Every finding on record at Abbotts Creek Center

Based on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents in 2 of 6 on the upper 100 hall. This deficient practice affected 2 of 6 residents reviewed for comfortable, clean, and homelike environment (Resident #46 and Resident #54).The findings included:a. An observation was conducted of Resident #46's room on 1/4/26 at 10:00 AM. The PTAC unit was noted to have dark brown spots that covered every vent slat of the unit. The room was occupied, and the PTAC was running at the time of the observation.b. An observation was conducted of Resident #54's room on 1/4/26 at 12:55 PM. The PTAC unit was noted to have a dark brown substance caked in the corners of every vent slat of the unit. The room was occupied, and the PTAC was running at the time of the observation.On 1/6/26 at 3:00 PM an observation of Resident #46's and Resident #54's room was conducted during a round with the Maintenance Director. He explained the Maintenance Department was responsible for cleaning the vents and filters of the PTAC units every 2 months. The Maintenance Director stated the last time he cleaned the PTAC units was October 2025. The Maintenance Director stated he was the only person who worked in the department and was behind in cleaning the PTAC units for December.The Housekeeping Manager was interviewed on 1/7/26 at 9:27 AM. He stated the Housekeeping Department was responsible for wiping down the top and front of the PTAC units when they clean the residents' rooms, but housekeeping does not have the required tools to clean the vents on the units. According to the Housekeeping Director, it was the responsibility of Maintenance to clean the vents of the PTAC units.On 1/7/26 at 1:44 PM the Administrator was interviewed and stated it was the responsibility of the Maintenance Director to ensure the PTAC units were kept clean. She stated maintenance should follow the every 2 month scheduled plan to clean the units.

Based on record review, observations, and interviews with staff, the Nurse Practitioner, and the Medical Director, the facility failed to obtain a physician's order for supplemental oxygen use for 1 of 1 resident reviewed for respiratory care (Resident #23).Findings included:Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. She was not coded as using supplemental oxygen.The active orders reviewed for Resident #23 did not include one for supplemental oxygen use.A review of the nurse's progress notes dated 12/28/25 revealed she assessed Resident #23 to have shortness of breath and reported it to the Medical Director for the resident to be assessed. A review of the progress notes revealed a written statement by the Nurse Practitioner during her assessment dated [DATE] to continue oxygen for Resident #23; however, there was no order written for supplemental oxygen use.An observation of Resident #23 on 1/4/26 at 10:02 AM revealed she was receiving supplemental oxygen by nasal cannula at a rate of 2 liters per minute (L/min), as indicated on the gauge of the bedside oxygen concentrator. Subsequent observations on 1/5/26 at 11:15 AM and on 1/6/26 at 10:15 AM revealed she continued to receive supplemental oxygen at a rate of 2 L/min by nasal cannula.Resident #23 was interviewed on 1/4/26 at 10:02 AM and stated she was placed on oxygen a few days ago when she had trouble breathing.An interview with Nurse #2 on 1/6/26 at 10:33 AM revealed that Resident #23 had an order for supplemental oxygen when she originally entered the facility a long time ago but was eventually weaned from it. Nurse #2 explained that Resident #23 had increased coughing and shortness of breath a week ago and was assessed by the Medical Director. She indicated she thought the Medical Director ordered supplemental oxygen for the resident at that time. However, Nurse #2 was unable to find an order for oxygen use in the medical record. On 1/6/26 at 10:53 AM, an interview was conducted with the Medical Director, who stated he assessed Resident #23 on 12/28/25 and noted she had increased wheezing and looked weaker than usual, but her oxygen saturation level was 95% on room air. He indicated he ordered nebulizer treatments and a steroid for the resident, but he did not order supplemental oxygen. The Medical Director stated he reviewed Resident #23's medical record later that evening and noted the resident was documented as receiving supplemental oxygen in the nurse's progress notes. He stated the resident should have had an order for administering supplemental oxygen before it was initiated. However, he indicated the resident was not at risk for any adverse outcome due to oxygen use at 2 L/min. The Nurse Practitioner (NP) was interviewed on 1/7/26 at 10:55 AM and stated that when she assessed Resident #23 on 12/31/25, the resident was already receiving supplemental oxygen at 2 L/min by nasal cannula. The NP indicated she wrote in her progress note to continue oxygen use since the resident was benefiting from it and a review of the resident's oxygen saturation level revealed she registered 93% on 2 L/min of supplemental oxygen. The NP explained she did not review the resident's orders and did not notice there was no order for oxygen use. According to the NP, the nurse should have obtained an order for supplemental oxygen use before applying it. On 1/7/26 at 1:47 PM, the Director of Nursing (DON) was interviewed and stated Resident #23 did have an order for oxygen use in the past, but it was discontinued. The DON indicated that if the resident needed supplemental oxygen again, staff should have obtained an order before applying it.

Based on record review, and interviews with the Medical Director and staff, the facility failed to hold blood pressure medication as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Residents #2 and #3). The findings included: 1) Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2 had severe cognitive impairment. Review of Resident #2's physician orders included an order dated 11/10/25 for Metoprolol (a medication for high blood pressure) 25 milligrams (mg) one tablet by mouth one time a day for hypertension. Hold for heart rate less than 60 or systolic blood pressure (the top number in the blood pressure reading) less than 100 or diastolic blood pressure (the bottom number in the blood pressure reading) less than 60. The December 2025 Medication Administration Record (MAR) was reviewed and revealed Resident #2 had received Metoprolol despite the heart rate below 60 on the following dates:12/13/25 heart rate was 52 administered by Nurse #3.12/14/25 heart rate was 52 administered by Nurse #3.12/16/25 heart rate was 53 administered by Nurse #4.12/18/25 heart rate was 55 administered by Nurse #5.12/20/25 heart rate was 59 administered by Nurse #4. On 1/6/26 at 8:47 AM, an interview occurred with the Medical Director. He reviewed Resident #2's medical record to include the December 2025 MAR and stated there were no negative outcomes from receiving Metoprolol outside the ordered parameter, however he would expect the nursing staff to follow the orders for the Metoprolol parameter as written. Nurse #5 was interviewed on 1/6/26 at 1:00 PM. Resident #2's December 2025 MAR was reviewed with her, and she verified that Metoprolol was administered on 12/18/25 despite the heart rate being below 60 when it should have been held and stated it was an oversight. Nurse #4 was interviewed via the phone on 1/6/26 at 1:56 PM. Resident #2's December 2025 MAR was reviewed with her and she verified that she had administered medications to Resident #2 on 12/16/25 and 12/20/25. She was unable to state why the Metoprolol was administered outside the parameter on 12/16/25 and 12/20/25, other than to say it was an oversight and the medication should have been held. Attempts to contact Nurse #3 were made without success. An interview was conducted with the Director of Nursing on 1/7/26 at 10:55 AM and stated she expected the nursing staff to follow physician orders including blood pressure medications with parameters to hold the medication. 2) Resident #3 was admitted to the facility on [DATE] with diagnoses that included hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3 was cognitively intact. Review of Resident #3's physician orders included an order dated 12/18/25 for Metoprolol (a medication for high blood pressure) 50 milligrams (mg) one tablet by mouth three times a day for hypertension. Hold for heart rate less than 60 or systolic blood pressure (the top number in the blood pressure reading) less than 100 or diastolic blood pressure (the bottom number in the blood pressure reading) less than 60. The January 2026 Medication Administration Record (MAR) was reviewed and revealed Resident #3 had received Metoprolol despite the systolic blood pressure below 100 on 1/2/26 at the 1:00 PM dose, the systolic blood pressure was 97 and was administered by Nurse #6.1/2/26 at the 9:00 PM dose, the systolic blood pressure was 97 and was administered by Nurse #7. On 1/6/26 at 8:47 AM, an interview occurred with the Medical Director. He reviewed Resident #3's medical record, to include the January 2026 MAR, and stated there were no negative outcomes from receiving Metoprolol outside the ordered parameter, however he would expect the nursing staff to follow the orders for the Metoprolol parameter as written. Nurse #6 was interviewed on 1/6/26 at 12:08 PM. Resident #3's January 2026 MAR was reviewed with him, and he verified that Metoprolol was administered on 1/2/26 at 1:00 PM, despite the systolic blood pressure being below 100 when it should have been held and stated it was an oversight. Attempts to contact Nurse #7 were made without success. An interview was conducted with the Director of Nursing on 1/7/26 at 10:55 AM and stated she expected the nursing staff to follow physician orders including blood pressure medications with parameters to hold the medication.

Based on observation and staff interviews, the facility failed to store and secure a controlled medication that required refrigeration within a separately locked, permanently affixed box within the medication room refrigerator. This deficient practice was for 1 of 2 medication storage rooms reviewed (103 Medication Storage Room).The findings included:An observation and interview were conducted on 01/04/26 at 10:35 AM of the 103 medication storage room refrigerator with Nurse #1. The observation revealed a 30 ml (milliliter) bottle of liquid lorazepam (a benzodiazepine) 2 mg (milligram) /ml located in the refrigerator door. Nurse #1 stated staff did not have a key to the lock box inside of the refrigerator and there was not a lock for the refrigerator door. Nurse #1 explained she was unsure why there was no key for the lock box within the refrigerator and it had been that way for a long time. Nurse #1 confirmed the lorazepam should have been secured within the medication storage refrigerator inside the affixed lock box. An interview was conducted on 01/06/26 at 11:27 AM with the Director of Nursing (DON). She stated she was unaware nurses did not have a key to the internal lock box in the medication refrigerator. She explained the controlled medications, including lorazepam, were to be stored in the secured lock box affixed within the refrigerator.An interview was conducted on 01/06/26 at 3:57 PM with the Administrator. She indicated she was unaware staff could not access the internal lock box in the medication refrigerator. She expected controlled medications that required refrigeration to be stored in the secured lock box affixed to the inside of the refrigerator.

Based on record review, observations, and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 28 out of 30 days reviewed (12/6/25 to 1/2/26). The facility also failed to ensure the resident census was present on the daily nurse staffing sheets for 2 of 3 days reviewed (1/3/26 and 1/4/26). The findings included: 1) A review of the facility's daily posting for nursing staff for the past 30 days as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 12/6/25 indicated that one (1) Medication Aide (MA) worked 7:00 AM to 7:30 PM. The daily posted nurse staffing sheet for 12/6/25 documented that One (1) MA worked 3:00 PM to 11:30. b. The nursing schedule for 12/7/25 indicated that one (1) MA worked from 7:00 AM to 7:30 PM. The daily posted nurse staffing sheet for 12/7/25 documented that one (1) MA worked 3:00 PM to 11:30 PM. c. The nursing schedule for 12/8/25 indicated that 3 Licensed Practical Nurses (LPNs) worked from 3:00 PM to 7:30 PM, 1 LPN worked from 7:00 PM to 7:30 AM and 3 Nurse Aides (NAs) worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/8/25 documented that one (1) LPN worked from 3:00 PM to 7:30 PM, no LPN worked 7:00 PM to 7:30 AM and 5 NAs worked 11:00 PM to 7:00 AM. d. The nursing schedule for 12/9/25 indicated that 4 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 12/9/25 documented that 6 NAs worked from 7:00 AM to 3:00 PM. e. The nursing schedule for 12/10/25 indicated that 3 LPNs worked from 7:00 AM to 3:00 PM, 3 LPNs worked from 3:00 PM to 7:30 PM, one (1) Registered Nurse (RN) worked 7:00 PM to 7:30 AM, one (1) LPN worked 7:00 PM to 7:30 AM, 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/10/25 documented that one (1) LPN worked 7:00 AM to 3:00 PM, no LPN worked 3:00 PM to 7:30 PM, no RN worked 7:00 PM to 7:30 AM and 2 NAs worked 11:00 PM to 7:00 AM. f. The nursing schedule for 12/11/25 indicated that 4 NAs worked 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM, one (1) RN worked 7:00 PM to 7:30 AM and one (1) LPN worked 7:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/11/25 documented that 6 NAs worked 7:00 AM to 3:00 PM, 6 NAs worked 3:00 PM to 11:00 PM, no RN worked 7:00 PM to 7:30 AM and 2 LPNs worked 7:00 PM to 7:30 AM. g. The nursing schedule for 12/12/25 indicated that 2 LPNs worked 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM, no MA worked that day, and one (1) LPN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/12/25 documented that 3 LPNs worked 7:00 AM to 3:00 PM, 6 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM and 3 LPNs worked 11:00 PM to 7:30 AM. h. The nursing schedule for 12/13/25 indicated that 2 LPNs worked 3:00 PM to 11:00 PM, no MA worked any shift, 2 LPNs worked 11:00 PM to 7:30 AM, one (1) RN worked 11:00 PM to 7:30 AM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/13/25 documented 3 LPNs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, 4 LPNs worked 11:00 PM to 7:30 AM, 3 RNs worked 11:00 PM to 7:30 AM and 6 NAs worked 11:00 PM to 7:00 AM. i. The nursing schedule for 12/14/25 indicated that 5 NAs worked 3:00 PM to 11:00 PM, no MA worked any shift, 4 NAs worked from 11:00 PM to 7:00 AM, one (1) LPN worked 11:00 PM to 7:30 AM, one (1) RN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/14/25 documented 3 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, 7 NAs worked 11:00 PM to 7:00 AM, 3 LPNs worked 11:00 PM to 7:30 AM and 3 RNs worked 11:00 PM to 7:30 AM. j. The nursing schedule for 12/15/25 indicated that 2 LPNs worked 7:00 AM to 3:00 PM, 4 NAs worked the 3:00 PM to 11:00 PM shift, one (1) LPN worked 3:00 PM to 11:00 PM and one (1) RN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/15/25 documented 4 LPNs worked 7:00 AM 3:00 PM, 8 NAs worked 3:00 PM to 11:00 PM, 2 LPNs worked 3:00 PM to 11:00 PM, and no RN worked 11:00 PM to 7:30 AM. k. The nursing schedule for 12/16/25 indicated that 5 NAs worked 3:00 PM to 11:00 PM, one (1) RN worked 7:00 PM to 11:00 PM, 4 NAs worked 11:00 PM to 7:00 AM, one (1) LPN worked 11:00 PM to 7:30 AM and one (1) RN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/16/25 documented 2 NAs worked 3:00 PM to 11:00 PM, no RN worked 7:00 PM to 11:00 PM, 3 NAs worked 11:00 PM to 7:00 AM, no LPN worked 11:00 PM to 7:30 AM and no RN worked 11:00 PM to 7:30 AM. l. The nursing schedule for 12/17/25 indicated that 6 NAs worked 7:00 AM to 3:00 PM, 3 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/17/25 documented 8 NAs 7:00 AM to 3:00 PM, one (1) NA worked 3:00 PM to 11:00 PM, no MA worked 3:00 PM to 11:30 PM, and 2 NAs worked 11:00 PM to 7:00 AM. m. The nursing schedule for 12/18/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, 5 NAs worked 3:00 PM to 11:00 PM, no MA worked any shift, 1 RN worked 3:00 PM to 11:30 PM, one (1) RN worked 7:00 PM to 7:30 AM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/18/25 documented 8 NAs worked from 7:00 AM to 3:00 PM, 3 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, no RN worked 3:00 PM to 11:30 PM, no RN worked 7:00 PM to 7:30 AM and 2 NAs worked 11:00 PM to 7:00 AM. n. The nursing schedule for 12/19/25 indicated 5 NAs worked 7:00 AM to 3:00 PM and one (1) RN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/19/25 documented 4 NAs worked 7:00 AM to 3:00 PM and 2 RNs worked 11:00 PM to 7:30 AM. o. The nursing schedule for 12/20/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, 5 NAs worked 3:00 PM to 11:00 PM, 3 LPNs worked 3:00 PM 11:00 PM, no MA worked any shift, and 2 LPNs worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/20/25 documented 4 NAs worked 7:00 AM to 3:00 PM, 3 NAs worked 3:00 PM to 11:00 PM, 4 LPNs worked 3:00 PM 11:00 PM, one (1) MA 3:00 PM to 11:30 PM, and 3 LPNs worked 11:00 PM to 7:30 AM. p. The nursing schedule for 12/21/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, 5 NAs worked 3:00 PM to 11:00 PM, no MA worked any shift, and 2 LPNs worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/21/25 documented 4 NAs worked from 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, and 3 LPNs worked from 11:00 PM to 7:30 AM. q. The nursing schedule for 12/22/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, 2 LPNs worked 7:00 AM to 3:00 PM, 2 RNs worked 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM, and 3 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/22/25 documented 3 NAs worked 7:00 AM to 3:00 PM, 4 LPNs worked 7:00 AM to 3:00 PM, no RNs worked 7:00 AM to 3:00 PM, one (1) NA worked 3:00 PM to 11:00 PM, and 2 NA worked 11:00 PM to 7:00 AM. r. The nursing schedule for 12/23/25 indicated 6 NAs worked 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM, 4 NAs worked 11:00 PM to 7:00 AM, no LPNs worked 11:00 PM to 7:30 AM and 2 RNs worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/23/25 documented 5 NAs worked 7:00 AM to 3:00 PM, one (1) NA worked 3:00 PM to 11:00 PM, 3 NAs worked 11:00 PM to 7:00 AM, one (1) LPN worked 11:00 PM to 7:30 AM and one (1) RN worked 11:00 PM to 7:30 AM. s. The nursing schedule for 12/24/25 indicated one (1) RN worked 7:00 AM to 3:00 PM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/24/25 documented no RN worked 7:00 AM to 3:00 PM and 3 NAs worked 11:00 PM to 7:00 AM. t. The nursing schedule for 12/25/25 indicated 5 NAs worked 3:00 PM to 11:00 PM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/25/25 documented 4 NAs worked 3:00 PM to 11:00 PM and 5 NAs worked 11:00 PM to 7:00 AM. u. The nursing schedule for 12/26/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, one (1) LPN worked 7:00 AM to 3:00 PM, 4 NAs worked 3:00 PM to 11:00 PM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/26/25 documented 4 NAs worked 7:00 AM to 3:00 PM, 2 LPNs worked 7:00 AM to 3:00 PM, 2 NAs worked 3:00 PM to 11:00 PM and 3 NAs worked 11:00 PM to 7:00 AM. v. The nursing schedule for 12/27/25 indicated 5 NAs worked 3:00 PM to 11:00 PM, no MA worked any shift and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/27/25 documented 4 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM and 3 NAs worked 11:00 PM to 7:00 AM. w. The nursing schedule for 12/28/25 indicated 5 NAs worked 7:00 AM to 3:00 PM, no MA worked any shift, and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 12/28/25 documented 6 NAs worked 7:00 AM to 3:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, and 3 NAs worked 11:00 PM to 7:00 AM. x. The nursing schedule for 12/29/25 indicated 6 NAs worked 7:00 AM to 3:00 PM, 3 NAs worked 11:00 PM to 7:00 AM, and 2 RNs worked from11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/29/25 documented 5 NAs worked from 7:00 AM to 3:00 PM, 6 NAs worked 11:00 PM to 7:00 AM, and no RNs worked from 11:00 PM to 7:30 AM. y. The nursing schedule for 12/30/25 indicated 4 NAs worked 7:00 AM to 3:00 PM, 4 NAs worked 11:00 PM to 7:00 AM, one (1) LPN worked 11:00 PM to 7:30 AM and one (1) RN worked 11:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 12/30/25 documented 5 NAs worked 7:00 AM to 3:00 PM, 3 NAs worked 11:00 PM to 7:00 AM, no LPN worked 11:00 PM to 7:30 AM and no RN worked 11:00 PM to 7:30 AM. z. The nursing schedule for 12/31/25 indicated 5 NAs worked 7:00 AM to 3:00 PM and 4 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 12/31/25 documented 7 NAs worked 7:00 AM to 3:00 PM and 2 NAs worked 3:00 PM to 11:00 PM. aa. The nursing schedule for 1/1/26 indicated 3 LPNs worked the 7:00 AM to 3:00 PM shift, 5 NAs worked the 3:00 PM to 11:00 PM shift, one (1) RN worked 3:00 PM to 11:30 PM and one (1) RN worked 7:00 PM to 7:30 AM. The daily posted nurse staffing sheet for 1/1/26 documented 4 LPNs worked the 7:00 AM to 3:00 PM shift, 4 NAs worked the 3:00 PM to 11:00 PM shift, no RN worked 3:00 PM to 11:30 PM and no RN worked 7:00 PM to 7:30 AM. bb. The nursing schedule for 1/2/26 indicated 5 NAs worked 7:00 AM to 3:00 PM, one (1) LPN worked the 7:00 AM to 3:00 PM shift, 4 NAs worked 3:00 PM to 11:00 PM, no MA worked any shift, 4 NAs worked 11:00 PM to 7:00 AM and 2 LPNs worked the 11:00 PM to 7:30 AM shift. The daily posted nurse staffing sheet for 1/2/26 documented 6 NAs worked 7:00 AM to 3:00 PM, 3 LPNs worked the 7:00 AM to 3:00 PM shift, 2 NAs worked 3:00 PM to 11:00 PM, one (1) MA worked 3:00 PM to 11:30 PM, 2 NAs worked 11:00 PM to 7:00 AM and one (1) LPN worked the 11:00 PM to 7:30 AM shift. On 1/6/26 at 9:36 AM, an interview occurred with the Scheduling Manager. She was able to review the staffing schedule and daily postings and verified the number of staff working from 12/6/25 to 1/2/26 did not match. She explained the facility had recently gone to a new payroll/scheduling system and stated the system was pulling staff for the daily postings from a data report rather than the actual working schedule. She stated she didn't know how to edit in the system to reflect the actual number of staff that worked in a day. The Administrator was interviewed on 1/7/26 at 11:03 AM. The staffing schedule and daily postings were reviewed, which did not match for the actual staff that worked on a certain day. She confirmed that the facility recently began using a new payroll/scheduling system and there was not a way for the Scheduling Manager to edit the daily postings to reflect the correct number of staff that had worked. She had reached out to the company that manages the system several times but has been unsuccessful in getting feedback. The Administrator added that the daily staff schedule posting and the staffing schedule should match for the number of staff worked on any given shift. 2) An observation was made in the lobby of the facility on 1/4/26 at 9:45 AM. A review of the facility's daily posting for nursing staff for 1/3/26 revealed no resident census number for the 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts. Additionally, the daily posting for the 7:00 AM to 3:00 PM shift on 1/4/26 demonstrated no resident census number. The Weekend Supervisor was interviewed on 1/5/26 at 1:15 PM. She reported the Staff Scheduler was responsible for completing the staff posting sheets for all days of the week. The Staff Scheduler was interviewed on 1/05/26 at 1:21 PM. She reviewed the daily nursing staff postings and noted that they did not include a resident census for the weekend dates of 1/3/26 and 1/4/26. She stated that she does not work on the weekends and completed the daily nursing staff postings on Monday when she returned to work. She stated that there was not a staff member assigned to complete the daily staff postings on the weekends. The Scheduler stated she was responsible for all the daily staffing sheets for the week, Sunday through Saturday. She stated that when she completed them on Friday, 1/2/26, her plan was to finish completing the resident census for 1/3/26 and 1/4/26 when she returned to work on Monday, 1/5/26. The Administrator was interviewed on 1/07/26 at 1:12 PM and stated she expected the resident census to be present on the daily nursing staff posting as required. The Administrator stated the weekend supervisor should have filled in the census on the posting and was not aware this was not being done.

Based on record review, observation, and staff interviews, the facility failed to develop a comprehensive person-centered plan to address anticoagulant, insulin, and antidepressant use for 1 of 15 residents reviewed for comprehensive care plans (Resident # 18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, and major depressive disorder. A review of the physician's orders dated 08/12/24 revealed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous Solution Pen Injector 100 unit/milliliter Inject as per sliding scale subcutaneously four times a day for diabetes mellitus - Insulin Glargine Subcutaneous Solution Inject 10 units subcutaneously in the morning for diabetes mellitus - Sertraline HCL Oral Tablet 50 milligrams Give 1 tablet via PEG Tube one time a day for depression - Apixaban Oral Tablet 5 milligrams Give 1 tablet via PEG Tube two times a day for atrial fibrillation A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively impaired, diagnosed with depression and received antidepressant medication for the seven days of the look back period. The MDS further revealed Resident #18 was diagnosed with diabetes and received insulin six days during the look back period. The MDS also revealed Resident #18 was diagnosed with atrial fibrillation and was marked yes for anticoagulant use during the look back period. A review of the care plan dated 08/18/24 revealed that Resident #18 did not have a person-centered care plan that addressed anticoagulant use, insulin use, and antidepressant use. On 09/27/24 at 12:37 PM an interview was conducted with the MDS Nurse, and she stated the admitting nurse was responsible for initiating a baseline care plan and then the MDS nurse built the comprehensive care plan from the baseline care plan. The MDS Nurse stated a traveling MDS Nurse completed Resident #18's admission MDS assessment. Attempts to reach the traveling MDS Nurse via telephone were unsuccessful. An interview was conducted with the Director of Nursing (DON) and Administrator on 09/27/24 at 12:29 PM and the DON stated the admitting nurse was responsible for the initiation of Resident #18's baseline care plan and then the MDS Nurse built on to the baseline care plan when he/she completed the comprehensive care plan. The DON stated the use of anticoagulant medication, insulin, and antidepressant medication should have been picked up and care planned on admission.

Based on record reviews and staff interviews, the facility failed to arrange home health services upon discharge for 1 of 4 sampled residents (Resident #54) reviewed for discharge planning. Findings included: Resident #54 was admitted to the facility on [DATE] with diagnosis of paroxysmal atrial fibrillation, dementia, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] indicated Resident #54 was severely cognitively impaired. The physician's order dated 5/29/24 documented Resident #54 was to discharge home on 5/31/24. The order revealed the resident would need a hospital bed related to her inability to transfer or lay flat. Resident would need a home health agency (HHA) for ADL (activities of daily living) assistance; home health nursing for medication management; physical therapy (PT) and occupational therapy (OT) to evaluate and treat; and a social worker (SW) for the community. The review of the Discharge Plan Documentation dated 5/30/24 completed by the facility's former Social Worker indicated Resident #54 was to be discharged home with her family, home health services and Hospice starting 5/31/24. A hospital bed was ordered for delivery to resident's home on 5/31/24. The Assessment and Plan included in the physician's Discharge Summary dated 5/31/24 indicated Resident#54's family would assist the HHA with the resident's ADL care at home. If the resident decided to participate with PT, the HHA would also provide PT if the resident was willing to participate. During an interview on 9/25/24 at 3:39 p.m., the Business Office Manager revealed the SW, who conducted the discharge planning at the time of Resident #54's discharge, no longer worked at the facility. She stated that after searching the resident's medical records and the facility's records, there was no documentation available indicating the SW made a referral for home health assistance for Resident #54. She further revealed the facility contacted the two home health providers the facility typically made referrals to and was informed they had no referrals for this resident. On 9/25/24 at 4:51 p.m., a telephone interview was conducted with the former Social Worker who was able to recall completing discharge planning with Resident #54 and her family member. She stated she made the referral for home health for the resident but could not recall if referral was made via email or during an onsite visit. During an interview on 9/27/24 at 4:22 p.m., the Administrator acknowledged the prior Social Worker failed to follow through with home health services for Resident #54.

Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled residents (Resident #4) observed to have medications bedside. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD). A review of Resident #4's electronic medical record (EMR) revealed physician orders for the following medications; -Albuterol Sulfate HFA (multidose inhaler) aerosol solution 108 MCG (micrograms) to be administered as 2 puffs inhaled orally one time a day for the treatment of asthma with a start date of 9/15/2023. -Breo Ellipta aerosol powder breath activated 100-25 MCG/INH to be administered 1 inhalation a day for treatment of COPD with a start date of 3/11/2021. -Ipratropium Bromide nasal solution 0.03 % to be administered 2 sprays in both nostrils three times a day for allergies with a start date of 10/13/2022. A review of the resident's EMR revealed there was no assessment for self-administration. The resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. An observation and interview were conducted on 12/12/2023 at 11:00AM of Resident #4 as she prepared to receive wound care treatment. The resident was observed to have a clear plastic bag of medications in the bed next to her. Upon inquiry, Resident #4 reported the nurse left her medications for her to administer and would be back around later to get the medications. Observed in the plastic bag were a multidose inhaler of albuterol, a multidose inhaler of Breo Ellipta, and a bottle of ipratropium bromide nasal spray. On 12/12/2023 at 11:15AM an interview was conducted with Nurse #1, who was assigned to Resident #4. Nurse #1 stated Resident #4 did not have a medication self-administration assessment and should not have medications bedside. She stated the night shift nurse may have left the medications in the resident's room. A second interview was conducted with Resident #4 on 12/12/2023 at 12:00PM. The resident stated Nurse #1 had given her the medications to self-administer. She stated she typically self-administered her inhaled medications. Resident #4's current care plan was last revised 10/15/2023. The resident was not care planned for the self-administration of medications. An interview was conducted on 12/12/2023 at 3:12 PM with the facility's Director of Nursing (DON). During this interview, the DON stated the facility had a process for safe self-administration of medications and that process was not followed. He further stated the medications were removed from Resident #4's bedside, the resident would be evaluated for safe self-administration of those medications per the facility's policy, and the nurse would be provided additional education.

Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and chronic obstructive pulmonary disease (COPD). A review of the active physician orders revealed an order dated 11/7/23, for oxygen at 2 liters via nasal cannula continuously. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact, had shortness of breath when lying flat and used oxygen. A review of Resident #25's active care plan, last reviewed 11/30/23, included a focus area for exhibited or was at risk for respiratory complications related to COPD and history of acute and chronic respiratory failure. One of the approaches was to provide oxygen as ordered via nasal cannula. On 12/11/23 at 10:00 AM, an observation was made of Resident #25 while she was lying in bed. The oxygen regulator on the concentrator was set at 4 liters flow when viewed horizontally, eye level. An observation occurred on 12/12/23 at 10:06 AM of Resident #25, which revealed the oxygen regulator on the concentrator was set at 4 liters flow by nasal cannula when viewed horizontally at eye level. Resident #25 was observed while lying in bed on 12/13/23 at 10:13 AM. The oxygen regulator on the concentrator was set at 4 liters flow when viewed horizontally at eye level. On 12/13/23 at 10:16 AM, an observation of Resident #25 was completed with Nurse #2, who confirmed the oxygen regulator on the concentrator was set at 4 liters when viewed horizontally at eye level. Nurse #2 adjusted the flow to administer 2 liters of oxygen as ordered. Nurse #2 stated that oxygen rates were checked when she provided medications through out the day. During an interview with the Director of Nursing on 12/13/23 at 12:51 PM, he indicated it was his expectation for oxygen to be delivered at the ordered rate.

Based on record review and Medical Director, and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was severely cognitively impaired and received hospice services. A review of Resident #2's medical record was completed on 12/12/2023 and revealed Resident #2 had a physician's order dated 10/11/2023 for Lorazepam (a psychotropic used to treat anxiety) 0.5 milligrams (mg) one tablet sublingually every four hours as needed for anxiety. The order for the Lorazepam was entered into the Electronic Medical Record (EMR) by Nurse #3 and did not have a stop date. Additionally, the medical record contained an order for hospice services dated 10/16/2023. A phone interview was conducted with Nurse #3 on 12/13/2023. She stated she was no longer employed by the facility, and she did not recall the resident or the order for lorazepam. Resident #2's progress notes included a monthly medication review by the pharmacy consultant dated 11/24/2023. The consultation report recommended the as needed (PRN) order for lorazepam be discontinued due to the order being greater than 14 days duration without a stop date. A paper copy of the recommendation was provided with the Medical Director's response. The Medical Director responded on 11/29/2023 and declined the recommendation noting the indication for the PRN psychotropic drug was hospice care, the duration of until she passes, with rationale for the extended period as hospice care. An interview occurred with the Medical Director on 12/13/2023 at 11:07 AM, who stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration, but he wrote Resident #2's order the way it was because she was on hospice. He wanted the medication to be available if she should need it. He was not aware the regulation extended to residents receiving end of life services.

Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening and failed to discard expired medications in 1 of 2 medication carts (100 Hall medication cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/12/23 at 11:35 AM of the 100 Hall medication cart in the presence of Nurse #1. The observation revealed no open date on the following multi-dose medications: a. One multi-dose Lantus insulin pen with 60 units out of 100 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. b. One multi-dose Victoza insulin pen with 10mg out of 18mg left in pen. The manufacturer's recommendation was to discard 30 days after opening. c. One multi-dose Glargine insulin pen with 220 units out of 300 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. d. One multi-dose package of Albuterol Sulfate 0.63mg/3ml nebulizer solution, 1 pouch contains 5 vials, 2 vials left in pouch. The manufacturer's recommendation was to discard 7 days after opening. e. One multi-dose package of Albuterol Sulfate 0.63mg/3ml nebulizer solution, 1 pouch contains 5 vials, 3 vials left in pouch. The manufacturer's recommendation was to discard 7 days after opening. Nurse #1 verified the medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses were to write the date on all multi-dose medications upon opening and check dates on all medications prior to administration to make sure they were not expired. She then stated she did not realize the medications were not dated. She further stated that the nurses should be checking the medication carts daily prior to administration. f. The observation also revealed one box of Loperamide Hydrochloride 2mg tablets with 17 of 24 tabs still in box with an expiration date of 08/2023 labeled on box. Nurse #1 verified the Loperamide had expired on 08/2023 and discarded the item. She then stated she did not realize there were expired medications on the cart. An interview was conducted with the Director of Nursing (DON) on 12/13/23 at 1:40 PM. He stated when the items were initially opened for administration the nurse was to write the open date on the medication. The expired medication should have been caught earlier and discarded. The nurses are to check dates prior to administering multi-use medications (insulins, eye drops, nebulizer treatments etc.). He also stated nurses should check dates daily, unit managers check carts weekly, and the pharmacist checks them monthly.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 02/05/21 and annual recertification and complaint survey on 07/11/22. This was for 3 deficiencies that were cited in the areas of Respiratory/Tracheostomy care and Suctioning and Label/Store Drugs & Biologicals which were previously cited on 02/05/21 and Resident Self-Admin Meds-Clinically Appropriate which was previously cited on 07/11/22. The deficient practice area was recited on the current recertification and complaint survey of 12/13/23. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F554-Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled residents observed to have medications bedside. During the facility's recertification and complaint survey of 07/11/22 the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident observed to have medications at bedside. 2. F695- Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care. During the facility's recertification survey of 02/05/21, the facility failed to obtain oxygen orders for 1 of 1 residents reviewed for oxygen. 3. F761-Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening and failed to discard expired medications in 1 of 2 medication carts (100 Hall medication cart) reviewed for medication storage and labeling. During the facility's recertification survey of 02/05/21, the facility failed to remove expired medications from 1 of the 2 medication carts, failed to document open dates of medication in 2 of 2 medication carts, and failed to secure and label unidentified loose pills in 2 of the 2 medication carts. An interview was conducted with the Administrator and facility Nurse Consultant on 12/13/23 at 3:08 PM. The Administrator stated that she felt the repeat citations were due to the facility's leadership turnover and due to the facility currently having an interim DON.

Based on observations, record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints and alarms (Residents #17 and #40), skin conditions (Residents #22 and 63) and medications (Residents #6 and #44). This was for 6 of 21 resident records reviewed. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly MDS assessment dated [DATE] indicated Resident #17 had severe cognitive impairment and was not coded for a wander/elopement alarm. Resident #17's active care plan, last reviewed 5/13/22 included a focus area wanders the facility and talking about leaving to go home. The interventions included a wander-alarm applied to the right ankle that was initiated on 2/3/22. On 7/6/22 at 2:39 PM, an observation occurred of Resident #17 while he was lying in bed watching TV. A wander-alarm bracelet was visible to his right ankle. A phone call was placed to the Clinical Reimbursement Coordinator (CRC) on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarms was not coded. She stated she was not the MDS Nurse at that time and would have been coded by the CRC, however the wander/elopement alarm should have been coded. An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #40's active care plan included a focus area that was initiated on 8/26/20 for risk for elopement related to cognitive loss/dementia and talks about searching for daddy. The interventions included a wander-alarm bracelet to the right ankle. A quarterly MDS assessment dated [DATE] indicated Resident #40 had severe cognitive impairment and was not coded for a wander/elopement alarm. On 7/7/22 at 2:34 PM, an observation was made of Resident #40 while she was lying in bed. A wander-alarm bracelet was visible to her right ankle. A phone call was placed to the CRC on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarms was not coded. She explained at that time she was new to the position and the CRC was checking to ensure her entries were correct before submitting. The MDS Nurse stated it was an oversight not to have coded the wander/elopement alarm for Resident #40. An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 3. Resident #22 was originally admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Infectious Disease progress note for 1/24/22 indicated Resident #22 had chronic open wounds over the right knee with tunneling and drainage with concern that the right knee prosthetic was infected causing abscesses. A review of a form titled Wound Evaluation and Management Summary completed by the Wound Physician, and dated 5/2/22, revealed the following skin conditions: - A traumatic wound to the right superior knee - A traumatic wound to the right medial knee - A shear wound to the right inferior knee - A wound to the right lateral knee - A wound to the right calf A quarterly MDS assessment dated [DATE] indicated Resident #22 had moderately impaired cognition. She was coded with five venous/arterial ulcers. Resident #22's active care plan, last revised 5/19/22, included a focus area for actual skin breakdown related to right shin and knee wounds due to infected hardware. A phone interview was completed with the VOHRA Wound Physician on 7/8/22 at 8:41 AM and explained Resident #22's wounds to her right knee and shin area were related to infection in her knee prosthetic and not venous/arterial related. A phone call was placed to the CRC on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and verified Resident #22 was coded with 5 arterial/venous ulcers. She explained the entry was completed by the CRC, who should have reviewed the Wound Evaluation and Management Summary as well as physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 4. Resident #63 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and was coded for a stage 4 pressure ulcer acquired at the facility. The MDS assessment dated [DATE] was completed by the corporate Clinical Reimbursement Coordinator (CRC). A wound care observation and resident interview was completed 7/7/22 at 11:50 AM with Resident #63. Resident #63 stated the pressure ulcer to her right heel had been open for 6 years. She continued that the area would improve then re-open and never completely healed. Resident #63 was care planned on 5/9/21 for a stage 2 pressure ulcer to her right heel. This care area was last revised on 5/21/22 The most recent quarterly MDS assessment dated [DATE] was also coded for a stage 4 pressure ulcer acquired at the facility. The MDS assessment dated [DATE] was completed by the MDS Nurse. An interview was completed on 7/6/22 at 3:12 PM with the MDS Nurse. She stated she began working at the facility for approximately 6 months as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated the corporate CRC worked remotely and trained her on how to complete a MDS assessment. She stated the corporate CRC reviewed all her MDS assessment's until her training ended about 2 weeks ago. The MDS Nurse stated she completed the 6/4/22 quarterly MDS assessment and copied what the corporate CRC had coded on Resident #63's quarterly MDS assessment dated [DATE]. She stated she was aware that Resident #63 had non-healing right heel pressure ulcer for as long as she had worked at the facility, but thought the corporate CRC knew more about coding the MDS assessment so she coded what the corporate CRC had coded on the quarterly MDS assessment completed 3/4/22. A telephone message was left for the corporate CRC to return surveyor's call on 7/8/22 at 9:50 AM. The Administrator and Interim DON were made aware on 7/8/22 at 11:30 AM that a message was left for the corporate CRC to return the surveyor's call. They suggested letting the facility attempt to contact the corporate CRC but no return phone calls were received. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #63's quarterly MDS assessment dated [DATE] and 6/4/22 should be coded accurately and reflect that her pressure ulcer was present on her admission on 5/9/21 and not facility acquired. 5. Resident #6 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was coded as taking an antipsychotic medication. The MDS assessment was completed by the corporate Clinical Reimbursement Coordinator (CRC). Resident #6's was care planned last revised on 12/1/21 for the use of [CONDITION(S)] medications related to her [CONDITION(S)]. Review of Resident #6's March, April, May, June and July 2022 Physician orders did not include any orders for an antipsychotic medication. The orders did however include an order dated 3/18/22 for [MEDICATION(S)] (anticonvulsant) for [CONDITION(S)]. An interview was completed on 7/8/22 at 10:15 AM with the MDS Nurse. She stated she began working at the facility for approximately 6 months ago as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated her MDS training ended about 2 weeks prior to the Interim DON starting on 6/21/22. The MDS Nurse stated the corporate CRC completed Resident #6's quarterly MDS assessment dated [DATE] and coded her [MEDICATION(S)] as an antipsychotic. She was unable to explain why the MDS assessment was coded inaccurately. A telephone message was left for the corporate CRC to return surveyor's call on 7/8/22 at 9:50 AM. The Administrator and Interim DON were made aware on 7/8/22 at 11:30 AM that a message was left for the corporate CRC to return the surveyor's call. They suggested letting the facility attempt to contact the corporate CRC but no return phone calls were received. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #6's medications should have been coded accurately on the quarterly MDS assessment dated [DATE] and was unable to explain why her [MEDICATION(S)] was coded as an antipsychotic. 6. Resident #44 was admitted to the facility on [DATE]. Resident #44 had a doctor's order dated 5/30/22 for [MEDICATION(S)] (an antianxiety medication) 150 milligrams (mgs) 1 tablet by mouth daily for depression. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #44 had received an antianxiety medication for 3 days during the assessment period. Review of the May and June 2022 Medication Administration Records (MAR) revealed that Resident #44 had received the [MEDICATION(S)] for 7 days during the assessment period (May 31 - June 6, 2022). The MDS Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse stated that she thought [MEDICATION(S)] was an antidepressant medication and indicated that it was an error on her part. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that she expected the MDS to be coded accurately.

Based on record reviews, observations, Medical Director, Wound Physician and staff interviews, the facility failed to provide treatments as ordered by the physician to non-pressure related wounds on the lower extremity for 1 of 2 residents reviewed for skin conditions (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Infectious Disease progress note dated 1/24/22, revealed Resident #22 had chronic open wounds over the right knee with tunneling and drainage due to right knee prosthetic infection. There were open areas around the right knee and an abscess to the right mid-shin. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 had moderately impaired cognition and displayed no behaviors or refusal of care during the look back period. She was coded with 5 venous/arterial ulcers and received application of nonsurgical dressings and ointments other than to her feet. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There are several areas on the right leg that drain, and the wound physician monitored weekly. Review of the active care plan, last revised 6/12/22, revealed a focus area for actual skin breakdown of the right shin and knee due to infected hardware. The interventions included to provide wound treatments as ordered and weekly wound assessment by in-house wound doctor to include measurements and description of wound status. a) The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right inferior knee, shear wound measured 3.8 centimeters (cm) in length and 0.6 cm in width and to continue the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the right inferior knee wound measured 4 cm in length and 0.8 cm in width. The order was changed to Calcium Alginate to the wound, cover with a dry dressing and wrap with gauze daily. A review of the June 2022 and July 2022 Medication Administration Records (MARs) and Treatment Administration Records (TARs) for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip that was present to the right inferior knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. b) The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right lateral knee wound measured 1.1 cm in length, 0.6 cm in width and 0.2 cm in depth. The facility was to continue with the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right lateral knee measured 0.8 cm in length, 0.5 cm in width and 0.1 cm in depth. The orders were changed to Calcium Alginate to the wound, cover with a dry dressing and wrap with gauze daily. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip from the right lateral knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. c) The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right superior knee measured 0.6 cm in length, 0.4 cm in width and 0.1 cm in depth. The facility was to continue the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 indicated the wound to the right superior knee measured 1 cm in length, 0.9 cm in width and 0.1 cm in depth. The orders were changed to Calcium Alginate to the wound and wrap with gauze daily. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed to around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip from the right superior knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. d) The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right calf wound measured 3.8 cm in length, 3.5 cm in width and 3 cm in depth. The facility was to continue the current treatment. A review of the Wound Evaluation and Management Summary completed by the Wound Physician on 5/16/22 indicated a change in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was to start using Calcium Alginate covered with a dry dressing and wrap with gauze daily. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right calf measured 2.5 cm in length, 1.8 cm in width and 0.1 cm in depth. The orders remained the same. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 5/16/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed to around the knee area, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing, cleaned the wound and reapplied a piece of Calcium Alginate, covered with a dry dressing and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. When asked about the Dakin's solution she stated that had been discontinued a while back. e) The Wound Evaluation and Management Summary form completed by the Wound Physician on 5/23/22 revealed a wound to the right shin that measured 2.8 cm in length, 2.5 cm in width and 1.5 cm in depth. The orders were to pack with [MEDICATION(S)] gauze, cover with Calcium Alginate and cover with a dry dressing daily. A review of the active physician orders, June 2022 and July 2022 MARs and TARs, for Resident #22, did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right shin measured 1.8 cm in length, 1.7 cm in width and 1.1 cm in depth. There were no changes to the order. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip that was present to the wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. f) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a wound to the right inferior calf that measured 3.4 cm in length and 2 cm in width. The facility was to apply Xeroform gauze (a non-adherent dressing with a mixture containing petroleum jelly) and wrap with gauze daily. A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. g) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a shear wound to the right superior, lateral (upper and to the side) calf that measured 1.5 cm in length, 0.6 cm in width and 0.1 cm in depth. The facility was to apply Calcium Alginate and a dry dressing daily. A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. h) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a wound to the right superior shin that measured 2 cm in length, 1.5 cm in width and 0.1 cm in depth. The facility was to apply Xeroform gauze and wrap with gauze daily A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. An interview occurred with Nurse #3 on 7/6/22 at 12:00 PM, who stated she had followed the orders in the July 2022 MAR and was unaware there were changes or additions to the treatment orders for Resident #22. She added she thought the open areas on her knee and calf were to be covered with Calcium Alginate. She explained she went by what was in the MAR and did not look at the Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/22 at 8:41 AM, a phone interview was completed with the Wound Physician. He explained he was at the facility once a week to assess and measure wounds for the residents that were on his caseload. A nurse rounded with him where he relayed the measurements as well as any changes to the treatment orders. He stated he thought the nurse was reviewing the treatment orders for accuracy from week to week and expected the facility to follow his recommendations unless the Medical Director changed them. The Wound Physician stated there would have been no harm to performing treatments according to the April 2022 orders as wound care for Resident #22 was palliative. Her wounds would continue to occur with difficulty healing due to the infected knee prosthetic and her decline for surgical intervention. The interim Director of Nursing (DON) was interviewed on 7/8/22 at 9:15 AM. She reviewed Resident #22's active physician orders, June 2022 and July 2022 MARs and TARs as well as Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained she had been rounding with the Wound Physician and would write what he stated about the wounds on a piece of paper, and often stated to keep the treatments the same. The interim DON stated she failed to review the Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director was interviewed on 7/8/22 at 11:13 AM and stated he left wound care orders to the Wound Physician if he was following the resident for wound care. He added he would expect the facility to follow the wound care orders as recommended.

Based on record review, observation and interview from the [CONDITION(S)] center staff, Physician, resident and facility staff, the facility failed to obtain orders for the care and monitoring of a [CONDITION(S)] resident (Resident #33) and failed to utilize the communication sheets to exchange information about resident's treatment and care with the [CONDITION(S)] center for 2 of 2 sampled residents reviewed for [CONDITION(S)] (Residents #33 & # 58). Findings included: 1. Resident #58 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #58 had severe cognitive impairment and was on [CONDITION(S)]. Resident #58 did not have a care plan or a baseline care plan for [CONDITION(S)] upon readmission. Review of Resident #58's medical records revealed no on-going communication with the [CONDITION(S)] center regarding resident's care and treatment. There were no pre and post [CONDITION(S)] weights from the [CONDITION(S)] center and there were no laboratory results since readmission. The Nurse Supervisor was interviewed on 7/7/22 at 9:02 AM. She stated that a communication binder was sent with the resident during [CONDITION(S)] days. Review of the [CONDITION(S)] binder, there were only 6 communication sheets (1/12/22, 4/4/22, 4/13/22, 6/8/22, 6/13/22 & 6/20/22) in the binder for Resident #58 for the last 6 months. Nurse #4, assigned to Resident #58, was interviewed on 7/7/22 at 10:40 AM. She stated that she works for an agency and was not familiar with the [CONDITION(S)] communication sheets. The [CONDITION(S)] Nurse was interviewed on 7/7/22 at 11:06 AM. She stated that the facility was supposed to bring the [CONDITION(S)] communication sheet with the resident during [CONDITION(S)] days. She reported that the [CONDITION(S)] nurse assigned to the resident completes the sheet with the pre and post weights and vital signs and returned the sheet back to the facility. She indicated that she was not sure if the sheets were received at the center or not since the [CONDITION(S)] center was not maintaining copies of the completed sheets. The Administrator was interviewed on 7/8/22 at 11:45 AM. She reported that the facility had just identified 2 [CONDITION(S)] residents including Resident #58 who did not have communication sheets completed during [CONDITION(S)] days. She stated that she would educate all the licensed staff including the agency staff regarding [CONDITION(S)] documentation, policy and procedure and assuring that the [CONDITION(S)] communication sheets were completed and sent with the resident to the [CONDITION(S)] center. 2. Resident #33 was admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission/5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #33 was cognitively intact and the MDS assessment was coded for [CONDITION(S)]. Review of Resident #33's July 2022 Physician orders included an order dated 5/18/22 which read the nurses were to check for a bruit (a loud swishing sound when listening to the fistula using a stethoscope) and thrill (vibrations felt when touching the fistula) every shift. There was an order dated 5/18/22 that read to document dry weights when Resident #33 returned from [CONDITION(S)] on Monday, Wednesday and Friday. Another order dated 5/26/22 was written for fluid restrictions of 1500 milliliters every day. There were no Physician orders for the monitoring of her arterial/vascular (AV) fistula for bleeding, signs and symptoms of infection, removing the dressing to her fistula the following day after [CONDITION(S)] and obtaining vital signs after returning from her [CONDITION(S)] treatments. An interview and observation was completed with Resident #33 on 7/5/22 at 1:00 PM. She stated she went to hemodialysis on Monday, Wednesday and Friday. She presented her left arm for observation. There was a large fistula noted to her upper left arm. She stated she reminded the staff and lab technicians that no blood pressure (B/P) or lab work were to be completed on her left arm. An interview was completed on 7/6/22 at 2:45 PM with the Administrator. She stated all [CONDITION(S)] residents to include Resident #33 took a notebook with the communication forms to each [CONDITION(S)] treatments for the [CONDITION(S)] staff and the facility to document her status pre and post [CONDITION(S)] treatment. She stated she was not aware that Resident #33's Physician orders did not include orders for monitoring her AV fistula for evidence of bleeding or obtaining Resident #33's vital signs upon her return from her [CONDITION(S)] treatments. Another interview was completed on 7/7/22 at 8:50 AM with Resident #33. She stated upon returning from [CONDITION(S)], the staff transferred her back to bed using a mechanical lift. She stated the staff did not take her vital signs upon her return from [CONDITION(S)] and she monitored her own fistula for bleeding after each [CONDITION(S)] treatment. Resident #33 stated she was given a form to take with her yesterday titled Hemodialysis Communication Record but she had only been given the form maybe one other time since her admission on 5/17/22. An interview was completed on 7/7/22 at 9:00 AM with Nursing Assistant (NA) #5. She stated she was not trained on care of [CONDITION(S)] resident but she was aware that a weight needed to be obtained pre and post [CONDITION(S)] treatment. An interview was completed on 7/7/22 at 9:02 AM with the Nursing Supervisor (NS). She stated it was her practice to obtain Resident #33's vital signs before and after her [CONDITION(S)]. The NS was unable to explain why there was no documented evidence that Resident #33's pre and post [CONDITION(S)] vital signs were obtained and entered into the electronic medical record. She stated Resident #33 took a [CONDITION(S)] communication notebook with her to every [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #33. The NS stated Resident #33's notebook should be located at the nurses station on the split hall. An interview was completed on 7/7/22 at 9:05 AM with Nurse #8. She stated she was very familiar with how to monitor a [CONDITION(S)] resident and it was her practice to check a resident's vital signs following a [CONDITION(S)] treatment because the blood pressure often dropped after a treatment. She stated she also monitored for evidence of bleeding at the [CONDITION(S)] access site and keeping the [CONDITION(S)] site dressing in place for 24 hours. Nurse #8 stated the only Physician orders for Resident #33 were to obtain a pre and post weight and to check Resident #33's AV fistula for a thrill and bruit each shift. An interview was completed on 7/7/22 at 9:10 AM with NA #4. She stated it was her practice to obtain a set of vital signs on all her residents first thing when she got to work but she was not working when Resident #33 returned from [CONDITION(S)]. She stated she was not aware of any additional monitoring that was needed for a [CONDITION(S)] resident. She stated she thought the nurse sent out a notebook with Resident #33 when she went to [CONDITION(S)]. An interview was completed on 7/7/22 at 9:20 AM with Nurse #3 working at the split nurses station assigned Resident #33. She stated on Resident #33's [CONDITION(S)] days, the staff got her up, got her dressed and ensured she ate her breakfast. Nurse #3 stated Resident #33 was always tired when she returned from [CONDITION(S)] and the staff just put her to bed. She stated her AV fistula was checked on every shift to a bruit and thrill and that it was her practice to remove the post [CONDITION(S)] AV fistula dressing around 3 or 4 hours after Resident #33's return. Nurse #3 stated normally Resident #33 took a notebook with communication forms inside for the [CONDITION(S)] staff to document any problems or new orders while she was at [CONDITION(S)]. An observation was completed with Nurse #3 to locate Resident #33's [CONDITION(S)] notebook with her [CONDITION(S)] communication forms inside but Nurse #3 was not able to locate Resident #33's [CONDITION(S)] communication notebook. Observations were completed at the rehabilitation nurses station and the long term care nurses station as well. No [CONDITION(S)] communication notebook was located for Resident #33. An interview was completed on 7/7/22 at 10:07 AM with the interim Director of Nursing (DON). She stated she was under the impression the staff were sending out a notebook with the communication forms inside for the facility and the [CONDITION(S)] clinic staff to document Resident #33's monitoring. The interim DON also stated she was not aware that the facility staff had not obtained Physician orders for the comprehensive care and monitoring of Resident #33. A telephone interview was completed on 7/7/22 at 11:06 AM with the [CONDITION(S)] center's Charge Nurse. She recalled Resident #33's [CONDITION(S)] treatment yesterday because she stated it was the first time the facility had sent the communication form with Resident #33. She stated there was a lack of communication between the facility and the [CONDITION(S)] clinic. An interview was completed on 7/7/22 at 3:05 PM with Nurse #6. She stated when she started working at the facility approximately 3 months ago, she never received any sort of training on the care and monitoring of a [CONDITION(S)] resident. She stated when caring for Resident #33, she only assessed her AV fistula for a bruit and thrill on her shift and did not obtain any vital signs or monitor for bleeding from her AV fistula because there were no orders to do so. An interview was completed on 7/8/22 at 11:00 AM with the Medical Director. He stated as long as Resident #33 remained a resident at the facility, orders should have been obtained for the monitoring of her vital signs, her AV fistula for signs of bleeding or infection and the removal of the post [CONDITION(S)] treatment dressing to her AV fistula. He also stated there must be ongoing communication between the facility and the [CONDITION(S)] clinic. An interview was completed on 7/8/22 at 11:42 AM with the Administrator. She was able to provide [CONDITION(S)] communication forms on Resident #33 dated 6/1/22 and another dated 7/6/22. She stated she expected the facility to obtain Physician orders for the care and monitoring of a [CONDITION(S)] resident. She further stated she expected the facility to ensure there was written communication between the facility and the [CONDITION(S)] center regarding Resident #33.

Based on record reviews, Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician for 2 of 6 residents whose medications were reviewed (Residents #40 and #18). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #40's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Call physician if systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 105. Hold if SBP less than 110. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 had severe cognitive impairment. The June 2022 and July 2022 Medication Administration Records (MARs) were reviewed and revealed Resident #40 had received [MEDICATION(S)], despite the SBP below 110 on the following dates: 6/5/22- SBP was 96 6/23/22- SBP was 100 6/25/22- SBP was 85 6/26/22- SBP was 102 6/27/22- SBP was 102 6/28/22- SBP was 97 6/29/22- SBP was 102 7/4/22- SBP was 100 An interview occurred with Nurse #1 on 7/7/22 at 12:01 PM who was assigned to Resident #40 on 6/25/22, 6/27/22, 6/28/22 and 7/4/22. Nurse #1 indicated she was aware the resident had parameters to hold the [MEDICATION(S)]. She reported she took the blood pressure and recorded on the MAR. Nurse #1 reviewed the June 2022 and July 2022 MARs, verified the [MEDICATION(S)] was administered despite the SBP being below 110 when it should have been held and responded it was an oversight. On 7/7/22 at 1:50 PM, an interview occurred with Nurse #3 who was assigned to Resident #40 on 6/5/22 and 6/23/22. The June 2022 MAR was reviewed with her, and she manually checked Resident #40's blood pressure before administering [MEDICATION(S)] due to the hold parameters ordered. She was unable to recall why the [MEDICATION(S)] was administered outside the parameters other than to say it was an error on her part and the medication should have been withheld. Attempts to contact Nurse #7 were made without success. She was assigned to Resident #40 on 6/26/22 and 6/29/22. The Medical Director (MD) was interviewed on 7/8/22 at 11:13 AM and stated if Resident #40 had received a few dosages of [MEDICATION(S)] outside the parameters it would not have caused any serious harm. The MD added he would have expected the nurses to follow the orders for [MEDICATION(S)] parameters as written. The Administrator and Director of Nursing (DON) was interviewed on 7/8/22 at 11:41 AM and stated she expected the nurses to follow doctor's orders including blood pressure medications with parameters to hold. 2. Resident # 18 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #18 had a doctor's order dated 4/27/21 for [MEDICATION(S)] XL (an antihypertensive medication) 37.5 milligrams (mgs) 1 tablet by mouth daily for hypertension - call the doctor if systolic blood pressure (SBP) is more than 180 or diastolic blood pressure (DBP) is more than 105 and to hold if SBP is less than 110. Review of the May and June 2022 Medication Administration Records (MARs) revealed that [MEDICATION(S)] was administered on 5/18/22 with the SBP of 104/68, on 6/5/22 with the SBP of 106/69, on 6/12/22 with the SBP of 108/61, and on 6/13/22 with the SBP of 108/61. Nurse #3, assigned to Resident #58 on 6/13/22, was interviewed on 7/6/22 at 1:40 PM. She stated that she normally checked the BP prior to administering the BP medications. The Nurse added that she was aware that Resident #18 had parameters to hold the BP medication, but she could not remember why the [MEDICATION(S)] was not held on 6/13/22 when the SBP was less than 110. Nurse #5, assigned to Resident #18 on 6/5/22 and 6/12/22, was interviewed on 7/6/22 at 2:58 PM. The Nurse stated that she could not remember if Resident #18 had parameters to hold his blood pressure medication. She reported that she normally checked the blood pressure prior to administering the blood pressure medication. Nurse #5 did not have an explanation as to why the [MEDICATION(S)] was administered on 6/5/22 and 6/12/22 when the SBP was below 110. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the nurses were expected to follow doctor ' s orders.

Based on record review, review of the medication manufacturer's instruction, observation and staff interview, the facility failed to have a medication error rate of less than 5 % as evidenced by 5 medication errors of 26 opportunities, resulting in a 19 % error rate for 2 of 3 residents observed during medication pass (Residents # 116 & # 56). Findings included: 1 a. Resident #56 was admitted to the facility on [DATE]. Resident #56 had a doctor's order dated 6/8/22 for [MEDICATION(S)] extended release (ER) 50 milligrams (mgs) 1 tablet by mouth daily for hypertension. There was no order to crush the medication. The manufacturer's instruction for [MEDICATION(S)] extended-release tablet indicated tablet should be swallowed whole and not chewed or crushed. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the [MEDICATION(S)] ER 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. b. Resident #56 had a doctor's order dated 6/27/22 for Potassium Chloride (KCL) extended release (ER) 20 milliequivalent (meq) 1 tablet by mouth twice a day for [CONDITION(S)]. There was no order to crush the medication. The manufacturer's instruction for KCL ER indicated swallow the tablets or capsules whole. Do not crush or chew extended-release capsules or tablets. Doing so can release all the drug at once, increasing the risk of side effects. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the KCL ER 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. c. Resident #56 had a doctor's order dated 6/8/22 for [MEDICATION(S)] delayed release 40 milligrams (mgs) 1 tablet by mouth twice a day for [CONDITION(S)] (GERD). There was no order to crush the medication. The manufacturer's instruction for [MEDICATION(S)] delayed release indicated do not split, chew or crush. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the [MEDICATION(S)] delayed release 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. d. Resident #56 had a doctor's order dated 6/8/22 for [MEDICATION(S)] delayed release 60 milligrams (mgs) 2 capsules by mouth daily for depression. There was no order to crush the medication. The manufacturer's instruction for [MEDICATION(S)] delayed release capsule indicated do not chew or crush and do not open delayed release capsule and sprinkle its contents on food or mix with liquids because these actions might affect the [MEDICATION(S)] coating. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications and mixed them with apple sauce. The Nurse was also observed to open the 2 capsules of [MEDICATION(S)] delayed release and mixed them with the crushed medications. Nurse #4 was observed to administer the crushed medication to the resident. Nurse #4 was interviewed on 7/8/22 at 9:40 AM. She stated that she was aware that ER medications were not supposed to be crushed but she was trained at this facility that ER medications could be crushed. She could not remember who provided the orientation training. The Director of Nursing and the Administrator were interviewed on 7/8/22 at 11:45 AM. They both stated that the expectation was ER medications should not be crushed unless there was a doctor's order. 2. Resident # 116 was admitted to the facility on [DATE]. Resident #116 had a doctor's order dated 6/16/22 for [MEDICATION(S)] 0.4 milligrams (mgs)/hour (hr.) 1 patch transdermal daily for [CONDITION(S)]. Remove at bedtime. Resident #116 was observed during the medication pass on 7/7/22 at 9:02 AM. Nurse #3 was observed to prepare the resident's medications including the [MEDICATION(S)] patch. Before applying the [MEDICATION(S)] patch, Nurse #3 observed the old [MEDICATION(S)] patch on the resident's chest wall. Nurse #3 was interviewed on 7/7/22 at 2:15 PM. The Nurse stated that the previous Director of Nursing (DON) had transcribed the [MEDICATION(S)] order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing and the Administrator were interviewed on 7/8/22 at 11:45 AM. They both stated that the expectation was for the staff to follow the doctor's order.

Based on record review, observation and staff and resident interview, the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident observed to have medications at bedside (Resident # 7). Findings included: Resident #7 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 7 had doctor's orders dated 6/18/22 for [MEDICATION(S)] 1 spray both nostrils daily for allergies, Turmeric 500 milligrams (mgs) 1 tablet by mouth daily for supplementation and B-12 1 tablet by mouth daily for supplementation. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #7's cognition was intact. Resident #7 was observed on 7/5/22 at 10:30 AM and on 7/6/22 at 2:30 PM to have the [MEDICATION(S)] nasal spray bottle, Turmeric bottle and B-12 bottle at bedside. When interviewed, Resident #7 stated that her husband had brought these medications from home for her to take. She verified that she had been taking these medications and the nurses knew about it. Review of Resident #7's medical records revealed that she did not have an assessment for self-administration of medication nor a doctor's order to self-administer medications. Nurse # 4 was interviewed on 7/7/22 at 9:20 AM. She stated that she had observed the bottles of [MEDICATION(S)], Turmeric and B-12 at Resident #7's bedside but she indicated that the resident did not have an order to self-administer medications. The Nurse added that she did not know who was responsible to assess the resident for self-administration since she works for an agency. The Director of Nursing (DON) was interviewed on 7/8/22 at 10:10 AM. The DON stated that she started as DON in June 2022. She did not know who was responsible for assessing the resident for self-administration of medication before she was the DON, however the policy stated that the DON was responsible for the assessment. She expected the nurses to inform her of resident's desire to self-administer medications. The DON added that she was not informed that Resident #7 was self-administering medications.

Based on record review and staff interview, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 2 sampled residents reviewed who were newly admitted (Residents # 58 & # 115). Findings included: 1. Resident # 115 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #115 was observed in bed with a suprapubic catheter in place. Review of Resident #115's medical records revealed that she did not have a baseline care plan developed as of 7/7/22. The Minimum Data Set (MDS) Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse reported that the admitting Nurse was responsible for initiating the baseline care plan and she reviewed the baseline care plan the next day during the clinical meeting. She stated that the baseline care for Resident #115 was missed. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the MDS Nurse was responsible for developing the baseline care plan and not the nurses. She added that she would inform the MDS Nurse of this. 2. Resident #58 was readmitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's medical records revealed that she did not have a baseline care plan developed as of 7/7/22. The Minimum Data Set (MDS) Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse stated that Resident #58 was a resident at the facility but was discharged to the hospital. When she was discharged , her care plan was canceled and was never reinstated upon readmission. She reported that the admitting Nurse was responsible for initiating the baseline care plan and she reviewed it the next day during the clinical meeting. She stated that the baseline care for Resident #58 was missed. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the MDS Nurse was responsible for developing the baseline care plan and not the nurses. She added that she would inform the MDS Nurse of this.

Based on observations, staff and resident interviews and record review, the facility failed to develop and implement a comprehensive care plan in the area of hemodialysis (Resident #33). This was for 1 of 2 residents reviewed for [CONDITION(S)]. The findings included: Resident #33 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission/5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact and the MDS was coded for [CONDITION(S)]. Review of Resident #33 admission comprehensive care plan did not include a care area with interventions for her hemodialysis. Review of the care plan revealed it was completed by the Interim Director of Nursing (DON). An interview and observation was completed with Resident #33 on 7/5/22 at 1:00 PM. She stated she went to hemodialysis on Monday, Wednesday and Friday. She presented her left arm for observation. There was a large fistula noted to her upper left arm. She stated she reminded the staff and lab technicians that no blood pressure (B/P) or lab work were to be completed on her left arm. An interview was completed on 7/8/22 at 10:15 AM with the MDS Nurse. She stated she began working at the facility for approximately 6 months ago as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated the corporate Clinical Reimbursement Coordinator (CRC) worked remotely and trained her on how to complete a comprehensive care plan. She stated the corporate CRC reviewed all her care plan's s up until her training ended about 2 weeks prior to the Interim DON starting on 6/21/22. She stated Resident #33 should have been comprehensively care planned for her hemodialysis and interventions implemented but it must have been overlooked. An interview was completed on 7/8/22 at 10:49 AM with the Interim DON. She stated she was working remotely for a week or so in June 2022 and she was tasked to do care plan reviews and audits. She stated it was during this time, she completed Resident #33's comprehensive care plan but did not think to care plan her for hemodialysis. The Interim DON stated it was an oversight and she should have care planned the resident for [CONDITION(S)]. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #33 should have been comprehensively care planned to include hemodialysis. She stated there was some transitioning going on then and somehow her comprehensive care plan was not fully completed or implemented.

Based on record review and interviews with resident, family, staff, outpatient Physician ' s Assistant, and facility Medical Director, the facility neglected to assess, monitor, document, communicate and provide medical treatment to a lumbar (lower back) surgical incision to promote healing and prevent complications. Resident #2 ' s lumbar surgical incision was not treated for [REDACTED]. Resident #2 was admitted to the hospital and was diagnosed with [REDACTED]. The facility also neglected to implement preventative measures for Resident #2, who was at high risk for pressure ulcers, to prevent the development of an ankle pressure ulcer. This was for 1 of 3 residents (Resident #2) reviewed for wound care. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing note dated 9/10/20 completed by Nurse #14 (the Nurse Supervisor) indicated Resident #2 was admitted to the facility following a laminectomy (a major spine surgery that removes a portion of the vertebral bone called the lamina). Resident #2 was alert and oriented to person, place, time, and situation. Nurse #14 indicated he had soiled dressings to his left buttock, inner fold of buttocks and coccyx (commonly referred to as the tailbone). The dressings were removed and revealed Moisture Associated Skin Damage (MASD) to these areas. This note made no mention of Resident #2 ' s lumbar (lower back) surgical incision. A skin assessment dated [DATE] completed by Nurse #14 (the Nurse Supervisor) indicated the following skin conditions: - Bruises to left abdomen, left knee - Discoloration to right elbow - Abrasion to left abdomen - MASD to buttocks, between medial buttock fold, and coccyx This skin assessment made no mention of Resident #2 ' s lumbar surgical incision. On 9/10/20 a care plan was initiated for Resident #2 with a focus area related to the risk for skin breakdown and actual skin breakdown. He was noted to have MASD. The goal was for healing of Resident #2 ' s skin impairment. The interventions initiated on 9/10/20 included: - Pat skin when drying, do not rub - Apply barrier cream with each cleansing - Observe skin condition daily with Activities of Daily Living (ADL) care and report abnormalities - Weekly skin check by nurse a. The nursing admission assessment dated [DATE] completed by Nurse #14 (the Nurse Supervisor) indicated Resident #2 was admitted for postoperative (post-op) care status [REDACTED]. She indicated Resident #2 ' s skin was warm and dry, he had bruising to left abdomen and left knee, an abrasion to left abdomen, and MASD to buttocks and coccyx. There were no other wounds or skin conditions noted. She made no mention of Resident #2 ' s lumbar surgical incision. Physician treatment orders from 09/10/20 to 9/28/20 for Resident #2 were reviewed and revealed there were no orders related to Resident #2 ' s lumbar surgical incision. A history and physical dated 9/12/20 completed by Resident #2 ' s physician (the facility ' s Medical Director). He indicated Resident #2 was in the hospital from 8/22/20 through 9/10/20. He had a laminectomy on 8/25/20 due to spinal stenosis causing leg weakness. The Nursing Assistant (NA), no name specified, indicated Resident #2 needed to be turned, he slept a lot, he was incontinent of bowel, and when they sat him up yesterday he was only able to tolerate 5 minutes before needing to lay back down. The physician indicated he woke Resident #2 up for his assessment. He was noted to be alert and oriented to person, place, and time. He was noted to be able to move his arms, but had trouble moving his legs. He was unable to turn by himself. On 9/14/20 the physician completed an addendum to the history and physical conducted for Resident #2 on 9/12/20. The addendum indicated Resident #2 ' s lumbar surgical incision was healing well. On 9/17/20 a weekly skin check was ordered to be completed and documented during the day shift (7A - 7P). Based on the schedule with assignments, Nurse #4 was assigned to Resident #2 during the day shift on 9/17/20. There were no skin assessments dated 9/17/20 and the section of the Treatment Administration Record (TAR) that required the nurse to sign off when the skin assessment and nursing documentation was completed was blank. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 ' s cognition was intact. He had no behaviors and no rejection of care. Resident #2 was dependent on 2 or more staff for bed mobility, transfers, toileting, personal hygiene and bathing. He required the extensive assistance of 2 or more for dressing. Resident #2 had an indwelling urinary catheter and was assessed as always incontinent of bowel. He was administered scheduled pain medications and PRN pain medications and self-reported frequent pain at a 7 on a scale of 0-10. Resident #2 was assessed with [REDACTED]. He had no pressure ulcers. On 9/22/20 a care plan related to ADL care was initiated for Resident #2. The focus area indicated that he was dependent for ADL care related to hospitalization ,[MEDICAL CONDITION], post-op back surgery, and limited mobility. The goal was for Resident #2 to improve current level of functioning with ADLs. The interventions included, in part: - Monitor for decline in ADL function - Provide cueing for safety and sequencing A skin assessment dated [DATE] at 3:00 PM completed by Nurse #1 indicated a new skin injury was identified. Nurse #1 assessed Resident #2 with a pressure ulcer to the left outer ankle, but made no mention of Resident #2 ' s lumbar surgical incision. On 9/28/20 Resident #2 attended a post-op outpatient follow up appointment for his lumbar laminectomy. The outpatient Physician ' s Assistant ' s (PA) progress note, completed 9/28/20 at 10:40 AM, indicated Resident #2 had breakdown of the inferior (lower) portion of his surgical incision. His staples were intact to superior (upper) portion of incision. There was malodorous (foul smelling) drainage from the inferior portion of the incision and breakdown of the incision was assessed as at least 2 to 3 cm deep with [DIAGNOSES REDACTED] (redness of the skin) of the surrounding tissue. The PA indicated she was concerned the surgical incision was infected and she sent Resident #2 to the Emergency Department (ED) for evaluation, imaging, and further management. A general note dated 9/28/20 at 5:03 PM completed by Nurse #7 indicated she was notified by Resident #2 ' s family member that he was sent to the hospital from his post-op outpatient follow up appointment due to his lumbar surgical incision being infected. The hospital record included an ED skin assessment that indicated Resident #2 had a midline lumbar surgical site wound, inferior portion of the wound was dehisced (opened up) with drainage noted and surrounding [DIAGNOSES REDACTED]. A CT scan of the lumbar spine was obtained which showed superficial dehiscence of the inferior portion of the lumbar wound and [MEDICAL CONDITION] (skin infection). He was seen for a neurosurgery consult and was admitted to the Neurosurgery Unit (NSU) on 9/28/20. The neurosurgery physician indicated plans were made with Infectious Disease (ID) specialists to attempt primary closure of the wound. Antibiotic therapy was pending intraoperative cultures. On 9/30/20 Resident #2 underwent surgical irrigation and debridement (removal of unhealthy tissue) and primary closure of his lumbar surgical wound. Wound cultures tested positive for E. Coli and intravenous (IV) antibiotics were initiated. ID specialists recommended to continue antibiotic therapy until at least 11/13/20. A review of Resident #2 ' s facility medical record from his admission on 9/10/20 through discharge on 9/28/20 included no measurements, nursing assessments, monitoring, or treatments of his lumbar surgical incision. There were also no physician's order [REDACTED]. Resident #2 ' s lumbar surgical incision was mentioned only twice in the facility medical record: 1) the 9/14/20 physician ' s addendum to his 9/12/20 note in which he indicated the incision was healing well on 9/12/20 and 2) the 9/28/20 general note completed by Nurse #14 that indicated she received a call from Resident #2 ' s family member reporting that the resident was sent to the hospital from his outpatient follow up appointment due to his surgical incision being infected. A grievance form dated 9/28/20 filed by Resident #2 ' s family member on 9/28/20 indicated Resident #2 had a post-op follow up appointment on this date and his surgical incision was found to be infected. The grievance indicated it was assigned to the Director of Nursing (DON) for investigation on 9/29/20 and the investigation was to be completed by 10/1/20. A review of the investigation completed by the DON, undated, indicated: - 9/10/20 admission skin check indicated no openings to the surgical incision - 9/12/20 physician note indicated the surgical incision was healing - 9/24/20 skin check note by Nurse #1 noted no openings to the surgical incision - Daily nursing notes had no documentation of the surgical incision opening - The DON spoke with Nurse #10 (no date provided). She worked with Resident #2 on 9/27/20 and she indicated she had not known the surgical incision was open nor had she observed the surgical incision. - The DON spoke with Nurse #9 (no date provided). She worked with Resident #2 on 9/26/20 and she indicated she had not observed the surgical incision. - The DON spoke with Nurse #5 (no date provided). This investigation indicated that she worked with Resident #2 during the night shift on 9/25/20 and she stated the surgical incision was open and draining and she covered it with a dry dressing. (Based on the staff schedule with assignments and nursing notes, Nurse #5 last worked with Resident #2 on 9/23/20 during the night shift. She had not worked on 9/25/20 as indicated in this investigation). The summary of the investigation indicated that the DON was unable to pinpoint the date the surgical incision opened. On 10/15/20 at 1:06 PM via email correspondence with the DON, all wound assessment and monitoring information was requested for Resident #2 ' s surgical incision. On 10/15/20 at 1:27 PM the DON responded that there was no wound assessment or monitoring for Resident #2 as his wound was surgical and was not a pressure ulcer. A phone interview was conducted with Resident #2 on 10/16/20 at 9:49 AM. Resident #2 stated that he depended on staff to provide assistance with all ADLs with the exception of eating. He explained that he was incontinent of bowel, was on a laxative that caused runny/loose stools, and he needed 2 staff ' s assistance for incontinent care. He further explained that he frequently needed to be turned and repositioned as he had difficulty finding a position that was comfortable. Resident #2 reported that during his stay at the facility as he was receiving care, one of the NAs told him that a couple of his staples came out, but not to worry about it. He was unable to recall the NAs name or the specific date, but he knew it occurred during the 1st shift (7:00 AM to 3:00 PM) and that this specific NA had worked with him on multiple occasions during the first shift. He reported that it was at least a week prior to his discharge from the facility to the hospital on [DATE]. He stated that he told his family member by phone about incident. Resident #2 indicated that he had pain from admission through discharge from his legs and his back and he was unable to determine if there was a change in pain level after the surgical incision site opened. A phone interview was conducted with Resident #2 ' s family member on 10/16/20 at 8:30 AM. She stated that she spoke with Resident #2 frequently by phone during his stay at the facility. She indicated that on 9/19/20 Resident #2 called her and said that sometime during that week one of the NAs told him a couple of his staples popped out when they were turning him. She reported that she spoke with the DON several times during Resident #2 ' s facility stay, and she asked how his surgical incision was healing, and she was told it was healing well. She indicated that the PA from Resident #2 ' s post-op follow up appointment called her on 9/28/20 and told her the surgical wound was infected and that she was sending him to the hospital. A phone interview was conducted with Nurse #14 (the Nurse Supervisor) on 10/15/20 at 2:30 PM. Nurse #14 stated that she assisted Nurse #1 with completing the admission for Resident #2 as he required 2 staff ' s assistance with care. She reported that she and Nurse #1 turned Resident #2 onto his side and viewed his lumbar surgical incision (9/10/20). She stated the incision was open to air (no dressing in place) and appeared to be healing nicely. Nurse #14 reviewed her admission assessment, skin assessment, and nursing note for 9/10/20 and revealed that she had not documented any information on Resident #2 ' s lumbar surgical incision. She reported there was no indication of the length of the incision, the number of staples, and/or the condition of the surgical incision. She stated that normally she would have put in her note the measurements and condition of the surgical incision. The Nurse Supervisor indicated she must have forgotten to enter this information. She reported that she recalled Resident #2 had MASD on his buttocks which was treated each shift with physician ordered Z-guard (skin paste protectant). Nurse #14 stated that she had not observed Resident #2 ' s surgical incision after his admission on 9/10/20. A phone interview was conducted with Nurse #1 on 10/16/20 at 2:55 PM. She stated that she and Nurse #14 (the Nurse Supervisor) completed the admission for Resident #2. She indicated she recalled Resident #2 ' s surgical incision was open to air and appeared to be healing with no signs of infection on the date of his admission (9/10/20). She reported that he had a number of staples in the incision, but she had not known how many as she had not counted or documented this information. The nursing schedule with assignments that indicated Nurse #1 had worked with Resident #2 on 4 dates after admission (9/11/20, 9/20/20, 9/24/20, and 9/25/20) was reviewed with Nurse #1. Nurse #1 revealed that on either 9/20/20 or 9/24/20 she observed a dressing on Resident #2 ' s surgical incision. She stated that she had not recalled the exact date she observed the dressing or what condition the dressing was in. She indicated that she remembered wondering why the dressing was on his surgical incision and asking the NA who was working with her (unable to recall a name) and they had not known why the dressing was on the surgical incision. Nurse #1 revealed she had not asked anyone else about the dressing and she had not completed any changes of the dressing as she reviewed the physician's order [REDACTED]. She further revealed that after she saw the dressing she just continued on with her work. She explained that she gave no further thought to figuring out why the dressing was in place, assessing the condition underneath the dressing, and/or notifying the physician of the dressing that was in place without a physician's order [REDACTED]. This interview with Nurse #1 continued. The skin assessment and SBAR dated 9/24/20 completed by Nurse #1 that indicated a new skin condition of a pressure ulcer to Resident #2 ' s left outer ankle were reviewed with Nurse #1. Nurse #1 stated that 9/24/20 was when she first identified the pressure ulcer on the left outer ankle of Resident #2. She was asked if she had observed the dressing on the surgical incision prior to, at the time of, or after this 9/24/20 identification of the left ankle pressure ulcer. She stated that she was not certain about this. Nurse #1 explained that she would not have completed a skin assessment or SBAR for the surgical incision because these were only completed for newly identified skin conditions and since someone else had placed a dressing on the surgical incision, that this person should have completed the appropriate documentation and notified the physician. A review of the staff schedule with assignments from Resident #2 ' s 9/10/20 admission through 9/28/20 discharge revealed Resident #2 ' s first shift NAs were most frequently NA #1 and NA #2. A phone interview was conducted with NA #1 on 10/16/20 at 11:53 AM. NA #1 stated she was an agency NA and she worked on Resident #2 ' s unit (200 hall) on the first shift on 9/16/20, 9/17/20, 9/19/20 through 9/21/20, 9/23/20 through 9/25/20, and 9/28/20. She indicated she was familiar with Resident #2 stating that he required the assistance of 2 or more staff for most ADLs, he was always incontinent of bowel, and he required frequent repositioning in bed as he was unable to turn himself. She stated that 2 NAs were normally working on the 200 hall unit and they worked together to provide assistance to Resident #2. NA #1 revealed she was providing care to Resident #2 at the time that a couple of his staples came out of his lumbar surgical incision. She stated that she was turning Resident #2 in bed with another NA when the staples came out. She was unable to recall the exact date, but she believed she was working with NA #2 at the time. She reported that she informed the Nurse on duty right after the staples came out, but she was unable to recall who the nurse was. NA #1 indicated that after the staples came out a dressing was placed on the surgical incision by the nurse. A phone interview was conducted with NA #2 on 10/16/20 at 10:50 AM. NA #2 stated she worked on Resident #2 ' s unit (200 hall) on the first shift on 9/10/20 through 9/13/20, 9/15/20 through 9/18/20, 9/21/20 through 9/24/20, 9/26/20, and 9/27/20. She indicated she was familiar with Resident #2 stating that he required the assistance of 2 or more staff for most ADLs, he was always incontinent of bowel, and he required frequent repositioning in bed as he was unable to turn himself. She confirmed NA #1 ' s statement that the NAs assigned to the 200 hall worked together to provide care to Resident #2. NA #2 stated that she had no recollection of working with Resident #2 at the time a couple of his staples came out. She indicated she had cooperatively worked with NA #1 on multiple dates to provide care to Resident #2. NA #2 reported that she remembered Resident #2 having a dressing on his surgical incision when she worked with him, but she was unable to recall when she first saw the dressing. A phone interview was conducted with Nurse #2 on 10/16/20 at 12:24 PM. Nurse #2 stated she was an agency nurse and she began working at the facility in September 2020. Based on the staff schedule with assignments and nursing documentation, Nurse #2 was assigned to Resident #2 during the night shift on 9/11/20 and 9/18/20. Nurse #2 revealed she recalled Resident #2 having a dressing on his surgical incision on 9/18/20. This was 10 days prior to Resident #2 ' s post op follow up appointment (9/28/20). Nurse #2 explained that she remembered seeing the dressing and noticing that there were no physician's order [REDACTED].#3) why there was a dressing on Resident #2 ' s surgical incision and she stated that she had not known why the dressing was in place and that it was on when she began her shift that morning 9/18/20. Nurse #2 reported that she had not recalled if there was any drainage on the dressing. She stated that she had not removed or replaced the dressing as there was no physician's order [REDACTED]. [REDACTED]. [REDACTED].#2 ' s surgical incision, unable to recall the date, and she told her that she saw the dressing in place to Resident #2 ' s surgical incision when she worked with him on 9/18/20. A phone interview was conducted with Nurse #5 on 10/16/20 at 11:40 AM. Based on the staff schedule with assignments and nursing documentation, Nurse #5 was assigned to Resident #2 during the night shift on 9/14/20, 9/15/20, 9/16/20, 9/20/20, and 9/23/20. She verified that she had not worked with Resident #2 on 9/25/20 as indicated in the grievance investigation. Nurse #5 stated that on one of these dates that she worked with Resident #2, unable to recall the exact date, she was going to complete the treatment of [REDACTED]. She indicated she had 2 NAs (unable to recall the NAs) assist her with turning the resident and that was when she noticed that there was dressing on Resident #2 ' s lumbar surgical incision. She reported that recalled the dressing had some yellowish drainage on it. Nurse #5 stated that she remembered thinking that the last time she saw the surgical incision there was not a dressing on it. Nurse #5 reported that she took the dressing off of the surgical incision and it looked like 1 or 2 staples were missing and she approximated there to be about 1 cm opening of the lower part of the incision. She indicated that this was just an approximation as she had not taken any measurements or completed any assessments of the surgical incision. Nurse #5 revealed that she had not looked for any physician's order [REDACTED]. She stated that she reported off to the oncoming nurse (unable to recall who the oncoming nurse was) that Resident #2 ' s surgical incision was open and that she should have the physician look at it if he came into the building that day. Nurse #5 explained that she assumed another nurse had informed the physician of the surgical incision opening since there was already a dressing on it, so she simply replaced the dressing, reported off to the oncoming nurse, and left when her shift was over. She was asked if she always observed Resident #2 ' s surgical incision site when she was assigned to him and she stated that although he required treatment to his buttocks every shift that it was possible she worked with him and had not made an observation of the surgical incision. Nurse #5 indicated that Resident #2 was incontinent of bowel and frequently had loose stools as he was on a laxative ([MEDICATION NAME]). She stated that this may have contributed to the surgical incision becoming infected. A phone interview was conducted with Nurse #13 on 10/16/20 at 8:00 AM. Nurse #13 indicated she was an agency nurse and she worked at the facility 36 hours per week. Based on the staff schedule with assignments and nursing documentation, Nurse #13 worked with Resident #2 on 9/22/20 and 9/23/20 during the day shift. She stated that she was unable to recall if Resident #2 had a dressing on his surgical incision when she worked with him. She reported that she would not have assessed or treated the surgical incision without a physician's order [REDACTED].>A phone interview was conducted with Nurse #4 on 10/16/20 at 10:00 AM. Nurse #4 stated he was an agency nurse and he worked at the facility for 4 days in September 2020. Based on the staff schedule with assignments and the nursing documentation, Nurse #4 worked with Resident #2 during the day shift on 9/16/20, 9/17/20, and 9/19/20. The physician's order [REDACTED].#2 was reviewed with Nurse #4. Nurse #4 stated that he had completed the skin check on 9/17/20, but forgot to document it and to sign off on the TAR. He reported that he was unable to recall with certainty what condition Resident #2 ' s surgical incision was in at that time. He explained that he couldn ' t remember if the surgical incision was open to air, was dressed, was open, or was closed. A phone interview was conducted with Nurse #8 on 10/16/20 at 10:20 AM. Nurse #8 stated she was an agency nurse and she worked at the facility on 1 date only, 9/21/20. Based on the staff scheduled with assignments and nursing documentation she worked with Resident #2 on 9/21/20. Nurse #8 reported that she no recollection of Resident #2, but she was certain that she completed no treatments for any resident on 9/21/20. A phone interview was conducted with Nurse #11 on 10/16/20 at 12:10 PM. Based on the staff schedule with assignments and nursing documentation, Nurse #11 was assigned to Resident #2 on during the day shift on 9/16/20. Nurse #11 reported she had no recollection of Resident #2. A phone interview was conducted with Nurse #10 on 10/16/20 at 12:23 PM. Based on the staff schedule with assignments and the nursing documentation, Nurse #10 was assigned to Resident #2 during the day shift on 9/27/20. Nurse #10 stated that she remembered Resident #2, but she was unable to recall what condition his surgical incision was in when she worked with him. She explained she didn ' t know if his surgical incision was open to air, was dressed, was open, or was closed. She stated that she was certain she had not changed a dressing or provided any other type of treatment to Resident #2 ' s surgical incision. A phone interview was conducted with Nurse #3 on 10/19/20 at 12:09 PM. Based on the staff schedule with assignments and the nursing documentation, Nurse #3 worked with Resident #2 on 9/12/20, 9/15/20, 9/18/20, 9/25/20, and 9/28/20. She indicated that she recalled when Resident #2 was first admitted to the facility that his surgical incision was open to air. She revealed that she had not known when the surgical incision first opened, but that she had seen it with a dressing in place when she was working with him. She further revealed that she had never changed the dressing to the surgical incision and she had never provided any other type of assessment, monitoring, or treatment to the surgical incision. Nurse #3 explained that she had not seen any physician's order [REDACTED]. She further indicated that she never thought about notifying the physician as she assumed this had been done by whoever initiated the dressing. A phone interview was attempted with Nurse #6 on 10/16/20 at 8:23 AM but she was unable to reached. Based on the staff schedule with assignments and nursing documentation, Nurse #6 worked with Resident #2 during the night shift on 9/10/20, 9/12/20, 9/13/20, 9/17/20, 9/21/20, 9/22/20, 9/24/20, 9/26/20, and 9/27/20. A phone interview was attempted with Nurse #9 on 10/16/20 at 11:51 AM but she was unable to be reached. Based on the staff schedule with assignments and nursing documentation, Nurse #9 worked with Resident #2 on 9/12/20, 9/13/20, 9/14/20, 9/25/20, and 9/26/20. A phone interview was attempted with Nurse #12 on 10/16/20 at 12:46 PM but she was unable to be reached. Based on the staff schedule with assignments and nursing documentation, Nurse #12 worked with Resident #2 on 9/13/20 during the day shift. A phone interview was conducted on 10/16/20 at 12:54 PM with Resident #2 ' s outpatient PA who conducted the post- op follow up appointment on 9/28/20. The PA indicated that she was familiar with Resident #2 and recalled his 9/28/20 follow up appointment. She stated that based on her assessment of the lumbar surgical wound she believed it was infected. She explained that there was drainage on the dressing which had a foul odor indicative of an infection, the inferior portion of the incision was open with [DIAGNOSES REDACTED] of the surrounding tissue, and the upper portion of the incision still had staples intact. She indicated that she sent Resident #2 straight to the ER for further evaluation and treatment. She stated that Resident #2 required hospitalization , surgical debridement of the wound, and IV antibiotic therapy. The PA reported that she believed this was preventable explaining that if the wound breakdown was identified earlier it could ' ve been treated with an antibiotic which most likely would have kept Resident #2 out of the hospital and from having another surgery. A phone interview was conducted with the DON on 10/19/20 at 3:32 PM. The DON ' s investigation into when Resident #2 ' s surgical incision opened was reviewed. She stated that she was unable to pinpoint the date Resident #2 ' s surgical incision opened as none of the nurses admitted to implementing the dressing. She verified that Nurse #5 had not worked with Resident #2 on 9/25/20 as indicated in the investigation. She revealed that this date should have been 9/23/20. The interview with Nurse #2 in which she stated she informed the DON that she saw a dressing on Resident #2 ' s surgical incision on 9/18/20 was reviewed with the DON. The DON verified that she had interviewed Nurse #2 and she was aware that she had seen the surgical incision dressed on 9/18/20. The DON was unable to explain why this information was not included in her investigation. NA #1 ' s interview that indicated she was working with Resident #2 when a couple of staples came out and the nurse implemented a dressing was shared with the DON. The staff schedules that indicated NA #1 had worked with Resident #2 on two dates prior to 9/18/20 were reviewed with the DON. These dates were 9/16/20 and 9/17/20. The DON stated that she had not interviewed any of NAs about the investigation and she was unaware of this information prior to this date (10/19/20). She acknowledged that based on Nurse #2 ' s interview that Resident #2 ' s surgical incision had a dressing on it prior to 9/18/20 and NA #1 ' s interview that she was working with Resident #2 when the staples came out and a nurse implemented the dressing, that the surgical incision opened on either 9/16/20 or 9/17/20 as these were the only dates NA #1 worked with Resident #2 prior to 9/18/20 (the date Nurse #2 observed the dressing in place). The DON reported that she expected the nurse who first identified that the surgical incision was open to enter an assessment into the electronic medical record (EMR), notify the physician and obtain treatment orders, enter treatment orders into the EMR, and complete the ordered treatment. The DON was asked what her expectation was for every nurse who worked with Resident #2 and observed the surgical incision with a dressing in place with no physician's order [REDACTED]. She stated s (TRUNCATED)

Based on record review and staff interviews, the facility failed to use a sling lift for transfer to prevent a [MEDICAL CONDITION] humerus (upper arm) for one of two residents reviewed for accidents, Resident #48. Instead the resident was transferred via a stand pivot sit transfer with the assistance of one agency staff nursing assistant. The findings included: Resident #48 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #48's Minimum Data Set (MDS) completed prior to revealed a quarterly assessment with an Assessment Reference Date (ARD) of 10/11/18. Review of the assessment revealed the following: The resident was coded as having had severe cognitive impairment. The resident was not coded as having had behaviors. The resident was coded as having required total assistance of 1-2 people for all Activities of Daily Living (ADLs) including transfers, such as from the bed to a wheelchair. The resident was coded as having had a limitation in functional range of motion to one side of her upper extremity. A review was completed of a document titled Lift Transfer Reposition-V2, dated 11/8/18, signed by the Director of Nursing (DON), and timed 10:15 AM for Resident #48. The resident was documented as unable to transfer without a device, unable to bear weight equal to or greater than 50% of her weight and required a total lift or sling lift. Review of a Progress Note, written by the DON, with an effective date of 11/8/18 and timed 10:15 AM revealed a lift evaluation of Resident #48 had been completed. The evaluation revealed the lift type for the resident was a total lift or sling lift. Review of Resident #48's Progress Notes revealed an entry dated 11/18/18 and timed 11:00 am by Nurse #1. The note documented the resident had a bruise to her left upper extremity (left arm), with no pain noted, and the resident was documented as having had agitation with ADLs and transfers. Review of a facility investigation report dated 11/21/18, and signed off by the Administrator, revealed an investigation regarding the Injury of Unknown Origin (IUO), the left upper arm fracture, for Resident #48. Review of the summary of the facility investigation revealed Nursing Assistant (NA) #2 had reported transferring Resident #48 independently without using the sling lift after having been misinformed of the resident's transfer status. The report stated the transfer conducted by NA #2 had caused bruising to the left upper arm and subsequent [MEDICAL CONDITION] arm. Further review of the submission report revealed a written statement by NA #2 in which she wrote on 11/17/18 she had transferred Resident #48 with a one person assistance, without using the sling lift, after having been told by facility staff that Resident #48 needed one person assistance for transferring, such as into and out of bed and to or from a wheelchair. The NA further wrote the resident had complained of pain with repositioning after the transfer and when she had other staff assist her in returning the resident to bed. The NA also wrote she was assigned to provide care for the resident on 11/18/18 and the resident had continued to complain of pain the following day. The NA wrote she had discovered bruising to the resident's left upper arm and had reported the bruising and the resident's complaints of pain to Nurse #1. An interview was conducted on 4/10/19 at 11:17 AM with Nurse #1. The nurse stated she remembered when it had been reported to her that Resident #48 had an injured left arm, it was on Sunday 11/18/18. The nurse stated when they went to turn the resident on 11/18/18, the resident was screaming, and the resident had a bruise to her left shoulder. The nurse stated the bruise was approximately the size of a softball and was yellowish in color. She stated when she had asked staff, including NA#2, about the bruise they stated it had been the first time they had seen the bruise. The nurse stated she had informed the resident's responsible party, contacted the physician, and had ordered an X-Ray of the left shoulder. Review was conducted of an X-Ray report for Resident #48 with a date of service of 11/19/18. The results of the X-Ray were there was an acute (sudden or recent) left humerus (upper arm) fracture. In addition, the X-Ray report documented the resident's bones appeared diffusely demineralized (a lack of minerals which provide bone strength such as calcium). Review of a Diagnostic Imaging report for Resident #48 with an exam date of 11/20/18 revealed a left shoulder X-Ray had been completed. The listed indications for the X-Ray included: left shoulder pain and left shoulder bruising. The conclusion of the X-Ray was there was an acute [MEDICAL CONDITION] upper arm, the bones were observed to have been extremely osteopenic (bone and mineral loss causing bones to lose strength to protect against fracture) with a somewhat moth-eaten appearance. The conclusion further stated the appearance could have represented a blood dyscrasia (an abnormal or disordered state of a body part) or [DIAGNOSES REDACTED] (a malignant (cancerous) tumor). An interview was conducted on 4/10/19 at 2:38 PM with the Staffing Coordinator (SC). She stated there was a symbol outside of the resident's door which indicated the type of transfer a resident required and she stated the information was also available in NA information book available at each nurses' station. She stated Resident #48 was not a one person assistance transfer in (MONTH) (YEAR) when her arm was fractured, the resident was a sling lift or total lift. The SC stated she and one other staff member did most of the updating of the NA information book. The SC stated there was further information available about the residents in the NA information book, information such as transfers and toileting. The SC stated as part of the orientation process for agency NAs, they were trained on how to check the NA information book, codes on the doors, and the facility equipment for transfers. She stated NA #2 was an agency NA and she would have been trained on referring to the NA information book at the time of her orientation. The door coding was put into place after NA #2 had completed her orientation. An interview was conducted on 4/10/19 at 3:31 PM with the Nurse Practice Educator (NPE). She stated a new practice to assist staff in being aware of the type of transfer a resident required through the use of a code on the resident's door and all staff had the key for the codes on a card affixed to their name tags. She stated the practice was put into place near the end of (YEAR). The NPE stated in addition to the code system, if a resident was a total or sling lift transfer, their names were on a list in the NA information book at each nurses' station. The NPE stated Resident #48 had been a total or sling lift transfer for a long time. The NPE stated it was her expectation for a NA to refer to the resources available to verify the appropriate transfer and equipment and to utilize the required equipment to safely transfer the resident. An interview was conducted on 4/11/19 at 11:26 AM with the Administrator. The Administrator stated his expectation was for residents to be transferred safely and to be transferred utilizing the correct transfer equipment per the resident's transfer evaluation.

Based on observation, record review, and staff interviews the facility failed to supervise a cognitively impaired wandering resident who had known exit-seeking behaviors from exiting the facility unsupervised for 1 of 3 sampled residents (Resident #1). The immediate jeopardy began on 01/24/18 when Resident #1 exited from the facility without staff's knowledge and was found outside on the loading dock. Immediate jeopardy was removed on 02/01/18 1:30 PM when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level D (isolated, not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and that all staff have been in-serviced. Findings included: Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #1 was severely cognitively impaired. The assessment revealed Resident #1 did not wander. Review of the Skilled Nursing Progress Note dated 01/14/18 revealed Resident #1 was confused and packed up all her clothing into her suitcase. Review of the General Progress Note dated 01/15/18 revealed Resident #1 made two attempts to open the door and go out. Consent was provided by Resident #1's family for placement of a wander device bracelet which was placed on the left ankle. Review of the Elopement Evaluation conducted 01/16/18 revealed Resident #1 was able to ambulate or propel a wheelchair independently and had attempted to pack her belongings. Resident #1 was impulsive, restless and agitated and had a wander device bracelet. Review of Resident #1's Care Plan dated 01/16/18 revealed she was at risk for elopement as she had made one or more attempts to leave the facility due to cognitive loss and dementia. The goal for Resident #1 was that she be kept safe within the facility every day. Interventions included diverting Resident #1 by providing alternative activities and by checking the placement and the function of the wander device. Review of the Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) dated 01/18/18-01/26/18 revealed Resident #1's wander device was checked every shift for placement and function by the nurses. Review of the Risk Management System report dated 01/25/18 revealed that on 01/24/18 at approximately 10:30 PM Resident #1 exited the facility's loading dock door and was found sitting on the loading dock by staff. Resident #1's wander device was in place. The wander device system was found to not be sensitive enough to pick up a signal from the device on Resident #1's ankle. On 01/25/18 all of the wander devices were tested and were working. The antenna for the wander system at the loading dock door was adjusted to make it more sensitive to the devices worn by wandering residents. Review of the Repair Requisition dated 01/24/18 revealed Resident #1's wander device was not setting off the alarm or locking the door. On 01/25/18 the Maintenance Director wrote that the antenna was lowered for lower coverage, rechecked, and was working correctly. Review of the Performance Improvement meeting note dated 01/25/18 revealed that all wander elopement device bracelets and systems were checked and in appropriate working order. It was noted that the Maintenance Director moved the system antennas down at the loading dock door to increase the sensitivity. There was also a signed statement from the Maintenance Director that the devices and systems had been tested , were in working order, and that the antenna at the loading dock door had been moved to increase its sensitivity. Review of the Change in Condition Follow-up Note dated 01/25/18 revealed Resident #1 continued to have confusion and wandering behavior. Resident #1 was exit seeking and became agitated when told she could not go out the doors. Review of the Skilled Nursing note dated 01/26/18 revealed Resident #1 was constantly exit seeking and was frequently seen pulling and pushing on door handles. Review of the General Progress Note dated 01/27/18 revealed Resident #1 was discharged from the facility in a previously planned discharge. In an observation and interview on 01/30/18 at 3:10 PM the Maintenance Director (MD) produced the January 2018 wander system log book which revealed the wander system door alarms were checked daily and functioned correctly. He stated he performed the system check during the week and the Weekend Supervisor checked the system on the weekends. The MD proceeded to perform a test of the wander elopement system. While holding the wander device in his hand he walked up to the loading dock door and the door locked. He then turned around and walked down the hallway approximately ten feet and turned around. The door unlocked. While still holding the wander device, he approached the door and pushed on it. The door did not lock and no alarm sounded to signal a wander device had exited the building when he walked out the door. In an interview immediately following the observation on 01/30/18 at approximately 3:30 PM the MD indicated if a resident who had a wander device attempted to open an alarmed door, the door should lock. He indicated that if the resident moved away from the door enough so the door would unlock and then approached the door again, the door may remain unlocked and allow the resident to exit the building without the alarm sounding. He stated the loading dock door was acting up during the test and that the door was not secure. The MD indicated when he checked the wander system he held a wander device in his hand but did not check the sensitivity of the device if it was on the lower leg. An observation was conducted on 01/31/18 at approximately 3:35 PM of the hallway leading to the loading dock, the loading dock itself, and the outside surrounding area with the MD after the interview, revealed the distance from Resident #1's room to the loading dock door was approximately 123 feet. The loading dock was approximately 2 feet from the ground and a metal railing was on the back to prevent a drop off. The loading dock angled to the ground and approximately 112 feet straight ahead from the bottom of the ramp was a barbed wire fence. Approximately 75 feet to the right of the bottom of the loading dock ramp was a driveway and from the driveway to the road was approximately 240 feet. In an interview on 01/30/18 at 3:46 PM the Director of Nursing (DON) stated Resident #1 was not appropriate for placement in the facility. She indicated a planned discharge to another facility was being worked on at the time of the elopement at the request of the resident's family. In an interview on 01/30/18 at 6:19 PM Nurse #1, who cared for Resident #1 the evening of the elopement, indicated Resident #1 would verbalize that she wanted to leave the facility and would attempt to open the exit doors leading outside. She stated on the night of the elopement she was approached by Resident #1's Nursing Assistant (NA #1) who told her she was unable to locate Resident #1 after providing care for another resident. NA #1 indicated to Nurse #1 that she had seen Resident #1 in the hallway last at approximately 10:30 PM. Nurse #1 and NA #1 began to look for Resident #1 and questioned other staff if they had seen Resident #1. She indicated the door alarm was not sounding. At approximately 10:40 PM Nurse #1 looked down the hallway outside Resident #1's room and was able to see her through the glass door sitting in a wheelchair on the loading dock wearing a long sleeve T-shirt, long pants, and shoes and socks but no jacket. Nurse #1 stated it was a cold and clear night. Nurse #1 stated she opened the loading dock door and brought Resident #1 back inside the facility. She stated the door alarm did not sound when Resident #1 was brought back into the facility and that it should have. Nurse #1 stated she assessed Resident #1 for injury and checked her vital signs. Resident #1's temperature was 97.4 degrees Fahrenheit. She indicated she notified the DON that Resident #1 had been found outside on the loading dock but did not document the incident or check Resident #1's wander device or the door alarm for functionality. She stated that she did lock the loading dock door but that the door could still be opened from the inside with just a little added effort. In an interview on 01/30/18 at 6:50 PM NA #1, who cared for Resident #1 the evening of the elopement, indicated Resident #1 had been saying all that day that she wanted to go home. She stated that at dinner time Resident #1 was carrying around her picture frames so she could take them with her. NA #1 indicated she had informed Nurse #1 that Resident #1 was carrying around the picture frames. NA #1 stated she would always check to see where Resident #1 was after providing care to another resident because she was determined to go home and would attempt to open the exit doors. She indicated that even though Resident #1 used a wheelchair, she would stand up and try to push hard on the exit doors to try and open them. NA #1 indicated she had tried to keep a close eye on Resident #1 that night because she had been trying to get out of the facility. NA #1 indicated she had been unable to locate Resident #1 and had last seen her at about 10:30 PM. NA #1 reported to Nurse #1 that she was unable to locate Resident #1 and they both began searching for her. NA #1 indicated that Nurse #1 saw Resident #1 through the glass of the door, sitting in a wheelchair on the loading dock. She stated the door alarm was not sounding and did not sound when Resident #1 was brought back into the building. NA #1 stated that the wander devices used for wandering residents did not work all the time and that the DON and the MD had been told of the problem. She could not remember when she had last informed the DON or the MD of problems with the door alarm. In an interview on 01/30/18 at 7:09 PM NA #2 indicated she had been working the night Resident #1 had been found on the loading dock. She stated she had seen Resident #1 sitting in the doorway of her room at about 10:25 PM when she had been on her way to the laundry room. NA #2 indicated NA #1 informed her they could not locate Resident #1. She stated she went to assist in the search and she and Nurse #1 saw Resident #1 through the glass of the door sitting on the loading dock in her wheelchair. She stated no alarm was sounding and when Nurse #1 brought Resident #1 back inside the alarm still did not sound. NA #2 said it was pretty cold outside and that Resident #1 was wearing a long sleeve shirt and pants, shoes and socks, but no jacket. She stated she wrapped a blanket around Resident #1 and took her to her room and assisted NA #1 to put the resident in bed. In an interview on 01/30/18 at 7:45 PM the DON stated that she knew Resident #1 had exit seeking behaviors. She indicated she had been informed by staff that the wander device alarms did not always work. She indicated that each time it was reported the alarms did not work the doors would be tested and they always worked. She was unable to recall when she had last been informed of problems with the door alarms. In an observation and interview on 01/31/18 at 8:50 AM the wander device door alarm on the loading dock door had been changed to a magnet lock door that could only be unlocked with a code or with an emergency opener. The MD demonstrated that the door was functioning and remained locked during attempts to open it. He stated no outside vendors had been asked to come in to check the wander device system as this was the only time he was aware of that the system did not function correctly. He indicated that with the previous system the antennae had not been picking up the signal if the device was on the resident's lower leg. In an observation and interview on 01/31/18 at 10:42 AM Nurse #4 removed the wander device code alert box from the medication cart. She approached each of her assigned residents and held the box to the resident's wander device. The green indicator lit up and the alarm sounded. Nurse #4 stated that if the green light lit up and the alarm went off it meant the device was working appropriately. She indicated the wander devices were checked each shift by the nurses and the test was documented on the Treatment Administration Record (TAR). She indicated that she had never had an issue with a resident's wander device. The Administrator was notified of the immediate jeopardy at 3:28 PM on 01/31/18. The facility provided a credible allegation of immediate jeopardy removal on 02/01/18 at 1:30 PM. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: 1. At approximately 10:30 PM on 01/24/18 a LPN (Licensed Practical Nurse) was sitting at the desk and got up to go begin shift change. As she was walking down the 100 hall a NA stopped her and stated she had seen resident a few minutes ago but now could not find. The LPN asked a second NA if she had seen her and the second NA stated she had seen her approximately 5 minutes ago while taking the laundry cart down the hall. The LPN and two NAs began a facility search looking for the resident. The second NA saw the resident sitting outside the doorway of her room located on the 100 hallway. She was sitting stationary at the time the second NA saw her outside of her room doorway (room [ROOM NUMBER]B). The resident was not heading toward the loading dock. As the LPN neared the end of the hall of the 100 hallway, she saw the resident through the glass door sitting in her wheelchair on the concrete slab outside of the facility door. The LPN immediately went outside and returned the resident inside the center. This was the same hall the resident was assigned to. The LPN then took the resident to her room and completed a body assessment with skin check, took vitals and checked the Wander Guard Device. The assessments and vitals were all normal. The Wander Guard Device was functioning appropriately. The wander guard alarm did not sound when the resident reentered the facility through the loading dock door. The wander guard device was placed on the residents left ankle. The LPN checked the wander guard bracelet with the Code Alert Transmitter Tester. The staff did not check the loading dock door for functioning due to previous malfunction and submitted a work order to Maintenance for repair. The LPN notified the Center Nurse Executive of the incident. The LPN informed the other on-coming nurse of the incident at change of shift so the resident could be monitored throughout the night. The LPN went throughout the facility and checked all residents wearing Wander Guards; all were in bed and accounted for. The resident was assisted to bed and provided with more frequent room checks. On the morning of 01/25/18 the Maintenance Director inspected the door according to a work order received from the previous night on 01/24/18. The work order stated that the Wander Guard system was not locking or alarming the back door. The Maintenance Director checked and moved the antennas down on the door frame for lower coverage and tested the function of the alarm, after the incident. The alarm was tested and was 100% functional. The alarm was tested by using the residents wander guard placed on the residents body, on each resident that had a wander guard placed. The wander guard for the resident was check by nursing for placement and functionality on day shift. The resident was discharged on [DATE]. The resident had a planned safe discharge due to an (name of insurance company) insurance cut on 01/26/18. The resident was discharged on [DATE] to (name of an assisted living memory care unit), per family request. The resident was wearing the Wander Guard Bracelet on her ankle, which was in a position that the antennas did not detect. The antennas were moved lower on 01/25/18, by the Maintenance Director, to increase the sensitivity of the system. The wander guard system was installed and used per manufacturer instructions. There are no manufacturer instructions regarding bracelet placement. The facility maintains a log of expiration dates for the wander guard bracelet and the bracelet is replaced with a new one, prior to the expiration date. There are no batteries connected to this system. The system is connected to facility power and emergency generator. The antenna placement on the door was not sensitive enough for the placement of the wander guard bracelet on the ankle. Once the antennas were moved down it increased the sensitivity and worked appropriately. 2. 100% of all staff (Nursing, Housekeeping, Dietary, Business Office and Rehab) was in-serviced on Elopement Procedures, which included assessing of residents which showed signs of wandering/exit seeking behaviors, responsiveness to alarms, placement of Wander Guard Bracelets, bracelet testing every shift, testing of bracelets to actual doors daily, on 01/31/18 and 02/01/18, by NPE (Nurse Practice Educator) and CNE (Center Nurse Executive). Staff in-service also included redirecting residents who wander off their assigned hallway with notification to the charge nurse. All licensed nurses were in-serviced on appropriate testing of Wander Guard door alarms. The Maintenance Director was in-serviced on 01/31/18, on appropriate testing of door alarms by CED (Center Executive Director) and the CNE. The Maintenance Director and the Social Service Director rechecked other residents wearing wander bracelets for proper position, function and expiration dates for the device. Maintenance Director has also rechecked all appropriate doors for audible alarm when the door was open prior to the resident entering the space, all doors functioned appropriately. 3. Nursing will continue to check residents for appropriate placement and function of wander bracelets every shift. Nursing will also begin testing door alarms on the night shift for the next 30 days to assure proper function. A testing bracelet will be used at each door to ensure lock down and audible alarm. Antennas were relocated lower on the door frame to ensure proper functioning of the bracelet placement, whether on wrist or ankle. The Maintenance Director will use the test bracelet at different levels, ie: ankle and wrist, to ensure proper lock down and alarm. The Maintenance Director will continue to conduct daily checks on all door alarms Monday through Friday. The Weekend Manager or weekend nursing supervisor will conduct door alarm checks on Saturday and Sunday. A testing bracelet will be used at each door to ensure lock down and audible alarm. 4. The person responsible for this credible allegation of immediate jeopardy removal was the Center Executive Director. The allegation of immediate jeopardy removal date was 02/01/18. The credible allegation was verified on 02/01/18 at 4:55 PM as evidenced by: In an observation with the MD on 02/01/18 beginning at 12:15 PM, doors leading to the outside of the facility were checked for functionality. The new magnet lock on the loading dock door remained locked when approached by the MD holding a wander device. In an interview on 02/01/18 at 12:28 PM the MD stated that the placement of the wander device did not matter. He indicated it could be placed on either the wrist or the ankle. In an interview on 02/01/18 at 3:15 PM the Activities Director stated she had been in-serviced on elopements and alarms. In an interview on 02/01/18 at 3:46 PM Nurse #2 stated she had been in-serviced on elopement and the new way of checking the wander alarmed doors. In an interview on 02/01/18 at 3:49 PM Nurse #3 stated she had been in-serviced on elopement and how to check the wander devices with the alarm monitor. In an interview on 02/01/18 at 3:51 PM NA #3 indicated she had been in-serviced on elopement and wandering residents. In an observation on 02/01/18 beginning at 12:42 PM the six residents who had wander devices were brought to the front door (only door with the wander system) and the functionality of the wander system and devices was checked. The system and devices locked the door when approached. When the residents were moved back from the door and the door lock was disengaged, staff opened the door and attempted to wheel the residents out the open door. The alarm sounded each time. Manufacturer instructions for the wander system and devices were reviewed. It was verified that placement of the wander devices could be placed on either the wrist or the ankle. The Door Inspection for Code Alert log for 02/01/18 was reviewed and revealed the front and loading dock doors had passed their lock down and alarm tests. Review of the February Treatment Administration Records (TAR) for each of the six residents revealed the wander devices had been checked for placement and functionality.