stated their policy allowed staff members to wear a surgical mask while they performed care for residents with COVID-19. Additionally, all vendors must follow their policy regarding PPE use when they provided care to residents with COVID-19, which included wearing a surgical mask, face shield, gown, and gloves. She stated signs were posted on the door which informed staff of the type of PPE required before staff entered the room. She stated the current sign used were sent to the facility a few months ago and could not remember who sent the signs. An interview with the Medical Director on 08/05/22 at 5:11 PM revealed he believed the facility was using N95 masks for staff providing care for residents with COVID-19. He further stated he would wear a N95 mask when he cared for with residents who were COVID-19 positive. The Administrator was notified an immediate jeopardy existed on August 4, 2022, at 6:00 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The alleged deficient practice indicates that staff members and a vendor did not have proper PPE to enter COVID-19 positive resident rooms and proper donning and doffing of PPE was not conducted. Residents who reside in the 600 hall have been identified of having the potential to be affected by the alleged deficient practice. All identified residents on the 600 hall were immediately assessed by the licensed nurse for signs and symptoms of COVID-19 on 8/4/2022. All identified residents are free from signs or symptoms of COVID-19. Under the direction of the Infection Preventionist and Medical Director, physicians orders were obtained and entered for signs and symptoms monitoring every shift for 72 hours. The Director of Nursing notified the licensed nurse of their responsibility to monitor symptoms and report irregularities to the physician immediately for further intervention on 8/4/22. MD orders are effective on 8/5/22. The Infection Preventionist will be responsible for the completion of this task. Residents identified as exposed and not up to date on vaccination were placed on transmission-based precautions on 8/4/2022 for potential exposure under the direction of the medical director. These residents will be on precautions for 10 days or 7 days if asymptomatic and have a negative test per CDC guidelines. The Infection Preventionist was notified of these precautions on 8/4/22 and will be responsible for overseeing the completion of this task. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 8/4/2022, the Director of Nursing and Medical Director reviewed CDC guidance for mask usage and updated the community policy regarding the use of N95 masks, including staff members to wear N95 masks when caring for residents who have a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/4/2022, the Infection Preventionist provided education to all staff and vendors present on the revised policy and practices. Education provided includes updated signage for transmission based precautions, placement of isolation storage devices, appropriate selection of personal protective equipment including use of N95 mask and face shields, and discontinuing use of surgical masks for resident COVID-19. Education has been provided on donning and doffing personal protective equipment and placing doffed equipment in trash receptacle before exiting room. Education reinforced sanitization of equipment including face shields. All staff and vendors who were not present for education will be educated on the updated practices on arrival to the community prior to the start of their shift and before providing resident care. The person responsible for overseeing the education and compliance of this plan is the Infection Preventionist. The facility has placed signage directing all vendors that they must see Infection Preventionist or 600 hall charge nurse for education prior to entering the COVID-19 positive rooms. The Infection Preventionist placed additional isolation bins outside COVID-19 positive rooms on 8/4/22. Bins contain disinfecting products, N95 masks, and face shields for staff and vendor use. The Infection Preventionist or other licensed nurse will replicate this practice for all new cases of COVID-19. All licensed nurses were educated of this responsibility beginning on 8/4/22 and prior to next shift. The noted items have been completed on August 6th, 2022. On 08/05/22, the facility's credible allegation for immediate jeopardy removal was validated by observations of updated signage placed on COVID-19 isolation rooms; observations of the COVID-19 isolation rooms verified staff wore the required PPE for enhanced droplet precautions; multiple interviews with facility staff revealed they received training and were able to describe the facility's policy on the use of required PPE for enhanced droplet precautions; and review of the updated facility policy regarding required PPE use verified staff were to use N95 masks when caring for residents who have a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interviews, and record review, the facility failed to ensure a dependent resident's fingernails were clean for 1 of 2 residents reviewed for Activities of Daily Living (ADL). (Resident #3) The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was severely impaired. The resident required extensive assistance with dressing, eating, toilet use, and personal hygiene. The MDS did not indicate resident was resistant to care. Review of Resident #3's care plan updated on 06/26/22 indicated the resident was care planned as having a self-care deficit for bathing, dressing, and feeding. The goal was for the resident to participate in self-care activities. Interventions included to evaluate resident's ability to perform ADL and provide assistance with ADL as needed. An observation conducted on 08/01/22 at 2:00 PM revealed Resident #3's fingernails contained dark brown debris under 10 of 10 fingernails. An observation conducted on 08/02/22 at 8:45 AM revealed Resident #3's fingernails contained dark brown debris under 10 of 10 fingernails. An observation conducted on 08/02/22 at 3:05 PM revealed Resident #3's fingernails contained dark brown debris under 10 of 10 fingernails. An observation conducted on 08/03/22 at 8:55 AM revealed Resident #3's fingernails contained dark brown debris under 10 of 10 fingernails. An interview was conducted with Nursing Assistant #3 (NA) on 08/03/22 at 9:00 AM revealed Resident #3 was receiving hospice services and received showers from the hospice aide on Mondays and Fridays. She stated the facility did not provide showers to Resident #3 but provided bed baths. She further indicated third shift dressed and provided personal care to Resident #3 in the morning. She indicated she was a Restorative Aide but was working on the floor to provide additional assistance to the floor NAs. In an interview conducted with Nurse #1 on 08/05/22 at 12:01 PM indicated Resident #3 did not refuse care. He stated NA #3 typically performed nail care for residents because she was a Restorative Aide who was part of a team who preformed monthly nail care. He indicated floor NAs could perform nail care as well. On 08/05/22 at 12:04 PM an interview was conducted with the Clinical Care Coordinator which revealed residents have a monthly spa day and nail care was provided. She indicated NA #3 did nail care in between spa days. Residents could get their nail care done when requested and when nails were visibly soiled. An interview was conducted with the Staff Development Coordinator on 08/05/22 at 11:45 AM. She stated staff were educated in orientation regarding personal care via handouts. Staff were also educated during annual skills check offs. She indicated the restorative team did nail care as needed; however, floor NAs could perform nail care as well. She stated it was not acceptable for Resident #3 to have dark brown debris under his nails. She indicated that prior to eating, each residents' nails were cleaned and if a staff member cleaned Resident #3's hands, they would have noticed his nails having dark brown debris under them. On 08/05/22 at 12:28 PM an interview was conducted with the Director of Nursing (DON) which revealed nail care was done with residents' weekly shower routine and as needed. She indicated residents' hands should be cleaned prior to eating. She further stated when a resident's hands and nails were visibly soiled, staff should clean them. Additionally, she stated cleaning under the nails was not considered nail care, but part of cleanliness.

Based on record review, staff interviews, and Pharmacist interview, the facility failed to ensure physician's orders for as needed [CONDITION(S)] medications had a 14 day stop date for 2 of 5 residents (Residents #240 and #9) reviewed for unnecessary medications. The findings included: 1. Resident #240 was admitted on [DATE] with a diagnoses that included non-Alzheimer's dementia and dementia without behavioral disturbances. A physician's order dated 7/5/22 indicated [MEDICATION(S)] (antipsychotic medication) tablet 1 milligram (mg) every 4 hours as needed (prn) for anxiety. There was no stop date. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #240's cognition was severely impaired. Resident #240 was assessed to have no mood or behaviors and received antipsychotic medication 3 of 7 days and was in a hospice program. A care plan initiated on 7/19/22 revealed Resident #240 used [CONDITION(S)] medications, and the goal was to reduce the use of the psychoactive medication. The interventions included administering medications as ordered and to discuss with the physician, family of ongoing need for use of medication. A review of Resident #240's Medication Administration Record (MAR) for July 2022 was reviewed and revealed that Resident #240 received [MEDICATION(S)] 1mg prn on 7/10/22, 7/13/22, 7/14/22, 7/15/22, 7/18/22, 7/21/22, 7/24/22, 7/25/22, 7/26/22, and 7/27/22. An interview was conducted with the Director of Nursing (DON) on 8/4/22 at 10:46 am. The DON indicated she did not realize that Resident #240 had received a prn antipsychotic. The DON indicated that the resident was on hospice and had these medication orders on admission to the facility and the orders should have been reviewed and a stop date provided. A telephone interview conducted with the Pharmacist on 8/4/22 at 10:57am revealed resident medications were reviewed monthly by the Consulting Pharmacist. The physician order for [MEDICATION(S)] 1 mg prn for Resident #240 was reviewed with him and stated a PRN antipsychotic required a stop date after 14 days. The Pharmacist indicated that the Consulting Pharmacist first review of these medications was due in August. An interview was conducted with the Nurse Practitioner (NP) on 8/4/22 at 2:10pm revealed she had reviewed Resident #240's medication and this order did not have a stop date but when she does her orders, she was conscious of PRN stop dates and this must have been an oversight. She further revealed that she did attend the 7/20/22 risk meeting and [MEDICATION(S)] order was discussed but that she did not realize it was a PRN. She also stated that Resident # 240 received Hospice services and that she felt that the order was appropriate due to behaviors however the medication order should have had a stop date and been reviewed. 2. Resident #9 was admitted on [DATE] with diagnoses that included dementia without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9's cognition was severely impaired. The MDS further coded Resident #9 to receive antipsychotic and antidepressant medications 7 out of 7 days. Review of physician's order dated 07/18/22 indicated [MEDICATION(S)] (an antipsychotic medication) 1 mg tablet by mouth every 4 hours as needed for delusions related to major depressive disorder and generalized anxiety disorder. There was no stop date indicated for this PRN antipsychotic medication order. An observation of Resident #9 on 08/03/22 at 8:45 AM revealed resident to be calm and did not indicate resident to be agitated, combative, or anxious. In a phone interview conducted on 08/04/22 at 10:57 AM with the Consulting Pharmacist indicated he was aware of the regulations for PRN antipsychotic medications. He confirmed he did not see a stop date on the physician order. He stated PRN antipsychotic orders would have a stop date of 14 days after they have been prescribed and then the resident would be reevaluated by the physician. An interview conducted with the Nurse Practitioner on 08/04/22 at 2:10 PM revealed Resident #9 was receiving hospice services and the hospice medical director ordered the PRN [MEDICATION(S)] in which the facility staff put the order into the resident's chart. She stated that the order for the PRN [MEDICATION(S)] should have a stop date. She stated when she writes orders for PRN antipsychotics, she is conscious of putting a stop date on the 14th day and the resident would have been reevaluated on the 14th day. She stated she typically reviews orders written by hospice but may have missed the stop date for this order. An interview conducted on 08/05/22 at 2:00 PM with the Director of Nursing (DON) revealed Resident #9 was receiving hospice services. She stated the hospice medical director did not recommend a stop date.

Based on staff interviews and record review the facility failed to accurately code the behavior section (Section E) on the Minimum Data Set (MDS) assessment for 3 of 13 residents (Resident #11, Resident #14 and Resident #23) reviewed for MDS accuracy. Findings included: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed dashes were coded in the behavior section for the items of behavior symptoms, rejection of care and wandering. On 3/4/21 at 9:44 AM an interview was completed with MDS Coordinator #1. She stated the Social Services Assistant (SSA) was responsible for the completion of section E on the MDS assessment. MDS Coordinator #1 reviewed the assessment and explained the SSA coded behavior symptoms, rejection of care and wandering items with a dash which indicated, no information. She added the SSA should have coded the items with 0, 1 or 2. During an interview with the SSA on 3/4/21 at 1:38 PM she explained she typically completed section E of the MDS assessment. She stated after she assessed Resident #11 she meant to code the behavior section with a 0, which indicated no behavior but mistakenly coded behavior symptoms, rejection of care and wandering items with a dash. The SSA said the inaccurate coding was a data entry error. A follow up interview was completed with MDS Coordinator #1 on 3/4/21 at 1:42 PM, during which she reported she had not checked the MDS assessment manually for accuracy once all disciplines entered their coding. She said the computer program indicated when each section was completed and then she closed out the assessment. The Executive Director was interviewed on 3/5/21 at 10:57 AM. He shared the facility was educating staff to ensure an MDS assessment was accurate and complete before the assessment was closed out. He said the MDS Coordinators needed to go through each section and verify accuracy and not depend on the computer system to indicate that the assessment was completed. 2. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed dashes were coded in the behavior section for the items of behavior symptoms, rejection of care and wandering. On 3/4/21 at 9:44 AM an interview was completed with MDS Coordinator #1. She stated the Social Services Assistant (SSA) was responsible for the completion of section E on the MDS assessment. MDS Coordinator #1 reviewed the assessment and explained the SSA coded behavior symptoms, rejection of care and wandering items with a dash which indicated, no information. She added the SSA should have coded the items with 0, 1 or 2. During an interview with the SSA on 3/4/21 at 1:38 PM she explained she typically completed section E of the MDS assessment. She stated after she assessed Resident #14 she meant to code the behavior section with a 0, which indicated no behavior but mistakenly coded behavior symptoms, rejection of care and wandering items with a dash. The SSA said the inaccurate coding was a data entry error. A follow up interview was completed with MDS Coordinator #1 on 3/4/21 at 1:42 PM, during which she reported she had not checked the MDS assessment manually for accuracy once all disciplines entered their coding. She said the computer program indicated when each section was completed and then she closed out the assessment. The Executive Director was interviewed on 3/5/21 at 10:57 AM. He shared the facility was educating staff to ensure an MDS assessment was accurate and complete before the assessment was closed out. He said the MDS Coordinators needed to go through each section and verify accuracy and not depend on the computer system to indicate that the assessment was completed. 3. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] revealed dashes were coded in the behavior section for the items of behavior symptoms, rejection of care and wandering. On 3/4/21 at 9:44 AM an interview was completed with MDS Coordinator #1. She stated the Social Services Assistant (SSA) was responsible for the completion of section E on the MDS assessment. MDS Coordinator #1 explained when the SSA coded behavior symptoms, rejection of care and wandering items with a dash it indicated, no information. She added the SSA should have coded the items with 0, 1 or 2. A follow up interview was completed with MDS Coordinator #1 on 3/4/21 at 1:42 PM, during which she reported she had not checked the MDS assessment manually for accuracy once all disciplines entered their coding. She said the computer program indicated when each section was completed and then she closed out the assessment. During an interview with the SSA on 3/5/21 at 10:19 AM she explained she typically completed section E of the MDS assessment. She stated after she assessed Resident #23 she meant to code the behavior section with a 0, which indicated no behavior but mistakenly coded behavior symptoms, rejection of care and wandering items with a dash. The SSA said the inaccurate coding was a data entry error. The Executive Director was interviewed on 3/5/21 at 10:57 AM. He shared the facility was educating staff to ensure an MDS assessment was accurate and complete before the assessment was closed out. He said the MDS Coordinators needed to go through each section and verify accuracy and not depend on the computer system to indicate that the assessment was completed.

Based on staff interviews and record review, the facility failed to develop a care plan that addressed discharge goals and plans for 1 of 1 resident (Resident #25) reviewed for discharge to the community. Findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #25 discharged home on[DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had moderately impaired cognition. The comprehensive care plan, updated 12/14/20 did not include information that addressed discharge planning. On 3/3/21 at 1:41 PM an interview was completed with the Social Services Assistant (SSA). She stated she had not completed a care plan for Resident #25 that addressed discharge planning and typically had not added discharge care plans to the comprehensive care plans for residents in the facility. SSA added that the MDS Coordinators might have added discharge goals/plans to the comprehensive care plan but wasn't sure. MDS Coordinator #1 was interviewed on 3/4/21 at 1:44 PM. She explained each discipline (including social services) wrote their own care plans that corresponded to the section of the MDS they completed. She said social services was responsible for discharge planning information on the care plan and should have completed a care plan that addressed Resident #25's discharge plans/goals. During an interview with the Executive Director on 3/5/21 at 11:04 AM he shared he was not aware that discharge planning needed to be included on the comprehensive care plan.

Based on record review, resident interview and staff interviews, the facility failed to provide services for range of motion for 1 of 3 residents (Resident #12) reviewed. The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #12 had intact cognition and required extensive assistance of one staff member with bed mobility, transfers, toileting and dressing. She required supervised assistance of one staff member for cueing in the area of walking in the room and facility corridor and was not steady when walking but was able to stabilize without human assistance. The Resident was coded to have no impairment of range of motion in the lower extremities. A review of the MDS dated [DATE] revealed Resident #12 required extensive assist of one person with walking in the room and facility corridor and was not steady when walking but was able to stabilize without human support. The Resident was coded to have no impairment of range of motion in the lower extremities. A review of the most recent MDS assessment dated [DATE] indicated Resident #12 had intact cognition. She required extensive assistance of two staff members with bed mobility, transferring, toileting and dressing. Walking was documented to occur less than one time during the 14-day lookback period and required two personal physical assistance. Walking was coded as not steady and only able to stabilize with human assistance. The Resident was coded to have impairment of range of motion in both lower extremities. On 03/02/21 at 2:34 PM an interview was conducted with Resident #12 and she revealed that she no longer received help with walking for exercise or weight bearing and that when she was discharged from therapy, in 2020, she was walking 100 feet in the hall. She stated she desired to walk with staff assistance. On 03/04/21 at 1:21 PM an interview was conducted with the Director of Rehab (DOR) services and she revealed that Resident #12 was last on the therapy case load, 6/4/2020 - 7/1/2020, for a decline in mobility. The resident was working with PT for sit to stand transfers, ambulation of 40 - 100 feet, exercises for the lower extremities and she required verbal cueing of staff to complete exercises. The discharge recommendations were for the resident to continue the exercises independently with staff cueing and to ambulate with recreational services. The DOR stated the discharge plans were discussed with the Resident and she agreed upon a transfer of gait program to participate late in the day, because the resident preferred evenings. Education was provided to staff regarding her performance and safety concerns. A personalized exercise chart and green stretch band was provided and hung in the room. The DOR added that due to a previous COVID outbreak and Resident hospitalization , the resident changed rooms and the exercise chart should have been moved with the resident. The DOR stated it was her expectation that the recommendations be carried out and care planned as recommended by the therapy staff or the staff should receive clarification orders from the primary care physician (PCP). An observation occurred on 03/04/21 at 1:38 PM with the DOR and there was not an exercise chart or green exercise band, hanging in Resident #12's room. On 3/04/21 at 2:01 PM an interview was conducted with Recreational therapist #1 and she revealed that the facility recreational therapist did assist Resident #12 with walking when she was discharged from physical therapy last July. She added that the Resident had a good participation record and walked in the evenings until December 2020. She stated that in December 2020 the facility discontinued recreational therapy as a preventative infection control measure due to a COVID 19 outbreak. She revealed that all of the residents had resumed recreational therapy once the facility had no positive COVID 19 test results. She added that Resident #12 was the only resident to not resume recreational therapy and walking with assistance of staff, due to her infection control isolation status. She revealed the Resident had a current [DIAGNOSES REDACTED]. On 3/4/21 at 2:21 PM an interview was conducted with the infection control preventionist and she revealed that shingles would not prevent a resident from participating in range of motion or walking activities if the resident met the current CDC recommendation. She added that Resident #12 would require a bandage or shield over the crusted shingles area but with proper precautions the Resident could work with recreational therapy. On 3/4/21 at 3:11 PM an interview occurred with the Director of Nursing and she revealed the facility can accommodate or find a way to provide exercise and ambulation to a resident with isolation. She stated it was her expectation that staff report to her if a resident was not currently receiving therapy recommended by the therapy rehabilitation team and that the Physical therapist recommendations be added to the care plan as needed. She added that she had not been made aware that Resident #12 had not been placed back on the recreational therapy list and that the Resident would require a new physical therapy consult, which would be requested immediately.

Based on record review and staff interviews, the facility failed to report to the state an injury of unknown origin (significant injury) within the required 2-hour timeframe for 1 of 3 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 had care plans dated 2/7/20 for being severely impaired with cognitive decision making, required extensive assistance with activities of daily living, incontinence, skin integrity, safety awareness and falls. A quarterly Minimum (MDS) data set [DATE] revealed the resident had moderate difficulty hearing. The resident was severely cognitively impaired. The resident had no behaviors and no rejection of care. The resident required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. He was independent with eating, and with locomotion off the unit. The resident required total dependence with bathing/showers. The resident was not steady when moving from a seated to standing position or with surface to surface transfers. The resident used a wheelchair and was always incontinent of urine and frequently incontinent of bowel. An incident report dated 2/28/20 revealed Resident #1 had a razorlike burn under his nose. The area was not assessed due to the resident eating. The incident report revealed the area swollen and slightly bruised. There was also blood noted in the resident's mouth. The resident was alert. The resident's power of attorney was notified via phone at 7:30 AM and a physical assessment was completed. The root cause analysis stated the resident may have bumped the side rail while turning. A nursing note dated 2/28/20 revealed a bruise was noted to the top lip, under nose. No complaints, pain nor discomfort were voiced at this time. No signs or symptoms of distress were noted. The resident was Unable to verbalize what happened at this time. Vital signs were stable. The power of attorney was contacted, and a message was left. A police report dated 3/2/20 at 3:01 PM revealed the incident was found on 2/28/20 and the crime incident involved a simple assault (physical). Unknown tools/weapons were used, and the premise type was unknown. An initial allegation report was submitted to the state on 3/2/20 at 1:08 PM. The date of the incident was 2/28/20 and the facility became aware of the incident on 2/28/20. It revealed the resident had bruising to his upper lip and a small cut under his upper lip. Nursing Assistant #1 was suspended on 2/27/20. A 5-day investigation report was submitted to the state (via fax) on 3/5/20 at 3:25 PM. The alleged employee was Nursing Assistant #1. The incident occurred on 2/28/20 and the facility became aware of the incident on 2/28/20. An investigation was completed, which included staff interviews. The resident had an injury of unknown origin and harm. Law enforcement were notified on 3/2/20. The results of the allegation for suspicion of a crime was not substantiated but NA #1 was terminated. The allegation/incident type was an injury of unknown source. The Administrator was interviewed on 3/10/20 at 9:43 AM. She stated they initially thought the resident hit his face on the siderail before she interviewed staff. The nursing staff thought the incident was an accident. The resident's family came in and were able to get more information out for the resident. The resident's story changed. Then that is when she completed the 24 hours report. She stated the resident's family came to the facility on Sunday 3/1/20 and on Monday 3/2/20, the family came to her office (about the resident's injury). The family stated what the resident was saying about being hit was accurate. She told the resident's family she was going to talk to the staff and was investigating it. That same day she (the family) called the police on 3/2/20. She completed her 5-day report on the 3/5/20. If a resident had a bruise of unknown origin, then she would report it. The resident wiggled in bed and got agitated. Sometimes the resident made a lot of noise at night. She stated on Friday the area was approximately less than ½ of an inch in size on the right side above his lip was red and swollen. It looked like a possible cut above his lip. The resident didn't want them to look it his mouth. She didn't notice any bruising to his hands/wrist. On Monday, the area had bruised under his nose and had small dots on the right side. The Administrator was interviewed on 3/10/20 at 2:22 PM. She stated that she would report the injury (to the state) that day if she didn't have a reasonable explanation of what occurred. The Administrator was interviewed on 3/10/20 at 2:38 PM. She stated she would expect for the regulations for reporting to be followed.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the Assessment Reference Date (ARD) of the previous MDS assessment for 1 of 13 (Resident #2) sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's medical record revealed a quarterly MDS assessment dated [DATE]. This was the last MDS assessment observed in Resident #2's medical record. An interview was conducted with the MDS nurse on 10/10/19 at 10:50 AM. She stated Resident #2 should have had a quarterly assessment done in (MONTH) of 2019 that did not get done. She stated the assessment got missed. An interview was conducted with the Director of Nursing on 10/10/19 at 2:12 PM. She stated there should have been an MDS assessment completed for Resident #2 in (MONTH) 2019 and that her expectation was that MDS assessments be completed within the required timeframes.

Based on observations, record review, and resident and staff interviews, the facility failed to include administration instructions in the physician's orders to specify when to administer two different dosages of the same pain medication ordered for 1 of 1 residents (Resident #155) reviewed for pain management. Findings included: Resident #155 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #155's record revealed that she was cognitively intact, required 1-2-person extensive assistance with activities of daily living, and was receiving therapy services. Review of Resident #155's baseline care plan dated for 10/2/19 was noted to address pain management due to compression fractures. Review of Physician Orders revealed that both of the following orders were placed on 10/2/19: [MEDICATION NAME] 5 mg tablet (10mg =2 tabs) orally as needed every three hours and [MEDICATION NAME] 5 mg tablet orally as needed every three hours. There were no further instructions included in the orders. Review of Resident #155's (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]=2 tabs) dosage until 10/6/19 at 8:58 AM for a pain level of 10 out of 10. All follow-up pain assessments for both [MEDICATION NAME] dosages administered from 10/2/19 to 10/7/19 were documented as effective for pain management within an hour of administration. During an observation and interview with Resident #155 on 10/7/19 at 2:00PM she was observed wearing her back brace while sitting up in her recliner. She stated that she had significant pain in her back at times but staff was giving her pain medications every three hours or so when she asked for it. She stated that the pain regimen was working for now. During an interview with the Director of Nursing on 10/9/19 at 4:15 PM she stated that as needed pain MEDICATION ORDERS FOR [REDACTED]. During an interview with Nurse #20 on 10/10/19 at 1:21 PM, when asked to review the two [MEDICATION NAME] orders in place for Resident #155, she stated that most as needed pain medication orders have specific instructions on which one to give based on pain severity. It would usually clarify and order to give the lower dosage for mild to moderate pain and the higher dosage for severe pain. She verified with this surveyor that there were no instructions included in the two as needed orders for [MEDICATION NAME]. During an interview with the Administrator on 10/10/19 at 4:15 PM she stated that it was her expectation that staff follow physicians' orders and that those orders would have directions to let staff know when to give the correct dose.

Based on observations and staff interviews, the facility 1). failed to lock an unattended medication cart for 1 of 4 medication carts (hall 400) and, 2). failed to properly store and dispose of an expired medication and an expired, unlabeled food item in 1 of 2 medication storage rooms that were used to store medications and supplies for the residents residing on the 400, 500 and 600 halls. The findings included: 1. An observation on 10/9/19 at 8:32 AM revealed Nurse #1 walking away out of eyesight from the medication cart on the 400 hall. The medication cart lock was not pushed in indicating a locked position. An interview on 10/9/19 at 8:47 AM with Nurse #1 revealed he walked away from the medication cart to retrieve a stock medication from the medication room and left the cart unlocked. He stated he knew he was supposed to lock the medication cart when unattended, he just forgot to do so. An interview on 10/10/19 at 1:28 PM with the Director of Nursing revealed she expected the medication carts to be locked when unattended. 2. An observation on 10/10/19 at 8:47 AM of the medication room for the residents residing on the 400, 500 and 600 halls revealed one fleet enema located with the house stock medications available for use with an expiration date of 9/2019. In the medication room refrigerator was observed an unlabeled Yoplait peach yogurt with an expiration date of 10/6/19. An interview conducted on 10/10/19 at 8:59 with Nurse #2 revealed everyone is responsible for the medication room being clean and checked for expired medications. She stated it is a group effort. Nurse #2 stated the yogurt should not have been in the refrigerator. An interview conducted on 10/10/19 at 1:28 PM with the Director of Nursing revealed her and the supply clerk go through the medication room at least every other week thoroughly, they stay on top of it. She stated she checked it yesterday but must have missed the yogurt and expired fleet enema.

Based on staff interviews and record review, the facility failed to accurately document code status in both the electronic medical record and paper chart for 1 of 15 residents (Resident #34) reviewed for advance directives. Findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had severe cognitive impairment. A review of the face sheet in the electronic medical record revealed an advance directive that included full code status (initiate cardio-pulmonary resuscitation should respirations and heartbeat stop). A review of the paper chart revealed a yellow form Do Not Resuscitate (DNR) order signed by the physician and effective 10/19/17. On 11/28/18 at 9:50 AM an interview was completed with Nurse #2. She said she identified a resident's code status when she looked at the outside of the paper chart. She stated if the writing on the outside of the paper chart was in black ink then the resident had a DNR order. She further stated the code status was also located in the electronic medical record on the face sheet. A review of the electronic medical record with Nurse #2 revealed Resident #34 was a full code. Nurse #2 reported if there was a DNR order it appeared next to the resident's name when she accessed the electronic medical record. On 11/19/18 at 9:46 AM an interview was completed with Nursing Supervisor #1. She stated if a resident's code status changed the physician wrote the order and the nurse entered the order in the electronic medical record. She further stated if a resident was admitted with a DNR order, the supervisor entered the order into the electronic medical record. A review of the paper chart with Nursing Supervisor #1 revealed a yellow DNR order dated 10/19/17. A review of the electronic medical record revealed a full code status. Nursing Supervisor #1 said she was not sure why the DNR order was not entered into the computer but that it should have been consistent with the paper chart. On 11/19/18 at 11:29 AM an interview was completed with the Administrator. She expected code status information be consistent in both the paper chart and electronic medical record.

Based on observations, record review and staff interviews, the facility failed to ensure infection control practices were followed by not dating oxygen tubing and nebulizer mask tubing for 1 of 1 of 1 (Resident #44) residents reviewed for respiratory care. Findings included: Resident #44 was re-admitted to the facility on [DATE] after a hospitalization for acute hypoxic [MEDICAL CONDITION] and an acute on chronic diastolic heart failure exacerbation. Resident #44 also had a [DIAGNOSES REDACTED]. A review of the physician's order [REDACTED]. An observation on 11/26/18 at 4:11 PM revealed oxygen at 2 liters per minute via nasal cannula in use. The oxygen tubing connected to an oxygen concentrator was not dated and a nebulizer mask with tubing attached that was on the residents bedside table uncovered and not dated. An observation on 11/28/18 at 9:54 AM revealed oxygen tubing connected to an oxygen tank attached to the back of the residents wheelchair not dated and a nebulizer mask and tubing observed open on bed, uncovered and not dated. An interview on 11/28/18 at 10:46 AM with the Director of Nursing revealed the oxygen tubing was changed weekly on Thursday by one of the restorative aides and she brings her a list upon completion. She stated she didn ' t know if there was a policy. A follow up interview on 11/28/18 at 11:06 with the Director of Nursing revealed the restorative aide also changes the nebulizer masks weekly on Thursday. She stated she expected this to be done. An interview on 11/28/18 at 11:45 with Restorative Aide #1 revealed she goes around to each room and changes the oxygen tubing, nebulizer tubing and sterile water for oxygen use every Thursday. She stated she gives a list to the Director of Nursing when she is through. She stated she doesn ' t know when new or re-admissions arrive so it ' s difficult to keep track. She stated when she is not working, the other restorative aide does the changing of the tubing. She did not know that Resident #44 was back from the hospital, so his tubing did not get changed.

Based on observations and resident and staff interviews, the facility failed to post the notice of location and availability of the facility's survey results. Findings included: During a tour of the facility on 11/26/18 at 11:00 AM an observation was made that survey results were located in a notebook binder on the lower shelf of a table in the reception area of the facility. An observation of the facility on 11/26/18 at 3:47 PM revealed there was no notice posted in the facility regarding the availability and location of recent survey results. On 11/27/18 at 2:30 PM the Resident Council interview was completed. During the meeting, the Resident Council members stated they had no knowledge of the location of the survey results notebook. An interview with the Resident Council President during the meeting revealed she didn't know what the survey results were, where they were located and had not seen any signage that directed residents to their location. An observation of the facility on 11/27/18 at 3:14 PM revealed there was no notice posted in the facility regarding the availability and location of recent survey results. An observation of the facility on 11/28/18 at 2:20 PM revealed there was no notice posted in the facility regarding the availability and location of recent survey results. An observation of the facility on 11/29/18 at 11:20 AM revealed there was no notice posted in the facility regarding the availability and location of recent survey results. An interview was completed with the Administrator on 11/29/18 at 11:27 AM. She stated she did not have a notice posted in the facility that identified the location of survey results and said she was unaware of the requirement. She said that going forward she expected a notice be posted that directed residents and families to the location of the survey results and planned to have the notice posted in the facility.

Based on record review and staff interviews, the facility failed to notify the Ombudsman in writing when 2 of 2 (Resident # 31 and Resident # 258) residents that were sent to the hospital. Findings included: 1). Resident #31 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. A record review revealed a physician ' s progress note dated 10/1/18 the revealed Resident #31 was seen for swelling in his lower extremities with concern for a blood clot. An order was given to send Resident #31 to the Emergency Department. A nurse ' s note dated 10/1/18 revealed Resident #31 was sent to the Emergency Department. An interview on 11/28/18 at 3:44 PM with the Social Worker revealed the move in coordinator was responsible for sending discharge notices to the ombudsman. An interview on 11/28/18 at 3:49 PM with the Move In Coordinator revealed she sent notices to the Ombudsman when a resident discharged , but did not send them when a resident was sent to the hospital. She revealed she wasn ' t aware she was required to do so. An interview on 11/29/18 at 12:36 PM with the Administrator revealed the Move-in Coordinator wasn ' t aware she needed to send discharge notices to the hospital and it was her expectation that the notices be sent. 2). Resident #258 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. A record review reveled a nurse ' s note dated 4/8/18 at 7:04 PM revealed the physician was made aware that Resident #258 ' s blood sugars were elevated and resident lethargic. An order was received to send the resident to the hospital for an evaluation. An interview on 11/28/18 at 3:44 PM with the Social Worker revealed the move in coordinator was responsible for sending discharge notices to the ombudsman. An interview on 11/28/18 at 3:49 PM with the Move In Coordinator revealed she sent notices to the Ombudsman when a resident discharged , but did not send them when a resident was sent to the hospital. She revealed she wasn ' t aware she was required to do so. An interview on 11/29/18 at 12:36 PM with the Administrator revealed the Move-in Coordinator wasn ' t aware she needed to send discharge notices to the hospital and it was her expectation that the notices be sent.

Based on staff and resident interviews, service representative interview, observation and document review the facility failed to prevent a resident fall, caused by a mechanical failure, by failing to have a automated mechanical ramp for a resident transportation van serviced when it had known incidents of working improperly for 1 of 1 residents (Resident #1) and failed to follow the manufacturer ' s schedule for maintenance of the automated mechanical ramp for 2 of 2 resident transportation vans, which resulted in a resident fall for 1 of 1 residents (Resident #1). Immediate Jeopardy began on 1/27/14 and was identified on 3/6/14. Immediate jeopardy was removed on 3/8/14. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. The findings included: According to the Operator's Manual ( Rev A) "Maintenance is necessary to ensure safe and trouble free (brand name of ramp) operation. General preventative maintenance consisting of inspecting your (brand name of ramp) systems along with cleaning and lubricating procedures should be part of your routine" (Page 47). "Regular preventative maintenance procedures will increase the service life of the (brand name of ramp), as well as enhancing safety" (Page 47). "Clean and lubricate the specified points approximately every 4 weeks or 100 cycles" (Page 47). "Preventative maintenance visual inspections and lubrication procedures do not take the place of the procedures specified in the Maintenance and Lubrication Schedule provided in the (brand name of ramp) Service Manual. The procedure section in the Maintenance and Lubrication Schedule must be performed at the recommended scheduled intervals by an authorized (name of manufacturer) service representative" (Page 48). "If there is any sign of damage, wear, abnormal condition or improper operation, discontinue (brand name of ramp) use immediately" (page 48). Resident #1 was admitted on [DATE] for aftercare following a hip replacement secondary to a hip fracture and was readmitted on [DATE]. She also was on dialysis three days a week. Review of the Admission Minimum Data Set (MDS) revealed Resident #1 was cognitively intact and used a walker or wheelchair for mobility. Review of the Event Report dated 1/27/14 at 5 PM revealed that Resident #1 had an attended fall while on the mechanical ramp in her wheelchair: "Van Driver/Nursing Assistant #1 (VD/NA #1) was in the process of getting (Resident #1) into a transportation van and the lift on the van started to go up without VD/NA #1 engaging any buttons causing (Resident #1) to fall backwards in her wc (wheelchair) " , "(Resident #1) sustained a bump on her head that did not bleed nor did she loose (sic) consciousness". The incident occurred at the dialysis clinic. Resident #1's condition prior to the incident was documented as alert, oriented and calm and after the incident it was alert, agitated and anxious. The report also indicated that the van was taken out of service immediately after the incident. A written statement signed by VD/NA #1, dated 1/27/14 revealed "On Mon [DATE] about 5 pm after picking up (Resident #2) from her doctors appointment I proceeded on New Garden Rd to pick up (Resident #1) from Dialysis. I had Resident #2 in a wheelchair, knowing that (Resident #1) could stand up from her wheelchair to be seated in the van seat. I pulled up in the front of the door. Lifted down the ramp of the Gray van. Proceeded into get (Resident #1) asking her if she felt comfortable standing up with my help to sit her in the chair of the van. She said yes. I proceeded up the ramp reaching over sideways positioning her to stand, the ramp came up throwing both of us her falling backward, the ramp was folding upward she fell backward in her wheelchair and myself twisting and jumped off the ramp, I got twisted myself, there was no open cuts on her, no blood. She was very shaken and very upset but she never lost consciousness " . Telephone Interview with VD/NA#1 on 1/31/14 at 4 PM was consistent with the above written statement from VD/NA#1. She stated that on 1/27/14 the van was turned off and she had the keys on her wrist when the incident occurred. VD/NA#1 said she had already pushed the remote button at the side door of the van to automatically lower the ramp for use. She also stated that she pushed the resident in her wheelchair onto the middle of the ramp, and was at the side of the wheelchair getting ready to help Resident #1 transfer from her wheelchair, to a seat on the van, when the ramp started to fold up on its own (the van only had one spot that could accommodate a wheelchair which was already taken by Resident #2). VD/NA#1 said that when the ramp started to move she reached for the resident's wheelchair, but could not reach it in time, and Resident #1 fell backward in her wheelchair and hit her head. VD/NA#1 also clarified that the ramp was not meant to move with people on it and that it was only supposed to move when a remote button was pushed to deploy or store the ramp. She added that the ramp was used for pushing residents in their wheelchairs into and out of the van or for walking residents into and out of the van; the ramp was not a mechanical lift. During the 1/31/14 telephone interview at 4 PM, VD/NA#1 said she knew she should not move the resident so she had a man who had seen the incident get help and 3 Nurses from the Dialysis clinic came out and got Resident #1 back in her wheelchair. VD/NA#1 did not know if these Nurses did an assessment before they got Resident #1 up. VD/NA#1 indicated that Resident #1 was very upset and while on the ground had been searching for her phone to call her family member. The resident did find her phone and notified her family member. VD/NA#1 said the Dialysis Nurses told the resident she should go to the emergency room (ER) but Resident #1 refused to go until her family member told her to get there. VD/NA#1 said the family member arrived about 10 minutes after the incident and wanted the resident assessed in the ER. Emergency Medical Services was called and took Resident #1 to the ER about 5 minutes later. Also during the 1/31/14 telephone interview at 4 PM, VD/NA#1 said she called VD/NA#2 to come and transport Resident #2; VD/NA#2 then called their supervisor to report the incident. VD/NA#1 also stated that she called the Maint Dir and he came to get Van #1. She added that when VD/NA#2 arrived they both got Resident #2 off of Van #1 by pushing her in her wheelchair down the ramp that was back in its lowered position and not moving; the ramp did not move while they transferred Resident #2 off of Van #1. Review of the Hospital Emergency Services Discharge Record dated 1/27/14 revealed Resident #1 was discharged with a [DIAGNOSES REDACTED]. While in the hospital Resident #1 had a CT scan of her head and spine which revealed " no acute inter-cranial process " and stable atrophy of the resident ' s spine. In addition the report noted that the nature of the injury was " rolled backwards down ramp and w/c fell backwards " . Resident #1 was not admitted to the hospital and was discharged back to the facility. Review of the electronic and hand written Nursing Notes for 1/27/14 revealed no Nursing Notes written that day. A Post Fall Assessment/Summary of Fall dated 1/28/14 revealed "staff member was assisting resident into the van at the dialysis center when the ramp began to rise. Malfunction of the equipment". The Root Cause of Fall was listed as "ramp on van malfunctioned causing both resident and staff to fall from ramp". A 1/28/14 update to the resident ' s care plan revealed "fall backward during load to van, do not transfer to seat, keep in w/c during transport/transfer". Review of the electronic Nursing Notes revealed a 1/28/14 note at 11:10 AM "no pain no c/o discomfort from fall". Review of the 72 Hour Event Follow-up in the hand written Medical Record chart revealed that on 1/28/14 at 5 PM Resident #1 ' s vital signs were within normal limits and she had "no c/o (complaints) event pain / achiness takes scheduled Norco (narcotic pain medication)". The sections for the remainder of the 72 hours post the fall event were blank. Review of the electronic Nursing Notes revealed a 1/28/14 note at 9:39 PM "no c/o pain as result of fall yesterday". After 1/28/14 through 1/31/14 there were no further post fall assessment notes in either the electronic or hand written medical record. On 1/31/14 at 4:30 PM telephone interview with the Service Representative (SR #1) where Van #1 was taken to be serviced revealed the van arrived at the shop to be serviced on 1/31/14 at 3PM. She stated that there had not been an appointment made so the ramp of the van could not be looked at until 2/3/14. SR #1 said that the last time Van #1 had been in their shop for service was November 2013. She added that in November she told the staff member who brought the vehicle in, that the manufacturer recommended that the ramp should have routine maintenance every 6 months and that a one time, complimentary, routine maintenance service had been done on the ramp at that time. SR #1 stated that the routine maintenance service entailed a checklist of service items including, but not limited to, checking for abnormal noises, cleaning, checking all bolts, ramp pivots and switches and checking the operation of switches and remotes. She added that when Van #1 was brought in on 1/31/14 the staff member who dropped it off said the ramp opened up on its own one time and did it with a resident on it. She also said that the facility staff member stated that the ramp operating on its own had happened before. SR#1 was unsure if the ramp had a weight capacity but provided the name of the manufacturer and brand name of the ramp. SR#1 added that the mechanics in her shop also indicated that if two people were on the ramp when it malfunctioned and tried to store itself, the motor would have burned itself from the weight of trying to store itself while two people were actually on it. She further indicated that the motor was not burned out. Interview with the Maintenance Director (Maint Dir) on 1/31/14 at 5:18 PM revealed that he had taken Van #1 for service in November 2013 because he had been told there was a problem with the ramp. He stated that VD/NA #1 and VD/NA #2 complained to him that the ramp was going up (stowing) and down (deploying) by itself. He added that when he checked the ramp he couldn't find anything wrong with it but then he moved the van to park it and when he shut off the engine the side door opened on its own and the ramp deployed. The Maint Dir stated that he had not activated the ramp by pushing the remote control, it just operated on its own. He also said that he immediately took the van out of service and a few days later he took it into the shop where conversion vans like Van #1 were serviced. The Maint Dir said that the shop he took Van #1 to in November said they could not find anything wrong with the ramp, so they performed a complementary routine maintenance service on the ramp. After this, Van #1 was again used for resident transportation at the facility. The Maint Dir did not recall being told by SR#1 that the manufacturer recommended that the ramp should have routine maintenance every 6 months. He also revealed that the ramp for Van #1 had been serviced in February 2013 because it wasn't working and a new control panel was put in when he took it for service at that time. He stated that he had never taken Van #1 or Van #2 for routine maintenance of the ramp in the 5 years he worked at the facility and did not believe anyone else had either. He noted that Van #2 had the same type of ramp as Van #1. In addition, he said that after November 2013 he recalled getting called twice about the ramp of Van #1 not closing to store itself, when the remote to close it was pushed. On one occasion he went to assist the Van Driver (#1 or #1 not specified) but the ramp had already started operating and was able to be stowed before he got there. On the other occasion the ramp was still down when he got there and he had to stow it manually. The Maint Dir said that he did not take Van #1 for service to the automated mechanical ramp after either of the post November 2013 incidents when it would not stow mechanically. He added that he had not informed the Administrator of these post November 2013 incidents of the Van #1 ramp not stowing. On 1/31/14 at 6:30 PM the Maint Dir indicated there were no service invoices for Van #2 but provided copy of the Invoices for the service to the ramp of Van #1. Review of the 3/11/13 invoice revealed: "customer states that lift inop (inoperable), installed new control board and kneel accuator completed ". The 11/21/13 invoice revealed: "customer states ramp won't go up at times, won ' t come down at times and door won't close at times. Could not duplicate this". "Performed complementary first service". There were no charges for the service on 11/21/13. During an interview with Resident #1, on 1/31/14 at 6:30 PM, she said that VD/NA#1 was not present with her on the ramp when it started to move and flipped her (Resident #1) backwards. Resident #1 said that VD/NA#1 wheeled her onto the front of the ramp but then stopped. Resident #1 said it looked like VD/NA#1 was going to have her (Resident #1) sit in a seat in the van because someone else (Resident #2) was already in the one wheelchair spot. When asked, Resident #1 stated that she did not recall VD/NA#1 asking her if she felt capable of transferring to a seat in the van. She said that VD/NA#1 entered the van and had her hands on the arms of the other resident's (Resident #2) wheelchair. Resident #1 said she presumed that VD/NA#1 had stepped into the van to move Resident #2 over so there would be room for her (Resident #1) to be assisted to sit in a seat in the rear of the van, but she did not know for sure as VD/NA#1 did not say anything about it. Resident #1 said that while VD/NA#1 was inside the van, and not standing on the ramp, the ramp started moving on its own and threw her (Resident #1) backwards with her legs over her head. She added that she hit her head and sustained a bump. Resident #1 said that VD/NA#1 reached out to try and stop the wheelchair from flipping but could not reach the wheelchair in time. According to Resident #1, VD/NA #1 repeatedly said "it's broken" after the incident. Resident #1 stated that staff from the Dialysis clinic got her back into her wheelchair and the nurse there said she needed to go to the emergency room (ER), but she (Resident #1) wanted to wait for her family member to arrive. Resident #1 had called her family member and after the family member arrived Resident #1 went to ER via Emergency Medical Services. Resident #1 said she sustained a large bump on the back of her head and had a headache from the incident but returned to the facility without being admitted to hospital. Resident #2 was not interviewable and was therefore not interviewed regarding the incident. Telephone interview with the Administrator on 2/4/14 at 11:30 AM revealed that she had not been informed of the 2 incidents when the ramp for Van #1 would not close (stow itself) mechanically which occurred after the maintenance service in November. She also indicated that after finding this out on 1/31/14, she interviewed both VD/NA #1 and VD/NA#2 and that VD/NA#2 had said she recalled at least one incident when the ramp would not close mechanically which she had reported to maintenance (post November 2013) but she was uncertain if she had witnessed and reported a second incident. The Administrator said VD/NA#1 denied being aware of any incidents of the ramp for Van #1 not closing mechanically. The Administrator was notified on 3/8/14 of the Immediate Jeopardy that began on 1/27/14. The facility presented a credible allegation of compliance on 3/8/14 which included: The van involved (#1) was immediately taken out of service on 1/27/14. The van was taken for repair and service on 1/31/14; it was not used following this date. Two wiring problems were repaired and the remote was disabled, however, this did not fix the problem. The van is now being traded in towards a new van and continues to be out of service until sold. A new van is being purchased. Both transportation aides have been educated by the Administrator to utilize our work order system for any vehicle problems and not to just call for assistance. This gets the problem into our system and these work orders are reviewed every week day by the Director of Plant Operations. They were also instructed to notify the Director of Home Care of any vehicle problems. Both transportation aides were also educated and given authority to take a vehicle out of service. They are to pull all keys for the vehicle and give written notice and the keys to the Director of Plant Operations, or if he is not available, the Health Center Administrator. All maintenance staff were educated by the Director of Plant Operations that any issues involving the mechanical ramps or mechanical lifts on the vehicles are to be taken to the authorized service provider for repair and the vehicle to remain out of service until repair completed. They were also educated on procedures for taking a vehicle out of service. Additional training on transportation to include the ramp operation, securing wheelchairs, and loading and unloading residents will be done with the transportation aides as well as other staff identified to potentially assist with transportation on Friday, February 28, 2014 by the Administrator and Director of Plant Operations. Weekly vehicle inspections have been implemented for both vehicles which include checking the operation of the mechanical ramps. Monthly preventative maintenance has been done and been scheduled for all vehicle ramps and lifts to clean and lubricate the equipment per the manufacturer_x0019_s instructions. Each vehicle has been serviced by the authorized service provider for the recommended six-month servicing. This is now scheduled in our preventative maintenance system as a recurring item to be done every six-months. Validation of the facility's credible allegation was conducted on 03/8/14. Review of the facility accident reports was conducted and there were none prior to the incident on 1/27/14. Additional, validation included observation of staff driver ' s license, facility provided cell phone, review of management agreement with Whitestone for transportation services, policy on transporting clients and emergency procedures, emergency protocol for transportation and reporting vehicle problem protocol, vehicle out of service forms, vehicle maintenance invoices, weekly maintenance checklist and staff education on reporting vehicle issues utilizing work order system for any vehicle problems. The observation included staff demonstrating the proper usage/operation of the van ramp and securing residents in the vehicle. Residents on all halls (100, 200, 300, 400, 500 and 600 halls) in the facility records were reviewed and observations were conducted on residents who had changes in conditions. The observations included interventions associated with falls, skin conditions, staff reporting/communication process from shift to shift, staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools (05/20/13). The SBAR(Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from 5/17/13-5/31/13 was reviewed. Reviews of maintenance checklist and invoices were completed to verify the implementation of the assessment tools and the functional process of staff communicating problems with the condition of the van between drivers. Staff interviews were conducted with the Whitestone maintenance staff and drivers to verify the implementation of the newly developed weekly vehicle checklist, utilization of the work order system for vehicle problems, out of service notification forms, policy on transporting clients and emergency procedures. The completion date for all in-services for maintenance and van drivers became effective 3/7/14. The Quality Assurance Audit reports dated 3/6/14 was reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance.