Every finding on record at Brunswick Health & Rehab Center

Based on record review and interviews with staff, Nurse Practitioner (NP) and Physician, the facility failed to ensure pain management was provided to Resident #61, who had severe cognitive impairment and was unable to verbalize the need for pain medication, following an unwitnessed fall on 7/14/25 that resulted in changes in the level of transfer assistance she needed for toileting and moving from chair to bed. Communication from the nursing staff to the Nurse Practitioner on 7/15/25 failed to include Resident #61 had an unwitnessed fall. The NP did not assess the lower extremities for pain and concluded that the source of the hip pain was nerve pain. The NP's plan was for staff to administer acetaminophen 650 milligrams for pain as previously ordered and educate the severely cognitively impaired resident to request pain medication. Resident #61 continued to have pain after the NP visit. Resident #61 was transferred to the emergency department on 7/19/25 for evaluation of a left femoral neck fracture. Resident #61 was prescribed hydromorphone (a potent narcotic medication used to treat moderate to severe pain) intravenous and cyclobenzaprine (a muscle relaxant) for pain. Resident #61 underwent a left hip hemiarthroplasty (a procedure in which the fractured ball or head of the hip is replaced) on 7/20/25 and returned to the facility. This deficiency affected 1 of 1 resident reviewed for pain management (Resident #61). Findings included: Resident #61 was admitted on [DATE] with diagnoses which included a history of a right femur fracture, osteoporosis, and dementia. Resident #61's physician orders revealed an order dated 2/2/25 for acetaminophen 650 milligrams (mg) every 6 hours as needed for pain unspecified site. Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a severe cognitive impairment, was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #61 did not have pain assessed and had one fall with no injury. Resident #61 required limited assistance with transfers, bed mobility and toileting and used a wheelchair for mobility. Resident #61 was usually able to make herself understood and understand others. During the assessment lookback period, Resident #61 occasionally had pain and pain rarely or never interfered with activities.A review of Resident #61's electronic Medication Administration Record revealed that on 7/14/25 on the day shift (7:00 AM to 7:00 PM) Nurse #5 documented the resident's pain level was 0 on a 10-point scale with 0 being no pain and 10 being the worst pain ever. Resident #61's electronic health record revealed that there was no nursing progress note documented on 7/14/25. There was no documentation that indicated Resident #61 experienced an unwitnessed fall, reported pain, or received an assessment of the left lower extremity or of the resident's ability to transfer, ambulate, or move.An interview was conducted with Nurse #5 on 4/9/26 at 9:58 AM. Nurse #5 was assigned to care for Resident #61 on 7/14/25, 7/17/25, and 7/19/25 during the 11:00 AM to 11:00 PM shifts. During the interview, Nurse #5 stated that he did not assess Resident #61 for pain or range of motion. He further reported that he did not recall Resident #61 reporting an unwitnessed fall on 7/14/25 or reporting pain on that date but he indicated that if Resident #61 fell, she could have gotten herself up without assistance. Nurse #5 indicated that Resident #61 was cognitively impaired and had an impaired ability to request pain medication.An interview was conducted with NA #10 on 4/9/26 at 2:00 PM. NA #10 was assigned to Resident #61 on 7/14/25 from 7:00 PM to 7:00 AM on 7/15/25. NA #10 did not recall if Resident #61 had any changes in condition, changes to her left leg or complaint of pain. NA #10 stated that if Resident #61 had pain during care she reported it to the nurse on duty. A nursing progress note dated 7/15/25 at 5:57 AM written by Nurse #11 revealed that Resident #61 stated she was having a lot of pain in her hip and a note was placed in the doctor's book (a facility internal communication logbook for non-urgent communication). The progress note did not indicate that a pain assessment or head to toe assessment was completed. A review of Resident #61's Medication Administration Record (MAR) revealed Nurse #11 did not document administration of pain medication from 7/14/25 at 7:00 PM through 7:00 AM on 7/15/25. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/14/25 on the night shift (7:00 PM to 7:00 AM) Nurse #5 documented the resident's pain level was 0. An interview with Nurse #11 on 4/8/26 at 5:15 PM via phone revealed that she was assigned to Resident #61 on 7/14/25 from 7:00 PM to 7:00 AM on 7/15/25. Nurse #11 stated that when she received report from the off going nurse on 7/14/25, she was not informed that Resident #61 had experienced a fall. She reported that during the night, the resident was having significant pain and was screaming and crying, which was not typical for her. Nurse #11 stated that she asked the Nurse Aide (NA) assigned to Resident #61 whether the resident had any changes and was informed that the resident was unable to ambulate, which was a change from her baseline. She reported that she documented the change in condition in the facility's internal communication log ( doctor's book) for the provider. Nurse #11 stated that she believed she had administered something for pain but could not recall specifically, adding that if it was not documented, she must not have given it. She was informed that the electronic Medication Administration Record did not contain documentation of an as needed dose of acetaminophen administered by her on 7/15/25. Nurse #11 stated that Resident #61 demonstrated pain by screaming, crying and grimacing but was unable to request pain medication. She stated that on the morning of 7/15/25, she reported the resident's increased pain to another nurse, though she did not recall which one. Nurse #11 stated that Resident #61 was unable to rate her pain or request pain medication. Nurse #11 was unable to state why she recorded Resident #61's pain as a 0 on a scale of 0 to 10 when the resident had demonstrated pain during her shift. An interview conducted with NA #4 on 4/8/26 at 6:00 PM revealed that she had been assigned to Resident #61 on 7/15/25, 7/16/25 and 7/19/25 from 7:00 AM to 7:00 PM. NA #4 stated that on 7/15/25, Resident #61 experienced significant pain and was yelling out when she attempted to transfer the resident from the bed to the wheelchair to go to the bathroom. NA #4 stated that she was familiar with Resident #61, and the resident did not usually demonstrate pain with transfers or moving. NA #4 stated that she informed the nurse on duty, although she did not recall which nurse she spoke to and did not know what actions were taken. NA #4 stated that she kept Resident #61 in bed for the remainder of the shift on 7/15/25 due to the resident's pain with movement and provided all care to the resident in bed on the subsequent days. NA #4 stated that Resident #61 was unable to rate her pain on a scale of 0 to 10 and was unable to request pain medication.A nursing progress note written by Nurse #12 dated 7/15/25 at 11:30 AM indicated that the note was a late entry that was recorded on 7/19/25 at 12:30 PM. The note indicated that Nurse #12 was assigned to Resident #61 on 7/15/25 when the resident reported that she had pain in her hips and knees. The note indicated that Resident #61 stated that she fell yesterday (7/14/25), was able to pull herself up and did not tell anyone. The note stated that Nurse #12 spoke to the Nurse Practitioner regarding Resident #61's pain and that the resident was screaming in pain when she was moved. The progress note stated that the NP informed Nurse #12 that Resident #61 complained of pain all the time. Nurse #12 informed the NP that the pain Resident #61 was demonstrating was not her normal behavior. The NP instructed staff to administer the previously ordered acetaminophen as needed and stated that he would evaluate the resident the following day. The progress note did not document a pain level or an assessment of Resident #61's lower extremities, nor did it indicate that the unwitnessed fall reported by Resident #61 had been communicated to the NP. A review of Resident #61's electronic Medication Administration Record revealed that acetaminophen 650 milligrams as needed was administered by Nurse #12 on 7/15/25 at 11:50 AM for pain and was documented as slightly effective. The MAR did not have numerical pain monitoring documented with the administration of the as needed medication for pain. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/15/25 on the day shift (7:00 AM to 7:00 PM) Nurse #12 documented the resident's pain level was 0. The surveyor attempted to interview Nurse #12 via phone, leaving voicemail messages and sending text messages on 4/8/26 at 5:02 PM and 4/9/26 at 2:36 PM, but no return call was received. Nurse #12 was assigned to Resident #61 on 7/15/25 from 7:00 AM to 7:00 PM and on 7/16/25 from 7:00 AM to 7:00 PM. A progress note written by the Nurse Practitioner (NP) dated 7/15/25 at 12:38 PM indicated that Resident #61's chief complaint was hip pain and indicated that the nursing staff reported the resident was having pain. The note stated that Resident #61 was oriented to person only, had forgetfulness with diagnosis of dementia and received medication for dementia. Resident #61 had anxiety and received the antianxiety medication lorazepam scheduled every 8 hours. The NP educated Resident #61 to request pain medication as needed. The note indicated that Resident #61 appeared sleepy and groggy, and that her pain was non specific. The assessment did not include documentation of an assessment of Resident #61's lower extremities. The assessment and plan indicated Resident #61 had nerve and hip pain with staff directed to administer acetaminophen as needed. The progress note indicated that the NP educated Resident #61 to ask for pain medication. An interview was conducted with the former Nurse Practitioner (NP) on 4/9/26 at 10:15 AM via phone. The NP stated that although he was no longer employed at the facility, he had been assigned to Resident #61 during July 2025. He explained that Resident #61 experienced intermittent pain, which he believed to be her baseline, and he assumed it was just her complaining when he was informed that she was having pain on 7/15/25. The NP reported that he was unaware the resident had experienced a fall when he was asked to evaluate her on 7/15/25. He stated that had he known Resident #61 had fallen and was reporting pain, he would have ordered x rays immediately. The NP acknowledged that he did not speak with staff on 7/15/25 to inquire about the resident's pain or any changes in her condition including pain with movement and ambulation. He stated that if a resident exhibited new onset of severe pain, with or without a fall, an x ray should have been ordered. The NP indicated that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. He stated that this could have caused the fracture to worsen with further displacement and that would result in increased pain. The NP stated that Resident #61 was not specific regarding her pain and was unable to rate her pain on a scale of 0 to 10. The NP stated that he did not know if the resident was able to request pain medication but stated that he instructed the staff to encourage the resident to ask for pain medication. A nursing progress note written by Nursing Supervisor #4 dated 7/15/25 at 4:13 PM indicated a Stop and Watch internal communication tool was received (it did not state who had provided the communication tool) regarding Resident #61's complaint of hip pain. The nurse assigned to Resident #61 (Nurse #12) requested that the Nurse Practitioner evaluate the resident. The Nurse Practitioner evaluated Resident #61. A physician order for acetaminophen as needed was already in place in Resident #61's list of ordered medications and the Nurse Practitioner recommended to encourage the resident to ask for the medication. An interview was conducted with Nursing Supervisor #4 via phone on 4/8/26 at 3:53 PM. Nursing Supervisor #4 stated that although she was no longer employed at the facility, she had served as a supervisor during July 2025. She reported that she became aware of Resident #61's pain after reviewing some information as part of her supervisory duties, though she could not recall the specific source of that information. Nurse Supervisor #4 stated that she did not assess Resident #61 even after receiving information indicating the resident was experiencing hip pain. Nursing Supervisor #4 was unable to state why she didn't assess Resident #61 and indicated that she probably should have. Nursing Supervisor #4 stated that she did not know if the assigned nurse assessed Resident #61 for the source of her pain, the intensity or any changes in mobility or range of motion. Nursing Supervisor #4 stated that it was the nurse assigned to Resident #61 that was responsible for administering pain medication and assessing the resident. Nursing Supervisor #4 stated that Resident #61 was unable to rate her pain on a scale of 0 to 10 and was not able to request pain medicationA review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/15/25 on the night shift (7:00 PM to 7:00 AM) Nurse #13 documented the resident's pain level was 0. Resident #61's electronic Medication Administration Record (MAR) for 7/16/25 revealed that acetaminophen 650 milligrams was administered by Nurse #13 for pain at 6:06 AM and was documented as effective. The MAR did not have numerical pain monitoring documented with the administration of the as needed medication for pain. Nurse #13 was assigned to Resident #61 on 7/15/25 from 7:00 PM to 7:00 AM on 7/16/25. The surveyor attempted to interview Nurse #13 via phone on 4/9/26 at 1:55 PM with a voicemail left with no return call received. An interview with NA #5 via phone on 4/9/26 at 8:26 AM revealed that she was assigned to Resident #61 on 7/16/25 from 7:00 PM to 11:00 PM and on 7/18/25 from 7:00 PM to 7:00 AM on 7/19/25. NA #5 stated that she assisted Resident #61 to the bathroom on 7/16/25 when the resident complained that her leg was hurting during the transfer. Because she was unfamiliar with Resident #61's baseline, NA #5 reported that she asked another NA, she did not recall which NA, how the resident had been doing. According to the other NA, the resident had been fine until a day or two earlier but had recently developed hip pain and required increased assistance. NA #5 stated that she did not report Resident #61's pain in her leg during the transfer as she assumed that the nurse was already aware since the other NA stated the resident was having pain for a day or two. NA #5 stated that she did not request that the nurse assess the resident to determine if the resident required pain medication and that the resident seemed a little better after she repositioned her. NA #5 stated that Resident #61 was unable to rate her pain or request pain medication.An interview conducted with NA #4 on 4/8/26 at 6:00 PM revealed that she had been assigned to Resident #61 on 7/15/25, 7/16/25 and 7/19/25 from 7:00 AM to 7:00 PM. NA #4 indicated that on 7/16/25 and 7/19/25 Resident #61 continued to demonstrate pain with movement, transfers and ambulation but she did not report this to the nurse assigned to the resident as she assumed the nurse was already aware.Resident #61's electronic health record revealed there were no nursing progress notes dated 7/16/25 or 7/17/25 with no documentation of an assessment of the resident's pain.Resident #61's electronic Medication Administration Record (MAR) for 7/16/25 revealed that acetaminophen was administered by Nurse #12 at 2:33 PM for pain and was documented as effective. Resident #61's electronic MAR indicated a pain level of 5 was documented by Nurse #12 for day shift on 7/16/25. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/16/25 on the night shift Nurse #11 documented the resident's pain level was 0 and no acetaminophen was administered.Resident #61's electronic MAR indicated a pain level of 4 was documented by Nurse #7 for the day shift on 7/17/25 and as needed acetaminophen was not administered.An interview with Nurse #7 on 4/8/26 at 4:18 PM via phone revealed that she was assigned to Resident #61 on 7/17/25 from 7:00 AM to 11:00 AM. Nurse #7 stated that she worked at the facility infrequently on an as needed basis and she did not recall Resident #61's condition, pain level, ability to express her pain level or request pain medication in July 2025. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/17/25 on the night shift Nurse #11 documented the resident's pain level was 0 and no acetaminophen was administered.An interview with Nurse #11 on 4/8/26 at 5:15 PM via phone revealed that she was assigned to Resident #61 on 7/16/25 from 7:00 PM to 7:00 AM on 7/17/25 and 7/17/25 from 7:00 PM to 7:00 AM on 7/18/25 but did not recall the resident's condition or pain level on those dates.An interview was conducted with NA #7 via phone at 9:50 AM on 4/9/26. NA #7 was assigned to Resident #61 on 7/18/25 from 7:00 AM to 7:00 PM but had also assisted other NAs with the resident's care and was familiar with the resident. NA #7 stated that Resident #61 was getting up, ambulating and transferring without difficulty in the weeks prior to 7/14/25. NA #7 recalled Resident #61 suddenly began having trouble transferring and ambulating and she could tell that the resident was having a lot of pain. NA #7 stated that Resident #61 was unable to express her pain level on a 0 to 10 pain scale due to dementia, but she demonstrated increased pain by wincing, grimacing and holding her hip. NA #7 stated that Resident #61 was unable to request pain medication. NA #7 stated that she assisted the X-ray technician on 7/18/25 to obtain Resident #61's x- rays and it was difficult to reposition the resident in bed due to pain. NA #7 did not recall a nurse assessing Resident #61 and she did not report the resident's increased pain with ambulation, transfers, and repositioning as she assumed that the nurse was aware. A nursing progress note written by Nursing Supervisor #4 dated 7/18/25 at 8:02 AM indicated that Resident #61 appeared to be in discomfort. The note indicated that Resident #61 verbalized hip pain but was unable to provide details due to resident's dementia. Mobile x-rays were ordered. The progress note did not reference a pain level or an assessment of Resident #61's left lower extremity. An interview was conducted with the Unit Manager #1 on 4/9/26 at 11:00 AM. Unit Manager #1 stated that in July 2025 she was the facility wound care nurse but was assigned to Resident #61 on 7/18/25 from 11:00 AM to 3:00 PM. Unit Manager #1 stated that Resident #61 was not scheduled for any medication during the time she was assigned to her, so she did not go into Resident #61's room and did not assess the resident. Unit Manager #1 stated that she did not recall if she was informed of Resident #61 having pain or any changes in mobility. Unit Manager #1 stated that she had not assessed Resident #61's pain but she did not think that Resident #61 was able to rate her pain on a 0 to 10 scale or request pain medication due to her dementia with impaired cognition. Resident #61's x-ray report of the mobile X-ray of the left hip dated 7/18/25 at 11:31 PM indicated an acute left femoral neck fracture with displacement. Resident #61's electronic MAR indicated that acetaminophen was administered by Nurse #5 on 7/19/25 at 10:36 AM and was documented as effective. The MAR did not have numerical pain monitoring documented with the administration of the as needed medication for pain. A nursing progress note in Resident #61's electronic health record dated 7/19/25 at 11:52 AM written by Nurse #5 stated that results of the x-ray completed on 7/18/25 indicated an acute left femoral neck fracture with displacement. A nursing progress note dated 7/19/25 at 12:45 PM written by Nurse #5 stated that Resident #61 was transferred to the emergency department for evaluation. A follow up interview with Nurse #5 on 4/9/26 at 4:15 PM revealed that he was assigned to Resident #61 on 7/19/25 from 11:00 AM to 11:00 PM. Nurse #5 stated that he came in early for his 11:00 AM to 11:00 PM shift on 7/19/25 and when he came on for his shift, he found the x-ray results for Resident #61 dated 7/18/25 on the fax machine. Nurse #5 did not recall if Resident #61 was able to indicate a pain level or request pain medication or if he administered the acetaminophen on 7/19/25 after seeing the x-ray result that indicated a fracture. Upon noting that the x-ray report indicated a fracture, he reported the results to the on-call provider and received an order to send Resident #61 to the hospital for evaluation. The hospital history and physical report dated 7/19/25 indicated that Resident #61 was sent to the emergency department for evaluation of a left femoral neck fracture. The report indicated that Resident #61 stated upon arrival to the emergency department that she had hip pain and orders were written on presentation for hydromorphone (a potent narcotic medication use to treat moderate to severe pain) 0.2 milligrams intravenous every 3 hours as needed and cyclobenzaprine (a muscle relaxant) 5 milligrams every 8 hours as needed for pain. The hospital medication administration record revealed that Resident #61 received acetaminophen 650 milligrams every 6 hours as needed for pain on 7/19/25 at 8:28 PM. Resident #61 received hydromorphone 0.2 milligrams intravenous on 7/20/25 at 9:37 AM. The hospital Discharge summary dated [DATE] indicated that Resident #61 underwent a left hip hemiarthroplasty on 7/20/25 without complications and was stable to return to the facility. An interview with the Director of Nursing (DON) on 4/9/26 at 1:25 PM revealed that she expected residents with pain would be thoroughly assessed regardless of the residents' cognitive status. The DON further stated that her expectation was for the nursing staff to monitor residents for pain, assess the resident, and report increased pain or any changes in condition to the physician for further evaluation. The DON stated that Resident #61 was unable to rate her pain on a scale of 0 to 10 and was unable to request pain medication but that the resident should have been assessed for pain using non-verbal indicators and provided with pain medication as needed.

Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to complete and document comprehensive assessments and failed to identify or recognize the significance of severe pain and changes in mobility, transfers and ambulation after the resident reported an unwitnessed fall. The NP was notified of the resident's hip pain on 7/15/25 and evaluated the resident but was not informed of the unwitnessed fall on 7/14/25. The NP indicated had he known Resident #61 had fallen and was reporting pain, he would have ordered x rays immediately. The NP was notified again on 7/18/25 the resident was reporting hip pain and an x-ray of the resident's bilateral hips was ordered. The resident experienced pain and decreased ability to ambulate and transfer from 7/14/25 (the day of an unwitnessed fall) through 7/19/25 when the facility acted on a mobile x-ray report that identified an acute left femoral neck fracture with displacement (a serious type of hip fracture where the broken bone ends separate causing severe pain, inability to walk and often shortening or external rotation of the leg). She was sent to the Emergency Department for evaluation and treatment. The resident underwent a hemiarthroplasty of the left femur (a procedure in which the fractured ball or head of the hip is replaced) with no complications as a result of the surgery. This failure to comprehensively assess a resident was for 1 of 3 residents reviewed for accidents (Resident #61). Findings included: Resident #61 was admitted on [DATE] with diagnosis which included a femur fracture, osteoporosis, and dementia. A review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had severe cognitive impairment, was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #61 did not have pain assessed and had one fall with no injury. Resident #61 required limited assistance with transfers, bed mobility and toileting.A review of Resident #61's electronic health record revealed that there was no nursing progress note documented on 7/14/25. There was no documentation indicating that Resident #61 experienced an unwitnessed fall, reported pain, or received an assessment of the lower extremity or of the resident's ability to transfer, ambulate, or move.An interview was conducted with Nurse #5 on 4/9/26 at 9:58 AM. Nurse #5 was assigned to care for Resident #61 on 7/14/25 during the 11:00 AM to 11:00 PM shifts. During the interview, Nurse #5 stated that he did not recall Resident #61's condition in July 2025 and could not remember whether he assessed the resident for pain or range of motion. He further reported that he did not recall Resident #61 reporting an unwitnessed fall on 7/14/25 or reporting pain on that date. Nurse #5 stated that Resident #61 would have been able to get up off the floor if she fell. A review of Resident #61's electronic Medication Administration Record revealed that on 7/14/25 on the day shift (7:00 AM to 7:00 PM) Nurse #5 documented the resident's pain level was 0 on a 10-point scale with 0 being no pain and 10 being the worst pain ever. A nursing progress note dated 7/15/25 at 5:57 AM written by Nurse #11 revealed that Resident #61 stated she was having a lot of pain in her hip and a note was placed in the doctor's book. The note did not indicate that Nurse #11 called the on-call provider or administered medication for pain. A review of Resident #61's Medication Administration Record (MAR) revealed Nurse #11 did not document administration of pain medication from 7/14/25 at 7:00 PM through 7:00 AM on 7/15/25. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/14/25 on the night shift (7:00 PM to 7:00 AM) Nurse #5 documented the resident's pain level was 0. An interview with Nurse #11 on 4/8/26 at 5:15 PM via phone revealed that she had been assigned to Resident #61 on 7/14/25 from 7:00 PM to 7:00 AM on 7/15/25. Nurse #11 stated that when she received report from the off going nurse on 7/14/25, she was not informed that Resident #61 had experienced a fall. She reported that during the night, the resident was having significant hip pain, which was not typical for her. Nurse #11 stated that she assessed Resident #61 but did not recall whether she assessed the resident's left leg for a leg length discrepancy or deformity. Nurse #11 stated that she asked the Nurse Aide assigned to Resident #61 whether the resident had any changes and was informed that the resident was unable to ambulate, which was a change from her baseline. She reported that she documented the change in condition in the facility's internal communication log ( doctor's book) for the provider. Nurse #11 stated that she believed she had administered something for pain but could not recall specifically, adding that if it was not documented, she must not have given it. She was informed that the electronic Medication Administration Record did not contain documentation of an as needed dose of acetaminophen administered by her on 7/15/25. Nurse #11 stated that she asked Resident #61 whether she had fallen, and the resident replied that she did not remember. She stated that she reported the resident's increased pain to another nurse on 7/15/25 at the end of her shift, though she did not recall which nurse it was.An interview was conducted with NA #10 on 4/9/26 at 2:00 PM. NA #10 was assigned to Resident #61 on 7/14/25 from 7:00 PM to 7:00 AM on 7/15/25. NA #10 did not recall if Resident #61 had any changes in condition, changes to her left leg or complaint of pain. NA stated that if Resident #61 had pain during care she reported it to the nurse on duty. A review of a nursing progress note written by Nurse #12 dated 7/15/25 at 11:30 AM indicated that the note was a late entry that was recorded on 7/19/25 at 12:30 PM. The note indicated that Nurse #12 was assigned to Resident #61 on 7/15/25 when the resident reported that she had pain in her hips and knees. The note indicated that Resident #61 stated that she fell yesterday (7/14/25), was able to pull herself up and did not tell anyone. Nurse #12 documented that she spoke to the Nurse Practitioner regarding Resident #61's pain and that the resident was screaming in pain when she was moved. The progress note stated that the NP's response to Nurse #12's report of Resident #61's pain was that the resident complained of pain all the time. Nurse #12 informed the NP that the pain Resident #61 was demonstrating was not her normal behavior. The NP instructed staff to administer acetaminophen as needed and stated that he would evaluate the resident the following day. The progress note did not document a pain level or an assessment of Resident #61's lower extremities, nor did it indicate that the unwitnessed fall reported by Resident #61 had been communicated to the NP. Nurse #12 was assigned to Resident #61 on 7/15/25 from 7:00 AM to 7:00 PM. Attempted to interview Nurse #12 via phone with voicemail messages left and texts sent on 4/8/26 at 5:02 PM and 4/9/26 at 2:36 PM with no return call received. A review of Resident #61's electronic Medication Administration Record revealed acetaminophen 650 milligrams as needed was administered by Nurse #12 on 7/15/25 at 11:50 AM for pain and was documented as slightly effective. The MAR did not have numerical pain monitoring documented with the administration of the as needed medication for pain. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/15/25 on the day shift Nurse #12 documented the resident's pain level was 0. Review of a progress note written by the Nurse Practitioner (NP) dated 7/15/25 at 12:38 PM indicated that Resident #61's chief complaint was hip pain. The history of present illness documented that nursing staff reported the resident was having pain. The NP educated Resident #61 to request pain medication as needed. The note indicated that Resident #61 appeared sleepy and groggy, and that her pain was non specific. The assessment did not include documentation of an assessment of Resident #61's lower extremities. The assessment and plan indicated Resident #61 had neuropathic or nerve and hip pain with staff directed to administer acetaminophen as needed. The resident was again educated to ask for pain medication. An interview was conducted with the former Nurse Practitioner (NP) on 4/9/26 at 10:15 AM via phone. The NP stated that although he was no longer employed at the facility, he had been assigned to Resident #61 during July 2025. He explained that Resident #61 experienced intermittent pain, which he believed to be her baseline, and he assumed it was just her complaining when he was informed that she was having pain on 7/15/25. The NP reported that he was unaware the resident had experienced a fall when he was asked to evaluate her on 7/15/25. He stated that had he known Resident #61 had fallen and was reporting pain, he would have ordered x rays immediately. The NP acknowledged that he did not recall speaking with staff, including Nurse #12, on 7/15/25 to inquire about the resident's pain or any changes in her condition including pain with movement and ambulation. He stated that if a resident exhibited new onset of severe pain, with or without a fall, an x ray should have been ordered. The NP stated that he did not assess Resident #61's legs or hips and that the resident was unable to specifically tell where the pain was due to her dementia. The NP indicated that if he had examined Resident #61's hips and legs, he may have determined where the pain was and would have ordered x-rays. The NP did not recall whether he communicated with the Medical Director regarding Resident #61. He reported that any communication they had was informal and consisted mainly of occasional updates and reviewing each other's progress notes. The NP indicated that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. He stated that this could have allowed the fracture to worsen. A nursing progress note written by Nursing Supervisor #4 dated 7/15/25 at 4:13 PM indicated a Stop and Watch internal communication tool was received regarding Resident #61's complaint of hip pain. The nurse assigned to Resident #61 requested that the Nurse Practitioner evaluate the resident. The Nurse Practitioner evaluated Resident #61. A physician order for acetaminophen as needed was already in place in Resident #61's list of ordered medications and the Nurse Practitioner recommended to encourage the resident to ask for the medication. Nurse #13 was assigned to Resident #61 on 7/15/25 from 7:00 PM to 7:00 AM on 7/16/25. Attempted to interview Nurse #13 via phone on 4/9/26 at 1:55 PM. A voicemail was left with no return call received. A review of Resident #61's electronic health record revealed no documentation by Nurse #13 on 7/15/25 with no assessment completed. A review of Resident #61's electronic Medication Administration Record revealed that acetaminophen 650 milligrams was documented as administered by Nurse #13 on 7/16/25 at 6:06 AM for pain and was documented as effective. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/15/25 on the night shift Nurse #13 documented the resident's pain level was 0. Nurse #12 was assigned to Resident #61 on 7/16/25 from 7:00 AM to 7:00 PM. Attempted to interview Nurse #12 via phone with voicemail messages left and texts sent on 4/8/26 at 5:02 PM and 4/9/26 at 2:36 PM with no return call received. A review of the electronic MAR for Resident #61 for July 2025 indicated that acetaminophen 650 mg was administered for pain by Nurse #12 on 7/16/25 at 2:33 PM and was documented as effective. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/16/25 on the day shift Nurse #12 documented the resident's pain level was 5. An interview with Nurse #11 on 4/8/26 at 5:15 PM via phone revealed she was also assigned to Resident #61 on 7/16/25 from 7:00 PM to 7:00 AM on 7/17/25 and on 7/17/25 from 7:00 PM to 7:00 AM on 7/18/25 but did not recall the resident's condition or pain level on those dates. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/16/25 on the night shift Nurse #11 documented the resident's pain level was 0. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/17/25 on the night shift Nurse #11 documented the resident's pain level was 0. An interview was conducted via phone with Nurse #7 on 4/8/25 at 4:18 PM. Nurse #7 was assigned to Resident #61 on 7/17/25 from 7:00 AM to 11:00 AM. Nurse #7 stated that she did not recall anything about Resident #61 or her condition in July 2025. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/17/25 on the day shift Nurse #7 documented the resident's pain level was 4. A review of Resident #61's electronic MAR for July 2025 revealed that the resident did not receive acetaminophen on 7/17/25 or 7/18/25. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/17/25 on the night shift Nurse #5 documented the resident's pain level was 0. A review of Resident #61's electronic health record revealed there were no nursing progress notes dated 7/16/25 or 7/17/25 with documentation of an assessment of the resident's lower extremity or ability to transfer, ambulate or move.An interview conducted with NA #4 on 4/8/26 at 6:00 PM revealed that she had been assigned to Resident #61 on 7/15/25, 7/16/25 and 7/19/25 from 7:00 AM to 7:00 PM. NA #4 stated that on 7/15/25, Resident #61 experienced significant pain when she attempted to transfer the resident from the bed to the wheelchair to go to the bathroom. She reported that she informed the nurse on duty on 7/15/25 when the pain started, although she did not recall which nurse she spoke to and did not know what actions were taken. NA #4 stated that she kept Resident #61 in bed for the remainder of the shift and on the other days also due to the resident's pain with movement and provided all care in bed. She did not recall whether Resident #61's leg showed any abnormalities. NA #4 also reported that Resident #61 slept intermittently throughout the day, which was a change from the resident's usual baseline. NA #4 indicated that on 7/16/25 and 7/19/25 Resident #61 continued to demonstrate pain with movement, transfers and ambulation. An interview with NA #5 via phone on 4/9/26 at 8:26 AM revealed that she was assigned to Resident #61 on 7/16/25 from 7:00 PM to 11:00 PM and on 7/18/25 from 7:00 PM to 7:00 AM on 7/19/25. NA #5 stated that she assisted Resident #61 to the bathroom on 7/16/25 when the resident complained that her leg was hurting during the transfer. Because she was unfamiliar with Resident #61's baseline, NA #5 reported that she asked another Nurse Aide how the resident had been doing. According to the other Nurse Aides, the resident had been fine until a day or two earlier but had recently developed hip pain and required increased assistance. NA #5 did not report Resident #61's pain when transferring to the assigned nurse as she assumed the nurse was already aware. Attempted to interview NA #6 who was assigned to work with Resident #61 on 7/15/25 from 7:00 PM to 7:00 AM on 7/16/25 and on 7/16/25 from 11:00 PM to 7:00 AM on 7/17/25. Attempts made via phone on 4/9/26 at 8:05 AM and at 11:15 AM with voice mail and text sent with no return call. A nursing progress note written by Nursing Supervisor #4 dated 7/18/25 at 8:02 AM indicated that Resident #61 appeared to be in discomfort. Resident #61 verbalized hip pain but was unable to provide details due to resident's dementia. The NP was contacted and x-rays were ordered. The progress note did not reference a pain level or an assessment of Resident #61's lower extremity. An interview was conducted with Nursing Supervisor #4 via phone on 4/8/26 at 3:53 PM. Nursing Supervisor #4 stated that although she was no longer employed at the facility, she had served as a supervisor during July 2025. She reported that she became aware of Resident #61's pain after reviewing some information as part of her supervisory duties, though she could not recall the specific source of that information. After reviewing the information, she obtained an order from the Nurse Practitioner for an x ray, but she did not remember the exact date this occurred. Nursing Supervisor #4 stated that she was not aware of any fall involving Resident #61, and she did not assess the resident even after receiving information indicating the resident was experiencing hip pain. The Nursing Supervisor was unable to state why she did not complete a comprehensive assessment of Resident #61's pain but stated that she probably should have. She reported that she received a Stop and Watch communication tool from a staff member, but she did not recall which one and explained that this tool served as an internal communication method to report changes in condition. As a Nursing Supervisor, she was responsible for following up on these reports, and a copy was also provided to the Director of Nursing for tracking purposes. The Nursing Supervisor stated that copies of the Stop and Watch communication tools were only kept for a short period of time and then they were shredded. A review of Resident #61's electronic health record revealed a physician order was entered by Nursing Supervisor #4 on 7/18/25 at 9:11 AM for x-rays of bilateral hips to rule out displacement or fracture. A nursing progress note in Resident #61's electronic health record dated 7/18/25 at 3:01 PM written by Unit Manager #1 indicated that x-rays of bilateral hips were completed. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/18/25 on the day shift Unit Manager #1 documented the resident's pain level was 0. An interview was conducted with NA #7 via phone at 9:50 AM on 4/9/26. NA #7 was assigned to Resident #61 on 7/18/25 from 7:00 AM to 7:00 PM. NA #7 stated that Resident #61 was getting up in the weeks prior to 7/14/25 and was able to transfer and ambulate without difficulty. NA #7 recalled Resident #61 suddenly began experiencing difficulty transferring and ambulating and she could tell that the resident was having a lot of pain. NA #7 stated that Resident #61 was not able to express her pain level, but she demonstrated increased pain and was having trouble getting around and therefore required increased assistance. NA #7 stated that she assisted the x ray technician to obtain Resident #61's x rays and it was difficult to reposition the resident in bed due to pain. NA #7 stated that she observed Resident #61 grimacing and wincing in pain. NA #7 stated that Resident #61 demonstrated increased pain when ambulating and transferring in the days prior to her transfer to the hospital for evaluation of the left hip fracture. NA #7 indicated that she was assigned to Resident #61 on 7/18/25 but she and the other NAs worked together, and she had helped one of the other NAs with Resident #61's care on one of the prior days. NA #7 stated that Resident #61 had dementia and had trouble expressing herself. NA #7 did not recall a nurse assessing Resident #61 and she did not report the resident's increased pain with ambulation and transfers on 7/18/25 as she assumed that the nurse was aware. An interview was conducted with the Unit Manager #1 on 4/9/26 at 11:00 AM. Unit Manager #1 stated that in July 2025 she was the facility wound care nurse but was assigned to Resident #61 on 7/18/25 from 11:00 AM to 3:00 PM. Unit Manager #1 stated that Resident #61 was not scheduled for medications while she was assigned to her, so she did not go into Resident #61's room and did not assess the resident. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/18/25 on the night shift Nurse #11 documented the resident's pain level was 0. A review of an x-ray report of the left hip dated 7/18/25 at 11:31 PM indicated Resident #61 had an acute left femoral neck fracture with displacement. A nursing progress note dated 7/19/25 at 11:52 AM written by Nurse #5 stated that results of the x-ray completed on 7/18/25 indicated an acute left femoral neck fracture with displacement. The note did not contain an assessment of the resident. A nursing progress note dated 7/19/25 at 12:45 PM written by Nurse #5 stated that Resident #61 was transferred to the emergency department for evaluation. A review of the pain monitoring documentation on Resident #61's July 2025 electronic MAR revealed that on 7/19/25 on the day shift Nurse #5 documented the resident's pain level was 0. An interview was conducted with Nurse #5 on 4/9/26 at 9:58 AM. Nurse #5 was assigned to care for Resident #61 on 7/17/25 and 7/19/25 during the 11:00 AM to 11:00 PM shifts. During the interview, Nurse #5 stated that he did not recall Resident #61's condition in July 2025 and could not remember whether he assessed the resident for pain or range of motion.A follow up interview with Nurse #5 on 4/9/26 at 4:15 PM revealed that he was assigned to Resident #61 on 7/19/25 from 11:00 AM to 11:00 PM. Nurse #5 stated when he came on for his shift, he found the x-ray results for Resident #61 dated 7/18/25 on the fax machine. Upon noting that the x -ray report indicated a fracture, he reported the results to the on-call provider and received an order to send Resident #61 to the hospital for evaluation. A review of the hospital history and physical report dated 7/19/25 indicated that Resident #61 was sent to the emergency department for evaluation of a femoral neck fracture. The report indicated that Resident #61 endorsed hip pain on arrival to the emergency department and orders were written on presentation for hydromorphone (a potent narcotic medication use to treat moderate to severe pain) 0.2 milligrams intravenous every 3 hours as needed and cyclobenzaprine (a muscle relaxant) 5 milligrams every 8 hours as needed for pain. A review of the hospital medication administration record revealed that Resident #61 received acetaminophen 650 milligrams every 6 hours as needed for pain on 7/19/25 at 8:28 PM. Resident #61 received hydromorphone 0.2 milligrams intravenous on 7/20/25 at 9:37 AM. A review of the hospital Discharge summary dated [DATE] indicated that Resident #61 underwent a left hip hemiarthroplasty on 7/20/25 without complications and was stable to return to the facility. The hospital discharge orders indicated that Resident #61 was to receive physical and occupational therapy and was able to bear weight as tolerated. An interview was conducted with the previous Medical Director on 4/9/26 at 10:30 AM via phone. The Medical Director stated that she was no longer employed at the facility but was in the position during July 2025. The Medical Director stated that there was the potential for complications related to a fracture being undiagnosed for several days by the resident being moved, transferred and ambulated. The Medical Director stated that there was the potential for worsening of the fracture. An interview with the Director of Nursing (DON) on 4/9/26 at 1:25 PM revealed that she expected all unwitnessed falls, as well as falls reported by a resident, family member, or visitor, to be reported immediately and for the resident to be thoroughly assessed for injuries. The DON further stated that her expectation was for the nursing staff to monitor residents for pain, assess the resident, and report increased pain or any changes in condition to the physician for further evaluation. The Director of Nursing stated that the x ray results were faxed to the facility and were also available in the computer system, and that all nurses had access to the log in information needed to obtain the results electronically. The Director of Nursing stated that she expected the nurse on the shift following the completion of the x rays to check both the fax machine and the computer system for the results. The DON was unable to confirm when Resident #61's x-ray results were received at the facility. The DON confirmed that the facility conducted an investigation when Resident #61 was diagnosed with an acute femoral fracture. The investigation determined that Nurse #12 was informed of an unwitnessed fall and failed to report the incident resulting in a delay in treatment. The DON indicated that it was important to complete and document all assessments thoroughly.

Based on record review, observations and resident, staff and Registered Dietitian (RD) interviews, the facility failed to maintain the ordered fluid restrictions, renal diet restrictions and provide double portions of protein per the physician order for 1 of 1 sampled resident receiving hemodialysis (Resident #7). Findings included:The National Kidney Foundation recommends specific dietary adjustments for individuals receiving hemodialysis, including strict restrictions on fluids, potassium, and phosphorus. High potassium levels can be dangerous for the heart, requiring limits on foods such as bananas, potatoes, tomatoes, and oranges. Fluid restrictions help prevent excessive weight gain and fluid buildup in the body. Processed foods should be avoided to reduce sodium and phosphorus intake. A high protein diet that includes lean meats, poultry, fish, and egg whites is recommended. Resident #7 was admitted on [DATE] with diagnosis which included renal dialysis, end stage renal disease, hyperkalemia (an elevated potassium level in the blood which can cause muscle weakness, heart palpitations and shortness of breath), and heart failure. A review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact with no behaviors, had a diagnosis of renal failure/end stage renal disease and received a therapeutic diet. A review of Resident #7's electronic health record revealed a physician order dated 3/30/26 for a renal diet with double protein portions and a 1000 milliliter (mL) fluid restriction per 24 hours. The special instructions specified that Dietary was to provide 600 mL per day, distributed as 240 mL at breakfast, 240 mL at lunch, and 120 mL at dinner. The order also directed nursing to provide the remaining 400 mL per 24 hours, with first shift (7:00 AM to 7:00 PM) providing 200 mL and second shift (7:00 PM to 7:00 AM) providing 200 mL each day.A Registered Dietitian (RD) progress note dated 3/30/26 indicated that Resident #7 remained on a renal diet with double protein portions every meal and 1000 mL per 24 hours fluid restriction. RD to continue monitoring weight trends, intakes, nutrition-related lab values, skin status, and medications per protocol. A review of Resident #7's care plan initiated on 8/19/25 and last revised on 3/30/26 indicated a nutritional status problem for increased nutrition and hydration risk related to end stage renal disease, hemodialysis, therapeutic diet, and fluid restriction. Interventions included: maintain fluid restriction as ordered and encourage compliance with the prescribed diet. A lunch tray observation was conducted with Resident # 7 on 4/7/26 at 12:30 PM. Resident's meal tray ticket stated renal diet, allergy to tea, fluid restriction of 1000 mL per day with 240 mL fluid limit at lunch and double portions of protein. The meal tray ticket indicated that the resident received beef ravioli, Italian blend vegetables, sherbet 4 ounces, water 8 ounces and beverage of choice 8 ounces. Observation of the meal tray revealed that the resident received a small serving of beef ravioli with tomato sauce, a small dish of potatoes and carrots, a dinner roll, 4 ounces strawberry ice cream, 8 ounces water and 8 ounces ginger ale. The total number of ounces on the resident's meal tray for the water, ginger ale and ice cream was 600 mL. Double portions of protein were not observed. The Medical Records Manager, who served Resident #7 his lunch meal on 4/7/26 at 12:30 PM, was observed asking the resident what he wanted to eat instead after he informed her that he could not eat the ravioli due to his tomato allergy and his renal diet restrictions. Resident #7 responded that he would like whatever he was permitted to have under his renal diet restrictions. The Medical Records Manager then asked Resident #7 if he wanted a deli ham sandwich, a turkey sandwich, or an egg salad sandwich. The resident stated that he was not supposed to eat processed deli meats, so he requested an egg salad sandwich instead. An interview with Resident #7 on 4/7/26 at 12:35 PM revealed that the facility did not follow his renal diet and that he was often served foods that were not appropriate for his dietary needs, including the potatoes that he received on his lunch tray and the processed lunch meat sandwich he was offered as an alternate meal instead of the ravioli with tomato sauce. Resident #7 stated that staff were not aware of his fluid restriction. An observation of his bedside table revealed a large 12 ounce Styrofoam cup containing orange juice. The resident stated that he was provided the orange juice with breakfast, but he was restricted from consuming large servings of fluid and could not have a large cup of orange juice. An interview with the Medical Records Manager on 4/7/25 at 12:40 PM revealed that she was a Nurse Aide and assisted with delivering meal trays and feeding residents as needed. She stated that when she delivered meal trays, she checked the meal tray ticket for allergies and the diet. The Medical Records Manager indicated that she did not notice that Resident #7 received more fluid on his meal tray than permitted under his ordered fluid restriction and that he did not receive a double portion of protein. The Medical Records Manager stated that she was not sure what a renal diet consisted of.An interview with the Dietary Manager was conducted on 4/7/26 at 3:15 PM. The Dietary Manager stated that a renal diet included restrictions such as no tomatoes, tomato sauce or bananas and avoidance of other things that are high in potassium. She reported that she maintained a posted list in the kitchen identifying foods to avoid on a renal diet and expected her staff to refer to the list when preparing Resident #7's meal trays. The Dietary Manager stated that the small serving of ravioli provided to Resident #7 at lunch did not meet the requirement for a double protein portion and was served in error. She also reported that the potatoes and carrots substituted for the Italian blend vegetables should not have been served due to the resident's renal diet restriction, which specifies avoiding potatoes. The Dietary Manager added that she believed Resident #7 could have the roll, as he frequently received sandwiches in his bag lunch when going to dialysis. Additionally, she confirmed that the meal tray ticket listing 8 ounces of water, 8 ounces of a beverage of choice, and 4 ounces of sherbet exceeded the resident's 240 mL fluid restriction and acknowledged this was an error for which she could not provide an explanation. The Dietary Manager stated that there was no system in place to ensure that residents consistently received the correct diet or appropriate items on their meal trays. An interview with [NAME] #1 was conducted on 4/7/26 at 3:30 PM. [NAME] #1 stated that a renal diet meant the resident was not to receive tomatoes, potatoes and a few other certain things. The [NAME] stated that there was a list posted in the kitchen that identified foods to avoid on a renal diet. [NAME] #1 stated that she did not check the list when she prepared Resident #7's lunch meal tray on 4/7/26. [NAME] #1 indicated she read the tray card when preparing the meals. An observation of Resident #7's breakfast tray on 4/8/26 at 8:30 AM revealed that the resident received 1 fried egg, 1 slice of toast and a 4-ounce (120 mL) cup of coffee. The meal tray ticket indicated Resident #7 was to receive a renal diet with double portion of protein with an allergy listed as tea and a fluid restriction of 1000 mL per day with 240 mL provided at breakfast and lunch and 120 mL at dinner. The ticket indicated that Resident #7 was to receive 4 ounces (120mL) coffee and did not list the food items that the resident received. An interview with the consultant Registered Dietitian (RD) on 4/8/26 at 1:40 PM revealed that Resident #7 was ordered a renal diet with double protein and a 1000 mL fluid restriction. The RD stated that increased fluids can cause risks of poor volume management. The RD indicated that increased protein was important for a resident receiving dialysis to counteract the protein losses during treatment, to prevent muscle wasting and combat chronic inflammation. The RD stated that a small serving of ravioli was not a double portion of protein and further 1 fried egg was not a double portion of protein. The RD indicated that 2 large fried eggs constituted a standard serving so a double serving was 3-4 eggs. An interview with the Director of Nursing on 4/9/26 at 4:43 PM revealed that she expected that fluid restrictions and diet restrictions would be followed as ordered by the physician. The Director of Nursing stated that the dietary department was responsible for preparing meal trays according to the physician's orders, while the nursing staff was responsible for reviewing the meal tray ticket to ensure the diet was correct. She further indicated that nursing staff should be knowledgeable about special diets, such as a renal diet, and any associated restrictions. If a resident received an item on their tray and the nursing staff were uncertain whether it was permitted, they were expected to consult the dietary department for clarification.

Based on observation, record review and resident and staff interviews, the facility failed to determine whether self-administration of medications was clinically appropriate for 1 of 1 resident reviewed for self-administration of medications (Resident #7).Findings included: Resident #7 was admitted [DATE] with the diagnosis of renal dialysis, end stage renal disease, gastrointestinal hemorrhage and anemia. A review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and had no behaviors. Review of Resident #7 ' s current care plan revealed that the resident was not care planned for self-administration of his medications. A review of Resident #7 ' s electronic medical record revealed no assessments were completed for the self-administration of his medications. A review of Resident #7's current physician's orders revealed no order for naproxen sodium (nonsteroidal anti-inflammatory drug) as needed for a headache and no order for lidocaine-prilocaine cream (prescription only topical anesthetic) to be applied to the fistula site prior to dialysis. The physician orders did not include an order for the resident to self-administer any of his medications.An observation was conducted on 4/7/26 at 9:10 AM as Resident #7 was sitting on the side of his bed in his room. An observation and interview conducted on 4/7/26 at 9:10 AM revealed an opened bottle of naproxen sodium 500 milligrams and 4 opened tubes of lidocaine-prilocaine cream on his overbed tray table. An interview was conducted on 4/7/26 at 9:15 AM with Medication Aide #1. At that time, Medication Aide #1 was outside of the Resident #7's room standing at the medication cart (not within view of the resident). Medication Aide #1 was assigned to Resident #7 on 4/7/26 from 7:00 AM to 11:00 AM. Medication Aide #1 stated that she was unaware that Resident #7 had medications in his room including the tubes of lidocaine cream and a bottle of naproxen observed on the overbed tray table. An interview conducted on 4/7/26 at 9:20 AM with Resident #7 revealed that he had naproxen in his room in case he had a headache and that he took the medication on occasion. Resident #7 indicated that he applied the lidocaine cream to his fistula prior to dialysis. Resident #7 stated that the medications were obtained from an outside pharmacy and his responsible party brought them into the facility. An interview was conducted with the Physician on 4/8/26 at 12:40 PM. The Physician explained that naproxen is a non steroidal anti inflammatory drug (NSAID) that Resident #7 should not self administer and that unsupervised use could lead to complications. The Physician indicated that the prescription lidocaine cream was an anesthetic and that unsupervised use of the lidocaine cream could cause complications. The Physician further stated that residents were to be assessed for the ability to safely self-administer medications. An interview with Unit Manager #1 on 4/8/26 at 12:00 PM confirmed that medications should not be kept at the bedside, as there were confused residents on the unit who sometimes entered other residents' rooms. Unit Manager #1 explained that residents must be assessed for their ability to self-administer medications, the medications must be secured, a physician's order must be obtained, and the care plan must be updated accordingly. Unit Manager #1 stated that she was unaware that Resident #7 was self-administering naproxen and lidocaine cream and that the medications were kept unsecured in his room.An interview was conducted on 4/9/26 at 4:43 PM with the Director of Nursing (DON). During the interview, concerns identified regarding a resident's self-administration of medications and the safe and secure storage of the medications were discussed. The DON stated that she was not aware that Resident #7 had medications in his room that he was self-administering. The DON stated that for a resident to self-administer medications, the resident had to be assessed for safety and if determined to be appropriate, a physician order was required specifying which medications were to be self-administered, the medications were to be stored properly, and the care plan was to be updated to reflect this.

Based on observations, record review, and interviews with staff, residents, and Nurse Practitioner, the facility failed to transfer Resident #72 with a slide board according to the care plan, placing the resident at risk for avoidable injury. On 5/25/25, Nurse Aide #9 transferred Resident #72 from the wheelchair to the bed without using the slide board. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #72). Findings included. Resident #72 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA), hemiplegia (total loss of motor function on one side of the body), hemiparesis (weakness on one side), and expressive aphasia (loss of the ability to produce spoken or written language). A care plan dated 4/29/25 revealed Resident #72 was at risk of falls and had an activities of daily living (ADL) functional deficit due to limited ability to transfer herself related to a recent CVA with right side hemiplegia. Interventions included to use the slide board for transfers from the wheelchair to bed. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #72 had moderately impaired cognition. She required substantial assistance to transfer to and from a bed to a wheelchair. She had no falls. A progress note dated 5/25/25 at 1:45 PM documented by Nurse #44 revealed Resident #72's roommate (Resident #12) approached this writer at the start of shift with concerns about Resident #72's current mood. Resident #72 stated that she was upset and crying over ADL care she had received overnight. This writer spoke with Resident #72, and she stated that she was upset because she felt that the Nurse Aide (#9) who worked with her did not properly transfer her into bed. Resident #72 stated that the Nurse Aide (Nurse Aide #9) had used her pants pulling her up out of her chair to put her into bed. During the transfer Nurse Aide #9 ripped her pants. Resident #72 was immediately assessed for any pain or injury with no complaints. Following the determination that Resident #72 was unharmed and feeling safe, the Director of Nursing was notified and an investigation was conducted. A progress note dated 5/26/25 documented by the Nurse Practitioner revealed Resident #72 was evaluated. Resident #72 stated the Nurse Aide (#9) was rough with her, but she was not injured. The exam revealed no physical injuries. The facility's 5 day investigation report dated 5/29/25 revealed on Sunday, 5/25/25 around 7:30 AM during shift change Resident #72's roommate (Resident #12) approached the nurses' station and reported to the oncoming Nurse Supervisor (Nurse #44) that Nurse Aide (Nurse Aide #9) transferred Resident #72 inappropriately and Resident #72 was upset about it. Resident #72's roommate (Resident #12) stated she offered the Nurse Aide (Nurse Aide #9) to use her gait belt, but the Nurse Aide (#9) stated she transferred Resident #72 the best she could since they were short staffed. The Nurse Supervisor (Nurse #44) interviewed Resident #72, and she was able to communicate that the Nurse Aide (Nurse Aide #9) did not transfer her correctly the night before. Nurse Aide #9 transferred Resident #72 from her wheelchair to the bed using the back of her pants causing the pants to be ripped. Resident #72 required two person assistance with a sliding board for transfers. Nurse Aide #9 was suspended pending the investigation and the police were notified. The Social Worker visited Resident #72 on 5/27/25 and reported she was in good spirits. It was determined that the Nurse Aide (Nurse Aide #9) did not follow Resident #72's correct transfer method causing unwanted stress to her and damage to her clothing. A written statement provided by Nurse Aide #9 dated 5/25/25 revealed in part; On 5/24/25 round 8:00 PM she went in Resident #72's room to assist her back to bed. Nurse Aide #9 informed Resident #72 that she had to place the sliding board under her and Resident #72 agreed. Once the sliding board was under Resident #72 the Nurse Aide locked the wheels and instructed Resident #72 to grab the bed rail. While Resident #72 was pulling the rail the Nurse Aide told Resident #72 she would be behind her holding the back of her pants to assist her to slide down the board. Resident #72 agreed. After the transfer was over Resident #72's roommate (Resident #12) asked if she would like to use her gait belt. Nurse Aide #9 replied no thanks she had already completed the transfer. After the transfer Resident #72 stated her arm was in pain and she was holding her arm. The Nurse Aide asked Resident #72 if it had occurred during the transfer and Resident #72 stated no. Nurse Aide #9 asked Resident #72 if she needed to notify the nurse to assess her arm or give her pain medication and Resident #72 stated no. Around 7:07 AM Nurse Aide #9 overheard Resident #72's roommate (Resident #12) talking with the oncoming Nurse Supervisor (Nurse #44) about how she transferred Resident #72. Nurse Aide #9 then went up and asked Resident #72's roommate (Resident #12) if everything was okay. The roommate explained that she did not agree with how she transferred Resident #72 and she should have had help. Resident #72's roommate claimed she was rough with her. Nurse Aide #9 agreed with her and told her she did the best she could but could have done better with help. Nurse Aide #9 explained that she was not rough; she was as gentle as she could be due to Resident #72 being very heavy. Nurse Aide #9 then proceeded down the hall to apologize to Resident #72 if she had hurt her during the transfer. Resident #72 told her she did not hurt her, and Nurse Aide #9 apologized to Resident #72. She clocked out at 7:15 AM on 5/25/25. During a phone interview on 4/9/26 at 12:00 PM Nurse Aide #9 stated she had already given her written statement and hung up the call. A written statement provided by the oncoming Nurse Supervisor (Nurse #44) revealed in part: On 5/25/25 she arrived for her shift at 6:45 AM. When she arrived on the unit Resident #72's roommate (Resident #12) informed Nurse #44 that she was concerned about the way Nurse Aide #9 had taken care of her roommate throughout the night. The roommate (Resident #12) stated that Nurse Aide #9 needed assistance and should have used the gait belt and told the Nurse Aide she had a gait belt she could use. Nurse Aide #9 approached the conversation and interrupted the conversation argumentatively stating that she didn't do anything wrong. Nurse Aide #9 stated that she took care of Resident #72 the best she could and worked alone because they were short staffed. Nurse #44 ended the conversation and told Resident #72's roommate (Resident #12) and Nurse Aide #9 that she would speak to them separately. Approximately 5 minutes later Nurse #44 walked toward Resident #72's room and witnessed Nurse Aide #9 walking out of Resident #72's room. Nurse #44 stopped Nurse Aide #9 and told her she needed to speak with her after she spoke with Resident #72. Upon entering Resident #72's room both Resident #72 and her roommate (Resident #12) appeared to be upset. Resident #72's roommate (Resident #12) stated that Nurse Aide #9 had returned to the room and told her that if she had a problem with her that she needed to come to her and not go to anyone else. Nurse #44 ensured that both residents were safe and assessed both residents for injury. She told the residents that Nurse Aide #9 would not be coming back into their room. Resident #72 stated that she was put into bed by Nurse Aide #9 during the night and she did not do it properly. Resident #72 stated that she needed to use a slide board and two people to help her. Resident #72 stated that Nurse Aide #9 lifted her from the chair by her pants ripping them. She stated that she made her upset and that she had cried. Resident #72 then stated that she was okay and felt safe. Nurse #44 then spoke with Nurse Aide #9 about the incident and informed her that she would not be working with the residents again. Nurse Aide #9 then left the unit for the end of her shift. Nurse #44 spoke with a second Nurse Aide (Nurse Aide #11) who worked that night (11:00 PM through 7:00 AM) and Nurse Aide #11 stated Nurse Aide #9 did not ask her for assistance during the night. Attempts were made to contact Nurse #44 on 4/9/26. There was no response. The Director of Nursing stated Nurse #44 no longer worked at the facility. During an observation and interview on 4/8/26 at 2:00 PM Resident #72 was observed lying in bed. Resident #72 had difficulty speaking due to her diagnosis of expressive aphasia. She was in no distress. Resident #72 stated the Nurse Aide (Nurse Aide #9) pulled her up out of the wheelchair by her pants and ripped her pants and they had to throw the pants away. Resident #72 stated it upset her, and she indicated she didn't feel safe during the transfer because she could not use her right arm or right leg. The most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #72's roommate (Resident #12) revealed she was cognitively intact. During an interview on 4/8/26 at 2:10 PM Resident #72's roommate (Resident #12) who was alert and oriented to person, place, and time stated she witnessed the transfer and the Nurse Aide (Nurse Aide #9) hoisted Resident #72 up out of the wheelchair by her pants and put her in bed. Her pants were ripped and the Nurse Aide (Nurse Aide #9) transferred her without any assistance and did not have a second person to help her. During an interview on 4/9/26 at 11:20 AM the Assistant Director of Nursing (ADON) stated she worked 7:00 PM until 11:00 PM on 5/24/25 and came in for medication pass only. The ADON stated Resident #72, or her roommate (Resident #12) did not report anything to her regarding this incident. The ADON stated Nurse Aide #9 did not ask her for help to transfer Resident #72 during that time. During a phone interview on 4/9/26 at 12:46 PM the Nurse Practitioner stated he evaluated Resident #72 the day after the incident and Resident #72 was upset about the incident. He stated Resident #72 required assistance with transfers due to immobility, and she was non-ambulatory, increased weight, hemiplegia, and she was not progressing with therapy. He stated Resident #72 had no physical injuries from the incident. During an interview on 4/9/26 at 3:00 PM the Director of Nursing (DON) stated the unsafe transfer incident was reported to her on 5/25/25 and Nurse Aide #9 was suspended pending an investigation. The DON stated Nurse Aide #9 should have used a slide board and two person assistance when transferring Resident #72 from her wheelchair to the bed. The DON stated through staff interviews, Resident #72 and her roommate (Resident #12) interviews, and after a conversation with Nurse Aide #9 she determined that Nurse Aide #9 did not use the slide board, gait belt, or two person assistance with the transfer on the night of 5/24/25. They terminated Nurse Aide #9. The DON stated on 5/25/25 that she and the Administrator made the decision to implement a plan of correction and monitor the plan and the audits in the Quality Assurance Performance Improvement Committee. The facility provided the following corrective action plan with a compliance date of 5/27/25 which included the following: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/25/25 the roommate for Resident #72 reported that a nursing assistant (Nurse Aide #9) was pulling on Resident #72 and did not use the slide board to perform her transfer. The weekend supervisor (Nurse #44) assessed the resident (Resident #72) and noted she was tearful but without physical harm. The resident (Resident #72) reported she felt safe at this time after talking with the Supervisor. Resident #72 was assessed by the Nurse Practitioner on 5/26/25 and reported she was uninjured but was upset about the incident. Nursing Aide #9 was sent home on 5/25/25 and terminated on 5/27/25. Nursing Aide (#9) reported that she did the best she could do due to staffing issues. An initial investigation report was sent to DHHS on 5/25/25, the police and APS were notified by the Director of Nursing. It was determined by the Interdisciplinary team that the root cause was Nurse Aide #9 made a poor choice and chose to transfer the Resident (Resident #72) alone instead of seeking additional assistance. Staffing sheets were reviewed by the Director of Nursing on 5/26/25 to ensure all scheduled staff on the night of 5/24/25 were present and that there was enough staff to perform care. No staffing issues were identified. On 5/25/25 the Director of Nursing and the Administrator made the decision to implement a plan of correction and monitor the plan and the audits in the Quality Assurance Performance Improvement Committee. On 5/26/25 an ADHOC Quality Assurance meeting was held. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/25/25 the Director of Nursing performed skin observations on cognitively impaired residents on the Rehabilitation Unit where Nurse Aide #9 was assigned to ensure there were no injuries of unknown origin or signs that a resident had been transferred incorrectly. All cognitively impaired residents in the facility were assessed by the DON and the Unit Managers to ensure they were transferred appropriately by conducting observations of resident transfers on various shifts and reviewing the resident's profile to ensure the transfer status was correct. All alert and oriented residents were interviewed by the DON and Unit Managers regarding safe transfers. There were no concerns identified. On 5/25/25 the Director of Nursing and the administrative nursing team interviewed cognitively intact residents residing on the Rehabilitation Unit to ensure they felt safe in the facility. No issues were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 5/25/25 the Director of Nursing educated all staff on how to review the resident profile to determine the transfer status, ensuring gait belts and slide boards were used when appropriate, customer service expectations, and the Abuse policy was reviewed. Any staff member that was unable to be educated was educated by the Director of Nursing prior to their next scheduled shift. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. The Director of Nursing or designee will observe transfers 3 times a week for 4 weeks on all halls on various shifts to ensure residents are being transferred according to their plan of care. In addition, the Director of Nursing will assess 3 cognitively impaired residents weekly for 4 weeks to ensure there are no signs of mistreatment or psychosocial distress and interview 3 cognitively intact residents weekly for 4 weeks to ensure the residents feel safe in the facility. The audits will be reviewed by the QA committee at the end of the monitoring period to ensure the plan is effective. The QAPI committee will determine the need for further intervention and auditing beyond 4 weeks to assure compliance is sustained. The facility alleged compliance of the corrective action plan on 5/27/25. Validation of the corrective action plan was completed on 4/9/26. This included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. Inservice training records were verified and included staff signatures. The initial audits including the weekly audits were reviewed to verify all residents on all halls across various shifts were included. Staff providing a safe transfer of a resident was observed during the validation. There were no concerns identified. The plan of correction with a completion date of 5/27/25 was validated.

Based on observation, record review and staff, resident and Physician interviews, the facility failed to ensure the medications were administered to the resident which had the potential for an adverse outcome for 1 of 1 resident observed with medication left at the bedside (Resident #7). Findings included:Resident #7 was admitted [DATE] with the diagnosis of renal dialysis, end stage renal disease, gastrointestinal hemorrhage and anemia.A review of Resident #7's electronic health record revealed a physician order dated 1/29/26 for velphoro (a phosphate binder which is used to lower phosphate in the blood of a resident with kidney disease), 500 milligrams take one tablet three times per day for hypokalemia (low blood potassium levels) at 7:00 AM, 11:00 AM and 4:00 PM. A review of Resident #7's electronic health record revealed a physician order dated 1/30/26 for sucralfate (a medication used to treat and prevent stomach ulcers) 1 gram tablet take 1/2 hour prior to meals and at bedtime at 8:00 AM, 11:00 AM, 5:00 PM and 8:00 PM.Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and had no behaviors.A review of Resident #7's electronic health record revealed a physician order dated 4/3/26 for midodrine (a medication used to treat orthostatic hypotension, a sudden drop in blood pressure upon standing, which constricts the blood vessels to raise the blood pressure) 10 milligrams tablet once per day and 5 milligrams twice per day. Hold for systolic blood pressure greater than 130 millimeters of mercury. An observation and interview on 4/7/26 at 9:10 AM revealed Resident #7 sitting on the edge of his bed in his room. Medication Aide #1 was outside the room at the medication cart and Resident #7's room was not visible from where she was standing. Four plastic medication cups containing medications were noted on Resident #7's bedside table. Two of the plastic medication cups contained one large round brown tablet, one cup contained one white oblong tablet and one small white pill, and the fourth medication cup contained a white oblong tablet. Upon noticing the medication cups in Resident #7's room Medication Aide #1 was called into the room. She observed the medication cups and confirmed that the medications present were those ordered for Resident #7. She identified the brown tablet as velphoro, the white oblong tablet was sucralfate, and the small white pill was midodrine. Medication Aide #1 stated that the medications must have been left in the room from a prior shift's medication pass. She confirmed that she was running late that morning, had not yet administered Resident #7's medications, and had not been in his room. Medication Aide #1 indicated that she was assigned to Resident #7 on 4/6/26 from 7:00 AM to 3:00 PM and stated that she did not recall leaving medications at the bedside at 8:00 AM or 11:00 AM when the resident had medications scheduled. She further stated that medications should never be left at the bedside and that residents should be observed swallowing their medications before staff leave the room. Medication Aide #1 disposed of the medications in the medication cups by placing the tablets in a bottle of destroyer solution located in the medication cart.An interview with Nurse #5 on 4/9/26 at 4:15 PM revealed that he was assigned to Resident #7 on 4/6/26 from 3:00 PM to 11:00 PM. Nurse #5 did not recall leaving medications at Resident #7's bedside on 4/6/26 when he administered the resident's medications. Nurse #5 stated that it was not appropriate to leave medications unattended and unsecured at the bedside. Nurse #5 stated that he was not aware that Resident #7 was self-administering medications and had not noticed medications left on Resident #7's bedside table. An interview conducted on 4/7/26 at 9:20 AM with Resident #7 revealed that the medication cups had been left on his bedside table, though he did not recall when they were placed there. Resident #7 stated that the nurses often left medications at his bedside for him to take, but they did not always inform him that the medications were there or that he was expected to take them.An interview with the Physician on 4/8/26 at 12:40 PM revealed that Resident #7 not receiving Velphoro, Sucralfate, and Midodrine as prescribed had the potential to result in significant adverse effects. The Physician further stated that failure to receive Velphoro, a phosphorus binding medication, as ordered could negatively impact Resident #7's electrolyte balance and result in adverse outcomes. An interview with Unit Manager #1 conducted on 4/8/26 at 12:00 PM revealed that medications were not to be left for a resident to take at a later time and that proper medication administration required remaining with the resident to ensure the medications were taken and swallowed. She further reported that she had not observed any medications left in Resident #7's room.An interview with the Director of Nursing (DON) on 4/9/26 at 4:43 PM revealed that she expected medications would not be left unattended and unsecured in a resident's room. The DON stated that staff were expected to remain with the resident and observe the resident taking and swallowing the medications before leaving the room. The DON further stated that medications were not to be left on the bedside table for the resident to take later and that residents were to be assessed for self-administration before they were allowed to have medications kept at the bedside.

Based on observation, record review and resident, staff and Registered Dietitian (RD) interviews, the facility failed to provide food that accommodated a documented allergy to tomatoes for 1 of 5 residents reviewed for nutrition (Resident #7).Findings included: Resident #7 was admitted on [DATE]. A review of Resident #7's care plan initiated on 8/19/25 indicated the top of the document listed the resident's food allergies as tea and tomatoes. Resident #7 was discharged to the hospital on 1/26/26 and was readmitted on [DATE]. A review of a hospital Discharge summary dated [DATE] indicated that Resident #7 had documented food allergies, including anaphylaxis to tea and mouth and throat swelling in response to tomatoes. Review of Resident #7's electronic health record revealed an area on the clinical dashboard that listed food allergies as tea and tomatoes. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact with no behaviors, had diagnoses of renal failure and end stage renal disease and received a therapeutic diet. A review of a cardiology progress note dated 3/17/26 indicated that Resident #7 had documented food allergies, including anaphylaxis to tea and mouth and throat swelling in response to tomatoes.Review of Resident #7's electronic health record revealed a physician order dated 3/30/26 for a renal diet with double protein portions and a 1000 milliliter fluid restriction per 24 hours. A nutritional status problem dated 3/30/26 indicated that Resident #7 was at risk for increased nutrition and hydration problems related to end stage renal disease, hemodialysis, therapeutic diet, and fluid restriction with tea allergy noted. The interventions included ensuring allergen avoidance. The resident's allergy to tomatoes was not included in the care plan.A lunch tray observation was conducted with Resident # 7 on 4/7/26 at 12:30 PM. Resident#7 was sitting on the edge of his bed when the Medical Records Director served Resident #7 his meal. Resident's meal tray ticket stated renal diet, allergy to tea, fluid restriction of 1000 milliliters per day and double portions of protein. The meal tray ticket indicated that the resident received beef ravioli with tomato sauce, Italian blend vegetables, sherbet 4 ounces, water 8 ounces and beverage of choice 8 ounces. Observation of the meal tray revealed that the resident received a small serving of beef ravioli with tomato sauce, a small dish of potatoes and carrots, a dinner roll, strawberry ice cream 4 ounces, 8 ounces water and 8 ounces ginger ale. Resident # 7 informed the Medical Records Director that he was allergic to tomatoes, and he requested an alternate meal. The Medical Records Director offered Resident #7 a deli ham or turkey sandwich or an egg salad sandwich. Resident #7 responded that he was not supposed to eat processed deli meat so he would have an egg salad sandwich instead. An interview with Resident #7 on 4/7/26 at 12:35 PM revealed that he was served tomato sauce today and he was unable to eat this due to his allergy and his renal restriction. Resident #7 stated that he was allergic to tomatoes and that they caused swelling of his face and mouth. Resident #7 stated that he had not talked to anyone from the kitchen regarding his diet, allergies, likes or dislikes since he was admitted to the facility. Resident #7 stated that he was served tomatoes and tomato sauce before and had told the staff that delivered the meal trays that he was not able to eat tomatoes. An interview with the Medical Records Manager on 4/7/25 at 12:40 PM revealed that she was a Nurse Aide and assisted with delivering meal trays and feeding residents as needed. She stated that when she delivered meal trays, she checked the meal tray ticket for allergies and the diet. The Medical Records Manager indicated that she was unaware that Resident #7 was allergic to tomatoes as it was not listed on the meal tray ticket. An interview conducted with Nurse Aide (NA) #1 on 4/9/26 at 5:00 PM indicated that she was familiar with Resident #7. However, NA #1 stated she was not aware that Resident #7 had an allergy to tomatoes. She reported that she typically checked the meal tray ticket for allergy information when she served resident meals. An interview was conducted with the Dietary Manager on 4/7/26 at 3:15 PM. The Dietary Manager stated that she was unaware that Resident #7 had an allergy to tomatoes. The Dietary Manager indicated that when a resident was admitted , she received the diet order from the nursing department, that nursing entered the allergies in the clinical record, but she was responsible for ensuring that food allergies were listed in her meal tray ticket system. The Dietary Manager indicated that usually if nursing entered an allergy it showed up in her system for the meal tray ticket. The Dietary Manager stated that she did not know why she did not have Resident #7's allergy to tomatoes on his meal tray ticket and that she would need to contact someone at the corporate office to investigate this. The Dietary Manager stated that she talked to residents regarding their likes and dislikes as needed but she did not have a form for this and did not document this information. The Dietary Manager indicated that she did not have any documentation of the last time she spoke with Resident #7, did not recall the last time she talked to him about his diet, allergies, likes or dislikes and did not recall reviewing Resident #7's clinical record for allergies. The Dietary Manager pulled up her meal tray ticket system and observed that tea was listed in the system as an allergy, but tomatoes were not and she again stated there was an error that it did not pull into the system from the clinical record. An interview with the Director of Nursing (DON) on 4/9/26 at 4:43 PM revealed that she expected that food allergies would be communicated from the nursing department to the dietary department and would be honored. The DON stated that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager's system but should also be included on the diet order slip that was provided to the dietary department.

Based on record review and responsible party (RP), staff, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to assess, diagnose and medically treat a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention: C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor). The facility failed to identify the seriousness of the symptoms of abdominal discomfort, frequent loose stools with foul odor, tiredness, loss of appetite, and inability to get out of bed and implement effective interventions. On [DATE] Resident #290 experienced decreased urine output and the facility failed to identify a medical emergency and failed to immediately transfer Resident #290 to the hospital on [DATE] when the nursing home received critical white blood cell count of 51.8 (normal range ,d+[DATE]). On [DATE] Resident #290 requested to be sent to the hospital because he was unable to eat or urinate. Once evaluated at the hospital on [DATE], the resident was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Vital signs at the emergency room were recorded as blood pressure ,d+[DATE] (normal ,d+[DATE]), pulse 120 (normal ,d+[DATE]), respirations 18, temperature 97.5. Laboratory results at the hospital indicated the C. diff test was positive and white blood cell count was 66.0. Resident #290 was diagnosed with septic shock (a life-threatening immune system reaction to an infection) secondary to C. Diff and passed away on [DATE]. This deficient practice was discovered for 1 of 3 residents reviewed for professional standards (Resident #290). Immediate Jeopardy began on [DATE] when Resident #290 began experiencing loose, malodorous stools and the facility did not assess, evaluate or treat the resident. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring of systems put in place are effective. Findings included: Resident #290's hospital discharge summary dated [DATE] indicated resident was admitted for a subdural hematoma (collection of blood between the brain and it's covering) due to a fall. The discharge summary indicated during the hospital stay resident underwent colonic decompression (a procedure to relieve pressure and remove gas and stool from the colon) on [DATE] and tolerated this well with excellent reduction in the colonic volume. The discharge summary indicated Resident #290 had a possible pseudo-obstruction, a condition where the colon appeared to be obstructed but there was no physical blockage. Resident #290 was admitted on [DATE] with diagnosis of subdural hematoma. Review of Resident #290's physician orders revealed there were no orders for laxatives or stools softeners. Review of Resident #290's electronic bowel movement record revealed the following: [DATE]- One large loose stool [DATE]- Two large stools [DATE]- Two large stools and a medium stool [DATE]- One large liquid stool with foul odor and one medium stool [DATE]- Four large loose stools and two medium stools [DATE]- One medium stool An interview was conducted via phone with Nursing Assistant (NA) # 5 on [DATE] at 12:20 PM. NA #5 was assigned to Resident #290 on [DATE] and [DATE]. NA #5 revealed Resident #290 had loose stools continuously. NA #5 stated Resident #290 had loose stools with a foul smell. NA #5 stated she reported this to the nurse, she could recall which one, and the nurse stated okay but did not indicate what was being done about the loose stools. Review of a NP progress note dated [DATE] indicated Resident #290's RP reported resident was having burning with urination and requested a urinalysis. Urinalysis was ordered. Review of Resident #290's admission Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact, was always incontinent of bowel and bladder and required moderate assistance with toileting. Resident's care plan dated [DATE] indicated a focus of urinary incontinence. Interventions included providing incontinence care after each incontinent episode and report signs of urinary tract infection. There was not a care plan, or interventions related to bowel incontinence or loose stools. Review of Resident #290's bowel record revealed the following: [DATE] - One large loose liquid stool [DATE] - One large and one medium stool [DATE] - Three large loose stools [DATE] - One medium and one large loose stool [DATE] - Two large and one medium stools [DATE] - One large loose stool Review of a NP progress note dated [DATE] indicated resident's RP had requested a urinalysis due to painful urination. The results of the urinalysis are pending. Review of Resident #290's physician orders revealed an order dated [DATE] for ciprofloxacin (an antibiotic used to treat infections including urinary tract infections) 500 milligrams (mg) twice per day by mouth for 7 days for urinary tract infection. Review of a NP progress note dated [DATE] indicated resident's chief complaint was urinary tract infection. Resident #290's RP requested a urinalysis due to painful urination. Urinalysis was positive for infection and antibiotic was ordered. Review of Resident #290's electronic bowel movement record revealed the following: [DATE] - Two medium and one large loose stool [DATE] - One large, loose stool [DATE] - One large stool [DATE] - One large loose stool [DATE] - One large stool [DATE] - Three medium stools [DATE] - No documentation [DATE] - One large loose liquid stool and a small stool A nursing progress note written by Nurse #11 on [DATE] stated Resident #290 refused to get up out of bed due to diarrhea. The note did not indicate any follow-up action, assessment or notification of the Nurse Practitioner or Medical Director. There was no documented nursing assessment. An interview was conducted with Nurse #11 on [DATE] at 2:15 PM. Nurse #11 was assigned to Resident #290 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #11 stated Resident #290 was admitted for rehabilitation and was supposed to go home. Nurse #11 stated some days Resident #290 was too tired to participate in therapy and was weak, but she did not complete an assessment of the resident and did not think this indicated he had an infection, and she did not report this to the NP. Nurse #11 stated Resident #290 had loose stools since he was admitted , and she did not know why. Nurse #11 stated the Nursing Assistants reported to her that he had loose stools, and she reported this to the Nurse Practitioner. Nurse #11 stated she did not recall if the NP did anything about the loose stools. Nurse #11 indicated Resident #290's responsible party visited often and would apologize to her and the other staff that the resident was having so many loose, foul-smelling stools. A physical therapy treatment encounter note dated [DATE] indicated Resident #290 refused treatment due to diarrhea. The note indicated nursing was made aware. An occupational therapy treatment encounter note dated [DATE] indicated the therapist approached the resident for treatment twice but resident refused due to having loose bowel movements. An interview was conducted on [DATE] at 3:30 PM with the Occupational Therapist (OT) who was assigned to Resident #290 on [DATE]. The OT stated Resident #290 had loose stools constantly while in the facility and it interfered with his therapy sessions due to the amount and frequency of the loose stools. Resident #290 complained during therapy of his stomach hurting at times. OT stated he informed the nurses assigned to Resident #290 that the resident was having frequent loose stools and assumed the nurses would follow up on this. The NAs were constantly having to change the resident. OT stated the former Rehabilitation Director reported to the nurses and NP about Resident #290's loose stools. Towards the end of his stay, the OT stated Resident #290 was refusing therapy, was more tired and complained of his stomach hurting. OT stated resident's condition was getting worse and worse just prior to him transferring to the hospital. An interview was conducted with the former Rehabilitation Director via phone on [DATE] at 10:30 AM. The former Rehabilitation Director stated she worked closely with Resident #290 and was familiar with him. The former Rehabilitation Director stated Resident #290 became progressively worse during his time in the facility and was medically declining. The former Rehabilitation Director stated the therapists communicated with the nursing staff and the Nurse Practitioner frequently regarding the changes they observed in Resident #290 and the frequent loose stools. The former Rehabilitation Director stated the nurses would say they would tell the Nurse Practitioner and that the loose stools were normal and would clear up eventually. The former Rehabilitation Director stated Resident #290 complained to the therapy staff about the loose stools and not feeling well. The former Rehabilitation Director stated the NP indicated the loose stools would resolve eventually and that was not the reason the resident was here. Review of an SBAR form (a nursing communication tool used to convey status which stands for Situation, Background, Assessment and Recommendation) indicated a change occurred on [DATE] at 3:58 PM. The form was completed by the Nursing Supervisor #3 on [DATE] at 9:51 AM. The description of the change indicated it was completed due to weight gain. It further indicated the change observed was weight loss. The Nurse Practitioner was notified of the weight change on [DATE] at 11:10 AM and no new orders were received. Review of the weights recorded in Resident #290's electronic health record revealed the following: [DATE] 211.2 pounds (lb.), [DATE] 213.6 lb., [DATE] 209 lb. Review of Resident #290's electronic bowel movement record revealed: [DATE] - One medium and a large loose stool [DATE] - No documentation A Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #290 had loose stools and was started on banana flakes for 1 week. The note did not indicate any testing was ordered regarding loose stools. The manufacturer's information indicated banana flakes are a natural product that may be used for chronic diarrhea and may be used in conjunction with treatment for Clostridium Difficile (C. diff). The manufacturer's information further stated banana flakes are to be mixed with water or juice and administered up to 3 times per day until diarrhea is resolved. Review of Resident #290's physician orders revealed an order written by the NP dated [DATE] for banana flakes one packet once per day. The order was discontinued on [DATE]. Review of Resident #290's electronic Medication Administration Record (MAR) revealed an entry for banana flakes one packet once per day with a start date of [DATE] and a discontinue date of [DATE]. Entries were signed with electronic signatures as given. A Nurse Practitioner progress note dated [DATE] stated Resident #290 continued to have loose stools. The note indicated the resident's responsible party contacted the Gastroenterologist who recommended a Kidney Ureter and Bladder (KUB) x-ray and stool samples due to loose stools. The NP note stated the KUB was ordered, and the stool samples were to be done as an outpatient after discharge. The progress note further stated to continue banana flakes once per day. If banana flakes are ineffective will start loperamide 2 milligrams once per day as needed. (Loperamide is a non-prescription medication used to control occasional loose stools usually taken after each loose stool. Loperamide is contraindicated in C.difficile due to slowing the movement of stool through the body allowing the C.difficile toxins to build up in the colon leading to more severe colitis or inflammation of the colon). Review of Resident #290's electronic health record revealed an order dated [DATE] to obtain a KUB. There was no order noted to obtain stool samples. Review of Resident #290's electronic bowel movement record revealed: [DATE] - Three large loose stools and one small stool Review of Resident #290's electronic bowel movement record revealed: [DATE] - One medium loose stool [DATE] - One medium stool [DATE] - Two large loose, liquid foul-smelling stools and a small liquid stool Attempts were made to interview NA #2 who was assigned to Resident #290 on [DATE], [DATE] and [DATE]. Messages were left on [DATE], [DATE], [DATE] and [DATE] with no return call received. Resident #290's electronic Medication Administration Record (MAR) indicated loperamide 2 milligrams once per day as needed with a start date of [DATE] and discontinue date of [DATE]. The electronic MAR indicated no entries were signed for loperamide as given. Review of a nursing progress note dated [DATE] indicated the KUB test results were received and reviewed by the Nurse Practitioner with normal abdominal study results received. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued to have loose stools. The NP progress note indicated Resident #290 was started on banana flakes with marginal improvement. The KUB was unremarkable. Stool sample to be done outpatient following discharge. Continue banana flakes and start loperamide as needed. An occupational therapy encounter note dated [DATE] indicated Resident #290 had increased fatigue. Review of Resident #290's electronic bowel movement record revealed: [DATE] - One large, loose stool [DATE] - Two large loose stools An interview was conducted with NA #8 on [DATE] at 2:22 PM. NA #8 was assigned to Resident #290 on [DATE] and [DATE]. NA #8 indicated that she was assigned to Resident #290 frequently and was familiar with his care. NA #8 stated Resident #290 had multiple loose, liquid stools during each shift. NA #8 indicated everyone knew that he was having liquid bowel movements that had a strong odor. NA #8 stated Resident #290 had liquid stools especially after he ate, and it was like everything ran right out of him. Resident #290 would ask for loperamide, and NA #8 stated she reported this to the nurse assigned to the resident, she could not recall which nurse, but she did not know if he ever received it. NA #8 stated she thought Resident #290 might have C. difficile due to the multiple liquid stools and strong odor but the nurses said it was normal for him. A Nurse Practitioner progress note dated [DATE] revealed Resident #290 continued to have loose stools and was started on banana flakes and loperamide was ordered as needed. Review of Resident #290's electronic bowel movement record revealed: [DATE] - No documentation Review of Resident #290's progress notes revealed a NP progress note dated [DATE] which indicated resident continued to have loose stools. Banana flakes were started and loperamide was ordered as needed. The KUB was unremarkable. The plan indicated continue the banana flakes and loperamide as needed. Review of Resident #290's electronic bowel movement record revealed: [DATE] - Two medium stools An interview was conducted on [DATE] at 11:15 AM with NA #4 who was assigned to Resident #290 on [DATE] and [DATE]. NA #4 stated she was assigned to Resident #290 just prior to him being sent to the hospital and he was very weak. NA #4 stated she was familiar with Resident #290 and was assigned to him often and assisted other staff with him. NA #4 stated Resident #290 had very loose, frequent stools with mucus and a strange, strong odor. NA #4 indicated the nurses were aware that he had loose, frequent stools and the nurses said he was having loose stools since admission so it must be normal for him. NA #4 stated Resident #290 had about 3 loose stools per shift. On [DATE], NA #4 stated Resident #290 was not doing well and had not urinated all day which was not normal for him. NA #4 stated she reported to Nurse #11 that the resident had not urinated that day. An interview was conducted with Nursing Supervisor #3 on [DATE] at 9:07 AM. Nursing Supervisor #3 stated she did not recall being informed of any problems with Resident #290's stools throughout his stay in the facility. Nursing Supervisor #3 stated she had not reviewed his bowel movement records. Nursing Supervisor #3 stated she recalled Resident #290's RP called her on [DATE] and reported that Resident #290 had complained of dizziness. Nursing Supervisor #3 stated she went and asked Resident #290 if he was dizzy and he said no. Nursing Supervisor #3 stated she did not obtain vital signs or complete a full assessment of the resident because she did not think it was significant. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued with loose stools. Resident #290 started on banana flakes and loperamide as needed. The KUB was unremarkable. A stool sample was to be completed outpatient after discharge. Resident with poor appetite and weakness. Review of Resident #290's physician orders revealed an order dated [DATE] entered by the NP to perform straight catheterization (a procedure in which a hollow tube drains urine from the bladder) once and obtain laboratory tests Complete Blood Count and Comprehensive Metabolic Panel due to decreased urination. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order for straight catheterization was electronically signed by Nurse # 11 on [DATE] at 6:30 PM. The amount of urinary output obtained was recorded as 100 milliliters. Review of Resident #290's laboratory results dated [DATE] indicated blood specimens were collected at 2:40 PM on [DATE]. A critical panic white blood cell count level of 51.8 thousand per microliter was called to the facility at 11:48 PM. The normal value for a white blood cell count is 4XXX,d+[DATE].9 thousand per microliter. Review of Resident #290's progress notes indicated a nursing progress note written by Nurse #6 dated [DATE] at 12:46 AM indicated the Nurse Practitioner on-call was notified of the critical laboratory value and new orders were received. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order to place an indwelling catheter was electronically signed as completed by Nurse #6 on [DATE] at 1:30 AM. Review of Resident #290's electronic health record revealed physician orders dated [DATE] for ceftriaxone (an antibiotic used to treat infections of the lungs, ears, skin and urinary tract) 2 grams intramuscular one-time only STAT (immediately) and hypodermoclysis (a method of administering fluids under the skin) 75 milliliters of fluid per hour continuously. Review of Resident #290's progress notes indicated a nursing progress note written by Nurse #6 dated [DATE] at 2:47 AM which indicated hypodermoclysis was placed into the abdomen with fluids running at 75 milliliters per hour. An interview was conducted via phone with Nurse #6 on [DATE] at 5:45 PM. Nurse #6 stated she was assigned to Resident #290 on [DATE] from 7:00 PM to 7:00 AM. Nurse #6 stated Resident #290 was very sick that night. Nurse #6 did not indicate that she assessed Resident #290 for specific symptoms, just stated that he appeared to not be feeling well. When she received the critical high lab results, she called the on-call provider. The on-call provider did not say to send the resident to the hospital and Nurse #6 stated she did not ask the on-call provider if she should send the resident to the hospital. Nurse #6 could not recall if she reported to the on-call provider that Resident #290 was designated as a Full Code status. Nurse #6 stated the on-call provider gave orders to administer an antibiotic, insert an indwelling catheter and administer fluids. Nurse #6 stated she inserted the catheter and Resident #290 did not have any urinary output from the indwelling catheter. Nurse #6 stated she did not call the on-call provider back to report the lack of urinary output and did not assess the resident for further symptoms, but she tried to encourage the resident to drink fluids throughout the night. Nurse #6 stated she did not recall if Resident #290 had loose stools that night, but she recalled he had loose stools throughout his stay at the facility. An interview was conducted on [DATE] at 2:20 PM with Nursing Assistant (NA) #3. NA #3 was assigned to Resident #290 on [DATE] from 7:00 AM to 3:00 PM. NA #3 stated she was familiar with Resident #290 and was assigned to him several times including the day he was sent to the hospital. NA #3 stated Resident #290 was having loose, runny stools all the time while he was in the facility. NA #3 stated she did not recall a foul odor. NA #3 stated she did not report the loose stools to the nurse since she assumed the nurses were already aware. Review of an Interact Nursing Home to hospital transfer form dated [DATE] completed by Nursing Supervisor #2 on [DATE] at 12:17 PM indicated Resident #290 was a full code, vital signs were as follows: Blood pressure ,d+[DATE], temperature 97, respirations 22, temperature 98.3 and oxygen saturation 92%. The reason for transfer was the resident requested transfer due to decreased urination. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] written by Nursing Supervisor #2 at 12:40 PM which indicated the resident requested to be sent to the hospital because he was unable to eat or urinate. The Nurse Practitioner was notified. The note indicated the Nurse Practitioner stated the resident was competent and to send him to the emergency room if that was what he wanted. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 2:31 written by Nursing Supervisor #2 indicated the resident was sent to the hospital for evaluation at 2:20 PM. An interview was conducted with the Nursing Supervisor #2 on [DATE] at 2:30 PM. Nursing Supervisor #2 stated she was familiar with Resident #290 and had worked with him since he was admitted . Nursing Supervisor #2 stated Resident #290 frequently had loose stools throughout his stay and she thought it was normal for the resident. She stated she had not reported the loose stools to the Nurse Practitioner or the Physician. Nursing Supervisor #2 stated he had banana flakes ordered that were supposed to help with the loose stools. Nursing Supervisor #2 stated the resident was not eating well, did not have any appetite and seemed very tired but she did not report these findings and did not think these were signs of infection or sepsis. Nursing Supervisor #2 stated she had not noticed a foul odor from his stools and it was not reported to her by staff. Normally if there was a resident having loose stools or stools with a foul odor it was reported to the provider for further orders. Nursing Supervisor #2 stated she recalled that Resident #290's family had received an order from the Gastroenterologist for some type of stool sample to be obtained but she did not think it had been collected or sent out. Nursing Supervisor #2 stated on [DATE], she was assigned to Resident #290, and he requested to be sent to the hospital. Nursing Supervisor #2 stated Resident #290 appeared very tired, but she did not recall anything abnormal about his condition at the time and did not think that being tired was a sign of infection or sepsis. Nursing Supervisor #2 stated she did not review Resident #290's bowel movement records prior to his transfer to the hospital and did not have a record of his urinary output. Review of an Emergency Medical Services (EMS) report dated [DATE] revealed EMS arrived on the scene at 2:12 PM and departed from the facility at 2:24 PM. The EMS narrative indicated the staff stated the reason for transport was Resident #290 was unable to urinate for 2 days. Staff reported straight catheterization was attempted. Staff reported possible infection but denied sepsis diagnosis or symptoms. When assessed by EMS the resident complained of weakness and being very tired. EMS noted the resident was having a hard time staying awake, was slow to respond to questions and complained of nausea. Intravenous access was attempted 3 times unsuccessfully. Vital signs obtained during transport to the hospital were as follows: 2:28 PM Blood pressure ,d+[DATE] Pulse 73 Respirations 16 Oxygen saturation 95% 2:35 PM Blood pressure ,d+[DATE], Pulse 20, Respirations and Oxygen saturation not recorded 2:50 PM Blood pressure ,d+[DATE], Pulse 45, Respirations 16, Oxygen saturation 94 2:52 PM Blood pressure ,d+[DATE], Pulse 65, Respirations 16, Oxygen saturation not recorded. Attempt was made on [DATE] at 2:00 PM to interview via phone the EMS personnel that responded to the call to transport Resident #290 to the hospital. A message was left with no return call. The Emergency Provider emergency room Note dated [DATE] indicated the resident arrived in the emergency room and was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Triage vital signs at the emergency room were recorded as blood pressure ,d+[DATE], pulse 120, respirations 18, temperature 97.5. Laboratory results at the hospital indicated the C. diff test was positive and white blood cell count was 66.0. Resident #290 was diagnosed with Septic Shock secondary to C. Diff. The hospital discharge summary dated [DATE] indicated Resident #290 was admitted on [DATE] with admitting diagnosis of septic shock secondary to C. difficile colitis. Resident #290 presented with a chief complaint of persistent diarrhea and dehydration with approximately 1 month of persistent malodorous diarrhea and dehydration. In the emergency department, the resident's blood pressure was ,d+[DATE] and pulse was 110. [NAME] blood count was 66 and resident tested positive for C. difficile. The resident was admitted to the intensive care unit. Resident's condition declined. Resident #290 deceased on [DATE] at 11:02 PM. Review of Resident #290's death certificate dated [DATE] indicated resident's cause of death was Sepsis, C. Diff and acute kidney injury. Review of the electronic medical record revealed no documentation in the nursing progress notes regarding Resident #290's loose stools during the duration of his stay at the facility. There was also no discovered mention of a family member or therapy staff expressing concern about the Resident #290's loose stools. An interview was conducted on [DATE] at 2:10 PM with the Evening Nursing Supervisor who stated Resident #290 had loose stools all the time since he was admitted , and she assumed this was normal for him. The Evening Nursing Supervisor stated she did not recall anyone reporting anything about resident's stools having a foul odor. The Evening Supervisor stated she had not reported the loose stools to the provider because she thought this was the baseline for him and she had not assessed him for any other symptoms. A telephone interview was conducted with Resident #290's RP on [DATE] at 9:20 AM. The RP stated she visited Resident #290 daily and sometimes twice per day indicated she observed Resident #290 had frequent loose stools that were malodorous, and the odor was noticeable in the hallway. The RP stated Resident #290 indicated he could not tell when he was urinating or having a bowel movement, that the stools were liquid and would just run out of him. The RP stated she had observed him with liquid feces running down his legs and stated she reported to the nurses' multiple times about the loose stools. The RP stated she talked to the NP frequently and reported to him the loose stools. The RP stated she called the Gastroenterologist to report the loose stools since the NP had not addressed it. The RP stated she reported to the Nursing Assistant on admission that resident had frequent bowel movements but not that he normally had loose stools. She further stated she informed the staff he had a procedure on his bowel in the hospital, but his bowel movements had returned to normal. The RP stated she was not asked by the nursing staff or the NP about C. diff and the resident did not have history of C. difficile or other bowel issues. The RP stated Resident #290 had a loss of appetite, nausea and stomach pain in the weeks before he went to the hospital. The RP indicated just prior to going to the hospital, the Nursing Assistant stated Resident #290 was not acting right and she observed this also. The RP reported this to Nurse #11 who asked her what she wanted done about it. The RP indicated on the morning of [DATE], she received a call from Nursing Supervisor #2 who informed her she thought Resident #290 was having anxiety and he requested to go to the hospital. The RP stated she arrived at the facility before the resident left via EMS to go to the hospital and indicated she observed the resident struggling to breathe and he stated he had an infection and knew something was wrong. EMS arrived and Nursing Supervisor #2 reported to EMS that Resident #290 was probably just anxious and stated she did not think he was septic. Nursing Supervisor #2 did not report to EMS that resident had loose stools. An interview conducted with the Nurse Practitioner on [DATE] at 3:00 PM revealed he was aware Resident #290 had constant loose stools during his stay in the facility and that this was a sign of C. Diff. The Nurse Practitioner stated Resident #290 was admitted for rehabilitation following a subdural hematoma and that was his focus. The NP stated Resident #290 had discharge plans during his stay so he thought the issue of loose stools would be addressed as an outpatient following discharge. The NP stated he ordered the Kidney Ureter and Bladder (KUB) x-ray after the family member consulted with the Gastroenterologist. The result of the KUB x-ray was normal. The NP stated he ordered banana flakes, but Resident #290 still could have had C. Diff. The NP stated he did not investigate why the resident was having loose stools or if he had any history of gastrointestinal issues. The NP stated continuous loose stools did not seem like a problem at the time, but in hindsight maybe he should have done something else. The NP stated he did not recall the Occupational or Physical Therapists or the Rehabilitation Director reporting that Resident #290 was weak, having diarrhea or not feeling well. A follow up interview was conducted with the Nurse Practitioner on [DATE] at 1:00 PM to obtain clarification of Resident 290's condition and the course of treatment. The Nurse Practitioner stated if he had known the resident had loose foul-smelling stools, he might have ordered a test for C. difficile. The Nurse Practitioner stated he talked to Resident #290's RP a couple of times during the resident's stay, but did not recall her having any concerns. The Nurse Practitioner stated the resident never really complained about anything, so he was not concerned. The Nurse Practitioner stated he was not notified of loose stools since admission. The NP stated if the resident was having loose stools more than 1 per day he would have expected t [TRUNCATED]

Based on record review and interviews with staff, the resident's Responsible Party (RP), Medical Director, and Nurse Practitioner (NP), the NP failed to communicate and collaborate with the Medical Director for a resident (Resident #290) who was presenting with signs of Clostridium Difficile (C. difficile or C. diff) According to the Centers for Disease Control and Prevention: C. diff-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor. For the period of [DATE], date of admission, through [DATE], the first date the NP had a progress note for Resident #290, the resident was recorded as having 42 stools in 24 days. Resident #290 was documented as having loose stools during each of the 6 progress notes the NP had for the resident, starting with the progress note dated [DATE], through the last progress note on [DATE]. For the period of [DATE] through [DATE] Resident #290 was recorded as having 15 stools in 8 days. From the [DATE] progress note through the date Resident #290 was discharged to the hospital, the NP did not consult with the Medical Director despite the resident's documented persistent and foul-smelling loose stools. Due to the resident's continued loose stools, and foul odor of the stools, the resident's RP reached out to a Gastroenterologist and received a recommendation for a stool sample to be sent in for analysis. Without consultation with the Medical Director, the NP elected to postpone obtaining and submitting the stool sample until after the resident's discharge. On [DATE] Resident #290 requested to be transferred to the hospital where he tested positive for C. diff, was diagnosed with septic shock secondary to C. diff and died in the hospital on [DATE]. The death certificate indicated the cause of death was septic shock secondary to C. diff and acute kidney injury. This occurred for 1 of 1 resident reviewed for coordination of care. Immediate jeopardy began on [DATE] when the NP failed to communicate and collaborate with the Medical Director regarding his knowledge of Resident #290's repeated loose and foul-smelling stools. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Review of the facility's Medical Director Agreement effective [DATE], indicated the Medical Director develops and periodically reviews and revises, as indicated, policies that govern practitioners in the facility other than physicians, including physician assistants and nurse practitioners; and guides the facility regarding clinical decision making and the provision of direct care. Review of the facility's Medical Director job description revealed the expectation the medical director provides guidance and oversight of the other providers in the facility. The Medical Director is available to assist providers to answer clinical questions regarding the residents to ensure that the resident-centered standard of practice is maintained. Resident #290's hospital discharge summary dated [DATE] indicated Resident #290 was admitted with a subdural hematoma. During the hospital stay, the resident underwent decompression of the colon (a procedure to reduce gas and feces in the colon) on [DATE] and tolerated the procedure well with reduction in the colon volume. Resident #290 was admitted to the facility on [DATE] with diagnosis of subdural hematoma. For the time period of [DATE] through [DATE] Resident #290 had a total of 42 stools documented with 12 of the 42 that were loose or liquid with one (1) that was described as having a foul odor according to the bowel movement records. The NP progress note dated [DATE] revealed Resident #290 was seen for a chief complaint of loose stools and was started on banana flakes (a medication to help with loose stools) for 1 week. The note did not include an assessment of Resident #290's abdomen or bowel sounds. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. Review of Resident #290's physician orders revealed an order written by the NP dated [DATE] for banana flakes one packet once per day. The order was discontinued on [DATE]. Review of Resident #290's electronic Medication Administration Record (MAR) revealed an entry for banana flakes one packet once per day with a start date of [DATE] and a discontinue date of [DATE]. All entries were signed with electronic signatures as given. For the date of [DATE] the Resident #290 had 3 large loose stools and a small stool according to the bowel movement record for Resident #290. The NP progress note dated [DATE] stated the nature of presenting problem was discharge to home. The note indicated Resident #290 continued to have loose stools. Resident #290's responsible party contacted the Gastroenterologist who recommended a Kidney Ureter and Bladder (KUB) x ray and a stool sample panel due to loose stools. The NP progress note stated the KUB was ordered, and the stool samples would be done outpatient after discharge. The progress note further stated to continue the banana flakes and if the banana flakes were ineffective would start loperamide (an anti-diarrheal medication) 2 milligrams once per day as needed. The progress note gave no indication the NP communicated the resident's condition to the Medical Director, nor did he consult the Gastroenterologist. Review of Resident #290's electronic health record revealed an order dated [DATE] to obtain a KUB. There was no order noted to obtain stool samples. For the time period of [DATE] through [DATE] Resident #290 had 5 stools total recorded with two described as loose and foul-smelling according to the bowel movement record for Resident #290. The NP progress note dated [DATE] indicated Resident #290 continued to have loose stools. Banana flakes were ordered with marginal improvement. KUB was unremarkable. The resident will have stool samples done outpatient following discharge. Continue banana flakes and start loperamide as needed. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director, nor did he consult with the Gastroenterologist. Resident #290's electronic Medication Administration Record (MAR) indicated loperamide 2 milligrams once per day as needed was ordered on [DATE]. The electronic MAR indicated no entries were signed for loperamide indicating loperamide was not administered. For the time period from [DATE] through [DATE] Resident #290 had 3 large loose stools according to the bowel movement record for Resident #290. The NP progress note dated [DATE] indicated the chief complaint was loose stools. The note indicated Resident #290 continued to have loose stools and was started on banana flakes and loperamide as needed. The progress note gave no indication that the NP communicated the resident's continued loose stools with the use of banana flakes to the Medical Director. The progress note gave no indication that the bowel movement records were evaluated to determine the effectiveness of the banana flakes. The NP progress note dated [DATE] indicated Resident #290's chief complaint was loose stools. The note indicated the resident continued to have loose stools. The note provided no indication that Resident #290's bowel movement records were reviewed. The plan indicated the KUB was unremarkable, to continue the banana flakes and continue loperamide as needed. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued with loose stools, had poor appetite and weakness. Banana flakes and loperamide were ordered, the KUB was unremarkable, and a stool sample would be completed as an outpatient after discharge. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. Review of Resident #290's physician orders revealed an order dated [DATE] entered by the NP to for a nurse at the facility to perform a urinary straight catheterization (a procedure in which a temporary catheter is used to drain urine from the bladder and then the catheter is immediately removed once the bladder is emptied) once and obtain the following laboratory tests; Complete Blood Count and Comprehensive Metabolic Panel due to decreased urination. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order for straight catheterization was electronically signed by Nurse #11 on [DATE] at 6:30 PM. The amount of urinary output obtained was recorded as 100 milliliters. For the time period from [DATE] to [DATE], Resident #290 had 1 large and 2 medium stools recorded according to the bowel movement record for Resident #290. Review of Resident #290's laboratory results dated [DATE] indicated a high panic level white blood cell (part of the body's immune system to fight infection) count (WBC) of 51.3 thousand per microliter (a normal WBC would be between 4.5 thousand and 11.0 thousand per microliter) was reported to the facility at 11:48 PM. The lab report was not signed off by the nurse as reviewed or communicated, nor was it signed off as reviewed by the NP, and it was not signed off as communicated to the MD by the NP. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] (Saturday) at 12:46 AM the Nurse Practitioner on-call (not Resident #290's NP) was notified of a high panic laboratory value and new orders were received. The progress note did not document the NP had reported the panic labs to the facility Medical Director. Review of Resident #290's electronic health record revealed physician orders dated [DATE] for ceftriaxone (an antibiotic) 2 grams intramuscular one-time only STAT (as soon as possible), hypodermoclysis (a method of administering fluids under the skin) 75 milliliters of fluid per hour to run continuously with no total amount specified and no time or date to stop the infusion and insert an indwelling urinary catheter. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order to place an indwelling catheter was electronically signed as completed by Nurse #6 on [DATE] at 1:30 AM. An interview was conducted via phone with Nurse #6 on [DATE] at 5:45 PM. Nurse #6 stated she was assigned to Resident #290 on [DATE] from 7:00 PM to 7:00 AM. Nurse #6 stated Resident #290 was very sick that night. Nurse #6 stated she inserted the catheter and Resident #290 did not have any urinary output from the indwelling catheter. Nurse #6 stated she did not call the on-call provider back to report the lack of urinary output and did not assess the resident for further symptoms. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 12:40 PM written by the Nursing Supervisor #2 indicated the resident requested to be sent to the hospital because he was unable to eat or urinate and the NP was notified. The NP indicated the resident was competent and to send him to the ER if that was what he wanted. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 2:31 written by Nursing Supervisor #2 indicated resident was sent to the hospital for evaluation at 2:20 PM. The Emergency Provider/emergency room Note dated [DATE] indicated the resident arrived in the emergency room and was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Laboratory results at the hospital indicated C. diff was positive, the white blood cell count was 66.0 thousand per microliter and the resident was diagnosed with Septic Shock secondary to C. diff. The hospital discharge summary dated [DATE] indicated Resident #290 was admitted on [DATE] with diagnosis of septic shock secondary to C. diff colitis. Resident #290 presented with a chief complaint of persistent diarrhea and dehydration with approximately 1 month of persistent malodorous diarrhea and dehydration. In the emergency department, the resident's blood pressure was ,d+[DATE] and pulse was 110. [NAME] blood count was 66 and resident tested positive for C. diff. The resident was admitted to the intensive care unit where his condition continued to decline. Resident #290 passed away on [DATE] at 11:02 PM. Review of Resident #290's death certificate dated [DATE] indicated resident's cause of death was Sepsis, C. diff and acute kidney injury. An interview conducted with the Nurse Practitioner on [DATE] at 3:00 PM revealed he was aware Resident #290 had loose stools during his stay in the facility. The NP revealed there was not a system in place for reviewing the residents he saw and their medical conditions with the Medical Director. The NP further indicated he reviewed residents he evaluated with the Medical Director on an as needed basis. The NP stated he did not think Resident #290's condition warranted consultation with the Medical Director because it did not seem that serious. The NP stated he based his assessment on what the resident told him and what was reported by the nursing staff. The NP indicated he thought the resident was being discharged several times due to potential discontinuation of insurance coverage and he wrote his notes and evaluations based on the resident only being in the facility for rehabilitation and would be returning home. Resident #290 did not in fact discharge from the facility until [DATE] when he was emergently sent to the hospital. The NP stated the resident did not report any problems and he used this as his basis for treatment. A telephone interview was conducted with Resident #290's RP on [DATE] at 9:20 AM. The RP stated she visited Resident #290 daily and sometimes twice per day. The RP indicated Resident #290 had frequent loose stools that had a foul odor that was noticeable in the hallway. The RP stated Resident #290 indicated he could not tell when he was urinating or having a bowel movement, that the stools were liquid and would just run out of him. The RP stated when she came in to visit, she had observed him with liquid feces running down his legs and she stated she reported to the nurses multiple times that the resident was having loose stools. The RP stated she talked to the NP frequently and reported to him the loose stools. The RP stated she called the Gastroenterologist to report the loose stools since the NP had not addressed it. The RP stated Resident #290 had a loss of appetite, nausea and stomach pain in the weeks before he went to the hospital. The RP stated she arrived at the facility before the resident left via EMS to go to the hospital and indicated she observed the resident struggling to breathe and he stated he had an infection and knew something was wrong. An interview was conducted via phone with the Medical Director on [DATE] at 12:05 PM. The Medical Director stated she was new in the position in the facility and new to working with the NP. She stated she visited the facility weekly mainly to complete the history and physicals for new admissions to meet the regulatory requirements. The Medical Director stated there was not a system in place for reviewing the residents seen by the NP each week. The Medical Director stated she expected she would have been notified by the NP regarding a significant change in a resident's condition including diarrhea, possible dehydration, and infection. The NP had not reported any other residents to her which were of concern. The Medical Director further stated she was not informed of the critical lab value (WBC of 51.3 thousand per microliter), and she would have expected to have been. The Medical Director stated there was not a system to ensure that she was notified of changes in residents including critical labs that were called in to the on-call provider but stated there should probably be a system for this. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:45 PM. The DON stated the NP was in the facility daily during the week and the Medical Director visited weekly. The DON stated she was not aware of what the working relationship was between the Medical Director and the NP. The DON indicated she assumed that changes were reported by the NP to the Medical Director. The DON stated she did not consult the Medical Director and did not know if the NP had consulted the Medical Director. A follow up telephone interview with the DON on [DATE] at 2:28 PM revealed prior to this incident, there was no protocol for communication between the Medical Director and the Nurse Practitioner. The DON further stated the Medical Director as the attending physician for the residents makes the regulatory visits and the Nurse Practitioner completes the acute visits. The DON stated the Medical Director, and the Nurse Practitioner were both employed by a contracted company which provided their physician, provider, and on call provider service. The contracted service provided a transcript on Monday mornings of the calls that were received over the weekend from the facility and the response. The Medical Director and the NP receive a copy of the transcript. The facility staff call the DON when a resident is sent to the hospital for evaluation on the weekend or at night. The DON updated the NP on Monday of all residents that were sent to the hospital on the weekends. The DON stated the NP wrote his own orders and progress notes and the attending physician or Medical Director did not sign off on the orders or notes. According to the DON, the Medical Director did not have a system for reviewing the visits the Nurse Practitioner completed. The Administrator was notified of immediate jeopardy on [DATE] at 4:45 PM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The Nurse Practitioner failed to communicate and collaborate with the Medical Director when Resident #290 had prolonged loose, liquid stools from admission on [DATE] through [DATE]. The Nurse Practitioner was made aware and implemented banana flakes on [DATE] and loperamide on [DATE]. Resident # 290 requested to go to the hospital on [DATE] at 12:40 PM due to not feeling well. Emergency Medical Services transferred resident to the hospital at 2:20 PM where he was diagnosed with Septic Shock Secondary to clostridium difficile. The Hospital Discharge Summary indicated Resident #290 died on [DATE] at 11:02 PM. All residents being seen by a Nurse Practitioner and/or Physician Assistant for acute change in condition have the potential to be affected. On [DATE] the Medical Director will review the provider notes for all residents with a change in condition that were seen by any of the Nurse Practitioners and/or Physician Assistants since [DATE]. Any new orders or suggestions made by the Medical Director will be communicated to the Nurse Practitioner/Physician Assistant and the Director of Nursing on [DATE] for follow-up. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Medical Director educated all Providers working with the facility on the clostridium difficile protocol. The protocol indicates that residents with three or more watery or loose stool in a 24 hour time span should have a medication review to ensure laxatives are not contributing to the loose stool. If the loose stool does not resolve within 24 hours of the laxatives being stopped or the resident was not receiving laxatives, a clostridium difficile test will be performed. The NP was included in the provider education. All education was implemented on [DATE] via telephone or face to face training and will be completed by [DATE]. On [DATE] the Director of Nursing was educated by the Regional Director of Clinical Services on providing the Medical Director with a list of residents that were seen by a Nurse Practitioner and/or Physician Assistant in the previous seven days, due to a change in condition, weekly for the Medical Director to review. The Director of Nursing will review all progress notes weekly to determine the residents that were seen in the past 7 days for a change in condition. The Medical Director will review the Nurse Practitioner and/or Physician Assistant progress notes weekly and communicate any suggestions to the Nurse Practitioners and/or Physician Assistants and the facility. The Regional Director of Clinical Services communicated the new review process to the provider groups Nurse Practitioners and/or Physician Assistants as well on [DATE]. The Medical Director was informed of the new review process by the Director of Nursing on [DATE] and is in agreement with the system of communication and collaboration. Alleged Date of immediate jeopardy removal: [DATE] The credible allegation of immediate jeopardy removal was validated on [DATE]. Interviews with the Nurse Practitioner, Physician Assistant, Medical Director and the Director of Nursing revealed they received education and training regarding the new process of checking residents' progress notes for significant changes. The Director of Nursing will provide the Medical Director with a list of all residents with significant changes for review. The Medical Director validated that she will review the progress notes of all residents with significant changes and communicate suggestions or changes in plan of care to the Nurse Practitioners, Physician Assistant and the facility. The Regional Clinical Consultant confirmed that she educated the Director of Nursing on the new process and auditing to be completed. The immediate jeopardy removal date of [DATE] was validated.

Based on record review, and resident and staff interviews, the facility failed to ensure residents' rights to maintain dignity for 2 of 2 residents reviewed for dignity. On the night of admission, Resident #242 informed Nurse Aide (NA) #9 she needed to use the bathroom, and NA #9 told her to just go in the bed. This resulted in the resident having to urinate in the bed, crying, and making her feel useless, bad and embarrassed. Additionally, NA #9 provided incontinence care to Resident #75 while he was in his room, standing up over his wheelchair, holding onto a walker. Resident #75 felt this was rude and insensitive. The findings included: 1) The Hospital Discharge Summary written by the hospital physician on 1/29/2025 for Resident #242 revealed she was admitted to the hospital on 1/22/2025 with acute respiratory failure with hypoxia (low oxygen levels). She was discharged from the hospital to the facility for rehab on 1/29/2025. Resident #242 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease with heart failure and stage 4 chronic kidney disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #242 was cognitively intact. She was coded for being occasionally incontinent of urine and frequently incontinent of bowel and required the assistance of 1 staff member with transferring and toileting. A Psychiatric Follow-Up Evaluation written by the Psych Physician Assistant (PA) on 2/6/2025, listed the chief complaint/ nature of presenting problem was Resident #242 reported a distressing incident with a Nurse Aide (NA) during admission last Wednesday night. It further read that the resident felt she was verbally abused by the NA because she was loud and rude while performing tasks. It stated an incident occurred during the weighing process while using a sling, she needed to use the bathroom, and the NA instructed her to just go in the bed. It further read that because of the incontinence episode she felt useless at the time but was not feeling any long-term effects. The report indicated Resident #242 was initially referred to Psych Services by the Medical Director because she had been experiencing depression for a year over the death of her son and had never talked to anyone about it. An interview with Resident #242 was completed on 2/6/2025 at 11:25 AM. Resident #242 stated that she had a really bad experience with a NA on the evening shift on 1/29/2025, when she was admitted to the facility. She further stated that when she was in the hospital she was getting up to the bathroom with assistance and using her walker. Resident #242 stated that NA #9 had refused to take her to the bathroom and told her she had to be evaluated by physical therapy before she could get out of bed. She further stated that NA #9 was slamming things around and yelling at her while performing tasks, such as weighing her in the lift, and changing the bed. Resident #242 stated she was not usually incontinent, and it made her feel bad and embarrassed to urinate in the bed, but she had no choice, because NA #9 did not get her a bed pan in time or get her up to the bathroom. She indicated that NA #9 was rough when touching her and she really felt like she had been manhandled. Resident #242 indicated that nobody should be treated the way she was treated the night she was admitted . Resident #242 stated she was crying and upset, and NA #9 had just slammed the door when she left the room. She further stated that she told the nurse aide on night shift that NA #9 was rude to her, but she didn't tell her the about the incident. Resident #242 indicated that the reason she waited until the next day to tell anyone was because her family member worked at the facility, and she didn't want to cause any problems. She stated she informed her family member about the incident first thing in the morning on 1/30/25, who told her she needed to report the incident to the management, and she did. Resident #242 stated she had never had anybody talk to her like that before and it still upset her. A telephone interview was completed with NA #9 on 2/6/2025 at 11:42 AM. NA #9 stated she was the NA that admitted Resident #242 on 1/29/2025 on the 3:00 PM to 11:00 PM shift. She further stated that while she was weighing the resident with the lift she had asked to go to the bathroom. She stated that Resident #242 came by ambulance on a stretcher, and she didn't know if she could walk or not, so she told her she would get her a bedpan. NA #9 indicated that Resident #242 became upset, and she was crying and asking for her walker or a wheelchair to go to the bathroom. She stated that she told Resident #242 she had to be evaluated by therapy before she was able to get out of bed. NA #9 insisted she was not yelling at Resident #242, but that she just talked very loudly. She indicated that Resident #242 told her she was going to report her, but she didn't do anything wrong. NA #9 stated she was on suspension for poor customer service related to this incident. A telephone interview was completed with Nurse #7 on 2/7/2025 at 9:31 AM. Nurse #7 stated she was the nurse that admitted Resident #242 on 1/29/2025. She further stated that therapy did not have to evaluate new residents prior to ambulation. Nurse #7 indicated nurses could make that decision based on assessment and report from the hospital staff. She stated that she had told NA #9 that Resident #242 was alert and oriented and she was able to ambulate with a walker or she could take her to the bathroom in a wheelchair, since she was a one-person assist. Nurse #7 indicated that she found out NA #9 refused to take Resident #242 to the bathroom when NA #9 was suspended the next day (1/30/25). An interview was conducted with the Admissions Director on 2/6/2025 at 2:30 PM. The Admissions Director stated that she went to Resident #242's room on the morning of 1/30/2025 to complete the admission paperwork. She further stated that Resident #242 had complained to her that a nurse aide was very loud and mean to her the night before. The Admissions Director indicated that Resident #242 appeared sad and stated she was upset, so she had filled out a Concern Form for her and gave it to the Business Office Manager who was the Acting Administrator that day. She stated the Business Office Manager was in charge when the Administrator was out of the building. An interview was completed with the Interim Director of Rehab on 2/7/2025 at 8:30 AM. The Interim Director of Rehab stated the facility did not have a policy that required therapy to evaluate all new residents prior to ambulation or getting out of bed. She stated the nurses could make that determination based on assessment and clinical evaluation. An interview with the Assistant Director of Nursing (ADON) occurred on 2/6/2025 at 2:55 PM. The ADON stated that there was not a policy for newly admitted residents that required they were to be seen by therapy prior to ambulation. She stated the nurses could make that determination based on assessment and clinical judgement. The ADON stated she was given the Concern Form for Resident #242 by the Business Office Manager on 1/30/25 and had she consulted with the DON on the phone regarding the incontinence episode and Resident #242 being upset. She indicated they decided to suspend NA #9 for poor customer service, and she had not returned to work at the facility. The ADON stated that NA #9 was very loud and that was the way she talked all the time. An interview was completed with the Director of Nursing on 2/7/2025 at 1:30 PM. The DON stated that the nursing staff was aware that newly admitted residents did not have to be seen by therapy prior to ambulation, and that nurses could make that determination. She further stated she had not been in the facility on 1/30/2025, but that the Assistant Director of Nursing (ADON) had called her and informed her of the incident. The DON stated that she was not aware until today that Resident #242 had to urinate in the bed and that she was crying and upset over the incident. She further stated that she was told that NA #9 was loud and rude to Resident #242. The DON indicated that she had instructed the nursing staff to suspend NA #9 for poor customer service for being loud and upsetting Resident #242. She further indicated that NA #9 received disciplinary action two other times for being loud and rude. An interview was completed with the Administrator on 2/7/2025 at 1:45 PM. The Administrator stated he was not at the facility on 1/30/2025 when Resident #242 reported the incident. He stated that the way it was explained to him, NA # 9 was just very loud and did not respond appropriately to Resident #242. The Administrator indicated that NA #9 should have gotten Resident #242 up to the bathroom instead of telling her to just go in the bed. He further indicated that NA #9 just had a very loud voice that could be interpreted by some people as yelling, but that was just how she spoke. 40044 2.) Resident #73 was admitted to the facility on [DATE]. The MDS quarterly assessment dated [DATE] revealed Resident #73 was cognitively intact. He required assistance by staff with activities of daily living (ADL). During an interview on 02/06/25 at 03:25 PM Resident #73 was alert and oriented to person, place, and time. He stated a nurse aide, name unknown, came into his room to provide care on the day he fell on [DATE]. He was seated in his wheelchair, and she stood him up, and changed his incontinence brief while he was standing up over the wheelchair and holding on to the walker placed in front of him. He stated this occurred in his room not in the bathroom. When she was done, he was trying to sit back in the wheelchair and he lost his balance and ended up landing on the floor. He stated that he did not like to be changed while standing up over the wheelchair and he especially didn't like that this occurred in his room and not in his bathroom. He stated he did not say anything to the nurse aide at the time, but he didn't like it. He stated the nurse aides had provided incontinence care to him while standing prior to this incident, and he would rather be assisted back to bed for incontinence care or taken into the bathroom for brief changes. He indicated that it was rude and insensitive to be changed while standing up over the wheelchair. During a phone interview on 02/06/25 at 03:30 PM Nurse Aide #9 stated she provided incontinence care to Resident #73 while he was standing up over his wheelchair and holding on to his walker when he fell on [DATE]. She stated this occurred in his room and not in the bathroom. She stated he was in a private room, and indicated the room did not have a privacy curtain. She stated there was a walker in his room, and she felt she could stand him up using the walker to provide his incontinence care. She stated she placed the walker in front of his wheelchair, she assisted him to stand, she pulled off his brief and provided incontinence care. She stated she thought it was okay to provide incontinence care while he was standing up over his wheelchair. She didn't recall Resident #73 saying anything to her at the time about being changed while standing up. She stated she had done this in the past with other residents too if they could stand up. She indicated that she didn't think to take him into the bathroom or assist him back to bed to provide incontinence care to maintain his dignity. She indicated she had received training on providing incontinence care. She stated she should have assisted Resident #73 back to bed or taken him into the bathroom to provide his incontinence care. During an interview on 02/07/25 at 4:15 PM Nurse #13 stated she was the unit charge nurse. She stated Resident #73 required staff assistance with activities of daily living (ADL). She stated Nurse Aide #9 should have assisted Resident #73 back to bed or at least taken him into the bathroom before removing his brief and providing incontinence care to maintain his dignity. During an interview on 02/07/25 at 4:38 PM the Director of Nursing (DON) stated Nurse Aide #9 should not have provided incontinence care while Resident #73 was standing up holding on to a walker. She indicated incontinence care should be provided by staff in a dignified manner such as assisting them back to bed or taking them into the bathroom. She stated Nurse Aide #9 no longer worked for the facility and staff education would be provided.

Based on observations, record review and staff interviews the facility failed to remove expired food items stored for use in the dry storage room and remove expired food items from 1 of 2 nourishment rooms. This practice had the potential to affect the food served to 92 out of 92 residents. Findings included: a. An initial tour of the facility's dry storage room on [DATE] at 11:00 AM with the Dietary Manager revealed the following expired items: - Twelve bottles of 14.5 fluid ounces of sugar free breakfast syrup expired on [DATE] - Four - 16 ounce bags plus ,d+[DATE] bag (8 ounces) of corn chips expired on [DATE] - One case with approximately 200 single packaged chocolate chip cookies in the case had expired on [DATE] - Ten - 24 ounces fruit punch powder mix 1lb. each with no expiration date. The packages were noted to be hard to touch and not soft and powdery. An interview with the Dietary Manager on [DATE] at 11:20 AM revealed she removed the syrup, corn chips and cookies from the dry storage and discarded them. She stated she did not know how long the fruit punch powder was stored in the dry storage area as it had no arrival date when received recorded on the packages and she had no idea how long they were sitting on the shelf. The Dietary Manager discarded the fruit punch powder mixes. She stated the stock was rotated weekly when the new delivery arrived. She stated she or the cook would rotate the stock to ensure there were no expired items or put the soon to be expired product in the front of the shelf to be used. The Dietary Manager stated the above items were overlooked and she would begin an in-service immediately. b. A tour of the nutrition rooms were conducted on [DATE] at 12:45 PM and the following was noted in 1 of 2 nutrition rooms: - The refrigerator temperature in the refrigerator labeled for resident's use only was 22 degrees Fahrenheit. - There were five (5) frozen 8 ounce bottles of supplemental shakes which had expired on [DATE]. - Five - 8 ounce bottles of supplemental shakes that had expired on [DATE] but were not frozen. An interview was conducted with the Dietary Manager on [DATE] at 12:45 PM. She revealed the Dietary Aide was responsible for ensuring the temperatures in the refrigerator were within acceptable range and removing any expired products. The Dietary Manager provided a log to indicate the nutrition room had been checked on [DATE] for the AM and PM shift, but the expired products were not removed. The Dietary Manager stated the Dietary Aide obviously overlooked it and she would start an in-service immediately. The Dietary Manager stated those products should have been removed from the refrigerator. The Dietary Manager stated the manufacturer's label did not indicate a do not freeze on the supplement shake bottle, but they still should have been removed because they were expired. She stated the Dietary Aide should have checked the temperature in the refrigerator to ensure it was at 35 - 38 degrees Fahrenheit. On [DATE] at 12:45 PM, the Dietary Aide who signed the log was not available for an interview. An interview was conducted with the Administrator on [DATE] at 5:30 PM. The Administrator stated he expected the kitchen Dietary Manager and the dietary staff to be following the guidelines to discard expired food items from the kitchen as well as the nutrition rooms. He stated expired foods could cause potential food borne illness to residents.

Based on observations, record review, and staff interviews, the facility failed to: 1) remove expired medications in accordance to the manufacturer's expiration date for 1 of 3 medication carts (Medication Cart #4); 2) remove loose pills of various sizes, colors, and shapes from 2 of 3 medication carts (Medication Cart #2 and Medication Cart #4); and 3) failed to secure medications observed at the bedside for 1 of 1 severely cognitively impaired resident (Resident #59) reviewed for medication storage. Findings included: 1.) An observation was conducted on 2/5/2025 at 1:45 PM of Medication Cart #4 in the presence of Nurse #7. The observation revealed 3 white pill halves were found loose in the drawers. The observation further revealed 7 doses of the stock medication loperamide Hydrochloride (HCL) 4 milligrams (mg) (an antidiarrheal medication) in individual blister packs with the manufacturer's expiration date of 12/2023 and 5 doses of loperamide HCL 4mg tablets with the manufacturer's expiration date of 9/2024. An interview was completed with Nurse #7 on 2/5/2025 at 1:45 PM. Nurse #7 stated there should not be any expired medications or loose pills on the cart. She further stated that it was the nurse's responsibility to check the carts for expired medications. 2.) An observation was conducted on 2/5/2025 at 12:45 PM of Medication Cart #2 in the presence of Nurse #8. The observation revealed 12 loose pills of various colors, shapes, and sizes were found in the drawers of the cart. An interview with Nurse #8 was completed on 2/5/2025 at 12:45 PM with Nurse #8. Nurse #8 stated that there were not supposed to be any loose pills on the cart. She further stated she had recently cleaned the cart, but pills could just pop out of the blister packs when placing them in or taking them out of the cart. An interview was completed with the Director of Nursing on 2/7/2025 at 1:30 PM. The DON stated there was not supposed to be any expired medications on the cart. She further stated that Pharmacy and the nursing staff had recently checked all the carts for expired medications, and she was not sure why the expired medications were not removed. The DON explained there should not be any loose pills in the carts, but sometimes they just popped out the blister packs during medication administration. She further explained it was the nurses' responsibility to check their carts frequently and to keep their carts clean and remove expired medications. 40044 3.) Resident #59 was admitted to the facility on [DATE] with diagnoses including Atrial fibrillation, chronic obstructive pulmonary disease (COPD), and hypertension. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #59 was severely cognitively impaired. During an observation on 02/04/25 at 12:15 PM a medication cup with 3 pills was observed on Resident #59's bedside table. Resident #59 stated the nurse brought them in earlier that morning. During an interview on 02/04/25 at 12:15 PM Nursing Supervisor #2 stated she completed Resident #59's medication pass at 9:50 AM today. She stated she went into his room and gave him his medications. She left the room to get his nutritional supplement and when she returned to the room, she thought he had taken all his medications. She stated the pills that were left in the medication cup at the bedside included Xarelto (anticoagulant), Losartan (antihypertensive), and Prednisone (corticosteroid used to treat inflammation). She stated she should have waited and observed him take all the medications before she left his room. During an interview on 02/07/25 at 4:56 PM the Director of Nursing stated the nurse should ensure that residents take all of their medications prior to leaving the room. She stated education would be provided.

Based on observations, record review, and staff interviews, the facility failed to implement the facility's infection control policy and procedures for Enhanced Barrier Precautions (EBP) when the Wound Nurse provided wound care for Resident #81's chronic wounds wearing gloves but no gown. This occurred for 1 of 3 staff observed for infection control practices (Wound Nurse). Findings included: The facility's Infection Control Policy revised 04/15/24 revealed Enhanced Barrier Precautions (EBP) were intended to prevent transmission of multi drug resistant organisms (MDRO's) via contaminated hands and clothing to high-risk residents. EBP were indicated for high contact care activities for residents with chronic wounds and indwelling devices. An observation of Resident #81 was conducted on 02/06/25 at 10:00 AM with the Wound Nurse. Resident #81 was noted to have multiple areas of open wounds on the left posterior lower extremity, bilateral great toes, and bilateral knees. There was no sign placed to indicate that Resident #81 was on Enhanced Barrier Precautions. There were no supplies near Resident #81's room to don prior to providing direct care. The Wound Nurse donned gloves prior to removing the dressing on the left posterior lower extremity wound but did not don a gown. She described the wound on the left lower extremity as a Stage IV wound. When asked if she should wear personal protective equipment (PPE) to include a gown and gloves prior to removing a dressing she stated she thought enhanced barrier precautions were only needed for residents with chronic wounds. During an interview with the Infection Control Preventionist Nurse on 02/06/25 at 11:00 AM she stated residents that received wound care should be placed on enhanced barrier precautions. She stated Resident #81 was admitted with chronic wounds. He was placed on enhanced barrier precautions on admission, but he contracted COVID during the current COVID outbreak in the facility, and he was placed on contact precautions. She stated after he came off contact precautions last week they forgot to continue the enhanced barrier precautions. She stated she would review all residents with wounds or an indwelling device to ensure they were on enhanced barrier precautions. During an interview on 02/07/25 at 4:00 PM the Director of Nursing (DON) stated staff had been trained on enhanced barrier precautions and were aware that residents receiving wound care to chronic wounds should be placed on enhanced barrier precautions. She stated the wound nurse should have donned a gown and gloves prior to wound care. She reported education would be provided.

Based on observations, record review, and staff, resident, and Medical Director interviews, the facility failed to have an effective system in place for communicating a therapy order for a left hand splint to nursing staff for 1 of 1 resident (Resident #71) reviewed for a contracture and limited range of motion. Findings included: Resident #71 was admitted to the facility on [DATE]. Diagnosis included stroke with left side weakness, difficulty in walking, and muscle weakness. There was no diagnosis for contractures. A physician's order was written on 05/22/2024 to evaluate and treat as needed for Physical Therapy and Occupational Therapy. Review of an Occupational Therapy note entered by Occupational Therapist (OT) #1 and dated 07/23/24 revealed splint / orthotic recommendations were none at this time. The note indicated OT #1 would continue to assess. The assessment revealed the following questions: Does resident present with contracture (s)? = Yes; Do impairments affect functional skills? = Yes. The note indicated OT #1 would continue to assess. The musculoskeletal assessment revealed the Range of Motion (ROM) and strength of the right upper extremity were within normal limits. Range of motion to left upper extremity (shoulder) was impaired, left elbow / forearm impaired; and left hand and wrist were impaired. The discharge summary note written by OT #1 dated 11/22/24 revealed on 09/19/24 a request for a splint was sent. On 11/18/24 the note indicated awaiting arrival as splint was on back order from initial supplier. The note stated OT #1 ordered the splint through a different supplier. The summary of skilled services note by OT #1 dated 11/20/24 revealed OT #1 provided moist hot pack to left hand to decrease pain and stiffness and traced left hand and molded Resident #71's hand splint to promote extension of digits and abduction of thumb in order to decrease risk of contractures. OT #1 refined the splint in order to maximize comfort and decrease risk of skin breakdown. OT #1's note indicated under additional skilled service: Instruction on care of splint and wear schedule and that resident was exhibiting pain. A treatment encounter note written by OT #1 dated 11/22/24 at 4:00 PM revealed in part resident and caregiver training: instructed resident and primary caregivers in the use of adaptive equipment and compensatory strategies in order to facilitate improved functional abilities with variable carryover demonstrated by caregivers. On the discharge summary note written by OT #1 dated 11/22/24, the note stated Resident #71 had a resting hand splint and could tolerate wearing with staff knowledgeable of splint wear (frequency of time the resident should wear the splint) as well as Resident #71. Occupation Therapist #1 no longer worked at the facility and could not be reached for an interview. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #71 was cognitively intact and demonstrated no behaviors. Resident #71 required set up with one staff physical assistance with eating, dependent with one staff physical assistance with toileting, substantial assistance with one staff physical assistance with showering, dressing, and transfers, and set up with one staff physical assistance with personal hygiene. The assessment indicated Resident #71 had received occupational therapy from 07/23/24 through 11/22/24, and the resident was receiving restorative nursing for transfers but none for splint or brace assistance. A review of Resident #71's care plan updated on 11/24/24 revealed a plan of care for left hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) related to a stroke (a result of poor blood flow to the brain). There was no care plan for range of motion or the use of splints. Review of the physician orders since 11/22/24 through 02/07/25 revealed there were no orders in place to apply a left hand splint for Resident #71. Review of the Medication Administration Record (MAR) from 11/22/24 through 02/07/25 revealed there were no orders for nursing staff to sign off that a left hand splint for Resident #71 was applied. An interview with Resident #71 on 02/03/25 at 11:30 AM revealed he had been working with therapy in the past and the Occupational Therapist told him she was going to order a splint for his left hand. Resident #71 stated the OT had made him a splint because the one she ordered was on back order. Resident #71 stated he had not seen the splint for some time and the staff have not inquired as to where it was and why it was not on him. He stated he has not seen the splint in weeks. Resident #71 stated he would wear the splint if it were applied. An observation of Resident #71 on 02/03/25 at 11:30 AM, 2:20 PM, 3:18 PM, and 4:30 PM revealed there was no left hand splint applied. There was no splint in view in his room at any of these times. Resident #71's hand was noted to be contracted. His fist was closed and he demonstrated difficulty when trying to open his hand and extend his fingers. An observation of Resident #71 on 02/05/225 at 10:07 AM, 12:30 PM and 2:45 PM and 4:10 PM revealed there was no left hand splint applied. There was no splint in view in his room at any of these times. An observation of Resident #71 on 02/06/25 at 9:30 AM, 1:17 PM and 4:38 PM revealed there was no left hand splint applied. There was no splint in view in his room at any of these times. An interview was conducted with Nurse Aide (NA) #8 on 02/06/25 at 2:42 PM revealed she was aware Resident #71 had a splint for his left hand. NA #8 stated whenever she was assigned to Resident #71 she would apply the splint. NA #8 stated she was not aware that the splint was missing or that it needed repair, but she had not worked with Resident #71 this week. NA #8 stated she could not recall the last time she was assigned to Resident #71. A follow up interview was conducted with Resident #71 on 02/07/25 at 9:00 AM. Resident #71 reported he had a splint for his left hand but he has not had it on because no one could find it. He reported that if the staff could find it and offer to put it on him, he would wear it. Resident #71 stated he has told nursing staff that he needed his splint applied and that he could not find it. An interview was conducted with NA #1 on 02/07/25 at 9:45 AM. NA #1 revealed she worked on Fridays and was familiar with Resident #71. She stated she did not recall him having a splint and if he had one she would have applied it. NA #1 stated Resident #71 had never asked her to apply a splint. NA #1 assisted in looking for the splint in Resident #71's room and it was noted to be located on the top shelf of his closet in visible site. The splint was removed from the closet and NA #1 asked Resident #71 if he would like to wear it. He stated yes. NA #1 attempted to apply the splint, but the splint was noted to have been missing a Velcro band to secure the splint to his hand. The splint was then removed by NA #1 and she stated she would have therapy look at it. Resident #71 stated he had never asked NA #1 to apply the splint in the past, but he had asked other nursing staff. An interview was conducted with Occupational Therapist (OT) #2 on 02/07/25 at 10:20 AM. OT #2 stated she was asked to evaluate Resident #71 on 02/06/25 by Resident #1's family member and Resident #71 because he would like to be discharged home. OT #2 stated she had been working at the facility for a month and was not aware of any splints for Resident #71, but she would look into it. During this interview, the Evening Supervisor arrived and provided the left hand splint to OT #2 for Resident #71 and stated that it needed to be repaired. At this time, the Evening Supervisor stated Resident #71 had it on yesterday 02/06/25 but it broke and now it needed to be repaired. The Evening Supervisor was made aware that the splint, according to the resident, was missing for and had not been applied in a long time. An interview with Nurse #5 on 02/07/25 at 3:10 PM revealed that he thought the resident wore a splint on occasion but he was not aware that it was a requirement. Nurse #5 stated there were no orders in the electronic record to apply a left hand splint and he was never in serviced by the therapy department on how to utilize the left hand splint or how often Resident #71 was supposed to wear the splint for his left hand contracture. Nurse #5 stated he did not recall if Resident #71 ever asked him to apply his left hand splint. An interview was conducted with Nurse #4 on 02/07/25 at 3:10 PM. Nurse #4 reported she had no knowledge of Resident #71 ever wearing a splint. She stated she never saw a splint in his room nor had he ever mentioned that he needed to wear his splint for his left hand contracture. Nurse #4 stated she had never been given any education on how to apply the left hand splint by therapy and there was no order to apply the splint in the electronic record. An interview was conducted with the interim Therapy Rehab Director on 02/07/25 at 3:30 PM. The Rehab Director provided documentation to support that OT #1 made Resident #71 a splint on 11/20/24. The Rehab Director confirmed OT #1's note stated that instruction on care of the splint and a wear schedule (frequency of how often the splint should be worn) was indicated on the treatment encounter note dated 11/22/24. The Rehab Director stated OT #1 should have educated the staff regarding the splint and the schedule and frequency of when the splint should be applied. Furthermore, she added, OT #1 should have implemented an order in the electronic record so that it would become a nursing measure. She stated once the order was entered with the wear schedule, it would trigger to the Medication Administration Record so that the nurses would know Resident #71 needed to have the splint applied and for how long. The Rehab Director stated OT #1 made the splint for Resident #71 in order to maintain range of motion and to prevent the left hand from getting more contracted. The Rehab Director stated that OT #1 should have followed through with her recommendation for the splint application and communicated the recommendation to the nursing staff to ensure the left hand splint was getting applied. An interview with the Director of Nursing (DON) on 02/07/25 at 5:30 PM revealed she had no knowledge of Resident #71 requiring a splint for his left hand contracture. The DON stated if she had known by OT #1 that he required a splint, she would have made sure the order was put in the electronic record so that it would trigger to the medication administration record to let nurses know it needed to be applied and she would have made sure it went into the Resident #71's profile so that nurse aides would know as well. An interview was conducted via phone with the Medical Director on 02/10/25 at 4:50 PM. The Medical Director stated she would have expected the therapist to follow through with her recommendation and communicate clear orders and instructions so the order could be implemented. The Medical Director stated not having the splint would put Resident #71 at further risk for his contracture to worsen.

Based on observations, record review, and resident and staff interviews, the facility failed to provide care in a safe manner during the provision of incontinence care resulting in the resident being lowered to the floor. This occurred for 1 of 3 residents reviewed for falls (Resident #73). Findings included. Resident #73 was admitted to the facility on [DATE] with diagnoses including muscle weakness and a history of falls with femur fracture. A care plan updated 12/02/24 revealed Resident #73 was at risk for falls, had a decline in his functional abilities, and self-care due to a history of falls with right femur fracture. Interventions included in part to use two-person assistance for all transfers. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #73 was cognitively intact. He had no falls at the time of assessment. His weight was 210 pounds. An incident report dated 01/30/25 at 2:30 PM completed by Nurse #5 revealed Resident #73 fell while being assisted by the nurse aide. He had no injuries and no complaints of pain. Resident #73 was alert and responded appropriately. During an interview on 02/06/25 at 3:25 PM Resident #73 was alert and oriented to person, place, and time. He stated the nurse aide, name unknown, came into his room to provide care on 01/30/25. He was seated in his wheelchair, and she stood him up, and changed his incontinence brief while he was standing up over the wheelchair and holding on to the walker placed in front of him. He stated the incident occurred in his room not in the bathroom. When she was done, he was trying to sit back in the wheelchair and he lost his balance and ended up landing on the floor. He stated he had no injuries from the fall. He reported there was only one nurse aide in the room with him during that incident. During a phone interview on 02/06/25 at 3:30 PM Nurse Aide #9 stated she was the nurse aide involved in the fall incident with Resident #73. She stated she had not worked with Resident #73 in over a month and when she last provided care to him, he used the sit to stand lift for transfers. She stated he had improved and there was a walker in his room, and she felt she could stand him up using the walker without the assistance of a second person. She stated she went in alone to do his incontinence care, and she did not ask another staff member for assistance to transfer him to a standing position. She did not use the gait belt to assist him while standing him up and she did not have a gait belt with her. She stated she placed the walker in front of his wheelchair, she assisted him to stand, she pulled off his brief and provided incontinence care while he was standing up over the wheelchair and holding on to the walker. She stated when she was done, she attempted to sit him back down in the wheelchair and he leaned to his right side, and she could not get him back in the wheelchair, so she lowered him to the floor. After she lowered him to the floor, she left the room to get Nurse #5. She and Nurse #5 transferred Resident #73 to the bed using the mechanical lift following the fall. She stated she thought it was okay to provide incontinence care while he was standing up. She stated she looked at his care plan prior to transferring him and it showed that he needed limited assistance. During an interview on 02/07/25 at 4:00 PM Nurse #5 stated Nurse Aide #9 notified him of the fall. He went in and assessed Resident #73 and there were no injuries. He stated he and Nurse Aide #9 transferred Resident #73 to bed using the mechanical lift. He indicated that Resident #73 required two-person assistance with all transfers. During an interview on 02/07/25 at 4:15 PM Nurse #13 stated she was the unit charge nurse. She stated Resident #73 has required two-person assistance with transfers since he was admitted in May 2024. She indicated he weighed over 200 pounds and was six feet tall. She stated staff were to review the care plan to determine transfer needs and Resident #73's care plan did show that he required two-person assistance with all transfers. During an interview on 02/07/25 at 4:38 PM the Director of Nursing (DON) stated Resident #73 required two-person assistance with all transfers. She stated Nurse Aide #9 should have asked another staff member for assistance before standing him up. She indicated she should not have provided incontinence care to a resident with weakness and a history of falls while he was standing up holding on to a walker. She stated Nurse Aide #9 no longer worked for the facility and staff education would be provided.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to maintain a resident's indwelling urinary catheter below the resident's bladder when the Wound Treatment Nurse placed the indwelling urinary catheter on the resident's bed during a sacral pressure ulcer dressing change and failed to cleanse the urethral meatus and catheter tubing during catheter care in a manner to prevent contamination/infection for 1 of 1 resident observed for urinary catheters (Resident #66). Findings included: Resident #66 was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of bladder. Review of Resident #66's care plan revealed a plan of care updated on 05/20/24 for an indwelling urinary catheter related to neurogenic bladder. The goal of care included Resident #66 will be free from catheter related complications with interventions to include monitor for discomfort, blood in the urine, cloudy urine, foul smelling urine, and change in mental status, administer peri care (cleaning of genital areas) per protocol, maintain urinary drainage bag below the bladder level, and monitor peri-area for redness, irritation and skin excoriation/breakdown. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #66 was cognitively intact. He was dependent with one staff physical assistance for bed mobility and activities of daily living (ADL) with impairment to both upper and lower extremities. Resident #66 had an indwelling urinary catheter and was always incontinent of bowel. Resident #66 had an unstageable pressure ulcer. A physician's order written on 12/03/24 revealed indwelling urinary catheter to drainage related to neurogenic bladder. a. An observation of wound care for Resident #66 was conducted on 02/05/25 at 9:30 AM with the Wound Treatment Nurse. Resident #66 was noted to have an indwelling urinary catheter inserted with a urinary drainage bag hanging below his bladder on the right side of the bed with approximately 400 milliliters of urine in the drainage bag. The tubing was not kinked and the stat lock (a device that secures a catheter in place to prevent movement and accidental removal) was in place on resident's right upper thigh. Prior to starting the wound treatment, the Wound Treatment Nurse removed the catheter from the lower right side of the bed and placed it on top of the resident's bed by the resident's feet. The indwelling catheter was level with the resident's bladder during the sacral pressure ulcer dressing change while Resident #66 was lying on his right side. Resident #66 was awake and alert and had no complaints of pain or discomfort. An interview was conducted with the Wound Treatment Nurse on 02/05/25 at 10:05 AM. The Wound Treatment Nurse stated she placed the catheter drainage bag on top of the resident's bed by the resident's feet to prevent it from kinking or twisting. The Wound Treatment Nurse stated the resident was lying on his right side and the catheter drainage bag was on his right side so she should have left the drainage bag positioned lower than his bladder while she was doing the dressing change since it was not kinked or at risk for getting occluded. An interview with the Director of Nursing (DON) on 02/07/25 at 5:00 PM was conducted. The DON stated the Wound Treatment Nurse should not have placed the catheter drainage bag on the bed while doing the pressure ulcer treatment and the catheter drainage bag should always be positioned below the bladder to prevent the urine from back flowing into the bladder which could potentially cause an infection. A phone interview with the Medical Director on 02/10/25 at 4:35 PM revealed there was no reason to put the urinary drainage bag on the bed and the drainage bag should always be lower than the bladder to prevent the back flow of urine into the bladder and prevent the risk of infection. b. An observation of catheter care was conducted with Nurse Aide (NA) #3 for Resident #66 on 02/05/25 at 10:15 AM. NA #3 proceeded to the bathroom and was noted to turn on the hot water valve to wet a wash cloth. NA #3 did not apply any soap to the wash cloth. NA #3 proceeded to take down Resident #66's brief and with one end of the wash cloth she started below the catheter tubing where it exited the urethra (tube that connects the urinary bladder to the urinary meatus) and pulled the wash cloth downwards, she then turned the wash cloth around to a clean area on the cloth and, again, started below the catheter tubing where it exited the urethra and pulled the wash cloth downwards and then she did it a third time with another end of the same cloth starting, again, below the catheter tubing where it exited the urethra. NA #3 did not pull back the urethral meatus (the opening of the urethra through which urine exits the body) and clean around the penis at any time. An interview was conducted with NA #3 on 02/05/25 at 10:20 AM. She reported she was trained on how to clean the catheter and she should have used warm soapy water and pulled back the meatus and thoroughly cleaned the penis. Furthermore, she stated she should have cleansed the entire tubing and should not have started below the insertion site, but at the insertion site. NA #3 stated she did not know why she did not clean the catheter as she was taught. An interview was conducted with the Director of Nursing (DON) on 02/07/25 at 5:00 PM. The DON stated NA #3 had been provided in service and education upon hire and yearly in the facility's skills fair on the proper way to clean a male residents' catheter. The DON provided the catheter care protocol that the facility used and per the instruction, NA #3 should have pulled the urethral meatus back and cleansed the area with warm soapy water and she should have cleansed the entire tubing from insertion site downward with a warm soapy cloth when she was cleaning the tubing. The DON stated cleansing the tubing and the urethral meatus helps prevent the resident from a potential infection. A phone interview with the Medical Director on 02/10/25 at 4:35 PM revealed she would have expected the nursing staff to be aware of the proper way to provide catheter care in order to prevent infection.

Based on observations, record review, and staff, Consulting Pharmacist, Psychiatric Physician Assistant, and the Medical Director interviews the facility failed to ensure an antianxiety medication was available from the pharmacy to administer as ordered by the physician resulting in 3 missed doses for 1 of 5 residents (Resident #53) reviewed for medication administration. Findings included: Resident #53 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder. A physician order was written on 04/30/24 for Lorazepam (medication to treat anxiety) 0.5 milligrams (mg) three times a day for anxiety disorder. A progress note written on 01/10/25 by Nurse #4 revealed Resident #53 missed dose of Lorazepam due to medication being out. The note stated the Physician and Responsible Party were aware and that Nurse #4 spoke with the pharmacy and they stated they would send the medication out tonight (01/10/25). Review of the medication administration record (MAR) revealed on 01/10/25 Resident #53 was not given her 8:00 AM dose, 2:00 PM dose and 8:00 PM dose of Lorazepam 0.5 mg as evidenced by the nursing initials by Nurse #4 and Nurse #13 being in parenthesis. Review of the facility's automated medication dispensing machine inventory log on 01/10/25 revealed Lorazepam 0.5 mg was listed as a medication to be available. The inventory log revealed that the amount to be available for use was 8 tablets, but the quantity on hand was recorded as 0. An interview with Nurse #4 on 02/05/25 at 3:20 PM revealed she worked on 01/10/25 and did not administer the prescribed Lorazepam to Resident #53 at 8:00 AM and 2:00 PM because the facility ran out of the medication. She stated she documented on the MAR it was not administered by putting parentheses around her initials. Nurse #4 stated Nurse #6 (nurse who worked on 01/09/25 from 7:00 PM - 7:00 AM) reported to her the morning of 01/10/25 that she notified Nurse Practitioner (NP) #1 that Resident #53 ran out of the Lorazepam and Nurse #6 told NP #1 he needed to do an escript to get it refilled. Nurse #4 stated she looked in the automated medication dispenser to see if there was any Lorazepam 0.5 mg tablets and there were none. Nurse #4 stated she notified the pharmacy that Resident #53 was out of Lorazepam and the pharmacy reported they had received the escript and were filling the order. Nurse #4 stated the pharmacy informed her that it would be delivered on the truck that went out that evening (01/10/25). Nurse #4 stated she passed on in report to the oncoming nurse (Nurse #13) that Resident #53 did not have any more Lorazepam 0.5 mg tablets and that the medication was being delivered sometime that evening. Nurse #4 stated the nurse on the medication carts were responsible for making sure Resident #53 had enough Lorazepam to be administered to ensure she did not run out of her medication. Nurse #4 stated the medication should have been reordered when the dispensing card indicated the medication was running low to prevent from running out of the medication. An interview was conducted with the Evening Supervisor Nurse on 02/05/25 at 3:30 PM. The Evening Supervisor Nurse stated the usual process for ordering controlled medications was that on Thursday or Friday before the weekend she would go through the medication carts to see which residents were due for a refill. She stated she would make a list and give it to NP #1 for him to write an escript and forward to the pharmacy. She stated the week of 01/10/25 she was out sick and she did not get the list for the NP. She stated although she did not get this list, it was ultimately up to the floor nurses to check their medications carts to see if they needed any refills of the controlled medications and to provide that list to the NP. An interview was conducted with the Psychiatric Physician Assistant (PA) via phone on 02/05/25 at 11:52 AM. The PA stated if the Lorazepam 0.5 mg was not available in the automated medication dispenser he would have expected the nurse to let him or the provider know what was available. At this time, the PA was made aware that Alprazolam 0.5 mg and Lorazepam IM 2mg/2ml were available in the automated medication dispenser. The PA stated if he were notified on 01/10/25 that the facility ran out of the Lorazepam, he would have modified the order and had the nurse administer Alprazolam at a lower dose since it was a stronger medication until her Lorazepam arrived to the facility. An interview was attempted via phone to Nurse #6 on 02/10/25 at 3:30 PM. Left message for returned call. Nurse #6 returned the call on 02/13/25 at 12:57 PM. An interview with Nurse #6 revealed on the night of 01/09/25 she administered the last dose of Lorazepam to Resident #53. She stated she notified NP #1 to do an escript because she had administered the last dose. Nurse #6 reported that the nurse on the medication cart was responsible for ensuring that there was enough of the medication on hand to be administered before the resident would need a refill. Nurse #6 stated she would check her cart on Thursdays and if the count of the medication was down to enough to administer for 4 days she would request an escript to be sent. Nurse #6 stated she did not know how it got overlooked for this medication not to be reordered. Nurse #6 stated usually there was Lorazepam 0.5 mg tablets in the automated medication dispenser, but if there were none available, she would check to see what other medications were available and could be considered to treat anxiety and get an order from the Physician to administer another medication until her medication arrived from pharmacy. An interview was conducted with the Pharmacy Manager via phone on 02/07/25 at 3:42 PM. The Pharmacy Manager stated she received an escript on 01/09/25 and the Lorazepam 0.5 mg tablets were sent out for delivery on 01/10/25 at 10:00 PM. The Pharmacy Manager stated if the medication was sent out for delivery from the pharmacy at 10:00 PM it was likely that it would not arrive to the facility until after midnight on 01/11/25. The Pharmacy Manager stated it can take up to 2 days to have the medication ready to be delivered and the facility should consider the time it takes to get medications delivered when refilling the prescription so they do not run out of the medication to be given. An interview was conducted with Nurse Practitioner (NP) #1 on 02/07/25 at 2:39 PM. NP #1 stated the nurses usually would give him a list of what prescriptions they needed refilled and then he would write an escript and send it to the pharmacy. NP #1 stated he did not recall giving any other orders when the nurse notified him that the Resident was out of her Lorazepam. An interview was conducted with the Director of Nursing (DON) on 02/07/25 at 5:15 PM. The DON reported she expected her nursing staff to be mindful of when controlled medications needed to be refilled and request an escript sooner than later so that residents do not go without their medication due to waiting for deliveries. The DON added each medication administration card has a color coded blue reorder line and nurses should be ordering before or at the line. The DON stated that there were other options in the automated medication dispenser Nurse #4 could have considered to get an order for to include Alprazolam and IM Lorazepam. The DON stated she would have expected Nurse #4 to let the provider be aware of what else was available in the automated medication dispenser to see if something else could have been ordered and administered. An interview was conducted with the Medical Director via phone on 01/10/25 at 4:30 PM. The Medical Director stated she was concerned that the facility was running out of medications and this was a reoccurring event and that controlled medications were not being filled in a timely manner.

Based on record review and Nurse Practitioner (NP), Medical Director, Consulting Pharmacist, Pyschiatric Physician Assistant, and staff interviews, the facility failed to prevent significant medication errors for 2 of 6 residents (Resident #241 and Resident #53) whose medications were reviewed. Nurse #12 administered medications to Resident #241 that were prescribed for Resident #295. The medications included amlodipine (used to treat blood pressure)/ valsartan (used to treat blood pressure), carvedilol (beta blocker used to treat blood pressure), duloxetine (used to treat depression), gabapentin (used to treat pain), memantine (used to treat dementia) and roflumilast (used to treat inflammation in chronic obstructive pulmonary disease). Resident #241 had no significant adverse effects as a result of the error. Additionally, the facility failed to administer Resident #53 a physician ordered antianxiety medication resulting in 3 missed doses. The findings included: 1) Resident #241 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), aphasia (difficulty with speech), and hemiplegia (muscle weakness affecting one side of the body) and hemiparalysis (paralysis on one side of the body). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #241 was severely cognitively impaired. The physician orders for Resident #241 for November 2024 included the following medications scheduled for morning medication pass 7:00 AM to 11:00 AM: -aspirin tablet, delayed release 81 milligrams (mg) 1 tablet by mouth for stroke and peripheral vascular disease. -baclofen 20 mg 1 tablet by mouth for muscle spasms -citalopram 20 mg 1 tablet by mouth for depression -levetiracetam 1000 mg tablet give 1 tablet by mouth for seizures -senna 8.6 mg tablets give 2 tablets for constipation -topiramate 25mg tablet give 1 by mouth for seizures The physician's orders for Resident #241 revealed he was not prescribed any antihypertensives (medications to treat blood pressure). The November 2024 Medication Administration Record (MAR) for Resident #241 revealed he was administered his morning medications by Nurse #12 on 11/18/2024. Resident #295 was admitted to the facility on [DATE]. Resident #295's Medication Administration Record included the following medications scheduled to be administered during the morning medication administration pass: -amlodipine-valsartan tablet 10-320 milligrams (mg) tablet by mouth for hypertension -carvedilol 25 mg tablet by mouth for hypertension -duloxetine capsules 30 mg by mouth for depression -gabapentin 600 mg tablet by mouth for pain -memantine 5 mg tablet by mouth for dementia -roflumilast 500 micrograms (mcg) tablet by mouth -nicotine patch 24 hour; 21mg/24 hour; 1 patch transdermal (to skin) (used to treat nicotine withdrawal). A progress note written by Nursing Supervisor #3 on 11/18/2024 at 12:52 PM, indicated Resident #241 had received the wrong morning medication. Nurse Practitioner (NP) #1 was notified and ordered neuro checks every 2 hours for 24 hours and vital signs every 2 hours for 24 hours. Resident #241's vital signs were recorded as blood pressure 134/65, pulse 47, respirations 18 and oxygen saturation 99%. Resident #241 was not showing any adverse effects from the medication. A telephone interview was completed with Nursing Supervisor #3 on 2/4/2025 at 4:28 PM. Nursing Supervisor #3 stated that the medication error occurred while Nurse #7 was orientating Nurse #12. She further stated that Nurse #7 had prepared the medications for Resident #295 and then had to go to the medication storage room to retrieve a nicotine patch. The Nursing Supervisor indicated Nurse #7 instructed Nurse #12 to administer the medications to Resident #295's room number, but instead, she administered them to Resident #241 in the next room. Nursing Supervisor #3 stated they immediately informed NP #1, and he came and assessed Resident #241, and the nurses monitored him closely. She further stated she no longer worked at the facility and could not remember the medications he received. An Event Report completed by Nursing Supervisor #3 for a Medication Error dated 11/18/2024 at 11:00 AM read in the description of error that Resident #241 was given Resident #295's morning medications. A review of the neuro checks and vital signs performed by the nurses for Resident #241 following the medication error on 11/18/24 were within normal limits. A telephone interview was completed with Nurse #7 on 2/5/2025 at 8:16 AM. Nurse #7 stated that on 11/18/2024 she was orienting Nurse #12 during the morning medication pass. She further stated that Nurse #12 had been in orientation for a couple of weeks. Nurse #7 indicated that she prepared the medications for Resident #295 and then realized she needed a nicotine patch from the medication storage room. She further indicated that Nurse #12 was standing right beside her when she was preparing the medications and thought she knew which resident they belonged to. She stated she instructed Nurse #12 to take the medications to Resident #295's room, but instead she went into the room next to it and administered them to Resident #241. Nurse #7 further stated that they had reported the incident immediately to Supervisor #3 and NP #1 and monitored Resident #241 closely. She indicated that since she was the nurse who prepared the medications, she should have administered the medications, and she should not have let a nurse in orientation go by herself to administer medications. Nurse #7 stated that Resident #241 was administered his morning medications on 11/18/2024. A telephone interview was completed with Nurse #12 on 2/5/2025 at 10:57 AM. Nurse #12 stated that she was in orientation at the facility on 11/18/2024 with Nurse #7. She further stated that Nurse #7 was in a hurry when she was preparing the medications, and she told her to take the medications to the wrong room number. Nurse #12 stated she could not remember the room number or the medications. She further stated that the resident was fine and had not suffered any ill effects from the medication. Nurse #12 indicated that she could understand Nurse #7 and there was no communication problem between them. She further indicated that she should not have administered the medications because she was not the nurse that prepared them. A progress note written by NP #1 on 11/18/2024 read in part that Resident #241 was being seen for a medication error that just occurred. It further read that Resident #241 received the wrong medications including amlodipine, valsartan, carvedilol, duloxetine, gabapentin, and roflumilast. NP #1 documented that Resident's #241's heart rate did dip into the high 40's (normal 60-100) and his blood pressure was 108/54 (normal 120/80) . The plan indicated that the nursing staff was to monitor the resident's vital signs and neuro checks every 2 hours for 24 hours, and there were no adverse effects at the time. The vital signs for Resident #241 were listed as blood pressure 123/58, pulse 56, respiratory rate 18 breaths per minute, and oxygen saturation 96%. An interview was completed with NP #1 on 2/5/2025 at 9:50 AM. NP #1stated that Resident #241 was given the wrong medication by a nurse that was in training. He further stated that Resident #241 received a couple of blood pressure medications, and this was concerning because he was not on any antihypertensive medications. NP #1 indicated he was immediately made aware of the situation and he went and assessed Resident #241 for any blood pressure changes, syncope (fainting), dizziness, or any mental status changes. He further indicated he was concerned about orthostatic changes (drop in blood pressure when going from sitting to standing position) and didn't want him to have a fall. NP #1 stated that if something was going to happen it would happen in the first 6-8 hours. He further stated he had ordered the nurses to monitor him closely and obtain his vital signs every 2 hours and neuro checks every 2 hours for 24 hours. NP #1 stated that Resident #241 did not have any lasting effect from the medications, just a temporary decrease in heart rate and blood pressure that had not warranted further treatment. A telephone interview was conducted with the Consulting Pharmacist on 2/7/2025 at 12:57 PM. The Consulting Pharmacist stated that if someone was administered amlodipine, valsartan, and carvedilol, the biggest concern would be for a drop in the blood pressure. He further stated it could be significant if the blood pressure or pulse dropped too fast and the person had syncope (fainting) episode and the person fell . The Pharmacy Consultant indicated that receiving all 3 blood pressure medications at the same time would not cause any lasting long-term effects. He stated as for the duloxetine, gabapentin, and memantine, these medications might make someone feel drowsy, groggy, or sleepy, but no long-term effects. The Consulting Pharmacist further stated that the only common side effect for roflumilast was weight loss, and one dose would not cause any effects, and neither would the vitamins. An interview was completed with the Medical Director on 2/7/2025 at 4:26 PM. The Medical Director stated the biggest concern with the medications that Resident #241 received were the blood pressure medications. She further stated that Resident #241 was not receiving any blood pressure medications at that time and receiving 3 blood pressure medications that even at their lowest dosages could lower his blood pressure significantly. The Medical Director indicated the most important thing would be to monitor his vital signs closely for several hours. She further indicated that the other medications he received probably had no effect on him because of his cognitive status. An interview was conducted with the Director of Nursing (DON) on 2/5/2025 at 10:35 AM. The DON stated the medication error involving Resident #241 on 11/18/2024 occurred when Nurse #12, who was in orientation, administered him another resident's medications. She further stated that Nurse #12 was in orientation for about 6 weeks when the incident occurred, and that she was having some difficulty learning the long-term care environment. The DON indicated that Nurse #7 was orientating Nurse #12 during the morning medication administration pass on 11/18/2024. She further indicated that Nurse #7 prepared Resident #295's medications and then realized she needed a nicotine patch from the medication storage room. The DON stated Nurse #7 instructed Nurse #12 to administer the medication to Resident #295's room number, but she went to the room next to it and administered the medications to Resident #241. She further stated the nurses had immediately reported the error to Unit Supervisor #3 and NP #1. The DON indicated NP #1 had assessed Resident #241 and wrote orders to monitor his vitals and perform neuro checks every 2 hours for 24 hours. She indicated that mistakes happen, but fortunately he did not experience any negative effects from the medications. She further stated that Nurse #7 should not have let a nurse in orientation go by themselves to pass medications. An interview was completed with the Administrator on 2/5/2025 at 10:45 AM. The Administrator stated that the medication error that involved Resident #241 was just a mistake and that it was an unfortunate incident that occurred. He further stated that he expected the nurses to give the right medications to the correct resident. 35173 2) Resident #53 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder and depression. A physician order was written on 04/30/24 for Lorazepam (medication to treat anxiety) 0.5 milligrams (mg) three times a day for anxiety disorder. The Minimum Data Set significant change assessment dated [DATE] revealed the resident was moderately cognitively impaired and did not demonstrate behaviors during this assessment. She received antipsychotics, antianxiety, and antidepressant medications. A progress note written on 01/10/25 by Nurse #4 revealed Resident #53 missed dose of Lorazepam due to medication being out. The note stated the Physician and Responsible Party were aware and that Nurse #4 spoke with the pharmacy and they stated they would send the medication out tonight (01/10/25). Review of the medication administration record (MAR) revealed on 01/10/25 Resident #53 was not given her 8:00 AM dose, 2:00 PM dose and 8:00 PM dose of Lorazepam 0.5 mg as evidenced by the nursing initials by Nurse #4 and Nurse #13 being in parenthesis. Review of the facility's automated medication dispensing machine inventory log on 01/10/25 revealed Lorazepam 0.5 mg was listed as a medication to be available. The inventory log revealed that the amount to be available for use was 8 tablets, but the quantity on hand was recorded as 0. The inventory log also revealed that there was a total of 4 vials of Lorazepam 2 milligrams per milliliter (mg/ml) available on hand and 10 tablets of Alprazolam (medication to treat anxiety) 0.5 mg available on hand. Review of nursing progress notes on 01/10/25 and 01/11/25 revealed there was no documentation regarding monitoring Resident #53's behaviors related to not receiving her scheduled Ativan. An interview with Nurse #4 on 02/05/25 at 3:20 PM revealed she worked on 01/10/25 and did not administer the prescribed Lorazepam to Resident #53 at 8:00 AM and 2:00 PM because the facility ran out of the medication. She stated she documented on the MAR it was not administered by putting parentheses around her initials. Nurse #4 stated Nurse #6 (nurse who worked on 01/09/25 from 7:00 PM - 7:00 AM) reported to her the morning of 01/10/25 that she notified Nurse Practitioner (NP) #1 that Resident #53 ran out of the Lorazepam and Nurse #6 told NP #1 he needed to do an escript to get it refilled. Nurse #4 stated she looked in the automated medication dispenser to see if there was any Lorazepam 0.5 mg tablets and there were none. Nurse #4 stated she should have made NP #1 aware that Alprazolam 0.5 mg tablets and Intramuscular Lorazepam 2 mg/ml vials were available in the automated medication dispenser as an alternative antianxiety medication for Resident #53 but she did not think of it. Nurse #4 stated she notified the pharmacy that Resident #53 was out of Lorazepam and the pharmacy reported they had received the escript and were filling the order. Nurse #4 stated the pharmacy informed her that it would be delivered on the truck that went out this evening (01/10/25). Nurse #4 stated she monitored Resident #53 for any signs or symptoms of withdrawal or increased anxiety during her shift from 7:00 AM to 7:00 PM and Resident #53 had no symptoms. Nurse #4 stated she passed on in report to the oncoming nurse (Nurse #13) that Resident #53 did not have any more Lorazepam 0.5 mg tablets and that the medication was being delivered sometime this evening. Nurse #4 stated she reported to the oncoming nurse to monitor for any signs of increased anxiety. Nurse #4 stated the nurse on the medication carts were responsible for making sure Resident #53 had enough Lorazepam to be administered to ensure she did not run out of her medication. Nurse #4 stated the medication should have been reordered when the dispensing card indicated the medication was running low to prevent from running out of the medication. An interview was conducted with the Psychiatric Physician Assistant (PA) via phone on 02/05/25 at 11:52 AM. The PA stated Resident #53 should not go without her Lorazepam; and as a result of missing 3 doses of the Lorazepam, Resident #53 was at risk for Lorazepam withdrawal. The PA stated with missing her prescribed doses for one day the withdrawal effects would be minor and she could have demonstrated increased anxiety. The PA stated he would expect that since Resident #53 had not received the prescribed anti-anxiety medication that she would be monitored for any signs and symptoms of withdrawal. An interview was attempted via phone to Nurse #13 who worked 7:00 PM to 7:00 AM on 01/10/25 into 01/11/25, but she did not return the call. An interview was attempted via phone to Nurse #6 on 02/10/25 at 3:30 PM. Left message for returned call. Nurse #6 returned the call on 02/13/25 at 12:57 PM. An interview with Nurse #6 revealed on the night of 01/09/25 she administered the last dose of Lorazepam to Resident #53. She stated she notified NP #1 to do an escript because she had administered the last dose. Nurse #6 reported that the nurse on the medication cart was responsible for ensuring that there was enough of the medication on hand to be administered before the resident would need a refill. Nurse #6 stated she would check her cart on Thursday and if the count of the medication was down to enough to administer for 4 days she would request an escript to be sent. Nurse #6 stated she did not know how it got overlooked for this medication not to be reordered. Nurse #6 stated usually there was Lorazepam 0.5 mg tablets in the automated medication dispenser, but if there were none available, she would check to see what other medications were available and could be considered to treat anxiety and get an order from the Physician to administer another medication until her medication arrived from pharmacy. An interview was conducted with the Consulting Pharmacist via phone on 02/07/25 at 1:09 PM. The Consulting Pharmacist stated he would be concerned with Resident #53 missing 3 doses of Lorazepam as she could have increased anxiety as a result of withdrawal. He stated he would expect the nursing staff to be monitoring the resident for any adverse effects from not having her Lorazepam. He also stated he would have expected the nursing staff to see what was available in the automated medication dispenser to be administered so there was no delay in the resident receiving her anti-anxiety medication. An interview was conducted with Nurse Practitioner (NP) #1 on 02/07/25 at 2:39 PM. NP #1 stated he did not recall giving any other orders when the nurse notified him that the Resident was out of her Lorazepam, but that he should have let the nurse know that another medication such as Alprazolam, at an equivalent dose, available in the automated medication dispenser could have be given until the Resident #53's medication arrived from pharmacy. NP #1 stated there were other options to consider administering to prevent the resident from having any potential increased anxiety or withdrawals. An interview was conducted with the Medical Director via phone on 01/10/25 at 4:30 PM. The Medical Director stated it was not really concerning to her that Resident #53 missed 3 doses of the Lorazepam. She stated, however, it was concerning that the facility was running out of medications and this was a reoccurring event and that controlled medications were not being filled in a timely manner.

Based on record review, and staff, Responsible Party (RP) and Medical Director interviews, the facility failed to communicate complete resident medical information to the receiving hospital for 1 of 1 resident reviewed for hospitalization (Resident #290). The findings included: Resident #290 was admitted to the facility on [DATE]. An Interact Nursing Home to hospital transfer form dated 1/18/25 was completed by Nursing Supervisor #2 on 1/28/25 at 12:17 PM. The transfer form indicated Resident #290 was a full code, vital signs were as follows: Blood pressure 110/50, respirations 22, temperature 98.0 degrees Fahrenheit, pulse 79 beats per minute and oxygen saturation 92%. The reason for transfer was resident request due to decreased urination. Resident #290's progress notes indicated a nursing progress note dated 1/18/25 at 12:40 PM written by Nursing Supervisor #2 indicated the resident requested to be sent to the hospital because he was unable to eat or urinate. The Nurse Practitioner (NP) was notified. The NP stated that the resident was competent and to send him to the emergency room (ER) if he wanted to. Review of an EMS report dated 1/18/25 revealed EMS arrived on the scene at 2:12 PM and departed from the facility at 2:24 PM. The staff stated Resident #290's chief complaint was he was unable to urinate. Resident #290's progress notes indicated a nursing progress note dated 1/18/25 written by Nursing Supervisor #2 indicated the resident was sent to the hospital for evaluation at 2:20 PM. The Emergency Provider/emergency room Note dated 1/18/25 indicated that when the resident arrived in the emergency room , he was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). The nurse at the facility reported to EMS that the resident's chief complaint was dysuria (difficulty urinating). Triage vital signs at the emergency room were recorded as blood pressure 90/53, pulse 120, respirations 18, temperature 97.5. Laboratory results at the hospital indicated Clostridium Difficile specimen was positive and white blood cell count was 66.0 thousand per microliter, a critically high elevation. Resident #290 was diagnosed with Septic Shock secondary to Clostridium Difficile. An interview was conducted with the Nursing Supervisor #2 on 2/4/25 at 2:30 PM. Nursing Supervisor #2 stated she was familiar with Resident #290 and had worked with him since he was admitted . Nursing Supervisor #2 stated the resident was not eating well, did not have any appetite and seemed very tired. Nursing Supervisor #2 stated on 1/18/25, she was assigned to Resident #290 when he requested to be sent to the hospital. Nursing Supervisor #2 stated she provided the EMS personnel with a copy of the transfer form and a list of the resident's medications. Nursing Supervisor #2 stated she tried to call the hospital to provide the receiving staff with a verbal report regarding resident's condition, but her call was disconnected. Nursing Supervisor #2 stated she had to complete a medication pass and did not call the hospital back to provide the report. An interview was conducted with Resident #290's RP on 2/5/25 at 9:20 AM indicated on the morning of 1/18/25, she received a call from Nursing Supervisor #2 who informed her she thought Resident #290 was anxious and he said he wanted to go to the hospital. The RP stated she arrived at the facility before EMS arrived to transport the resident to the hospital. The RP stated that Nursing Supervisor #2 reported to EMS that Resident #290 was probably just anxious and stated she did not think he was septic. The Nursing Supervisor did not report to EMS that the resident had loose stools. An interview with the Medical Director on 2/7/25 at 4:30 PM revealed she expected that the nurse transferring a resident to the hospital would call the hospital and provide a complete report on the resident's condition and reason for transfer for an appropriate transfer of care. An interview with the Director of Nursing (DON) on 2/7/25 at 4:40 PM revealed she expected the nurses to not only provide EMS with the list of medications and transfer form but also to call the hospital and provide a complete report when transferring a resident to the hospital. The DON stated the nurses were aware that this was her expectation and she did not know that Nursing Supervisor #2 had not done so.

Based on observations, record review, staff and Physician interviews, the facility failed to administer eye drops as prescribed to a resident (Resident # 35) resulting in 9 extra doses of an eye drop that was prescribed for post cataract surgery care. The deficient practice was found for 1 of 5 residents reviewed for unnecessary medications. Findings included: Resident #35 was admitted to the facility on [DATE] with diagnosis which included in part: cataract, stroke, macular degeneration, and glaucoma. Resident #35's 11/25/23 annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact, had adequate vision. A physician order dated 11/26/23 for Easy Cataract eye drops twice per day, apply one drop to the left eye was entered into Resident #35's electronic health record. Review of a post operative progress note dated 12/7/23 written by the eye care provider indicated to change Resident #35's order for Easy Cataract eye drops one time per day every other day to the left eye. The order was entered into the electronic Medication Administration Record (MAR) for Resident #35 for Easy Cataracts drops for 1 drop in left eye every other day once per day for cataract disease. The order was entered by Nurse #1. Medication pass observation was made on 12/13/23 at 9:30 AM with Medication Aide #1 as she administered medication to Resident #35. Interview with Medication Aide #1 on 12/13/23 at 9:30 AM revealed Resident #35 had an entry for Easy Cataract eye drops to be administered every other day at 8:30 AM and twice per day at 9:30 AM and 9:30 PM. Med Aide #1 did not know why there were 2 entries for the eye drops but stated she administered them as written. Medication Aide #1 stated she had administered Resident #35's Easy Cataract eye drops every day as written on the electronic MAR. During a medication pass reconciliation, a review of the December 2023 Medication Administration Record (MAR) revealed an entry for Easy Cataract eye drops one time a day every other day for cataract disease at 8:30 AM was started on 12/9/23. The December MAR indicated Resident #35 had the following entries completed for Easy Cataract eye drops: on 12/9/23 at 8:30 AM, 9:30 AM and 9:30 PM (2 extra doses administered), on 12/10/23 at 9:30 AM and 9:30 PM (2 extra doses administered), on 12/11/23 at 8:30 AM, 9:30 AM and 9:30 PM (2 extra doses administered),on 12/12/23 at 9:30 AM and 9:30 PM (2 extra doses administered), and 12/13/23 at 8:30 AM and 9:30 AM (1 extra dose administered). The duplicate order on the electronic MAR resulted in 9 extra doses administered from 12/9/23 through 12/13/23. Interview with Nurse #1 on 12/13/23 at 11:30 AM revealed she entered the new order into the electronic health record for Easy Cataract eye drops on time per day every other day per the physician order on 12/7/23. Nurse #1 stated the previous order for Easy Cataract eye drops twice per day daily should have ended when the new order was started. Nurse #1 stated she thought the previous order would drop off the MAR when the new order was entered and did not realize she needed to discontinue the old order. Interview on 12/13/23 at 1:25 PM with the Physician revealed not providing the medication according to the physician order was a medication error and had the potential for adverse effects. An interview on 12/13/23 at 9:50 AM with the Director of Nursing (DON) revealed she expected that residents received the correct dose of medications and that physician orders were followed as written. The DON stated that when new orders were transcribed in the electronic health record, the previous order was to be discontinued.

Based on observations, record review, staff, Psychiatric Social Worker, Nurse Practitioner, Medical Director, and Psychiatric Physician's Assistant interviews the facility failed to protect a resident's right to be free from mental abuse by a visitor when the visitor was found to have posted a video recording of a cognitively impaired resident that included a caption with a demeaning comment, and the visitor was heard on the video mocking and ridiculing the resident while the resident was lying in bed and exhibiting behaviors of yelling out. This occurred to 1 of 1 Resident (Resident #1) reviewed for visitor to resident abuse. The video was posted on two social media platforms. This action would have caused a reasonable person psychosocial harm such as feelings of shame, humiliation, agitation, and degradation. Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part; vascular dementia with mood disturbance and cerebral vascular accident (CVA). A care plan dated 06/12/23 revealed Resident #1 had severely impaired cognition and received antianxiety medication due to agitation. The goal of care included Resident #1's cognitive deficits would not infringe on their rights or the rights of others. Interventions included to administer medications as ordered and to be patient with the resident. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive two-person assistance with activities of daily living (ADLs). He received antianxiety and antidepressant medications. A progress note dated 10/06/23 at 1:06 PM documented by the Director of Nursing (DON) revealed; this morning the facility was notified that another residents family videoed Resident #1 in his room yelling out and posted it to social media. Immediate interventions included Resident #1 was monitored and had no adverse effects noted regarding the incident. No new skin impairments were noted. His vital signs were stable. He was responsive, pleasant, and cooperative. He had full range of motion to all extremities. Neurological checks were within normal limits. He had no complaints of pain. His skin tone was normal, warm, and dry. His respirations were unlabored. His heart rate was within normal limits. Resident #1's Responsible Party (RP) was notified of the occurrence. Resident #1 had no signs or symptoms of anxiety or depression. Resident #1 was unable to state that he had visitors. Resident was pleasant and smiling when speaking. The Nurse Practitioner (#1) was made aware, with no new orders given. A Social Services note dated 10/06/23 at 2:33 PM documented by Social Worker #1 revealed; Today I went to visit with Resident #1 to ensure he had no concerns of distress following a reported incident. He was sleeping peacefully, while his (RP) was at his bedside. An Interdisciplinary Team (IDT) meeting note dated 10/10/23 at 1:28 PM revealed Resident #1 was being monitored for negative outcomes related to a recent incident involving individuals visiting the facility. No negative outcomes had been noted at this time, but we will continue to monitor. The attendees included the Administrator, DON, unit managers, AIT (Administrator in Training) , and Dietary Manager. A progress note dated 10/10/23 at 5:00 PM documented by the Unit Manager revealed; during the weekly review, the team discussed Resident's #1's alleged abuse. This resident's mood and affect were pleasant and cooperative. He was involved in activities and participated daily. He was yelling less frequently and was easily redirected once his needs were met. A progress note dated 10/12/23 documented by Nurse Practitioner #1 revealed Resident #1 was lying in bed, he was in no acute distress, and he was inattentive during the exam. His eyes opened spontaneously, and he was not willing to answer questions. He had baseline dementia though he was able to make his needs known. His mood was stable, and he was followed by Psychiatric Services. The plan of care included in part to continue antidepressant medications. An encounter note dated 10/24/23 at 11:00 PM documented by Nurse Practitioner #1 revealed in part; staff reported Resident #1 was screaming and calling out last night with altered mental status, and disturbing other residents as they slept. In September he was getting as needed Ativan (antianxiety medication) however it was then changed to scheduled dosing twice a day. He also currently had an active UTI (urinary tract infection) which had affected his mentation. Generally, he is resting in bed with his eyes closed during the day. I discussed with staff the impact of his altered circadian rhythm and his sleep wake cycle as he was sleeping all day, he will then be awake and more active during the night. The plan of care included in part; Trazadone (hypnotic) 50 milligrams as needed for insomnia at bedtime and continue scheduled Ativan. An observation was conducted of Resident #1 on 11/01/23 at 1:00 PM. Resident #1 was observed lying in bed with his eyes closed. He was in no distress. During an interview on 11/01/23 at 1:45 PM the DON stated a staff member (#1) notified her on the morning of 10/06/23 that she saw a video posted on social media of Resident #1. She stated the video was made by another residents family member (Visitor #1) who posted it to social media on the evening of 10/05/23. She stated the video showed Resident #1 lying in bed yelling out and being taunted by Visitor #1. She stated a second person, Visitor #2, was also heard saying something about going down to say something to Resident #1 if he did not stop yelling. She stated Visitor #1 recorded from the doorway of Resident #1's room, as he was in the bed closest to the door. She stated Resident #1 was recorded fully clothed but yelling out. She stated Visitor #1 was heard on the video saying, why are yelling, and you're disturbing my babies. The Administrator, the Police, and Resident #1's RP were notified. She stated the Administrator called Visitor #1 on 10/06/23, and she stated she didn't see anything wrong with what she did and stated she would apologize to the resident. The Administrator informed her that she would not be allowed to have any contact with Resident #1. They informed her that she or Visitor #2 could no longer visit without supervision from the facility Social Worker or the family members legal guardian Adult Protective Services (APS). She stated APS was made aware of this incident and agreed with this plan. She indicated staff members were also aware that if Visitor #1 or Visitor #2 were observed in the facility unsupervised they were to immediately notify a manger, the DON, or the Administrator. She stated the Police Officer informed them that it was not a criminal matter. She stated Visitor #1 or Visitor #2 had not been to the facility since the incident occurred. The DON stated Resident #1 had severe dementia and didn't know that this had occurred, and stated due to his severe cognitive impairment he would not be able to recall this incident. He had behaviors such as yelling out which escalated in the evenings. She stated these behaviors occurred prior to this incident and continued to occur, and he received Ativan scheduled twice a day for these behaviors. She stated she started an investigation on 10/06/23 which included resident assessments for safety, skin assessments, and staff interviews. In-service training was initiated on 10/06/23. She stated a sign was posted on the front entrance door stating no video recordings were allowed without permission. She stated audits of residents were being conducted according to their abuse protocol which included skin assessments for signs or symptoms of abuse. The audit included speaking with alert and oriented residents using a questionnaire asking if; any abuse had occurred including verbal, physical, or mental abuse, had they ever witnessed abuse, and what would they do if they did witness abuse. She stated the audits were ongoing 3 times a week over the next 4 weeks. She stated they informed Visitor #1 to remove the post from social media and stated as far as she knew it had been removed. She stated she saved a recording of the social media post to have for the investigation. An observation was made of the social media post of Resident #1 by the surveyor along with the DON. The caption read; This explicative is so funny!! Then it showed Resident #1 lying in bed, yelling out. Resident #1 was fully clothed. Visitor #1 was heard laughing at Resident #1 and taunting him saying you want to get up, you can get up, and you're disturbing my babies, and she continued to laugh at him. Visitor #2 was not heard on the video recording. During an interview on 11/01/23 at 2:00 PM the Medical Director stated Resident #1 was a [AGE] year-old resident who was admitted [DATE] with vascular dementia and CVA and had severely impaired cognition. He stated his last evaluation was done on 09/20/23 before the incident. He stated the Nurse Practitioner (#1) had evaluated him since the incident on 10/05/23. He stated he was not aware of the incident, but he had not had any staff member report any change in his behaviors to him since that time. He stated Resident #1 had behaviors of yelling out prior to and since this incident and was followed by Psychiatric services. He stated having a video recorded and then posted to social media was an invasion of the residents privacy, and stated it was a demeaning act that was carried out by the visitor. He indicated a reasonable person would not want to be recorded and posted on social media. He indicated a reasonable person would be distraught and humiliated if this were to happen to them. An interview was conducted on 11/01/23 at 3:00 PM with Staff member #1 who viewed the video on social media and reported it to the Administrator and DON. She stated she had worked at the facility for over 5 years and was familiar with Resident #1. She stated on the morning of 10/06/23 she was on social media and came across the video of Resident #1. She stated the video started out with Resident #1 yelling, and then Visitor #2 was heard saying something about he was going to go down and say something to Resident #1 if he didn't stop yelling. Resident #1 continued to yell and was saying he wanted to get up, and Visitor #1 told him he was scaring her babies who were with her visiting. She stated as Resident #1 continued to yell, Visitor #1 put the camera on his face and was laughing at him then it was posted on social media. She stated one of the social media platforms where the video was posted, automatically deleted the video after 24 hours but on the other social media platform the video would continue to be there unless it was removed by the person who posted it. She stated she thought the video had been removed by Visitor #1 after the Administrator called her. She stated she immediately reported it to the Administrator because the content was very inappropriate. She stated following the incident she had received training on abuse and on video recording in the facility, and to immediately report if this was witnessed. During an interview on 11/01/23 at 4:00 PM Nurse Aide #1 stated she was Resident #1's assigned nurse aide on the evening of 10/05/23. She stated she did not witness Visitor #1 or Visitor #2 going to Resident #1's room and recording him on video. She indicated she was made aware of the social media posting the day the Administrator and DON were made aware. She stated she must have been passing dinner trays during that time, which included going onto another hallway to pass trays, and stated it must have occurred when she was on the other hallway. She stated she was aware that Visitor #1 was visiting her family member but never saw Visitor #1 or Visitor #2 until they were leaving the facility which was around dinner time. She stated if she had witnessed the incident, she would have immediately reported it to management. She stated Resident #1 was not oriented and had behaviors such as yelling out even though he would not need anything. She stated he had these behaviors before the incident and continued to have behaviors of yelling out. She stated she had received abuse training since the incident. A phone interview was conducted on 11/01/23 at 5:30 PM with the Psychiatric Social Worker who provided social services to Resident #1. She indicated she was not aware of the incident regarding Resident #1. She stated her initial visit with Resident #1 was on 08/09/23 and the most recent visit was on 10/22/23. She stated when she first met him on 08/09/23 he had a history of anxiety, depression, tearfulness, and insomnia. She stated on her last visit he was depressed, and she noted he had a hard time getting comfortable. She stated Resident #1 had severe cognitive impairment and he did not mention anything to her about being recorded or being unsafe in the facility. She stated she didn't think that Resident #1 would be aware of the incident happening or have any knowledge of social media and the repercussions of having a video posted. She stated due to his cognitive impairment Resident #1 would not be able to express his feelings or give a discernable response regarding being exposed on social media. She indicated having a video of him lying in bed yelling out would be demeaning and a reasonable person would be humiliated, and it could cause a person to have psychosocial harm if that happened to them. During an interview on 11/02/23 at 2:00 PM Nurse Practitioner #1 stated she was made aware of the incident regarding Resident #1. She stated Resident #1 had severe dementia and had behaviors of yelling out before and after the incident. She stated due to his age, and dementia, he would not be aware of the video and would not be aware of any implication of having the video posted on social media. She stated on her last evaluation on 10/30/23 Resident #1 was calm, and not in distress and appeared to be at baseline. She stated Resident #1 had sundowning at night but no change in behaviors that had been reported to her. She stated he received antianxiety medication which was scheduled for administration twice a day. She stated no reasonable person would want a video of them in a nursing facility posted on social media. She indicated this could cause a person to experience psychosocial harm. During an interview on 11/02/23 at 2:30 PM Nurse #1 stated he was the assigned nurse to Resident #1 on 10/05/23, the evening the incident occurred. He stated around 5:30- 6:00 PM Visitor #1 along with a male friend (Visitor #2) came in to visit with Visitor #1's family member. He stated Resident #1 had dementia with behaviors and yelled out, but he would calm with interventions from staff. He stated the nurse aides had been down a couple of times to calm Resident #1 but that evening he continued to yell out. He stated he never saw Visitor #1 or Visitor #2 go down to Resident #1's room and didn't see them until they were leaving the facility around 7:00 PM. He stated if he had witnessed her videoing Resident #1, he would have stopped it and would have informed her that it was inappropriate. He stated soon after at 7:00 PM a nurse aid who Resident #1 responded very well to came in for her shift and Resident #1 did calm down when she went in with him. He stated he routinely provided care to Resident #1 and the behaviors of yelling out occurred prior to the incident and he continued to have these behaviors primarily in the evenings and during the night. He stated Resident #1 had increased agitation at times before and following the incident and received scheduled anti-anxiety medication twice a day. He stated he had never witnessed Visitor #1 or Visitor #2 being inappropriate or saying anything to other residents before this incident. He stated he had received abuse training and training on video recordings since the incident. During an interview on 11/02/23 at 3:00 PM Nurse Aide #2 stated she was assigned to part of Resident #1's hall that evening but she was not his assigned nurse aide. She stated she was shocked at the video, and she was not aware that evening that a video had been made. She stated she and Nurse Aide #1 must have been passing trays on another hall during that time because she never saw Visitor #1 or Visitor #2 go down to Resident #1's room. She stated she saw the video after being told by staff the next day. She stated Visitor #1 didn't really visit often as far as she was aware but stated she could be loud at times when she did visit. She stated she had never witnessed Visitor #1 or Visitor #2 being inappropriate or saying anything to other residents. She stated she did receive abuse training since the incident. During an interview on 11/02/23 at 3:30 PM with the Unit Manager she stated she had never been at the facility when Visitor #1or Visitor #2 were there. She stated she was not aware of any concerns regarding Visitor #1 or Visitor #2 prior to this incident. She stated Resident #1 had dementia, with longtime behaviors, and was followed by Psychiatric Services. She stated there had been no change in Resident #1's behaviors, and stated he yelled out before the incident and still continued to do so. She stated Visitor #1 or Visitor #2 had not returned to the facility since the incident, but future visits would be supervised. She stated staff education was provided by the DON regarding not videoing a resident, whether visitor or staff. She stated weekly audits were ongoing. An interview was conducted on 11/02/23 at 6:00 PM with the Administrator along with the DON. The Administrator stated he was disturbed by the incident and immediately called Visitor #1 on 10/06/23 when he was made aware. He stated Visitor #1 didn't think it was wrong to record another resident in the facility. He stated he informed her that it was not appropriate and to remove the video from social media. He also informed Visitor #1 that future visits to the facility would be supervised. He stated a full investigation was completed and the police were notified. He stated a police officer came to the facility to investigate but stated it was a civil matter and not a criminal matter. He stated Resident #1's RP was notified along with APS and the State Agency. A phone interview was conducted on 11/06/23 at 10:45 AM with the Psychiatric Physician's Assistant. She stated she was the Psychiatric provider for Resident #1. She stated she was not aware of the incident regarding the video recording. She stated Resident #1 had severe dementia with behaviors and had no concept of reality and would not have any concept of this incident. She stated Resident #1 was actively delusional and yelling out which was a behavior prior to this incident and the behaviors continued to occur. She stated she evaluated him last on 10/17/23 and his mood was stable. She stated a reasonable person would experience psychosocial harm and would be extremely distraught and humiliated if this were to occur to them. Further observations were made during the investigation of Resident #1. He was observed each time lying in bed with his eyes closed. He was in no distress. He would arouse to his name but could not participate in meaningful conversation. Alert and oriented residents were interviewed during the investigation, and each stated they felt safe in the facility and had no concerns with visitors coming into the facility. Attempts were made to contact Resident #1's RP during the investigation. There was no response. The corrective action for the noncompliance dated 10/06/23 was as follows: On 10/06/23 at 9:00 AM the DON was notified by a staff member that they observed Resident #1 on social media being recorded by Visitor #1. The recording was made the night before (10/05/23) around dinner time of him in his room. He was recorded on video yelling out with Visitor #1 laughing at him. On 10/06/23 at 10:00 AM the DON and Administrator were notified that Visitor #1 posted the video on a 2nd social media platform. The facility was also notified that Visitor #2 stated he was going to go down to Resident #1's room if he did not stop yelling. On 10/06/23 at 10:30 AM the State Agency was notified. On 10/06/23 at 10:45 AM Resident #1's Responsible Party was notified. On 10/06/23 at 11:00 AM the Police were notified. On 10/06/23 at 12:00 PM staff who worked the evening of 10/05/23 were interviewed. Staff interviews revealed Resident #1 was heard yelling out and staff provided assistance to calm him. Each staff member interviewed stated they knew Visitor #1 was in the facility to visit her family member, but no staff observed her going in any other residents room. On 10/06/23 at 1:00 PM the Social Worker visited with Resident #1, he was pleasant and cooperative. He was unaware of the recording that occurred on 10/05/23 due to his advanced dementia. Resident #1 stated he felt safe. On 10/06/23 at 2:00 PM the Administrator spoke with Visitor #1 and requested the video to be removed from social media sites. Visitor #1 was informed that recording a resident was not allowed and future visits would need to be supervised with the facility Social Worker or with the APS representative. Visitor #1 verbally agreed to this arrangement. On 10/06/23 at 3:30 PM the Administrator and DON met with Resident #1's RP. Signs were placed on entrance doors of the facility to remind visitors that residents could not be recorded on video without consent. On 10/06/23 alert and oriented residents were interviewed regarding abuse, skin assessments were conducted of cognitively impaired residents. Audits of residents were conducted according to the abuse protocol which included body audits/skin assessments for signs or symptoms of abuse. The audit included speaking with alert and oriented residents using a questionnaire asking if; any abuse had occurred including verbal, physical, or mental abuse, had they ever witnessed abuse, and what would they do if they witnessed abuse. No concerns were identified. On 10/06/23 in-service training was initiated for all staff. The training included in part; the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents. Facility staff must immediately report all such allegations to the Administrator. Investigations would begin immediately. The facility would not tolerate exploitation of a resident which included abuse that was facilitated or caused by taking or using photographs or audio-visual recordings in any manner that would demean or humiliate a resident. Education was provided on what actions to take if this was observed by staff. All staff would be required to complete training prior to their next shift. On 10/06/23 staff had been instructed if Visitor #1 or Visitor #2 were in the facility unsupervised, they should immediately notify a manager, the DON, or the Administrator. On 10/10/23 an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held. A risk tool was initiated which included questions about abuse to alert, and oriented residents, and observations of cognitively impaired residents. Monitoring and body audits would be conducted x 12 weeks and reviewed monthly in QAPI meetings x 3 months. On 11/02/23 the DON stated all staff were aware of Visitor #1 and Visitor #2 requiring supervised visits moving forward. She stated staff had been instructed that if they saw Visitor #1 or Visitor #2 in the facility unsupervised, they should immediately notify a manager, the DON, or the Administrator. She indicated supervision would be with the Social Worker, DON, Administrator, or a manger if the Social Worker was not in the facility. She stated Visitor #1 was also informed supervised visits could be conducted with the APS representative as well, and arrangements would need to be made with APS. She stated after completing the investigation it was determined that audits would be conducted for only 4 weeks. She stated audit results would be forwarded to the QAPI committee monthly x 1 month. The QAPI committee will meet and review the results of audits and determine the need for continued monitoring. She stated the next QAPI meeting would be held November 2023. Validation of the corrective action was completed on 11/02/23. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. Interviews were conducted with alert and oriented residents and observations were made of cognitively impaired residents. The audits were verified. There were no concerns identified. The next QAPI meeting was scheduled to be held November 2023 where audit results would be discussed. The facility's alleged compliance with the corrective action plan on 10/07/23 was validated.

Based on record review, observations, resident, staff, and Nurse Practitioner (NP) interviews, and review of the restraint manufacturer's training video, the facility failed to properly secure a resident in her wheelchair during transport in the van by not utilizing the shoulder strap for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #51). During a facility van transport Resident #51's wheelchair fell over to the right resulting in a head contusion and skin lacerations to her right arm, elbow, and pinky finger, this occurred while the transport driver was in heavy traffic and making a left turn. Resident #51 was sent to the emergency room for evaluation and treatment and returned to the facility later in the evening. Findings included: The restraint manufacturer's instructional video for the proper use of the van's safety restraints during transportation was reviewed on 9/1/2022. The video specified that after the wheelchair was secured in the van, the van's lap belt strap was to be placed between the wheelchair arm and the resident to secure the resident to the wheelchair. The manufacturer's instructions further specified to make sure that the van's shoulder strap was in place once the lap belt was properly placed on the resident. Resident #51 was admitted to the facility on [DATE]. Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and utilized a wheelchair for locomotion on and off the unit. A nursing progress note written on 8/18/2022 by the Director of Nursing (DON) revealed she had received a phone call at 1:47 PM from the Transport Driver that stated Resident #51's wheelchair had tipped over to the right side when she was turning on a curve and Resident #51 had hit her head on the floor, and she had lacerations to right arm, elbow, and pinky finger. The note further indicated when the Transport Driver returned Resident #51 to the facility, she was tearful and stated that it had scared her. The note indicated that Resident #51's vital signs were stable, neurological checks were within normal limits, and she had no complaints of pain. Pressure was applied to laceration to right side of head with scant amount of bleeding noted, skin tears to right arm areas were cleaned and dressings placed. The note further revealed the Nurse Practitioner (NP) was in the facility when the resident returned, and he assessed the resident and sent order to send her to the emergency department (ED) for evaluation and treatment. Resident #51 was not assessed by a licensed professional prior to returning to the facility. A review of the written statement written by the Transport Driver on 8/18/2022 revealed in part, I had to transport Resident #51 to a dermatology appointment. I put resident on our lift to raise up in the van while I was with her. Chair was locked both wheels. I then unlocked her wheelchair wheels and rolled her into position to secure the wheelchair. Her lap belt was secured, and her wheelchair frame was secured with 4 locks to the frame of the chair. 2 locks in front and 2 locks to the rear. Then I checked to make sure her seatbelt wasn't too tight across her stomach. I could put 2 fingers underneath and resident stated it was fine. We then started to the appointment. Construction and traffic were very heavy on Route 57 having to stop 3 times due to heavy traffic and construction. When we got to the stop light to make a left turn, the light turned green and an 18-[NAME] was in front of me, he turned and then I turned right behind him. Then driving straight, I heard a commotion in the back. Resident #51's wheelchair had turned not completely over to the right. I then pulled over immediately and I went back to Resident #51 and her wheelchair was not laying flat on the floor, the arms of the wheelchair didn't touch the floor. I was trying to help her, but the seat belt she had on, and the locks (4) of them that were on the frame of the chair were pulled so tight that I could barely budge them to unlock them to unlock the hooks that were securing her wheelchair by the frame. I finally was able to get the locks unlocked from the frame trying not to let the chair fall completely to the floor, because she was still secured from the lap belt. With all my strength I got the wheelchair back up right. Resident #51 stated her right hand was stinging and I saw she had a little skin tear, then on her right arm I saw some blood and she had a skin tear around the elbow area. After placing the wheelchair with her still in it back up, Resident #51 asked if she was going to her doctor's appointment. I am very upset what took place, but first thing I did was put a band aid on her pinky and right forearm, we then returned to the facility. The Post Fall Huddle Form dated 8/18/2022 revealed the Interdisciplinary Team had determined the root cause of the fall was the shoulder safety strap was not engaged. The emergency department Physician report for Resident #51 dated 8/18/22 at 3:32 PM revealed that after profuse irrigation and exploration the 3-millimeter (mm) x 0.5mm laceration to right arm was repaired with sterile skin adhesive. There was no evidence of nerve, vessel or tendon injury or foreign body. The 0.5mm scalp wound was repaired with Dermabond with good results. Computed Tomography (CT) scan of the brain/head was negative for acute cranial abnormality. Resident #51 was discharged back to the facility. A nursing progress note written by Nurse #9 on 8/18/22 revealed Resident #51 returned to the facility at 6:45 PM with the RP. An interview was conducted with Resident #51 on 9/1/2022 at 3:25 PM. She stated 2 weeks ago while being transported in the facility van, the driver took a sharp turn and she fell over and hit her head on the floor. She indicated her shoulder strap was not on, but her lap belt was on, and the wheelchair was strapped to the floor. Resident #51 further stated she did not drop her stuffed dog and was not leaning over the wheelchair when the incident occurred. Resident #51 stated she went to the hospital, and she had a laceration to the right side of her head and abrasions to right arm, elbow, and pinky finger. An interview was conducted with DON on 9/1/2022 at 6:55 PM, She stated that the only person that drives the transport van at the facility was the Transport Driver. She further stated that when Transport Driver is not working, the facility utilizes the contracted transport service. An interview was conducted with Transport Driver on 9/1/2022 at 7:00 PM. She stated that when the incident occurred, she had been working at the facility for about a month, and that she felt like her training was adequate. She further stated that she had secured the wheelchair to the floor of the van with the 4 retractable locks. She then secured the belt around the waist and checked with her two fingers to ensure it was secure enough. Transport Driver stated she was in a lot of heavy traffic on the road when she finally got through construction. She further stated an 18-[NAME] was in front of her and they were turning left at the stop light. The Transport Driver stated she had made the turn and started to go straight when she heard Resident #51's animated dog (resident's puppy) bark. She stated she did not see the dog; she just heard it. She further stated that when she heard the dog bark, she was no longer making the turn and was driving straight. She stated her first thought was for the resident not to bend over and reach for the dog or climb out of the wheelchair to reach it. She stated she was moving at about 8-9 miles per hour at the time and didn't know what made the wheelchair tip over. She indicated that once she heard the dog she pulled over and went immediately to the back of the van. She stated that Resident #51 was still strapped in her wheelchair with the seatbelt. She further stated that the 2 retractable locks were still secured to the front of the wheelchair and the 2 back ones were also still secured. She indicated that the wheelchair arm was about 5 inches from the floor. She stated she forgot to secure Resident #51 with the shoulder strap, and it was a mistake. The Transport driver stated that she had not asked Resident #51 what happened, she just wanted to get her back upright. She further stated that she had not seen the stuffed dog on the floor. She indicated she had been able get the wheelchair up to position because the wheelchair was not completely down on the floor. She stated that Resident #51 never came out of the wheelchair and seatbelt. She further stated that when she raised the wheelchair up it was still in the same spot it had been in originally, because the retractable locks were still secured. She stated that Resident #51 did not say much, and she wasn't crying. She stated she just kept observing Resident #51 in the mirror and she was not crying or anything. She indicated Resident #51 had a skin tear on her right forearm and some blood on the right side of her head. She stated Resident #51 did not complain of pain or headache, and she was not dizzy. An interview and observation of the Transport Driver securing a wheelchair in the transport van occurred on 9/1/2022 at 7:25 PM. The Transport Driver lowered the lift to the ground and proceeded to load the wheelchair facing forward and locked the brakes. She stated she would ask the resident to hold on to the bars as the lift was raised up into the van. She unlocked the wheelchair brakes and backed the wheelchair into place in the van and locked the brakes. The Transport Driver pulled the retractable locks one at a time from the floor and secured the wheelchair with S hooks to the front frame of the wheelchair. She then went to the back of the wheelchair and applied the retractable locks to the frame of the wheelchair one at a time. The Transport Driver checked all the straps to make sure they were secure and attached properly. She applied the seat belt and put 2 fingers underneath the strap to make sure it wasn't too tight. The Transport Driver applied the shoulder strap and stated that on 8/18/2022 she forgot to secure Resident #51 with the shoulder strap. The Transport Driver then tried to wiggle the wheelchair to see if it would move and it did not move. The Transport Driver stated that when she heard Resident #51's stuffed dog bark, she had looked in the mirror and observed the resident's wheelchair tipped over on the right side. She further stated that she had immediately pulled over in a parking lot and went back to help Resident #51. She indicated that Resident #51's head was laying up against the van lift and the wheelchair was approximately 5 inches off the floor. She stated that she knew she couldn't release the retractable locks because Resident #51 would have fallen hard on the floor. She further indicated that her written statement was wrong because she had not released the retractable locks. She further stated that it had taken all her strength to upright the wheelchair and it went right back into the same place. The Transport Driver stated that she had checked all the retractable locks and they were secure. She further stated that if the shoulder strap had been on Resident #51 the wheelchair would not have tipped over. She indicated that she had been trained that in case of an emergency, she was supposed to call 911, but all she could think of was getting the resident back to the facility as soon as possible. An interview was conducted with the Administrator on 9/1/2022 at 8:06 PM. He stated that he was the person who was responsible for the Transport Driver's training and competencies. The Administrator further stated that he had watched the wheelchair lift video and the video for the retractable locks and safety straps with the Transport Driver. He then stated that the competencies were demonstrated and repeat demonstration by the Transport Driver. He stated that she had performed all the steps correctly. The Administrator indicated that the Transport Driver was trained to engage the shoulder strap when transporting residents in wheelchairs in the van. He stated that he and the Receptionist, and the Medical Records Director, had done ride-a-longs with the Transport Driver, and she had done everything correctly. The Administrator stated that the Transport Driver had driven very safely and obeyed the posted traffic signs. He further stated that the facility had done a background check on her, and her driving record and driver's license was verified and was in good standing. The Administrator indicated the Transport Driver had no tickets or accidents on her record. He stated that he was the first person to enter the van on the day of the incident and he had verified that the retractable locks were secure to the frame of the chair and the seatbelt was on Resident #51, but the shoulder strap was not engaged. He further stated that the ADON had assessed Resident #51's head and applied gauze and the resident was unloaded from the van. He indicated that the Transport Driver stated she had forgotten to apply the shoulder strap. The Administrator stated that the Transport Driver was reeducated that evening and passed her competencies when he retested her on 8/18/2022. The Administrator stated that on 8/18/2022 corrective action was completed with the Transport Driver. He indicated that the facility staff had interviewed the alert and oriented residents on 8/18/2022 that had been transported in the van by the Transport Driver. The Administrator further indicated that all the residents stated they were secured properly in the van, and they felt safe riding with the Transport Driver. He stated that the facility staff had performed skin checks on the residents that were not alert and oriented on 8/18/2022 with no negative findings. He stated that everyone makes mistakes, and he did not think she would forget to utilize the shoulder strap again. The Administrator stated that to monitor for on-going compliance he or his designee were completing the Van/Restraint competency tool for all arrivals and departures: 5 days a week when driver has transportation x 1 month, then 3 days a week x 1 month, then weekly x 1 month. He stated that all findings would be reported to the QAPI team for review and additional follow-up as needed. A telephone interview was conducted with the Director of Nursing (DON) on 9/2/2022 at 10:14 AM. The DON stated that the Transport Driver had called her 8/18/2022 and she was very upset and crying. She further stated that the Transport Driver had told her she was driving the van and going around a curve when Resident #51's wheelchair had tipped over. She stated that the Transport Driver told her the resident was okay, and was alert and oriented, and not complaining of pain. The DON stated that the Transport Driver indicated that she was only about 10 minutes away and she was turning around and bringing the resident back to the facility. She indicated that the first thing she said to the Transport Driver was did you call 911? The DON stated that they unloaded the Resident and brought her into to the facility. She stated that the nurse practitioner (NP) was at the facility, and he assessed Resident #51 and observed that she had hit her head and it was bleeding, he stated to call EMS and send her to the hospital. The DON indicated that while they were waiting for EMS to arrive, she had called the responsible party (RP) and the Assistant Director of Nursing (ADON) treated the skin tears. A telephone interview was conducted with the Administrator's designee for the Restraint competency Audit Tool, the front desk Receptionist, on 9/2/2022 at 10:55 AM. She stated that the Administrator had trained her to check the wheelchair of the resident being transported after they are loaded on the van and before it departed. The Receptionist further stated that she ensured the shoulder strap was correctly applied and the seat belt was secure, then she checked all 4 retractable locks to make sure they were placed securely. She indicated that after she performed the checks, she would try to wiggle the wheelchair to make sure it would not move. She further stated when she was finished with the checks the van was allowed to depart. The Receptionist stated that she watched for the van to return, and then she went out and performed the same checks upon arrival. She further stated that she documented the findings on the Van Restraint Audit sheet, which is a component of the plan of correction (POC). An interview was conducted with the resident (Resident #17) who was riding in the wheelchair in the van in front of Resident #51 on 8/18/2022. She stated that was the first time she had ever been transported in the van. Resident #17 further stated that the Transport Driver had secured her wheelchair with the locks on the floor, secured her seatbelt, and applied the shoulder strap. Resident #17 stated there was a lot of traffic and construction and big vehicles like trucks and buses. The driver was not driving fast at all. She indicated that there was a lot of stop and go traffic. Resident #17 further stated she could not see the resident behind her because she was not able to turn around once she was secured in, but she and Resident #51 were conversing back and forth. She stated she heard a scream behind her, and the Transport Driver pulled over immediately and parked the van and went to help the resident behind her. Resident #17 stated she could not remember exactly what the van was doing at the time of the scream, but she thought they were going straight and not very fast. She added that the Transport Driver had done a very good job maneuvering the van in the heavy traffic and the construction. Resident #17 stated that the Transport Driver was an excellent driver, and she had felt safe in the van. She further stated she would get on the van again with the Transport Driver. A telephone interview was conducted with the NP on 9/2/2022 at 12:47 PM. He stated that when assessed Resident #51 on 8/18/2022 she had a scalp wound to her right parietal lobe and it was bleeding. The NP indicated that he spoke to the facility staff and determined that Resident #51 needed to be sent to the ER for evaluation and treatment. The Administrator was notified of the Immediate Jeopardy on 9/1/2022 at 8:44 PM. The facility submitted the following Plan of Correction: F689 Root Cause Analysis completed 8/18/2022 The Transport Driver forgot to engage the shoulder strap for Resident #51, resulting in a head contusion and abrasions to right arm. The Corrective action for noncompliance was completed on 8/19/2022. 1. On 8/18/2022 the facility driver failed to secure the shoulder strap during transport for resident #51. The wheelchair tipped to the right side in the van causing her to strike her head, resulting in a contusion and a skin tear. Once at facility the resident was assessed by the facility provider and sent to the hospital for evaluation and treatment. Resident returned to the facility later in the day. 2. On 8/18/2022 to identify other potentially affected residents the Administrator/designee interviewed all alert and oriented residents that were transported by the facility for 30 days prior to the incident to ensure that when they were transported, they were securely transported with a shoulder strap. No new issues were identified. All residents that were transported in the facility van in the past 30 days that were cognitively impaired received skin assessment with no skin issues identified. Van Driver received education QRT Max training video, Competency for securing wheelchair and resident in van, and competency for loading/unloading passenger in van. The transportation van securement straps, lab belt and shoulder belt were assessed for functionality by the Administrator with no findings noted. Drive along was done to verify van driver competency by the Administrator. On 8/18/2022 corrective action was completed with the employee. 3. To monitor for on-going compliance the Administrator/Designee will perform Van restraint competency tool: 5 days a week when driver has transportation x 1 month, then 3 days x one month, then weekly x one month. 4. Administrator/Designee to monitor for on-going patterns and trends and report findings to the QAPI team for review and additional f/u as indicated. The Quality Assurance Committee members are as follows: Administrator Director of Nursing Assistant Director of Nursing Life Enrichment Director Dietary Manager Director of Social Services Housekeeping Supervisor Medical Director Nurse Practitioner Completion Date: 8/19/2022 As part of the validation process on 9/1/2022 through 9/2/2022, the plan of correction was reviewed and included a sample of staff which included the Transport Driver, Administrator, Receptionist regarding in services and training related to deficient practice. The Transport driver verified the reeducation and training, and the continuing audits. A review of all the documents provided to correct the deficient practice was completed. The completion date of 8/19/2022 was confirmed.

Based on physician interview, resident interview, staff interview, and record review the facility failed to protect the right to be free of verbal and physical abuse for 2 of 3 sampled residents (Resident #2 and #3) who were reviewed for abuse. Nursing Assistant (NA) #1 verbally cursed and insulted Resident #2, and physically grabbed Resident #2 by the genitals when she forcefully transferred the resident from his bed to a wheelchair. Resident #2 reported that he experienced embarrassment, fear, and anxiety created by the verbal and physical abuse inflicted on him by NA #1. Additionally, the facility failed to prevent NA #1 from verbally abusing Resident #3 as she cared for the resident. Resident #3 was visibly shaken and scared as a result of this abuse, requiring a staff member to sit with the resident for 15 minutes to calm her nerves. Immediate Jeopardy (IJ) began on 12/12/18 when NA #1 used profanity and insults and grabbed Resident #2 by the genitals when transferring the resident from his bed to his wheelchair. IJ was removed on 01/10/19 when the facility implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance with this tag at a lower scope and severity level of G (actual harm that is not immediate jeopardy) for example number 2. Findings included: 1. Record review revealed that Resident #2 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. Review of Resident #2's care plan revealed on 12/06/18 the following problem was added: Resident has altered cardiac status r/t (in regard to) CAD ([MEDICAL CONDITION]), complete heart block, a-fib was identified as a problem in Resident #2's care plan. Interventions to this problem included, Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. The resident's 12/07/18 admission minimum data set (MDS) documented he had no impairment to his cognition, he exhibited no [MEDICAL CONDITION]/[MEDICAL CONDITION]/behaviors including resistance to care, he required extensive assistance from two staff members with bed mobility and transfers, he required extensive assistance by a staff member with locomotion on and off the unit, he did not walk in the room or corridor during the look back period, he was not steady on his feet when transferring between the bed and chair and vice versa, he had range of motion impairment on both sides of his lower extremities, he used his wheelchair for mobility, he was 72 inches tall and weighed 240 pounds, and he experienced occasional moderate pain in last 5 days making it difficult to sleep and limiting his day-to-day activities. A nursing note written on 12/12/2018 at 6:03 PM documented, Resident up in w/c (wheelchair) this AM & OOF (and out of facility) for MD (doctor's) (appointment) per orders. Resident left facility (at 9:55 AM), transported via _____ (name of contracted transport company), accompanied by NA (#2). Received report via telephone (at 10:20 AM) from NA that resident having c/o (complaints of) 'Not feeling right' (and) resident is also stating, 'I need you to take me to the hospital instead of to my (appointment).' ___ (name of transport company) took resident to ED per resident's request. During a telephone interview with Nurse #11 on 01/10/19 at 11:23 AM she stated she was the nurse who discharged the resident on 12/12/18 for his surgical procedure in Wilmington. She reported the resident was alert and oriented, and he was a little forgetful the first couple of weeks in the facility. She commented the resident was reliable and could express his needs to staff. According to Nurse #11, Resident #2 was nervous about his upcoming surgery when he left the faciity on [DATE]. A 12/12/18 ED encounter note documented, While in route to (Wilmington) the patient was diverted to this ED because he stated he felt he was too short of breath to continue his ride to (Wilmington). A 12/15/18 hospital discharge summary documented Resident #2 was hospitalized between 12/13/18 and 12/15/18 for re-implantation of his pacemaker. He (Resident #2) does admit that he is anxious to return back to Brunswick Health and Rehabilitation. He had considered going to a different (nursing home), but will return there as this is more convenient .Earlier today he had an episode of feeling overwhelmed with dyspnea, chest pain, and nausea. He thought this was due to a panic attack A 12/15/18 physician order [REDACTED]. A statement written by Resident #2 on 12/16/18 documented, Awakened from sleep had to get weighed. NA said to stand up. Had trouble moving from bed to wheelchair. No slide board used. Just pulled on a chair. Told her that legs ached. She was mumbling, but I could not understand. I asked for a Hoyer lift, but was told it was to be done her way. When back in room same procedure getting back to bed. Tried to lift me over the side of the chair and on bed. Started to lose control and tumbled on top of me at the same time uttering curses and taking the name of the Lord in vain. When .the end is near, having a procedure done, and in a total panic this is not good for the rehab facility, the family, or the patient An undated typed statement signed by Resident #2 documented, (NA #1) forced (Resident #2) into wheelchair without sliding board and yanked him up out of the bed. Resident told NA that he did not need to be yanked. NA told him to get in chair by himself. NA grabbed him by the waist. She then put one hand on his back and one hand on his groin in order to transfer resident into the wheelchair from the bed. She threw him into the wheelchair and told him not to move. NA would not let resident use leg rest on wheelchair to transport down the hall to get weight. Resident had to hold his legs up the entire way down to get weighed. Resident could not get on the scale on his own, however, NA told him to get up on his own. NA pulled him up onto the scale. On the way back down the hall, the resident asked the NA to stop so he could rest his legs since he was having to hold legs up by his hands. NA did not stop when he asked her to. His heels were dragging. NA refused to use the sliding board to transfer resident back into bed from the wheelchair. She grabbed him around his chest tightly. She must have lost her balance in the process and they started to do down. Resident hit his back on the bed and the NA fell on top of the resident. This information was not reported initially to the staff. During a telephone interview with Resident #2 on 01/08/19 at 3:46 PM he stated before he was transported to an appointment in Wilmington for pacemaker re-implantation on the morning of 12/12/18, NA #1 entered his room where he was in bed, and told him that she needed to weigh him before he left the building. He reported because he tried to inform the NA that she was not transferring and transporting him correctly she became angry with him, stating, We are going to do this my way. He also commented she called him a SOB (derogatory term), dirty old man, and stated he should be dead by now. According to Resident #2, NA #1 groped him during the transfer from the bed to the wheelchair with one hand around his waist and the other in his groin. He stated he did not share what happened to him on 12/12/18 until after his surgical procedure was completed because he was so stressed, anxious, fearful, and embarrassed about the way NA #1 treated him. However, he stated holding all this inside was very stressful, and he felt the way NA #1 talked to him contributed to having to detour to another hospital emergency department (ED) on the way to Wilmington, due to dizziness and feeling weak and faint. He explained this delayed his pacemaker re-insertion by a day. Resident #2 reported he finally shared how he was treated by NA #1 with a nurse because he was afraid other residents who could not speak for themselves were also abused by this same staff member. During a telephone interview with NA #1 on 01/09/19 at 1:20 PM she stated she needed to obtain a weight for Resident #2 on the morning of 12/12/18. She reported the resident was fully dressed and laying across his bed. She commented she used a sliding board to transfer the resident off the bed and to put him back on the bed after she weighed him in his wheelchair. According to NA #1, another staff member told her Resident #2 commented to her that NA #1 was very firm with him. She stated she was called in for a meeting with the Administrator and Director of Nursing (DON), and they accused her of abuse. She reported she never used profanity toward Resident #2, and she was only trying to motivate the resident to do as much for himself as possible. The NA commented she had never been accused of abusive behavior before so she quit her job. During a telephone interview with the driver of the contracted transport van on 01/08/19 at 4:11 PM she stated she had transported Resident #2 before, but on 12/12/18 the resident was more anxious and fidgety than usual. She reported when she picked the resident up from the nursing home he complained of and exhibited signs and symptoms of excruciating pain in his legs. She stated the resident was wiggling and appeared miserable. In route to his Wilmington appointment she commented the resident complained of being dizzy, became short winded, stated he felt really hot, and the resident turned red and was very flushed. She stated she told the resident she needed to either call 911 or take him to an ED before continuing on to Wilmington. During an interview with NA #7 on 01/09/19 at 10:52 AM she stated she traveled with Resident #2 in the transit van on the morning of 12/12/18. She reported the resident was a little nervous and anxious about the long trip to Wilmington, and was frustrated because he wanted to be transported via stretcher rather than in a wheelchair. She commented not far into the trip the resident complained of dizziness and began looking pale and weak. According to NA #7, the resident requested to be taken to a local ED to be checked out. A statement written by Nurse #6 on 12/16/18 documented, (Resident #2) told this nurse that (NA #1) was rough when transferring him from bed to chair (with) 1 x assist, pt (patient) is a slide board. Pt told this nurse that (NA #1) told him 'it was her way and that he needed to stop being so stubborn and stand up.' Pt stated that (NA #1) was putting him back to bed and said, 'Jesus Christ, can't you do anything to help. During an interview with Nurse #6 on 01/09/19 at 8:50 AM she stated on 12/16/18 as she was asking Resident #2 how his surgical procedure went he confided in her that NA #1 had been rude and crude to him after she (Nurse #6) checked on him the morning of 12/12/18. He explained to Nurse #6 that when NA #1 insisted on transferring him incorrectly she informed him, You're going to break my f-----g (expletive) back, you're f-----g lazy. He also informed Nurse #2 that when he was unable to stand to be weighed NA #1 stated, You're here for f-----g rehab, and you should be able to stand up on your f----g own. According to Nurse #6, she could tell by Resident #2's facial expressions that he was visibly upset and his hands were shaking while he was relaying the account to her. The nurse stated she and Resident #2 were asked to write statements about what they were told or experienced. She reported Resident #2 did not say anything else to her about NA #1 until a couple of weeks later when the resident commented he was remembering more details about his ordeal with the NA. She reported the resident commented he was embarrassed to tell anyone, but NA #1 grabbed his testicles when she was attempting to stand him up from the bed. Nurse #6 stated she immediately informed her Administrator and DON. She reported Resident #2 was alert and oriented but could be forgetful at times. She also commented the resident had anxiety issues, and she felt he was afraid of dying. She remarked that the resident had a couple of near-panic attacks when he first arrived in the facility due to his health conditions with the resident reporting chest pain but having vital signs which were all within normal limits. Review of Resident #2's care plan revealed on 12/21/18 the following problem was added: Resident is on anti-anxiety therapy was identified as a problem in Resident #2's care plan. Interventions to this problem included, Implement non-pharmacological interventions specific for the resident. During a 01/09/19 3:36 PM interview with the Administrator he stated that NA #1 was suspended on 12/12/18 after a nurse shared her 12/08/18 observation of NA #1 verbally abusing Resident #3 who had some cognitive impairment. He commented NA #1 did not work any more in the nursing home after 12/12/18. He reported NA #1 was terminated on 12/13/18 after verbally abusing Resident #3. During an interview with the Administrator on 01/08/19 at 11:15 AM he stated when Resident #2 reported verbal abuse by NA #1 on 12/16/18 his complaint added even more validity to earlier accusations that NA #1 verbally abused Resident #3 (who had moderate cognitive impairment) since Resident #2's cognition was intact, and the staff considered him to be alert and reliable. However, he commented on 12/27/18 Resident #2 added to the recollection of his interaction with NA #1, stating she groped his crotch while transferring him incorrectly. According to the Administrator, he immediately contacted the sheriff's department, relaying to them Resident #2's account of what happened and the resident's desire to prosecute the NA for physical abuse. He explained the facility was waiting on the sheriff report before making a decision about the occurrence of physical/sexual abuse against Resident #2. During a telephone interview with the sheriff investigator assigned to Resident #2's case on 01/08/19 at 1:55 PM he reported his investigation was still on-going. He stated he needed to talk to the resident's spouse and the accused NA, and he had not done so yet. During a telephone conversation with the facility's Medical Director and Resident #2's primary physician on 01/09/19 at 11:16 AM she stated the resident had elevated levels of anxiety brought on by his health experiences and the severity of his illness. She reported she thought there was an emotional component that led to his detour to a local ED in route to his surgical appointment. She commented Resident #2 had shared with her how he was treated by NA #1, and she felt this treatment probably contributed to even more elevation in his anxiety levels. She explained elevated levels of anxiety were not beneficial for a resident with a pacemaker because the resident's [MEDICATION NAME] levels became elevated and [MEDICAL CONDITION] develop. According to the Medical Director, after hearing about his interaction with NA #2, she had concerns about dignity, verbal abuse, and physical abuse. She stated Resident #2 was treated in a demeaning manner, and what happened to him was a horrible thing, heartbreaking. During an interview with the DON on 01/10/19 at 5:58 PM she stated the facility had zero tolerance for the abuse of residents by staff members. She reported the use of demeaning language and expletives when communicating with residents was a form of verbal abuse. She commented groping a resident in the crotch could be physical/sexual abuse or could be an example of poor transfer technique depending on the intent of the perpetrator. During an interview with the Administrator at 6:02 PM on 01/10/19 he stated Resident #2 made significant progress with therapy and was discharged home on[DATE] with family. Upon being informed about the profanity NA #1 used against Resident #2, as reported by Nurse #6 during her interview, the Administrator reported this was the first time he had heard this information. He explained Nurse #6 should have informed the management team about the NA's use of the F word against Resident #2 because this elevated the level of the verbal abuse. The Administrator and DON were notified of the Immediate Jeopardy on 01/09/19 at 6:05 PM. On 01/10/19 at 5:36 PM the facility provided an acceptable credible allegation for IJ removal. The facility's credible allegation for IJ removal for the deficiency at F600 included the following information: A verbal abuse allegation was made on 12/16/18 by Resident #2 regarding staff member NA #1. Per resident on 12/12/18 NA #1 stated she spoke to him inappropriately saying the following stop being so stubborn and stand up, Jesus Christ, can't you do anything to help and that she was hateful. *A Facility Reportable Incident submitted on 12/16/18. *An investigation was initiated by the Administrator and Director of Nursing. *Following a thorough investigation the 5 day final facility reportable was submitted on 12/21/18. *The allegation was substantiated. Employee had been suspended on 12/12/18 pending another investigation and was subsequently terminated. *Skin checks were completed on non-interviewable residents on 12/14/18 by the Director of Nursing and licensed nurses. No issues were identified. *Interviewable residents were questioned on 12/14/18 on care and concerns by DON, ADON, Social Services and/or designees. Concerns were shared regarding NA#1. She was terminated on 12/13/18. *Abuse re-education completed on 12/20/18 by the DON and/or designee for staff. The abuse education included the abuse policy, first ensuring the safety of the resident, an abuse quiz including types of abuse and notification to Administrator and/or Director of Nursing immediately. A physical abuse allegation was made on 12/27/18 by Resident #2 regarding staff member NA #1. Per the resident on 12/12/18 NA #1 forced him into a wheelchair, put one hand on his groin and one hand on his back to transfer him to a wheelchair, threw him into the wheelchair, refused to use a sliding board to transfer back in bed, grabbed him around his chest tightly. Resident also signed statement that he did not report to staff initially. *A Facility Reportable Incident submitted on 12/27/18. *An investigation was initiated by the Administrator and Director of Nursing. *Brunswick County Sheriff's office was contacted by the resident and social worker on 12/27/18. No charges were filed. *A skin check was conducted on 12/27/18 on resident #2 by the DON. There were no issues. *NA#1 was already terminated due to previous allegation on 12/13/18. *Following a thorough investigation the 5 day final facility reportable was submitted on 01/02/19. *Resident had a planned discharge home on 01/02/19. Root Cause Analysis: The facility failed to properly educate staff on the abuse policy including timeliness of reporting and the accuracy of statements including who, what, when, where, how and why. The Procedure for Implementing the Acceptable Plan of Correction for the specific deficiency cited: All residents have the potential to be affected. The Administrator, Regional Director of Clinical Services and DON started in-house education on 01/09/19 related to F600 Abuse. The education was performed to ensure staff was properly trained on abuse, aware there is zero tolerance, reporting timely as well as accurately. Education will continue via telephone for staff not available 01/09/19 or 01/10/19 in person. These staff members will not be permitted to work until education is received. New hires will be educated to abuse policy upon hire. The Regional Vice president of Operations re-educated the Licensed Nursing Home Administrator and DON on abuse, policy and procedures and conducting a proper/thorough investigation on 01/09/19. The monitoring procedure to assure the Plan of Correction is corrected and the specific deficiency cited remains corrected and in compliance with regulatory requirements: On 01/10/19 random staff interviews are being conducted by Administrator related to abuse and reporting. On 01/10/19 facility resident interviews are being conducted by Department Managers for those residents that are interviewable related to abuse. Questions include if resident feels safe in the community, if you feel as if you have been abused and have you been treated with dignity and respect. On 01/10/19 body checks were completed for those residents that are not interviewable by licensed nurses. On 01/10/19 all interviewable residents will be re-educated on 01/10/19 by the Activity Director on resident rights including immediately reporting any issues of concern including abuse, dignity and respect. This same education will be provided during monthly resident council meetings x 3 months. Facility Administrative/Department Managers will start abuse questionnaires with all staff on 01/10/19 related to abuse and policy. The audits will be completed on 3 staff, 3 x weekly. Any negative findings will be addressed immediately by the Administrator and/or Director of Nursing. DON and/or ADON will conduct 3 skin checks on 3 non interviewable residents, 3 x weekly. Any negative findings will be addressed immediately by the Administrator and/or Director of Nursing. On 01/10/19 resident questionnaires will be conducted with 3 residents weekly related to abuse. Any negative findings will be addressed immediately by Administrator and/or Director of Nursing. The facility will conduct an Ad Hoc Quality Assurance Performance Improvement meeting on 01/10/19 with the facility interdisciplinary team, the Regional Vice President of Operations, Regional Director of Clinical Services the Medical Director to review the corrective measures. The title of the person responsible for implementing the acceptable plan of correction is the Administrator. Immediate Jeopardy removal date: 01/10/19 Validation: Immediate Jeopardy (IJ) was removed on 01/10/19 at 5:36 PM. Validation of the credible allegation for IJ removal was completed as evidenced by interviews with 9 staff members representing various disciplines and shifts to verify abuse and abuse reporting in-servicing and by interviews with 7 residents having intact cognition about whether they had ever been abused by facility staff. 28 skin checks were reviewed for residents who were unable to respond to questions about abuse, and none of those checks revealed documentation of skin impairment indicative of abuse infliction. Responses from 9 staff education questionnaires and 57 staff abuse quizzes were reviewed; revealing staff understood the in-servicing they received. Responses from 29 resident education questionnaires were reviewed; revealing residents understood how to report abuse if it happened to them. All questionnaires and quizzes were reviewed and the questions in them seemed appropriate to gauge understanding of the abuse education. The Administrator and DON confirmed they had been re-educated by the Regional Vice president of Operations on abuse, policy and procedures, and conducting a proper/thorough abuse investigation. 2. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had mild cognitive impairments. The resident needed extensive assistance with toilet use, personal hygiene, and was independent with eating. Resident #3's care plan goals dated 08/21/18: revealed the resident needed oxygen and diuretic therapy related to [MEDICAL CONDITION] [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. Resident had behaviors, refused care, refused showers, and was verbally abusive to staff as evidenced by yelling. Review of the facility incident reports from 12/08/18 through 12/11/18 revealed there was no incident report for alleged verbal abuse of Resident #3 by Nursing Aide (NA) #1 on 12/08/18. Review of the nurse's notes from 12/08/18 through 12/12/18 revealed no documentation of Nurse #1or Nurse #2 or NA #2 having concerns that NA #1 had been verbally abusive to Resident #3 on the night of 12/08/18. Review of the facility 5 day Abuse Summary dated 12/18/18 revealed on 12/12/18 at or around 8:00 AM Nurse #1 reported to the Administrator and DON that on 12/08/18 she heard Nursing Aide (NA) #1 tell Resident #4 that she was hateful and she could ring her call bell, but she wasn't going to answer it. The DON and Administrator interviewed the other nurse on duty Nurse #2 and she also stated that she didn't hear the exchange, but said the resident was anxious throughout the night. The Administrator and DON also interviewed the other NA on duty NA #2. She stated that she heard Resident #3 yelling out and went to her room. NA #1 told her to get out, and said Resident #3 doesn't need any company tonight because she's hateful. On 12/16/18 Resident #2 said NA #1 told him, during a transfer, Jesus can't you do anything yourself, and considered it abusive. After investigating the incident the facility substantiated abuse. An abuse in-service was initiated with staff, and NA #1 was terminated from employment. Three incident/accident witness statement reports were provided by the Administrator on 01/07/19. The first report from Nurse #1 revealed on 12/08/18 during the night shift she was sitting at the nurses station and overheard NA #1 say to Resident #3 you are a hateful woman, and you can ring your call light all night, and I don't have to come back into your room. The second report from NA #2 revealed on 12/08/18 during the night shift she heard Resident #3 yelling, and she immediately went to Resident #3's room to check on the cause of the yelling, and was told by NA #1 to get out of Resident #3's room, she didn't need any company tonight because Resident #3 was being hateful. NA #2 said she came out of Resident #3's room, walked to the nursing station and spoke to Nurse #1 whom NA #2 stated heard the whole conversation. NA #2 stated that NA #1 repeated the same statement to Nurse #2. NA #2 said Resident #3 was fearful of NA #1. The third report from NA #1 revealed on 12/08/18 during the night shift Resident #3 yelled to get my stuff off of floor. NA #1 told Resident #3 there's nothing on the floor, calm down. NA #1 then stated she told resident, she was being mean, and to stop being mean. NA #1 told NA #2 to leave resident's room, so she could calm down, that she was having one of her episodes. An interview conducted on 01/07/19 at 3:50 PM with Resident #3 revealed she could not remember anything that happened on 12/08/18. She said she did not remember staff being mean or hateful to her. Resident #3 said she was treated well at the facility, and had no staff concerns. An interview conducted on 01/08/19 at 3:43 PM with NA #2 revealed, on the night of 12/08/18 she heard Resident #3 screaming. She said when she went into Resident #3's room to check on the cause of the screaming, NA #1 told her that Resident #3 had been mean and hateful, and did not need any company or visitors. NA #1 told NA #2 that Resident #3 was hateful, didn't need visits, and threatened to take away the resident's call bell. NA #2 said she went to the nursing station, which was only 2 doors away, and relayed the verbal event to Nurse #1 and Nurse #2, who both heard it. An interview conducted on 01/08/19 at 4:42 PM with the DON revealed the first time she heard of Resident #3's verbal abuse allegation was from NA #2, which was after their 12/12/18 staff town hall meeting. An interview conducted on 01/09/19 at 11:50 AM with Nurse #1 revealed, on the night of 12/08/18 after NA #1's verbal interaction with Resident #3, and after the resident yelled get me out of here Nurse #1 observed Resident #3 was visibly shaken and scared. The nurse said, after NA #1's verbal confrontation with Resident #3, she felt it was necessary for her to sit with the resident for about 10 minutes, verbally reassuring her that it was going to be okay. She said, after the 10 minutes, she left to get the resident warm juice, which the resident liked, and sat with her for an additional 5 minutes. Nurse #1 said after sitting with the resident, and giving her the juice, the resident was more relaxed and calm. Nurse #1 said she told the resident that she would be right at the nursing station, two doors down, if she needed anything else. Nurse #1 said she again checked on the resident when NA #1 was in the resident's bathroom, and the resident pointed to NA #1, and nodded yes 3 times to Nurse #1 that it was NA #1 who was verbally hateful to her. An interview conducted on 01/10/19 at 6:05 PM with the Administrator revealed the statements made to Resident #3 on 12/08/18 by NA #1, calling her a mean old lady, was verbal abuse, and would not be tolerated. He said it was his expectation that the night staff should have immediately called either the DON or himself, when they thought there was any indication of possible abuse, and they did not.