Every finding on record at Woodlands Nursing & Rehabilitation Center

Based on record review and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of oxygen therapy for 1 of 1 resident reviewed for oxygen therapy (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. The MDS dated [DATE] indicated Resident #4 was cognitively intact and was not coded for oxygen therapy. The Care Plan, last revised 7/21/25, included the focus of requiring oxygen therapy with an intervention that specified to give medications as ordered by physician. An observation and interview with Resident #4 were conducted on 8/7/25 at 10:55 AM. He was observed lying in his bed with oxygen being administered via nasal canula tubing (a tube with nasal prongs that allows oxygen delivery from an oxygen source) which was connected to an oxygen concentrator. He was awake and alert. When asked if he knew what his oxygen rate was supposed to be he stated that he really was not sure. He explained he had COPD and some other lung issues and used oxygen continuously. An interview was conducted with the MDS Coordinator on 8/7/25 at 11:28 AM. The MDS Coordinator stated she did not code Resident #4's oxygen therapy on the 7/21/25 MDS assessment due to operator error. An interview was conducted with the Director of Nursing (DON) on 8/7/25 at 12:04 PM. The DON stated it was her expectation that the MDS Coordinator be aware of residents on oxygen therapy and to make sure the MDS assessments were accurately coded. An interview was conducted with the Administrator on 8/8/25 at 1:38 PM. The Administrator stated it was her expectation that the MDS assessments were coded accurately.

Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with newly evident mental health diagnoses for 1 of 1 sampled resident reviewed for PASRR (Resident #62). The findings included:Resident #62 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder, post-traumatic stress disorder, and adjustment disorder with anxiety.The admission Minimum Data Set, dated [DATE] had Resident #62 coded as cognitively intact and was not currently considered by the state level II PASRR process to have serious mental illness.A review of the North Carolina Medicaid Uniform Screening Tool (NC MUST) for PASRR screenings dated 01/26/2010 revealed a negative PASRR level I determination.An interview with the Social Worker was conducted on 08/08/2025 at 11:15 AM. She stated Resident #62 did not have any mental health diagnoses in 2010 when the PASRR level I was completed but she did have the diagnoses of major depressive disorder, post-traumatic stress disorder, and adjustment disorder with anxiety when she was readmitted on [DATE]. Those diagnoses should have prompted a PASRR level II screening to be completed but it slipped through the cracks. An interview with the Director of Nursing (DON) was conducted on 08/08/2025 at 11:37 AM. She stated Resident #62 did have mental health diagnoses of major depressive disorder, post-traumatic stress disorder, and adjustment disorder with anxiety when she was readmitted on [DATE]. The Social Worker was expected to submit a PASRR level II screening when she was admitted but it was overlooked and there was not a plan of correction (POC) completed prior to investigation.

Based on record review and staff interviews the facility failed to administer significant medications to 4 out of 16 residents (Resident #1, #18, #21, and #48) reviewed for medication administration. The facility also failed to follow medication administration guidelines for not crushing certain medications for 1 out of 16 residents reviewed for medication administration (Resident #42). Findings included: 1a) Resident #1 was admitted originally into the facility 01/31/22 and was readmitted on [DATE] with the diagnoses of cerebral infarction, chronic systolic congestive heart failure, hypothyroidism, hypertensive heart and chronic kidney disease with heart failure, epilepsy, and type 2 diabetes mellitus. A review of Resident #1's quarterly Minimum Data Set, dated dated dated [DATE]included that she is severely cognitively impaired, has diagnoses of heart failure, diabetes mellitus, stroke, dementia, seizure disorder, and schizophrenia. It further revealed that she had received insulin injections on 7 days and was taking high risk drug classifications of a diuretic and antidepressant. A review of Resident #1's comprehensive care plan initiated on 3/24/23 included the focus and interventions of a seizure disorder with a risk for injuries, the interventions included give seizure medication as ordered by doctor and to monitor/document the side effects and effectiveness. The focus and interventions of she used an antidepressant medication and had an increased risk for adverse side effects, the interventions included giving the antidepressant medication as ordered by the physician and to observe for/document side effects and effectiveness. The focus and interventions of the potential for dehydration or fluid volume deficit related to status post gastrostomy tube hydration and oral medications the interventions included to administer medications as ordered and monitor/document side effects and effectiveness. A focus and interventions of she had diabetes mellitus with risk for complications interventions included to administer diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness, and to monitor blood glucose levels as ordered by the physician. A review of Resident #1's November 2023 Medication Administration Record revealed no documentation of her medications scheduled for 9:00 AM on 11/29/23. These medications included: furosemide 40 mg daily for heart failure, phenobarbital 30 mg twice a day for seizures, and her blood sugar was not documented at 8:00 AM or 11:00 AM which determined if she received any human insulin per sliding scale. A review of Resident #1's facility record did not indicate adverse effects were noted by the medications not being administered. b) Resident #18 was admitted into the facility on [DATE] with the diagnoses of dementia, schizophrenia, sick sinus syndrome, hypertensive heart, and chronic kidney disease without heart failure. A review of Resident #18's quarterly Minimum Data Set, dated dated dated [DATE] indicated that he was moderately cognitively impaired, and had diagnoses of hypertension, dementia, schizophrenia, renal insufficiency, and coronary artery disease. A review of Resident #18's comprehensive care plan dated 8/2/21 and revised 8/1/24 included the focus he received antipsychotic medication related to a diagnosis of paranoid schizophrenia with a risk of adverse side effects, the interventions included administer medication as ordered by the physician and discuss possible side effects with the resident and his responsible party. A review of Resident #18's Medication Administration Record revealed no documentation of his scheduled medications scheduled for 9:00 AM on 11/29/23. These medications included haloperidol 5 mg daily for schizophrenia, amlodipine besylate 5 mg daily for hypertension, and carvedilol 3.125 mg daily for hypertension. A review of Resident #18 medical record did not indicate adverse effects were noted from the medications not being administered. c) Resident #21 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebrovascular accident, hypertension, and seizures. A review of Resident #21 quarterly Minimum Data Set, dated dated dated [DATE] included he was cognitively intact and had diagnoses of a stroke, hypertension, and seizures. A review of Resident #21's comprehensive care plan included a focus initiated on 2/22/16 that he was receiving an antiseizure medication with risk for toxic side effects and was at risk for injury due to seizure activity with interventions to administer medication as ordered by the physician. A focus initiated on 1/26/18 that he had hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects including orthostatic hypotension and increased heart rate and effectiveness. A review of Resident #21's Medication Administration Record revealed no documentation of his scheduled medications for 9 AM on 11/29/23. These medications included levetiracetam 1000mg twice a day for seizures, hydralazine hydrochloride 100 mg three times a day for hypertension, and labetalol hydrochloride 200 mg three times a day for hypertension. An interview conducted with Resident #21 on 5/2/24 at 1:00 PM indicated that he was not aware of ever missing any medications since his admission into the facility. A review of Resident #21's medical record did not indicate adverse effects were noted from the medications not being administered. d) Resident #48 was admitted into the facility on [DATE] with diagnoses of cerebral vascular accident, diabetes mellitus, hypertension, and hyperlipidemia. A review of Resident #48's quarterly Minimum Data Set, dated dated dated [DATE] included that she was moderately cognitively impaired. A review of Resident #48's Comprehensive Care Plan dated initiated 5/12/21 included a focus of diabetes mellitus with a risk for complications with interventions of administer sliding scale insulin as ordered and give diabetes medications as ordered by the physician. A focus of at risk of complication of coronary artery disease related to hyperlipidemia with interventions of to give medications to control cholesterol level as ordered by the physician. A review of Resident #48's Medication Administration Record revealed no documentation of her scheduled medications for 9:00 AM on 11/29/23. These medications included insulin glargine inject 24 units subcutaneously one time a day for diabetes mellitus, metoprolol tartrate 25 mg daily for hypertension, amlodipine besylate 10 mg daily for hypertension, and a blood glucose check one time a day and to notify the physician if the blood glucose is less than 70 milligrams per deciliter or greater than 220 mg per deciliter. A telephone interview was conducted on 5/6/24 at 10:07 AM with Nurse #12 who was scheduled on 11/29/23 to pass the 9:00 AM medications. She indicated she was not sure what time she had arrived at work on 11/29/23 however the facility was notorious for calling her in at the last minute. She further indicated that when she arrives late, she walks into several things requiring her immediate attention. She further stated that if the medications were not documented then the medications were not passed by her due to other issues, she was taking care of. A review of Nurse #12's timecard indicated that she clocked in for work at 8:00 AM. An interview was conducted on 5/6/24 at 10:33 AM with Medication Aide #12 who was originally scheduled to pass medications on 11/29/23 at 9:00 AM. She revealed that her job duties had been switched from a medication aide to nursing assistant duties due to call-ins on 11/29/23 and that she had not passed any medications prior to her job duties being changed. An interview was conducted on 5/6/24 at 11:09 AM with the Director of Nursing revealed that she could not say if she was aware of the 9:00 AM medications not being administered on 11/29/23. She indicated that the normal procedure was for the nurse to notify the unit supervisor who then notified the Director of Nursing if there was an issue with the nurse passing medications to ensure the medications were given. An interview with the Unit Supervisor could not be completed as he was out of the country. An interview was conducted on 5/6/24 at 12:45 PM with the Physician who stated that there was a potential for harm if blood glucose were not obtained as ordered and if diabetic, antihypertensive, heart failure, antiseizure medications were not administered to Residents as prescribed. He was unaware of any increased monitoring or adverse effects related to the residents not being administered these types of medications the morning of 11/29/23. He stated that he was not aware of the medications not being administered on 11/29/23 which he expected to take place when these types of medications were not administered. An interview was conducted on 5/6/24 at 1:30 PM with the Interim Administrator revealed that if there was an issue with administering medications that the nurse should have notified the unit supervisor so that arrangements to ensure the medications were administered could be accomplished. 2) Resident #42 was admitted into the facility on [DATE] with multiple diagnoses including atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow), gastroesophageal reflux disease, and arthritis. A review of Resident #42's admission Minimum Data Set, dated dated dated [DATE] revealed she was moderately cognitively intact, had loss of food or fluids while drinking or eating, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complained of difficulty or pain with swallowing, she had no weight loss and was on a mechanically altered diet. A review of Resident #42's comprehensive care plan initiated on 3/18/24 included that she needed to be set up and supervised during meals and that she was on a mechanically altered diet. A review of Resident #42's admission Physician orders for March 2024 included the following: Cardizem(used to treat high blood pressure) Controlled Delivery 120 milligrams (mg) daily , enteric coated aspirin (used to lower the risk of a heart attack, stroke and blood clots) 81 mg daily, Protonix (used to treat gastroesophageal reflux disease (GERD) and a damaged esophagus (the tube that allows food and liquid from the throat to pass to the stomach) delayed release 40 mg tablet daily, Tylenol 8 hour extended release one tablet every 8 hours as needed for pain, and pentoxifylline (used to treat poor blood circulation) extended release 400 mg tablet twice daily. A review of Resident #42's Pharmacy Consultant review dated 3/21/24 included the following: the electronic medical record indicates medications are crushed. Please consider the following alternatives: 1) Change Cardizem CD 120 milligram (mg) capsule daily to diltiazem 30 mg (work with cardiology for change). 2) Change aspirin enteric coated 81 mg daily to aspirin chewable 81 mg daily. 3) Change protonix 40 mg delayed release to protonix 40 mg granule packet daily. 4) Change Tylenol 8 hour extended release 650 mg give one tablet every 8 hours as needed for pain to Tylenol 325 mg give 2 tablets as needed for pain. 5) Evaluate pentoxifylline extended release 40 mg tab twice a day for alternative as this extended release should not be crushed An interview with the Pharmacy Consultant on 5/7/24 at 10:22 AM indicated that the aspirin was enteric coated to reduce the risk of stomach irritation, the protonix, pentoxifylline and Tylenol were designed to be released into the resident's system slowly and by crushing the medication the delayed release was compromised. An interview was conducted on 5/7/24 at 10:31 AM with Nurse #13 indicated that she crushed Resident #42's medication prior to giving it to her. She further indicated that she does not remember if the medications are flagged on the electronic record not to be crushed and does not remember if there is a list of do not crush medications on the medication cart. She stated that she was aware of only the enteric coated medications were not to be crushed but not the other medications. An interview was conducted on 5/7/23 at 3:11 PM with Nurse # 14 revealed that she crushed Resident #42's medication. She indicated that there is a list of do not crush medications on the medication cart but does not remember if the medications are flagged in the electronic record to not crush. She stated that she knew the enteric medications should not be crushed and she thought the pentoxifylline was not to be crushed. An interview was attempted with the physician, but he was unavailable.

Based on record review and staff interviews the facility failed to maintain documentation of current Covid-19 vaccination status, eligibility screening, education, and offering of Covid-19 vaccination for facility staff. The failures regarding education, offering the vaccine, and maintaining records were found for 4 of 12 facility staff (Staff #1, Staff #2, Staff #3, and Staff #4) reviewed for infection control. The findings included: Facility Covid-19 Staff Vaccination Policy last revised 8/2023 indicated all newly hired employees will be offered the Covid-19 Vaccine. Current employees will be offered the vaccine when there is a change in the vaccine content or if they previously refused and now would like to obtain the vaccine. The facility Staff Vaccination Policy also indicated a master tracker would be created to list all current staff who routinely enter the facility and updated on an ongoing basis as new staff are onboarded. The tracker will include vaccination status and proof of vaccination will be maintained in a secured location. Review of facility records revealed Staff #1 was hired 2/9/2024, Staff #2 was hired 1/29/24, Staff #3 was hired 1/16/24 and Staff #4 was hired 4/25/24. The facility records revealed no documentation of the facility screening the four staff members for Covid-19 vaccine eligibility, offering the vaccine and educating the staff on the benefits, risks, and potential side effects of the vaccine. An interview was conducted with the facility Infection Preventionist (IP) on 5/3/24 at 9:12 AM. The IP explained she started working at the facility end of January 2024 and she could not find any records of employee Covid-19 vaccination documentation. The IP indicated she started looking for the staff Covid-19 vaccine tracking and documentation when the survey team asked for the information on 4/29/24 which she could not locate, and she started keeping the staff vaccination records straight on 5/2/24. She verbalized she was not made aware during hire that the staff vaccination records were not kept and that she needed to track it, screen, offer and provide education on Covid-19 vaccines to staff. During an interview on 5/3/24 at 9:30 AM with the Director of Nursing (DON), she stated she thought the previous Infection Preventionist (IP) was keeping track of staff Covid-19 vaccination status and offering education regarding Covid-19 vaccination. The DON stated going forward the current IP was going to keep track of employee vaccination status, screen, educate and offer Covid vaccines to facility staff. An interview was conducted on 5/3/24 at 10:11 AM with the facility Interim Administrator. She stated going forward all new hired employees would be screened for Covid-19 vaccination eligibility, offered the vaccine, and educated on the benefits, risks, and potential side effects of the vaccine. The Administrator further stated going forward, the IP or designee would ensure staff Covid vaccination status, screening and education was tracked and documented accurately.

Based on record review and staff interviews, the facility failed to provide a CMS-10123 (Centers for Medicare and Medicaid Services) Notice of Medicare Non-Coverage (NOMNC) at least two days prior to discharge from Medicare part A services for 1 of 3 sampled residents (Resident #127). The findings included: Resident #127 was admitted to the facility under skilled Medicare Part A services to receive physical, occupational and speech therapy on 11/02/2023. Review of the Admission Minimum Data Set (MDS) dated [DATE] indicated the resident's cognition was intact. She was dependent on staff for eating, toileting and personal hygiene. Review of the Physical Therapy discharge summary note indicated the date of services started on 11/03/2023 until 11/22/2023. Review of the Occupational Therapy discharge summary note indicated the date of services started on 11/03/2023 until 11/23/2023. A review of the medical record revealed a CMS-10123 NOMNC letter was issued, and the Responsible Party (RP) was notified on 11/28/2023 by the Business Office Manager that skilled services would be ending on 11/30/2023. An interview was conducted with the Social Worker (SW) on 05/02/2024 at 2:30PM SW indicated she did not have a reason for why the NOMNC was not sent out as soon as the resident was discharged from Rehab services. She added that the Business Office Manager was responsible for issuing the NOMNC letter. An interview with the Rehabilitation Director on 05/02/2023 at 11:42 AM revealed that the rehabilitation services for Resident #127 ended on 11/23/2023 and the resident did not have any other skilled services remaining. He indicated that the Business Office Manager should have provided the and NOMNC letter to the Responsible Party (RP) when the rehab services ended on 11/23/2023. An interview was conducted with the Business Office Manager on 05/02/2024 at 2:19 PM and she revealed that Resident #127's Medicare A coverage was to end on 11/23/2023 and this should have been discussed with the RP before 11/23/2023. She said that it was her responsibility to check with the family if they had filed for NOMNC appeal. The Business Office Manager added she did not know the reason the NOMNC was not sent out to RP before 11/23/2023. She indicated that she was aware that the NOMNC was to be issued 2 days prior to the end of services. The Business Office Manager indicated she notified the resident and the RP on 11/28/2023 about the NOMNC letter for Resident#127 skilled services. She indicated that The NOMNC letter was missed and was sent later which was on 11/28/2023. An interview was conducted on 05/03/2024 at 3:01 PM with the interim Administrator and she revealed it was her expectation that the residents at the facility or RP should be provided appropriate notices prior to being discharged from Medicare.

Based on record review, staff, pharmacist, and Nurse Practitioner (NP) interviews the facility failed to respond to the consultant pharmacist's recommendations for 1 out of 5 residents reviewed for unnecessary medications (Resident #42). Findings include: Resident #42 was admitted into the facility on [DATE] with multiple diagnoses including atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow), gastroesophageal reflux disease, and arthritis. A review of Resident #42's admission Physician orders for March 2024 included the following: Cardizem Controlled Delivery 120 milligrams (mg) daily, enteric coated aspirin 81 mg daily, Protonix delayed release 40 mg tablet daily, Tylenol 8 hour extended release one tablet every 8 hours as needed for pain, and pentoxifylline extended release 400 mg tablet twice daily. A review of Resident #42's Pharmacy Consultant review dated 3/21/24 included the following: the electronic medical record indicates medications are crushed. Please consider the following alternatives: 1) Change Cardizem CD 120 milligram (mg) capsule daily to diltiazem 30 mg (work with cardiology for change). 2) Change aspirin enteric coated 81 mg daily to aspirin chewable 81 mg daily. 3) Change Protonix 40 mg delayed release to Protonix 40 mg granule packet daily. 4) Change Tylenol 8 hour extended release 650 mg give one tablet every 8 hours as needed for pain to Tylenol 325 mg give 2 tablets as needed for pain. 5) Evaluate pentoxifylline extended release 40 mg tab twice a day for alternative as this extended release should not be crushed. On the Pharmacy Note to the Attending Physician/Prescriber dated 3/21/24 there was a note dated 3/15/24 stating Cardizem changed to twice a day did not want to make any changes per the Nurse Practitioner. There was no other documentation in Resident #42's medical record regarding the Pharmacy Consultant review dated 3/21/24. An interview with the Director of Nursing on 5/2/24 at 10:00 AM stated that when she gets the Pharmacy Consultant Recommendations that she forwards them to the physician. She further stated that she does not always get them back. She further stated that she did not know who put the note on the Pharmacy Consultant review dated 3/21/24. An interview with the Nurse Practitioner on 5/2/24 at 1:55 PM revealed that she changed the Cardizem in March 2024 due to Resident #42 having increased episodes of atrial fibrillation and had an appointment with cardiology scheduled who manages Resident #42. She stated that the nursing staff usually speaks to her regarding any pharmacy recommendations and did not know why she did not address the other medications at that time. An interview with the Regional Director of Operations on 5/2/24 at 2:15 PM indicated that the physicians should be responding to the pharmacist regarding their medication regime reviews. An interview with the Pharmacy Consultant on 5/3/24 at 3:00 PM indicated that she expected the physician or their designee to respond to her recommendations and if the physician did not want to change a resident's medication that the rationale would be documented in the resident's medical record or on the communication form.

Based on record review, staff interview, Physician interview, and Responsible Party interview the facility failed to implement a discharge planning process that identified changes resulting in modifications to a resident's discharge plan for one (Resident # 1) of three residents reviewed for discharge. The facility failed to follow up on a pending x-ray result before discharging a resident home. When the results came in after the resident was discharged , they showed the resident had a fracture. The findings included: Resident # 1 was admitted to the facility on [DATE]. The resident had diagnoses which in part included dementia, hypertension, diabetes, a history of metabolic encephalopathy, and debility. Resident # 1's care plan, dated 7/13/23, noted the plan was for Resident # 1 to discharge home after therapy was completed. Resident # 1's admission Minimum Data Set assessment, dated 7/21/23, coded the resident as cognitively impaired. She was assessed to need extensive assistance with her transfers and walking. The Rehabilitation Director was interviewed on 8/30/23 at 1:40 PM and reported the following. Resident # 1 had lost an appeal for her insurance to cover her stay any longer. Therefore, she was planning to discharge home with family. The last day therapy provided treatment services was on 7/27/23. At that time, Resident # 1 was ambulatory. Therapy was working on the resident climbing steps. At discharge, staff were still doing 75% of the work to help Resident # 1 up the steps. The facility Social Worker was interviewed on 9/1/23 at 1:10 PM and reported the following. She saw Resident # 1 on the morning of 7/28/23. Insurance was no longer covering for Resident # 1 to be at the facility. The family was planning to take her home on 7/29/23 and discharge home health had been set up. On 7/28/23 at 10:00 AM Nurse # 2 documented a nursing entry for Resident # 1 noting the following. The resident had been found on the floor at the end of the bed laying on her right side. She was alert and oriented. She complained of left hip pain (the hip opposite of the one on which she was found). The physician ordered a two- view x-ray of the left hip. Nurse # 2 was interviewed on 8/31/23 at 1:37 PM and reported the following. She verified Resident #1 had a fall on 7/28/23 and she completed an assessment of the resident. She indicated the resident was not complaining of pain in the hip on which she was found, but rather the opposite hip. She completed her assessment and found no obvious deformity. The physician ordered an x-ray. She administered some pain medication, and the pain medication was helpful. The X-ray technician did not arrive before her shift ended. Nurse # 3 was assigned to care for Resident # 1 on the 3:00 PM to 11:00 PM shift on 7/28/23. An attempt was made to interview Nurse # 3 on 8/31/23 at 2:30 PM and she could not be reached. During an interview with the Director of Nursing (DON) on 9/1/23 at 11:10 AM, the DON reported she had spoken to Nurse # 3 on 8/4/23 while she (the DON) was investigating the care Resident # 1 had received at the facility. The DON indicated Nurse # 3 reported that the x-ray results did not arrive on 7/28/23 during the 3:00-11:00 PM shift and the resident had not complained of pain. during her shift. Nurse # 3 had reported to the DON that she passed the information (that the resident had fallen, and x-rays were pending) on to Nurse # 4 during change of shift report. Nurse # 4 was assigned to care for Resident # 1 on the 11:00 PM to 7:00 AM shift which began on 7/28/23. An attempt was made to reach Nurse # 4 on 8/31/23 at 2:28 PM and the nurse could not be reached for interview. During an interview with the Director of Nursing (DON) on 9/1/23 at 11:10 AM, the DON reported she had spoken to Nurse # 4 on 8/4/23 while she was investigating the care Resident # 1 had received at the facility. The DON indicated Nurse # 4 reported Resident # 1 had not complained of pain during his shift. Nurse # 4 had reported to the DON that he had checked the fax machine for x-ray results and there were none there during his shift. Nurse # 4 also reported to the DON that he passed the information (that the resident had fallen, and x-rays were pending) on to Nurse # 1 during change of shift report. On 7/29/23 at 12:30 PM Nurse # 1 documented the following nursing note in Resident #1's record. Resident has been discharged from facility with daughter. Resident was brought out to car with wheelchair. Resident needed a significant amount of assistance from family to enter into car. Resident was alert and could make needs known. Complained of pain in right hip. Resident was discharged with medications and instructions for medication were gone over with daughter. Daughter voiced understanding. On 7/29/23 at 2:30 PM the physician noted a late entry which in part read, This is a discharge visit as the patient has reached maximum benefits with therapy at this time and will be discharging home. Patient had a fall today, but patient denies pain to me. (During an interview on 9/1/23 at 3:47 PM with Resident # 1's physician, the physician clarified he was aware the fall was 7/28/23 and not 7/29/23).) On 7/29/23 at 4:02 PM Nurse # 1 documented the following note in Resident # 1's record, This nurse just received x-ray results. Shows a mildly comminuted impacted intertrochanteric fracture with various deformity. Physician notified and advised nurse to have family take resident to the [emergency room ] ER. Daughter informed and stated that she had already taken her to the ER. Nurse # 1 was interviewed on 8/31/23 at 1:53 PM and reported the following. On 7/29/23 she had not received anything in report about Resident # 1 falling the previous day or that an x-ray was done and results were still pending. The resident did have some left hip pain that morning, and the nurse knew the physician had been in to see Resident #1 that morning and thought it was okay to send her home. He had written her prescriptions and did not mention a pending x-ray result. The family came and assisted Resident # 1 to the wheelchair. She then accompanied the resident and her family to the car which was a Sports Utility Vehicle (SUV). Per facility protocol she was not supposed to assist in getting the resident into a private vehicle but she observed as two family members assisted. The resident did not have trouble standing, but she had trouble turning and getting into the vehicle and appeared to have some hip pain. It took about five to ten minutes for the resident to get in the vehicle. When she was in the vehicle, the nurse returned to her unit. She still had medications to pass and then she reviewed Resident # 1's record. She saw for the first time that Resident # 1 had fallen the previous day (7/28/23) and an x-ray had been done with no results ever received. She called the x-ray company and they told her they would send the report. It took a little time for the report to come through. When the report was sent, it noted Resident # 1 had a fractured hip. She immediately called the physician who instructed that she call the family and inform them the resident needed to go to the hospital. She called the family and they said they had already taken the resident to the hospital. Resident # 1's Responsible Party was interviewed on 8/30/23 at 11:55 AM and reported the following. Resident # 1 had hip pain after her last fall (7/28/23) at the facility. They (the facility) had an x-ray completed of the resident's hip, and she had inquired about the results on the day of her fall, but the staff kept saying they were waiting on the results. On the day of discharge, she had assisted Resident # 1 to the wheelchair. The staff told her it was okay for the resident to go home so she interpreted that the x-ray had been okay. It took a long time to get Resident # 1 in the vehicle and she still had some hip pain at that time. Therefore, instead of taking her home, she took her to the hospital where they identified that she had a fractured hip. After she had already taken Resident # 1 to the hospital, the facility called and let her know the x-ray results showed Resident # 1's hip was fractured. Review of Resident # 1's hospital records revealed she was evaluated in the ED (emergency department) on 7/29/23 at 12:54 PM and found to have a left hip fracture. The ED physician noted, On evaluation, patient is lying comfortably in bed and is in no acute distress. Inspection of the left lower extremity reveals minimally shortened and externally rotated left lower extremity with focal bony tenderness to palpation (tenderness limited to the bone when examined by touch) of the left anterior (front) hip. Patient has decreased range of motion of the left hip secondary to pain. Unremarkable examination of the right lower extremity. On 7/31/23 the resident underwent surgery and was discharged from the hospital on 8/3/23. The facility's medical director, who served as Resident # 1's physician during her residency, was interviewed on 9/1/23 at 3:47 PM and reported the following. He had seen Resident # 1 on the morning of discharge (7/29/23). He knew she had fallen the previous day but she had no complaints of pain when he saw her. He recalled the family wanted to leave the facility with Resident #1 by 11:00 AM. He knew the x-ray report was still pending at the time of his discharge visit on the morning of 7/29/23 and thought he had a conversation with the nurse on duty that morning, but he could not recall for sure. He thought the facility would wait to get the x-ray report back before letting the resident leave and was not sure where the breakdown was in communicating about that. The physician felt that standing the resident to get in the wheelchair and into the car probably did not worsen Resident # 1's fracture but he could not say for sure. He reported the fracture was a mild fracture. The Administrator and Director of Nursing were interviewed on 9/1/23 at 11:10 AM and reported the following. They were aware the resident had been discharged without the results of the x-ray being known and had investigated the incident. According to the DON, Nurse # 1 should have reviewed the record prior to discharging the resident to make sure all pending orders were completed and updated the physician when the resident had trouble getting into the vehicle. Also, the DON reported normally they did not have trouble getting an x-ray report from the mobile x-ray company. She had not been able to identify the specific breakdown because Nurse # 3 and Nurse # 4 reported they had passed along the information in shift change report that x-ray results were still pending following Resident # 1's fall, but Nurse # 1 had reported that she had not received the information in shift change report. The Administrator and DON stated they had completed a corrective action plan to address the incident. On 9/1/23 the facility provided the following corrective action plan with a completion date of 8/4/23. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 1 no longer resides at the facility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 07/31/23 the Director of Nursing identified residents that were potentially impacted by this practice by completing an 100 % audit all current residents with x-rays ordered to ensure they were received and reviewed timely, audits were completed on all current/discharged residents for the past 30 days. This was completed on 07/31/23. The results indicated that no other residents were identified with this concern. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 08/01/23, the Assistant Director of Nursing in-serviced all Nursing, Nursing Assistant and medication Aides staff (including agency) on following up on x-ray results and to report the results timely to the MD (medical physician). On 08/01/23 All Nurses were also educated that if there is a complaint of pain or concern during discharge the resident is to be returned to the facility, assessed and the MD notified. On 08/01/23 In-service for Nursing Assistants: Please inform the nurse if there are any concerns noted for a resident prior to discharge, for example a change in their condition, increase pain or family expressing any concerns. As of 08/04/23 100% of Nurses, Nursing Assistant and Medication Aides members have attended the in-service. The Director of Nursing will ensure that any of the above-identified staff who do not complete the in-service training by 08/04/23 will not be allowed to work until the training is completed. A copy of this in-service will be placed in the agency book so all new agency staff will have this training. This will also be added to the new orientation packet for all new staff. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; The Director of Nursing will monitor x-ray orders and results being received and reported in a timely manner, weekly for 2 weeks and monthly for 3 months for compliance by utilizing the QA discharge tool. The DON will audit all discharges to ensure there are no x-ray reports pending prior to discharge this will be completed weekly x3, then monthly until resolved utilizing the QA discharge tool. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and the on-going auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Date of Compliance 08/04/23 During the complaint investigation of 8/30/23 to 9/1/23 the facility's action plan was validated by the following. Two additional residents, who had been discharged since Resident # 1 resided at the facility, were placed on a sample for review. Record review, staff interviews, and physician interviews revealed staff were assuring diagnostic studies were done and results back before discharge. The facility provided documented evidence of their inservice training and audits which had been noted in the corrective action plan. It was validated with Nurse # 1 on 8/31/23 at 1:53 PM that she had attended the inservice training and was aware not to discharge a resident without reviewing the record. On 9/1/23 the facility's corrective action plan was verified as completed on 8/4/23.

Based on facility and emergency department record review, observation, and interviews with staff, residents, dialysis staff and contract transportation staff, the facility failed to ensure a transportation driver followed emergency protocol after Resident #1's fall from his wheelchair during van transportation. The driver failed to request emergency aid and continued driving with Resident #1 on the floor of the van. The resident had bleeding from his below the knee amputation sites and pain on his right shoulder. This situation had the high likelihood to cause serious injury and harm. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included bilateral below the knee (BKA) amputations and kidney failure requiring dialysis. Resident #1's admission Minimum Data Set (MDS) dated [DATE] indicated moderately impaired cognition. He required extensive assistance with transfers and locomotion. He had not had any falls in the past 6 months or since admission. He required pain medication as needed for frequent pain. He had surgical wounds at admission. He required dialysis. A written statement dated 1/6/23 from Resident #1 indicated the transportation driver hit his brakes and the seatbelt hooked to the wall gave out and he fell to the floor. The driver tried to get him up, but Resident #1 asked him to leave him on the floor. Resident #1 was lying on his stomach on the floor of the van. Resident #1 reported pain to bilateral BKA stumps and his shoulder. During an interview on 2/9/23 at 11:35 AM, Resident #1 revealed that on 1/6/23 he did not have his usual driver for dialysis. Resident #1 indicated the driver was speeding during the 8-minute drive to dialysis. A car turned out in front of the van and the driver hit his brakes causing Resident #1 to fall from the chair onto his face and amputation stumps on the floor of the van. Resident #1 indicated the driver continued driving 3-5 minutes to the dialysis clinic. The driver went into the dialysis clinic to ask for help and returned with the Dialysis Nurse Supervisor. Resident #1 indicated he and the Dialysis Nurse Supervisor recommended the driver call an ambulance and he was taken to the hospital via ambulance. A written statement from the transportation driver dated 1/6/23 indicated he had been driving for the contract transportation company for nine months. The day of the accident, he secured Resident #1 and Resident #4 into the van before leaving the facility. During the drive, a car pulled out into the street and the driver slammed on his brakes causing Resident #1 to fall from his wheelchair. The transportation driver pulled over to the side of the road and turned on his hazard lights. Resident #1 indicated he was fine and wanted to get back into his wheelchair. The driver tried to pick Resident #1 up and get him into his wheelchair but was unsuccessful. Resident #1 requested the driver take him to the dialysis clinic for assistance getting up to the chair. The transportation driver drove to the dialysis clinic for assistance. The dialysis clinic suggested the transportation driver call an ambulance. Resident #1's wheelchair remained strapped into the van with a large cushion to the seat. The transportation driver believed Resident slipped through the seatbelt due to the large slippery cushion. A telephone interview was conducted on 2/9/23 at 2:10 PM with the Transportation Driver. He revealed that during a drive to dialysis, a car pulled out in front of him, and he had to hit the brakes to avoid hitting the car. He heard Resident #1 call out and turned around to him lying the floor of the van. The transportation driver revealed he pulled over and turned on the van's hazard lights. Resident #1 requested the driver continue to the dialysis clinic across the street. The transportation driver recalled Resident #1 said he was not hurt and wanted the dialysis staff to assist him back to his chair. The driver then drove the van across the street with Resident #1 lying on the floor of the van. The transportation driver went into the dialysis clinic to request assistance getting Resident back into his chair. The dialysis nurse supervisor instructed the transportation driver to call an ambulance. Resident #1 was taken to the hospital via ambulance. The driver indicated he was trained to pull the vehicle to a safe spot and call 911 in the event of an accident, but Resident #1 stated he was fine and did not need an ambulance. The facility interviewed the other passenger of the van during the drive to dialysis about his account of Resident #1's fall. A written statement on behalf of Resident #4 (no date) indicated that on 1/6/23 the driver stopped suddenly and then he heard the driver say, What are you doing on the floor? He did not know what happened. The driver drove the van to dialysis to ask for help. During an interview on 2/9/23 at 1:10 PM, Resident #4 indicated he did not know how Resident #1 fell from his wheelchair during transportation to dialysis. He did not hear Resident #1 fall; he only heard the driver address the fall. Resident #4 indicated the driver continued driving 1 minute to the dialysis clinic following the fall to ask for assistance. Resident #4 was admitted to the facility on [DATE] with diagnoses that included kidney failure requiring dialysis and blindness. His quarterly MDS dated [DATE] indicated he was cognitively intact. A telephone interview was conducted on 2/9/23 at 1:55 PM, the Dialysis Nurse Supervisor indicated the transportation driver arrived at the clinic and came to her office asking for assistance getting Resident #1 off the floor of the van. When she arrived at the van, Resident #1 was face down on the floor of the van with the wheelchair and seatbelt next to him. She did not recall if the wheelchair was strapped into the van. Resident #1 was requesting a mechanical lift to get him back into his wheelchair. The Dialysis Nurse Supervisor indicated she instructed the van driver to call an ambulance. The emergency medical technicians got Resident #1 into a seated position and revealed bleeding to his amputation sites. Resident #1 was complaining of pain and was taken to the hospital. An Emergency Department Provider note dated 1/6/23 indicated Resident #1 was thrown from his wheelchair onto his bilateral amputation stumps during transportation to dialysis from the facility. Resident #1 was bleeding from his amputation sites. He was not on blood thinners at that time. Resident #1 complained of pain at his amputation sites and his right shoulder. Resident #1's x-rays were negative for leg or arm fractures. A Nursing Progress Note dated 1/6/23 at 9:40 AM indicated Resident #1 called the facility to inform his nurse he fell from his wheelchair in the contract transportation van on the way to dialysis. Resident #1 indicated he fell from his wheelchair when the transportation driver hit his brakes and he was at the hospital. An Investigation Guide to determine the cause of the accident completed by the Administrator dated 1/6/23 indicated Resident #1 fell in the contract transportation van while traveling to dialysis. The transportation driver proceeded to the dialysis clinic for assistance with getting Resident #1 off the floor of the van. The dialysis clinic staff advised the transportation driver to call an ambulance and Resident #1 was taken to the hospital. The investigation guide did not indicate if the driver stopped immediately following the fall. The root cause of the fall was determined to be operator error in securing the resident with safety restraints. A written statement dated 1/6/23 from the Contract Transportation Company owner indicated the transportation driver had been terminated. During an interview on 2/9/23 at 2:35 PM, the Contract Transportation Company owner revealed each transportation van had posted written instructions on what to do in an emergency. The owner revealed the driver should have called an ambulance and not moved the vehicle with Resident #1 on the floor. An observation was made on 2/9/23 at 2:40 PM of signage posted in the contract van In the event of an accident instructions included: pull the van over to a safe area, do not move the resident if they have fallen from the chair, call 911 first then call the facility Director of Nursing (DON). The contract transportation company owner indicated this was posted in the van during the accident. A Google Maps search indicated the distance from the named intersection to the dialysis clinic was 0.2 miles and would take one minute by vehicle. During an interview on 2/10/23 at 3:50 PM, the Director of Nursing (DON) indicated that following Resident #1's fall in the contract consultation van, he was transported to the hospital for evaluation. The DON revealed the driver should have stopped immediately and called an ambulance. During an interview on 2/10/23 at 4:15 PM, the Administrator revealed the driver should have pulled the vehicle over and called an ambulance immediately following Resident #1's fall from his wheelchair. She indicated that services with the contract transportation company were suspended following the accident and had not been reinstated. The facility's transportation staff was educated on what to do in an emergency following the incident. The facility had no further van accidents following Resident #1's fall. The Administrator and DON were notified of the immediate jeopardy on 2/9/23 at 6:15 PM. The facility provided the following corrective action plan with a completion date of 1/12/23. Problem identified: On 1/6/2023, Resident #1 was traveling to the dialysis center via wheelchair transported by the contract transport company. The van driver hit his brakes and Resident #1 was propelled from the wheelchair landing on the floor of the van on his stomach. Immediate action identified: Resident #1 was sent to the emergency room for evaluation on 1/6/2023. Upon completion of the evaluation, the resident was sent back to the facility with pain control medications and bowel protocol. Systemic changes made: On 1/6/2023, the facility suspended all transports scheduled with the contract transportation company until an inspection of the safety mechanisms could be conducted and a review of van driver training was completed. On 1/10/2023, the Administrator began contacting all current van transport companies used to transport facility residents. The following was requested: Current van inspection and training material and documentation of training for all van drivers utilized for facility transports. On 1/11/2023, all nurses, nurse aides, Transportation Aides, Maintenance Staff, and Administration staff were in-serviced by the staff development coordinator on the following: in the event of an emergency, call 911. Monitoring process: A quality assurance monitor Van Transports Audits will be completed by the Transportation Aide or Maintenance Director or designee weekly x 4 weeks then monthly x 3 months until resolved by the Quality Assurance (QA) Committee. The Van Transport QA Tool will monitor all resident transport checklists to ensure checks are being completed prior to each van transport and are compliant. Reports of the audit will be given to the Director of Nursing to report in the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality-of-Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Support Nurse and Health Information Management and meets weekly Onsite validation was completed on 2/10/23 through staff interviews, observation, and record review. Staff were interviewed to validate in-service completion on van safety and what to do in a van emergency. Residents were interviewed and indicated they felt safe during van transportation. Documentation of van safety audits were reviewed. QA (Quality Assurance) meeting signatures were reviewed. The facility's corrective action plan was validated to be completed as of 1/12/23.

Based on facility and emergency department record review, observation, and interviews with staff, residents, dialysis staff and contract transportation staff, the facility failed to ensure positioning and securement was according to manufacturer's recommendations to provide a safe contract van transport. Resident #1 fell from his wheelchair when the transportation driver put on the brakes. The resident had bleeding from his below the knee amputation sites and pain on his right shoulder. This situation had the high likelihood to cause serious injury and harm. This deficient practice affected 1 of 3 residents (Resident #1). Findings included: According to the Use and Care Manual updated 2014 for the four-point wheelchair securement system used by the contract transportation company details the following instructions for securing a passenger: 1. Make sure chair's Pelvic Belt is buckled over occupant's hips. 2. Attach Shoulder Belt Pin Connector to Pin located on Shoulder Belt Height Adjuster 3. Pull Shoulder Belt over occupant's chest and attach Shoulder Belt Pelvic Connector to Pin on Compliant Pelvic Belt 4. Adjust Shoulder Belt Height so that Shoulder Belt rests on shoulder. After the occupant and vehicle are secured, the occupant is ready for transportation 5. Attach Shoulder Belt Pin Connector to Pin on Rear Retractor closest to wall. 6. Attach the Pelvic Belt Pin Connector to Pin on Rear Retractor closest to the aisle. 7. Pull the Shoulder Belt over occupant's chest and buckle Shoulder Belt Pelvic Connector to Removable Pelvic Belt. 8. Adjust Shoulder Belt Height so that Shoulder Belt rests on shoulder. After the occupant and vehicle are secured, the occupant is ready for transportation. Resident #1 was admitted to the facility on [DATE] with diagnoses that included left below the knee amputation (BKA) performed in December 2022 and a right BKA performed in November 2022 and kidney failure requiring dialysis. Resident #1's admission Minimum Data Set, dated dated dated [DATE] indicated moderately impaired cognition. He required extensive assistance with transfers and locomotion. He had not had any falls in the past 6 months or since admission. He required pain medication as needed for frequent pain. He had surgical wounds at admission. He required dialysis. A Nursing Progress Note dated 1/6/23 at 9:40 AM indicated Resident #1 called the facility to inform his nurse that he fell from his wheelchair in the contract transportation van on the way to dialysis. Resident #1 indicated he fell from his wheelchair when the transportation driver hit his brakes and he was at the hospital. An Emergency Department Provider note dated 1/6/23 indicated Resident #1 was thrown from his wheelchair onto his bilateral amputation stumps during transportation to dialysis from the facility. Resident #1 was bleeding from his amputation sites. He was not on blood thinners at that time and did not lose consciousness. Resident #1 complained of pain at his amputation sites and his right shoulder. Redness and bleeding were noted to the amputation sites. Staples were intact to his incisions. Resident #1's x-rays were negative for leg or arm fractures. The Emergency Department After Visit Summary dated 1/6/23 included new orders for a pain medication. Diagnoses included fall and pain of amputation stump of both lower extremities. An Investigation Guide to determine the cause of the accident completed by the Administrator dated 1/6/23 indicated Resident #1 fell in the contract transportation van while traveling to dialysis. The transportation driver proceeded to the dialysis clinic for assistance with getting Resident #1 off the floor of the van. The dialysis clinic staff advised the transportation driver to call an ambulance and Resident #1 was taken to the hospital. The root cause of the fall was determined to be operator error in securing the resident with safety restraints. A written statement dated 1/6/23 from Resident #1 indicated the transportation driver hit his brakes and the seatbelt hooked to the wall gave out and he fell to the floor. The driver tried to get him up but Resident #1 asked him to leave him on the floor. Resident #1 was lying on his stomach on the floor of the van. Resident #1 reported pain to bilateral BKA stumps and his shoulder. During an interview on 2/9/23 at 11:35 AM, Resident #1 revealed that on 1/6/23, he did not have his usual driver for dialysis. The transportation driver pushed Resident #1 in his wheelchair into the van, locked the wheels, and used four straps to secure the wheelchair to the floor of the van. Resident #1 indicated an additional lap belt came up from the floor across his lap and connected a shoulder belt to the wall. Resident #1 indicated the transportation driver was speeding during the 8-minute drive to dialysis. A car turned out in front of the van and the driver hit his brakes. Resident #1 indicated the shoulder belt attached to the wall tightened and then pulled out of the wall causing Resident #1 to fall forward with the wheelchair falling on top of him. Resident #1 indicated the buckle around his waist remained buckled through the fall. Resident#1 fell on to his hands and amputation stumps causing pain and bleeding to his amputation sites. Resident #1 indicated the driver continued driving 3-5 minutes to the dialysis clinic with him on the floor of the van. Resident #1 indicated that he was transported by ambulance to the hospital where he received x-rays of his arms and legs, wound cleaning and dressing changes, and pain medication. The staples to his amputation sites were intact and he did not require hospital admission or additional wound care. He returned to the facility that day. Resident #1 indicated he was seen by the facility's wound care team and the wounds looked ok. Resident #1 revealed he had seen his vascular surgeon and would need further surgery to his amputation site. Resident #1 indicated the transportation company no longer took him to dialysis and that he took the facility's transportation van since the fall. A written statement from the transportation driver dated 1/6/23 indicated he had been driving for the contract transportation company for nine months. He indicated he properly secured Resident #1 into the van prior to leaving the facility. A car pulled out into the street and the driver slammed on his brakes causing Resident #1 to fall from his wheelchair. The transportation driver pulled over to the side of the road and turned on his hazard lights. Resident #1 indicated he was fine and wanted to get back into his wheelchair. The driver tried to pick Resident #1 up and get him into his wheelchair but was unsuccessful. Resident #1 requested the driver take him to the dialysis clinic for assistance getting up to the chair. The transportation driver drove to the dialysis clinic for assistance. The dialysis clinic suggested the transportation driver call an ambulance. Resident #1's wheelchair remained strapped into the van with a large cushion to the seat. The transportation driver believed Resident slipped through the seatbelt due to the large slippery cushion. A telephone interview was conducted on 2/9/23 at 2:10 PM with the Transportation Driver. He revealed that prior to leaving the facility, he strapped Resident #1's wheelchair into the van using four floor straps for the wheels. A lap belt hooked into the floor, went across Resident #1's lap, and connected to a shoulder belt that hooked to the wall. He recalled checking each strap before leaving the facility and did not recall any issues. The Transportation Driver indicated that a car pulled out in front of him while driving and he had to hit the brakes to avoid hitting the car. He heard Resident #1 call out and turned around to find him lying the floor of the van. The transportation driver revealed he pulled over and turned on the van's hazard lights. The transportation driver recalled Resident #1's wheelchair, lap belt, and shoulder belt remained strapped into the van. The driver continued driving to the dialysis clinic to request assistance getting him off the floor. The clinical nurse supervisor assisted him in calling an ambulance. The transportation driver believed Resident #1 slipped under the lap belt or flipped over it. The transportation driver indicated he then noticed two cushions in the seat of Resident #1's wheelchair. He was not aware Resident #1 was sitting on these cushions prior to leaving the facility. A written statement dated 1/6/23 from the Contract Transportation Company owner indicated the transportation driver had been terminated. During an interview on 2/9/23 at 2:35 PM, the Contract Transportation Company owner believed one of the straps must have disconnected for Resident #1 to fall. He indicated all employees were trained on proper strap and belt securement for wheelchair use in the transportation van. He revealed the driver no longer worked for the company. A Wound Care Nurse Practitioner (NP) note dated 1/10/23 indicated Resident #1 was complaining of moderate to severe pain, worse on the left stump than right. The left amputation site appearance was improved with no evidence of dehiscence (separation of wound opening) or infection. Minimal yellow tissue was noted along the incision line. Redness was noted around the wound. The right stump incision was intact and well approximated. Staples were intact to both amputation sites. A Google Maps search indicated the distance from the named intersection to the dialysis clinic was 0.2 miles and would take one minute by vehicle. A telephone interview was conducted on 2/9/23 at 1:55 PM; the Dialysis Nurse Supervisor indicated the transportation driver arrived at the clinic and came to her office asking for assistance getting Resident #1 off the floor of the van. When she arrived at the van, Resident #1 was face down on the floor of the van with the wheelchair and seatbelt next to him. She did not recall if the wheelchair was strapped into the van. The Dialysis Nurse Supervisor indicated she instructed the van driver to call an ambulance. The emergency medical technicians got Resident #1 into a seated position and revealed bleeding to his amputation sites. Resident #1 was complaining of pain. During an interview on 2/9/23 at 5:05 PM, the Wound Care NP revealed that Resident #1's wounds remained intact while at the facility. She noted increased necrotic tissue to the wound site but revealed it could have been natural progression and not caused by the fall. During an interview on 2/10/23 at 3:50 PM, the Director of Nursing (DON) indicated that following Resident #1's fall in the contract transportation van, he was transported to the hospital for evaluation. Upon his return to the facility, a skin assessment was completed, pain checks were initiated, and an investigation was started. Resident #1 did not sustain additional injury to his amputation sites. The DON indicated that the contract transportation company was suspended from transporting residents from the facility. The contract transportation owner brought the van to the facility for a fall reenactment and a safety audit with the regional safety officer. The facility determined the cause of the fall was operator error of van safety belts. Education on van safety, proper cushions and slings for van transport was provided to all staff. The DON indicated that she and the Administrator conducted van safety audits and the maintenance director completed vehicle inspections. During an interview on 2/10/23 at 4:15 PM, the Administrator revealed Resident #1 reported to her in his statement that the transportation driver hit his brakes, his shoulder belt disconnected from the wall, and he was thrown from his wheelchair to the floor of the van. The facility began an investigation on 1/6/23. The Contract Transportation Company owner provided the van for inspection and accident reenactment of the fall. The safety team determined the cause of the fall was operator error due to not properly securing the shoulder belt. The contract transportation company services were suspended pending the company provided education records for their employees. The Administrator indicated that the facility began educating staff on van safety, safe chair devices (pillows, cushions) for transportation use. The DON and administrator began van safety audits, the maintenance director began weekly van inspections, and the facility's transportation driver began filling out a checklist for each ride. The facility had had no further van accidents since Resident #1's fall. The Administrator and DON were notified of the Immediate Jeopardy on 2/9/23 at 6:15 PM. The facility provided the following corrective action plan with a completion date of 1/12/23. Problem identified: On 1/6/2023, resident #1 was traveling to the dialysis center via wheelchair transported the contract transportation company. The van driver hit his brakes and Resident #1 was propelled from the wheelchair landing on the floor of the van on his stomach. Immediate action identified: Resident #1 was sent to the emergency room for evaluation on 1/6/2023. Upon completion of the evaluation, the resident was sent back to the facility with pain control medications and bowel protocol. On 1/9/2023, the administrator initiated a grip mat to his wheelchair while using the sling on dialysis days Monday, Wednesday, and Fridays. This task was initiated in PCC on 1/10/2023 by the nurse consultant. On 1/11/2023, the resident was issued a wheelchair cushion with straps to utilize while sitting up in his wheelchair. On 1/6/2023, the facility suspended all transports scheduled with the contract transportation company until an inspection of the safety mechanisms could be conducted and review of van driver training was completed. On 1/10/2023, the Administrator began contacting all current van transport companies used to transport facility residents. The following was requested: Current van inspections and training material and documentation of training for all van drivers utilized for facility transports. On 1/10/2023, all dialysis residents were reviewed by the DON to identify which residents required the use of a sling for transfer to the dialysis treatment chair. Only one resident was identified and that was Resident #1. On 1/10/2023, the Nurse management team audited all current residents by inspecting each room and current seating device (wheelchair, geriatric recliner, or other chair) for the use of pillows or facility non-issued cushions or cushions of fabric nature. If any of the described cushions were noted, the nurse managers replaced the device with a facility issued cushion Systemic changes made: On 1/11/2023, all nurses, nurse aides, Transportation Aides, Maintenance Staff, and Administration staff were in-serviced by the staff development coordinator on the following: appropriate slings to be used in wheelchairs during transportation, appropriate chair cushions and pillows to be used during transportation. Monitoring process: A quality assurance monitor Van Transports will be completed by the Transportation Aide or Maintenance Director or designee weekly x 4 weeks then monthly x 3 months until resolved by the Quality Assurance (QA) Committee. The Van Transport QA Tool will monitor all resident transport checklists to ensure checks are being completed prior to each van transport and are compliant. Reports of the audit will be given to the Director of Nursing to report in the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality-of-Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Support Nurse and Health Information Management and meets weekly. Onsite validation was completed on 2/10/23 through staff interviews, observation, and record review. Staff were interviewed to validate in-service completion on van safety and what to do in a van emergency. An observation was made of Resident #1 loaded into the facility's transportation van. Resident #1 was up to his wheelchair with a blue mesh sling in place. Resident #1 and the facility transportation driver indicated this was the sling used at the dialysis clinic. The facility transportation used the chair lift, wheeled Resident #1 into place, and secured his chair using four floor straps with hooks, a lap belt, and a shoulder belt. She tested the straps by moving the wheelchair back and forth. She implemented the wheelchair's brakes. Resident #1 indicated he felt secure and safe. Residents were interviewed and indicated they felt safe during van transportation. Documentation of van safety audits were reviewed. QA (Quality Assurance) meeting signatures were reviewed. The facility's corrective action plan was validated to be completed as of 1/12/23.

Based on record review, observations, and interviews with resident and staff, the facility failed to ensure residents diagnosed with Post-Traumatic Stress Disorder (PTSD) had person-centered care plans developed with individualized approaches that direct staff on how to care for their assessed needs for 2 of 3 residents (Resident #24 and Resident #52) reviewed for PTSD. The findings included: 1. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses that included depression and Post Traumatic Stress Disorder (PTSD). A review of the Trauma-Informed Care and Diverse Resident Admission Assessment. dated 03/10/2021 revealed Resident#24 was identified with a traumatic life altering circumstances of war. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24's cognition was intact. He had no behaviors and no rejection of care. A review of Resident #24's care plan revised on 09/16/22. Revealed Resident #24 was not care planned for individualized approaches related to her history of trauma. An observation and interview were conducted for Resident #24 on 11/29/2022 at 10:30 AM. The resident was lying in bed and no behavioral symptoms were noted. The resident indicated he did not have any psychiatrist services at the moment. An interview was conducted with Nursing Assistant (NA) #1 on 11/29/22 at 10:55 AM. She indicated that she was unaware Resident #24 had a history of PTSD. She further indicated there were no specific interventions or approaches to care for Resident #24. During an interview with the Social Worker (SW) on 11/29/21 at 1:00 PM, She verified that Resident #24's care plan included no person centered and individualized approaches to care for Resident #24 in relation to her diagnosis of PTSD. The SW acknowledged that a care plan that provided the staff with non-pharmacological interventions and approaches to care was essential for the staff to know how best to care for Resident #24. During an interview with Minimum Data Set (MDS) nurse on 11/29/2022 at 1:22 PM, she verified that Resident #24 had a diagnosis of PTSD. She stated that it was essential for the facility staff to have a care plan in place that provided them with person-centered approaches to care for Resident #24 in relation to her history of PTSD. An interview was conducted with Nurse #1 on 11/30/22 at 11:30 AM. She indicated that she was unaware Resident #24 had a diagnosis of PTSD. She further indicated there were no specific interventions or approaches to care for Resident #24 An interview was conducted with the Director of Nursing (DON) and Administrator on 11/30/22 at 12:14 PM. They both indicated their expectation was for a care plan to be developed that included person-centered and individualized approaches to care for residents who had a diagnosis of PTSD. 2. Resident #52 was admitted to the facility on [DATE] with multiple diagnoses that included depression, anxiety, and Post Traumatic Stress Disorder (PTSD). Review of hospital discharge summary dated 05/12/2022 revealed Resident#52 was discharged from the hospital with a diagnosis of PTSD. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52's cognition was intact. He had no behaviors and no rejection of care and had a diagnosis of PTSD. A review of Resident #52's care plan revised on 11/16/22. Revealed Resident #52 was not care planned for individualized approaches related to her history of PTSD. An observation and interview were conducted for Resident #52 on 11/28/2022 at 11:30 AM. The resident was lying in bed and no behavioral symptoms were noted. During interview he indicated he was unhappy at the facility because he had been sick and was just readmitted from the hospital recently. He indicated he would like to move to another facility. An interview was conducted with Nursing Assistant (NA) #1 on 11/29/22 at 10:55 AM. She indicated that she was unaware Resident #52 had a history of PTSD. She further indicated there were no specific interventions or approaches to care for Resident #52. An interview was conducted with Nurse #1 on 11/30/22 at 11:30 PM. She indicated that she was unaware Resident #52 had a diagnosis of PTSD. She further indicated there were no specific interventions or approaches to care for Resident #52. During an interview with the SW on 11/29/21 at 1:00 PM, She verified that Resident #52's care plan included no person centered and individualized approaches to care for Resident #52 in relation to her diagnosis of PTSD. The SW acknowledged that a care plan that provided the staff with non-pharmacological interventions and approaches to care was essential for the staff to know how best to care for Resident #24. During an interview with Minimum Data Set (MDS) nurse on 11/29/2022 at 1:22 PM, she verified that Resident #52 had a history of PTSD. She stated that it was essential for the facility staff to have a care plan in place that provided them with person-centered approaches to care for Resident #52 in relation to her history of PTSD. An interview was conducted with the Director of Nursing (DON) and Administrator on 11/30/22 at 12:14 PM. They both indicated their expectation was for a care plan to be developed that included person-centered and individualized approaches to care for residents who had a diagnosis of PTSD.

Based on observations, record review and interviews with facility staff, the facility failed to date opened food items stored for use in the reach-in refrigerator and to discard foods past their use by date for 1 of 1 reach-in refrigerator. This practice had the potential to affect foods served to the residents. The findings included: On [DATE] at 10:36 AM an observation of the of the reach-in refrigerator was conducted with the Dietary Manager. The observation revealed a plastic container of what appeared to be left over pudding unlabeled and there was no date or time noted, and a cheese sandwich unlabeled with no date. There was also a plastic container of leftover sliced mixed fruit dated [DATE] and peaches with date of [DATE]. On [DATE] at 10:50 AM the Dietary Manager stated food items that did not contain a label should have been labeled properly. She added the items past seven days old should have been discarded by the dietary staff. The Dietary Manager also continued to explain that staff had called out the weekend and one of cooks had quit so someone had forgot to remove the expired food and failed to label the containers. She was unsure if the items were checked over the weekend and stated all foods in storage should have been labeled and expired dated foods should have been removed after seven days. She stated she did not have enough people in the kitchen on the weekend to complete all the tasks. During an interview with the Administrator on [DATE] at 2:00 PM she stated food items stored in any of the facility refrigerators should be labeled and dated correctly.

Based on record review and staff interviews the facility failed to have code status in the medical record for 1 of 1 resident reviewed for code status (Resident #46). Findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses which included anemia, coronary artery disease, heart failure and hypertension. Review of Resident #46' significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired. An interview with Resident #46 was conducted on 11/28/2022 at 11:29AM. The resident indicated she did not recall any staff member reviewing code status with her. A review of Resident #46's physician orders for the month of November 2022 revealed no order for code status. An interview with Nurse #1 was conducted on 11/30/22 at 9:20 AM. She stated Resident #46's code status should be in the electronic medical record. Resident #46's electronic record was reviewed with Nurse #1, and she indicated the code status should be at the top of the resident's electronic record which would have populated when the code status order was entered. An interview with the Admission Coordinator was conducted on 12/01/22 at 12:25 PM. She stated that she reviewed code status information with families or the residents during the admission to the facility. She stated the Social Worker (SW) was responsible for reviewing the code status with families or residents during a readmission. The Admission Coordinator indicated she did not know the reason why Resident #46's code status was not indicated in her electronic record. The Social Worker (SW) was unavailable for an interview. An interview was conducted on 12/01/2022 at 11:15 AM with the Director of Nursing (DON). The DON revealed it was her expectation for the resident's code status to be in the medical record on the same day of admission. She indicated Resident #46 should have had orders with her code status in the record. On 12/01/22 at 2:12 PM an interview was conducted with the Administrator who stated she expected all residents to have code status indicated in their electronic medical record when admitted or readmitted to the facility.

Based on observations, record review, resident and staff interviews, the facility failed to provide nursing staff of sufficient quantity resulting in bed baths given when showers were preferred. This affected 1 of 1 resident (Resident #12) reviewed for choices. The findings included: This tag is cross referred to: F561: Based on observations, record review, resident and staff interviews, the facility failed to provide a resident with their preferred number of showers a week for 1 of 1 sampled resident reviewed for choices (Resident #12). During an interview on 5/13/21 at 11:30 AM, NA #2 stated some weekends they were short staffed, and two NAs were required to care for 15-20 residents. She stated it was difficult for two NA to provide showers for the residents scheduled and would substitute a bed bath. She further stated the residents communicated their preferences, but it was hard to accommodate due to being short staffed. She stated it was ok to substitute a bed bath for a shower. During an interview 5/14/21 at 9:30 AM, the nursing staff scheduler reported the facility has part time NAs, nurses, and agency staff to provide care when they were short staffed or when staff calls out. She stated she was a NA and can assist in providing care when staffing was short. During an interview 5/14/21 at 2:30 PM, NA #3 recalled working at the facility briefly though a nursing staffing agency. She reported staffing on the weekends often short staffed due to call outs and often care went undone due to this. She recalled showers not completed due to being short staffed. During an interview on 5/14/21 at 2:45 PM, the Director of Nursing (DON) reported staffing is based on resident acuity and census numbers. She stated staff would bring workload concerns to her, but she had not heard any concerns about not being able to get work done. She further stated if she had heard concerns, she would have worked to find a resolution. She stated leadership nurses were available to assist with NA tasks and agency staff was always available. During an interview 5/14/21 at 3:40 PM, the Administrator reported that staffing agency staff is always available if nursing staff may be short. The expectation is that residents have needs met according to preference and showers were given as scheduled.

Based on observations, record review, resident and staff interviews, the facility failed to provide a resident with their preferred number of showers a week for 1 of 1 sampled resident reviewed for choices (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 3/19/19 indicated a self-care performance deficit related to [CONDITION(S)]. Goals included allow plenty of time of complete tasks and help as needed. Resident #12's Annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. The MDS indicated he needed 1-person assistance with bathing, extensive assistance with dressing, toileting, and grooming. The MDS assessment indicated Resident #12 did not refuse evaluation or care. Review of facility shower schedule indicated Resident #12 was scheduled to get a shower on Wednesday and Saturday on evening shift (between 3 PM- 11 PM). Review of Resident #12's Daily Care Task list from 4/13/21 to 5/13/21 indicated the following: Wednesday, 4/14/21: shower on evening shift Saturday, 4/17/21: bed bath on evening shift Wednesday, 4/21/21: shower on evening shift Saturday, 4/24/21: no documentation on evening shift Wednesday, 4/28/21: no documentation on evening shift Saturday, 5/1/21: bed bath on evening shift Wednesday, 5/5/21: shower on evening shift Saturday, 5/8/21: bed bath on evening shift During an interview 5/10/21 at 3:00 PM, Resident #12 stated he had not been getting showers twice a week as scheduled. He stated he did not get a shower Saturday 5/8/21 and no one offered a shower. This had been an on ongoing issue for months. He stated he received bed baths daily but showers only once per week, although he wanted showers twice a week. At initial visit, Resident #12 appeared clean and well groomed, dressed in street clothes, and was up to wheelchair in room. At a follow up observation on 5/12/21 at 9:30 AM, Resident #12 appeared groomed and dressed up to wheelchair. He reported staff got him up that morning and assisted with personal hygiene. During an interview 5/12/21 at 11:15 AM, the MDS nurse stated that Nurse Aides (NA) were responsible for giving showers. She further stated shower preference were not in the Care Plan, but staff knew the Resident #12's preference because he had been there so long. During an interview on 5/12/21 at 3:10 pm, Nurse Aide (NA) #1 indicated that she assisted Resident #12 with showers on Wednesdays. She stated he usually is ready for his shower when she gets there. She further stated he has not declined a shower nor requested a different time since she has worked with him. NA #1 stated she does not work usually work weekends and does not know if Resident #12 received Saturday showers. She stated if NAs cannot get the scheduled tasks completed, it should be communicated to the charge nurse. During an interview 5/14/21 at 10:30 AM, Nurse #1 reported he worked the weekend of 5/8/21. He did not recall the NA reporting issues providing showers 5/8/21. He further stated residents should get shower regardless of short staffing. He reported Resident #12 did get a shower on 5/13/21 (Thursday) by evening shift. During an interview 5/14/21 at 2:30 PM, NA #3 recalled being assigned to Resident #12 5/8/21 until 9 PM. She stated she did not recall seeing Resident #12 on the shower schedule list and she did not give him a shower. Prior to leaving the facility, she gave report the other NAs on duty and the charge nurse. NA #4 was assigned to Resident #12 on 4/24/21 and 5/1/21 evening shift and could not be reached for interview at multiple attempts. During an interview on 5/14/21 at 2:45 PM, the Director of Nursing (DON) stated nursing staff should be offering showers as scheduled and documenting refusal. If residents wanted to change shower days or times, staff would work with residents to accommodate. She further stated shower preferences should be communicated through the Care Plan. The DON further indicated staff felt comfortable bringing workload concerns to her, but she had not heard any concerns about not being able to get work done. She further stated if she had heard concerns, she would have worked to find a resolution. She stated leadership nurses were available to assist with NA tasks and agency staff was always available. NAs should report to the charge Nurse if they cannot get their tasks completed. During an interview 5/14/21 at 3:40 PM, the Administrator stated residents should be getting showers according to preference.

Based on staff interviews and record review, the facility failed to apply for a level II (Preadmission Screening and Resident Review) PASRR screening for 3 of 5 residents reviewed for PASRR II screenings (Resident# 52, Resident 35 and Resident 21). Findings included: 1.A review of the medical record revealed Resident # 52 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE] noted Resident # 52 to be severely cognitively impaired and needed extensive assistance with bed mobility, transfer, dressing, eating, toileting and personal hygiene. The MDS coded the resident to have the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS did not code Resident # 52 to have been evaluated for a PASRR level II. On 05/12/2021 at 10:10 AM, the Admission Coordinator who was a former Social Worker (SW) was interviewed. She stated she did not know the reason the PASRR level II screening for Resident # 52 was not completed. The Admission coordinator further indicated she could not find the letter indicating PASRR II screening was completed for Resident # 52. In an interview on 05/12/2021 at 1:30 PM, the Administrator expressed the PASARR level II information is expected to be completed immediately if a resident has psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A review of the medical record revealed Resident # 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS) dated [DATE] noted Resident # 35's cognition to be intact and he required extensive assistance with bed mobility and transfer. The MDS coded the resident to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/12/2021 at 10:10 AM, the Admission Coordinator who was a former Social Worker (SW) was interviewed. She stated she did not know the reason the PASRR level II screening for Resident # 35 was not completed. The Admission coordinator further indicated she could not find the letter indicating PASRR II screening was completed for Resident # 35. In an interview on 05/12/2021 at 1:30 PM, the Administrator expressed the PASARR level II information is expected to be completed immediately if a resident has psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. A review of the medical record revealed Resident # 21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS) dated [DATE] noted Resident # 21's cognition to be moderately impaired, he required extensive assistance with bed mobility and dressing. The resident was coded for the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS did not code Resident # 21 to have been evaluated for a PASRR level II. On 05/12/2021 at 10:10 AM, the Admission Coordinator who was a former Social Worker (SW) was interviewed. She stated she did not know the reason the PASRR level II screening for Resident # 21 was not completed. The Admission coordinator further indicated she could not find the letter indicating PASRR II screening was completed for Resident # 21. In an interview on 05/12/2021 at 1:30 PM, the Administrator expressed the PASARR level II information is expected to be completed immediately if a resident has psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations and staff interviews, the facility failed to discard expired medications in 2 of 2 medication storage rooms (the 300/400 Hall Med Room and the 500 Hall Med Room); and failed to store medications in accordance with the manufacturer's storage instructions in 1 of 3 medication carts observed (200 Hall med cart). The findings included: 1. Accompanied by Nurse #1, an observation was made on 5/10/21 at 3:30 PM of the 300/400 Hall Med Room. The observation revealed six (6) intravenous (IV) solution bags containing [MEDICATION(S)] (an antibiotic) dispensed for Resident #37 were stored in the med room refrigerator. The bags were labeled with a pharmacy expiration date of 5/9/21. Upon review of the labeling on the IV bags, Nurse #1 confirmed the intravenous solution bags were expired and he was observed to remove them from the med room refrigerator. A follow-up interview was conducted on 5/11/21 at 4:15 PM with Nurse #1. During this interview, the nurse reported he gave the intravenous solution bags containing [MEDICATION(S)] to the Director of Nursing (DON) so they could be sent back to the pharmacy. In the presence of Registered Nurse (RN) Supervisor #1, an interview was conducted with the facility ' s DON on 5/12/21 at 9:00 AM. During the interview, the DON acknowledged the IV solution bags of [MEDICATION(S)] were expired when found and reported she was in the process of sending them back to the pharmacy. The DON stated this medication had been discontinued for the resident but did not get sent back to the pharmacy as it should have been. The DON reported she would have expected the IV solution bags to have been brought to her so they could have been sent back as quickly as possible. 2. Accompanied by Nurse #2, an observation was made on 5/10/21 at 3:45 PM of the 500 Hall Med Room. The observation revealed three (3) - 15 milliliter (ml) stock bottles of [MEDICATION(S)] lubricant eye drops (an over-the-counter eye drop indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse #2 on 5/10/21 at 3:50 PM. During the interview, the nurse confirmed the [MEDICATION(S)] eye drops were expired and needed to be sent back to the pharmacy. In the presence of Registered Nurse (RN) Supervisor #1, an interview was conducted with the facility ' s Director of Nursing (DON) on 5/12/21 at 9:00 AM. During the interview, the DON reported she had not been made aware of the expired eye drops stored with the stock medications in the 500 Hall Med Room. When asked, the DON stated she would have expected any expired prescription or over-the-counter (OTC) medications to be brought to her for discarding or return to the pharmacy. 3. Accompanied by Med Aide #1, an observation was made on 5/11/21 at 11:00 AM of the 200 Hall medication cart. The observation revealed two - 80 micrograms (mcg) / 4.5 mcg [MEDICATION(S)] / [MEDICATION(S)] aerosol inhalers labeled for Resident #17 were stored lying down on their side in the top drawer of the medication cart. One inhaler was labeled as dispensed from the pharmacy on 4/15/21; the second inhaler ' s label indicated it was dispensed from the pharmacy on 5/10/21. A bright orange pharmacy auxiliary sticker adhered to each plastic canister of the aerosol inhalers read in part: .Store with mouthpiece down . [MEDICATION(S)] / [MEDICATION(S)] is a combination medication containing an inhaled corticosteroid used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 5/11/21 at 11:10 AM with Med Aide #1. During the interview, the medication aide reviewed the pharmacy auxiliary sticker placed on the [MEDICATION(S)]/[MEDICATION(S)] inhalers. Med Aide #1 stated she had not previously noticed the instructions which indicated the inhalers needed to be stored with the mouth piece down. A review of Resident #17's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] In the presence of Registered Nurse (RN) Supervisor #1, an interview was conducted with the facility ' s Director of Nursing (DON) on 5/12/21 at 9:00 AM. During the interview, the DON discussed her expectations for the proper storage of medications. The DON reported she would expect nursing staff to store inhalers with the mouth piece down when indicated by the manufacturer and/or pharmacy instructions. She stated, I think this is an education issue. 4. Accompanied by Med Aide #1, an observation was made on 5/11/21 at 11:00 AM of the 200 Hall medication cart. The observation revealed a 160 micrograms (mcg) / 4.5 mcg [MEDICATION(S)] / [MEDICATION(S)] aerosol inhaler dispensed from the pharmacy on 4/25/21 and labeled for Resident #49 was stored lying down on its side in the top drawer of the medication cart. A bright orange pharmacy auxiliary sticker adhered to the plastic canister of the aerosol inhaler read in part: .Store with mouthpiece down . [MEDICATION(S)] / [MEDICATION(S)] is a combination medication containing an inhaled corticosteroid used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 5/11/21 at 11:10 AM with Med Aide #1. During the interview, the medication aide reviewed the pharmacy auxiliary sticker placed on the [MEDICATION(S)] / [MEDICATION(S)] inhaler. Med Aide #1 stated she had not previously noticed the storage instructions which indicated the inhaler needed to be stored with the mouth piece down. A review of Resident #49's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In the presence of Registered Nurse (RN) Supervisor #1, an interview was conducted with the facility ' s Director of Nursing (DON) on 5/12/21 at 9:00 AM. During the interview, the DON discussed her expectations for the proper storage of medications. The DON reported she would expect nursing staff to store inhalers with the mouth piece down when indicated by the manufacturer and/or pharmacy instructions. She stated, I think this is an education issue. 5. Accompanied by Med Aide #1, an observation was made on 5/11/21 at 11:00 AM of the 200 Hall medication cart. The observation revealed an opened bottle of 1% [MEDICATION(S)] ophthalmic suspension (a steroid eye drop medication) was stored lying down on its side in the top drawer of the medication cart. The manufacturer ' s storage instructions printed on the label of the box containing the eye drops read in capital letters, Store Upright. An interview was conducted on 5/11/21 at 11:10 AM with Med Aide #1. During the interview, the medication aide was shown the manufacturer ' s storage instructions printed on the label of the eye drop medication. Med Aide #1 reported she was not aware the medication needed to be stored in an upright position. In the presence of Registered Nurse (RN) Supervisor #1, an interview was conducted with the facility ' s Director of Nursing (DON) on 5/12/21 at 9:00 AM. During the interview, the DON discussed her expectations for the proper storage of medications included making sure nursing staff were educated to ensure ophthalmic suspensions were stored upright. She stated, I think this is an education issue.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the area of active [DIAGNOSES REDACTED].#47 and #52 ). Findings included: Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. Minimum Data Set ((MDS) dated [DATE] indicated Resident #47 was cognitively impaired, MDS's section I under active diagnosis, Resident #47 was not coded for the [DIAGNOSES REDACTED]. The care plan updated 10/25/2019 revealed Resident #47 was care planned for Antipsychotic medication related to [DIAGNOSES REDACTED]. The goals included risk for adverse reactions related to use of antipsychotic medication will be minimized through current interventions x 90 days. During the interview on 11/20/2019 at 1:29 PM, MDS nurse reviewed the [DIAGNOSES REDACTED].#47 had [MEDICAL CONDITION] as one of his diagnosis. The MDS nurse explained it was an error on her part and she was going to make correction on the MDS to reflect Resident #47's [DIAGNOSES REDACTED]. During an interview on 11/20/2019 at 1:35 pm with the Director of Nursing (DON) she acknowledged Resident #47's section I should have been coded with the [DIAGNOSES REDACTED]. Interview with the Administrator on 11/21/19 at 2 :15 PM reported the MDS coordinator should have coded section I of the MDS accurately because the resident had [MEDICAL CONDITION] diagnosis. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #52 ' s Care Plan dated 7/29/19, read in part, I receive antipsychotic medication. Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #52 was cognitively impaired, MDS ' s Section I - Active [DIAGNOSES REDACTED]. The Consultant Pharmacist Medication Regimen Review dated 8/30/19 revealed the [DIAGNOSES REDACTED]. Resident #52 ' s (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #52 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Section I - Active [DIAGNOSES REDACTED]. During an interview on 11/21/19 at 12:10 PM, the facility MDS Nurse stated she made a coding error for the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She explained it was a human error. She explained she was going to make correction on the MDS to reflect Resident #52 ' s [DIAGNOSES REDACTED]. Interview with the Administrator on 11/21/19 at 1:45 PM, she stated MDS assessments should be coded accurately and the MDS Nurse was correcting the error to annotate the [DIAGNOSES REDACTED].

Based on record review, observation and facility staff and resident interview, the facility failed to provide ongoing communication documentation with the [MEDICAL TREATMENT] center for 1 of 1 resident (Resident #8). The findings included: Resident #8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive Annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 was cognitively intact and required limited assistance with all her activities of daily living. The MDS indicated the resident required [MEDICAL TREATMENT] three times a week for End Stage [MEDICAL CONDITION]. Review of Resident #8's Care Plan, initiated 03/05/18 and revised on 09/25/18, revealed the resident had End Stage [MEDICAL CONDITION] and was at risk for complications due to [MEDICAL TREATMENT]. The Care Plan interventions included arrangement of transportation to [MEDICAL TREATMENT], communication with [MEDICAL TREATMENT] center for any adjustment in care or treatment plan, assessment of the resident upon return from [MEDICAL TREATMENT] treatments and to monitor [MEDICAL TREATMENT] site. An interview was conducted with Resident #8 on 01/18/19 at 9:20 AM. She stated she went to [MEDICAL TREATMENT] usually three times a week. She stated the facility gives her some papers to take but she does not know what the facility staff does with them after she returns from [MEDICAL TREATMENT]. An interview was conducted with Nurse #1 on 01/18/19 at 09:46 AM. Nurse #1 confirmed she was the nurse who worked with Resident #8 during the day shift. Nurse #1 indicated residents going to [MEDICAL TREATMENT] have a Communication Book to provide pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] information. She explained Resident #8 would not take her Communication Book and would take only her communication sheets and sometimes Resident #8 would forget her sheets and not return them. A review of the Resident #8 [MEDICAL TREATMENT] Communication Book revealed no on-going communication documentation from the [MEDICAL TREATMENT] center to the facility for 14 days of 18 days reviewed for the months of (MONTH) (YEAR) through (MONTH) 18, 2019. There were 2 days of 18 days where Resident #8 refused to go to the [MEDICAL TREATMENT] center. An interview was conducted with the Facility Transporter o 01/18/19 at 10:30 AM. The Transporter revealed every [MEDICAL TREATMENT] resident has a [MEDICAL TREATMENT] Communication Book. Each resident is given their indivdual [MEDICAL TREATMENT] Communication Book to provide to the [MEDICAL TREATMENT] center on arrival. The resident returned the book back to the facility post treatment. She stated Resident #8 would refuse to take her [MEDICAL TREATMENT] Communication Book and would take her individual sheets to the [MEDICAL TREATMENT] center. She explained she did not know if Resident #8 returned her sheets to the nursing staff. An interview was conducted with the Director of Nursing (DON) and the Administrator on 01/18/19 at 3:30 PM. The DON and the Administrator stated the facility expectation was for all [MEDICAL TREATMENT] residents to have an individual [MEDICAL TREATMENT] Communication Book. Their expectation was for the Transporter to provide the [MEDICAL TREATMENT] center the Communication Book to ensure communication of pre and post [MEDICAL TREATMENT] treatment. The expectation was for the Transporter to return each Communication Book back to the facility's nursing staff on the return of the resident to the facility.

Based on record review and staff interviews the facility failed to transfer a resident from the bed to the wheel chair with both wheel chair brakes securely locked, resulting in a left [MEDICAL CONDITION] which required surgical repair for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Area Assessment (CAAs) Summary dated 11/21/17 triggered for falls related to balance problems during transition and surface to surface transfer (transfer between bed and chair) not steady and only able to stabilize with staff assistance of two. She had [MEDICAL CONDITION]/[MEDICAL CONDITION]. She had [MEDICAL CONDITION]. The CAAs read to proceed to care plan. Review of the updated Care Plan dated 5/9/18 documented a focus area of: Activities of Daily Living (ADL) self-care performance deficit related to a [DIAGNOSES REDACTED]. Interventions included staff assistance with transfers (stand pivot). The care plan did not document the number of staff needed for the transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as having short and long-term memory problems and severely impaired cognitively for making daily decisions. Resident #1 required extensive two-person assistance for bed mobility and transfers. She had both upper and lower range of motion limitations to the left side of her body. Review of the Incident report dated 8/22/18 documented at approximately 6:00AM Nurse #1 was notified by Medication Aide #1 that Resident #1 had fallen. Upon entering the resident's room, Resident #1 was observed lying supine (on her back) in the floor with the lift pad for the stand to sit lift under the resident's back and a pillow had been placed under her head. NA #1, also in the room, stated that as she attempted to put Resident #1 in the wheelchair, the wheelchair scooted back (the brake on one side of the w/c was not securely set although NA #1 thought it was) and Resident #1 started sliding out of the chair. NA #1 stated she assisted Resident #1 to the floor to prevent injury to the resident. Review of the general nursing note dated 8/22/18 by Nurse #1 documented at approximately 6:00 AM revealed Nurse #1 was notified by Medication Aide #1 that resident #1 had fallen. When Nurse #1 entered the resident's room the resident was lying on her back on the floor with the lift pad from the stand to sit lift under her back and a pillow under her head. Nurse #1 documented NA #1 was also in room and stated as she attempted to put Resident #1 in the wheelchair scooted back (the brake on one side of the wheelchair was not securely set although NA #1 thought it was). The note further read Resident #1 started sliding out of the chair and NA #1 assisted her to the floor. The note read that Nurse #1 called the after-hour's phone number for the clinic and spoke with the on-call nurse, who stated she would advise the facility of any new orders. The note continued by documenting the day shift Nursing Assistant thought Resident #1's leg appeared swollen, so Nurse #1 re-assessed the leg and found the upper part of the thigh/hip area of the left extremity swollen and slightly bruised. Nurse #1 telephoned the clinic again to update the physician. Nurse #1 called the responsible party to inform her of the fall and passed all pertinent information on to Nurse #2. Review of the general nursing note dated 8/22/18 by Nurse #2 documented she received information related to a fall on the 11pm-7am shift with Resident #1. The note read that authorization for an x-ray would have to wait until the clinic opened at 8AM. Nurse #2 assessed Resident #1's leg at 8:00AM and noted the area to be swollen and sore to touch. Writer called clinic several times after, unable to reach provider and left a voicemail message. She called again to the clinic and expressed to receptionist that it was urgent that she speak to the provider. The provider returned the call and gave an order to send Resident #1 to the hospital for evaluation. The responsible party was made aware. The resident left the facility without any signs of distress. Review of the hospital admission and physical dated 8/22/18 documented Resident #1 was seen in the emergency roiagnom on [DATE] with left hip pain. The note documented Resident #1 was being moved at the facility when she was noted to have pain and swelling to the left upper thigh. The x-ray showed left hip comminuted and mildly displaced intertrochanteric [MEDICAL CONDITION] with associated [MEDICAL CONDITION] and severe Osteopenia. She had some pain to the left leg with any movement. The hospital notes stated that at baseline, the resident was not ambulatory. Surgical stabilization was performed on 8/23/18 and the resident was discharged back to the facility on [DATE]. Review of the statement from Nurse Aide #1 dated 8/23/18 read I (NA #1) was in the process of placing Resident #1 in her wheelchair. As I was placing her in her chair the wheelchair rolled back from under her and Resident #1 began to slide to the floor. As she was sliding I immediately placed her gently on the floor. After that I informed the nurse and nurse came immediately and checked Resident #1 out by doing an observation, vitals and skin assessment. During an interview with NA #1 on 10/1/18 at 4:21 PM she stated she was trying to transfer Resident #1 by pivoting her from the bed to the wheelchair without the use of the lift and the chair slid backwards. She stated the wheelchair was locked. She stated she eased Resident #1 to the floor because she was sliding. She then went to get one of the nurses. She did place a pillow under the resident's head. She stated the nurse came in and assessed the resident and the nurse, another staff person and herself placed the resident back in bed. She stated she was not using the lift and was not sure why there would have been a pad behind the resident. During a follow up interview with NA #1 on 10/2/18 at 12:27 PM she stated when she locked the wheelchair she pushed both levers down to put on the brakes. She stated the wheelchair did not look any different to her than any other wheelchair. She stated this was the second time she had worked with the resident and thought she only needed one person to transfer from her bed to the chair. Review of the updated Care Plan dated 8/27/18 documented staff assistance of two persons for transferring. During an interview on 10/1/18 at 12:44 PM the Director of Nursing (DON) stated prior to the fall Resident #1 was a stand and pivot for transfers. The DON did not emphasize if a lift was needed, but that the resident was a stand and pivot transfer. She also did not state if the resident was a one person or two-person transfer. During an interview with Nurse #1 on 10/1/18 at 3:30 PM she stated she was working on the 500 hall when Medication Aide #1 notified her that Resident #1 was on the floor. She stated she entered the room with Medication Aide #1 and Resident #1 was lying on her back on the floor. She stated the resident had the sit to stand lift pad behind her back and a pillow under her head. Her legs were stretched out. She stated Nursing Assistant #1 was staying close to the bed and told her as she was placing Resident #1 in the wheelchair, the brake was not locked, and the chair slid backwards. The resident began sliding and she lowered her to the floor. She stated there were no other witnesses other the NA #1. She stated she did look at the wheelchair and one side was not locked. She stated the sit to stand lift was in the room at the time. Nurse #1 stated that she believed NA #1 had used the sit to stand lift because NA #1 informed Nurse #1 that as she lowered the resident the wheelchair moved. She stated NA #1, Medication Aide #1 and herself lifted Resident #1 and placed her into the wheelchair. The resident complained that one leg was tender. She oftentimes hollers out when receiving care, so this was not new. She stated there was no bruising or bleeding, just tenderness. She further stated that within an hour or two the leg began swelling. During an interview with Medication Aide (MA) #1 on 10/1/18 at 1:46 PM she stated NA #1 came to her to let her know Resident #1 was on the floor. She stated she notified Nurse #1 that the resident was on the floor. The nurse and MA #1 entered the room at the same. She stated when they entered the room the resident was lying on the floor with a pad under her and a pillow under her head. Resident #1 was on her back. Nurse #1 assessed the resident in her presence. MA #1 stated she did not know why the lift pad was under the resident as she thought the resident was a stand and pivot transfer without a lift. She stated during the assessment Resident #1 stated she hurt. She stated at the time of the assessment the wheelchair was out to the side of the resident and the Resident was on the floor. She stated following the assessment the nurse, nursing assistant and she lifted Resident #1 and placed her in the wheelchair. At this time the resident tried to stretch her legs and stated her left leg hurt. During an interview with Nurse #2 on 10/1/18 at 2:00 PM she stated she was the oncoming day shift nurse on 8/22/18 and she was told the resident fell at her bedside and was lowered to the floor. She stated she called clinic of a sister facility since Resident #1 was their resident but housed in this facility about sending the resident to the hospital but was informed the physician had to be notified first. She stated when she re-assessed Resident #1's left leg, the leg was swollen and painful to touch only and there was some bruising beginning. She stated that was when she called the clinic again and the Physician's Assistant gave an order to send her to the hospital. During a follow up interview with the Director of Nursing on 10/1/18 at 2:37 PM she stated the resident was a stand and pivot transfer without a lift prior to fall and after the fall she required two-person assistance and then was changed to a mechanical lift transfer. She stated the pad was under the resident because the staff were going to get her back up with the lift. She then stated she did not know how the staff got her back up from the floor. During an interview with the RN Nurse Consultant on 10/1/18 at 3:45 PM she stated the facility identified the root cause as the wheelchair brake not being locked and did an audit of all wheelchairs on 8/29/18. Staff were in-serviced on the correct application of wheelchair brakes on 8 /30/18. She stated staff should always lock the wheelchair prior to placing a resident in the chair. During a follow up interview with RN Nurse Consultant on 10/2/18 at 11:50am she stated the wheelchair was locked but the hand brakes went in different directions as one pulled upward to lock, and one side pushed downward. She stated the wheelchair was locked but did scoot when the resident was lowered close to the chair. She stated the wheelchair was no longer in use because the Maintenance Director changed the hand brakes to be identical when locked. During the investigation the Maintenance Director was unavailable for interview. During an interview with the Corporate Minimum Data Set (MDS) nurse on 10/2/18 at 11:25 AM she stated in reviewing the most recent MDS prior to the fall Section G (Functional Status) had two columns and Resident #1 was assessed as an extensive two-person transfer. She further stated whenever we code section G the two persons transfer only had to happen once to be coded as needing two persons. It may not have been truly reflective as to what the resident required daily. She stated on 5/9/18 the resident was a stand and pivot transfer. On 8/27/18 she was changed to requiring staff assistance of two staff members and on 9/3/18 she was changed to a mechanical lift transfer. During an interview with the Physician's Assistant on 10/2/18 at 11:03 AM she stated the resident was bedbound and did not get up on her own. She stated Resident #1 had been slow to recover from her [MEDICAL CONDITION] and had left sided [MEDICAL CONDITION] (or weakness). Her Dementia was progressing. She stated Resident #1 did have a [DIAGNOSES REDACTED]. She stated staff should be using and should have been using a mechanical lift for all transfers for Resident #1 prior to her fall and after her fall. The wheelchair should always be locked prior to placing a resident in the chair. She stated Resident #1 was a high fall risk and a [DIAGNOSES REDACTED]. She stated she was not in the facility at the time of the fall but there had to be enough force when she landed or was placed on the floor to fracture the hip. She further stated she believed the hip broke when Resident #1 was placed on the floor. During an interview with the prior Administrator on 10/2/18 at 11:59 AM he stated he was the interim Administrator at the time of the fall and did assist the maintenance director in doing a 100% audit of all the wheelchairs in the facility. He stated if he remembered correctly after discussing the wheelchair with the Maintenance director both sides of the wheelchair brakes were different. They had either been installed incorrectly or were not acting right. The brake did not go up against the tire correctly and therefore did not lock tightly. He stated he did not write up a plan of correction but possibly the consultants did. During an interview with the Director of Nursing (DON) on 10/2/18 at 12:29 PM she stated the facility did an audit of the wheelchairs in the building and educated the staff regarding wheelchair brakes and how they should look and work. She stated part of the education process was if staff saw a wheelchair that wasn't working properly they were to notify Maintenance. She stated the Maintenance director did weekly monitoring on wheelchairs. She stated on Resident #1's wheelchair one side of the wheelchair had a brake that went up to lock and one side went down to lock. We did an investigation and the root cause analysis led us to believe it was the locking system, we did a 100% audit of the wheelchairs and we did education of staff, there was never one person in charge of monitoring because the Nursing Assistants (NAs) were responsible to report if there was a problem. The DON stated when she checked the wheelchair, the wheels locked, and the tires did not move but the chair slid backwards like the tires were bald. During an interview with the Administrator on 10/2/18 at 1:20 PM she stated it was expected that the staff would check to make sure the wheelchairs were functioning properly prior to placing a resident in the wheelchair. She further stated that the previous Administrator may have done a plan of correction. She stated that the facility had components of a plan of correction, such as wheel chair audits, education and the maintenance director's weekly wheel chair checks from 9/1/18 - 9/29/18 but no written plan of correction.

Based on facility record review, hospital record review and staff interviews the facility failed to update a care plan to reflect how a resident was assessed on the Minimum Data Set (MDS) Assessment for transfers for 1 of 3 residents reviewed for falls (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Area Assessment (CAAs) Summary dated 11/21/17 triggered for falls related to balance problems during transition and surface to surface transfer (transfer between bed and chair) not steady and only able to stabilize with staff assistance of two. She had [MEDICAL CONDITION]/[MEDICAL CONDITION]. She had [MEDICAL CONDITION]. The CAAs read to proceed to care plan. Review of the updated Care Plan dated 5/9/18 documented a focus area of: Activities of Daily Living (ADL) self-care performance deficit related to a [DIAGNOSES REDACTED]. Interventions included staff assistance with transfers (stand pivot). The care plan did not document the number of staff needed for the transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as having short and long-term memory problems and severely impaired cognitively for making daily decisions. Resident #1 required extensive two-person assistance for bed mobility and transfers. She had both upper and lower range of motion limitations to the left side of her body. Review of the Incident report dated 8/22/18 documented at approximately 6:00AM Nurse #1 was notified by Medication Aide #1 that Resident #1 had fallen. Upon entering the resident's room, Resident #1 was observed lying supine (on her back) in the floor with the lift pad for the stand to sit lift under the resident's back and a pillow had been placed under her head. NA #1, also in the room, stated that as she attempted to put Resident #1 in the wheelchair, the wheelchair scooted back (the brake on one side of the w/c was not securely set although NA #1 thought it was) and Resident #1 started sliding out of the chair. NA #1 stated she assisted Resident #1 to the floor to prevent injury to the resident. Review of the general nursing note dated 8/22/18 by Nurse #1 documented at approximately 6:00 AM revealed Nurse #1 was notified by Medication Aide #1 that resident #1 had fallen. When Nurse #1 entered the resident's room the resident was lying on her back on the floor with the lift pad from the stand to sit lift under her back and a pillow under her head. Nurse #1 documented NA #1 was also in room and stated as she attempted to put Resident #1 in the wheelchair scooted back (the brake on one side of the wheelchair was not securely set although NA #1 thought it was). The note further read Resident #1 started sliding out of the chair and NA #1 assisted her to the floor. Review of the statement from Nurse Aide #1 dated 8/23/18 read I (NA #1) was in the process of placing Resident #1 in her wheelchair. As I was placing her in her chair the wheelchair rolled back from under her and Resident #1 began to slide to the floor. As she was sliding I immediately placed her gently on the floor. During an interview with NA #1 on 10/1/18 at 4:21 PM she stated she was trying to transfer Resident #1 by pivoting her from the bed to the wheelchair without the use of the lift and the chair slid backwards. She stated the wheelchair was locked. She stated she eased Resident #1 to the floor because she was sliding. During a follow up interview with NA #1 on 10/2/18 at 12:27 PM she stated this was the second time she had worked with the resident and thought she only needed one person to transfer from her bed to the chair. During an interview with Nurse #1 on 10/1/18 at 3:30 PM she stated she was working on the 500 hall when Medication Aide #1 notified her that Resident #1 was on the floor. She stated she entered the room with Medication Aide #1 and Resident #1 was lying on her back on the floor. She stated the resident had the sit to stand lift pad behind her back and a pillow under her head. Her legs were stretched out. She stated Nursing Assistant #1 was staying close to the bed and told her as she was placing Resident #1 in the wheelchair, the brake was not locked, and the chair slid backwards. The resident began sliding and she lowered her to the floor. She stated there were no other witnesses other the NA #1. She stated she did look at the wheelchair and one side was not locked. She stated the sit to stand lift was in the room at the time. Nurse #1 stated that she believed NA #1 had used the sit to stand lift because NA #1 informed Nurse #1 that as she lowered the resident the wheelchair moved. During an interview with Medication Aide (MA) #1 on 10/1/18 at 1:46 PM she stated NA #1 came to her to let her know Resident #1 was on the floor. She stated she notified Nurse #1 that the resident was on the floor. The nurse and MA #1 entered the room at the same. She stated when they entered the room the resident was lying on the floor with a pad under her and a pillow under her head. Resident #1 was on her back. Nurse #1 assessed the resident in her presence. During an interview with the Director of Nursing on 10/1/18 at 2:37 PM she stated the resident was a stand and pivot transfer without a lift prior to fall and after the fall she required two-person assistance and then was changed to a mechanical lift transfer. She stated the pad was under the resident because the staff were going to get her back up with the lift. She then stated she did not know how the staff got her back up from the floor. During an interview with the Corporate Minimum Data Set (MDS) nurse on 10/2/18 at 11:25 AM she stated in reviewing the most recent MDS prior to the fall Section G (Functional Status) had two columns and Resident #1 was assessed as an extensive two-person transfer. She further stated whenever we code section G the two persons transfer only had to happen once to be coded as needing two persons. It may not have been truly reflective as to what the resident required daily. She stated on 5/9/18 the resident was a stand and pivot transfer. On 8/27/18 she was changed to requiring staff assistance of two staff members and on 9/3/18 she was changed to a mechanical lift transfer. During an interview with the Physician's Assistant on 10/2/18 at 11:03 AM she stated the resident was bedbound and did not get up on her own. She stated Resident #1 had been slow to recover from her [MEDICAL CONDITION] and had left sided [MEDICAL CONDITION] (or weakness). Her Dementia was progressing. She stated Resident #1 did have a [DIAGNOSES REDACTED]. She stated staff should be using and should have been using a mechanical lift for all transfers for Resident #1 prior to her fall and after her fall. The wheelchair should always be locked prior to placing a resident in the chair. She stated Resident #1 was a high fall risk and a [DIAGNOSES REDACTED]. She stated she was not in the facility at the time of the fall but there had to be enough force when she landed or was placed on the floor to fracture the hip. She further stated she believed the hip broke when Resident #1 was placed on the floor.

Based on record review, observation, video surveillance recording review, and resident and staff interviews, the facility failed to maintain a safe environment for a cognitively impaired, wandering resident for one of three residents reviewed for accidents (Resident #1). Resident #1 had an expired wander guard bracelet which did not trigger-lock the exit door and the resident was able to exit the facility unsupervised. Immediate jeopardy (IJ) began on [DATE] when Resident #1 exited the facility unsupervised, was missing for 40 minutes, and was found in a heavily wooded area adjacent to the facility property. The IJ was removed on [DATE] when the facility implemented a credible allegation of IJ removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: Resident #1 was admitted on [DATE] with the cumulative [DIAGNOSES REDACTED]. The 5-day, in-progress Minimum Data Set ((MDS) dated [DATE] for Resident #1 was reviewed and revealed an assessment of adequate hearing, clear speech, was understood and sometimes understands. Cognition was severely impaired. His mood was little interest in doing things and there were no behaviors. The remaining assessments were not completed. The resident participated in the assessment. The resident ' s care plan was updated on [DATE] to reflect wandering behaviors. An elopement incident report dated [DATE] was completed. The elopement was within the first 72 hours of admission and the resident ' s wander guard (WG) (radio emitter bracelet that locks or alarms the exit door when approached) was expired. Resident #1 ' s [DATE] elopement was observed on [DATE] of the facility ' s surveillance video camera numbers 7, 19, 25, 26, 27, and 31 which record the resident halls and exit doors. The video recording had no sound. On [DATE] at 12:26 pm the resident was observed fully dressed in sneakers, wearing a baseball cap, looking around on the sloped hall that has exit doors to the two gated courtyards with an entry door that enters at the end of hall 500 with a facility exit door (door has a wander guard alarm). At 12:31 pm the resident was observed to enter the gated-locked court yard from the long-sloped hall that leads to hall 500 with a facility exit door. At 12:37 pm the resident re-entered the building into hall 500 from another door in the court yard that is near the facility exit door. At 12:37 pm the resident walked through hall 500 ' s facility exit door. The door did not lock. The resident was observed to run across the pavement into the nearby woods. At 1:06 pm ,[DATE] staff members were observed to be looking in all rooms from cameras 25, 29, 31. At 1:09 pm a staff member was observed to exit the building looking around the facility grounds. At 1:16 pm staff used camera recordings to view the resident ' s activity (per Maintenance Manager who is responsible). At 1:30 pm the Director of Nursing (DON) was observed on recording to enter the woods across the pavement from hall 500 ' s facility exit door. At 1:31 pm five staff members were observed on recording to enter the woods behind the DON with 2 more staff immediately behind them. At 1:40 pm the resident was recorded walking back from the woods with staff. Timeframe 12:37 pm leaves building and 1:40 pm resident walked back to the building with staff. On [DATE] at 9:45 am an observation was done of Resident #1 in his room. The resident was sitting on his bed and was observed to ambulate independently and steadily. There was a sitter in the room with 1:1 supervision. The resident had minor scratches to his arms and legs that were healing. The resident walked to the front door with staff and the wander guard triggered the door to lock. The door would not open until the resident stepped 10 feet away from the door. The door was opened by an oncoming visitor who had a resident with him wearing a wander guard and the alarm sounded. On [DATE] at 10:15 am an interview was conducted with the Maintenance Manager (MM) who stated that there was an elopement on [DATE]. The staff could not find Resident #1 in the building so the MM provided the facility camera recording and the resident was observed to exit out of the main rehabilitation exit door on Hall 500. The wander guard did not alarm. On the film the resident was seen exiting to the gated courtyard on the long main hall that leads to hall 500 and re-entered onto hall 500 nearest to the hall 500 exit door (which bypasses the nursing station) and exited the building. While in the building, the resident was video recorded looking around for staff before he eloped. The resident was seen on camera running into the woods. Five staff members looked for the resident who was found in the woods next to the facility. The resident had minor scratches from the brush. The resident had to be coaxed and led by his hand to return to the facility. MM checked the wander guard and it was not working, it had expired. The door was checked with a working wander guard and it locked. The exit doors that have alarms and wander guard locking mechanisms are checked weekly and found to be working. On [DATE] at 10:30 am an observation was done of the MM ' s evaluation of all facility exit doors. Hall 100 ' s emergency exit door that was required to alarm when opened was shut off and did not alarm. The MM used a key to turn the alarm on and it tested okay. On [DATE] at 9:40 am an interview was conducted with Nurse #1 who was assigned to Resident #1 on [DATE] day shift. Nurse #1 had worked at the facility for approximately [AGE] years and was very familiar with the facility policy. Nurse #1 stated she noticed Resident #1 was missing on [DATE] at approximately 12:45 pm. The resident had recently been to therapy and was sitting in a chair at the nurses ' station. Nurse #1 looked on hall 400 to find the resident and he was not found so the DON was notified, and a code PINK was called. Code PINK is where all the rooms in the facility are checked and the surveillance cameras are observed to evaluate for exiting activity. Nurse #1 stated she does not remember the time the resident was identified on camera recording when he left the building through hall 500 exit door. Nurse #1 stated that the resident was found in the woods adjacent to the facility. When the resident was first seen he proceeded to run. The resident was gone (missing) for approximately 20 - 30 minutes. The resident was assessed, and no injury was found. The resident ' s wander guard was not operating. Nurse #1 also stated that Resident #2 was admitted the day before he eloped and had a wander guard placed. Nurse #1 stated she had not known that the resident was a wanderer. The wander guards were checked every night shift with a testing device and there was a listing of all residents with wander guards at each nurses ' station. Nurse #1 stated she did not know if the resident ' s wander guard was tested the night of [DATE]. On [DATE] at 10:18 am an interview was conducted with the occupational therapist (OT) #1 who stated on [DATE] she worked with Resident #2 in the therapy room. The resident was cooperative and did not state he did not want to be here or wanted to leave. The resident was intermittently confused and was able to communicate. Hallucinations were noted and then rationale conversation. When the physical therapy session was completed the resident was placed at hall 400 nurses ' station at 12:20 pm. The nurse was given report. OT #1 stated she then went to lunch. The resident was wearing shoes at the time. On [DATE] at 10:35 am an interview was conducted with Nursing Assistant (NA) #1 who was assigned to Resident #1 on [DATE] on day shift. The resident was newly admitted and was supervised due to potential for wandering. On [DATE] the resident received a shower at approximately 10:00 am. The resident was cooperative and did not verbalize that he wanted to leave or not be at the facility. NA #1 stated the last time she saw Resident #1 he was sitting at the nurses ' station. NA #1 stated that she noticed Resident #1 was missing around 12:20 to 12:30 pm when the trays were brought to the hall. The resident can walk around the facility independently. All rooms were immediately checked, and a code PINK was called because the resident was not found. The family was called to determine if the resident left with the family, and he had not. The grounds outside the building were also checked concurrently with room check. NA #1 stated that about 10 minutes into the search, the video recordings were observed which revealed the resident had exited the building into the woods and an outside search in the woods was started. The resident was found. The resident was missing for approximately 20 minutes. The resident was assessed by the nurse and was found to have no injury. The resident was provided water because he was sweating. The resident was placed on an every 10-minute watch for the day and evening shift. The resident ' s wander guard was not working and was replaced with a tested /working wander guard. On [DATE] at 5:00 pm an interview was conducted with the DON who stated Resident #1 was placed on 10-minute checks for 24 hours. The DON stated that the process for wander guard check was changed on [DATE] to document its presence and the expiration date. The root cause analysis for the elopement was a non-working wander guard. On [DATE] at 5:15 pm an interview was conducted with the Corporate Nursing Consultant who stated and provided the non-working wander guard which was dated ,[DATE] and expired. The Administrator, Corporate Nurse Consultant and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:54 pm. The facility provided an acceptable credible allegation for immediate jeopardy removal on [DATE] which included the following: Plan to correct specific deficiency and facts that led to the alleged deficient practice The resident was admitted to the facility on (MONTH) 15th (YEAR), with risk assessment completed on admission and deemed to be a moderate risk for elopement; therefore wanderguard bracelet was initiated and added to the patient ' s plan of care. He has the [DIAGNOSES REDACTED]. On (MONTH) 17th (YEAR) at 12:37 pm, resident # 1 went out the back door and walked across the parking lot to the wooded area adjacent to the facility. He said he was looking for his wife. The resident was found in the woods around 1:40 pm. The resident was assessed by the nurse upon entering the facility on (MONTH) 17, (YEAR) and the MD and RP were notified of the event. There were minor scratches noted to resident ' s legs. 1:1 was initiated for this resident to ensure his safety. 1:1 was maintained 24 hours a day from [DATE] immediately upon return to the facility until [DATE] at 11 PM. Investigation completed and found that the wanderguard placed on the resident was expired therefore interdisciplinary team members concluded with the placement of an active non-expired wanderguard, all other wander management systems were functioning, therefore wander management system would keep resident sufficiently monitored. Upon return to the facility on [DATE], resident ' s wanderguard was immediately replaced by the Director of Nursing with a current wanderguard (i.e. one not expired). An REQ (Review to Ensure Quality) was initiated on 08.17.18. The wanderguard was found to be not be working correctly because it was expired, expiration date was noted to be ,[DATE]. Expired wanderguard bracelet was found to be the root cause for the deficient practice. The wanderguard bracelets for this particular wandering monitoring management system have an expiration date or ' life ' of approximately 3 years, unfortunately the wanderguard bracelet placed on this patient expired ,[DATE]; the licensed nurse who applied the watchmate bracelet was not aware of the expiration date when she applied the wanderguard bracelet to the patient. The licensed nurse had not received education that the wanderguards had expiration dates. The wanderguard was retrieved from a locked cart located at the nursing station of the ,[DATE] hall area, located central within the facility. The cart was audited to ensure no other expired wanderguard bracelets, as was all other storage carts located within the facility, nursing stations, desk, offices, central supply units, and maintenance shop. All audits of these areas were complete by close of business on Friday, (MONTH) 17, (YEAR). Director of nursing ensured all audits were sufficiently completed. Procedure for implementing a plan of correction for the alleged deficient practice On 08.17.18, the Unit Manager and the scheduler, checked 100% of all the other residents with wander guards in use residing within the facility which include 6 total skilled residents, there were no other wander guards found expired and all were functioning properly. The wander guard bracelets were checked by utilizing the manufacturer (wanderguard checker ' ); when placed directly beside the wanderguard the transmitter will beep repetitively and a light turns green located on the ' checker ' . On 08.17.18, the Director of Nursing began in-servicing all nurses on the following: · Elopement Prevention and Maintenance with Wanderguard alarm systems. o All resident will be assessed on admission and quarterly for elopement risk. o Residents found at risk shall be identified by staff in the care plan and care guides. o Transmitter bracelets (wanderguard) will be attached to wrist or ankle after being checked for expiration date and tested to make sure they were functioning properly. · Return demonstration of how to find expiration date to ensure that it is not expired on the wander guard device and how to check to ensure it is working. · All nursing staff (RN, LPN, Nurse Aide) to be trained prior to being allowed to work, this includes full time, part time and PRN employees. · This will also be added to the facility new hire orientation. Education began on [DATE] and was completed on [DATE] except for four employees that only work on the weekend or on vacation. These employees will not be allowed to work until they have received this education. The Director of Nursing will ensure that this education occurs prior to the employee working again. The Maintenance Director will add alarming boxes on [DATE] before 12:00 pm to the exit doors which lead to the patio area or any other exit area with the potential that have on/off switches for exterior gates with keypads and/or the doors are found to be otherwise not monitored. The alarming boxes will alert the staff anytime the doors exiting to the patio or gated areas are opened. All doors and alarms are checked daily by maintenance director or managers on duty. However, on [DATE] the maintenance director had been interrupted during his monitoring of the devices, he would have completed the audit prior to end of day, however, when the surveyor accompanied by the Maintenance Director arrived at the door to the 100 hall exit it was found to be turned to the off position . The 100 hall alarming box was immediately turned to the on postion by the maintenance director and found to be functioning once engaged to the on position. The facility initiated re-education [DATE] of all staff regarding the alarming boxes to ensure boxes are not turned off following door opening/closing. The facility will monitor each exit door with alarming boxes installed every shift during licensed nurse walking rounds to validate alarming boxes are turned to the on position and functioning. All education is being completed by licensed personnel and will be completed prior to employees working their next scheduled shifts until 100% complete and will be added to the new orientation hires to be completed prior to working independently. The facility updated all physician orders [REDACTED]. The physician orders [REDACTED]. The licensed nurse will be responsible to ensure the wander transmitter is checked for proper function, placement, and expiration date each shift; after verifying, the licensed nurse will then initial as validation the process was completed in the electronic medication administration record. Monitoring Procedure The Director of Nursing and/or Nurse Manager will monitor residents with wander guard bracelets to ensure their daily bracelet check has been completed by the licensed nurses to ensure placement, function, and expiration date. The licensed nurse will use the wanderguard checking device each shift for each wanderguard to ensure the device is in place, functioning, and not expired. This will be accomplished by reviewing the MAR/TAR to validate the documentation by the licensed nurse in the daily clinical meeting for all residents with wanderguard orders. The DON and/or nurse manager will review the orders and documentation compliance for 2 residents per day in the clinical meeting for those residents that have a wander guard bracelet. This will be completed daily for 2 weeks and then weekly for 3 months or until resolved by the Quality Assurance Committee. If inconsistencies are identified, the staff member will be reeducated on checking the wander guard bracelet per the MD order in PCC. This monitoring was initiated on 8.23.18. The Director of Nursing will print a monthly report from the electronic health record of all residents with orders for wanderguard monitoring, any resident with a bracelet found to have an expiration date within the following 60 days will have a new wanderguard applied with an updated expiration date. Order will be updated to coincide with new wanderguard placement. All newly admitted residents who are assessed to require a wander management transmitter, will have orders reviewed during the daily clinical quality reviews by the Director of Nursing and/or Unit Manager to ensure the orders include the expiration dates of the transmitters effective [DATE]. All expired wander management transmitters will be discarded by licensed personnel when removed from use. Reports will be presented to the weekly QA committee by the Director of Nursing to ensure corrective action for trends or ongoing concerns is initiated as appropriate. The weekly QA Meeting is attended by the DON, Wound Nurse, MDS Coordinator, Unit Manager, Support Nurse, Therapy, HIM, Dietary Manager and the Administrator. The Director of Nursing and the licensed Administrator will be responsible for implementing the credible allegation. Immediate Jeopardy removal date: [DATE] Validation: Immediate Jeopardy (IJ) was removed on [DATE] at 2:45 pm when validation was completed of the credible allegation for IJ removal as evidenced by interviews of two licensed nurses, two nursing assistants, one housekeeper, and the Maintenance Manager for evidence of in-service completion and a review of the new elopement process policy and evaluation and new documentation requirement of the wander guard bracelet presence, expiration date, and working condition.

Based on record review, observation, video surveillance recording review, and resident and staff interviews, the facility failed to prevent resident to resident abuse in the form of inappropriate touching for one of three residents reviewed for abuse (Resident #3). Resident #2 was observed to have his hand underneath the Resident #3 ' s dress with Resident #2 ' s hand moving up and down near Resident #2 ' s groin area. Resident #3 was assessed by two facility nurses and was found to have tender labia tissue. Findings included: 1a. Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, usually understands, and was understood. The resident was unable to complete the cognitive assessment. The resident required extensive assistance for all activities of daily living. The active [DIAGNOSES REDACTED]. On [DATE] at 4:00 pm Resident #3 was observed sitting in her wheel chair with a private aide present in her room. The private aide had to speak up and face the resident for the resident to hear. The resident was oriented to self with limited orientation to situation. While in Resident #3 ' s room, Resident #2 attempted to enter, and the private aide informed Resident #2 to get out of here. Resident #2 stated he wanted to talk to the Surveyor. Surveyor exited Resident #3 ' s room and staff escorted Resident #2 away. Both Resident #2 and #3 reside on the same hall. The facility ' s video surveillance (no sound) dated [DATE] was reviewed and revealed Resident #3 inappropriately touched Resident #2 as follows: · At 9:58 pm Resident #3 was alone in the (dining room) DR. · At 10:03 Resident #2 returned to the DR near the computer and was observed frequently stroking his own head. · At 10:08 pm Resident #2 placed his scooter to the right of Resident #3 ' s wheel chair parallel. Resident #3 was noted to be fidgeting quickly with the towel that was on her lap. Resident #2 ' s arm can be seen over the right side of his scooter and his forearm and hand are not visible. Resident #3 ' s dress appears to be moving up and down in the center of her dress near her groin. Resident #3 began folding and unfolding the bib towel on her lap nervously during this encounter. Resident #2 ' s hand and arm appeared to be under Resident #3 ' s dress. Resident #3 ' s hand was observed to push at Resident #2 ' s arm. Resident #3 ' s dress continued to move up and down in the center of her lap near her groin and she continued to nervously fold and unfold the towel on her lap and on the right wheel chair arm until staff arrived. Total encounter time of Resident #2 was alone and inappropriately touched Resident #3 in the DR was 18 minutes. · At 10:26 pm Nursing Assistant (NA) #2 arrived to get Resident #3 and quickly wheeled her out of the DR. When Resident #3 was wheeled away from Resident #2 ' s scooter in plain front view of the camera her dress on the right side was up to her upper thigh/groin and the left side of the dress was down below her knee. 1b. Resident #2 was admitted to the facility on [DATE] and had the cumulative [DIAGNOSES REDACTED]. A review of the quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, and understands and was understood. The cognition was intact, and no behaviors were exhibited. The resident required limited assistance with bathing and dressing, and supervision for transfer and meals. Locomotion was set up only. Active [DIAGNOSES REDACTED]. Health note dated [DATE] at 11:43 am the resident was diagnosed with [REDACTED]. (no mention of behavior change). Nurses ' note dated [DATE] late entry for [DATE] the resident was placed on 1:1 supervision for allegation of abuse. The resident had unusual behavior (type not provided). Assessment on [DATE] revealed the resident had no behaviors and was started on antibiotics [DATE]. Nurses ' note [DATE] late entry: the resident continued on antibiotics. No additional behaviors noted. Interviews of staff reveal no further episodes of inappropriate behaviors no further inappropriate jesters or touching. Will schedule psychiatry evaluation and follow. Psychiatry appointment scheduled for [DATE]. The staff will continue to monitor. Plan of care updated [DATE]. Nurses ' note dated [DATE] late entry: On Monday night, [DATE], the resident stayed in his room for the duration of my shift, 11:00 p.m. - 7:00 a.m. He was under constant monitoring during the shift. There was a Certified Nursing Assistant posted on the hall and the medication aide was at the nurse's station. This resident did not come out of his room or interact with any residents at any time during this shift. On [DATE] at 3:45 pm an interview was conducted with Resident #2 who was oriented to self, situation, and time. Resident #2 was able to remember and state to provide detail of [DATE] in the dining room when Resident #3 was present. Resident #2 stated that he was in the dining room listening to music on the computer. Resident #3 was there. Resident #2 stated that was the first time he had touched Resident #3 (Resident #2 was smiling). Resident #2 commented that many of his friends in the facility had died or were sick and not able to visit with him. Resident #2 did not comment on what the facility staff said to him about Resident #3. On [DATE] at 4:00 pm an interview was conducted with Resident #3 ' s private aide who stated she was aware of an altercation between Resident #2 and Resident #3. The private aide stated that Resident #3 was a religious person and would not consent to sexual relations in a public place with a man she does not know. The private aide stated that the resident had dementia and was not able to consent to sexual relations. The resident was frequently confused and not oriented to her surroundings. On [DATE] at 4:30 pm an interview was conducted with NA #2 who stated on [DATE] at approximately 10:25 pm the NA entered the DR to retrieve Resident #3 to help her get to bed. NA #2 stated upon entry to the DR and walking near to Residents #2 and #3 that were next to each other, NA #2 observed Resident #2 with his hand and forearm under the dress of Resident #3 and her dress moving up and down near her groin. When Resident #2 saw NA #2, he moved his hand down to the resident ' s sock and touched it. NA #2 noted that Resident #3 had brown matter on his fingers and nails that resembled stool. NA #2 stated that Resident #3 looked nervous and was fidgeting with her towel bib which was unusual. NA #2 stated that she immediately took the resident to her assigned nurse, Nurse #2, and informed her of what she observed. Nurse #1 was also informed of NA #2 ' s observation for a second witness. NA #2 stated that Nurse #s 1 and 2 took Resident #3 to her room to assess her. NA #2 was directed to find Resident #2 and to supervise him. NA #2 found Resident #2 in the hall bathroom washing his hands of brown matter. NA #2 asked Resident #2 what he was washing, and he stated nothing. NA #2 supervised Resident #2 for the remainder of the shift. On [DATE] at 5:55 pm an interview was conducted with Nurse #1 who stated she was informed by NA #2 that Resident #2 had his hand moving up and under the dressing and inside the undergarment of Resident #3. NA #2 also stated that she thought Resident #2 had penetrated Resident #3 ' s private with his hand. Nurse #1 stated that she and Nurse #2 assessed Resident #3 who had stool in her undergarment. After incontinence care Nurse #2 assessed that Resident #3 was tender upon touch of her labia with no other injury noted. Nurse #1 stated that Resident #3 could not give consent to sexual contact due to cognitive deficit and was not able to make decisions due to a cognitive deficit. On [DATE] at 6:30 pm an interview was conducted with the DON who stated Resident #3 ' s resident representative was informed of the inappropriate touching on [DATE] after the DON had the opportunity to review the video recording and speak to staff. On [DATE] at 6:30 pm an interview was conducted with the DON who stated Resident #2 had his first psychiatry evaluation yesterday and was placed on an anti-depressant after the death of his son. Psychiatry was to follow. On [DATE] a second counseling was done by the DON with Resident #3 which was more successful than the first counseling on [DATE]. The resident was more receptive and made some of the same comments to the DON that he made during surveyor interview, except he did not admit inappropriately touching the resident. Resident #2 commented they were friends and he knew the family (of Resident #3). Documentation was provided of the counseling. The DON stated that she now understood a resident with a cognitive deficit cannot give sexual consent and informed Resident #2 that touching was not permitted and what he did not wrong. Resident #3 was supervised 1:1 for 24 hours and is currently continuously staff supervised throughout the facility for his interaction with all residents. During the course of the survey Resident #2 was observed to have free movement in his scooter throughout the facility. He was not observed communicating with Resident #3. On [DATE] at 6:30 pm an interview was conducted with the DON. The DON stated that she now understood a resident with a cognitive deficit cannot give sexual consent and informed Resident #2 that touching was not permitted and what he did not wrong. Resident #3 was supervised 1:1 for 24 hours and is currently continuously staff supervised throughout the facility for his interaction with all residents. She stated Resident #3 ' s resident representative was informed of the inappropriate touching on [DATE] after the DON had the opportunity to review the video recording and speak to staff. On [DATE] at 6:45 pm an interview was conducted with the Administrator who stated that he was aware of the altercation between Residents #2 and #3. The DON was handling the facility investigation and staff education and the 24 hour and 5-day report to the State. On [DATE] at 12:15 pm an interview was conducted with NA #3 who stated she had worked at the facility for a year and was very familiar with Resident #2. The inappropriate touching was a new behavior. NA #3 stated that when she entered the dining room (DR) some of the lights were out. She checked both residents and there was nothing wrong. The lights were sometimes turned off to watch a movie on television (TV) in the DR. The TV was playing at the time she checked the DR and did not think anything was wrong with the lighting. There were always two emergency lights on in the back of the DR. The two residents knew each other and have talked many times before in various places of the facility. Resident #2 was known by this staff member for almost a year and has not had any of this type of behavior before. The management did educate and set up a plan for the resident to be watched throughout the facility for his interactions with all residents after the incident. The resident was care planned for behaviors and Resident #2 was monitored for his communication/interaction with all residents. Resident #2 was currently under close observation.

Based on record review, and staff and physician interviews, the facility failed to immediately notify the resident's physician of an acute change in the resident's condition for one of three sampled residents (Resident #1) reviewed for notification of change when Resident #1 complained of respiratory distress and chest pain and became unresponsive. Resident #1 was pronounced deceased upon arrival to the hospital. Immediate jeopardy began on [DATE] when Resident #1 complained of respiratory distress and chest pain, an acute (sudden) change of condition for Resident #1, and became unresponsive. Immediate Jeopardy was abated on [DATE] at 3:15 PM when the facility provided a credible allegation of compliance. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. Findings included: Resident #1 was admitted [DATE] with a past medical history which included dependent [MEDICAL CONDITION] (swelling), and bilateral carotid stenosis. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was cognitively intact, had no behaviors or rejection of care noted in the seven day look back period, required extensive assistance for all activities of daily living except eating and locomotion, and was impaired on 1 upper and 1 lower side. Active [DIAGNOSES REDACTED]. Resident #1 was always understood, had no swallowing difficulties, and received no special treatments, procedures, or programs. A review of the physician orders [REDACTED].#1 was a full code, and the staff could use facility standing orders for chest pain and respiratory difficulty. A review of the Routine Physician Standing Orders for Resident #1 included: 9) Chest Pain: [MEDICATION NAME] 0.4mg (milligrams) SL (sublingual) every 5 minutes x (times) 3 doses as needed for chest pain. Monitor BP (blood pressure) with each dose. *Notify MD (physician) immediately after initial dose.* and 12) Oxygen: O2 (oxygen) at 2L (liters) per min (minute) via NC (nasal cannula) or mask prn (as needed) for respiratory distress/labored respirations and notify MD immediately. Documentation in Resident #1's record was reviewed for the events on [DATE]. No nursing notes were present in the record. The facility was able to locate an incident report dated [DATE] at 2:13 AM. An incident report dated [DATE] at 2:13 AM was reviewed. The incident description read, The fire alarms started going off in the building and all the doors shut. Five minutes into the alarm steady going the resident (Resident #1) sat up in his bed and stated that he couldn't breath(e). I told the resident to take short breaths and calm down. I was checking his chart at the same time to see if he had anxiety. I seen he did not have anxiety. Then the resident started saying that his chest was hurting and he laid back on his bed and was having short breaths. I felt his carotid artery and felt a faint pulse and his breaths were getting more shadow (shallow) by the moment. I told the CNA (nursing assistant) to call 911 and another CNA to check his vital signs and stay with him until the ambulance gets here. The ambulance came and when they got here he was not breathing. They started CPR (cardiopulmonary resuscitation) on him immediately and was doing several other things. When they took him out on the stretcher they were still doing CPR. His doctor is at (an assisted living facility) so therefore we could not notify doctor. Further review of the incident report revealed Resident #1 was comatose (unarousable to verbal or physical stimuli) at the time of the incident. The report was electronically signed by Nurse #1. A telephone interview with the Maintenance Director was conducted on [DATE] at 5:10 PM. He stated he received a phone call at approximately 1:00 AM from the company used to monitor the facility ' s fire system. They told him there was an alarm going off. He stated, I called the facility and sure enough they were going off. The first time the fire alarm went off on [DATE] was at 1:04 AM. A telephone interview was conducted with Nurse #1 on [DATE] at 1:20 PM. She stated she believed Resident #1 got scared and could not breathe related to the fire alarm going off. She stated, I was the only licensed nurse for all 3 units that night. The fire alarm went off so I was trying to call the DON (Director of Nursing) but she didn't answer. I was on the hall giving out my meds right in front of (Resident #1 ' s) room. I think he got scared and said he couldn't breathe. I looked for any antianxiety medications but he didn ' t have any ordered. I looked and saw he had lots of heart stuff going on. The NA (nursing assistant) couldn't dial 911 from the desk, I don ' t know why. I was in the room talking to the resident to try and calm him down. I assessed him. He was breaking out in sweat, his breathing started slowing down, and his pulse was slow. He complained of chest pain and not being able to breathe. He was having symptoms of a [MEDICAL CONDITION]. He was still breathing and coherent and kept saying he couldn't breathe and his chest hurt until the ambulance got there. Then he got real quiet when EMS (Emergency Medical Services) got there. When the ambulance got there they started CPR (Cardiopulmonary resuscitation). (Resident #1) couldn't talk to Emergency Medical Services (EMS) because he was unresponsive. I didn ' t put him on oxygen because I was so scared. This was the first death I ever saw and it really shook me. A telephone interview was conducted on [DATE] at 3:40 PM with NA #1. She stated, I know the fire alarms were going off that night. (Resident #1) started yelling out that he couldn't breathe and was having chest pain. I heard him screaming out. The nurse (Nurse #1) asked me to go in and check on him. It seemed like he was calmer after a little while so I went across the hall to do incontinence care for another resident. When I came out of her room, (Resident #1) was screaming out again about chest pain so Nurse #1 asked me to call his doctor. I said you want me to call his doctor? But I never could find the doctor's number. So I got another NA (NA #2) to come help me with (Resident #1). The nurse (Nurse #1) was still at her medication cart. She (Nurse #1) didn't come in to (Resident #1's) room until I yelled out that he was unresponsive. An additional interview was conducted with NA #1 on [DATE] at 12:05 PM. She stated, I was in the room when he (Resident #1) became unresponsive. I called his name 3 times. He responded the first time, but not the next two times. I yelled out to NA #2 to get his vitals and yelled out to his nurse (Nurse #1) should we start CPR. She came in, checked a pulse in his neck, and said he had a pulse so we didn ' t need to do CPR. She (Nurse #1) then walked out of the room. She (Nurse #1) never checked to see if he (Resident #1) was responsive or breathing. I saw no respirations so I ran out and called 911. NA #2 stayed at the bedside and his nurse (Nurse #1) was at her cart on the other side of the hall. When EMS got there no one was in the room with him. His nurse (Nurse #1) was sitting behind the nurses' desk at that time getting his paperwork together. They (EMS) asked me why no one was doing CPR. I told them his nurse said he was breathing and had a pulse so we didn't do CPR. He wasn' t his normal color either. His face was darker-not purple exactly- but darker. I think it was about 5 minutes from the time I called 911 until EMS arrived. Altogether, I think he wasn't breathing for about 10 minutes. Attempts to interview NA #2 were unsuccessful. A telephone interview with Resident #1's physician was conducted on [DATE] at 6:00 pm. He stated, In general, he (Resident #1) could have had a better outcome had the AED (Automated External Defibrillator) been used immediately. We could've acted more immediately with CPR or the AED, and the AED could've helped rescusitative measures. The physician also stated he was not notified of a change in condition for Resident #1 on [DATE], but a review of the call log for his practice indicated a call was received at 2:19 AM from the facility to notify them of Resident #1's death. An interview with the Administrator on [DATE] at 9:50AM. She stated, I was notified of the incident by the DON at the time when I came in the next day. She (the DON) was notified that morning of the incident after she arrived for work. My expectations for a nurse or staff member finding a resident in respiratory distress and complaining of chest pain is to get vital signs, get an oxygen saturation level and put the resident on oxygen. Staff have to find out the code status in the electronic medical record, and call 911. The nurse is to look at the standing orders to see if they could give [MEDICATION NAME] or complete other standing orders. If the resident is unresponsive and is a full code they have to start CPR. A nurse should be able to detect a significant change in a resident ' s condition. She also stated no standing orders were initiated by staff, the CPR policy was not followed, Nurse #1 had not recognized a change in Resident #1's condition, and the facility investigation revealed the resident's responsible nurse was not in the room when EMS arrived. She also stated no facility administration personnel, and no physician was notified. She added the facility standing orders for chest pain and oxygen should have been used, but were not. Resident #1 had a significant change in condition which resulted in cardiac and respiratory arrest. The Administrator was notified of the immediate jeopardy on [DATE] at 2:45 PM. Immediate Jeopardy was abated on [DATE] at 3:15 PM when the facility provided a credible allegation of compliance. The nursing home provided the following credible allegation of compliance. On [DATE], Resident #1 experienced a change in condition which included shortness of breath and chest pain. 911 was called and CPR was started by the emergency medical team upon their arrival. The resident expired on [DATE]. The nurse assigned to the resident at the time of the event was suspended on [DATE]. An investigation was initiated and the assigned nurse never returned to work and was terminated. The CNA assigned to the resident at the time of the event, received education from the Director of Nursing on Changes in condition on [DATE]. In addition to this, another LPN and CNA were working in the building at the time of the event. The LPN received education from the Director of Nursing on Changes in Condition on [DATE]. The CNA did not return to the facility after the event. On [DATE] the nurse leadership team (the Quality Assurance Consultants and MDS nurse) in conjunction (with) the staff nurses assessed all current patients to determine if any patient was experiencing a change in condition (see list below). One patient was identified to have a bruise to his thumb. The MD was notified on [DATE] since this required a non-immediate notification. No orders were received but an investigation was initiated to determine the cause. Education was provided on [DATE] by the nurse leadership team (Quality Assurance Nurse Consultants, Director of Nursing, Staff Development Coordinator and RN managers) to all registered nurses (RN), licensed practical nurses (LPN), medication aides, and nursing assistants (full time, part time and as needed staff) to include how and when to use the automatic external defibrillator and the following: Changes in a patient condition occur for many different reasons. Some of the most common changes in condition include: · change in vital signs, · neuro checks, · lethargy/sedation, · restlessness, · change in mental status, · confusion, · slurred speech, · onset of muscle weakness, · decreased appetite (wt. loss), · skin changes, · constipation, · respiratory depression (slowed rate of breathing, one of the more serious concerns), · nausea/vomiting, · dizziness, · weakness, · dry mouth, · difficulty in urination, · change in continence, · falls and · sleepiness. · New onset of pain or worsening pain unrelieved by interventions. A [MEDICAL CONDITION] may also occur suddenly. Patients may have a combination of systems such as pain/discomfort or tightness between shoulder blades, arm, chest, jaw, left arm, or upper abdomen. Pain may occur during rest and can be described as a clenched fist in the chest. Some patients may encounter dizziness, fatigue, lightheadedness, clammy skin, cold sweat, or sweating. They may also have gastrointestinal symptoms such as heartburn, indigestion, nausea, or vomiting. Also it is common for patients to experience anxiety, feeling of impending dome, sensation of an abnormal heartbeat, shortness of breath, or shoulder discomfort. What to do when I notice a change of condition? · If you are not a nurse, then notify the nurse immediately of the changes you have noticed. Even small changes can be very important since they may indicate bigger problems to come. · Nurses should assess the patient. This assessment may require vital signs, blood glucose levels, and a physical assessment. Assessment needs will vary depending on the patient ' s complaint or signs/symptoms. LPN ' s can also collect data related to a patient ' s condition. They should refer to the Interact Change in Condition Cards for guidance regarding immediate notification. The Interact Change in Condition Cards is a document that contains an alphabetized list of signs and symptoms that commonly occur with residents. The document then indicates what patient indicators would require immediate notification and which would require non immediate notification. This document is attached to this in-service and is located at the nursing station. If an LPN do not contact the MD with their findings they must immediately notify either the RN in the building or the RN on call to ensure that their actions are appropriate. · The patient ' s chart should also be reviewed by the nurse in order to determine if a patient had a condition that may explain the signs and symptoms they are experiencing. For example if a patient has a history of [MEDICAL CONDITION] and is having anxiety, then you should consider that the patient may be having a [MEDICAL CONDITION]. · Signs and symptoms of a [MEDICAL CONDITION] include: pain/discomfort or tightness between shoulder blades, arm, chest, jaw, left arm, or upper abdomen. Pain may occur during rest and can be described as a clenched fist in the chest. Some patients may encounter dizziness, fatigue, lightheadedness, clammy skin, cold sweat, or sweating. They may also have gastrointestinal symptoms such as heartburn, indigestion, nausea, or vomiting. Also it is common for patients to experience anxiety, feeling of impending dome, sensation of an abnormal heartbeat, shortness of breath, or shoulder discomfort · If interventions are available by using the standing orders, patient current orders, or items identified in the plan of care then they should be implemented as appropriate. This may include Tylenol for fever etc. · The nurse should check on the patient experiencing the change at least every 5 minutes. If a patient is having trouble breathing, chest pain or extreme anxiety the nurse should assign someone to stay with the person while interventions are being initiated. · Interventions should be implemented immediately when change is identified. · Assessment results and interventions must be documented in the medical record. · Determine when to notify the physician. Some changes require immediate notification of the physician while others may be appropriate to wait until the physician next rounds. Immediate Notification is required with any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change (i.e. more severe) in relation to usual symptoms and signs OR unrelieved by measures already prescribed. Non-immediate notification is appropriate with new or worsening symptoms that do not meet that criteria. INTERACT has a change in condition clinical guide that is very helpful in determining when to notify the physicians. This tool is also attached to this in-service. · Phone numbers for physicians are located at the nursing stations. If a physician does not respond to an emergency within an hour you must notify the supervisor on call for further instructions. · Notify the responsible party and document this in the nursing notes. · CPR should be initiated when respirations and pulse are absent. Unless the patient is a DNR or if there are obvious clinical signs of death. So if a patient is found without respiration or pulse and obvious signs of prolonged death exist such as rigor mortis, dilated pupils or cyanosis. · Only staff who have been trained in CPR should conduct CPR on a patient. · 911 should be contacted promptly when ordered by a physician or if the patient is actively coding. · An Automatic External Defibrillator is located at the ,[DATE] hall nursing station. Any employee who has not received this education by [DATE] will not be allowed to work until the education is provided. The administrator will ensure that all that should receive this education do. This training will be incorporated into the new hire orientation process for all licensed nursing, medication aides and nursing assistants. On [DATE] at 3:15 PM, the credible allegation was validated. Staff interviews with licensed nurses, and unlicensed nursing assistants revealed the facility had implemented corrective measures which included in-services of licensed nurses and unlicensed nursing assistants to recognize and report a change in resident condition, and the proper facility procedure and protocol for physician notification for residents experiencing an acute change in condition.

Based on record review and facility staff, physician and emergency medical services personnel interviews, the facility failed to effectively intervene in an emergent situation, and failed to initiate emergency medical services immediately for one of three sampled residents (Resident #1) reviewed. Resident #1 was pronounced deceased upon arrival to the hospital. Immediate Jeopardy began on [DATE] when Resident #1 complained of respiratory distress and chest pain, became unresponsive, exhibited signs and symptoms of an acute event, and interventions were not implemented. Immediate Jeopardy was abated on [DATE] at 3:15 PM when the facility provided a credible allegation of compliance. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. Findings included: A review of the facility ' s most recent Cardio [MEDICAL CONDITION] Resuscitation (CPR) policy, revised ,[DATE] revealed: It is the policy of this nursing facility to act affirmatively to preserve the life of all residents. It is the policy of this facility to initiate Basic Life Support (BLS) CPR as defined by the American Heart Association (AHA) or the American Red Cross equivalent. This will be done by trained staff that have completed either of the above mentioned courses and have a current certification. Facility staff will initiate full code and/or resuscitative measures as warranted by a resident ' s cardiac or [MEDICAL CONDITION] arrest. Further review of the policy revealed If a resident is noted with a significant change of condition the staff member should immediately alert the nurse for the resident and a code blue called over the intercom. All nurses and staff should respond to the room. The crash cart shall be taken to the room. The staff nurse responsible for resident begins an assessment of the resident and implements CPR if the resident is a full code status. Staff should follow the AHA basic life support procedures based on their most recent training. Resident #1 was admitted [DATE] with a past medical history which included dependent [MEDICAL CONDITION] (swelling), and bilateral carotid stenosis. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was cognitively intact, had no behaviors or rejection of care noted in the seven day look back period, required extensive assistance for all activities of daily living (ADLs) except eating and locomotion, and was impaired on 1 upper and 1 lower side. Active [DIAGNOSES REDACTED]. Resident #1 was always understood, had no swallowing difficulties, and received no special treatments, procedures, or programs. A review of the physician orders [REDACTED].#1 was a full code, and the staff could use facility standing orders related to chest pain or respiratory distress. A review of the Routine Physician Standing Orders for Resident #1 included: Chest Pain: [MEDICATION NAME] 0.4mg (milligrams) SL (sublingual) every 5 minutes x (times) 3 doses as needed for chest pain. Monitor BP (blood pressure) with each dose. *Notify MD (physician) immediately after initial dose.* and Oxygen: O2 (oxygen) at 2L (liters) per min (minute) via NC (nasal cannula) or mask prn (as needed) for respiratory distress/labored respirations and notify MD immediately. Documentation in Resident #1's record was reviewed for the events on [DATE]. No nursing notes were present in the record. An incident report dated [DATE] at 2:13 AM was reviewed. The incident description read, The fire alarms started going off in the building and all the doors shut. Five minutes into the alarm steady going the resident (Resident #1) sat up in his bed and stated that he couldn ' t breath(e). I told the resident to take short breaths and calm down. I was checking his chart at the same time to see if he had anxiety. I seen he did not have anxiety. Then the resident started saying that his chest was hurting and he laid back on his bed and was having short breaths. I felt his carotid artery and felt a faint pulse and his breaths were getting more shadow (shallow) by the moment. I told the CNA (nursing assistant) to call 911 and another CNA to check his vital signs and stay with him until the ambulance gets here. The ambulance came and when they got here he was not breathing. They started CPR (cardiopulmonary resuscitation) on him immediately and doing several other things. When they took him out on the stretcher they were still doing CPR. Nurse #1 also indicated Resident #1 ' s physician was not notified. Further review of the incident report revealed Resident #1 was comatose (unarousable to verbal or physical stimuli) at the time of the incident. The report was electronically signed by Nurse #1. A telephone interview was conducted with Nurse #1 on [DATE] at 1:20 PM. She stated she believed Resident #1 got scared and could not breathe related to (r/t) the fire alarm going off. She stated, The fire alarm went off so I was trying to call the DON (Director of Nursing) but she didn ' t answer. I was on the hall giving out my meds right in front of (Resident #1 ' s) room. I think he got scared and said he couldn ' t breathe. I looked for any antianxiety medications but he didn ' t have any ordered. I looked and saw he had lots of heart stuff going on. The NA (nursing assistant) couldn ' t dial 911 from the desk, I don ' t know why. I was in the room talking to the resident to try and calm him down. I assessed him. He was breaking out in sweat, his breathing started slowing down, and his pulse was slow. He complained of chest pain and not being able to breathe. He was having symptoms of a [MEDICAL CONDITION]. He was still breathing and coherent and kept saying he couldn ' t breathe and his chest hurt until the ambulance got there. Then he got real quiet when EMS (Emergency Medical Services) got there. When the ambulance got there they started CPR (Cardiopulmonary resuscitation). (Resident #1) couldn ' t talk to Emergency Medical Services (EMS) because he was unresponsive. I didn ' t put him on oxygen because I was so scared. This was the first death I ever saw and it really shook me. Nurse #1 also stated her BLS certification was current. A telephone interview was conducted on [DATE] at 3:00 PM with Nurse #2 typically assigned to work 7 pm through 7 am on weekends. She stated, I was working on the front Hall - the 100 and 200 Hall. There was never a code paged overhead that night. All I know is the fire alarms went off. I was trying to find the fire panel. That why I went down that hallway where (Resident #1) resided. I walked by the hallway 2 or 3 times and no one told me of any problems. Once I got the alarm problem situated one of the NAs was at the front door. She handed me a cell phone and said EMS is on the phone and said they may need my help on the 300 Hall with the defibrillator. I got on the phone with EMS and they wanted to speak to the resident's nurse. I handed her (Nurse #1) the phone to speak to EMS. I asked her if she needed help with anything. She told EMS to hold on while she handed the phone to his (Resident #1) nurse. She (Nurse #1) handed the phone to an NA (NA #2) and said EMS wants to talk to you. The NA was taking vital signs on Resident #1 at the time, but never wrote them down. The nurse (Nurse #1) wasn't at the bedside near the patient. I asked again if she (Nurse #1) needed help, and she said no again. I couldn't tell if (Resident #1) was breathing or had a pulse. His color was pale. I assumed they had it under control. None of the equipment for a code was near the room. If there is a resident who has a low heart rate, is sweating and complaining of shortness of breath and chest pain you have to call a code blue overhead. There was no code called over the intercom that night. Nurse #2 also stated her BLS CPR was current. A telephone interview was conducted on [DATE] at 3:40 PM with NA #1. She stated, I know the fire alarms were going off that night. (Resident #1) panicked, I thought, and started yelling out that he couldn't breathe and was having chest pain. I heard him screaming out. The nurse (Nurse #1) asked me to go in and check on him. She asked if he had taken his medications that she had left. His cup was empty, but he couldn't remember if he had taken them. It seemed like he was calmer after a little while so I went across the hall to do incontinence care for another resident. When I came out of her room, (Resident #1) was screaming out again about chest pain so Nurse #1 asked me to call his doctor. I said you want me to call his doctor? But I never could find the doctor's number. So I got another NA (NA #2) to come help me with (Resident #1). The nurse (Nurse #1) was still at her medication cart. She (Nurse #1) didn't come in to (Resident #1's) room until I yelled out that he was unresponsive. I asked about CPR. She checked his neck and said he had a faint pulse so we didn't start CPR. She never asked about vital signs so we never wrote down the ones we got. When EMS got here, they went in his (Resident #1 ' s) room and asked why we hadn't started CPR. I said his (Resident #1 ' s) nurse told me he had a pulse so we didn't start CPR. I don't think he had a pulse though. When EMS started asking me questions I told them I was just an NA and they should speak to his nurse. She (Nurse #1) was sitting at the nursing station trying to get paperwork together for him to go to the hospital. A code was never paged overhead. No one put oxygen on him. His roommate was also hollering for someone to come help him. NA #1 also stated her BLS CPR was current. An additional interview was conducted with NA #1 on [DATE] at 12:05 PM. She stated, I was in the room when he (Resident #1) became unresponsive. I called his name 3 times. He responded the first time, but not the next two times. I yelled out NA #2 to get his vitals and yelled out to his nurse (Nurse #1) should we start CPR. She came in, checked a pulse in his neck, and said he had a pulse so we didn ' t need to do CPR. She (Nurse #1) then walked out of the room. She (Nurse #1) never checked to see if he (Resident #1) was responsive or breathing. I saw no respirations so I ran out and called 911. NA #2 stayed at the bedside and his nurse (Nurse #1) was at her cart on the other side of the hall. When EMS got there no one was in the room with him. His nurse (Nurse #1) was sitting behind the nurses ' desk at that time getting his paperwork together. They (EMS) asked me why no one was doing CPR. I told them his nurse said he was breathing and had a pulse so we didn ' t do CPR. He wasn ' t his normal color either. His face was darker-not purple exactly- but darker. I think it was about 5 minutes from the time I called 911 until EMS arrived. All together, I think he wasn ' t breathing for about 10 minutes. Attempts to interview NA #2 were unsuccessful. A telephone interview with the Maintenance Director was conducted on [DATE] at 5:10 PM. He stated he received a phone call at approximately 1:00 AM from the company used to monitor the facility ' s fire system. They told him there was an alarm going off. He stated he called the facility and the fire alarms were heard sounding. He also stated, I called our monitoring company and their log book indicated the fire alarm went off the first time 1:04 AM on [DATE]. A review of the EMS report dated [DATE] revealed EMS received a 911 call from the facility at 1:35 AM and arrived at Resident #1 ' s bedside at 1:43 AM. Resident #1 was unresponsive, pulseless, and without respirations when EMS arrived at the bedside. EMS immediately initiated CPR and asked the NA in the room why staff had not started CPR. The NA (NA#1) stated Resident #1 ' s nurse (Nurse #1) thought he had a pulse and CPR was not needed. The narrative written by the responsible Paramedic (Paramedic #1) read, in part, Arrived on scene to be greeted by staff members. Led to pts (patient ' s) room. Staff members are not cooperative when attempting to gather information as to who the pt is, the pts history, and the events leading to his present condition. Upon arriving at pts room the pt is noted to be in a supine (lying on his back) position and no evidence of breathing. Pt is pulseless, apneic, and unresponsive. CPR is initiated. According to staff pt does not have a DNR (Do Not Resuscitate). Staff member is asked to go get pts nurse in order to get some information on the pt. Just prior to departing scene pts nurse (Nurse #1) states that the pt was complaining of chest pain and shortness of breath prior to going into [MEDICAL CONDITION]. The EMS report was electronically signed by Paramedic #1. A telephone interview was conducted on [DATE] at 12:20 PM with Paramedic #1 who responded on [DATE]. She stated, One of the staff members greeted me at the door and took us to the resident ' s (Resident #1) room. There was an NA in there. When we walked in the resident (Resident #1) was apneic. I asked staff why they weren ' t doing CPR. She (NA #1) said the nurse (Nurse #1) walked out and she didn ' t know what to do. I sent her out to get the nurse. All of this took place while we were doing CPR. The nurse never once came to the patient ' s room. When we were leaving the nurse was standing outside the patient ' s door with his paperwork and I asked her what happened. That ' s when she told me about the chest pain. That was the only time I saw this patient ' s nurse. There was no movement of the patient ' s chest at any time we were there. When we walked to the doorway of his room I could see he wasn ' t breathing and his mouth was hanging open. That ' s why we started CPR. There was nothing in the room. No equipment, no oxygen, and no crash cart. I never witnessed the patient taking any breaths. A telephone interview with the facility physician was conducted on [DATE] at 6:00 PM. He stated, In general, he (Resident #1) could have had a better outcome had the AED (Automated External Defibrillator) been used immediately. We could've acted more immediately with CPR or the AED, and the AED could've helped rescusitative measures. An interview with the Administrator on [DATE] at 9:50 AM. She stated, I was notified of the incident by the DON at the time when I came in the next day. She (the DON) was notified that morning of the incident after she arrived for work. My expectations for a nurse or staff member finding a resident in respiratory distress and complaining of chest pain is to get vital signs, get an oxygen saturation level and put the resident on oxygen. Staff have to find out the code status in the electronic medical record, and call 911. The nurse is to look at the standing orders to see if they could give [MEDICATION NAME] or complete other standing orders. If the resident is unresponsive and is a full code they have to start CPR. A nurse should be able to detect a significant change in a resident ' s condition. She also stated no standing orders for chest pain or oxygen were initiated by staff, the CPR policy was not followed, Nurse #1 had not recognized a change in Resident #1 ' s condition, had not immediately initiated EMS, and had not effectively intervened in an emergent situation. She also stated the facility investigation revealed the resident ' s responsible nurse was not in the room when EMS arrived, and no facility administration personnel, the DON, or physician was notified. She added the facility standing orders for chest pain and oxygen should have been used, but were not. The Administrator also stated the crash cart was supplied with oxygen and an Automated External Defibrillator (AED). She stated an AED was part of BLS training and there was one located at the nursing station for the hall where Resident #1 had resided. The Administrator was notified of the immediate jeopardy on [DATE] at 2:45 PM. The facility ' s credible allegation was provided on [DATE] at 9:00 AM and the immediate jeopardy was abated on [DATE] at 3:15 PM. On [DATE], resident #1 experienced a change in condition which included shortness of breath and chest pain. 911 was called and CPR was started by the emergency medical team upon their arrival. The resident expired on [DATE]. The nurse assigned to the resident at the time of the event was suspended on [DATE]. An investigation was initiated and the assigned nurse never returned to work and was terminated. The CNA assigned to the resident at the time of the event, received education from the Director of Nursing on Changes in condition on [DATE]. In addition to this, another LPN and CNA were working in the building at the time of the event. The LPN received education from the Director of Nursing on Changes in Condition on [DATE]. The CNA did not return to the facility after the event. On [DATE] the nurse leadership team (the Quality Assurance Consultants and MDS nurse) in conjunction the staff nurses assessed all current patients to determine if any patient was experiencing a change in condition (see list below). One patient was identified to have a bruise to his thumb. The MD was notified on [DATE] since this required a non-immediate notification. No orders were received but an investigation was initiated to determine the cause. Education was provided by the nurse leadership team (Quality Assurance Nurse Consultants, Director of Nursing, Staff Development Coordinator and RN managers) to all registered nurses, licensed practical nurses, medication aides, and nursing assistants (full time, part time and as needed staff) to include how and when to use the automatic external defibrillator and the following: Changes in a patient condition occur for many different reasons. Some of the most common changes in condition include: · change in vital signs, · neuro checks, · lethargy/sedation, · restlessness, · change in mental status, · confusion, · slurred speech, · onset of muscle weakness, · decreased appetite (wt loss), · skin changes, · constipation, · respiratory depression (slowed rate of breathing, one of the more serious concerns), · nausea/vomiting, · dizziness, · weakness, · dry mouth, · difficulty in urination, · change in continence, · falls and · sleepiness. · New onset of pain or worsening pain unrelieved by interventions. · A [MEDICAL CONDITION] may also occur suddenly. Patients may have a combination of systems such as pain/discomfort or tightness between shoulder blades, arm, chest, jaw, left arm, or upper abdomen. Pain may occur during rest and can be described as a clenched fist in the chest. Some patients may encounter dizziness, fatigue, lightheadedness, clammy skin, cold sweat, or sweating. They may also have gastrointestinal symptoms such as heartburn, indigestion, nausea, or vomiting. Also it is common for patients to experience anxiety, feeling of impending dome, sensation of an abnormal heartbeat, shortness of breath, or shoulder discomfort. What to do when I notice a change of condition? · If you are not a nurse, then notify the nurse immediately of the changes you have noticed. Even small changes can be very important since they may indicate bigger problems to come. · Nurses should assess the patient. This assessment may require vital signs, blood glucose levels, and a physical assessment. Assessment needs will vary depending on the patient ' s complaint or signs/symptoms. LPN ' s can also collect data related to a patient ' s condition. They should refer to the Interact Change in Condition Cards for guidance regarding immediate notification. The Interact Change in Condition Cards is a document that contains an alphabetized list of signs and symptoms that commonly occur with residents. The document then indicates what patient indicators would require immediate notification and which would require non immediate notification. This document is attached to this inservice and is located at the nursing station. If an LPN do not contact the MD with their findings they must immediately notify either the RN in the building or the RN on call to ensure that their actions are appropriate. · The patient ' s chart should also be reviewed by the nurse in order to determine if a patient had a condition that may explain the signs and symptoms they are experiencing. For example if a patient has a history of [MEDICAL CONDITION] and is having anxiety, then you should consider that the patient may be having a [MEDICAL CONDITION]. · Signs and symptoms of a [MEDICAL CONDITION] include: pain/discomfort or tightness between shoulder blades, arm, chest, jaw, left arm, or upper abdomen. Pain may occur during rest and can be described as a clenched fist in the chest. Some patients may encounter dizziness, fatigue, lightheadedness, clammy skin, cold sweat, or sweating. They may also have gastrointestinal symptoms such as heartburn, indigestion, nausea, or vomiting. Also it is common for patients to experience anxiety, feeling of impending dome, sensation of an abnormal heartbeat, shortness of breath, or shoulder discomfort · If interventions are available by using the standing orders, patient current orders, or items identified in the plan of care then they should be implemented as appropriate. This may include Tylenol for fever etc. · The nurse should check on the patient experiencing the change at least every 5 minutes. If a patient is having trouble breathing, chest pain or extreme anxiety the nurse should assign someone to stay with the person while interventions are being initiated. · Interventions should be implemented immediately when change is identified. · Assessment results and interventions must be documented in the medical record. · Determine when to notify the physician. Some changes require immediate notification of the physician while others may be appropriate to wait until the physician next rounds. Immediate Notification is required with any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change (ie more severe) in relation to usual symptoms and signs OR unrelieved by measures already prescribed. Non-immediate notification is appropriate with new or worsening symptoms that do not meet that criteria. INTERACT has a change in condition clinical guide that is very helpful in determining when to notify the physicians. This tool is also attached to this in-service. · Phone numbers for physicians are located at the nursing stations. If a physician does not respond to an emergency within an hour you must notify the supervisor on call for further instructions. · Notify the responsible party and document this in the nursing notes. · CPR should be initiated when respirations and pulse are absent. Unless the patient is a DNR or if there are obvious clinical signs of death. So if a patient is found without respiration or pulse and obvious signs of prolonged death exist such as rigor mortis, dilated pupils or cyanosis. · Only staff who have been trained in CPR should conduct CPR on a patient. · 911 should be contacted promptly when ordered by a physician or if the patient is actively coding. · An Automatic External Defibrillator is located at the ,[DATE] hall nursing station. Any employee who has not received this education by [DATE] will not be allowed to work until the education is provided. The administrator will ensure that all that should receive this education do. This training will be incorporated into the new hire orientation process for all licensed nursing, medication aides and nursing assistants. On [DATE] at 3:15 PM, the credible allegation was validated. Staff interviews with nurses, and nursing assistants revealed the facility had implemented corrective measures which included in-services of nurses and nursing assistants to recognize and report a change in resident condition, and the proper facility procedure and protocol for residents experiencing an acute change in condition.

Based on record review, and facility staff interviews, the facility's administration failed to implement policies and procedures related to staff effectively intervening in an emergent situation, ensure staff recognized a significant change in a resident who required emergent interventions, and immediately notify Emergency Medical Services, the resident ' s physician, and facility administration for one of three (Resident #1) sampled residents. Resident #1 was pronounced deceased at the hospital. Immediate jeopardy began on [DATE] when Resident #1 complained of respiratory distress and chest pain, an acute (sudden) change of condition for Resident #1, and became unresponsive. Immediate Jeopardy was abated on [DATE] at 3:15 PM when the facility provided a credible allegation of compliance. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. Findings included: Cross reference to F 157: Based on record review, and staff and physician interviews, the facility failed to immediately notify the resident's physician of an acute change in the resident ' s condition for one of three sampled residents (Resident #1) reviewed for notification of change when Resident #1 complained of respiratory distress and chest pain and became unresponsive. Cross reference to F 309: Based on record review and facility staff, physician and emergency medical services personnel interviews, the facility failed to effectively intervene in an emergent situation, and failed to initiate emergency medical services immediately for one of three sampled residents (Resident #1) reviewed. Resident #1 was pronounced deceased upon arrival to the hospital. The Administrator was notified of the immediate jeopardy on [DATE] at 2:45 PM. The facility ' s credible allegation was provided on [DATE] at 9:00 AM and the immediate jeopardy was abated on [DATE] at 3:15 PM. On [DATE], Resident #1 experienced a change in condition which included shortness of breath and chest pain. 911 was called and CPR was started by the emergency medical team upon their arrival. The resident expired on [DATE]. On [DATE] thru [DATE] the Quality Assurance Nurse Consultants reviewed all current resident charts and patients discharged for the past 2 weeks to determine if significant changes were identified if the MD had been notified and if interventions had been initiated as appropriate for the event. No adverse event that would require a corrective action plan was identified. The administrator also confirmed that there are no other current corrective action plans that are being monitored except for this plan that is being implemented. On [DATE] the regional director of operations inserviced the administrator and director of nursing on the need to properly complete and follow up on any quality improvement activities related to adverse events. The inservice included: · All adverse events identified via daily clinical, rounds or other quality assurance processes require a prompt and through investigation and corrective action plan. · Corrective action plans should include corrective action for the affected patient and potentially affected patients, systematic changes and quality assurance review to ensure continued compliance. · Corrective action plans should be reviewed daily during stand up meeting to ensure that progress is made on educating all staff, implementing all corrective actions and conducting quality assurance audits. If items are missed or not completed timely strategies must be developed to ensure that they are completed timely going forward. · The corrective action plans must be reviewed by the Regional Director of Operations and the Quality Assurance Nurse Consultant. · Every week the Quality Assurance Tools must be submitted to the Regional Director of Operations and the Quality Assurance Nurse Consultant. The Administrative/Leadership Team has a zero tolerance policy for employees who fail to meet and follow policies and procedures that are in place in reference to responding appropriately to resident emergencies, including reporting of these emergencies to Administrator and Director of Nursing. Progressive disciplinary action up to termination will be implemented for employees who fail to adhere to these policies. In addition, when warranted the employee will also be reported to the Board of Nursing and/or Healthcare Personnel Registry. All nurses have been made aware of their obligation to report adverse events to the Administrator and/or Director of Nursing immediately after resident has received appropriate care and their M.D. and representative have been notified. This nursing education also included instructions on how to contact them 24 hours/7days per week. On [DATE] at 3:15 PM, the credible allegation was validated. Interviews with the Administrator and Director of Nursing revealed the facility had implemented corrective measures which included in-service on the need to properly complete and follow up on any quality improvement activities related to adverse events.

Based on observation, record review, resident interview, and staff interviews for one (Resident # 1) out of three sampled residents with a history of accidents the facility failed to assure the resident was assessed by licensed staff before moving the resident and following the accident. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident ' s admission MDS (minimum data set) assessment, dated 9/2/16, revealed the resident needed extensive assistance from two staff members for transfers. There was no (BIMS) brief interview of mental status assessment due to the resident not being understood on the date of assessment. Review of the resident ' s care plan revealed the staff updated the resident ' s care plan on 9/2/16. One updated care plan problem was the resident ' s risk for falls related to her balance problems and psychoactive drug use. The facility ' s goal for Resident # 1 was she not sustain any injuries. One of the care plan approaches was to encourage the resident to stand up slowly to avoid falls. Record review revealed the facility had completed a significant change assessment on 10/14/16 after the resident had sustained a fracture on 10/2/16. According to the 10/14/16 MDS assessment, the resident had a BIMS (brief interview for mental status) score of 12 on a scale of 1 to 15. Review of the resident ' s record revealed a nursing note that was entered on 10/6/16 at 10:13 PM by Nurse # 1 regarding an incident which had occurred previously on 10/2/16. The note read, 10/2/16, CNA (certified nursing assistant) reported that when she was transferring resident to bed with a stand up lift, she noted that the resident was misaligned on the holding slings and was slipping to her side. CNA called for help from the Medtech who was by the door, the medtech got in resident ' s room and assisted to transfer resident safely to a w/c (wheelchair). On further eval, resident was noted in w/c, mood was calm, and she denies pain. Staff continues to monitor resident throughout shift, resident did not verbalize pain during personal care, resident did not ask for PRN (as needed) [MEDICATION NAME] all night. Statements from the investigation were reviewed. NA # 1 ' s statement was dated 10/3/16 and read as follows, On [DATE]-2016 at 10 PM I was putting (Resident # 1) to bed. I used the standup lift on her the correct way. Before I lift in the air she was moving and I told her to be still so that is how she almost got out of the strips. (Medication aide) was there so he helped me put her to bed and I asked him do I need to do a report he told me that I did not have to do a report if she did not fall on the floor. She did not say that she was in pain at all last night. According to an interview with the administrator on 11/10/16 at 12:40 PM NA # 1 was no longer an employee of the facility and could not be reached for interview. MA # 1 was interviewed on 11/10/16 at 10:10 AM. The MA stated on the evening of the incident he was in the hallway within the vicinity of a room, which according to the facility map was three doors down from Resident # 1 ' s room, when he heard a crash and a scream. The MA stated he went to Resident # 1 ' s room and found part of the sling was on the resident and part of the sling was off of the resident. The MA stated the resident was in a position where she was not completely on the floor but her leg was bent and underneath the mechanical lift. The MA stated he helped NA # 1 transfer the resident to the wheelchair and she complained of pain for about ten minutes and then seemed to quit hurting. The MA did not know how the resident ' s leg had gotten under the mechanical lift. The MA stated he had reported the incident to Nurse # 1. According to MA # 1 he helped transfer the resident to the wheelchair without getting the nurse because the resident was suspended and not totally on the floor. MA # 1 stated he did not help transfer the resident to bed from the wheelchair, and that had been done by the NA after he had left the room. Nurse # 1 was interviewed on 11/11/16 at 1:35 PM. Nurse # 1 stated he had responsibilities on multiple facility halls on the evening of 10/2/16. Nurse # 1 stated NA # 1 and MA # 1 did not mention Resident #1 ' s incident until around 10:30 PM. Nurse # 1 stated they approached him and let him know the resident had started to slip from the mechanical lift sling earlier in the shift and it was Nurse # 1 ' s understanding they were just asking him what constituted a reportable fall. Nurse # 1 stated NA # 1 and MA # 1 did not report to him that the resident had fallen, been hurt, or that her leg had been bent. Nurse # 1 stated Resident # 1 received medications to help her rest. Nurse # 1 stated when he was approached by NA # 1 and MA #1 around 10:30 PM, Resident # 1 was already asleep and therefore since it had not been presented to him that she was hurt he did not awaken her at 10:30 PM to assess her. Nurse # 1 stated he did see Resident # 1 around 6 AM morning medication rounds but he did not assess her because she had rested well through the night, it had not been reported to him that she had been hurt, and the resident did not complain to him at that time. The nurse stated if it had been made clear to him that the resident had been injured then he would have assessed her. The DON (director of nursing) was interviewed on 11/9/16 at 3:10 PM and she provided documentation of the facility ' s investigation into the incident. The DON stated the following details were found from her investigation. NA # 1 was the nurse aide involved in the incident. (MA) Medication aide # 1 and Nurse # 1 had assigned responsibilities for Resident # 1 ' s hall on the evening of the incident. The DON stated she had talked to Resident # 1 on 10/3/16 and the resident complained of the previous day ' s incident to her. The DON stated she assessed the resident needed to be further evaluated and assured on 10/3/16 the resident had follow up which identified the fracture. The DON stated during her investigation she had talked to Nurse # 1 and he had reported he thought the resident was okay. Record review revealed the resident had an x-ray completed the day following the 10/2/16 incident. The 10/3/16 x-ray result showed an acute oblique fracture involving the distal end of fibula. Record review revealed the resident was transferred to the hospital on [DATE] where she was placed in a soft cast to her lower left extremity and returned to the facility on that date. On 11/9/16 at 11:05 AM the resident was observed to have a cast to her left lower leg. The resident stated part of a lift fell on her leg when a NA was transferring her. The resident stated it had hurt and broken her ankle when it fell . The resident stated it seemed like a bar of steel had fallen on her ankle.

Based on observation, record review, resident interview, and staff interviews for one (Resident # 1) out of three sampled residents with a history of accidents the facility failed to transfer the resident safely and the resident sustained [REDACTED]. Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident ' s admission MDS (minimum data set) assessment, dated 9/2/16, revealed the resident needed extensive assistance from two staff members for transfers. There was no (BIMS) brief interview of mental status due to the resident not being understood on the date of assessment. Review of the resident ' s care plan revealed the staff updated the resident ' s care plan on 9/2/16. One updated care plan problem was the resident ' s risk for falls related to her balance problems and psychoactive drug use. The facility ' s goal for Resident # 1 was she not sustain any injuries. One of the care plan approaches was to encourage the resident to stand up slowly to address her risk for falls. The care plan did not indicate the resident used a mechanical lift but that she was able to stand without one. Record review revealed the facility had completed a significant change assessment on 10/14/16 after the resident had sustained a fracture on 10/2/16. According to the 10/14/16 MDS assessment, the resident had a BIMS (brief interview for mental status) score of 12 on a scale of 1 to 15 and required total assistance for transfers. Review of the resident ' s record revealed a nursing note that was entered on 10/6/16 at 10:13 PM by Nurse # 1 regarding an incident which had occurred previously on 10/2/16. The note read, 10/2/16, CNA (certified nursing assistant) reported that when she was transferring resident to bed with a stand up lift, she noted that the resident was misaligned on the holding slings and was slipping to her side. CNA called for help from the Medtech who was by the door, the medtech got in resident ' s room and assisted to transfer resident safely to a w/c (wheelchair). On further eval, resident was noted in w/c, mood was calm, and she denies pain. Staff continues to monitor resident throughout shift, resident did not verbalize pain during personal care, resident did not ask for PRN (as needed) analgesics all night. Record review revealed the resident had an x-ray completed the day following the 10/2/16 incident. The 10/3/16 x-ray result showed an acute oblique fracture involving the distal end of fibula. Record review revealed the resident was transferred to the hospital on [DATE] where she was placed in a soft cast to her lower left extremity and returned to the facility on that date. On 11/9/16 at 11:05 AM the resident was observed to have a cast to her left lower leg. The resident stated part of a lift fell on her leg when a NA was transferring her. The resident stated it had hurt and broken her ankle when it fell . The resident stated it seemed like a bar of steel had fallen on her ankle. The DON (director of nursing) was interviewed on 11/9/16 at 3:10 PM and provided documentation of the facility ' s investigation into the incident. The DON stated the following details were found from her investigation. NA # 1 was the nurse aide involved in the incident. (MA) Medication aide # 1 and Nurse # 1 had assigned responsibilities for Resident # 1 ' s hall on the evening of the incident. Prior to the incident, the facility had assessed that Resident # 1 needed assistance to stand and pivot and was not care planned for the use of a mechanical lift. The DON stated NA # 1 had cared for Resident # 1 while the resident had resided at another facility, and NA # 1 had used a sit to stand lift with the resident while caring for her at the other facility. The DON stated on the night of the incident, NA # 1 had decided to use the sit to stand mechanical lift with Resident # 1 and the resident was reportedly uncooperative and slipped from the sling. The DON stated she had obtained statements during her investigation. The DON was asked about the resident ' s comments regarding part of the lift falling on the resident. The DON stated the facility had not been able to determine how that would have been possible. The DON accompanied the surveyor to the resident ' s room and also took the mechanical sit to stand lift used for that particular hall into the resident ' s room. The resident was asked again about the incident while the mechanical lift was in the room. The resident stated part of the lift had fallen on her leg but she was unsure how it had happened. The DON stated none of the parts were removable and they had not identified how part of the lift could have impacted the resident ' s leg during the incomplete transfer. Statements from the investigation were reviewed. NA # 1 ' s statement was dated 10/3/16 and read as follows, On [DATE]-2016 at 10 PM I was putting (Resident # 1) to bed. I used the standup lift on her the correct way. Before I lift in the air she was moving and I told her to be still so that is how she almost got out of the strips. (Medication aide) was there so he helped me put her to bed and I asked him do I need to do a report he told me that I did not have to do a report if she did not fall on the floor. She do not say that she was in pain at all last night. The medication aide ' s statement was reviewed. It read, On Sunday, October 4, 2016 around 7:30-8:30 PM, I heard a scream on (Resident ' s) hall. Upon entering room (of resident), I witnessed a CNA who name I do not remember (new) with (resident) halfway out of a sit and stand lift. Her left leg seemed to have been bent but the rest of her body did not seem to have made contact with the floor. At that moment, I assisted the CNA in picking (Resident) off the floor and into her wheelchair. (Resident) complained of pain but did not continue for long after the incident, the CNA and I asked the LPN (licensed practical nurse) if we need or should write an incident report but he seemed unsure. There was no statement in the investigative file written by Nurse # 1. According to an interview with the administrator on 11/10/16 at 12:40 PM NA # 1 was no longer an employee of the facility for a reason unrelated to the incident. Per the administrator the NA had recently failed to show up for scheduled duty without calling. The NA could not be reached for interview. MA # 1 was interviewed on 11/10/16 at 10:10 AM. The MA stated on the evening of the incident he was in the hallway within the vicinity of a room, which according to the facility map was three doors down from Resident # 1 ' s room, when he heard a crash and a scream. The MA stated he went to Resident # 1 ' s room and found part of the sling was on the resident and part of the sling was off of the resident. The MA stated the resident was in a position where she was not completely on the floor but her leg was bent and underneath the mechanical lift. The MA stated he helped NA # 1 transfer the resident to the wheelchair and she complained of pain for about ten minutes and then seemed to quit hurting. The MA did not know how the resident ' s leg had gotten under the mechanical lift. The MA stated he had reported the incident to Nurse # 1. Nurse # 1 was interviewed on 11/11/16 at 1:35 PM. Nurse # 1 stated he had responsibilities on multiple facility halls on the evening of 10/2/16. Nurse # 1 stated NA # 1 and MA # 1 did not mention Resident #1 ' s incident until around 10:30 PM. Nurse # 1 stated they approached him and let him know the resident had started to slip from the mechanical lift sling earlier in the shift and it was Nurse # 1 ' s understanding they were just asking him what constituted a reportable fall. Nurse # 1 stated NA # 1 and MA # 1 did not report to him that the resident had fallen, been hurt, or that her leg had been bent. Nurse # 1 stated Resident # 1 received medications to help her rest. Nurse # 1 stated when he was approached by NA # 1 and MA #1 around 10:30 PM, Resident # 1 was already asleep and therefore since it had not been presented to him that she was hurt he did not awaken her at 10:30 PM. Nurse # 1 did not know how her leg could have gotten caught under the lift. The regional licensed technician for the company, who manufacturers the mechanical lift used in the incident, was interviewed on 11/14/16 at 1:51 PM. The technician stated in trying to reenact the events that led to an incident, he therefore tried to determine what had failed to be done correctly or if the lift had been at fault. The technician stated it took great force to turn a lift over and he did not know how any part of the lift could have fallen on the resident. The regional licensed technician for the company was interviewed again on 11/16/16 at 12:42 PM. The technician stated he had completed a check of the lift that day. Interview with the technician revealed it was his opinion that even if the resident had been uncooperative it should not have resulted in the lift tilting or the resident slipping from the sling if it had been applied correctly. On 11/9/16 at 3:10 PM the DON stated she had identified on 10/3/16 that mechanical lift transfers needed to be addressed in their QA (quality assurance) program. The DON stated she was able to determine, that on the incident date, NA # 1 had not referenced the computerized Kardex which provided instructions for Resident # 1 to be a stand and pivot transfer. The DON stated the facility felt the resident had sustained injury because she had been uncooperative during the mechanical lift transfer, and if the proper transfer had been done then the accident could have been avoided. The DON stated all staff members were educated to refer to the Kardex for resident transfer needs; all staff members were inserviced on proper mechanical lift transfer techniques; all residents were reassessed for transfer needs; audits were done to assure compliance; and it continued to be monitored in their QA program. The DON presented written documentation that their QA (quality assurance) program had implemented corrective action. The QA documentation was reviewed revealing the following. According to documentation all residents were assessed to determine their transfer status and all residents ' lift mobility assessments were reviewed to assure that all lift recommendations were still appropriate for all residents. This assessment was documented as beginning on 10/5/16 and completed on 10/25/16. Care plans and Kardexs were updated per the facility ' s quality assurance review. Education for staff regarding transfers and referencing the Kardex were begun on 10/5/16 and completed on 10/25/16. The facility ' s QA included a plan for weekly audits for four weeks following the incident and then were to be continued monthly for two months. Results of the audits were to be discussed in quality assurance to determine if further action was needed. According to the quality assurance records, these audits were begun on 10/12/16. There was evidence five residents were observed by facility administrative staff on 10/12/16 and weekly thereafter per their quality assurance plan. There was documentation the auditor noted that they observed if the transfer device and sling matched the resident ' s care plan; what transfer and sling/device was used; if the proper technique was used; and if the nurse aide demonstrated proper technique in accessing Kardex instructions prior to transferring a resident. The facility also had documentation of fifty one staff attestation forms on which staff members had signed they had completed the transfer and lift safety education program conducted by the facility. On 11/9/16 at 11:25 AM Resident # 1 was observed to be transferred safely from the wheelchair to her bed by a mechanical lift and the assistance of two staff members per her plan of care.

Based on observation, staff interviews and records review, the facility failed to prevent two resident falls contributed to staff error (Resident 4 and Resident 1) resulting in injuries for 2 of 3 residents reviewed for accidents. The facility also failed analyze the circumstances surrounding the fall for 1 of 3 (Resident #1) residents reviewed for accidents. Findings included: 1. Resident #4 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #4 had severe cognitive impairment and behaviors directed toward himself. He was coded for extensive assistance of one staff for bed mobility and hygiene and incontinent of bowel and bladder. A review of an incident report dated 10/4/15 at 2:00 AM, the nurse was called to the room to observe Resident #4 lying on the floor face down with the bed in the highest position. The aide stated when she was changing him, he fell off the side of the bed. He sustained a laceration to his outer left forearm and screamed in pain during assessment for range of motion in his legs. Emergency medical services was notified and Resident #4 was sent out for evaluation. The original x-ray was negative for any fractures at the hospital and Resident #4 was returned to the facility. A nursing note dated 10/5/15 at 9:41 PM indicated a repeat x-ray was done at 5:30 PM per physician orders [REDACTED]. The x-ray completed at the facility on 10/5/15 indicated Resident #4 had an acute fracture of the left femoral neck and he was sent back out the hospital for surgical intervention. He was readmitted to the facility on [DATE]. There was a care plan for falls initiated on 10/12/15 upon Resident # 4 ' s readmission from the hospital after sustaining a left femur fracture when he fell from the bed. Interventions included to record and document all falls with the goal of understanding, eliminating and correcting any causative factors if possible. Interventions also included keeping the call light in reach and explain to the resident the need to use the call light. The care plan included praise for complaint behaviors, and reminding him of his limitations, frequent incontinence checks and frequent staff observation. In an observation on 1/11/16 at 11:45 AM, Resident #4 appeared contracted in both upper and lower extremities and lying on his right side in the fetal position. He was yelling out periodically and did not appear aware of his surroundings or circumstance. He was clean and well groomed, absent odors and dressed for weather. His bed was in the low position and his quarter rails were engaged. He was lying on an alternating air mattress. During the wound care observation and interview 1/11/16 at 11:45 AM, the treatment nurse stated Resident #4 was not able to reposition himself without staff assistance. She recalled the fall last October and understood it was due to staff error. In an interview on 1/12/16 at 8:45 AM, the director of nursing (DON) stated it was determined the aide left the resident unattended to get supplies. The aide was terminated. The aide was not available for interview. In a telephone interview on 1/12/16 at 10:40 AM, Nurse #3 stated the aide who left Resident #4 unattended had come in late that night. She stated she had over slept because she had taken a pain pill earlier in the day. Nurse #3 stated she had not had any issues with the aide ' s performance prior to this incident. She recalled the aide stated Resident #4 had stool and she did not have enough supplies. She had raised the bed to the highest position and left him to get more supplies. Nurse #3 stated she obtained the aide ' s statement and there was no other issues with her on that shift. She reported the incident to the DON that morning. Nurse #3 stated Resident #4 was unable to move about in the bed and always stayed in the fetal positon. In an interview on 1/12/16 at 12:30 PM, the administrator stated it was her expectation the staff provide ADL assistance safely and not leave a resident unattended. 2. Resident #1 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #1 annual Care Area assessment dated [DATE] read that Resident #1 was totally dependent on staff to perform all transfers and mobility and her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated had severe cognitive impairment, no behaviors, required extensive assistance with bed mobility by two staff, total staff assistance using a lift for transfers, extensive assistance with hygiene by two staff, impairment on both sides and non-ambulatory. Resident #1 was coded as having a urinary catheter due to a stage 4 sacral pressure ulcer but always incontinent of bowel. Resident #1 was care planned for falls. The care plan was reviewed 10/20/15, 12/15/15 and again on 12/25/15. The interventions included to check incontinence routinely and as needed, assess medication as a contributing factor, assess for proper fitting clothing, record and document all falls with goal of determining causative factors to eliminate or correct them if possible and keep the call light in reach and explain to resident how and why she need to use it. A review of the incident report dated 12/25/15 indicated at 6:50 AM, Nurse #2 was called to the room by the nursing assistant (NA) #1. Resident #1 was observed on the floor next to the bed on her right side. There was discoloration noted to Resident #1 ' s forehead and her nose was bleeding. Emergency medical services (EMS) was contact to take Resident #1 to the hospital for evaluation. A review of the hospital records dated 12/25/15 indicated Resident #1 was dropped from the bed during care. The bed was elevated approximately 4 feet when the fall occurred. A CT scan of Resident #1 ' s head and cervical spine indicated no injury. She was returned to the facility later that same day. In an interview on 1/11/16 at 9:30 AM, Nurse #1 stated she was coming in to work first shift on 12/25/15 when NA #1 walked out of the room into the hall and stated Resident #1 rolled out of the bed. Nurse #1 went into the room and observed Resident #1 lying on the floor on her right side. She had bumped her forehead and she was bleeding from her cheek. NA #1 stated she rolled Resident #1 over to provide incontinence care when she rolled out of the bed. Nurse #1 stated the quarter side rail were observed up and the bed was in the high position. In an observation on 1/11/16 at 11:15 AM, Resident #1 was lying in bed on an alternating air mattress. The bed was observed in the low position. Quarter rails were observed in place and engaged. She was nonverbal and appeared unaware of her surroundings or circumstances. She appeared clean, absent of odors and dressed for weather. The treatment nurse recalled the fall that occurred on 12/25/15. She stated it was her understanding that the aide rolled Resident #1 over too far resulting in her falling from the bed. During a wound care observation and interview on 1/11/16 at 11:15 AM, the treatment nurse stated when performing wound care she always had assistance because Resident #1 could not assist with holding herself on her side and the altering air mattress caused shifting of body weight periodically. In an interview on 1/11/16 at 2:00 PM, NA #2 stated she never provided any of Resident #1 ' s activities of daily living (ADLs) unassisted. She stated Resident #1 was dead weight and she could not hold onto the side rail to avoid a fall. She stated the kardex in the computer did not indicate how much assistance was needed but she was not comfortable doing Resident #1 unassisted. In a telephone interview on 1/11/16 at 2:40 PM, NA #1 stated she worked third shift on 12/24/15. She stated she was doing her last round on Resident #1 and had asked for help to provide her incontinence care but all the other staff stated they were too busy. NA #1 stated she did not feel comfortable completing Resident #1s incontinence care alone but on this occasion, she did it anyway. She stated Resident #1 had stool so she raised the bed to the highest positon and pulled Resident #1 close to her and turned her over to wipe her when Resident #1 rolled over onto the floor. NA #1 stated she stepped out of the room and saw Nurse #1 coming up the hall and got her to assess Resident #1. NA #1 stated Resident #1 was lying on her right side and she was bleeding from her cheek. She stated the electronic kardex did not indicate that two staff were needed to perform her ADLs. Since the fall, NA #1 stated she made sure she got help caring for Resident #1. NA #1 stated she was asked to write a statement but she was never asked to come in and discuss the fall or did she receive any phone calls about the incident. NA #1 stated she worked with Resident #1 again on third shift on 12/28/15. On the morning of 12/29/15, the staff development coordinator (SDC) did an in-service for all the aides on safely rolling a resident while in the bed to prevent a fall. In an interview on 1/11/16 at 4:00 PM, NA #3 stated she always sought out assistance with proving incontinence care for Resident #1 because she was a heavy lady who could not keep herself from rolling all the way over. NA #3 stated the mattress on her bed also would inflate and deflate causing Resident #1 to shift in the bed unsafely. In an interview on 1/12/16 at 8:30 AM, Nurse #2 stated she worked third shift on 12/24/15 and recalled the fall Resident #1 sustained. She stated NA #1 called her to the room but Nurse #1 beat her there. Resident #1 was observed on the floor. She stated she called EMS and asked NA #1 what happened. She stated that NA #1 stated she rolled onto the floor while she was proving incontinence care. In an interview on 1/12/16, the SDC stated she was asked to in-service all the aides on bed mobility but she was not informed the education was in response to the fall that occurred on 12/25/15. She stated she had not done any observations with NA #1 or any aides to ensure bed mobility was being done safely. In an interview on 1/12/16 at 11:20AM, the director of nursing stated she did not do an investigation into the fall Resident #1 sustained on 12/25/15 because she felt it was an isolated incident. She did direct the SDC to educate all the aides because she felt the fall was the fault of the aide. In an interview on 1/12/16 at 12:30 PM, the administrator stated it was her expectation the staff provide ADL assistance safely and wait for assistance if required before attempting to render care alone

Based on observations, record review, facility, physician, pharmacist and resident interviews, the facility used an anti dandruff shampoo that contained anti fungal medication to treat facial razor bumps which was against manufacturer recommendations for use causing cellulitis/chemical burns to the face for 1 of 3 residents reviewed (Resident #50). The findings included: According to the manufacturer's instructions for anti dandruff shampoo with selenium sulfide, "Avoid getting this medication into your eyes, inside your nose or mouth, or on any areas of broken/inflamed skin since it may cause irritation. If this occurs, flush the area with plenty of water. Rinse thoroughly. Do not leave this medication on your hair, scalp, or skin for a longer period or use it more often than directed. Your condition will not clear faster, but side effects may be increased. A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction: rash, itching, swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing." Resident #50 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The most recent quarterly Minimum (MDS) data set [DATE] documented the resident was cognitively intact. Review of an electronically signed nurse's notes by Nurse #3 dated [DATE] read "resident skin assessed today. Resident has hair bumps located on his cheeks, areas not open, resident with no open areas noted." Further review of a nurse's note by Nurse #3 dated [DATE] at 4:01 pm read in part "resident complained of (c/o) left side jaw pain due to bumps on his face. Medical Doctor (MD) was notified by RN (Registered Nurse) supervisor. MD stated he would be in the facility tomorrow and assess resident's face then. PRN (as needed) medication has been administered to resident. Resident stated area (bump) next to his lip hurts." On [DATE] at 2:14pm during an interview, Nurse #3 stated the areas initially presented as hair bumps on [DATE]. She stated the resident complained of pain to the areas at the time. Nurse #3 stated she medicated Resident #50 with Percocet for pain and applied bactroban topically to the affected areas. She further stated if she had applied the ointment or administered the Percocet for pain, the medications would be documented on the Medication Administration Record. Review of the [DATE] Medication Administration Record (MAR) revealed an order for [REDACTED]. The same MAR did not reveal documentation of administration of Percocet for [DATE] to Resident #50. Further review of the [DATE] Treatment Administration Record (TAR) revealed the order for Bactroban was discontinued on [DATE]. Nurse #1 further stated that when she returned to work on [DATE], Resident #50 continued to have the bumps on his face with a black shadow appearance and was complaining of increased pain. She stated Resident #50 stated the green cream the facility had been applying was not working. Nurse #3 stated she informed nursing supervisor (Registered Nurse #1) of the resident's complaints and condition. Review of the physician visit dated [DATE] read in part "The patient has had a facial rash and darkening over the past week. Apparently some cream was placed on his face, he is not sure and it got acutely worse. He was having an open area on the left cheek area, but that seemed to clear up. There were some bumps, but then after some cream, he tells me was placed on him, he got this tightening and dark rash. It is starting to peel off in front of me at this time. He tells it does burn and he does feel a little swollen." Further review of the physical exam read in part "facial area reveals the peeling dark areas with a small lesion in the left cheek area, minimally tender. There is some thickness to the facial lesion, but it is throughout the entire face, but sparing the lips and nose." Review of the physician order [REDACTED]. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]." Review of a written statement dated [DATE] by Treatment Nurse #2 read in part "This nurse observed (Resident #50) to have darkened areas intermingled with reddened areas as well as swelling to both cheeks and lower earlobes. This patient complained of extreme pain this am and was medicated with prn Percocet. The areas to this patient ' s face appeared to be " chemical burns." Over the past week I as well as other staff members have observed this patient wearing a green solution (which was in a medicine cup) all over his cheeks and leaving it there, allowing it to dry. He stated it was given to him by the treatment nurse. When questioned, (Treatment Nurse #1) stated the resident had been assessed by the wound care doctor who was providing treatment. It wasn't until today upon seeing the resident ' s face in this condition that I (Treatment Nurse #2) questioned the accuracy of this treatment. I saw the wound care doctor in the facility making rounds, so I asked him what he had prescribed for Resident #50's face particularly that of which was green in color. I first had to refresh his memory as to who (Resident #50) was and after typing in his computer to look up the information, he stated he had not formerly "seen" (Resident #50). I then found Treatment Nurse#1 and questioned her as to what she had been putting on Resident #50's face. She stated (anti dandruff shampoo), " it was something I was trying but it's not working so we're going to do something else." I checked the patient's chart and found no orders for (anti dandruff shampoo), only for bactroban. I immediately reported these findings to the Assistant Director of Nursing and Director of Nursing. Note: This patient had been applying the (anti dandruff) to his entire cheeks and letting it dry/not washing it off from day to day per his statement and the observations of staff members." Review of an electronically signed nurse's note by the Treatment Nurse #2 dated [DATE] at 11:29 am read in part "patient has ordered ABT (antibiotic) for the face which will be initiated once it arrives from the pharmacy. Also receiving prednisone for facial swelling which he has tolerated well without side/adverse effects noted. Patient complained of facial pain and is being medicated with prn Percocet at this time." Review of a nurse's note by the Treatment Nurse #2 dated [DATE] at 9:44am read in part "bilateral face, chin, upper lip and earlobes continue with dark areas intermingled with red areas of excoriation/irritation for which patient complained of pain. Receiving po ABT/Prednisone/topical ointment/cream which is tolerated well without side/adverse effects noted." During an interview on [DATE] at 10:11 am, Treatment Nurse #2 verified her written statement. She stated chemical burn meant dark, thick areas where the skin had died . She further stated the resident was complaining of extreme pain to the facial area. Treatment Nurse #2 stated the resident did not usually complain of pain. She stated she verified with Treatment Nurse #1 that the green solution was anti dandruff shampoo. An attempt was made to contact Treatment Nurse #1 on [DATE] at 4:00 pm which was not successful. A second attempt was made on [DATE] at 12:26 pm to contact Treatment Nurse #1 which was not successful. Treatment Nurse #1 was no longer employed by the facility. On [DATE] at 11:15 am an observation was made of the Treatment Nurse #2 applying bactroban cream to an open lesion to the top of the nose and the right lower chin area. Three other small grayish colored lesions with skin intact were noted to the right outer chin area. During an interview on [DATE] at 10:15 am, Resident #50 stated the staff had been putting a green cream on his face which burnt him. He stated he was feeling itching and burning. Resident #50 further stated he has required pain medication for the pain to his face. He stated the nurse that was putting the cream on his face was no longer employed by the facility. In an interview on [DATE] at 11:32 am, Nursing Assistant (NA) #1 stated she has been shaving Resident #50 over the past few years. She further stated she observed peeling of the resident's skin on both sides of his cheeks extending down to the hairline of the beard. In an interview on [DATE] at 3:07 pm, the RN (Registered Nurse) supervisor stated she visited the facility on [DATE] around 5 pm at which time seen the resident with a greenish discolored cream on his face in the hairline area. She further stated the resident had some opened areas on his face. She stated Resident #50 was complaining of facial pain. She further stated she did not know what the green discolored cream was and that she did not assist the resident with cleaning his face. In an interview on [DATE] at 5:30 pm, the Director of Nursing (DON) stated she was informed on [DATE] of the allegation of "chemical burns" to Resident #50's face. She further stated she was informed that Treatment Nurse #1 had applied anti dandruff on the resident's face. The DON further stated she assessed the resident at the time the allegation was reported to her. She stated the resident's skin on his face was blackened and hardened. She stated she felt like Treatment Nurse #1 applied the anti dandruff shampoo to the resident's face to help the resident. During an interview on [DATE] at 10:37 am, the Assistant Director of Nursing (ADON) stated she had observed Resident #50 with a green creamlike substance on his face on two different occasions. She stated she did not know what the green substance was on the resident's face and that she did not assist the resident with washing his face. She further stated it was reported to her by Treatment Nurse #2 that the resident was experiencing pain as a result of the application of the green creamlike substance. The ADON stated Resident #50's lips were swollen when she assessed him on [DATE]. She further stated she recalled being informed the resident had suffered chemical burns as a result of the green creamlike unidentified substance. In an interview on [DATE] at 11:39 am, the Transportation Director stated she had seen the resident with a green substance on his face on multiple occasions. She further stated she recalled Resident #50's face had a brown film of peeling skin on Monday, [DATE]. She further verified the resident had a dermatology appointment scheduled for [DATE]. On [DATE] at 11:46 am during an interview, the facility pharmacist stated anti dandruff shampoo should not be applied to broken or irritated skin. She further stated anti dandruff shampoo could cause further irritation to broken or irritated skin. During an interview on [DATE] at 11:54 am, NA #2 stated she recalled the resident having a bluish green cream on his face. She stated she did not assist the resident with washing his face because she thought it was something the nurse had put on the resident's face. She further stated the next time she seen the resident his face was all dark. In an interview on [DATE] at 12:01 pm, NA #1 stated she recalled the resident had a bluish green substance on "those sore areas on his face." She stated she did not recall how many times she had seen the resident with the bluish green unidentified substance. On [DATE] at 12:10 pm in an interview, the attending physician stated he was informed that a green cream was used on the resident's face. The physician stated he did not prescribe anti dandruff shampoo for Resident #50. He further stated anti dandruff shampoo with selenium sulfide should not have been used on an area of broken skin because it could cause further irritation. The attending physician stated Resident #50 did have an open lesion on his face on examination on [DATE]. The attending physician further stated it was his expectation for the nurse to notify him to get an order before using a medication or treatment for [REDACTED].

Based on record review, observation and staff interviews, the facility failed to respond immediately to the emergent need of a resident who verbalized difficultly breathing, shortness of breath and an empty oxygen cylinder, which resulted in anxiety, panic and frustration for 1 of 4 residents dependent on supplemental oxygen (Resident #40). Findings included: Resident #40 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set was in process of being completed. The FL2 (a level of care screening tool) dated 8/6/14 revealed Resident #40's mental orientation was constant to person, place and time. Ambulation and transfers required supervision. Special treatment included continuous oxygen therapy. The admission care plan dated 8/29/14 listed [MEDICAL CONDITIONS] as a diagnosis. Oxygen therapy was indicated as an approach to be used with care. A review of the Physician orders [REDACTED]. A review of a disciplinary action notice signed by Nurse #1 on 9/4/14 in part read "unsatisfactory or incompetent work, failed to properly assess resident with respiratory status." On 9/4/14 at 10:07 am, an observation revealed Nurse #1 exited the med room on her way back to the medication cart and was stopped by Resident #40 at the nurse's station in her wheelchair as the nurse exited from the med room. The resident stated to her "I am short of breath and can not breathe, it is hard for me to get air, there's no air coming from my oxygen tank on the back of my wheelchair, I'm so frustrated right now, I need your help." The resident was observed with deep breathing, use of accessory muscles (internal and external intercostal muscles to aide in breathing which include neck and shoulders) with breathing and shortness of breath. Nurse #1 responded "Go to your room, I'll be there after a while" and walked away without assessing the resident's voiced concerns and continued with her med pass. The resident was observed to be 50 feet or greater from her room, which was located down the hallway and to the right in the corner and out of sight of Nurse #1. Resident #40 yelled "Somebody please help me, she (Nurse #1) is not listening to me, I am short of breath and can't breathe and I need someone to help me now. The resident was observed to be frustrated and there was no other staff present at the time she voiced her concerns to Nurse #1 - the resident began to panic as she looked for someone to help her. The oxygen cylinder gauge on the back of the resident's wheelchair was observed "empty" of oxygen. Upon looking for someone on the 500 unit where the resident was located, to help the resident, there was no staff member physically in sight. At 10:08 am NA (Nursing Assistant) #1 was observed and notified the resident oxygen cylinder was empty and she complained to Nurse #1 of shortness of breath/difficult breathing and needed immediate medical attention. NA (Nursing Assistant) #1 asked Resident #1 was she okay and the resident explained to her she could not breathe, no air was coming from her oxygen tank and that she had told Nurse #1 who instructed her to go back to her room. NA #1 immediately looked at the oxygen gauge, removed the oxygen cylinder in its entirety from the holder on the back of the wheelchair, then accompanied by the activities director, the resident was escorted in her wheelchair to the 300/400 hall nurses station to get another oxygen cylinder. At 10:13 am, the resident's oxygen saturation was assessed by the medication aide at 95% on room air; however the resident continued with shortness of breath, deep breathing, anxiety and flushed in color. At 10:14 am, oxygen per a new oxygen cylinder at 2 liters per minutes was applied by nasal cannula and Nurse #1 arrived and adjusted the nasal cannula for proper fit and then asked Resident #40 "Are you okay?" The resident did not respond to her. At 10:15 am, the resident stated "I feel much better now and I'm not as frustrated" with no labored (difficultly) breathing observed. A review of the MAR indicated [REDACTED]. Per follow up at 11:27 am, Nurse #1 documented the medication was effective. On 9/4/14 at 10:30 am, Nurse #1 in the presence of the Director of Nursing, acknowledged she was Resident #1's primary nurse. She stated she was aware the resident was ordered to have continuous oxygen. She indicated she instructed the resident to go to her room because she was in the middle of her medication pass when the resident stopped her in route from the med room. Nurse #1 stated there was no other emergency concern she was attending to when Resident #40 informed her she was short of breath and could not breathe. She further acknowledged Resident #40's concerns should have been her priority at the time the resident informed her she was short of breath and could not breathe, however she felt the resident was capable of going back to her room independently, as she instructed her and placing herself on the oxygen concentrator; until she had an opportunity to get to her because the resident was alert and capable of doing such a task independently. Nurse #1 acknowledged her response was inappropriate when the resident requested help from her and she continued with her med pass. She concluded she did not check to ensure the oxygen cylinder located on the back of the resident's wheelchair had sufficient oxygen, since taking over care of the resident on her shift at 7:00 am. On 9/4/14 at 10:35 am, the Director of Nursing (DON) stated she expected Nurse #1 to have immediately stopped her med pass and assessed the resident, situation and provided immediate care to Resident #40. On 9/4/14 at 10:53 am, the DON indicated she discussed in conference with Nurse #1 regarding the concern of not responding immediately to Resident #40's complaint of shortness of breath and difficultly breathing. The DON added she explained to Nurse #1 she failed to assess Resident #40's respiratory status; however during the discussion Nurse #1 responded she did not feel the concern was a priority, therefore, Nurse #1 was no longer employed at the facility effective immediately.

Based on record review, observation and staff interviews, the facility failed to immediately assess and provide care to a resident who verbalized difficultly breathing and shortness of breath for 1 of 4 residents, who was dependent on supplemental oxygen (Resident #40). Findings included: Resident #40 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set was in process of being completed. The FL2 (a level of care screening tool) dated 8/6/14 revealed Resident #40's mental orientation was constant to person, place and time. Ambulation and transfers required supervision. Special treatment included continuous oxygen therapy. The admission care plan dated 8/29/14 listed [MEDICAL CONDITIONS] as a diagnosis. Oxygen therapy was indicated as an approach to be used with care. A review of the Physician orders [REDACTED]. 1. [MEDICATION NAME] inhalant spray one puff (inhalation) four times a day as needed for shortness of breath. [MEDICATION NAME] is used in persons with [MEDICAL CONDITION] to prevent sudden bronshospams ([MEDICATION NAME]) of the muscles in the bronchiole (passageway by which air passage through the nose and mouth to the lungs). 2. Oxygen at 2 liters per minute via nasal cannula continuous every day. 3. Montelukast 10 milligram (mg) one tablet by mouth every day for shortness breath. Montelukast prevent shortness of breath, wheezing and asthma attacks. A review if the Medication Administration Record [REDACTED]. On 9/4/14 at 10:07 am, an observation revealed Nurse #1 exited the med room on her way back to the medication cart and was stopped by Resident #40 at the nurse's station in her wheelchair as the nurse exited from the med room. The resident stated to her "I am short of breath and can not breathe, it is hard for me to get air, there's no air coming from my oxygen tank on the back of my wheelchair, I'm so frustrated right now, I need your help." The resident was observed with deep breathing, use of accessory muscles (internal and external intercostal muscles to aide in breathing which include neck and shoulders) with breathing and shortness of breath. Nurse #1 responded "Go to your room, I'll be there after a while" and walked a way without assessing the resident's voiced concerns and continued with her med pass. The resident was observed to be 50 feet or greater from her room, which was located down the hallway and to the right in the corner and out of sight of Nurse #1. Resident #40 yelled "Somebody please help me, she (Nurse #1) is not listening to me, I am short of breath and can't breathe and I need someone to help me now. The resident was observed to be frustrated and there was no other staff present at the time she voiced her concerns to Nurse #1 - the resident began to panic as she looked for someone to help her. The oxygen cylinder gauge on the back of the resident's wheelchair was observed "empty" of oxygen. Upon looking for someone on the 500 unit where the resident was located, to help the resident, there was no staff member physically in sight. At 10:08 am NA (Nursing Assistant) #1 was observed and notified the resident oxygen cylinder was empty and she complained to Nurse #1 of shortness of breath/difficult breathing and needed immediate medical attention. NA (Nursing Assistant) #1 asked Resident #1 was she okay and the resident explained to her she could not breathe, no air was coming from her oxygen tank and that she had told Nurse #1 who instructed her to go back to her room. NA #1 immediately looked at the oxygen gauge, removed the oxygen cylinder in its entirety from the holder on the back of the wheelchair, then accompanied by the activities director, the resident was escorted in her wheelchair to the 300/400 hall nurses station to get another oxygen cylinder. At 10:13 am, the resident's oxygen saturation was assessed by the medication aide at 95% on room air; however the resident continued with shortness of breath, deep breathing and anxiety and flushed in color. At 10:14 am, oxygen per a new oxygen cylinder at 2 liters per minutes was applied by nasal cannula and Nurse #1 arrived and adjusted the nasal cannula for proper fit and then asked Resident #40 "Are you okay?" The resident did not respond to her. At 10:15 am, the resident stated "I feel much better now and I'm not as frustrated" with no labored (difficultly) breathing observed. A review of the MAR indicated [REDACTED]. Per follow up at 11:27 am, Nurse #1 documented the medication was effective. On 9/4/14 at 10:30 am, Nurse #1 in the presence of the director of nursing, acknowledged she was Resident #1's primary nurse. She stated she was aware the resident was ordered to have continuous oxygen. She indicated she instructed the resident to go to her room because she was in the middle of her medication pass when the resident stopped her in route from the med room. Nurse #1 stated there was no other emergency concern she was attending to when Resident #40 informed her she was short of breath and could not breathe. She further acknowledged Resident #40's concerns should have been her priority at the time the resident informed her she was short of breath and could not breathe; however she felt the resident was capable of going back to her room independently, as she instructed her and placing herself on the oxygen concentrator; until she had an opportunity to get to her because the resident was alert and capable of doing such a task independently. Nurse #1 acknowledged her response was inappropriate when the resident requested help from her and she continued with her med pass. She concluded she did not check to ensure the oxygen cylinder located on the back of the resident's wheelchair had sufficient oxygen, since taking over care of the resident on her shift at 7:00 am. On 9/4/14 at 10:35 am, the Director of Nursing (DON) stated "Every nurse should know if a resident is having trouble breathing, the nurse should immediately address the issue." The DON further stated she expected Nurse #1 to have immediately stopped her med pass and assessed the resident, situation and provided immediate care to Resident #40. On 9/4/14 at 11:00 am, Nurse #2 stated supply oxygen cylinders are kept on the 300/400 (one unit) medication room only for backup cylinder oxygen. On 9/4/14 at 11:05 am, in an attempt to interview Resident #40, the DON and Nurse #2 were observed by the resident's bedside talking to the resident in her room, while she rested in the bed. Upon their exit and entering the room the resident stated "I am okay now, I don't want to cause any trouble for anyone here." Resident #40 would not elaborate further concerning her previous complaint to Nurse #1 or the respiratory episode she experienced. On 9/4/14 at 11:20 am, NA #1 stated she worked with Resident #40 regularly and she had never seen the resident act the way she did. She added she believed the resident was short of breath and could not breathe properly when she informed her. NA #1 added the resident was alert and was capable of making her needs known to the staff. On 9/4/14 at 11:26 am, the Activity Director stated when she heard Resident #40 state she needed help and was having difficulties breathing, she escorted the resident behind NA #1 who had the oxygen cylinder to the next nurses station because she wanted to ensure the resident received oxygen. On 9/4/14 at 12:30 pm, the administrator provided a copy of the MAR. The MAR indicated [REDACTED].

Based on staff, physician interviews and record reviews, the facility failed to notify the physician of continued respiratory distress, that the resident's condition worsened and the resident became unresponsive in 1 of 3 sampled residents with a change in condition (Resident #1). Immediate Jeopardy began on [DATE] and was identified on [DATE] at 1:00 PM. Immediate Jeopardy was removed on [DATE] at 6:30 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy).The facility was in the process of full implementation and monitoring their corrective action. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated that resident #1 had no short term or long term memory problems and no documented behavioral problems. He was coded as cognitively intact and the MDS indicated that he depended extensively on staff for all of his activities of daily living. Resident #1 was not coded as having a prognosis of less than 6 months life expectancy. Resident #1 required continuous oxygen at 4 liters/minute using a nasal cannula. A review of resident #1's medical record indicated that he was his own responsible party and signed his admission paperwork to include the Code Status Resuscitation Request/Order form indicating he would like to be resuscitated in the event of a cardiac or respiratory arrest. This document was dated [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the medical record indicated that routine vital signs were taken on [DATE] at 12:20 PM. Resident #1's vital signs at that time were as follows: blood pressure ,[DATE], pulse 110, respirations 20. A nursing note written by nurse #1 indicated that resident #1 was observed at or around 2:30 PM slumped over in his chair. He was clammy with an oxygen saturation of 81%. The nursing note did not indicate if his oxygen was in use at the time he was found. He was given a breathing treatment and his oxygen saturation increased to 95% on 4 liters/ minutes of oxygen using a nasal cannula. Resident #1's vital signs were as follows: blood pressure ,[DATE] (low), pulse 78, respiration 48 (elevated) and temperature 97.9 F. The nursing note indicated resident #1 refused to go to hospital for evaluation and he did not want his family notified. The nursing note also indicated that the director of nursing (DON) assessed resident #1 and the physician was notified. A review of the Situational Background Assessment Recommendation (SBAR) form dated [DATE] indicated nurse #1 reported that resident #1 was cyanotic (blue or purple discoloration of the skin), short of breath and anxious. The SBAR form indicated the physician instructed the staff to observe resident #1 and monitor his vital signs. This form indicated the DON was aware of the physician's directive at 2:30 PM. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A review of resident #1's medical record indicated no ongoing assessment from approximately 2:30 PM until approximately 6:15 PM when emergency medical services (EMS) was notified. There was no evidence of any ongoing assessment of resident #1's respiratory or mental status changes. According to the EMS report, on [DATE] at approximately 6:15 PM, the call came into the department and they arrived on the scene at 6:27 PM and cardio [MEDICAL CONDITION] resuscitation (CPR) was in progress by facility staff. Resident #1 was found without a pulse, not breathing and unresponsive. His skin was cold to the touch. Resident #1 was pronounced dead at 6:45 PM. In an interview on [DATE] at 12:11 PM, nurse #1 stated that on [DATE] at approximately 2:30 PM she asked the DON to look at resident #1 because she wanted to send him out but he refused to go to hospital. Nurse #1 stated that the DON stated the hospital could not do anything for resident #1 that the facility could not do. The DON instructed nurse #1 to notify the physician. Nurse #1 stated that she completed a SBAR report with the physician instructions to observe resident #1 and monitor his vital signs and notify him for changes in his respiratory or mental status. Nurse #1 stated that the DON and nurse #2 who was the ,[DATE] shift nurse, were present at the nursing station when the physician was notified. Nurse #1 stated she also reported to nurse #2 in her shift change report the physician ' s instructions. Nurse #1 stated resident #1 was a full code and she did not feel comfortable with the DON and physician ' s instruction. Nurse #1 could not recall if she specifically stated that resident #1 was cyanotic or a full code but that she thought she did. She stated the SBAR form indicated that resident #1 was found cyanotic and his code status. In an interview on [DATE] at 1:30 PM, nursing assistant (NA) #1 stated on [DATE] at approximately 2:45 PM, she saw resident #1 in the bed. She said he had a mask on his face receiving at breathing treatment. She stated he removed that mask and stated he couldn't breathe. NA #1 told him to keep treatment in place. NA #1 stated she did not go back into resident #1 ' s room because her shift ended at 3:00 PM and she reported off to the NA #2 who was to work with resident #1 on 2nd shift. In an interview on [DATE] at 2:00 PM, the DON stated that nurse #1 asked her to look at resident #1. She said he was in the bed with a breathing treatment in progress when she entered the room. She said he was in a hospital gown and he was wet with urine and that this was unusual for resident #1. She stated she instructed nurse #1 to check resident #1 for an impaction. She instructed nurse #1 to administer a suppository. The DON stated she ensured resident #1's head of his bed was up and his oxygen was in place. The DON stated nurse #1 called the physician around the time of shift change. The DON stated awareness of resident #1's code status. The DON stated she did not actually assess resident #1 but rather was present during the impaction removal by nurse #1. The DON stated awareness of resident #1's vital signs. She stated she stayed in the room while he was cleaned up and ensured his oxygen was in place and the head of his bed was up. The DON stated she was at the nursing station when nurse #1 notified the physician. She could not recall if nurse #1 made the physician aware of resident #1 full code status. The DON stated she not make contact with floor staff again prior to leaving work that day around 6:00 PM. In an interview on [DATE] at 3:00 PM, medication aide (MA) #2 stated she went to see resident #1 at the beginning of her shift. She stated resident #1 was thrashing about in the bed and unable to respond to her questions. She stated his oxygen was in place at the time. MA #2 stated she returned to the nursing station and stated she thought resident #1 was dying. MA #2 stated the DON, nurse #1 and nurse #2 were standing at the nursing station and no nurse went to the room with her to see resident #1. MA #2 asked nurse #1 if they were sending him to the hospital. Nurse #1 told her that the DON told her not to send him out. Nurse #1 stated the physician told them to monitor for any further decline in his condition and call him back. MA #2 stated that at 4:34 PM, she tried to give resident #1's his scheduled medication but he was not responsive enough to take his medicine. She stated she told nurse #2 about resident #1's change in condition. MA #2 stated nurse #2 did not go to the room to assess resident #1 to her knowledge. MA #2 stated that around 6:15 PM, she heard a code announced and she responded to resident #1's room to find the MDS nurse initiating CPR. On [DATE] at 11:12 AM, in a telephone interview, NA #2 stated that on [DATE] around 3:00 PM, NA #1 told her that resident #1 had not been himself all day and she needed to keep an eye on him. NA #2 stated she was not instructed to get any vital signs or what conditions she was to notify nurse #2. NA #2 stated she was told to "keep an eye on him" by nurse #2. NA #2 stated she went to room to see resident #1 and noted that he appeared to be in distress. She described distress as uncomfortable, moving around in bed, unable able to responds to her questions and gasping for breath. NA #2 stated resident #1's head was off of the pillow and she put his bed back on pillow. NA #2 was unsure if his oxygen was in place. NA #2 left room but she continued to check on resident #1 every ,[DATE] minutes. NA #2 stated at dinner time, she was passing trays and got to his room and she noted he looked worse. She stated resident #1 was unconscious, was not breathing but still warm. NA #2 stated she went to the doorway and called for a nurse. The MDS nurse and MA #2 came to the room and started CPR. NA #2 got the crash cart. NA #2 stated that nurse # 4 also responded to the room and nurse # 2 called 911. In a telephone interview on [DATE] at 3:20 PM, nurse #2 stated that nurse #1 asked DON to look at resident #1 around shift change so nurse #2 also went into the room to see resident #1 since she was going to be caring for him that shift. Nurse #2 said he was gasping for air with his oxygen in place. His eyes were open but he was not responsive. Nurse #2 said she was instructed to monitor resident #1 for worsening in his condition and call the physician for further decline. Nurse #2 stated she was aware that resident #1 was a full code. She stated that she went to the room around 4:15 PM to check the blood sugar of the room mate, and that there was no change in his condition at the time. She stated he was still gasping for air and writhing about in the bed. Nurse 2 said that around 6:00 PM or so, the MDS nurse told her that resident #1 was not looking good. The MDS nurse reported to her that resident #1 was less responsive, pale and breathing sporadically. Nurse #2 said she did not go look at resident #2 but rather called the physician. The physician gave an order to send resident #1 out to the hospital but he apparently he went into respiratory arrest and CPR was started. Nurse #2 stated she did not chart any changes in condition because none occurred until he coded around 6:15 PM. In an interview on [DATE] at 1:50 PM, the MDS nurse stated that it was around 6:00 PM or so when NA #2 motioned for her to come to room. She stated resident #1 was lying on side gasping breath. His oxygen was in place. She performed a sternal rub without a reaction. Resident #1 had no pulse so she called a code and told NA #2 to get the crash cart. The MDS nurse stated that she felt resident #1 should have been sent him out earlier that day since he was a full code and he was having trouble breathing. She said even though he didn't want to go, she felt resident #1 was not mentally in any condition to make a rational decision. She stated she did not think anyone was taking his vital signs and was aware the physician told the staff to monitor his condition and call him for any changes. In a telephone interview on [DATE] at 2:30 PM, the physician recalled getting a phone call on [DATE] about resident #1 being in respiratory distress and that he refused to go to the hospital. The physician recalled that nurse #1 stated she administered his ordered breathing treatment when he was found slumped over in the chair because is oxygen saturation rate was 81%. The physician stated awareness that his oxygen saturation rate went up to 95% on 4 liters/minute of oxygen. The physician could not recall if the staff at the facility informed him that resident #1 was a full code but he knew that resident #1 was his on responsible party and that he thought he was a Do Not Resuscitate (DNR). He recalled that resident #1 was already on 4 liters/minutes of oxygen and stated that was as high as he could go. He recalled telling the staff to monitor his vital signs and respiratory status. The physician was unable to recall if he was called again that day about resident #1. In a telephone interview on [DATE] at 5:00 PM, the physician stated he did not give specific orders but if resident #1 was experiencing respiratory distress, he would have expected the nurses to assess his breathing and respirations, vital signs and called him for any changes in his breathing, respiratory status or changes in his mental status. The physician stated he thought he received a second call that afternoon asking to send him out to the hospital and he told them send him out for evaluation. The physician stated he was unsure of time of the second call. On [DATE] at 10:30 AM, the administrator stated her expectation would have been that when resident #1's respiratory and mental status changed, the physician would be notified and sent to the hospital for evaluation given the seriousness of his condition and vital signs. The administrator was notified of the immediate jeopardy on [DATE] and 1:00 PM. What corrective action will be accomplished for those residents affected by the deficient practice? -Resident #1 expired in the facility on [DATE]. Review of the resident record indicates the resident was his own responsible party and requested that his family not be notified of his change in condition and he declined offers of hospitalization . The record indicated the physician was notified of the resident ' s change in condition and his desire not to be hospitalized . The physician indicated to continue to monitor the resident although the option of hospitalization was declined by the resident. -The Director of Nursing was terminated by the administrator on [DATE]. What corrective action will be accomplished for those residents having potential to be affected by the same deficient practice? -The facility has determined that all residents have the potential to be affected but currently, after review of 24 hour shift reports, there is no evidence of any deficient physician or resident representative communication on [DATE]. What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not occur? -All licensed nursing staff have been assigned on-line learning course " Effective Communication " which includes the SBAR tool for communication to the physician, [DATE]. -All licensed nursing staff will be in-serviced by the DON or appropriate designee regarding the following and attached. F Tag 157: Notification of Change, Facility policy on Change in Resident Status which includes notification of physician, Validation Checklist for Notification of Changes, and Documentation of Notification on [DATE], ongoing. -Any licensed staff member who has not been trained as of [DATE] will not be allowed to report for duty until training is complete. -This information will be included as additional training in licensed nursing orientation and annual re-orientation. -24 hour nursing reports will be reviewed by the supervising or charge nurse each shift for identification of proper notification of physician and resident representative as needed and per facility policy. Any discrepancies in notification will be corrected by the supervising or charge nurse reviewing the 24 hour report, beginning [DATE] and ongoing. -Validation Checklist will be utilized by the nurse in charge of the resident with a change in condition requiring physician and resident representative for a period of 4 weeks, beginning [DATE]. -F-157 Notification of Change audits will be conducted by the DON, or appropriate designee weekly x 4 weeks, monthly x 2 months, quarterly x 3 quarters, and as needed. How will performance be monitored and how often? -24 hour reports will be reviewed by the facility administrative team 5 x per week x 4 weeks for compliance with plan as stated above and Validation of Notification forms during Morning Meeting. Non-compliance will be discussed during this meeting with immediate notifications made as needed and the nurse (s) responsible for any non-compliance re-in-serviced and disciplined by the DON or appropriate designee. The review of the 24 hour report will by continued with a minimum of weekly reviews x 3 weeks, monthly reviews, x 2 months, followed by quarterly x 3 quarters, and as needed, ongoing. -Review of the Validation reports will be reviewed 5 days per week by the Facility Administrative Staff during Morning Meeting x 1 week, followed by weekly x 3 weeks, followed by quarterly x 3 quarters, and as needed, ongoing. -Review of Notification of Change Audits will be reviewed by the facility Administrative Staff during Morning Meeting weekly x 4 weeks, followed by monthly x 2 months, followed by quarterly x 3 quarters, a as needed, ongoing. -This plan and its outcomes will be reviewed by the QA committee during the monthly QA meeting. Any deviations of the plan will be examined using a RCA approach to the issue and amendments to the plan as needed. This review, outcomes, recommendations, and monitoring will be included in the facility QA meeting minutes. Any changes to the plan above will be documented in the QA meeting minutes, appropriate staff re-in-serviced to changes in the plan. Any changes made to the above plan will require the monitoring of such changes to begin at the initial review schedule of 5 days/week x 1 week; weekly x 3 weeks; monthly x 2 months, quarterly x 3 quarters, and as needed. On [DATE] at 7:30 PM, verification of the credible allegation was evidenced by interviews of direct care nursing staff related to the notification of a change in a residents' status, communication with the physician utilizing the SBAR tool, review of the 24 hour report to identify concerns for the physician to be made aware. The nurses were aware of the validation checklist for all current residents with any noted changes in condition.

Based on staff, physician interviews and record review, the facility failed to assess and monitor a resident experiencing a significant change in condition (respiratory distress) and failed to seek medical intervention for a resident in respiratory distress in 1 of 3 residents sampled with a change in condition (Resident #1). Immediate Jeopardy began on [DATE] and was identified on [DATE] at 1:00 PM. Immediate Jeopardy was removed on [DATE] at 6:30 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated that resident #1 had no short term or long term memory problems and no documented behavioral problems. He was coded as cognitively intact and the MDS indicated that he depended extensively on staff for all of his activities of daily living. Resident #1 was not coded as having a prognosis of less than 6 months life expectancy. Resident #1 required continuous oxygen at 4 liters/minute using a nasal cannula. A review of resident #1's medical record indicated that he was his own responsible party and signed his admission paperwork to include the Code Status Resuscitation Request/Order form indicating he would like to be resuscitated in the event of a cardiac or respiratory arrest. This document was dated [DATE]. A review of the physician orders [REDACTED]. There were no medications or breathing treatments ordered that could have been given as needed for shortness of breath. A review of resident #1's bowel record indicated that resident #1 had a stool on [DATE] described at medium and soft formed. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the medical record indicated that routine vital signs were taken on [DATE] at 12:20 PM. Resident #1's vital signs at that time were as follows: blood pressure ,[DATE], pulse 110, respirations 20. In a nursing note written by nurse #1, she indicated that resident #1 was observed at or around 2:30 PM slumped over in his chair. He was clammy with an oxygen saturation of 81%. The nursing note did not indicate if his oxygen was in use at the time he was found. He was given a breathing treatment and his oxygen saturation increased to 95% on 4 liters/ minutes of oxygen using a nasal cannula. Resident #1's vital signs were as follows: blood pressure ,[DATE] (low), pulse 78, respiration 48 (elevated) and temperature 97.9 F. The nursing note indicated resident #1 refused to go to hospital for evaluation and he did not want his family notified. The nursing note also indicated that the director of nursing (DON) assessed resident #1 and the physician was notified. On [DATE] at 2:30 PM, nurse #1 completed a Situational Background Assessment Recommendation (SBAR) form. This form indicated nurse #1 reported to the physician that resident #1 was cyanotic (blue or purple coloration of the skin), short of breath and anxious. This form indicated that the he physician instructed the staff to observe resident #1 and monitor his vital signs. This form indicated the DON was aware of the physician's directive. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A review of resident #1's medical record indicated no ongoing assessment from approximately 2:30 PM until approximately 6:15 PM when emergency medical services (EMS) was notified. There was no evidence of any ongoing assessment of resident #1's respiratory or mental status changes. According to the EMS report, on [DATE] at approximately 6:15 PM, the call came into the department and they arrived on the scene at 6:27 PM and cardio [MEDICAL CONDITION] resuscitation (CPR) was in progress by facility staff. Resident #1 was found without a pulse, not breathing and unresponsive. His skin was cold to the touch. Resident #1 was pronounced dead at 6:45 PM. In an interview on [DATE] at 12:11 PM, nurse #1 stated that on [DATE] at approximately 2:30 PM, she and MA # 1 assisted resident #1 in getting in the bed. Nurse #1 stated she asked the DON to look at resident #1 because she wanted to send him out but he refused to go to hospital. Nurse #1 stated that the DON stated the hospital could not do anything for resident #1 that the facility could not do. Nurse #1 stated the DON instructed her to check resident #1 for an impaction. Nurse #1 stated the DON stated " did you ever think that was his problem? " Nurse #1 stated she checked resident #1 for an impaction and there was noted medium amount of hard stool removed. A suppository was administered after the stool was removed. Nurse #1 stated did not check resident #1's medical record to see if he had a recent bowel movement. She stated she called the physician and completed a SBAR report with the physician instructions to observe resident #1 and monitor his vital signs and to notify him for changes in his respiratory or mental status. Nurse #1 could not recall if she informed the physician of dis-impacting resident #1 and administrating a suppository. Nurse #1 stated that the DON and nurse #2 were present at the nursing station when the physician was notified. Nurse #1 stated she also reported to nurse #2, the ,[DATE] shift nurse, in her shift change report the physician ' s instructions. Nurse #1 stated resident #1 was a full code and she did not feel comfortable with the DON and physician ' s instruction. Nurse #1 could not recall if she specifically stated that resident #1 was a full code but that she thought she did. She stated his code status was indicated on the SBAR form. Nurse #1 stated she could not recall if nurse #2 went to the room to observe resident #1 prior to her leaving the facility at the end of her shift. In an interview on [DATE] at 12:20 PM, medication aide #1 (MA) stated she helped assist nurse #1 in getting resident #1 into the bed on [DATE] at approximately 2:30 PM. She stated resident #1 refused to go to the hospital so nurse #1 went to talk to the DON. Nursing assistant #1 came to her in resident #1 ' s room and told her another resident requested a pain medication. MA #1 asked NA #1 to stay with resident #1. MA #1 stated sometime shortly after she returned to her medication cart, the DON approached her and requested a Ducolax suppository for resident #1. In an interview on [DATE] at 130 PM, NA #1 stated on [DATE] at approximately 2:45 PM, she saw resident #1 already in the bed. NA #1 stated MA # 1 asked her to stay with resident #1 until nurse #1 returned. NA #1 stated resident #1 had a mask on his face receiving at breathing treatment. She stated he removed that mask and stated he couldn ' t breathe. NA #1 told him to keep treatment in place. NA #1 stated that once nurse #1 and the DON were in the room, she left to complete her rounds and report off to NA #2. In an interview on [DATE] at 2:00 PM, the DON stated that nurse #1 asked her to look at resident #1. She said he was in the bed with a breathing treatment in progress when she entered the room. She said he was in a hospital gown and he was wet with urine and that this was unusual for resident #1. She stated she instructed nurse #1 to check resident #1 for an impaction. She instructed nurse #1 to administer a suppository. The DON stated she did not check the medical record to see when resident #1 last had a bowel movement. The DON stated she ensured resident #1's head of his bed was up and his oxygen was in place. The DON stated nurse #1 called the physician around the time of shift change. The DON stated awareness of resident #1's code status. The DON stated she did not actually assess resident #1 but rather was present during the impaction removal by nurse #1. The DON stated awareness of resident #1's vital signs. She stated she stayed in the room while he was cleaned up and ensured his oxygen was in place and the head of his bed was up. The DON stated she was at the nursing station when nurse #1 notified the physician. She could not recall if nurse #1 made the physician aware of resident #1 full code status. The DON asked nurse #1 if she had checked resident #1 for an impaction because she wanted to be sure that resident #1 was not being sent out to the hospital unnecessarily. The DON stated she felt overwhelmed because of the acuity of the residents being admitted to the facility and stated she had to be sure a trip to the emergency room was warranted. The DON stated she did not think it was an emergency at the time and felt that the stool evacuation would be effective in easing resident #1's distress. The DON stated she was aware that nurse #1 was not satisfied with her directive. The DON stated that could have impacted her decision not to return to the floor to reassess the condition of resident #1. The DON stated she did not make contact with floor staff again prior to leaving work that day around 6:00 PM. In an interview on [DATE] at 3:00 PM, MA #2 stated she went to see resident #1 at the beginning of her shift. She stated when she saw him, he was thrashing about in the bed and unable to respond to her questions. She stated his oxygen was in place at the time. MA #2 stated she returned to the nursing station and stated she thought resident #1 was dying. MA #2 stated the DON, nurse #1 and nurse #2 were standing at the nursing station and no nurse went to the room with her to see resident #1. MA #2 asked nurse #1 if they were sending him to the hospital. Nurse #1 told her that the DON told her not to send him out. Nurse #1 stated the physician told them to monitor for any further decline in his condition and call him back. MA #2 stated that she was not aware if nurse #2 went to the room to see resident #1. MA #2 stated that at 4:34 PM, she tried to give resident #1 ' s his scheduled medication but he was not responsive enough to take his medicine. She stated she told nurse #2 about resident #1's change in condition. MA #2 stated nurse #2 did not go to the room to assess resident #1 to her knowledge. MA #2 stated that around 6:15 PM, she heard a code announced and she responded to resident #1's room to find the MDS nurse initiating CPR. In a telephone interview on [DATE] at 11:12 AM, NA #2 stated that on [DATE] around 3:00 PM, NA #1 told her that resident #1 had not been himself all day and she needed to keep an eye on him. NA #2 stated she was not instructed to get any vital signs or what conditions she was to notify nurse #2. NA #2 stated she was told to " keep an eye on him " by nurse #2. NA #2 stated she went to room to see resident #1 and noted that he appeared to be in distress. She described distress as uncomfortable, moving around in bed, unable able to responds to her questions and gasping for breath. NA #2 stated resident #1's head was off of the pillow and she put his bed back on pillow. NA #2 was unsure if his oxygen was in place. NA #2 left the room but she continued to check on resident #1 every ,[DATE] minutes. NA #2 stated at dinner time, she was passing trays and got to his room and she noted he looked worse. She stated resident #1 was unconscious, was not breathing but still warm. NA #2 stated she went to the doorway and called for a nurse. The MDS nurse and MA #2 came to the room and started CPR. NA #2 got the crash cart. NA #2 stated that nurse # 4 also responded to the room and nurse # 2 called 911. In a telephone interview on [DATE] at 3:20 PM, nurse #2 stated that nurse #1 asked DON to look at resident #1 around shift change so nurse #2 also went into the room to see resident #1 since she was going to be caring for him that shift. Nurse #2 said he was gasping for air with his oxygen in place. His eyes were open but he was not responsive. Nurse #2 said she was instructed to monitor resident #1 for worsening in his condition and call the physician for further decline. Nurse #2 stated she was aware that resident #1 was a full code. She stated that she went to the room around 4:15 PM to check the blood sugar of the room mate, and that there was no change in his condition at the time. She stated he was still gasping for air and writhing about in the bed. Nurse 2 said that around 6:00 PM or so, the MDS nurse told her that resident #1 was not looking good. The MDS nurse reported to her that resident #1 was less responsive, pale and breathing sporadically. Nurse #2 said she did not go look at resident #2 but rather called the physician. The physician gave an order to send resident #1 out to the hospital but he apparently he went into respiratory arrest and CPR was started. Nurse #2 stated she did not note any changes in condition from approximately 4:15 PM when she checked the room mate blood glucose level and until he coded around 6:15 PM. Nurse #2 stated she did not go and observe resident #1 after MA #2 told her he was not able to take his 4:30 PM medication. Nurse #2 stated she did not recall if MA #2 reported that resident #1 was not responsive. Nurse #2 indicated resident #1 was ordered a breathing treatment every hour hours and his next one was due at 6:00 PM and she planned to administer the breathing treatment but resident #1 coded before she got to administer it. In an interview on [DATE] at 1:50 PM, the MDS nurse stated that it was around 6:00 PM or so when NA #2 motioned for her to come to room. She stated resident #1 was lying on side gasping breath. His oxygen was in place. She performed a sternal rub without a reaction. Resident #1 had no pulse so she called a code and told NA #2 to get the crash cart. The MDS nurse stated that she felt resident #1 should have been sent him out earlier that day since he was a full code and he was having trouble breathing. She said even though he didn't want to go, she felt resident #1 he was not mentally in any condition to make a rational decision. She stated she did not think anyone was taking his vital signs and was aware the physician told the staff to monitor his condition and call him for any changes. In an interview on [DATE] at 3:30 PM, nurse #3 stated around 6:00 PM or so on [DATE], a code was announced on the overhead system. She responded to the room and the MDS nurse and MA #2 were performing CPR. Once EMS arrived, they took over the code and pronounced resident #1 dead at 645 PM. In a telephone interview on [DATE] at 2:30 PM, the physician recalled getting a phone call on [DATE] about resident #1 being in respiratory distress and that he refused to go to the hospital. The physician recalled that nurse #1 stated she administered his ordered breathing treatment when he was found slumped over in the chair because is oxygen saturation rate was 81%. The physician stated awareness that his oxygen saturation rate went up to 95% on 4 liters/minute of oxygen. The physician stated that because his oxygen saturation rate improved after the breathing treatment, he felt observation was an adequate intervention at the time. The physician could not recall if the staff at the facility informed him that resident #1 was a full code but he knew that resident #1 was his own responsible party and that he thought he was a Do Not Resuscitate (DNR). He recalled that resident #1 was already on 4 liters/minutes of oxygen and stated that was as high as he could go. He recalled telling the staff to monitor his vital signs and respiratory status. The physician was unable to recall if he was called again that day about resident #1. In a telephone interview on [DATE] at 5:00 PM, the physician stated he did not give specific orders but if resident #1 was experiencing respiratory distress, he would have expected the nurses to assess his breathing and respirations, vital signs and called him for any changes in his breathing, respiratory status or changes in his mental status. The physician stated he thought he received a second call that afternoon asking to send him out to the hospital and he told them send him out for evaluation. The physician stated he was unsure of time of the second call. In an interview on [DATE] at 10:30 AM, the administrator stated her expectation would have been that when resident #1's respiratory and mental status changed, the physician would be notified and sent to the hospital for evaluation given the seriousness of his condition and vital signs. The administrator was notified of the immediate jeopardy on [DATE] and 1:00 PM. What corrective action will be accomplished for those residents affected by the deficient practice? -Resident #1 expired on [DATE] What corrective action will be accomplished for those residents having potential to be affected by the same deficient practice? -It is determined that all residents have the potential to be affected. -Audit of all residents advanced directives was conducted by the social worker to determine the accuracy of such directives as compared to the wishes of the individual resident, as cognitively appropriate on [DATE] -A review of the 24 hour reports was completed by the DON, or appropriate designee, on [DATE] there is no evidence of any deficient physician or resident representative communication or lack of assessment by nursing staff for resident ' s requiring such interventions What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not occur? -All licensed nursing staff will be re-in-serviced by the DON, or appropriate designee, as to the standard criteria for monitoring resident ' s condition as listed below, but not limited to: VS (Temperature, Pulse, Respirations, Blood Pressure, Pulse Ox), Level of Consciousness and Responsiveness, Level of Cognition on [DATE] and ongoing. Any licensed nursing staff who has not been in-serviced as of [DATE] will not be allowed to report for duty until training is complete. -All licensed nursing staff will be re-in-serviced on Documentation Standards by the DON, or appropriate designee (see attached) on [DATE] and ongoing. -All licensed nursing staff will be in-serviced by the DON or appropriate designee regarding the following and attached: F Tag 309: Quality of Care, Facility Policy on Change in Resident Status which includes notification of physician, Validation Checklist for Notification of Changes, Practice Guideline for Notification of Changes, Documentation of Notification, on [DATE]. Any licensed nursing staff who has not been in-serviced as of [DATE] will not be allowed to report for duty until training is complete. This information will be included as additional training in licensed nursing orientation and annual re-orientation. For applicable residents (those in need of targeted monitoring) 5% chart audit of nursing documentation will be conducted daily x 5 days, followed by weekly x 3 weeks, followed by monthly x 2 months, followed by quarterly x 3 quarters. Beginning [DATE], and ongoing. This audit will identify the validation through documentation of monitoring applicable resident ' s condition and related notification of physician and resident representative as appropriate. How will performance be monitored and how often? -24 hour reports will be reviewed by the facility administrative team 5 x per week x 4 weeks for compliance with plan and Validation of Notification forms during Morning Meeting. Non-compliance will be discussed during this meeting with immediate notifications made as needed and the nurse(s) responsible for any non-compliance re-in-serviced and disciplined by the DON or appropriate designee. [DATE] and ongoing. The review of the 24 hour report will be continued with a minimum of weekly reviews x 3 weeks, monthly reviews x 2 months, followed by quarterly x 3 quarters, and as needed. Review of Advanced Directives Audits, and Notification of Change Audits will be reviewed by the facility Administrative Staff during Morning Meeting weekly x 4 weeks, followed by monthly, x 2 months, followed by quarterly x 3 quarters and as needed, [DATE] and ongoing. This plan and its outcomes will be reviewed by the QA committee during the monthly QA meeting. Any deviations of the plan will be examined using a RCA approach to the issue and amendments to the plan as needed. This review, outcomes, recommendations and monitoring will be included in the facility QA meeting minutes. Any changes to the plan above will be documented in the QA meeting minutes, appropriate staff re-in-serviced to changes in the plan. Ongoing Any changes made to the above plan will require the monitoring of such changes to begin at the initial review schedule of 5 days/week x 1 week, weekly x 3 weeks, monthly x 2 months, quarterly x 3 quarters, and as needed. Ongoing On [DATE] at 7:30 PM, verification of the credible allegation was evidenced by interviews of direct care nursing staff related to the notification of a change in a residents' status, communication with the physician utilizing the SBAR tool, review of the 24 hours report to identify concerns for the physician to be made aware. The nurses were aware of the validation checklist for all current residents with any noted changes in condition.