Every finding on record at Autumn Care of Waynesville

Based on observation and staff interviews, the facility failed to discard food past its use-by date in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents.The findings included:An observation of the walk-in cooler with the Food Services Director on 5/31/26 at 9:48 AM revealed a box of four 5-pound bags of shredded coleslaw with a use-by date of 5/28/26 stamped on the bags.An interview on 5/31/26 at 9:57 AM with the Food Services Director revealed she and the other dietary staff were responsible for checking the cooler daily for food that needed to be discarded. She indicated the shredded coleslaw bags should have been discarded according to their use-by date. The Food Services Director reported she had checked the cooler that morning. An interview on 6/04/26 at 11:23 AM with the Administrator revealed the Food Services Director was responsible for ensuring expired foods were discarded. She indicated the bags of shredded coleslaw should have been discarded according to their use-by date and expected dietary staff would follow policy to determine when food needed to be discarded.

Based on record review and staff interviews, the facility failed to develop a person-centered individualized care plan for 1 of 3 residents reviewed for urinary catheters (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was moderately cognitively impaired, was dependent on staff for toileting hygiene and was always incontinent of both urine and bowel.Resident #6's care plan which was last reviewed and revised on 3/11/26 indicated no information about care for an indwelling catheter.A review of a physician's order dated 3/12/26 indicated catheter care: change indwelling urinary catheter as needed. An interview with MDS Nurse #1 on 6/4/26 at 12:41 PM revealed she last updated Resident #6's care plan on 3/11/26. During the interview, MDS Nurse #1 looked through Resident #6's medical record and noted that Resident #6's catheter was initiated on 3/12/26, and this was why she did not know that Resident #6 had an indwelling urinary catheter because she had just updated her care plan the day before. MDS Nurse #1 stated that she checked the orders whenever she updated the care plans. She also stated that she updated the care plans whenever she was made aware of any changes with the residents and if she was told during the morning meetings about any new information. MDS Nurse #1 stated nursing should be trained to update the care plans when needed, and if she had known about Resident #6's urinary catheter, she would have updated her care plan.An interview with the Director of Nursing (DON) on 6/4/26 at 2:25 PM revealed MDS should be keeping up with a list of residents with indwelling urinary catheters. The DON stated the MDS nurses were supposed to check the daily orders, and that Resident #6's care plan should have been updated if there was a new order for a urinary catheter.

Based on observations, record review, resident, staff, and Physician Assistant (PA) interviews, the facility failed to follow a physician order to float Resident #47's heels while in bed as tolerated during three observations. Additionally, the facility failed to implement a bowel protocol for Resident #43 who had not had a bowel movement documented in 6 days. This deficient practice occurred for 2 of 4 residents (Resident #47 and Resident #43) reviewed for quality of care. The findings included: 1. Resident #47 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease (progressive circulation disorder that narrows or blocks blood vessels). On 4/16/26 there was a physician order stating to float heels when in bed as tolerated every shift. On 4/22/26 the admission Minimum Data Set (MDS) assessment indicated Resident #47 was cognitively intact. She needed substantial/maximal assistance to roll left and right. The admission MDS also indicated that she had no wounds and had a pressure reducing device for her bed. The 5/11/26 care plan had a focus area regarding skin integrity and one of the approaches was to offload heels in bed as tolerated. On 5/31/26 at 12:54 PM an interview was held with Resident #47. She stated that she had a sore on her left heel. She stated that it was causing her pain having the heel on her mattress. On 5/31/26 at 12:54 PM an observation was made of Resident #47 heels. Both heels laid on a pressure reducing mattress with no socks. The left heel had a round 1 inch in diameter scab. On 6/2/26 Resident #47 had a bilateral lower extremity arterial duplex ultrasound and the Medical Director deemed the left heel wound an arterial wound with arterial insufficiency (narrowed or blocked arteries slowing blood flow) as the main contributing factor to wound development. On 6/3/26 at 9:15 AM a second observation was made of Resident #47 and both of her heels laid on her mattress with no socks. On 6/3/26 at 10:26 AM an interview was held with a Physician Assistant (PA). She stated that she had just learned of the heel wound on 6/1/26. The PA stated that Resident #47 was on Hospice and spent a lot of time in her bed, but she recently decided to end Hospice care. When the PA saw her today, she also observed that her heels were not being floated. On 6/3/26 at 12:50 PM an interview was held with Nurse Aide (NA) #1 who was assigned to Resident #47. The NA stated that she was not aware that Resident #47's heels were to be floated. NA #1 went and spoke to Resident #47 about floating her heels and got a pillow to float them. On 6/3/26 at 12:55 PM an interview was held with NA #2. NA #2 also did not know that Resident #47's heels were to be floated as tolerated. On 6/3/26 at 2:38 PM an interview was held with Unit Manager #2. She stated that each NA had a tablet to pull down the care plan for each resident and it showed that Resident #47 heels were to be floated as tolerated and that Resident #47 could decline having them floated. On 6/4/26 at 11:39 AM a third observation was made of Resident #47 and neither of her heels were being floated. They were observed laying on her mattress and the Resident had socks on. Resident #47 was sleeping so was unable to be interviewed. On 6/4/26 at 3:00 PM an interview was held with the Director of Nursing (DON). She stated the staff should be following the physician orders and be offering Resident #47's heels to be floated if she wanted. On 6/4/26 at 3:30 PM multiple telephone calls were made to the Medical Director. He did not return any of the calls. On 6/4/26 at 3:46 PM an interview was held with the Administrator. She stated that she would expect the staff to be following the plan of care, and she would be reviewing the care plans and making sure each approach was entered into the tablets that the NAs use. 2. Review of a facility bowel protocol policy reviewed last on 1/31/26 read in part, If 48 hours without a bowel movement (BM): -Give Miralax (polyethylene glycol) (laxative) 17 grams (gm) in 4-8 ounces (oz) liquid -If no BM by 10 AM the following day, repeat Miralax 17 gm in 4-8 oz liquid -If no BM by the next morning, administer enemeez micro enema 5 milliliters (ml) rectally. If no BM within an hour, contact provider. Resident #43 was admitted to the facility on [DATE]. His diagnoses included dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented he had severe cognitive impairment. The MDS indicated he did not have behaviors or rejection of care. The MDS reported he required substantial/ maximal assistance with his activity of daily living (ADL) tasks, toileting hygiene, and transfers. The MDS documented he was frequently incontinent of bowel. Resident #43 did not have a care plan for constipation. Resident #43's physician orders did not include any medication that could cause constipation. His physician orders did not include any medications to move his bowels prior to 5/7/26. A nursing note on 5/1/26 documented Resident #43 was transferred to the hospital for evaluation due to a change in mental status. A hospital emergency room (ER) report dated 5/1/26 documented Resident #43 had a scan of his abdomen during an ER visit showing chronic constipation. The ER report did not include any information that indicated he received any treatment or medication for his bowels during his ER visit. The report did not include any discharge orders for bowel medications. The ER report included he was being discharged back to the facility and included orders for an antibiotic for treatment of possible pneumonia. A hospital abdominal scan dated 5/1/26 read, large colonic stool burden with features of chronic constipation. A nursing note dated 5/2/26 by Nurse #3 documented Resident #43 returned to the facility on 5/2/26 at 12:30 AM. The note did not mention the abdominal scan showing constipation or any orders for bowel medications. An interview was conducted with Nurse #3 on 6/4/26 at 2:50 PM. Nurse #3 worked night shift (10:30 PM- 6:30 AM) and was Resident #43's assigned nurse on 5/1/26, 5/2/26, 5/3/26, 5/4/26, 5/5/26, and 5/6/26. She thought she recalled Resident #43 returning with paperwork from his ER visit on 5/2/26. She recalled his chest scan had shown there was fluid in his lungs and that he had returned with a new order for an antibiotic. Nurse #3 stated she did not recall a scan that showed anything bad about his bowels and thought there was an abdominal scan that said small or moderate stool in his colon. Nurse #3 then said she was not sure and might be mixing up the abdominal scans from his 5/1/26 and 5/8/26 ER visits. She said she could not remember for sure what his 5/1/26 ER visit abdominal scan showed or that she had seen it. Nurse #3 stated if there was a scan that had shown something significant, she would have notified the on-call provider about what it said. Nurse #3 stated she did not recall anything abnormal occurring with Resident #43 during the night shifts she worked from 5/1/26-5/6/26 after he returned from the hospital. She stated Resident #43 had not had any episodes of emesis. She reported she had not assessed his abdomen because he had not had any acute issues to indicate she needed to do so. She did not recall receiving in report Resident #43 had not had a BM. Resident #43's electronic medical record documented he had not had a bowel movement from 5/1/26 through 5/8/26. Review of the May 2026 Medication Administration Report (MAR) revealed he had not received any medications to move his bowels from 5/1/26 through 5/6/26. A progress note documented by PA #1 dated 5/6/26 stated Resident #43 was being seen for follow up after his ER visit on 5/1/26. The note indicated Resident #43 had returned from the ER on [DATE] with a diagnosis of possible aspiration pneumonia and was started on an antibiotic. PA #1's note under physical exam stated abdomen, soft, nontender, with no rebound or guarding. Under assessment and plan the note stated constipation: chronic constipation was noted as an incidental finding on imaging obtained during recent ER visit. Add Miralax (polyethylene glycol) once daily to the current medication regimen. An order dated 5/7/26 was entered by PA #1 at 6:24 AM and read, polyethylene glycol 17 gm once a day, mix with 8 ounces of water. Review of the May 2026 MAR indicated Resident #43 received polyethylene glycol as ordered on 5/7/26 and 5/8/26. A nursing note dated 5/7/26 at 9:32 AM by Nurse #1 documented a Nurse Aide (NA) reported Resident #43 was vomiting. The note additionally documented Nurse #1 notified the provider and received orders for Zofran (antinausea medication) 4 milligrams every 8 hours as needed and to give Resident #43 an enema (laxative) for constipation. The nursing note indicated to contact the provider if vomiting gets worse or doesn't stop, or if the enema does not work. An order dated 5/7/26 read, administer, 1 enema per rectum once a day as needed. The MAR documented the enema was administered as ordered on 5/7/26. An order dated 5/7/26 read, ondansetron (Zofran) 4 mg, take 4 mg as needed every 8 hours for nausea/ vomiting (N/V). The MAR documented Zofran was administered as ordered. An interview was conducted with NA #3 on 6/4/26 at 11:10 AM. NA #3 reported she was Resident #43's assigned NA on day shift on 5/1/26, 5/4/26, 5/5/26, 5/6/26, 5/7/26 and 5/8/26, She recalled Resident #43 vomiting on 5/7/26. She said the vomit was dark brown in color and that she notified the nurse. She could not recall which nurse she had notified. She said Resident #43 was incontinent of bowel and was unable to take himself to the bathroom. NA #3 explained she sometimes got swamped with performing resident care and missed charting. She could not remember for sure if Resident #43 had a BM or not when she had worked from 5/1/26 to 5/8/26 but did not think he had. An interview was conducted with Nurse #1 on 6/4/26 at 12:37 PM. She stated she was Resident #43's assigned nurse on 5/7/26 day shift (6:30 AM-2:30 PM). Nurse #1 reported a NA notified her on 5/7/26 sometime after breakfast Resident #43 was vomiting, she could not remember who the NA was that notified her. She reported she went and assessed Resident #43. Nurse #1 stated the vomit was a dark brown color. She recalled he had bowel sounds present in all four abdominal quadrants and did not have any abdominal tenderness. She did not recall his abdomen being distended. She reported Resident #43 was incontinent of bowel and was unable to toilet himself without assistance. She stated she contacted PA #1 and notified her about what was going on with Resident #43. Nurse #1 stated she checked Resident #43's BM record and let PA #1 know his record did not show he had had a BM in several days. Nurse # could not recall how many days his record indicated it had been since his last BM. She recalled PA #1 provided orders for Zofran and an enema to be administered. Nurse #1 reported she gave the Zofran and administered the enema to Resident #43 before lunch. She stated the Zofran was effective and Resident #43 stopped vomiting for a few hours after he took the Zofran. She stated around lunch time Resident #43 vomited again, and he had not had BM results from the enema. Nurse #1 recalled she contacted PA #1 again and PA #1 ordered a Kidney Ureter Bladder (KUB) x-ray. Nurse #1 stated she was assigned to work on a different hall for the evening shift (2:30 PM-10:30 PM) and gave report to the oncoming evening shift nurse, Nurse #4. Nurse #1 explained the process of how residents were identified when they had not had a BM. She stated nurse management printed a BM report every day. She said the BM report was left at the nursing desk by management, and the nurses were told to check the list. Nurse #1 explained if a resident had not had a BM in 3 days or greater, the bowel protocol was started. She explained the bowel protocol included to administer Miralax (laxative), then if still no BM by the next day to administer Miralax again, and then if still no BM the next day to administer an enemeez (mini enema (laxative)). Nurse #1 explained she typically checked the BM report log but did not recall if Resident #43 was flagged on the BM report log for not having a BM. She did not recall if she went back and checked the log to see when Resident #43's last BM was but said she had checked Resident #43's BM record in his electronic medical chart to see when he had last had a BM documented. She did not recall the date of his last BM but said it had been several days. A nursing note dated 5/7/26 at 10:30 PM by Nurse #4 read, results received from KUB and indicated the on-call provider was notified of the results and that there were no new orders. The note stated to notify the provider of any further vomiting. An interview was conducted with Nurse #4 on 6/4/26 at 1:43 PM. She was Resident #43's assigned evening shift nurse on 5/7/26. She recalled the portable x-ray company came to the facility and completed the KUB x-ray for Resident #43 on the evening shift. She did not recall what time they came. She remembered the KUB results came back on her shift and showed some constipation. Nurse #4 stated she notified the on-call provider of the KUB results. Nurse #4 stated Resident #43 had one small episode of vomiting on her shift and she gave him Zofran. She recalled the vomit was a dark brown color. She reported the Zofran was effective and he did not have any more vomiting on her shift. Nurse #4 stated she notified the on-call provider of the KUB results and vomiting episode. She recalled the on-call provider did not give any additional orders except to notify them if he had any additional vomiting and said she reported that to the oncoming night shift nurse, Nurse #5. A KUB report dated 5/7/26 read; no obstruction or ileus. Moderate stool burden, suggesting constipation. Nurse #5 was the assigned night shift nurse for Resident #43 on 5/7/26. Nurse #5 was unavailable for interview. An interview was conducted with Nurse #6 on 6/3/26 at 4:35 PM. She was the assigned day shift nurse for Resident #43 on 5/4/26, 5/5/26, and 5/8/26. She did not recall Resident #43 being flagged on the BM log for not having a BM. She explained there was a bowel protocol that was supposed to be followed if a resident had not had a BM in 3 days. She was unable to recall what the bowel protocol was. She recalled Resident #43 vomited on 5/8/26 and said that she contacted the on-call provider and obtained an order to send him to the ER. She stated on 5/8/26 when he went to the ER his abdomen was distended but was not tender and that he had normal bowel sounds present. She reported Resident #43 was incontinent of bowel and was unable to take himself to the bathroom. Prior to 5/8/26 she did not recall Resident #43's abdomen being distended, tender, or him having any issues with his bowels. An interview was conducted with Nurse #7 on 6/4/26 at 4:29 PM. He was the assigned nurse for Resident #43 for evening shift on 5/3/26 and 5/8/26. He stated when he arrived for his shift on 5/8/26 the day shift nurse was in the process of sending Resident #43 to the hospital. He did not recall who the day shift nurse was. He did not recall Resident #43 having any issues during his shift on 5/3/26. A nursing note dated 5/9/26 at 3:02 AM by Nurse #3 documented Resident #43 was admitted to the hospital. A hospital Discharge summary dated [DATE] indicated Resident #43 arrived at the ER from the facility on 5/8/26 due to concerns of gastrointestinal (GI) bleed. The note stated per Emergency Medical Services (EMS) the facility reported constipation since 4/30/26 and coffee ground emesis (vomit). The discharge summary documented, EMS saw coffee-ground emesis in the emesis basin. The hospital course indicated scans were completed of the abdomen and pelvis. The discharge summary stated the abdominal scan was consistent with acute cholecystitis (inflammation of the gall bladder) with suspected choledocholithiasis (presence of gallstones in the bile duct), but no active gastrointestinal (GI) bleeding was identified. There was noted to be a large colonic stool burden. The note stated he underwent endoscopic retrograde cholangiopancreatography (ERCP) (procedure to remove gallstones) on 5/13/26 with stone removal and that he had significant clinical improvement almost immediately after GI intervention. The discharge summary said his hemoglobin (blood cells that carry oxygen) had been trended and was fairly stable, doubt any significant GI bleeding however he may have esophagitis for which protonix (medication to treat gastric reflux) was started. The note additionally stated he was started on Dulcolax (laxative) suppository daily as needed for constipation. The discharge diagnosis included Choledocholithiasis (the presence of a gallstone in the bile duct) and that he was status post ERCP. A nursing noted dated 5/15/26 documented Resident #43 was readmitted to the facility on [DATE]. Resident #43's electronic medical record documented bowel movements and indicated Resident #43 had no further bowel issues since being readmitted to the facility on [DATE]. An interview was conducted with PA #1 on 6/3/26 at 9:22 AM. The PA recalled Resident #43 was sent to the ER on [DATE] and returned over the weekend on 5/2/26. She reported she returned to the facility on Monday 5/4/26 and had her office request the notes and diagnostics from his 5/1/26 ER visit. PA #1 reported she reviewed the ER notes on 5/6/26 and had seen Resident #43. She recalled an abdominal scan from his 5/1/26 ER visit showed constipation and stated she had ordered Miralax to treat his constipation. She stated the facility had a no BM list staff were supposed review a bowel protocol they were supposed to follow if a resident was flagged for not having a BM. She stated she thought the bowel protocol was supposed to start if a resident had not had a BM in over 2 days, but she was not certain. She did not know how it was missed that Resident #43 had not had a BM. PA #1 reported Resident #43's constipation could have caused his vomiting. She additionally explained Resident #43 was diagnosed with cholelithiasis during his 5/8/26 hospitalization and said it could have caused the vomiting too. She stated she could not say for sure his vomiting was not from his acute gall bladder. An interview and observation were conducted with the Regional Director of Nursing on 6/4/26 at 12:19 PM. She provided a BM report log from 4/20/26 through 5/10/26. Resident #43 was not flagged on the report for not having a BM. The Regional DON stated Resident #43 should have flagged on the report but didn't. She stated the information technology (IT) department for the electronic computer system had been contacted to determine why Resident #43 had not been flagged on the report. She stated she was told there had been an updated to the electronic computer system around the beginning of May and that a glitch may have occurred in the system. She stated Resident #43 should have flagged on the BM report for not having a BM but did not and that was why it had been missed. An interview was conducted with the Director of Nursing (DON) on 6/4/26 at 2:25 PM. She stated the bowel protocol was supposed to start when a resident was flagged on the BM report log for not having a BM in 48 hours. The DON explained Resident #43 not having a BM was missed because he had not pulled to the BM report log. An interview was conducted with the Administrator on 6/4/26 at 3:46 PM The Administrator stated Resident #43 not having a BM was missed because there was an error in the electronic computer system and Resident #43 was not flagged on the BM report log for not having a BM.

Based on record review, observation and interviews with the resident, staff and the Hospice Nurse, the facility failed to provide a physician's order and an indication for use of an indwelling catheter for 1 of 3 residents reviewed for urinary catheters (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, anemia, hypertension and diabetes. Review of Resident #6's medical record indicated no urinary diagnosis listed. She was most recently re-admitted from the hospital on 1/23/26 for left brachial deep vein thrombosis (blood clot in a deep vein in the left arm) and was re-admitted to the facility with hospice care on 1/23/26. There was no mention of the indwelling urinary catheter in the hospital discharge summary.Further review of Resident #6's medical record indicated no physician's order or progress notes related to the indwelling urinary catheter.A hospice note dated 1/23/26 in Resident #6's medical record indicated the presence of an indwelling urinary catheter which was patent, intact and connected to bedside drainage. The note did not include a physician's order or indication for the use of the catheter.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was moderately cognitively impaired, was dependent on staff for toileting hygiene and was always incontinent of both urine and bowel. Resident #6 received hospice care.Resident #6's care plan which was last reviewed and revised on 3/11/26 indicated no information about care for an indwelling catheter.A phone interview with the Hospice Nurse on 6/4/26 at 1:08 PM revealed Resident #6 was re-admitted from the hospital with the indwelling urinary catheter in place. The Hospice Nurse stated that she had offered Resident #6 to have the urinary catheter removed, but Resident #6 was adamant that she wanted to keep it. The Hospice Nurse stated that she did not know the official diagnosis to support the use of the indwelling urinary catheter. She further stated that she knew Resident #6 complained of urinary symptoms a lot and had frequent urinary tract infections, but Resident #6 did not want to have the urinary catheter removed. The Hospice Nurse stated that the urinary catheter could be used for comfort reasons, and she did not think there had been any issues with Resident #6 having the catheter in place.A review of a physician's order dated 3/12/26 indicated catheter care: change indwelling urinary catheter as needed. This order was entered into Resident #6's medical record by Nurse #1. An interview with Nurse #1 on 6/4/26 at 2:02 PM revealed the Hospice Nurse asked her to place an order for the care of Resident #6's indwelling urinary catheter on 3/12/26. Nurse #1 stated that Resident #6 already had a catheter in place at that time. Nurse #1 stated that she was not sure how Resident #6 obtained the indwelling urinary catheter, but that Resident #6 might have been re-admitted from the hospital with it in place. Nurse #6 further stated that she normally would look for the diagnosis that would support the catheter use and if there was none, she would reach out to the medical provider, but in Resident #6's case, she did not question the order to change the urinary catheter because Resident #6 was a hospice resident and hospice usually had different reasonings for the use of indwelling urinary catheters.An observation and interview with Resident #6 were conducted on 6/1/26 at 8:56 AM. Resident #6 was lying in bed, and she was observed to have an indwelling urinary catheter which was hooked to the bedframe on the right side of her bed. Resident #6 stated that she requested to have the catheter placed for convenience because she was having to wait long for incontinence care to be provided to her. Resident #6 could not recall when the catheter was inserted.An interview with Unit Manager #1 on 6/4/26 at 3:07 PM revealed she did not know that Resident #6 did not have a diagnosis to support the use of her indwelling urinary catheter. Unit Manager #1 stated that she started working at the facility in March and might have been in orientation when an order was started for Resident #6's indwelling catheter. Unit Manager #1 stated that she checked all the new orders daily, but she did not note that Resident #6 had an order for an indwelling urinary catheter. Unit Manager #1 stated that she was not aware of Resident #6's concerns about not being provided incontinence care and requesting to have an indwelling catheter placed. Unit Manager #1 further stated that there should have been a reason to place an indwelling urinary catheter, and it should have been included in the physician's order.An interview with MDS Nurse #1 on 6/4/26 at 12:41 PM revealed she did not know that Resident #6 had an indwelling urinary catheter. During the interview, MDS Nurse #1 looked through Resident #6's medical record and noted an order to change Resident #6's urinary catheter as needed on 3/12/26, but there was no order for the use of the indwelling urinary catheter. She stated she could not determine when Resident #6's catheter was started and it might have been when Resident #6 went into hospice care. MDS Nurse #1 scanned through the hospice notes and did not find any information about Resident #6's indwelling urinary catheter. MDS Nurse #1 stated she could not find any diagnosis for Resident #6 that supported the use of the indwelling urinary catheter. She also stated that although Resident #6 had a right to request for a catheter, the doctor had to document justification for its use and MDS Nurse #1 did not see any reason for the urinary catheter.An interview with the Director of Nursing (DON) on 6/4/26 at 2:25 PM revealed she had just started working at the facility when Resident #6 was re-admitted to the facility from the hospital in January. The DON stated Resident #6 might have been re-admitted to the facility with an indwelling urinary catheter. The DON stated that the administrative nurses usually checked the orders and if the resident did not have a qualifying diagnosis for the catheter, then they needed to either get an appropriate diagnosis or have the catheter discontinued. The DON stated Resident #6 not having a diagnosis for her indwelling catheter was an oversight. The DON stated they reviewed orders in the morning meetings, but she did not remember talking about Resident #6's indwelling urinary catheter.An interview with the Administrator on 6/4/26 at 4:10 PM revealed Resident #6 should have an appropriate diagnosis for the urinary catheter, and the clinical team who reviewed the orders in the morning meeting should have caught this concern.Attempts were made to interview the Medical Director, but they were not successful.

Based on observation and staff interviews, the facility failed to ensure [NAME] Wing Medication Cart #1 was secured while unattended for 1 of 4 medication carts observed for medication storage (West Wing Medication Cart #1).The findings include:On 6/3/26 a continuous observation was made on of the [NAME] Wing Medication Cart #1 from 2:40 PM till 2:55 PM. The cart was observed with the lock button not pushed in to secure the cart. [NAME] Wing Medication Cart #1 was sitting at the nurses' station for approximately 15 minutes when Resident #87 wheeled himself next to the medication cart opened the 3rd drawer down from the top and looked in and took his hand and swept the top of the medication blister packs and then closed the drawer. He then opened the 4th drawer and looked inside and then closed the drawer and continued on his way. Nurse #2 was sitting at the desk using the computer. Nurse #2 was informed of the situation at 2:55 PM and quickly got up and pushed the lock button in to secure the medication cart.On 6/3/26 at 2:55 PM an interview was conducted with Nurse #2. She stated that she had just finished counting medications with the Unit Manager #2 and she thought the Unit Manager #2 had secured the medication cart. Nurse #2 stated the cart should have been locked since it was not being used.On 6/3/26 at 3:15 PM an interview was held with the Unit Manager #2. She stated that she was informed that one of the medication carts had been left unlocked. She thought Nurse #2 had locked the [NAME] Wing Medication Cart #1 after counting medications with her. She stated that the medication cart should have been locked and it was a mistake. On 6/4/26 at 2:50 PM an interview was held with the Director of Nursing (DON) who stated that all medication carts should be locked and secured when unattended.On 6/4/26 at 3:49 PM an interview was held with the Administrator who stated she would expect the medication cart to be locked and secured.

Based on observation and staff interviews, the facility failed to follow their infection control policies and procedures for clean dressing change and hand hygiene when Wound Nurse Aide (NA) #1 failed to change her gloves and perform hand hygiene while performing wound care for Resident #5. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Wound NA #1). Findings included:Review of the facility's policy and procedure last approved 12/12/25 entitled Clean Dressing Change Policy read in part Where sterile technique is not ordered or indicated, wounds will be dressed using clean technique which avoids direct contamination of material and supplies.-Check for any dressing present, remove and wrap in gloves as you take gloves off, discard in trash bag.-Perform hand hygiene-Don clean gloves-Cleanse with ordered solution or normal saline soaked gauze pads.-Remove gloves and discard-Perform hand hygiene and don clean gloves.-Apply new dressing as ordered Review of the facility's policy and procedure last approved 4/3/26 entitled Hand Hygiene Policy read in part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:-before moving from work on a soiled body site to a clean body site on the same patient.-After touching a patient or the patient's immediate environment.-After contact with blood, body fluids, or contaminated surfaces.-Immediately after glove removal An observation was completed on 6/3/26 from 7:59 AM to 8:24 AM of Wound NA #1 performing wound care for Resident #5. Wound NA #1 performed hand hygiene when she entered Resident #5's room and put on clean gloves and a gown. She removed the soiled dressing from Resident #5's left ischium (lower back part of the hip bone) pressure ulcer wound and discarded it in the trash; she did not change her gloves or perform hand hygiene after removing the dressing. Using the same gloves Wound NA #1 proceeded to clean the wound; she did not change her gloves after cleaning the wound. Wound NA #1 then applied gauze moistened with 0.25 % Dakin's (medical grade bleach solution used to treat wounds) solution to the wound bed and covered the wound with an absorbent dressing. Wound NA #1 removed her gloves and washed her hands at the sink located in Resident #5's room and put on clean gloves. She then removed the soiled dressing from Resident #5's right ischium pressure ulcer wound and discarded it in the trash; she did not change her gloves after removing the dressing. Using the same gloves Wound NA #1 cleaned the wound; she did not change her gloves after cleaning the wound. Wound NA #1 then applied calcium alginate (specialized highly absorbent wound dressing) to the wound bed and covered the wound with an absorbent dressing. She removed her gloves and washed her hands at the sink located in the room and put on clean gloves. Wound NA #1 then removed the offloading boat from Resident #5's right foot and removed the dressing from her right heel pressure ulcer and discarded it in the trash. Using the same pair of gloves, Wound NA #1 cleaned the wound, applied calcium alginate to the wound bed, covered the wound with a bordered dressing, and reapplied the offloading boot to her right foot. Wound NA #1 removed her gown and gloves, discarded them into the trash, washed her hands at the sink in the room, and exited the room. An interview was conducted with Wound NA #1 on 6/3/26 at 8:25 AM. Wound NA #1 stated she was supposed to remove her gloves, perform hand hygiene, and put on new clean gloves after she removed the dirty dressing and after cleaning the wound. She said she should have performed hand hygiene and put on clean gloves before she applied the new dressings. Wound NA #1 stated she normally changed her gloves during wound care but had forgotten to change them during Resident #5's wound care today. She reported she had received training on infection control practices for wound care. An interview was conducted with the Infection Preventionist (IP) on 6/3/26 at 10:33 AM. The IP stated Wound NA #1 should have removed her gloves, performed hand hygiene and put on new clean gloves after removing Resident #5's old dressings. She stated Wound NA #1 should have also performed hand hygiene and put on a new pair of gloves after cleaning the wounds before she applied the new dressings. The IP stated Wound NA #1 should follow the facility's infection control policies and clean dressing change policy. She reported Wound NA #1 had received infection control training and training for wound care. The IP indicated she was surprised that Wound NA #1 had not changed her gloves. An interview was conducted with the Director of Nursing (DON) on 6/3/26 at 1:56 PM. The DON stated Wound NA #1 should follow the facility's infection control and clean dressing change policies. The DON said Wound NA #1 should have changed her gloves and performed hand hygiene after she removed Resident #5's dirty dressings before she applied the new clean dressings. She was not sure why Wound NA #1 had not changed her gloves. An interview was conducted with the Administrator on 6/4/26 at 3:46 PM. The Administrator said Wound NA #1 should have changed her gloves during Resident #5's wound care and should have followed the facility's infection control and dressing change policies.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) for a resident (Resident #3) when Nurse #1 performed wound care without donning a gown. The deficient practice occurred for 1 of 1 staff member (Nurse #1) observed for infection control practices during wound care.Findings included:The facility's Enhanced Barriers policy last revised 5/19/2025 revealed EBP are indicated for high contact care activities for high-risk residents. High-risk residents are those with chronic wounds and indwelling devices. Staff engaging in high-contact activities will don (put on) both gloves and gown before initiating the activity and remove before exiting the room. Review of Resident #3's 5-day Minimum Data Set, dated [DATE] revealed he had an unstageable pressure injury. An observation was conducted on 9/09/25 at 10:38 AM while Resident #3 received wound care to his left heel. Nurse #1 was observed to enter Resident #3's room without a gown. Nurse #3 performed hand hygiene and donned gloves. She removed the soiled dressing, removed her gloves and performed hand hygiene. She donned gloves and washed and dried the wound and removed her gloves. She performed hand hygiene, donned gloves, applied skin prep, applied clean gauze, covered wound with pad and clean gauze which was secured with tape. She removed her gloves and performed hand hygiene. She did not wear a gown during the process. An interview on 9/09/25 at 10:50 AM with Nurse #1 revealed she had forgotten to wear her gown during wound care. She stated she had received infection prevention education on EBP and knew she was supposed to follow EPB during wound care, but her nerves had gotten the better of her. An interview on 9/09/25 at 12:05 PM with the Director of Nursing and the Administrator revealed Nurse #1 had received Infection Prevention training and should have worn a gown during wound care. They stated Nurse #1 was nervous and had made a human mistake.

Based on record review, staff, and Adult Protective Services (APS) Social Worker (SW) interviews, the facility failed to follow and implement their abuse policy and procedures in the areas of protecting, investigating, and reporting to the Administrator, the State Agency, and/or law enforcement for 2 of 4 residents (Resident #51 and Resident #65) reviewed for abuse. Nursing Assistant (NA) #1 observed NA #2 strike Resident #65 with an open hand during care and did not immediately intervene, did not report the incident immediately to the Administrator, and NA #2 continued to work on the floor with other residents. This failure resulted in a lack of protection for other residents. The findings included: Review of the facility policy titled North Carolina Resident Abuse Policy, revised 7/11/24 indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedure in this policy. If a staff member is accused or suspected of abuse, the facility will immediately remove the staff member from resident care area. The accused staff member will be removed from the facility pending the outcome of the investigation. 1. Resident #65 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #65's significant change Minimum Data Set, dated dated dated [DATE] revealed she was severely cognitively impaired. The initial allegation report was completed by the Administrator and dated 3/07/25. The incident date was 3/07/25. The date the facility became aware of the incident was 3/07/25 at 10:00 PM. Allegation details reported that staff alleged witnessing NA #2 strike Resident #65 while providing care. An interview on 5/21/25 at 12:55 PM with NA #1 revealed she was present in the room at the time of the incident which occurred on 3/07/25 around 10:30PM. She stated she and NA #2 were settling Resident #65 in bed after her shower. She stated NA #3 was in the room and she did not know what he had heard or seen. NA #1 stated she observed NA #2 hit Resident #65 with her open hand on the resident's left lower arm. NA #2 stated to NA #1 that she did not care anymore and had no sympathy for the resident. NA #1 stated she and NA #2 and NA #3 exited the room. NA #1 stated after the incident, she observed NA #2 walk down the hall where she was assigned and she was available to provide care for the facility residents. NA #1 stated she was in shock and did not know what to do. NA #1 stated she got off work on 3/07/25 at 10:30 PM, so she clocked out and left the facility right after the incident. She stated she was afraid to report the incident to the on-duty nurse, Nurse #1, because she was afraid of a confrontation with NA #2. She did not report it until after she got home, which was about a 15-minute drive. NA #1 stated she contacted the Director of Nursing and reported the incident, but did not remember the time of the call. An interview on 5/21/25 at 3:34 PM with Nurse #1 revealed she was on duty on 3/07/25 when the physical abuse incident occurred. She stated she was unaware of the incident until the Director of Nursing (DON) called her after 11:00 PM. She did not remember the exact time but took the telephone to NA #2 so she could talk with the DON. She stated a Law Enforcement Officer arrived at the facility, talked with NA #2 and escorted her out of the facility. Nurse #1 assessed Resident #65 who had no bruises, welts, discoloration or other injuries noted. An interview on 5/21/25 at 2:36 PM with the Director of Nursing (DON) revealed that NA #1 had called her after 11:00 PM on 3/07/25 to report the incident. The DON had called the facility, talked to Nurse #1 and NA #2 was asked to leave the building. NA #1 reported to the DON that she had observed Resident #65 hit NA #2 and NA #2 hit the resident. NA #1 also stated she felt uncomfortable reporting the incident to Nurse #1, so she waited until she got home to call the DON to report the incident. The DON indicated she had called the facility, talked to Nurse #1 and NA #2 was asked to leave the building. She stated she personally talked to NA #2 on the telephone, told her she was being suspended and asked her to leave the building. NA #2 was still in the facility working her shift (2:30 PM - 6:30 AM) when the DON called the facility and talked with Nurse #1 and NA #2. As NA #2 was leaving the facility, a Law Enforcement Officer arrived at the facility and escorted her out of the building. The DON instructed Nurse #1 to complete a full skin assessment on Resident #65 and notify the on-call physician and the resident representative. The facility notified the Department of Social Services of the incident. An interview on 5/22/25 at 9:31 AM with the Administrator revealed he had been notified about the incident and an investigation had been completed. He stated that NA #1 should have reported the incident immediately, but she had been afraid to report the incident with NA #2 present. 50046 2. Resident #51 was admitted to the facility on [DATE] with a diagnosis of dementia. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had short-term and long-term memory problems. The MDS noted her cognitive skills for daily decision making were moderately impaired. Resident # 89 was admitted to facility on 1/7/25 with diagnoses that included bipolar disorder (psychiatric disorder). The admission 5-day MDS dated [DATE] revealed Resident #89 was cognitively intact. During a phone interview with an Adult Protective Services (APS) Social Worker (SW) on 5/21/25 at 12:25 PM she revealed she came to the facility on [DATE] to investigate a staff to resident abuse allegation. The APS SW stated she had talked with the facility SW and explained she was investigating an alleged staff to resident abuse allegation for Resident #51 that had been reported by the resident's roommate, Resident #89. The APS SW recalled the facility SW stating she did not know anything about it and that Unit Manager (UM) #1 would be better to talk to about it. The APS SW stated the facility SW took her to UM #1's office. The APS SW recalled herself, UM #1, and the facility SW sitting in UM #1's office and talking about the allegation. The APS SW reported she told UM #1 she was at the facility to investigate a staff to resident abuse allegation involving Resident #51 that had been reported by Resident #89. The APS SW stated the abuse allegation was not substantiated. The facility SW was unavailable for interview. An interview was conducted with UM #1 on 5/21/25 at 2:09 PM. UM #1 reported she remembered an APS SW coming to the facility to visit Resident #89 and Resident #51. She recalled talking with the APS SW but did not remember the details of the conversation. UM #1 reported she did not recall the APS SW saying she was investigating a staff to resident abuse allegation for Resident #51 that was reported by Resident #89. Review of the Facility Reportable Incidents revealed there was no record of the alleged staff to resident abuse incident reported to APS by Resident #89 for Resident #51. An interview was conducted with the Administrator on 5/20/25 at 11:00 AM. The Administrator was not aware of an abuse allegation involving Resident #51 from February 2025 or March 2025. The Administrator explained he would continue to look for information. On 5/20/25 at 2:45 PM the Administrator provided a letter dated 3/14/25 addressed to the Administrator titled North Carolina Department of Health and Human Services Division of Aging and Adult Services Notice to Administrator: Completion of Evaluation. The letter revealed the following information: APS received a phone call from Resident #51's roommate, Resident #89, reporting that Resident #51 had gotten beat up last night. The timeline told to APS from Resident #89 was a bit scattered and it was unclear if this happened last night or a couple of days or weeks ago. Resident #89 was unable to state who the perpetrator was, but she indicated it was not a resident and alluded to it being a staff person. When telling APS the information, Resident #89 seemed scared, like someone was listening. The APS SW's investigation on 3/14/25 did not confirm/substantiate abuse or the need for protection as the APS SW did not know who the alleged perpetrator was, what time of day it happened, or what day it happened. An additional interview was conducted with the Administrator on 5/20/25 at 2:45 PM. The Administrator stated the facility SW was unavailable due medical leave. He reported he had found the letter APS regarding the abuse allegation and investigation involving Resident #51 in a file located in the SW's desk. The Administrator stated the SW had not mentioned the letter to him. The Administrator explained he had not been aware of the letter or allegation before he found the letter today (5/20/25). The Administrator said if he had been aware of the staff to resident abuse allegation he would have followed the facility's abuse investigation and reporting process, which would have included reporting the allegation to the state agency and law enforcement. An interview was conducted with the Director of Nursing (DON) on 5/21/25 at 3:02 PM. The DON stated she had not been aware of the staff to resident abuse allegation involving Resident #51 or that APS had come to the facility and completed an investigation.

Based on record review, and staff and family interviews, the facility failed to determine if a resident with cognitive impairment had a Resident Representative before allowing the resident to sign admission paperwork for 1 of 1 resident (Resident #91) reviewed for resident rights. Findings included: Resident #91was admitted to the facility on [DATE] with diagnosis that included dementia. Resident #91was discharged from the facility to another skilled nursing facility on 4/18/25. A hospital discharge summary dated 3/6/25 stated Resident #1 had advanced dementia. Resident #91's face sheet was reviewed and revealed Resident #91 was listed as the first primary contact as the primary financial contact receive account receivable (A/R) statement. Resident #91's [Family Member] was listed as the second contact as the emergency contact. An additional family member was listed as the third contact as the Resident Representative. Resident #91's Spouse was not listed on her contact list. Review of Resident #91's facility admission agreement paperwork revealed the paperwork had been signed by Resident #91 on 3/11/25 and was witnessed by the former Admission Coordinator. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had severe cognitive impairment. An interview was conducted with Resident #91's Family Member, who was her legal representative on 5/21/25 at 12:10 PM. She reported it was not until Resident #91 left the facility and the Family Member had signed admission paperwork for Resident #91 at the new facility that she became concerned about the admission paperwork because she had not signed any of it when Resident #91 was admitted to the facility on [DATE]. The Family Member stated she called the facility after Resident #91 had moved to ask about who had signed the admission paperwork for Resident #91 and was told by the former Admission Coordinator Resident #91 had signed the paperwork. The Family Member explained Resident #91 had dementia and would not understand anything she signed. She verbalized the facility had told her, Resident #91's Spouse had been present in the room when Resident #91 had signed the admission paperwork. The Family Member stated the facility did not say why they did not have Resident #91's spouse sign the paperwork instead of Resident #91. She recalled the former Admission Coordinator was very quick to say Resident #91 had signed but her Spouse was present. The Family Member stated the Spouse was present and they could have had him sign the paperwork, but they had Resident #91 sign it. The Family Member stated Resident #91 was not competent to sign the paperwork. The Family Member explained Resident #91 knew who she was but was not aware of her surroundings. She felt the facility should have known from Resident #91's medical history that she could not sign paperwork. The Family Member explained Resident #91's Spouse was overwhelmed and would not have known what he was signing. She said he would not have understood the paperwork either and that he would have just signed it. The Family Member stated she had been at the facility a lot and if she was not there the facility could have called her, and she would have come to sign the paperwork. The Family Member reported she felt the admission paperwork for Resident #91 should have been signed by someone who understood what the paperwork was, and that the admission paperwork would have been a foreign language to her parents. An interview was conducted with the former Admission Coordinator on 5/21/25 at 2:33 PM. She stated the admission paperwork was completed and signed electronically using a tablet device. She recalled Resident #91, and stated she was aware Resident #91 had a diagnosis of dementia from her hospital admission paperwork but that she was not aware of the extent of her dementia. She recalled completing the admission paperwork with Resident #91 and her Spouse. The former Admission Coordinator said she had talked with Resident #91 and her Spouse about the paperwork and that Resident #91's cognition seemed perfectly fine. The former Admission Coordinator stated she had asked if Resident #91 had a power of attorney (POA) and the Spouse and Resident #91 had said no. She reported that both Resident #91 and her Spouse participated in the conversation. The former Admission Coordinator reported she felt they understood what was being discussed. The former Admission Coordinator stated she was unsure if Resident #91 or her Spouse were able to retain the information discussed. The former Admission Coordinator stated she was aware of what dementia was and agreed memory impairment and short-term memory loss were features of dementia. The former Admission Coordinator reported the Spouse had said to let Resident #91 sign the admission paperwork and that was why she had let Resident #91 sign the documents. She explained if a resident was cognitive enough to sign or there was a family member in the room who said the resident was coherent enough to sign she let the resident sign. She stated if a resident was able to sit up, talk, tell her where they were, and was very aware then the resident was okay to sign the admission paperwork. She reported if a resident was not alert/ oriented enough to sign their admission paperwork she would reach out to the POA or family to complete the paperwork. She said if the Spouse or legal representative was in the room then they should be the person who signed the paperwork. The former Admission Coordinator explained she had not been aware Resident #91 had a POA until Resident #91 was getting ready to discharge from the facility. She stated Resident #91's [Family Member] had called and asked about who had signed Resident #91's admission paperwork and the daughter had told her at that time she was Resident #91's POA. The former Admission Coordinator said the facility did not have a copy of Resident #91's POA paperwork. She reported that Resident #91's daughter emailed the POA (Health Care) paperwork to the facility close to the day of the resident's discharge, but did not give an exact date. After the former Admission Coordinator received the POA paperwork she added it to Resident #91's medical record. An interview was conducted on 5/21/25 at 3:10 PM with the Director of Nursing (DON). The DON reported that the admission paperwork should be signed by the Resident Representative (RR) or POA if a resident had cognitive impairments. The DON said even if a spouse or POA was in the room and said to let them sign, they could not because they would be signing a legal document they did not understand. The DON recalled Resident #91 and said she did not think Resident #91 was competent to sign her own admission paperwork. An interview was conducted with the Administrator on 5/22/25 at 2:04 PM. The Administrator stated he remembered Resident #91 and was aware she had dementia. He reported Resident #91 should not have signed her admission paperwork because they were legal documents and she had dementia. The Administrator stated Resident #91's authorized legal representative should have signed the papers. He said he had not been aware of the situation previously and was not sure what had happened.

Based on record review and staff interviews, the facility failed to protect a severely cognitively impaired resident (Resident #65) from the right to be free of physical abuse. On 3/07/27 around 10:30 PM, when Nursing Assistant (NA) #1, and NA #2 were providing care for Resident #65, the resident became agitated and combative. NA #2 struck the resident with an open hand on her lower left arm. The deficient practice occurred for 1 of 4 residents reviewed for abuse. Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses which included dementia and hypertension. Resident #65's care plan revised 4/02/25 revealed a problem area of cognitive loss/dementia due to progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought process related to a diagnosis of dementia. The goal was for the resident to maintain her highest level of cognition. Approaches included: to be patient with resident; break tasks and activities into manageable subtasks; give one instruction at a time; and gently redirect the resident when she made inappropriate actions. Resident #65's significant change Minimum Data Set, dated dated dated [DATE] revealed she was severely cognitively impaired and was dependent or required substantial assistance for activities of daily living. She was not assessed to have behavioral problems during the lookback period. Nurse Aide (NA) #2's handwritten statement was undated and read I changed (Resident #65's) bed while NA #3 and NA #1 gave her a shower. Got her in bed and she likes to hit. I blocked her with my arm and grabbed her hands so she wouldn't hit. NA #1 and NA #3 were in the room, and I never hit her she hit me! A telephone interview with NA #2 was attempted but unsuccessful. A typed statement from NA #1 dated 3/09/25 read, Around [9:50 PM] [NA #1, NA #2, and NA #3] went to [Resident #65's] room who was in bed and agitated. (NA #2 and NA #1) transferred [Resident #65] on the lift while [NA #3] handled the lift. [NA #3 and NA #1] gave [Resident #65] the shower in the shower room while [NA #2] stayed in the room and changed the linen. [Resident #65] finished her shower and was brought back to her room and placed back in bed with the lift. [NA #2 and NA #1] rolled [Resident #65] to get the lift pad and towels from under her. [Resident #65] was rolled towards [NA #2], while [NA #1] was drying her back [Resident #65] was hit [NA #2] several times. When [Resident #65] was placed on her back, [NA #2] struck [Resident #65] on the left forearm. She went down [Resident #65's] face and said, Get you're a-s over. Afterwards [NA #2] stated to [NA #1 and NA #3] she has no sympathy for (resident). An interview on 5/21/25 at 12:55 PM with NA #1 revealed she was present in the room at the time of the incident between Resident #65 and NA #2 which occurred on 3/07/25 around 10:30PM. She stated she and NA #2 were settling Resident #65 in bed after her shower. She stated NA #3 was in the room and she did not know what he had heard or seen. As NA #1 and NA #2 were turning Resident #65 to remove the lift pad and wet linens from under her, NA #1 observed the resident hit NA #2. NA #1 stated she observed NA #2 hit Resident #65 with her open hand on the resident's left lower arm. The resident did not say or do anything in response to being hit on the arm. NA #2 stated to NA #1 that she did not care anymore and had no sympathy for the resident. NA #1 stated she did not say anything to NA #2 about seeing NA #2 hit the resident. NA #1 stated she just froze and didn't know what to say or do. NA #1 stated she and NA #2 and NA #3 exited the room. NA #1 stated she was in shock and did not know what to do. NA #1 stated she got off work at 10:30 PM, so she clocked out and left the facility right after the incident. She stated she was afraid to report the incident to the on-duty nurse, Nurse #1, because she was afraid of a confrontation with NA #2. NA #1 indicated she did not report it until after she got home, which was about a 15-minute drive. NA #1 further stated she contacted the Director of Nursing and reported the incident, but did not remember the time of the call. NA #3's emailed statement dated 3/08/25 at 12:24 AM read, Hello [Administrator], The following is my report on the events of the period of time (roughly 10:00-10:25 PM) in which the incident discussed allegedly occurred: [NA #1] and myself had just finished giving [Resident #65] a shower. We used the full mechanical lift to transport [Resident #65] from the shower chair to her bed, where she was then laid down on her side. I left the room for about 10 seconds while I moved the lift out of the room and retrieved washcloths to finish cleaning [Resident #65]. During this period, [Resident #65] exclaimed pain/discomfort several times, which is not at all unusual for any of us, seeing as she has experienced this discomfort with most forms of movement for the entirety of my employment. [NA #1 and NA #2] finished cleaning and preparing [Resident #65] for bed while I mostly either stood by for occasional help or worked on cleaning the floor ([Resident #65] had also defecated while being transferred), so I can't say I observed the entire interaction. In regard to the matter at hand, I did hear [NA #2] exclaim some frustration with [Resident #65] for hitting her while we finished cleaning her, but at no point did I hear or see anything that indicated to me that [NA #2] hit [Resident #65]. Please let me know if there are any further details that you would like me to clarify. An interview on 5/21/25 at 9:29 AM with NA #3 revealed he was present in the room on 3/07/25 at the time of the incident. He stated he was cleaning the floor and heard NA #2 tell Resident #65 not to hit her. He was unaware of the incident until he was driving home and received a call from the Administrator. NA #3 indicated he did not have any further conversations with NA #1 or NA #2 that evening. Nurse #1's progress note dated 3/07/25 11:58 PM (recorded as late entry on 3/08/25 at 8:34 AM) read in part that Resident #65 was assessed from head to toe. No new discoloration, swelling, bruising, injury noted. Patient appears to have no pain or discomfort noted. On-call physician was notified. Law Enforcement Officer escorted NA #2 out of the facility. An interview on 5/21/25 at 3:34 PM with Nurse #1 revealed she was on duty on 3/07/25 when the physical abuse incident occurred between NA #2 and Resident #65. She stated she was unaware of the incident until the Director of Nursing (DON) called her after 11:00 PM. She did not remember the exact time but she took the telephone to NA #2 so she could talk with the DON. She stated a Law Enforcement Officer arrived at the facility, talked with NA #2 and escorted her out of the facility. Nurse #1 assessed Resident #65 who had no bruises, welts, discoloration or other injuries noted and no discomfort was observed. An interview on 5/21/25 at 2:36 PM with the Director of Nursing (DON) revealed that NA #1 had called her after 11:00 PM on 3/07/25 to report the incident. NA #1 stated that she had observed Resident #65 hit NA #2 and NA #2 hit the resident. NA #1 also stated she felt uncomfortable reporting the incident to Nurse #1, so she waited until she got home to call the DON to report the incident. The DON indicated she had called the facility, talked to Nurse #1 and NA #2 was asked to leave the building. She stated she personally talked to NA #2 on the telephone, told her she was being suspended and asked her to leave the building. NA #2 was still in the facility working her shift when the DON called the facility and talked with Nurse #1 and NA #2. As NA #2 was leaving the facility, a Law Enforcement Officer arrived at the facility and escorted her out of the building. The DON instructed Nurse #1 to complete a full skin assessment on Resident #65 and notify the on-call physician. An interview on 5/22/25 at 9:31 AM with the Administrator revealed he had been notified by the DON that NA #1 had observed NA #2 hit Resident #65 on her left lower arm immediately after she was notified by NA #1 which was after 11:00 PM on 3/0725. The Administrator stated he contacted Law Enforcement. During the investigation, he talked with NA #2 who stated that NA #1 perceived the incident incorrectly. The allegation was investigated, and the facility did not substantiate it. The Administrator stated NA #2 was terminated for poor customer service. The police did not press charges against NA #2. The facility provided a corrective action plan which was not acceptable to the State Agency due to not including observations of nurse aides providing care in their audits to ensure the deficient practice will not recur.

Based on record reviews and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, Lorazepam, prescribed for anxiety/restlessness had a stop date of 14 days for 1 or 6 residents (Resident #80) reviewed for unnecessary medications. The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses which included restlessness and agitation. Resident #80's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was severely cognitively impaired and was coded for hospice care. A physician's order dated 12/03/24 at 1:07 PM read for Lorazepam (antianxiety medication) 0.5 milligrams (mg) every 4 hours as needed (PRN) for anxiety/restlessness. There was no stop date. Review of the monthly drug regimen review consultation report dated 12/14/24 completed by the Consultant Pharmacist revealed a recommendation to discontinue the PRN Lorazepam or add a stop date. The physician's response signed by the Physician and undated read to accept the recommendation above and implement as written. No stop date or discontinuation date was written on the recommendation. A review of Resident #80's December 2024 and January 2025 Medication Administration Records (MARs) revealed the Lorazepam 0.5 mg every 4 hours PRN for anxiety and restlessness remained an active order. Review of Resident #80's February 2025 and March 2025 MARs revealed per staff documentation, Resident #80 had received Lorazepam the following doses: 4 doses in February 2025, 14 doses in March 2025, 7 doses in April, and 7 doses between May 1st and 19th, 2025. Review of the monthly drug regimen review consultation report dated 3/23/25 completed by the Consultant Pharmacist revealed a recommendation to discontinue the PRN Lorazepam or add a stop date. The physician's response signed by the Physician's Assistant dated 4/02/25 read to add a stop date of 4/15/25 to the Lorazepam order. Review of Resident #80's April 2025, and May (1st through the 19th) 2025 Medication Administration records revealed through staff documentation, Resident #80 received 7 doses of Lorazepam in April, and 7 doses between May 1st and 19th, 2025. Review of the monthly drug regimen review consultation report dated 4/19/25 completed by the Consultant Pharmacist revealed a recommendation to discontinue the PRN Lorazepam or add a stop date. The Physician's response signed by the Physician's Assistant dated 4/28/25 was to decline the recommendation with the rationale it was a hospice patient order. An interview on 5/21/25 at 9:44 AM with Nurse #2 revealed she received the monthly drug regimen review consultation reports, distributed them to the physicians, and ensured the recommendations were completed. She stated that since Resident #80 was on hospice, their Lorazepam PRN order did not require a stop date. Nurse #2 indicated she noted the resident was on hospice on the pharmacy consultation report and had not entered a stop date for the December 2024, March 2025 or April 2025 monthly drug regiment review consultation reports. An interview on 5/21/25 at 10:08 AM with Nurse #3 revealed she also received the pharmacy medication reviews, distributed them to the physicians, and ensured the recommendations were completed. She stated that since Resident #80 was on hospice, their Lorazepam PRN order did not require a stop date. Nurse #3 stated it was her understanding that hospice resident PRN psychotropic medications did not require a stop date. An interview on 5/21/25 at 10:13 AM with the Director of Nursing (DON) revealed the staff thought that hospice residents did not require a stop date for their psychotropic medications. The DON indicated she was aware of the regulation which required a stop date for psychotropic medications and was unaware that Nurse #2 and Nurse #3 thought that hospice residents were an exception. She was unaware that Resident #65's Lorazepam did not have a stop date and said the facility should follow regulations. An interview on 5/22/25 at 9:35 AM with the Administrator revealed he believed hospice wanted their residents to have their psychotropic medications to be continued but was aware of the requirement for PRN psychotropic medications to have a stop date.

Based on observation and staff interviews, the facility failed to remove four containers of fortified nutritional shake nectar consistency that had a used by date of [DATE]. The four expired containers were found in 1 of 2 nourishment rooms. These practices had the potential to affect any residents that used nectar thickened consistency. The findings included: On [DATE] at 8:25 AM the east side nourishment room was observed and in one of the cupboards there were four containers of fortified nutritional shake with nectar consistency that had a used by date of [DATE]. On [DATE] at 9:13 AM an interview was conducted with the Dietary Manager. The Dietary Manager stated she had no idea how the 4 containers of nutritional shake were missed. The Dietary Manager stated that she inspects both nourishment rooms daily and somehow it got missed. The Dietary Manager stated after hearing about the expired nutritional shakes she inspected both nourishment rooms and all the nutritional shake products she had in the kitchen to ensure there were no other expired containers. The only explanation for the product being missed could possibly be the Dietary Manager's newer staff stocking the nourishment room and placing new products in front of the older product. On [DATE] at 10:37 AM an interview was conducted with the Administrator. He stated that he had been made aware of the expired nutritional shake, and he can't explain how it was missed, but would expect the product to be removed. All food products should be inspected and removed if they are expired.

Based on record review and interviews with resident and staff, the facility failed to remove used lidocaine and clonidine patches as specified by the physician for 2 of 3 residents reviewed for unnecessary medications (Resident #1 and Resident #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including heart failure and high blood pressure. The physician's orders dated 05/22/24 revealed Resident #1 had an order to receive 1 patch of clonidine 0.3 milligrams (mg)/24 hours once every 7 days for high blood pressure. A review of the care plan for heart failure initiated on 07/08/24 revealed Resident #1 was at risk for cardiopulmonary symptoms related to high blood pressure. The goal was to remain free from cardiac crisis through the review date. Interventions included providing medication as ordered. The Medication Administration Records (MARs) indicated Resident #1 had received clonidine patch once every 7 days since it was initiated on 05/22/24. The last 3 patches of clonidine were administered on 08/07/24, 08/14/24, and 08/21/24 before Resident #1 was admitted to the hospital on 08/25/24. Further review of MARs revealed the last 2 patches of clonidine were administered by Medication Aide #1 (MA). A review of the nurse's progress notes revealed Resident #1 was noted with acute changes in the level of consciousness on 08/25/24 in the evening. Nurse #2 checked his vital signs including blood pressure and it was within the normal ranges of 112/72. Then she called the on-call provider to obtain an order to send Resident #1 to the emergency department (ED) for evaluation and treatment. The medical records indicated Resident #1's blood pressure was within the normal range of 112/72 on 08/25/24 at 9:15 PM before he was transferred to the ED. Further review of Resident #1's blood pressure records from 08/15/24 through 08/25/24 indicated they were within the normal ranges. A review of the hospital discharge summary dated 08/29/24 revealed Resident #1 was sent to ED on 08/25/24 in the evening due to altered mental status. His blood pressure upon arriving at the ED at 10:10 PM remained normal at 148/74. Nursing staff in ED reported Resident #1 was found to have 2 clonidine patches with different application dates on his body. Resident #1 was later diagnosed with pneumonia and urinary tract infections in the hospital. An attempt to conduct a phone interview with Nurse #2 on 11/26/24 at 8:48 AM was unsuccessful. She did not return the call. During an interview conducted on 11/26/24 at 8:54 AM, MA #1 confirmed she had applied the clonidine patch for Resident #1 on 08/14/24 and 08/21/24. Typically, she and other nursing staff would apply the patch to a clean, dry, and intact skin area on Resident #1's shoulder and rotated sites each time. She recalled before she applied the patch on 08/21/24, she could not find the used clonidine patch that had applied on 08/14/24 despite checking both shoulders and other part of Resident #1's body. She even asked a nurse aide to assist her searching for the used clonidine patch without any success. She thought the clonidine patch could have fallen off during shower. It was not unusual as had happened to other residents before. After trying to look for the used clonidine patch and unsuccessful, she written the date of application on the new clonidine patch and applied it to Resident #1's right shoulder. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/26/24 at 10:02 AM. She confirmed receiving reports from the hospital that Resident #1 was found with 2 clonidine patches with different application dates on his body upon arriving ED. She interviewed MA #1 and found that she could not find the used clonidine patch before applying the new one on 08/21/24. MA #1 explained to her that she had looked all over Resident #1's body, even with the help from a nurse aide for long periods of time, but still could not find the used clonidine patch. The ADON stated the used clonidine patch could have been stuck to the clothing. She added despite having 2 clonidine patches on 08/25/24, Resident #1 did not suffer any adverse reactions as his blood pressures were stable after the last clonidine patches were applied on 08/21/24, and even upon arriving ED on 8/25/24. She stated Resident #1 could have developed tolerance to clonidine patch after being treated with it for years. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including lower back pain. A review of the baseline care plan for pain initiated on 11/19/24 revealed Resident #2 was admitted to the facility after having surgery. She reported having lower back and surgical pains. The goal was to keep her pain under control until the next review date. Interventions included providing pain medications as ordered. The physician's orders dated 11/20/24 revealed Resident #2 had an order to receive 1 patch of lidocaine 4% adhesive patch once daily. The order specified to apply the lidocaine patch to the mid-back in the morning and removed it at bedtime. A review of the MARs indicated Resident #2 had received 1 lidocaine patch once daily since it started on 11/22/24. Further review of the MARs indicated the lidocaine patch that applied on 11/25/24 morning was removed on 11/25/24 in the evening. During a medication pass observation conducted on 11/26/24 at 9:19 AM, Nurse #3 was observed applying a lidocaine patch to Resident #2 in her room. Nurse #3 started by dating the new lidocaine patch. When she lifted Resident 2's clothing at the back, the used lidocaine patch dated 11/25/24 was still attached to Resident #2's mid-back region. Nurse #3 removed the used lidocaine patch before applying the new patch to the mid-back of Resident #2. An interview was conducted with Resident #2 on 11/26/24 at 9:21 AM. She stated the lidocaine patch was applied yesterday morning and the evening nurse did not remove it last night. She denied having any adverse reactions from the lidocaine patch that was attached overnight. During an interview conducted on 11/26/24 at 9:23 AM, Nurse #3 confirmed she was the nurse who applied the lidocaine patch for Resident #2 yesterday morning. She expected the second shift nurse to remove it as specified by the order. A phone interview was conducted with Nurse #4 on 11/26/24 at 9:39 AM. She confirmed she was providing care for Resident #2 on 11/25/24 in the second shift. She explained she was not aware of the order of removing the lidocaine patch at bedtime for Resident #2 as she did not recall seeing the order in her computer when she was doing medication pass on 11/25/24 in the evening. She could not recall removing any lidocaine patch for Resident #2 on 11/25/24. During an interview conducted on 11/26/24 at 10:38 AM, the Director of Nursing (DON) stated the order of lidocaine removal at bedtime was unclear and it might have caused confusion among nurses. It was her expectation for all the nurses to remove the lidocaine and clonidine patches in a timely manner as specified by the physician's order. An attempt to conduct a phone interview with the Medical Director on 11/26/24 at 11:48 AM was unsuccessful. He did not return the call.

Based on observations, record review and Resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews nursing staff failed to identify the seriousness of a change in condition for a resident with a diagnosis of insulin dependent diabetes and provide thorough ongoing monitoring and comprehensive assessments. On [DATE] at 2:30 PM Nurse #2 reported to Nurse #1 Resident #280 was sleepy all day. Nurse #1 did not assess Resident #280 until 5:00 PM and observed the resident was only responsive to painful stimuli and obtained a set of vital signs but did not check her blood sugar. The on-call provider was contacted, and Nurse #1 was instructed to transfer Resident #280 to the emergency room . Lack of effective communication between Nurse #1 and oncoming Paramedic #1 (employed by the facility and functioning as a nurse) resulted in Emergency Medical Services (EMS) not being contacted until 8:10 PM. Resident #280 was unresponsive with a blood sugar of 74 and was transferred to the emergency room . Resident #280 was admitted to the hospital with a primary diagnosis of metabolic encephalopathy (brain dysfunction), was transferred to hospice on [DATE], and expired on [DATE]. Resident #282 was admitted on [DATE] and the facility failed to administer sliding scale insulin (insulin dose based on predefined blood sugar ranges) per the hospital discharge summary or monitor blood sugar levels per the physician orders for a resident with a diagnosis of insulin dependent diabetes. On [DATE] Resident #282 reported extreme thirst and requested for her blood sugar to be checked. Resident #282's blood sugar was 548 (normal range 80 to 130) and a blood sugar greater than 300 could indicate diabetic ketoacidosis which is a dangerous and life-threatening complication of diabetes that occurs when your body does not get enough insulin.) The facility failed to assess a resident for the cause of significant weight gain and edema (swelling caused by too much fluid trapped in the body's tissues) (Resident #18). The deficient practice occurred for 3 of 3 sampled residents (Residents #280, #282 and #18). Immediate jeopardy for Resident #280 began on [DATE] when nurses failed to identify and effectively respond to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. Immediate jeopardy for Resident #282 began on [DATE] when the facility failed to administer sliding scale insulin or monitor blood sugar levels. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #3 was cited at t lower scope and severity of D. The findings included: 1. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. A review of Resident #280's physicians orders from [DATE] through [DATE] revealed the following: A standing order dated [DATE] through [DATE] for blood glucose levels to be checked in the morning and at night for the first 4 days and to inform MD of results. Review of Resident #280's physician orders and documentation from [DATE] through [DATE] revealed no further orders for blood sugars to be checked and no notification was made to the MD regarding blood sugars. The Medication Administration Record (MAR) for January revealed the following blood sugars: [DATE] at 9:44 pm Resident #280's blood sugar was 175 mg/dL. [DATE] at 5:17 am Resident #280's blood sugar was 137 mg/dL. [DATE] at 4:45 pm Resident #280's blood sugar was 166 mg/dL. [DATE] at 5:06 pm Resident #280's blood sugar was 158 mg/dL. [DATE] at 6:21 am Resident #280's blood sugar was 136 mg/dL. [DATE] at 4:46 pm Resident #280's blood sugar was 164 mg/dL. [DATE] at 6:10 am Resident #280's blood sugar was 135 mg/dL. An order dated [DATE] through [DATE] for Insulin Glargine (long-acting insulin) Subcutaneous Solution 16 units to be injected subcutaneously (under the skin) at bedtime for type 2 diabetes. A review of Resident #280's Medication Administration Record (MAR) from [DATE] to [DATE] revealed initialed administrations for Insulin Glargine 16 units subcutaneously daily. A review of the care plan dated [DATE] revealed Resident #280 was at risk for hypoglycemia with a goal to be free of signs and symptoms of hypoglycemia. Interventions included for nursing staff to assess blood sugars as per order and as needed for symptoms of hypoglycemia/hyperglycemia. The care plan further revealed Resident #280 was at risk for altered cardiac and respiratory status with a goal that Resident #280 would not have a preventable crisis. Interventions included for nursing staff to monitor oxygen saturations as needed, to monitor for signs and symptoms of decreased cardiac output (rapid, slow, weak, or diminished pulse, hypotension, hypertension, dizziness, syncope, dyspnea, chest pain, restlessness, cyanosis, alerted mental status, congestion, or shortness of breath). A review of Resident #280's blood sugar summary revealed the last blood sugar obtained was on [DATE] and was 135 milligrams per deciliter (mg/dL) at that time. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact and had not exhibited any behaviors. She was not documented as being on hospice services or receiving insulin. A review of the breakfast meal intake documented by Nurse Aide (NA #1) revealed Resident #280 ate ,d+[DATE]% on [DATE]. Vital signs were obtained on [DATE] at 12:12 pm by Nurse #2. Resident #280's blood pressure was ,d+[DATE], heart rate was 64 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 92% via nasal canula at an unknown rate, and her temperature was 97.6 degrees Fahrenheit. An interview was conducted on [DATE] at 11:47 am with Nurse #2. Nurse #2 reported she worked from 6:30 am to 2:30 pm on [DATE] with Resident #280. She reported she vaguely remembered Resident #280 but recalled her being sleepy. She reported she had not thought it was unusual because she had not worked with Resident #280 often. Nurse #2 reported she did not perform or document a head-to-toe assessment on Resident #280 but had obtained vital signs on [DATE] at 12:12 pm and reported her vital signs were stable. An attempt was made to interview Nurse Aide (NA) #1 on [DATE] who worked first shift (6:30 am to 2:30 pm) on [DATE]. NA#1 was unable to recall Resident #280. A review of the lunch intake documented by NA #1 revealed Resident #280 ate ,d+[DATE]% of her meal on [DATE]. A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Nurse Practitioner #2 was unable to be interviewed. An interview was conducted on [DATE] at 10:41 am with Nurse #1. Nurse #1 reported she worked first shift (6:30 am to 6:30 pm) and usually floated between halls. She reported on [DATE] she floated to 200-hall (Resident #280's hall) at 2:30 pm and relieved Nurse #2. Nurse #2 informed Nurse #1 that Resident #280 had been sleepy all day. Nurse #1 stated after she finished report she took time to get adjusted and started passing medications. She reported she did not go check on Resident #280 until 5:00 pm, at which time the resident was only responsive to painful stimuli. Nurse #1 reported she obtained vital signs after she realized Resident #280 was only responsive to painful stimuli and stated she had not checked her blood sugar. She reported she consulted their on-call telehealth provider around 6:00 pm. Nurse #1 reported the on-call provider had advised her to send Resident #280 to the emergency room around 6:30 pm. She reported she then gave the report to Paramedic #1, printed off Resident #280's information for EMS, and left for the day. She reported she had not notified Resident #280's family or called EMS because she was under the assumption that Paramedic #1 would. Nurse #1 stated she gave shift report to Paramedic #1 (employed by the facility and functioning as a nurse) on [DATE] at 6:30 pm when Paramedic #1 started his shift. A review of the dinner intake for Resident #280 revealed no recorded on [DATE]. Vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm by Nurse #1 per her report). Resident #280's blood pressure was ,d+[DATE], heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). Further review of Resident #280's medical record revealed no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1 (employed by the facility) on [DATE] at 9:19 pm revealed Resident #280 had a change in condition in the last 24 hours and he was told in shift change report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the emergency room . A telephone interview was conducted on [DATE] at 11:02 am with Paramedic #1. Paramedic #1 reported he was not able to remember the events involving Resident #280 on [DATE]. He stated he would have documented any assessment, monitoring, vital signs, and/or interventions in his nursing note. A follow-up telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he started his shift at 6:30 pm on [DATE] and received report from Nurse #1. Paramedic #1 stated Nurse #1 reported Resident #280 was only responsive to a sternal rub. Paramedic #1 reported Nurse #1 had contacted the on-call provider, had received orders from the on-call provider to send Resident #280 to the emergency room , and asked him to check on Resident #280 while she gathered the paperwork for transfer. Paramedic #1 reported he assessed Resident #280 at 6:30 pm, at which time Resident #280 was able to communicate verbally. Paramedic #1 stated he assessed Resident #280's heart sounds, lung sounds, and pulses however he had not reassessed Resident #280's vital signs because she appeared stable. Paramedic #1 reported he was under the impression Nurse #1 had called EMS. Paramedic #1 reported he started his medication pass and checked the hall to see if an EMS stretcher was in the hall. Paramedic #1 reported he called to check the status of EMS at 8:00 pm at which time he was told EMS had never been notified. Paramedic #1 stated at that time he requested an ambulance, which arrived shortly after, and transferred Resident #280 out of the facility. He reported he failed to document his assessments because he had forgotten. A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the emergency room . A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency roiagnom on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. An interview was conducted on [DATE] at 11:17 am with the Director of Nursing (DON). The DON reported Resident #280 was found unresponsive and with stable vital signs on [DATE]. She reported Nurse #1 contacted the on-call telehealth provider around 5:00 pm. The DON reported Paramedic #1 checked on Resident #280 around 8:00 pm while he was performing his walking rounds and realized that the ambulance had still not arrived to get the resident. A follow-up interview was conducted on [DATE] at 6:00 pm with the DON. The DON reported Nurse #1 should have never left her shift without calling EMS. An interview was conducted on [DATE] at 6:08 pm with the Administrator. The Administrator reported he had not been made aware of the events leading up to Resident #280 being transferred to the hospital on [DATE] until the DON informed him on [DATE]. He reported Nurse #1 should have not left the building without initiating EMS for Resident #280 and that there was a huge delay in notifying EMS. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he had assessed Resident #280 on the morning of [DATE] and reported Resident #280 was alert at that time. The MD stated he was not made aware of Resident #280's change in condition until after she had been admitted to the hospital. The MD stated he would expect facility staff to notify a provider if a resident had an acute change in mental status. He reported the resident would need to be evaluated and transferred to the hospital for further treatment and evaluation when there was an acute change in mental status to identify and treat the cause. The MD stated he was not aware of the delay in initiating EMS and the lack of monitoring until today ([DATE]). The Administrator was made aware of Immediate Jeopardy on [DATE] at 6:08 pm. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance: Nurse #1 reported she was notified during a report from Nurse #2 at 2:30 pm that Resident #280 had been excessively sleepy that morning ([DATE]). Nurse #1 reported she had not assessed Resident #280 until 5:00 pm, at which time she was only responsive to painful stimuli. Nurse #1 contacted the on-call Medical Service to have Resident #280 assessed at 6:00 pm and was advised at 6:30 pm to transfer her to the hospital. Nurse #1 only checked Resident #280's vital signs once, did not obtain oxygen saturations or blood sugar and did not activate 911 when resident was found to be unresponsive at 5 pm. Nurse #1 stated she printed out the medical record after she had given the report to Paramedic #1. Nurse #1 reported she was under the assumption that Paramedic #1 would contact Emergency Medical Services (EMS). Paramedic #1 completed walking rounds of his assigned unit on [DATE] at 8:00 pm and realized that Resident #280 had not been transported to the hospital and contacted EMS at 8:10 pm, at what time he was informed that EMS was never called for transport. EMS arrived on [DATE] at 8:13 pm and transported Resident #280 to the hospital where she was diagnosed with acute metabolic encephalopathy related to sepsis from urinary tract infection versus bacteremia from wounds, dehydration, and hypoglycemia. Resident #280 was transferred to hospital on [DATE] and did not return to the facility. On [DATE] the Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. On [DATE] the Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital in the last 30 days to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found. On [DATE] the Director of Nursing or Designee audited Nursing progress notes from the last 72 hours to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found. On [DATE] the Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately and if they felt they had a delay in treatment. The Director of Nursing or Designee audited Nursing progress notes from the last 72 hours of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted. On [DATE] the Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions in the last 72 hours that were not addressed. No negative findings were noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Director of Nursing or Designee educated all Certified Nursing Assistants on reporting any change of condition of residents to the nurse immediately. The Director of Nursing or Designee will ensure Certified Nursing Assistants that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temperature, Oxygen Saturation and Blood Sugar if resident is a Diabetic. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. On [DATE] Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The staff that were not working on [DATE] will be trained prior to their next shift. The Director of Nursing or Designee will ensure all staff that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. On [DATE] Ad Hoc QAPI was completed regarding effective communication between staff in Medical Emergencies, timeliness of assessment, monitoring, and following provider orders to include transferring resident to hospital related to change of condition. On [DATE] the Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the orientation process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation, and Blood Sugar if resident is a Diabetic. The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education during Orientation on the Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility. Alleged Date of Immediate Jeopardy removal: [DATE] On [DATE], the facility's plan for Immediate Jeopardy removal effective [DATE] was validated by the following: documentation and interviews with staff. Review of the audits for residents with a BIMS less than 12 revealed no issues. In-service sign-in sheets were reviewed with no issues found. Review of the training for Nurses and Nurse Aides (NAs) revealed both had been educated regarding prompt and timely monitoring and assessment of change of condition including blood pressure, pulse, temperature, respirations, oxygen saturation levels, and blood sugars. Education was also provided on documenting assessments and monitoring for change of condition, to include obtaining vital signs when a change in condition is noted, informing the provider in a timely manner of any change in condition, promptly following any orders given by the provider (including calling 911 and sending to the emergency room ), and effective communication between staff during a medical emergency. Staff interviews were conducted, no staff had seen any change in the condition of their residents over the last 72 hours. The facility's Immediate Jeopardy removal date of [DATE] was confirmed. 2. Resident #282 was admitted to the facility after hospitalization on [DATE] (Friday) with diagnosis of diabetes. A review of Resident #282's hospital discharge orders dated [DATE] revealed an order for Humalog (quick acting insulin) Kwikpen subcutaneous, on a sliding scale (,d+[DATE]=4 units, ,d+[DATE]=6 units, ,d+[DATE]=8 units, ,d+[DATE]=10 units, 350 and greater=12 units), to be administered before meals and at bedtime. The hospital discharge orders also revealed an order for insulin Glargine 23 units to be administered at bedtime daily. A review of the admission nursing assessment completed and dated [DATE] at 5:43 pm, revealed Resident #282 was documented as having been alert and oriented. Review of the facility's Laboratory Procedures standing orders, signed by the Medical Director on [DATE], revealed residents a history of diabetes blood sugars should be checked in the morning and at night for four days and nursing staff should notify the Medical Director (MD) with values and for further orders for blood sugars. There were no blood sugar results documented in Resident #282's medical record on [DATE], [DATE] or [DATE]. An interview was conducted on [DATE] at 1:19 pm with Nurse #5. Nurse #5 reported she worked second shift (2:30 pm to 10:30 pm) and was assigned to the 200-hall. She reported Resident #282 was admitted from the hospital on [DATE] during her shift and had only completed part of the admission assessment before she left. She reported she did not enter Resident #282's discharge orders from the hospital because that was usually done by the Assistant Director of Nursing (ADON), or the Director of Nursing (DON) and she believed the DON had already completed the orders. An order entered in the Electronic Health Record (EHR) by the DON dated [DATE] at 5:33 pm for Insulin Glargine (long-acting insulin) 23 units subcutaneous to be given at bedtime. There was no evidence of the Humalog Kwikpen order, or an order to check blood sugar levels, as written in the hospital discharge orders by the DON. An interview was conducted on [DATE] at 10:55 am with Nurse #4. Nurse #4 reported she worked third shift on [DATE] (10:30 pm to 6:30 am) and was covering the 200 hall where Resident #282 resided. She reported that she had received a report from Nurse #5. Nurse #4 stated Nurse #5 had completed Resident #282's admission assessment but had not signed the assessment. She verbalized she had not verified the information charted was correct and had not verified Resident #282's hospital discharge orders with the orders in the facility's Electronic Medical Record (EMR) and signed her name to the assessment. She reported she was aware Resident #282 was a diabetic, but she had not checked her blood glucose level because it was a busy night. A review of the care plan dated [DATE] revealed Resident #282 was at risk for unstable blood sugars related to diabetes with a goal to remain free of symptoms and complications of hyperglycemia and hypoglycemia. Interventions included staff were to administer oral hypoglycemic [medications] and/or insulin [injectable medication] as directed by the physician, assess blood glucose levels as ordered and PRN [as needed], monitor labs as directed by the physician, monitor/educate resident for signs and symptoms of hyperglycemia (increased thirst, hunger, and increased urination), and monitor/educate for signs/symptoms of hypoglycemia (tachycardia, dizziness, sweating, headache, fatigue, and visual changes). According to the Medication Administration Record (MAR) for the month of [DATE], Resident #280 received Insulin Glargine 23 units at 8:00 pm on [DATE], [DATE], and [DATE]. The April MAR did not include the Humalog Kwikpen order or an order to check blood sugar levels. An interview was conducted on [DATE] at 9:12 am with Resident #282. Resident #282 reported around 12:00 am on [DATE] (Sunday night/Monday morning) she had told Nurse #3 that she was thirsty, felt like she could not get enough to drink, and was more tired than usual. She verbalized that she knew her blood sugar was high because it had gotten high before and had experienced those symptoms when her blood sugar was high in the past. Resident #282 reported the facility nursing staff had not checked her blood glucose level until [DATE] when she asked them to. A review of a nurse's note dated [DATE] at 12:46 am revealed Nurse #3 notified the on-call telehealth provider that Resident #282's blood sugar was 548. An interview was conducted on [DATE] at 4:41 pm with Nurse #3. Nurse #3 reported on [DATE] around midnight, Resident #282 kept asking for water and reported that she was thirsty. She reported Resident #282 had asked to have her blood glucose checked. Nurse #3 stated when she checked it, Resident #282's blood sugar was greater than 500 and she immediately notified the physician through their on-call electronic system and received orders to address the hyperglycemia and notify Resident #282's primary care provider (PCP) in the morning so that her medications could be reviewed. Nurse #3 reported there were no orders to check blood sugars until she notified the on-call electronic system [DATE]. A review of Resident #282's physician's orders dated [DATE] and timed 12:30 AM revealed the following: -Insulin Lispro (quick acting insulin) 10 units to be administered subcutaneously one time. -Blood glucose to be checked at 2:30 am and to report blood glucose level less than 70 and greater than 400 to a provider. A review of Resident #282's April MAR revealed the following: -Insulin Lispro 10 units was administered to Resident #282 on [DATE] at 12:30 am by Nurse #3. -Resident #282's blood glucose was checked at 2:30 am by Nurse #3 and was 355. A review of Resident #282's blood sugar checks revealed a blood sugar check was performed on [DATE] at 7:03 am at which time Resident #282's blood sugar was 274. An interview was conducted on [DATE] at 2:29 pm with the Director of Nursing (DON). The DON reported that she or the ADON did most of the orders for newly admitted residents. She reported the medication reconciliation was completed as soon as new residents arrived at the facility. The DON reported she entered the admission orders for Resident #282 on [DATE] at 5:33 pm and had overlooked that the resident was on sliding scale insulin at the hospital. She also reported that she forgot to enter an order for Resident #282's blood sugar to be checked. The DON stated that not having her blood sugars monitored and not receiving sliding scale insulin could have contributed to Resident #282 having a blood glucose of greater than 500 on [DATE]. An interview was conducted on [DATE] at 12:05 pm with the Nurse Practitioner (NP). The NP stated the admission nurse was responsible for entering the hospital discharge orders until she could assess the resident. She reported she worked at the facility on Mondays, Wednesdays, and Fridays, but she was not at the facility when Resident #282 was admitted . She was not aware the DON had not entered all of Resident #282's discharge orders from the hospital and verbalized she would have expected the DON to enter all the discharge medications until she could have seen the resident. She reported that not having scheduled sliding scale insulin and blood glucose checks could have contributed to Resident #282 having a blood sugar of greater than 500. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD stated when a resident was newly admitted from the hospital that the medication reconciliation should be performed immediately. He stated the facility had standing orders to have blood sugar checked if a resident received insulin. The MD reported he was not aware Resident #282 had not had her blood glucose levels checked until [DATE] and would have expected her blood sugar to be checked the day she had arrived and to continue to check blood sugars as per the facility's Laboratory Procedures standing orders. He reported not receiving sliding scale insulin and not having her blood sugars checked, could have resulted in Resident #282's blood sugar being greater than 500. An interview was conducted on [DATE] at 9:22 am with the Administrator. The Administr [TRUNCATED]

Based on record review, facility staff and Medical Director (MD) interviews, the facility failed to ensure that facility staff (Nurse #1 and Paramedic #1) had completed Skills Competency's and required floor/unit orientation days with a preceptor prior to taking a resident assignment independently. On [DATE] at 2:30 pm, Nurse #2 informed Nurse #1 that Resident #280 had been excessively sleepy during her shift. Nurse #1 failed to assess Resident #280 until 5:00 pm, at which time Resident #280 was only responsive to painful stimuli. Nurse #1 was instructed at 6:30 pm to transfer Resident #280 to the hospital for evaluation and treatment. Nurse #1 failed to notify Emergency Medical Services (EMS) and was under the assumption that the oncoming staff member, Paramedic #1 (employed by the facility and functioning as a nurse), was going to notify EMS. Paramedic #1 failed to assess Resident #280 until 8:00 pm when he realized that EMS had not come to transfer the resident. Paramedic #1 called EMS at 8:10 pm and was told that EMS had not been contacted. Resident #280 was transferred to the hospital and later died . The deficient practice occurred for 2 of 5 facility staff members (Nurse #1 and Paramedic #1) reviewed for competency and had the high likelihood for causing the potential for serious harm to other residents. Immediate jeopardy began on [DATE] when the failure to verify Nurse #1 and Paramedic #1's competency and skills resulted in delayed treatment of Resident #280. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: A review of Paramedic #1's job description, titled Paramedic for alternative practice setting, revealed duties which included providing direct nursing care to residents, assess resident's needs, develop individual care plan, administer nursing care, evaluate nursing care, and supervise nursing assistants and other personnel in the delivery of nursing care within his scope of practice. The job description further revealed that Paramedic #1 had not signed that he had reviewed his job description and agreed to abide by his job description during employment. Paramedic #1's job description was signed by the Director of Nursing (DON) on [DATE] and by the MD. A review of Paramedic #1's Orientation and Skills Competency Checklist dated [DATE] and was hired on [DATE] revealed he had not been checked off on the following: who to contact if needed supplies are not found, tube feeding, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and correct tube placement. The Orientation and Skills Competency Checklists were signed as complete by Paramedic #1 on [DATE] and by the DON on [DATE]. The Orientation and Skills Competency Checklists revealed areas for the employee (Paramedic #1), DON, and Nurse preceptors to sign, however there was no space for the MD to sign as verification the Competency Checklist had been completed. An interview was conducted on [DATE] at 9:08 am with the SDC verified that Paramedic #1's Orientation and Skills Competency Checklist revealed he had not been checked off on who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, correct tube placement, and the DON had signed verifying it was completed on [DATE]. She reported she was unsure why Paramedic #1's competency skills checks were not completed and that she had not noticed it. She verbalized all areas should have been checked off prior to Paramedic #1 taking a resident assignment independently . An interview was conducted on [DATE] at 9:25 am with the DON regarding Paramedic #1. The DON verified that Paramedic #1's Orientation and Skills Competency Checklist revealed he had not been checked off on who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, correct tube placement, and she had signed verifying it was completed on [DATE]. She reported she was unsure why Paramedic #1's competency skills checks were not completed and that it must have been an oversight. She verbalized all areas should have been checked off prior to Paramedic #1 taking a resident assignment independently. A review of Nurse #1's Orientation and Skills Competency Checklist dated [DATE] and was hired on [DATE] revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell (medication dispensing machine), Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or Electronic), Head to Toe Assessment and Documentation, Device List, Vital Signs, and had not completed her 4 required days of floor/unit training with a preceptor. The DON and Nurse #1 had signed the Checklist as complete. The Orientation and Skills Competency Checklists revealed areas for the employee (Nurse #1), DON, and Nurse preceptors to sign, however there was no space for the MD to sign as verification the Competency Checklist had been completed. An interview was conducted on [DATE] at 9:08 am with the Staff Development Coordinator (SDC) regarding Nurse #1. The SDC reported most of the facility staff orientation was completed by Human Resources. She reported as the SDC she educated facility staff about Personal Protective Equipment (PPE), handwashing, and administered their drug test. The SDC verbalized floor nursing staff completed skills competency check offs for newly hired employees during their required floor/unit training days. She stated after the Skills Competency Check List had been completed, the DON or her would review the competency and sign off to verify that the competencies had been completed. The SDC stated that precepting staff are required to date and sign/initial all skills areas of the competency sheet. She reported if a date or initials were missing next to a competency skill, it would be assumed that the staff member had not completed that competency check. She reported the DON would make the determination if a facility staff member could take a resident assignment independently without having completed all the competency skill check offs. The SDC verified that Nurse #1's Orientation and Skills Competency Checklist revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell, Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, had not completed her 4 required days of floor/unit training with a preceptor, and the DON had signed verifying it was completed on [DATE]. She reported she was unsure why Nurse #1's competency skills checks were not completed and that she had not noticed it. She verbalized all areas should have been checked off prior to Nurse #1 taking a resident assignment independently. An interview was conducted on [DATE] at 9:25 am with the DON regarding Nurse #1. The DON reported the SDC was responsible for ensuring staff had completed Competency Skills Checkoffs and the required floor/unit training days. She reported that competencies were required to be completed before a Nurse or Paramedic would have a resident assignment on their own. The DON verified that Nurse #1's Orientation and Skills Competency Checklist revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell, Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, had not completed her 4 required days of floor/unit training with a preceptor, and that she had signed verifying it was completed on [DATE]. She reported that she did not notice there were missing competency skills checks on Nurse #1's form, and that she must have overlooked it. She reported the skills competency checks should have been completed prior to Nurse #1 taking a resident assignment independently. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. Resident #280's vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm per Nurse #1). Resident #280's blood pressure was ,d+[DATE], heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Further review of Resident #280's medical record revealed no head-to-toe assessment, no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1(employed by the facility employed by the facility and functioning as a nurse) the last 24 hours and he was told in report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the emergency room . A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the emergency room . A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency roiagnom on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. A telephone interview was conducted on [DATE] at 1:12 pm with Nurse #1. Nurse #1 reported she had received training for Pharmacy Services, Emergency box and/or Omnicell (medication dispensing machine), Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or Electronic), Head to Toe Assessment and Documentation, Device List, and Vital Signs. She reported she was not aware those skills had not been checked and initialed on the Orientation and Skills Competency Checklist. Nurse #1 reported she received at least five days of training and had spent each shift on a different hall with a different preceptor. Nurse #1 was not able to explain why the orientation days were not reflected on the Orientation and Skills Competency Checklist. She reported she was not able to recall if Resident #280 was a diabetic, but she voiced she would have referred to the Electronic Health Record (EHR). A telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he had not received much of an orientation and from what he was able to recall it was approximately three days long. He reported during those three days he was partnered with a seasoned nurse at the facility, shown how to use the computer system, which assessments to complete, and information about the facility/residents. Paramedic #1 reported since he had learned the computer charting quickly, the nurse preceptor had recommended he be released to start on his own. Paramedic #1 reported he was aware there were areas of his Competency Skills Checkoffs that were not completed, but he thought the areas missing were administrative sections that had not pertained to his role. He was unaware who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and correct tube placement had not been checked off. An interview was conducted on [DATE] at 10:45 am with the Administrator. The Administrator was not aware Nurse #1 and Paramedic #1 had not completed their Skills Competency Checkoffs and did not know why they had not been completed. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he was aware that Paramedics worked in the facility and performed nursing tasks. He reported that he would have wanted Paramedics and Nurses to have completed competency skills checks prior to taking a resident assignment independently and practicing under his license. He reported that he was unaware that Nurse #1 had not completed her competency skills check offs and required orientation days and he reported he was also unaware Paramedic #1 had not completed his competency skills check offs. Paramedic #1 signed the Orientation and Skills Competency Checklists on [DATE]. The Administrator was notified of Immediate Jeopardy on [DATE] at 10:50 am. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure that Nurse #1 and Paramedic #1 had completed Orientation and Skills Competency Checklists prior to taking a resident assignment/medication cart. Review of Nurse #1's Orientation and Skills Competency Checklist, signed by the Director of Nursing (DON) as complete on [DATE], revealed Nurse #1 had not been signed off on Pharmacy Services, emergency medication back up kit and or electronic medication dispenser (Omni Cell), Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, and had not completed her 4 required days of floor/unit training with a preceptor. Review of Paramedic #1's Orientation and Skills Competency Checklist, signed by the DON as complete on [DATE], revealed Paramedic#1 had not been signed off for the following: who to contact if needed supplies are not found, tube feeding, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and checking for proper tube placement prior to each use per policy. On [DATE] Nurse #1 will complete the required days of floor/unit training with a preceptor prior to her next shift assigned to work. The Director of Nursing or Designee will sign off competencies for Nurse #1 on the Pharmacy Services, use of emergency medication back up kit, and or electronic medication dispenser (Omni Cell), Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs prior to next shift assigned to work. Paramedic #1 was working his two weeks' notice and the Director of Nursing released him on [DATE] before his two-week notice expired. On [DATE] The Director of Nursing or Designee audited the employee files of licensed staff and Paramedics to ensure orientation and skills competency checklist were completed, any negative findings will be corrected immediately, and staff placed back into orientation or skills check off completed for any area missed during orientation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Regional Director of Clinical Services educated the Director of Nursing, Assistant Director of Nursing, Administrator, Scheduler and Human Resources on the orientation process to include the required days of floor/unit training with a preceptor and completion of the skills competency checklist. On [DATE] the Director of Nursing or Designee will ensure all newly hired licensed staff have completed the required days of floor/unit training with a preceptor prior to being given an assignment. On [DATE] the Assistant Director of Nursing or Designee will complete the skill competency checklist for all newly hired licensed staff and Paramedics. The Director of Nursing or Designee will ensure all newly hired licensed staff and Paramedics have completed skills competency checklist prior to being given an assignment. On [DATE] Ad Hoc QAPI was completed related to following orientation policy and ensuring the skill checklist is completed for licensed staff and Paramedics prior to taking their first assignment. Alleged Date Immediate Jeopardy removal: [DATE] On [DATE], the facility's plan for Immediate Jeopardy removal effective [DATE] was validated by the following: documentation and interviews with staff. Review of the in-service sign in sheets revealed the Scheduler, DON, Assistant Director of Nursing (ADON)/SDC, Human Resources (HR), and Administrator received education regarding the orientation process, completion of the required number of floor/orientation days with a preceptor, and the importance of ensuring that all skills competency checks were completed for facility staff members prior to taking an assignment independently. Review of the facility documentation dated [DATE] revealed audits were completed for all Nurse Aides (NA), Nurses, and Paramedics. The facility's Immediate Jeopardy removal date of [DATE] was confirmed.

Based on record reviews, staff, and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect when Resident # 280 experienced a medical emergency and emergency medical services (EMS) were not provided. The resident was only responsive to painful stimuli on [DATE] around 5:00 PM and 911 was not initiated until 8:10 PM. Resident #280 was transferred to the hospital and diagnosed with metabolic encephalopathy (a problem in the brain caused by a chemical imbalance) due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. On [DATE] Resident #280 was discharged to hospice care for comfort care. On [DATE] Resident #280 expired. This occurred for 1 of 3 residents reviewed for neglect. Immediate jeopardy began on [DATE] when EMS was not initiated for a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: 1. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. A review of the care plan dated [DATE] revealed Resident #280 was at risk for hypoglycemia with a goal to be free of signs and symptoms of hypoglycemia. Interventions included for nursing staff to assess blood sugars as per order and as needed for symptoms of hypoglycemia/hyperglycemia. The care plan further revealed Resident #280 was at risk for altered cardiac and respiratory status with a goal that Resident #280 would not have a preventable crisis. Interventions included for nursing staff to monitor oxygen saturations as needed, to monitor for signs and symptoms of decreased cardiac output (rapid, slow, weak, or diminished pulse, hypotension, hypertension, dizziness, syncope, dyspnea, chest pain, restlessness, cyanosis, alerted mental status, congestion, or shortness of breath). An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact and had not exhibited any behaviors. She was not documented as being on hospice services or receiving insulin. A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Nurse Practitioner #2 was unable to be interviewed. An interview was conducted on [DATE] at 10:41 am with Nurse #1. Nurse #1 reported she worked first shift (6:30 am to 6:30 pm) and usually floated between halls. She reported on [DATE] she floated to 200-hall (Resident #280's hall) at 2:30 pm and relieved Nurse #2. Nurse #2 informed Nurse #1 that Resident #280 had been sleepy all day. Nurse #1 stated after she finished report she took time to get adjusted and started passing medications. She reported she did not go check on Resident #280 until 5:00 pm, at which time the resident was only responsive to painful stimuli. Nurse #1 reported she obtained vital signs after she realized Resident #280 was only responsive to painful stimuli and stated she had not checked her blood sugar. She reported she consulted their on-call telehealth provider around 6:00 pm. Nurse #1 reported the on-call provider had advised her to send Resident #280 to the emergency room around 6:30 pm. She reported she then gave the report to Paramedic #1, printed off Resident #280's information for EMS, and left for the day. She reported she had not notified Resident #280's family or called EMS because she was under the assumption that Paramedic #1 would. Nurse #1 stated she gave shift report to Paramedic #1 (employed by the facility and functioning as a nurse) on [DATE] at 6:30 pm when Paramedic #1 started his shift. Nurse #1 stated she felt as though she had neglected Resident #280 because she should have not relied on Paramedic #1 to initiate EMS and complete her work. Vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm by Nurse #1 per her report). Resident #280's blood pressure was ,d+[DATE], heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). Further review of Resident #280's medical record revealed no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1 (employed by the facility) on [DATE] at 9:19 pm revealed Resident #280 had a change in condition in the last 24 hours and he was told in shift change report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the emergency room . A telephone interview was conducted on [DATE] at 11:02 am with Paramedic #1. Paramedic #1 reported he was not able to remember the events involving Resident #280 on [DATE]. He stated he would have documented any assessment, monitoring, vital signs, and/or interventions in his nursing note. A follow-up telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he started his shift at 6:30 pm on [DATE] and received report from Nurse #1. Paramedic #1 stated Nurse #1 reported Resident #280 was only responsive to a sternal rub. Paramedic #1 reported Nurse #1 had contacted the on-call provider, had received orders from the on-call provider to send Resident #280 to the emergency room , and asked him to check on Resident #280 while she gathered the paperwork for transfer. Paramedic #1 reported he assessed Resident #280 at 6:30 pm, at which time Resident #280 was able to communicate verbally. Paramedic #1 stated he assessed Resident #280's heart sounds, lung sounds, and pulses however he had not reassessed Resident #280's vital signs because she appeared stable. Paramedic #1 reported he was under the impression Nurse #1 had called EMS. Paramedic #1 reported he started his medication pass and checked the hall to see if an EMS stretcher was in the hall. Paramedic #1 reported he called to check the status of EMS at 8:00 pm at which time he was told EMS had never been notified. Paramedic #1 stated at that time he requested an ambulance, which arrived shortly after, and transferred Resident #280 out of the facility. He reported he failed to document his assessments because he had forgotten. Paramedic #1 stated Nurse #1 should have initiated EMS prior to leaving the facility. He did not speak to the incident as neglect. A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the emergency room . A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency roiagnom on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. An interview was conducted on [DATE] at 6:00 pm with the Director of Nursing (DON). The DON reported Resident #280 was found unresponsive and with stable vital signs on [DATE]. The DON reported Nurse #1 made an error by not initiating EMS and that Nurse #1 should have never left her shift without calling EMS. The DON stated Nurse #1 and Paramedic #1 should have performed head-to-toe assessments, ongoing assessments, and ongoing vital signs (including blood sugars). The DON reported she had not felt as though Nurse #1 or Paramedic #1 neglected Resident #280. An interview was conducted on [DATE] at 6:08 pm with the Administrator. The Administrator reported he had not been made aware of the events leading up to Resident #280 being transferred to the hospital on [DATE] until the DON informed him on [DATE]. He reported Nurse #1 should not have left the building without initiating EMS for Resident #280 and that there was a huge delay in care. He reported he was not aware that Nurse #1 had not performed a head-to-toe assessment, ongoing assessment, and ongoing vital signs (including blood sugar checks). The Administrator reported he had not felt as though Nurse #1 or Paramedic #1 neglected Resident #280. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he had assessed Resident #280 on the morning of [DATE] and reported Resident #280 was alert at that time. The MD stated he was not aware of the delay in initiating EMS and the lack of monitoring until today ([DATE]) and reported Resident #280 should have been monitored until she was transferred to the hospital. The Administrator was notified of Immediate Jeopardy on [DATE] at 6:08 pm. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Nurse #1 reported she was notified during report from Nurse #2 at 2:30 pm that Resident #280 had been excessively sleepy that morning ([DATE]). Nurse #1 reported she had not assessed Resident #280 until 5:00 pm, at which time she was only responsive to painful stimuli. Nurse #1 contacted the on-call Medical Service to have Resident #280 assessed at 6:00 pm and was advised at 6:30 pm to transfer her to the hospital. Nurse #1 only checked Resident #280's vital sings once, did not obtain oxygen saturations or blood sugar and did not activate 911 when resident was found to be unresponsive at 5 pm. Nurse #1 stated she printed out the medical record after she had given report to Paramedic #1. Nurse #1 reported she was under the assumption that Paramedic #1 would contact Emergency Medical Services (EMS). Paramedic #1 completed walking rounds of his assigned unit on [DATE] at 8:00 pm and realized that Resident #280 had not be transported to the hospital and contacted EMS at 8:10 pm, at what time he was informed that EMS was never called for transport. EMS arrived on [DATE] at 8:13 pm and transported Resident #280 to the hospital where she was diagnosed with acute metabolic encephalopathy related to sepsis from urinary tract infection versus bacteremia from wounds, dehydration, and hypoglycemia. Resident #280 was transferred to hospital on [DATE] and did not return to the facility. On [DATE] the Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. On [DATE] the Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital in the last 30 days to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found. On [DATE] the Director of Nursing or Designee audited Nursing progress notes from the last 72 hours to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found. On [DATE] the Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately, if they had any concerns of neglect and if they felt they had a delay in treatment. No negative findings were noted. The Director of Nursing or Designee audited Nursing progress notes from the last 72 hours of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted. Specify the action of the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions in the last 72 hours that were not addressed and if they were aware of any resident neglect. No negative findings were noted. On [DATE] the Director of Nursing or Designee educated all staff on reporting any change of condition to the nurse immediately. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] the Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic and the Abuse and Neglect Policy. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated all staff on the Abuse and Neglect Policy. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] Ad Hoc QAPI was completed regarding Abuse and Neglect. In addition, effective communication between staff in Medical Emergencies, timeliness of assessment and monitoring of change of conditions to include transferring resident to hospital. On [DATE] the Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the Orientation Process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education on the Effective Communication during a Medical Emergency, Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic in Orientation. The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, the Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility. Immediate jeopardy removal date: [DATE] The credible allegation was validated [DATE] onsite. Staff interviews revealed that NAs, Medication Technicians, and Nurses had received in-service education regarding abuse and neglect which included how to keep the residents safe, reporting the issue to the immediate supervisor, reporting change in condition, and effective communication among staff. Nursing staff also received specific education related to neglect and how/who to report suspensions of neglect. A review of education revealed staff had received neglect training. The immediate jeopardy removal date of [DATE] was validated.

Based on record review, family and staff interviews, the facility failed to prevent a pressure injury for a resident wearing a hinged knee brace. Resident #280 sustained an open pressure injury that became infected, had developed dead tissue, and wound treatments had not been completed. The deficient practice was identified for 1 of 2 residents (Resident #280) reviewed for pressure ulcers. The findings included: Review of the Orthopedic Progress note dated 1/5/2024 (prior to admission to the facility) revealed Resident #280 was treated nonoperatively for a right proximal tibia (bone in the lower leg) fracture and required a hinged knee brace locked in extension (leg straight) for her right leg. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula. A review of the physician's orders dated 1/11/2024 revealed Resident #280 was to always wear a hinged knee brace on her right leg for six weeks. A review of the care plan dated 1/12/2024 revealed Resident #280 was at risk for skin breakdown due to fragile skin, impaired mobility, muscle weakness, decreased safety awareness, and incontinence with goals and interventions which included completing skin checks per protocol, and to monitor/document/report any changes in color/temperature/sensation/pain/drainage/odor to the Physician. A review of an Occupation Therapy Evaluation and Treatment Plan dated 1/12/2024 revealed Resident #280 wore an immobilizer on her right lower extremity. Further review of the documentation revealed there were no skin assessments of the right lower extremity completed. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact, had not exhibited any behaviors, and was not documented as having any wounds. A wound assessment completed by Paramedic #2 (employed by the facility, functioning as the Wound Care Nurse) dated 1/30/2024 revealed Resident #280 had a right posterior calf abrasion (scrape) where the hinged knee brace was located. The wound was documented as being 5.0 centimeters (cm) in length, 2.0 cm in width, and 0.1 cm in depth. The wound was documented as a new wound, facility acquired, with a pink wound bed, scant (very small) amount of serosanguineous (yellow and bloody in color) drainage, with no odor, and the physician was notified by Paramedic #2 on 1/30/2024 at 4:00 pm. Orders were received at that time to clean the wound, apply triple antibiotic ointment, to apply an island dressing (breathable, non-sticking dressing), and to change the dressing every Monday, Wednesday, and Friday or as needed until the wound was healed. Wound care documentation provided by Paramedic #2 revealed wound care had been performed on 1/30/2024. No documentation was provided for 1/31/2024 (Wednesday), 2/2/2024 (Friday), 2/5/2024 (Monday), and 2/7/2024 (Wednesday). A wound assessment dated [DATE] revealed Resident #280's right posterior calf wound measured 7.5 cm in length, 7.5 cm in width, and 0.3 cm in depth. The wound was documented as having a moderate amount of serous (yellow-colored fluid) drainage, a pink wound bed, and no wound odor. Orders were received at that time to clean the wound, pat the wound dry, apply Calcium Alginate (wound dressing to treat draining wounds) to the wound bed, to cover with foam dressing, and to change the dressing every Monday, Wednesday, and Friday or as needed until the wound was healed. Wound care documentation provided by Paramedic #2 revealed wound care had been performed on 2/8/2024. No documentation was provided for 2/9/2023 (Friday), 2/12/2024 (Monday) and 2/14/2024 (Wednesday). A wound assessment dated [DATE] revealed Resident #280's right posterior calf wound measured 7.5 cm in length, 7.6 cm in width, and 0.4 cm in depth. The wound was documented as having moderate serous drainage with a black wound bed and a faint wound odor. The physician was notified by Paramedic #2 on 2/14/2024 at 10:00 am and orders were received for the wound to be cleaned, patted dry, to apply Half Strength Dakin's (diluted bleach solution)-soaked gauze, to cover with an abdominal dressing, and wrap in gauze. Wound care documentation provided by Paramedic #2 revealed wound care had been performed on 2/15/2024. No documentation was provided for 2/16/2024 (Friday), 2/19/2024 (Monday), and 2/21/2024 (Wednesday). A wound assessment dated [DATE] revealed Resident #280's right posterior calf wound measured 7.1 cm in length, 6.5 cm in width, and 0.4 cm in depth. The wound was documented as having moderate serous drainage with a pink wound bed. No peri wound assessment was documented. Wound care documentation provided by Paramedic #2 revealed wound care had been performed on 2/22/2024. No documentation was provided for 2/23/2024 (Friday) and 2/26/2024 (Monday). Resident #280 was no longer at the facility; therefore, no observation of the wound was able to be made. An interview was conducted on 4/29/2024 at 9:55 am with Paramedic #2. Paramedic #2 reported Resident #280 was ordered to wear a knee brace on her right leg. She reported on 1/30/2024 she had removed the knee brace to assess Resident #280's skin, after Resident #280 had verbalized she thought the brace was rubbing her right leg and she was having pain. When Paramedic #2 removed the knee brace, she realized the brace had rubbed against the back of Resident #280's right leg and verbalized the knee brace was not padded. Paramedic #2 reported the new abrasion to the provider and had the Physical Therapy Director pad the brace to prevent further rubbing of the skin. Paramedic #2 reported the right posterior leg wound continued to get worse and she assessed the skin underneath the brace when she performed Resident #280's wound care. Paramedic #2 did not comment on why she had not consistently performed wound care for Resident #280. An interview was conducted on 5/2/2024 at 12:11 pm with the NP. The NP reported Paramedic #2 had notified her Resident #280's wounds were not healing on 2/9/2024. The NP was not aware Resident #280's brace had not been padded on admission. An interview was conducted on 5/3/2024 at 9:19 am with the Physical Therapy Director. The Physical Therapy Director reported he was asked by Paramedic #2 to pad Resident #280's knee brace. The Physical Therapy Director stated Occupation Therapy (OT) looked at knee braces when a resident was admitted and if there was any indication the brace would rub/had rubbed the skin, the brace would be padded at that time. The Physical Therapy Director was unable to provide documentation where OT had evaluated the brace upon Resident #280's admission to the facility. An interview was conducted on 5/3/2024 at 8:50 am with the Director of Nursing (DON). The DON was not aware Resident #280 had sustained a pressure injury from her hinged knee brace and had no further comments. An interview was conducted on 5/3/2024 at 9:33 am with the Administrator. The Administrator was not aware Resident #280 had sustained a pressure injury from her hinged knee brace. He had no comments related to Resident #280's injury.

Based on record reviews, family member, staff, resident, and lift company representative interviews the facility failed to prevent injury when transferring a resident (Resident #280) from a wheelchair to the bed causing a laceration to the resident's left lower leg which required a transfer to the emergency department and treatment of the laceration with sutures. The facility failed to provide a safe transfer when they did not use a mechanical sit-to-stand lift in accordance with manufacturer instructions to transfer a resident (Resident #60). This deficient practice occurred for 2 of 3 residents (Resident #280 and Resident #60) reviewed for accidents and hazards. The findings included: 1. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg). A review of the care plan dated 1/12/2024 revealed Resident #280 was at risk for skin breakdown due to fragile skin, impaired mobility, muscle weakness, decreased safety awareness, and incontinence with goals and interventions which included avoiding mechanical trauma. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact and had not exhibited any behaviors. An interview was conducted on 4/29/2024 at 10:09 am with Physical Therapy Assistant (PTA) #1. PTA #1 reported she worked with Resident #280 on 1/22/2024 and she and PTA #2 were transferring Resident #280 from her wheelchair to the bed. PTA #1 reported that she and PTA #2 stood Resident #280 up and pushed the wheelchair back. PTA #1 reported Resident #280 did a stand pivot transfer to the side of the bed and sat down. PTA #1 then observed a drop of blood on the back of Resident #280's left leg and an area of open skin approximately 1 inch in length. PTA #1 reported Nurse #6 was called to the room and took over from there. PTA #1 reported she had not observed anything sharp on Resident #280's wheelchair or her bed. An interview was conducted on 5/2/2024 at 11:41 am with PTA #2. PTA #2 reported she worked with Resident #280 on 1/22/2024. She reported that she and PTA #1 were transferring Resident #280 from her wheelchair to the bed. PTA #2 reported Resident #280 stepped with her left leg towards the bed and then Resident #280 stepped back with her right leg towards the bed. PTA #2 stated Resident #280's nose began to bleed, and she saw blood on the ground. PTA #2 stated when she looked at the floor, she saw a lot of blood on the back of Resident #280's left leg and observed a jagged wound approximately 2 inches long. PTA #2 reported she immediately applied pressure to the wound and got Nurse #6. PTA #2 reported Resident #280 was taken to the emergency room and Resident #280's wheelchair was never taken out of service. PTA #2 reported she had not observed anything sharp on Resident #280's wheelchair or her bed. A telephone interview was conducted on 5/2/2024 at 3:46 pm with Resident #280's Family Member #1. Family Member #1 reported Family Member #2 was in the room on 1/22/2024 with Resident #280 when therapy transferred her from the wheelchair to the bed. Family Member #1 reported Family Member #2 witnessed a large screw sticking out from the left front leg of the wheelchair and that the screw had snagged Resident #280's skin when the Physical Therapy Assistants had transferred Resident #280 from her wheelchair to her bed. Family Member #1 was unsure if the wheelchair had been taken out of service and verified there was no padding on the wheelchair legs until after the incident on 1/22/2024. Family Member #1 reported she had not noticed the screw sticking out of Resident #280's wheelchair prior to 1/22/2024. A telephone interview was conducted on 5/8/2024 at 11:21 am with Family Member #2. Family Member #2 reported she was in the room on 1/22/2024 with Resident #280 was transferred from her wheelchair to the bed and sustained a laceration. Family Member #2 reported PTA #1 and PTA #2 had helped Resident #280 to stand, and one of the Physical Therapy Assistants had jerked the wheelchair back at which time her leg caught a screw/bolt on the left leg of the wheelchair and snagged her left leg. The Physical Therapy Assistants continued to pivot Resident #280 to the bed and realized the back of Resident #280's left leg was bleeding. Family Member #2 reported the wound was in a V shape and approximately 2 inches on both sides. She reported Resident #280's pajama pants were saturated with blood and had to be thrown away. Family Member #2 reported her concern about the screw/bolt on the wheelchair to PTA #1 and PTA #2 and was told by PTA #1 and PTA #2 there was no way the screw/bolt could have cut Resident #280's left leg. Review of a nursing note written by Nurse #6 dated 1/22/2024 at 4:16 pm revealed she was called to Resident #280's room and observed a large laceration with fatty tissue exposed on the left lateral calf. She documented Resident #280 was being transferred from the wheelchair to the bed with two people assisting her. Nurse #6 further documented pressure was applied to the wound and wheelchair leg rests/connector had sharp metal but there were no exposed jagged edges. An interview was conducted on 5/2/2024 at 2:33 pm with Nurse #6. Nurse #6 reported she was called to Resident #280's room by Physical Therapy Assistant (PTA) #1 and PTA #2 on 1/22/2024 after Resident #280 sustained a laceration to her left lower leg during a transfer from the wheelchair to the bed. Nurse #6 recalled a pretty large wound and reported the wound was full thickness with tissue exposed. She reported it was unclear what it was hit on. She reported that someone had come and taken the wheelchair out of service after Resident #280 was taken to the hospital. She reported there was sharp metal on the legs of the wheelchair itself. She reported the legs of the wheelchair had been removed prior to her arriving. Review of the Emergency Medical Services documentation dated 1/22/2024 at 3:50 pm revealed Resident #280 was found sitting on the side of the bed with a laceration about 8 inches long on her left calf area and bleeding had been controlled by nursing home staff. Documentation further revealed the laceration was from blunt force trauma by a sharp object. Review of the emergency room (ER) note dated 1/22/2024 at 5:50 pm revealed Resident #280 arrived at the emergency room via Emergency Medical Services (EMS) and was transferring from her wheelchair to the bed when she sustained a laceration to the lateral aspect of the left lower leg. Documentation further revealed Resident #280 reported she believed she leg was caught due to an exposed metal edge. Wound documentation revealed a lengthy laceration to the lateral left lower leg measuring roughly 10 centimeters with exposed adipose tissue. The emergency room Physician ordered for Resident #280 to receive a tetanus vaccine in the emergency room , for the facility to keep the area clean and dry, change dressings routinely, clean the area with soap and water, apply antibiotic ointment with dressing changes, and to remove sutures in two weeks. The number of sutures was not included in the ER note. An interview was conducted on 5/3/2024 at 9:17 am with the Physical Therapy Director. The Physical Therapy Director reported he was aware of the incident that occurred on 1/22/2024 when Resident #280 was being transferred from the wheelchair to the bed. He reported the wheelchair was not taken out of service but that he did pad the wheelchair legs after the incident. He reported that he was not able to recall any sharp metal or screws sticking out of Resident #280's wheelchair and he was not able to determine what Resident #280 had been cut on. The Physical Therapy Director verified the wheelchair Resident #280 used belonged to the facility. An interview was conducted on 4/29/2024 at 3:48 pm with the Maintenance Director. The Maintenance Director reported facility staff were responsible for letting him know if any equipment or devices were broken by writing it down in the maintenance book located at each of the nurse's stations. The Maintenance Director reported he checked the maintenance book every morning when he arrived at the facility. He reported he did not save his maintenance logs or the forms that had been placed in the maintenance book because he was not aware that he needed to do so. He reported he was not able to recall Resident #280's wheelchair being taken out of service or brought to him for padding. He reported he relied on facility staff to report issues. An interview was conducted on 5/3/2024 at 8:50 am with the Director of Nursing (DON). The DON reported she was aware of a wound Resident #280 sustained when she was transferred from the wheelchair to the bed with Physical Therapy on 1/22/2024. The DON stated she was aware there was a laceration to the back of Resident #280's left leg and reported after the laceration occurred, the Physical Therapy Director had taken the wheelchair out of service to pad it and then returned it back to Resident #280's room. The DON reported she had not looked at the wheelchair after the incident and was unsure what Resident #280 cut her left leg on. 50046 2. Review of the facility's sit-to-stand lift manufacturer manual Operating and Product Care Instructions dated June 2003, read in part: Unauthorized modifications on the equipment may affect its safety and are in breach of any equipment warranty. The manufacturer will not be held responsible for any accidents or incidents or lack of performance that occur because of any unauthorized modifications. Lower leg straps: Pass around the knee supports, then around the patients lower calve. Ensure that the straps are firm but comfortable. Push the lift in close to make full lower leg contact with the knee support. Maximum lifting capacities: Basic lift 350 pounds (lbs.). All Slings 350 lbs. Resident #60 was readmitted to the facility on [DATE] with diagnoses including morbid (severe) obesity. Review of Resident #60's electronic medical records revealed a weight recorded on 4/4/24 of 340.8 lbs. Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was dependent on transfers. Review of Resident #60's care plan revised 4/14/24 revealed she had self-care deficit related to complications due to decreased mobility. The intervention was to transfer with the sit to stand lift with 2 staff assisting for safe transfer into the wheelchair from the bed. An interview was conducted on 4/29/24 at 8:45 AM with Resident #60. She said she had used the sit-to-stand lift for a month. The knee brace molds on the sit-to-stand lift did not fit her legs. She said therapy had added padding to the lift knee brace using pillows to help make it more comfortable. An interview was conducted on 4/30/24 at 11:01 AM with the Director of Rehabilitation. He said that Resident #60's lower legs did not fit into the sit-to stand lift knee brace molds and that the brace edge hit along the outside of her legs. He stated he had used pillows for padding the front of the knee brace and the leg safety straps were fastened when the pillows were positioned. The Rehab Director said that during the morning stand up meeting different lift options were discussed with the Administrator. He stated they decided to use the lift they had and pad it. An observation was conducted on 4/30/24 at 2:15 PM with the Rehabilitation Director while Resident #60 was transferred with the sit-to stand lift. The observation revealed Resident #60's lower legs, knees and shins were too large to fit into the knee brace molds of the lift. The knees and shins extended over the edge of the knee brace by 3 inches on each side. The Director of Rehabilitation tucked a pillow between Resident #60's knees and the lift knee brace after the leg safety strap was fastened. An interview was conducted on 5/1/24 at 2:36 PM with the Quality Assurance (QA) nurse. She said the sit-stand-lift could not be altered in any way and that adding pillows to the knee brace for padding altered the lift. She stated it had been discussed during the morning meeting that the pillows caused the safety leg straps on the lift to not fasten correctly. The purpose of the knee brace was to keep a resident's knees from buckling during a transfer. If the legs did not fit into the knee brace molds or leg straps were loose, then the legs could buckle and cause injury. An interview was conducted on 5/1/24 at 3:33 PM with the DON. She stated therapy had wanted to alter the knee brace of the sit-to-stand lift and the safety leg straps by putting pillows between the resident and the knee brace and leaving the leg safety straps loose. She had told the nursing staff not to do that or alter the lift when transferring. She stated the sit-stand-lift was not safe for Resident #60 to use if it was altered with pillows. An interview was conducted on 5/2/24 at 8:51 AM with Physical Therapy Assistant (PTA) #3. She said Resident #60 had discomfort using the sit-to-stand lift because her legs did not fit the knee brace and that pillows were used to pad the knee brace to relieve the discomfort. She stated she was concerned that adding pillows was altering the lift and using a lift that had been altered was unsafe. PTA #3 stated the pillows could cause her knees to buckle during a lift transfer. An interview was performed on 05/02/24 at 9:18 with Nurse Aide (NA) #2. She stated the Director of Rehab had told her to use pillows to pad the sit- to- stand lift. She stated that they put pillows in between Resident #60's knees and the knee brace of the sit-stand-lift when they transferred her. She said the leg safety straps did not fasten if the pillows were placed first. She said nursing management never told her that pillows were not to be used. An interview was conducted on 5/2/24 at 10:53 AM with the Administrator. He said the total mechanical lift was used to transfer Resident #60, but that she had requested to use the sit-to-stand lift instead to work on therapy goals of standing and walking. He stated he was aware Resident #60 was unable to use the sit-to- stand lift comfortably because her legs did not fit the knee brace. The Administrator said the Rehabilitation Director told him the current sit-to-stand lift was appropriate and that he could use pillows to pad the knee brace edges. The Administrator stated the leg safety straps were not long enough to go around Resident #60's legs and the pillows. He said the nursing staff was instructed not to use pillows to pad the knee brace of the sit-to-stand lift to transfer Resident #60 and not to alter the sit-to-stand lift by the DON. He was not aware that therapy used pillows or altered the sit-to-stand lift. A telephone interview was conducted on 5/7/24 at 2:53 PM with the sit to stand lift company representative. He reviewed the instruction manual for using the sit-to-stand lift and he did not recommend any pillows or additives be used and stated that inserting pillows altered the lift. The Representative stated pillows or any other additive could 100% jeopardize the safety of the lift and increase the risk of an accident. He discussed the purpose of the sit-stand-lift knee brace was to keep the resident's knees from buckling while they were in the lift. He said it was not safe to put a resident in a standing position on the sit-to-stand lift without a knee brace directly against the resident's lower extremities.

Based on observations and staff interviews, the facility failed to maintain clean and sanitary kitchen conditions as evidence by debris present on the kitchen floor and in the tile grout, dried food particles on a utility cart that was used to store clean dishware, dried debris on the steam table hood, dried debris on the outside oven surfaces. The facility also failed to ensure ready for use metal pans, insulated dome plate covers, insulated plate under liners, and dishware were clean and not stacked wet. This occurred for 2 of 2 kitchen observations. These practices had the potential to affect food served to residents. The findings included: 1. An initial tour of the kitchen occurred on 4/28/24 at 11:00 AM with the Dietary Manager (DM). The initial observation of the serving line and dishwashing area revealed the following: a. Dishware that was ready for use was put away and stacked wet (wet-nested). - 2 out of 10 divided plates - 20 out of 24 insulated plate under liner bottoms - 3 out of 5 large rectangle metal pans - 5 out of 6 deep small square metal pans b. Dishware that was ready for use was put away and stacked dirty. - 3 out of 10 divided plates had yellow particles. - 13 out of 16 saucers had yellow and black particles. - 7 out of 20 dinner plates had yellow, brown and/or black particles. - 10 out of 20 insulted plate dome plate covers had white and black particles. - 1 out 2 small rectangle metal pans had brown/black particles. - 5 out of 6 small square metal pans had brown/black particles. c. A plastic utility cart was observed to be dirty with loose and dried food particles, and dried orange crusted debris present on the cart surface and along the edges of the cart. The utility cart was used to store clean stacked dishes including diner plates, saucers, and dome plate covers. d. The kitchen floors had loose trash and food debris present on the floor surface and in the tile grout. e. The oven had food particles and dried brown crusted debris along the outer surfaces of the oven. f. The steam table hood had food particles and dried crusted debris along the top and edges of the hood. The underneath of the steam table hood had a large amount of dried brown crusted debris along the entire length of the underneath of the hood. An interview was performed with the DM on 4/28/24 at 11:20 AM. The DM stated dietary staff normally let the dishes sit until they are dry and put them on a rack to dry. She said the dietary staff normally checked to ensure dishes were clean and dry before putting them away. The DM said the kitchen was short staffed this morning (4/28/24) because of a call out. The DM said they were not usually short staffed except for when they had a call out and she would come and help when there was a call out if needed. She explained she thought the dietary staff this morning got in a hurry and were rushing because they were short staffed and didn't let the dishes sit and dry or check them to ensure they were clean. The DM said the dietary staff should have checked the dishes to ensure they were clean and dry before putting them away and stacking. The DM stated the steam table hood was cleaned after every meal and the top/ underneath of the hood should be cleaned every night. The DM looked at the underneath of the steam table hood and said she was not aware the underneath was dirty. She said there was no cleaning schedule for the underneath of the steam table hood but that there should be. She said the outside surfaces of the oven were scheduled to be cleaned today per the kitchens cleaning schedule. 2. A follow up observation of the kitchen was completed on 4/30/24 at 11:34 AM with DM and the following concerns were identified: g. Dishware that was ready for use was put away and stacked wet (wet-nested). - 4 out of 15 insulated plate liner bottoms - 1 out of 3 divided plates h. Dishware that was ready to be used was put away and stacked dirty. - 8 out of 20 small round plates had brown/yellow particles. An additional interview was completed with DM on 4/30/24 at 11: 40 AM. The DM stated she had educated the dietary staff on checking to ensure dishware was dry and clean before being stacked and put away for use. She said she was not sure why the dishware was wet nested or dirty. The DM stated that was a problem and needed to be fixed. An interview with Dietary Aide #1 was conducted on 5/1/24 at 1:10 PM. She stated everyone who worked in the kitchen helped wash dishes. She explained the process for cleaning/ washing dishes. She said dietary received the dirty tray cart back from the dining room or halls. She stated the dietary staff would wear gloves when handling the dirty dishes. Dietary Aide #1 explained 2 staff would handle the dirty dishes and a different staff member handled the clean dishes to prevent any contamination between the dirty and clean dishes. She said one staff would scrap, she explained the scrap duty as separating the dishes on the tray and removing any trash or uneaten food from the trays/ dishes and discarding the waste. She said a second person would then load the dirty dishes into the dish machine washing tray and push the tray into the dish washer. Dietary Aide #1 said there was a red light on the dishwash machine that blinked and let them know when the dishes were done, and the machine can be opened. She stated a third person removed the clean dishes out of the dishwasher and made sure the dishes were clean and free from any food. She explained this was done by doing a visual inspection when the dishes came out of the machine and then the dishes were set up to dry. She said the dishes were left in the dishwash tray and set up in the dishwash tray at an angle that would allow them to dry. Dietary Aide # 1 stated once the dishes were dry, they would be stacked on the appropriate cart until next use. She said the person who put away and stacked the dishes should perform a secondary check to ensure the dishes were clean and dry before stacking them. She said the dietary staff also checked the dishes when they plated the food in the tray line and did not use a dish if it was wet or dirty. An interview was performed on 05/02/24 at 10:48 AM with the Administrator. He stated he was surprised about the kitchen sanitation. He stated he thought the kitchen was shorthanded and was rushing to get everything done. He stated the dietary staff should have checked the dishes to ensure they were clean and dry before putting them away.

Based on record reviews, staff, resident, and lift company representative interviews the facility failed to accommodate the needs of a bariatric resident who needed a mechanical sit-to-stand lift with a larger knee brace for transfers for 1 of 1 resident (Resident #60) reviewed for accommodation of needs. The findings included: Resident #60 was readmitted to the facility on [DATE] with diagnoses including morbid (severe) obesity and a history of nontraumatic intracranial hemorrhage (bleeding in the brain). Review of Resident #60's electronic medical records revealed a weight recorded on 4/4/24 of 340.8 lbs Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was dependent for transfers. Review of Resident #60's care plan revised 4/14/24 revealed she had self-care deficit related to complications due to decreased mobility. The intervention was to transfer with the sit to stand lift with 2 staff assisting for safe transfer into the wheelchair from the bed. An interview and observation was conducted on 4/29/24 at 8:45 AM with Resident #60. She said she had used the sit-to-stand lift for a month. The knee brace molds on the sit-to-stand lift did not fit her legs. The edges of the knee brace dug into the edges of her lower legs along her shins and her knees, and it hurt. She stated the discomfort was 4 out of 10 to her knees and shins during transfers using the sit-to-stand lift. An observation of the leg, knees and skin revealed no visible marks or bruising. She said therapy had added padding to the lift knee brace using pillows. She stated the pillows helped, but that there was still discomfort. Resident #60 said the Administrator, the Director of Nursing (DON), and therapy had spoken with her about the lift and were aware the lift hurt her legs. She stated the Administrator told her they would rent a bariatric sit-to-stand lift. An interview was conducted on 4/30/24 at 11:01 AM with the Director of Rehabilitation. He said he was aware that the sit-to-stand lift was uncomfortable and that it hurt Resident #60's legs and shins. He said that her lower legs did not fit into the knee brace molds and that the brace edge hit along the outside of her legs. He had used pillows for padding the front of the knee brace and the leg safety straps were fastened when the pillows were positioned. He stated that even with the padding Resident #60 complained of pain. During the morning stand up meeting renting a bariatric lift had been discussed with the Administrator. They decided to use the lift they had and pad it. He did not know the plan to obtain the correct sized sit-to-stand lift. An observation and interview was conducted on 4/30/24 at 2:15 PM with the Rehabilitation Director while Resident #60 was transferred with the sit-to stand lift. The observation revealed Resident #60's lower legs, knees and shins were too large to fit into the knee brace molds of the lift. The knees and shins extended over the edge of the knee brace by 3 inches on each side. The Director of Rehabilitation tucked a pillow between Resident #60's knees after the leg safety strap was fastened. She complained her discomfort was 3 out 10 level along her shins and legs. An interview was conducted on 05/01/24 at 8:23 AM with the Maintenance Director. He stated the Administrator had asked him to contact the lift supply company about a month ago to ask about renting a wider or bariatric sit-stand-lift. The lift supply company did not rent bariatric lifts, they sold them. The information was given to the Administrator. He stated he had not reached out to any other medical equipment retailers to enquire if they rented bariatric lifts. An interview was conducted on 5/1/24 at 2:36 PM with the Quality Assurance (QA) nurse. She said the sit-stand-lift lift could not be altered in any way and that adding pillows to the knee brace for padding altered the lift. She stated it had been discussed during the morning meeting that the pillows caused the safety leg straps on the lift to not fasten correctly. The purpose of the knee brace was to keep a resident's knees from buckling during a transfer. If the legs did not fit into the knee brace molds or leg straps were loose, then the legs could buckle and cause injury. She stated Resident #60 needed a bariatric sit-to stand lift for her legs to fit into the knee brace. She stated renting a bariatric lift had been discussed in the morning meeting but that she did not know about the decision. An interview was conducted on 5/1/24 at 3:33 PM with the DON. She stated therapy had wanted to alter the knee brace of the sit-to-stand lift and the safety leg straps by putting pillows between the resident and the knee brace and leaving the leg safety straps loose. She had told the nursing staff not to do that or alter the lift when transferring. She stated the sit-stand-lift was not safe for Resident #60. The facility needed to purchase a bariatric sit-to-stand lift. She said the total mechanical lift should be used until then. An interview was conducted on 5/2/24 at 8:51 AM with Physical Therapy Assistant (PTA) #3. She stated Resident #60 complained of pain when she used the sit- to- stand lift from the knee brace on her legs. Pillows were used to relieve the discomfort. She was concerned that adding pillows was altering the lift and using a lift that had been altered was unsafe. The pillows could cause her knees to buckle during a lift transfer. An interview was performed on 05/02/24 at 9:18 with Nurse Aide (NA) #2. She stated the Director of Rehab had told her to use pillows to pad the sit- to- stand lift. She stated that they put pillows in between Resident #60's knees and the knee brace of the sit-stand-lift when they transferred her because the leg safety straps did not fasten if the pillows were placed first. She said nursing management never told her that pillows were not to be used. An interview was conducted on 5/2/24 at 10:53 AM with the Administrator. He stated he was aware Resident #60 was unable to use the sit-to- stand lift comfortably. He said the total mechanical lift was used to transfer Resident #60, but that she had requested to use the sit-to-stand lift instead to work on therapy goals of standing and walking. The facility had looked into renting a bariatric lift which was unsuccessful. Then they looked at purchasing a bariatric sit-stand-lift. The Rehabilitation Director stated the current sit-to-stand lift was appropriate and to use pillows to pad the edges. The leg safety straps were not long enough to go around Resident #60's legs and the pillows. The nursing staff was instructed not to use pillows to pad the knee brace of the sit-to-stand lift to transfer Resident #60 and not to alter the sit-to-stand lift. He was not aware that therapy used pillows or altered the sit-to-stand lift A telephone interview was conducted on 5/7/24 at 2:53 PM with the sit to stand lift company representative. He stated the facility's sit-to-stand lift had an older knee brace mold model.The newer model had a silicone flex knee brace pad, and it was more flexible and comfortable and would fit a larger range of residents. He reviewed the instruction manual for using the sit-to-stand lift and he did not recommend any pillows or additives be used and stated that inserting pillows altered the lift. Pillows or any other additive could 100% jeopardize the safety of the lift and increase the risk of an accident. The purpose of the sit-stand-lift knee brace was to keep the resident's knees from buckling while they were in the lift. He said it was not safe to put a resident in a standing position on the sit-to-stand lift without a knee brace directly against the resident's lower extremities.