Every finding on record at Autumn Care of Drexel

Based on observations, record reviews, and staff interviews, the facility failed to implement their Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) when the Wound Nurse and Nurse Aide (NA) #1 failed to wear a gown while providing wound care to Resident #12. Resident #12 was admitted to the facility with a chronic heel wound with drainage. This deficient practice occurred for 2 of 8 staff observed for infection control practices (Wound Nurse and NA #1).The findings included:Review of the Enhanced Barrier Precautions policy and procedure which is part of the Infection Control policies and procedures last revised on 04/15/26 revealed the following:Policy: Enhanced Barrier Precautions (EBP) are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk resident during high contact activities.High risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and traches) and for all those colonized or infected with a MDRO currently targeted by the Centers for Disease Control and Prevention (CDC).High contact care activities are activities that may result in transfer of MDROs to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use and wound care.Procedure:Standard precautions such as hand hygiene always apply.Staff engaging in high-contact activities will don both gloves and gown before initiating the activity and remove personal protective equipment (PPE) before exiting the room or area where the activity occurred.Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.An observation of wound care on 05/12/26 at 12:33 PM on Resident #12 revealed the Wound Nurse and NA #1 went into the room with mask and gloves but no gown. There was no sign on the door indicating the resident was on EBP and there were no supplies in a caddie on the door or cabinet in the hallway outside the door. Resident #12 was sitting up in his wheelchair beside his bed and the door to his room was open. The Wound Nurse began with Resident #12's right leg and foot. He washed his hands with soap and water and donned gloves but did not don a gown and proceeded to paint the wound on the resident's right leg with betadine. NA #1 washed her hands with soap and water and donned clean gloves but no gown to hold Resident #12's right leg up for the Wound Nurse. The Wound Nurse doffed his gloves, washed his hands with soap and water and donned clean gloves and removed the old dressing from Resident #12's right heel while NA #1 held his leg up. The old dressing had a moderate amount of serosanguinous drainage (thin watery fluid with pale pink, light red, or blood-tinged drainage from wound). The Wound Nurse doffed his gloves, washed his hands and donned clean gloves and cleaned the wound with wound cleanser-soaked gauze. He doffed his gloves, washed his hands and donned clean gloves and applied calcium alginate (highly absorbent wound dressing frequently utilized in wound care to manage heavy drainage) and covered with a bordered gauze dressing. The Wound Nurse and NA #1 doffed their gloves, washed their hands and donned clean gloves but no gown and the Wound Nurse removed the old dressing on Resident #12's 3rd toe on the left foot. He proceeded to doff his gloves, sanitize his hands and donned clean gloves and cleansed the 3rd toe with wound cleanser-soaked gauze. The Wound Nurse doffed his gloves, sanitized his hands and donned clean gloves and applied calcium alginate and bandage to the toe. He then doffed his gloves, sanitized his hands and donned clean gloves but no gown and while NA #1 held his left leg up removed the dressing on the left heel. The Wound Nurse doffed his gloves, sanitized his hands and donned clean gloves and applied calcium alginate to the heel and covered with bordered gauze dressing. He doffed his gloves, washed his hands with soap and water and donned clean gloves and gathered his supplies and barrier off the overbed table and took them out of the room. NA #1 doffed her gloves, washed her hands and took the trash out of Resident #12's room.An interview on 05/12/26 at 12:53 PM with the Wound Nurse revealed that since there was no sign on the door he thought he didn't have to wear a gown into Resident #12's room to do his wound care. The Wound Nurse stated he had talked with the Infection Preventionist (IP) and learned that he should have worn a gown into Resident #12's room to provide wound care. An interview on 05/12/26 at 2:33 PM with NA #1 revealed she didn't wear a gown in the room to assist the Wound Nurse with wound care because there was no sign on the door and the Wound Nurse had not worn a gown. NA #1 stated she had since learned that she and the Wound Nurse should have worn a gown in the room.An interview on 05/14/26 at 10:26 AM with the IP revealed Resident #12 should have had a sign on his door for EBP with a caddie on the door or cabinet in the hall with personal protective equipment (PPE) available. She stated the resident had just moved from a different hall and his sign had probably been left on his previous room door along with the supplies. The IP stated she would have expected the Wound Nurse and NA #1 to have worn a gown into Resident #12's room to provide wound care.An interview on 05/14/26 at 10:43 AM with the Director of Nursing (DON) revealed she would have expected the Wound Nurse and NA #1 to have worn a gown while providing wound care to Resident #12. She further stated wound care was a high contact activity and the Wound Nurse and NA #1 should have worn a gown.

Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan in the area of anticoagulant (blood thinner) medication use for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe or complete paralysis of one side of the body) following a cerebral infarction (a blocked or narrowed blood vessel that cuts off blood flow to a part of the brain) and chronic atrial fibrillation (a sustained irregular heart rhythm). A review of the active medication orders for Resident #8 revealed an order for rivaroxaban (an anticoagulant medication) 20 milligrams (mg) by mouth; take daily with evening meal for history of cerebral infarction. The medication had a start date of 12/30/2025. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #8 dated 04/21/2026 indicated Resident #8 was receiving an anticoagulant. A review of Resident #8's Medication Administration Record from 12/30/2025 through 05/13/2026 revealed Resident #8 received rivaroxaban 20 mg daily with her evening meal.A review of Resident #8's comprehensive care plan dated 12/30/2025 and updated on 04/27/2026 did not include any care plan focus area or interventions related to Resident #8 receiving an anticoagulant medication.On 05/13/2026 at 12:25 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident #8's care plans and stated it did not address the anticoagulant medication. The MDS Coordinator explained that care plans were reviewed following completion of the MDS assessment. The MDS Coordinator further explained the care plan should include the use of an anticoagulant medication and she must have overlooked the anticoagulant medication when she updated the care plan on 04/27/2026. An interview was conducted with the Administrator on 05/14/2026 at 11:04 AM. The Administrator stated she expected all resident care plans to be reflective of high-risk medications including the use of anticoagulant medications.

Based on record reviews, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during Resident Council meetings for twelve of thirteen months reviewed (May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, March 2026, April 2026, and May 2026).The findings included:Review of the Resident Council Meeting minutes for the period May 2025 through May 2026 revealed the following:The Resident Council Meeting minutes dated 05/06/25 revealed the Old Business section noted no concerns. Under the New Business section there were noted concerns from residents regarding staff being slow answering call lights on the 3:00 PM to 11:00 PM shift on the 200 hall. A grievance form was not attached to the minutes. There were 15 residents in attendance including Resident #4 who was the president of the resident council and Residents #39, #46, #80 and #89.The Resident Council Meeting minutes dated 06/04/25 revealed the Old Business section noted no concerns. Under the New Business section there were noted concerns of call lights not being answered in a timely manner, staff turning off call lights and not meeting the needs of residents and not returning for a long time and when the residents turned the call light back on, staff questioned residents as to why they turned their call light back on. The residents also voiced concerns of ice was not being passed on 2nd and 3rd shift on all halls. A grievance form was completed on 06/04/25 regarding call lights not being answered in a timely manner and turning off call lights, not returning for long periods of time and ice not being passed on 2nd and 3rd shift. The grievance form was assigned to the Director of Nursing (DON) on 06/04/26 for completion. There were 15 residents in attendance including Residents #39, #46, #80 and #89.The Resident Council Meeting minutes dated 07/01/25 revealed the Old Business section noted call lights not being answered in a timely manner, ice not being passed daily on all shifts. The resolution on the grievance form completed on 06/04/26 was that inservice education was provided to staff regarding when answering call lights, they were to address the resident's needs at the time of entering the room and not just tell the resident they would be back, cut off the call light and not return. A sporadic call bell audit was completed for four weeks but only one room was checked per day. The grievance was documented as resolved on 06/18/25. Under the New Business section there were complaints that call lights were still not being answered in a timely manner especially on the 200 hall and ice was not being passed routinely. A grievance form was completed on 07/01/25 regarding call lights not being answered in a timely manner especially on the 200 hall and ice not being passed routinely. The grievance form completed on 07/01/25 was assigned to the DON. There were 12 residents in attendance including Residents #4, #46, and #80.The Resident Council Meeting minutes dated 08/04/25 revealed the Old Business section noted call lights were not being answered timely on 200 hall and ice was not being passed routinely. The resolution on the grievance form completed on 07/01/25 was that staff were educated on answering call light in a timely manner and not turning lights off until the resident's needs were met and that ice was to be passed to residents each shift. The resolution was effective 07/15/26. Under New Business there were no complaints. There were 12 residents in attendance including Residents #4, #46 and #80.The Resident Council Meeting minutes dated 09/02/25 Under the Old Business section there were no complaints or follow-up. Under the New Business section there were complaints of issue still with call lights being answered and ice not being passed. A grievance form was completed on 09/02/25 regarding issue still with call lights being answered and ice not being passed. The grievance form dated 09/02/25 was assigned to the DON. There were 12 residents in attendance including Residents #4, #46 and #80.The Resident Council Meeting minutes dated 10/07/25 revealed the Old Business section noted an issue with call lights and ice not being passed. A grievance form completed on 09/02/26 revealed all staff were inserviced on answering call lights and clinical staff were educated on passing ice on all 3 shifts. The resolution date was 09/16/25. Under the New Business section there were complaints about call lights being answered in a timely manner, staff with attitudes (cursing and aggressive tone of voice), staff still turning call lights off before care provided and not returning, water pitchers not being washed weekly and ice not being passed on every shift daily. A grievance form was completed on 10/07/25 regarding call lights not being answered in a timely manner, staff with attitudes, staff turning call light off before care was provided and not returning, ice not being passed on every shift daily, and water pitchers not being washed weekly. The grievance form was assigned to the DON. There were 12 residents in attendance including Residents #4, #46 and #80.The Resident Council Meeting minutes dated 11/03/25 revealed the Old Business section noted issues with call lights not being answered in a timely manner, staff turning call lights off and not meeting needs or returning to meet needs, attitudes of staff, passing ice and water and not washing watcher pitchers. The resolution on the grievance form completed on 10/07/25 was that staff were educated on professional standards with families, maintaining professional standards with difficult family members and staff to refrain from use of cursing and/or aggressive tone of voice. Staff were educated on call lights to be answered and reminded of water pitcher cleaning schedule and passing ice each shift. Audits of call light response time were conducted on 10/10/25 at different times of day from 9:30 AM to 3:30 PM, on 10/17/25 at different times from 9:53 AM to 11:34 AM, on 10/25/25 at different times from 9:16 AM to 3:37 PM and on 10/31/25 from 11:40 AM to 3:28 PM with no concerns for the response time. The response times ranged from seconds to 8 minutes being the longest wait time. The resolution date was 10/21/25. Under the New Business section there were complaints of call lights not being answered in a timely manner, call lights being turned off before taking care of the resident's need, leaving the room and not returning and ice not being passed on each shift daily and water pitchers not being washed weekly. A grievance form was completed on 11/03/25 regarding call lights not being answered in a timely manner, call lights being turned off before taking care of the resident's need, leaving the room and not returning, ice not being passed on each shift daily and water pitchers not being washed weekly. The grievance form was assigned to the DON. There were 10 residents in attendance including Residents #4, #46 and #80.The Resident Council Meeting minutes dated 12/01/25 revealed the Old Business section noted issues with call lights, ice not being passed routinely, and water pitcher washing schedule. The resolution on the grievance form completed on 11/03/26 was that a water pitcher washing schedule was implemented and reviewed with all staff during the Town Hall meeting. Unit Managers were to check with staff Monday through Friday about passing ice and weekend Nursing Supervisor to check on Saturday and Sunday. The Manager on Duty on weekends was to also check on halls for call lights. The resolution date was 11/17/25. Under the New Business section, the residents indicated call lights were still being turned off without resident needs being met and when residents turned the call light back on staff told residents they were not supposed to turn their call lights back on and resident's responded to staff that they had not met their needs. A grievance form was completed on 12/01/25 regarding call lights and ice not being passed as ongoing problem. The grievance form was assigned to the DON. There were 13 residents in attendance including Residents #4, #46, #80 and #89The Resident Council Meeting minutes dated 01/06/26 revealed under the Old Business complaints about call lights not being answered and ice not being passed as ongoing problem. The resolution on the grievance form dated 12/01/25 was that administrative staff were to check that ice was being passed and they were trying to go cups of ice or ice water for 2 weeks. The resolution date was 12/15/25. Under the New Business section, it was noted there were no complaints. There were 15 residents in attendance including Residents #4, #6, #46, #75, #80 and #89.The Resident Council Meeting minutes dated 03/03/26 revealed the Old Business section had no noted concerns. Under the New Business section, it was noted that call light response time was still a problem, ice not being passed consistently was still a problem and care not being provided during meal times was a problem. A grievance form was completed on 03/03/26 stating that call light response time, ice being passed and resident care not being provided during meal time was still a problem. The grievance form completed on 03/03/26 was assigned to the DON. There were 14 residents in attendance including Residents #4, #6, #39, #46, #75, #80 and #89.The Resident Council Meeting minutes dated 04/07/26 revealed the Old Business section had complaints that call light response time was still a problem, ice not being passed consistently was still a problem and care not being provided during meal times was a problem. The resolution on the grievance form completed on 03/03/26 was that ongoing education was provided to staff on call lights being answered timely, ice being passed, and care being provided during meal time. Staff were instructed that call lights were to be and needs met in a timely manner, ice was to be passed on all three shifts, and care was to be provided during meal times unless staff were actively feeding another resident and then other staff were to assist in meeting the residents' needs. The resolution date was 04/21/26. Under the New Business section there were no new complaints. There were 12 residents in attendance including Residents #4, #6, #39, #46, #75, #80 and #89.The Resident Council Meeting minutes dated 05/05/26 revealed the Old Business section had no noted concerns. Under the New Business section, it was noted that call lights were still not being answered in a timely manner, ice was not being passed consistently and the coffee on the hall cart was either empty or cold at breakfast. A grievance form was completed on 05/05/26 regarding call lights still not being answered in a timely manner, ice not being passed consistently and coffee on the hall cart empty or cold at breakfast. The grievance form completed on 05/05/26 was assigned to the DON. There were 12 residents in attendance including Residents #4, #46, #62, #75, #80 and #89.The resolution on the grievance form completed on 05/05/26 was the nurses will be educated that they will be held accountable to ensure the nurse aides are answering call lights timely and that ice is being passed each shift. Staff were also educated where snacks were located during hours when the kitchen was closed and Dietary educated to send more coffee out on halls in the morning hours. The resolution date was 05/19/26.A Resident Council group interview was conducted on 05/12/26 at 2:00 PM. There were 10 residents in attendance. During the interview, Residents # 39, #46, #62 and #80 who all resided on the 200 hall and attended Resident Council meetings regularly, all stated they felt the facility staff did not really address their concerns because the response they typically received from staff was staff were being educated, but there was no resolution because the concerns continued to happen. Residents #6, #39, #62, #75 agreed with the other residents that the call lights not being answered timely was a continual problem although the staff had been educated, the residents stated they just wanted resolution and their needs to be met. The residents all agreed they would like to know they were being heard and receive feedback from administration on the efforts that had been made or attempted and to resolve their concerns about the call lights. Resident #4 who was the Resident Council president stated she resided on another hall and had not had any issues with her call light being answered timely or ice and water being passed.During an interview with the Activities Director on 05/12/26 at 2:44 PM, she stated she arranged the Resident Council Meetings but that the Social Worker was the one who attended the meetings and recorded the meeting minutes. During an interview with the Social Worker on 05/12/26 at 2:49 PM, she stated she attended the Resident Council Meetings and recorded the minutes from the meetings. The Social Worker stated if the members discussed any concerns with any of the staff or departments that she completed a grievance form and assigned it to the appropriate department head. The Social Worker further stated they had 2 weeks to take action and complete the grievance form with the action taken towards resolution and then she discussed it with the residents at the next scheduled Resident Council Meeting. The Social Worker agreed that the call light response time, passing ice on all shifts and providing care during meal time had been discussed numerous times during meetings with the residents and that there still was no resolution to the resident's issues. The Social Worker stated that staff had been educated several times over the last 13 months about answering call lights and passing ice and that it was discouraging that this was still a concern with the residents.During an interview with the Director of Nursing (DON) on 05/14/26 at 10:37 AM, she stated she had been assigned the grievance forms from Resident Council Meetings regarding clinical issues. The DON further revealed they had done ongoing education about answering call lights in a timely manner and had talked with staff about answering call lights during Town Hall meetings. The DON stated they had recently reiterated to staff that all staff can answer call lights not just nurses and Nurse Aides (NA) and had hoped that would help with the call light response time. The DON further stated they had discussed on more than one occasion that the staff should not turn off the call light and tell the resident they would be back and then not go back to address their need. The DON stated that the administrative staff had discussed educating the staff not to turn the call light off if the resident's need had not been met but said they had not yet implemented that directive. The DON stated she felt like the issues with the 200 hall were related to the residents on that hall being alert and oriented and able to vocalize their needs more than some of the other residents on other halls. The DON stated 200 hall was a challenging hall because there were a lot of residents on that hall with behaviors and said their perception also could be that they were waiting a longer time than they actually were waiting. The DON further stated there were always 2 NAs on that hall on both 1st and 2nd shift and if there was an extra NA on shift they usually floated between 100 and 200 to help the staff. The DON added they had hired several positions and were hoping to get more continuity with the nurses and NAs on each hall and hoped that would help in resolving this ongoing issue with the call lights. She stated the issue with the ice and water being passed had been resolved since they had assigned a NA on the assignment sheet to pass ice and water each shift.During an interview with the Administrator on 05/14/26 at 11:15 AM, she stated that she had only been in the facility for a couple of weeks but said they were hoping to get resolution to the call light response for the residents. The Administrator stated her expectation was for the resident's call lights to be answered as quickly as possible but said sometimes they may have to wait but certainly the light should not be turned off and staff not return timely to meet the resident's needs. The Administrator stated it was an opportunity for improvement.

Based on record review, staff, Medical Director and Consulting Pharmacist interviews, the facility failed to prevent a significant medication error when Nurse #1 administered 30 units of insulin glargine (a long acting insulin that lasts for 24 hours and does not have a peak of onset) intended for Resident #31 to Resident #16. Resident #16 did not have a diagnosis of diabetes or a physician's order for insulin. Resident #16 was assessed by the Nurse Practitioner (NP) and immediately started on intravenous (IV) dextrose (a solution that contains sugar) fluids for 24 hours. The NP also ordered finger stick blood sugars every hour for 24 hours with instructions to notify the provider if Resident #16's blood sugar was below 90 (Normal range is between 70-99). Resident #16's blood sugar dropped to 61 during the night, Nurse #2 notified the on-call provider and gave Resident #16 eight ounces of orange juice and a snack while she waited for a response from the provider. The on-call provider responded and ordered glucagon (a medication used to increase a resident's blood sugar level) 1milligram (mg) and for Resident #16's blood sugar to be rechecked after 15 minutes. Nurse #2 administered glucagon 1mg subcutaneously (SQ) and the blood sugar recheck was 152. Hypoglycemia (defined as a blood sugar level below 70) can be serious and life threatening if gone untreated; symptoms include tremors, palpitations, anxiety, sweating, dizziness, weakness, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. There was a high likelihood for serious harm. This was for 1 of 3 residents reviewed for unnecessary medications (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE]. Resident #16 did not have a diagnosis of diabetes mellitus. Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired; Resident #16 was coded that she had not received insulin. Review of Resident #16's physician's orders dated April 2025 revealed no active orders or insulin. Review of Resident #16's April 2025 Medication Administration Record (MAR) revealed no active orders for insulin glargine. Review of Resident #31's physician's orders dated April 2025 revealed an active order for insulin glargine inject 30 units SQ every morning for type 2 diabetes mellitus. Review of Resident #16's medical record revealed a Nurse Practitioner progress note dated 4/14/2025 read in part: Resident #16 was seen today after she was given 30 units of long-acting insulin. No hypoglycemia. She is alert and seated in her wheelchair, conversant. Seated in wheelchair in no acute distress. Plan: Administer D5W (dextrose 5% in water- an infusion used to provide the body with extra water and calories from sugar) at 75 milliliters (ml) an hour for 24 hours. Close monitoring of blood sugar and vital signs, see orders. Review of Resident #16's physician's orders from the NP for 4/14/2025 revealed the following: -Monitor blood sugar for 24 hours- check blood sugar every hour- notify NP if blood sugar is less than 90. -Monitor for signs and symptoms of hypoglycemia- paleness, shakiness, sweating, headache, hunger/nausea, rapid/irregular heartbeat, fatigue, dizziness/lightheadedness, changes in level of consciousness every hour -Monitor vital signs every hour x 8 hours then every 4 hours x 4 -Condition change charting for 72 hours related to medication error -D5W at 75 milliliters (ml) /hour for 24 hours -D5 1/2NS (dextrose 5% in normal saline- an infusion used to provide the body with extra fluids and calories from sugar) at 75ml/hour for 24 hours The Nurse Practitioner was not available for interview during the survey. A nursing progress note written by Nurse #1 on 4/14/2025 at 10:08 am revealed she had made a medication error for Resident #16. The note revealed orders received for intravenous (IV) fluids, blood sugar and vitals were to be checked every hour for 24 hours, resident representative had been notified, and blood sugars were 138 and 129. A telephone interview was conducted with Nurse #1 on 04/23/25 at 9:41 AM. Nurse #1 stated on 4/14/2025 two residents were sitting at the table in the dining room, and she (Nurse #1) administered insulin to Resident #16, insulin that was ordered for Resident #31. Nurse #1 stated she immediately realized her mistake and reported the error to the NP and received orders to check blood sugars and vitals every hour. Nurse #1 was unsure of the exact amount of insulin she had administered to Resident #16 but stated it was the dose intended for Resident #31. Nurse #1 stated she reported the medication error to the assistant Director of Nursing (ADON) and Director of Nursing (DON) and Resident 16's family member. On 4/14/2025 Nurse #1 was scheduled to work 7am-7pm on a hall she was not normally assigned. Nurse #1 stated she failed to administer the right medication to the right resident when she failed to verify the resident's identity prior to insulin being administered and by administering medication in the dining room and not in the resident's room. Nurse #1 stated as soon as the insulin was administered to Resident #16, Nurse #1 realized Resident #31, who was seated next to Resident #16, was intended to receive the insulin. Nurse #1 stated the medication error was a total mishap, a human error and she was normally more focused. Nurse #1 stated Resident #31 received her insulin as ordered after the medication error with Resident #16. A nursing progress note written by Nurse #4 on 04/14/2025 at 10:25 am revealed a subcutaneous (SQ) IV was placed in the left lower quadrant of Resident #16's abdomen. D5W was infused at 75 ml per hour for 24 hours. During a telephone interview on 04/23/25 at 10:49 AM Nurse #4 stated on 4/14/2025 she (Nurse #4) was assigned to Resident #16's hall from 7am to 11pm. Nurse #4 was informed that Nurse #1 had administered insulin to Resident #16 who was not a diabetic and did not require insulin. Nurse #4 assessed and monitored Resident #16 through the rest of her shifts on 4/14/2025 and 7am to 3pm on 4/15/2025. Nurse #4 entered the orders received from the NP and checked Resident #16's blood sugar and vital signs every hour as ordered. Nurse #4 stated she did not observe any hypoglycemic episodes while she monitored Resident #16. Nurse #4 stated Resident #16 was alert to self and place, and some of Resident #16's family had visited Resident #16 on 4/14/2025. Nurse #4 stated the NP orders indicated to notify the NP if Resident # 16's blood sugar went below 90. Nurse #4 stated Resident #16's blood sugars had not been below 90 during her shifts. Nurse #4 stated she instructed the nursing assistants to monitor if Resident #16 did not eat well at meals and extra snacks would be given if needed. Nurse #4 stated Resident #16's vital signs remained stable. During a follow up interview on 4/24/2025 at 9:48am Nurse #4 stated Resident # 16 was not able to communicate with a nurse that she was not supposed to receive insulin. Review of Resident #16's medical record revealed her blood sugar was 61 documented at 12:35 am on 4/15/2025, and 77 documented at 1:13 am on 4/15/2025 by Nurse #2. Review of a progress written by Nurse #2 on 04/15/25 revealed that she notified the on-call provider and received orders on 4/15/2025 for Glucagon reconstituted solution 1mg injection- give 1milligram (mg) SQ and recheck blood sugar (BS) in 15 minutes related to low blood sugar. And to check blood sugar at hour of sleep if BS is greater than 90 NO rechecks are required. During a telephone interview on 4/23/2025 at 10:58 am Nurse #2 stated on 4/14/2025 she was scheduled to work 7pm to 7am and received report that Resident #16 had received the insulin by mistake, Resident #16 was not diabetic. Nurse #2 took over care for Resident #16 at 11pm on 4/14/2025. Nurse #2 stated the facility was out of D5W IV fluids, and new orders were received to start D5 1/2NS at 75ml per hour for remainder of the order. Nurse #2 stated Resident #16's blood sugar dropped to 61 around midnight and Resident #16 was given orange juice and a snack while Nurse #2 waited for a response from the on-call NP. Nurse #2 stated she received the order for glucagon 1mg, and it was administered to Resident #16 as ordered. Nurse #2 stated she stayed with Resident #16 for about 2 hours while the blood sugars were low, and Resident #16 remained alert and able to eat the snacks and drink fluids with no signs of hypoglycemia. During an interview on 4/23/2025 at 1:40 pm the Medical Director stated if a non-diabetic resident received 30 units of long-acting insulin it could cause hypoglycemic events. During a telephone interview on 4/24/2025 at 12:44 pm the Consulting Pharmacist stated if a non-diabetic resident received 30 units of long-acting insulin it could have caused blood sugars to drop, pain or hypoglycemic issues. During an interview on 4/24/2025 at 1:10 pm the Director of Nursing (DON) stated she expected nurses not to administer medications in the dining room and for the correct medication to be administered to the correct resident. The DON stated she expected nurses to follow the 6 medication rights which included the right medication, right dose, right route, right rate and the right time for the right resident. The DON stated that the medication error occurred when Nurse #1 administered insulin in the dining room and failed to verify the identity of the resident prior to medication being administered. During an interview on 4/24/2025 at 2:18pm the Administrator stated she expected the nurses to follow the 6 medication rights when they administer medication. The Administrator was notified of immediate jeopardy on 4/23/2025 at 4:15 pm. The facility provided the following corrective action plan with the completion date of 4/17/2025: How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 4/14/2025 at 8:34 am Nurse #1 administered Lantus 30 units to Resident #16 who did not have an order for Lantus and immediately reported this to the Director of Nursing and the Provider. The Provider immediately assessed Resident #16 and gave orders to check finger stick blood sugar every hour until 9:00am on 4/15/2025, notify Provider if finger stick blood sugar is below 90 milligrams (mg) per deciliter, Dextrose IV solution for 24 hours and monitor for signs and symptoms of hypoglycemia until 4/15/2025. On 4/14/2025 Provider gave order to monitor Resident #16's vital signs every hour for 8 hours and then vital signs every 4 hours for 16 hours. Resident #16's vital signs remained stable throughout monitoring. On 4/15/2025 at 12:30 am Resident #16 finger stick blood glucose was 61 milligrams per deciliter, on call was notified and while awaiting return call Nurse #2 gave 8oz of orange juice and a snack, Resident #16 was alert and oriented with no signs and symptoms of distress. Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:00 am and was 77 milligrams per deciliter, on call Provider returned call at 1:10 am and gave order to administer Glucagon 1mg now times one dose and recheck finger stick blood sugar in 15 minutes. Nurse #2 administered Glucagon 1mg to Resident #16 at 1:15 am and Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:32 am and Resident #16 finger stick blood glucose was 152 milligrams per deciliter. The remaining hourly blood sugar checks were 90 or above. The Resident #1's Responsible Party was notified of medication error on 4/14/2025 at 10:08am. Nurse #1 was suspended pending investigation on 4/14/2025. The Director of Nursing contacted the Board of Nursing regarding the medication error on 4/15/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 4/14/2025 the Director of Nursing and or Designee reviewed the finger stick blood glucose levels of all residents who require glucose monitoring from 4/13/2025 to 4/14/2025, which captured 24 hours prior to incident to ensure residents had no levels that would indicate signs and symptoms of hypoglycemia. The Director of Nursing and or Designee audited residents who had active orders for blood glucose monitoring and insulin on 4/14/2025 to ensure the insulin was administered per orders. No concerns were identified. On 4/15/2025 the Director of Nursing interviewed cognitively intact residents with Brief Interview Mental Status score of 12 or above to ensure they had no concerns with receiving incorrect medications and cognitively impaired residents with Brief Interview Mental Status score below 12 were assessed by the Director of Nursing and or Designee to ensure no signs and symptoms of hypoglycemia were noted. No concerns were identified. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? To prevent this from happening again the Director of Nursing and or Designee started education on 4/14/2025 for all Licensed Nurses and Medication Aides including Agency Licensed Nurses and Medication Aides currently working in facility on not administering medications in the dining room and to follow the 6 rights of medication administration, to include the medication is administered to the right resident by verifying using the picture of each resident in the electronic health record. Licensed Nurses and Medication Aides not currently working in facility were educated via phone or in person by the Director of Nursing and or Designee by 4/15/2025 and will not be allowed to work until they have received this education. Any Nurse on leave or paid time off will be provided the education prior to working their next shift by the Director of Nursing and or Designee. The Director of Nursing has list of any Licensed Nurses and/or Medication Aides that are on leave or paid time off that need this education prior to working. The Director of Nursing was educated on 4/15/2025 by the Regional Director of Clinical Services on ensuring any Licensed Nurse or Medication Aide who is on leave or on paid time off received this education prior to their first shift of working. This education will be provided in new hire orientation for all Licensed Nurses and Medication Aides. Agency Licensed Nurses and/or agency Medication Aides will receive this education prior to working. The Director of Nursing called and spoke with each agencies credentialing and/or education specialist regarding education needed for the medication error plan of correction and sent the facility specific plan of correction education packet to the 2 agencies that provide contract staff to this facility 4/14/2025. The agency ensures the Licensed Nurses and or Medication Aides received this education prior to being scheduled at this facility. The Agencies provided confirmation to the Director of Nursing via individual staff education email that all agency Licensed Nurses and/or Medication Aides had received this education prior to working in facility. The Director of Nursing educated the Scheduler on ensuring continuity of staff to attempt to keep them on the same assignment as much as possible to prevent medication errors. This education was completed on 4/15/2025. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? To monitor and maintain compliance starting 4/17/2025 the Director of Nursing and or Designee will observe 3 medication passes for Licensed Nurses and/or Medication Aides weekly to include all three shifts for 8 weeks and then monthly for 1 month to ensure medications are administered as ordered. Starting 4/17/2025 the Director of Nursing and or Designee will observe 5 residents in Dining Room weekly for 8 weeks and then monthly for 1 month to ensure no medications are being passed in the dining room. The Administrator and Director of Nursing discussed Resident #16's medication error on 4/14/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 4/15/2025 with the Interdisciplinary team to discuss the incident with Resident #16 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 4/15/2025 regarding the medication error and the interventions that were put in place for Resident #16 and the plan of correction to prevent the medication errors. The Director of Nursing implemented the plan of correction to prevent medication errors on 4/14/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. On 4/24/25, the facility's corrective action plan effective 4/17/25 was validated by the following: During medication pass observations of licensed nursing staff reviewing residents with an active order for insulin on their electronic medical chart, checking the resident's picture and room number to assure they had the correct resident, and administering the correct dosage of insulin to the correct resident inside their room with no issues or concerns noted. Licensed Nurses and Medication Aide interviews revealed they had received education on 6 rights of medication administration to include checking resident electronic medical chart to ensure resident order for insulin and name, room number, and picture of resident to receive insulin. They were also educated on administering insulin inside resident rooms and not in the dining room during meals and reporting a medication error immediately to their supervisor. The facility scheduler received education on trying to schedule nursing staff as much as possible to their same assigned halls consistently to help with continuity of care and prevention of medication errors. Administrative staff interviews revealed they provided staff education and completed weekly monitoring audits of ensuring medications including insulin are not being administered in the dining rooms during mealtimes, medication passes for all three shifts to ensure medications including insulin are administered as ordered to the correct resident. Education and Auditing tools were reviewed, with no new issues noted. Documents were reviewed from the Facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. Medication pass was observed on 4/22/2025 and 4/23/2025 with 0% error rate. The facility's corrective action plan with an IJ removal date of 04/17/25 was validated. IJ removal date is 04/17/25.

Based on observations, record review, Medical Director, resident and staff interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #34) with left side weakness and vascular dementia with incontinent care. The resident was rolled onto her left side then left in her bed unattended with the side rails down. Resident #34 was unable to hold herself up and she fell off the side of the bed onto the floor. The resident sustained a laceration to her nose, bruises to her face, and was transferred to the hospital for treatment. She received medical glue to the laceration on her nose, and a hospital CT (computed tomography) scan revealed the resident had suffered a fractured nose due to the fall. The resident was discharged back to the facility on [DATE]. Resident #34 stated that this was the worst fall she had suffered and was more painful than the birth of her children. This was reviewed for 1 of 3 residents (Resident #34) for the prevention of accidents. Findings Included: Resident #34 was admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis) and hemiparesis (partial weakness) affecting the left non-dominant side and vascular dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and had been assessed as being dependent on staff for all activities of daily living and was frequently incontinent of bladder and bowel. Resident #34 was also assessed as requiring bed rails to assist with bed mobility. Review of a nursing progress note written by Nurse #3 dated 4/12/25 revealed Resident #34 rolled out of bed while her gown was being changed by Nursing Assistant (NA) #1. Siderails on the bed were down. Resident #34 was lying face-down on the floor beside the bed. Moderate amount of bleeding from a laceration to the bridge of her nose. Pressure bandage was applied to the nose and bruising evident on the face. Resident #34 complained of pain in left hip and her head. Resident #34's Responsible Person (RP) was contacted, and she stated a desire to have Resident #34 go to the emergency room (ER). Nurse Practitioner (NP) notified. Resident #34 was alert and oriented x4, denied dizziness or nausea. Emergency Management System (EMS) called. Resident #34 left the facility via stretcher with EMS in stable condition. Report called to hospital ER charge nurse. Review of fall incident report written by Nurse #3 dated 4/12/25 revealed Resident #34 rolled out of bed while her gown was being changed by NA #1. Siderails were down and Resident #34 was lying face down on floor beside the bed. Moderate amount of bleeding from a laceration to the bridge of Resident #34 nose, pressure bandage applied. Bruising evident to Resident #34 face and complaints of pain to left hip and head. RP notified and stated her desire for Resident #34 to be sent to ER. NP also notified. Resident #34 was alert and oriented x4 and denied any loss of consciousness, dizziness, or nausea. EMS was called and Resident #34 left facility via stretcher with EMS in stable condition. Report was called to ER nurse. Review of a hospital discharge summary dated 4/12/25 revealed Resident #34 from a local skilled nursing facility, non-ambulatory, was receiving personal care and apparently fell from the bed into the floor. She sustained a significant nasal laceration (deep cut on top of nose), bruises to her face and was brought to the Emergency Department (ED) where she was found to have a fractured nasal bridge. Glue was placed for nasal laceration. Resident #34 was discharged back to the skilled nursing facility in stable and improved condition with orders to follow-up with primary care physician. Review of a nursing progress note written by Nurse #3 dated 4/12/25 revealed Resident #34 returned from ER via EMS at 6:40 AM in stable condition and alert and oriented X4. Neurological checks remain at baseline. Per report from the hospital ER charge nurse, Resident #34's CT scans were negative for head and neck fractures. Fractured nasal bridge with laceration (glued at ER). No new orders received, follow up with NP. Resident #34 was instructed to leave bed in a low position and call for assistance. Attempted an interview with Nurse #3 and was unsuccessful. Review of physician progress note written by the NP dated 4/12/25 revealed Resident #34 was being seen for follow-up from fall out of bed requiring visit to ER. Resident #34 had a fractured nose, laceration on forehead, entire face black and purple, eyes, lips, and nose all swollen. At time of assessment, Resident #34's pain was controlled, mentation intact, and no neurological deficits noted. Resident #34's vitals were also stable, and breathing was within normal limits. NP ordered pain medication every four hours as needed, nose spray, and cold compresses as needed to face. RP was at bedside and aware of the incident and NP noted no other concerns at this time. Review of NP order for Resident #34 dated 4/12/25 revealed the following: Hydrocodone Acetaminophen 5/325 milligrams (MG) 1 tablet by mouth every 4 hours as needed for treatment of pain. Flonase nasal spray 1 spray in each nostril two times per day for edema (swelling) Cold compress to face every 4 hours as needed for edema Attempted an interview with NP and was unsuccessful. Review of fall incident statement provided by Resident #34 dated 4/12/25 revealed Resident #34 rang her call light and NA #1 came in and assisted with her care and noted her brief and gown were wet. NA #1 changed her brief and went to get her gown out of the closet. NA #1 returned, and Resident #34 stated she was going to fall, and she proceeded to roll off of the left side of the bed into the floor. Resident #34 stated her bed rails were down at the time of the fall. Review of fall incident statement written by NA #1 dated 4/12/25 revealed on 4/12/25 at 2:30 AM, NA #1 provided routine care for Resident #34. Upon entering Resident #34's room observed bed rails were down and assumed was her preference during care. NA #1 elevated Resident #34's bed and began care by rolling Resident #34 onto her left side. As care progressed, NA #1 removed Resident #34's brief and pad and recommended changing her gown. NA #1 proceeded to get Resident #34's gown and her weight began to take her over the left side of the bed resulting in her fall. A telephone interview was conducted with NA #1 on 4/24/25 at 6:08 PM revealed he was familiar with Resident #34 and provided her care the morning of 4/12/25. He stated that on 4/12/25 around 2:30 AM, he went into Resident #34's room to answer her call-light and she informed him that both her brief and gown were wet, and she needed to be changed. He revealed he elevated Resident #34's bed to right above waist level, rolled her onto her left side and provided Resident #34 incontinence care by cleaning and changing her brief. NA #1 stated he left Resident #34 rolled over onto her left side facing the window, walked over to her closet on the opposite side of the room by the door to get her a clean gown to change into. He revealed as he was coming back towards Resident #34's bed he heard Resident #34 say I'm falling and observed her weight take her over the side of the bed and she fell into the floor between the bed and the air conditioner on the wall. He stated he immediately went to the nurse's desk and informed Nurse #2 of the fall and she and Nurse #3 responded to Resident #34 room and began providing treatment he believed to her nose which was bleeding. NA #1 stated Resident #34 did have quarter bed rails that were not raised, and he was later informed that her bed was also not locked. NA #1 also stated the incident was an accident and human error on his part and that he had since been re-educated on incontinence care, making sure assistive devices such as bed rails were being used, and making sure resident beds were locked. Attempted an interview with Nurse #2 and was unsuccessful. Review of fall incident statement provided by Nurse #2 dated 4/12/25 revealed on 4/12/25 NA #1 informed her and Nurse #3 that Resident #34 had fallen while in the middle of changing her. When Nurse #2 arrived at Resident #34's room, she was on the left side of the bed (on floor) face down. Nurse #3 assessed Resident #34 while Nurse #2 started pressure to the bleeding areas. Resident #34 stated I was trying to grab the rail and went over, it was an accident, it wasn't his fault. Resident #34 was lifted off the floor to her bed, was alert and talking. Nurse #2 stayed with Resident #34 until EMS arrived. An interview and observation with Resident #34 was conducted on 4/23/25 at 2:30 PM and revealed a couple of weeks ago she had suffered a fall from her bed during incontinence care and broke her nose. She stated during the middle of the night she had wet herself through her brief and gown and used her call light to ask for staff assistance. She revealed NA #1 came into her room to answer her call light and she informed him she needed to be changed and that her gown was also wet and needed to be changed. Resident #34 stated NA #1 elevated her bed to about his waist and began changing her brief. She revealed after NA #1 finished changing her brief, he then went over to her closet located on the other side of her room to get her a clean gown. She stated when NA #1 went to get her new gown she was still rolled over onto her left side in bed facing the window and as NA #1 was coming back towards the bed with her gown was when she fell off the side of the bed onto the floor between the bed and the air conditioner and broke her nose. Resident #34 stated she was [AGE] years old, and this was the worst fall she had ever suffered and was more painful than the birth of her three children. Observation of Resident #34 revealed laceration to the top of the nose which appeared scabbed over, faint bruising to both sides of nose and underneath both eyes, and faint bruising on top of both the right and left hand. An interview was conducted with the Medical Director on 4/23/25 at 2:47 PM revealed he was not as familiar with Resident #34 and believed his NP was notified of Resident #34's fall. He stated to his knowledge NP followed up with Resident #34's fall and fractured nose on 4/12/25 after her return from the hospital. The Medical Director revealed based on Resident #34's diagnosis of muscle weakness and being left alone while rolled onto her side with nothing to hold up her weight could have contributed to her fall. He stated staff should follow guidelines to ensure all residents were safe while receiving care. An interview was conducted with the Physical Therapy Assistant (PTA) on 4/24/25 at 1:45 PM revealed she was familiar with Resident #34, had provided her with therapy services off and on since her admission. She stated Resident #34 had been referred to therapy due to her most recent fall and was currently receiving therapy services for strengthening and movement for her left-sided weakness. She revealed Resident #34 had minimal use of her left side, wore a splint on her left hand during waking hours and a palm guard during her sleeping hours to prevent contracture of the left hand. Quarter rails had been applied to the bed for assistance with bed mobility, and bed placed in lowered position to assist with any falls. The PTA stated any residents could be considered a fall risk while left alone in their bed and rolled onto their side. Staff should not walk off or leave any residents alone in their beds while rolled onto their sides while providing care. She revealed Resident #34 being left alone and rolled onto her weaker side with nothing to assist her with holding up her weight could have contributed to her fall. An interview was conducted with the Director of Nursing (DON) on 4/24/25 at 4:07 PM revealed she was familiar with Resident #34. The DON stated she received a telephone call on the morning of 4/12/25 from Nurse #3 stating Resident #34 had fallen off the bed during incontinence care, had bleeding from her nose, bruises to her face, was complaining of pain, the on-call physician had been notified, and they were sending Resident #34 out to the ER for further treatment. She revealed she contacted the Administrator, and the Administrator went into the facility on [DATE] and initiated the investigation of the fall. She stated her understanding of the fall was that NA #1 had gone into Resident #34's room to assist with incontinent care and after providing her initial care had gone to the closet to get Resident #34 a clean gown and upon his return to the bed was when Resident #34 fell . The DON revealed Resident #34 was sent to the ER and did return with a fractured nose that was treated with ice packs and pain medication and all other CT scans to her head, neck, hands, and knees were negative for any further injury. She stated Resident #34 had quarter bed rails to assist with her bed mobility that were not raised, and her bed was not locked prior to care. She revealed she believed Resident #34's fall occurred due to human error and oversight on NA #1's part and since the incident all staff had been educated on incontinence care and assuring all resident beds were locked and assistive devices in place prior to providing care. An interview was conducted with the Administrator on 4/24/25 at 5:17 PM revealed she was familiar with Resident #34. The Administrator stated on the morning of 4/12/25 she received a telephone call from the DON about Resident #34's fall during incontinence care and that she was being sent out to the ER for further evaluation. She revealed she went into the facility on [DATE] to begin the investigation on the fall and received statements from NA #1, Nurse #2 and Resident #34 once she returned from the ER. The Administrator stated she also had nursing staff to complete audits on all other residents with assistive devices making sure they were intact during resident care, all resident beds were locked, and that education with staff on incontinence care including audits of staff providing incontinence care was initiated. She revealed her understanding of the fall was that NA #1 had gone into Resident #34's room to provide incontinence care and while NA #1 was retrieving a gown for Resident #34 to be changed into she fell into the floor between her bed and the wall. The Administrator stated Resident #34's bed rails were not raised, and her bed was not locked while NA #1 was providing her care. She revealed Resident #34 was sent out to the hospital ER immediately and CT scan was performed showing her nose was fractured but no other injuries were found. She stated Resident #34 did return to the facility that same day and was seen by the NP who ordered ice packs and pain medication for treatment. The Administrator revealed she believed the incident with Resident #34 was due to human error and oversight on the part of NA #1 and that all staff have been re-educated on incontinent care and making sure residents were not left alone during care, assistive devices including bed rails are in place and all resident beds are locked prior to performing resident care. The facility provided the following Corrective Action Plan with a correction date of 4/15/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Certified Nursing Assistant #1 was performing incontinence care on 04/12/25 and changing Resident #34's gown while she was in bed and the quarter rails were not in a raised position. CNA #1 assisted Resident #34 to turn and the bed was not locked and rolled away from the wall and Resident #34 rolled out of bed onto the floor between bed and wall. Resident #34 was assessed by nurse, Provider and Resident #34's responsible party was notified on 4/12/2025. Resident #34 was sent to hospital on 4/12/2025 for evaluation. Resident #34 returned from the hospital on 4/12/2025 and noted to have a nasal bone fracture. Provider assessed upon return on 4/12/2025 and gave orders for ice packs every 4 hours as needed to face for edema, Flonase nasal spray 1 spray in each nostril two times per day for edema and Hydrocodone acetaminophen 5/325 milligrams every 4 hours as needed for pain. Resident #34 continued to complain of pain and on 4/14/205 Provider ordered chest, thoracic, lumbar, bilateral hands and right knee x rays. Results of x rays were all negative. CNA #1 was suspended by the Director of Nursing on 4/12/205 pending investigation. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: The Director of Nursing and or Designee audited current residents who use side rails to ensure they were up while residents were in bed and assessed if the residents still required or requested side rails. This audit was completed on 4/14/2025. The Director of Nursing and or Designee audited current beds in the facility to ensure they were locked. This audit was completed on 4/14/2025. No areas of concern were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: To prevent this from happening again the Director of Nursing and or Designee started education on 4/12/2025 for nursing staff including Agency Nursing staff currently working in facility to ensure residents safety during care when resident is in the bed, including not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position and any assistive devices needed are in place and that the bed is locked prior to providing care. Examples, Bed rails for positioning, pillows and or wedges. This education was provided to all certified nursing assistants by the Director of Nursing and or Designee, also included safe handling during Bed Mobility to include not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position, adjusting bed to proper height, stand on side of bed to which the resident will roll, Position arms/legs appropriately; position residents arm, which is closest to you, out to the side of their body, flex the resident knee furthest from you, position residents furthest arm across their chest and roll resident towards you by placing one hand behind the residents shoulder and the other on their hip, The Director of Nursing and or Designee observed with return demonstration incontinent care, turning and repositioning in bed and bed mobility with all certified nursing assistants to ensure they were competent. These observations were completed by 4/14/2025. Nursing staff not currently working in facility were educated via phone or in person by the Director of Nursing and or Designee by 4/14/205 and will not be allowed to work until they have received this education. Any Nursing staff on leave or paid time off will be provided the education prior to working their next shift by the Director of Nursing and or Designee. The Director of Nursing has list of any nursing staff that are on leave or paid time off that need this education prior to working. This education will be provided in new hire orientation for nursing staff. Agency nursing staff will receive this education prior to working. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: To monitor and maintain compliance starting 4/17/2025 the Director of Nursing and or Designee will observe care being provided to 5 residents weekly for 8 weeks and monthly for 1 month to ensure residents safety during care when resident is in the bed, including not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position and any assistive devices needed are in place and that the bed is locked prior to providing care. The Administrator and Director of Nursing discussed Resident #34's incident on 4/13/2025 and determined the need to have an ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 4/14/2025 with the Interdisciplinary team to discuss the incident with Resident #34 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 4/14/2025 regarding the incident and the interventions that were put in place for Resident #34 and the plan of correction to prevent further incidents and or accidents. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Date of Compliance: April 15, 2025 On 4/24/25, the facility's corrective action plan effective 4/15/25 was validated by the following: Observations of residents being provided incontinence care, assistive devices being used during care including bed rails, and resident beds being in a locked position while in use with no issues or concerns noted. Nursing staff interviews revealed they had received education on providing incontinent care to residents safely, making sure all assistive devices for residents used while in bed or during care were present, and resident beds were locked prior to providing care. Administrative staff interviews revealed they provided staff education on ensuring resident safety, assistive devices were in place and resident beds were locked prior to performing resident care. Administrative staff completed return demonstrations with staff and were also completing weekly audits of resident care to ensure safety of residents during care, positioning of residents during care, resident assistive devices are present and being used correctly, and resident beds are locked prior to providing care. Auditing tools and documents were reviewed from the Facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. The facility's action plan was validated to be completed as of 4/15/25.

Based on observations and staff interviews, the facility failed to ensure ready to use dishware was cleaned and dried before being stored, food was dated/labeled in the walk-in freezer, walk-in cooler, and dry goods storage area. This occurred for 1 of 2 kitchen observations. This had the potential to affect food served and distributed to 88 of 88 residents who received an oral diet. The findings included: The initial tour of the kitchen occurred on 04/21/25 at 9:30 AM with the Dietary Manager. The initial observation of the dishware storage area revealed the following: a. Dishware that was ready for use was put away and stacked wet. -4 out of 4 metal serving bins were stacked flat upside down visibly wet with pooled water on the sides and water pooled around the rim. -22 small plastic bowls stacked right side up. 3 out of 22 bowls were observed with small amount of pooled water in the base of the bowls. -2 of 8 clear small plastic dessert bowls were stacked right side up with small amount of pooled water in base of the bowls. b. Dishware that was ready for use was put away/or stacked with food debris/insects on them. -1 of 4 metal serving bins observed with one piece of red food debris dried to the side. -2 of 4 plastic bins observed with visible brown sticky substance to the side and bottom. The substance was dull in appearance and sticky when touched. -1 of 22 small plastic dessert bowls were observed with 2 gnats dead in the bowl in small amount of pooled water. c. Frozen items in the walk-in freezer were observed with no date on packaging. -1 of 1 opened box of frozen green beans observed with no date on box. -1 of 1 opened box of diced green peppers observed with no date on box. -1 of 1 opened box of French bread observed with no date on box. -1 of 1 opened box of cookie dough observed with no date on box. -1 of 1 opened box of biscuit dough observed with no date on box. d. Opened items in dry good storage area not labeled with opened date/use by date. -2 of 2 bottles of chocolate syrup observed with no date. -2 of 2 opened cereal bags observed with no opened date/use by date label. e. Items in the walk-in cooler were not dated. -1 of 1 box of strawberries observed with no date on box. An interview with the Dietary Manager on 04/22/25 at 1:42 PM revealed she stated that dishware was to be cleaned, dried thoroughly, and stored facing down to prevent pooling water, debris, or insects. She stated food stored in the walk-in freezer, dry goods area, and walk-in cooler should be labeled and dated when opened. An interview with the Administrator 04/23/25 at 2:33 PM revealed she expected food to be labeled and dated, and dishware should be washed, dried thoroughly, and stored before use.

Based on observations, record reviews, resident, staff, family, and physician interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #86). This deficient practice occurred for 1 of 3 residents reviewed for respiratory care and services. Findings included: Resident #86 was admitted to the facility on [DATE]. Resident #86 had diagnoses which included myoneural disorder (a neuromuscular disorder which leads to progressive muscle weakness and paralysis which affects breathing). Review of the Electronic Medical Record (EMR) revealed a physician order for Resident #86 dated 04/17/2025 at 10:17 AM for oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia. Review of the baseline care plan dated 04/17/2025 revealed Resident #86 was receiving oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia. Resident #86's 5-Day Minimum Data Set (MDS) assessment was in progress and not yet completed. Review of the Brief Interview for Mental Status (BIMS) dated 04/17/2025 revealed Resident #86 was cognitively intact. An observation of Resident #86 was completed on 04/21/2025 at 11:53 AM. Resident #86 was in her room sitting up in her wheelchair with her nasal cannula in her nostrils and her portable oxygen tank was set at 2 LPM. On 04/22/2025 at 11:55 AM Resident #86 was observed lying in bed with her NC in her nostrils and the oxygen concentrator was set at 1.5 LPM. An additional observation of Resident #86 was made on 04/22/2025 at 4:03 PM. Resident #86 was in her room sitting up in her wheelchair with her NC in her nostrils and the portable oxygen tank was set at 1.5 LPM. Resident #86 was observed to not be in distress. An interview was conducted with Resident #86 on 04/22/2025 at 4:04 PM. Resident #86 stated she had been on oxygen since she was hospitalized with a severe respiratory illness about a year ago. Resident #86 also stated she does not adjust the oxygen flow rate on her oxygen concentrator or the portable oxygen tank. Resident #86 stated the nursing staff take care of her oxygen settings. An observation of Resident #86 was conducted on 04/23/2025 at 11:06 AM. Resident #86 was in her room sitting up in her wheelchair with her NC in her nostrils and her portable oxygen tank was set at 2 LPM. Resident #86 was observed to not be in distress. An interview was completed on 04/23/2025 at 11:10 AM with nursing assistant (NA) #2 who was assigned to Resident #86. NA #2 stated she always made sure the NC was in the resident's nostrils correctly and she checked to make sure the oxygen concentrator was plugged up in the electrical outlet. NA #2 stated she did not do anything with oxygen settings or adjust the oxygen flow rate on the oxygen concentrator or the portable oxygen tank. An interview was conducted on 04/23/2025 at 12:18 PM with Nurse #5 who was assigned to Resident #86 on 04/22/2025 and 04/23/2025. Nurse #5 stated that all residents receiving oxygen should have a physician's order for oxygen which would include the flow rate. Nurse #5 also stated the flow rate should be set as ordered by the physician. Nurse #5 further stated she checks the oxygen flow rate during her morning rounds and medication pass but she had not checked Resident #86's oxygen settings on 04/23/2025. Nurse #5 further explained if a resident got up to the wheelchair, the NA would turn the portable tank on and set the flow rate. An interview was conducted with the Assistant Director of Nursing (ADON) on 04/23/2025 at 12:32 PM. The ADON stated the nurses should check to make residents are receiving the correct oxygen flow rate as prescribed by the physician. The ADON stated the licensed nurses should be managing the oxygen flow rates on the oxygen concentrators and the portable oxygen tanks. The ADON further stated the NAs should not be setting, adjusting, or changing the oxygen flow rates on the oxygen concentrator or the portable oxygen tanks. An interview was conducted with the Medical Director on 04/23/2025 at 2:03 PM. The Medical Director stated all residents receiving oxygen required an active physician's order for the prescribed LPM of oxygen they were to receive. The Medical Director further stated nursing staff should follow the physician's orders for providing oxygen including the prescribed flow rate. An interview was conducted with NA #3 on 04/24/2025 at 9:00 AM. NA #3 stated the nurses were supposed to adjust the flow rate of oxygen for residents and turn on the oxygen concentrator and the portable oxygen tanks. An interview was conducted with NA #4 on 04/24/2025 at 9:45 AM. NA #4 stated he did set the oxygen levels on portable oxygen tanks when changing residents from the oxygen concentrator to the portable oxygen tank or if the portable oxygen tank was empty and he needed to replace it with a full tank. NA #4 further explained he usually looked at the settings on the oxygen concentrator for the correct liters and he would set the portable oxygen tank to the same oxygen flow rate as the oxygen concentrator. An interview was conducted with the Director of Nursing (DON) on 04/24/2025 at 3:53 PM. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained she expected the nursing staff to provide oxygen at the prescribed flow rate as ordered by the physician. The DON explained the NAs should not adjust the flow rate on the oxygen concentrators or the portable oxygen tanks. The DON further explained the NAs should leave the resident on the oxygen concentrator and the nurse should switch the resident over to the portable oxygen tank and set the flow rate as ordered by the physician. The DON also stated oxygen was considered a medication, and the licensed nursing staff should follow the physician's order for the prescribed oxygen flow rate, ensure residents were receiving the correct flow rate of oxygen, and make any adjustments or changes to the flow rate. An interview was conducted on 04/24/2025 at 4:58 PM with the Administrator. The Administrator stated she expected the nursing staff to follow the physician's order for providing oxygen including the correct flow rate and only the licensed nurses should set, adjust, or change the oxygen flow rate based on the physician's order.

Based on record review and staff interviews, the facility failed to maintain daily posted staffing sheets for 134 of 385 days (9/21/2024-12/31/2024, 1/4/2025, 1/5/2025, 1/11/2025, 1/12/2025, 1/18/2025, 1/19/2025, 1/25/2025, 1/26/2025, 2/1/2025, 2/2/2025, 2/8/2025, 2/9/2025, 2/15/2025, 2/16/2025, 2/22/2025, 2/23/2025, 3/1/2025, 3/2/2025, 3/8/2025, 3/9/2025, 3/15/2025, 3/16/2025, 3/22/2025, 3/23,2025, 3/29/205, 3/30/2025, 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/19/2025, 4/20/2025) reviewed for daily posted staffing information. The findings included: Review of the daily posted staffing sheets for September 2024 revealed no information was available for the days of 9/21/2024- 9/30/2025 Review of the daily posted staffing sheets for October 2024 revealed no information was available for the days of 10/1/2024- 10/31/2024. Review of the daily posted staffing sheets for November 2024 revealed no information was available for the days of 11/1/2024- 11/30/2024. Review of the daily posted staffing sheets for December 2024 revealed no information was available for the days of 12/1/2024- 12/31/2024. Review of the daily posted staffing sheets for January 2025 revealed no information was available for 1/4/2025, 1/5/2025, 1/11/2025, 1/12/2025, 1/18/2025, 1/19/2025, 1/25/2025, 1/26/2025. Review of the daily posted staffing sheets for February 2025 revealed no information was available for 2/1/2025, 2/2/2025, 2/8/2025, 2/9/2025, 2/15/2025, 2/16/2025, 2/22/2025, 2/23/2025. Review of the daily posted staffing sheets for March 2025 revealed no information was available for 3/1/2025, 3/2/2025, 3/8/2025, 3/9/2025, 3/15/2025, 3/16/2025, 3/22/2025, 3/23,2025, 3/29/205, 3/30/2025. Review of the daily posted staffing sheets for April 2025 revealed no information was available for 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/19/2025, 4/20/2025. An interview was conducted with the scheduler on 4/24/2025 at 10:56 am revealed the scheduler started in the position in January of 2025. The scheduler stated she had been trained by the previous scheduler and received help from the Director of Nursing and Assistant Director of Nursing. The scheduler was not aware daily posted staffing sheets had to be completed on the weekends and verified no posted daily staffing sheet had been completed on the weekends since she had worked as the scheduler. The scheduler was not aware daily posted staffing sheets had to be kept for 18 months. The scheduler thought there had been daily posted staffing sheets for September through December 2024 but they were not able to be located. During an interview with the Director of Nursing (DON) on 4/24/2024 at 1:10 pm the DON stated the scheduler was responsible to complete and maintain the daily posted staffing sheets. The DON stated there was not a designated staff member to complete daily posted staffing sheets on the weekends. The DON stated the former scheduler and Assistant Director of Nursing had helped to train the new scheduler. The DON was aware the daily posted staffing sheets needed to be completed every day and maintained for 18 months. During an interview on 4/24/2025 at 2:18pm the Administrator stated the scheduler was responsible for the daily posted staffing sheets. The Administrator expected the daily posted staffing sheets to be completed daily and maintained for 18 months.

Based on observations, record review, and Nurse Practitioner (NP) and staff interviews, the facility failed to prevent an accident when staff was assisting a resident with advanced Parkinson's disease (disorder of the central nervous system that affects movement) to the dining room in her wheelchair without the use of foot pedals. The resident was unable to keep her feet up while in her wheelchair without the assistance of her foot pedals which allowed her foot to drop, causing her shoe to fall off and her shoe to become stuck underneath the wheel of the wheelchair. This caused the wheelchair to stop abruptly and the resident to fall forward out of the wheelchair and hit her head on the floor. The resident sustained a large gash above her left eye and was transferred to the hospital for treatment. She received 11 stitches, and a hospital CT (computed tomography) scan revealed the resident had also suffered a small subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it) due to the fall. The resident was admitted to the hospital for further evaluation and treatment and was discharged back to the facility on [DATE] once the hematoma had resolved. This was for 1 of 3 residents reviewed for the prevention of accidents (Resident #1). Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, muscle weakness, and history of falling. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and had been assessed as being dependent on staff for all activities of daily living, was a two-person assist for transfers, and required a wheelchair for mobility. Review of nursing progress note dated 7/21/24 read in part: Resident #1 was sent to the emergency department (ED) by emergency medical services (EMS) via stretcher. Nursing assistant (NA) #1 on hall was pushing resident in wheelchair down the hall towards the dining room for dinner. Nurse #1 was sitting at nurse's station charting when the incident occurred. NA #1 stated Resident #1 shoe came off and she did not see it and went over the shoe with the wheelchair and the resident fell face forward on the floor. Laceration above left eye observed. Compression dressing to area, EMS called, and vital signs (VS) taken. Staff remained with Resident #1 while awaiting EMS. Resident #1's daughter was notified of the incident and stated, she was going to meet her mother at the hospital. The NP was notified of the incident as well as the unit manager (UM) and Director of Nursing (DON). A telephone interview was conducted with Nursing Assistant (NA) #1 on 8/14/24 at 2:47 PM revealed she was familiar with Resident #1. She stated she had been working on the evening of 7/21/24 and was assigned to Resident #1. She revealed prior to her transporting Resident #1 to the dining room, she and another staff person had assisted Resident #1 from her bed to her wheelchair and did not apply her foot pedals. NA #1 stated when she returned to transport Resident #1 to the dining room, she had forgotten about the foot pedals and as they were moving, she realized she did not have her foot pedals on and asked Resident #1 to hold her feet up. She revealed while transporting Resident #1 down the hall towards the dining room, her foot dropped, and her shoe fell off and became stuck underneath the wheel. She stated she was not aware Resident #1's foot had dropped or her shoe had fallen off and was stuck under the wheel until her wheelchair stopped abruptly, and Resident #1 fell forward from the wheelchair onto the floor. NA #1 revealed she stayed with Resident #1 and hollered for help from Nurse #1 who had been sitting at the nurse desk. She stated Nurse #1 assessed Resident #1, called 911, and applied a compress to a laceration above her left eye until the EMS came and then they took over treatment and transferred Resident #1 to the hospital. She revealed while Resident #1 was at the hospital she received stitches for the laceration above her left eye and a CT scan showed she had suffered a hematoma from the fall, so she was admitted for further treatment. NA #1 stated the Administrator and DON came to the facility that evening and she informed them of what happened, and they educated her on wheelchair and fall safety to include the use of foot pedals and the following day she reenacted for the DON how the fall occurred and continued to receive education and was also observed transferring residents, transporting residents, and making sure all residents had their correct adaptive equipment in place. She also stated that nursing staff had a list of all residents who require any type of adaptive equipment to include foot pedals and when they should be applied. She revealed she had seen Resident #1 being transported without her foot pedals before and was able to hold her feet up and she just didn't think about applying her foot pedals prior to transporting her. An interview was conducted with Nurse #1 on 8/14/24 at 2:07 PM revealed she was familiar with Resident #1. She stated she had been working on the evening of Resident #1's fall and was sitting at the nurse desk charting when she heard NA #1 down the hall asking for help. She stated when she started down the hall towards the dining room, she observed NA #1 with Resident #1 who was lying in the floor in front of her wheelchair, her shoe was off, and she was bleeding from a laceration over her left eye. She revealed she assessed Resident #1 who was alert and conscious with no complaints of pain and visible signs of injury other than the laceration above the left eye. Nurse #1 stated 911 was called and she applied a compress to Resident #1's laceration above her eye and then once EMS arrived, they took over care and transported Resident #1 to the hospital where she was admitted for treatment of the eye laceration and a hematoma. She revealed she spoke with NA #1 about what happened, NA #1 had stated she was transporting Resident #1 in her wheelchair to the dining room when she dropped her foot, and her shoe fell off. She stated when Resident #1's shoe fell off it became stuck underneath the wheel causing the wheelchair to stop abruptly and Resident #1 to fall forward out of the wheelchair and into the floor. Nurse #1 revealed when NA #1 was asked about Resident #1's foot pedals not being applied to her wheelchair, NA #1 stated she had seen Resident #1 being transported without her foot pedals before and she would hold her feet up, so it just slipped her mind, and she didn't think about applying them prior to transporting her. She stated immediately following Resident #1's fall, she notified the Administrator and DON who came to the facility that evening and began investigating the incident and all nursing staff were educated on wheelchair and fall safety, all resident adaptive equipment and they received an updated list of all residents with required adaptive equipment which included foot pedals, and this list would be updated anytime there was a change with the equipment, new order was added, or a new admission. Review of hospital discharge summary dated 7/26/24 read in part: admitted on [DATE], resident of local skilled nursing facility for the last 5 years, non-ambulatory, was being taken to the dining room via wheelchair and apparently fell from the wheelchair when her shoe came off. She sustained a significant left supraorbital ridge facial laceration (deep cut above left eye socket), contusion to her face and brought to the ED where she was found to have a small left frontal subarachnoid hemorrhage. Neurosurgery was consulted by telemedicine and recommend a follow-up CT scan in 6 hours which was stable. Resident #1 was admitted to the hospital. Resident #1 had advanced Parkinsonism with dysphagia. Resident #1 was discharged back to the skilled nursing facility in stable and improved condition. She is high risk for readmission given disease process. Resident #1 is an extremely high fall risk given her disease process and would always recommend one-to-one supervision with transfers and toileting. Sutures were placed 7/21/24 for left laceration, will need removal in 7-10 days from placement. Review of nursing progress noted dated 7/26/24 read in part: Resident #1 returned to facility via EMS via stretcher after being sent to ED on 7/21/24 for fall resulting in head injury. Resident #1 had laceration with sutures intact to left eyebrow and a scab to the left knee that was also intact. Small bruises in various stages to her upper extremities were healing. The principal problem and reason for admission to the hospital on 7/21/24 was a subarachnoid hemorrhage following injury which after monitoring at hospital and multiple CT scans had resolved. Resident #1 does have history of advanced Parkinson's disease and upon returning to the facility was at baseline for orientation. Resident #1 will continue to be monitored and antibiotic ointment to be applied to residents sutured laceration above left eyebrow, sutures to be removed in about 3-7 days (sutures placed on 7/21/24). Resident #1 was resting in bed with no complaint of pain or discomfort at this time. Observation on 8/14/24 at 12:15 PM revealed Resident #1 inside of her room, sitting in her wheelchair waiting to be assisted to the dining room for her lunch meal. Resident #1 was also observed with her foot pedals and kickboard in place. Observations also revealed no issues with Resident #1 being transported to the dining room and assisted with her lunch meal by the Assistant Director of Nursing (ADON). An interview was conducted with the ADON on 8/14/24 at 1:02 PM revealed she was familiar with Resident #1. She stated she was not working on the evening Resident #1 fell from her wheelchair but was notified of the fall the following morning by the DON. She revealed she was informed Resident #1 was being transported in her wheelchair to the dining room for supper and did not have her foot pedals on her wheelchair which caused her foot to drop, her shoe to come off becoming stuck under the wheel, and the wheelchair stopped abruptly causing Resident #1 to fall into the floor. The ADON stated she was informed that Resident #1 did sustain a laceration above her left eye and was sent out immediately to the hospital for treatment and hospital CT scan showed she had suffered a hematoma which cleared prior to her return. She revealed part of her responsibilities as the ADON was to provide training on resident safety while providing care to all nursing staff and newly hired staff, but that specific wheelchair safety and training was provided by therapy. She stated therapy would also be responsible for making sure an order was in place for residents with required equipment including foot pedals. The ADON revealed since Resident #1's fall, all staff had been educated on the importance of wheelchair and fall safety, also resident checklists for all adaptive equipment including foot pedals were updated to include how and when those should be applied. These checklists were provided to all staff and placed at the nurse station and the list would be updated with any changes, new orders, new admissions, and staff would be notified of the changes. An interview was conducted with the Director of Therapy on 8/14/24 at 3:08 PM revealed she was familiar with Resident #1 and had previously provided her with therapy services. She stated prior to Resident #1 fall she had not been required, ordered, or care planned to have her foot pedals always applied to her wheelchair. She revealed due to Resident #1 advanced Parkinson's disease she would have good days and bad days and depending on the day would determine her capability of being able to hold her feet up while being transported for short period of time. The Director of Therapy stated the following day after the fall, therapy assessed all wheelchair residents for foot pedal use, updated the resident adaptive equipment list to include application of foot pedals, provided copies of list to all nursing staff, and assisted with educating staff on wheelchair and fall safety and foot pedal applications. She revealed she also assisted the MDS nurses with updating each wheelchair resident's care plans to address how and when foot pedals should be applied. An interview was conducted with the Administrator and Director of Nursing on 8/14/24 at 3:31 PM revealed they were familiar with Resident #1. The Administrator stated on the evening of 7/21/24, she and the DON were notified by Nurse #1 about Resident #1's fall, the laceration to her left eye, and being sent out to the hospital for treatment. She revealed she and the DON went to the facility and began their investigation of the incident. The Administrator stated she and the DON received statements from Nurse #1 and NA #1 about the fall and were informed NA #1 was transporting Resident #1 in her wheelchair to the dining room when her foot dropped, her shoe fell off becoming stuck under the wheel, and the wheelchair stopped abruptly causing Resident #1 to fall into the floor. She revealed they were also informed NA #1 had not applied Resident #1's foot pedals to her wheelchair which allowed her foot to drop causing her to fall. The DON stated she began education on wheelchair, fall, and transfer safety with NA #1 that evening and the following day completed a reenactment of the incident and continued education with all staff. She revealed all wheelchair residents were assessed for foot pedals and the resident master adaptive equipment list was updated to include foot pedals and copies of list were made available to all staff and at each nursing station. The DON stated the resident list would be updated by therapy with any changes in equipment, new orders received, or with new admissions and MDS nurses would update resident care plans to reflect these changes. She revealed the facility began audits of wheelchair residents requiring foot pedals being applied to wheelchair 3x's week A telephone interview was conducted with the Nurse Practitioner (NP) on 8/14/24 at 4:29 PM revealed she was familiar with Resident #1. She stated she was notified of Resident #1's fall and continued her treatment for the laceration above her left eye upon her return to the facility. She revealed prior to Resident #1 fall she had never written an order and was not aware of an order from therapy of Resident #1 being required to have her foot pedals applied while being transported in her wheelchair and on occasion had seen Resident #1 able to hold her feet up while being transported in the facility. She stated Resident #1 does suffer from advanced Parkinson's disease and it appeared the disease was progressing, and she would not be able to continue to follow commands as well or hold her feet up for a long period of time. The NP stated after Resident #1 fall, all staff, herself included, had been educated on wheelchair and fall safety, applications of foot pedals and adaptive equipment for residents and when and how those should be applied, and an updated list of all residents and their required adaptive equipment to include foot pedals was provided and a copy was placed at each nurse station. She revealed if a resident has a change with their equipment, new order, or a new admission then she or therapy would let the DON and the MDS nurses know so they could update the list and the resident care plan. The facility provided the following Corrective Action Plan with a compliance date of 7/24/24: The facility identified concern with providing supervision to prevent accidents for residents. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices. On 7/21/2024 Resident #1 was assessed by Nurse #1 and made comfortable on the floor because moving her could have caused more damage until her neck and spine were stabilized. On 7/21/2024 first aid was provided for the laceration to her forehead and pressure was held to stop the bleeding by the Nurse #1. On 7/21/2024 new orders were received to be sent to the Emergency Department for evaluation and treatment. On 7/21/2024 Emergency Medical Services were called by nurses. On 7/21/2024 Responsible Party was made aware of the fall and resident being transported to the Emergency Department. On 7/21/2024, the Director of Nursing provided 1:1 education to the Certified Nursing Assistant #1 who was transporting the resident in wheelchair regarding the need for foot pedals during transport for any resident who is unable to hold their feet up when in w/c and that feet should be placed on pedals during transport. On 7/22/2024 the Director of Nursing provided the Certified Nursing Assistant #1 who was transporting Resident #1 in the wheelchair without foot pedals, training on resident handling and proper body mechanics as well as the lift program skills check off. On 7/22/2024 Certified Nursing Assistant #1 who was transporting Resident #1 in the wheelchair without foot pedals, demonstrated how the incident occurred with the Director of Nursing and Unit Manager. Address how the facility will identify other residents having the potential to be affected by the same deficient practice The Director of Nursing and Director of Rehabilitation audited all residents and identified those residents that were unable to propel self or hold their feet up during transport in wheelchairs and if they did not have pedals, they were provided for safety. This audit was completed on 7/22/2024. On 7/22/2024 the Director of Nursing placed a list of residents who required foot pedals for transport in a wheelchair at each nurse's station. On 7/22/2024 the Director of Nursing or Designee updated the Master Device list for each resident who required foot pedals for transport in wheelchair. The master device list is a running list with each resident name and room number and their required adaptive equipment. On 7/22/2024 the Director of Nursing or Designee updated the care plans and resident profile for each resident identified to be at risk to include requiring foot pedals for transport in wheelchair. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur On 7/22/2024 the Director of Nursing or Designee educated all staff on when residents are unable to hold their feet up during transport in w/c and required foot pedals prior to transporting in wheelchair and a list of residents requiring foot pedals for transport in wheelchair is provided at each nurse's station. The care plan and resident profile were updated for those residents who require foot pedals for transport in wheelchair. This education was completed on 7/22/2024. Those staff who were not working were educated via phone, during this education staff were asked questions and feedback to obtain understanding of education and were included during observation audits at the facility. This education will be provided to new employees during orientation. The Director of Nursing or Designee had all Licensed Nurses and Certified Nursing Assistant complete a safety and accident prevention quiz. These quizzes were completed by 7/23/204. The Director of Nursing or Director of Rehabilitation will evaluate newly admitted residents, provide foot pedals if indicated, and notify MDS nurse who will update residents care plans, profile and the master device list and the nursing station list to reflect need of foot pedals during transport in wheelchair. The MDS nurse will also inform management of any updates to resident care plans regarding adaptive equipment and provide them and therapy with an updated master device list. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained The Administrator and DON discussed on 7/21/24 and determined to have ADHOC QAPI on 7/22/24. ADHOC QAPI was held on 7/22/2024 with the Interdisciplinary team to discuss the incident with Resident #1 and educate the team on the interventions that were put into place to prevent further incidents. The Interdisciplinary Team discussed the incident and will monitor weekly for 8 weeks and take it to QAPI for the next 3 months for review and recommendations. The Director of Nursing or Designee will complete an observation audit 3 times per week for 8 weeks then monthly x 1 to ensure that residents that unable to hold their feet up during transport in wheelchair have foot pedals on while being transported in a wheelchair. Date of Compliance: July 24, 2024 On 8/14/24, the facility's corrective action plan effective 7/24/24 was validated by the following: Observations of residents in wheelchairs with foot pedals applied being transported in the facility with no issues or concerns noted. Nursing staff interviews revealed they had received education on fall safety, wheelchair safety when transporting resident, foot pedals and all adaptive equipment requirements and how and when to use them, accident prevention, notifying therapy or administration if foot pedals are needed, and reviewing the master resident adaptive equipment list to see what equipment each resident should have and how and when it should be applied. The updated master resident adaptive equipment list to include foot pedals was placed at each nurse station as a reminder. Therapy staff interviews revealed they would continue to assess residents for any wheelchair needs to include foot pedals and assist MDS nurses with updating the master resident adaptive equipment list and notifying nursing staff of the changes. MDS nurses received education on updating wheelchair resident care plans to include foot pedals, updating master resident adaptive equipment list anytime there was a change, new order, or new admission, and notifying therapy and administration of the change. Administrative staff interviews revealed they provided staff education and were completing weekly audits of wheelchair residents to assure foot pedals have been applied while being transported in their wheelchairs and also reviewing the master resident adaptive equipment list to assure it was reflecting the status of each resident and being updated when any changes, new orders, or new admission had occurred. Auditing tools were reviewed. Documents were reviewed from the facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. Review of Resident #1's revised care plan dated 7/22/24 revealed her risk for falls characterized by multiple risk factors related to her history of falls and Parkinson's disease. She had a goal to minimize risks for falls and injuries related to falls through the next review. Interventions for Resident #1 included staff education related to wheelchair pedals and transporting residents, 20 inch reclining high back wheelchair with 2-inch pressure relieving cushion, bilateral standard footrests, kick plate and rear anti-tippers, evaluate needs for adaptive equipment, educate/direct the use of assistive devices, and transfers with 2-person assist. The facility's compliance date of 7/24/24 was validated.

Based on resident interviews and staff interviews the facility failed to have systems in place for providing evening snacks to residents for 5 of 5 halls. The deficient practice had the potential to affect all residents requesting an evening snack. The findings included: An interview conducted on 02/13/24 at 6:30 AM with Nurse Aide (NA) #2 revealed she worked second shift and residents during second shift (3:00 PM to 11:00 PM) had not received a bedtime snack on multiple days because staff were unable to get into the nourishment room on either floor. NA #2 further revealed the nourishment rooms had a code that was not provided to them, and the kitchen was locked. The NA indicated she had reported this to a Nurse on duty over the past few months but could not recall which Nurse. An interview conducted with Nurse #1 on 02/13/24 at 7:20 AM revealed nursing staff were often unable to access the kitchen and nourishment rooms at night to retrieve snacks because the doors had a code that had not been provided to her. The Nurse further revealed she had reported these concerns and was told the code would be written at the nurses ' desk but had not occurred. An interview conducted during a Resident Council Meeting on 02/13/24 at 1:50 PM revealed residents had not received or been offered snacks in the evenings by nursing staff. The Resident Council President (Resident #58) and Resident #1 both stated nursing staff did not offer evening snacks frequently and when residents asked nursing staff for snacks, they were told nursing staff were unable to get in the nourishment room or there were no snacks available. An interview conducted with the Dietary Manager (DM) on 02/13/24 at 9:50 AM revealed four weeks ago she was made aware by residents that there were several nights residents had not received a bedtime snack. The DM further revealed dietary staff checked and stocked the nourishment rooms daily and felt that nursing were not offering bedtime snacks as needed for the residents. The DM indicated she had tried to educate staff on providing bedtime snacks to all residents. The DM indicated she was not sure how staff were educated on the codes for the doors on the nourishment rooms. An interview conducted with the Administrator on 02/14/24 at 2:40 PM revealed she expected there to always be snacks available for residents. The Administrator further revealed nursing staff should know the codes for the nourishment rooms and dietary should be stocking enough for residents as well. The Administrator indicated nursing staff could have asked the Director of Nursing or Unit Managers for the codes to the nourishment rooms.

Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and failed to remove expired food items in 1of 1 walk-in cooler and 1 of 2 nourishment rooms (First Floor). These practices had the potential to affect food served to residents. Findings included: a. An observation and interview were conducted on [DATE] at 9:15 AM with Dietary Cook #1 in the walk-in cooler revealed eleven sandwiches, six grilled cheese sandwiches, tomato soup in a container with saran wrap on top, and four cups of lima beans which were unlabeled and not dated. The Dietary Cook believed the sandwiches and grilled cheese sandwiches were made the day prior but was unsure when they had been prepared and needed to be discarded. The Dietary Cook was unable to determine when the other items had been prepared. Observations further revealed leftover roasted potatoes with the expiration/discard date of [DATE]. Dietary Cook #1 stated the dietary staff member that puts the food item in the walk in the cooler was responsible for labeling and dating the container and the roasted potatoes should have been discarded. b. An observation and interview with Nurse Aide (NA) #1 were conducted on the first floor in the nourishment room on [DATE] at 10:00 AM revealed a carton with 18 eggs with no resident ' s name or date, two opened 8-ounce cartons of milk with no resident ' s name or dated opened, an opened 8 ounce bottle of nutritional drink which was not labeled with a resident ' s name or dated, and two wrapped sandwiches that were not labeled or dated. Nurse Aide #1 stated dietary staff checked nourishment rooms daily, but nursing staff had been educated to label items in the refrigerator with resident names and dates. NA #1 indicated these food items should not be in the refrigerator and she discarded them. An interview conducted with Dietary Aide #2 on [DATE] at 9:45 AM revealed Dietary Cooks were responsible for checking items in the kitchen and Dietary Aides were responsible to check nourishment rooms daily. Dietary Aide #2 further revealed she did not know why items in the nourishment room were not labeled. The interview further revealed dietary staff checked the nourishment rooms twice a day and discarded expired and unlabeled items but had not checked the nourishments rooms that morning. An interview conducted with Dietary Manager (DM) on [DATE] at 9:50 AM revealed dietary staff checked the nourishment rooms twice a day and were educated to discard any food items that were not labeled or dated. The DM indicated all food items in the walk-in cooler should have been labeled and discarded appropriately. An interview conducted with the Administrator on [DATE] at 2:40 PM revealed she expected dietary staff to label all dietary items and discard any expired food items as well.

Based on observations, record review, staff, and Hospice Nurse Aide interviews, the facility failed to provide incontinence care to prevent a resident (Resident #45) from having urinary incontinence through her brief, pants, lift pad and onto her wheelchair pad for 1 of 3 residents reviewed for activities of daily living for dependent residents. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included hemiplegia following a stroke, dysphagia, muscle weakness and dementia. Review of Resident #45's care plan dated 12/07/23 revealed a focus area for the resident having an activities of daily living (ADL) self-care deficit due to stroke with left hemiparesis and resident required extensive to total assistance with ADL. Resident #45 was also at risk for further unavoidable declines related to diagnosis of dementia. The interventions included assist with activities of daily living (ADL), dressing, grooming, toileting, promote independence and dignity, and provide positive reinforcement for all activities, transfers with assist of mechanical lift, and refer to therapy as needed. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and dependent on 1-2 staff members for all activities of daily living except eating. The assessment also revealed Resident #45 had less than 6 months life expectancy and was followed by hospice. An observation on 02/13/24 at 10:17 AM of Resident #45 receiving incontinence care from the Hospice NA revealed when Resident #45 was lifted via mechanical lift from her wheelchair to her bed the wheelchair cushion had a spot that was wet and the Hospice NA wiped it with a paper towel and it was wet with yellow colored liquid. The Hospice NA wiped the liquid from the cushion and cleaned the cushion. As the resident was being lifted from the chair to the bed by the Hospice Nurse Aide (NA) and NA #4, her lift pad was noted to be wet in the area she was sitting on it and her pants were wet in the crotch area from front to back. When the Hospice NA removed Resident #45's brief, it was observed to be saturated from front to back with urine and the brief filling had started to bunch up in areas. The Hospice NA proceeded to clean the resident and applied a clean brief. Interview on 02/13/24 at 10:47 AM with the Hospice NA revealed she came to see Resident #45 on Monday, Tuesday, and Friday and on Monday provided Resident #45 with a shower and on Tuesday and Friday provided her with a bed bath. The Hospice NA stated she used to come around 1:00 PM and Resident #45 would have been up since early morning and would be wet. She further stated she had found the resident wet before through her clothing but couldn't recall when the last time she found the resident that way. Interview on 02/13/24 at 1:58 PM with NA #4 and NA #5 who were assigned to the 500 hall residents on 1st shift on 02/13/24 revealed they had changed Resident #45 and gotten her dressed around 7:30 AM before they had gotten her up in the wheelchair. NA #5 stated they had put her back to bed around 9:30 and changed her again but later in the conversation realized it was not Resident #45 they had changed at 9:30 AM but was another resident. NA #4 and NA #5 could not remember getting her back to bed or changing her after 7:30 AM and before she had been changed at 10:17 AM. NA #4 and NA #5 stated they usually did rounds at 7:00 AM, 9:00 AM, 11:30 AM and 1:30 PM for their shift. NA #4 and NA #5 stated she usually drank a lot of fluids during her meals but could not recall having found her wet through her clothing before today. NA #4 stated she heard the Hospice NA say the resident was wet through her clothing but said she didn't see the wetness because she was operating the lift to get the resident back to bed. Interview on 02/14/24 with Nurse #3 revealed she had been assigned to care for Resident #45 on 02/13/24 and 02/14/24. She stated the staff usually got Resident #45 up around 7:30 so she was up for breakfast and said sometimes 3rd shift got her up if she wanted to get up after they got her dressed. Nurse #3 further stated she was not aware Resident #45 had wet through her clothing on 02/13/24 and said she typically did not find her that way. Nurse #3 stated maintenance and housekeeping had washed the wheelchairs the night before but said she didn't think the NAs would have put her in a wet wheelchair. Nurse #3 said she was not sure why Resident #45 had wet through her clothing because she was not on a diuretic and wasn't sure what or how many fluids, she had to drink at breakfast that morning. Interview on 02/14/24 at 12:38 PM with the Director of Nursing (DON) revealed she would not expect a resident to go without incontinence care until they were wet through their clothing and was not sure if that had happened with Resident #45 before or not.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident with mental health diagnoses upon admission for 1 of 3 residents reviewed for PASRR (Resident #47). The findings include: Review of Resident #47's medical record revealed a PASRR level I screening had been completed on 08/08/2018. No further PASRR documentation was discovered in Resident #47's medical record. Resident #47 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and dementia with mood disorder. During an interview on 02/14/24 at 1:20 PM with the Social Worker (SW), she revealed she had been employed as the facility SW for the past [AGE] years and was responsible for completing PASRR referrals upon resident admission. She revealed she would review a resident's diagnoses once they were admitted to see if they would require a level II PASRR referral to be completed. The SW stated Resident #47 had been admitted from the hospital and she believed she had simply overlooked the date of the previous PASRR determination and the admission diagnoses. She explained that based on Resident #47's admission diagnoses of bipolar disorder and dementia with mood disorder, and the date of the preadmission PASRR level I, she should have completed the paperwork for a PASRR level II referral. During an interview on 02/14/24 at 2:38 PM with the Administrator she revealed a PASRR level II referral should be completed in a timely manner upon admission for a resident with a mental health diagnosis. She stated based on Resident #47's admission diagnoses of bipolar disorder and dementia with mood disorder, a PASRR level II referral should have been completed.

Based on record review, observations, and interviews with residents, staff and the Nurse Practitioner, the facility failed to assess the ability of a resident to self-administer for 1 of 4 residents observed (Resident#88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses of allergies. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was cognitively intact and needed supervision with most activities of daily living. A review of Resident #88's medical record indicated no documentation that Resident #88 was assessed for self-administration of medications. Resident #88 did not have a physician's order for self-administration of medications. A review of Resident #88's order summary for February 2024 indicated an active physician's order for Fluticasone Propionate Nasal Suspension 50 micrograms - two sprays both nostrils in morning for allergies and instructions to shake well. During an initial observation of a medication pass for Resident #88 on 02/13/24 at 08:00 AM with Medication Aid (MA) #3 for administration of nasal spray to the resident. The MA #3 sat the nasal spray in front of the resident without shaking the vial. The resident administered the nasal spray of two sprays in each nostril independently without shaking the bottle. An interview with Resident #88 on 02/13/24 at 08:00 AM revealed that he had some confusion about the nasal spray and how many sprays he should use per nostril. Resident #88 stated he was not aware that the nasal spray needed to be shaken before use. An interview with MA #3 on 02/13/24 at 8:45 AM revealed she always allowed resident #88 to administer his own nasal spray. MA #3 stated she was aware that residents needed to have a physician order and a self-administration assessment before they could be allowed to administer their medications. MA #3 stated she was not aware that Resident #88 did not have a evaluation for self-medication of the medication, and stated she should have checked before the resident was allowed to self- administer any medication. An interview with the Director of Nursing (DON) on 02/14/24 at 12:35 PM revealed she was not aware that Resident #88 had been self-administrating his nasal spray. The DON stated that before self-administration could occur residents had to be assessed for safety reasons and the doctor had to give a order for self-administration. Her expectation was that staff be aware if a resident could self-administer before they allowed the resident to do so.

Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities resulting in a medication error rate of 6.25% for 2 of 4 residents (Resident #26 and Resident #76) observed during medication administration observation. The findings included: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN). A Physician order dated 05/13/12 revealed Resident #26 was to receive Metoprolol Tartrate 25 mg (milligrams) one tablet by mouth twice a day for hypertension. Instructions on the physician orders read to hold medication for systolic pressure less than 100 or a heart rate less than 60. During medication pass observation 02/14/24 at 8:15 AM Nurse #2 prepared medications for Resident #26. Nurse #2 was observed taking a Metoprolol Tartrate 25mg tablet out of a blister package and placing it in a medicine cup. The label on the blister package included instructions to hold medication for systolic pressure less than 100 or a heart rate less than 60. Nurse #2 was asked if she had a current set of vitals on the resident and she stated no she did not. Nurse #2 proceeded to Resident #26 room at 8:35 AM and administered the Metoprolol Tartrate 25mg tablet to the resident. An interview with Nurse #2 on 02/14/24 at 10:12 AM revealed Resident #26 was no longer on daily vitals, so they no longer checked Resident #26 vitals before giving the metoprolol. Nurse #2 revealed she did not notice the instructions on top of the blister package or on the medication administration record. 2. Resident #76 was admitted to the facility on [DATE] with a diagnosis that includes coronary artery disease, and heart failure. A Physician order dated 12/08/23 revealed Resident #76 was to receive Aspirin (ASA) 81 mg (milligrams) one tablet by mouth once a day for coronary artery disease. During medication pass observation 02/13/24 at 8:35 AM Medication Aid (MA) # 3 prepared medications for Resident #76. MA #3 was observed taking an ASA 325mg tablet out of an opened stock medication bottle and placing it in a medicine cup. MA #3 proceeded to Resident #76's room at 8:45 AM and administered the ASA 325 mg tablet to the resident. On 02/13/24 at 9:30 AM an interview and observation were conducted with Medication Aid (MA) #3. MA #3 returned the medication cart and reviewed Resident #76's ASA order and she confirmed the resident had a physician order for ASA 81 mg. She stated that the two bottles of ASA were next to each other in the medication cart, and she just grabbed the wrong bottle. MA # 3 explained she had separated the two bottles of ASA so that this mistake did not happen again. On 02/14/24 at 12:35 PM an interview was conducted with the Director of Nursing (DON). During the interview, DON was notified of the medication error rate of 6.25%. The DON stated she expected nurses and med aids to check the five rights before medications were given and to check vital signs as ordered when administering medications.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 07/07/22 and follow-up and complaint investigation survey that occurred on 09/21/22. This was for one deficiency cited in July 2022 in the area of infection control and one deficiency cited in September 2022 in the area of maintain a medication error rate of 5% or less and both were subsequently cited on the current recertification and complaint investigation survey of 02/14/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F880: Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure and did not doff her gloves, sanitize her hands, and don clean gloves after cleansing the hip wound and before applying the treatment to the wound for a resident (Resident #55). During the recertification and complaint investigation survey conducted on 07/07/22, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy during wound care treatment for 1 of 3 sampled residents reviewed. F 759: Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities resulting in a medication error rate of 6.25% for 2 of 4 residents (Resident #26 and Resident #76) observed during medication administration observation. During the follow-up and complaint investigation survey conducted on 09/21/22, the facility failed to administer the correct dosage for 3 medications and omission of 2 medications. These errors constituted 5 out of 28 opportunities, resulting in a medication error rate of 17.86% for 2 of 5 residents observed during medication administration. During an interview on 02/14/24 at 2:38 PM with the Administrator, she reported her quality assurance team met monthly and included the Medical Director, pharmacist, registered dietician, and all the department heads who attend monthly. She reported they currently had Process Improvement Plans (PIPs) addressing abuse and said they would be adding PIPs for infection control and medication compliance. The Administrator stated she felt like repeat tags were due to oversight and human error.

Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure and did not doff her gloves, sanitize her hands, and don clean gloves after cleansing the hip wound and before applying the treatment to the wound for a resident (Resident #55). The Treatment Nurse only doffed her right glove, sanitized her right hand, and donned a clean glove on her right hand after removing the soiled dressing from the resident's hip wound, did not doff her gloves after cleansing the wound, did not sanitize her hands, and did not don clean gloves before proceeding to apply the treatment to the hip wound and covering the wound with a clean border gauze dressing. This occurred for 1 of 3 residents reviewed for wound care. The findings included: The facility's policy entitled Hand Hygiene/Handwashing Policy which is part of their Infection Control Policies and Procedures last revised on 05/03/23 under Procedure read in part: 3. Perform hand hygiene: a. Before and after having direct contact with residents. b. After removing gloves. d. After contact with body fluids or excretions, mucous membranes, non-intact skin and/or wound dressings. 5. Hand Rub Method: a. Apply a palm full of the product in a cupped hand, covering all surfaces. b. Rub hands palm to palm. c. Right palm over left dorsum with interlaced fingers and vice versa. d. Palm to palm with fingers interlaced. e. Backs of fingers to opposing palms with fingers interlocked. f. Rotational rubbing of left thumb clasped in right palm and vice versa. g. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. h. Once dry, your hands are clean. A wound observation was made on 02/13/24 at 9:30 AM on Resident #55 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on a clean surface on the overbed table. The Treatment Nurse washed her hands with soap and water and donned a clean pair of gloves and proceeded to remove the resident's wound dressing and treatment with her right hand. She walked over to the sink and doffed her right-hand glove, sanitized her right hand, and placed a clean glove on the right hand, walked back over to the resident and cleansed her wound with wound cleanser-soaked gauze. The Treatment Nurse then without doffing her gloves, sanitizing her hands, or donning clean gloves, proceeded to trim and apply the treatment to the wound bed. After applying the treatment, the Treatment Nurse doffed her gloves, sanitized her hands, donned clean gloves, and applied the border gauze dressing to the left hip wound. An interview on 02/14/24 at 12:21 PM with the Treatment Nurse revealed she did not realize she had not taken her gloves off and sanitized her hands and applied clean gloves after cleansing the wound. She stated she should have doffed her gloves, sanitized her hands, and donned clean gloves prior to applying the treatment to Resident #55's wound. The Treatment Nurse stated she didn't realize it was not appropriate to just cleanse one hand since she had not touched anything dirty with her left hand but said she had touched the resident's skin and should have sanitized both hands. She further stated she was nervous about being watched and just didn't think through the process. An interview on 02/14/24 at 12:36 PM with the Director of Nursing (DON) revealed she expected the Treatment Nurse to follow the policy and procedure of Hand Hygiene/Handwashing at the facility. The DON stated it was best practice to remove both gloves and sanitize both hands and apply clean gloves to both hands and was not sure why she had not followed that procedure during wound care for Resident #55.

Based on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of wrong dosage for 3 medications and omission of 2 medications. These errors constituted 5 out of 28 opportunities, resulting in a medication error rate of 17.86% for 2 of 5 residents (Residents #1 and Resident #2) observed during medication administration. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 9/21/22 at 7:49 AM of Nurse #1 while she administered medications to Resident #1. She pulled a medication card labeled as [MEDICATION(S)] 20 mg (milligram) tablets and popped one tablet into a medication cup. She entered Resident #1's room and proceeded to administer this medication to her. An interview with Nurse #1 on 9/21/22 at 2:58 PM revealed she didn't notice that the card of [MEDICATION(S)] tablets was marked as 20 milligrams and she should have administered two tablets instead of one. Nurse #1 stated it was her first time being assigned to work on the hall in 3 months and was not very familiar with the residents and their medications. An interview with the Director of Nursing (DON) on 9/21/22 at 3:45 PM revealed Nurse #1 should have looked at the card of [MEDICATION(S)] tablets and checked the dosage before administering this medication to Resident #1. The DON stated Nurse #1 should have administered two [MEDICATION(S)] 20 mg tablets instead of one. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. 5/16/22 - Guaifenesin Extended Release (ER) 12-hour 600 mg (milligrams) give 1 tablet by mouth two times a day for congestion. b. 5/16/22 - [MEDICATION(S)] 30 mg - give 1 capsule by mouth in the morning and 2 capsules by mouth at bedtime for depression. c. 5/17/22 - [MEDICATION(S)] 10 mg - give 1 tablet by mouth in the morning for hypertension. d. 6/14/22 - Cranberry tablet 250 mg - give 2 tablets by mouth in the morning for [CONDITION(S)] (urinary tract infection) prevention. On 9/21/22 at 8:05 AM, Nurse #1 was observed as she prepared and administered Resident #2's medications. Nurse #1 searched for Resident #2's [MEDICATION(S)] and [MEDICATION(S)] medication cards in the 200 hall medication cart but could not find them. Nurse #1 re-ordered Resident #2's [MEDICATION(S)] online and called the pharmacy to order a refill of Resident #2's [MEDICATION(S)]. Nurse #1 proceeded to pull the rest of Resident #2's medications which included one capsule of Cranberry 250 mg and one tablet of Guaifenesin 400 mg. An interview with Nurse #1 on 9/21/22 at 2:58 PM revealed she didn't notice that the order for the Cranberry capsules indicated to give 2 capsules and that she had always given the Guaifenesin to Resident #2 because she had never seen a stock bottle of Guaifenesin ER being available at the facility. An observation of the upstairs medication room on 9/21/22 at 3:10 PM with Nurse #1 and the Director of Nursing (DON) revealed an automated dispensing cabinet which contained stock medications. The DON stated that [MEDICATION(S)] was available in the stock cabinet. However, [MEDICATION(S)] was not available. Nurse #1 stated that she didn't know she had access to the stock cabinet but that she had been trained on how to get medications out of it. The DON showed Nurse #1 a list of access codes posted on the side of the cabinet, and it included Nurse #1's username that she could have used to access the cabinet and retrieve medications that were not available in her medication cart. An interview with the Director of Nursing (DON) on 9/21/22 at 3:45 PM revealed Nurse #1 should have pulled the [MEDICATION(S)] off the stock cabinet and since [MEDICATION(S)] was not available, she should have called the pharmacy and requested to have it sent to the facility as soon as possible. The DON stated that Nurse #1 should have looked at the order for Cranberry capsules and she should have given Resident #2 two capsules instead of one capsule as indicated in the order. The DON also stated that Resident #2's family used to supply her Guaifenesin ER, but they wanted them to obtain it from the pharmacy once their supply was depleted. The DON confirmed that they didn't have Guaifenesin ER available on stock and only had the regular Guaifenesin which came in a lower dosage. Nurse #1 should have called the pharmacy or the Nurse Practitioner to clarify the order about the Guaifenesin ER. Further interview with the DON revealed the nurses were supposed to verify the right resident and they should be checking the medication cards to see if they were the same as the order indicated in the computer before giving medications to the residents.

Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to provide effective leadership and implement effective systems to manage pressure ulcers, laboratory tests and physician notification. This failure affected 2 of 3 residents reviewed for administration (Resident #36 and Resident #11). Immediate Jeopardy began on 3/3/22 when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition that involved Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: This tag is cross-referred to: F-580: Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral [CONDITION(S)]. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36). F-686: Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from 3/3/22 to 3/10/22). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11). An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed one of the factors that contributed to the facility's not having effective leadership was due to the facility's lack of Administrative nurses to help the Director of Nursing. The RDCS stated the facility had experienced a quick turnover of Administrative nurses including an Assistant Director of Nursing who was supposed to oversee the unit managers on the floor. They had recently hired 2 unit managers, but they sometimes got pulled to work on the hall and away from their Administrative duties. The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of 7/3/22. I. Facility failed to provide effective leadership and implement systems to manage pressure ulcers, laboratory tests and physician notification. II. Regional team to include the Regional Vice President of Operations and the Regional Director of Clinical Services identified there were breakdown in the execution of critical clinical services. a. Regional team immediately provided oversight and education to the leadership staff. b. Policies related to pressure ulcers and notification for change in condition were reviewed to assure they would be appropriate for the center, and they were deemed to be appropriate. Issues related to pressure ulcers and notifications were not policy driven but issues were identified with implementation of the policy, so education occurred. The center's process for handling labs. and laboratory supplies was reviewed and found to be inadequate, so process was updated and put into place effective 7/2/22. c. Education to the Administrator and DON was provided by the Regional Vice President of Operations and the Regional Director of Clinical Services. d. Education included policies and implementing systems for oversight and execution of critical nursing systems identified in the immediate jeopardy. These were completed on 7/2/22. 1. Education to the pressure ulcer policy was completed and implemented on 7/2/22. 2. Education for updated process for laboratory testing and acquiring laboratory supplies was completed and implemented on 7/2/22. 3. Notification for resident change in condition policy and procedure was educated and implemented on 7/2/22. 4. Leadership education also included the company's QAPI process and morning clinical meeting process. Completed 7/2/22. III. Regional team member will participate in each QAPI meeting with the center for the next 3 months to assure appropriate issues are identified and follow-up is put into place. IV. Regional team member will participate in the center's morning clinical meeting on a weekly basis for the next 30 days to assure meeting is thorough and captures any clinical issues that need to be addressed. V. Regional team member will review all audits and in-services related to this plan for the next three months on a weekly basis and repeat in-servicing as appropriate. VI. The Regional team will randomly audit 3 resident charts per week for the next three months to assure accuracy of pressure ulcer documentation, lab. testing compliance and appropriate physician notification. VII. Regional team has set an expectation that the center will hold QAPI meetings monthly. Clinical morning meetings and daily stand-up meetings will be held daily Monday through Friday according to policy. VIII. Regional team will conduct a weekly leadership meeting that involves the Regional Vice President or designee, Regional Director of Clinical Services or designee, the facility Administrator and facility Director of Nursing for the next 3 months. Other regional or corporate staff will be invited as appropriate. This leadership meeting will review progress to the plan of correction for the current survey, review process or policy changes that have been implemented for effectiveness and discuss any current issues needing addressed on a clinical level. Date of removal for alleged IJ is 7/3/22. The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22. A root cause analysis was completed by the Regional Vice President of Operations which identified the following root causes for the IJ concerns identified at the survey: new leadership, agency staffing and adherence to company systems. The audit tools completed by the facility on skin status and laboratory results were reviewed. The physician/Nurse Practitioner were notified of results from the audits for additional follow-up as needed. On 7/2/22, the Regional Vice President of Operations provided education with the new Administrator and Director of Nursing on identifying issues with immediate jeopardy cited and discussed with them the components of the regulations for F-580, F-686, and F-835. The education also included QA (Quality Assurance) roles and responsibilities, morning stand-up, clinical stand-up, pressure ulcer policy, policy on resident change in condition, laboratory process, correction plans and monitoring processes. Interviews with nurses and nurse aides revealed they received education on identifying any changes in resident condition including skin issues, changes in vital signs and daily habits and reporting these changes to the nurses and the medical providers. An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was conducted on 7/2/22 with the following key personnel in attendance: Administrator, Regional Director of Clinical Services, Regional Vice President for Operations, Nurse Practitioner and Director of Nursing. They discussed conducting weekly risk meetings to put practice back in place to ensure IDT discusses key resident conditions, makes recommendations and changes to care plans as needed.

Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral [CONDITION(S)]. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36). Immediate Jeopardy began on 3/3/22 when the facility failed to notify the physician or Nurse Practitioner and obtain treatment orders for new pressure ulcer identified on Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: Resident #36 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was recently readmitted on [DATE] from the hospital due to acute [CONDITION(S)] and advanced [CONDITION(S)]. An Admission Skin Evaluation completed by Nurse #1 on 3/3/22 indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place. An interview with Nurse #1 on 6/28/22 at 3:10 PM revealed she observed an open area on Resident #36's sacrum on 3/3/22 which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied [MEDICATION(S)] and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she did not obtain an order. Resident #36's Treatment Administration Record for March 2022 indicated no treatment orders for Resident #36's sacral pressure ulcer until 3/10/22 when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days. An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on [DATE] and she was not sure if she had checked her re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #1 stated she didn't get around to assessing Resident #36's sacrum until 3/10/22 when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility. An interview with Nurse #3 on 6/30/22 at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody. A phone interview with Resident #36's family member on 6/27/22 at 4:33 PM revealed she didn't find out about Resident #36's worsened pressure ulcer until 3/14/22 when a nurse aide asked her if she had seen Resident #36's bottom recently. Resident #36's family member stated, it looked terrible, it had an odor and looked deep. She said she informed UM #1 that she wanted the wound clinic to look at Resident #36, but she was told that they were going to get the in-house wound care provider to look at her. A phone interview with the Wound Physician Assistant (PA) on 6/30/22 at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on 3/3/22 nor when they started treatment on Resident #36's sacral pressure ulcer on 3/10/22 when it got worse. On 3/31/22, he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on 4/7/22 that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on 4/14/22, he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on 4/7/22 and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial. An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run it due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs. An interview with the Nurse Practitioner (NP) on 6/29/22 at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on 4/11/22 when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on 4/1/22 and 4/8/22 that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the nurses should have notified her on 3/3/22 when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA. The Report of Consultation from the Wound Center dated 4/13/22 for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress. An Infectious Disease Visit Note dated 4/25/22 in Resident #36's medical record indicated Resident #36 was seen for sacral [CONDITION(S)]. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair. The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of 7/3/22. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36. The nurse who completed the admission assessment on Resident #36 and did not notify the physician or Nurse Practitioner of the pressure ulcer or obtain treatment orders. Resident #36's wound deteriorated over seven days to a stage 4 and there was no notification to the physician or Nurse Practitioner. Facility completed a total body skin assessment and record review on all current residents on 7/1/22 by the unit managers to find no missed notifications or deterioration of residents' wounds, pressure sores or changes in skin integrity. An assessment of Resident #36 revealed on 7/2/22, that there was no further deterioration on the wound, treatment orders in place per physician order, resident being followed by the local wound care clinic. *Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Regional Director of Clinical Services (RDCS) completed education to Director of Nursing (DON) and unit managers (UM) on 7/1/22. The facility process is as follows: a. Licensed nurse completes admission skin assessment, and weekly skin assessment in electronic medical record; b. If any deterioration of skin area or new area observed, the licensed nurse notifies and documents physician or Nurse Practitioner immediately and obtains treatment orders, c. Licensed nurse is to complete notification and documentation of responsible party, d. Notification of DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). All licensed nurses including agency nurses were in-serviced by 7/2/22 from DON or unit manager on completing and documenting admission skin assessments and weekly skin assessments. Licensed nurses are responsible for immediate notification of physician or Nurse Practitioner when they observe any deteriorating wound/pressure ulcer, new wounds/pressure ulcers, or significant change in condition and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed nurses are responsible for notification and documentation of responsible party. Licensed nurses are responsible for notification to DON/UM via call or tiger texting. Nurse aides including agency nurse aides have been in-serviced by 7/2/22 by DON/designee on reporting any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to the licensed nurse immediately. DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by 7/2/22. Nurses and nurse aides will not be allowed to work until they receive education. New nurses and nurse aides hired after 7/2/22 will receive education during orientation. Beginning the week of 7/4/22, the DON or designee will review five random resident's medical record per week for any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to ensure any negative changes have been communicated to the physician/Nurse Practitioner. The alleged date of IJ removal is 7/3/22. The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22. A review of in-service education records from 7/1/22 to 7/2/22 revealed education was provided to nurses and nurse aides on topics that included reporting any changes in the residents' baseline condition such change in vital signs, change in activity, and change in daily habits to the nurse. Any new orders, changes in residents' conditions, reports, skin integrity issues and laboratory results that have not been addressed need to be communicated timely to the physician/Nurse Practitioner, family, and the Director of Nursing. Interviews with the nursing staff revealed they had been educated on when to report a resident's change in condition as well as who to report the change in condition to. They also verbalized the different signs of changes and what observations to look for while working with the residents at the facility. The nurses stated they had been educated on notifying the physician of changes such as a new pressure wound or open area, any signs of wound infection and any wound deterioration. The laboratory book was observed at the nurses' station, and it included an audit tool that included information on the resident's name, laboratory test order date, laboratory test ordered, date the results were obtained, any critical laboratory test results and the date and time the medical provider was notified.

Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from [DATE] to [DATE]). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11). Immediate Jeopardy began on [DATE] when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity level of D. The findings included: 1. Resident #36 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was recently readmitted on [DATE] from the hospital due to acute [CONDITION(S)] and advanced [CONDITION(S)]. An Admission Skin Evaluation completed by Nurse #1 on [DATE] indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place. A Weekly Skin Evaluation completed by Nurse #2 on [DATE] indicated Resident #36 had a wound to sacrum and left lower buttock with treatment in place. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact, had no rejection of care behaviors and required extensive physical assistance with bed mobility, locomotion, and toilet use. Resident #36 had impairment on one side of her upper extremities and used a wheelchair. The MDS further indicated Resident #36 was frequently incontinent of urine, but she was always continent of bowel. Resident #36 was at risk of developing pressure ulcers/injuries, had moisture-associated skin damage but no pressure ulcers. An interview with Resident #36 on [DATE] at 10:04 AM revealed when staff came to change her and got her up out of bed this morning, she was wet and had to be changed. Resident #36 stated staff did check in on her during the night to see if she was wet, but she did not recall the name of the nurse aide or the time they came in. She stated she looked up at the clock on the wall and said she had waited for about 30 minutes this morning for them to come change her. Resident #36 stated she typically went to the bathroom before going to bed in the evening which could be anywhere from 6:30 PM to 9:00 PM depending on how long staff took to help her in bed. She was assisted with incontinence care and to bed around 7:30 PM the night before. Resident #36 further stated staff would get her up in the morning before breakfast, she would stay up through lunch, staff would lie her down after lunch, get her up about 30 minutes before supper, and then put her to bed between 6:30 PM to 9:00 PM. Resident #36 stated she never refused to lie down in bed and stated it felt good to get off her bottom for a while. She also did not refuse assistance with positioning on her side in bed and stated staff did come in and offer to turn her. Resident #36 stated she has had a pressure ulcer to her sacrum for a long time and it hurt. She said it felt like something was sticking her all the time. An interview with Nurse #1 on [DATE] at 3:10 PM revealed she observed an open area on Resident #36's sacrum on [DATE] which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied [MEDICATION(S)] and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she didn't get an order. Nurse #1 also stated she didn't think she had to complete a wound assessment because wound assessments were usually completed by the Unit Managers whenever they rounded with the Wound Physician Assistant. Nurse #1 further stated Resident #36 always had an issue with her sacral area and they had struggled to keep it intact because Resident #36 liked to sit up in her wheelchair during the day, but she was adamant about having her naps and usually lied down in bed after lunch. Resident #36 also had sensitive skin. Prior to her hospitalization , Resident #36 often rang her call light, was continent of both urine and bowel and walked to the bathroom with staff assistance. After coming back from the hospital on [DATE], Resident #36 got a little weaker, but she was still ambulatory. Nurse #1 also stated Resident #36 did not refuse to be turned to her side but often preferred to lie flat on her back. An interview with Nurse #2 on [DATE] at 3:36 PM revealed she completed a skin check on Resident #36 on [DATE] and observed a foam dressing on her sacrum. Nurse #2 stated she knew Resident #36 had a pressure ulcer on her sacrum, but she did not remove the dressing to assess the wound underneath. Nurse #2 stated she did not have a reason as to why she did not complete a wound assessment on Resident #36's sacral pressure ulcer. Nurse #2 further stated back in February 2022 prior to Resident #36's hospitalization , staff used to roll Resident #36's wheelchair to the bathroom and assisted her to use the commode but when she came back from the hospital, Resident #36 had a decline and they often had to provide incontinence care to her, but she never refused to be turned on her side while in bed. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] for Resident #36 indicated she was at moderate risk for developing pressure ulcers due to slightly limited sensory perception, very moist skin, very limited mobility, chairfast, adequate nutrition and problem with friction and shear. Complete lifting without sliding against sheets was impossible. Resident #36's Treatment Administration Record for [DATE] indicated no treatment orders for Resident #36's sacral pressure ulcer until [DATE] when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days. An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on [DATE] and she was not sure if she had checked her re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #1 stated Nurse #1 should have initiated a treatment when she observed an open area to Resident #36's sacrum on [DATE] and she should have completed a wound assessment. UM #1 stated she remembered Resident #36's family member telling her to make sure they kept an eye on her sacrum because an area on her sacrum had opened when she came back from the hospital. UM #1 stated she didn't get around to assessing Resident #36's sacrum until [DATE] when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility. UM #1 stated she did not think about documenting an assessment or complete measurements of Resident #36's pressure ulcer on [DATE] because she was going to be seen by the Wound PA the next week. An interview with Nurse #3 on [DATE] at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 denied ever handing a foam dressing to the nurse aides and asking them to place it on Resident #36's sacrum. She recalled placing a dressing according to the treatment record whenever the nurse aides told her Resident #36's dressing was off. She also stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody. A phone interview with Nurse Aide (NA) #1 on [DATE] at 10:19 AM revealed she took care of Resident #36 on the day shift, but she always came in early to help the night shift aides get the residents up in the mornings. NA #1 stated there were multiple times when she would come in early that she would see Resident #36's call light on and her bed would be soaked from urine. At those times, Resident #36 was still continent of urine and whenever she asked Resident #36 if the staff had come to check on her, she told her that they came in and turned her light off, thinking that she was asleep and didn't come back. NA #1 stated there were multiple times when she would come in and observed Resident #36 without a dressing to her sacrum and her clothes would be soaked from drainage from her wound. Whenever she asked the night shift nurse aides, they couldn't tell her anything as to why Resident #36 did not have a dressing on to her sacrum. NA #1 stated Resident #36 always had a soft, boggy, purplish red spot on her sacrum that would close and re-open, but she had no clue as to how she got the hole on her sacrum which had a lot of drainage and smelled really bad. NA #1 reported there had been some nurses who had handed her a dressing to put on Resident #36's sacrum and she did it in order to help out, but she got written up for it when she reported this to UM #1. She also stated that Resident #36 never refused to lie down after lunch and never refused to be turned and repositioned in bed. A phone interview with Nurse #4 on [DATE] at 7:44 PM revealed she worked with Resident #36 on the night shift, but she didn't remember having to replace her sacral pressure ulcer dressing. Nurse #4 stated she relied on the nurse aides to report to her if her dressing had come off whenever they did their incontinence rounds. Resident #36 usually got up after Nurse #4 had already left, and Resident #36 never refused to be turned and repositioned to her sides when in bed. Nurse #4 stated she had concerns about the nurses not completing skin assessments and wound assessments which were usually scheduled for the day and evening shifts. She stated she would often see alerts on the electronic medical record that they were past due and some of them would even be over 15 days late. Nurse #4 further stated she reported this to UM #1 and the DON, but she wasn't sure if anything had been done about it. The Wound Evaluation and Management Reports in Resident #36's medical record indicated she was seen by the Wound Physician Assistant (PA) on the following dates: [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm (centimeters) in length, 1.5 cm in width and 0.3 cm in depth. The pressure ulcer was covered with excessive necrotic tissue and had mild serous drainage. Will treat with sodium hypochlorite solution moistened gauze and foam daily. No signs of acute infection. [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.5 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue and had mild serous drainage. Wound had remained stable in diameter but increased in depth. No signs of acute infection. Wound was debrided with scalpel. Wound depth increased to 15 mm (millimeters). Will change treatment to [MEDICATION(S)], filling the narrow wound with the [MEDICATION(S)] and covering with calcium alginate and foam daily. [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.8 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue. Wound had remained stable in size, but depth had increased due to debridement. Patient had moderate drainage, so a wound culture and sensitivity was taken. Awaiting results. Wound debrided with scalpel removing necrotic tissue. Will order a low air loss mattress and discuss with therapy to get her set up with a pressure relief cushion. [DATE] - Unstageable pressure ulcer to the sacrum measured 3 cm in length, 1.5 cm in width and 2 cm in depth. Wound now had undermining of 20 mm at 12 o'clock position. Wound culture and sensitivity had an unknown issue last week, so it was redone this week. No exposed bone present at this time. Mild odor and mild drainage present, no [CONDITION(S)] or pain. Wound debrided with scalpel. Less necrotic tissue present this week than before. Treated wound with sodium hypochlorite solution moistened gauze, lightly packed in the wound and foam daily. A phone interview with the Wound Physician Assistant (PA) on [DATE] at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on [DATE] nor when they started treatment on Resident #36's sacral pressure ulcer on [DATE] when it got worse. The Wound PA stated he would not have recommended to use the occlusive dressing that was started on [DATE] because he didn't typically use it on the sacrum, and it was not appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated if the facility provided consistent treatment to Resident #36's pressure ulcer, it would have made a difference in preventing the pressure ulcer from worsening. The Wound PA stated Resident #36's pressure ulcer could have been avoided if the facility provided the appropriate treatment and took preventive measures such as offloading and regular skin checks. The Wound PA further stated he expected the nurses to perform skin checks by looking at all surfaces of the skin from head to toe and paying particular attention to skin folds and creases which were susceptible to fungal infections. The Wound PA also stated if a dressing was present, the nurses were supposed to remove the dressing so they could visualize and assess the wound underneath especially for residents who were not currently being treated by him. On [DATE], he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on [DATE] that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on [DATE], he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on [DATE] and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial. But he couldn't say it would have made a difference if the infection had already reached the bone. And he didn't see any exposed bone after debridement, so he didn't think to do a bone biopsy. The Wound PA stated Resident #36's pressure ulcer was avoidable. An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs. No one from the laboratory sent any of the swabs that she had requested. An interview with the Nurse Practitioner (NP) on [DATE] at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on [DATE] when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on [DATE] and [DATE] that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the nurses should have notified her on [DATE] when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA. The Report of Consultation from the Wound Center dated [DATE] for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress. An Infectious Disease Visit Note dated [DATE] in Resident #36's medical record indicated Resident #36 was seen for sacral [CONDITION(S)]. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair. An observation of wound care was made on [DATE] at 2:43 PM on Resident #36 and performed by Nurse #3 and assisted by Nurse Aide (NA) #2. Resident #36 was turned towards her left side while NA #2 stood facing Resident #36 and supported her trunk. Nurse #3 sprayed wound cleanser into the sacral pressure ulcer which measured approximately 2 cm (centimeters) in length, 3 cm in width and 2 cm in depth. The wound bed had beefy red granulation tissue with 20% slough (yellow/white material in the wound bed consisting of dead cells). The skin surrounding the wound was red. Nurse #3 applied skin prep barrier to the surrounding skin and well over towards the right buttock. Nurse #3 cut a piece of green foam that fit exactly into the wound bed and applied it to the wound. She cut a plastic drape in half, cut, and measured a hole to fit the foam and applied it to cover Resident #36's buttocks and sacral area. She cut another piece of green foam approximately 6 inches long and 1 inch wide to serve as a bridge to the foam covering the wound. Nurse #3 placed the bridge over the plastic drape and covered it with another piece of plastic drape. She cut a small piece of the drape at the top and placed the track pad with the tubing towards Resident #36's sacrum. She secured the track pad with another piece of tape and then coiled the tubing into a circle and taped it to Resident #36's right hip. Nurse #3 connected the tubing to the canister that was placed inside the wound vac and turned the machine on. The wound vac was set at 125 mmHg (millimeters Mercury). The Administrator was notified of Immediate Jeopardy on [DATE] at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of [DATE]. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #36 readmitted on [DATE] and had an identified wound/pressure ulcer without physician notification or ordered treatment. The facility failed to assess, obtain treatment orders from physician, identify deterioration of the pressure ulcer, and process a wound culture which resulted in a serious adverse outcome. A culture was ordered by physician and completed however not resulted by lab. twice from an expired swab and dry specimen. The facility failed to follow up on lab. results and did not ensure lab. supplies were not expired. Facility completed a full body skin assessment and record review on all current residents on [DATE] by the unit managers. Resident #36 was the only identified resident who has suffered an adverse outcome related to non-compliance. The Regional Director of Clinical Services (RDCS) audited lab. supplies to ensure appropriate supplies on hand. An assessment of Resident #36 revealed on [DATE], no further deterioration of pressure ulcer, treatment orders in place per physician order, resident being followed by local wound care clinic. *Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Regional Director of Clinical Services (RDCS) educated the Director of Nursing (DON) and nurse unit managers (UM) of the existing/revised process of labs. on [DATE]. Process is as follows for labs.: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax. In addition, the DON/designee are responsible for tracking lab. results beginning [DATE]. If a licensed nurse is contacted by the lab. about a problem, the licensed nurse will be responsible for notifying physician and reentering the order and obtaining sample. Any pressure ulcers or skin conditions that are referred to wound physician are communicated via order and requested resident information are communicated by DON and/or UM. No licensed nurse can initiate treatments without a physician order. On [DATE], the RDCS also completed education with DON and unit managers on the process of notification. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin area or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). The DON/unit managers along with Wound Nurse Practitioner are responsible for weekly wound/pressure ulcer measurements and assessments. A comprehensive list of wounds will be maintained by the DON/unit managers. Licensed nurses including agency nurses were in-serviced [DATE] by the DON and unit managers on facility process for labs., facility process for notification, location of lab. supplies, responsibilities and of admission and weekly skin assessments, completing weekly wound assessment. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin rea or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. No licensed nurse can initiate treatments without a physician order. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). If any changes in resident conditions, including skin, deterioration (change in size, appearance, skin color, smell, drainage, redness) of wounds/pressure sores, physical or mental changes the licensed nurse must report findings to physician immediately. Facility process for labs. is as follows: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax. The nurse aides, including agency nurse aides will be in-serviced by [DATE] by DON/designee on reporting any changes in resident's condition including skin, (such as: redness, drainage, open areas, odor, temperature, and complaints of pain) to the licensed nurse immediately. DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by [DATE]. Nurses and nurse aides will not be allowed to work until they receive education. New nurses and nurse aides hired after [DATE] will receive education during orientation. The DON/unit managers are responsible for tracking labs. and notification of physician during clinical morning meeting beginning the week of [DATE]. The facilities interdisciplinary team (IDT) will continue to conduct a weekly resident review of all residents with pressure sores to discuss and document pressure ulcers. The alleged date of IJ removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. On [DATE], the facility's credible allegation was validated through record reviews and staff interviews. The facility provided education documentation for all staff on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on performing and documenting weekly wound assessments, notification of the physician, Nurse Practitioner and wound doctor of new/worsening pressure ulcers, actions to take if new/deteriorating pressure ulcer observed and what changes in skin integrity to report, following up and processing of laboratory orders and reviewing laboratory process to ensure supplies were within date. The nursing aides were interviewed and described the different signs of changes in skin integrity to be reported to the nurse during provision of care. The in-service also included reporting all changes in condition and signs of wound infection/wound deterioration to the nurse. A skin/wound audit was completed on [DATE] for any unreported skin issues and the results were compared with the skin assessment documentation, if the physician was notified, if family was notified and if care plan was updated. This was verified through interviews with the Unit Managers and MDS Coordinator who completed the audits. The RDCS completed an audit of all laboratory supplies on [DATE] wherein she removed and discarded expired laboratory supplies and validated that all current in house supplies were sufficient in quantity and there were no other expired supplies in house. She also completed a laboratory audit on [DATE] and checked all laboratory orders within the last 7 days if they had obtained the results and if the physician was notified of the results. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was severely cognitively impaired, had no rejection of care behaviors and required extensive physical assistance with bed mobility and transfer. She had impairment to both sides of upper and lower extremities. The MDS further indicated Resident #11 had one stage 3 pressure ulcer, one stage 4 pressure ulcer, one deep tissue injury and one venous ulcer. Resident #11's care plan revised on [DATE] indicated Resident #36 had impaired skin integrity to left heel, left leg and right leg. Interventions included consult with wound care provider as indicated, elevate heels off mattress per routine, inspect skin during routine care daily, pillows for positioning as needed, turn, and reposition during care rounds and as needed and treatment as indicated to impaired skin. The Weekly Wound assessment dated [DATE] indicated Resident #36 had a stage 4 pressure ulcer to the right lower extremity posterior that measured 13.5 cm (centimeters) in length, 3 cm in width and 0.5 cm in depth. The wound had moderate serous drainage with pink and red wound bed and faint odor. The wound had maceration to peri wound. She was seen and evaluated by the Wound Physician Assistant. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place to correct a deficiency for failure to provide supervision to prevent accident at tag F 323 that was cited during the recertification survey conducted in January 2015. F 323 was recited again on the current recertification and complaint survey. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: F 323 Provide supervision to prevent accidents: Based on observations, record reviews and physician and staff interviews the facility failed to provide supervision for a resident who fell from bed and had a subarachnoid hemorrhage (bleed in the brain) and for a resident who fell from bed with facial lacerations and a concussion for 2 of 3 sampled residents sampled for falls. (Resident #58 and #55). During the previous recertification of 01/30/15, the facility was cited a deficiency at F 323 for failure to secure ½ side rails to residents' beds to prevent injuries for 3 of 6 beds (Resident #s 77, 45 and 57). During an interview on 11/06/15 at 2:52 PM the Administrator explained she and staff had just attended a fall prevention program and would be presenting information at the next Quality Assessment and Assurance Committee meeting in December. She stated resident falls were discussed in the morning meetings and they had implemented plans to decrease alarms in the facility. She further stated the biggest thing that had been done was to hire 5 additional staff for the bath team and an additional restorative aide to increase supervision of residents however, there had been no staff increases for night shift. She explained they had increased the number of activities in the evenings and they were planning to look at resident sleep patterns to keep residents up later in the evening to promote sleep and decrease falls.

Based on record reviews and physician and staff interviews the facility failed to assess and provide a resident sufficient fluids to maintain hydration for 1 of 3 residents sampled for hydration. (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent discharge Minimum Data Set ((MDS) dated [DATE] indicated Resident #58 was severely impaired in cognition for daily decision making and was totally dependent on staff for eating. The MDS also indicated Resident #58 was always incontinent of bladder and bowel. A review of a physician's orders [REDACTED]. A review of a quarterly nutrition note dated 09/30/15 at 4:04 PM revealed Resident #58 was on a puree diet and her meal intake was poor and now required total assistance with meals. The notes further indicated Resident #58 received magic cups with meals to promote weight gain and HI Cal supplement 120 milliliters (ml) three times a day for added calories and nutrition and dietary would continue to observe for changes in nutritional status. A review of meal intakes, fluid intakes and supplements revealed the following daily oral intakes: 09/30/15 total oral fluid intake was 1,020 ml 10/01/15 total oral fluid intake was 1,140 ml 10/02/15 total oral fluid intake was 1,320 ml 10/03/15 total oral fluid intake was 1080 ml 10/04/15 total oral fluid intake was 780 ml 10/05/15 total oral fluid intake was 1,140 ml A review of a nurse's note dated 10/06/15 at 1:50 PM revealed Resident #58 continued to not eat well. The notes indicated Resident #58 blew bubbles in drinks and her positioning was a factor because she leaned over with her hand over her mouth most of time. A review of meal intakes, fluid intakes and supplements revealed the following daily oral intakes: 10/06/15 total oral fluid intake was 540 ml 10/07/15 total oral fluid intake was 95 ml A review of a nurse's note dated 10/08/15 at 2:30 PM revealed Resident #58's meal intake had been poor for several days and at lunch meal today, resident had a blank look and refused meal. The notes indicated Resident #58 was assisted back to her room into bed by staff and staff noted Resident #58 had a non-productive cough during transfer into bed. The notes revealed her blood pressure was 126/58, temperature 96.9 Fahrenheit, pulse 97 and respirations were 20. The notes further revealed staff was unable to obtain an oxygen percentage reading and oxygen was placed on Resident #58 and her oxygen saturation was 95 percent on 2 liters of oxygen via nasal cannula. The notes indicated information was faxed to the physician with a request for chest x-ray and urinalysis with culture and sensitivity and was awaiting a return facsimile (fax) from the physician. A review of meal intakes, fluid intake and total supplements for 10/08/15 revealed there was no indication of any meal intake or fluid intake. A review of a nurse's note dated 10/09/15 indicated at approximately 5:45 AM NA #2 called Nurse #1 in to Resident #58's room and the resident was lying on the floor next to her bed on her right side in between the bed and night stand. The notes further indicated Resident #58 was transferred back to bed with a mechanical lift and a physical assessment revealed a laceration on the right side of her head with a small amount of bleeding and her right hip was red. A review of a nurse's note dated 10/09/15 revealed emergency medical services was called at approximately 6:00 AM and Resident #58 was transported to the emergency room (ER) for evaluation. A review of an ER visit note dated 10/09/15 revealed Resident #58 presented to the ER following a fall and was frail and elderly. A section labeled impression and plan revealed acute [MEDICAL CONDITION]; [MEDICAL CONDITION] (high sodium levels in the blood) and [MEDICAL CONDITION] (high potassium levels in the blood) and admit to the intensive care unit. A review of laboratory results dated [DATE] revealed the following: Sodium 177 high (normal range 136-145) Potassium 5.9 high (normal range 3.5-5.1) BUN (to evaluate kidney function) 217 high (normal range 7-22) Creatinine (to evaluate kidney function) 12.70 high (normal range 0.6-1.0) A review of a hospital history and physical dated 10/09/15 revealed Resident #58 was transferred to the hospital for further evaluation and was found to have severe [MEDICAL CONDITION] as well as kidney injury. A section labeled impression and plan indicated nephrology (kidney specialist) had been consulted and Resident #58 had received intravenous fluids and follow up with urine sodium, urine creatinine and a renal (kidney) ultrasound studies. A review of renal ultrasound results dated 10/10/15 revealed no evidence of renal obstruction. A review of a hospital discharge summary dated 10/11/15 revealed Resident #58 had been admitted to the hospital after she had fallen and was found to have azotemia (a high build-up of nitrogen waste products) with acute kidney injury and was also found to have [MEDICAL CONDITION] due to sodium was as high as 177. The summary revealed Resident #58 appeared to be in an infantile position and woke up with a sternal rub but only moaned and a discussion with family revealed this was worse than her normal baseline. The summary also revealed nephrology was consulted and she was given intravenous fluids of 5 percent [MEDICATION NAME] and water and her sodium had been improving and creatinine improved mildly but was still much more elevated. The summary indicated due to worsening dementia, worsening clinical status for the past few weeks, not receiving nutrition and due to current clinical condition family was interested in hospice and would be discharged for comfort measures. During an interview on 11/05/15 at 6:35 AM with Nurse Aide (NA) #2 she stated was assigned to care for Resident #58 on the night shift and the resident would drink water when she offered it to her but slept most of the night so she didn't drink much. During an interview on 11/05/15 at 7:02 AM with Nurse #4 she stated sometimes she was assigned to care for Resident #58 and sometimes she was the nursing supervisor on night shift. She stated normally Resident #58 did not drink water during the night and she was not aware Resident #58 had decreased oral intake before she fell out of bed on 10/09/15. During an interview on 11/05/15 at 4:33 PM with Nurse #3 she explained Resident #58 held her hands in front of her mouth and staff had to assist her to lower them to eat and drink. She stated NAs were supposed to report to the nurse when a resident did not eat or drink. She explained Resident #58 drank a high calorie supplement and as soon as they noticed a decrease in meal intake or fluid intake they were to report it to the physician or nurse practitioner. She stated she did not recall talking with dietary or the physician or nurse practitioner about Resident #58's decreased meal intake or fluid intake before she went to the hospital on [DATE]. During an interview on 11/06/15 at 6:54 AM with Nurse #1 she verified she was assigned to care for Resident #58 during the night shift on 10/09/15. She stated she was not aware Resident #58 had decreased meal intakes and decreased fluid intakes. She further stated no one had reported to her Resident #58 was not eating or drinking and no information was passed on to her in shift report. She explained she got a urine specimen before Resident #58 fell on [DATE] but did not remember what color the urine was or if it was dark or had an odor. During an interview 11/06/15 at 9:41 AM with Resident #58's physician who was also the facility Medical Director he confirmed after review of the emergency room documentation on 10/09/15 Resident #58 was in acute dehydration and her fluid volume was low. He stated usually staff let him know if a resident declined in appetite and fluids but he did not remember if staff had called him or what specifically they reported. He stated he expected staff to let him know if a resident was not eating or drinking so options could be considered. He further stated staff did not report a dramatic change in her condition before she fell and went to the hospital on [DATE]. During an interview on 11/06/15 at 1:24 PM the Assistant Director of Nursing explained she expected for NAs to inform the nurse when a resident was not eating or drinking well. She stated then the nurse should follow up with family and get with dietary and see what they could do. She stated she didn't remember anything specific about Resident #58's decrease meal intakes or fluid intakes. She further stated what should have happened was staff should have immediately let the nurse know and should have documented it. She confirmed there were days before 10/09/15 when no meal intake or fluid intake was documented and somebody should have reported it and it should have been caught. During an interview on 11/06/15 at 1:50 PM with the Director of Nursing (DON) she stated she expected for nursing staff to monitor residents for any acute changes and NAs were expected to notify the nurses if there was a change. She explained the Medical Director called the facility every day at lunch time and he came to the facility 2 days a week to see residents and the Nurse Practitioner also visited residents in the facility and she expected for nursing staff to recognize changes and notify the physician or nurse practitioner. She stated after review of meal intakes and fluid intakes for Resident #58 there should have been a more thorough assessment completed and documented in Resident #58's medical record and the physician should have been notified to discuss options. She explained Resident #58 needed encouragement to eat and had always been a resident staff had to prompt to eat. The DON confirmed Resident #58 was last seen by dietary on 09/30/15 for her quarterly nutrition review but should have been seen when her meal intakes and fluid intakes decreased.

Based on observations, record reviews and physician and staff interviews the facility failed to provide supervision for a resident who fell from bed and had a subarachnoid hemorrhage (bleed in the brain) and for a resident who fell from bed with facial lacerations and a concussion for 2 of 3 sampled residents sampled for falls. (Resident #58 and #55). The findings included: 1. Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent discharge Minimum Data Set ((MDS) dated [DATE] indicated Resident #58 was severely impaired in cognition for daily decision making and required extensive assistance with bed mobility and transfers. The MDS also indicated Resident #58 was always incontinent of bladder and bowel. A review of a nurse's note revealed on [DATE] at approximately 11:00 PM a Nurse Aide (NA) informed Nurse #1 she heard someone talking while making rounds and saw Resident #58 lying on the floor in her room, on her right side facing the sink, with her back to the night stand. A review of a fall investigation report revealed Resident #58 had an unwitnessed fall in her room on [DATE] at 11:00 PM. The report indicated Resident #58 was disoriented and confused and had poor safety awareness. The report further indicated Resident #58 was barefoot and had last been toileted around 9:00 PM. The report revealed additional interventions were put into place to provide frequent re-direction from staff and increase visual checks. A review of a care plan titled fall risk needs dated [DATE] indicated Resident #58 needed extensive assistance related to cognitive impairment, had poor safety awareness and a history of falls. The goal was for Resident #58 to have no injuries from falls through next review and interventions were listed in part for frequent visual checks, non-skid strips to bedside floor, bed in low position, therapy referrals as needed and offer toileting during care rounds and as needed. A review of a nurse's note dated [DATE] at 5:45 AM indicated Nurse #4 who was also a nursing supervisor was called to Resident #58's room and the resident was observed lying in floor on her right side. The notes revealed Resident #58 was assisted back into bed and had a contusion (bruising) to right side of forehead and red area to right hip. The notes further revealed physician's orders [REDACTED].#58 to the emergency room (ER) for evaluation. A review of a nurse's note dated [DATE] indicated at approximately 5:45 AM NA #2 called Nurse #1 in to Resident #58's room and the resident was lying on the floor next to her bed on her right side in between the bed and night stand. The notes further indicated Resident #58 was transferred back to bed with a mechanical lift and a physical assessment revealed a laceration on the right side of her head with a small amount of bleeding and her right hip was red. A review of a nurse's note dated [DATE] revealed emergency medical services was called at approximately 6:00 AM and Resident #58 was transported to the ER for evaluation. A review of an ER documentation dated [DATE] indicated Resident #58 presented to the ER following a fall. The notes revealed Resident #58 had bleeding on her right scalp and a section labeled impression and plan revealed a traumatic subarachnoid (a space in the brain that is filled with cerebrospinal fluid and contains large blood vessels that supply the brain and spinal cord) hemorrhage and admit to intensive care unit. A review of a hospital history and physical dated [DATE] revealed Resident #58 was transferred to the hospital for further evaluation after a fall and was found to have a subarachnoid hemorrhage that was discussed with the neurosurgeon and there was no intervention recommended. A section labeled impression and plan revealed a subarachnoid hemorrhage, acute kidney injury and dementia. A review of a computerized axial tomography (CT) scan dated [DATE] revealed a small amount of subarachnoid hemorrhage over the left occipital temporal area (at the back of the head) and critical findings of acute subarachnoid hemorrhage was discussed with the ER physician. A review of a fall investigation document dated [DATE] revealed Resident #58 had an unwitnessed fall in her room on [DATE] at approximately 5:45 AM. The document indicated Resident #58 was disoriented and confused at the time of the fall, had poor safety awareness and both half-length side rails were up. A fall scene investigation report indicated Resident #58 had a fall on [DATE] at 5:45 AM and revealed the last time Resident #58 was checked was 3:00 AM and she was dry. A root cause of the fall was safety unawareness and new interventions to prevent future falls was frequent checks. A review of a hospital discharge summary dated [DATE] revealed Resident #58 was admitted to the hospital after she had fallen and was found to have a subarachnoid hemorrhage on her CT scan. The summary further revealed neurosurgery was consulted and there was nothing for them to do and due to worsening dementia, worsening clinical status and current clinical condition, Resident #58's family was interested in hospice. The notes indicated hospice was consulted and Resident #58 would be discharged for comfort care. A review of a written statement dated [DATE] by NA #2 indicated around 5:45 AM on [DATE] she walked into Resident #58's room to get her dressed and found her lying on the floor next to her bed. The statement further indicated she notified the nurse and they used a lift to get Resident #58 off the floor and she noticed a small cut on the side of Resident #58's head. The statement also indicated Resident #58's bed was in the low position. A review of a nurse's note dated [DATE] at 4:15 PM revealed in part Resident #58 returned to the facility and had a small scabbed area to her right forehead above her eye. A review of a nurse's note dated [DATE] at 8:00 PM indicated hospice services. A review of a nurse's note dated [DATE] at 8:35 PM indicated Resident #58 had expired at the facility. During an interview on [DATE] at 6:35 AM with NA #2 she confirmed she was assigned to Resident #58's care during the night shift when she fell on [DATE]. She explained she was making her last rounds of the night after 5:00 AM and Nurse #1 was standing at a medication cart in the hallway near Resident #58's room. She stated she walked inside the door of Resident #58's room and saw the resident on the floor and she turned back to the doorway and told Nurse #1 that Resident #58 was on the floor. She explained she saw Resident #58 in the floor with her head pointed toward the head of bed and her feet were toward the foot of bed. She further explained there was a short side rail that moved some when she wiggled it and there was no bed alarm. She stated she was not told anything about increasing visual checks or rounds and she was unaware Resident #58 had a fall previously. She explained Resident #58 could not walk and she did not know how she fell out of the bed but she had seen her squirming in bed that night so she had raised the foot of the bed up a little and made sure she was in the center of the bed when she had last checked her on her routine rounds. During an interview on [DATE] at 7:02 AM with Nurse #4 she confirmed she was working on night shift as the nursing supervisor on [DATE] and was called to Resident #58's room and she was lying on her right side on the floor with her head pointed toward the head of the bed and close to being in between the night stand and bed. She stated Nurse #1 and NA #2 were in the room and they were checking Resident #58 over. She explained she assessed Resident #58 and she had a bruise to her right forehead and side of head but did not recall seeing blood. She stated Resident #58 did not talk but made sounds and she was not making any loud noises. She explained it was facility policy to send residents out to the ER if there was suspicion they hit their head. She confirmed Resident #58 had fallen once a couple of weeks before the fall on [DATE] and stated Resident #58 was totally dependent on staff for care, could not use a call bell and after the fall on [DATE] staff were supposed to redirect and watch her closer. She explained the nurse aides (NAs) made rounds to check residents every 2 hours and if residents were to have increased visual checks that meant NAs should watch the resident more closely. She stated it was her expectation if Resident #58 had acted restless staff should have let her know and if a NA saw a resident wiggling or squirming they should check them to see if they were wet or soiled and reposition them. She explained she put new interventions in the computer for the NAs but she had never looked to see what the NAs could see once the interventions were put it in and there was also a care guide in the resident's closet that listed fall interventions. During an interview on [DATE] at 6:41 AM with NA #7 she stated she had provided care for Resident #58 on occasion at night. She explained Resident #58 could not get up by herself and required 2 staff assistance and had not been on fall precautions that she was aware of. She further stated if a resident was supposed to have frequent checks that meant to check on the resident between rounds that were done every 2 hours. During an interview on [DATE] at 6:54 AM with Nurse #1 she verified she worked the night shift on [DATE] and she had just pulled the medication cart past Resident #58's room when NA#2 called her to come in the resident's room. She explained when she walked in the room she saw Resident #58 on the floor and she was laying on her right side with her back toward the bed and her head toward the night stand. She stated she had a red mark on her right hip and she had a small laceration on the right side of her forehead at the hairline and there was a small amount of blood. She explained she called the nursing supervisor and she came and they assessed Resident #58 and then they lifted her into bed with a full body mechanical lift. She stated she recalled Resident #58 had side rails on her bed that were up and she had fallen a few weeks before and was in the same position on the floor as on [DATE]. She stated she did not hear anything when Resident #58 fell and she had put in the computer system for Resident #58 to have frequent visual checks. She explained NAs made rounds every 2 hours but frequent visual checks meant staff should peek in on Resident #58 every hour. She stated NA #2 did not report to her that Resident #58 had been moving around in bed or anything that might have made her think Resident #58 would fall. She explained they put in the computer system for NAs to do frequent visual checks when a resident required them and it was supposed to be on the care guide in the resident's closet but she could not recall what was listed on Resident #58's care guide. During an interview on [DATE] at 9:41 AM with Resident #58's physician who was also the facility Medical Director he stated Resident #58 had been declining due to Alzheimer's disease and could not communicate clearly. He further stated he was surprised Resident #58 fell out of bed but that's why they had to have fall precautions in place. He explained Resident #58's family had requested she receive hospice services and to keep her comfortable when she was readmitted to the facility because of advanced stage dementia. During an interview on [DATE] at 1:24 PM with the Assistant Director of Nursing she stated NAs were expected to make rounds on residents every 2 hours and if they were to have frequent visual checks that meant the resident needed to be checked more frequently. She explained frequent visual checks was entered in the computer and on the care guide so the NA would know to go to the resident's room and check them more frequently. During an interview on [DATE] at 1:50 PM with the Director of Nursing she stated it was her expectation to treat every resident as a fall risk. She stated frequent visual checks meant for staff to pay more attention to the resident more closely. She explained it was her expectation for NAs to make routine rounds on residents every 2 hours but if frequent visual checks were indicated they should check on them in between the every 2 hour routine rounds. She explained the fall team met every morning Monday through Friday and discussed each resident's fall and recommendations and interventions were documented and communicated with direct care staff. She further explained falls that occurred on the weekend were discussed at the Monday morning meeting. She stated it was also her expectation for nurses and NAs to communicate about residents and to monitor them. During an interview on [DATE] at 3:40 PM with physical therapist #2 he explained after Resident #58 fell on [DATE] she was evaluated by therapy and was assessed to be at her previous baseline level so no therapy was indicated. He stated after the second fall on [DATE] she went to the hospital and when she came back she was on hospice care so no therapy was indicated. 2) Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #55's medical record revealed an unwitnessed fall on [DATE] at 3:10 AM. The fall investigation specified the resident was found sitting on the floor, wearing non-skid plain white socks, and had sustained no injuries. Further review of the medical record revealed no new interventions were put into place to prevent future falls, resident was encouraged to be careful, and the resident had declined the use of side rails. Further review of Resident #55's care plan did not indicate a fall risk needs care plan, goal, and/or interventions after the fall on [DATE]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #55 had severe cognitive impairment and was coded to need limited assistance with bed mobility, transfers, dressing, and toileting. The MDS further revealed Resident #55 was independent with ambulation and was unsteady with balance and required staff assistance. Further review of the MDS indicated Resident #55 used a walker and a wheelchair as her mobility devices. Further review of the medical record revealed Resident #55 had a fall on [DATE] at 8:40 PM. The fall investigation specified the fall was unwitnessed, the resident was trying to assist another resident when both fell on the floor, and Resident #55 sustained a 2.5 centimeter (cm) laceration to the back of the head and was transported to a local hospital for evaluation and treatment. The report further indicated the resident obtained a staple to the back of the head and was transported back to the facility and an intervention for Resident #55 to have non-skid socks on every shift. Review of a care plan dated [DATE] indicated Resident #55 had fall risk needs with no goal indicated and an intervention of non-skid socks on every shift. There was no care plan for fall risk needs prior to [DATE]. Resident #55 had an unwitnessed fall on [DATE] at 6:30 AM. The fall investigation specified the resident had poor safety awareness, history of falls, was not wearing non-skid socks and/or shoes and was encouraged to always wear proper foot wear and call for assistance when needed. The report further indicated interventions for Resident #55 was for non-skid footwear, frequent visual checks, non-skid strips to the floor at bedside, call light within reach and bed and chair alarms. Resident #55's care plan was updated on [DATE] for fall risk needs with no goal indicated and interventions which included a risk for falls assessment, frequent visual checks, safety reminders, non-skid strips in the floor at bedside, non-skid footwear for transfers and/or ambulation, call light within reach, bed alarm and chair alarm. Review of the medical record indicated Resident #55 had an unwitnessed fall on [DATE] at 9:00 AM. The fall investigation revealed the resident had poor safety awareness transferring from the bed to the wheelchair with the wheelchair brakes unlocked, history of falls and unable to remember to wait for assistance. The interventions included frequent visual checks, non-skid footwear, call bell within reach, bed in lowest position when occupied, an order was received for an antibiotic related to a urinary tract infection (UTI) and therapy to screen due to increased weakness. Further review of the medical record indicated Resident #55 had sustained unwitnessed fall on [DATE] at 4:00 PM. The fall investigation revealed Resident #55 had fallen in her bathroom, sustained 2 lacerations to the forehead, and a hematoma (swelling of clotted blood within the tissues) over the left eye with no loss of consciousness. Resident #55 was transported to a local hospital by emergency medical services (EMS) ambulance for evaluation and treatment. The investigation report indicated a new intervention for frequent monitoring of the resident. A review of the hospital records dated [DATE] indicated Resident #55 had a traumatic injury, with forehead lacerations, a concussion with unknown loss of consciousness, and pain to the left side of the face and head. Laceration #1 was 2 centimeters (cm) in length to the left scalp area and laceration #2 was 2 cm in length at the left side forehead area with both lacerations being sutured and the bleeding controlled. An updated care plan of [DATE] indicated Resident #55 was at risk for falls related to history of falls, difficulty in walking, lack of coordination, generalized weakness, urinary tract infection and poor safety awareness. The care plan had no goal indicated with interventions which included medical record charting related to the falls for 3 days, a fall risk assessment, check the bed alarm every shift, neurological checks for 72 hours, call light within reach and check chair alarm every shift. On [DATE] at 10:30 AM, Resident #55 was observed lying in bed and was observed to have a large hematoma and 2 lacerations with sutures intact above the left eye and in the area of the forehead with bruising across the resident's forehead and around both eyes. Resident #55's bed was observed to have bilateral side rails in the upright position attached in the middle portion of the resident's bed. On [DATE] at 6:30 AM, Resident #55 was observed lying on her back in bed asleep. Resident #55's bed was observed with bilateral side rails in the upright position attached in the middle portion of the resident's bed. On [DATE] at 6:40 AM, an interview was conducted with nurse aide (NA) #1. NA #1 stated he was unaware of what frequent monitoring of a resident meant and that he was expected to make rounds (check) on his assigned residents every 2 hours which also included turning and positioning and the changing of the residents brief if it was wet or soiled. NA #1 indicated Resident #55 required limited assistance with her activities of daily living (ADLs) and he would not have considered the resident to be a fall risk prior to the falls on [DATE]. NA #1 further indicated after Resident #55's 2 falls on [DATE] she was considered a fall risk and the side rails was placed on the resident's bed after the falls. On [DATE] at 6:50 AM, an interview was conducted with NA #3. She stated she was unaware of what frequent monitoring meant and that she was expected to check, change the brief if it was wet or soiled and turn and reposition a resident every 2 hours. She further stated Resident #55 required limited assistance from staff and was unaware of the resident being a fall risk until after the resident had the 2 bad falls on [DATE] at which time Resident #55 was considered to be a fall risk and the side rails were placed in the middle portion of the resident's bed. On [DATE] at 7:30 AM, an interview was conducted with Nurse #3. She stated Resident #55 was independent before the 2 falls on [DATE]. Nurse #3 further stated after the falls the resident had declined rapidly, was placed on Hospice services and was dependent on staff for most all of her ADLs. On [DATE] at 2:50 PM, an interview was conducted with NA #5. He stated Resident #55 was not considered a fall risk, required limited assistance with ADLs and had not had any side rails on her bed until after the 2 falls on [DATE]. NA #5 indicated he was unaware Resident #55 required frequent monitoring. NA #5 further indicated he made rounds on Resident #55 every 2 hours and that he had not been advised and/or asked to make additional rounds/checks on the resident. On [DATE] at 6:35 AM, an interview was conducted with Nurse #1. She stated Resident #55 required limited assistance of ADLs before the resident had the falls on [DATE] and since the falls the resident has been more dependent on staff for all of her ADLs. Nurse #1 further stated she was unaware of frequent visual checks/monitoring of Resident #55 and expected the NAs to make rounds/check on residents every 2 hours. Nurse #1 indicated when the resident had returned from the hospital on [DATE] she had initiated the frequent nurse monitoring as per the facility policy which included neurological checks every 2 hours for the first 24 hours, then every 4 hours for the next 24 hours, and then every 8 hour shift for the next 24 hours. On [DATE] at 1:50 PM, an interview was conducted with the Director of Nursing (DON). She stated Resident #55 was independent with her ADLs before the 2 falls on [DATE]. The DON indicated frequent visual checks/monitoring would alert the staff that they should pay more attention to the resident and lay eyes on the resident every 15 minutes. The DON stated she was unaware that the interviewed NAs were unaware of what frequent visual checks/monitoring meant and that frequent visual checks/monitoring was not the sole intervention for falls.

Based on observations, staff interviews and record review the facility failed to develop a plan of action for preventing reoccurrences of breaks in infection control precautions after a resident diagnosed with [REDACTED]. The facility failed to establish proper infection control precautions for 4 residents diagnosed with [REDACTED].#39, 97 and 85) . Immediate jeopardy began on 10/25/14 when Resident #85 was diagnosed with [REDACTED].#129 and on 11/10/14 the Western Region Quality Assurance Nurse in-serviced the Director of Nursing and Assistant Director of Nursing on following the proper guidelines for co-horting residents with [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and the Quality Assurance Committee failed to identify the need for implementing a plan of action to prevent reoccurrences in breaks in infection control with residents diagnosed with [REDACTED].#s 39 and 97). Immediate jeopardy was removed on 01/30/15 at 4:59 PM when the facility implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity Level E (a pattern deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place. The findings included: Cross refer F 441. On 01/29/15 at 4:35 PM the Administrator and Assistant Director of Nursing (ADON) were interviewed about the facility's Quality Assurance Program (QA). The Administrator explained that the ADON was new in her role and still in training but would be expected to lead the QA committee and requested that she participate in the interview. The Administrator reported that a "core group" consisting of herself, the Director of Nursing (DON), ADON, the Medical Director, Pharmacist and Staff Development Coordinator met monthly to review newly identified problems, review current action plans and develop new action plans for identified areas of concerns. The Administrator reported part of the QA process was to review audits from departments to determine if acceptable thresholds were being met and if not, the committee worked to determine if a plan of action was needed to achieve compliance. The Administrator added that the ADON presented infection control reports to the QA committee. The Administrator reported that infection control was a topic that was discussed at each QA meeting but that she was not aware of any recent significant issues with breaks in infection control that required a plan of action. The Administrator provided the QA Committee's sign-in sheets and minutes discussed. Review of the sign-in sheets and minutes revealed that the QA committee met November 2014, the committee did not meet in December 2014 but met January 2015. On 01/30/15 at 10:10 AM the Western Region Quality Assurance Nurse (QA Nurse) was interviewed about the infection control concerns related to the facility's failure to implement infection control precautions timely. She reported that she became aware of a concern with Resident #129, investigated and determined that the facility allowed the Residents #85 and #129 to share a room and educated the DON and ADON on 11/10/14 on the guidelines for separating residents with infections. On 01/30/15 at 10:35 AM the Administrator and Director of Nursing (DON) were notified of immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 01/30/15 at 4:59 PM. The following interventions were put in place by the facility to remove the Immediate Jeopardy. Autumn Care of Drexel Credible Allegation of Compliance (01/30/2015) F 520 On 11/10/2014, the DON and ADON were re-in-serviced, by the Regional Nurse Consultant for co-horting residents with [MEDICAL CONDITION] Resistant Staph Aureus. Reviewed North Carolina state recommendations per statewide program for infection control epidemiology (SPICE). Private room if available, do not co-hort with immunosuppressed residents, no residents with open wounds, catheters, ostomies, etc. Additionally instructed to immediately initiate room change when a post op patient is in room with a resident who has a tested positive with a culture or active symptoms [MEDICAL CONDITION]. The DON and ADON were retrained on 01/30/15 by the facility administrator for the following: (The ADON serves as the Infection Control Nurse.) The QA committee consists of the Administrator, DON, ADON, SDC, Medical Director, and Pharmacist, each of whom will be in-serviced by the administrator prior to next QA committee meeting. Contact isolation recommendations and procedures including proper technique when to initiate contact precautions. 1. When to initiate a room change for a resident with active symptoms and or a positive culture report. 2. If available place resident in a private room. 3. Do not co-hort with immunosuppressed residents, residents with open wounds, catheters, ostomies. 4. Do not co-hort post op residents with surgical wounds with resident compromised [MEDICAL CONDITION]. This should be an immediate room change when a room is available preference being a private room. 5. Apply knowledge and training for contact isolation, co-horting residents, private rooms, ensuring training new systems is enforced. New system in place: 1. The DON and or ADON will review infection tracking forms 5 days per week for accuracy in identifying infection and adherence to policy and procedure for implementing appropriate and timely contact isolation precautions. 2. The DON and or ADON will print the physicians order report for a specified duration from the electronic medical record 5 days a week Monday- Friday in order to review all culture orders to ensure proper adherence to policy and procedure for implementing appropriate and timely contact isolation precautions. 3. The RN supervisor will print the physician order [REDACTED]. Once the RN Supervisor reviews the report it is placed in the DON communication box located at the nurse's station. The DON and or ADON will audit the report to ensure adherence to policy and procedure for applying contact isolation precautions when indicated. 4. The DON and or ADON will audit facility staff weekly for adherence/compliance for appropriate personal protective equipment and procedures for contact isolation. 5. The ADON will transcribe any pertinent data to the infection control line list. 6. The DON and or ADON will report findings to the quality assurance committee quarterly for review. Any further corrective action will be immediately implemented by the QA committee. Immediate Jeopardy was removed on 01/30/15 at 4:59 PM when the facility provided evidence of that all members of the QA Committee will be in-serviced prior to the next QA meeting on reporting, identifying and developing plan of actions for concerns that reflect system failure. The Administrator and Assistant Director of Nursing also provided evidence of knowledge related to the QA system, function of the QA committee and how the QA system monitors for necessary follow up.

Based on observations, physician, resident, and staff interviews, and record reviews, the facility failed to effectively implement a systemic infection control program by not following policies and procedures for cohorting for 1 of 1 resident diagnosed with [REDACTED].#85), not having an effective system in place to identify and implement contact precautions for 3 of 3 residents diagnosed with [REDACTED].#39 and #97), failing to wash hands between catheter care and wound care for 1 of 1 resident (Resident #39), and failing to clean or disinfect supplies for 1 of 1 resident observed receiving wound care (Resident #39). Immediate Jeopardy began on 10/25/14 when the facility failed to effectively implement a systemic infection control program by not following policies and procedures for cohorting for Resident # 85 diagnosed with [REDACTED]. Immediate Jeopardy began on 01/14/15 for Resident # 39 when the facility failed to effectively implement a systemic infection control program by not following policies and procedures to identify and implement contact precautions to prevent the spread of infection (MRSA). Immediate Jeopardy began on 01/22/15 for Resident # 97 when the facility failed to effectively implement a systemic infection control program by not following policies and procedures to identify and implement contact precaustion for MRSA. Immediate Jeopardy was removed on 01/30/15 at 4:59 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings included: A review of a facility infection control policy dated 11/01/13 revealed it was the policy of this facility to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The policy specified the facility develops, implements, and maintains an Infection Control Program in order to prevent, recognize, and control, to the extent possible the onset and spread of infection within this facility. Facility components of the Infection Control Program include an Infection Control Nurse who is a Registered Nurse to serve as the coordinator of this facility's Infection Control Program. Responsibilities of the Infection Control Nurse outlined in the policy included review of cultures and other diagnostic test results consistent with potential infections and to detect clusters and trends. The policy identified Methicillin Resistant Staphylococcus Aureus (MRSA) as a multiple drug resistant organism and specified the facility would initiate transmission-based precautions for residents who were actively infected with these organisms. The policy revealed that depending on the situation, residents on contact precautions may include the following: a private room, cohorting, or sharing a room with a roommate with limited risk factors (e.g., without indwelling devices, without pressure ulcers and not immunocompromised). The policy further included the infection control program will prevent and control outbreaks and cross-contamination using transmission-base precautions in addition to standard precautions and implement hand hygiene (hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. The policy specified facility surveillance would ensure reusable equipment was appropriately cleaned or disinfected. The policy identified person-to-person contact as a mode of transmission of infections. The policy specified to prevent the transmission of infection within the facility, pertinent signage would be posted on the resident's door and verbal reporting would be conducted between staff. 1. Resident #129 was admitted to the facility on [DATE] for short term rehabilitation following a total knee replacement. The most recent MDS dated [DATE] specified the resident was cognitively intact. Resident #129 discharged home on[DATE]. Resident #85 was admitted to the facility on [DATE] into a semi-private room with a roommate (Resident #129). Resident #85's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident was cognitively intact and had one venous/arterial ulcer. Review of Resident #85's medical record revealed a nurse's entry dated 10/21/14 that the resident's right lower extremity was red, swollen, warm and painful to touch and the physician was notified. On 10/22/14 the physician ordered a wound culture from the right lower leg and started Resident #85 on antibiotics for an infection in the right lower leg. Review of Resident #85's medical record revealed a document titled "Laboratory Result Summary" dated 10/25/14 at 3:01 PM that specified Resident #85 had heavy growth of Methicillin-resistant Staphylococcus aureus (MRSA). Further review of Resident #85's medical record revealed a nurse's entry made by Nurse #1 dated 10/25/14 that specified Resident #85's wound continued to have bloody drainage and that the physician ordered to continue the antibiotic for the wound infection and start intravenous (IV) [MEDICATION NAME] (antibiotic) for MRSA in the leg wound. Further review of the physician's orders and nurses' entries did not specify Resident #85 was placed on isolation precautions related to the [DIAGNOSES REDACTED]. A nurse's entry dated 10/28/14 specified Resident #85 was on contact precautions for MRSA. A nurse's entry dated 10/29/14 specified Resident #85's ace wrap to the right lower leg was changed due to "excessive weeping" of plaster from the Unna boot (a protective covering worn on the foot). Review of Resident #85's "admission/transfer/discharge" report and review of Resident #129's "admission/transfer/discharge" report, the residents remained in the same room until 10/29/14 when Resident #85 was moved to a private room. On 11/11/14 the physician ordered a wound culture to the right lower leg. The wound culture report dated 11/14/14 specified that the wound did not have growth of MRSA. Resident #85 was discharged home on[DATE]. On 01/30/15 at 4:55 PM Nurse #1 was interviewed and reported that he remembered Resident #85 but could not recall details of her admission to the facility. He stated that he did not recall receiving the laboratory report confirming that Resident #85 had MRSA in her leg wound on 10/25/14 or that the resident was on contact precautions. He stated that he was trained that when he received laboratory results of a resident with MRSA he would contact the physician for orders and implement contact precautions if ordered to do so. On 01/29/15 at 9:35 AM the Assistant Director of Nursing/Infection Control Nurse (ADON) was interviewed and reported that if a wound infected with MRSA had heavy drainage the resident was placed in a private room if possible or placed in a room with another resident with similar diagnoses. The ADON stated that a resident with MRSA would not be allowed to share a room with a resident that had a fresh surgical wound. The ADON was questioned about Resident #85's [DIAGNOSES REDACTED].#85's laboratory culture because of lack of communication. She stated that Resident #85 was in a semi-private room with Resident #129 that had a fresh surgical wound. The ADON stated that the residents remained in the same room from 10/25/14 through 10/29/14. She stated that she was not involved in the room change but added that the residents should not have been allowed to stay in the same room because of Resident #85's weeping wounds and Resident #129's fresh surgical wound. The ADON stated that the room change should have occurred on 10/25/14 when the facility became aware of Resident #85's MRSA. On 01/30/15 at 10:00 AM the Administrator was interviewed and reported that it was not ideal for the residents to share a room but it was the only option at the time until a private room became available. The Administrator added that contact precautions were implemented and she felt staff followed the required precautions. On 01/30/15 at 10:10 AM the Western Region Quality Assurance Nurse (QA Nurse) was interviewed and reported that she expected facilities to reference the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) guidelines for handling residents with MRSA and deciding when to implement contact precautions. She stated that in the case of Resident #85 and Resident #129 the residents should have been separated on 10/25/14 when Resident #85 was diagnosed with [REDACTED].#129 had a fresh surgical wound. She stated that she educated the DON and ADON regarding this practice. On 01/30/15 at 10:20 AM the DON was interviewed and reported that Resident #85 was placed on contact precautions on 10/25/14 but allowed to share a room with Resident #129. The DON stated that the residents were allowed to remain in the same room because a private room was not available for Resident #85 to move to. On 01/30/15 at 11:20 AM Resident #129 was interviewed on the telephone and reported that she was admitted to the facility into a semi-private room. She explained that the facility informed her that she was going to get a roommate that she identified as Resident #85. Resident #129 added that one day her roommate was started on IV antibiotics. Family members of Resident #85 informed Resident #129 that Resident #85's IV antibiotics were to treat an infection called MRSA. Resident #129 stated that she was scheduled for an appointment with her physician on 10/29/14 and she notified him that she was sharing a room with a resident with MRSA. She stated that the physician contacted the facility requesting a room change for the resident because of her recent knee surgery. Resident #129 stated that a room change occurred the same day as her appointment and that she discharged home a few days later. Resident #129 reported that she was not diagnosed with [REDACTED]. 2. Resident #39 was admitted to the facility 12/09/14 with [DIAGNOSES REDACTED]. A discharge summary from the hospital dated 12/09/14 specified cultures obtained from the sacral wound grew Escherichia (E.) coli which required antibiotic therapy. A care plan effective 12/09/14 identified Resident #39 with an infectious process as evidenced by a need for antibiotics and a pressure ulcer on the sacrum. The care plan goal specified the infection would be resolved with no complications within the next 30 days. Interventions included observe for signs and symptoms of infection and treatment of [REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognition was intact. The MDS specified the resident required extensive staff assistance with transfers, bed mobility, dressing, and toilet use. The MDS further specified the resident was admitted with an indwelling urinary catheter, experienced occasional bowel incontinence, and had 1 unstageable pressure ulcer. A Care Area Assessment (CAA) described Resident #39 as alert and oriented, had an unstageable pressure ulcer, and experienced occasional episodes of bowel incontinence. A review of Resident #39's medical record revealed a report written by the Wound Care Physician on 01/09/15. The report specified some areas of exposed bone were noted in the sacral wound. Further review revealed a biopsy of this bone was obtained and sent to the laboratory (lab) for culture and sensitivity. Additional medical record review revealed a lab result summary was faxed to the facility 01/14/15 at 3:01 PM. The report specified this was the final report from the culture and sensitivity. The report included documentation of moderate growth of MRSA was obtained and contact precautions were required for residents in healthcare facilities. This report was initialed by Resident #39's attending physician in the facility indicating the physician had been informed of these findings. There was no physician's order to implement contact precautions in the resident's medical record. An observation was conducted of the Staff Development Coordinator (SDC) providing urinary catheter care and a dressing change for the sacral wound for Resident #39 on 01/28/15 at 9:33 AM. Upon entering Resident #39's room, no contact precaution sign was observed on the door and no personal protective equipment was provided. Resident #39 was observed wearing a disposable brief which was removed. The SDC washed her hands, donned gloves, and properly performed catheter care first. She changed her gloves without washing her hands and proceeded with the dressing change to the sacral wound. The old dressing was in place and was observed not completely covering the sacral wound. The outside of the dressing contained smears of drainage which appeared clear with some streaks of red. An area approximately the size of a deck of cards of the same color drainage was observed on the resident's disposable brief. The SDC removed the old dressing. The wound was observed to be approximately the size of a small grapefruit. After removing the dressing, the SDC changed gloves and proceeded to clean the wound with cleanser that was in a non disposable spray bottle. As she positioned the bottle to spray all areas of the wound, the bottle made contact with a pad under the resident. The SDC placed the bottle directly on the resident's over bed table when she had completed the cleansing process. The SDC was observed following the physician's orders for the dressing change. When the process was complete, the SDC was observed removing her gloves, washing her hands, and gathering up supplies including the spray bottle from the resident's over bed table. The SDC proceeded to the treatment cart located in the hallway outside the resident's room. She was observed pulling open a plastic zip bag she had removed from a treatment cart drawer. She was observed holding the spray bottle of cleanser over the bag with the intent of placing it into the bag. When asked if she was going to clean the bottle first, she stopped and wiped the reusable spray cleanser bottle with a disposable disinfectant wipe. An interview was conducted with the SDC immediately following this dressing change. The SDC stated she knew the resident had an infection in the sacral wound but did not know what organism caused the infection. She stated if a sign indicating contact precautions had been posted on the resident's door, she would have worn a disposable gown. An additional interview was conducted with the SDC on 01/28/15 at 10:53 AM. The SDC stated she assessed all facility wounds every other week. She added she made rounds with the Wound Care Physician that visited Resident #39 every Friday. The nurses on the halls were responsible for providing wound care on a daily basis. An interview was conducted via phone with the attending physician on 01/28/15 at 3:21 PM. He stated if his initials were on the lab results report, he had seen it. The physician explained the facility usually initiated contact precautions as needed. An interview was conducted on 01/28/15 at 3:53 PM with the Assistant Director of Nursing (ADON) who also functioned as the Infection Control Nurse. The ADON stated Resident #39 was admitted to the facility on an antibiotic. She stated she was aware that Resident #39 had an infection but she was not sure what kind of infection. The ADON checked her infection tracking book and stated there was no documentation explaining why the resident was on the antibiotic. She added she was not aware of the actual culture that was obtained on 01/09/15 and she was not aware the culture identified MRSA in the sacral wound. The ADON stated each morning she reviewed lab report books at the nursing station and talked with the floor nurses to gather information regarding initiation of antibiotics on previous day. She stated she got a report at the end of the month generated by the pharmacy of all residents in the facility on antibiotics. The ADON stated she had been told the facility did not use contact precautions on known MRSA infections unless the wound had copious amounts of drainage. She explained if the drainage could be contained, contact precautions would not be needed. The ADON explained she had been in this position for 2 months. The previous ADON came to the facility on ce a week to help her learn her duties which included infection control. An interview was conducted with the Director of Nursing (DON) on 01/28/15 at 4:26 PM. The DON stated contact precautions were not used in this facility for MRSA if the drainage could be contained. The DON added if the attending physician had wanted contact precautions when he reviewed the lab results dated 01/14/15, he would have ordered those precautions. The DON stated the wound cleanser container should not have been placed back in the treatment cart without being disinfected first. An additional interview was conducted with the ADON on 01/29/15 at 3:17 PM. The ADON stated she expected hands were washed and gloves were changed when going from urinary catheter care to attending to a dressing change for a wound. An interview was conducted with the Housekeeping Supervisor (HS) on 01/29/15 at 4:31 PM. The HS stated a resident's room with a sign for contact precautions alerted the housekeepers that an active infectious process was going on in that room. She stated the housekeeper would clean the room first thing in the morning and again around mid day. The HS added after cleaning the room, the mop water and mop head would be changed before going on to the next resident's room. An interview was conducted with the Regional Director of Operations (RDO) on 01/29/15 at 4:47 PM. The RDO stated the nurse that received the laboratory report identifying MRSA should have contacted the attending physician to request contact isolation and ask if any new treatments should be started. The RDO added contact precautions should have been initiated at that time. The RDO stated the lab results should have been reported to the ADON, the Infection Control Nurse, at this time. An additional interview was conducted with the SDC on 01/30/15 at 2:03 PM. The SDC stated it was her normal practice to wash her hands between urinary catheter care and wound care. She stated she just forgot the day she was being observed. The SDC added she normally cleaned reusable supplies with a disinfectant before returning them to the plastic bag in the treatment cart. She explained each resident had their own labeled plastic bag with their supplies in it. She added the plastic bag did not go into the resident's room, only the supplies that were required to provide wound care. An interview was conducted via phone with Nurse Supervisor (NS) #2 on 01/30/15 at 4:00 PM. NS #2 stated she did not recall receiving the lab results faxed to the facility on [DATE] that contained information of MRSA in Resident #39 s sacral wound. She stated her usual practice when she received a lab report requiring contact precautions was to make a copy of the report and give it to the floor nurse to initiate contact precautions. NS #2 added she did not visually check to see if the nurse followed through. She added she would fax the report to the attending physician. NS #2 stated if the ADON was not there, she would not report the lab results identifying MRSA in the wound to her. 3. Resident #97 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) indicated the resident's cognition was moderately impaired. The MDS coded the resident required limited assistance for activities of daily living and independent with locomotion on and off the unit. Medical record review revealed a laboratory (lab) report faxed to the facility on [DATE] at 3:01 PM. The report specified this was the final analysis of the culture of a sputum specimen obtained 01/19/15. The report indicated the culture grew a moderate amount of MRSA. The report contained instructions that contact precautions were required in healthcare facilities. A tour of the hall where Resident #97 resided was conducted on 01/26/15 at 9:43 AM. No observations were made of contact precaution signs or containers for personal protective equipment on that hall. An interview was conducted with the Housekeeping Supervisor (HS) on 01/29/15 at 4:31 PM. The HS stated a resident's room with a sign for contact precautions alerted the housekeepers that an active infectious process was going on in that room. She stated the housekeeper would clean the room first thing in the morning and again around mid day. The HS added after cleaning the room, the mop water and mop head would be changed before going on to the next resident's room. An interview was conducted with the Regional Director of Operations (RDO) on 01/29/15 at 4:47 PM. The RDO added contact precautions should have been initiated when the lab report indicating MRSA was received via fax. The RDO stated the lab results should have been reported to the ADON, the Infection Control Nurse, and the physician should be called for any additional orders. An interview was conducted on 01/30/15 at 9:37 AM with the Assistant Director of Nursing (ADON) who also functioned as the Infection Control Nurse. The ADON stated if MRSA was identified and could be contained, it would not be necessary to initiate any isolation precautions. The ADON explained contained meant the infected area was protected by a dressing, brief, or was not exposed to air where other people could handle or touch it. She added if sputum could not be contained and was cultured to have MRSA, the resident would be placed in a private room if available. The ADON further stated residents with MRSA in sputum could cohort with another non infected resident if that resident did not have a fresh surgical wound or was not otherwise compromised. An interview was conducted with Nurse Supervisor (NS) #1 on 01/30/15 at 1:31 PM. NS #1 stated he did receive the faxed lab report that noted Resident #97's sputum culture was positive for MRSA on 01/22/15. NS #1 stated he did notify the physician and initiate contact precautions at that time. He stated the instructions documented on the lab report made him think contact precautions were needed. NS #1 added he was unable to recall if he notified the ADON, who served as the Infection Control Nurse. An additional interview was conducted with the DON on 01/30/15 at 1:52 PM. The DON stated Resident #97 was placed on contact precautions when the lab report of 01/22/15 identified MRSA in the resident's sputum. She stated the resident was monitored over the weekend. The resident was observed to contain his sputum in a cup so the contact precautions were removed. An interview was conducted with Resident #97 in the resident's room on 01/30/15 at 3:30 PM. A contact precaution sign was observed on the resident's room door. Resident #97 was observed in the bed by the window with the curtain pulled between his bed and his roommate's bed. He stated facility staff had not worn the mask and disposable gown until today. The resident pointed to a disposable cup on his over bed table. He stated when he coughed up sputum he spit it in the cup. An additional interview was conducted with the ADON on 01/30/15 at 4:24 PM. She stated she did not receive notification from the nursing staff that Resident #97's sputum was identified to contain MRSA. Autumn Care of Drexel Credible Allegation of Compliance (01/30/2015) F 441 1 a. Resident # 39 was admitted to facility on 12/09/2014. [DIAGNOSES REDACTED]. Wound culture 1/09/15. Final report 1/14/15 reveals moderate growth Methicillin Resistant Staph Aureus (MRSA). b. Resident # 117 was admitted to facility on 12/01/2014. Diagnosis: [REDACTED]. Wound culture 12/12/14 resulted moderate growth MRSA. Wound culture result 12/31/14 reveals Light growth MRSA. hospitalized from [DATE] -12/19/14 with left foot infection. c. Resident # 97 admitted to facility 11/12/2013. Diagnosis: [REDACTED]. Sputum culture January 19/15 results 1/22/15 reveals moderate growth MRSA. d. Resident # 85 admitted to facility 10/25/14: Diagnosis: [REDACTED]. Wound culture 10/28/2014 revealed MRSA. She was discharged from the facility to home 12/19/2014. This resident was placed on contact isolation on 10/24/2014, and transferred to private room on 10/29/14 when the room became available. Wound culture of 11/11/14 reveals negative for MRSA. Resident did not discharge on antibiotics. Residents #39, 117 and 85 were placed on contact isolation on 01/30/15. The residents in contact isolation were informed by the Assistant Director of Nursing (ADON) they were in contact isolation related to an infection and staff and visitors will wear appropriate PPE upon entering rooms 1/30/2015. Responsible parties/family members were notified of the residents' isolation 1/30/15 by the ADON. Contact isolation: gowning, gloving, bagging at source, donning PPE before entering room. Doff prior to leave room, wash hands, individual equipment: i.e.: dedicated stethoscope, sphygmomanometer, and wound equipment. The following departments have been in-serviced Infection control practice for contact isolation, by the Director of Nursing on 1/30/15: Therapy department, Environmental services, Dietary, Maintenance, Activities, Direct care staff, including aides, licensed nurses, administrative nurses in-serviced for infection control specifically contact isolation for residents with active symptoms and positive cultures for MRSA: Policy and procedure for contact isolation, infection control, precautions. Licensed nurses are re- trained to place residents in appropriate isolation the day a positive culture report is received or upon identified active symptoms with pending culture as well as co-horting residents with MRSA, not placing MRSA residents with new post op residents, immunocompromised residents, residents with wounds, trachs, catheters, and invasive devices. The ADON was inserviced 01/30/2015 by the administrator for: 1. Contact isolation recommendations and procedures including proper technique when to initiate contact precautions. 2. When to initiate a room change for a resident with active symptoms and or a positive culture report. 3. If available place resident in a private room. 4. Do not co-hort with immunosuppressed residents, residents with open wounds, catheters, ostomies. 5. Do not co-hort post op residents with surgical wounds with resident compromised with MRSA. This should be an immediate room change when a room is available preference being a private room. 6. Apply knowledge and training for contact isolation, co-horting residents, private rooms, ensuring training new systems is enforced. 7. The ADON was inserviced to print the physicians order report for a specified duration from the electronic healthcare record in order to monitor all culture orders. 8. ADON after reviewing the report, audits resident room to ensure proper contact isolation sign on door and isolation cart placed outside room. ADON ensures treatment equipment is placed in resident room and staff are aware and implement appropriate procedure per policy for contact isolation. 9. ADON re-educated to transcribe all pertinent data from report to the infection control line list for follow up. 10. ADON instructed that any resident with active signs of MRSA is placed in contact isolation pending culture report. All residents have potential to be affected therefore a 100% audit of all cultures and sensitivities since January 1, 2015 was completed by the Administrator and Infection Control Nurse on 1/30/15. 3 residents with MRSA were identified and have been placed in contact isolation. New system in place: 1. On admission the admitting nurse reviews admission paper work to identify residents with an infection. The admitting nurse initiates the proper isolation based on current treatment, diagnosis, labs, and active symptoms. 2. The admitting nurse also communicates to ADON by initiating the infection "tracking form # V01" which is available at each nurse's station in Electronic medical record. 3. The admitting nurse is responsible for implementing the required isolation precautions for infection control measures by placing isolation sign on door, and isolation cart outside room. 4. Residents with new onset infection, resident will be placed on isolation in compliance with active symptoms pending culture results. 5. The ADON pulls the "Physician orders within a specified duration," report 5 days weekly and the RN supervisor pulls the "Physician orders within a specified duration" on the weekends. Review of this report reveals all physician orders transcribed in the previous 24 hours. When any cultures are ordered the ADON will document the orders on the infection control line list. 6. The ADON will follow up for the finalized report in 48-72 hours. Any residents displaying active symptoms will be placed in appropriate isolation pending results of the culture report. 7. All nursing staff must receive inservice education for the current system in place for contact isolation and residents with active signs of infection prior to being allowed to work. Immediate Jeopardy was removed on 01/30/15 at 4:59 PM when the facility provided evidence of additional in-service training for all nursing staff related to proper implementation of infection control precautions. The Administrator and Assistant Director of Nursing provided additional evidence of the new notification system to alert the ADON of a resident with MRSA.