Every finding on record at Autumn Care of Nash

Based on record review and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Resident #86 requested toileting assistance from Nurse Aide (NA) #1 to use the bed pan for a bowel movement and the NA told the resident to have a bowel movement in his brief. A reasonable person expects to be assisted with toileting needs by their caregiver and would have experienced embarrassment when told to have a bowel movement in their brief rather than be assisted with toileting needs as requested. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #86). Findings included:Resident #86 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact. He had no behaviors and was dependent on staff for toileting and transfers. Resident #86 was coded as continent of bowel and bladder. Review of the facility's investigation documentation completed by the Administrator revealed on [DATE] Resident #86 and a family member filed a grievance about him being told to make a bowel movement in his brief when he asked Nurse Aide (NA) #1 for incontinence assistance on [DATE] at approximately 9:30 PM. NA #1 confessed this statement to the Administrator via telephone on [DATE]. It was determined that NA #1 was unsure of her resources to be able to care for the residents appropriately, and she did not know who she could ask for assistance at the time of the incident. She told Resident #86 once he had the bowel movement to turn on his call light prior to the end of her shift at 11:00 PM. At 11:00 PM, NA #2 completed her first round on Resident #86 and asked if he needed to go to the bathroom or if he needed his brief changed. He stated that he did not. NA #2 asked if she could check, and he said that it would be fine. She found Resident #86 to be clean and dry. The facility interviewed alert and oriented residents regarding dignity, and skin checks were performed on all non-interviewable residents. No concerns were found. Corrective actions included mandatory inservice for all staff on resident rights (dignity/respect). In addition, NA #1 was immediately suspended and when she returned to work the following week, she received a one-on-one education on dignity/respect. During a phone interview with Resident #86's family member on [DATE] at 2:49 PM they indicated that the resident was discharged from the facility on [DATE] and has since expired. During a phone interview on [DATE] at 1:44 PM, NA #1 recalled on the evening of [DATE] that it was her first day on the floor by herself. It was around 9:30 PM when final rounds were performed, and Resident #86 wanted to use the bedpan. She stated she felt overwhelmed because multiple residents rang the call bell at the same time, and she had never worked with Resident #86 before. All other nursing staff were busy. NA #1 stated she asked Resident #86 politely if he could have a bowel movement in his brief, and she would return to change him. However, she got busy with other residents and forgot to go back to his room before her shift was over at 11:00 PM. She indicated that she now knew what she said to Resident #86 was wrong, and she was suspended for 1.5 weeks during the investigation. Upon return, she received one on one education related to dignity/respect. An interview was conducted with NA #2. She revealed that she worked during the overnight shift on [DATE], and she was interviewed by the Administrator on [DATE] due to Resident #86's complaint on [DATE]. She reported that on [DATE] at 11:00 PM, she performed her first rounds and Resident #86 was dry/clean. The Director of Nursing (DON) was interviewed on [DATE] at 10:28 AM. She revealed that NA #1 was of a small body frame, and Resident #86 was a larger man, and NA #1 informed her she felt she could not put the resident on the bed pan. The DON stated that NA #1 could have retrieved the nurse on duty to help her with the bed pan. She (the DON) indicated NA #1 should have said, let me find someone else to assist and will return as soon as I can. NA #1 was suspended, educated, and re-initiated in NA training. An interview was conducted with the Administrator on [DATE] at 11:14 AM. He revealed that NA #1 should have told Resident #86 when he rang his call bell on [DATE] that she would get help and be right back. She was re-educated on dignity and why what she said was not appropriate. The facility provided the following corrective action plan with a completion date of [DATE]:- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #86 was told that he should go to the bathroom in his brief by his assigned nursing assistant at approximately 9:30 pm on [DATE]. Resident #86 was checked on during the overnight shift that began on [DATE] by the nursing assistant at 11:00 PM, 1:30 AM, 3:00 AM, and 5:30 AM. Per the nurse and nursing assistant assigned to the resident, the resident did not voice any issues or care needs until 5:30 AM at which point the resident had a bowel movement and activities of daily living care was provided. The resident was interviewed by the Director of Nursing and a grievance form was completed. The resident voiced the Administrator on [DATE] he was content with the facility's response according to the grievance form. - Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All cognitively intact residents were interviewed by the Nurse Supervisor and the Manager on Duty by [DATE] to ensure they had not been instructed by staff members to use their brief instead of assisting the resident to the bathroom. They were also asked if they felt safe or threatened. Skin checks were performed on cognitively impaired residents by the Nurse Supervisor and the Manager on Duty by [DATE] to identify care issues or any skin breakdown that could have been a result of a lack of care. No new issues were found. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The Administrator and designees educated all staff on residents' rights pertaining to dignity and respect. Education was initiated on [DATE] and completed by [DATE], on treating all resident as valued individuals in that help should be provided to maintain health and mental well-being. All new hires will be educated during orientation. Those that could not be educated prior to [DATE] were educated by the Director of Nursing via telephone and a signature was obtained upon their next scheduled shift. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The decision to take the plan of correction and monitoring to the Quality Assurance Performance Improvement Committee was determined on [DATE]. The Administrator or designee will complete an interview audit by interviewing 5 random cognitively intact residents weekly to determine if any staff member had refused care when asked, and 5 skin assessments on cognitively impaired residents weekly to identify care issues for 12 weeks. The audits will be presented to and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The Quality Assurance and Performance Improvement Committee may extend the monitoring period or change the plan of correction to ensure compliance. The corrective action plan completion date was [DATE]. The facility's corrective action plan was verified on [DATE] by the following:Interviews and record review verified Resident #86 was provided with incontinence care after NA #1 told him to make a bowel movement in his brief and before 11:00 PM. He did not require further care until 5:30 am. Record review revealed all cognitively impaired residents had skin assessments completed on [DATE] and cognitively intact residents were interviewed on [DATE] to identify any signs of mistreatment including incidents involving dignity issues. No issues were identified. Interviews with nursing staff revealed they were educated on treating residents with dignity, providing care to residents when they are asked for assistance and immediately reporting resident mistreatment to include incidents involving dignity issues. Record reviews of residents and interviews with cognitively intact residents confirmed weekly audits were completed by the senior management team for the duration of the monitoring period. The compliance date of [DATE] was validated.

Based on observations, record review, and staff, resident, and Medical Director interviews, the facility failed to notify the physician of a significant change when the resident's feeding tube site was identified by staff as visibly irritated, leaking, and caused the resident pain when touched for 1 of 1 sampled resident reviewed for feeding tube care (Resident #64). Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses that included gastrostomy status (an artificial opening into the stomach through the abdomen wall to provide nutritional support). Review of Resident #64's physician orders revealed that on 4/5/25 a new order was initiated for nurses to clean the gastronomy tube (g-tube) site with normal saline and then apply a calcium alginate cover with split gauze twice daily until healed. Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 was moderately cognitively impaired and she had a feeding tube. Review of the treatment administration record (TAR) for Resident #64 during the month of July 2025 revealed that Nurse #1 signed off on the order for g-tube site care on 7/23/25. During an interview with Nurse Aide (NA) #3 on 7/24/25 at 8:35 AM, she revealed that during care this morning, Resident #64's g-tube site had a smell and gurgling sounds/movements. The site looked very red, the gauze was saturated, and it needed to be removed during Resident #64's bath that morning. NA #3 stated she told Nurse #1 about her concerns when she observed Resident #64's g-tube site this morning. An observation of Resident #64's g-tube site was conducted in conjunction with an interview on 7/24/25 at 8:40 AM. Resident #64 gave permission to observe her g-tube site. There was a large area of redness (excoriation) indicating irritation on the outer area of the skin fold holding the g-tube. The surgical site could not be seen entirely due to Resident #64's positioning causing a large skin fold holding the g-tube in between. A white discharge was observed leaking causing buildup inside the skin fold. When asked, Resident #64 stated she felt pain when the skin fold was opened, or the red area was touched. There was no gauze surrounding the site. Nurse #1 was interviewed on 7/24/25 at 8:55 AM. She stated that when she cleaned Resident #64's g-tube site on 7/23/25 during the day, she observed an odor like curdled milk from the feeding that leaked. The leaking and odor were new observations. She also noticed redness around the site, which was a daily occurrence for Resident #64, and she did not complain of pain on 7/23/25. Nurse #1 stated she had not had a chance to clean it yet this morning. An interview and observation of Resident #64 were conducted with the ADON on 7/24/25 at 8:59 AM. She revealed that Nurse #1 was the unit manager for the 300-hall, but Nurse #1 would cover the cart if there was a call out. The ADON confirmed the presence of leakage and an excoriated area around the g-tube site. She further confirmed Resident #64 stated the area was painful to the touch. She stated that Nurse #1 should have addressed this concern yesterday and notified the provider on 7/23/25 because the pain, leaking, and discomfort was a significant change. During the interview and observation of the resident with the ADON, Nurse #1 entered Resident #64's room at 9:04 AM. She observed the g-tube site and stated it looked about the same, just not as red as yesterday. Nurse #1 indicated that NA #3 told her earlier that morning the gauze was wet and removed during the bath this morning due to being soiled. She said if she thought there was an issue, she would have notified the provider on 7/23/25. Nurse #2, who worked overnight on 7/23/25 beginning at 11:00 PM, was interviewed on 7/25/2025 at 8:59 AM. She confirmed that the area was red (excoriated) around Resident #64's g-tube site where the gauze was placed and when she administered medications via the tube, the flow machine (a medical device used to allow a controlled liquid flow through a tube) said that it was clogged. However, that did not seem to be the case because she was able to administer the medications and flushes. Nurse #2 stated that she did not look at the actual g-tube surgical opening to assess. Resident #64 had been in and out to the Emergency Department (ED) several times during July due to g-tube site complications, and they sent her back saying it was fine. She stated when she had concerns with the g-tube site in the past, she called the on-call provider, and they suggested for the Medical Director to look at it the next morning. Nurse #2 stated she would have sent Resident #64 out to the ED to be evaluated and ensure the tube feed infusion was sufficient. However, due to her experience with notifying the provider, she stated she notified Nurse #1 (the oncoming day shift nurse on 7/24/25) instead. Nurse #1 told her that she had the same problem with Resident #64's tube feeding site this past week. During an interview with the Director of Nursing (DON) on 7/25/25 at 10:11 AM, she revealed the red skin around the g-tube site had been a chronic issue, and the resident was seen by the wound provider last year. She indicated if Nurse #2 reported an issue to Nurse #1 about Resident #64's g-tube site leaking and being painful to the touch, Nurse #1 should have evaluated the area and notified the Medical Director, who was in the building the morning of 7/24/25. Since Resident #64's g-tube site issue was not a life-threatening emergency, having the oncoming dayshift nurse address it seemed to be appropriate. The Medical Director was interviewed by phone on 7/30/25 at 8:38 AM. He stated that historically, Resident #64 has had issues with her g-tube being replaced. He indicated that he had not seen the g-tube site recently (within the last few months). He stated if there was a new or active concern such as new discomfort/pain/excoriation, he was not made aware. The Medical Director stated he would want to be notified of the concerns observed on 7/23/25 and 7/24/25 because the symptoms could worsen if not addressed.

Based on record review, staff and resident interviews, Pharmacy Manager and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 3 residents reviewed for misappropriation of property (Resident #96 and Resident #18). The findings included:The facility's Abuse, Neglect, and Exploitation policy last revised on 7/11/24 revealed it was the facility's policy to report all allegations to the Administrator/Abuse Coordinator. The policy further read that the Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. The policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without consent. a. Resident #96 was admitted to the facility on [DATE] with diagnoses which included joint replacement surgery. Resident #96 discharged from the facility on 3/03/25.Resident #96 had a physician order dated 2/04/25 for oxycodone (an opioid pain medication) 5 milligram (mg) tablet; give one tablet by mouth every 4 hours as needed for pain for up to 7 days. The order was discontinued on 2/11/25.The Medication Administration Record (MAR) for February 2025 revealed Resident #96 was administered the oxycodone 5 mg tablet on 2/06/25 at 10:25 am for pain by Nurse #3 and was noted as effective. No other doses were documented as administered.A review of Resident #96's prescriptions for schedule II-IV controlled medication revealed hand-written prescriptions for oxycodone 5 mg tablet x 30 tablets were sent to the pharmacy and received at the facility on the following dates in February 2025:2/06/25 oxycodone 5 mg tablet x 30 tablets were received by the facility staff.2/13/25 oxycodone 5 mg tablet x 30 tablets were received by the facility staff.2/18/25 oxycodone 5 mg tablet x 30 tablets were received by the facility staff.2/24/25 oxycodone 5 mg tablet x 30 tablets were received by the facility staff.b. Resident #18 was admitted to the facility on [DATE] with diagnoses which included osteoarthritis, fracture of right ulna (forearm bone), and gout.Resident #18 had a physician order dated 4/30/24 for oxycodone (an opioid pain medication) 5 milligram (mg) tablet, administer 1 tablet every 4 hours as needed for pain.A review of Resident #18's prescriptions for schedule II-IV controlled medication revealed hand-written prescriptions for oxycodone 5 mg tablet x 30 tablets were received at the facility on the following dates in February 2025:1/31/25 oxycodone 5 mg tablet x 30 tablets were ordered and were delivered to the facility on 2/04/25.2/12/25 oxycodone 5 mg tablet x 30 tablets were ordered and were delivered to the facility on 2/18/25.2/18/25 oxycodone 5 mg tablet x 30 tablets were ordered and delivered to the facility on 2/24/25.The Medication Administration Record (MAR) for February 2025 revealed Resident #18 was administered the oxycodone 5 mg tablet on the following dates and times:2/04/25 at 9:41 pm by Nurse #4 and the medication was noted as effective.2/05/25 at 7:40 pm by Nurse #4 and the medication was noted as effective.2/11/25 at 8:25 pm by Nurse #4 and the medication was noted as effective.2/12/25 at 8:24 pm by Nurse #4 and the medication was noted as effective.2/17/25 at 9:04 pm by Nurse #4 and the medication was noted as effective.2/24/25 at 7:32 pm by Nurse #4 and the medication was noted as effective.2/26/25 at 10: 25 am by Nurse #5 and the medication was noted as effective.2/28/25 at 7:42 pm by Nurse #4 and the medication was noted as effective.An interview was conducted with Resident #18 on 7/25/25 at 1:10 pm. Resident #18 revealed her pain was controlled and she had no issues getting pain medication when needed. Resident #18 stated she did not often have pain and she did not recall a time when she could not get the medication.A review of the initial allegation report revealed the facility became aware of the misappropriation of facility property on 2/28/25 at 12:00 pm when the Director of Nursing (DON) determined narcotic medications were delivered for a resident that no longer had an active physician order. An allegation of diversion of facility drugs was submitted for Resident #96 and Nurse #3 was suspended pending the outcome of the investigation. The Administrator submitted the initial allegation report on 2/28/25 at 2:48 pm.A review of the 5-day investigation report dated 3/06/25 revealed the allegation of diversion of facility drugs was substantiated by the facility and identified two residents (Resident #96 and Resident #18) who were affected. The DON noted the number of narcotic count down sheets (used to record the administration of the medication) and the number of narcotic medication cards that were unaccounted for was 7 in total. Resident #96 was found to be missing 4 medication cards and declining count sheets for oxycodone 5 mg tablets and Resident #18 was found to be missing 3 medication cards and declining count sheets for oxycodone 5 mg tablets. Each medication card contained 30 tablets. Nurse #3 was terminated and reported to the North Carolina Board of Nursing.An attempt to conduct a telephone interview with Nurse #9, who reported the narcotic concern to the DON on 7/25/25 at 3:34 pm was unsuccessful.A telephone interview was conducted on 7/25/25 at 12:33 pm with the Pharmacy Manager who revealed when the facility submitted the hand written prescriptions for the oxycodone 5 mg tablets the orders would be processed and delivered to the facility with the next pharmacy delivery unless the prescription was ordered too early, in which case it would be sent when next available. The Pharmacy Manager stated that when narcotics were delivered to the facility the medication would have a narcotic count down sheet for each 30 pack of tablets sent and the receiving nurse would have to sign the delivery sheet that the medication was received. The Pharmacy Manager reported the pharmacy was notified of the missing narcotics, confirmed the narcotics were not returned to pharmacy, and assisted the facility with their investigation.An interview was conducted with the Medical Director on 7/25/25 at 3:07 pm who revealed he previously had left a few signed blank prescription slips at the facility for emergency use, normally with the DON or Assistant Director of Nursing (ADON). The Medical Director stated he no longer provided the facility with the signed blank prescription slips since he was able to electronically submit prescriptions to the pharmacy at any time for the needs of the residents. The Medical Director stated Nurse #3 was previously employed by the facility as the ADON before she returned as a staff nurse, but he was unable to confirm when Nurse #3 obtained the signed blank prescription slips to order narcotics from the pharmacy for Resident #96 and Resident #18. During an interview on 7/25/25 at 11:47 am with the Director of Nursing she revealed that Nurse #9 who reported a concern regarding Resident #96's narcotics due to finding a declining count sheet on the floor at the nursing station. The DON stated she began an investigation on 2/28/25 and found that Resident #96's oxycodone had been ordered several times after the order was discontinued. The DON stated that during the investigation the facility determined that Resident #18 also had multiple prescriptions sent to the pharmacy for oxycodone 5 mg tablets and based on the medication administration documentation and interview, Resident #18 had not taken the oxycodone pain medication often enough to require multiple prescriptions. The DON stated she spoke with Resident #18 upon identification of the findings and Resident #18 stated she did not use the pain medication often but she had no concerns regarding her pain management or availability of the medication. The DON stated Nurse #3 was interviewed when she identified that the handwriting on the oxycodone prescriptions for both residents belonged to Nurse #3 and she stated Nurse #3 initially denied all suspicions and was suspended until the investigation could be completed. The DON stated that after Nurse #3's suspension, Nurse #3 contacted the DON and admitted that she wrote the prescriptions and took the medications from the facility. The DON stated the investigation determined that the ordered narcotics as well as the narcotic count down sheets for Resident #96 and Resident #18 were removed from the facility upon delivery by Nurse #3. The DON stated Nurse #3 ordered the medications on days that she worked so they would be delivered to the facility before she ended her shift and removed the narcotics from the medication carts along with the declining count sheets so there was no way of tracking the medications. The DON stated they were unable to locate any of the ordered narcotics or count down sheets at the facility and she confirmed with the pharmacy that the narcotics ordered for Resident #96 and Resident #18 were not returned. The DON stated Nurse #3 was terminated and she was reported to the North Carolina Board of Nursing (NCBON) for diversion of narcotics.The Administrator was interviewed on 7/25/25 at 3:43 pm who revealed when the facility became aware of the possible drug diversion the facility immediately reported the allegation to the appropriate authorities and initiated a full investigation. The Administrator stated the DON was responsible for the investigation and determined that Nurse #3 had written the prescriptions and removed Resident #96's and Resident #18's ordered oxycodone from the facility when the medications were delivered.Upon discovery of the occurrence, the facility implemented the following quality assurance measures: On 2/28/25 it was determined that there were narcotics delivered to a resident that no longer had an order for the medications. The medications were not in the facility and had not been returned to the pharmacy. On 2/28/25 the DON contacted the pharmacy and obtained copies of the written prescriptions that had been faxed from the facility fax machine and the investigation conducted. A root cause analysis was completed and it was determined that there was no system in place to ensure medications were actually received on delivery and the facility had no system to ensure medications and declining count sheets were removed from the cart appropriately. The decision to monitor the system for receipt of narcotics and removal of medication and count down sheets from medication carts was made on 3/06/25 by the Administrator and Director of Nursing and was presented to the Quality Assurance Performance Improvement (QAPI) Committee on 3/06/25 during an Ad-Hoc (as needed) meeting. The facility provided the following corrective action plan with completion date of 3/07/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 2/28/25 The Director of Nursing (DON) interviewed the identified residents regarding pain medication administration, pain medication availability, and pain management with no identified concerns. On 2/28/25 the Regional Director of Clinical Services initiated a review of the pharmacy delivery tickets and conducted an interview with the Nurse that was scheduled on the dates the prescriptions were faxed to the pharmacy. The Nurse (Nurse #3) was interviewed and suspended pending further investigation. On 2/28/25 at 1:00 pm the Administrator notified law enforcement of the reasonable suspicion of a crime. On 2/28/25 at 2:48 pm the Administrator submitted the initial allegation report to the State Agency regarding diversion of facility drugs. On 3/03/25 at 11:04 am the DON submitted information to the North Carolina Board of Nursing (NCBON) regarding Nurse #3 and diversion of narcotics. On 3/03/25 the Administrator educated the Medical Director not to provide any staff members, nursing administration included, with signed blank prescription slips at the facility. On 3/06/25 the Administrator notified the Department of Social Services regarding misappropriation of resident property. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 2/28/25 the DON searched each nursing station for any signed blank prescriptions with no issues identified. The DON posted information at each nursing station that no pre-signed prescriptions were to be used by nursing staff. On 2/28/25 the DON completed a pain assessment for all cognitively impaired residents in the facility; the pain assessments were documented in the electronic health record. No issues were identified during the assessments. On 2/28/25 The DON interviewed all cognitively intact residents in the facility regarding pain medication availability, administration of pain medication, and pain management. There were no negative findings from the interviews. On 3/05/25 the Regional Director of Clinical Services conducted an audit of all narcotic delivery tickets from 2/01/25 through 3/02/25 and compared to declining count sheets to ensure each medication delivered to the facility was accounted for. The negative findings included a total of 9 declining count sheets and 9 missing medication cards were identified. Upon further investigation in coordination with the Pharmacy it was determined that in total the facility had 7 missing medication cards and declining count sheets for 2 identified residents. The 7 missing medications and declining count sheets were for the medication oxycodone 5 milligram tablets and were ordered for Resident #96 and Resident #18. The pharmacy was contacted and confirmed there were no documented returns for the missing 7 medication cards and the medications were not located at the facility throughout the investigation. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 2/28/25 the DON implemented a new narcotic count sheet which required the nurses to enter specific details about medications delivered and the details as to when the medication was removed from the medication cart, which would include any narcotic medication brought in by a resident or family upon admission. On 2/28/25 the DON initiated education to all nursing staff which included the newly developed narcotic count sheet, implementation that two nurses are required to sign and validate the narcotic medication and the count sheet were added to the medication cart upon delivery, only administrative nurses will remove completed or returned narcotic from the medication cart and book, and that no nurse was to fill out a pre-signed hard script (prescription). This education was completed on 3/05/25. On 2/28/25 the DON initiated facility wide education on the Abuse policy which included misappropriation of resident property. The education was completed on 3/06/25. Education will be done by the DON or designee at orientation for all new hire nurses on the process of receiving and removing narcotic medication. All new hire staff will be educated on the Abuse policy including misappropriation of resident property upon orientation to the facility. No staff member will be allowed to work until the education has been received and verbalize understanding. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. To ensure ongoing compliance the DON or designee will review the pharmacy delivery tickets 5 times per week for 12 weeks to ensure each narcotic that was delivered to the facility was added to the medication cart correctly. The DON or designee will review the narcotic log book 5 times per week for 12 weeks to ensure each card that was removed from the medication cart was listed correctly on the narcotic count sheet and was validated by the DON or designee. The DON or designee will conduct 2 pain interviews for cognitively intact residents and 2 pain assessments on cognitively impaired residents weekly for 12 weeks. Any issues identified during the monitoring process will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee which consists of the DON, Administrator, Assistant DON, Social Worker, Admissions Coordinator, Activity Coordinator, Minimum Data Set (MDS) Nurse, and the Medical Director. The audits will be reviewed monthly for 3 months by the QAPI team and the plan will be changed or audits extended to ensure ongoing compliance. The alleged date of compliance was 3/07/25. The facility's corrective action plan was verified on 7/25/25 by the following:A random narcotic count sheet and narcotic medication card reconciliation review was conducted with no identified concerns. The review of the receipt and removal of the narcotic medication audits to date revealed no identified concerns. A record review was completed of the staff signature logs for the education with no concerns identified. Record review of resident interviews with cognitively intact residents and pain assessments for cognitively impaired residents confirmed weekly audits were completed to date.Interviews were conducted with random residents who were prescribed narcotic pain medication with no concerns identified regarding pain management. Interviews with nursing staff revealed they were educated on receipt of pharmacy order, the process to add newly received narcotics to the medication cart, and removal of narcotics to be completed by nursing administration. Interviews with staff confirmed education was conducted regarding abuse and misappropriation of resident property. The compliance date of 3/07/25 was validated.

Based on record review and staff interviews, the facility failed to develop a care plan for 1 of 5 residents reviewed for psychotropic medications (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included vascular dementia.Review of a physician's order dated 7/9/25 revealed an order for Olanzapine 2.5 milligrams (MG), take 1 tablet by mouth at bedtime. (Olanzapine is an antipsychotic medication used to treat mental health conditions and regulate your mood, behaviors and thoughts)The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had severe cognitive impairment and received antipsychotic medication on a routine basis.Review of Resident #2 ‘s Comprehensive Care Plan dated 10/29/24 and revised 7/11/25 contained no information or interventions regarding antipsychotic medications.An interview conducted with the MDS nurse on 7/24/25 at 10:00 AM. The nurse was observed to review Resident #2's care plan and stated it must have been an oversight that Resident #2 was not care planned for the antipsychotic medication.On 7/25/25 at 3:55 PM an interview was conducted with the Administrator who stated he expected that antipsychotics would be included in the resident's care plan.

Based on record review, and staff, Pharmacy Manager, and Medical Director interviews, the facility failed to have effective systems in place for the inventory of controlled substances which resulted in a narcotic medication being ordered for a resident that did not have a physician order and the medication being diverted from the facility for 1 of 3 residents reviewed for misappropriation of resident's property (Resident #96). The findings included:Review of the Inventory Control of Controlled Substances Policy last revised 8/01/24, read in part a facility representative should regularly check the inventory records to reconcile inventory. The policy further noted this process should include current and discontinued inventory of controlled substances to the log used in the facility's-controlled medication inventory system.Resident #96 was admitted to the facility on [DATE] with diagnoses which included joint replacement surgery. Resident #96 discharged from the facility on 3/03/25.Resident #96 had a physician order dated 2/04/25 for oxycodone (an opioid pain medication) 5 milligram (mg) tablet; give one tablet by mouth every 4 hours as needed for pain for up to 7 days. The order was discontinued on 2/11/25.A review of Resident #96's hand-written prescriptions for schedule II-IV controlled medication and the prescription manifest (log of medications received at the facility) confirmed prescriptions for oxycodone 5 mg tablet x 30 tablets per medication card were received at the facility after the physician order was discontinued on 2/13/25, 2/18/24, and 2/24/25.A telephone interview was conducted on 7/25/25 at 12:33 pm with the Pharmacy Manager who revealed when the facility submitted the hand written prescriptions for Resident #96's oxycodone 5 mg tablet the order was processed and delivered to the facility. The Pharmacy Manager stated the written prescriptions received from the facility were considered a physician order and she stated the pharmacy staff were not responsible to confirm that there was an active order in the facility electronic health record prior to processing the order for Resident #96. The Pharmacy Manager stated the facility was responsible for the management the medication once it was delivered to the facility. During an interview on 7/25/25 at 3:07 pm the Medical Director revealed that in the past he had left a few signed blank prescription slips at the facility with the DON or ADON for emergency use only when he was unable to be reached or unable to provide a prescription for resident medication. The Medical Director stated Nurse #3 was previously employed by the facility as ADON before she returned as a staff nurse recently, but he was unable to confirm when Nurse #3 obtained the signed blank prescription slips to order narcotics from the pharmacy for Resident #96 without his knowledge.During an interview on 7/25/25 at 11:47 am with the Director of Nursing she revealed the facility did not have a process in place to make sure that narcotic medication that was delivered to the facility was put in the medication cart and verified as current order. She stated the nurses would sign for the medication and then put the pharmacy manifest (delivery sheet) in a bin in the medication storage room but there was not a process in place for reviewing to make sure the medications were correct, that the order was confirmed, and that the medication was in the cart. The DON stated Nurse #3 was interviewed when she identified that the handwriting on the oxycodone prescriptions for Resident #96 belonged to Nurse #3. The DON stated Nurse #3 was suspended until the investigation could be completed and that Nurse #3 later contacted her and admitted that she wrote the prescriptions for Resident #96's oxycodone and took the medications from the facility. The DON stated Nurse #3 was terminated and she was reported to the North Carolina Board of Nursing (NCBON) for diversion of narcotics.The Administrator was interviewed on 7/25/25 at 3:43 pm who revealed the facility was unable to confirm how Nurse #3 obtained the signed blank prescriptions to order the medication for Resident #96. The Administrator stated the DON was responsible for the investigation and determined that Nurse #3 had written the oxycodone prescriptions for Resident #96 after the order was discontinued and that Nurse #3 had taken the medication from the facility. Upon discovery of the occurrence, the facility implemented the following quality assurance measures: On 2/28/25 it was determined that there were narcotics delivered to a resident that no longer had an order for the medications. The medications were not in the facility and had not been returned to the pharmacy. On 2/28/25 the DON contacted the pharmacy and obtained copies of the written prescriptions that had been faxed from the facility fax machine and the investigation conducted. A root cause analysis was completed and it was determined that there was no system in place to ensure medications were actually received on delivery and the facility had no system to ensure medications and declining count sheets were removed from the cart appropriately. The decision to monitor the system for receipt of narcotics, confirmation of active orders, and the removal of the medication and count down sheets from medication carts was made on 3/06/25 by the Administrator and Director of Nursing and was presented to the Quality Assurance Performance Improvement (QAPI) Committee on 3/06/25 during an Ad-Hoc (as needed) meeting.The facility provided the following corrective action plan with a completion date of 3/07/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 2/28/25 The Director of Nursing (DON) interviewed the identified resident regarding pain medication administration, pain medication availability, and pain management with no identified concerns. On 2/28/25 the Regional Director of Clinical Services initiated a review of the pharmacy delivery tickets and conducted an interview with the Nurse that was scheduled on the dates the prescriptions were faxed to the pharmacy. The Nurse (Nurse #3) was interviewed and suspended pending further investigation.On 2/28/25 at 1:00 pm the Administrator notified law enforcement of the reasonable suspicion of a crime. On 2/28/25 at 2:48 pm the Administrator submitted the initial allegation report to the State Agency regarding diversion of facility drugs.On 3/03/25 at 11:04 am the DON submitted information to the North Carolina Board of Nursing (NCBON) regarding Nurse #3 and diversion of narcotics. On 3/03/25 the Administrator educated the Medical Director not to provide any staff members, nursing administration included, with signed blank prescription slips at the facility. On 3/06/25 the Administrator notified the Department of Social Services regarding misappropriation of resident property. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 2/28/25 the DON searched each nursing station for any signed blank prescriptions with no issues identified. The DON posted information at each nursing station that no pre-signed prescriptions were to be used by nursing staff. On 2/28/25 the DON completed a pain assessment for all cognitively impaired residents in the facility; the pain assessments were documented in the electronic health record. No issues were identified during the assessments. On 2/28/25 The DON interviewed all cognitively intact residents in the facility regarding pain medication availability, administration of pain medication, and pain management. There were no negative findings from the interviews. On 2/28/25 the DON started a review of all current narcotic delivery tickets in the pharmacy management system and the pharmacy website to ensure the delivered narcotics were for residents with active orders, no other concerns were identified.On 3/05/25 the Regional Director of Clinical Services conducted an audit of all narcotic delivery tickets from 2/01/25 through 3/02/25 and compared to declining count sheets to ensure each medication delivered to the facility was accounted for. The delivery tickets were also reviewed by the Regional Director of Clinical Services to ensure that all narcotic delivery tickets from 2/01/25 through 3/2/25 were written for prescribed narcotics and were for active orders. The only narcotic delivered to the facility for a resident without an active order were for the affected resident, Resident #96. The pharmacy was contacted and confirmed there were no documented returns for the ordered medication and the medication was not located at the facility throughout the investigation. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 2/28/25 the DON implemented a new narcotic count sheet which required the nurses to enter specific details about medications delivered and the details as to when the medication was removed from the medication cart, which would include any narcotic medication brought in by a resident or family upon admission. On 2/28/25 the Director of Nursing initiated an audit tool for review and confirmation of all narcotic delivery tickets in the pharmacy management system and the pharmacy website to ensure the delivered narcotics were for residents with active orders.On 2/28/25 the DON initiated education to all nursing staff which included that no nurse was to fill out a pre-signed hard script (prescription) for resident medications and the process for the newly developed narcotic count sheet. Education also included the implementation that two nurses are required to sign and validate the narcotic medication and the count sheet were added to the medication cart upon delivery, only administrative nurses will remove completed or returned narcotic from the medication cart and book, and that the narcotic delivery tickets were to be returned to the DON or designee for review and confirmation of resident active orders. This education was completed on 3/05/25. Education will be done by the DON or designee at orientation for all new hire nurses on the process of ordering, receiving, and removing narcotic medication. All new hire staff will be educated on the Abuse policy including misappropriation of resident property upon orientation to the facility. No staff member will be allowed to work until the education has been received and verbalize understanding. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. To ensure ongoing compliance the DON or designee will review the pharmacy delivery tickets and the pharmacy management system 5 times per week for 12 weeks to ensure each narcotic that was delivered to the facility was added to the medication cart correctly and the delivered narcotic was for residents with an active order. The DON or designee will review the narcotic log book 5 times per week for 12 weeks to ensure each card that was removed from the medication cart was listed correctly on the narcotic count sheet and was validated by the DON or designee. The DON or designee will conduct 2 pain interviews for cognitively intact residents and 2 pain assessments on cognitively impaired residents weekly for 12 weeks. Any issues identified during the monitoring process will be reviewed by the Quality Assurance Performance Improvement Committee which consists of the DON, Administrator, Assistant DON, Social Worker, Admissions Coordinator, Activity Coordinator, Minimum Data Set Nurse, and the Medical Director. The audits will be reviewed monthly for 3 months by the QAPI team and the plan will be changed or audits extended to ensure ongoing compliance. The alleged date of compliance was 3/07/25. The facility's corrective action plan was verified on 7/25/25 by the following:A random narcotic count sheet and narcotic medication card reconciliation review was conducted with no identified concerns. A random pharmacy manifest log and active order review was completed with no identified concerns. A record review was completed of the staff signature logs for the education with no concerns identified. The review of the receipt and removal of the narcotic medication audits to date revealed no identified concerns. The narcotic delivery and active order audit was reviewed with no identified concerns to date. Record review of resident interviews with cognitively intact residents and pain assessments for cognitively impaired residents confirmed weekly audits were completed to date.Interviews were conducted with random residents who were prescribed narcotic pain medication with no concerns identified regarding pain management. Interviews with nursing staff revealed they were educated on receipt of pharmacy orders, the process to add received narcotics to the medication cart and to return the pharmacy delivery sheet to the DON after the medication was received. The nursing staff also confirmed that education was provided to not use any signed blank prescriptions for any resident medication needs and that removal of all narcotics from the medication carts was to be completed by nursing administration. Interviews with staff confirmed education was conducted regarding abuse and misappropriation of resident property. The compliance date of 3/07/25 was validated.

Based on record review and staff interviews, the facility failed to maintain an accurate medication administration record for 1 of 5 residents reviewed for medication administration (Resident #36).The findings included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included seizures.1a. Review of a physician order dated 5/1/24 revealed Lamotrigine 200 milligrams (mg) was to be administered two times a day for seizures. (Lamotrigine is an anticonvulsant medication used to treat and prevent seizures)Review of Resident #36's June Medication Administration Record (MAR) revealed no documentation of Resident #36's receiving her 8:00 PM dose of Lamotrigine on 6/2/25, 6/4/25, 6/10/25, 6/11/25, 6/12/25, 6/17/25, and 6/18/25.1b. Review of a physician order dated 5/1/24 revealed Phenobarbital 60 mg was to be given at bedtime for seizures. (Phenobarbital is a barbiturate derivative medication used to treat seizures)Review of Resident #36's June MAR revealed no documentation of Resident #36's receiving her 8:00 PM dose of Phenobarbital on 6/2/25, 6/4/25, 6/10/25, 6/11/25, 6/12/25, 6/17/25, and 6/18/25.During an interview with Nurse #10 on 7/24/25 at 3:29 PM she stated she was familiar with Resident #36 and worked with her often. Nurse #10 reported Resident #36 usually came to the medication cart to request her evening medications after dinner. Nurse #10 stated there were no issues with Resident #36 refusing her medications. Nurse #10 stated she had administered Resident #36's seizure medications in the evening on 6/2/25, 6/4/25, 6/10/25, 6/11/25, 6/12/25, 6/17/25, 6/18/25. Nurse #10 stated medication administration documentation should have been completed when the medication was given. Nurse #10 stated she had missed the documentation because her assignment was heavy and busy. Nurse #10 further indicated she had met the Director of Nursing (DON) (6/19/25) and the missing documentation was brought to her attention. Nurse #10 further stated she was educated by the DON on how to go back into the MAR to complete the missing documentation. Nurse #10 stated she thought she had fixed the missing documentation.An interview was conducted with the DON 7/24/25 at 4:25 PM. The DON stated she went to Nurse #10 on 6/19/25 when she reviewed Resident #36's MAR and saw the missing documentation. The DON stated she educated Nurse #10 on how to edit the MAR to complete the missing documentation. The DON stated she expected that all medications administered would be documented in the MAR. She further stated if the medication was administered and the documentation was missed, she expected the employee would amend the MAR to reflect the administration of the medication.An interview was conducted with the Administrator on 7/25/25 at 3:53 PM. The Administrator stated he expected that all medication doses given would be documented. The Administrator further stated he expected that when missing documentation was brought to staff's attention the missing documentation would have been corrected.

Based on record review and resident and staff interviews, the facility failed to notify the Ombudsman in writing of an unplanned discharge to home for 1 of 3 residents reviewed for discharge (Resident #68). In addition, the facility failed to notify the Resident Representative in writing of the reason for the transfer/discharge to the hospital and failed to provide a copy of the bed hold policy to the resident and Resident Representative for 3 of 4 residents reviewed for hospitalization (Resident #5, Resident #36, and Resident #54).The findings included: 1. Resident #68 was admitted to the facility on [DATE]. The Discharge Against Medical Advice (AMA) form dated 6/16/25 revealed Resident #68 was signed out from the facility by the Responsible Party (RP) against medical advice. The Discharge Against Medical Advice form was signed by the Director of Social Services. The Ombudsman Notification for June 2025 (a list residents that was provided to the Ombudsman to notify of resident transfers/discharges that occurred from 6/1/25 through 6/30/25) revealed Resident #68’s AMA discharge from the facility on 6/16/25 was not included in the notification information sent to the Ombudsman. During an interview on 7/24/25 at 8:53 am the Director of Social Services revealed she did not notify the Ombudsman of Resident #68’s AMA discharge to home. The Director of Social Services stated that she notified the Ombudsman of transfers to the hospital only and not any residents that discharged home. An interview was conducted with the Administrator on 7/24/25 at 2:59 pm who revealed the Director of Social Service was responsible to notify the Ombudsman of transfers from the facility but he was not sure if that included residents that discharged home. 2. Resident #5 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was independent with daily decision making. A review of Resident #5’s progress notes revealed he was discharged to the hospital on 7/10/2025 and had not readmitted to the facility. Review of Resident #5’s medical record revealed no documentation Resident #5, or his Resident Representative received written notification of the reason for his transfer/discharge to the hospital or received a copy of the bed hold policy. Multiple attempts made to contact Resident #5’s Representative were unsuccessful. An interview was completed on 7/24/2025 at 3:24 pm with Nurse #4. The Nurse stated she completed Resident #5’s hospital discharge paperwork on 7/10/2025. Nurse #4 revealed she completed the written notification of the reason for transfer/discharge form and the bed hold policy, made a copy of both, sent the original with Resident #5 to the hospital and placed the copies in the medical records bin at the nurse’s station for the Medical Records staff member to pick up. The Medical Records staff member was unavailable for interview. An interview was completed on 7/23/2025 at 3:48 pm with the Social Worker. The Social Worker revealed she did not send any written notification or bed hold policy information to residents or their representatives. The Social Worker stated the nurses sent the bed hold policy and written notification of transfer/discharge to the hospital when a resident was transferred to the hospital. The Social Worker revealed she used to get a copy of the written notification of reason for transfer/discharge to send to the Resident Representative but no longer did. The Social Worker was unable to state why she stopped getting copies of the notifications. An interview was completed on 7/23/2025 at 3:52 pm with the Business Office Manager. The Business Office Manager stated she was responsible for contacting the resident’s representative to review the option to pay to hold a resident’s bed while they were admitted into the hospital. The Business Office Manager stated she did not document these discussions in the residents’ electronic medical record. An interview was completed on 7/25/2025 at 1:51 pm with the Director of Nursing (DON). The DON revealed nursing staff sent a copy of the bed hold policy and written notification of the reason for transfer/discharge to the hospital. The DON stated nursing also made copies of these forms and placed them in the medical records bin at the nursing station. The DON stated the copies were retrieved the next day and all discharges were discussed during the daily morning clinical meeting. The DON verified the Social Worker attended this meeting. The DON revealed the Medical Records staff member scanned the forms into the resident’s medical record. An interview was completed on 7/25/2025 at 1:43 pm with the Administrator. The Administrator stated the bed hold policy was sent with the residents when they were transferred to the hospital. The Administrator revealed the Business Office Manager contacted the Resident Representative the following day to review the bed hold policy and provided the option of paying the fee to hold the resident’s bed while they were admitted to the hospital. The Administrator stated it was his expectation that the Business Office Manager document in a resident’s electronic medical record discussions with Resident Representatives or a resident regarding the bed hold policy. 3. Resident #36 was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] revealed Resident #36 was independent with daily decision making. A review of Resident #36’s progress notes revealed she was discharged to the hospital on 6/19/2025 and was readmitted to the facility on [DATE]. Review of Resident #36’s medical record revealed no documentation Resident #36, or her Resident Representative received written notification of the reason for her transfer/discharge to the hospital or received a copy of the bed hold policy. An interview was completed on 7/23/2025 at 3:48 pm with the Social Worker. The Social Worker revealed she did not send any written notification or bed hold policy information to residents or their representatives. The Social Worker stated the nurses sent the bed hold policy and written notification of transfer/discharge to the hospital when a resident was transferred to the hospital. The Social Worker revealed she used to get a copy of the written notification of reason for transfer/discharge to send to the Resident Representative but no longer did. The Social Worker was unable to state why she stopped getting copies of the notifications. An interview was completed on 7/23/2025 at 3:52 pm with the Business Office Manager. The Business Office Manager stated she was responsible for contacting the resident’s representative to review the option to pay to hold a resident’s bed while they were admitted into the hospital. The Business Office Manager stated she did not document these discussions in the residents’ electronic medical record. An interview was completed on 7/25/2025 at 1:51 pm with the Director of Nursing (DON). The DON revealed nursing staff sent a copy of the bed hold policy and written notification of the reason for transfer/discharge to the hospital. The DON stated nursing also made copies of these forms and placed them in the medical records bin at the nursing station. The DON stated the copies were retrieved the next day and all discharges were discussed during the daily morning clinical meeting. The DON verified the Social Worker attended this meeting. The DON revealed the Medical Records staff member scanned the forms into the resident’s medical record. The Medical Records staff member was unavailable for interview. An interview was completed on 7/25/2025 at 1:43 pm with the Administrator. The Administrator stated the bed hold policy was sent with the residents when they were transferred to the hospital. The Administrator revealed the Business Office Manager contacted the Resident Representative the following day to review the bed hold policy and provide the option of paying the fee to hold the resident’s bed while they were admitted to the hospital. The Administrator stated it was his expectation that the Business Office Manager document in a resident’s electronic medical record discussions with Resident Representatives or a resident regarding the bed hold policy. 4. Resident #54 was admitted to the facility on [DATE]. The MDS assessment dated [DATE] revealed Resident #54 was cognitively intact. A review of Resident #54’s progress notes revealed she was discharged to the hospital on 7/9/2025 and was readmitted to the facility on [DATE]. Review of Resident #54’s medical record revealed no documentation Resident #54, or her Resident Representative received written notification of the reason for her transfer/discharge to the hospital or received a copy of the bed hold policy. An interview was completed on 7/24/2025 at 1:45 pm with Resident #54. Resident #54 stated she was unable to recall if she received a copy of the bed hold policy when she discharged to the hospital on 7/9/2025. An interview was completed on 7/24/2025 at 4:05 pm with Nurse #10. The Nurse was unable to recall if she completed Resident #54’s transfer paperwork on 7/9/2025. Nurse #10 revealed she sent a copy of the bed hold policy and written notification of the reason for transfer/discharge to the hospital when a resident transferred to the hospital. Nurse #10 stated she placed copies of those forms in the medical records bin at the nursing station. The Medical Records staff member was unavailable for interview. An interview was completed on 7/23/2025 at 3:48 pm with the Social Worker. The Social Worker revealed she did not send any written notification or bed hold policy information to residents or their representatives. The Social Worker stated the nurses sent the bed hold policy and written notification of transfer/discharge to the hospital when a resident was transferred to the hospital. The Social Worker revealed she used to get a copy of the written notification of reason for transfer/discharge to send to the Resident Representative but no longer did. The Social Worker was unable to state why she stopped getting copies of the notifications. An interview was completed on 7/23/2025 at 3:52 pm with the Business Office Manager. The Business Office Manager stated she was responsible for contacting the resident’s representative to review the option to pay to hold a resident’s bed while they were admitted into the hospital. The Business Office Manager stated she did not document these discussions in the residents’ electronic medical record. An interview was completed on 7/25/2025 at 1:51 pm with the Director of Nursing (DON). The DON revealed nursing staff sent a copy of the bed hold policy and written notification of the reason for transfer/discharge to the hospital. The DON stated nursing also made copies of these forms and placed them in the medical records bin at the nursing station. The DON stated the copies were retrieved the next day and all discharges were discussed during the daily morning clinical meeting. The DON verified the Social Worker attended this meeting. The DON revealed the Medical Records staff member scanned the forms into the resident’s medical record. An interview was completed on 7/25/2025 at 1:43 pm with the Administrator. The Administrator stated the bed hold policy was sent with the residents when they were transferred to the hospital. The Administrator revealed the Business Office Manager contacted the Resident Representative the following day to review the bed hold policy and provide the option of paying the fee to hold the resident’s bed while they were admitted to the hospital. The Administrator stated it was his expectation that the Business Office Manager document in a resident’s electronic medical record discussions with Resident Representatives or a resident regarding the bed hold policy.

Based on record review, and staff and Medical Doctor interviews, the facility failed to enter a physician's order into the electronic medical record and document the administration of a medication for 1 of 4 residents reviewed for medication administration documentation (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] for surgical aftercare following surgery on the digestive system. Documentation in a nursing progress note dated 5/8/2025 at 12:59 PM written by Nurse #1 revealed Resident #1 was observed vomiting, the physician was notified, and an order was obtained for ondansetron (a medication used to prevent nausea and vomiting) 4 milligrams (mg) every 6 hours as needed. There was no documentation in the electronic medical record of a physician's order for ondansetron or documentation on the medication administration record (MAR) of its administration ondansetron for Resident #1 during the resident's stay at the facility. Nurse #1 was interviewed on 5/21/2025 at 11:36 AM. Nurse #1 explained she was notified on the morning medication pass on 5/8/2025 by a family member of Resident #1 that Resident #1 was vomiting and feeling very nauseous. Nurse #1 further explained she called Medical Doctor (MD) #1 and received the order for ondansetron to be administered to Resident #1. Nurse #1 indicated that the medication ondansetron was available for the residents in medication storage. Nurse #1 did not recall if she gave the medication ondansetron to Resident #1 and could not explain why the medication ondansetron did not appear on the physician orders or the MAR for Resident #1. Nurse #3 was interviewed on 5/21/2025 at 12:01 PM. She explained that she took over the medication cart from Nurse #1 on 5/8/2025 at approximately 12:00 PM. In the nursing report given to her from Nurse #1 on that day, it was explained that Resident #1 was vomiting, an order for ondansetron was obtained, and ondansetron was administered. Nurse #3 confirmed her awareness that Resident #1 would require monitoring after receiving the ondansetron on that day. MD #1 was interviewed on 5/21/2025 at 4:09 PM. He stated he was not the physician for Resident #1, but because he was the facility medical director, he was sometimes called for medical orders for other residents. MD #1 did not recall giving the order for ondansetron for Resident #1 on 5/8/2025 due to the frequency with which he received calls regarding residents. MD #1 confirmed that if he gave a verbal order, he would expect the order to be documented and implemented. The Director of Nursing (DON) was interviewed on 5/22/2025 at 8:21 AM. The DON stated she did not find any documentation or evidence in the electronic medical record of Resident #1 indicating an order for the medication ondansetron was entered into the record or the administration of ondansetron. The DON thought ondansetron was likely given to Resident #1 on 5/8/2025 but she could not confirm that. The DON stated she expected that the nurses would enter the physician orders into the electronic medical record once received and then document the administration of the medication on the MAR. The DON felt the documentation was important for the continuity of care and the monitoring of Resident #1 if she received the medication ondansetron.

Based on observations, record review, and staff interviews the facility failed to maintain dignity when a resident had an uncovered urinary drainage bag with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents. This deficient practice was for 1 of 3 residents reviewed for dignity. (Resident #213) The findings included: Resident #213 was admitted to the facility on [DATE] with the diagnosis of urinary retention. An admission Minimum Data Set assessment dated [DATE] revealed the Resident was severely cognitively impaired, required substantial to maximum assistance from staff to complete activities of daily living, was incontinent of bowel, and was coded as having a urinary catheter. An observation of Resident #213 occurred on 6/10/24 at 9:45am. Resident #213 was observed in her room, in bed with her urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #213 occurred on 6/10/24 11:03am. Resident #213 was observed in her room, in bed with her urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #213 occurred on 6/10/24 12:36pm. Resident #213 was observed in her room, in bed with her urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An interview was completed with Nurse #2 on 6/10/24 at 12:44pm. Nurse #2 verified she was Resident #213's nurse for that day and was aware the Resident had a urinary catheter. The Nurse stated the urinary catheter bag should have been covered. Nurse #2 revealed she did not know why it was not covered but stated she would retrieve a privacy cover for the Resident's catheter bag. An interview was completed with Nursing Assistant (NA) #1 on 6/11/24 at 1:14pm. The NA verified she was Resident #213's NA during the dayshift on 6/10/24. The NA stated she was unable to recall if the Resident's urinary catheter bag was covered on 6/10/24. An interview was completed with the Director of Nursing (DON) on 6/13/24 at 10:13am. The DON stated the residents' urinary catheter bag should be covered to avoid any dignity issues. The DON revealed Resident #213's urinary catheter bag was normally covered with a privacy bag and was unsure why the catheter bag was uncovered.

Based on interviews with staff and record review the facility failed to complete a baseline care plan within 48 hours of admission to address the immediate needs for 1 of 3 newly admitted residents reviewed (Resident #213). The findings included: Resident #213 was admitted to the facility on [DATE] with diagnoses that included diabetes, atrial fibrillation, and muscle weakness. An admission Minimum Data Set assessment dated [DATE] revealed the Resident was severely cognitively impaired, required substantial to maximum assistance from staff to complete activities of daily living, was incontinent of bowel and bladder, and was coded as having a urinary catheter. A review of Resident #213's medical record revealed the 48-hour baseline care plan was completed on 6/10/24. An interview was completed on 6/11/24 with the Director of Nursing (DON). The DON indicated it was the receiving nurse's responsibility to initiate the baseline care plan within 48 hours to meet the Resident's immediate needs. The DON stated the facility had recently converted to a new electronic charting system and the baseline care plan was no longer automatically generated as before. An interview was completed with Nurse #1 on 6/12/24 at 2:48pm. The Nurse revealed she was the admitting nurse for Resident #213 on 5/29/24. Nurse #1 stated she was aware new admissions required a 48-hour baseline care plan. Nurse #1 indicated she believed the care plan was generated from information entered in each section of the admission assessment. An interview was completed on 6/13/24 at 10:11am with the Administrator. He indicated the baseline care plans should be completed within 48 hours of the admission of a new resident to meet their needs.

Based on record review and staff interview the facility failed to implement a comprehensive care plan for 1 of 1 resident who received renal dialysis (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, renal dialysis, and diabetes mellitus. Review of the annual Minimum Data Set, dated dated dated [DATE] revealed that Resident #43 was mildly cognitively impaired, required set up assistance with eating and was coded for receiving dialysis. Review of the physician order dated 12/21/21 revealed an order for Novasource renal, one time a day for weight loss. Review of the physician order dated 1/25/23 revealed an order for fluid restriction 1,200 cubic centimeters (cc) every day. Dietary to give 840cc q day. Nursing to give 660 cc q day. Nursing 1st shift to give-270cc, nursing 2nd shift to give 270cc, 3rd shift to give-120cc. Review of the physician's order dated 2/8/22 revealed Resident #43 had a diet order as renal diet, regular texture. Review of Resident #43's medical record revealed no nutritional care plan that addressed fluid restrictions, or the nutritional interventions implemented to help him achieve his goal of fluid restrictions. An interview on 2/8/23 at 10:53 with Minimum Data Set (MDS) Nurse #6 revealed during their care plan meetings, they would put down Dialysis and the patient should have been care planned then. An interview on 2/9/23 at 12:14 PM the Administrator revealed the Minimum Data Set Nurse should have care planned the resident.

Based on record review and staff interviews the facility failed to ensure a resident receiving dialysis had a physician's order for 1 of 1 sampled resident reviewed for receiving dialysis. (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease, and renal dialysis. Resident #43's care plan dated 11/27/20 noted he was on hemodialysis related to diagnoses of end stage renal disease. Staff were to provide diet as ordered, if resident has dialysis shunt, palpate for distal thrill and auscultate for bruit, monitor for bleeding, hemorrhage, sepsis, monitor skin around vascular access for, redness. Report to physician/Dialysis center: fever, chills, hypotension. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident as having moderately impaired cognition. The MDS coded Resident #43 as receiving dialysis. Resident #43's medical record was reviewed and revealed there was no physician order for dialysis. An interview with Nurse #2 on 2/09/22 at 9:57 AM revealed there was no order for his dialysis. She indicated the dialysis order for Resident #43 should be in computer. An interview with the Unit Manager Nurse #3 on 2/9/23 at 10:38 AM she indicated that technically Resident #43 had no physician order for his dialysis. The Unit Manager Nurse # 3 revealed the resident went out to the hospital on 10/7/21 and when he came back the new order should have been put in at that time. An interview with the Administrator on 2/09/23 at 12:14 PM revealed with a newly admitted resident the unit manager would take the orders off their hospital discharge orders and put into the resident record. He indicated the resident should have a dialysis order and they would get one for the resident.

Based on observations and staff interviews, the facility failed to (1)maintain drywall in good repair as evidenced by drywall that was scratched and peeling off the wall behind resident beds and adjacent walls in occupied resident rooms for (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), 2) ensure privacy curtains were free of stains (room [ROOM NUMBER] and room [ROOM NUMBER]), and 3) and ensure a tube feeding pump, a tube feeding pole, and suction equipment were in clean and sanitary condition (room [ROOM NUMBER]) for 3 of 4 halls observed. Findings included: 1. During observations on 2/07/23 at 8:30 am through 10:30 am the following rooms had damaged drywall. a. room [ROOM NUMBER] had a hole approximately eight inches long with multiple areas of peeled drywall on wall on the side of the door bed. The window bed area had an area measuring approximately 3.5 feet (ft) in length from the corner of the room to the window with exposed peeling drywall, hardened spackle with cracks, and without paint. b. room [ROOM NUMBER] an area approximately 3 ft. in length above the head of the bed with cracked spackle areas without paint. c. room [ROOM NUMBER] was observed with an area approximately 5 ft. by 5 ft. with dried, cracked spackle without paint, and multiple tears in the drywall surrounding the area. d. room [ROOM NUMBER] with an area approximately 3 ft. x 3 ft behind the head of the bed with dried, cracked spackle without paint. e. room [ROOM NUMBER] had an area approximately 3 ft. in length with unpainted area with multiple drywall tears and hardened areas of cracked spackle. f. room [ROOM NUMBER] the door and windows beds were observed with an area above head of the bed, and along the side of the bed with multiple areas of torn drywall and dried spackle without paint. g. room [ROOM NUMBER] door bed was observed with an open hole in the drywall above the head of the bed and an area of hardened spackle around the hole. h. room [ROOM NUMBER] was observed with an area approximately 3 ft. x 2 ft. of hardened cracked spackle without paint behind recliner and multiple sections approximately 4 ft. in length behind the head of bed with cracked spackle without paint. i. room [ROOM NUMBER] was observed with an area behind the head of bed measuring approximately 2 ft. in length with torn drywall and cracked spackle areas. j. room [ROOM NUMBER] was observed with an area measuring approximately 6 ft. in length on the wall alongside the bed with cracked spackle without paint. k. An observation of room [ROOM NUMBER] was conducted on 2/7/23 at 12:31 PM. The wall behind the bed revealed two areas of spackled dry wall. There was a large area of spackled dry wall at the head of the bed. l. An observation of room [ROOM NUMBER] was conducted on 2/7/23 at 12:43 PM. There was a large area of spackled dry wall at the head of the bed. m. An observation of room [ROOM NUMBER] was conducted on 2/7/23 at 12:45 PM. The wall behind the bed revealed two areas of spackled dry wall. There was a large area of spackled dry wall at the head of the bed. n. An observation of room [ROOM NUMBER] was conducted on 2/8/23 at 4:02 PM. The wall behind the bed revealed two areas of spackled dry wall. There was a large area of spackled dry wall at the head of the bed. o. An observation of room [ROOM NUMBER] was conducted on 2/8/23 at 4:06 PM. There was a large area of spackled dry wall at the head of the bed. p. On 2/7/23 at 1:57 PM an observation of room [ROOM NUMBER] Bed A revealed the spackled drywall at the head of bed and the spackled drywall beside the door was marred. Bed B the spackled drywall at the head of bed was observed to be scratched. q. On 2/8/23 at 3:45 PM an observation of room [ROOM NUMBER] Bed A revealed the spackled drywall at the head of bed and the spackled drywall beside the door were scratched. Bed B the spackled drywall at the head of bed was observed to be scratched. r. On 2/8/23 at 3:47 PM an observation of room [ROOM NUMBER] Bed A revealed the spackled drywall at the head of bed and the spackled drywall beside the door were scratched. Bed B the spackled drywall at the head of bed was observed to be scratched. s. On 2/8/23 at 3:50 PM an observation of room [ROOM NUMBER] Bed A revealed spackled drywall at the head of the bed was scratched. t. Observations on 2/9/23 at 1:51 PM revealed the spackled drywall in rooms 601, 605 and 606 were in the same condition. During an interview on 2/09/23 at 8:52 am the Maintenance Director revealed he had a list of rooms that needed repair, but he had not been able to complete the work on the rooms. He stated he started the repair but would get pulled to do something else and it was hard to get back to complete the work. During an interview on 2/09/23 at 11:18 am the Administrator revealed he spoke to the Maintenance Director but had not created a plan to complete the repairs to the rooms. He stated the repairs involved the resident to be out of the room for the completion of the work which made it difficult to complete the work. 2a. During an observation on 2/06/23 at 9:51 am in room [ROOM NUMBER] the privacy curtain had dark brown stains and a white hardened substance on multiple areas of the curtain. b. During an observation on 2/06/23 at 10:58 am and again on 2/09/23 at 12:00 pm the middle privacy curtain in room [ROOM NUMBER] had multiple dark brown hardened stains on the curtain. During an interview on 2/07/23 at 2:04 pm the Housekeeping Supervisor revealed the privacy curtains were taken down once a month on the scheduled deep cleaning day and when visibly dirty. He stated the privacy curtains should have been removed and laundered when they were visibly dirty. During an interview on 2/09/23 at 1:49 pm the Administrator revealed the housekeeping department was responsible to maintain clean privacy curtains and they were expected to be laundered when needed. 3. During an observation on 2/06/23 at 9:51 am in room [ROOM NUMBER] the tube feed pump was observed to have multiple areas of hardened beige substance on the top and down the front of the feeding pump. The tube feeding pole had a dried beige substance down the pole and on all four legs of the pole. A suction machine was observed on the bedside table near the head of the bed with a heavy dust build up on the machine and a dried brown substance on the top and inside of the suction canister. During an interview on 2/07/23 at 1:55 pm Nurse #1 revealed the housekeeping department was required to clean the tube feed pump, tube feed pole, and the suction machine during the daily cleaning of room [ROOM NUMBER]. Nurse #1 stated the suction machine was no longer used and she would remove the machine from the room. An interview was conducted on 2/07/23 at 2:10 pm with the Housekeeping Supervisor. He revealed all surfaces were to be cleaned every time the room was cleaned which included wiping down the suction machine and tube feed pole. The Housekeeping Supervisor stated the feeding tube pole should have removed from the room and taken outside to scrape the buildup off the legs and pole. An interview with the Director of Nursing on 2/09/23 at 9:20 am revealed the housekeeping department was expected to clean the tube feed pump, tube feed pole, and the suction machine when they completed the daily cleaning of room [ROOM NUMBER]. During an interview on 2/09/23 at 1:49 pm the Administrator revealed the suction machine, the tube feed pump, and the tube feed pole was the responsibility of the nursing department. He stated nursing staff was expected to wipe spills when they occurred and was to notify the housekeeping department when the tube feed pole required additional cleaning. 41772 20710

Based on staff interviews and record reviews, the facility failed to post accurate Daily Nurse Staffing Information that reflected the Daily Shift Assignment for licensed nurses for 6 out of 30 days. The findings included: A review of the Posted Nurse Staffing Information was conducted on 2/7/23 for the dates of 1/6/23 through 2/6/23. Comparison of the Posted Nurse Staffing Information with the Daily Shift Assignments revealed there was no Registered Nurse (RN) included on the Posted Nurse Staffing Information for the following days: 1/7/23, 1/8/23, 1/21/23, 1/22/23, 2/4/23, and 2/5/23. An interview was conducted with the facility staff scheduler on 2/7/22 at 3:29 PM. The scheduler stated there had been an RN Supervisor scheduled for 7 AM to 7 PM on the dates of 1/7/23, 1/8/23, 1/21/23, 1/22/23, 2/4/23, 2/5/23. She stated that she was not aware that the Posted Nurse Staffing Information should include the RN Supervisor. An interview was conducted with the Administrator on 2/8/22 at 4:02 PM. The Administrator stated he was not aware that the RN Supervisor had to be reflected on the Posted Nurse Staffing Information since they were not part of the daily nursing hours. The Administrator further stated the Posted Nurse Staffing Information would be updated to reflect the RN coverage.

Based on observation, and staff interview the facility failed to maintain the kitchen clean and in a sanitary condition to prevent food borne illness by failing to clean one of one steam table shelves and failed to degrease baking sheets. The findings included: During the initial tour on 2/14/22 at 9:35 AM three baking sheets, were observed on top of the convection oven. The sheet pans had a buildup of dried food particles/grease under the 1-inch rim. On 2/17/22 at 9:09 AM 2 sets of baking sheets nested rolls to proof, were observed warming on top of the convection oven. The sheet pans had a buildup of dried food particles/grease under the 1-inch rim. One rolling cart with 6 sheet pans stored upside to dry was observed. The sheet pans had a buildup of dried food particles/grease under the 1-inch rim. In an interview on 2/17/22 at 10:08 AM the dietary manager stated she would have staff clean the steam table shelf and use the degreaser to clean the sheet pans. During an observation of the kitchen on 2/15/22 at 11:44 AM the steamtable area was observed. The 6-foot underside of the was observed to have splashes of dark dried food particles. An observation of the steamtable area was conducted with the dietary manager on 2/17/22 at 10:08 AM revealed the steamtable to be in the same condition. In an interview on 2/17/22 at 10:08 AM the dietary manager stated she would have staff clean the steam table shelf and use the degreaser to clean the sheet pans.

Based on observation, policy review and staff interview the facility failed to maintain the area surrounding the dumpster free of debris for 2 of 2 dumpsters observed. The findings included: During an observation of the dumpster area on 2/16/22 at 1:34 PM, 2 disposable gloves, and assorted papers were observed beside dumpster # 1. A Styrofoam cup, assorted papers, straw papers, 2 empty plastic drink bottles, and jelly cup were observed behind dumpster #1 and dumpster # 2. During an observation of the dumpster area on 2/17/22 at 8:15 AM, 3 disposable gloves, and assorted papers were observed beside dumpster # 1. One Styrofoam cup, assorted papers, straw papers, 2 empty plastic drink bottles, and jelly cup were behind dumpster #1 and dumpster # 2. An observation of the dumpster area was conducted with the dietary manager on 2/17/22 at 10:08 AM revealed the dumpster area to be in the same condition. During an interview on 2/17/22 at 10:08 AM the dietary manager stated housekeeping took the trash to the dumpster the dietary department did not. In an interview on 2/17/22 at 10:09 AM the floor technician stated he took the trash out for the kitchen. He indicated some of the trash fell off when the garbage truck emptied the dumpster, and he felt the driver should clean up the dumpster area. During an interview on 02/17/22 11:17 AM the Administrator indicated he would have staff check and clean the dumpster area.

Based on record review and Administrator interview, the facility failed to implement a Legionella prevention program with a water management program or testing protocols. This deficient practice had the potential to affect all 54 residents. Findings included: Review of the Legionella Assessment and Prevention Program policy revised on 9/9/19 revealed the facility would ensure a Legionella assessment was conducted in accordance with state and federal requirements. The assessment included multiple control measures of temperature management, physical controls, disinfection level control, visual inspection/environmental testing for pathogens, and temperature management. The Administrator would assign the responsible person to complete the assessment and maintain proper documentation. During an interview with the Administrator on 2/17/22 at 10:35 AM, he revealed the facility had policies and procedures to monitor for Legionella last revised on 9/9/19. He stated the water was last tested in September 2019, and Legionella was not detected. The Administrator further stated the town of Nashville did not perform Legionella testing regularly for the facility, but they did test for [MEDICATION(S)] and contaminants/disinfectant biproducts/other contaminants. The Administrator indicated at 12:03 PM that he did not have any documentation of water temperature or testing for Legionella available since 2019. He stated this was due to the previous maintenance supervisor not performing the necessary water testing, who left the facility without notice 3 months ago.

Based on record reviews, staff, pharmacist, and Physician Assistant interviews the facility failed to ensure Physician's order for as needed (PRN) [CONDITION(S)] medications were time limited in duration for 1 of 5 Residents (Resident #202) reviewed for unnecessary medications. The findings included: Resident #202 was admitted to the facility on [DATE] with diagnoses that included a stroke of the spinal cord, major depressive disorder, and muscle weakness. A Physician's order dated for 1/31/22 indicated [MEDICATION(S)] 0.5mg 1 tab twice daily PRN was ordered without a stop date. The admission Minimum Data Assessment completed on 2/7/22 indicated the Resident was cognitively intact. Resident #202 was not coded as having received a PRN [CONDITION(S)] medication during the assessment period. A care plan was initiated on 2/1/22 for the use of antianxiety medication. Interventions included administer medication as prescribed by the Physician, monitor/report any negative side effects, and implement nonpharmacological interventions when able. An interview was completed with the Director of Nursing on 2/16/22 at 1:25pm. She indicated when Residents were newly admitted to the facility, the discharge medication regimen was reviewed for any PRN psychotropics without stop dates. The medication regimen was then reviewed with the facility physician and stop dates were implemented where indicated. The Physician reassessed Residents for continued use and extended the duration of the medication as needed. The DON indicated she was unsure why Resident #202's PRN [MEDICATION(S)] did not include a stop date. A telephone interview was completed with the Pharmacy Consultant on 2/16/22 at 1/30pm. She indicated when she completed medication regimen reviews, if a PRN [CONDITION(S)] medication was found to be ordered without a stop date, she would complete a pharmacy recommendation to the Physician to include a stop date or discontinue the medication. She further stated a monthly medication review regimen had not yet been completed on Resident #202 because of his recent admission. A telephone interview was completed with the facility's Physician Assistant on 2/17/22 at 8:27am. She indicated that she was aware that all PRN [CONDITION(S)] medications need stop dates when prescribing. She stated she evaluated Resident #202 on 2/2/22 for his continued use of PRN [MEDICATION(S)] for 14 days but was not aware the facility did not include a stop date for the medication. An interview was completed with the DON on 2/17/22 at 2:48pm. It was her expectation all PRN [CONDITION(S)] medication include stop dates.

Based on record review and staff interviews, the facility failed to notify resident's Responsible Party of pressure ulcer changes for 2 of 2 residents reviewed for pressure ulcers. (Resident #3 and 4). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was discharge to hospital on 07/23/21. Record review of Change in Condition (CIC) Evaluation dated 06/30/21 revealed that Resident #3 was identified to have a pressure ulcer to sacrum. The pressure ulcer was measured approximately 2 centimeters (cm) in diameter with a necrotic (black) middle. The nurse notified Resident #3's Responsible Party (RP) of new pressure ulcer, treatment, and consult for wound physician. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 was cognitively impaired, had an indwelling catheter, and required extensive assist for transfers, dressing, personal hygiene, and toileting. Resident #3 was coded for an unstageable pressure ulcer. Record review of weekly wound assessment dated [DATE] revealed the pressure ulcer had increased in size and measured 3.0 x 3.0 cm in size with pink wound bed. The family notification section was not completed. Record review of weekly wound assessment dated [DATE] revealed the pressure ulcer had increase in size and measured 3.7 x 4.3 x 0.1 cm with yellow wound bed. The treatment order was changed by the wound physician. The family notification section was not completed. Record review of weekly wound assessment dated [DATE] revealed the pressure ulcer had increased in size and measured 11.0 x 15.0 x 0.1 cm and was described as deteriorating with necrotic (dead cells/tissue) wound bed. The family notification section was not completed. Record review of weekly wound assessment dated [DATE] revealed pressure ulcer had increased in size and measured 11.5 x 16.0 x 0.1 cm in size and was described as deteriorating with necrotic wound bed. The treatment order was changed by the wound physician. The family notification section was not completed. Record review of Wound Evaluation and Management Summary report revealed that the wound physician performed a bedside debridement (removal of damaged tissue) for Resident #3's pressure ulcer on 07/05/21, 07/12/21, and 07/19/21. During a telephone interview on 09/16/21 at 9:37 am the wound physician revealed the facility was responsible to notify Resident #3's RP of the pressure ulcer progress. During a telephone interview on 9/14/21 at 2:20 pm Resident #3's RP revealed that the facility did not notify her of the increase in size and description of the pressure ulcer. The RP stated that she did not receive an update of the wound until Resident #3 was at the hospital. During an interview on 09/15/21 at 10:05 am Nurse #3 revealed that notification for pressure ulcer change was documented on the weekly wound assessment, CIC, or a nursing progress note. Nurse #3 was unable to state why Resident #3's RP was not notified of pressure ulcer changes. During an interview on 09/15/21 at 11:00 am Nurse #2 revealed that the floor nurse was responsible to notify the RP of change in pressure ulcer and document the information in a nurse progress note. She reported that the wound physicians do not notify RP on pressure ulcer changes. Nurse #2 stated that she believed the RP was notified however the floor nurse did not document the information as required. Nurse #2 was not able to state why Resident #3's RP was not notified of pressure ulcer changes. During an interview on 09/15/21 at 12:40 pm the Assistant Director of Nursing (ADON) revealed the floor nurse was responsible to notify the RP of change in wound size or description, new orders, and update if stable or declined after weekly wound rounds. The ADON stated the floor nurse documented notification of the RP in a nurse progress note or the weekly wound assessment. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was cognitively intact. She required extensive assistance for ADLs, turning, repositioning, and transfers. Resident #4 was coded for stage 3 and stage 4 pressure ulcers present on admission/reentry. Record review of the weekly wound assessment dated [DATE] revealed the pressure ulcer increased in size from previous assessment and measured 8.5 x 10.2 x 1.7 centimeters (cm) with tunneling (passageway under the skin) of 2.0 cm and 5% bone exposed. The family notification section was not completed. Record review of the weekly wound assessment dated [DATE] revealed the wound increased in size from previous assessment and measured 8.5 x 10.1 x 1.8 cm with tunneling of 2.4 cm and 5% bone exposed. The treatment was changed by the wound physician. The family notification section was not completed. Record review of the weekly wound assessment dated [DATE] revealed the wound increased in size from previous assessment and measured 8.0 x 12.0 x 1.4 cm with tunneling of 2.0 cm and 10% bone exposed. The wound was described as unable to progress to a healing phase. The family notification section was not completed. During an interview on 09/15/21 at 10:05 am Nurse #3 revealed that RP notification for pressure ulcers was documented on weekly wound assessment, CIC, or in a nursing progress note. Nurse #3 was unable to state why Resident #4's RP was not notified of pressure ulcer changes. During a telephone interview on 09/16/21 at 9:37 am the wound physician revealed the facility was responsible to notify Resident #4's RP of the pressure ulcer progress. During a telephone interview on 09/14/21 at 1:38 pm Resident #4's RP revealed she had received pressure ulcer updates weekly, but she had not received any updated information for several months. During an interview on 09/15/21 at 11:00 am Nurse #2 revealed the floor nurse was responsible to notify Resident #4's RP weekly on pressure ulcer progress and document the notification in a nursing progress note or CIC. Nurse #2 reviewed record and was unable to provide nursing notes or CIC for notification of pressure ulcer updates to RP. Nurse #2 was unable to state why Resident #4's RP was not notified of the pressure ulcer changes. During an interview on 09/15/21 at 11:11 am Nurse #1 revealed that notification of change in condition has not been identified as problem at the facility and that the floor nurse had updated the resident RPs on pressure ulcer progress. During an interview on 09/15/21 at 12:40 pm the Assistant Director of Nursing (ADON) revealed the floor nurse was responsible to provide weekly updated pressure ulcer information to resident RP that included improvement, decline, stability, and treatment change. During an interview on 09/15/21 at 12:59 pm the Administrator revealed that notification of change in condition was completed by nursing and documented in a nursing progress note or a CIC.

Based on record review, staff, hospice, and emergency medical services (EMS) interviews the facility failed to clarify code status resulting in a transfer to hospital and intubation for 1 of 3 residents reviewed for advance directives (Resident #1). Findings included: Resident #1 was admitted to facility on 04/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on 04/27/21 revealed Resident #1 was a full code. The most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively impaired and was not on hospice service. Record review of document titled Hospice Notice of Admission to Nursing Center revealed that Resident #1 was admitted to hospice services on 05/11/21 without an advance directive recorded. During a telephone interview on 07/07/21 at 10:43 am Resident #1 ' s Responsible Party (RP) revealed that on 05/11/21 Resident #1 was admitted to hospice services and was designated as Do Not Resuscitate (DNR). The RP reported that once admitted to hospice services her understanding was that Resident #1 would not be sent to the hospital without the facility consulting the Hospice Nurse. Record review of Nurse #5 ' s note dated 05/11/21 at 2:30 pm revealed that the Hospice Nurse was at facility to evaluate Resident #1 for hospice services. No new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 07/07/21 at 1:45 pm Nurse #5 revealed that she was Resident #1 ' s nurse on 05/11/21 and did not receive physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Nurse #3 ' s note dated 05/26/2021 at 7:00 am revealed she entered Resident #1 room at 4:50 am and found Resident #1 had labored breathing, respirations were 28 breaths per minute, and oxygen saturation was 69%. Nurse #3 called the physician and reported that Resident #1 had difficulty breathing and was a hospice patient. The physician ordered Resident #1 out to the hospital by emergency medical services (EMS). During an interview on 07/07/21 at 11:09 am Nurse #3 revealed that on 05/26/21 Resident #1 had conflicting code status information. She reported that Resident #1 had a full code physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not able to remember why EMS did not take the DNR form with Resident #1 when she was transported to the hospital. Record review of Emergency Medical Services report dated 05/26/21 revealed that EMS arrived at the facility at 5:20 am. Resident #1 was provided oxygen support and was transported to the hospital for respiratory distress. No advance directive was provided or documented on the EMS report. During a telephone interview on 07/14/2021 at 10:26 am Lead Emergency Medical Technician (EMT) revealed that Resident #1 ' s was hypoxic (low oxygen) and placed an oxygen mask with 10 liter per minute and increased to 15 liters to stabilize her for transport to the hospital. The facility staff did not provide a DNR. Hospital record dated for 05/26/21 revealed that Resident #1 arrived at the emergency room at 6:12 am, Resident #1 was immediately intubated (tube placed into windpipe to get air into lungs) and placed on ventilator (a machine that assists with breathing). The emergency room physician spoke with Resident #1 ' s family at 10:31 am and the decision was made to extubate (remove the breathing tube). Resident #1 was extubated at 11:13 am with family and physician at bedside. Resident #1 was transported back to the facility at 12:05 pm by EMS accompanied by an active DNR physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1 ' s electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/07/21 at 10:43 am the Hospice Nurse revealed that facility staff was notified of Resident #1 ' s hospice admission and DNR physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/07/21 at 10:57 am Nurse #1 revealed that resident code status book was at each nursing station and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated she referred to the code status book and the electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/07/21 at 1:38 pm Social Worker (SW) revealed that the RP had enrolled Resident #1 in hospice services without her assistance and was a DNR. She stated she was aware Resident #1 was a DNR from the daily clinical meeting. The SW indicated she had not obtained the consult for advance directive and had no way to track the physician order. During an interview on 07/09/21 at 2:16 pm Nurse #4 revealed that she was aware of Resident #1 ' s desire for DNR from discussion at clinical meeting but was unsure why the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 07/07/21 at 1:50 pm the Administrator revealed if he had received the advance directive from the Hospice Nurse, he would have given it to the nurse responsible for the Resident #1. He reported that he did not receive the advance directive from the Hospice Nurse on 05/11/21 and the Director of Nursing (DON) was not in the facility on that date to have received the advance directive. The DON was unavailable for interview. The facilty submitted a Corrective Action Plan for F 578 reviewed by an Informal Dispute Resolution (IDR) panel on 08/23/21. The Corrective Action Plan was reviewed and verified by the IDR panel as an acceptable plan completed by the facility on 06/09/21 for the following reasons: -when Resident #1 returned from the hospital the residents code status was immediately updated and corrected both with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -Education was immediately started and completed on 05/26/21 (to all working staff) on the meaning of DNR and obtaining orders and entering them timely. This education was provided to all staff. And all new staff since then were educated upon hire with evidence of this being provided to the panel members. -the facility is reviewing all new orders and ensuring any changes to the advance directive are entered into the electronic medical record and the code status book which is kept at the nursing station. -Code status books were audited daily from 05/26/21 through 06/09/21 then the audits were moved to weekly. -Per the information presented to the IDR panel, the facility reported the auditing information to the QAPI committee prior to the survey. The facility provided information and reported in the IDR meeting that the monitoring of the corrective action plan through QAPI was ongoing. -the facility alleged compliance was achieved on 05/26/21 before the survey team entered the facility on 07/07/21. The panel determined that the facility's compliance date for the deficient practice was 6/9/21 based on completion of the daily audits.

Based on interviews of facility staff, hospice, physician and emergency medical technician, and record reviews, the facility failed to provide oxygen for one of one resident who had an oxygen saturation rate of 69% that decreased to 50-60 %. (Resident #1). Findings included: Resident #1 was admitted to facility on 04/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician Standing Orders dated 04/25/17 revealed oxygen to be administered at 2 liters per minute by nasal cannula or mask for respiratory distress and to notify physician as soon as possible. Record review of Oxygen Administration Policy dated 12/16/19 revealed during an emergency, oxygen may be administered, and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on 04/27/21 revealed Resident #1 was a full code and was not on oxygen therapy. Review of oxygen saturation rates for Resident #1 for the month of May were 92% to 98%. The most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively impaired and was not coded for oxygen therapy. Record review revealed that Resident #1 was admitted to hospice services on 05/11/21. During a telephone interview on 07/19/21 at 9:06 am NA #2 revealed that during resident care Resident #1 was breathing slow and was pale in the face. She immediately notified Nurse #3. NA #2 indicated she left the room when Nurse #3 entered. NA #2 stated that she was unable to remember if oxygen was administered by Nurse #3. She stated she did not obtain oxygen for Resident #1. Record review of Nurse #3's note dated 05/26/2021 at 7:00 am revealed that upon entering Resident #1's room at 4:50 am she found Resident #1 had labored breathing and oxygen saturation was 69%. Nurse #3 called the physician and reported that Resident #1 had difficulty breathing. The physician ordered Resident #1 out to the hospital by emergency medical services (EMS). No supplemental oxygen was documented as ordered or administered. During an interview on 07/16/21 at 4:40 pm Nurse #3 revealed that on 05/26/21 at 4:50 am Resident #1 had abnormal breathing and her skin was pale in color. Resident #1 was awake and made eye contact with her. Resident #1 pulse was strong and fast. She was not verbally responding to questions. Nurse #3 stated that she elevated the head of the bed to provide comfort and help assist with breathing before she called the physician. She indicated that she did not put oxygen on Resident #1. She reported When asked why she had not gotten her oxygen, she indicated she wanted to quickly prepare Resident #1 for transport to the hospital. Record review of Emergency Medical Services report dated 05/26/21 revealed that EMS arrived at Resident #1's room at 5:20 am. Resident #1 was pale, rapid shallow breathing, and pulse oxygen level recorded between 50-60%. EMS provided oxygen to Resident #1 by oxygen mask at 10 liters per minute and pulse oxygen level increased to 70%. Oxygen support was increased to 15 liters per minute at 5:37 am and pulse oxygen level increased to 82%. Resident #1 was transported to the hospital at 5:42 am with respiratory distress. During a telephone interview on 07/14/2021 at 10:26 am Lead Emergency Medical Technician (EMT) revealed that Resident #1 was hypoxic (low oxygen) and placed an oxygen mask with 10 liters per minute and increased to 15 liters per minute to stabilize her for transport. EMT indicated he was unable to remember if oxygen was applied to Resident #1 prior to his arrival. Record review of hospital records dated for 05/26/2021 revealed Resident #1 arrived at hospital with EMS actively bagging (manually ventilating) Resident #1. Emergency document revealed that at 6:12 am the emergency room physician intubated (tube placed in the windpipe to assist with breathing) and Resident #1 was placed on a ventilator (a machine that assists with breathing). The responsible party indicated Resident #1's desire was not to be resuscitated. She was extubated and returned to the facility with an active Do Not Resuscitate (DNR) order. Interview conducted on 07/08/2021 at 3:00 pm and follow up interview on 07/19/21 at 8:29 am with Director of Hospice Services revealed Resident #1 was admitted to Hospice service on 05/11/21 with Do Not Resuscitate order. She reported the facility was educated to contact hospice when a hospice patient had a change in condition. Hospice did not have standing orders. She indicated that Resident #1 orders were given as they were notified by the facility. Orders were to manage symptoms, keep her comfortable, and to continue care of Resident #1 in the facility. During a telephone interview on 07/20/21 at 8:52 am Nurse #4 revealed that Nurses were educated on Physician Standing Orders upon hire and were aware the Physician Standing Orders were located at the nursing stations and in the narcotic books. She stated that oxygen administration was included on the Physician Standing Orders. Nurse #4 indicated that an oxygen saturation rate of 69% required oxygen was administered at 2 liters per minute to start and physician notified. During a telephone interview on 07/19/21 at 12:50 pm the Physician revealed that with a saturation rate of 69% Resident #1 required oxygen to begin at 2 liters per minute and increased until oxygen saturation levels improved to 90%. Physician indicated Resident #1 needed oxygen administered for comfort and would not be sent to the hospital.

Based on record review, staff, hospice and emergency medical technician interviews, the facility failed to notify Hospice of a Residents acute change in condition resulting in an unnecessary transfer to the hospital and intubation for 1 of 1 sampled resident. (Resident #1) Findings Include: Record review of the Hospice Nursing Facility Services Agreement dated [DATE] revealed in section: Monitoring of Residential Hospice Patient Nursing facility shall immediately inform Hospice of any change of condition of a Residential Hospice Patient. Patient Transfer Nursing facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of hospice. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) dated for [DATE] indicated Resident #1 was cognitively impaired and was not on hospice service. The hospice admission contract for Resident #1 revealed she was admitted to services on [DATE]. Hospice notes for Resident #1 dated [DATE], [DATE], and [DATE] indicated that Hospice visits were made to facility and during each visit, the Hospice Nurse reminded staff there was Hospice Nurse on call 24 hours a day 7 days a week. Nurse's#3 note dated [DATE] at 7:00 am revealed she entered Resident #1 room at 4:50 am and found Resident #1 had labored breathing . Her respirations were 28 breaths per minute and her oxygen saturation was 69% . She was pale in color. Supplemental oxygen was not documented as administered. Nurse #3 called the physician and reported that Resident #1 had difficulty breathing and was a hospice patient. The physician ordered Resident #1 out to the hospital by emergency medical services. Record review of Emergency Medical Services report dated for [DATE] at 5:47 am indicated that at 5:20am Resident #1 was in respiratory distress and there was no advance directive. Resident #1 was placed on oxygen at 10 liters per minute (lpm) and was increased to 15 lpm, with condition improvement. Resident #1 arrived at hospital at 5:47 am where the hospital respiratory staff took over ventilation and report were given. Hospital Records dated for [DATE] revealed Resident #1 arrived with Emergency Medical Services (EMS) actively bagging (manually ventilating) Resident #1. Emergency document revealed that at 6:12 am the emergency room physician immediately intubated (tube placed in the windpipe to assist with breathing) and was placed on a ventilator (a machine that assists with breathing). Documentation at 6:58 am revealed EMS was not made aware nor had possession of paperwork that Resident #1 was on Hospice and a DNR. The doctor spoke with Resident #1 family at 10:31 am the decision was made to extubate (remove the breathing tube) from her and transfer her back to the facility. Resident #1 was extubated at 11:13 am. Nurse's Note #5 dated for [DATE] at 12:23 pm indicated Resident #1 returned to the facility accompanied by her family. Nurse's Note #3 dated for [DATE] at 1:52 am revealed Resident #1 expired with family at her bedside. Interview conducted with Hospice Nurse on [DATE] at 10:43 am revealed Resident #1 was admitted into hospice service on [DATE]. The facility staff were notified Resident#1 was admitted to hospice and to contact the on-call hospice nurse with any significant change in the Resident's health. The Hospice Nurse indicated anytime there was a change in condition of a Hospice patient, the facility was to call Hospice and the Nurse would guide the facility on how to proceed. Interview conducted with Nurse #3 on [DATE] at 11:09 am stated she was called to the Resident's #1 room on [DATE] at 4:50 am by the Nursing Assistant (N.A.) Resident #1 had difficulty breathing. Nurse #3 assessed Resident #1 vital signs and repositioned her to assist with better oxygenation. She indicated that Resident #1 had a Do Not Resuscitate (DNR) yellow form and the medical record indicated she was a full code. The family was contacted unsuccessfully to clarify Resident #1's code status. Nurse #3 stated she contacted the physician on-call and informed her Resident #1 was having difficulty breathing, there were conflicting code statuses, and that Resident #1 was a current Hospice patient. The physician indicated to send Resident #1 to the hospital. Nurse #3 was unable to remember why she did not call the Hospice Nurse and why EMS did not take the DNR form. Interview conducted on [DATE] at 3:00 pm with Director of Hospice Services revealed the facility was educated to contact hospice when a hospice patient had a change in condition, the Hospice Nurse assessed and managed care in the facility setting. Interview conducted on [DATE] at 1:27 pm Administrator stated nursing was to reach out to the Hospice Nurse first while a hospice patient was declining. He stated hospice directed the care. Interview conducted on [DATE] at 1:40 pm Director of Nursing stated once a decline was noted in a hospice Resident, the facility was to call the Hospice Nurse to direct the Resident's care. Interview conducted on [DATE] at 2:16 pm with Nurse #4 revealed nursing staff were to contact the on-call Hospice Nurse if a hospice patient declined. The Hospice Nurse instructed staff on what to do next. She also indicated each nurse's station had a hospice book with current hospice residents used to communicate between the facility and hospice provider. Interview conducted on [DATE] at 10:26 am with Lead Emergency Medical Technician (EMT) indicated he was not told by facility staff that Resident #1 was a Hospice patient or had a DNR. He indicated Resident #1 was severely hypoxic, required a rebreather mask, and was immediately transferred to the hospital emergency room staff. Interview conducted on [DATE] at 3:50 pm with the on-call physician revealed she was on-call the morning of [DATE] and she did not recall a conversation with the facility regarding Resident #1. She reviewed her call message log and stated the information in log did not extend back to ,d+[DATE]. The facilty submitted a Corrective Action Plan for F 849 reviewed by an Informal Dispute Resolution (IDR) panel on [DATE]. The Corrective Action Plan was reviewed and verified by the IDR panel as an acceptable plan completed by the facility on [DATE] for the following reasons: -when Resident #1 returned to the facility the code status was communicated to the facility staff and it was immediately updated and corrected both with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -Education was immediately started and completed on notifying the hospice provider first when a hospice resident has a change in condition before calling the facilities on call provider. Education included the hospice policy on communicating information about the hospice resident to the facility staff as the DNR was placed in the book but not communicated to the facility nurse. -the facility is reviewing all new orders and ensuring any changes to the advance directive are entered into the electronic medical record and the code status book which is kept at the nursing station. Currently the facility had no other hospice residents however the audits used to ensure no discrepancies with code status would cover any resident in the facility weather they were hospice or not. -Code status books were audited daily from [DATE] through [DATE] then the audits were moved to weekly. -Per the information presented to the IDR panel the facility reported the auditing information to the QAPI committee prior to the survey. The facility provided information and reported in the IDR that the monitoring of the corrective action plan through QAPI was ongoing. -the facility alleged compliance was achieved on [DATE] before the survey team entered the facility on [DATE]. The panel determined that the facility's date of compliance was [DATE] based on the information provided to the panel. The facility updated the Hospice contract on [DATE].

Based on observations, interviews with residents, staff and the primary care physician (PCP) and record review the facility failed to provide a safe transfer for 1 of 3 residents (Resident #1) reviewed for a fall. Failing to provide a safe transfer resulted in Resident #1 sustaining a fracture of his pelvis and fractured ribs. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent fall risk evaluation, dated 5/27/16 indicated Resident #1 was at high risk of falls. Review of a 9/4/16 Restorative Functional Assessment indicated that while the resident did not ambulate, he required assistance to maintain balance, had left side weakness, was chair bound and had joint limitations in his left shoulder, wrist, hip, knee and ankle. A 10/24/16 nurse's note that was identified as a late entry for 10/21/16 indicated Resident #1 required a total lift with green sling for transfers related to inability to hold sit to stand mechanical lift with both hands and the resident's leg came off the lift even when strapped at the base. Nursing notes dated 11/16/16 at 12:22 PM indicated Resident #1 had been reassessed for transfer status. Documentation indicated staff would use the total lift, with the blue sling and the assistance of 1 staff for transfers. Monthly nursing notes dated 11/30/16 at 7:55 AM indicated Resident #1 was a one person physical assist with transfers. It was noted that staff used the total lift for transfers. The most recent Minimum Data Set (MDS), a quarterly dated 12/1/16 identified Resident #1 as alert and oriented with no behaviors. The resident was coded on the MDS as requiring extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Transfer was coded as 2+ person physical assist. Functional limitation in range of motion was coded as impairment on one side of upper and lower extremities. The MDS indicated the resident had experienced no falls since the previous assessment. The 12/4/16 Restorative Functional Assessment indicated the resident was alert and oriented, understood others and always followed directions. He was unable to ambulate and balance required assistance to maintain. The resident was documented as requiring the assistance of two staff members for transfers and was chair bound due to left sided weakness. Joint limitations remained in the left shoulder, wrist, ankle and foot. The assessment indicated the resident easily fatigued and had no weight bearing. Poor hand/eye coordination was also identified. The care plan reviewed on 12/14/16 indicated Resident #1 was at risk of falls due to a history of falls, use of psychotropic medication and left sided weakness. Interventions to protect the resident included assessing previous falls to determine pattern/trend, assist with mobility as needed, bed in low position, call bell in reach, environment free of clutter, mechanical lift per routine using a blue lift pad, medication review, non-skid foot wear when out of bed, not to be left alone when toileting and therapy referral as indicated. Monthly nursing notes dated 12/30/16 at 7:55 AM indicated Resident #1 was alert and oriented x 3, pleasant and cooperative. He required physical assistance of one with transfers. The note indicated the resident was working with therapy on strengthening and transfers. He was identified with left sided weakness per baseline. Review of a nursing note written on 2/9/17 at 7:34 PM indicated the nurse had been called to the room by the nursing assistant (NA) #1. The NA told the nurse the resident had fallen out of the sit to stand lift. The resident was found lying on the bathroom floor. The nurse documented Resident #1 stated his back hurt. The nurse documented the NA stated the resident was on the sit to stand lift and took his arm out of the sling causing him to fall. The nurse documented Resident #1 agreed with the circumstances of the fall. When Resident #1 was placed back in bed, he stated it was painful to take a deep breath and complained of left hip pain. The PCP and RP were notified and Resident #1 was sent to the hospital. emergency room (ER) documentation, dated 2/9/17, indicated Resident #1 told the ER physician he had been dropped on the toilet from a lift. The physician noted the resident had a fracture of his left hip and fractures of the left 7th and 8th ribs. Notes indicated Resident #1 was in severe pain requiring Morphine for pain control. On 2/13/17 at 7:12 PM, Resident #2, who was the room-mate of Resident #1 was interviewed. The resident stated Resident #1 had a stroke and could not use his left arm and leg; adding a sit to stand lift was used for Resident #1's transfers. On 2/9/17, Resident #2 added NA #1 came into the room to transfer the resident to the bathroom. When he was placed in the bathroom, the NA left the room. Resident #2 stated he heard an awful sound and then heard Resident #1 yelling for help. Resident #2 stated he opened the bathroom door and saw Resident #1 had fallen; adding he appeared to be tangled in the belts on the lift. He stated the NA returned to the room and told him he needed to get out of the way. Then the nurse and eventually the Director of Nursing (DON) came into the room. Resident #2 stated he had not been interviewed about what he had seen and heard. When he tried to tell administration, he was told the incident was none of his concern. Nurse #1 was interviewed on 2/14/17 at 11:34 AM. She stated she was Resident #1's primary 7:00 AM to 3:00 PM nurse. The nurse stated with Resident #1 having diarrhea for at least 3 weeks during January he was weak and pale. Nurse #1 stated Resident #1 had left sided weakness and a sit to stand mechanical lift was used for transferring the resident from bed to chair. NA #1 was interviewed on 2/14/17 on 1:27 PM. The NA stated she worked on different halls and while she primarily worked first shift, she at times, would stay over and work second shift. The NA stated information about resident transfer status could be found on the door by the resident's name. She explained the coding and added Resident #1 was transferred with a sit to stand lift using a green sling with the assistance of 2 staff. The NA added Resident #1 was heavy and because of that, he required 2 staff members to assist with his transfer. The NA acknowledged on 2/9/17 she had transferred Resident #1 by herself. She added she had asked NA#2 who was on break to assist with the transfer. NA #2 advised NA #1 to wait and she would assist when her break was completed. Rather than wait for NA #2 to assist, NA #1 stated she transferred Resident #1 alone because he was ready to go to the bathroom and he had fallen. The NA stated she had not asked Nurse #2 to help her transfer the resident because she was busy passing medication. Other than NA #2, NA #1 acknowledged she had not requested any other staff member assistance and had not told Resident #1 it was unsafe and requested that he wait until NA #2 could help. The NA then stated she thought she had noticed the coding for Resident #1 indicated he was to be transferred with 1 staff assisting and did not know he was a 2 person assist until the Director of Nursing (DON) told her after the fall. NA #1 stated the incident occurred around 7:30 PM. She added Resident #1 was sitting in his wheelchair. She had pushed the sit to stand lift in front of him and secured him with the straps around his legs, his waist and under his arms. When the resident was secured, she had lifted him and was headed for the bathroom. NA #1 added most of the lift was in the bathroom and she had almost arrived to the toilet when the resident's left hand dropped from the handle and then he let go with his right hand and fell . NA #1 stated Resident #1 landed on the bathroom floor on his left side. The NA stated she unclipped the straps and moved the lift. She then went to get Nurse #2. She acknowledged Resident #2, the room-mate, was in the room at the time. At the time of the fall, Resident #1 complained of hip pain and stated his back felt tight. NA #1 added after the fall, she had to do a return demonstration of how she had lifted the resident for the DON, Administrator and the corporate nurse. NA #1 stated she knew the resident had been sick, but had been told by other NAs that he was improving. She acknowledged Resident #1 was alert and oriented. The Restorative NA (RNA) was interviewed on 2/14/17 at 2:23 PM. The RNA stated she was familiar with Resident #1 since she provided range of motion to his legs and assisted with splinting his left arm. She added the resident was unable to bear weight and used a sit to stand for transfer. The RNA stated as long as Resident #1 was strapped in properly, there was no issue with using the sit to stand lift. The RNA stated she had worked with Resident #1 during his recent illness and had found him to be weak and unable to move as much. On 2/14/17 at 1:58 PM, the Administrator was interviewed. He stated to the best of his knowledge, Resident #1's fall occurred when NA #1 was assisting him to the bathroom using the sit to stand lift. The NA had told him she had looked at the signage on the door and thought the resident's transfer status was with the sit to stand with 1 staff assisting. The Administrator added Resident #1 actually had been assessed as requiring 2 staff to assist and NA #1 had read the directions incorrectly. NA #1 had reported Resident #1's left hand shot up and then he let go with his right hand. He slid to the floor and landed on his left side. The NA then notified Nurse #2 who assessed the resident. The RP and the PCP were notified and Resident #1 was transferred to the hospital. The following day, the signage on the doors was reviewed to see if there were any issues. The staff found the signage had a very small 2 that had slipped down and had been blocked. He stated as NA #1 glanced at the signage, she went into the room thinking Resident #1 only required 1 person to assist with transfer. The Administrator stated Resident #1 had been acutely sick leading up to the fall and had been out on 2/9/17 for a family visit. He added fatigue may have played a part in the resident's fall. On 2/14/17 at 2:46 PM, NA #1 demonstrated how she had transferred Resident #1 using the sit to stand lift with the Administrator playing the part of Resident #1 during the lift. The NA stated Resident #1 was able to lift his feet, including his left foot, and place them on the foot of the sit to stand lift. The NA confirmed she had used a green pad as indicated by the dot on the door. The NA stated the resident's wheelchair was setting between the bed and the bathroom door facing the hallway. NA #1 then placed the pad/sling around the Administrators waist and buckled the waist pad. Another strap was placed behind his back and under his arm and clipped to the handle bar. The NA added when she had buckled the two buckles to the waist belt on Resident #1, she had only heard one click which indicated only one of the buckles had been securely fastened, but did not stop to check and make sure both buckles were secure. The NA stated Resident #1's left hand was placed on the left handle of the lift. Since he was unable to grab the handle, she had placed his thumb under the handle. The NA added Resident #1 was able to grip the right handle bar of the lift. NA #1 then took the Administrator's arm and raised it approximately 6-8 inches high and over the bar of the left, resting by his side. After the resident's left arm drop, the NA stated Resident #1 let go of the right handle bar which led Resident #1 to slide downward. As he slid downward, the waist buckles came undone causing Resident #1 to fall, landing in the bathroom floor on his left side. The Facility's Rehabilitation Manager (RM) was interviewed on 2/14/17 at 3:18 PM. She stated Resident #1 had been referred to therapy for evaluation of transfer safety on 1/6/17. The RM stated the resident was able to bear weight and was able to raise his arm as described by the NA during her previous demonstration. The RM stated Resident #1 had progressed during therapy and had been upgraded from total mechanical lift to the sit to stand lift. NA #2 was interviewed via telephone on 2/14/17 at 3:25 PM. She stated Resident #1 was alert and oriented and required assistance with transfer and bed mobility. She stated the resident had left sided weakness and could only lift his left arm if he did so with his right hand. She stated on 2/9/17, prior to the resident's fall, NA #1 had not asked her to help transfer Resident #1. The NA stated she was unaware of Resident #1's fall until NA #1 went to get her to help transfer the resident to bed. NA #1 reported to her that Resident #1's left arm slipped and he let go with his right hand. NA #2 stated Resident #1 reported to her the same story when asked. On 2/14/17 at 4:30 PM, Nurse #2 was interviewed. Nurse #2 stated she was the primary second shift nurse for Resident #1 and had been the nurse on duty on 2/9/17 when the resident fell . The nurse stated during January 2017, Resident #1 had diarrhea for approximately 3 weeks which left him physically weak and depressed. He was more lethargic and stated he was weak and tired. She added that typically Resident #1 would be up in his wheelchair, but for 3 weeks during his illness, he stayed mostly in bed. Nurse #2 stated Resident #1 was unable to independently or voluntarily move his left arm and was only able to move his left arm if he used his right hand to move the arm. She stated if his left foot fell off the wheelchair foot rest, he either used his right leg or hand to place his left foot back or would call staff to help him place his left foot back on the foot rest. The nurse gave another example and stated when she put lotion on the resident's foot, she would have to lift his foot from the bed because he was unable to do so independently. On the night of 2/9/17, Nurse #2 stated NA #1 came to get her from the nurse's station and told her Resident #1 had fallen out of the lift. The nurse stated she remembered entering the resident's room at 7:30 PM and remembered asking NA #1 if she had securely fastened the resident in the lift. The NA had replied yes. The nurse stated when she arrived in Resident #1's room, she observed him sitting on the bathroom floor with his left side propped against the toilet and maintaining position with right hand. Nurse #2 stated she asked the resident specifically if he had been secured in the lift and he replied yes. When she asked what happened, he replied that stupid arm of mine (left) slipped out and I let go with the right and fell out of the sling. The nurse stated when she asked the NA about the waist straps being tight, the NA replied they were, but NA #1 had not mentioned she was unsure if the buckles had been secured. Nurse #2 stated when she arrived in the bathroom, the NA had already undone all the straps. The nurse added the room-mate was aware of what had happened as was NA #2. The nurse stated NA #1 had not asked her for assistance with the transfer. Nurse #2 stated if NA #1 had not been sure the waist buckles were secure, she would have expected the NA to stop and make sure the buckles were securely fastened before lifting Resident #1. The DON was interviewed 2/15/17 at 8:43 AM. The DON stated the NAs assigned to residents were to look at the color on the resident's door and the code to determine what sling and mechanical lift plus the number of staff needed to lift a resident. She stated Resident #1 had been assessed as requiring 2 staff members to transfer him with the use of a sit to stand lift. The DON added she was in the facility when the resident fell . Nurse #2 had motioned to her to come and on arriving in Resident #1's room, he had already been placed back to bed. The DON added she asked NA #1 what happened and had been told the resident let go of the lift and fell . The DON stated this story was confirmed by Resident #1. She added when she tried to talk with Resident #1 to get more information, he stated, I just let go and I don't want to talk about it. She stated she did not pursue with more questions due to the resident's pain status. The DON stated the room-mate was in the room during the fall and was alert and oriented. She acknowledged Resident #2 had not been interviewed and concluded since his interview was not included the investigation would not be considered complete. During the investigation and re-enactment, the DON stated she could not remember NA #1 stating she was unsure if the waist buckles had been secured. She added based on Resident #1's last assessment, 2 staff people should have been present during the transfer. The DON added if NA #1 had been unsure of how many staff were required for the transfer, she should have asked the nurse. The DON stated she was unable to determine if the fall could have been prevented, but stated when Resident #1 let go of the lift it increased his chance of falling. During an interview with Resident #1 on 2 /15/17 at 10:20 AM, he acknowledged he had been really sick during January 2017 that left him weak. The resident stated he was unsure what had caused the fall on 2/9/17, but confirmed the NA had fastened the straps behind his knees, around his waist and under his arms. He was unable to remember if he had let go of the lift and stated all he knew was he ended up on the floor. Resident #1 confirmed and demonstrated his inability to voluntarily lift his left foot/leg or left arm/hand. The Administrator added on 2/15/17 at 10:44 AM that on Friday, 2/10/17, he visited the resident in the hospital. At that point, the resident stated he felt he had been buckled in the lift. The resident's PCP, was interviewed via phone on 2/15/17 at 11:20 AM. She indicated that due to Resident #1's size he needed 2 staff people to assist with transfers. The PCP added that due to the fall on 2/9/17, Resident #1 had sustained a pelvic fracture requiring surgical repair and broken ribs.