Every finding on record at Brunswick Cove Nursing Center

Based on record review and interviews with the staff, Consultant Pharmacist, Nurse Practitioner (NP), and Medical Director, the facility failed to prevent a significant medication error when Nurse #1 administered Resident #2 Haldol (an antipsychotic medication used to treat severe behavioral issues) IM (intramuscular) (delivered via injection) 20 milligrams (mg) instead of the ordered 2 mg. This deficient practice affected 1 of 3 residents reviewed for significant medication errors. The findings included: Hospital records indicated Resident #2 had been admitted from 2/3/26 through 2/9/26 for hip pain following a fall. His principal discharge diagnosis was failure to thrive in an adult. The hospital records also indicated he had active problems that included recurrent falls, severe protein-calorie malnutrition, benign paroxysmal positional vertigo (dizziness) and Parkinson's disease. Resident #2 was discharged from the hospital with recommendations to continue the following psychotropic medications (medications that alter a person's brain chemistry to modify a person's mood, thoughts, perceptions and behaviors): clozapine (antipsychotic medication that can be used off-label to treat severe behavioral issues) 12.5 mg twice a day for psychosis in Parkinson's disease, clonazepam (antianxiety medication) 0.5 mg at bedtime as needed for anxiety, and Remeron (antidepressant medication) 30 mg at bedtime. Resident #2 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, adult failure to thrive, severe protein-calorie malnutrition, benign paroxysmal vertigo, history of falling, depression and cognitive communication deficit. Physician orders for Resident #2 on admission [DATE]) included the following psychotropic medications: clozapine 6.25 mg in the morning for psychosis in Parkinson's disease, clozapine 12.5 mg at bedtime for psychosis in Parkinson's disease, clonazepam 0.5 mg every 24 hours as needed for anxiety, and Remeron 30 mg at bedtime for depression. A Progress Note written by Nurse #2 on 2/10/26 at 11:32 AM indicated at 10:50 AM Resident #2 was observed walking to the bathroom on his own when staff tried to help and the resident got aggressive. Nurse #2 wrote that the resident punched her in the stomach and punched Nurse #3 in the stomach twice. The NP was made aware and gave orders to administer 2 mg Haldol IM every 8 hours as needed (prn) for agitation, fighting, and restlessness. An interview was conducted with Nurse #2 on 2/19/26 at 10:41 AM. Nurse #2 confirmed she worked on 2/10/26 and was assigned to care for Resident #2 that day. She indicated at approximately 11:00 AM that morning she and Nurse #3 assisted Resident #2 to the bathroom. She stated as they were assisting the resident, he head-butted Nurse #3 in the chest and slapped Nurse #3 on her buttocks. Nurse #2 stated his behavior escalated and became violent. She stated they were unable to redirect him. She indicated she spoke with the NP, who was present at the facility, and made her aware of the resident's behaviors. The NP gave a verbal order for Haldol 2 mg IM. Nurse #2 stated before she left the nurses' station to obtain the medication from the emergency medication supply, she returned to Resident #2's room to reassess him. She stated the resident's behavior had continued to escalate. Nurse #2 reported the NP then asked if she wanted another nurse to retrieve the medication, and she agreed. A Progress Note written by Nurse #1 on 2/10/26 at 12:30 PM indicated she received a verbal order from the NP for IM Haldol immediately related to verbal and physical aggression towards staff. The note indicated she administered a 20 mg IM dose instead of the 2 mg dose that was ordered. The provider was made aware immediately and the resident was sent out to Emergency Department (ED) for evaluation. An interview was conducted with Nurse #1 on 2/17/26 at 2:35 PM. Nurse #1 stated she was a Unit Manager and had worked on 2/10/26. She indicated the NP came to the nurse's station and informed her the nurses needed assistance. A verbal order was given for Haldol IM and she went to obtain the medication from the emergency medication supply. Nurse #1 explained that the order for the Haldol was not yet written, and she could not recall if the NP told her how much Haldol was to be given; yet for some reason, 20 mg stuck in her head. She stated she did not think to repeat the order back to the NP before she went to obtain the medication. She stated the only form of Haldol located in the emergency medication supply was vials that contained 5 mg/milliliter (ml). She stated there were 4 vials of Haldol 5 mg/ml in the emergency medication supply, and she took all 4 vials and then went to the supply room to get a needle and syringe. She indicated she administered 20 mg of Haldol IM to Resident #2. Nurse #1 stated the resident did not react to the injection. Nurse #1 indicated that she went to nurse's station and informed Nurse #2 and the NP that she administered 20 mg of Haldol to Resident #2. Nurse #1 stated that no one questioned her when she said 20 mg. Nurse #1 stated she went to a different nurse's station to complete paperwork she had been working on when she noticed the NP had left the written Haldol order there on her computer for her (Nurse #1) to enter it into the medical record. She explained that as she entered the order and got to the part where she had to enter the equation of what was on hand into the order, she said that was when it clicked that she had administered 20 mg instead of 2 mg. Nurse #1 stated she immediately went to Nurse #2 and informed her of the medication error, instructed Nurse #2 to monitor the resident for lethargy, and then went to inform the NP of the error. She stated the NP gave her orders to send the resident out to the hospital for cardiac monitoring. Nurse #1 stated Emergency Medical Services (EMS) arrived within 15 minutes and took the resident to the hospital. During an interview with Nurse #2 on 2/19/26 at 10:41 AM she stated that she was at the nurses' station on 2/10/26 when Nurse #1 came to inform her and the NP that she had made a medication error and administered 20 mg of Haldol instead of 2 mg to Resident #2. Nurse #2 stated she attempted to assess the resident and obtain vital signs. She explained that she placed a blood pressure cuff on the resident's arm; however, she could not obtain a reading because he would not remain still. Nurse #2 stated she notified the NP and Nurse #1, and the decision was made to call EMS and transfer the resident to the ED. Nurse #2 stated later that day the hospital contacted the facility and reported Resident #2 was stable and remained mildly agitated. An interview was conducted with the NP on 2/18/26 at 11:18 AM. She stated on 2/10/26 she observed Resident #2 kicking, punching, scratching, and grabbing at staff and observed as staff tried redirecting him with methods such as providing him an activity, offering him food and drink, and toileting; however, these methods did not help him and his behaviors continued to escalate. She further explained Resident #2 had just been admitted to the facility the day before and prior to this episode, these behaviors had never been witnessed. The NP reported that the resident's hospital paperwork indicated he had a history of delirium (sudden, temporary, and fluctuating state of severe confusion and reduced awareness), so it was expected that he would have some behaviors transitioning to the facility. The NP stated she reviewed Resident #2's medical record for any medication allergies and then made the decision to write an order for Haldol 2 mg IM. She stated she gave Nurse #1 a verbal order for the medication first and then wrote the order. The NP stated she clearly recalled that she instructed Nurse #1 to administer Haldol 2 mg IM injection. She reported she told Nurse #1 that she would write the order and leave it there for her to enter it into the medical record later. The NP stated Nurse #1 left to get the medication out of the emergency medication supply and she (the NP) wrote the order and then left to continue rounding on other residents. The NP indicated that shortly after, Nurse #1 came to her and informed her that she had administered 20 mg of Haldol to Resident #1 instead of 2 mg of Haldol. She explained that Haldol could cause over-sedation which then could lead to cardiac symptoms such as heart arrhythmias (abnormal heart rhythm) and respiratory depression (a dangerous condition where breathing becomes too slow or shallow, causing carbon dioxide to build up in the blood) and that at higher doses could increase these risks. She further explained that due to that reason, she instructed Nurse #1 to transfer Resident #2 to the ED for evaluation and monitoring. She reported that she observed Resident #2 prior to his ED transfer sitting in his wheelchair at the nurses' station and that he did not exhibit any signs or symptoms of acute distress. She said at that point, the resident was awake, alert, sitting calmly, and was not displaying any behaviors. The NP stated she assessed the resident and that his heart and lungs were within normal limits and he appeared stable. Resident #2's admission History and Physical completed by the Medical Director, dated 2/10/26, indicated the hospital discharge summary for the resident's stay prior to admission indicated he had significant hallucinations. The Medical Director's assessment included psychosis related to Parkinson's disease. The resident was admitted on clozapine. Resident #2 was noted to require close monitoring and psychiatric follow-up due to his diagnosis and medication regimen. The Medical Director documented that after evaluating the resident at the facility that day (2/10/26), he received a call from the facility reporting a medication error. The NP had ordered Haldol 2 mg IM, however, Resident #2 received 20 mg and was transferred to the ED for monitoring. The hospital record indicated on 2/10/26 Resident #2 presented to the hospital due to agitation and aggressive behavior at the facility. The resident had been discharged from the hospital to the facility the day before (2/9/26) for physical debility related to Parkinson's disease. After admission to the facility, he developed worsening paranoia and aggressive behaviors, including attempts of physical assault. Facility staff administered 20 mg of Haldol IM in error when a lower dose had been intended. Resident #2's heart was a normal rate and rhythm, he was able to protect his airway, laboratory studies were appropriate, and electrocardiogram (EKG) showed no arrhythmias. The resident remained paranoid and suspicious of others and the hospital admitted him for further evaluation and monitoring. The Hospitalist (physician in charge of Resident #2's care) consulted with Resident #2's neurologist who provided recommendations for low dose Seroquel or low dose Risperdal (both antipsychotic medications) should they require additional medications to treat his paranoia, psychosis and delusions (firm, fixed, and false beliefs that cannot be changed by evidence or reason) while he was in the hospital. Resident #2's family member had been pleased with his mobility progress while at the hospital and elected to take him home with plans for outpatient physical therapy. The resident had no outbursts while at the hospital, however his paranoid delusions persisted and the Hospitalist ordered for home Clozapine therapy, adjusted to 12.5 mg twice a day. Resident was discharged home on 2/13/26. A telephone interview was conducted with the Medical Director on 2/18/26 at 2:55 PM. The Medical Director stated that once staff identified the medication error on 2/10/26, the resident was immediately transferred to the hospital for evaluation and treatment. He explained that he was informed of the medication error on 2/10/26 by Nurse #1 after Resident #2 had already been transferred to the hospital. The Medical Director stated that due to the medication error and the potential for serious harm, sending the resident to the hospital for evaluation and monitoring was appropriate. He reported that based on the information provided to him by Nurse #1 after the medication error occurred, the resident appeared to pose a danger to himself and staff on 2/10/26. The Medical Director stated he believed the order for Haldol 2 mg IM was appropriate at that time. He reported that Haldol and other antipsychotic medications carried a risk of cardiac arrhythmias. He indicated he could not state how quickly cardiac symptoms could occur after a high dose of Haldol and indicated the question would be better addressed by the Consultant Pharmacist. During the interview, the Medical Director reviewed the hospital record for Resident #2 and stated the resident was monitored in the ED for 24 hours and did not experience cardiac arrhythmias. An interview was conducted with the facility's Consultant Pharmacist on 2/18/26 at 3:27 PM. She stated the DON informed her of the medication error for Resident #2 on 2/11/26. The Consultant Pharmacist stated that based on the reported behaviors, an order for Haldol 2 mg IM was appropriate. She explained that 2 mg IM is considered a starting dose. She stated that in an acute psychotic episode, the dose may be repeated hourly, depending on the resident's response. The Consultant Pharmacist indicated that Haldol dosing depended on the individual. She explained that common side effects of a 2 mg dose include sleepiness and a calming effect, with the goal of calming the individual without causing sleep. She further explained that the potential for adverse effects increased as the dose increased. She stated higher doses increased the risk of cardiac symptoms, including QT prolongation (an electrical abnormality seen on an EKG in which the heart muscle takes longer than normal to recharge between beats). She reported Haldol could also cause respiratory depression and coma in overdose situations. The Consultant Pharmacist stated that 20 mg was not automatically considered an overdose. She stated she reviewed the Haldol package insert and noted the maximum recommended dose listed was 30 mg. The Consultant Pharmacist stated that although 20 mg was below the listed maximum dose, it was a high dose given at one time and sending Resident #2 to the ED for monitoring was appropriate. An interview was conducted with the DON on 2/19/26 at 12:23 PM. The DON stated the medication error occurred during an incident in which the resident was combative and aggressive toward staff. The DON stated the nurse (Nurse #1) who received the order did not repeat the order back to the NP. She stated this breakdown in the process contributed to the medication error. The DON stated it was her expectation that nurses follow best practices when receiving and implementing medication orders and indicated that best practices included repeating the verbal order back to the NP. An interview with the Administrator was conducted on 2/20/26 at 9:28 AM. The Administrator stated it was his expectation the nurses follow the physician's medication orders. He stated that nurses should check and double-check orders to ensure they administer the correct medication and dose. The facility provided a corrective action plan that was not acceptable to the state survey agency.

Based on observations, record review and staff and Wound Physician interviews, the facility failed to follow a physician order for a wound treatment for 1 of 3 residents (Resident #16) observed for pressure ulcers.Findings included: Resident #16 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, wedge compression fracture of third thoracic vertebra and chronic pain. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #16's cognition was intact. He had impairments on both sides to upper and lower extremities and was coded as having a stage 3 pressure ulcer and one unstageable ulcer (deep tissue injury) not present on admission during this assessment. Review of Resident #16's care plan updated on 11/14/25 revealed a plan of care was in place for actual impairments to skin integrity related to quadriplegia with a goal that wounds will show improvement by the next review date. Interventions included in part, monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the physician orders revealed the following orders were in place for wound care: o Cleanse left outer ankle with normal saline, pat dry, apply calcium alginate (highly absorbent bandage ideal for controlling bleeding and lifts dead tissue from the wound) to wound bed, cover with clean dry dressing every day shift every Tuesday, Thursday, Saturday for stage 3 pressure ulcer written on 11/24/25.o Cleanse left outer knee with normal saline, pat dry, apply petroleum (non-adherent dressing to keep wounds moist, prevent sticking and offer a barrier) gauze to wound bed, cover with clean dry dressing every day shift every Tuesday, Thursday, Saturday for abrasion written on 11/24/25.o Cleanse right inner foot with normal saline, pat dry, apply petroleum gauze to wound bed, cover with clean dry dressing every day shift every Tuesday, Thursday, Saturday for deep tissue injury (DTI) written on 11/25/25. An observation of wound care was conducted on 12/03/25 at 1:50 PM with the Wound Treatment Nurse (WTN). During the wound care observation of the lower extremities the Wound Treatment Nurse removed a dated dressing initialed by Nurse #3 on 12/02/25 to Resident #16's right ankle and left ankle. The WTN stated there was supposed to be a dressing to right inner foot and pointed to the DTI noted just under the great toe. She stated the wound on the right ankle had resolved a couple of weeks ago and she was not made aware that it had reopened. The WTN stated there was no treatment ordered for the right ankle and she did not know why Nurse #3 had a dressing on it or why Nurse #3 did not let her know it had reopened. The WTN removed the dressing to the right ankle and noted it was petroleum gauze in place. The wound on the right ankle was noted to be bleeding when she removed the dressing. The WTN stated when the wound was previously present to the right ankle, she used calcium alginate for the treatment to aid in drying the wound up. She stated she would not have put petroleum on it as that would keep it moist. She stated the treatment that was on there was the petroleum and that dressing should have been on the DTI not the right ankle. The WTN stated she would be reviewing the reopened area with the wound physician on 12/04/25. The Wound Treatment Nurse added that Nurse #3 was doing the wound care on 12/02/25 to help out the WTN, and when the WTN provided care on Resident #16 on 12/01/25 the right ankle pressure ulcer was still resolved. A phone interview was conducted with Nurse #3 on 12/03/25 at 5:21 PM who completed the wound treatments for this resident on 12/02/25 to help out the WTN. Nurse #3 stated when she did wound care, she followed the physician orders and brought in all the necessary supplies to do the wound care. She stated she thought there was an order for the right ankle and put a dressing on it. She stated the wound was open and bleeding. At this time, the orders were reviewed with Nurse #3 and there was no order to apply a petroleum dressing to the right ankle. Nurse #3 stated she put the wrong dressing on the wrong area and confirmed she should have put the dressing on the right inner foot not the ankle. An interview with the Director of Nursing (DON) on 12/04/25 at 8:50 AM revealed her expectation of wound care was that any time a floor nurse identified a new wound on a resident, they should notify the physician or nurse practitioner and the Wound Treatment Nurse for a treatment order. The DON also stated she would expect her nursing staff to ensure they are following the prescribed orders when applying dressings to wounds. A follow up interview was conducted with the Wound Treatment Nurse on 12/04/25 at 9:30 AM. The WTN stated there was no note put in the binder notifying her regarding the new pressure ulcer to the right ankle. She stated the binder was new and was just implemented because it was determined through the interdisciplinary team that the facility had concerns with wound care communication. An interview was conducted with the Wound Physician on 12/04/25 at 11:45 AM. The Wound Physician stated he would have expected Nurse #3 to put the correct dressing on the correct wound. He also stated that any new wounds should be reported to the facility provider (Physician or Nurse Practitioner) as well as the Wound Treatment Nurse so the appropriate treatment can be implemented.

Based on observation, record review, and resident, staff and Nurse Practitioner (NP) interviews, the facility failed to provide supervision and ensure a smoking apron was worn for 1 of 1 resident identified as requiring supervision with smoking reviewed for smoking (Resident #99).Resident #99 was admitted into the facility on 9/30/20 with diagnoses of nontraumatic subdural hemorrhage (bleeding between the brain and its tough outer covering), syncope (a temporary loss of consciousness) and collapse (fall). A diagnosis of narcolepsy (a chronic condition where the brain cannot regulate sleep-wake cycles, causing overwhelming daytime sleepiness and sudden sleep during activities) was added on 12/9/22.Resident #99's quarterly Minimum Data Set, dated [DATE] revealed she was cognitively intact and had no impairment of her upper extremities.A review of Resident #99's smoking assessment dated [DATE], completed by the Social Service Assistant, determined Resident #99 was safe to smoke without supervision.A review of Resident #99's nursing progress note documented by Nurse #13 on 7/21/25 revealed the resident reported to her the fire from her cigarette fell onto her shirt and pants, and she went down the hallway with her clothes burning, and she was able to put it out with a cup water. A hole was noted on the bottom on her shirt along with the front of her pants. The resident denied any pain or discomfort. A complete body audit was completed and no burns or injuries were noted.Nurse #13 was not interviewed during the survey as she was no longer employed by the facility, and no contact information was available.A further review of Resident #99's medical record indicated a body audit conducted on 7/21/25 after the incident by Nurse #13 revealed no injury to Resident #99.A review of Resident #99's smoking assessment dated [DATE], completed by the Social Service Assistant, determined Resident #99 required supervision and a smoke apron related to recent burn marks on clothing.An interview conducted on 12/2/25 at 1:35 PM with the Social Service Assistant indicated that she completed the smoking assessment for Resident #99 on 7/21/25 and Resident #99 was determined to be a supervised smoker. She further indicated that she told the Social Service Worker the outcome of the assessments, who then informed the department heads. The Social Service Assistant stated that the smoking assessments were done quarterly and as needed.An interview conducted on 12/2/25 at 1:45 PM with the Social Service Worker revealed on 7/21/25 he had given Resident #99 a smoking apron, however, Resident #99 refused to wear it, and he had informed the department heads of the change in Resident #99's smoking status. He further stated with the incident on 7/21/25 and Resident #99's diagnosis of narcolepsy she should remain a supervised smoker.An observation with the Social Service Worker on 12/2/25 at 1:55 PM revealed Resident #99's smoking apron was located in a dresser drawer in her room.Resident #99's comprehensive care plan indicated a focus problem, revised on 7/21/25, of Resident #99 being a supervised smoker and to was to wear a smoking apron.Review of Resident #99's medical record from 7/22/25 to 12/2/25 revealed there were no documented incidents of burn marks on the resident's clothing as result of smoking or other smoking related injuries.An observation conducted on 12/2/25 at 9:19 AM of Resident #99 smoking revealed she was able to get outside to smoke independently and was not supervised by a facility staff member and was not wearing the smoking apron. There were no burn marks noted on the residents clothing and observations were made of her using a lighter to light her cigarette and the use of the appropriate fireproof receptacle to put her cigarette ashes in and extinguish her cigarette. An observation conducted on 12/2/25 at 10:05 AM of Resident #99 smoking revealed she was able to get outside to smoke independently and was not supervised by a facility staff member and was not wearing the smoking apron. There were no burn marks noted on the residents clothing and observations were made of her using a lighter to light her cigarette and the use of the appropriate fireproof receptacle to put her cigarette ashes in and extinguish her cigarette.An interview conducted on 12/2/25 at 12:55 PM with Resident #99 revealed that she went out to smoke whenever she wanted and had her own cigarettes and lighter that she kept in her room. She further revealed that no one had to watch her smoke and she did not wear an apron because she had never burnt herself. Resident #99 indicated that the facility had given her a apron to wear when she smoked but she does not wear it and it was in her dresser drawer.An interview conducted on 12/2/25 at 1:05 PM with Nurse Aide #1, assigned to Resident #99, indicated that Resident #99 was an independent smoker. Nurse Assistant #1 further indicated that she always asked the nurse if a resident required supervision when they smoked if she did not know. Nurse Aide #1 stated that any resident who smoked and was not supervised was allowed to have their cigarettes and lighter with them and could go outside to smoke anytime they wanted. An interview conducted on 12/2/25 at 1:15 PM with Nurse #12, assigned to Resident #99, revealed there was a period of time a few months back that Resident #99 was a supervised smoker for a few days after she had burned her shirt however at this time Resident #99 was an independent smoker.An interview conducted on 12/3/25 at 10:45 AM with the Nurse Practitioner indicated that at no time had she treated Resident #99 for burns related to her cigarette smoking and the facility conducted assessments on the residents who smoked to determine if they required supervision while smoking or not.An interview conducted on 12/2/25 at 2:40 PM with the Director of Nursing indicated that the staff should have been aware that Resident #99 was a supervised smoker. The Director of Nursing further indicated that Resident #99 should have had no smoking materials in her possession and should have been monitored and wore a smoking apron when she smoked.An interview conducted on 12/2/25 at 2:20 PM with the Administrator revealed that with changes in key nursing personnel there had been a lack of communication at times which he believed happened in this instance.

Based on record review, and resident, staff, Nurse Practitioner, and Wound Physician interviews, the facility failed to provide treatment for surgical wound as specified in the hospital discharge summary (Resident #48) and failed to offload a neck/shoulder contracture as ordered (Resident #6). This was for 2 of 3 residents reviewed for skin integrity (Resident #48 and Resident #6). Findings included: 1) Review of the hospital discharge summary orders dated 11/18/25 revealed Resident #48 was status post (recent past event) a left total hip replacement with surgical incision to left hip. The physician order sheet indicated Per facility guidelines Aquacel protocol, change every 5-7 days or as needed. Aquacel is wound care dressing that absorbs and locks in drainage and bacteria. Resident #48 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of hip and left hip replacement. The Minimum Data Set admission assessment dated [DATE] revealed Resident #48 was moderately cognitively impaired and was assessed as having a surgical wound. A nurse's note written on 11/18/25 by Nurse #7 revealed, Aquacel dressing in place, resident admitted this shift. A physician's order written on 11/18/25 directed nursing staff to monitor surgical incision to left hip for signs and symptoms of infection every shift for prevention. Document findings in nurses note. A physician's order written on 11/18/25 revealed cleanse surgical incision to left hip with normal saline solution (NSS), pat dry with gauze and cover with a clean dry dressing. There were no orders transcribed into the list of physician's orders to apply or change an Aquacel dressing in 5-7 days or as needed. An interview was conducted with Unit Manager #1 on 12/03/25 at 1:00 PM. Unit Manager #1 revealed she was the admitting nurse, and she did not see the wound order on the discharge instructions. She stated she only saw one page of the discharge summary orders from the hospital and an FL2 form (a medical form that lists physicians' recommended care needs and medications). She stated on the FL2 form it was noted on the first page Resident #48 had a surgical incision to left hip. She stated since she did not see any other orders for his surgical hip wound, she implemented an order after discussing with the Nurse Practitioner to cleanse with NSS, pat dry and cover with clean dry dressing daily. Unit Manager #1 stated it was not until 12/01/25 that she realized from the Wound Treatment Nurse that she overlooked the discharge wound orders to change Aquacel dressing to left hip in 5-7 days or as needed. She stated the order for changing the Aquacel never made it to the Treatment Administration Record (TAR) because she overlooked it. She stated she would have expected the floor nurses to question the current order when they noticed the Aquacel dressing in place and not just signed the TAR and put in a nursing note. The nurses should have clarified the order with the physician. Resident #48's care plan dated 11/18/25 revealed a plan of care was in place for actual impairment to skin integrity of left hip, left ankle, right ankle and venous insufficiency with a goal that resident would not have any complications related to surgical incision of left hip through the review date. Interventions included keep skin clean and dry. Use lotion on dry skin. Do not apply on surgical incision and monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, and signs and symptoms of infection to physician. An interview was conducted with Resident #48 on 12/01/25 at 3:08 PM. Resident #48 stated he had just a had hip replacement and he had staples to his left hip with a dressing. Resident #48 stated none of the nurses changed the dressing to his hip since he was admitted . The November 2025 Treatment Administration Record (TAR) revealed an order to cleanse surgical incision to left hip with NSS, pat dry with gauze, and cover with a clean dry dressing every day shift. On 11/18/25, Nurse #7 signed off the treatment as evidenced by a check mark and her initials. A nurse's note written on 11/18/25 by Nurse #7 read Aquacel dressing in place, resident admitted this shift. An interview was conducted with Nurse #7 via phone on 12/03/25 at 7:25 PM. Nurse #7 stated she worked on 11/18/25 and was assigned to Resident #48. She stated if there was a checkmark with her initials on the TAR then it meant she signed it off, but it must have been in error because she did not follow the order to cleanse with NSS. Nurse #7 stated Resident #48 was noted to have an Aquacel dressing in place and nurses do not usually remove the Aquacel dressings because it had to be done by the surgeon. Nurse #7 stated she should have clarified the treatment order when she noticed the Aquacel dressing. She stated the Aquacel dressing was intact and did not have any drainage noted on the outside. From 11/19/25 through 11/23/25 Nurse #5 signed off the treatment with a #9 (a key code that meant to see nurse's notes). Nurse's notes written on 11/19/25 through 11/23/25 referenced Aquacel in place. An interview was conducted with Nurse #5 via phone on 12/03/25 at 8:32 PM. Nurse #5 I think this is supposed to be #5 stated she looked at the discharge summary and did not see any orders to remove the Aquacel dressing on Resident #48. She stated she knew with Aquacel dressings, nurses are supposed to keep them in place for a certain amount of time. She stated she worked from 11/19/25 through 11/23/25 and she did not follow the order that was in place to cleanse with NSS because the Aquacel was in place and that was confusing to her. She stated she should have clarified the order on 11/19/25 and not just kept putting in a note that the Aquacel was in place. Nurse #5 stated she discussed the treatment orders with the Wound Treatment Nurse at some point (she could not recall which day), and the WTN was going to clarify the order. Nurse #5 stated she should have followed up after she let the WTN know about the order and the Aquacel dressing being in place. On 11/24/25, the Wound Treatment Nurse signed off the treatment with a #9. A nurse's note written on 11/24/25 by the Wound Treatment Nurse read Aquacel in place. There was no documentation on 11/25/25 or 11/26/25. On 11/27/25, Nurse #8 signed off the treatment as evidenced by a checkmark and her initials. An interview was attempted with Nurse #8 via phone on 12/04/25 at 10:00 AM. Nurse #8 did not return call. On 11/28/25 and 11/30/25, Nurse #10 signed off the treatment with a #9. A nurse's note written on 11/28/25 by Nurse #10 read Aquacel to left hip in place no drainage noted. A nurse's note written on 11/30/25 by Nurse #10 read Aquacel in place. An interview was conducted with Nurse #10 via phone on 12/04/25 at 10:18 AM. Nurse #10 stated she recalled an order being in place for Resident #48 to cleanse his surgical hip wound with normal saline. She stated she observed that Resident #48 had an Aquacel dressing and was not certain if it was supposed to be removed because there were no orders to remove it. Nurse #10 stated she texted the on-call Nurse who was the Director of Nursing (DON) on 11/28/25 about the order and the DON reached out to the Wound Treatment Nurse who said to leave the Aquacel dressing in place until the Wound Treatment Nurse returned on Monday (12/01/25). Nurse #10 stated she thought the Wound Treatment Nurse would know best about the order and that was why she called the DON to reach out to her to see what she wanted to do instead of notifying the physician and getting clarification orders. Nurse #10 stated the Aquacel dressing was intact and there was no drainage or seepage, so she left it alone. On 11/29/25 Nurse #11 signed off the treatment as evidenced by a checkmark and her initials. An interview was attempted with Nurse #11 via phone on 12/04/25 at 10:00 AM. Nurse #11 did not return the call. The December 2025 TAR revealed an order to cleanse surgical incision to left hip with NSS, pat dry with gauze, and cover with a clean dry dressing every day shift. There was no documentation on 12/01/25 and 12/02/25. An interview was conducted with the Wound Treatment Nurse on 12/03/25 at 11:00 AM. She stated she received a call from the Director of Nursing (DON) on Friday 11/28/25. She stated the DON stated a nurse (Nurse #10) was questioning that there was an order in place to change the dressing daily, but there was an Aquacel dressing in place and asked the Wound Treatment Nurse for clarification. The WTN stated she told the DON that she would look at the orders on Monday 12/01/25 when she returned and for Nurse #10 to record #9 and document the Aquacel was dry and intact. The Wound Treatment Nurse stated on 11/24/25, she recalled the wound treatment order to cleanse with normal saline and cover with dry dressing and remembered thinking to herself she needed to clarify that order because Resident #48 had an Aquacel dressing in place. The Wound Treatment Nurse stated she meant to clarify the order before she left for the holiday and got distracted and that was why there was no documentation in the treatment record for 11/25/25 and 11/26/25. The WTN stated when she came back on 12/01/25, she looked at the discharge summary orders and saw the Aquacel dressing order to change every 5 to 7 days. The Wound Treatment Nurse stated she called the Wound Physician and told him that Resident #48 had a follow up orthopedic appointment on 12/03/25 and that the facility did not have Aquacel in the building; but there was an order to change it every 5 – 7 days per protocol. The Wound Treatment Nurse stated the Wound Physician said to leave the dressing place (Aquacel). The Wound Treatment Nurse stated when she reviewed the orders on 12/01/25 she realized the order to change the Aquacel dressing to the left hip was not transcribed on 11/18/25. The Wound Treatment Nurse stated the Aquacel dressing should have been ordered and should have been changed between 11/23/25 and 11/25/25. An interview with the Director of Nursing (DON) on 12/04/25 at 8:50 AM revealed she recalled the day that Nurse #10 reached out to her because she was the Nurse on call that day. The DON stated she sent a text message to the Wound Treatment Nurse on 11/28/25 and told her that Nurse #10 was questioning what to do about the Aquacel dressing and the new dressing order. The DON stated the Wound Treatment stated to put #9 on the TAR and document that the dressing was dry and intact and she would look at it when she got back. The DON stated the order should have been clarified when it was first observed on 11/18/25 that he had an Aquacel dressing. She stated according to the discharge summary orders that were overlooked, the Aquacel dressing should have been removed between the fifth day which would have been 11/23/25 and the seventh day which would have been 11/25/25. An interview was conducted with the Nurse Practitioner on 12/03/25 at 2:00 PM. The Nurse Practitioner stated she did not recall discussing the order Unit Manager #1 put in place to cleanse the wound with normal saline, but she could have. She stated she would have expected the nurses to get clarification regarding the Aquacel dressing and when to remove it. She stated she discharged the resident on 12/02/25 and saw the Aquacel dressing in place. It was intact and she did not remove it. She stated she did not observe any drainage on the dressing. An interview was conducted with Wound Physician on 12/04/25 at 11:50 PM. The Wound Physician stated the Aquacel dressing can be removed by the nurses at the facility and should have been according to the discharge summary orders by 11/25/25. He stated the Aquacel dressing helps to absorb fluid and that was why it does not get changed for about five to seven days in the case of any post-operative drainage. 2). Resident #6 was initially admitted to the facility on [DATE] with the last readmission on [DATE]. His diagnoses included rheumatoid arthritis of multiple sites, type 2 diabetes and cellulitis. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact. He was dependent with personal hygiene, bathing/showers, and dressing upper and lower body and required partial to moderate assistance with rolling left and right in bed. A physician order dated 11/26/25 indicated please offload left neck/shoulder contracture, keep left neck fold clean and dry every 8 hours. A Nurse Practitioner (NP) progress note dated 11/26/25 indicated the chief complaint for the visit was altered mental status and confusion. The note also indicated that the left neck and shoulder was red, moist, and macerated. The NP had discussed with staff strategies to offload contractures and keep crevices clean and dry as possible. The note indicated it was ok to apply interdry (moisture wicking fabric) to left neck skin fold for moisture wicking properties. The NP order dated 11/26/25 indicated please offload left neck/shoulder contracture, keep left neck fold clean and dry every 8 hours (6:00 AM, 2:00 PM and 10:00 PM). A review of Resident #6's Treatment Administration Record (TAR) for December 2025 revealed Nurse #2 had not initialed as completed offloading Resident #6's left neck/shoulder contracture at 6:00 AM on 12/3/25 as ordered. During an observation on 12/3/25 at 12:30 PM with Nurse #1, Resident #6 was observed in bed with no offloading or moisture wicking fabric to the left neck/shoulder. Redness was noted to the left neck area. Nurse #1 stated that she had not looked earlier during her shift which started at 7:00 AM to see if there was anything in place to offload the left neck/shoulder contracture. She stated that the neck was supposed to be offloaded with a rolled washcloth and an interdry or an abdominal pad (highly absorbent and cushioning dressing) to wick away the moisture. Nurse #1 indicated she should have checked Resident #6's neck earlier during her shift to ensure the night shift nurse had placed something to offload Resident #6's left neck/shoulder contracture. Nurse #1 further stated that Resident #6's neck area had not gotten worse from her previous observation of the area on 12/2/25. An interview was conducted on 12/3/25 at 2:11 PM with the nurse (Nurse #2) who was assigned to care for Resident #6 on 12/2/25 at 7:00 PM to 12/3/25 at 7:00 AM. Nurse #2 stated she could not recall if Resident #6 had a rolled towel or anything in place for offloading. She further stated that she had administered all of Resident #6's medications during her shift, the Resident was not in pain, and that she could not recall placing anything to offload Resident #6's left neck/shoulder contracture. Nurse #2 stated that she had reviewed the TARs, and she could not tell how she missed the order at 6:00 AM. During an interview on 12/3/25 at 1:29 PM with the Nurse Practitioner (NP), she indicated that she had given an order to offload Resident #6's left neck/shoulder contracture after she noted Resident #6's left neck area was red, moist and macerated on 11/26/25. The NP verbalized she had told nursing staff that they should roll a towel and put it between the left ear and shoulder and that they could apply interdry to wick away the moisture and prevent further skin breakdown. The NP indicated she expected nurses to follow provider orders and if the area was not off loaded as ordered it could lead to further skin breakdown, infection and sepsis. During an interview on 12/4/25 at 8:55 AM with the Director of Nursing (DON), she stated nursing staff should have offloaded Resident #6's left neck/shoulder contracture as ordered or seek further clarification from the provider if they had any questions. During an interview on 12/4/25 at 10:02 AM with the Administrator, he stated that he expected nursing staff to follow physician orders.

Based on record review, observations, and staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 4 residents reviewed for respiratory care (Resident #72). The findings included:Resident #72 was admitted to the facility on [DATE]. His diagnoses included hypertension, and chronic obstructive pulmonary disease (COPD).A physician order dated 2/22/24 indicated administer oxygen via nasal cannula at 2 liters per minute continuously.Resident #72's care plan had a care focus area initiated on 2/24/24 that indicated Resident #72 was at risk for shortness of breath related to COPD and chronic respiratory failure. Interventions included administering oxygen via nasal cannula as ordered.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was severely cognitively impaired. His diagnoses included chronic obstructive pulmonary disease. He was coded for shortness of breath or trouble breathing with exertion and when lying flat.During observation on 12/2/25 at 11:06 AM Resident #72 was observed with the oxygen nasal cannula in place. Resident #72's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. During observation on 12/3/25 at 12:19 PM Resident #72 was observed with the oxygen nasal cannula in place. Resident #72's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. Resident #72's oxygen regulator was verified with Nurse #1 to be set at 3 liters per minute. An interview was conducted on 12/3/25 at 12:20 PM with Nurse #1 who was assigned to care for Resident #72 on 12/2/25 and 12/3/25 during the day shift (7:00 AM - 7:00 PM). Nurse #1 stated Resident #72 had a physician order for oxygen at 2 liters per minute via nasal cannula. She further explained she would normally check the setting on the oxygen concentrator when she went to the room, but she had not checked it earlier that morning when she was in Resident #72's room.Attempts to interview the nurse who was assigned to care for Resident #72 on night shift 12/2/25 at 7:00 PM to 12/3/25 at 7:00 AM were unsuccessful. An interview was conducted on 12/3/25 at 1:29 PM with the Nurse Practitioner (NP). She stated she expected nurses to ensure oxygen was set at the ordered rate and if they needed to titrate the oxygen rate, she expected nurses to call the provider to request adjustment to the oxygen rate.An interview was conducted on 12/3/25 at 4:17 PM with the Director of Nursing (DON). She stated Nurse #1 should have verified that Resident #72's oxygen regulator was set at the physician ordered rate. The DON explained she expected nursing staff to follow physician orders and to request an updated order if there was a need to titrate the oxygen. She stated nurses should verify oxygen rates when they assumed the residents' care and throughout their shift.During an interview on 12/4/25 at 10:02 AM with the Administrator, he stated he expected nurses to monitor the oxygen setting to ensure that it was set at the provider ordered rate.

Based on observations, record review, and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident (Resident #105) with a pressure ulcer wound when the Wound Treatment Nurse was providing resident care without wearing the required personal protective equipment (PPE) for 1 of 4 staff observed for infection control. Findings included: The facility policy dated 07/26/22 titled, Enhanced Barrier Precautions an infection control intervention designed to reduce the transmission of multi-drug resistant organisms. It employs targeted personal protective equipment (PPE) use during high contact resident activities to include, in part, dressing, bathing, providing hygiene, changing linens or briefs. High contact residents included, in part, wound care; any skin opening requiring a dressing, and enteral feeding tubes. An observation of Resident #105's doorway to her room revealed a small magnetic banner at the entrance of the resident's room on the door frame that had the letters EPB with the letters A (a bed) and B (b bed) the letter B was circled. There was no visible personal protective equipment (gowns, gloves) noted in Resident #105's room and there was no signage posted in the room to indicate what healthcare personnel must apply during high contact resident care activities. An observation of wound care was conducted on 12/03/25 with the Wound Treatment Nurse at 1:17 PM. The Wound Treatment Nurse entered Resident 105's room and proceeded to inform the resident she was going to do her pressure ulcer dressing change. The Wound Treatment Nurse washed her hands and applied gloves, but she did not put on a protective gown. The Wound Treatment Nurse removed the existing dressing on Resident #105. She then removed her gloves, applied hand sanitizer and reapplied clean gloves, but she did not put on a protective gown. She cleansed the wound and applied the physician ordered treatment. An interview with the Wound Treatment Nurse on 12/03/25 at 1:38 PM revealed she realized halfway through that she forgot to put on a gown while doing her pressure ulcer treatment. The Wound Treatment Nurse stated on the rehabilitation hall where Resident #105 resided, the PPE was kept on top of the resident closets, and the signage should have been posted on the outside of the resident's bathroom door. She stated if she had seen the signage out in the open, it would have helped her to remember to apply the PPE. The Wound Treatment Nurse stated the residents' rooms should have the Enhanced Barrier Precaution signage hanging in the resident's room as well as having the magnetic banner on the door frame, but she did not know why there was no signage in Resident #105's room. The Wound Treatment Nurse stated that the signage indicated that staff should wear gloves and gowns for high contact resident care which included wound care that required a dressing, but the magnetic banner only indicated there was EBP in the room and which bed (as indicated by a circle around the letter). An interview with the Director of Nursing (DON) on 10/02/25 at 3:30 PM revealed she would have expected the staff member to apply the appropriate PPE to include a gown whenever she was providing care to a resident with an open wound. She stated the Enhanced Barrier Precaution policy was in place to protect other residents and staff members from infection and that more education needed to be given to the staff. The DON added that on the Rehabilitation Hall the gowns were put on top of the resident's closet and there should have been signage on the bathroom door as well as the magnetic banner on the entrance door.

Based on observations, record review, staff and physician and pharmacist technician specialist interviews, the facility failed to obtain an order to flush a percutaneous intravenous central catheter (PICC) with normal saline and heparin (blood thinning agent) flushes for 1 of 1 resident (Resident #129) reviewed for intravenous (IV) antibiotics. Findings included: Resident #129 was admitted to the facility on [DATE]. Diagnoses included diabetic foot ulcer, pain, osteomyelitis (bone infection), and left toes amputations. The Minimum Data Set 5 day assessment dated [DATE] revealed Resident #129 was moderately cognitively impaired and had impairment to one side to his lower extremity. Resident #129 was assessed as having a pressure ulcer and a surgical wound and was receiving intravenous (IV) medications. A physician's order written on 11/19/25 to monitor double lumen PICC dressing to right upper extremity to ensure the dressing was clean, dry and intact every shift for infection prevention. A physician's order written on 11/19/25 for Meropenem (antibiotic) IV Solution reconstituted one gram (gm) use 100 milliliters IV every 8 hours for infection of bone and bone marrow until 12/24/25 to infuse over 30 minutes. There were no physician orders for the administration of saline or heparin flushes. Review of the Medication Administration Record for November from 11/19/25 through 11/30/25 revealed Resident #129 received the Meropenem antibiotic 3 times daily for a total of 34 doses as evidenced by a checkmark and nursing initials. Review of the Medication Administration Record for December from 12/01/25 through 12/03/25 revealed Resident #129 received the Meropenem antibiotic 3 times daily for a total of 7 doses as evidenced by a checkmark and nursing initials. A physician's order written on 11/20/25 change double lumen (two access ports) to the right upper extremity PICC line dressing and hub (access point) every day shift on Tuesday for infection prevention. A physician's order written on 11/21/25 for Vancomycin Hydrochloride (antibiotic) IV Solution 1.5 grams/250 milliliters (ml) IV in the morning for infection to bone and bone marrow until 12/24/25 to infuse minimally over 2.5 hours. There were no physician orders for the administration of saline or heparin flushes. Review of the Medication Administration Record for November from 11/19/25 through 11/30/25 revealed Resident #129 received the Vancomycin antibiotic daily for 11 days as evidenced by a checkmark and nursing initials. Review of the Medication Administration Record for December from 12/01/25 through 12/03/25 revealed Resident #129 received the Vancomycin antibiotic daily for 3 days as evidenced by a checkmark and nursing initials. An observation of Resident #129's medications with Unit Manager #1 on 12/03/25 at 11:30 AM revealed a box of prefilled 10ml saline flushes individually wrapped and labeled with Resident #129's name and a box of prefilled 5ml heparin flushes individually wrapped labeled with Resident #129's name. There were noted to be several saline and heparin flushes removed from each box. An interview with Nurse #4 on 12/03/25 at 11:23 AM revealed when she administered the Meropenem IV Antibiotic IV she would first sanitize the hub with an alcohol wipe, flush the access port with 10ml saline flush, and start the medication as ordered. She stated when the medication was completed, she would flush the catheter line with 10ml saline again and then flush with 5ml of a heparin flush. Nurse #4 confirmed there were no orders written to flush the IV catheter, but the pharmacy provided the flushes for Resident #129 so she used them. She stated the flushes were to keep the catheter line patent (unobstructed). Nurse #4 stated she should have clarified the orders with the Physician for the flushes. An interview was conducted with Nurse #6 via phone on 12/03/25 at 12:30 PM. Nurse #6 reported whenever a resident had an IV antibiotic the protocol was to flush with 10ml of normal saline, give the antibiotic, flush with 10ml saline again and then flush with 5ml of heparin. At this time, the orders were reviewed with Nurse #6 and she confirmed there were no actual orders to flush the IV catheter with saline or heparin. She stated there were available prefilled flushes labeled for Resident #129 on the medication cart and in the medication room for saline and heparin flushes and from experience she knew that the catheter line should be flushed before and after the administration of an IV antibiotic to keep the line patent. Nurse #6 stated she should have clarified with the physician and entered the orders in the electronic medical record. An interview was conducted with the Nurse Practitioner on 12/03/25 at 1:10 PM and revealed there should have been specific orders in place for both the saline and the heparin flushes. She stated she would enter both those orders now. The Nurse Practitioner stated the saline and heparin flushes were important because they kept the catheter line open and prevented blockages. The NP stated having the orders on the eMAR ensured the flushes were being administered. An interview was conducted with Nurse #3 via phone on 12/03/25 at 5:21 PM. Nurse #3 reported that when she hung the IV antibiotics for administration she always used the SASH (saline, antibiotic, saline, heparin) method which meant she would flush the catheter line with 10ml saline, start the antibiotic, when the antibiotic was finished, she would flush the catheter line again with 10ml saline and then flush the catheter line with 5ml heparin. She stated she did not realize there were no specific orders for the saline and heparin flushes, but that Resident #129 had labeled saline and heparin flushes to use and she just followed the protocol that she knew to do as a Registered Nurse. Nurse #3 stated she should have obtained the orders from the physician for clarity for the saline and heparin flushes. An interview was conducted with Nurse #5 via phone on 12/03/25 at 8:32 PM. Nurse #5 stated she worked the night shift and administered the Vancomycin and the Meropenem antibiotics scheduled for 6:00 AM. She stated she would swab the access port with an alcohol wipe and follow the SASH protocol. Nurse #5 stated she thought there were orders for the flushes. She stated the facility was provided with prefilled saline and heparin flushes labeled for Resident #129, and she knew by experience with IV antibiotics you have to flush the catheter line to keep it patent. Nurse #5 stated she should have obtained orders to flush the IV catheter. She stated there were no complications with the IV catheter line; it had always been patent. An interview was conducted with the Quality Assurance Pharmacy Technician Specialist via phone on 12/04/25 at 12:58 PM. The Pharmacy Technician stated that since there was an order for intravenous antibiotics for Resident #129, the pharmacy automatically sent the prefilled saline and heparin flushes labeled for that resident. She stated that what they (the pharmacy) enters into their software system did not go across to the facility's electronic medication administration record (eMAR) so the facility was responsible for entering their orders. The Pharmacy Technician stated the facility should have entered the 10ml saline flush and the 5ml heparin flush into their eMAR. An interview was conducted with the Physician via phone on 12/04/25 at 2:02 PM. The Physician stated he would have absolutely expected the nursing staff to obtain orders for the heparin and saline flushes when the orders for the antibiotics were written. The Physician added, the orders needed to be in place to maintain patency of the catheter line and prevent blockages. The Physician added that although it seemed the nursing staff were utilizing the correct method to flush the intravenous catheter, he still would have expected the orders to be entered into the eMAR to document that the flushes were being given. An interview was conducted with Director of Nursing (DON) on 12/04/25 at 8:50 AM. The DON stated although the nursing staff was following best practice and following the SASH method, they should have obtained clarification orders regarding the saline and heparin flushes.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of medication, dental and continence for 4 of 30 residents whose MDS assessments were reviewed (Resident # 283, Resident #99, Resident #76 and Resident #115). Findings included: 1. Resident # 283 was admitted on [DATE] with diagnosis which included major depressive disorder. Review of Resident #283's physician orders revealed an order dated 12/19/23 for Aripiprazole 5 milligrams (mg). Give 1 tablet by mouth every 12 hours related to major depressive disorder. Review of Resident #283's December 2023 electronic Medication Administration Record revealed resident received Aripiprazole 5 mg 1 tablet every 12 hours related to major depressive disorder. Review of Resident #283's admission Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact and had no behaviors. The MDS indicated Resident #283 received an antipsychotic medication, an antidepressant and anticoagulant. The antipsychotic medication review was coded as no antipsychotic medication was not received since admission. An interview was conducted with MDS Coordinator #1 on 7/25/24 at 10:15 AM. MDS Coordinator #1 stated it was an error that the antipsychotic medication was not coded on the MDS assessment. An interview was conducted on 7/25/24 at 3:15 PM with the Director of Nursing (DON). The DON revealed that she expected that the MDS assessments would be completed accurately. 2. Resident # 99 was admitted to the facility on [DATE] with medical diagnosis which included: diabetes, stroke and peripheral vascular disease. Review of Resident #99's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact and had no broken natural teeth. An interview and observation were conducted with Resident #99 on 7/22/24 at 11:51 AM. Observation revealed Resident #99 had multiple broken upper teeth. Resident #99 stated her cardiologist advised she was not a candidate for dental procedures. An interview was conducted with MDS Coordinator #1 on 7/25/24 at 10:15 AM. MDS Coordinator #1 stated Resident #99's MDS assessment was miscoded when the dental section indicated resident did not have any dental issues. MDS Coordinator #1 stated the MDS assessments should be accurate and include the resident's current condition. An interview was conducted with the DON on 7/25/24 at 3:15 PM. The DON revealed that she expected that the MDS assessments would be completed accurately. 3. Resident #76 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease and failure to thrive. Review of Resident #76's electronic health record revealed a progress note dated 6/27/24 at 9:00 PM which indicated the resident was alert, required minimal assistance with care and was continent of bowel and bladder. Review of Resident #76's annual Minimum Data Set (MDS) assessment dated [DATE] indicated resident was always continent of bladder and occasionally incontinent of bowel. An interview was conducted with Resident #76 on 7/22/24 at 1:15 PM. Resident #76 stated she was able to take herself to the bathroom and was continent of bowel and bladder. An interview was conducted with the MDS Coordinator #1 on 7/25/24 at 10:15 AM. MDS Coordinator #1 indicated it was human error that bowel and bladder was miscoded on Resident #76's annual MDS assessment dated [DATE]. An interview was conducted with the DON on 7/25/24 at 3:15 PM. The DON stated she expected that the MDS assessments would be completed accurately. 39731 4. Resident #115 was admitted to the facility on [DATE] with diagnoses that included depression, dementia and agitation. A review of the physician's orders revealed Resident #115 received olanzapine (an antipsychotic medication) 10 mg at bedtime since 3/11/24 for delusions. Resident #115's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment revealed Resident #115 was assessed as having severe cognitive impairment. He received antipsychotic and antianxiety medication during the lookback period. The assessment was further coded as antipsychotics not being received on the question related to gradual dosage reduction of antipsychotic medication. During an interview with MDS Coordinator #1 on 7/24/24 at 4:12 PM she stated Resident #115 received antipsychotic medication during the lookback period and the assessment question regarding a gradual dose reduction was coded incorrectly. An interview was conducted with the DON on 7/25/24 at 3:15 PM. The DON stated she expected that the MDS assessments would be completed accurately.

Based on record review, staff, Nurse Practitioner and Physician interviews, the facility failed to ensure a resident had an ophthalmology appointment scheduled as ordered on 1/11/24, 2/13/24 and 3/26/24 resulting in the resident not seen until 4/19/24 and failed to obtain the retinol specialist appointment recommended by the ophthalmologist for 1 of 1 resident (Resident #101) reviewed for vision. Findings included: Resident #101 was admitted on [DATE] with diagnoses which included post traumatic brain injury and Parkinson's Disease. Resident #101's electronic health record revealed a Nurse Practitioner progress note dated 1/11/24 which indicated resident had a visual disturbance and the note indicated the resident needed to see an ophthalmologist. Resident #101's electronic health record revealed a physician order entered by Nurse #8 dated 1/11/24 for ophthalmology consult for visual disturbances of the left eye with history of cataract about [AGE] years ago. An interview was conducted with Nurse #8 on 7/25/24 at 2:50 PM. Nurse #8 stated she worked at the facility through an agency. Nurse #8 stated she was not able to enter orders in the computer, did not know why the order showed that she entered it. Nurse #8 stated she did not know anything about an order for an ophthalmologist consult for Resident #101. Resident #101's electronic health record revealed a Neurology consultation note dated 2/5/24 which indicated resident complained of acute visual changes which started 4 weeks ago. The note indicated Resident #101 was very concerned about his vision and needed an ophthalmologist appointment for vision concerns. Resident #101's electronic health record revealed a 2/13/24 physician progress note which indicated a second request was made for resident to have an ophthalmology appointment. Resident #101had a new complaint of diplopia (double vision) and vision changes. Resident #101's electronic health record revealed a physician order entered by Nurse #7 dated 2/13/24 for an ophthalmology appointment due to visual changes and diplopia (double vision). Attempts were made to interview Nurse #7 via phone with messages left. No return call was received. Resident #101's electronic health record revealed a physician progress note dated 3/18/24. The physician note stated neurology requested resident to have an appointment with ophthalmology secondary to double vision to the left eye. The note further indicated on the last encounter 1 month ago, an ophthalmologist appointment was requested. Resident #101 continued to complain of left sided vision changes. Resident #101's electronic health record revealed a 3/26/24 Nurse Practitioner (NP) progress note which indicated an order was written once again for a referral to an ophthalmologist due to visual changes and blurred vision of the left eye. Resident #101's electronic health record revealed a physician order entered by Nurse #7 dated 3/26/24 for an ophthalmology consult for evaluation of blurred vision. Attempts were made to interview Nurse #7 via phone with messages left. No return call was received. Resident #101's electronic health record revealed a 4/19/24 ophthalmology chart note which indicated resident presented for a first eye exam. The ophthalmology chart note indicated Resident #101 had a comprehensive eye exam and presented with right eye blurriness and left eye was totally blurry. Resident #101 was unable to see out of the left eye. The note stated Resident #101 required urgent referral within 1 to 2 weeks to a retinol specialist for further assessment and possible treatment. Resident #101's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and had adequate vision. Resident #101's care plan last revised on 6/4/24 revealed vision was not addressed. An interview was conducted with Resident #101 on 7/22/24 at 11:50 AM. Resident #101 stated his main concern was that he needed to see a retinol specialist. Resident #101 expressed concern about his vision and the need for an appointment to find out more about what was going on with his eye. He indicated there were no changes with his daily function. An interview was conducted with the Medical Records Specialist on 7/24/24 at 4:30 PM. The Medical Records Specialist indicated she was responsible for coordinating podiatry, dental and ophthalmology visits for the facility. The Medical Records Specialist indicated typically the facility provided ophthalmology services in house but the company the facility used did not have a provider to send to the facility since August 2023. The Medical Records Specialist stated she informed the Director of Nursing that there was not an ophthalmologist available to provide services at the facility. An interview was conducted with MDS Coordinator #1 on 7/25/24 at 10:15 AM. She stated she tested his vision for the MDS assessment by having him identify objects and read a sentence. MDS Coordinator #1 stated if a resident's record had an order for a referral to see a specialist and she did not see evidence that it was done, she would discuss it with the provider and follow up with staff regarding the appointment. MDS Coordinator #1 stated she did not recall any follow up that she had completed regarding the ophthalmologist or retinol specialist appointments for Resident #101. A follow up interview with MDS Coordinator #1 was conducted on 7/25/24 at 12:05 PM. MDS Coordinator #1 stated a care plan meeting was held with Resident #101 on 6/17/24 and during the meeting, he stated he was worried about his vision. The DON attended the meeting and put in a request for the physician to discuss the results of his April ophthalmologist appointment. MDS Coordinator #1 stated Resident #101 was scheduled for a follow up appointment with the ophthalmologist on 8/7/24 at 2:30 PM. An interview was conducted with the Transportation Specialist on 7/25/24 at 2:45. The Transportation Specialist stated she was responsible for scheduling appointments after she received an appointment tracker form from the nurse with the order written by the physician or NP. After she received the form, the Transportation Specialist stated she faxed the resident's demographic records to the office and would wait a few days or weeks to call the office to see if the appointment could be scheduled. The transportation specialist was unable to provide an appointment tracker form for Resident #101 for ophthalmologist or retinol specialist appointments or records of calls that she made to obtain the appointments. The Transportation Specialist was unable to recall why there was a delay in obtaining Resident #101's ophthalmology appointment. The Transportation Specialist stated she did not know about the order for the retinol specialist consult for Resident #101. An interview was conducted with the Nurse Practitioner (NP) on 7/25/24 at 10:45 AM. The NP stated she wrote orders for appointments and there was a delay in obtaining them. The NP stated it was hard to get appointments made for residents. The NP stated it was important for Resident #101's overall care to be seen by the ophthalmologist and the retinol specialist. The NP indicated the facility should follow orders to obtain appointments. An interview was conducted with the Physician on 7/24/24 at 11:45 AM. The Physician stated he was not sure why there was a delay in obtaining appointments. The Physician indicated referrals were always a problem and obtaining appointments with specialists could be difficult. The Physician stated orders were rewritten several times for the ophthalmology appointment for Resident #101 as it was not made. The Physician stated he expected the facility should follow up to clarify if an appointment had been made by the ophthalmologist for the resident to be seen by the retinol specialist and the nursing staff should communicate the status of appointments. An interview was conducted with the Director of Nursing (DON) on 7/25/24 at 3:15 PM. The DON stated there was a system process failure with the referrals for appointments. When an order was written for a consult or an appointment, the nurse was supposed to complete an appointment tracker form and give it to the Transportation Specialist. The DON stated Nurse #7 worked as needed (PRN) and may not have been aware of the process for obtaining appointments. The DON further indicated the consult note from the ophthalmologist was scanned into the electronic record and may not have been reviewed by the NP or physician. The DON stated she expected that when a provider wrote an order for an appointment it would be obtained in a timely manner and the status of the order would be communicated to the provider.

Based on record review, staff interviews and Consultant Pharmacist interview the facility failed to ensure the facility staff reviewed pharmacy recommendations and documented any action taken or a rationale for no action taken on the pharmacy request for 1 of 5 residents reviewed for drug regimen review (Resident #115). The findings included: Resident #115 was admitted to the facility on [DATE] with diagnoses that included depression, dementia and agitation. A review of the physician's orders revealed Resident #115 received olanzapine (antipsychotic medication) 10 milligrams (mg) at bedtime since 3/11/24 for psychotic disturbance with mood disturbance and anxiety. A review of the electronic medical record revealed there was no AIMS (Abnormal Involuntary Movement Scale) completed. Resident #115's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment, revealed Resident #115 was assessed as having severe cognitive impairment. He received antipsychotic and antianxiety medication during the lookback period. Review of the Consultant Pharmacist's notes revealed an AIMS assessment was recommended on 3/20/24, 4/16/24, 5/22/24, and 6/17/24. There were no responses to the recommendations on the Medication Regiment Reviews. An interview on 7/25/24 at 2:03 PM with the Consultant Pharmacist revealed an AIMS assessment should have been done due to Resident #115 being placed on antipsychotic medication. An interview was conducted with the current Director of Nursing (DON) on 7/24/24 at 11:02 AM who stated the Consultant Pharmacist's recommendations should be reviewed and addressed by the DON or designee. She stated an AIMS should have been completed when the resident was placed on an antipsychotic medication and every 92 days afterwards.

Based on record review and staff and Consulting pharmacist interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 of 5 residents (Resident #11) reviewed for unnecessary medications who received psychotropic medications. The findings included: Resident #115 was admitted to the facility on [DATE] with diagnoses that included psychotic disturbance with mood disturbance and anxiety. A review of the physician's orders revealed Resident #115 received olanzapine (antipsychotic medication) 10 milligrams (mg) at bedtime since 3/11/24 for delusions. A review of the electronic medical record revealed there was no AIMS completed. Resident #115's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment, revealed Resident #115 was assessed as having severe cognitive impairment. He received antipsychotic and antianxiety medication during the lookback period. Review of the Consultant Pharmacist's notes revealed an AIMS assessment was recommended on 3/20/24, 4/16/24, 5/22/24, and 6/17/24. An interview on 7/25/24 at 2:03 PM with the Consultant Pharmacist revealed an AIMS assessment should have been done due to Resident #115 being placed on antipsychotic medication. An interview was completed with the Quality Assurance Nurse on 7/24/24 at 11:07 AM who stated it must have been an oversight. She reported she was responsible for completing the AIMS when recommended by the consulting pharmacist. During an interview with the Director of Nursing on 7/24/24 at 11:02 AM she stated after reviewing Resident #115's record he had never had an AIMS assessment completed. She stated it should have been done but the computer system did not automatically trigger for nursing staff to do the assessment.

Based on record reviews, observation, resident and staff interviews the facility failed to develop a comprehensive person-centered care plan for the focus areas of antidepressant and antiplatelet medications, continence and indwelling catheter for 3 of 30 residents (Resident #76, Resident #99 and Resident #283) reviewed for comprehensive care plans. Findings included: 1.Resident #76 was admitted to the facility on [DATE] with diagnoses of depression, anxiety and insomnia. Review of Resident #76's electronic health record revealed a progress note dated 6/27/24 at 9:00 PM which indicated resident was alert and required minimal assistance with care. Resident #76 was continent of bowel and bladder and was non ambulatory. Review of Resident #76's annual Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact, was always continent of bladder and occasionally incontinent of bowel. The MDS indicated Resident #76 received antianxiety, antidepressant, antibiotic, opioid, and antiplatelet medications. The Care Area Assessment (CAA) for psychotropic medication dated 6/28/24 indicated to proceed to the care plan to address psychotropic medication use. Review of Resident #76's care plan last updated on 6/28/24 revealed a focus area of occasional bladder incontinence and at risk for skin breakdown. Resident #76's care plan did not include a focus area of antidepressant or antiplatelet medication use. Review of Resident #76's July 2024 electronic Medication Administration Record revealed electronically signed entries for duloxetine (an antidepressant medication) 60 milligram (mg) once per day, doxepin (an antidepressant medication) 50 mg 2 capsules at bedtime for insomnia, and aspirin 81 mg once per day. An interview was conducted with Resident #76 on 7/22/24 at 1:15 PM. Resident #76 stated she was able to take herself to the bathroom and was continent of bowel and bladder. An interview was conducted on 7/25/24 at 10:15 AM with MDS Coordinator #1. MDS Coordinator #1 stated care plans should be accurate and reflect the resident's current condition. MDS Coordinator #1 stated medications including antidepressants and antiplatelet medications should be included in the care plan. MDS Coordinator #1 verified Resident #76 received antidepressants and antiplatelet medications and should have been included in the resident's care plan. MDS Coordinator #1 further indicated Resident #76's care plan did not accurately reflect resident's continence and toileting ability An interview was conducted on 7/25/24 at 3:15 PM with the Director of Nursing (DON). The DON stated she expected the care plans would be person centered and accurately reflect the resident's condition including medications and continence. 2. Resident #99 was admitted to the facility on [DATE] with diagnoses of stroke and peripheral vascular disease. Review of Resident #99's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact, was frequently incontinent of bladder and always incontinent of bowel. Resident #99 was coded as having received antiplatelet and anticoagulant medications. The Care Area Assessment (CAA) for incontinence dated 5/20/24 indicated to proceed to the care plan to address bladder and bowel incontinence. Review of Resident #99's most recent care plan dated 5/20/24 revealed a focus area of incontinence of bladder. Interventions included notifying nursing if incontinent during activities and clean peri area with each incontinence episode. Resident #99's care plan did not include incontinence of bowel, constipation or medications received for constipation. Resident #99's care plan did not include a focus area of antiplatelet medication use. Review of Resident #99's July 2024 electronic Medication Administration Record revealed electronically signed entries for: aspirin 81 mg one time per day for prevention, clopidogrel bisulfate 75 mg one time per day related to history of transient ischemic attack and cerebral infarct, polyethylene glycol 17 gram (gm) once per day for constipation, senna glycoside 8.6 mg give 2 tablets at bedtime for constipation. An interview and observation were conducted with Resident #99 on 7/22/24 at 11:51 AM. Resident #99 stated she had incontinence of bowel and bladder, required incontinence care with thorough cleansing of her peri area and had areas of skin breakdown. Observation indicated Resident #99 had a small bruise on her hand. Resident #99 stated she received blood thinning medication and bruised easily. An interview was conducted with MDS Coordinator #1 on 7/25/24 at 10:15 AM. MDS Coordinator #1 stated the care plans were to be accurate and include the resident's current condition. MDS Coordinator #1 stated Resident #99's care plan should have included bowel incontinence and medications. An interview was conducted on 7/25/24 at 3:15 PM with the DON. The DON stated she expected the care plans would be person centered and accurately reflect the resident's condition including incontinence and medications. 3. Resident #283 was admitted on [DATE] with diagnosis which included in part urinary retention. Review of Resident #283's physician orders revealed an order dated 12/26/23 for indwelling catheter to bedside drainage due to urinary retention. Review of Resident #283's admission MDS dated [DATE] revealed resident was cognitively intact, had an indwelling catheter and was always incontinent of bladder and bowel. The Care Area Assessment (CAA) for incontinence/catheter dated 12/26/23 was reviewed and indicated to proceed to the care plan to address use of a catheter. Review of a care plan dated 12/26/23 revealed a focus area of bowel and bladder incontinence. The goal indicated resident will remain free from skin breakdown due to incontinence and brief use. Interventions included Resident #283 used disposable briefs, cleanse peri-area after incontinence episodes, and check frequently for incontinence. Resident #283's care plan did not include a focus area of indwelling catheter. An interview was conducted with MDS Coordinator #1 on 7/25/24 at 10:15 AM. MDS Coordinator #1 stated the care plans should be accurate and include the resident's current condition. MDS Coordinator #1 indicated indwelling catheter should have been included in Resident #283's care plan. An interview was conducted on 7/25/24 at 3:15 PM with the DON. The DON stated she expected the care plans would be person centered and accurately reflect the resident's condition. The DON indicated an indwelling catheter should have been included in the care plan.

Based on record review, Physician interview, Nurse Practitioner (NP) interview, staff interviews, and Responsible Party (RP) interview, the facility failed to notify the resident's (Resident #89) Responsible Party (RP) and the facility Physician of the resident's fall and change in condition for 1 of 4 sampled residents reviewed for change of condition. Findings included: Resident #89 was originally admitted to the facility on [DATE]; she was readmitted on [DATE]. Her diagnoses included malignant neoplasm of colon, weakness, malignant neoplasm of unspecified ovary. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #89 was cognitively intact. She was independent concerning mobility which included sitting to lying, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walking 10 ft, walking 50 feet with 2 turns, and walking 150ft. She was in hospice care. Review of Resident#89's electronic medical record (EMR) listed her daughter #1 as her responsible person (RP). Review of Nurse #1's progress notes revealed on 7/14/2024 resident #89 was found lying on the floor beside her bed. She had fallen out of bed and hit her head on the trash can. She was found to have a 1/2-centimeter (cm) laceration over left eyebrow. Resident #89's family who lived locally, (daughter #2 and resident #89's son in law), came to visit her. The nursing documentation further stated resident #89 knew daughter #2 and her son in law and spoke with them at that time. An interview was conducted on 07/23/24 12:28 PM with Nurse #1. She stated she did not witness the fall. She added resident #89 was in hospice and had a do not resuscitate order (DNR). She stated she was notified by Nurse #2 that resident fell and had a gash on her head. She stated resident #89 was placed back to bed and she was still talking at that time. Nurse #1 asked Nurse #2 if resident needed to go out. Nurse #1 stated Nurse #2 called resident #89's hospice nurse. Nurse #1 stated daughter #2 and son in law came to visit resident #89 and was informed about the fall. Nurse #1 added daughter #2 came to the nursing desk to tell them resident #89 fell asleep and they would come back another time. Nurse #1 stated the hospice nurse arrived and stated the hospice nurse called the physician and daughter #1 (RP) in North Dakota (ND) who told her she did not want resident #89 to be sent out. Nurse #1 added the next day the Nurse Practitioner (NP) came in and spoke to daughter #2 and son in law (who live locally), as well as daughter #1. The hospice supervisor was present as well. Daughter #1 living in ND was put on speaker phone and stated she did not want resident #89 sent out. An interview was conducted on 7/23/24 at 3:00pm with daughter #2 who was present after resident #89 fell . She stated she and her husband walked into resident #89's room and was told by staff resident had just fallen. She stated resident #89 responded to her. Approximately 15-20 minutes later resident #89's eyes closed, and she started snoring. She then called her brother, who lives locally and told him something wasn't right. At that point resident #89 opened her eyes, leading daughter #2 to think she was overreacting. She stated she went out to nursing desk and told them resident#89 was asleep and they would come back. She stated around 7pm her sister/resident #89's RP called her and told her the hospice nurse called her and informed her resident #89 fell and she had symptoms of a possible brain bleed. An interview was conducted on 7/23/24 at 2:41pm with resident #89's daughter #1/RP. She stated she found out about resident #89's fall and unconscious state from the Hospice Nurse the evening of 7/14/2024. Daughter #1 was not notified by the facility until the next day that resident #89 fell and was not responsive. An interview was conducted on 07/24/24 at 11:56 AM with Nurse #2. She stated she recalled resident #89 fell and hit her head. She believes she was the one who called hospice. She stated she was present when hospice came, however does not recall a phone conversation with resident #89's RP. She does recall another daughter being present. She stated resident #89 had been declining in the previous weeks. She recalled that resident #89 was alert at the time she left her shift. An interview was conducted on 07/24/24 at 2:29 PM with the Hospice Nurse. She stated the facility called her about resident #89's fall. She arrived at the facility between 5:30-6:00pm on 7/14/2024 and spoke to Nurse #2 who told her resident #89 had a small cut on her forehead and was talking since the last report. The hospice nurse stated she walked into resident #89's room, found her lying in bed asleep and snoring. She attempted to wake her, performed a sternal rub, and got no response. She checked her pupils which were pin-point and fixed. She stated she then went down to the nurse's station and called resident #89's RP to inform her what happened. The RP told the Hospice Nurse the facility hadn't contacted her yet about it. The Hospice Nurse and resident #89's RP discussed the options of sending her to the hospital or keeping her at the facility and keeping her comfortable; the RP told the Hospice Nurse not to send resident #89 out, to just keep her comfortable. After leaving the facility, the hospice nurse stated resident #89's RP called her back and told her she was concerned after speaking to a male nurse, that resident would not be made comfortable/monitored for seizures/get the care she needed. The Hospice Nurse stated she told the RP she would stay the night with her and returned to the facility around 9:30pm. The Hospice Nurse stated she stayed with resident and received updated pain medication orders from as needed to every 2 hours after speaking with her hospice physician. The Hospice Nurse stated she did not notice any seizure activity. Review of the Nurse Practitioner's progress note dated 7/15/2024 revealed she was not made aware of this resident #89's condition until she came in to do rounds. The NP's progress note indicated she had a detailed conversation with resident #89's son, Hospice Nurse, and her RP (via telephone) at which time resident #89's RP wanted her to have comfort measures only. The NP's progress note included that the facility staff/hospice team were made aware of the importance of contacting teamhealth whenever there is a change and or a need to speak to a provider regarding her care. During an interview on 7/24/24 at 10:41AM with the facility Nurse Practitioner she indicated resident #89's RP did not want her sent out. She added she would expect to be notified of any changes in status. An interview was conducted with the facility physician on 7/24/24 at 11:33 AM, who stated per review of NP's progress note dated 7/15/24, she was not notified of resident #89's fall until 7/15/24. He further added that his review of on call records for his practice revealed no notations of any incoming calls from facility on 7/14/2024-7/15/2024. Although he was not on call on 7/14/2024, he would expect the facility to contact the on-call provider for changes in a resident's condition.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services for 2 of 3 (Resident #112 and Resident #115) residents reviewed for beneficiary protection review. The findings included: 1. Resident #112 was admitted to the facility on [DATE] and admitted to Medicare Part A services. Resident #112's admission Minimum Data Set assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #112's Medicare Part A skilled services ended on 4/30/24 and he remained in the facility. Review of Resident #112's medical records revealed a NOMNC (Notice of Medicare Non-Coverage) was signed on 4/26/24. Record review revealed no SNF ABN was provided to the resident. An interview was conducted with Resident #112 on 7/25/24 at 12:05 PM and he stated he could not recall signing or receiving any forms when his Medicare Part A skilled services ended. An interview was conducted with the facility Social Worker on 7/23/24 at 11:51AM who stated he did not complete the SNF ABN form when Resident #112 remained in the facility. He stated he was unaware the SNF ABN form was necessary when a resident remained in the facility after Medicare Part A skilled services ended. An interview was conducted with the facility Administrator on 7/25/24 at 12:15 PM who stated she was unaware the SNF ABN form was necessary when a resident remained in the facility after Medicare Part A skilled services ended. 2. Resident #115 was admitted to the facility on [DATE] and admitted to Medicare Part A skilled services. Resident #115's admission Minimum Data Set assessment dated [DATE] revealed the resident hadsevere cognitive impairment. Resident #115's Medicare Part A skilled services ended on 2/9/24 and he remained in the facility. Review of Resident #115's medical records revealed a NOMNC was signed by the resident on 2/6/24. Record review revealed no SNF ABN was provided to the resident. An interview was conducted with the facility Social Worker on 7/23/24 at 11:51AM who stated he did not complete the SNF ABN form when Resident #115 remained in the facility. He stated he was unaware the SNF ABN form was necessary when a resident remained in the facility after Medicare Part A skilled services ended. An interview was conducted with the facility Administrator on 7/25/24 at 12:15 PM who stated she was unaware the SNF ABN form was necessary when a resident remained in the facility after Medicare Part A skilled services ended.

Based on record review, observations, staff and physician interviews, the facility failed to apply signage indicating the use of oxygen outside the resident's room for 2 of 2 residents reviewed for oxygen use (Resident #11 and Resident #112). The findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses which included asthma. The care plan dated 6/19/24 indicated Resident #11 was using oxygen continuously at 2 LPM (liters per minutes). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was cognitively intact and coded for the use of oxygen. A physician's order for Resident #11 dated 7/18/24 for 2 LPM oxygen continuous via nasal cannula and checks every shift. During an observation and interview on 7/22/24 at 10:14 am, there was no signage outside Resident #11's room indicating the use of oxygen. Resident #11 was observed not wearing her oxygen via nasal cannula at 2 LPM. The oxygen concentrator was observed on the left side of the bed in Resident #11's room. She stated she did not need oxygen. In an observation on 7/24/24 at 11:12 am, there was no signage outside Resident #11's room indicating the use of oxygen. The oxygen concentrator was observed on the left side of the bed in Resident #11's room. Resident #11 was observed not wearing her oxygen via nasal cannula at 2 LPM. During an interview with MA #2 (Medication Aide) on 7/23/24 at 2:58 pm, she stated Resident #11 was on continuous oxygen at 2 LPM. On 7/23/24 at 3:00 pm in an interview with Nurse #1, she explained she did not recognize there was no Oxygen in use, no smoking signage outside her door. She stated an Oxygen in use, no smoking signage should have been placed outside Resident #11's door when the oxygen was ordered by the physician or when nursing staff recognized the signage was not outside the door. On 7/24/24 at 2:36 pm in during an interview with the Director of Nursing, she stated nursing should have placed an Oxygen in use, no smoking sign on Resident #11's door indicating oxygen in use when the order was written by the physician. She further explained the nursing staff should have placed the Oxygen in use, no smoking sign outside Resident #11's when they placed the oxygen concentrator in her room. During an interview with the physician on 7/24/24 at 11:35 am, he stated Resident #11 had an order for continuous oxygen at 2 LPM via nasal cannula. He further stated the staff did not inform him Resident #11 was not wearing her oxygen. He indicated Resident # 11's oxygen saturation rates were within normal limits and there was no adverse outcome for Resident #11 not wearing her oxygen. 2. Resident #112 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic respiratory failure, interstitial pulmonary disease. A physician's order for Resident #112 dated 3/4/24 revealed 2 LPM oxygen continuous via nasal cannular and checks every shift. Review or the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #112 was cognitively intact and coded for the use of oxygen. During an observation on 7/22/24 at 11:00 am, there was no signage outside Resident #112's room indicating the use of oxygen. The oxygen concentrator was observed by the bedside in Resident #112's room. Resident #112 was observed sitting in the dining room watching television without his oxygen. In an observation on 7/23/24 at 11:00 am, there was no signage outside Resident #112's room indicating the use of oxygen. The oxygen concentrator was observed on the left side of the bed in Resident #112's room. Resident #112 was observed not wearing his oxygen. During an interview with Resident #112 on 7/23/24 at 11:09 am, stated he did take his oxygen off when he was not in his room. He liked to go to the dining room and watch television. He further stated he would wear his oxygen while he was in his room. During an interview on 7/23/24 at 3:15 pm with Nurse #5, she indicated it was the nursing staff's responsibility for placing the red oxygen signage on Resident #112's door. She further indicated she did not know why Resident #112 did not have the oxygen signage on his door. She also stated that he would take his oxygen off when he was not in his room. On 7/24/24 at 2:36 pm in during an interview with the Director of Nursing, she stated nursing should have placed an Oxygen in use, no smoking sign on Resident #112's door indicating oxygen in use when the order was written by the physician. She further explained the nursing staff should have placed the Oxygen in use, no smoking sign outside Resident #112's when they placed the oxygen concentrator in his room. During an interview with the physician on 7/24/24 at 11:35 am, he stated Resident #112 had an order for continuous oxygen at 2 LPM via nasal cannula. He indicated he was aware of Resident # 112 removing his oxygen while out of his room. He indicated his saturation rates were within normal limits and there was no adverse outcome for Resident #112 not wearing his oxygen while out of his room.

Based on record review and resident, family and staff interviews, the facility failed to speak to a resident in a respectful manner for 1 of 1 resident reviewed for dignity and respect (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, acute ischemic heart disease, chronic obstructive pulmonary disease, congestive heart failure and weakness. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact and required the extensive assistance of staff for bed mobility, toileting and personal hygiene. The MDS assessment indicated Resident #1 was always incontinent of her bowels and bladder. Review of Resident #1's Care Plan, dated 05/04/23, revealed she had an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility. An interview was conducted with Resident #1 on 07/05/23 at 12:07 p.m. Resident #1's family member was present at the time of the interview. When asked if the staff treated her with dignity and respect, Resident #1 said, sometimes and sometimes they are rude to me. When asked to explain further or to give an example, Resident #1 explained she did not want to get anyone in trouble or fired nor did she want anyone to come into her room at night to accuse her of getting them in trouble. At that time, Resident #1's family remarked to her that she should tell of an incident she had told him about during their visit - an incident that occurred that morning. Resident #1 stated she was not sure of the exact time, but thought it had been between the hours of 4:00 a.m. to 6:00 a.m. She explained she had pushed her call bell to request assistance for incontinent care and NA #1 had entered her room to provide care. Resident #1 explained NA #1 spoken rudely to her during the task. When asked if she had reported the incident to anyone, Resident #1 indicated she had informed Nurse #1 when he came in her room to give her medication and she thought he had reported it to the dayshift nurse, Nurse #2. During an interview with Nurse #2 on 07/05/23 at 12:56 p.m., Nurse #2 stated Nurse #1 reported Resident #1 had complained about NA #1 being rude towards her. Nurse #2 explained NA #1 was from another country and had an accent when speaking. Nurse #2 explained Resident #1 might have perceived NA #1 was being rude because NA #1 sometimes spoke loudly when talking with residents in an effort to make herself better heard and understood. Nurse #2 further explained that Nurse #1 had reported to her that after he had spoken with NA #1 about the resident's complaint and how NA #1 then returned to Resident #1's room with two other nursing assistants (NA #2 and NA #3) and began questioning Resident #1, wanting to know why she had complained, that she had not been trying to hurt her, and asked the resident why she would have lied about the incident. During an interview with NA #1 on 07/05/23 at 3:22 p.m., NA #1 explained she entered Resident #1's room to provide incontinent care just before 6:00 a.m. After explaining to the resident the care she was going to perform, NA #1 stated Resident #1 consented and then she put the head of the bed down and asked the resident to turn. NA #1 explained Resident #1 has a lot of pain and instead of physically helping the resident turn to her side, she asked the resident to turn in the bed and then she provided the incontinent care. NA #1 stated she later heard the resident had complained against her and she went back to Resident #1's room and brought NA #2 and NA #3 with her to confront the resident and asked her, why did you lie on me? NA #1 stated she did not point her fingers at the resident, nor did she raise her voice. NA #1 further explained that Nurse #1 had told her Resident #1 had been crying and complained she had been rough with her during the care. NA #1 stated she probably should not have returned to Resident #1's room and also stated that she did not bring the two other nursing assistants with her, that they had followed her in. During an interview with Nurse #1 on 07/05/23 at 4:49 p.m., Nurse #1 stated he had entered Resident #1's room around 6:00 a.m. to give her medication. He explained the resident was upset, anxious and tearful and when he had asked her what had happened to upset her, she told him NA #1 had been rude with her during care and she was not used to being treated that way. Nurse #1 indicated he told her he would speak with NA #1. Nurse #1 stated he went on down the hall to continue his medication pass when he saw a group of nursing assistants down the hall by the other nurses' station. He stated as he was explaining to them that one size does not fit all in regard to the type of care they provide different residents, NA #1 came out of a resident's room and told him the resident had lied to him about her having treated the resident rudely. He stated after their meeting, he saw NA #1 walk down the hall with NA #2 and NA #3 and clarified he did not know they were on their way to Resident #1's room, that he just thought the three of them were going on a break together. Nurse #1 stated he continued his medication pass when he heard NA #1 yelling from inside of Resident #1's room and he immediately walked back down the hall to the resident's room. He explained NA #2 was standing in the doorway of Resident #1's room and NA #1 and NA #3 were standing over the resident's bed and NA #1 was yelling at the resident, what are you lying for, what are you lying for, you're lying and stated NA #1 just kept yelling and repeating the same statements over and over to the resident. Nurse #1 stated he thought Resident #1 was frightened and he called the nursing assistants to come out of the resident's room. When asked if he had ever had any in-service trainings on abuse, Nurse #1 said he knew what he saw and heard was verbal abuse and reiterated it was definitely verbal abuse. Nurse #1 stated the yelling by NA #1 was so loud that another resident (Resident #2) had come out of his room to see what the commotion was about and when he saw the nursing assistants coming out of Resident #1's room he told them, you're getting paid to take care of the residents, not yell at them. A second interview was conducted with Resident #1 on 07/06/232 at 9:06 a.m. Resident #1 stated she had a good night. The resident also remarked that she was in her right mind and said she was not scared of the nursing assistants, but they had hurt her feelings. Resident #1 explained the way she had been yelled at by NA #1 was just rude and that Nurse #1 had told her their behavior was unacceptable. Resident #1 stated she does not like anyone treating her like dirt. An interview was conducted with Resident #2 on 07/06/23 at 9:16 a.m. Resident #2's MDS, dated [DATE], indicated he was cognitively intact. Resident #2 explained he did not see the nursing assistants, but he heard them. He stated he left his room to go and get his medications from Nurse #1 and stated he heard NA #1 screaming, not yelling at Resident #1 from within Resident #1's room. Resident #2 stated when the nursing assistants left Resident #1's room, he told them (as they passed him going back up the hall), they pay to stay here, and you get paid to take care of them and if you were to ever talk to me that way you wouldn't have a job. Resident #2 indicated the nursing assistants did not respond to him. An interview was conducted with NA #2 on 07/06/23 at 9:41 a.m. NA #2 explained she had only gone to Resident #1's room to gather the trash from the room and the bathroom. NA #2 stated NA #1 was just talking with the resident, asking her why she would lie and say the things she did to Nurse #1. NA #2 indicated NA #1 used her normal tone of voice but did keep repeating her questions to the resident. NA #2 stated Resident #1 was hysterical and that she kept changing her story to NA #1. NA #2 explained that she thought Resident #1 thought they were going to do something to her because she saw all of us in there. NA #2 stated she felt it might have been intimidating to the resident because she might have thought we were going to do something to her but indicated they were not planning on doing anything to the resident, that NA #1 just wanted to know why the resident thought she had been rude with her during the care. NA #2 stated she told NA #1 to come on, we've got other residents to get changed as they work together to help each other make rounds. NA #2 stated the other nursing assistant involved, NA #3, had been standing beside NA #1 at the resident's bed and indicated that NA #3 did not say anything to the resident and had told NA #1, come on, let's go. An interview was conducted with NA #3 on 07/06/23 at 10:09 a.m. NA #3 explained she was assigned to take care of Resident #1 from 11:00 p.m. to 7:00 a.m. on 07/04/23. NA #3 explained she had gone to the resident's room to get her sister (NA #1) out of the room because she knew that in this line of care, we are not supposed to argue with residents. NA #3 explained after NA #1 kept asking the questions over and over, it got loud, and she did not want the situation to escalate and stated she grabbed NA #1's hand and between her and NA #2, they got NA #1 out of Resident #1's room. When asked to describe their positions in the room in relation to the resident lying in her bed, NA #2 explained Resident #1's bed faced the door, with the head of the bed against the wall where the window was. She further explained the resident's right side of the bed was against the wall and NA #1 was on the left side of the bed by the foot of the bed. NA #3 explained she was just inside the door to the room until she went up to NA #1 and took her by the hand and encouraged her to walk away. NA #3 stated she felt that NA #1 was not upset, that she just wanted to know why the resident told the nurse what she did. During an interview with the Administrator on 07/06/23 at 9:25 a.m., the Administrator explained NA #1 is not from the United States and speaks with an accent that can sometimes be difficult to understand. The Administrator felt the way she spoke with Resident #1 on the morning of 07/05/23 was secondary to her sociocultural perspective in that she spoke loudly to the resident to make herself better understood. The Administrator indicated that she will be doing one-to-one training with NA #1 as well as sensory training with all of her staff.

Based on record review and resident, family and staff interviews, the facility failed to speak to a resident in a respectful manner for 1 of 1 resident reviewed for dignity and respect (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, acute ischemic heart disease, chronic obstructive pulmonary disease, congestive heart failure and weakness. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact and required the extensive assistance of staff for bed mobility, toileting and personal hygiene. The MDS assessment indicated Resident #1 was always incontinent of her bowels and bladder. Review of Resident #1's Care Plan, dated 05/04/23, revealed she had an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility. An interview was conducted with Resident #1 on 07/05/23 at 12:07 p.m. Resident #1's family member was present at the time of the interview. When asked if the staff treated her with dignity and respect, Resident #1 said, sometimes and sometimes they are rude to me. When asked to explain further or to give an example, Resident #1 explained she did not want to get anyone in trouble or fired nor did she want anyone to come into her room at night to accuse her of getting them in trouble. At that time, Resident #1's family remarked to her that she should tell of an incident she had told him about during their visit - an incident that occurred that morning. Resident #1 stated she was not sure of the exact time, but thought it had been between the hours of 4:00 a.m. to 6:00 a.m. She explained she had pushed her call bell to request assistance for incontinent care and NA #1 had entered her room to provide care. Resident #1 explained NA #1 spoken rudely to her during the task. When asked if she had reported the incident to anyone, Resident #1 indicated she had informed Nurse #1 when he came in her room to give her medication and she thought he had reported it to the dayshift nurse, Nurse #2. During an interview with Nurse #2 on 07/05/23 at 12:56 p.m., Nurse #2 stated Nurse #1 reported Resident #1 had complained about NA #1 being rude towards her. Nurse #2 explained NA #1 was from another country and had an accent when speaking. Nurse #2 explained Resident #1 might have perceived NA #1 was being rude because NA #1 sometimes spoke loudly when talking with residents in an effort to make herself better heard and understood. Nurse #2 further explained that Nurse #1 had reported to her that after he had spoken with NA #1 about the resident's complaint and how NA #1 then returned to Resident #1's room with two other nursing assistants (NA #2 and NA #3) and began questioning Resident #1, wanting to know why she had complained, that she had not been trying to hurt her, and asked the resident why she would have lied about the incident. During an interview with NA #1 on 07/05/23 at 3:22 p.m., NA #1 explained she entered Resident #1's room to provide incontinent care just before 6:00 a.m. After explaining to the resident the care she was going to perform, NA #1 stated Resident #1 consented and then she put the head of the bed down and asked the resident to turn. NA #1 explained Resident #1 has a lot of pain and instead of physically helping the resident turn to her side, she asked the resident to turn in the bed and then she provided the incontinent care. NA #1 stated she later heard the resident had complained against her and she went back to Resident #1's room and brought NA #2 and NA #3 with her to confront the resident and asked her, why did you lie on me? NA #1 stated she did not point her fingers at the resident, nor did she raise her voice. NA #1 further explained that Nurse #1 had told her Resident #1 had been crying and complained she had been rough with her during the care. NA #1 stated she probably should not have returned to Resident #1's room and also stated that she did not bring the two other nursing assistants with her, that they had followed her in. During an interview with Nurse #1 on 07/05/23 at 4:49 p.m., Nurse #1 stated he had entered Resident #1's room around 6:00 a.m. to give her medication. He explained the resident was upset, anxious and tearful and when he had asked her what had happened to upset her, she told him NA #1 had been rude with her during care and she was not used to being treated that way. Nurse #1 indicated he told her he would speak with NA #1. Nurse #1 stated he went on down the hall to continue his medication pass when he saw a group of nursing assistants down the hall by the other nurses' station. He stated as he was explaining to them that one size does not fit all in regard to the type of care they provide different residents, NA #1 came out of a resident's room and told him the resident had lied to him about her having treated the resident rudely. He stated after their meeting, he saw NA #1 walk down the hall with NA #2 and NA #3 and clarified he did not know they were on their way to Resident #1's room, that he just thought the three of them were going on a break together. Nurse #1 stated he continued his medication pass when he heard NA #1 yelling from inside of Resident #1's room and he immediately walked back down the hall to the resident's room. He explained NA #2 was standing in the doorway of Resident #1's room and NA #1 and NA #3 were standing over the resident's bed and NA #1 was yelling at the resident, what are you lying for, what are you lying for, you're lying and stated NA #1 just kept yelling and repeating the same statements over and over to the resident. Nurse #1 stated he thought Resident #1 was frightened and he called the nursing assistants to come out of the resident's room. When asked if he had ever had any in-service trainings on abuse, Nurse #1 said he knew what he saw and heard was verbal abuse and reiterated it was definitely verbal abuse. Nurse #1 stated the yelling by NA #1 was so loud that another resident (Resident #2) had come out of his room to see what the commotion was about and when he saw the nursing assistants coming out of Resident #1's room he told them, you're getting paid to take care of the residents, not yell at them. A second interview was conducted with Resident #1 on 07/06/232 at 9:06 a.m. Resident #1 stated she had a good night. The resident also remarked that she was in her right mind and said she was not scared of the nursing assistants, but they had hurt her feelings. Resident #1 explained the way she had been yelled at by NA #1 was just rude and that Nurse #1 had told her their behavior was unacceptable. Resident #1 stated she does not like anyone treating her like dirt. An interview was conducted with Resident #2 on 07/06/23 at 9:16 a.m. Resident #2's MDS, dated [DATE], indicated he was cognitively intact. Resident #2 explained he did not see the nursing assistants, but he heard them. He stated he left his room to go and get his medications from Nurse #1 and stated he heard NA #1 screaming, not yelling at Resident #1 from within Resident #1's room. Resident #2 stated when the nursing assistants left Resident #1's room, he told them (as they passed him going back up the hall), they pay to stay here, and you get paid to take care of them and if you were to ever talk to me that way you wouldn't have a job. Resident #2 indicated the nursing assistants did not respond to him. An interview was conducted with NA #2 on 07/06/23 at 9:41 a.m. NA #2 explained she had only gone to Resident #1's room to gather the trash from the room and the bathroom. NA #2 stated NA #1 was just talking with the resident, asking her why she would lie and say the things she did to Nurse #1. NA #2 indicated NA #1 used her normal tone of voice but did keep repeating her questions to the resident. NA #2 stated Resident #1 was hysterical and that she kept changing her story to NA #1. NA #2 explained that she thought Resident #1 thought they were going to do something to her because she saw all of us in there. NA #2 stated she felt it might have been intimidating to the resident because she might have thought we were going to do something to her but indicated they were not planning on doing anything to the resident, that NA #1 just wanted to know why the resident thought she had been rude with her during the care. NA #2 stated she told NA #1 to come on, we've got other residents to get changed as they work together to help each other make rounds. NA #2 stated the other nursing assistant involved, NA #3, had been standing beside NA #1 at the resident's bed and indicated that NA #3 did not say anything to the resident and had told NA #1, come on, let's go. An interview was conducted with NA #3 on 07/06/23 at 10:09 a.m. NA #3 explained she was assigned to take care of Resident #1 from 11:00 p.m. to 7:00 a.m. on 07/04/23. NA #3 explained she had gone to the resident's room to get her sister (NA #1) out of the room because she knew that in this line of care, we are not supposed to argue with residents. NA #3 explained after NA #1 kept asking the questions over and over, it got loud, and she did not want the situation to escalate and stated she grabbed NA #1's hand and between her and NA #2, they got NA #1 out of Resident #1's room. When asked to describe their positions in the room in relation to the resident lying in her bed, NA #2 explained Resident #1's bed faced the door, with the head of the bed against the wall where the window was. She further explained the resident's right side of the bed was against the wall and NA #1 was on the left side of the bed by the foot of the bed. NA #3 explained she was just inside the door to the room until she went up to NA #1 and took her by the hand and encouraged her to walk away. NA #3 stated she felt that NA #1 was not upset, that she just wanted to know why the resident told the nurse what she did. During an interview with the Administrator on 07/06/23 at 9:25 a.m., the Administrator explained NA #1 is not from the United States and speaks with an accent that can sometimes be difficult to understand. The Administrator felt the way she spoke with Resident #1 on the morning of 07/05/23 was secondary to her sociocultural perspective in that she spoke loudly to the resident to make herself better understood. The Administrator indicated that she will be doing one-to-one training with NA #1 as well as sensory training with all of her staff.

Based on observation and staff interviews, the facility failed to date foods stored for use in one of one kitchen walk-in refrigerator. Findings included: A tour was conducted on 5/22/23 at 10:10 AM, with the Dietary Manager of the kitchen walk-in refrigerator. Observations were made of 4 prepared side salads with no date, 8 wrapped sandwiches with no date, 2 blocks of cheese with no date, and an opened bag of sliced turkey with no date. During an interview on 5/22/23 at 10:15 AM, the Dietary Manager revealed that it was everyone in the kitchen's responsibility to ensure foods stored in the walk-in refrigerator were labeled and dated. She revealed she rounded frequently to ensure things were labeled in the walk-in refrigerator. During an interview on 5/25/23 at 8:30 AM, the Registered Dietitian indicated food and nutrition staff received frequent in-servicing on labeling and dating foods stored in the walk-in refrigerator. During an interview on 5/25/23 at 11:15 AM, the Administrator revealed she monitors the kitchen walk-in refrigerator occasionally. She revealed it was the responsibility of food and nutrition staff to ensure foods stored in the walk-in refrigerator were dated.

Based on observations, record review, and staff interviews, the facility ' s Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in February of 2022. This was for one recited deficiency in the area of food and nutrition services. The continued failure of the facility during the two federal surveys of record shows a pattern of the facility ' s inability to sustain and effective QAPI program. Findings included: This tag is cross referenced to: F812: Based on observation and staff interviews, the facility failed to date foods stored for use in one of one kitchen walk-in refrigerator. This had the potential to affect 106 of 106 residents. During the recertification survey of 2/10/22, the facility was cited for F812 for failure to date and discard foods from the walk-in refrigerator and nourishment room refrigerators. During an interview on 5/25/23 at 8:30 AM, the Registered Dietitian (RD) indicated that she attended QAPI meetings when she was able. She indicated that labeling foods in the refrigerator was an ongoing issue, but she believed the facility had made progress. The RD indicated she checked the walk-in refrigerators frequently to ensure foods were labeled and dated. During an interview on 5/25/23 at 11:15 AM, the Administrator revealed food and nutrition issues were discussed each month in QAPI meetings. She indicated that she checked the refrigerators in the kitchen frequently and had not found any issues.

Based on record review, staff and Responsible Party (RP) interviews, the facility failed to invite the RP to the care plan meeting for 1 of 1 resident (Resident #81) reviewed for care plans. Findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia and Diabetes Mellitus. Review of Resident #81's 2/2/23 admission Minimum Data Set assessment revealed resident had severe cognitive impairment and required extensive assistance or total dependence for most activities of daily living. An interview on 5/22/23 at 2:20 PM with Resident #81's RP revealed she had not been invited to a care plan meeting. An interview on 5/23/23 at 3:02 PM with the Social Worker (SW) revealed he was responsible for inviting the RP to the care plan meetings. He stated he did not keep records or documentation about inviting an RP to a care plan meeting. The SW stated that the RP should have been invited to the care plan meeting and that Resident #81 had a care plan meeting on 3/07/23. An interview on 5/24/23 at 9:37 AM with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Administrator revealed Resident #81's RP should have been invited to the care plan meeting.

Based on record review, staff and resident interviews, the facility failed to protect a resident ' s right to be free from mistreatment after notifying the Ombudsman of not getting showers for 1 of 1 residents (Resident #1) reviewed for abuse. Findings included: Resident #1 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set annual assessment dated [DATE] revealed the resident was cognitively aware, demonstrated no moods or behaviors, and required total dependence with two staff physical assistance with bed mobility, transfers, and bathing. Resident #1 had an impairment to one side to the upper and lower extremities and used a wheelchair. An observation of Resident #1 on 05/10/21 at 1:30 PM revealed an alert and oriented resident lying in her bed. Her hair was pulled back in a ponytail. An interview was conducted with Resident #1 on 05/10/21 at 1:30 PM. Resident #1 reported on 05/04/21 three nursing aides (NAs) came into her room yelling and were mad because it was the near the end of their shift and they had to give her a shower. Resident #1 stated one of the NAs stated, We have to give you a shower because you went and called the Ombudsman! Resident #1 stated they transferred her from her bed to the shower bed with a mechanical lift in a rushed and roughed manner and brought her to the shower room. Resident #1 stated she asked them to get her body wash, shampoo and cream rinse and was told You won ' t need that! Resident #1 stated while in the shower room she barely got wet and her ponytail holder was not taken out of her hair and she had requested cream rinse and was told You ' re getting a shower, that ' s all you are entitled to, be grateful. Resident #1 reported she told the NAs the water temperature was scalding, and the response from one of the NAs was You ' re getting a shower, be quiet. Resident #1 stated one of the NAs turned the water temperature down. Resident #1 stated she felt the NAs were being mean to her during her shower because she had called the Ombudsman about not getting showers and they were retaliating against her. Resident #1 stated after the shower, she was placed in the dining room to eat lunch and was left in the shower chair with wet hair. Resident #1 stated she asked for a towel for her head because her hair was still wet, and NA #3 brought the towel and just put it on top of her head. Resident #1 stated she asked for her glasses, her tea and her saltshaker and NA #3 brought her those items. Resident #1 reported she usually ate her meals in her room, but stated she felt the NAs brought her to the dining room instead of back to her room because they were punishing her for calling the Ombudsman. Resident #1 stated she had lunch in the dining room and remained there until about 3:00 PM when the Wound Treatment Nurse (WTN) came and put her back to bed. Resident #1 stated she told the WTN what happened to her while she was in the shower and the WTN assessed her and reported she had no [CONDITION(S)] or redness noted anywhere on her body. Resident #1 reported she did not have any pain after the shower on 05/04/21 and added that usually one only aid showered her, but she needed two aids to be transferred with the lift. Resident #1 stated she had a horrible day that day and she was very upset the aides were behaving that way. A written statement by Nursing Assistant (NA) #1 on 05/05/21 revealed NA #1 gave Resident #1 a shower accompanied by two of her coworkers. The statement indicated at 11:15 AM entered resident ' s room with the mechanical lift and bath bed, entered the shower room at 11:30 AM, shampooed her hair and washed her body twice and rinsed her off from head to toe and then lifted her on mechanical lift and put her into the Geri chair and placed her in the dining room for lunch. An interview with NA #1 was not conducted. The Administrator reported NA #1 was on vacation and could not be reached. A written statement by NA #2 on 05/05/21 revealed NA #2 went into Resident #1 ' s room to get her ready for a shower. The statement indicated we put her on a lift pad, then we transferred her to the shower bed, pushed her into the shower where we started her bath. We washed her twice, washed her hair, we then dried her, put her clothes on, put back on lift pad, and transferred her to a Geri chair. Brushed her hair, put it in a ponytail and Resident #1 took it out. An interview with NA #2 was conducted on 05/11/21 at 9:26 AM. NA #2 reported on 05/05/21 she was doing her rounds and when she got finished about 11:15 AM, the nurse wrote NA #1 a note to give Resident #1 a bath. NA #2 stated she suggested to NA #1 since lunch trays were soon to come out maybe they could do the shower tomorrow and NA #1 told NA #2 No, we need to do it now. NA #2 stated her, and NA #1 entered Resident #1 ' s room and we told her we were getting her up and giving her shower. NA #2 stated we did not fuss about it because we knew it had to be done. NA #2 reported that her and NA #1 did not say much while we were in the room and they just transferred the resident from her bed to shower bed. NA #2 added, we were not rough with the resident and we were not yelling at the resident. NA #2 stated we proceeded to roll her down the hall, and rolled her into the shower room, and the water was already turned on by NA #1. NA #2 stated we asked for NA #3 to help us because it would be quicker with the three of us and safer for the resident because one side of the shower bed did not lock so it helped to have 3 people. NA #2 reported the resident was in the shower stall on the left and when NA #3 started to shower the resident with the water, the Resident stated it was too hot and NA #3 turned it down, then she stated it was too cold and NA #3 adjusted it again it for her. NA #2 stated that they had the facility stock supplies in the shower room and would usually use those supplies. NA #2 stated she did not know if Resident #1 preferred to have her own supplies and did not recall the resident asking for her own supplies. NA #2 reported NA #1 took her ponytail out and washed her hair and she and NA #3 washed her body. She stated we washed her, rinsed her off and washed her again and rinsed her again. NA #2 reported when they were done, they dried her off and put a bath towel under her and over her and rolled her over to place the lift pad under her. They got her dressed in a gown because she chose to not to wear clothes and her hair was put back up in ponytail. NA #2 stated we then transferred her to the Geri chair and took her to the dining room. NA #2 stated they did not keep her in the shower chair when they brought her to the dining room. NA #2 stated the resident asked for a towel for her hair and was complaining that her was still wet and she took her ponytail out. NA #2 reported the resident complained about never getting out of bed, so we asked her if she wanted to eat in the dining room. NA #2 reported the resident seemed to enjoy being up and talking with the other residents in the dining room and eating having a good time. NA #2 stated she had asked for her tea and her saltshaker and a towel for her hair and NA #3 brought her those items. NA #2 reported that she did not speak to the resident in a derogatory way or treat her rough while transferring and showering her. She stated, nothing like what the resident said happened. NA #2 added, the shower door was slightly opened and because we were in the shower room with water running, we may have had our voices raised, but we were not yelling at her. A written statement by NA #3 dated 05/06/21 revealed NA #3 was sitting at the desk charting on the computer when NA #1 and NA #2 came to the shower room with Resident #1 on the shower bed. NA #3 was asked to come and assist with turning her on the shower bed because the bed only locked on one side. During her shower, she stated it was warm and she turned it down and she stated it was cold, then she stated it was okay. The statement indicated after she was bathed twice and rinsed, NA #3 assisted with drying her off and getting her dressed and the other 2 aides helped to get her dressed and put the lift pad under her so she could be transferred to the Geri chair and placed at the table in the dining room for lunch. While at the table, Resident #1 requested a towel, her glasses, and her saltshaker from her room. All three things were given to her. An interview was conducted with NA #3 on 05/10/21 at 2:30 PM on 05/10/21. NA #3 stated on 05/04/21, she was sitting at the nurse ' s station charting. NA #1 and NA #2 went to Resident # 1 ' s room to get her ready and transferred her onto the shower bed and while bringing the resident to the shower room had asked her to help so they could turn her safely. NA #3 stated when we got in the shower room, we took the lift pad out from under her and began her shower. NA #3 reported the Resident stated the water was too hot, so she turned the water down, then she said it was too cold, so she adjusted it again and she said that was fine. NA #3 reported the resident got washed, rinsed, washed again, and rinsed again. NA #3 stated they washed her hair with an all in one shampoo and conditioner and did not recall the resident asking for her specific shower products. NA #3 stated we usually used what was provided for us by the facility and it was kept in the shower room. NA #3 reported that the resident ' s hair was taken out of the ponytail before they washed it. NA #3 reported we placed bath blankets on the shower bed, placed the lift pad on the shower bed and blankets and used towels to dry Resident #1 and we put a towel on her hair. We got her dressed on the shower bed and then transferred her to the Geri chair. NA #3 stated we rolled Resident #1 to the dining room in the Geri chair. NA #3 stated we would never place a resident in the dining area in a shower bed. NA #3 believed that the resident thought because NA #1 combed her hair and put it back in the ponytail while it was still wet, that we never took the rubber band out of her hair. NA #3 stated when she was in the dining room either the resident or the nurse took the ponytail out because she saw that her hair was down when she asked for a towel for her head. NA #3 stated she wrapped the towel on the resident ' s head and tucked it in, and she did not just put it on top of her head. NA #3 stated she had asked for her tea, glasses and saltshaker from her room and she got them for her. NA #3 stated the resident had not been up for a while, so they offered to put her in the dining room, and she agreed. NA #3 added, Resident #1 did not say she didn ' t want to sit in the dining room. She stayed in there for a good little while and talked to other residents and ate her lunch. NA #3 denied telling the resident she was lucky she was even getting a shower. NA #3 stated their voices may have been elevated in the shower room because they were talking over the running water, but they were not yelling or speaking to the resident in an inappropriate way. A written statement by Nurse #1 on 05/05/21 revealed on 05/04/21 at approximately 12:00 PM, Nurse #1 observed Resident #1 exiting the shower room on the Geri chair. Skin was pale and dry and wet hair at shoulders. Hair was soft and easily placed in a ponytail with my fingers running through her hair. The shower room door was opened twice during the shower with the NA requesting a clean gown and Geri chair to another NA. An interview was conducted with Nurse #1 on 05/11/21 at 10:02 AM. Nurse #1 reported on 05/04/21, the ADON had come out and told her that she had made an arrangement with the Ombudsman to make sure Resident #1 received a shower once a week and she was supposed to get it on Monday but there was only one aid on Monday and to make sure on Tuesday the resident got her shower. Nurse #1 reported on 05/05/21 she informed NA #1 and NA #2 to make sure Resident #1 got her shower now. NA #1 and NA #2 got the shower bed and the mechanical lift and went into Resident #1 ' s room. Once they got the resident on the shower bed and were transferring Resident #1 to the shower room, they asked NA #3 to help. Nurse #1 stated one of the aides opened the door twice during the shower to request a clean gown and then another time to request the Geri chair. Nurse #1 stated at about 11:45 AM they came out of the shower room with Resident #1 in her Geri chair and brought her to the dining area. Nurse #1 stated the resident did not seem to be in any emotional distress or upset when she came out of the shower room or while having lunch in the dining room. Nurse #1 stated Resident #1 had 12:00 medications to be given and when she brought them to her in the dining area she noticed Resident #1 ' s hair on her shoulders because it was long and curly. Nurse #1 stated the resident complained that they did not put cream rinse in her hair and the nurse touched her hair and stated to the resident it ' s really soft, someone must have combed it. Nurse #1 added, at this time she put her hair up in a ponytail with the rubber band the resident provided her from her pocket. Nurse #1 stated the staff were speaking loudly while in the shower room, but she could not hear what they were saying, but it did not sound like yelling. Nurse #1 stated if it sounded like the aides were yelling or speaking inappropriately toward Resident #1, she would have gone into the shower room immediately. Nurse #1 stated Resident #1 reported to her the water was too hot in the shower, so she looked over her skin to see if she was reddened anywhere and her skin was noted to be pale and she did not have any complaints of pain. Nurse #1 reported she and the WTN assisted her back to her bed about 2:45 PM and Resident #1 never reported any kind of mistreatment or verbal abuse from the aides to her. A written statement by the Wound Treatment Nurse (WTN) on 05/05/21 revealed on 05/04/21 at approximately 3:00 PM, the WTN arrived on station 4 and saw Resident #1 sitting slumped over to the left side in a Geri chair at the station 4 dining area. The WTN took Resident #1 back to her room via the Geri chair with Nurse #1 who assisted with transferring the resident from the Geri chair back to her bed utilizing the mechanical lift. The resident ' s skin was within normal limits. A typed statement by the WTN dated 05/05/21 read: Complaint from Resident #1 as told to Wound Treatment Nurse, RN 05/05/21. On the morning of Tuesday, 05/04/21 sometime after 11:00 AM, three NAs, came into Resident #1 ' s room yelling and screaming at Resident #1 that she had called the damn ombudsman so they had to give her a shower. She was moved very roughly from her bed to the shower bed with a mechanical lift, all the while the NAs continued to scream and yell about the Ombudsman and having to give Resident #1 a shower. As she was being moved to the shower bed, Resident #1 asked them to get her body wash, shampoo, and cream rinse. It was stated that she wouldn ' t need them. Resident #1 stated that the shower lasted about 5 minutes, she barely got wet, the ponytail holder was not even taken out of her hair. Resident #1 requested cream rinse for her hair and was told You ' re getting a shower, that ' s all you are entitled to, be grateful. She stated that the water was scalding, but when she protested she was told you ' re getting a shower, be quiet. They continued to yell at Resident #1 throughout the shower. When the 5 minute shower was over, she was not dried off, a gown was put on her while she was still wet and she was transferred from the shower bed into the Geri chair without being told that she was not going back to her room or asking if she wanted to be in the Geri chair. She was wheeled into the station 4 dining area with no towel on her head and still wet. Resident #1 stated she was positioned with her back to the nurse ' s station but could hear the NAs talking among themselves. She asked to be taken back to her room on several occasions, but no one answered her. She requested water with no response, then out of nowhere Nurse #1 appeared with a cup of ice water for which she was very grateful. The resident felt she was brought into the dining room as punishment for requesting to have a shower. One of the comments a NA made was Resident #1 called the damn ombudsman and we got stuck. The resident requested her glasses so that she could see what she was eating and was told to shut up. Eventually NA #3 brought her glasses, tea, and saltshaker. An interview was conducted with the Wound Treatment Nurse on 05/11/21 at 10:18 AM. The WTN stated at 2:45 PM on 05/04/21 she had seen Resident #1 sitting in the dining room which was highly unusual because she was not usually out of her room. The WTN stated the resident was in a Geri chair, slumped over to the left side and was nodding off and on. The WTN stated she and Nurse #1 assisted the resident back to bed and when Nurse #1 left the room Resident #1 reported to her that she had a horrible day and informed the WTN the NAs were yelling at her and gave her a scalding hot shower. The WTN reported she assessed her skin immediately and there were no signs or symptoms of [CONDITION(S)] and the resident had no complaints of pain. The WTN nurse stated she took the residents ' statement and typed it up and left a copy on the Director of Nursing ' s (DON) desk. The WTN stated the resident was genuinely upset while she shared her experience about the shower and the way the 3 NAs treated her. The WTN stated she should have handed the typed statement to the DON to be sure the DON saw the allegation and not just have left it on her desk. An interview with the Ombudsman via phone on 05/11/21 at 10:36 AM revealed he had had many meetings with Resident #1 over the last couple of months due to her requesting showers over and over again and never receiving one. The Ombudsman reported the explanation he received from the DON was that she the resident would get cleaned up with every wound care dressing on Monday, Wednesday and Friday, but the resident stated it was just cleaning up and she would prefer to have a shower. The Ombudsman reported he spoke to the DON who had put Resident #1 on the schedule for Monday showers so it could be worked in around the time of the wound care. He stated he told Resident #1 to call him if she did not get her shower on Mondays. The Ombudsman stated he was notified by Resident #1 ' s Power of Attorney (POA) on Tuesday 05/05/21 that Resident #1 did not get a shower on Monday because she was told by the staff there was not enough staff on Monday so she would get a shower on Tuesday. The Ombudsman told the POA he would go and see the Resident. The Ombudsman stated when he arrived at the facility, the Resident had given him a written statement about the abusive tone, demands as to why did you call the damn ombudsman and about the shower water being scalding hot but the staff turned the water down, and how the aids gave such a quick shower, she did not feel like she even got a shower. Additionally, the statement noted that the Resident wanted to use her own products, but they would not let her, and they did not take out her ponytail, and left her in dining room until the end of shift. The Ombudsman reported he spoke to the DON and she said she was interviewing the staff involved and then the DON, ADON, and the Administrator showed him the written statements by NA #1 and NA #2 but stated they still had to interview one other person (NA #3). The Ombudsman stated the Administrator told him she was in the hallway on 05/04/21 when Resident #1 came out of the shower room and she did not notice anything wrong with Resident #1, nor did Resident #1 report anything to her. An interview was conducted with the Director of Nursing on 05/11/12 at 1:25 PM. The DON reported when she became aware of the incident in the shower for Resident #1 by the Ombudsman, she asked the three NAs, the WTN, and Nurse #1 to complete a statement regarding Resident #1 and her shower. The DON stated she visited Resident #1 ' s room on 05/05/21 and asked if she was okay and the resident stated she was fine. The DON stated the resident never reported any of the concerns to her. The DON stated she changed the resident ' s shower day to Wednesday instead of Mondays because there was a particular NA who worked the 3 -11 shift on Wednesday that Resident #1 preferred to have do her showers. The DON added that herself, the Assistant Director of Nursing (ADON) or the assigned floor nurse were to be in the resident ' s presence whenever she was getting a shower or personal care. An interview was conducted with the Administrator on 05/11/12 at 1:25 PM. The Administrator reported after the Ombudsman reported the resident ' s allegation to her and the DON on 05/05/21, she had gone to Resident #1 ' s room to see if she was okay and felt safe. The Administrator reported Resident #1 told the Administrator on 05/05/21 she was fine and felt safe. The Administrator stated she had the Maintenance Director check the water temperatures of the shower room and the temperature was 105 degrees at the highest temperature for the shower on the right stall and 108 degrees at the highest temperature for shower stall on the left side which was the stall Resident #1 had her shower in. The Administrator reported she did not feel the resident was abused because she was alert and oriented and would have reported what had happened to her. The Administrator added, if the staff spoke to her the way the Ombudsman and the Resident were reporting they spoke to her, then it was inappropriate, but she did not see it as abuse. A review of the hot water systems check list log revealed the temperatures for the shower room on station 4 on 05/05/21 revealed the water temperature was 105 degrees Fahrenheit for the shower on the right stall and 108 degrees Fahrenheit for the shower stall on the left side. An interview with the Maintenance Director on 05/10/21 at 12:40 PM revealed the hot water temperature range should be between 105 degrees Fahrenheit to 120 degrees Fahrenheit. The Maintenance Director stated the water temperatures were checked and logged weekly. An observation of the water temperatures for the station 4 shower room was conducted on 05/10/21 at 12:40 PM with the Maintenance Director. The water temperature was 105 degrees at the highest temperature for the shower on the right stall and 108 degrees at the highest temperature for the shower stall on the left side. A review of the In-Service Sign in Sheet dated 05/06/21 titled Resident Abuse revealed nurses, nursing assistants, medication technicians and therapy staff and administrative staff were in serviced to include Nurse #1, the Wound Treatment Nurse and NA #1, NA#2, and NA #3.

Based on Medical Director (MD) interview, Physician Assistant (PA) interview, staff interview, and record review the facility failed to notify the MD of results from the Doppler ultrasound he ordered on [DATE] and failed to notify the PA for six days of resident refusal of a vascular consult which he ordered resulting in the inability of treatment options to be discussed with 1 of 1 sampled residents (Resident #4) before the resident experienced an above-the-knee amputation (AKA) after being hosptalized on [DATE]. The facility also failed to inform the physician for 1 of 2 sampled residents (Resident #10) with orders for vascular consults that they were unable to schedule the resident's appointment for venous surgical consultation. Findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with documented [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] following hospitalization with [DIAGNOSES REDACTED]. A 08/26/17 physician progress notes [REDACTED].#1 who became the facility's MD effective the early part of September 2017) documented, He (Resident #4) now c/o (complaints of) bilateral foot pain. He has NIDDM (non-insulin dependent diabetes mellitus) and evidence of PAD (peripheral artery disease) with diminished pulses. I ordered [MEDICATION NAME] (medication for management of diabetic [MEDICAL CONDITION]) and bilateral leg arterial studies with ABI's (ankle-brachial indices). The physician's physical exam documented, Peripheral Pulses: Dorsalis Pedis Pulse (pulse across the top of the foot): decreased on the left and the right. Popliteal Pulse (pulse across the back of the knee): decreased on the left and the right. The physician's Assessment and Plan documented, Pain in both feet: ABI and PAD studies. A 08/26/17 physician order [REDACTED]. Findings from a 08/28/17 mobile ultrasound documented Resident #4's right ankle brachial index was 0, and there was no flow detected in the right proximal femoral (thigh) artery, right Popliteal artery, right anterior tibia (ankle) artery, and right posterior tibia artery. (These ultrasound results were not found in the resident's chart on 10/19/17). PA #2's 09/25/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, Nursing is asking for clarification on a verbal order given earlier to the station nurse by (PA #1) for a Doppler US (ultrasound) study of resident's lower extremities. It is my understanding that the verbal order was given by (PA #1) after station nurse informed her that the resident had been reporting intermittent leg pain. The station nurse now informs me she has discovered a lower extremity (LE) Doppler in the resident's chart dated 08/28/17. PA #2 documented, I reviewed with him the results of the 08/28/17 LE Doppler study, and told him that I might need to send him to the hospital ED (emergency department) today, or to a vascular surgeon for further evaluation. (This was the first documentation in Resident #4's medical record that a physician had reviewed his 08/28/17 Doppler results). A 09/25/17 order, written by PA #2, documented that Resident #4 was being referred for consultation with a vascular surgeon, and results of the 08/28/17 ultrasound were to accompany the resident to this appointment. A 09/27/17 nurse's note documented an appointment with the vascular surgeon was scheduled for Resident #4 on 10/05/17, and the transportation aide was aware of the appointment. A 10/09/17 12:00 PM nurse's note documented, Communication sheet made to see dr (doctor) patient's foot swollen and black and blisters found on right foot. Wound referral also made. Patient not complaining of pain in foot. A 10/10/17 2:30 PM nurse's note documented, Resident is up in w/c. Resident refused care (with name of vascular surgeon). Resident would not sign paperwork giving (name of vascular surgeon) permission to give care. Resident is alert and oriented. A 10/11/17 2:30 PM nurse's note documented, .Resident's foot has gotten worse since the visit to (name of vascular surgeon)'s office. Resident agreed to be sent to the hospital today Unable to feel pulse in (right) foot. PA #2's 10/11/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, (Resident #4's) station nurse paged me this morning to request that I see him today, because of sudden skin discoloration; especially involving his toes on his right foot Prior to going into (Resident #4's) room, the station nurse informed me that he was transported to (name of vascular surgeon)'s office several days ago. However, (Resident #4) refused to allow (name of vascular surgeon) to examine him; so (facility) transporter brought back to SNF (skilled nursing facility). I had not been informed of (Resident #4's) refusal of treatment. When I entered (Resident #4's) room, (facility) wound care nurse was already checking for distal pulses in the right foot. He is not able to illicit pedis or posterior tibia pulses. His right leg below the knee is cold. His left leg is warm. I am unable to palpate a femoral (thigh) pulse in the right leg A 10/17/17 hospital Discharge Summary documented, The patient was admitted on [DATE] for dry gangrene of RLE up to mid-calf. Discussion was had with HCPOA (health care power of attorney) for right above knee amputation. The patient underwent the above procedure. He was hemodynamically stable The AKA wound was clean, dry and intact. There were no signs of infection or hematoma formation. He was discharged back to SNF on 10/17/17 in a stable medical condition . At 5:12 PM on 10/19/17 Physician #1, the facility's MD, stated he was not notified of the resident's Doppler results, but he only took on responsibilities as medical director around first of September 2017, and he was not exactly sure what system the facility had in place at that time for notification of lab and test results. He reported he supervised two PAs who were more familiar with the facility and residents, and they mainly looked at test and lab results. He stated the PAs called him with abnormal lab results or if they had questions about results. After reviewing Resident #4's 08/28/17 Doppler results, he stated the resident should have seen a vascular surgeon immediately, as soon as possible, so treatment options could have been discussed with the resident. He commented if nothing was done, the resident would start losing parts of his legs. The MD explained the results of the 08/28/17 Doppler were poor with the resident's right lower extremity completely occluded. However, he stated that the surgeon or vascular specialist should have had the opportunity to assess and decide if options such as laser treatment, stents, or bypasses could have possibly saved Resident #4's right foot and leg. The MD commented that he had seen incidents in which if the proximal circulation was enhanced then there could be some improvement in the distal circulation also. He reported the treatment goal was obviously to save the resident's foot and leg if at all possible. At 9:40 AM on 10/20/17 the Director of Nursing (DON) stated once lab or test results were reviewed by the physician or PAs they were supposed to be initialed and placed back in the medical record. At 11:20 AM on 10/20/17 PA #2 stated he started working with/for the new MD (Physician #1) on 09/06/17. He reported this MD was Resident #4's physician prior to assuming his new role on 09/06/17. According to PA #2, he first saw Resident #4 on 09/25/17 in conjunction with the hall nurse's concern over appearance of the resident's right leg and foot. He stated 09/25/17 was the first time he had reviewed the 08/28/17 Doppler results. He commented on 09/25/17 there were faint pedal pulses and there was warmth to the resident's feet and toes. (PA #1 documented on the same day the resident's right lower extremity was cool to touch and without pulses). He stated the resident was lethargic which he thought was his baseline. He reported at that time there was no blackness to the toes. He stated he saw the resident again on 10/11/17 in response to hall nurse's concerns about changes in the appearance of the resident's right foot. He reported on 10/11/17 the resident's toes on his right foot were now black, and the right foot had gotten worse with no pulses in the right foot. According to PA #2, the resident's leg from the knee down was ice cold. PA #2 stated on 10/11/17 he was told that Resident #4 refused his vascular consult on 10/05/17 and so he sent the resident to the ED on 10/11/17. The PA stated he would not comment on the apparent gap of almost a month between the 08/28/17 Doppler and the first review of Doppler results on 09/25/17 (because the MD ordered the Doppler on 08/26/17, and he was not working for the MD at that time). The PA reported lab/test results from tests which he ordered were left in a box in the facility for him to review when he was in the building on Mondays, Wednesdays, and Fridays. However, he commented he was not the one who ordered the resident's Doppler on 08/26/17, and he was not sure what system the MD had in place to make sure the lab/test results he ordered were obtained and available for review. At 1:10 PM on 10/20/17 the Director of Nursing (DON) stated mobile lab/test results were faxed to the facility. She reported when faxes were collected, and there were mobile lab/test results among the faxes, this information was given to medical records to forward to the physicians so they could sign off on them and write orders that might be generated from the results. At 2:54 PM on 10/20/17 the Medical Records Clerk stated it was her responsibility to retrieve faxes and distribute them to the nurses who in turn made sure lab/test results got to the respective physicians who ordered them. She reported she handled so many faxes that she was unsure if she ever collected any Doppler results for Resident #4. 2. Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's Quarterly Minimum Data Set (MDS) revealed [DIAGNOSES REDACTED]. Resident #10 was cognitively aware and had 3 arterial/venous ulcers. Review of the [DIAGNOSES REDACTED].#10's medical record included [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the Medication Record - Treatments for September 2017 revealed Resident #10 was scheduled to receive daily treatments for venous ulcers on the right and left lower legs. Review of the physician's Telephone Order dated 09/04/17 revealed an order to send Resident #10 out for a venous surgical consult. In an interview on 10/19/17 at 11:30 AM the Transportation Aide (TA), who also scheduled resident appointments, stated she called to schedule an appointment for a venous surgical consult for Resident #10 on 09/05/17. She indicated she was unable to schedule the appointment because the surgeon's office needed to speak with Resident #10's family before an appointment could be scheduled. The TA stated she had left several messages for Resident #10's Responsible Party (RP) to contact the surgeon's office but had not heard back from the RP or the surgeon's office. She indicated Resident #10's RP visited often but she had not approached the RP to ask about the scheduling of the appointment. The TA stated she had made no attempt to follow-up with the vascular surgeon's office to see if the consult appointment could be scheduled following the initial contact with the office. She indicated she had not notified the Physician that there was a delay in getting the requested consult. In an interview on 10/19/17 at 11:40 AM the Director of Nursing (DON) indicated if a staff member was unable to schedule a requested consult she expected them to speak with the physician within a few days to see if a referral to a different physician for consult would be appropriate. In an interview on 10/19/17 at 4:55 PM Resident #10's Physician #1 stated he was not aware that the surgical consult he ordered had not been scheduled. He indicated that when he wrote an order for [REDACTED]. He indicated Resident #10 could have been sent to a different vascular surgeon or he could have ordered a Venous Doppler study instead. In a telephone interview on 10/20/17 at 10:08 AM Resident #10's RP stated she was aware that a surgical consult had been ordered but had not been told when it was scheduled or which physician the appointment would be with. She stated that she had not requested Resident #10 be sent to any particular vascular surgeon. She indicated it would have been fine with her to send Resident #10 to another surgeon if an appointment could not be made with the surgeon the facility had picked. In a follow-up interview on 10/20/17 at 1:06 PM the DON stated that there was not a nurse who followed up to make sure appointments or consults were scheduled and completed. She indicated if there was an issue with making an appointment the TA would let her know. The DON stated the TA had not informed her that Resident #10's venous consult had not been scheduled.

Based on observation, Medical Director (MD) interview, Physician Assistant (PA) interview, resident interview, staff interview, and record review the facility neglected 1 of 1 sampled residents (Resident #4) who experienced an above-the-knee amputation (AKA) by failing to provide vascular consultation and failing to consistently document assessment of the resident's right lower extremity (RLE) before the resident experienced the AKA. Findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with documented [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] following hospitalization with [DIAGNOSES REDACTED]. A 08/26/17 physician progress notes [REDACTED].#1 who became the facility's MD effective the early part of September 2017) documented, He (Resident #4) now c/o (complaints of) bilateral foot pain. He has NIDDM (non-insulin dependent diabetes mellitus) and evidence of PAD (peripheral artery disease) with diminished pulses. I ordered [MEDICATION NAME] (medication for management of diabetic [MEDICAL CONDITION]) and bilateral leg arterial studies with ABI's (ankle-brachial indices). The physician's physical exam documented, Peripheral Pulses: Dorsalis Pedis Pulse (pulse across the top of the foot): decreased on the left and the right. Popliteal Pulse (pulse across the back of the knee): decreased on the left and the right. The physician's Assessment and Plan documented, Pain in both feet: ABI and PAD studies. A 08/26/17 physician order [REDACTED]. Findings from a 08/28/17 mobile ultrasound documented there was no flow detected in Resident #4's right proximal femoral (thigh) artery, right Popliteal artery, right anterior tibia (ankle) artery, and right posterior tibia artery. The Impression section documented, Evidence of significant bilateral inflow senses to both lower extremities, more severe on the right side. Occlusion of the right proximal femoral, popliteal and tibial arteries. (These ultrasound results were not found in the resident's chart on 10/19/17). On her undated Physician Communication Form Nurse #10 documented Resident #4 had swollen right foot and toes and complaining of pain in right foot and toes, also noted discoloration. PA #1's undated response was, RLE (right lower extremity) cool to touch, purple discoloration. (No) DP (Doppler) noted. STAT (at once) Doppler U/S (ultrasound) arterial RLE. A 09/25/17 cancellation notice documented the STAT Doppler for Resident #4 was canceled because this was already performed. PA #2's 09/25/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, Nursing is asking for clarification on a verbal order given earlier to the station nurse by (PA #1) for a Doppler US (ultrasound) study of resident's lower extremities. It is my understanding that the verbal order was given by (PA #1) after station nurse informed her that the resident had been reporting intermittent leg pain. The station nurse now informs me she has discovered a LE Doppler in the resident's chart dated 08/28/17. PA #2 documented, I reviewed with him the results of the 08/28/17 LE Doppler study, and told him that I might need to send him to the hospital ED (emergency department) today, or to a vascular surgeon for further evaluation. (This was the first documentation in Resident #4's medical record that a physician had reviewed his Doppler results). A 09/25/17 order, written by PA #2, documented that Resident #4 was being referred for consultation with a vascular surgeon, and results of the 08/28/17 ultrasound were to accompany the resident to this appointment. A 09/27/17 nurse's note documented an appointment with the vascular surgeon was scheduled for Resident #4 on 10/05/17, and the transportation aide was aware of the appointment. A 10/09/17 12:00 PM nurse's note documented, Communication sheet made to see dr (doctor) patient's foot swollen and black and blisters found on right foot. Wound referral also made. Patient not complaining of pain in foot. A 10/10/17 2:30 PM nurse's note documented, Resident is up in w/c. Resident refused care (with name of vascular surgeon). Resident would not sign paperwork giving (name of vascular surgeon) permission to give care. Resident is alert and oriented. A 10/11/17 2:30 PM nurse's note documented, .Resident's foot has gotten worse since the visit to (name of vascular surgeon)'s office. Resident agreed to be sent to the hospital today Unable to feel pulse in (right) foot. (A 10/09/17 nurse's note and this 10/11/17 nurse's notes were the only ones in the medical record which documented information about the appearance of or the pulses in the resident's foot). PA #2's 10/11/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, (Resident #4's) station nurse paged me this morning to request that I see him today, because of sudden skin discoloration; especially involving his toes on his right foot Prior to going into (Resident #4's) room, the station nurse informed me that he was transported to (name of vascular surgeon)'s office several days ago. However, (Resident #4) refused to allow (name of vascular surgeon) to examine him; so (facility) transporter brought back to SNF (skilled nursing facility). I had not been informed of (Resident #4's) refusal of treatment. When I entered (Resident #4's) room, (facility) wound care nurse was already checking for distal pulses in the right foot. He is not able to illicit pedis or posterior tibia pulses. His right leg below the knee is cold. His left leg is warm. I am unable to palpate a femoral (thigh) pulse in the right leg A 10/11/17 hospital History and Physical documented, .His right foot is black, is insensate. There is no motor. The ischemia (loss of blood supply) extends for the entire foot onto the distal leg. There was no evidence of [MEDICAL CONDITION] or [DIAGNOSES REDACTED] but simply terminal ischemia. He has no Doppler signals. He is not able to provide a time line as to when the events occurred, and there is no information from the data sent from the care facility. He is not a candidate for revascularization or limb salvage. The degree of ischemia of the right lower extremity is severe and terminal, and his only option is an amputation A 10/17/17 hospital Discharge Summary documented, The patient was admitted on [DATE] for dry gangrene of RLE up to mid-calf. Discussion was had with HCPOA (health care power of attorney) for right above knee amputation. The patient underwent the above procedure. He was hemodynamically stable The AKA wound was clean, dry and intact. There were no signs of infection or hematoma formation. He was discharged back to SNF (skilled nursing facility) on 10/17/17 in a stable medical condition . At 4:07 PM on 10/19/17 Resident #4's primary first shift Nursing Assistant, (NA) #9, stated for the last 1 ½ months prior to going out to the hospital on [DATE] the resident gradually deteriorated physically and mentally. He reported the resident was mumbling, not making sense, sometimes would not even talk, sometimes could not even feed himself, stayed in bed, and did not walk during the week before going out to the hospital. However, the NA commented the resident never complained of pain. The NA remarked the level of care required by Resident #4 definitely increased. According to NA #9, he provided the resident bed baths on first shift. He stated in early September the resident's feet had reddened and blackened areas, two weeks later the resident's right foot was getting darker/blacker, and the week that the resident went out to the hospital the resident's right foot had blisters on it. He commented he reported these changes to the hall nurses. At 4:17 PM on 10/19/17 Nurse #1, who cared for Resident #4 from 7:00 AM to 7:00 PM, stated she filled out the preliminary paperwork with Resident #4, and he stated he would see the vascular surgeon. She stated the transporter reported to her that when she got the resident to the surgeon's office, and she requested for him to sign the release, the resident shook his head no. She commented she told PA #2 that the resident refused to be seen by the surgeon so PA #2 sent the resident out to the hospital where they felt the resident would be more willing to cooperate with doctors. She stated the resident did not complain of pain in his feet, but was not getting out of his bed or ambulating as much the last 2 - 3 weeks before being sent out to the hospital. At 5:12 PM on 10/19/17 Physician #1, the facility's MD, stated he was not notified of the resident's Doppler results, but he only took on responsibilities as medical director around first of September 2017, and he was not exactly sure what system the facility had in place at that time for notification of lab and test results. He reported he supervised two PAs who were more familiar with the facility and residents, and they mainly looked at test and lab results. He stated the PAs called him with abnormal lab results or if they had questions about results. After reviewing Resident #4's 08/28/17 Doppler results, he stated the resident should have seen a vascular surgeon immediately, as soon as possible, so treatment options could have been discussed with the resident. He commented if nothing was done, the resident would start losing parts of his legs. The MD explained the results of the 08/28/17 Doppler were poor with the resident's right lower extremity completely occluded. However, he stated that the surgeon or vascular specialist should have had the opportunity to assess and decide if options such as laser treatment, stents, or bypasses could have possibly saved Resident #4's right foot and leg. The MD commented that he had seen incidents in which if the proximal circulation was enhanced then there could be some improvement in the distal circulation also. He reported the treatment goal was obviously to save the resident's foot and leg if at all possible. At 10:07 AM on 10/20/17 Nurse #1 stated she observed Resident #4's feet daily, but may not have documented on the appearance of his legs and feet, and the only thing she noticed was that the resident's right foot became gradually darker in coloration. At 11:20 AM on 10/20/17 PA #2 stated he started working with/for the new MD (Physician #1) on 09/06/17. He reported this MD was Resident #4's physician prior to assuming his new role on 09/06/17. According to PA #2, he first saw Resident #4 on 09/25/17 in conjunction with the hall nurse's concern over appearance of the resident's right leg and foot. He stated 09/25/17 was the first time he had reviewed the 08/28/17 Doppler results. He commented on 09/25/17 there were faint pedal pulses and there was warmth to the resident's feet and toes. (PA #1 documented on the same day the resident's right lower extremity was cool to touch and without pulses). He stated the resident was lethargic which he thought was his baseline. He reported at that time there was no blackness to the toes. He stated he saw the resident again on 10/11/17 in response to hall nurse's concerns about changes in the appearance of the resident's right foot. He reported on 10/11/17 the resident's toes on his right foot were now black, and the right foot had gotten worse with no pulses in the right foot. According to PA #2, the resident's leg from the knee down was ice cold. PA #2 stated on 10/11/17 he was told that Resident #4 refused his vascular consult on 10/05/17 and so he sent the resident to the ED on 10/11/17. The PA stated he would not comment on the apparent gap of almost a month between the 08/28/17 Doppler and the first review of Doppler results on 09/25/17 (because the MD ordered the Doppler on 08/26/17, and he was not working for the MD at that time). The PA reported lab/test results from tests which he ordered were left in a box in the facility for him to review when he was in the building on Mondays, Wednesdays, and Fridays. However, he commented he was not the one who ordered the resident's Doppler on 08/26/17, and he was not sure what system the MD had in place to make sure the lab/test results he ordered were obtained and available for review. At 12:12 PM on 10/20/17 Resident #4 stated he had pain at a level of 10 daily in the weeks before going out to the hospital. He reported he told staff members about this pain, but became silent, and would or could not identify those staff members that he had communicated his pain to. (Pain was only documented by the staff on 08/23/17, 08/24/17, and 09/01/17 in Daily Skilled Nurses Notes between 08/14/17 and 09/20/17. There were no nurse's notes in the medical record between 09/21/17 and 09/26/17, and sporadic nurse's notes between 09/27/17 and 10/11/17 did not document the presence of pain). At 1:10 PM on 10/20/17 the Director of Nursing (DON) stated assessment of Resident #4's pain associated with his lower extremities and assessment of the resident's right foot, including appearance and pulses, should be documented in the nurse's notes. At 1:38 PM on 10/20/17 PA #1 (who saw the Resident #4 before PA #2 on 09/25/17) stated there were no Doppler results in the chart when she reviewed it on 09/25/17. She reported on 09/25/17 Resident #4's right leg was blue and cold, and his right foot was cold and purple/blue. She also commented there were no pedal pulses in the right lower extremity. According to PA #1, after examining Resident #4 on 09/25/17 she knew the resident had serious problems so told the hall nurse if she could not get a STAT (immediate) Doppler to make sure the resident got to a vascular doctor as soon as possible (later PA #2 canceled the STAT Doppler because he obtained the results from the resident's 08/26/17 Doppler). At 2:50 PM on 10/20/17 Nurse #1 stated she thought she checked the pulses in Resident #4's lower extremities maybe every other day, and they were consistently getting fainter. She reported she should have documented the pulses and appearance of the right foot in her nurse's notes, but did not always do that. She commented she thought the Treatment Nurse was checking the pulses sometimes. (The only nurse's note documenting information about pulses in Resident #4's right LE was made on 10/11/17). At 4:25 PM on 10/26/17, during a returned phone call, Nurse #11, who cared for Resident #4 from 7:00 PM to 7:00 AM, stated she was very alarmed when she found out that Resident #4 did not go to his vascular consult on 10/05/17 because she remembered thinking that the resident's right foot had undergone major changes since his admission. She reported she thought the resident's right leg was getting colder, and his right foot was getting darker. She commented she thought most of the assessment of the resident's right foot (appearance and pulses) was done by the 7:00 AM to 7:00 PM nurse because the resident was early to bed and early to rise so she did not see him that much. According to Nurse #11, she did not recall Resident #4 being in chronic pain, but she was sure she sometimes administered prn (as needed) pain medications due to pain in his right leg and foot. She stated Resident #4 was sometimes slow to respond and did not talk a lot, but she considered him to be alert and oriented and able to express his needs.

Based on observation, Medical Director (MD), Physician Assistant (PA), resident, and staff interviews, and record review the facility failed to provide arterial/venous circulatory consultation, following a Doppler ultrasound on 08/28/17, during which there could have been discussion about available treatment options for 1 of 1 sampled residents (Resident #4) who later experienced a loss of limbs. The lack of documented follow-up assessment by staff and the lack of consultation contributed to the deterioration of the resident's right foot and leg for over a 40-day period, resulting in an above-the-knee amputation (AKA) after the resident was hosptalized on [DATE]. Findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with documented [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] following hospitalization with [DIAGNOSES REDACTED]. The resident's 08/14/17 Admission Nursing Assessment documented he was alert but disoriented to time and place. The resident's 08/21/17 admission minimum data set (MDS) documented the resident's cognition was moderately impaired, he had sleeping and appetite problems, exhibited no behaviors including resistance to care, he required extensive assistance from a staff member with bed mobility/dressing/hygiene/bathing, he required limited assistance from a staff member with transfers, he required staff supervision in the form of set-up help with locomotion on and off the unit and eating, he did not walk in his room or the corridor during the look-back period, he was frequently incontinent of bowel and bladder, and he was on scheduled pain medications but reported no presence of pain during the look-back period. A 08/23/17 Daily Skilled Nurses Note documented Resident #4 was experiencing pain in his right foot at an intensity of 8 on a scale of 1 - 10, with 10 being the highest level of pain. A 08/24/17 Daily Skilled Nurses Note documented Resident #4 was experiencing pain in his right foot at an intensity of 6 on a scale of 1 - 10. The resident's 08/25/17 care plan identified at times has episodes of decreased cognition as a problem. An intervention to this problem was explain all procedures and treatments. A 08/26/17 physician progress notes [REDACTED].#1 who became the facility's MD effective the early part of September 2017) documented, He (Resident #4) now c/o (complains of) bilateral foot pain. He has NIDDM (non-insulin dependent diabetes mellitus) and evidence of PAD (peripheral artery disease) with diminished pulses. I ordered [MEDICATION NAME] (medication for management of diabetic [MEDICAL CONDITION]) and bilateral leg arterial studies with ABI's (ankle-brachial indices). The physician's physical exam documented, Peripheral Pulses: Dorsalis Pedis Pulse (pulse across the top of the foot): decreased on the left and the right. Popliteal Pulse (pulse across the back of the knee): decreased on the left and the right. The physician's Assessment and Plan documented, Pain in both feet: ABI and PAD studies. A 08/26/17 physician order [REDACTED]. Findings from a 08/28/17 mobile ultrasound documented there was no flow detected in Resident #4's right proximal femoral (thigh) artery, right Popliteal artery, right anterior tibia (ankle) artery, and right posterior tibia artery. The Impression section documented, Evidence of significant bilateral inflow senses to both lower extremities, more severe on the right side. Occlusion of the right proximal femoral, popliteal and tibial arteries. (These ultrasound results were not found in the resident's chart on 10/19/17). A 09/01/17 Daily Skilled Nurses Note documented Resident #4 was experiencing pain in his feet and bilateral lower extremity, but the intensity of the pain was not assessed. A 09/08/17 nurse's note documented, (no) foot problems nail care provided. A 09/11/17 Physical Therapy (PT) Discharge Summary documented Resident #4 had been on PT caseload since 08/15/17, and was being discharged from PT on 09/11/17, having met his ambulation goal of ambulating 60 feet safely with front wheeled walker and modified independence on even surfaces. A 09/15/17 nurse's note documented, (up) to w/c (wheelchair) daily & goes out to smoke ad lib, tries to get others to push him. Routine [MEDICATION NAME] for BLE (bilateral lower extremity) pain. Walks (with) walker short distances (no) s/s (signs and symptoms) of discomfort or distress noted. On her undated Physician Communication Form Nurse #10 documented Resident #4 had swollen right foot and toes and complaining of pain in right foot and toes, also noted discoloration. PA #1's undated response was, RLE (right lower extremity) cool to touch, purple discoloration. (No) DP (Doppler) noted. STAT (at once) Doppler U/S (ultrasound) arterial RLE. A 09/25/17 cancellation notice documented the STAT Doppler for Resident #4 was canceled because this was already performed. PA #2's 09/25/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, Nursing is asking for clarification on a verbal order given earlier to the station nurse by (PA #1) for a Doppler US (ultrasound) study of resident's lower extremities. It is my understanding that the verbal order was given by (PA #1) after station nurse informed her that the resident had been reporting intermittent leg pain. The station nurse now informs me she has discovered a LE Doppler in the resident's chart dated 08/28/17. PA #2 documented, This is the first time I have met this resident. He is a heavy smoker, and he tells me he has been a heavy smoker throughout his entire adult life .On today's visit, he admits to having occasional intermittent foot pain & some increased weakness in both legs. He feels the pain mostly on the tops of his feet. He says the pain is slightly worse in right foot. He denies loss of LE sensation I reviewed with him the results of the 08/28/17 LE Doppler study, and told him that I might need to send him to the hospital ED (emergency department) today, or to a vascular surgeon for further evaluation. I would categorized his overall affect as flat, but he was alert & oriented. He spoke few words to me, and most responses to my .questions were yes or no answers, or a shake or nod of his head. I did my best to educate him about the seriousness of his LE [MEDICAL CONDITION]. I did not sugar coat this for him. I explained that in almost 100% of serious [MEDICAL CONDITIONS] cases like his--the natural progression leads to amputation of the affected extremities. I urged him to immediately stop smoking, and offered him assistance with smoking cessation medications. He answered no to my offer. Based on my exam findings today, I told (Resident #4) that I was going to be sending him to a vascular surgeon for further evaluation of his [MEDICAL CONDITION]. I further explained to him that he may or may not be a surgical candidate for fixing the arteries in his legs. The physical exam portion of PA #2's note documented, .dorsalis pedis & distal tibia (ankle) pulses are palpable in both feet. 2 point sensory discrimination intact bilateral feet & toes. No pain elicited in either foot during b/l (bilateral) foot exams. Skin intact bilaterally with left leg slightly warmer than right. When right leg is elevated for approx (imately) 2 to 3 minutes the right leg approximates that of left leg. A 09/25/17 order, written by PA #2, documented that Resident #4 was being referred for consultation with a vascular surgeon, and results of the 08/28/17 ultrasound were to accompany the resident to this appointment. A 09/27/17 nurse's note documented an appointment with the vascular surgeon was scheduled for Resident #4 on 10/05/17, and the transportation aide was aware of the appointment. A 10/09/17 12:00 PM nurse's note documented, Communication sheet made to see dr (doctor) patient's foot swollen and black and blisters found on right foot. Wound referral also made. Patient not complaining of pain in foot. A 10/10/17 2:30 PM nurse's note documented, Resident is up in w/c (wheelchair). Resident refused care (with name of vascular surgeon). Resident would not sign paperwork giving (name of vascular surgeon) permission to give care. Resident is alert and oriented. A 10/11/17 2:30 PM nurse's note documented, .Resident's foot has gotten worse since the visit to (name of vascular surgeon)'s office. Resident agreed to be sent to the hospital today Unable to feel pulse in (right) foot. (A 10/09/17 nurse's note and this 10/11/17 nurse's notes were the only ones in the medical record which documented information about the appearance of or the pulses in the resident's foot). PA #2's 10/11/17 progress note (not present in Resident #4's medical record on 10/19/17, and not electronically signed by PA #2 until 10/22/17) documented, (Resident #4's) station nurse paged me this morning to request that I see him today, because of sudden skin discoloration; especially involving his toes on his right foot Prior to going into (Resident #4's) room, the station nurse informed me that he was transported to (name of vascular surgeon)'s office several days ago. However, (Resident #4) refused to allow (name of vascular surgeon) to examine him; so (facility) transporter brought back to SNF (skilled nursing facility). I had not been informed of (Resident #4's) refusal of treatment. When I entered (Resident #4's) room, (facility) wound care nurse was already checking for distal pulses in the right foot. He is not able to illicit pedis or posterior tibia pulses. His right leg below the knee is cold. His left leg is warm. I am unable to palpate a femoral (thigh) pulse in the right leg. (Resident #4) denies leg pain today. He would not answer me when I asked him why he refused to allow (name of vascular surgeon) to examine him several days ago. I informed him that he was now facing a serious medical emergency & reminded him of our conversation we had earlier in late September. He has continued to smoke unabated. He gave me permission to send to the Hospital ED (emergency department) for evaluation & treatment. A hospital ED (emergency department) report, history and physical, and discharge summary documented Resident #4 was hospitalized from [DATE] - 10/17/17. Patient presents to the emergency department for a cold leg. This is a pleasant . male who comes from (name of facility) for arterial occlusion of the right lower extremity. Patient has a history of bad vascular disease and family says that a couple years ago he was just put on medicine because of the bad flow of blood in his legs but did not need surgery and sometime recently he has had problems with some pain and decreased flow to the leg. He is unable to tell me when it started hurting how long it was hurting when it stopped hurting and he cannot tell me much history as to how this occurred today nursing home sent him in because he had a very cold foot with black toes and no pulses they could palpate. I was able to get some notes from the nursing home, notes from today and also speaking with his family member who is his medical power of attorney, showing that patient saw (name of vascular surgeon) in the office on October fifth for a possible arterial occlusion but refused care at that time and then sent back to the nursing home. Patient's family members here who is his medical power of attorney and she says he does not have the capacity to make any medical decisions for himself and cannot make an informed decision. She said the nursing home had not notified her that he had gone to the doctor that day or was being sent to the doctor that day so she could be with him. The patient . is not able to consent. His (family member designation) who is his power-of-attorney is present and consenting for him. He was referred from (name of nursing home) with a mummified right foot, severe ischemia (inadequate supply of blood) of some period of time more than hours if not days. His right foot is black, is insensate. There is no motor. The ischemia extends for the entire foot onto the distal leg. There was no evidence of [MEDICAL CONDITION] or [DIAGNOSES REDACTED] but simply terminal ischemia. He has no Doppler signals. He is not able to provide a time line as to when the events occurred, and there is no information from the data sent from the care facility. He is not a candidate for revascularization or limb salvage. The degree of ischemia of the right lower extremity is severe and terminal, and his only option is an amputation. This was discussed with (family member designation) in front of the patient as much as the patient can understand. They were informed of the options of no intervention which could lead to progressive complications which could lead to death versus . amputation. The patient was admitted on [DATE] for dry gangrene of RLE up to mid-calf. Discussion was had with HCPOA (health care power of attorney) for right above knee amputation. The patient underwent the above procedure. He was hemodynamically stable The AKA wound was clean, dry and intact. There were no signs of infection or hematoma formation. He was discharged back to SNF on 10/17/17 in a stable medical condition . At 12:06 PM on 10/19/17 the Transport Aide stated on 09/27/17 she obtained the first available appointment with the vascular surgeon for Resident #4. She documented on her own forms in her own handwriting that she had notified Family Member #1 of the appointment on 09/29/17 at 11:13 AM by leaving a voice mail on the family member's phone. She explained that she received no response or return call from Family Member #1 so on 10/02/17 at 2:50 PM she attempted to make phone contact again. As documented on her own forms in her own handwriting, the Transport Aide was unable to leave a message this time because the voice mailbox was full. The transporter reported she took Resident #4 to his 10/05/17 vascular surgery appointment. She commented the resident was asked to sign consent papers so the doctor could examine him. The transporter stated the resident did not seem to understand why he was signing his name so she explained to him that he was giving the doctor permission to examine him, the resident stated okay, but then again asked why he was signing the form, she explained again, the resident said okay, but instead of signing the form, shook his head and stated no. She reported she had no alternative but to bring the resident back to the facility. (Observation of the resident's face page in his medical record and the transport form supplied to the transporter revealed Family Member #1 was documented as the first emergency contact. However, there was a handwritten sticky note in Resident #4's medical record documenting Family Member #2 was to be contacted first). At 12:42 PM on 10/19/17 the facility Administrator stated Resident #4 was his own responsible party (RP), he had not been deemed incompetent, and therefore notifying his family of appointments and changes in condition was a courtesy. At 12:50 PM on 10/19/17 Social Worker (SW) #2 and #3 and the Care and Admissions Coordinator stated Resident #4 signed all his admission paperwork, and review of hospital paperwork revealed no documentation of guardianship or power of attorney, but two family members were named as emergency contacts. They reported there was discussion with all residents and families that residents were considered their own responsible parties unless documentation was provided which was registered through the court system naming family members as legal guardians or POAs. They commented Resident #4 was alert and oriented, but had periods of confusion. SW #3 stated she was assigned to Resident #4, and she commented she had only spoken to the two emergency contacts over the phone during a care plan meeting. She stated initially Family Member #1 was listed as the first emergency contact on facility paperwork, but because Family Member #2 lived closer to the nursing home, Family Member #1 gave permission for Family Member #2 to be contacted first, and a note was put in the resident's record to this effect. According to SW #3, during the admission process Resident #4 stated no family had any papers having control over his health or financial information. All three staff members stated Resident #4 was considered his own responsible party. At 4:07 PM on 10/19/17 Resident #4's primary first shift Nursing Assistant, (NA) #9, stated for the last 1 ½ months prior to going out to the hospital on [DATE] the resident gradually deteriorated physically and mentally. He reported the resident was mumbling, not making sense, sometimes would not even talk, sometimes could not even feed himself, stayed in bed, and did not walk during the week before going out to the hospital. However, the NA commented the resident never complained of pain. The NA remarked the level of care required by Resident #4 definitely increased. According to NA #9, he provided the resident bed baths on first shift. He stated in early September the resident's feet had reddened and blackened areas, two weeks later the resident's right foot was getting darker/blacker, and the week that the resident went out to the hospital the resident's right foot had blisters on it. He commented he reported these changes to the hall nurses. At 4:17 PM on 10/19/17 Nurse #1, who cared for Resident #4 from 7:00 AM to 7:00 PM, stated she filled out the preliminary paperwork with Resident #4, and he stated he would see the vascular surgeon. She stated the transporter reported to her that when she got the resident to the surgeon's office, and she requested for him to sign the release, the resident shook his head no. She commented she told PA #2 that the resident refused to be seen by the surgeon so PA #2 sent the resident out to the hospital where they felt the resident would be more willing to cooperate with doctors. She stated the resident did not complain of pain in his feet, but was not getting out of his bed or ambulating as much the last 2 - 3 weeks before being sent out to the hospital. She reported there was a note in the resident's chart to call Family Member #2 first when there were changes in the resident's condition. She commented Resident #4 was alert and able to express his needs before going out to the hospital, but he was frequently confused about time and location and was not always reliable or understandable. At 5:12 PM on 10/19/17 Physician #1, the facility's MD, stated he was not notified of the resident's Doppler results, but he only took on responsibilities as MD around first of September 2017, and he was not exactly sure what system the facility had in place at that time for notification of lab and test results. He reported he supervised two PAs who were more familiar with the facility and residents, and they mainly looked at test and lab results. He stated the PAs called him with abnormal lab results or if they had questions about results. After reviewing Resident #4's 08/28/17 Doppler results, he stated the resident should have seen a vascular surgeon immediately, as soon as possible, so treatment options could have been discussed with the resident. He commented if nothing was done, the resident would start losing parts of his legs. The MD explained the results of the 08/28/17 doppler were poor with the resident's right lower extremity completely occluded. However, he stated that the surgeon or vascular specialist should have had the opportunity to assess and decide if options such as laser treatment, stents, or bypasses could have possibly saved Resident #4's right foot and leg. The MD commented that he had seen incidents in which if the proximal circulation was enhanced then there could be some improvement in the distal circulation also. He reported the treatment goal was obviously to save the resident's foot and leg if at all possible. At 9:25 AM on 10/20/17 the facility's Treatment Nurse stated he did not assess Resident #4's right leg/foot before his 10/11/17 hospitalization because the impairment was vascular in nature, and there was no wound for him to observe. At 9:40 AM on 10/20/17 the Director of Nursing (DON) stated once lab or test results were reviewed by the physician or PAs they were supposed to be initialed and placed back in the medical record. At 10:07 AM on 10/20/17 Nurse #1 stated she observed Resident #4's feet daily, but may not have documented on the appearance of his legs and feet, and the only thing she noticed was that the resident's right foot became gradually darker in coloration. She reported Resident #4 needed more assistance with his activities of daily living, was a little more lethargic, but still got out of bed with staff assistance before he went out to the hospital on [DATE]. At 10:12 AM on 10/20/17 NA #2 stated she cared for Resident #4 a couple of days before he went out to the hospital on [DATE], and she noticed the resident's right foot was swollen, darker in color than the rest of his body, and the resident was lethargic. However, she reported the resident was able to express his needs, and did not complain of pain. She commented the resident did get out of bed, but needed a lot of assistance. At 10:47 AM on 10/20/17, during a telephone interview, Nurse #10 stated she could not remember the exact date of her Physician Communication Form (believed to be 09/25/17 based on physician orders [REDACTED].#4's right foot, but she reported a PA was in the building and immediately assessed the resident. She commented NA #9 had come to her stating the resident's right foot was getting very dark, and the resident was complaining of pain in the foot. According to Nurse #10, Resident #4 told her his pain level was just less than 5 on a 1 - 10 scale, and the right foot and toes were a very dark brown. She also commented the right foot was slightly swollen. At 11:20 AM on 10/20/17 PA #2 stated he started working with/for the new MD (Physician #1) on 09/06/17. He reported this MD was Resident #4's physician prior to assuming his new role on 09/06/17. According to PA #2, he first saw Resident #4 on 09/25/17 in conjunction with the hall nurse's concern over appearance of the resident's right leg and foot. He stated 09/25/17 was the first time he had reviewed the 08/28/17 Doppler results. He commented on 09/25/17 there were faint pedal pulses and there was warmth to the resident's feet and toes. (PA #1 documented on the same day the resident's right lower extremity was cool to touch and without pulses). He stated the resident was lethargic which he thought was his baseline. He reported at that time there was no blackness to the toes. He stated he saw the resident again on 10/11/17 in response to hall nurse's concerns about changes in the appearance of the resident's right foot. He reported on 10/11/17 the resident's toes on his right foot were now black, and the right foot had gotten worse with no pulses in the right foot. According to PA #2, the resident's leg from the knee down was ice cold. PA #2 stated on 10/11/17 he was told that Resident #4 refused his vascular consult on 10/05/17, and so he sent the resident to the ED on 10/11/17. He stated on 10/11/17 he raised the resident's leg up in hopes of getting warmth, but the intervention was not successful. He reported there were no blisters or [MEDICAL CONDITION] to the resident's right foot, but there was dry skin and the toes were black. He stated the right LE was now completely occluded which had been foreshadowed by severe stenosis documented on the 08/28/17 Doppler and a heavy smoking habit. He commented he asked the resident why he would not see the surgeon, and the resident stated he did not know. However, he reported the resident agreed to go to the hospital for treatment. The PA stated he would not comment on the apparent gap of almost a month between the 08/28/17 Doppler and the first review of Doppler results on 09/25/17 (because the MD ordered the Doppler on 08/26/17, and he was not working for the medical director at that time). The PA reported lab/test results from tests which he ordered were left in a box in the facility for him to review when he was in the building on Mondays, Wednesdays, and Fridays. However, he commented he was not the one who ordered the resident's Doppler on 08/26/17, and he was not sure what system the MD had in place to make sure the lab/test results he ordered were obtained and available for review. At 11:43 AM on 10/20/17, during a telephone interview with Family Member #2, she stated she was the medical power of attorney for Resident #4 in the hospital, but did not have court registered documents yet. She reported the facility was aware she was in the process of getting legal documents. She commented previously when the resident was in another facility in this same area he was sent out for an arteriogram. She reported the family was told that the resident was at high risk for severe vascular issues and that the right foot and leg needed to be monitored carefully. She stated she thought it would have made a difference if family went with Resident #4 to the surgical appointment because the resident trusted his family, and they could have talked him into being seen by the surgeon. At 12:12 PM on 10/20/17 Resident #4 stated he had pain at a level of 10 daily in the weeks before going out to the hospital. He reported he told staff members about this pain, but then he became silent, and would or could not identify those staff members that he had communicated his pain to. (Pain was only documented by the staff on 08/23/17, 08/24/17, and 09/01/17 in Daily Skilled Nurses Notes between 08/14/17 and 09/20/17. There were no nurse's notes in the medical record between 09/21/17 and 09/26/17, and sporadic nurse's notes between 09/27/17 and 10/11/17 did not document the presence of pain). At 1:10 PM on 10/20/17 the Director of Nursing (DON) stated mobile lab/test results were faxed to the facility. She reported when faxes were collected, and there were mobile lab/test results among the faxes, this information was given to medical records to forward to the physicians so they could sign off on them and write orders that might be generated from the results. The DON also commented assessment of Resident #4's pain associated with his lower extremities and assessment of the resident's right foot, including appearance and pulses, should be documented in the nurse's notes. At 1:38 PM on 10/20/17 PA #1 (who saw the Resident #4 before PA #2 on 09/25/17) stated there were no Doppler results in the chart when she reviewed it on 09/25/17. She reported on 09/25/17 Resident #4's right leg was blue and cold, and his right foot was cold and purple/blue. She also commented there were no pedal pulses in the right lower extremity. According to PA #1, after examining Resident #4 on 09/25/17 she knew the resident had serious problems so told the hall nurse if she could not get a STAT (immediate) Doppler to make sure the resident got to a vascular doctor as soon as possible (later PA #2 canceled the STAT Doppler because he obtained the results from the resident's 08/26/17 Doppler). At 2:50 PM on 10/20/17 Nurse #1 stated she thought she checked the pulses in Resident #4's lower extremities maybe every other day, and they were consistently getting fainter. She reported she should have documented the pulses and appearance of the right foot in her nurse's notes, but did not always do that. She commented she thought the Treatment Nurse was checking the pulses sometimes. (The only nurse's note documenting information about pulses in Resident #4's right LE was made on 10/11/17). At 2:54 PM on 10/20/17 the Medical Records Clerk stated it was her responsibility to retrieve faxes and distribute them to the nurses who in turn made sure lab/test results got to the respective physicians who ordered them. She reported she handled so many faxes that she was unsure if she ever collected any Doppler results for Resident #4. At 4:25 PM on 10/26/17, during a returned phone call, Nurse #11, who cared for Resident #4 from 7:00 PM to 7:00 AM, stated she was very alarmed when she found out that Resident #4 did not go to his vascular consult on 10/05/17 because she remembered thinking that the resident's right foot had undergone major changes since his admission. She reported she thought the resident's right leg was getting colder, and his right foot was getting darker. She commented she thought most of the assessment of the resident's right foot (appearance and pulses) was done by the 7:00 AM to 7:00 PM nurse because the resident was early to bed and early to rise so she did not see him that much. According to Nurse #11, she did not recall Resident #4 being in chronic pain, but she was sure she sometimes administered prn (as needed) pain medications due to pain in his right leg and foot. She stated Resident #4 was sometimes slow to respond and did not talk a lot, but she considered him to be alert and oriented and able to express his needs.

Based on resident interviews, staff interviews and record review, the facility failed to ensure that 4 of 15 sampled residents (Residents #4, #12, #13 and #14) were free from the verbal abuse of staff. Findings include: 1. On 12/21/11 record review for Resident # 13 revealed the resident was admitted on [DATE] and the MDS (Minimum Data set) dated 9/30/11 revealed the resident was assessed as being cognitively intact, and that on 11/8/11 Resident # 13 filed a grievance with the facility. The facility Grievance Log revealed under comments for Resident # 13: Staff made inapp (inappropriate) statement. On 12/21/11 at 11:30 am, Resident # 13 was interviewed regarding the grievance log entry. The resident stated that since admission in March, Nurse # 2 had been the weekend nurse and that Nurse # 2 made little comments that the resident let pass. The resident indicted that the greivance started out about a pain medication; that since 1983 Resident # 13 had 8 back surgeries with metal rods and as recent as September 16 of this year had had neck surgery. Resident # 13 stated, " I was on pain management before I came to this facility. The pain management doctor told me with my surgeries I am no different than a diabetic that needs medication --that I will need some pain medication to be comfortable enough to function. That is all I want to do. I am taking the same pain medications here at the facility from Dr. (Name) that I had taken from the pain management clinic " . Resident # 13 said, " I couldn't take the comments anymore-I had asked for pain medication and Nurse # 2 said that you drug addictis are something else--you are not in any more pain that I am. I responded I am not a drug addict and Nurse # 2 said even if medication is perscription you are still a drug addict. I told the Monday nurse and he told me he was going to the Social Worker. The ADON and a couple of others spoke with me. The ADON asked if I was uncomfortable with Nurse # 2 on the unit and the ADON took Nurse # 2 off my hall. Most of the nurses are fine-I just got tired of Nurse # 2 ' s comments. I just want to be out of enough pain to function. " The resident began crying at this point in the interviw and stated., " I am not a drug addict " . When asked how it felt, the resident stated this made me feel this high and indicated about 1/2 inch high by putting finger and thumb close together and said, " I told Nurse # 2 if you had to walk one day in my shoes you would see. Nurse # 2 also said I did not need a wheelchair-I could use a walker. " Resident # 13 explained that she could use a walker to walk a short distance like to the Nurses Station, but needed a wheelchiar to go a longer distance like to the dining room. Resident # 13 stated Nurse # 2 had never refused to give her pain medication. When asked if Nurse # 2 had worked on the hall since, the resident replied that Nurse # 2 had only worked once since that day and that was this past weekend on Saturday--when they were short and that it was OK. On 12/21/11 at 8:15 am, Social Worker # 1 (SW # 1) was interviewed regarding the Grievance Log entry for Resident # 13. A document entitled Grievance/Complaint Report dated 11/8/11 for Resident # 13 was provided for review and revealed the following: Resident asked for PRN meds. Nurse (name of Nurse # 2) said, " You and I both know that you don ' t need them--that you are not any more in pain that anything. Resident put on button for 8:00 meds (name Nurse # 2) said, " You druggies are unbelievable. You ' re ridiculous. The report was signed by SW # 1. The report also revealed was that the individual designated to take action on the concern was the (Name) Director of Nursing (DON) and the assigned date was 11/8/11. SW # 1 stated a copy of the above named report was given to the DON as the grievance involved the Nursing Department and further indicated the DON usually provided feedback on what was done. SW # 1 stated she did not have a follow up report from the DON on this grievance yet. SW # 1 also stated she considered Resident # 13 to be reliable, especially since Resident # 13 was not a complainer-was humble and gracious and information had been known to be accurate. SW # 1 stated she has heard Nurse # 2 interact with residents while SW # 1 was going up and down the halls and that Nurse # 2 ' s tone in not nurturing. SW # 1 stated it is the job of the Social Worker to see how residents are doing. When asked if the grievance of Resident 13 was abuse, SW # 1 stated she would not call it abuse and stated Nurse # 2 ' s tone needed to be improved-heard Nurse # 2 had worked in a jail. SW # 1 stated residents needed to be treated with respect and dignity. On 12/21/11 at 10:20 am an interview was conducted with the Director of Nursing (DON). The DON stated an abuse allegation would be reported to her and a report filed by her or the administrator. The DON stated the concern for Resident # 12 from the Grievance Log was received by both the ADON and DON. The DON stated she had concerns about several nurses-Nurse # 2, Nurse # 3, and Nurse # 6 were the names of the nurses she could recall. The DON stated the ADON talked to Nurse # 3 about making pre-conceived judgments about resident being drug-seeking with narcotics. The DON stated they had re-educated staff and had Hospice come in to talk to the nurses. The DON stated Nurse # 3 had been employed on a PRN (as needed) basis and was no longer used. The DON stated Nurse # 2 and Nurse # 6 were put through in-services about inappropriate comments to residents about pain medications. The DON stated Nurse # 2 was still here as Nurse # 2 was receptive to education-she was from a prison experience. The DON stated the other two (Nurse # 3 and Nurse # 6) acted like they did not care so they were not used anymore. The DON stated she spoke with Resident # 13 to investigate the incident. The DON stated she looked at the incident that was reported to her as a dignity issue and not as abuse. When asked if this incident would be something that would be reported on a 24 hour report and why it was not considered verbal abuse, the DON stated it was not considered abuse and was not reported on a 24 hour report because the resident ' s stories changed-first she was told by one of the residents it was Nurse # 3 and then that it was Nurse # 2. The DON also stated only one other resident had had problems with Nurse # 2. When asked for what type of concerns a 24 hour report would be filed, the DON stated the 24 hour report would be filed for incidents of unknown origin, for abuse if it looked like the investigation was turning into something, for physical abuse or loss of money. When asked when a 24 hour report would be filed, the DON stated first the incident would be investigated and then depending on what was found a 24 hour report would be done. 2. On 12/21/11, record review for Resident # 12 revealed the resident was assessed on the quarterly MDS (Minimum Data Set) dated 9/5/11 as being cognitively intact and that on 11/8/11 Resident # 12 filed a grievance with the facility. The facility Grievance Log revealed under comments for Resident # 12: Staff made inapp (inappropriate) statement. On 12/21/11 at 11:00 am, Resident # 12 was interviewed about the entry on the facility Grievance Log and stated the grievance was about Nurse # 2. The resident stated that Nurse # 2 was just mean and gave this example: " Nurse # 2 brought meds-[MEDICATION NAME]-- it was a scheduled medication but it was not in the cup. When I asked where the medication was, Nurse # 2 got mad and upset then went right outside the door and brought the medication back. The medication was in Nurse # 2 ' s hand. " To the best of Resident # 12 ' s memory, this happened on two different occasions. The resident stated Nurse # 2 also said, " I am going to keep my eye on you because I knew you in jail. " After I told the Social Worker (SW) and Assistant Director of Nursing (ADON), Nurse # 2 really got angry and slurred words under (pronoun) breath about me and would say can't you see I am busy when I requested a sleeping medication. Once when I asked if I got a sleeping pill at 7:00 pm or 8:00 pm Nurse # 2 responded, " You get it when I bring it. " When asked how this resident felt, the resident responded " It really bothers me-it makes me angry and if I don't go along with Nurse # 2, I feel Nurse # 2 is trying to get me kicked out. Nurse # 2 said I did not need to be in the facility and that I did not need a wheelchair. " The resident stated (pronoun) stayed in the room when Nurse # 2 was around and that Nurse # 2 stared when she saw (pronoun) in the halls. On 12/21/11 at 3: 05 pm, Resident # 12 stated in an interview that the last interaction with Nurse # 2 was just before Nurse # 2 was re-assigned off the hall where Resident # 12 ' s room was located. Resident # 12 was not sure of the date of reassignment. On 12/21/11 at 8:15 am, Social Worker # 1 (SW # 1) was interviewed regarding the Grievance Log entry for Resident # 12. A document entitled Grievance/Complaint Report dated 11/8/11 for Resident # 12 was provided for review and revealed the following: (Name of Nurse # 2 (weekend nurse). (Pronoun) Resident # 12 asked (name of Nurse # 2) for medication and (name of Nurse # 2) said " y ' all get so addicted to these pills. " (Name of Nurse # 2) is nasty to the residents. (Name of Nurse # 2) ignores you when you try to ask something. The report was signed by SW # 1 and also revealed that the individual designated to take action on the concern was the (Name) Director of Nursing (DON) and the assigned date was 11/8/11. SW # 1 stated a copy of the above named report was given to the DON as the grievance involved the Nursing Department and further indicated the DON usually provided feedback on what was done. SW # 1 stated she did not have a follow up report from the DON on this grievance yet. SW # 1 also stated she considered Resident # 12 to be reliable. SW # 1 stated she has heard Nurse # 2 interact with residents while SW # 1 was going up and down the halls and that Nurse # 2 ' s tone in not nurturing. SW # 1 stated it is the job of the Social Worker to see how residents are doing. When asked if the grievance of Resident # 12 was abuse, SW # 1 stated she would not call it abuse and stated Nurse # 2 ' s tone needed to be improved-heard Nurse # 2 had worked in a jail. SW # 1 stated residents needed to be treated with respect and dignity. On 12/21/11 at 10:20 am an interview was conducted with the Director of Nursing (DON). The DON stated an abuse allegation would be reported to her and a report filed by her or the administrator. The DON stated the concern for Resident # 12 from the Grievance Log was received by both the ADON and DON. The DON stated she had concerns about several nurses-Nurse # 2, Nurse # 3, and Nurse # 6 were the names of the nurses she could recall. The DON stated the ADON talked to Nurse # 3 about making pre-conceived judgments about resident being drug-seeking with narcotics. The DON stated they had re-educated staff and had Hospice come in to talk to the nurses. The DON stated Nurse # 3 had been employed on a PRN (as needed) basis and was no longer used. The DON stated Nurse # 2 and Nurse # 6 were put through in-services about inappropriate comments to residents about pain medications. The DON stated Nurse # 2 was still here as Nurse # 2 was receptive to education-she was from a prison experience. The DON stated the other two (Nurse # 3 and Nurse # 6) acted like they did not care so they were not used anymore. The DON stated she spoke with Resident # 12 to investigate the incident. The DON stated she looked at the incident that was reported to her as a dignity issue and not as abuse. When asked if this incident would be something that would be reported on a 24 hour report and why it was not considered verbal abuse, the DON stated it was not considered abuse and was not reported on a 24 hour report because the resident ' s stories changed-first she was told by one of the residents it was Nurse # 3 and then that it was Nurse # 2. The DON also stated only one other resident had had problems with Nurse # 2. When asked for what type of concerns a 24 hour report would be filed, the DON stated the 24 hour report would be filed for incidents of unknown origin, for abuse if it looked like the investigation was turning into something, for physical abuse or loss of money. When asked when a 24 hour report would be filed, the DON stated first the incident would be investigated and then depending on what was found a 24 hour report would be done. 3. On 12/21/11 record review for Resident # 4 revealed the resident was assessed on the MDS (Minimum Data Set) dated 10/24/11 as being cognitively intact. On 12/21/11 at 3:30 pm Resident # 4 was interviewed regarding interactions with facility staff. Resident # 4 was asked how residents were treated by nurses-if nurses talked rough or mean to the residents. Resident # 4 stated one staff person was overheard yelling at a resident in another room acorss the hall but Resident # 4 did not know who the staff person was. Resident # 4 stated Nurse # 2 was distant and not straightforward. Resident # 4 stated if a resident has a special need I heard them tell Nurse # 2 they would wait and ask the next shift. When asked how Nurse # 2 talked to Resident # 4, Resident # 4 stated Nurse # 2 is rude and that Nurse # 2 is the only one here like that. Resident # 4 stated that the first time I met Nurse # 2 I thought Nurse # 2 was just having a bad day--but had seen Nurse # 2 like this several times since. When asked when the last interaction with Nurse # 2 was, Resident # 4 stated that it was two weekends ago and that Nurse # 2 was a weekend nurse. Resident # 4 had not talked to anyone at the facility about Nurse # 2 and was not personally threatened by Nurse # 2 but saw the way older residents in wheelchairs shrank back or slumped down when Nurse # 2 walked by. 4. On 12/21/11 at 4:00 pm, Resident # 14 was interviewed regarding interactions with facility staff. Resident # 14 was included on a list of alert and oriented residents provided by the facility. When asked how facility staff treated Resident # 14, Resident # 14 responded that some are ok and that some are harsh. When asked to give specific examples, Resident # 14 stated one nurse (Named Nurse # 2) is like a warden-a drill sergeant and treats us like we are in the Army. Resident # 14 stated that Nurse # 2 did not believe me when I said I tried to eat healthy (I am having trouble with diabetes). Resident # 14 stated I heard Nurse # 2 yell at patients-told them to get back into their rooms until Nurse # 2 said they could come out. When asked when the last interaction with Nurse # 2 was, Resident # 14 stated it was this past Saturday (December 17, 2011). Resident # 14 stated Nurse # 2 said you better do this or you better do that. Resident # 14 said she saw older, delicate residents cringe when Nurse # 2 opened her mouth. Resident # 14 stated that Resident # 14 did not feel this was the place for Nurse # 2 to be. Resident # 14 stated Nurse # 2 hugged some residents and was mean to others.