Every finding on record at Belaire Health Care Center

Based on record review and staff interviews the facility failed to ensure the arbitration agreement clearly communicated that the right to rescind within 30 days could be requested verbally or in writing. Additionally, the facility failed to ensure the arbitration agreement stated that with each new admission more than 30 days after discharge, a new arbitration agreement would be offered and the facility failed to maintain a formal written policy governing the arbitration agreement process. The deficient practice has the potential to affect all residents admitted to the facility. The census was 72.Findings included:Record review of the facility Addendum to the Business Contract Arbitration Agreement revealed the following paragraph.The Resident and/or the Responsible Party understands that (1) they have the right to seek legal counsel concerning this Addendum, (2) the execution of the Addendum is not a precondition to admission to the Health Care Center (HCC) or the furnishing of services to the Resident by HCC, and (3) this Addendum may be rescinded by written notice, sent registered or certified mail, postage prepaid, return receipt requested, to HCC from the Resident and/or Responsible Party within 30 days of signature. Such notice shall be deemed to have been given upon receipt. If not rescinded within 30 days, this Addendum shall remain in effect for all care and services rendered at HCC, even if such care and services are rendered following the Resident's discharge and readmission to HCC. Review also revealed the Addendum to the Business Contract Arbitration Agreement was contained in the admission packet and did not contain a specific line or sheet for the Resident and/or Responsible Party to indicate if they declined to sign the Arbitration Agreement. The facility provided a list of all the current residents that had signed Arbitration agreements, and the list contained 60 residents. An interview was conducted on 9/3/2026 at 3:18 PM with the Admission's Director who stated she was in her first week of employment at the facility, but she was familiar with the Arbitration Agreements. The admission Director verified the Arbitration Agreement was contained within the admission packet. The admission Director indicated she explained the Arbitration Agreement to the Resident and/or Resident Representative while going through the admission packet which was electronically signed. The admission Director stated she did not think there was an official formal Arbitration Policy, just the Addendum to the Business Contract Arbitration Agreement. The admission Director stated the Resident and/or Resident Representative signed the entire admission agreement electronically at the end of the document which then populated the signature onto the signature lines included in admission packet, which included the Arbitration agreement. The Admissions Director explained there was not a separate sheet or signature line for declination of the Addendum to the Business Contract Arbitration Agreement. The Admissions Director stated if the Resident and/or Resident Representative declined to sign the Addendum to the Business Contract Arbitration Agreement, the agreement had to be manually deleted from the admission packet. An interview was conducted on 9/3/2026 at 3:35 PM with the Administrator and Nurse Consultant. The Administrator and Nurse Consultant verified the facility's Addendum to the Business Contract Arbitration Agreement was part of the admission packet, and there was not a specific formal Arbitration policy. The Nurse Consultant stated she was working on a specific Arbitration Policy, but it was currently not completed. The Administrator and Nurse Consultant agreed the Addendum to the Business Contract Arbitration Agreement clearly stated that a written notice must be sent certified mail withing 30 days to rescind the Addendum to the Business Contract Arbitration Agreement, and that the Addendum to the Business Contract Arbitration Agreement did not specifically state that a new Arbitration Agreement would be signed with each new admission more than 30 days after discharge. The Nurse Consultant informed that the facility did administer new Addendum to the Business Contract Arbitration Agreement when residents were re-admitted after 30 days of discharge and that since it was part of the admission agreement, readmissions also reviewed the Addendum to the Business Contract Arbitration Agreement less than 30 days after discharge.

Based on observations and staff interviews, the facility failed to maintain clean and sanitary nourishment rooms for 2 of 2 nourishment rooms reviewed for environment (Nourishment room [ROOM NUMBER] and Nourishment room [ROOM NUMBER]). The findings included: a. On 8/31/26 at 10:40 AM the following observations of Nourishment room [ROOM NUMBER] were made with the presence of the Dietary Manager:The cabinet under the sink, located to the side of the ice machine in Nourishment room [ROOM NUMBER], revealed moisture damage and buckling, to the lower right side of the cabinet. The inside of the cabinet revealed moisture damage and blackish brown spots of matter on the floor and right-side wall of the cabinets. Observations of 3 small facility coolers used for residents with thickened liquids were located inside the cabinet and revealed blackish brown spots of matter on the top and bottoms of the coolers. The floor and the back wall behind the ice machine in Nourishment room [ROOM NUMBER] revealed blackish matter along the molding and underneath the exposed and decayed wood, light, beige-colored puffy growths among the blackish matter on the floor and corner molding. b. On 8/31/26 at 10:55 AM the following observations of Nourishment room [ROOM NUMBER] were made with the presence of the Dietary Manager:The cabinet under the sink, located to the side of the ice machine in Nourishment room # 2, revealed moisture damage to the lower right side of the cabinet. The inside of the cabinet revealed moisture damage and blackish brown spots of matter on the floor and right-side wall of the cabinets. The floor and the back wall behind the ice machine in Nourishment room [ROOM NUMBER] revealed blackish matter along the molding and underneath the exposed and decayed wood, light, beige-colored puffy growths among the blackish matter on the floor and corner molding. An interview on 8/31/26 at 10:55 AM with the Dietary Manager revealed she was aware of the moisture damage to the back walls and sink cabinets in both nourishment rooms but was not aware of the growth build-up that she assumed was mold and that Maintenance was responsible for any repairs in the nourishment rooms. She stated she was not aware of the coolers being inside of the sink cabinet in Nourishment room [ROOM NUMBER] and that they were not supposed to keep anything inside of the sink cabinets. She revealed the dietary staff were supposed to be washing and cleaning any facility cooler daily and she was not aware the coolers had been left inside of the sink cabinet with what she assumed was mold on them. The Dietary Manager stated she was not aware of those coolers being used for residents and that she would make sure that all staff knew that no coolers were to be placed inside the sink cabinets and should be taken to the kitchen daily to be washed and cleaned.An interview on 9/3/26 at 1:15 PM with the Maintenance Director revealed that he was aware of the moisture damage and the conditions of the back walls and the sink cabinets in both nourishment rooms. He stated the condensation from the ice machines in those rooms would splash up onto the back walls and outside of the cabinets when it was hitting the floor. He stated that he was not aware of growth buildup to the back wall or to the outside or inside of the cabinets but could understand how that could happen due to those areas staying wet. The Maintenance Director stated that he would assume the blackish or light beige or yellow colored matter on the back wall, floor, and inside of the cabinets was mold. He explained the facility would need to clean the mold, repair the moisture damage to the back walls, floor, and molding, replace the cabinets located under the sinks and attach a piece of plastic to the outsides of the cabinets and the back walls in both nourishment rooms which should keep the condensation from the ice machines from causing the same problems again.An interview with the Administrator on 9/3/26 at 3:32 PM revealed he had not been made aware of the moisture damage or the growth build-up in both nourishment rooms and the coolers being left inside of the sink cabinet with what he also assumed was mold on them until today. He stated nothing should be left inside the sink cabinets, and he would assure staff were made aware that all facility coolers were taken to the kitchen daily to be washed and cleaned and placed back inside the upper cabinets or counters of the nourishment rooms. The Administrator revealed that he and the Maintenance Director would assure the mold was cleaned and the areas of the back walls were repaired, sink cabinets were replaced, and a barrier was placed onto them to keep this same problem from reoccurring.

Based on record review, Responsible Party, staff, Consulting Pharmacist and Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident representative in advance of the risks and benefits of psychotropic medications prior to the initiation or increase of the medications for 1 of 5 residents reviewed for unnecessary medications (Resident #9).The findings included:Resident #9 was readmitted on [DATE] with diagnoses of Parkinson's Disease, dementia, major depressive disorder.Record review revealed Resident #9 readmitted on [DATE] with an order for quetiapine fumarate (atypical antipsychotic prescribed to treat major depressive disorder) 25 milligrams (mg) give one tablet by mouth at bedtime which was discontinued on 8/24/2026 by the Psychiatric NP.Record review revealed Resident #9 had a Resident Representative who was his emergency contact and was responsible for Resident #9's healthcare decisions.Resident #9's comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was moderately cognitively impaired and indicated Resident #9 received antipsychotic medication during the 7-day lookback.Resident #9 had an active order dated 8/24/2026 for sertraline (an antidepressant medication) 25mg give one tablet by mouth daily for depression.A progress note written by the Psychiatric Nurse Practitioner (NP) dated 8/24/2026 indicated Resident #9 was experiencing depression symptoms and the plan was to discontinue quetiapine fumarate and start sertraline 25mg by mouth daily for depression.Record review revealed Resident #9 had an active order dated 8/25/2026 for mirtazapine (antidepressant also prescribed off label for appetite stimulant) 7.5 mg by mouth at bedtime for appetite stimulant/depression.A progress note written by the Facility Nurse Practitioner dated 8/25/2026 revealed a decrease in Resident #9's appetite and food intake with a plan to start mirtazapine 7.5 mg by mouth daily at bedtime to stimulate appetite. Resident #9's Medication Administration Record (MAR) from 8/11/2026 to 9/3/2026 indicated Resident #9 was administered quetiapine fumarate, sertraline and mirtazapine as ordered by the physician.A review of Resident #9's medical record revealed no information indicating Resident #9's Responsible Party was informed in advance of the risks and benefits of initiating quetiapine fumarate, sertraline and mirtazapine.A review of Resident #9's medical record with Unit Manager #1 and the Director of Nursing revealed there was no Psychotropic medication consent completed for Resident #9 when he was admitted on quetiapine fumarate, and when sertraline and mirtazapine were initiated.A telephone interview was conducted on 9/4/2026 at 4:14 PM with Resident #9's Responsible Party who did not recall being informed of the side effects, risks and benefits of quetiapine fumarate, sertraline and mirtazapine.An interview was conducted on 9/3/2026 at 11:54 AM with Nurse #1 who stated she was familiar with the facility psychotropic policy, and that psychotropic medications needed to have a consent obtained when a resident was admitted on a psychotropic medication. Nurse #1 stated that when a resident was admitted on a psychotropic medication the consent would be completed by the nurse that admitted the resident. Nurse #1 thought the unit managers were responsible for obtaining psychotropic medication consents for new psychotropic medications or increased doses because they reported the new medication orders to the unit manager.An interview was conducted on 9/3/2026 at 11:57 AM with Unit Manager #1 who verified a resident admitted on a psychotropic medication would need a psychotropic medication consent completed. Unit Manager #1 stated she had only been in her current position for a couple weeks and wanted to finish the interview and record review with the DON present. The interview was completed with the DON present Unit Manager #1 indicated a psychotropic medication consent could be completed by the floor nurse or unit managers when a psychotropic medication was initiated or increased. A telephone interview was conducted on 9/3/2026 at 9:50 AM with the Psychiatric Nurse Practitioner (NP) who stated she was familiar with Resident #9. The Psychiatric NP revealed Resident #9 had previously been on sertraline but had a gradual dose reduction and was previously discontinued, The Psychiatric NP stated she discontinued the quetiapine fumarate and started Resident #9 on sertraline as she felt it was more appropriate due to his previous time on sertraline. The Psychiatric NP verified the order for sertraline on 8/24/2026 required a new psychotropic medication consent as well as the quetiapine fumarate and mirtazapine required a psychotropic consent to be obtained when the medication was initiated or the dose increased. The Psychiatric NP stated the facility was responsible for obtaining the psychotropic consent.An interview was conducted on 9/3/2026 at 11:33 AM with the facility NP who stated she was familiar with Resident #9. The facility NP confirmed it is standard for the facility to obtain psychotropic consents when a psychotropic medication was initiated or increased.A telephone interview was conducted on 9/3/2026 at 1:05 PM with the Consulting Pharmacist who verified quetiapine fumarate, sertraline and mirtazapine were psychotropic medications that required a psychotropic medication consent when started or the dose was increased. The Consulting Pharmacist indicated he did spot checks during his monthly reviews to make sure residents taking psychotropic medications had the required consents, but he did not check every resident every month.An interview was conducted on 9/3/2026 at 12:10 PM with the DON who stated psychotropic medication consents should have been completed for Resident #9 for the quetiapine fumarate, sertraline and mirtazapine. The DON stated the consents must have been overlooked and missed by accident. The DON stated the nurses on the floor or unit managers could obtain the psychotropic medication consent.An interview was conducted on 9/3/2026 at 3:50 PM with the Administrator who stated the policy for psychotropic medications should be followed and the consents should have been completed for Resident #9 for quetiapine fumarate, sertraline and mirtazapine.

Based on observations, record review, and interviews with Responsible Parties (RPs), representatives of the continuous radar-monitoring system company, and facility staff, the facility failed to obtain written consent and educate the resident or Responsible Party regarding the use of a continuous radar-monitoring system mounted on the wall above the resident's bed for 3 of 7 sampled residents with a monitoring system (Resident #6, Resident #15, and Resident #18). The facility also failed to have an effective system in place to communicate with the continuous radar-monitoring system company regarding when the monitoring system should be activated and deactivated for residents.Findings included: A review of the continuous radar-monitoring system's website revealed the mounted device continuously monitored vital signs and activity through clothing and bedding using radar-based sensors. Subtle skin movements from the patient's heartbeat were detected, measured, and tracked around the clock. The data was sent to a centralized dashboard, giving facility staff access to patient insights, analysis, and alerts (neteera.com). a. Resident #6 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact. An observation on 08/31/26 at 12:05 PM revealed Resident #6 had a small, white device with no lens or light mounted above her bed which was pointed directly at her bed. An interview conducted on 09/03/26 at 1:43 PM with Resident #6 revealed she was not aware of what the small, white device was in her room, but it had been there since admission. She stated she had not received any education on what the device was, however, someone from the facility (whom she could not recall their name) came into her room on 09/01/26 and asked her to sign a consent form for the device. She stated the staff member did not explain what the device was and she felt like it was an invasion of privacy. Resident #6 stated she was also upset because nothing about the monitoring device was mentioned until the week of 08/31/26 while surveyors were in the building. An informed consent document describing the continuous radar-monitoring system was signed by Resident #6 with a date of 09/01/26. A telephone interview with continuous radar-monitoring device Representative #2 occurred on 09/03/26 at 11:37 AM. He stated the device in Resident #6's room used continuous radar technology and would monitor metrics such as heart rate and respirations on all residents. An active list of residents in the facility who were connected and receiving continuous radar-monitoring services was provided to the surveyor on 09/02/26. Resident #6 was on the active list as being connected and monitored. The facility and Representative #1 stated they could not tell when Resident #6's continuous radar monitor had been activated. b. Resident #15 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was severely cognitively impaired. An observation on 09/03/26 at 2:36 PM revealed Resident #15 had a small, white device with no lens or light mounted above her bed which was pointed directly at his bed. An interview conducted on 09/03/26 at 1:22 PM with Resident #15's Responsible Party revealed he was contacted on 09/01/26 by a facility staff member (name he could not recall) regarding a continuous monitoring system that was used in the facility and to obtain consent for it. He explained that he did not give consent to use of the device because it didn't seem like it was important. He stated he wasn't asked on admission if he gave consent for the device to monitor Resident #15 nor was he aware there were offsite clinicians reviewing the resident's medical record or observing the information that was collected. An informed consent document describing the continuous radar-monitoring system was signed on 09/01/26 by Resident #15's Responsible Party as not giving consent to the services provided. An active list of residents in the facility who were connected and receiving continuous radar-monitoring services was provided to the surveyor on 09/02/26. Resident #15 was on the active list as being connected and monitored. c. Resident #18 was admitted to the facility on [DATE]. Resident #18's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. An observation on 08/31/26 at 12:04 PM revealed Resident #18 had a small, white device with no lens or light mounted above her bed which was pointed directly at her bed. On 08/31/2026 at 12:05 PM an interview with Resident #18's Responsible Party revealed she did not know what the small white device mounted on the wall was. She indicated she signed the admission paperwork for Resident #18 and did not recall signing a consent form for the device or having staff explain the device to her. An informed consent document describing the continuous radar-monitoring system was signed on 08/31/26 by Resident #18's Responsible Party as not giving consent to the services provided. An active list of residents in the facility who were connected and receiving continuous radar-monitoring services was provided to the surveyor on 9/02/26. Resident #18 was on the active list as being connected and monitored. An interview was conducted on 9/01/26 at 9:28 AM with the Director of Nursing (DON). During the interview she stated staff had been asked to obtain consent for the continuous monitor devices on 8/31/26 and 9/01/26 after the State Surveyor had asked to see the consents. The DON explained the facility had a new Admissions Director who did not know she was supposed to obtain consent for the monitoring devices. The DON stated she was not aware that Resident #18's Responsible Party did not agree to the services and Resident #18 was actively monitored. A telephone interview with continuous radar-monitoring company Representative #1 was conducted on 09/01/26 at 10:35 AM. Representative #1 stated the facility utilized a continuous radar-monitoring system that used radar technology and was connected to each resident's electronic medical record (EMR) to assess and process information. The monitoring system recorded the resident's heart rate and respirations and could detect when a resident was declining or experiencing a change in condition. Information identified by the system would be sent via email to the Director of Nursing (DON). Representative #1 stated the corporation had approximately 1,500 home-based clinicians who reviewed the data collected from residents and monitored the information for trending patterns. The system would also generate a document for the DON that included information gathered from the residents' EMR. Representative #1 stated there was no camera involved in the monitoring system and that it only collected information from the resident within an 8- to 10-foot radius around the residents' bed. Representative #1 stated the monitoring system was not supposed to be automatically activated upon a resident's admission without informed consent. He stated it was the facility's responsibility to obtain informed consent from the resident upon admission before the monitoring system was activated. Representative #1 stated that if informed consent was not received or signed by the resident, the monitoring system would be turned off. He stated the facility had been utilizing the organization since January and was expected to obtain informed consent for the monitoring system upon each resident's admission. Therefore, the facility was responsible for ensuring the required consent was obtained prior to the resident being monitored by the system. Representative #1 was also asked about the process for discontinuing the monitoring system when a resident was discharged from the facility. He stated it was the responsibility of the facility to update the organization and let them know when a resident discharged . The interview revealed the continuous radar-monitoring systems were placed in each room and the company relied on the facility to let them know when to turn it off. The monitor would remain activated unless the company was notified. An interview was conducted on 09/01/26 at 9:28 AM with the Director of Nursing (DON). During the interview she stated staff had been asked to obtain consent for the continuous monitor device on 08/31/26 and 09/01/26 after the State Surveyor had asked to see the consents. The DON explained the facility had a new Admissions Director who did not know she was supposed to obtain consent for the monitoring devices. The DON stated she was not aware that Resident #15's Responsible Party did not agree to the services and the resident was actively monitored. An interview was conducted on 09/01/26 at 10:01 AM with the Admissions Director. During the interview she stated she was new to the position and that the continuous monitoring device paperwork was not included in the admission packet which she went through with the residents upon admission. She explained she had received orientation from another Admissions Director from another facility and was not aware she was supposed to have obtained consent for the continuous monitoring devices. An interview was conducted on 09/03/26 at 11:56 PM with the Administrator. During the interview he stated the continuous monitoring system was set up by their corporate office and consents were supposed to be obtained and completed upon admission. He stated if consent was not obtained then a resident should not be on the monitoring list. The interview revealed the facility did not realize consents were not being obtained by Admissions staff. The Administrator stated he was not aware Resident #15's Responsible Party had not given consent for the continuous monitoring device and that he was actively monitored.

Based on observations and staff interviews, the facility failed to post in an area that was visible and accessible to residents, families, and visitors a list of names, addresses (mailing and email) and telephone numbers for all required state agencies and advocacy groups including the State Survey Agency, State Long-Term Care Ombudsman, Adult Protective Services, Resident Advocacy Network, Home and Community Based Service Programs, and Medicaid Fraud Control Unit information. These observations occurred on 3 of 4 days (9/01/26, 9/02/26 and 9/03/26) of the onsite portion of the recertification survey.The findings included:Observations of all facility hallways accessible to residents on 9/01/26 at 10:19 AM, 9/02/26 at 3:23 PM and 9/03/26 at 11:33 AM revealed the State Long-Term Care Ombudsman poster hung in the back hallway with the employee postings. The State Survey Agency, Adult Protective Services, Resident Advocacy Network, Home and Community Based Service Programs and Medicaid Fraud Control Unit postings were not observed. During a Resident Council meeting on 9/02/26 at 10:57 AM, Resident #27 and Resident #37 indicated they knew there were phone numbers on the wall in the front hall of the facility but didn't know what all the numbers were for. They were not aware of the Ombudsman poster in the back hallway.A walking tour of the facility and interview on 09/03/26 at 12:37 PM with the Discharge Planner revealed she was responsible for the required postings in the facility, and the Ombudsman posting was the only required posting observed. She reported she was not aware of which numbers were required to be posted and acknowledged the required numbers were not posted in the facility. An interview on 9/03/26 at 1:26 PM with the Administrator revealed he did not know which numbers were required to be posted. He acknowledged that the required contact information should be posted where residents could readily access the information and reported that having these numbers available was important to ensure residents' rights were maintained.

Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 4 residents reviewed for activities (Resident #31, #44, #78, and #80). During interview, Resident #44 cried when speaking about his inability to enjoy his retirement because he was not able to do things outside such as eating at a restaurant, going to a baseball game, going out to see Christmas lights, socializing, going into a store and being able to touch items and shop for himself. Other residents expressed not being able to leave the facility made them feel like a dog, unimportant, sad, and they missed getting out with the group to shop, attend community activities, and socialize.The findings included: A review of the July 2025 activity calendar revealed scheduled activities for inside of the facility during the week and on the weekends. There were no activities scheduled outside of the facility. Observation on 7/28/25 at 9:00 AM revealed the facility was located within a business and residential area that was within driving distance to numerous local and commercial shops, grocery stores, local and commercial coffee shops, fast food, and sit-down restaurants. a. Resident #31 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #31 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #31 was cognitively intact. An interview conducted with Resident #31 on 7/29/25 at 1:30 PM during the Resident Council meeting revealed there had not been a scheduled group activity outside of the facility since his admission in December 2024. He stated he believed they might have discussed scheduled activities outside of the facility maybe once during their Resident Council meeting and it was said that residents have families that take them out and the facility does not have a van. He stated in his opinion group activities outside of the facility were important to the residents that they were able to go and participate because it allowed them socialization with the group and outside world, helped with their health, made them feel normal and that they weren't just stuck in a facility. Resident #31 stated not being able to leave the facility and participate in group activities outside the facility had sometimes made him feel like a dog, that he was unimportant, and had lost some of his own independence. He revealed personally being able to go shopping, go out to ball games and community activities, and socializing with other people outside of the facility was very important to him and would make him feel more human and like he was still important. b. Resident #44 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #44 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #44 was cognitively intact. An interview was conducted with Resident #44 on 7/29/25 at 1:30 PM during the Resident Council meeting revealed he had been at the facility since November 2024 and there had not been a scheduled group activity outside of the facility since his admission. He stated he had been told by staff and other residents that they were not able to go out to activities outside the facility because they didn't have a van at the facility. Resident #44 began crying and stated he was sorry for crying but that he was retired and was not able to enjoy his retirement and that going out to eat at a restaurant, going to a baseball game, going out to see Christmas lights, socializing, going into a store and being able to touch items and shop for your own personal belongings made you feel independent and normal. He stated he felt that not being able to do those things since his admission made him sad, miss his home life more, like he was not able to enjoy his retirement, become more reliant on staff and not as social as he used to be. Resident #44 revealed he would just like the opportunity to enjoy those things again. c. Resident #78 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #78 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #78 was cognitively intact. An interview conducted with Resident #78 on 7/29/25 at 1:30 PM during the Resident Council meeting revealed that since she had been admitted to the facility there had been no scheduled activities outside of the facility. She revealed not having scheduled activities outside of the facility made her feel sad, depressed, and like she was missing out on the world. Resident #78 stated she would like the opportunity to go shopping for herself or to eat at a restaurant and socialize with other people. d. Resident #80 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #80 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #80 was cognitively intact. An interview conducted with Resident #80 on 7/29/25 at 1:30 PM during Resident Council meeting revealed that since she had been to the facility there had been no scheduled activities outside of the facility. She stated she participated in a monthly Resident Council meeting and they had discussed with the Activities Director about scheduling activities outside of the facility. She revealed they were always told that it was not possible because the facility was not able to provide transportation due to not having a facility van. Resident #80 stated not having the opportunity to participate in activities outside of the facility made her feel sad, unimportant, and like she was losing her independence. She revealed that she felt it was important for residents to have scheduled activities outside of the facility because not all of the residents at the facility had family that could take them out or shop for them. She also revealed having scheduled activities outside of the facility allowed residents to feel normal and to be able to shop and purchase their own items, maintain their independence, and to be able to socialize with the real world. An interview conducted with the Activity Director on 7/30/25 at 12:11 PM revealed she had been working as the Activity Director at the facility for the past 5 years and part of her responsibilities were scheduling and implementing resident activities for each month. She stated since she began working at the facility as the Activity Director, she had not scheduled any resident group activities outside of the facility due to the facility not having their own van and residents having families that could take them out when they wanted to go. She revealed to her knowledge; the facility had never had a van and had always relied on contract transport for resident appointments only. The Activity Director stated she believed she had discussed scheduled activities outside of the facility maybe once over the past year and the residents she spoke with stated they had family that could take them out. She revealed she had been doing some personal shopping for residents so they could continue to receive their preferences but understood that this was not the same as the residents being able to leave the facility and shop for themselves, eat a meal together at a restaurant, participate in community activities, or watch a movie outside of the facility. She stated she felt like activities outside of the facility for those residents who could participate were important for their overall mental and physical well-being and allowed them some independence. An interview conducted with the Administrator on 7/30/25 at 3:41 PM revealed he was unaware of residents wanting to participate in activities outside of the facility over the past year. He stated he would investigate the issue and see what alternative transportation methods were available that could be used to assist the residents being able to participate in activities outside of the facility.

Based on observations, record reviews, and resident and staff interviews, the facility failed to provide incontinence care when a resident requested (Resident #44). The facility also failed to provide a privacy cover for urinary drainage bag which allowed the urinary drainage bag contents to be visible (Resident #31). This deficient practice was for 2 of 6 residents reviewed for dignity (Residents #44 and Resident #31).1. Resident #44 was admitted on [DATE] with diagnoses which included cerebrovascular accident (stroke), hypertension (high blood pressure), unspecified mood disorder, recurrent major depressive disorder. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was cognitively intact, received a diuretic (a drug that causes the kidneys to make more urine) daily, was always incontinent of bowel and bladder, and required maximal assistance with incontinence care and toileting. A review of Resident #44's skin assessment dated [DATE] revealed redness to bilateral buttocks. An interview with Resident #44 was conducted on 07/30/25 at 1:32 PM. Resident #44 stated that he was incontinent of both bowel and bladder. Resident #44 indicated staff would not change him when he turned on call bell for incontinence care. Resident #44 reported staff would enter his room, turn off the call bell, and tell him they can't change him right now, or they were not his assigned staff and won't provide incontinence care. Resident #44 stated staff refused to provide incontinence care during mealtimes until all trays were picked up. Resident #44 reported he felt self-conscious of odors due to incontinence of bowels. Resident #44 verbalized it was hard to enjoy meals and activities due to concern about odor. Resident #44 reported staff have stated not again when he soiled himself but could not recall a specific time or staff. Resident #44 reported that he would be so soiled with stool from waiting, he would have to be taken to the shower to be hosed off. Resident #44 indicated he asked staff to change him before the 7:00 PM shift started so he would not have to wait for 7:00 PM to 7:00 AM staff to change him before bedtime because it took them so long to answer the call bell. Resident #44 stated he felt the staff don't care and it makes him feel like he can have a nervous breakdown. Resident #44 stated I lay in the bed at night and think how much I hate this place. An interview with Nursing Assistant (NA) #1 was conducted on 07/29/25 at 1:39 PM. NA #1 was familiar with Resident #44 and stated NAs would change any resident when needed and did not tell residents to wait. NA #1 stated it was hard to change residents during meals because they were busy in the dining room. An interview with the Unit Manager was conducted on 07/29/25 at 1:55 PM. The Unit Manager stated Resident #44 was always incontinent with bowel and bladder. The Unit Manager reported she was not aware Resident #44 reported staff had told him they could not provide him with incontinence care during mealtimes. The Unit Manager indicated staff would change residents while passing trays if Resident #44 requested it, but it was difficult because staff were busy during meals. Resident #44 required 1 staff assistance for toileting and personal hygiene, and staff took him to the bathroom for toileting.An interview with the Director of Nursing (DON) was conducted on 07/29/25 at 2:38 PM. The DON stated Resident #44 was incontinent with bowel and bladder. The DON indicated Resident #44 had not voiced concern about call bell wait times or staff would not provide care. An interview with the Administrator was conducted on 07/30/25 at 3:48 PM. The Administrator stated he expected staff to answer call bells in a timely manner. The Administrator stated, it takes no special skill to answer the call bell. The Administrator indicated the Ombudsman came in recently and reported residents had complained of lack of incontinence care and waiting for long periods of time for call bells to be answered. The Administrator stated staff should answer the call bell and if they were not able to provide the care, they need to find the staff qualified to do so. Staff should go back and tell the residents what they did and who would follow up to provide care. 2. Resident #31 was admitted on [DATE] with diagnoses which included cerebral infarction due to thrombus (stroke due to a blood clot), anxiety disorder, recurrent major depressive disorder, and neuromuscular dysfunction of the bladder (a condition when nerve damage impairs the bladder's ability to store and release urine properly). A quarterly MDS dated [DATE] revealed Resident #31 was moderately cognitively impaired, had an indwelling catheter, was always incontinent of bowel, and required assistance for hygiene. Resident #31's care plan dated 12/20/24 revealed plans for assistance with activities of daily living (ADLs), indwelling urinary catheter, and bowel incontinence. Urinary catheter care plan stated goal was to prevent complications due to catheter use. Interventions listed included maintain catheter privacy bag.An initial observation of Resident #31 was conducted on 07/27/25 at 9:07 AM when the Survey Team entered the facility. Resident #31 was seated in a wheelchair outside the facility entrance patio. Resident #31's urinary drainage bag was observed hanging below the wheelchair and was fully exposed and half full of urine. A second observation of Resident #31 on 07/27/25 at 11:02 AM. Resident #31 was propelling himself down the main hallway in his wheelchair. Resident #31's urinary drainage bag was observed hanging below wheelchair fully exposed and half full of urine. An interview with NA #1 was conducted on 07/29/25 at 1:39 PM. NA #1 was familiar with Resident #31 and stated she had not realized that Resident #31 did not have a privacy cover on his bedside drainage bag on 07/27/25. An interview was conducted with Resident #31 on 07/30/25 at 1:32 PM. Resident #31 stated it bothered him when his urine was visible in the urinary drainage bag while he was in his wheelchair. Resident #31 indicated that the staff applied a leg bag to his catheter on 07/30/25. Resident #31 stated he preferred the bedside drainage bag, but the leg bag could not be seen by others. An interview with the DON was conducted on 07/29/25 at 2:38 PM. The DON stated Resident #31 had an indwelling urinary catheter. The DON stated all residents with catheters should have a privacy cover on bedside drainage bag. The DON indicated Resident #31 had not voiced concern about the urinary catheter before to her.

Based on record reviews, and Hospital Case Manager, Emergency Medical Services (EMS) Transporter, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident remained in the hospital for over two weeks despite being cleared to return to the nursing home on the same day. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #92).Findings included: Resident #92 was admitted to the facility on [DATE] and discharged on 4/09/25 with diagnoses including intellectual disability, muscle weakness, and spinal cord disease. Review of 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #92 was severely cognitively impaired with wandering, verbal, and physical behaviors towards others. Review of nursing progress note written by Nurse #3 dated 4/09/25 revealed Resident #92 was combative with nursing staff. One-to-one interventions attempted with no changes in combative behavior. Resident #92 was yelling, screaming, hitting, and kicking staff. Diversional activities attempted with snacks, games, reading, and music not effective. Provider to evaluate. Resident #92 was currently at the nurse's station for high viewing area and one-to-one staff care. Resident #92 continues to hit, kick, yell, and scream and attempting to get out of her chair several times. Review of Nurse Practitioner (NP) progress noted dated 4/09/25 revealed Resident #92 seen for altered mental status. Nursing observations, evaluations, and recommendations are combative to self and to others. Hitting, kicking, spitting, punching, running, attempting to exit the facility, throwing self onto floor, and risk for hurting self and others. Recommendations to send to emergency room (ER) for evaluation and treatment for altered mental status and risk of hurting self and others. Review of the NP order dated 4/09/25 revealed Resident #92 was to be sent out to hospital for evaluation and treatment for altered mental status. Review of nursing progress note written by Nurse #3 dated 4/09/25 revealed Resident #92 was being sent to the ER for evaluation and treatment for altered mental status and risk of hurting self and others. Left a message for Resident #92's responsible person requesting a return call to the facility. Emergency Medical Services (EMS) transported Resident #92 to ER for evaluation and treatment.Attempts to contact Nurse #3 for interview were not successful. Review of EMS transport records dated 4/09/25 revealed at 12:43 PM EMS was dispatched to the facility. Chief complaint was about a resident with behavioral issues. Upon arrival, Resident #92 presented with behavioral issues that facility stated began approximately at 12:00 PM on this date with a duration of about 1 hour. Additionally, a general exam was conducted, lasting approximately 10 minutes. Resident #92 reported no possible injuries and was experiencing mild distress. There were no abnormalities upon examination. The primary impression was a behavioral/psychiatric episode, with a secondary impression of a general exam. Resident #92 was safely transferred to the ambulance using a stretcher. Resident #92 was transported to the closest hospital facility by non-emergent transport. Upon arrival at the destination, Resident #92's condition remained unchanged.On 4/09/25 at 3:29 PM EMS was dispatched to the hospital for medical transport back to nursing facility. Upon arrival, Resident #92 was found in assigned room and was transferred from bed onto the stretcher. Resident #92 was alert and oriented to residents normal. Resident #92 had no complaints throughout duration of transport other than wanting to go back to the group home where she had been for several years. Upon arrival at the nursing facility at 4:15 PM, EMS was met outside of the facility by nursing staff (no name listed) and was told Resident #92 was not allowed on the property and EMS were not to bring her inside. EMS called their supervisor and Adult Protective Services (APS) were contacted and were told to standby while arrangements were made for Resident #92. After contacting the hospital staff, EMS were advised to return Resident #92 to the ER until further arrangements could be made. EMS cleared facility at 5:03 PM transported Resident #92 back to hospital facility. Resident #92 arrived at hospital facility at 5:23 PM, alert and oriented and no complaints during transport.A telephone interview with the EMS transporter on 7/30/25 at 8:45 AM revealed EMS received a telephone call on 4/09/25 at 12:43 PM from the facility to transport Resident #92 to the ER for altered mental status and combative behaviors. He stated EMS arrived at the facility at 12:59 PM and Resident #92 was transported to the hospital ER for evaluation and treatment. He revealed EMS received a telephone call on 4/09/25 at 3:29 PM from the hospital to transport Resident #92 back to the facility. The EMS transporter stated upon arrival at the facility on 4/09/25 at 4:15 PM they were met outside by a nursing staff (no name listed) and were informed they were not taking Resident #92 back at the facility, Resident #92 was not allowed on the facility property and EMS was not allowed to come inside with Resident #92. He revealed they called the EMS supervisor who instructed them to contact Adult Protective Services (APS). He stated they contacted APS and were informed the facility was not allowed to refuse to take Resident #92 back and if they continued to refuse to take her back, to contact the hospital to see if they would allow Resident #92 to come back until other arrangements could be made. The EMS transporter revealed the staff at the facility continued to refuse to allow Resident #92 back into the facility, so they transported Resident #92 back to the hospital and notified hospital staff the facility was refusing to take Resident #92 back. He stated they left Resident #92 at the hospital and to his knowledge she was admitted back into the hospital until other arrangements could be made. Review of hospital case manager notes for Resident #92 dated 4/09/25 revealed the following: 4/09/25- Resident #92 was brought into hospital ER via EMS transport from nursing facility for complaints of altered mental status, combative behavior, and risk to self or others. Upon assessment, Resident #92 a was alert and oriented to baseline, no threats of harm to self or others, and no behaviors present. Resident #92 showed no signs of injury and no complaints of pain. (CBC), urinalysis, and lithium level check were completed, and ranges were within normal limits. Medications reviewed with no changes. Recommendations for Resident #92 discharge back to skilled nursing facility and follow up with psych and primary care physician. Resident #92 discharged and transported back to skilled nursing facility via EMS. 4/09/25- Resident #92 was brought back to hospital ER via EMS transport from nursing facility. EMS transport reported nursing facility refused Resident #92 and would not allow her back at their facility. Resident #92 was currently resting in ER, alert and oriented to baseline, no behaviors present, and no complaints of injury or pain. Attempted contact with nursing facility with no answer. Contacted previous assisted living facility, unable to take Resident #92 due to requiring rehab services and skilled nursing level of care. Resident #92 was admitted to hospital for treatment until alternative placement could be arranged. 4/21/25- Resident #92 discharged from and transported via EMS to previous assisted living facility. Resident #92 referral for home health to continue therapy and nursing services. Follow-up with psych and primary care physician. A telephone interview with the hospital case manager on 7/30/25 at 9:15 AM revealed she was familiar with Resident #92. She stated on 4/09/25 Resident #92 was brought into the ER for altered mental status. She revealed Resident #92 was assessed by the hospital provider, lab work was completed, lithium levels were checked, and all were within normal limits. Medications were reviewed with no changes. She revealed Resident #92 appeared to be at baseline with no behaviors present while at the hospital. The hospital case manager stated the hospital provider recommended Resident #92 to be discharged back to the facility and to follow up with psych and her primary physician. She revealed Resident #92 was transported back to the facility by EMS at 3:30 PM. She stated typically the ER nurse would notify the facility when a resident was being discharged and transported back to the facility but there was no note entered to state if the ER nurse contacted the facility regarding Resident #92's return to the facility. The hospital case manager revealed on 4/09/25 around 5:30 PM, EMS transported Resident #92 back to the hospital stating the facility refused to take her back and would not allow Resident #92 back into their facility. She stated they attempted to contact the facility but could not get anyone from the facility to answer their call. She revealed they also attempted to contact Resident #92's previous assisted living facility about placement but they could not accept Resident #92 due to her requiring rehab services and skilled level of care. The hospital case manager stated Resident #92 had to be admitted to the hospital since the facility refused to take her back and they were unable to locate an alternative placement. She revealed during Resident #92's hospital stay she received the treatments and therapy services she was supposed to receive at the facility, and she was able to be discharged back to her assisted living facility on 4/21/25. An interview conducted with the Director of Nursing (DON) on 7/30/25 at 12:33 PM revealed she was out of the facility during the week of 4/07/25 through 4/10/25 and was not familiar with Resident #92's admission or discharge. She stated she had no knowledge of Resident #92 ever being sent out to the hospital or not allowed to return. When asked if she believed Nurse #3 or any of the other nursing staff would have spoken with EMS and refused to take Resident #92 back, she stated Nurse #1 only worked the 7:00 AM to 3:00 PM shift and was not at the facility when EMS transported Resident #92 back. She revealed all nursing staff were aware that only herself or the Administrator have the authority to admit or discharge a resident, and she did not believe that any of her nursing staff would make the decision to refuse to take a resident back or notify EMS the facility was refusing to take a resident back. The DON stated no resident should be refused to return back to the facility and Resident #92 should have been allowed to return until an alternative placement if needed could have been located. An interview conducted with the admission Coordinator on 7/30/25 at 1:10 PM revealed she had begun her position at the facility in May 2025 and was not familiar with Resident #92. An interview conducted with the Social Worker on 7/30/25 at 1:20 PM revealed she was not familiar with Resident #92 and was not aware of anyone from the facility refusing to allow a resident to return to the facility after a hospital stay. The SW stated she had never received a telephone call or voicemail from the hospital regarding Resident #92 and typically anytime she received a telephone call from the hospital about a resident discharge to the facility, she would typically transfer the call to the DON or Administrator. An interview conducted with Unit Manager (UM) #1 on 7/30/25 at 2:10 PM revealed she believed she was working on 4/09/25 from 7:00 AM to 7:00 PM. She stated she could not really recall Resident #92 specifically but did remember an incident with a female resident who was sitting at the nurse's desk and having combative behavior towards staff and trying to throw herself from her wheelchair into the floor. She revealed she believed the nurse working the day shift (could not recall which nurse) had informed the NP of the resident's behaviors and received an order for the resident to be sent out to the hospital. UM #1 stated to her knowledge the resident was sent out to the hospital for an evaluation. She revealed she was not aware of the resident ever returning to the facility and had no knowledge of any nursing staff refusing the resident to return to the facility or going outside and speaking with EMS. She stated that typically when it comes to resident admissions or discharges, the DON and Administrative staff were notified and they were the only ones that could authorize resident admissions and discharges. An interview conducted with Nurse #1 on 7/30/25 at 3:30 PM revealed she was working at the facility on 4/09/25 from 7:00 AM to 7:00 PM. She stated she did not recall Resident #92 and was not aware of her being sent out to the hospital or not being allowed to return. She revealed she would never tell anyone and was not aware of any other nursing staff that would tell anyone whether a resident was or was not allowed to return to the facility. Nurse #1 stated to her knowledge all decisions regarding resident admissions and discharges were always handled by the DON and the Administrative staff. An interview conducted with Nurse #4 on 7/30/25 at 3:35 PM revealed she was also working at the facility on 4/09/25 from 7:00 AM to 7:00 PM. She stated she could not recall Resident #92 or an incident of her being sent out to the hospital and not being allowed to return. She revealed she denied ever telling anyone and was not aware of any other nursing staff telling anyone whether a resident was or was not allowed to return to the facility. An interview conducted with the Administrator on 7/30/25 at 3:41 PM revealed he was not familiar with Resident #92. He stated he did not recall any incident where EMS had been turned away and a resident was not allowed to return to the facility after a hospital stay. He revealed himself and the DON were the only people at the facility with the authority to refuse to accept a resident back from the hospital. The Administrator stated his DON was out of the facility during that week and he did not recall speaking to anyone about Resident #92 or giving any of his staff the authority to refuse a resident to return to the facility. He revealed Resident #92 should have been allowed to return to their facility regardless of her behaviors until an alternative placement that could better serve her needs could have been arranged.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with new mental health diagnoses for 2 of 3 residents (Resident #37 and #6) reviewed for PASRR. The findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. PASRR level I was completed on 5/13/17 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #37 was diagnosed with delusional disorder on 7/11/17, impulsive disorder on 3/30/18, mood affective disorder on 3/30/18, and attention-deficit hyperactivity disorder on 7/05/18. No PASRR level II was completed. An interview on 7/30/25 at 1:20 PM with Social Worker (SW) revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II and their paperwork required them to be reviewed every 30 or 60 days, had a change in condition, or received a new mental health diagnosis. SW revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission. SW stated based on Resident #37's mental health diagnosis, a PASRR level II should have been completed. During an interview on 7/30/25 at 3:41 PM with the Administrator revealed PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. He stated based on Resident #37's mental health diagnosis, PASRR level II should have been completed. 2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] and PASRR level I was completed 7/08/25 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #6 was diagnosed with psychotic disorder on 7/11/25, anxiety disorder, and major depressive disorder on 7/11/25. No PASRR level II was completed. An interview on 7/30/25 at 1:20 PM with Social Worker (SW) revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II and their paperwork required them to be reviewed every 30 or 60 days, had a change in condition, or received a new mental health diagnosis. SW revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission. SW stated based on Resident #6's mental health diagnosis, a PASRR level II should have been completed. During an interview on 7/30/25 at 3:41 PM with the Administrator revealed PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. He stated based on Resident #6's mental health diagnosis, PASRR level II should have been completed

Based on observations, record review, and staff interviews, the facility failed to post cautionary signage outside of resident room that indicated the use of oxygen for 1 of 8 residents reviewed for respiratory care (Resident #95).Findings included: Resident #95 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia (low oxygen levels). A review of Resident #95's care plan created on 07/21/25 revealed a plan for oxygen therapy to relieve hypoxia due to COPD. The stated goal was that Resident #95 would be free from respiratory complications. Interventions included oxygen via nasal cannula as ordered, monitor for signs of respiratory distress and notify provider if indicated, and administer medications as ordered. Resident #95's physician orders revealed an order dated 07/22/25 for oxygen via nasal cannula as needed for shortness of breath at 2 liters per minute.Resident #95's admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #95 was cognitively intact, dependent on staff for all activities of daily living, and coded for COPD, respiratory failure, and oxygen use. An observation of Resident #95 in her room on 07/27/25 at 12:13 PM revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #95's room indicating oxygen in use.A second observation of Resident #95 in her room on 07/28/25 at 9:28 AM revealed the oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage outside of Resident #95's room indicating oxygen in use. A third observation of Resident #95 in her room on 07/28/25 at 3:40 PM revealed the oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage outside of Resident #95's room indicating oxygen in use. Nurse #1's interview on 07/28/25 at 3:48 PM revealed Resident #95 received oxygen continuously. Nurse #1 stated that she did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms. Nurse #1 indicated that she had not noticed that Resident #95 did not have an oxygen sign on door. An interview conducted with the Director of Nursing (DON) on 07/29/25 at 3:05 PM revealed the DON placed the concentrator into room and applied oxygen to Resident #95, but cautionary signage was overlooked. The DON indicated oxygen in use cautionary signage should be posted outside the doors of all residents' rooms that used oxygen.

Based on record review, and staff, Resident Representative, and Home Health Nurse interviews, the facility failed to include discharge instructions for a daily surgical wound dressing change for 1 of 3 sampled residents with wound care (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] and was discharged home on 5/18/25. Review of Resident #1's consultation records revealed an orthopedic consultation dated 5/16/25 with an order for daily dry dressing change to right hip. Resident #1's discharge Minimum Data Set assessment dated [DATE] revealed she was independent for decision making. Review of Resident #1's facility discharge instructions dated 5/18/25 for home care revealed no daily surgical wound dressing instructions. An interview on 6/24/25 at 9:56 AM with Resident #1's Representative revealed Resident #1 did not receive surgical wound care instructions when the resident was discharged from the facility on 05/18/25 until seen by Home Health on 05/21/25. An interview on 6/24/25 at 11:01 AM with the Director of Nursing (DON) revealed that Resident #1 had been transported to an outside orthopedic follow-up appointment on 5/15/25. The DON stated it was an oversight, and she had not entered the order for the resident to have daily dry dressing change to her right hip. An interview on 6/24/25 at 1:11 PM with Nurse #2 revealed she had discharged Resident #1 on 5/18/25. She stated she was not aware of the order for daily dressing change to right hip and had not told the resident or resident representative about the surgical dressing changes. An interview on 6/24/25 at 1:30 PM with the Home Health Nurse revealed she had seen and assessed Resident #1 on 5/21/25 in her home. She stated there were no instructions for the surgical wound dressing changes on the facility referral orders. She stated she had changed the right hip surgical dressing on 5/21/25 and there were no signs or symptoms of infection. She stated the wound had slight drainage and the staples were intact.

Based on record review, and staff, and orthopedic office Practice Manager interviews, the facility failed to provide care for a surgical wound as ordered by the consultant orthopedic physician for a daily surgical dressing for 1 of 3 sampled residents with wound care (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Hospital Discharge summary dated [DATE] revealed Resident #1 had diagnoses which included closed fracture of neck of right femur with routine healing. No surgical wound care instructions were noted on the hospital discharge summary. Review of facility orders revealed Resident #1 had a physician's order dated 5/08/25 to monitor the surgical dressing to right hip every shift and report any signs or symptoms of infection to physician every day and night shift for surgical wound care. Review of Resident #1's consultation records revealed an orthopedic consultation dated 5/16/25 with an order for daily dry dressing change to right hip. Review of facility orders revealed no order for daily dry dressing change to right hip. Review of the Treatment Administration Record (TAR) dated May 2025 revealed no record of a daily dry dressing for Resident #1. Resident #1's discharge Minimum Data Set assessment dated [DATE] revealed she was independent for decision making. An interview on 6/24/25 at 11:01 AM with the Director of Nursing (DON) revealed that Resident #1 had been transported to an outside orthopedic follow-up appointment on 5/15/25. She stated the consultation note was dated incorrectly and the resident had been seen on 5/15/25 instead of 5/16/25. She also stated she had been filling in as the unit manager on 5/15/25 and had been responsible for reviewing the orthopedic note and ensuring the orders were entered into the resident's electronic health record. The DON stated it was an oversight, and she had not entered the order for the resident to have daily dry dressing change to her right hip. An interview on 6/24/25 at 12:39 PM with Nurse #1 revealed she had been on duty and assigned to Resident #1 on 5/15/25 when she went for her orthopedic surgical follow up visit. She stated that she could not recall if she had received Resident #1's consultation paperwork when she returned to the facility. She stated she did not know why the surgical dressing change order was not entered in the resident's electronic health record. An interview on 6/24/25 at 1:11 PM with Nurse #2 revealed she had worked on 5/17/25 and been assigned to Resident #1. She was unaware of any orders for surgical wound dressing to be changed and had not changed the dressing. She also worked on 5/18/25 and had provided discharge instructions for Resident #1 on 5/18/25. She stated she was not aware of the order for daily dressing change to right hip and had not changed the dressing prior to discharge and had not told Resident #1 or Resident Representative about the daily dry dressing. An interview on 6/24/25 at 2:06 PM with the orthopedic office Practice Manager revealed it was normal practice for the surgical dressing to stay in place until the 1st post operative visit. He also stated that the surgeon noted no signs or symptoms of wound infection on her 5/15/25 visit. An interview on 6/24/25 at 2:21 PM with the Administrator revealed the facility staff should transcribe and follow physician's orders.

Based on record reviews and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) application was completed for a resident admitted with mental health diagnoses for 2 of 2 residents (Resident #12 and #55) reviewed for PASRR. The findings included: 1. Resident #12 was admitted to the facility on [DATE] with a diagnosis that included, in part, schizoaffective disorder. Review of Resident #12's medical record revealed the resident had a PASRR level I completed prior to her admission to the facility. The resident had a history of schizoaffective disorder and major depressive disorder as part of her admission. No PASRR level II had been completed per review of Resident #12's medical record. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired, and she had no mood or behaviors. The MDS was not coded for a level II PASRR. Resident #12's care plan dated 10/05/2023 revealed she was care planned for psychotropic medications, behavior related to schizoaffective disorder, anxiety disorders, and psychiatric services. Interventions included to administer medications as ordered, assure the resident that they were safe if they became distressed, continue psychiatric services as ordered, redirect resident to subjects that matter to her if behaviors occurred, and to take the resident to a quiet place if she became overstimulated. Review of Resident #12 medical record revealed she was followed by psychiatric services for medication management. During an interview on 05/08/2024 at 6:30 PM with the Admission Director, she revealed she received the resident's hospital information which included the PASRR number. She stated that the PASRR number was entered into the resident's chart and the Social Worker handled the PASRR process after that. An interview was conducted on 05/09/2024 at 10:38 AM with the Regional Discharge Planning Specialist. The Regional Discharge Planning Specialist stated that the facility had recently hired a Social Worker, but the position had been vacant for about one month. The Regional Discharge Planning Specialist further stated that a PASRR application should be completed upon a resident's admission with a serious mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. She also revealed that based on Resident #12's admission diagnoses of schizoaffective disorder and major depression, paperwork for a PASRR level II referral should have been completed. Unsuccessful attempts were made to contact the previous Social Worker. An interview was conducted on 05/09/24 at 11:00 AM with the Administrator. The Administrator revealed a PASRR application should be completed for any resident with a serious mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated that based on Resident #12's diagnoses of schizoaffective disorder and major depressive disorder, a PASRR level II referral should have been completed. 2. Resident #55 was admitted on [DATE] with diagnoses that included, in part, post-traumatic stress disorder (PTSD), major depressive disorder (MDD), anxiety disorder, and suicidal ideations. Review of Resident #55's medical record revealed the resident had a PASRR level I completed prior to his admission to the facility. The resident had a history of post-traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and suicidal ideations upon admission to the facility. No PASRR level II had been completed per review of Resident #55's medical record. Review of the quarterly Minimum Data Set (MDS) dated [DATE] reveal Resident #55 had intact cognition. The MDS also revealed Resident #55 had no mood or behaviors for the 7-day look back period. The MDS was not coded for a level II PASRR. Review of Resident 55's care plan dated 01/26/2024 revealed he had a risk for behaviors related to depressive disorder, anxiety, and use of psychotropic medications. Interventions included to administer medications as ordered, assure the resident that they were safe if they became distressed, continue psychiatric services as ordered, redirect resident to subjects that matter to him if behaviors occurred, and to take the resident to a quiet place if he became overstimulated. Resident #55 received psychiatric services for medication management beginning 01/29/2024 and continued on psychiatric service case load during his stay at the facility. An interview was conducted with Resident #55 on 05/06/2024 at 2:34 PM. Resident #55 stated that he had mental health issues for quite a long while. He also revealed that he served in the military and most of his mental health issue resulted from his military service. He stated that he had been doing much better since being admitted to the facility and seeing the psychiatrist. During an interview on 05/08/2024 at 6:30 PM with the Admission Director, she revealed she received the resident's hospital information which included the PASRR number. She stated that the PASRR number was entered into the resident's chart and the Social Worker handled the PASRR process after that. An interview was conducted on 05/09/2024 at 10:38 AM with the Regional Discharge Planning Specialist. The Regional Discharge Planning Specialist stated that the facility had recently hired a Social Worker, but the position had been vacant for about one month. The Regional Discharge Planning Specialist further stated that a PASRR application should be completed upon a resident's admission with a serious mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. She also revealed that based on Resident #55's admission diagnoses of PTSD, MDD, anxiety disorder and suicidal ideations, paperwork for a PASRR level II referral should have been completed. Unsuccessful attempts to contact the previous Social Worker were made. An interview was conducted on 05/09/24 at 11:00 AM with the Administrator. The Administrator revealed a PASRR application should be completed for any resident with a serious mental health diagnosis or anytime a resident had a change of condition or a newly added mental health diagnosis. He stated that based on Resident #55's diagnoses of PTSD, MDD, anxiety disorder and suicidal ideations, a PASRR level II referral should have been completed.

Based on record review, family, staff, Nurse Practitioner (NP), Physician's Assistant (PA), and physician (MD) interviews, the facility failed to communicate with Resident #1's Medical Provider about intermittent loose stools following an order for polyethylene glycol (a medication used to treat occasional constipation and soften stool) with a history of Clostridium difficile (a bacterial infection in the colon which have symptoms that range from diarrhea to life-threatening damage to the colon), also known as C-difficile. The facility failed to notify the medical provider of an abnormal stool culture for a resident with C-difficile. The facility failed to notify the medical provider of acute changes in condition consisting of multiple loose stools, increased confusion, disorientation, and new behavior of attempting to climb out of bed on [DATE], and low blood pressure that were not at her baseline. Resident #1 was sent to the emergency room and was diagnosed with sepsis (a life-threatening complication of a current infection), hypothermia, and type 2 myocardial infarction (heart attack). Resident #1 expired on [DATE]. This deficient practice affected 1 of 2 residents reviewed for physician notification. The immediate jeopardy began on [DATE] when Resident #1's physician was not notified of acute changes in the resident's condition. The 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 to ensure the completion of education and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included status post cystitis without hematuria (bladder inflammation without blood present in the urine) and surgical intervention of calculus of the bile duct with chronic cholecystitis without obstruction (gallstones) and abdominal hernia without obstruction or gangrene and a history of C-Difficile colitis. A hospital discharge summary dated [DATE] indicated Resident #1 presented to the emergency room (ER) with abdominal pain and vomiting which required abdominal surgery for the gallstones. A physician's order dated [DATE] indicated Amoxicillin/Clavulanate ,d+[DATE] milligrams (mg) (antibiotic used to treat infection) three times per day for 3 days for cystitis. Additionally, Lisinopril (ace-inhibitor used to treat heart failure and blood pressure)10mg daily by mouth was ordered for hypertension. A one-day post admission progress note dated [DATE] written by the NP indicated Resident #1 was admitted to the facility after being hospitalized from [DATE] through [DATE] status post endoscopic retrograde cholangiopancreatography (a procedure using a scope to diagnose and treat problems of the biliary or pancreatic system) on [DATE] and cholecystitis with choledocholithiasis (gallstones), incarcerated hiatal hernia (part of intestine trapped in the sac of a hernia which can become life threatening if untreated) on [DATE]. The note indicated Resident #1 was to receive Amoxicillin/ Clavulanate ,d+[DATE] mg by mouth three times per day from [DATE] through [DATE]. The note also indicated she was positive for constipation as she was pushing and straining to have a bowel movement last night ([DATE]) with her abdomen soft, non-tender, and without hepatospleenomegaly (liver and spleen enlargement). The note also revealed Resident #1 had hospital labs on [DATE] which indicated the following values: slightly elevated white blood cells (WBC) 12.07 and a normal creatinine (test used to monitor kidney function) level of 0.9. The assessment listed the following: negative for behaviors, no gastrointestinal (GI) upset with ability to tolerate foods and liquids, and hypertension with systolic blood pressures ranging between 120's to 140's on treatment of Lisinopril daily and monitor blood pressure daily. A physician's order dated [DATE] indicated Loperamide 2 mg (medication used to treat loose stools) tablet after each loose stool as needed for diarrhea x 1 day. A review of the nurses' progress notes for [DATE] revealed nothing related to loose stools or contacting the Medical Provider to obtain an order for Loperamide. A review of the Medication Administration Record (MAR) dated [DATE] revealed Nurse #6 administered Resident #1 a single dose of Loperamide on [DATE]. Attempts to contact Nurse #6 were unsuccessful. A skilled progress note written by Nurse #7 dated [DATE] at 4:23 PM indicated Resident #1 complained of loose stool after lunch. The note did not indicate Nurse #7 notified the Medical Provider of Resident #1's loose stools. A review of the MAR dated [DATE] indicated Nurse #7 administered Resident #1 a single dose of Loperamide on [DATE]. An interview on [DATE] at 10:00 AM with Nurse #7 revealed she could not recall Resident #1 as she was moved to the South Unit shortly after admission and Nurse #7 had no further involvement with her care. She could not recall notifying the Medical Provider of the loose stools. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident #1 received Loperamide 2mg on [DATE] at 10:29 AM and again on [DATE] at 5:14 PM. A provider progress note was written by the NP on [DATE] indicated Resident #1 was seen for a 3-day post admission visit. The note indicated Resident #1 was not feeling well and had complained to her (the NP) that she began to experience loose stools over the weekend, and she had already experienced 3 diarrhea/ water stools that day prior to the visit. Resident #1 complained of abdominal pain but no nausea or vomiting. Resident #1 felt bloated with indigestion. The note indicated Resident #1 had reported to the NP about her history of C-Difficile on [DATE]. The note further indicated orders were provided to obtain a stool specimen to test for C-Difficile and discontinue Loperamide that was administered over the weekend. A physician order dated [DATE] indicated obtain stool specimen to test for C-Difficile. A laboratory report dated [DATE] indicated Resident #1 was positive for C -difficile colitis. A progress note written by the NP on [DATE] for a 5-day post admission visit. The note indicated Resident #1 continued to complain of diarrhea, abdominal pain, and indigestion. C-Difficile culture continued to be pending at the time of the visit. Resident #1 is currently not able to eat well, continued to have a soft, non-tender abdomen with hyperactive bowel sounds and negative for bladder distention. The note indicated Resident #1 had experienced 6 watery stools that day prior to the visit. The note further indicated new orders were received to start Cholestyramine 1 packet by mouth daily (used off label for bile acid diarrhea) and continue to monitor Resident #1's condition pending C-Difficile laboratory results. The note further indicated Resident #1 had blood pressure of ,d+[DATE] and to continue the Lisinopril as ordered. A nurse progress note written by the Unit Manager dated [DATE] indicated she spoke with the family member regarding Resident #1's abnormal lab results and testing positive for C-Difficile colitis and antibiotic therapy would be initiated. A physician's order dated [DATE] indicated Cholestyramine Light Oral Packet 4 grams (GM) give one packet by mouth one time a day related to diarrhea. A physician's order dated [DATE] indicated Vancomycin (antibiotic) 125 milligrams give one tablet four times a day for C-difficile. The order was discontinued on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact. An Admission History and Physical (H&P) written by the MD dated [DATE] indicated Resident #1 was positive for diarrhea, negative for confusion, and negative for dysuria or bladder distension. It also revealed Resident #1's abdomen was soft, non-tender, and no guarding or rebound present with normal cognition with good memory recall both recent and remote. The note stated Resident #1 had a laboratory test on [DATE] which was positive for C-Difficile. A laboratory report dated [DATE] indicated Resident #1's white blood cell (test to determine immune ability to fight infection) count was elevated to 26.7 (normal being 4.1 to 10.9), Creatinine (test for kidney function) was normal at 1.16 (normal being 0.5 to 1.20) and C-reactive protein was 28.70 (test for inflammation in the body- normal being less than 0.50). This report indicated it was reviewed by the Nurse Practitioner on [DATE] at 10:31 AM. A provider progress note written by the NP dated [DATE] indicated Resident #1 had been placed on quarantine for C-Difficile and continued to have watery stools, abdominal pain, and now nausea was present. Laboratory results were reviewed with the following noted: elevated WBC of 26.7, low calcium at 8, elevated BUN 21.1, normal creatinine at 1.16, low sodium at 132, and a high CRP of 28.7. At this visit, Resident #1 was positive for weakness and fatigue, decrease strength and mobility, and negative for confusion or bladder distension. Resident #1's plan of care listed included the following: Start intravenous (IV) fluids (Normal Saline 60 cubic centimeters (cc) per hour for 48 hours) secondary to a low sodium level. Repeat CBC and CMP on Monday ([DATE]) to compare trends. Resident was previously prescribed Vancomycin orally, but secondary to high WBC she was switched to Flagyl 500mg IV every 6 hours x 7 days. Discontinue Vancomycin once Flagyl had started. At this visit, Resident #1's blood pressures were reviewed to be between 120's and 140's systolic and staff were to administer Lisinopril as ordered. A physician's order dated [DATE] indicated Sodium Chloride 0.45% intravenous. Give 60 (ml) milliliters per hour for 3 days for dehydration, acute kidney injury and C-Difficile. The order was discontinued on [DATE]. A physician's order dated [DATE] indicated Flagyl (antibiotic) 500 mg per 100 (ml). Provide 500 mg (IV) intravenously every six hours for Enterocolitis (fecal bacteria) due to C-difficile for 7 days. A laboratory report dated [DATE] indicated Resident #1's white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. These lab reports indicated they were reviewed by both the PA and NP on [DATE] at 9:47 AM and 8:37 PM. A provider progress note written by the NP dated [DATE] indicated Resident #1 was seen for a 14-day post admission visit. The note indicated during this visit Resident #1 remained on IV fluids which completed [DATE] and Flagyl via midline IV and reported the diarrhea was uncontrollable. A review of the laboratory results dated [DATE] listed the following values: white blood cell count was normal at 9.0, C-reactive protein (a protein produced by the liver) remained elevated at 15.8 and Creatinine was normal at 0.90. The plan of care included the following: Continue Flagyl until completed and addressed a significant improvement in Resident #1's laboratory results with a normal WBC and improving BUN, Creatinine, and sodium levels. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued on Lisinopril for treatment. No new orders were given on this visit. A provider progress note written by the NP dated [DATE] indicated Resident #1 had a slight improvement but continued to have diarrhea with staff reports of decrease odorous stools. New orders included: extend the Flagyl IV for a total of 10 days. A physician's order dated [DATE] indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for an additional 3 days. A physician's order dated [DATE] indicated Flagyl 500 mg by mouth twice daily for C-difficile. The order was discontinued on [DATE]. A surgeon's consultation form dated [DATE] indicated Resident #1 was seen for a follow up with constipation and new orders were given for polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A nurse progress note written by Nurse #4 dated [DATE] indicated Resident #1 was seen for a surgical consult and new orders to advance diet and give polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. The note did not indicate Nurse #4 notified the Medical Provider of the new order or ongoing loose stools following antibiotic therapy. An interview with Nurse #4 on [DATE] at 9:00 AM revealed she could not recall the order provided by the surgical consult but entered as previously educated from the surgical consultation communication form. Nurse #4 did not question the order because the antibiotic treatment for C-Difficile was completed. Nurse #4 also could not recall if she notified the Medical Provider of the new order or that Resident #1 continued to have loose stools following antibiotic therapy. A physician's order dated [DATE] indicated polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A provider note written by the NP dated [DATE] indicated Resident #1 was seen for a 21-day post admission visit. The noted reflected Resident #1 had improved with GI symptoms but continued with on and off diarrhea mixed with some semi-formed stools. The note indicated Resident #1's had completed her IV antibiotics. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued Lisinopril for treatment. No new orders were given on this visit. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident #1 received the following: - Amoxicillin/Clavulanate ,d+[DATE] mg one tablet every 8 hours for 3 days ([DATE] through [DATE] for a total 8 doses) - Lisinopril 10 mg daily ([DATE] through [DATE] except [DATE], [DATE], and [DATE] because BP was outside of the parameters) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (,d+[DATE] through ,d+[DATE]) - Vancomycin 125 milligrams give one tablet. Four times a day for C difficile (,d+[DATE] and ,d+[DATE]) - Sodium chloride intravenous solution 0.4%. Used 60 milliliters per hour intravenously every shift for acute kidney injury, dehydration, and C difficile times three days (,d+[DATE] through ,d+[DATE]) - Flagyl 500 milligrams per 10ML. Provide 500 milligrams intravenously every six hours for Enterocolitis due to C difficile ([DATE] x 2 doses, [DATE]-[DATE] x 4 doses, and [DATE] x 1 dose) - Flagyl 500 mg by mouth twice daily for C difficile ([DATE] x 2 doses) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation ([DATE]-[DATE]) A nurse progress note written by Nurse #5 dated [DATE] indicated Resident #1 was noted to have yellow liquid jelly like stool. The note also indicated Resident #1 had recently stopped IV antibiotics for C-difficile and a stool sample had been collected. The note did not indicate that a Medical Provider was contacted about the ongoing loose stools or that the order had been obtained from the Medical Provider for the stool culture. A review of the daily nurse assignment sheets indicated Nurse #5 was being oriented by Nurse #1 on [DATE]. Nurse #5 was unavailable for interview. An interview on [DATE] at 11:30 AM with Nurse #1 revealed she had been the primary day shift nurse (7:00 AM to 7:00 PM) on the South Unit on [DATE] where Resident #1 resided. Nurse #1 indicated she recalled Resident #1 was positive for C difficile and had been transferred to her unit last month due to requirements of isolation for the infection. Nurse #1 stated Resident #1 was, at baseline, alert and oriented x 4 (person, place, time and event), incontinent of bowel and bladder and had frequent loose stools containing a mucus while on her unit. Nurse #1 said that she recalled Resident #1 continued to have loose stools after being taken off precautions and therefore on [DATE], she placed a note in the medical provider's binder to alert them of the ongoing loose stools so they would provide an order for the laboratory test for C-Difficile but did not contact a Medical Provider in person or via telephone. Nurse #1 explained she obtained a stool sample at that time and sent it to the laboratory to test for C-Difficile. Attempts were made to interview Nurse #8 who worked [DATE] (7:00 PM- 7:00 AM) without success. Nurse Aide documentation dated [DATE] reflected Resident #1 had four loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1's orientation (ability to recall person, place, time, and event) changed throughout the day and had semi formed stools on day shift. The note did not reflect the Medical Provider was notified of the ongoing loose stools or Resident #1's orientation changes. An interview with Nurse #4 on [DATE] at 9:00 AM revealed worked day shift on [DATE] and she could not recall the resident other than what was charted regarding orientation changes. She recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. An interview on [DATE] at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and documented on the following days in [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. NA#1 indicated she could not recall any specific day, but Resident #1 was normally alert and oriented, able to make her needs known, incontinent of bowel and bladder with multiple loose stools which frequently contained mucous the entire time she had been on the South Unit. NA #1 stated she made Nurse #1 aware of the ongoing loose stools. An interview with Nurse Aide #2 (NA #2) on [DATE] at 11:55 AM revealed that she worked on the South unit on night shift and documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she made the nurse aware of loose stools but could not recall the names of each nurse daily. An interview with Nurse Aide #3 (NA #3) on [DATE] at 1:45 PM revealed she worked on the South unit where Resident #1 resided and documented on night shift on the following dates in [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. NA #3 stated Resident #1 diarrhea and mucous like stools on each shift she worked and had alerted the nurse on duty each shift but could not recall the names of all nurses she alerted. A laboratory report dated [DATE] indicated Resident #1 was positive for C difficile. The report reflected the laboratory notified the facility of the abnormal lab and spoke with Nurse #2 on [DATE] at 9:34 PM. The report indicated it was reviewed by the Physician's Assistant on [DATE] at 1:18 PM. It however did not indicate a provider was notified of the abnormality on [DATE] when the laboratory notified Nurse #2 of the critical results. A review of Resident #1's medical record revealed she was not seen by a facility Medical Provider after the abnormal C. difficile result. Attempts were made to interview Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review of the nurses' progress notes indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. An interview with the PA on [DATE] at 11:20 AM revealed she was not familiar with Resident #1 and had not provided her with any direct care. The PA stated because a resident can test positive for C-Difficile for up to 90 days she would not have treated her with Resident #1 experiencing ongoing intermittent loose stools. A review of Resident #1's medical record revealed the last time she was seen by a medical provider was on [DATE] and there were no physician orders for the treatment of C-Difficile colitis after the positive test results were received. An interview with the Nurse Practitioner (NP) on [DATE] at 3:24 PM and 4:02 PM revealed she was familiar with Resident #1 and recalled her to be alert and oriented x 4 (accurately aware of person, place, time and event). The NP stated shortly after her admission she began having loose stools and she ordered a laboratory test for C-Difficile which resulted as positive, and treatment was ordered at the time. The NP indicated the treatment was for Vancomycin oral and Flagyl both IV and oral. The NP recalled Resident #1 continuing to have loose stools but thought another provider had placed her on treatment following the second positive stool culture and therefore did not order any further treatment. The NP could not recall anything other than thinking another provider had handled the 2nd C-Diff lab nor being aware of orientation changes noted on [DATE]. An interview with the Physician (MD) on [DATE] at 4:08 PM revealed he was aware Resident #1 had been treated for C-Difficile shortly after her admission; however, he had not been made aware of the abnormal laboratory results on [DATE] and did not prescribe treatment for the ongoing loose stools. The MD stated the ongoing loose stools could have been exacerbated from the Polyethylene glycol prescribed by the surgeon at Resident #1's follow-up appointment on [DATE]. He acknowledged the only visit he had with Resident #1 was on [DATE]. He did not recall any further updates to Resident #1's condition. The MD indicated he would expect the lab to be reviewed by the PA and proper monitoring or interventions to be placed. A nurse's progress note dated [DATE] indicated Resident #1 had semi formed stools on day shift. The note did not indicate a Medical Provider was notified of the stools. Nurse Aide documentation dated [DATE] reflected Resident #1 had seven loose/diarrhea stools. A review of the MAR dated [DATE] indicated Resident #1 received the following: - Lisinopril 10mg daily ([DATE] through [DATE]) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day ([DATE]) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea ([DATE] through [DATE]) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth one time a day related to Constipation ([DATE], [DATE], [DATE]) A nurse progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented with a blood pressure of ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with diarrhea. The note indicated MD was aware and staff should continue to monitor. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented and her BP was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had loose stools during day shift and Polyethylene glycol was held due to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. Nurse Aide documentation dated [DATE] reflected Resident #1 had eight loose/diarrhea stools. A late entry nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools. Nurse Aide documentation dated [DATE] reflected Resident #1 had thirteen loose/diarrhea stools. An interview on [DATE] at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and was on duty on the following days in [DATE]: [DATE] and [DATE]. NA #1 indicated she had made the hall nurse on duty aware of the ongoing loose stools each shift although she could not recall the names of each nurse daily. A nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools. Nurse Aide documentation dated [DATE] reflected Resident #1 had one loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated [DATE] did not indicate Resident #1's cognitive status Her blood pressure was listed as ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools or that Resident #1 had experienced a low blood pressure. An interview with Nurse #4 on [DATE] at 9:00 AM revealed she could not recall the resident other than what was charted regarding orientation changes or low blood pressure. She recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #2 dated [DATE] indicated on night shift (,d+[DATE] at 7:00 PM through ,d+[DATE] at 7:00 AM) Resident #1 was alert and oriented and able to make needs known. Resident#1 had a blood pressure of ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during night shift. The note indicated Loperamide was administered without any favorable effects. The note did not indicate a Medical Provider was notified of the loose stools or that Loperamide had to be administered. Attempts to interview Nurse #2 were unsuccessful. A nurse's Progress note written by Nurse #1 dated [DATE] indicated Resident #1's Polyethylene glycol was held secondary to loose stools on day shift. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A nurse progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A review of Resident #1's medical record revealed no progress notes written by Nurse #3 on [DATE]. A telephone interview with Nurse #3 on [DATE] at 9:38 AM revealed she acknowledged she worked the South unit on [DATE] on night shift but could not recall Resident #1 to include any stools or behaviors on [DATE] due to her working all the units and her working on an as needed basis only. She could not recall notifying the Medical Provider of Resident #1's loose stools, change in cognition, or behaviors. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. An interview with Nurse Aide #2 (NA #2) on [DATE] at 11:55 AM revealed that she worked on the South unit on night shift and documented on the following dates in [DATE]: [DATE], [DATE], [DATE], and [DATE]. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she was aware Resident #1 had C-Difficile and therefore alerted Nurse #2 of the resident having loose stools but did not alert the nurse with each loose stool because they were aware of them. An interview with Nurse Aide #3 (NA #3) on [DATE] at 1:45 PM revealed she worked on the South unit where Resident #1 resided on night shift on [DATE]. NA #3 stated on the night of [DATE], Resident #1 was more confused than normal. She indicated during her shift, Resident #1 continued to have mucous stools but did not ring her light to be changed as she normally would, was disoriented and trying to climb out of bed. NA #3 said she told Nurse #2. Attempts were made to contact Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. Attempts to interview Nurse #2 were unsuccessful. Nurse Aide documentation dated [DATE] reflected Resident #1 eight had loose/diarrhea stools. A nurse's Progress note written by Nurse #1 dated [DATE] at 2:30 PM indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A late entry nurse progress note written by Nurse #1 on [DATE] at 3:19 PM indicated on [DATE] at approximately 3:30 PM, Nurse #1 was informed that Resident #1 had a low blood pressure and appeared confused. The note indicated Nurse #1 assessed Resident #1's blood pressure manually and found the value to be at baseline for the patient at ,d+[DATE]. Confusion noted also to be at baseline. The note did not indicate a Medical Provider was notified of Resident #1's low blood pressure, lethargy, confusion, behaviors, her inability to take her morning medications, or ongoing loose stools. An interview on [DATE] at 1:00 PM with Physical Therapy Assistant #1 revealed he was assigned to Resident #1's therapy treatment for physical therapy on [DATE]. PTA #1 indicated when he entered the room between 3:00 and 4:00 PM, he noticed Resident #1 was not herself as she had previously had a very social based personality when he had worked with her a couple of weeks prior. PTA #1 indicated on this date, Resident #1 appeared more lethargic and confused. PTA #1 stated he made attempts to sit Resident #1 on the edge of the bed thinking she would arouse to her normal self with stimulation. He indicated he alerted Certified Occupational Therapy Assistant (COTA #1) who was nearby and asked him to look at obvious concerns of Resident #1's change from the previous time he had worked with her. He indicated that COTA #1 entered the room and agreed that Resident #1 was not at her baseline as he routinely provided therapy for her. During this discussion between PTA #1 and COTA #1, Nurse #1 entered the room to give Resident #1 her medications. He said he mentioned to Nurse #1 that Resident #1 was acting different, but the nurse did not respond to his statement. PTA #1 stated when medications were administered by Nurse #1, Resident #1 spit the medications out, the nurse collected the pills, and the nurse left

Based on record review and family, staff, Nurse Practitioner (NP), Physician Assistant (PA), and physician (MD) interviews, the facility failed to complete comprehensive assessments and determine the need for medical interventions for a resident who continued to experience loose stools post antibiotic treatment for Clostridium Difficile (C-Difficile) which ended on [DATE]. (C-difficile is a bacterium that causes an infection of the colon. Symptoms can range from diarrhea to life-threatening damage to the colon.). The afternoon of [DATE] the resident had a significant change in condition including increased lethargy and confusion, low blood pressure, spitting out her pills and hollering out. There was no comprehensive assessment completed to determine if there was the need to seek medical attention. Staff did not recognize the significant change in condition until late in the evening on [DATE] and the resident was sent to the hospital for an evaluation. Hospital records dated [DATE] indicated the resident was diagnosed with sepsis with acute organ dysfunction, acute encephalopathy secondary to infectious process, hypothermia, and type 2 myocardial infarction (heart attack). The resident expired on [DATE]. This deficient practice occurred for 1 of 2 residents reviewed for quality of care/providing care according to professsional standards (Resident #1). The immediate jeopardy began on [DATE] when the facility failed to effectively respond to and seek medical attention when Resident #1 had a significant change in condition. The 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 to ensure the completion of education and monitoring systems put into place are effective. This deficient practice occurred for 1 of 2 residents reviewed for quality of care. The findings included: A hospital discharge summary dated [DATE] indicated Resident #1 presented to the emergency room (ER) with abdominal pain and vomiting which required abdominal surgery for the gallstones. The discharge summary reflected Resident #1 received intravenous (IV) antibiotics for chronic leukocytosis (high white blood cell count) (WBC 11.41) and cholecystitis (inflammation of the gall bladder) which was corrected with the cholecystectomy (surgical removal of the gallbladder). It also listed cystitis without hematuria as resolved and orders for Amoxicillin-Clavulanate (antibiotic) ,d+[DATE] milligrams (mg) 1 tablet by mouth every 8 hours for 3 days. Resident #1 was admitted to the facility on [DATE] with diagnoses that included status post cystitis without hematuria (bladder inflammation without blood present in the urine) and surgical intervention of calculus of the bile duct with chronic cholecystitis without obstruction (gallstones) and abdominal hernia without obstruction or gangrene and hypertension. A physician's order dated [DATE] indicated Amoxicillin ,d+[DATE] milligrams (mg) three times per day for 3 days for cystitis. Additionally, Lisinopril 10mg daily by mouth was ordered for hypertension. A one-day post admission progress note dated [DATE] written by the NP indicated Resident #1 was admitted to the facility after being hospitalized from [DATE] through [DATE] status post endoscopic retrograde cholangiopancreatography (a procedure using a scope to diagnose and treat problems of the biliary or pancreatic system) on [DATE] and cholecystitis with choledocholithiasis (gallstones), incarcerated hiatal hernia (part of intestine trapped in the sac of a hernia which can become life threatening if untreated) on [DATE]. The note indicated Resident #1 was to receive Amoxicillin ,d+[DATE] by mouth three times per day from [DATE] through [DATE]. The note also indicated she was positive for constipation as she was pushing and straining to have a bowel movement last night ([DATE]) with her abdomen soft, non-tender, and without hepatospleenomegaly. The note also revealed Resident #1 had hospital labs on [DATE] which indicated the following values: slightly elevated white blood cells (WBC) 12.07 and a normal creatinine level of 0.9. The assessment listed the following: negative for behaviors, no gastrointestinal (GI) upset with ability to tolerate foods and liquids, and hypertension with systolic blood pressures ranging between 120's to 140's on treatment of Lisinopril daily and monitor blood pressure daily. A physician's order dated [DATE] indicated Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day. A review of the nurses' progress notes for [DATE] revealed nothing related to loose stools. A skilled progress note written by Nurse #7 dated [DATE] at 4:23 PM indicated Resident #1 complained of loose stool after lunch. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident #1 received Loperamide 2mg on [DATE] at 10:29 AM by Nurse #6 and again on [DATE] at 5:14 PM by Nurse #7. Attempts to contact Nurse #6 were unsuccessful. An interview on [DATE] at 10:00 AM with Nurse #7 revealed she could not recall Resident #1 as she was moved to the South Unit shortly after admission and Nurse #7 had no further involvement with her care. A provider progress note written by the NP on [DATE] indicated Resident #1 was seen for a 3-day post admission visit. The note indicated Resident #1 was not feeling well and had complained that loose stools began over the weekend, and she had already experienced 3 diarrhea water stools that day. Resident #1 complained of abdominal pain but no nausea or vomiting. Resident #1 felt bloated with indigestion. The note indicated Resident #1 had reported a history of C-Difficile on [DATE]. Orders were provided to obtain a stool specimen to test for C-Difficile and discontinue Loperamide that was administered over the weekend. A physician order dated [DATE] indicated obtain stool specimen to test for C-Difficile. A laboratory report dated [DATE] indicated Resident #1 was positive for C -difficile colitis. A progress note was written by the NP on [DATE] for a 5-day post admission visit. The note indicated Resident #1 continued to complain of diarrhea, abdominal pain, and indigestion. C-Difficile culture continued to be pending at the time of the visit. Resident #1 is currently not able to eat well. Continues to have a soft, non-tender abdomen with hyperactive bowels sounds and negative for bladder distention. The note indicated Resident #1 had experienced 6 watery stools the day prior to the visit. New orders were received to start Cholestyramine 1 packet orally daily and continue to monitor Resident #1's condition pending C-Difficile laboratory results. The note further indicated Resident #1 had blood pressure of ,d+[DATE] and to continue the Lisinopril as ordered. A nurse progress note written by the Unit Manager dated [DATE] indicated she spoke with the family member regarding Resident #1's abnormal lab results and testing positive for C-Difficile colitis and antibiotic therapy would be initiated. A physician's order dated [DATE] indicated Cholestyramine (used for bile acid diarrhea) Light Oral Packet 4 grams (GM) give one packet by mouth one time a day related to diarrhea. A physician's order dated [DATE] indicated Vancomycin (antibiotic) 125 milligrams give one tablet four times a day for C-difficile. The order was discontinued on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and no behaviors were noted. An Admission History and Physical (H&P) written by the MD dated [DATE] indicated Resident #1 was positive for diarrhea, negative for confusion, and negative for dysuria or bladder distension. It also revealed Resident #1's abdomen was soft, non-tender, and no guarding or rebound present with normal cognition with good memory recall both recent and remote. The note stated Resident #1 had a laboratory test on [DATE] which was positive for C-Difficile. A laboratory report dated [DATE] indicated Resident #1's white blood cell (test to determine immune ability to fight infection) count was elevated to 26.7 (normal being 4.1 to 10.9), Creatinine (test for kidney function) was normal at 1.16 (normal being 0.5 to 1.20) and C-reactive protein was 28.70 (test for inflammation in the body- normal being less than 0.50). A provider progress note written by the NP dated [DATE] indicated Resident #1 had been placed on quarantine for C-Difficile and continued to have watery stools, abdominal pain, and now nausea. Laboratory results were reviewed with the following noted: elevated WBC of 26.7, low calcium at 8, elevated BUN 21.1, normal creatinine at 1.16, low sodium at 132, and a high CRP of 28.7. At this visit, Resident #1 was positive for weakness and fatigue, decrease strength and mobility, and negative for confusion or bladder distension. Resident #1's plan of care listed included the following: Start IV fluids (Normal Saline 60 cubic centimeters (cc) per hour for 48 hours) secondary to a low sodium level. Repeat CBC and CMP on Monday ([DATE]) to compare for trends. Resident was previously prescribed Vancomycin, but secondary to high WBC she was switched to Flagyl 500mg every 6 hours x 7 days. Discontinue Vancomycin once Flagyl has started. At this visit, Resident #1's blood pressures were reviewed to be between 120's and 140's systolic and continued on Lisinopril. A physician's order dated [DATE] indicated Sodium Chloride 0.45% intravenous. Give 60 milliliters per hour for 3 days for dehydration, acute kidney injury and C-Difficile. The order was discontinued on [DATE]. A physician's order dated [DATE] indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for 7 days. A laboratory report dated [DATE] indicated Resident #1's white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. A provider progress note written by the NP dated [DATE] indicated Resident #1 was seen for a 14-day post admission visit. The note indicated during this visit Resident #1 remained on IV fluids which completed [DATE] and Flagyl via midline IV and reported the diarrhea was uncontrollable. A review of the laboratory results dated [DATE] listed the following values: white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. The plan of care included the following: Continue Flagyl until completed and addressed a significant improvement in Resident #1's laboratory results with a normal WBC and improving BUN, Creatinine, and sodium levels. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued on Lisinopril for treatment. No new orders were given on this visit. A provider progress note written by the NP dated [DATE] indicated Resident #1 had a slight improvement but continued to have diarrhea with staff reports of decrease odorous stools. New orders included: extend the Flagyl IV for a total of 10 days. A physician's order dated [DATE] indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for an additional 3 days. A physician's order dated [DATE] indicated Flagyl 500 mg by mouth twice daily for C-difficile. The order was discontinued on [DATE]. A surgeon's consultation form dated [DATE] indicated Resident #1 was seen for a follow up with constipation and new orders were given for polyethylene glycol 17 grams per scoop, a laxative used to treat occasional constipation and soften stool. Give one scoop by mouth once a day related to constipation. A nurse progress note written by Nurse #4 dated [DATE] indicated Resident #1 was seen for a surgical consult and new orders to advance diet and give polyethylene glycol 17 grams per scoop, a laxative used to treat occasional constipation and soften stool. Give one scoop by mouth once a day related to constipation. An interview with Nurse #4 on [DATE] at 9:00 AM revealed she could not recall the order provided by the surgical consult but entered as previously educated from the surgical consultation communication form. Nurse #4 did not question the order because the antibiotic treatment for C-Difficile was completed. A physician's order dated [DATE] indicated polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A provider note written by the NP dated [DATE] indicated Resident #1 was seen for a 21-day post admission visit. The noted reflected Resident #1 had improved with GI symptoms but continued with on and off diarrhea mixed with some semi-formed stools. The note indicated Resident #1's had completed her IV antibiotics. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued Lisinopril for treatment. No new orders were given on this visit. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident #1 received the following: - Amoxicillin/Clavulanate ,d+[DATE] mg one tablet every 8 hours for 3 days ([DATE] through [DATE] for a total 8 doses) - Lisinopril 10 mg daily ([DATE] through [DATE] except [DATE], [DATE], and [DATE] because BP was outside of the parameters) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day ([DATE] and [DATE]) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (,d+[DATE] through ,d+[DATE]) - Vancomycin 125 milligrams give one tablet. Four times a day for C difficile (,d+[DATE] and ,d+[DATE]) - Sodium chloride intravenous solution 0.4%. Used 60 milliliters per hour intravenously every shift for acute kidney injury, dehydration, and C difficile times three days (,d+[DATE] through ,d+[DATE]) - Flagyl 500 milligrams per 10ML. Provide 500 milligrams intravenously every six hours for Enterocolitis due to C difficile ([DATE] x 2 doses, [DATE]-[DATE] x 4 doses, and [DATE] x 1 dose) - Flagyl 500 mg by mouth twice daily for C difficile ([DATE] x 2 doses) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation ([DATE]-[DATE]) A nurse progress note written by Nurse #5 dated [DATE] indicated Resident #1 was noted to have yellow liquid jelly like stool. The note also indicated Resident #1 had recently stopped IV antibiotics for C-difficile and a stool sample had been collected. A review of the daily nurse assignment sheets indicated Nurse #5 was being oriented by Nurse #1 on [DATE]. Nurse #5 was unavailable for interview. An interview on [DATE] at 11:30 AM with Nurse #1 revealed she had been the primary day shift nurse (7:00 AM to 7:00 PM) on the South Unit on [DATE] where Resident #1 resided. Nurse #1 indicated she recalled Resident #1 was positive for C difficile and had been transferred to her unit last month due to requirements of isolation for the infection. Nurse #1 stated Resident #1 was, at baseline, alert and oriented x 4 (person, place, time and event), incontinent of bowel and bladder and had frequent loose stools containing a mucus while on her unit. Nurse #1 said that she recalled Resident #1 continued to have loose stools after being taken off precautions and therefore on [DATE], she placed a note in the medical provider's binder to alert them of the ongoing loose stools so they would provide an order for the laboratory test for C-Difficile. Nurse #1 explained she obtained a stool sample at that time and sent it to the laboratory to test for C-Difficile. Attempts were made to interview Nurse #8 who worked ,d+[DATE] (7:00 PM- 7:00 AM) without success. Nurse Aide documentation dated [DATE] reflected Resident #1 had four loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1's orientation (ability to recall person, place, time, and event) changed throughout the day and had semi formed stools on day shift. An interview with Nurse #4 on [DATE] at 9:00 AM revealed worked day shift on [DATE] and she could not recall the resident other than what was charted regarding orientation changes. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. An interview on [DATE] at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and documented on the following days in [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. NA#1 indicated she could not recall any specific day, but Resident #1 was normally alert and oriented, able to make her needs known, incontinent of bowel and bladder with multiple loose stools which frequently contained mucous the entire time she had been on the South Unit. NA #1 stated she made Nurse #1 aware of the ongoing loose stools. An interview with Nurse Aide #2 (NA #2) on [DATE] at 11:55 AM revealed that she worked on the South unit on night shift and documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she made the nurse aware of loose stools but could not recall the names of each nurse daily. An interview with Nurse Aide #3 (NA #3) on [DATE] at 1:45 PM revealed she worked on the South unit where Resident #1 resided and documented on night shift on the following dates in [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. NA #3 stated Resident #1 diarrhea and mucous like stools on each shift she worked and had alerted the nurse on duty each shift but could not recall the names of all nurses she alerted. A laboratory report dated [DATE] indicated Resident #1 was positive for C-difficile. The report reflected the laboratory notified the facility of the abnormal lab and spoke with Nurse #2 on [DATE] at 9:34 PM. The report indicated it was reviewed by the Physician Assistant on [DATE] at 1:18 PM. Attempts were made to interview Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. An interview with the PA on [DATE] at 11:20 AM revealed she was not familiar with Resident #1 and had not provided her with any direct care. The PA stated because a resident can test positive for C-Difficile for up to 90 days she would not have treated her with ongoing intermittent loose stools. A review of Resident #1's medical record revealed the last time she was seen by a medical provider was on [DATE] and there were no physician orders for the treatment of C-Difficile colitis after the positive test results were received on [DATE]. An interview with the Nurse Practitioner (NP) on [DATE] at 3:24 PM and 4:02 PM revealed she was familiar with Resident #1 and recalled her to be alert and oriented x 4. The NP stated shortly after admission she began having loose stools and she ordered a laboratory test for C-Difficile which resulted as positive, and treatment was ordered at the time. The NP indicated the treatment was for Vancomycin oral and Flagyl both IV and oral. The NP recalled Resident #1 continuing to have loose stools but thought another provider had placed her on treatment and therefore did not order any further treatment. The NP could not recall anything other than thinking another provider had handled the 2nd C-Diff lab nor being aware of orientation changes noted on [DATE]. An interview with the Physician (MD) on [DATE] at 4:08 PM revealed he was aware Resident #1 had been treated for C-Difficile shortly after her admission; however, he had not been made aware of the abnormal laboratory results on [DATE] and did not prescribe treatment for the ongoing loose stools. The MD stated the ongoing loose stools could have been exacerbated from the Polyethylene glycol prescribed by the surgeon at Resident #1's follow-up appointment on [DATE]. He acknowledged the only visit he had with Resident #1 was on [DATE]. He did not recall any further updates to Resident #1's condition. The MD indicated he would expect the lab to be reviewed by the PA and proper monitoring or interventions to be placed. A nurse's progress note dated [DATE] indicated Resident #1 had semi formed stools on day shift. Nurse Aide documentation dated [DATE] reflected Resident #1 had seven loose/diarrhea stools. A review of the MAR dated [DATE] indicated Resident #1 received the following: - Lisinopril 10mg daily ([DATE] through [DATE]) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day ([DATE]) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea ([DATE] through [DATE]) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth one time a day related to Constipation ([DATE], [DATE], [DATE]) A nurse progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented with a blood pressure of ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with diarrhea. The note indicated MD was aware and staff should continue to monitor. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented and her BP was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had loose stools during day shift and Polyethylene glycol was held due to loose stools. Nurse Aide documentation dated [DATE] reflected Resident #1 had eight loose/diarrhea stools. An interview on [DATE] at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and was on duty on the following days in [DATE]: [DATE] and [DATE]. NA #1 indicated she had made the hall nurse on duty aware of the ongoing loose stools each shift although she could not recall the names of each nurse daily. A late entry nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. Nurse Aide documentation dated [DATE] reflected Resident #1 had thirteen loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated [DATE] indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. Nurse Aide documentation dated [DATE] reflected Resident #1 had one loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated [DATE] did not indicate Resident #1's cognitive status. Her blood pressure was listed as ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. An interview with Nurse #4 on [DATE] at 9:00 AM revealed she recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #2 dated [DATE] indicated on night shift ([DATE] at 7:00 PM through [DATE] at 7:00 AM) Resident #1 was alert and oriented and able to make needs known. Resident#1 had a blood pressure of ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during night shift. The note indicated Imodium AD was administered without any favorable effects. Attempts to interview Nurse #2 were unsuccessful. A nurse progress note written by Nurse #1 dated [DATE] indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. A review of Resident #1's medical record revealed no progress notes written by Nurse #3 on [DATE]. A telephone interview with Nurse #3 on [DATE] at 9:38 AM revealed she acknowledged she worked the South unit on [DATE] on night shift but could not recall Resident #1 to include any stools or behaviors on [DATE] due to her working all the units and her working on an as needed basis only. Nurse Aide documentation dated [DATE] reflected Resident #1 had six loose/diarrhea stools. An interview with NA #2 on [DATE] at 11:55 AM revealed that she worked on the South unit on night shift and documented on the following dates in [DATE]: [DATE], [DATE], [DATE], and [DATE]. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she was aware Resident #1 had C-Difficile and therefore alerted Nurse #2 of the resident having loose stools but did not alert the nurse with each loose stool because they were aware of them. An interview with NA #3 on [DATE] at 1:45 PM revealed she worked on the South unit where Resident #1 resided on night shift on [DATE]. NA #3 stated on the night of [DATE], Resident #1 was more confused than normal. She indicated during her shift, Resident #1 continued to have mucous stools but did not ring her light to be changed as she normally would, was disoriented and trying to climb out of bed. NA #3 said she told Nurse #2. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. Attempts were made to interview Nurse #2 without success. Nurse Aide documentation dated [DATE] reflected Resident #1 eight had loose/diarrhea stools. A nurse's Progress note written by Nurse #1 dated [DATE] at 2:30 PM indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was ,d+[DATE]. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. A late entry nurse progress note written by Nurse #1 on [DATE] at 3:19 PM indicated on [DATE] at approximately 3:30 PM, Nurse #1 was informed that Resident #1 had a low blood pressure and appeared confused. The note indicated Nurse #1 assessed Resident #1's blood pressure manually and found the value to be at baseline for the patient at ,d+[DATE]. Confusion noted also to be at baseline. An interview on [DATE] at 1:00 PM with Physical Therapy Assistant #1 revealed he was assigned to Resident #1's therapy treatment for physical therapy on [DATE]. PTA #1 indicated when he entered the room between 3:00 and 4:00 PM, he noticed Resident #1 was not herself as she had previously had a very social based personality when he had worked with her a couple of weeks prior. PTA #1 indicated on this date, Resident #1 appeared more lethargic and confused. PTA #1 stated he made attempts to sit Resident #1 on the edge of the bed thinking she would arouse to her normal self with stimulation. He indicated he alerted Certified Occupational Therapy Assistant (COTA #1) who was nearby and asked him to look at obvious concerns of Resident #1's change from the previous time he had worked with her. He indicated that COTA #1 entered the room and agreed that Resident #1 was not at her baseline as he routinely provided therapy for her. During this discussion between PTA #1 and COTA #1, Nurse #1 entered the room to give Resident #1 her medications. He said he mentioned to Nurse #1 that Resident #1 was acting different, but the nurse did not respond to his statement. PTA #1 stated when medications were administered by Nurse #1, Resident #1 spit the medications out, the nurse collected the pills, and the nurse left the room. PTA #1 indicated Resident #1 continued to remain confused and uncooperative with therapy after the nurse left the room. He explained he and COTA #1 obtained vital signs using the robot-nurse. He stated it took them approximately 20 minutes or so to obtain two blood pressures due to Resident #1 was fidgety and restless. Resident #1's blood pressure was obtained and readings for blood pressure reflected between the 60s and 70s mmHg (millimeters of mercury) systolic (normal being greater than ,d+[DATE]). PTA #1 stated he and COTA #1 placed Resident #1 back in a supine position in bed and left the room to locate Nurse #1. PTA #1 stated Resident #1 was fidgety and agitated during the therapy treatment but did not recall any behaviors such as hollering out while he was in her room. PTA #1 stated he approached Nurse #1 who was at her medication cart in the hallway and alerted her that Resident #1's blood pressure readings had been low, stated what they were, and she had increase confusion, not acting like herself, and was unable to participate in therapy. PTA #1 stated Nurse #1 replied to him that Resident #1's blood pressure was normally low at baseline and did not appear concerned with reports by him. PTA #1 stated Nurse #1 never told him that she would assess Resident #1 and evaluate his concerns of the change of condition. PTA #1 stated he left the nurse at the medication cart and proceeded towards the therapy room. When he passed the MDS Nurse Coordinator's office, he entered the office and requested the nurse to review Resident #1's previous blood pressures and alerted her of the low blood pressure readings that he and COTA #1 had obtained. PTA #1 stated the MDS Nurse noted the blood pressures obtained by the PTA #1 and COTA #1 were lower than Resident #1's baseline. PTA #1 stated the MDS Nurse contacted the Staff Development Coordinator (SDC) Nurse via phone who said she was leaving for the day but would go and recheck Resident #1's blood pressure. An interview with COTA #1 on [DATE] at 12:30 PM revealed he was alerted on [DATE] in the afternoon (he could not recall exact time) by PTA #1 that he was concerned that Resident #1 was not her normal self. COTA #1 stated he entered Resident #1's room with PTA #1 and recognized Resident #1 appeared drowsy, confused, and agitated. He said while he and PTA #1 were in the room the hall nurse (Nurse #1) entered the room with the resident's medications and attempted to administer them, but Resident #1 spit them all out on her clothes. COTA #1 stated while Nurse #1 was in the room, PTA #1 mentioned to Nurse #1 that Resident #1 did not seem to be at her baseline, but Nurse #1 did not acknowledge the statement, but instead quickly retrieved the medications Resident #1 spit out and left the room. COTA #1 indicated he and PTA #1 continued to attempt to get Resident #1 to participate without success then decided to obtain vital signs on Resident #1. COTA #1 indicated he and PTA #1 obtained two sets of vital signs secondary to the first [TRUNCATED]

Based on observation, record review, resident and staff interviews the facility failed to maintain the dignity of residents by failing to provide enough size 3X briefs for 4 of 4 residents that wore 3X briefs (Residents #8, #55, #40, and #28). This resulted in residents experiencing fear of embarrassment, physical discomfort, not participating in activities, feeling upset, bothered, and crying. This practice affected all residents that wore size 3X briefs. The findings included: 1) Resident #8 was admitted to the facility on [DATE] with diagnoses that included diastolic heart failure, hypertension, and muscle weakness. Review of the most recent Minimum Data Set for Resident #8 dated 10/28/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive 1 person assist with bed mobility, transfers, toileting, and hygiene. She required limited 1 person assist with walking in her room. Resident #8 was occasionally incontinent of bladder and bowel. During an interview with Resident #8 on 1/4/22 at 12:19 PM she revealed she wore a size 3X brief and the facility frequently ran out. She stated they were running low on that day, and she knew because NA #4 came to her room to find a brief for another resident. NA #4 came to her room and said they could not find a 3X brief for a resident down the hall. NA #4 asked Resident #8 if she could take a 3X brief from her room. Resident #8 stated this happened frequently, we run out of briefs weekly, that's why I keep a few stashed away in my room. She stated when the facility was low on briefs, she would frequently wear the green (2X) so that some of the other residents could have what was left of the 3X briefs. She stated the 2X briefs were too small for her, but she could fit them better than some of the other residents. Resident #8 further stated she could go to the restroom with staff assistance. She stated making it to the restroom without wetting was difficult because she was on 160 milligrams (mg) of a diuretic (a medication that rid the body of excess fluid through the kidneys) daily. She explained that she sometimes wore a pull up when she was up in the chair, but if she didn't make it to the restroom in time those things don't hold, my clothes will be wet. She further explained that when they have activities she does not go if there were no 3X briefs available for her to wear. She stated sometimes residents wet themselves during activities and it may be visible on their clothing and other residents stare and point. She said this had happened to her once in the past and her clothing and the floor was wet, and she was embarrassed. She revealed she does not go to activities without a 3X brief because I am afraid to be embarrassed like that again. She further revealed the NAs encouraged her to go to activities anyway, they told her things happen, and not to worry about it. If she was wet, they would help her get changed. Resident #8 stated she was sure the NAs would help her if she was wet, but she would still be embarrassed. On 01/04/23 at 4:48 PM an interview conducted with NA #4 revealed earlier on her shift she had to go to Resident #8's room and ask for a brief because a resident down the hall did not have one and was upset and crying. She stated she also found a few more briefs for that resident. NA #8 stated she did not report being short of 3X briefs to anyone on that day. During an interview on 1/5/23 at 10:54 AM, NA #5 revealed Resident #8 wore size 3X briefs. Resident #8 had recently needed to use more briefs because of a medication she was taking. NA #5 explained when the facility ran out of 3X briefs Resident #8 would stay in her room rather than go to activities. Resident #8 would not go to activities because she was afraid the smaller briefs would leak, and she would be embarrassed. An interview conducted on 1/6/23 at 10:23 AM with NA #6 revealed Resident #8 knew when she needed to use the restroom, but often her brief would have to be changed because she could not always make it before wetting the brief. She stated Resident #8 was a very heavy wetter. During an interview on 01/06/23 11:28 AM the Activities Director revealed Resident #8 had told her in the past that she didn't want to come to activities related to her diuretic, but she was not aware of issues with briefs. She stated she encouraged residents to come to activities anyway. She told them they could try coming to activities with a blanket covering their lap. 2) Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, shortness of breath, diabetes, and muscle weakness. The most recent Minimum Data Set for Resident #55 dated 10/15/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive one person assist with bed mobility, toileting, and personal hygiene. Resident #55 was frequently incontinent of bladder and bowel. During an interview and observation on 1/4/23 at 5:25 PM Resident #55 revealed she was told she was supposed to wear a green (size 2X) brief, but they were too tight. She told the NAs the 2X briefs were too small and the white (3X) briefs fit better and were more comfortable. She further stated she had an old scar from a surgery she had last year, and the 2X brief rubbed that area and caused her pain, I told them (staff) it hurts. Resident #55 revealed she had on a 3X brief that day, but when the facility ran out, they would bring her the 2X brief. An observation was made, Resident #55 was wearing a 3X brief that fit well. Resident #55 explained that she gets upset when the facility runs out of the 3X briefs. She felt like the NA's were trying to stuff her into something she couldn't fit, and it hurt her stomach. During an interview and observation on 1/5/23 at 10:51 AM Resident #55 revealed she was changed by staff 3 times during night shift and each change was with a 2X brief. She stated staff said that was all they had; they could not find any 3X briefs. Resident #55 was observed with a 2X brief on that fit tightly around her waist. Resident #55 pointed out a reddened area wear the brief was fastened. The reddened area was observed as irritation, the resident's skin was intact. During an interview on 1/6/23 at 10:53 AM NA #6 revealed Resident #55 was incontinent and wore 3X briefs. Resident #55 had expressed to NA #6 that she did not like to wear the 2X briefs because they were too small and rubbed her stomach. 3) Resident #40 was admitted to the facility on [DATE] with diagnoses that included stroke, muscle weakness, dysphagia, seizures, shortness of breath, and major depressive disorder. The most recent Minimum Data Set for Resident #40 dated 12/15/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive 1 person assist with bed mobility, toileting, and personal hygiene. Resident #40 was always incontinent of bowel and bladder. During an interview on 1/4/23 at 5:47 PM Resident #40 revealed she was often told that the facility was out of size 3X briefs. The NAs would often go check other resident's rooms for a 3X brief. If they could not find one, they would put her on the smaller green (2X) brief. Resident #40 stated the 2X briefs were too small and uncomfortable. The 2X briefs were too tight and rubbed, they sometimes made her skin sore. She further stated when she voids in the green briefs it leaks and gets her bed wet, and she did not like to be in a wet bed. Resident #40 recalled a time when the facility was almost out of briefs and an NA told her she needed to pee more than once in her brief before she could be changed. She stated that she did not remember the NAs name, but she was very upset and bothered about the whole situation with the briefs. She revealed this had been an ongoing issue and she did not understand why the facility could not order enough 3X briefs. During an interview on 10/5/23 at 10:54 AM NA #5 revealed Resident #40 was incontinent and wore a size 3X brief. 4) Resident #28 was admitted to the facility on [DATE] with diagnoses that included heart failure, muscle weakness, shortness of breath, neuropathy, anxiety, and major depressive disorder. The most recent Minimum Data Set for Resident #28 dated 10/10/22 revealed she was cognitively intact with no rejection of care. She required extensive 1 person assist with toileting and personal hygiene. Resident #28 was occasionally incontinent of bladder and frequently incontinent of bowel. An interview conducted with Resident #28 on 1/4/23 at 5:37 PM that revealed one of the NAs told her there were no more briefs today. She revealed she was crying but declined to say why she was crying. Resident #28 stated NA #4 found some briefs for her and brought them to her room. The facility was sometimes short on 3X briefs, and she usually had some extras in her room. During an interview on 1/4/22 at 4:48 PM NA #4 revealed that morning Resident #28 did not have any briefs and the resident was upset and crying. She further revealed sometimes the NAs put briefs in the resident's rooms, and she went to another room and got a brief for Resident #28. NA #4 stated that Resident #28 wore a 3X brief and the facility sometimes ran out of 3X briefs. An interview was conducted on 1/5/23 at 8:53 AM where Central Supply revealed she was aware that Resident #28 would get upset because she thought she was going to run out of briefs. Yesterday staff let her know the resident was upset and more briefs were brought to Resident #28's room. During an interview on 10/5/23 at 10:54 AM NA #5 revealed Resident #28 was crying on the day before (10/4/23) because she had no briefs. She stated she thought another NA found some briefs for her from another resident's room. During an interview on 1/6/23 at 12:32 PM with the Director of Nursing (DON) revealed she was unaware of any issue with the amount of 3X briefs available to residents until 1/4/23 when Resident #28 told her she was upset because the NAs told her there were no more 3X briefs. The DON stated the NAs found some briefs for the resident. During an interview on 1/6/23 at 11:52 AM the Administrator revealed Central Supply ordered supplies for the facility and she used an inventory list to do so. The facility received supply shipments on Mondays. The Administrator further revealed she was not aware of any issues or a shortage of 3X briefs in the facility. No issues had been reported to her. She indicated that having 3-4 briefs per resident per day until the next shipment on 1/9/23 was insufficient. She stated if there were not enough briefs or an issue with ordering, she should be notified so she could help by reaching out to a sister facility or go out and purchase what was needed for the residents. She further stated the residents should not have to worry about having briefs or how many they could use. During an interview on 1/6/23 at 12:32 PM with the DON revealed she was unaware of any issue with the amount of 3X briefs available to residents until 1/4/23 when she was told by one of the residents. The DON further revealed she does not recall ever obtaining supplies from a sister facility. The DON indicated the number of briefs that were in the facility on that day would not be enough to last until Monday when the next delivery would arrive. She stated she expected the NAs to round and provide incontinent care as needed. She also expected the residents to have the briefs they needed and not have to worry about it.

Based on observation, record review, resident and staff interviews the facility failed to order and provide enough size 3X briefs for 4 of 4 residents that wore 3X briefs (Residents #8, #55, #40, and #28). The residents reported the facility was often out of 3X briefs and the 2X briefs were too small, hurt my stomach, uncomfortable, too tight, rubbed and sometimes made my skin soreand they leaked. Resident #55 was observed wearing a 2X brief that fit tightly around her waist and there was a reddened area where the brief was fastened. This practice affected all residents that wore size 3X briefs. The findings included: 1) Resident #8 was admitted to the facility on [DATE] with diagnoses that included diastolic heart failure, hypertension, and muscle weakness. Review of the quarterly Minimum Data Set for Resident #8 dated 10/28/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive 1 person assist with bed mobility, transfers, toileting, and hygiene. She required limited 1 person assist with walking in her room. Resident #8 was occasionally incontinent of bladder and bowel. Resident #8's care plan revised on 11/12/22 revealed: Resident #8 had bladder incontinence related to impaired mobility. The interventions included provide peri-care as needed and with each incontinent episode. Resident #8 had bowel incontinence related to impaired mobility. The interventions included assist with toileting as needed, provide peri-care after each incontinent episode, and provide loose fitting easy to remove clothing. Resident #8 required assistance with activities of daily living (ADL) related to heart failure. The interventions included assist resident with bed mobility, transfers, and repositioning. 1/4 rails to aid in the resident's mobility. Review of Physician orders for Resident #8 included: Furosemide tablet 80 milligrams (mg), give 1 tablet by mouth two times a day for edema related to heart failure, do not change times. 10/14/22 During an interview with Resident #8 on 1/4/22 at 12:19 PM she revealed she wore a size 3X brief and the facility frequently ran out. She stated they were running low on that day, and she knew because NA #4 came to her room to find a brief for another resident. NA #4 came to her room and said they could not find a 3X brief for a resident down the hall. NA #4 asked Resident #8 if she could take a 3X brief from her room. Resident #8 stated this happened frequently, We run out of briefs weekly, that's why I keep a few stashed away in my room. She stated when the facility was low on briefs, she would frequently wear the green (2X) so that some of the other residents could have what was left of the 3X briefs. She stated the 2X briefs were too small for her, but she could fit them better than some of the other residents. Resident #8 further stated she could go to the restroom with staff assistance. She stated making it to the restroom without wetting was difficult because she was on 160mg of a diuretic (a medication that rid the body of excess fluid through the kidneys) daily. She explained that she sometimes wore a pull up when she was up in the chair, but if she doesn't make it to the restroom in time those things don't hold, my clothes will be wet. On 01/04/23 at 4:48 PM an interview conducted with NA #4 revealed earlier on her shift she had to go to Resident #8's room and ask for a brief because a resident down the hall did not have one and was upset and crying. She stated she also found a few more briefs for that resident. NA #8 stated she did not report being short of 3X briefs to anyone on that day. During an interview on 1/5/23 at 10:54 AM, NA #5 revealed Resident #8 wore size 3X briefs. Resident #8 had recently needed to use more briefs because of a medication she was taking. NA #5 explained when the facility ran out of 3X briefs Resident #8 would stay in her room rather than go to activities. Resident #8 would not go to activities because she was afraid the smaller briefs would leak, and she would be embarrassed. An interview conducted on 1/6/23 at 10:23 AM with NA #6 revealed Resident #8 knew when she needed to use the restroom, but often her brief would have to be changed because she could not always make it before wetting the brief. She stated Resident #8 was a very heavy wetter. During an interview on 01/06/23 11:28 AM the Activities Director revealed Resident #8 had told her in the past that she didn't want to come to activities related to her diuretic, but she was not aware of issues with briefs. 2) Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, shortness of breath, diabetes, and muscle weakness. The quarterly Minimum Data Set for Resident #55 dated 10/15/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive one person assist with bed mobility, toileting, and personal hygiene. Resident #55 was frequently incontinent of bladder and bowel. Review of Resident #55's care plan updated on 10/25/22 revealed: Resident #55 was frequently incontinent of bladder and bowel and was not a candidate for a toileting program due to lack of bowel and bladder control. The interventions included check and change briefs frequently and as needed and provide toileting hygiene with brief changes. Resident #55 required assistance with ADLs related to chronic health conditions and weakness. The interventions included assist with bed mobility. During an interview and observation on 1/4/23 at 5:25 PM Resident #55 revealed she was told she was supposed to wear a green (size 2X) brief, but they were too tight. She told the NAs the 2X briefs were too small and the white (3X) briefs fit better and were more comfortable. She further stated she had an old scar from a surgery she had last year, and the 2X brief rubbed that area and caused her pain. I told them (staff) it hurts. Resident #55 revealed she had on a 3X brief that day, but when the facility ran out, they would bring her the 2X brief. An observation was made, Resident #55 was wearing a 3X brief that fit well. She felt like the NAs were trying to stuff her into something she couldn't fit, and it hurts her stomach. During an interview and observation on 1/5/23 at 10:51 AM Resident #55 revealed she was changed by staff 3 times during night shift and each change was with a 2X brief. She stated staff said that was all they had; they could not find any 3X briefs. Resident #55 was observed with a 2X brief on that fit tightly around her waist. Resident #55 pointed out a reddened area where the brief was fastened. The reddened area was observed as irritation, the resident's skin was intact. During an interview on 1/6/23 at 10:53 AM NA #6 revealed Resident #55 was incontinent and wore 3X briefs. Resident #55 had expressed to NA #6 that she did not like to wear the 2X briefs because they were too small and rubbed her stomach. 3) Resident #40 was admitted to the facility on [DATE] with diagnoses that included stroke, muscle weakness, dysphagia, seizures, shortness of breath, and major depressive disorder. The quarterly Minimum Data Set for Resident #40 dated 12/15/22 revealed she was cognitively intact with no behaviors or rejection of care. She required extensive 1 person assist with bed mobility, toileting, and personal hygiene. Resident #40 was always incontinent of bowel and bladder. Review of Resident #40's care plan revised on 11/15/22 revealed: Resident #40 required assistance with activities of daily living related to deficits from a stroke. The interventions included assist with bed mobility and repositioning, 1/4 rail to assist with bed mobility. Resident #40 had bladder incontinence related to impaired mobility. The interventions included clean peri-area with each incontinent episode. Resident #40 had bowel incontinence related to impaired mobility. The interventions included assist with toileting, provide peri-care with each incontinent episode and provide loose fitting, easy to remove clothing. During an interview on 1/4/23 at 5:47 PM Resident #40 revealed she was often told that the facility was out of size 3X briefs. The NAs would often go check other resident's rooms for a 3X brief. If they could not find one, they would put her on the smaller green (2X) brief. Resident #40 stated the 2X briefs were too small and uncomfortable. The 2X briefs were too tight and rubbed, they sometimes made her skin sore. She further stated when she voids in the green briefs it leaks and gets her bed wet, and she did not like to be in a wet bed. She revealed this had been an ongoing issue and she did not understand why the facility could not order enough 3X briefs. During an interview on 10/5/23 at 10:54 AM NA #5 revealed Resident #40 was incontinent and wore a size 3X brief. 4) Resident #28 was admitted to the facility on [DATE] with diagnoses that included heart failure, muscle weakness, shortness of breath, neuropathy, anxiety, and major depressive disorder. The most recent Minimum Data Set for Resident #28 dated 10/10/22 revealed she was cognitively intact with no rejection of care. She required extensive 1 person assist with toileting and personal hygiene. Resident #28 was occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident #28's care plan dated 10/13/22 revealed: Resident #28 required assistance with activities of daily living related to advanced age and chronic health conditions. The interventions included assist resident with toileting and transfers Resident #28 was at risk for pressure ulcers related to incontinence. The interventions included keep skin as clean and dry as possible. Review of Physician orders for Resident #28 included: Furosemide Tablet 40 MG, give 1 tablet by mouth two times a day related to essential hypertension 4/28/22 An interview conducted with Resident #28 on 1/4/23 at 5:37 PM that revealed one of the NAs told her there were no more briefs today. Resident #28 stated NA #4 found some briefs for her and brought them to her room. The facility was sometimes short on 3X briefs, and she usually had some extras in her room. During an interview on 1/4/22 at 4:48 PM NA #4 revealed sometimes the NAs put briefs in the resident's rooms, and she went to another room and got a brief for Resident #28. NA #4 stated that Resident #28 wore a 3X brief and the facility sometimes ran out of 3X briefs. NA #4 indicated when she provided incontinent care to her residents, she knew what sized brief they needed by looking at their body size. She stated the briefs were stored in the north and south unit supply rooms. She explained that NAs sometimes left briefs in the resident's rooms, so when they could not find briefs in the supply rooms they would look in other residents rooms for the briefs. During an interview on 1/5/23 at 10:54 AM, NA #5 revealed that finding 3X briefs in the facility was difficult at times. She would sometimes need to go to other resident's rooms to look for 3X briefs. NA #5 further revealed if the facility was short or out of briefs, she would let Central Supply know and sometimes the residents would have to wear the next size down. She thought there were about 12 residents in the facility that wore 3X briefs. During an interview on 1/6/23 at 11:13 AM Nurse #6 revealed the facility frequently ran low on briefs, especially the 3X. She knew when the facility was running low or out because she would see the NAs scrambling around and looking in other resident's rooms for briefs. She further stated when they were out of 3X briefs the NAs would have to use a smaller size and leave the sides unfastened. An interview conducted on 1/6/23 at 10:23 AM with NA #6 revealed the facility sometimes ran low on size 3X briefs. She stated she worked 12-hour shifts and on a normal shift she changed the brief of her incontinent residents 3 to 5 times per shift. Residents that were on diuretics she had to change more often, possibly 6 or 7 times. An interview and observation were conducted on 1/5/22 at 8:53 AM with Central Supply that revealed when she ordered supplies for the facility, she used a list for items that she orders weekly. She also placed a clipboard at the nurse station for each unit. Staff were to write in any supplies they were running low on and needed to be reordered on the clipboard. These requests were picked up on Tuesday mornings. Staff could also tell her when they needed supplies. She placed orders for the following week on Tuesdays by lunch, and supply deliveries arrived on the following Monday. This surveyor asked Central Supply how she calculated the number of briefs she needed to order. She stated, I know what size brief each resident wears. She reported there were approximately 10 resident that wore 3X briefs in the facility. She stated she did not have an actual list of residents and their brief sizes, but she had a mental list. She further stated there was a list that the home office had, and she would try to obtain that list. An observation of the north and south unit supply rooms were made with Central Supply. The North supply room had a total of 41 size 3X briefs and the south supply room had a total of 9 size 3X briefs. Central Supply stated the next scheduled delivery for briefs was on Monday 1/9/23. She further stated the NAs sometimes store briefs inside the resident's rooms and she was sure there were more briefs in the building. An observation of the north and south unit clipboards revealed no requests for 3X briefs for that week. Central Supply stated she was in the process of trying to place an emergency order for the facility, but it had not been placed yet. Review of the weekly supply order placed on 1/4/23 by Central Supply revealed there were 6 cases of 3X briefs ordered for the facility. Each case contained 48 briefs, for a total of 288 briefs for the facility for the week of 1/9/23 - 1/15/23. Approximately 4 briefs per resident per day were ordered for the week of 1/9/23 - 1/15/23. A second interview and observation were conducted on 1/5/22 at 11:20 AM with Central Supply. Central Supply stated there were more 3X briefs found in resident's rooms. An observation with Central Supply was completed of 9 resident's rooms where extra briefs were found. A total of 66 size 3X briefs were counted from resident's rooms. Central Supply revealed that with the 50 briefs that were in the supply room the total 3X briefs for the residents in the facility would be 116 briefs until delivery on Monday 1/9/23. There would be approximately 3 briefs per resident per day until delivery on Monday 1/9/23. Central Supply stated she was unable to obtain a copy of the list of residents that wore 3X briefs from the home office. During an interview on 1/6/23 at 11:43 AM Central Supply revealed she had not completed the emergency order yet, she was still working on it. During an interview on 1/6/23 at 12:32 PM with the Director of Nursing (DON) revealed she was unaware of any issue with the amount of 3X briefs available to residents until 1/4/23 when Resident #28 told her she was upset because the NAs told her there were no more 3X briefs. The DON stated the NAs found some briefs for the resident. She further stated she was not involved in ordering or inventory of briefs. During an interview on 1/6/23 at 12:32 PM with the DON revealed she was unaware of any issue with the amount of 3X briefs available to residents until 1/4/23 when she was told by one of the residents. The DON further revealed she does not recall ever obtaining supplies from a sister facility. The DON indicated the number of briefs that were in the facility on that day would not be enough to last until Monday when the next delivery would arrive. She stated she expected the NAs to round and provide incontinent care as needed. She also expected the residents to have the briefs they needed and not have to worry about it. During an interview on 1/6/23 at 11:52 AM the Administrator revealed Central Supply ordered supplies for the facility and she used an inventory list to do so. The facility received supply shipments on Mondays. The Administrator further revealed she was not aware of any issues or a shortage of 3X briefs in the facility. No issues had been reported to her. She indicated that having 3-4 briefs per resident per day until the next shipment on 1/9/23 was insufficient. She stated if there were not enough briefs or an issue with ordering, she should be notified so she could help by reaching out to a sister facility or go out and purchase what was needed for the residents. She further stated the residents should not have to worry about having briefs or how many they could use.

Based on record review, observations and staff interviews, the facility failed to accurately enter the code status as full code in the Care Plan for 1 of 3 sampled residents (Resident #35) and the facility failed to revise the Care Plan for 1 of 1 sampled resident to include fluid restrictions and non-compliance with fluid restrictions (Resident #64). The findings included: 1. Resident# 35 was admitted to the facility on [DATE]. A physician's order dated 7/5/22 indicated Resident # 35 was a full code. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident# 35 had severely impaired cognition. A signed MOST form revealed Resident #35 had a full code status. A Care Plan dated 11/17/22 indicated Resident #35 had a code status of Do Not Resuscitate. A Care Plan dated 8/19/22 indicated Resident #35 had a code status of Do Not Resuscitate. An interview with the MDS Coordinator on 1/4/23 at 4:20 PM revealed she was responsible for entering the code status into the Care Plan. During the interview, she reviewed the Care Plan that showed Do Not Resuscitate (DNR), the physician's order that showed full code, and the Resident's medical record profile that showed full code for Resident #35. She then stated she must have made a mistake when she entered the wrong code status of DNR into the Care Plan. She further revealed she would normally transcribe the code status from the orders or during morning meetings, after a resident is admitted and enter the information into the MDS and the Care Plan. An interview with the Director of Nursing (DON) indicated she expected the code status to be accurately entered into the Care Plan as a result of a transcription from physician orders. An interview with the Administrator revealed it was her expectation that all orders such as a code status, are reflected accurately on the Care Plan. 20934 2. Resident #64 was admitted to the facility on [DATE]. Resident #64's diagnoses included cellulitis of right and left lower limbs and localized edema, among others. Review of October 2022 physician orders revealed an order to restrict fluids to 1500 cubic centimeters (cc) daily. A care plan dated 10/28/22 recorded Resident #64 was at risk for nutritional decline with a goal to provide optimal nutrition and hydration status by meeting her nutrition and hydration needs. The care plan did not include the 1500 cc fluid restriction or that Resident #64 was non-compliant. A quarterly Minimum Data Set, dated dated dated [DATE], assessed Resident #64 with clear speech, able to understand/be understood, adequate hearing/vision, independent with eating and intact cognition. Resident #64 was observed on 1/3/23 at 1:00 PM and 1/5/23 at 12:50 PM in her room drinking ice water independently from a 20-ounce cup kept at her bedside. Resident #64 stated on 1/5/23 at 12:50 PM that the physician placed her on fluid restrictions, but that she drank water all the time throughout the day. Resident #64 stated that staff knew that she drank a lot of water and provided her water whenever she asked. She stated, I might drink too much, but I like my water. An interview with Nurse #1 on 1/5/23 at 12:53 PM revealed Resident #64 drank water with her medications and staff provided her water whenever she asked. An interview with Nurse #3 on 1/5/23 at 1:33 PM revealed Resident #64 was aware of her fluid restrictions but drank independently and asked for water whenever she wanted. During an interview with the Registered Dietitian (RD) on 01/05/23 at 4:09 PM, the RD stated that she completed the nutrition section of the care plans. The RD stated that Resident #64 was non-compliant with her fluid restrictions and kept water at the bedside at her request. The RD stated that her non-compliance with her fluid restrictions should have been added to the care plan. The Director of Nursing (DON) was interviewed on 1/5/23 at 2:15 PM. The interview revealed that Resident #64 was non-compliant with her fluid restrictions and that the family of Resident #64 was adamant that she keeps water at the bedside. The DON stated that the care plan did not currently include her fluid restriction or non-compliance but that it would be updated. The Administrator stated on 1/05/23 at 6:00 PM that Resident #64 was non-compliant with fluid restrictions and her care plan should have included that. The Administrator stated that she would ensure the care plan was updated.

Based on observation, record review and staff interviews, the facility failed to provide correct portions of pureed foods per the menu for 2 of 3 residents with a diet order for pureed foods (Resident #42 and #27). This failure had the potential to affect residents receiving pureed food. The findings included: A continuous observation of the lunch meal tray line occurred on 1/5/23 from 11:38 AM to 12:28 PM. On 1/5/23 at 12:23 PM, a 2-ounce serving utensil was observed used to plate pureed ham for Resident #42 and pureed beef for Resident #27. The plates for these residents were placed on the cart for delivery. Review of the lunch menu with the Dietary Manager (DM) revealed Residents with a diet order for pureed foods should receive a 4-ounce portion of pureed ham and a 5.33-ounce portion of pureed beef. During an interview on 1/5/23 at 12:25 PM, Dietary Aide #1 stated that the DM placed the serving utensils on the tray line, and she just picked up the utensils to plate the pureed foods for Residents #42 and #27. The DM stated in interview on 1/5/23 at 12:23 PM that she put the serving utensils on the tray line, but that Dietary Aide #1 picked up the wrong serving utensil for the pureed foods. The DM stated she checked the serving utensils on the line but did not notice that Dietary Aide #1 had the wrong size utensils to use when serving pureed meats. During an interview on 01/05/23 at 3:53 PM the Registered Dietitian stated that she expected residents with a diet order for pureed foods to receive foods in the portions according to the menu. The Administrator stated in interview on 01/05/23 at 6:00 PM that she expected dietary staff to serve foods per the menu at the correct portions.

Based on observation, record review, and interviews with resident and staff, the facility failed to maintain wheelchair armrests in good repair for 2 of 5 residents reviewed for mobility device (Resident #177 and #180). The findings included: 1.a. Resident #177 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #177 with severe impairment in cognition and her primary mobility device was a wheelchair. During an observation conducted on 01/03/23 at 11:15 AM, the right armrest of Resident #177's wheelchair was in disrepair with multiple torn spots and ripped lines. During the interview, Resident #177 was unable to tell the surveyor whether the broken armrest had caused any skin irritation to her right arm. On 01/04/23 at 12:39 PM, Resident #177 was seen sitting in her wheelchair in dining room and the right armrest remained in disrepair. She was wearing short sleeves and her right arm was seen in contact with the armrest during the observation. b. Resident #180 was admitted to the facility on [DATE]. Resident #180's MDS was not completed at the time of the observation. During an observation conducted on 01/04/23 at 12:39 PM, Resident #180 was seen sitting in her wheelchair at the same table with Resident #177 in the dining room. The left armrest was in disrepair with multiple torn spots, ripped lines, and cracks. She was wearing short sleeves and her left arm was seen in contact with the armrest during the observation. During an interview conducted on 01/04/23 at 12:52 PM, Resident #180 stated she had used the wheelchair for just a couple days, and the armrest had not caused any skin irritation so far. Interview with Nurse Aide (NA) #3 on 01/04/23 at 12:42 PM revealed Resident #177 and Resident #180 were from the same hall, and she was the NA who had transported Resident #177 to the dining room this afternoon. She acknowledged that both Residents' wheelchair armrests were in disrepair. She explained she did not pay attention to Resident #177's armrest when she transported her to the dining room. During an interview conducted on 01/04/23 at 12:47 PM, Nurse #4 stated she had provided care for Resident #177 and Resident #180 in the past few days. She stated the armrests for both Residents' wheelchairs were in disrepair and needed to be fixed immediately. She had not noticed both Residents' armrests were torn, ripped, and cracks. She assessed both Residents immediately and noted intact skin. During a joint observation with the Maintenance Director on 01/04/23 at 1:10 PM, he acknowledged that both Resident #177 and Resident #180's armrests were in disrepair and needed to be fixed immediately. During the subsequent interview conducted on 01/04/23 at 1:12 PM, the Maintenance Director stated that he did not know both wheelchairs were in disrepair and explained he had not received any work orders for wheelchair repairs recently. He explained he did not check all wheelchairs routinely, but mainly depended on work orders submitted by rehab and nursing staff to report repair needs. He checked work order boxes located in the nurse stations at least once daily. Interview with the Director of Nursing (DON) on 01/04/23 at 1:22 PM revealed she expected all the staff to report repair needs to maintenance department either via work orders or verbal notification in timely manner. It was her expectation for all the wheelchairs to be in good repair all the time. Interview with the Administrator on 01/06/23 at 11:33 AM revealed it was her expectation to have all the care equipment to remain in good repair all the time.

Based on observations, record review, staff, resident, van driver and transportation owner interviews, the facility failed to secure a resident to ensure a safe van transport for a resident who had double above the knee amputations for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). During a van transport Resident #1 fell backwards in her wheelchair, hitting her head on the back door of the van but no injuries were identified. Resident #1 was taken to the hospital for evaluation and returned to the facility the same day. Findings included: The undated manufacturer's instructions, for the transport van's wheel chair securement system utilized by the facility, titled, Vehicle Anchorages and Accessories for 4-Point Wheelchair Securement Systems, for the securement system used in the transport van to secure residents who were seated in wheelchairs during transports was made up of 4 wheelchair tie downs, 1 occupant lap belt, 1 occupant shoulder belt and floor anchorages. The instructions read in part, Secure Passenger: 1. Attach Lap Belts-Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. On the aisle side, attach belt with female buckle to rear tie-down in connector ensuring buckle rests on passenger's hip. On the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle. 2. Attach Shoulder Belt-Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto la belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. The manufacturer's instructions provided no guidance regarding occupants sitting on pillows or having adequate back support while they were seated in their wheel chair during transport. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum (MDS) data set [DATE], revealed Resident #1 was cognitively intact and was able to make decisions about her care. She had bilateral above the knee amputations and required assistance with activities of daily living and was totally dependent on 2 people and a mechanical lift for transfers. Review of Resident #1's care plan, dated 10/16/20, revealed goals and interventions for assistance with transfers, fall prevention, resolve pressure ulcers, pain, and anticoagulant use. Review of the facility's investigation, dated 10/21/20 and completed by the Director of Nursing (DON), revealed Resident #1 fell backward in her wheelchair while being transported in the transport van. She was alert and oriented and talking. The driver unhooked the belts holding the wheelchair in an upright position and the patient was laying on her back in the wheelchair and the driver had her head laying in his lap. The resident was noted to have a pillow and wheelchair cushion in her wheelchair. Nursing staff did not note any injuries however the resident was sent to the hospital for examination. The DON interviewed the resident. She stated she was not strapped in tight enough. The resident had bilateral above the knee amputations. Because of the amputations, the pillow and cushion in the wheelchair and the wheelchair not being tightly locked down, this made the resident top heavy causing the wheelchair to topple backward. The pillow was removed from Resident #1's wheelchair. The transport company supervisor was notified. Review of the Emergency Department (ED) report revealed Resident #1 was evaluated on 10/21/20 at 12:55 PM for evaluation of headache, neck pain and left shoulder pain after a fall. A computerized tomography scan (CT) of the head and cervical spine were negative for any acute fractures, dislocations, hemorrhage or mass-effects. Resident's cervical spine was cleared. X-rays were negative for any acute fractures or dislocations. She was resting comfortably in bed and stable for discharge. The resident returned to the facility the same day. An interview, conducted with Resident #1 on 11/2/20 at 10:45 AM, revealed on 10/21/20, she was sitting in her wheelchair, on top of a large pillow which was on top of the wheelchair cushion waiting to be transported in the van. She stated she needed the large pillow in the wheelchair because it was too uncomfortable sitting on the wheelchair cushion for the 45-minute transport to and from [MEDICAL TREATMENT]. While seated in her wheelchair the van driver put her in the van. The shoulder belt was placed across her left shoulder and hooked on the right side. The lap belt was placed across her abdomen. She stated there was a S hook and he hooked both to the wheel chair's front wheels. Resident #1 explained the van driver shut the door to the van and started to transport her to [MEDICAL TREATMENT]. She stated when the van driver accelerated the van and turned left out of the facility parking lot her wheelchair flipped backwards and the back of her head hit the back door of the van. She stated the wheelchair laid on her right stump and she had a knot on her left arm. She stated she never lost consciousness and did not think the back wheels to her wheel chair were locked down. The resident stated she was not injured in the incident. Review of the statement by the van driver, signed and dated 10/21/20 at 12:20 PM, revealed the incident occurred on 10/21/20 at 11:20 AM. During transport the resident fell backwards from wheelchair. The resident had a seatbelt on and the wheelchair was fully restrained. A telephone interview was conducted with the van driver (VD) on 11/2/20 at 12:45 PM. The VD stated he prior to transporting Resident #1 on 10/21/20 he assured all 4 of the van's wheel chair wheel chair securement straps, 2 in the front and 2 in the back, were tight and secured to the resident's wheel chair. He asked Resident #1 if the seatbelt was tight enough and she responded yes. The VD explained after he pulled out of the facility parking lot, he heard Resident #1 say I've fallen, help me. The driver stated he stopped the van and called the facility. After calling the facility, he went to the back door of the van and held the resident's head in his lap until the Director of Nursing (DON) arrived. The VD stated after the DON got to the van, he loosened the straps holding the front wheels of the resident's wheelchair at 2 points and disengaged the straps in the back at two points that were around the frame of the wheelchair. The van driver stated he always checked the van's wheel chair securement straps before he transported a resident in a wheel chair. He stated the resident had been sitting on a pillow in the wheelchair. She came out of the wheelchair and was laying in the floor of the van. The wheelchair was in an upright position. The DON had someone call EMS. EMS arrived and transported the resident to the emergency department. The VD stated the transportation company's owner came to the site of the incident and had him demonstrate how he had anchored the straps and reviewed the company's policies and procedures. The VD stated he return demonstrated to the owner how he hooked the straps when securing Resident #1. A telephone interview with Nurse #1, conducted on 11/2/20 at 1:00 PM, revealed she was working inside the facility and heard a page for help needed outside. She went to the van. The wheelchair was laying down and the straps were connected at 4 points. The straps had to be unhooked at all 4 points to get the chair out. The front left strap was tight and difficult to unhook. Nurse #1 stated she crawled into the van, did an assessment then worked to get Resident #1 out of the wheelchair into a sitting position in the floor of the van. She used her knees to support the resident's back and neck until the ambulance arrived. An interview, conducted with the Director of Nursing (DON) on 11/2/20 at 2:00 PM, revealed on 10/21/20, she was sitting in her office and heard an overhead page stat to the road. The transport van was stopped in the road in front of the facility. She approached the van. The DON explained the front wheels of the resident's wheelchair were suspended in the air and the resident's stumps were still in the chair. The chair was tilted all the way back touching the floor of the van and her head toward the back door. Resident #1 was alert and oriented and said her shoulder and her right leg were hurting. The DON stated she asked the discharge planner, who was at the scene, to call 911 and to call the resident's husband to let him know they were sending her to the emergency department (ED). Emergency medical services (EMS) arrived and transported her to the hospital. The DON called the nurse consultant and the corporate office and was instructed to get statements from staff and the driver. The owner of the transportation company came to the facility. The DON reported the incident during the facility's morning meeting on 10/22/20. Since the resident had bilateral above-the-knee amputations and was top heavy, the decision was made to transport her in a geri chair from that point on. The DON stated she confirmed that the transportation owner had trained the van drivers on safely transporting the residents before she allowed them to transport residents after the incident. She received a copy of the education document, dated 10/21/20 and provided by the owner, which included the following education: 1. Check the frame of wheelchair/geri-chair to ensure intact, no cracks or missing screws; 2. Safety belts are in good working order; 3. Ensure clients are secure in wheelchair and all straps are in place and working properly; 4. Review Safe Procedures for Transporting Clients using Wheelchair/Geri-chair. On 10/23/20, the first time the resident was transported in the geri chair following the incident, the DON stated she observed the resident being strapped into the van in the geri chair and it was secured at all 4 points, 2 points in the front and 2 points in the back to the floor anchors. The driver placed the seatbelt around the resident and secured it. The DON stated the seatbelt was in an appropriate position for a safe transport. An interview, conducted with the owner of the transportation company on 11/2/20 at 12:00 PM, revealed he went to the van immediately after the incident occurred. He stated the van driver anchored all 4 wheels of the wheelchair, secured the lap belt and the shoulder harness. He stated the resident was sitting in the wheelchair on a large pillow, which had her sitting up high in the wheelchair. He stated he had trained the drivers in all safety aspects, including anchoring the straps, checking the resident and not moving the resident, what to do if something happened, make the resident safe and call 911. He stated that he and the driver thought during the transport Resident #1 had little back support because she was sitting up high on a pillow in the wheelchair. That was the first time the VD had transported Resident #1. Immediately after the incident, he had the VD return demonstrate how he strapped the wheelchair down and reviewed policies and procedures with him. The owner stated competencies for the drivers were completed at hire and when needed thereafter. The owner stated, since the incident, he instructed the drivers not to transport residents who are sitting on pillows when using a regular wheelchair. He stated he recommended to the facility that Resident #1 be transported using a geri-chair since geri-chairs are considered a type of wheelchair by the Americans with Disabilities Act of 1990. The owner specified his company transports residents in geri chairs a lot and thought that using a geri chair would be a safer option for Resident #1. The owner stated he provided education to the drivers on 10/21/20 before they transported any residents after the incident. Review of the therapy notes revealed on 10/21/20, Physical Therapist (PT) #1 wrote a note that Resident #1 complained of soreness and discomfort on her bottom. She insisted on having a large pillow on top of the wheelchair cushion while in the wheelchair. An interview, conducted with PT #1 on 11/2/20 at 1:35 PM, revealed PT #1 evaluated Resident #1 who had bilateral above-the-knee amputations and had left side [MEDICAL CONDITION]. The resident was in the facility for rehabilitation related to the recent amputation of her right leg. She had no core stability and was dependent on a mechanical lift for transfers. She had a cushion in her wheelchair but complained about not being able to tolerate the cushion. She used a large pillow on top of the cushion when she was in her wheelchair. PT #1 had recommended to the resident that she not use the large pillow as it defeats the purpose of the wheelchair cushion. The resident insisted on using the large pillow, especially when she went to [MEDICAL TREATMENT] as it was a 45-minute ride one way. Prior to the incident, the PT stated they had recommended to the resident not to use the large pillow but she continued to use it. An interview, conducted with the Rehab Manager (RM) on 11/2/20 at 1:55 PM, revealed on 10/21/20 at 2:33 PM, she observed the wheelchair that the resident had been sitting in at the time of the incident. The wheelchair was in the lowest position. There was a huge pillow in the chair, on top of the wheelchair cushion. The RM stated the resident had bilateral above the knee amputations with left side [MEDICAL CONDITION]. She had poor sitting balance. They have since put anti-tippers on her wheelchair. Since the incident on 10/21/20, Resident #1 had been transported in the van using a geri-chair. On 11/24/20 at 9:42 AM, a conference call with the Rehab Manager and the DON revealed the therapy department nor the nursing department evaluated Resident #1 for safe wheelchair transport prior to the incident on 10/21/20. An on-site observation, conducted on 11/2/20 at 11:16 AM, revealed Resident #1 was sitting in a geri-chair with no pillow and was placed in the transport van. The driver placed the seatbelt around the resident's upper abdomen and secured the seatbelt to the floor anchors, one on the left side and one on the right side of the wheelchair. The geri chair was secured to floor anchors in 4 points, 2 in the front and 2 in the back. The driver checked all 4 anchor points for chair movement and checked to assure the seatbelt was tight and securely anchored. Another observation conducted on 11/2/20 at 11:40 AM revealed the DON checked Resident #1's chair to assure no movement of the chair and that the seatbelt was securely placed around her and anchored to the floor anchors. The DON also completed audits on 2 additional residents, one audit completed before the resident left the facility and one audit completed when the resident returned to the facility. Before the residents left the facility, the DON checked the security of the wheelchairs anchored at the 4 points, 2 in the front and 2 in the back as well as the seatbelt. When the one resident returned to the facility, she checked the 4 anchor points and the seatbelt to assure all had been secured for the transport back to the facility. A telephone interview, conducted with the Administrator on 11/3/20 at 11:30 AM, revealed he was not involved with investigating the incident. The DON conducted the investigation and reported the findings to him. He presented the incident, the findings of the investigation and the plan of correction to the QA committee on 11/2/20. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: All items listed on this self-imposed action plan have been completed and implemented on 10/22/20 with ongoing monitoring to ensure compliance. This concludes the action plan and any potential citations associated with this action plan should be considered past noncompliance as of 10/22/20. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: - 10/21/20 Resident #1 was assessed by the DON following the fall in the van. - 10/21/20 Physician was notified and Resident #1 was transferred to the hospital for evaluation. Resident #1 returned to the facility on [DATE] with no injuries. - 10/21/20 The van owner assessed the straps and the anchors inside the van. He conducted education for the van drivers which included checking the frame of the wheelchair/geri chair to ensure intact, no cracks and inspect all hardware, safety belts in good working order, ensure clients were secure in wheelchair and all straps in place and working properly and reviewed the safe procedures for transporting clients using wheelchairs/geri-chairs. IDENTIFICATION OF OTHER RESIDENTS: -All resident's wheelchairs were assessed to assure that no pillows were in the wheelchair in addition to a wheelchair cushion. -The DON interviewed the other interviewable residents, who were being transported by the van company, to assure the straps and seatbelt were secure when they were transported. No concerns were voiced. -The Rehab Department assessed Resident #1's wheelchair and the other 5 residents' wheelchairs, who were using the transportation van, to assure the residents were in the correct wheelchair and using the appropriate wheelchair cushion. Rehab staff added anti-tippers to Resident #1's wheelchair MEASURES FOR SYSTEMIC CHANGE: -10/21/20 The van owner assessed the straps and the anchors inside the van. -10/21/20 The van owner conducted education for the van drivers which included checking the frame of the wheelchair/geri wheelchairs/geri-chairs. The van drivers return demonstrated the safety checks. -10/21/21 The van drivers will complete the pre-trip checklist before each transport. -10/22/20 An in-service was provided to all nursing staff to assure no residents are sitting on a pillow in their wheelchair. HOW CORRECTIVE ACTION WILL BE MONITORED: -On 10/21/20 all residents were assessed for use of pillows in wheelchairs. All pillows were removed from resident wheelchairs. -On 10/21/20 the plan was made to randomly check at least 3 residents being transported to an appointment or to [MEDICAL TREATMENT] by the DON or designee, starting on 10/22/20, daily x 2 weeks, 3 x week x 2 weeks weekly x 4 weeks then monthly x 2 months. -10/21/20 the DON and the Administrator will review the audits monthly to identify any patterns or trends and will adjust the plan to maintain compliance. -10/21/20 The DON and the Administrator will review the plan during the monthly QAPI meeting, and the audits will continue at the discretion of the QAPI committee. -On 10/22/20 the DON or designee began audits of at least 3 residents being transported daily for 2 weeks, then 3 times a week for 2 weeks, then weekly for 4 weeks then monthly for 2 months. The Administrator was responsible for compliance. The date for the decision to QA and monitor was 10/21/20. End of QAPI/POC November 12, 2020. Resident #1 was discharged home with home health on 11/12/20. The Performance Improvement Project (PIP) was a self-imposed action plan that was reviewed in the QAPI meeting on November 13, 2020. On 11/13/20 at 10:15AM, during the Partial Extended Survey, an interview was conducted with Resident #2. She stated she was transported by the transport van three times a week for [MEDICAL TREATMENT]. She stated the van driver locked her wheelchair down in the front and in the back after he puts her in the van. He then put the seatbelt around her and locked it. He checked to make sure the wheelchair would not move and he made sure the seatbelt was on tight enough. She stated she does not sit on a pillow in her wheelchair and she has never felt unsafe when the van has taken her to [MEDICAL TREATMENT] and back. On 11/13/20 at 10:45AM, an observation was made of the van driver preparing to transport Resident #2 in a wheelchair. He demonstrated how he connected the securement system to the wheelchair at 4 points, 2 in the front and 2 in the back and secured the seatbelt around Resident #2 then secured the seatbelt to the floor anchors. He checked to assure the resident was not sitting on a pillow. The DON was observed checking behind the van driver to assure all 4 anchor points were secure and the seatbelt was securely intact around the resident and secured to the floor anchors. She rocked the wheelchair back and forth and pulled on the seatbelt straps to confirm the wheelchair and the resident were secure for transport. An interview, conducted 11/13/20 at 10:50 AM with the van driver, revealed he was re-educated on 10/21/20 by the van owner regarding securing all 4 anchor points to the wheelchair and to assure the seatbelt is securely fastened and secured to the floor anchor. He stated he was instructed not to transport a resident if they were sitting on top of a pillow in a wheelchair. On 11/13/20 at 1:00 PM the facility's plan for past noncompliance was validated by the following: 1) Review of the in-service training records revealed all four van drivers had been in-serviced on the van's securement system including return demonstrations on 10/21/20. 2) Review of the in-service training record revealed all the nursing staff were in-serviced on 10/22/20 regarding no resident had a pillow in their wheelchair. 3) Interviews were completed with the driver of the incident and the van owner. 4) The interviews validated the van drivers had undergone training regarding the safe application of the securement system including lap belts and shoulder harness. 5) A review of the facility's audits verified they were completed as specified in their self-imposed action plan. 6) Compliance was achieved on 10/22/20 when all the nursing staff were educated regarding there should be no pillows in resident wheelchairs.