Every finding on record at Chowan River Nursing and Rehabilitation Center

Based on observations, record review, staff and Pharmacist interviews, the facility failed to remove expired medication and refrigerate medications according to the manufacturer's recommendations for 1 of 3 medication refrigerators observed for medication storage (Refrigerator #3).The findings included:a. An observation was conducted of the medication room on 7/29/26 at 3:42 PM with the Director of Nursing (DON). Refrigerator #3 contained 31 doses of the influenza high dose vaccine with an expiration date of 6/2026. The DON confirmed the vaccines were expired and removed the expired vaccines. An immediate interview was conducted with the DON on 7/29/26 at 3:44 PM. The DON stated the night shift nurses were responsible for checking the medication refrigerators during the night shift. The DON stated the night shift nurses were to ensure that expired medications were discarded or returned to the pharmacy. b. A review of manufacturer's package insert indicated that Prevnar 20 should be refrigerated with temperature between 2 to 8 Celsius (C) (36 F to 46 Fahrenheit (F)). Do not freeze and to discard the medication if the vaccine has been frozen.An observation was conducted with the DON of Refrigerator #3 on 7/29/26 at 3:46 PM. Refrigerator #3 contained 3 boxes with 10 injections in each of Prevnar 20 pneumococcal vaccine that were encased in ice. Ice was also observed on the chiller compartment at the top left of Refrigerator #3. Review of the Refrigerator #3 temperature log revealed no issues. The DON immediately removed the pneumococcal vaccines. An immediate interview was conducted with the DON on 7/29/26 at 3:48 PM. The DON stated the night shift nurses were responsible for checking the medication refrigerator temperatures daily, observing the inside of the refrigerator for ice, and defrosting the medication refrigerators as needed as part of the medication refrigerator daily check. A telephone interview was conducted with Nurse #2 on 7/30/26 at 3:20 PM. Nurse #2 confirmed that she worked on the night shift from 7:00 PM on 7/26/26 to 7:00 AM on 7/27/26. Nurse #2 stated that during her shift she checked the medication room refrigerator for expired medications and temperature. Nurse #2 stated that expired medications were either discarded or returned to the pharmacy. Nurse #2 stated if there were issues with the medication refrigerator maintaining the correct temperature, she adjusted the thermostat to correct. Nurse #2 stated if refrigerator temperatures remained out of range, she notified maintenance of the issue. Nurse #2 denied that there had been any issues with Refrigerator #3 having ice during her shift and she had not seen the frozen or expired vaccines. A telephone interview was conducted with Nurse #1 on 7/29/26 at 3:04 PM. Nurse #1 confirmed that she worked on the night shift from 7:00 PM on 7/27/26 to 7:00 AM on 7/28/26. Nurse #1 stated that during her shift she looked at expiration dates of medications before she administered the medication. Nurse #1 admitted that she did not look at every medication to verify if the medication was expired. Nurse #1 stated she was responsible for checking the medication room refrigerator for expired medications during her shift. Nurse #1 denied that she had looked at the influenza vaccine expiration dates during her shift. She also confirmed that she was responsible for checking the refrigerator temperatures during her shift. Nurse #1 stated she could not recall seeing any ice in Refrigerator #3 when she last worked. A telephone interview was conducted with the Pharmacist on 7/30/26 at 1:32 PM. The Pharmacist stated expired vaccines should be removed from the medication refrigerator and sent back to the pharmacy or discarded. She stated that medication temperatures should be monitored daily and vaccines were to be stored according to the manufacturer's suggestion. The Pharmacist stated that the frozen vaccines should have been returned to the pharmacy or discarded.A follow up interview was conducted with the DON on 7/30/26 at 4:00 PM. The DON stated she expected nursing staff to follow manufacturer's guidelines when storing the Prevnar 20 vaccine and the expired influenza vaccines should have been discarded. An interview was conducted with the Administrator on 7/30/26 at 4:28 PM. The Administrator stated he expected medication refrigerators would be maintained and defrosted as needed and expired medications returned or disposed of per the medication storage regulation.

Based on observations, record review, resident, and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of roaches in a resident's room and in the staff bathroom in the lobby for 2 of 5 areas observed for pest control. Findings included:a. During a tour of the facility on 7/27/26 at 11:43 AM a light brown roach which was approximately an inch long was observed on the floor of the staff bathroom located next to the reception office in the lobby. The roach was observed to be alive and crawled towards the commode then turned back toward the cabinet below the sink. b. An observation was conducted in Resident #44's room in conjunction with an interview with Resident #44 on 7/27/26 at 11:45 AM. The observation revealed a roach the size of a pea was crawling on the floor towards the door to the hallway. Housekeeping Staff #1 was observed to enter the room and stepped on the roach. An interview with Resident #44 revealed she saw roaches that size 2-3 times a week in her room and further explained she sometimes had seen some larger roaches a couple of times a month. Housekeeping Staff #1 was not interviewed.Pest control summary of services from the pest control company were reviewed for the following dates of 09/08/25, 09/15/25, 09/29/25, 10/06/25, 10/112/25, 10/20/25, 11/03/25, 11/17/25, 11/24/25, 12/01/25, 12/8/25, 12/22/25, 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, 02/16/26, 02/23/26, 03/02/26, 03/09/26, 03/23/26, 03/30/26, 04/13/26, 05/04/26, 05/18/26, 05/25/26, 6/15/26, 6/22/26, 6/29/26, 07/6/26, 07/13/26, and 07/20/26. Summary of services documented on the above dates included spot treated in the bathrooms, resident rooms, dining rooms, kitchen and interior and exterior doorways for German roaches and general pest control. The pest control summary services showed that dead roaches were observed in the dining and storage area in hall two.Telephone attempts to speak with the Pest Control Technician on 7/28/26 11:03 AM, 7/29/26 at 2:22 PM, and on 7/30/26 at 8:59 AM were unsuccessful. Messages were left for the Pest Control Technician requesting a return call, but the calls were not returned. During a resident council meeting on 7/29/26 at 2:34 PM, the residents reported the roach problem in the facility was ongoing. The residents reported roaches would come out more in the night than during the day and would be observed crawling on the floors and walls in the rooms. In an interview conducted on 7/27/26 at 3:00 PM with Nursing Aide #1(NA#1) she stated she had spotted roaches in resident rooms in the past crawling on the walls and reported seeing the roaches to the nurse. On 7/30/26 at 9:02 AM an interview was completed with the maintenance director who stated the roach problem in the facility was ongoing. He stated the pest control company technician came to the facility every week to treat areas noted to have roaches, but the roach problem was persistent. The maintenance director explained he had not talked to the pest control technician about the persistent roach concerns at the facility. The maintenance manager director further stated the pests were more prevalent in resident rooms and bathrooms than in the commons areas such as the dining and activities room. In an interview with Director of Nursing (DON) on 7/30/26 at 9:34 AM she revealed the pest control company was treating the ongoing roach problem, and it was getting better. She stated the pest control company technician came in every week to the facility to treat the roaches and water bugs. She stated that the roaches continued to show up in resident rooms. On 7/30/26 at 10:30 AM, an interview was conducted with Administrator. The Administrator stated he started working at the facility two months ago and did notice the problem of roaches. The Administrator further stated it seemed the pest control company who was treating the building was not doing a good job and had been servicing the building for many years. The Administrator explained they were in the process of switching pest control companies. He further stated he did not expect roaches to be in the residents' rooms or anywhere in the facility, and for the exterminator to do a good job.

Based on observation, record review, resident, staff, and physician interviews, the facility failed to obtain a physician order for the use of an indwelling urinary catheter for 1 of 4 residents (Resident #26) reviewed for urinary catheter.The findings included:A hospital Discharge summary dated [DATE] revealed Resident #26 had an indwelling urinary catheter placed during his hospital stay and was discharged with the catheter in place but did not specify the size of the catheter.Resident #26 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (urinary tract conditions that potentially caused abnormal urine backflow and an enlarged prostate).A nursing progress note dated 7/12/26 created by Nurse #3 revealed Resident #26 had an indwelling urinary catheter in place draining clear yellow urine. A care plan dated 7/13/26 indicated Resident #26 required an indwelling urinary catheter. Interventions included changing catheter per Physician orders and/or facility protocol, catheter care per facility policy, and maintaining a closed drainage system with an unobstructed urine flow.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and was coded for the use of an indwelling urinary catheter.Record review of the Physician's orders revealed no order for Resident #26's indwelling urinary catheter.An observation on 7/27/26 at 3:40 PM revealed Resident #26 was sitting up in his wheelchair with the indwelling urinary catheter drainage bag hung from the rail on the wheelchair and below the level of the bladder. An interview was completed on 7/30/26 at 10:54 AM with Resident #26. The Resident revealed the indwelling urinary catheter was placed during his hospital stay due to difficulties with completely emptying his bladder. Resident #26 stated he has an appointment with urology for follow up treatment.An interview was completed on 7/30/26 at 3:37 PM with Nurse # 4. The Nurse revealed she received Resident #26's discharge summary from the hospital on 7/10/26. Nurse #4 stated she reviewed the summary, input his medication orders, indwelling urinary catheter care orders, and any other required orders. Nurse #4 stated she reviewed the orders with the facility's Physician to ensure no orders needed to be updated. Nurse #4 stated she assessed Resident #26 and was aware he had an indwelling urinary catheter. The Nurse stated when a discharge summary does not include the urinary catheter size, she observed what size the resident currently had placed and reviewed with the Physician to receive an order for it. Nurse #4 was unable to say why she did not enter an order for Resident's #26's indwelling urinary catheter.An interview was completed on 7/30/26 at 2:31 PM with Nurse #3. The Nurse revealed she was assigned to care for Resident #26 on 7/12/26. Nurse #3 she reviewed Resident #26's Physician's orders and discovered there was no order for use of an indwelling urinary catheter. Nurse #3 stated she was not aware she could enter the order for the catheter use, so she entered a progress note describing the size of the indwelling urinary catheter.An interview was completed on 7/29/26 at 1:30 PM with the Medical Director. He revealed an indwelling urinary catheter required a Physician's order. The Medical Director stated the order for Resident #26's indwelling urinary catheter should have been entered upon admission.An interview was completed on 7/30/26 at 3:30 PM with the Director of Nursing (DON). The DON stated the Unit Management Nurses were responsible for inputting hospital discharge orders, and an available nurse reviewed the order summary in a resident's electronic medical record. The DON revealed all new admissions were reviewed at the next clinical morning meeting. The DON stated all indwelling urinary catheters are required to have an order for usage. The DON was unable to state how the order was overlooked.An interview was completed on 7/30/26 at 4:42 PM with the Administrator. The Administrator stated nursing was required to ensure that Physician orders were in place to properly care for Resident # 26's indwelling urinary catheter.

Based on staff interview and review of the Facility Assessment, the facility failed to have an accurate Facility Assessment that recorded the current administrative staff. This deficient practice had the potential to affect 58 of 58 residents. The findings included:The Facility Assessment was reviewed and was noted to have been updated and reviewed with the facility's Quality Assurance Performance and Improvement (QAPI) committee on 3/30/26. Page 1 of the Facility Assessment recorded the name of the former Administrator.An interview was completed on 7/30/26 at 4:45 PM with the facility's Administrator. The Administrator revealed he was not employed by the facility when the current Facility Assessment was reviewed and updated on 3/30/26. The Administrator stated he had reviewed the current Facility Assessment but mistakenly did not update the administrative staff.

Based on record reviews and staff interviews, the facility failed to notify the resident and resident's representative (RR) in writing of the reason for the transfer/discharge to the hospital and failed to send a copy of the discharge notice to the Ombudsman for 4 of 5 residents. (Resident #57, Resident #24, Resident #2, and Resident #8) The facility also failed to notify the resident and/or Resident's Representative of the facility policy for bed hold for 1 of 5 residents reviewed for hospitalization. (Resident #8) The findings included:1.Resident #57 was admitted to the facility 3/28/25.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had moderately impaired cognitive skills for daily decision. He exhibited inattention and alerted level of consciousness. The nursing progress note dated 6/18/26 revealed Resident #57 was sent out to the hospital at 5:28 PM with increased temperature and decreased oxygen saturation. Resident #57 did not return back to the facility.The nursing progress note dated 6/19/26 at 4:16 AM revealed Resident #57 was admitted to the hospital with a diagnosis of sepsis. The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) or Ombudsman for Resident # 57's hospital transfer dated 6/18/26.An attempt to reach Resident #57's RR by phone on 7/28/26 at 3:00 PM was unsuccessful. During an interview with the Social Worker on 7/29/26 at 12:27 PM, she stated she had started working at the facility late November 2025. The Social Worker stated she was not responsible for sending out written notification of hospital transfer or bed hold policy to the RR and she did not know who was responsible for sending out that information.An interview conducted with the Ombudsman on 7/30/26 at 10:11 AM revealed she had not received notification of any residents transferred out for the month of June 2026.During an interview with the admission Director on 7/30/26 at 10:45 AM, revealed she started working at the facility in October 2025. The admission Director stated she had not been involved in the process of sending written notification of transfer to the hospital or sending the bed hold policy. The admission Director stated she received notifications and monitored the hospital portal for residents that transferred to the hospital. The admission Director stated she was notified a couple of weeks ago that she would be responsible for sending out the written notification of transfer/discharge to the hospital.An interview was conducted with the Administrator on 7/29/26 at 11:20 AM. The Administrator stated the admission Director was responsible for sending written notification of transfer/discharge to the hospital. He stated it was recently brought to his attention that the written notification was not being sent to the RR. The Administrator stated the admission Director had direct contact with the hospital and the hospital portal that tracked acute discharges to the hospital. The Administrator stated the admission Director had not been sending the written notification of transfer to hospital or bed hold policy to the RR. The Administrator stated he would be reviewing written notification of hospital transfer and bed hold policy to the RR expectations with the admission Director.2. Resident #24 was admitted to the facility 9/18/12.The quarterly MDS dated [DATE] revealed Resident #24 had moderate cognitive impairment.a. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 2/15/26 revealed Resident #24 was sent out to the hospital at 8:43 PM for altered mental status and uncontrolled pain. The nursing progress note dated 2/18/26 revealed Resident #24 was readmitted to the facility at 12:44 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) for Resident # 24's hospital transfer dated 2/15/26. The Ombudsman received notification of hospital transfer on 3/2/26. b. The nursing progress note dated 6/1/26 revealed Resident #24 had altered mental status and visual hallucinations and was sent out to the hospital at 2:14 PM. Resident #24 was readmitted to the facility on [DATE].The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR)and Ombudsman for Resident # 24's hospital transfer dated 6/1/26. During an interview with the Social Worker on 7/29/26 at 12:27 PM, she stated she had started working at the facility late November 2025. The Social Worker stated she was not responsible for sending out written notification of hospital transfer or bed hold policy to the RR and she did not know who was responsible for sending out that information.An interview conducted with the Ombudsman on 7/30/26 at 10:11 AM revealed she had received notification of Resident #24's hospital transfer on 2/15/26. The Ombudsman stated the facility stopped sending the monthly list of admission/discharge residents transferred to the hospital in May 2026. The Ombudsman stated she had not received notification of any residents transferred out for the month of June 2026. During an interview with the admission Director on 7/30/26 at 10:45 AM, she started working at the facility in October 2025. The admission Director stated she had not been involved in the process of sending written notification of transfer to the hospital or sending the bed hold policy. The admission Director stated she received notifications and monitored the hospital portal for residents that transferred to the hospital. The admission Director stated she was notified a couple of weeks ago that she would be responsible for sending out the written notification of transfer/discharge to the hospital.An interview was conducted with the Administrator on 7/29/26 at 11:20 AM. The Administrator stated the admission Director was responsible for sending written notification of transfer/discharge to the hospital. He stated it was recently brought to his attention that the written notification was not being sent to the RR. The Administrator stated the admission Director had direct contact with the hospital and the hospital portal that tracked acute discharges to the hospital. The Administrator stated the admission Director had not been sending the written notification of transfer to hospital or bed hold policy to the RR. The Administrator stated he would be reviewing written notification of hospital transfer and bed hold policy to the RR expectations with the admission Director.3. Resident #2 was admitted to the facility 7/8/19 and readmitted on [DATE].The annual MDS dated [DATE] revealed Resident #2 was cognitively intact.a. The nursing progress note dated 6/4/25 revealed Resident #2 had decreased blood pressure and shortness of breath and was sent out to the hospital at 11:00 AM.The nursing progress note dated 6/8/25 revealed Resident #2 was readmitted to the facility at 2:45 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) for Resident # 2's hospital transfer dated 6/4/25. The Ombudsman received notification of hospital transfer on 7/2/25.b. The nursing progress note dated 8/18/25 revealed Resident #2 had active rectal bleeding and was sent out to the hospital at 12:20 AM.The nursing progress note dated 8/23/25 revealed Resident #2 was readmitted to the facility at 4:49 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) for Resident # 2's hospital transfer dated 8/18/25. The Ombudsman received notification of hospital transfer on 9/3/25. c. The nursing progress note dated 10/1/25 revealed Resident #2 had nausea, dizziness and low blood pressure and was sent to the hospital at 8:30 PM. Resident #2 was readmitted to the facility on [DATE].The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) for Resident # 2's hospital transfer dated 10/1/25. The Ombudsman received notification of hospital transfer 11/2/25.d. The nursing progress note dated 4/11/2026 revealed Resident #2 had a large burgundy colored stool and was sent out to the hospital at 11:20 AM.The nursing progress note dated 4/14/2026 revealed Resident #2 was readmitted to the facility at 6:24 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) or Ombudsman for Resident # 2's hospital transfer dated 4/11/26. An interview was conducted with Resident #2's RR on 7/30/26 at 9:12 AM. The RR stated he had never received written notification of transfer discharge when Resident #2 was transferred to the hospital.During an interview with the Social Worker on 7/29/26 at 12:27 PM, she stated she had started working at the facility late November 2025. The Social Worker stated she was not responsible for sending out written notification of hospital transfer or bed hold policy to the RR and she did not know who was responsible for sending out that information.An interview conducted with the Ombudsman on 7/30/26 at 10:11 AM revealed she received notification of Resident #2's hospital transfers for the months of June 2025, August 2025 and October 2025. The Ombudsman stated the facility stopped sending the monthly list of admission/discharge residents transferred to the hospital in May 2026. The Ombudsman stated she had not received notification of any residents transferred out for the month of June 2026During an interview with the admission Director on 7/30/26 at 10:45 AM, she started working at the facility in October 2025. The admission Director stated she had not been involved in the process of sending written notification of transfer to the hospital or sending the bed hold policy. The admission Director stated she received notifications and monitored the hospital portal for residents that transferred to the hospital. The admission Director stated she was notified a couple of weeks ago that she would be responsible for sending out the written notification of transfer/discharge to the hospital. An interview was conducted with the Administrator on 7/29/26 at 11:20 AM. The Administrator stated the admission Director was responsible for sending written notification of transfer/discharge to the hospital. He stated it was recently brought to his attention that the written notification was not being sent to the RR. The Administrator stated the admission Director had direct contact with the hospital and the hospital portal that tracked acute discharges to the hospital. The Administrator stated the admission Director had not been sending the written notification of transfer to hospital or bed hold policy to the RR. The Administrator stated he would be reviewing written notification of hospital transfer and bed hold policy to the RR expectations with the admission Director.4. Resident #8 was admitted to the facility 3/17/26.The quarterly MDS dated [DATE] revealed Resident #8 had severe cognitive impairment.a. The nursing progress note dated 4/18/26 revealed Resident #8 had pain in her face, back, arm, leg, and buttocks and was sent out to the hospital.Resident #8 was readmitted to the facility on [DATE].The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) or Ombudsman and there was no documentation that bed hold policy was sent for Resident # 8's hospital transfer dated 4/18/26. b. The nursing progress note dated 5/24/26 revealed Resident #8 fell forward while ambulating in the hallway and complained of a headache and back pain. Resident #8 was sent to the hospital at 7:42 PM. Resident #8 was readmitted to the facility on [DATE].An attempt to reach Resident #8's RR on 07/30/2026 at 12:17 PM was unsuccessful. The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative (RR) or Ombudsman for Resident # 8's hospital transfer dated 5/24/26.During an interview with the Social Worker on 7/29/26 at 12:27 PM, she stated she had started working at the facility late November 2025. The Social Worker stated she was not responsible for sending out written notification of hospital transfer or bed hold policy to the RR and she did not know who was responsible for sending out that information.An interview conducted with the Ombudsman on 7/30/26 at 10:11 AM revealed she did not receive notification of Resident #8's hospital transfer on 4/18/26. The Ombudsman stated the facility stopped sending the monthly list of admission/discharge residents transferred to the hospital in May 2026. The Ombudsman stated she had not received notification of any residents transferred out for the month of June 2026.During an interview with the admission Director on 7/30/26 at 10:45 AM, she started working at the facility in October 2025. The admission Director stated she had not been involved in the process of sending written notification of transfer to the hospital or sending the bed hold policy. The admission Director stated she received notifications and monitored the hospital portal for residents that transferred to the hospital. The AdmissionDirector stated she was notified a couple of weeks ago that she would be responsible for sending out the written notification of transfer/discharge to the hospital.An interview was conducted with the Administrator on 7/29/26 at 11:20 AM. The Administrator stated the admission Director was responsible for sending written notification of transfer/discharge to the hospital. He stated it was recently brought to his attention that the written notification was not being sent to the RR. The Administrator stated the admission Director had direct contact with the hospital and the hospital portal that tracked acute discharges to the hospital. The Administrator stated the admission Director had not been sending the written notification of transfer to hospital or bed hold policy to the RR. The Administrator stated he would be reviewing written notification of hospital transfer and bed hold policy to the RR expectations with the admission Director.

Based on observations, record reviews and staff interviews, the facility failed to restrict the fluid intake for a resident with End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) as ordered by the physician for 1 of 1 sampled resident reviewed for dialysis (Resident #114). The findings included: Resident #114 was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure, chronic pulmonary edema, and dependence on renal dialysis. Review of Resident #114's care plan initiated on 2/28/25 identified the resident was at risk for complications due to hemodialysis, End Stage Renal Disease (ESDR). Resident is on 1500 ml (milliliters)/day restriction. The interventions to this problem included providing diet as ordered and fluid restriction as ordered by the physician. Review of the medical record revealed a physician's order dated 3/4/25 for 1500 ml fluid restriction: Nurse to give 240ml per shift every day and night shift. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #114 had severe cognitive impairment with no behaviors. Resident #114 was independent with eating and required staff assistance for setting up her tray. She was receiving hemodialysis. Review of the March 2025 medication administration record (MAR) revealed an order dated 3/4/25 for Fluid Restriction: Nurse to give 240 ml per shift every day and night shift. Nursing staff initialed as provided through 3/10/25 when Resident went to the hospital. The order was discontinued on 3/14/25 when Resident #114 reentered the facility after a hospital stay. Resident #114 was discharged to the hospital on 3/10/25 and readmitted to the facility on [DATE]. The hospital discharge summary dated 3/14/25 specified under diet that Resident should not have more than 1400 ml of fluid per day. Review of Resident #114's physician orders revealed no order was entered on 3/14/25 for the 1400 ml per day fluid restriction. Resident #114 was discharged to the hospital on 3/23/25 and was readmitted to the facility on [DATE]. Review of the medical record revealed a physician order dated 3/28/25 for No Added Salt diet, Regular texture and thin consistency fluids. Resident #114 was ordered a 1200 ml a day fluid restriction. The order was received and processed by the Unit Nurse Coordinator. Review of the MAR from 3/14/25 to 4/2/25 revealed no entry for nursing staff to document fluid intake for Resident #114. An interview was conducted with the Unit Nurse Coordinator on 04/02/25 at 01:22 PM. The Unit Nurse Coordinator stated once she entered the fluid restriction order for Resident #114 on 3/28/25, she put the information on the dietary sheet and took it to the kitchen. The Unit Nurse Coordinator stated she did not have a discussion with the dietary department about the fluid distribution. The Unit Nurse Coordinator was unable to state why she did not consult with the dietary department about Resident #114's fluid distribution for nursing staff. She stated a breakdown of the fluid distribution for nursing should go on the MAR. The Unit Nurse Coordinator stated the nurse taking off the fluid restriction order was responsible for putting the fluid distribution on the MAR. An interview was conducted with Nurse #2 on 4/2/25 at 11:05 AM. Review of the electronic medical record with Nurse #2 revealed she was unaware of the change in Resident #114's fluid restriction volume. She stated once an order for fluid restriction was received it was the nurse's responsibility to complete the dietary notification slip and give it to the dietary staff. Nurse #2 stated Dietary had a chart that explained the amount of fluid the resident was to receive from dietary and nursing. Nurse #2 stated she had been giving Resident #114 240 milliliters (ml) of fluid every day and night shift. Nurse #2 stated it was the nurse's responsibility to enter the order for nursing fluid intake on the Medication Administration Record (MAR). Nurse #2 An interview was conducted with the Dietary Manager (DM) on 4/2/25 at 11:10 AM. The DM stated she was aware that Resident #114's fluid restriction had changed. The Dietary Manager stated she received a dietary notification slip on 3/28/25. The Dietary manager stated dietary had been putting 1,080 milliliters (ml) of fluid divided between breakfast, lunch and dinner. An observation of a discussion was conducted of Nurse #2 and the Dietary Manager on 4/2/25 at 11:13 AM. Nurse #2 and the Dietary Manager discussed the distribution of fluids for Resident #114 over 24 hours. Nurse #2 indicated to the Dietary Manager that Nursing would only be able to give the resident 120 ml of fluid if dietary was sending out 1,080 ml with meals. Nurse #2 stated that the amount of fluid was not sufficient for Resident #114's medication pass. The Dietary manager removed 240 ml from her dietary fluid distribution so that nursing would have enough fluids to administer with medications. An interview was conducted with the Director of Nursing on 4/2/25 at 11:20 AM. Resident #114's medical record was reviewed during the interview and revealed a physician order for 1500 ml fluid restriction prior to the resident going to the hospital on 3/10/25. Further review revealed Resident #114 did not have an order entered on the MAR for fluid restriction when she came back to the facility on [DATE]. The DON stated the order must have fallen off the orders, because Resident #114 had a fluid restriction order with distribution for nursing staff prior to her going to the hospital. Continued review of the medical record revealed there was no order for fluid intake from nursing for Resident #114 for the 1200 ml fluid restriction entered on 3/28/25. The DON stated an order for fluid restrictions should have been entered by the nurse who received the order. She stated the nurse, and dietary would collaborate and discuss the amount of fluid from dietary and nursing. The DON stated an order was then entered on the MAR to reflect the amount of fluid to be provided by nursing staff. The DON stated the updated fluid restriction order had not been entered correctly by the Unit Nurse Coordinator on 3/28/25, so that information did not trigger on the 24-hour report. The DON further stated that the Unit Coordinator did not collaborate with the dietary department for Resident #114's fluid restriction breakdown so there was no nursing order for the amount of fluid to be provided by nursing staff. An interview was conducted with the Administrator on 04/02/25 at 05:10 PM. The Administrator stated she expected that dietary and nursing would communicate so that fluid restrictions would be validated.

Based on record review and staff interview, the facility failed to update the care plan to reflect the change in smoking status for 1 of 1 sampled resident (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses that included nicotine dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 33 was unable to answer questions to perform an adequate BIMS assessment. Resident #33 was coded as having impairment on one side to upper extremity and lower extremity. The comprehensive care plan for Resident #33 was last updated on 3/10/25. The care plan included in part the focus area of Resident #33 is a safe smoker. The interventions included to evaluate residents' continued ability to smoke safely on a consistent and regular basis. Review of Resident #33's most recent smoking evaluation dated 3/28/25 revealed the resident required supervised smoking due to his being an unsafe smoker and requires direct supervision whole smoking because he allows lit material to fall outside of the ashtray. This evaluation was completed by Nurse #4. Attempts to interview Nurse #4 by phone were unsuccessful. An interview was conducted with the MDS Coordinator on 4/1/25 at 1:05 PM. She indicated staff took turns going out with the residents on smoking duty. The MDS Coordinator stated she had observed Resident #33 on 3/28/25 and did not see any indication his smoking status had changed. She stated the interdisciplinary team reviews the 24-hour report in the standup meeting every morning and the stand down meeting in the evening. The MDS Coordinator stated the change in smoking status was supposed to be placed on the 24-hour report so it would be discussed in stand-up/stand down meeting and care plan updated at that time. MDS Coordinator stated the 24-hour report was part of the electronic medical record and it was populated by the information the nurses place on the report. The MDS Coordinator stated she must have overlooked Resident #33's smoking assessment on 3/28/25. The MDS Coordinator stated she was responsible for updating the care plan after the change in Resident #33's smoking status. An interview was conducted with the DON on 04/01/25 at 01:13 PM. The DON stated that the 24-hour report was reviewed every morning in the morning meeting. She stated the nurse was responsible for making sure the change to Resident #33's smoking status was communicated on the 24-hour report. The DON stated Nurse #4 should have updated the care plan to reflect the resident's status.

Based on observation, record review, and resident and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 3 residents reviewed for medication administration (Resident #10). The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbances and chronic obstructive pulmonary disease. Resident #10's care plan last reviewed 1/22/25 did not include self-administration of medication. There was not an assessment of Resident #10 in the medical record to determine if it was safe for the resident to self-administer medications. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Review of the medical record revealed a physician order dated 3/1/24 for Fluticasone-Salmeterol 250-50 MCG/ACT (micrograms per actuation) Aerosol Powder (a medication used to relax the muscles in the airways to improve breathing). Breath activated 1 puff inhale orally two times a day for shortness of breath/wheezing. On 03/31/25 at 10:36 AM Resident #10 was observed with a Fluticasone-Salmeterol inhaler sitting on her bedside table. Resident #10 reported Nurse #3 left the inhaler there for her to take because she had asked to wait. Resident #10 stated she had administered the inhaler herself, and Nurse #10 would come back to pick up the inhaler An interview was conducted with Nurse #3 on 03/31/25 at10:43 AM. Nurse #3 stated she was supposed to make sure Resident #10 administered the inhaler and rinsed her mouth out after administration. Nurse #3 stated she was supposed to get the inhaler back after the medication was administered. Nurse #3 stated she was talking to other staff in the room and forgot to get the inhaler back. An interview was conducted with the Director of Nursing on 03/31/25 at 11:53 AM. The DON stated Nurse #3 should have stayed with Resident #10 and watched her take the medication. The DON further stated once Resident #10 told the nurse that she wanted to wait to take the medication Nurse #3 should have taken the medication out of the room and brought it back later. An interview was conducted with the Administrator on 04/02/25 at 05:11 PM. The Administrator stated she expected Resident #10 would have been assessed for self-administration and the medication placed in a secure location.

Based on observation, record review, and staff interviews, the facility failed to obtain a physician order for the management of a peripherally inserted central catheter (PICC) for 1 of 2 residents reviewed for intravenous antibiotic use (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy (disorder that occurs when urine flow is blocked in the urinary tract), urinary tract infection, and diabetes. Review of Resident #41's active March 2025 Physician Orders revealed an order dated 3/26/25 for Piperacillin-Sodium Tazobactam Solution (antibiotic), administer 4.5 grams intravenously every 12 hours for 10 days. There were no orders for a PICC line. An interview was completed on 4/1/25 at 2:32 pm with Nurse #2 who revealed she received the PICC line placement order and intravenous antibiotic order from the Physician on 3/26/25. Nurse #2 stated she entered the order for the intravenous antibiotic so the pharmacy would fill and send the medication as soon as possible. Nurse #2 revealed the Unit Nurse Coordinator normally followed up and entered the orders for the PICC line and the management of it. Nurse #2 stated she was unsure why the orders were not entered that day (3/26/25). Nurse #2 stated she knew from previous experience to flush the PICC line prior to medication administration and after medication administration. A nursing progress note dated 3/26/25 by Nurse #3 stated at 11:30 am vascular wellness placed a PICC line in the Resident #41's left upper arm per the Physician's order. The note revealed the antibiotic was administered to Resident #41 per Physician's order. Resident #41 had a care plan initiated 3/26/25 for a urinary tract infection requiring intravenous antibiotics with interventions that included medications as ordered by the Physician, enhanced barrier precautions, and monitor for redness or drainage around PICC line site. An observation on 4/1/25 at 12:49 pm with Resident #41 revealed a single lumen (1 port) PICC line (form of intravenous access that can be used for a prolonged period for the administration of medications) was located in the left upper arm with antibiotic medication infusing. An interview was completed on 4/1/25 at 1:03 pm with Nurse #1 who was assigned to administer Resident #41's antibiotic medication on 4/1/25. Nurse #1 stated she did notice that PICC line management orders were not entered, but she stated she flushed the PICC line before and after the antibiotic medication was administered. She stated she knew from previous experience that the PICC line required to be flushed prior to the antibiotic to make sure it was not clogged and after the medication was completed to make sure all the medication was administered. Nurse #1 stated she did not know if other orders were required for Resident #41's PICC line use and management. A telephone interview was completed on 4/1/25 at 3:05pm with the facility's Physician. The Physician revealed he recalled providing the verbal order for the PICC line placement and intravenous antibiotic for Resident #41. The Physician stated it was his expectation the facility entered the orders for the PICC line and its management in the Resident's electronic medical records. An interview was completed on 4/2/25 at 10:43 am with the Director of Nursing (DON). The DON stated the Unit Nurse Coordinator, and the (ADON) assisted floor nurses with entering resident treatment and medication orders. The DON stated the facility did not have standing orders for PICC line use and management. The DON revealed physician orders for the use and management of Resident #41's PICC line should have been entered when order for the intravenous antibiotic was entered. The DON was unable to state how the orders were missed for Resident #41's PICC line and the management of it. An interview was completed on 4/2/25 at 4:45 pm with the facility Administrator. The Administrator stated she felt it was a break in communication between nursing staff as to who was going to enter the orders for Resident #41.

Based on record reviews and staff interviews, the facility failed to provide written notice of discharge or transfer including the reason for the hospital transfer to the resident and resident representative for 2 of 5 residents reviewed for hospitalization (Resident #44, Resident #114). The findings included: 1. Resident #44 was admitted to the facility on [DATE]. Review of an incident note dated 11/26/24 revealed Resident #44 was sent to the emergency department due to complaint of left hip pain. Resident #44 was readmitted to the facility on [DATE]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had severe cognitive impairment. There was no evidence in the electronic medical record that written notification of discharge or transfer was provided to the resident or resident representative when the resident was transferred to the hospital. The Social Worker was not available for interview. An interview was conducted with the Administrator on 4/2/25 at 5:05PM. The Administrator stated the Social Worker was responsible for providing the written notice of discharge or transfer. The Administrator stated the Social Worker was new in the position and the facility had arranged for her to do onsite training at a sister facility to learn what forms and duties she was required to complete. The Administrator further stated the written notice of discharge or transfer should include the reason for the transfer and should be sent to the resident or resident representative anytime a resident is transferred to the hospital. 2. Resident #114 was admitted to the facility on [DATE]. Review of the health status note dated 3/11/25 revealed Resident #114 was in the hospital. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 had severe cognitive impairment. Resident #114 was readmitted to the facility on [DATE]. There was no evidence in the electronic medical record that written notification of discharge or transfer was provided to the resident or resident representative when the resident was transferred to the hospital. The Social Worker was not available for interview. An interview was conducted with the Administrator on 4/2/25 at 5:05PM. The Administrator stated the Social Worker was responsible for providing the written notice of discharge or transfer. The Administrator stated the Social Worker was new in the position and the facility had arranged for her to do onsite training at a sister facility to learn what forms and duties she was required to complete. The Administrator further stated the written notice of discharge or transfer should include the reason for the transfer and should be sent to the resident or resident representative anytime a resident is transferred to the hospital.

Based on record review, family, staff, and physician interviews the facility failed to provide notification to the physician and responsible party upon initial observance of maggots in and on the dressing of a heel wound for one (Resident #1) of three residents reviewed for notification of a change in condition. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses some of which included Type 2 Diabetes Mellitus with diabetic peripheral neuropathy, chronic kidney disease, and diabetic foot ulcers. Nurse #2 was interviewed on 5/29/2024 at 12:39 PM and again at 2:33 PM. Nurse #2 revealed the following events as occurring and reconfirmed the events upon a second interview. Nurse #2 stated she worked the 7:00 AM to 7:00 PM shift and was assigned to care for Resident #1. Nurse #2 stated it was approximately 3:30 PM to 4:00 PM and she obtained the assistance of NA #2 to hold up the left lower limb of Resident #1 to perform wound care on a left heel wound. Nurse #2 stated she sprayed wound cleanser on the bandage to soak it and remove the bandage. Nurse #2 stated as she removed the bandage a maggot dropped onto the barrier pad underneath the heel. Nurse #2 stated a family member of Resident #1 walked into the room while wound care was being provided. Nurse #2 stated she did not say anything to NA #2 when the maggot dropped down but looked at NA #2 so as not to alert the family member in the room. Nurse #2 stated she observed ten but less than 20 maggots on the wound and dressing of Resident #1. Nurse #2 stated she cleaned out all the maggots and cleaned the wound well with the wound cleanser before completing the wound care orders and rewrapped the dressing. Nurse #2 stated after leaving the room, she approached NA #2 and told her she saw maggots in the wound of Resident #1 and for her to go and find the DON to tell her. Nurse #2 stated all of this occurred on 5/14/2024. Nurse #2 stated she did notify the DON who told her she, the DON, would take care of everything including talking to the family of Resident #1. Nurse #2 stated she went back to her nursing duties on 5/14/2024 and left the notification of the physician and the family to the DON. Nurse #2 stated the only error she made was in not documenting the notification of the DON of the maggots in the wound and dressing. Nurse #2 stated she recalled the date of 5/14/2024 because she recalled the date on the bandage prior to its removal. Nurse #2 indicated she spoke with the DON again on 5/16/2024 in the morning confirming with her she did perform the dressing change on 5/14/2024 and she did see maggots in the wound and dressing on that day. Nurse #2 stated she did not perform wound care on Resident #1 on 5/16/2024 but, she knew the dressing change and wound care orders were completed after Resident #1 took a shower. NA #2 was interviewed on 5/29/2024 at 2:50 PM. NA #2 confirmed on the 3:00 PM to 11:00 PM shift on 5/14/2024 she was assigned to care for Resident #1. NA #2 stated Nurse #2 requested her help in positioning Resident #1 for wound care. NA #2 revealed when she was holding the left leg of Resident #1, a maggot dropped down on the pad below the heel, but she did not know what it was at the time. NA #2 stated she did not look at the heel wound, nor did she see any other maggots. NA #2 reiterated it was her responsibility to hold the left leg and that was what she did. NA #2 confirmed a family member did enter the room during the wound care treatment on that day. NA #2 stated upon completion of the wound care she removed the trash from room. NA #2 revealed Nurse #2 approached her in the hallway and asked her if she knew what it was that dropped onto the pad below the heel. NA #2 told her she did not know, and Nurse #2 told her it was a maggot. NA #2 then revealed Nurse #2 told her to go find the DON and tell her about the maggot. NA #2 stated she looked for the DON, but the DON had already left for the day so, she returned to her nurse aide duties. NA #1 was interviewed on 5/29/2024 at 12:15 PM. NA #1 stated on her initial morning rounds for her 7:00 AM to 3:00 PM shift, as she was assisting Resident #1 with care, she observed a maggot in the bed near the left foot of Resident #1 and one maggot on the floor. NA #1 could not recall what day this occurred. NA #1 revealed she immediately reported this to the Unit Manager (Nurse #1) in the hallway. NA #1 stated Nurse #1 came into the room of Resident #1, saw the maggots, and went to notify the DON while NA #1 stripped the bed and threw the maggots in the garbage. NA #1 could not recall what day this occurred. Nurse #1 was interviewed on 5/29/2024 at 12:37 PM. Nurse #1 stated as soon as she clocked in for the day on 5/16/2024 she was notified by NA #1 of maggots in the room of Resident #1, and she went to the room of Resident #1 and observed a maggot on the bed. Nurse #1 confirmed she notified the DON and accompanied NA #1 to the shower room to assess the wounds of Resident #1 and administer wound care after the shower. The DON was interviewed on 5/29/2024 at 11:35 AM. The DON stated Resident #1 was reported to have a maggot observed on the bed and another one on the floor, but she herself never saw them. The DON explained on 5/16/2024 she was not in the building but was notified Certified Nursing Assistant (NA) #1 found the maggots in the room of Resident #1. The DON revealed she came to the building and was told by NA #1 she observed one maggot on the floor and one on the blanket in the bed on Resident #1 close to his left heel wound. NA #1 reported to the DON she had already thrown the maggots away in the garbage immediately. The DON stated she spoke with Nurse #2, the nurse assigned to care for Resident #1 from 7:00 AM to 7:00 PM on 5/16/2024 and was told she had already completed wound care for Resident #1, and she too had seen the maggots. The DON stated when the RP arrived at the facility, she spoke with him in her office and informed him of the maggot or maggots observed in the bed and on the floor as well as the steps that were being taken to prevent reoccurrence of maggots. The DON stated she then called the physician (MD #1) for Resident #1 to inform him of the maggot observations by the nursing staff. The DON was reinterviewed on 5/29/2024 at 1:50 PM. The DON was adamant she was only made aware of the one maggot on the bed and one on the floor observed by NA #1 on 5/16/2024. The DON stated when she spoke with Nurse #2 on 5/16/2024 she assumed she was talking about performing wound care for Resident #1on the morning of 5/16/2024 and observing a maggot at that time. An interview was conducted with the responsible party (RP) for Resident #1 on 5/29/2024 at 11:13 AM. The RP for Resident #1 revealed the following information. A couple of weeks ago the RP came to visit Resident #1 in the facility in the morning. When the RP arrived at the facility he was notified by the Director of Nursing (DON), a maggot had been observed by the nursing staff on the foot of Resident #1. The RP of Resident #1 asked the DON what the facility was going to do about it and what steps were going to be taken so that it does not happen again. The DON told the RP, Resident #1 was going to be taken to the shower and the room of Resident #1 was going to be deep cleaned to find the source of the maggot or maggots. The Administrator was interviewed on 5/29/2204 at 3:30 PM. The Administrator confirmed Nurse #2 should have called the Director of Nursing and the physician immediately upon visualizing the maggots on 5/14/2024. The Administrator also confirmed that the responsible party for Resident #1 should have notified as soon as possible as well. Documentation in a physician's follow up note dated 5/16/2024 revealed in part, Reviewed most recent wound care notes. Alerted this morning, a few hours ago, of the patient potentially having in his left heel some maggot formation. Since that time, the wound has been inspected and thoroughly cleansed and dressed. It is doing well. On my inspection this afternoon, there is no evidence of any maggot formation. The patient is not septic or toxic. He appears at baseline. He denies any pain. I do not think there is any significant decomposition in his sacral right heel or left heel wounds. MD #1, the physician for Resident #1, was interviewed on 5/30/2024 at 9:30 AM. MD #1 stated he would have wanted to be notified on 5/14/2024 if maggots were found in the left heel wound of Resident #1. MD #1 stated if he had been notified of 5/14/2024 he would have come to the facility to visualize the wound and to make sure the wound was cleaned appropriately. MD #1 stated he came to the facility on [DATE] and observed the left heel wound for Resident #1. MD #1 stated all the wounds to include the left heel wound, looked good and did not appear to be infected. MD #1 stated although historically maggots had been used to debride wounds without causing harm, it was not currently good practice.

Based on record review, family, staff, and physician interviews the facility failed to determine if a higher level of care was needed when maggots were observed in a heel wound for one (Resident #1) of three residents reviewed for professional standards of care for wounds. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses some of which included Type 2 Diabetes Mellitus with diabetic peripheral neuropathy, chronic kidney disease, and diabetic foot ulcers. Resident #1 had a physician's order initiated on 4/8/204 for the left heel ulcer to be cleaned with normal saline/dermal wound cleanser, application of Aquacel Ag to the wound bed, and cover with a dry dressing every other day and as needed. Aquacel Ag is a sterile, soft, non-woven dressing that contains ionic silver, a broad-spectrum antimicrobial agent. Documentation on a wound ulcer flow sheet dated as completed 5/10/2024 revealed Resident #1 had a Stage 4 left heel wound 6.2 inches in length, 7.8 inches in width, and an undefined depth. Documentation on the Treatment Administration Record (TAR) supplementary documentation dated 5/11/2024 at 11:13 PM for Resident #1 revealed wound care for both heels was administered by Nurse #4. Nurse #4 was interviewed on 5/30/2024 at 8:40 AM. Nurse #4 revealed she had worked in the facility on 5/11/2024 and 5/12/2024 for the 7:00 PM to 7:00 AM shift. Nurse #4 revealed she had been told in the report when she arrived at 7:00 PM on 5/11/2024 the facility was in between treatment nurses and there would not be a wound care nurse in the facility to perform wound care for Resident #1 on 5/12/2024 as scheduled. Nurse #4 confirmed she performed wound care for Resident #1 to include his left heel wound on 5/11/2024. Nurse #4 stated she did not see any maggots on the left heel wound and the wound looked good. Nurse #4 stated she did not see Resident #1 again until late on 5/12/2024 when he returned to the facility after a visit out with his family. Nurse #4 stated Resident #1 returned to the facility on [DATE] with his dressing intact and she did not note any concerns. Nurse Aide (NA #1) was interviewed on 5/29/2024 at 5:04 PM. NA #1 revealed she was assigned to care for Resident #1 on 5/12/2024 for the 7:00 AM to 3:00 PM shift. NA #1 stated she assisted Resident #1 in getting dressed on 5/12/2024 prior to leaving with his family at approximately 8:00 AM and he did not return to the facility on her shift that day. NA #1 revealed both dressings were intact because she would have told the nurse if either dressing was not intact prior to Resident #1 leaving the facility on 5/12/2024. Documentation on the TAR dated 5/14/2024 and 5/16/2024 revealed Nurse #2 administered wound care for the left heel of Resident #1. Nurse #2 was interviewed on 5/29/2024 at 12:39 PM and again at 2:33 PM. Nurse #2 revealed the following events as occurring and reconfirmed the events upon a second interview. Nurse #2 stated she worked the 7:00 AM to 7:00 PM shift and was assigned to care for Resident #1. Nurse #2 stated it was approximately 3:30 PM to 4:00 PM and she obtained the assistance of NA #2 to hold up the left lower limb of Resident #1 to perform wound care on a left heel wound. Nurse #2 stated she sprayed wound cleanser on the bandage to soak it and remove the bandage. Nurse #2 stated as she removed the bandage a maggot dropped onto the barrier pad underneath the heel. Nurse #2 stated a family member of Resident #1 walked into the room while wound care was being provided. Nurse #2 stated she did not say anything to NA #2 when the maggot dropped down but looked at NA #2 so as not to alert the family member in the room. Nurse #2 stated she observed ten but less than 20 maggots on the wound and dressing of Resident #1. Nurse #2 stated she cleaned out all the maggots and cleaned the wound well with the wound cleanser before completing the wound care orders and rewrapped the dressing. Nurse #2 stated after leaving the room, she approached NA #2 and told her she saw maggots in the wound of Resident #1 and for her to go and find the DON to tell her. Nurse #2 stated all of this occurred on 5/14/2024. Nurse #2 stated she did notify the DON who told her she, the DON, would take care of everything including talking to the family of Resident #1. Nurse #2 stated she went back to her nursing duties on 5/14/2024 and left the notification of the physician and the family to the DON. Nurse #2 stated the only error she made was in not documenting the notification of the DON of the maggots in the wound and dressing. Nurse #2 stated she recalled the date of 5/14/2024 because she recalled the date on the bandage prior to its removal. Nurse #2 indicated she spoke with the DON again on 5/16/2024 in the morning confirming with her she did perform the dressing change on 5/14/2024 and she did see maggots in the wound and dressing on that day. Nurse #2 stated she did not perform wound care on Resident #1 on 5/16/2024 but, she knew the dressing change and wound care orders were completed after Resident #1 took a shower. Review of the nursing notes documentation on 5/14/2024 and 5/16/2024 did not reveal any documentation of the observance of maggots on or near the wounds for Resident #1. NA #2 was interviewed on 5/29/2024 at 2:50 PM. NA #2 confirmed on the 3:00 PM to 11:00 PM shift on 5/14/2024 she was assigned to care for Resident #1. NA #2 stated Nurse #2 requested her help in positioning Resident #1 for wound care. NA #2 revealed when she was holding the left leg of Resident #1, a maggot dropped down on the pad below the heel, but she did not know what it was at the time. NA #2 stated she did not look at the heel wound, nor did she see any other maggots. NA #2 reiterated it was her responsibility to hold the left leg and that was what she did. NA #2 confirmed a family member did enter the room during the wound care treatment on that day. NA #2 stated upon completion of the wound care she removed the trash from room. NA #2 revealed Nurse #2 approached her in the hallway and asked her if she knew what it was that dropped onto the pad below the heel. NA #2 told her she did not know, and Nurse #2 told her it was a maggot. NA #2 then revealed Nurse #2 told her to go find the DON and tell her about the maggot. NA #2 stated she looked for the DON, but the DON had already left for the day so, she returned to her nurse aide duties. NA #1 was interviewed on 5/29/2024 at 12:15 PM. NA #1 stated on her initial morning rounds for her 7:00 AM to 3:00 PM shift, as she was assisting Resident #1 with care, she observed a maggot in the bed near the left foot of Resident #1 and one maggot on the floor. NA #1 could not recall what day this occurred. NA #1 revealed she immediately reported this to the Unit Manager (Nurse #1) in the hallway. NA #1 stated Nurse #1 came into the room of Resident #1, saw the maggots, and went to notify the DON while NA #1 stripped the bed and threw the maggots in the garbage. NA #1 could not recall what day this occurred. Nurse #1 was interviewed on 5/29/2024 at 12:37 PM. Nurse #1 stated as soon as she clocked in for the day on 5/16/2024 she was notified by NA #1 of maggots in the room of Resident #1, and she went to the room of Resident #1 and observed a maggot on the bed. Nurse #1 confirmed she notified the DON and accompanied NA #1 to the shower room to assess the wounds of Resident #1 and administer wound care after the shower. The DON was interviewed on 5/29/2024 at 11:35 AM. The DON stated Resident #1 was reported to have a maggot observed on the bed and another one on the floor, but she herself never saw them. The DON explained on 5/16/2024 she was not in the building but was notified Certified Nursing Assistant (NA) #1 found the maggots in the room of Resident #1. The DON revealed she came to the building and was told by NA #1 she observed one maggot on the floor and one on the blanket in the bed on Resident #1 close to his left heel wound. NA #1 reported to the DON she had already thrown the maggots away in the garbage immediately. The DON stated she spoke with Nurse #2, the nurse assigned to care for Resident #1 from 7:00 AM to 7:00 PM on 5/16/2024 and was told she had already completed wound care for Resident #1, and she too had seen the maggots. The DON stated she immediately had Resident #1 taken to the shower room to have his entire body cleaned, his wounds assessed, and his wound care treatments redone. The DON stated she had the room of Resident #1 deep cleaned to include the floor, bed, curtains, blinds, and cabinets. The DON said any food or snacks that were open were discarded and any additional food was put in a covered plastic container. The DON stated that in addition, the soft padded boot Resident #1 wore was cleaned. The DON stated when the RP arrived at the facility, she spoke with him in her office and informed him of the maggot or maggots observed in the bed and on the floor as well as the steps that were being taken to prevent reoccurrence of maggots. The DON stated she then called the physician (MD #1) for Resident #1 to inform him of the maggot observations by the nursing staff. An interview was conducted with the responsible party (RP) for Resident #1 on 5/29/2024 at 11:13 AM. The RP for Resident #1 revealed the following information. A couple of weeks ago the RP came to visit Resident #1 in the facility in the morning. When the RP arrived at the facility he was notified by the Director of Nursing (DON), a maggot had been observed by the nursing staff on the foot of Resident #1. The RP of Resident #1 asked the DON what the facility was going to do about it and what steps were going to be taken so that it does not happen again. The DON told the RP, Resident #1 was going to be taken to the shower and the room of Resident #1 was going to be deep cleaned to find the source of the maggot or maggots. The RP requested Resident #1 be taken to the emergency room for assessment of the wound because he was greatly concerned there might be more maggots or wound care was not being done properly at the facility. Documentation in the nursing notes dated 5/16/2024 revealed Resident #1 was sent to the emergency room for an evaluation of his wounds at the request of his RP and returned to the facility with no new orders. The DON was interviewed on 6/30/2024 at 8:30 AM. The DON stated she spoke with Nurse #2 and confirmed Nurse #2 had told her she saw 10 but less than 20 maggots on the left heel wound of Resident #1 on 5/14/2024 during wound care. The DON denied Nurse #2 had contacted her to tell her about the maggots seen in the wound of Resident #1 on 5/14/2024 and that the first occurrence of her being notified was on the morning of 5/16/2024. The DON stated that the actions she took on the morning of 5/16/2024 to have the wound assessed by the physician and the deep cleaning of the room to find the source of the maggots would have been completed on 5/14/2024, had she known of the maggots. The DON stated when she spoke with Nurse #2 on 5/16/2024 she assumed Nurse #2 was talking about performing wound care for Resident #1on the morning of 5/16/2024. Documentation in a physician's follow up note dated 5/16/2024 revealed in part, Reviewed most recent wound care notes. Alerted this morning, a few hours ago, of the patient potentially having in his left heel some maggot formation. Since that time, the wound has been inspected and thoroughly cleansed and dressed. It is doing well. On my inspection this afternoon, there is no evidence of any maggot formation. The patient is not septic or toxic. He appears at baseline. He denies any pain. I do not think there is any significant decomposition in his sacral right heel or left heel wounds. MD #1, the physician for Resident #1, was interviewed on 5/30/2024 at 9:30 AM. MD #1 stated he would have wanted to be notified on 5/14/2024 if maggots were found in the left heel wound of Resident #1. MD #1 stated if he had been notified of 5/14/2024 he would have come to the facility to visualize the wound and to make sure the wound was cleaned appropriately. MD #1 stated he wished he had a picture or at least a written description on 5/14/2024 so that he could determine if the wound was cleaned appropriately and evaluate the treatment that was provided for the removal of the maggots in the left heel wound of Resident #1. MD #1 confirmed he came to the facility on [DATE] and observed the left heel wound for Resident #1. MD #1 stated all the wounds to include the left heel wound, looked good and did not appear to be infected. MD #1 stated although historically maggots had been used to debride wounds without causing harm, it was not currently good practice. MD #1 stated after he evaluated the wounds of Resident #1 on 5/16/2024, the RP for Resident #1 requested Resident #1 be sent to the emergency room for wound evaluation confirming no more maggots or concerns were found.

Based on record review and staff interviews the facility failed to accurately code a Flowsheet of Non-ulcer Skin Conditions for the use of a gastrostomy tube (a tube inserted into the stomach used to provide nutrition) for 1 of 18 residents (Resident #13) reviewed for accuracy of assessments. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included a stroke resulting in left sided weakness, and dysphagia (difficulty swallowing). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had a gastrostomy tube and did not indicate they used an indwelling urinary catheter. The Flowsheets of Non-Ulcer Skin Conditions dated 1/31/2024. 2/7/2024, and 2/14/2024 indicated Resident #13 had an indwelling urinary catheter. The February 2024 Physician Order Summary revealed an order to infuse tube feeding solution at 65 milliliters per hour continuous via gastrostomy tube. The order summary did not reveal an order for the use of an indwelling urinary catheter for Resident #13. An observation completed of Resident #13 on 2/19/2024 at 2:00pm revealed the use of a gastrostomy tube for the delivery of nutrition but did not reveal the use of an indwelling urinary catheter. An interview was completed on 2/20/2024 at 1:17pm with the Assistant Director of Nursing (ADON). The ADON revealed Resident #13 did not have an indwelling urinary catheter but did have a gastrostomy tube. The ADON verified she completed the Flowsheet of Non-Ulcer Skin Conditions dated 2/7/2024, and 2/14/2024. She indicated the flowsheet should have been noted as the Resident having a gastrostomy tube and not a urinary catheter. The ADON stated she mistakenly checked the wrong box when completing the form. An interview was completed on 2/20/2024 at 2:00pm with the Wound Nurse. The Nurse revealed Resident #13 did not have an indwelling urinary catheter but did have a gastrostomy tube. The Wound Nurse verified he completed the Flowsheet of Non-Ulcer Skin Conditions dated 1/31/2024. He indicated the flowsheet should have been coded as the Resident having a gastrostomy tube and not a urinary catheter. The Nurse stated he mistakenly checked the wrong box when completing the form. An interview was completed on 2/22/24 at 9:06am with the Director of Nursing (DON) and the Clinical Director. The DON stated the flowsheet should have accurately reflected Resident #13's use of medical devices.

Based on observations, staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 3/4/21 focused infection control survey and recertification and complaint survey on 4/30/21. This was for a recited deficiency on the current recertification survey in the area of infection control. The continued failure during three federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F880: Based on observation, staff interviews, record review, the facility failed to perform hand hygiene between glove changes and failed to change soiled gloves before placing a clean dressing on the pressure ulcer for 1 of 3 residents observed for pressure ulcer treatment (Resident #28). During the recertification and complaint survey on 4/30/21 the facility was cited for failing to implement their procedures for PPE and hand hygiene. During the focused infection control survey on 3/4/21 the facility was cited for failure to post transmission-based precaution signage on quarantined resident's doors. An interview was completed on 12/2/22 at 11:10am with the Administrator and Corporate Consultant. The Administrator indicated the QAA committee meets monthly to discuss the facility's ongoing performance improvement plans. The Corporate Consultant indicated it was her expectation the facility continued to follow the QAA process and monitor those issues within the facility so they would not receive a recited deficiency.

Based on observation, staff interviews, record review, the facility failed to perform hand hygiene between glove changes and failed to change soiled gloves before placing a clean dressing on the pressure ulcer for 1 of 3 residents observed for pressure ulcer treatment (Resident #28). Findings included: Record review of the Facility Infection Prevention and Control Program (IPCP) Policy dated 3/10/20 revealed the facility was responsible to establish and maintain an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. The IPCP objectives included to provide hand hygiene procedures to be followed by staff involved in direct resident contact. Record review of the Facility Wound Dressing Change Observation Audit Tool (no date) revealed gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities (e.g., after removal of soiled dressings, before handling clean supplies). During a continuous observation of a pressure ulcer treatment on 12/01/22 at 9:40 am through 9:55 am the Wound Nurse was observed to perform hand hygiene, don clean gloves, and remove the soiled dressing from Resident #28's sacral wound. She then removed the dirty gloves and donned clean gloves. No hand hygiene was completed prior to donning the clean gloves. She then cleaned the wound bed and surrounding skin with normal saline and patted dry with gauze pads. The Wound Nurse did not perform hand hygiene or change the dirty gloves and placed the clean dressing on the sacral wound bed with the dirty gloves. The Wound Nurse then removed the dirty gloves and donned clean gloves and completed the pressure ulcer treatment. No hand hygiene was completed prior to donning clean gloves. During an interview on 12/01/22 at 9:57 am the Wound Nurse revealed she was required to use hand sanitizer before donning gloves and should have changed the dirty gloves before touching the new dressing for Resident #28's pressure ulcer treatment. The Wound Nurse stated she normally performed hand hygiene and changed gloves when performing wound treatments but was unable to state why she did not complete it correctly during the observation. During an interview on 12/01/22 at 1:50 pm the Infection Preventionist revealed the Wound Nurse was required to use hand sanitizer or soap and water in between glove changes and she was to remove the dirty gloves, perform hand hygiene and don clean gloves between cleaning the wound and applying the new dressing. During an interview on 12/02/22 at 9:35 am the Director of Nursing (DON) revealed hand hygiene with either liquid hand sanitizer or soap and water was to be performed when gloves were removed. The DON stated the Wound Nurse had received education on hand hygiene and should have changed gloves and performed hand hygiene before touching the new wound dressing for Resident #28. During an interview on 12/02/22 at 9:44 am the Administrator revealed the Wound Nurse was expected to change gloves and perform hand hygiene as required during the pressure ulcer treatment for Resident #28.

Based on resident and staff interviews the facility failed to make personal funds available for 3 of 3 residents reviewed for personal funds (Resident #6, Resident #4, and Resident #7). The findings included: 1a. Resident #6 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. On 4/7/22 at 12:15 PM Resident #6 stated in an interview that the facility received his social security check on the third of each month and that he still could not get his $30.00 that he is allowed from his check each month. Resident #6 further stated he went to the business office today and was told they had not been to the bank. On 4/8/22 at 9:50 AM a second interview was conducted with Resident #6 who stated he frequently got his money late and one month recently it was the 15th of the month before he could get his $30.00. b. Resident #4 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. On 4/7/22 at 12:22 PM Resident #4 stated in an interview he had to wait until the middle of the month to get his $30.00 from his social security check and wanted to know why it took so long for him to get his money. The Resident stated that he needed his money. c. Resident #7 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. On 4/7/22 at 12:22 PM Resident #7 stated in an interview that the facility got his social security check on the 3rd of the month, and he had been up to the office on April 3rd, 4th, and 6th and again today and they still did not have his $30.00. Resident #7 stated: I only get #30.00 a month and I need it. On 4/8/22 at 10:15 AM Receptionist #1 stated in an interview that when resident's came and asked for their money they saw the person in Payroll and he would pull up the resident's account to see how much money was in the account and would do the paperwork and the resident would sign the form and then come to her and she would give the resident the money and the paperwork would then go to the Business Office Manager. Receptionist #1 further stated she did not think the residents were able to get any money yesterday and that around April 1, 22 there was $75 in the box and 2 residents asked for $30.00 and that left $15.00 in the box, and she gave the Business Office Manager the forms and let her know there was only $15.00 left in the box. On 4/8/22 at 10:25 AM the Business Office Manager (BOM) stated in an interview that she had worked in the facility for 2 weeks and they had a new Administrator, and she was waiting for approval for her to sign the checks and when it was approved, she would get the check signed and cashed so the residents could get their money. The Business Office Manager stated the Vice President of Operations was supposed to be on the signature card at the bank but until this was confirmed, she could not sign the check. An interview was conducted with the Vice President of Operations and the Interim Administrator on 4/8/22 at 2:28 PM The Vice President of Operations stated the previous administrator thought he had to go to the bank in another town (which was where he lived) to cash the check and by the time he got off work and got there the bank was closed and she thought this had been the reason in the past for the delay. The Interim Administrator stated she had worked at the facility for one week and had requested authorization to sign the checks and was waiting for approval. The Vice President of Operations stated the residents should be able to get their money and she was working on the problem today.

Based on record review, staff, registered dietician and physician interview the facility failed to implement a comprehensive approach to pressure ulcer care and services for a resident who was at risk for pressure ulcers for 2 (Resident #229 and Resident #34) of 6 residents reviewed for pressure ulcers. The findings included: 1. Resident #229 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Dysarthria is a weakness in the muscles used for speech which often causes slowed or slurred speech. On [DATE] the resident was diagnosed with COVID-19 and transferred to a COVID only facility. The resident was readmitted to the facility on [DATE]. An admission progress note revealed the following: Was admitted from a sister facility COVID only. Excoriation to sacrum with blanchable redness. A pressure ulcer risk assessment dated [DATE] noted the resident was at high risk for pressure ulcers. Prevention interventions were documented as follows: Turning and repositioning. Moisturizer/cream. Barrier cream at bedside. Skin alterations: Left flank and coccyx - redness. A non-ulcer skin sheet dated [DATE] noted excoriation to the sacrum and the physician had been notified. Excoriation sacrum: 8 centimeters (cm) by 5 cm by 0.2 cm. The resident's Care Plan revised on [DATE] noted the resident was at risk for skin breakdown or development of pressure ulcers related to physical limitation. The interventions included the following: Staff to report to nurse any red or open areas. Pressure relieving mattress, float heels when in bed, turn and position frequently, use a draw sheet for turning if needed. The interventions included bunny boots to feet and heels and observe skin daily for any changes and report any abnormal observations. The Care Plan revealed the resident had excoriation to the buttocks. The interventions were to administer medications and treatment as ordered and to observe for changes in skin integrity or skin impairment and notify the physician as necessary. On [DATE] a progress note revealed there was the excoriation to the sacrum had healed and noted a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The MDS noted the resident required extensive assistance with bed mobility, was not ambulatory and required total assistance with dressing, toileting, personal hygiene, bathing and was able to feed herself after tray set-up. The MDS noted the resident had limited range of motion of both upper and both lower extremities and was incontinent of bowel and bladder. The resident's weight on the MDS was 166 pounds with no significant weight loss or gain. The MDS revealed the resident was at risk for pressure ulcers and had one unstageable pressure ulcer on admission and moisture associated skin damage. The MDS noted a pressure reducing device was used for the bed and chair and the resident received pressure ulcer care and the application of a non-surgical dressing. A note by the registered dietician (RD) dated [DATE] noted the following: Resident was admitted with COVID. PO (by mouth) intake approximately 50 percent of a regular diet. Name of nutritional drink 90ccs three times a day for prevention of weight loss. Pressure ulcer toe and excoriation of the sacrum. (Healed on [DATE]). Interventions for wound healing: Multivitamin and name of protein supplement 30ccs twice a day. [MEDICATION(S)] (Protein) level 2.9 (low). No [CONDITION(S)] reported at this time. Current body weight 164.4 pounds. Current diet order meets requirements. Wound healing interventions in place as well as intervention for the prevention of weight loss. Will continue to monitor. A physician's note dated [DATE] revealed the resident had intermittent episodes of mental status changes and a history of urinary tract infections. PO intake appears to be fairly stable overall. The note revealed the physician had been told the resident had some sacral excoriation versus breakdown being reported as excoriation versus unstageable sacral pressure wounds and possibly some eschar formation. No signs of infection or drainage or odor. The Physical Examination revealed the following. She is awake, alert and oriented at baseline. She definitely looks more chronically ill than she did prior to COVID. Mucous membranes are moist. Given her body habitus and assistance, I was not able to completely visualize the sacral area. Notes from the treatment nurse noted to be sacral area approximately 5 by 8 cm area as well. (On admission, now healed). The Plan revealed the following: Continue the course for now, offloading, nutritional support. Certainly, need to trend and obtain accurate weights. Notify if any changes acutely. Notify of any changes acutely if any skin breakdown or changes acutely otherwise. Otherwise continue wound treatment with local wound protocol and nutritional support. A Wound Ulcer Sheet dated [DATE] noted a new Stage II pressure ulcer on the sacrum that measured 2.0 cm by 1.5 cm by 0.1 cm with a small amount of serous drainage, eschar and redness but no infection. Cleanse with normal saline, pat dry and apply (name of) dressing. This dressing has calcium alginate and silver. The dressing is a highly absorbent dressing that protects the wound bed. The silver in the dressing helps to protect against infection. Section 12. MD (medical doctor) Notification Date was not filled out. There were no documentation in the progress notes that the physician had been notified of the new skin breakdown. A Situational-Background-Assessment-Recommendations (SBAR) note dated [DATE] at 4:51 AM noted the following: Skin wound ulcer. Unresponsive. Vital signs: Blood Pressure (BP) ,d+[DATE]. Temperature 99.8 degrees Fahrenheit. Pulse 80 irregular. Respirations 24. Apical heart rate 100. Most recent weight 150.5 pounds. Unresponsive, low BP, temperature and sacral decubitus. To ED for evaluation. A nurse's progress note dated [DATE] at 4:51 revealed the nurse went to the room to help the nursing assistant change the dressing and the resident was found to be unresponsive. BP ,d+[DATE]. Temperature 99.8 degrees Fahrenheit. Pulse 88. Respirations 24. Apical pulse 100, Did sternal rub with no response. Physician notified and new orders given to send the resident to the hospital for evaluation. Resident left facility at 5:15 AM. Called to get report on resident and resident septic, urinary tract infection and decubitus. Resident to be admitted . A progress note dated [DATE] at 5:09 PM that read: N.O. (new order). Cleanse stage 2 sacrum wound with NS (normal saline), pat dry, apply (name of dressing). Measurements of wound 2x1.5x0.1 (2cm by 1.5cm by 0.1cm). Has eschar and redness around wound, upper sacrum has excoriation, barrier cream applied. This note was a late entry documented by the treatment nurse after the resident had been discharged to the hospital. Review of the Emergency Department (ED) Record dated [DATE] at 5:36 AM revealed the following: A female that presents with unresponsiveness. BP ,d+[DATE]. Temperature 100.6 degrees Fahrenheit. Pulse 104. Respirations 26. Weight 67.9 kilograms (149 pounds). Physical Exam: Patient appears pale, breathing on her own. Responds with grunting to sternal rub. Sacral decub (decubitus) with black eschar, purulent drainage noted in an area of the wound with palpation. Medical Decision Making/Plan: Presents unresponsive from nursing home, [CONDITION(S)] noted. Suspect [CONDITION(S)]. Urine possible source as well as sacral decubitus which is notable for purulent drainage. Laboratory (Lab) studies conducted in the ED included the following: COVID test negative. Serum White Blood Cell (WBC) count 29,000 (Normal range 4.,d+[DATE].0) indicating infection. Hemoglobin 9.7 (12.,d+[DATE].0). Hematocrit 29.7 (35.,d+[DATE].0). Sodium 138 (,d+[DATE]). Potassium 3.8 (3.,d+[DATE].4). chloride 106 (,d+[DATE]). Glucose 130 (,d+[DATE]). Blood Urea [MEDICATION(S)] (BUN) 39 (,d+[DATE]). Creatinine 1.19 (0.,d+[DATE].11). Total Protein 5.6 (6.,d+[DATE].1). [MEDICATION(S)] 2.3 (3.,d+[DATE].6). Urinalysis positive for infection. Urine Culture showed greater than 100,000 colonies per milliliter of [CONDITION(S)] Pneumoniae. One Blood Culture was negative at 5 days and one Blood Culture grew Enterococcus Faecalis. The Admission History and Physical noted the following: In the ED was found to be febrile with temperature 100.6 degrees Fahrenheit. WBC 29,000. Hypotensive and elevated Troponin. Urinalysis suggested urinary tract infection (UTI). Head CAT Scan negative and chest x-ray showed pulmonary [CONDITION(S)]. Given intravenous fluids without improvement in the BP and started on a medication to increase the blood pressure. Patient also noted to have sacral decubitus that appeared to be infected. Due to septic shock, hospitalist asked to admit for further care. The Hospital Discharge Summary noted the patient was brought to the ED due to unresponsiveness. Patient with infected sacral ulcer initially treated with broad spectrum antibiotics and pressors (medication to increase blood pressure) for septic shock. Family elected comfort care given her overall poor prognosis. Expired on [DATE] at 11:10 PM. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Unstageable sacral pressure ulcer. Wound infection, dementia, severe protein calorie malnutrition and MI (Myocardial Infarction or heart attack). An interview was conducted with the Treatment Nurse on [DATE] at 9:42 AM who stated on [DATE] the resident had a excoriation of the sacrum when readmitted to the facility. The Treatment Nurse stated the nursing assistants (NAs) would come and tell her if she needed to look at a skin issue and thinks one of the NAs got her to look at the new stage II wound for this resident on [DATE]. The Treatment Nurse further stated she followed the standing orders for treatment but forgot to write the new order and she put in the order on [DATE]. The Treatment Nurse continued and stated she had been working in the facility for about 3 days and was new and still learning and did not notify the doctor about the change in the resident's skin condition. On [DATE] at 1:49 PM an interview was conducted with the Director of Nursing (DON). The DON stated they have a morning meeting with the department heads, including dietary and discuss changes in condition. The DON further stated any worsening of the wound the physician should be notified to get new orders for treatment even though they have standing orders for wounds. The DON stated the nurses were not required to do weekly skin assessments and the NAs were supposed to report any skin changes to the nurse daily. On [DATE] at 12:25 PM a telephone interview was conducted with Medication (Med) Aide #1 who stated she worked first shift with the resident. The Med Aide stated she did not recall if the resident had any skin issues. An interview was conducted with Med Aide #2 on [DATE] at 12:40 PM. The Med Aide stated the resident had some skin issues when she returned from the COVID facility but did not recall if she developed anything new after that. On [DATE] at 1:25 PM an interview was conducted with the Unit Manager (UM) who stated if there was not a treatment ordered she would not have seen her sacrum. On [DATE] at 2:50 PM an interview was conducted with Nurse #1 who was assigned to the resident on night shift on ,d+[DATE]-,d+[DATE] and sent the resident to the hospital. The Nurse stated she went in the resident's room around 5:00 AM during her medication pass and was unable to wake up the resident even with a sternal rub. The Nurse stated in report she had been told the resident had a sacral ulcer with some drainage and bleeding. The Nurse further stated the resident had a bowel movement and she assisted the NA to change the resident. The Nurse continued and stated when she first saw the wound the dressing had been removed due to soiling and there was no drainage or bleeding but she could not remember the appearance of the wound. The Nurse stated she checked the resident's blood sugar which was good and her vital signs were not bad but she called the doctor and got orders to send her out to the hospital. Attempts were made to interview other nurses and NAs that cared for the resident but either the staff member could not be reached or the staff member could not recall the resident. On [DATE] at 2:50 PM an interview was conducted with the physician that cared for the resident while in the facility. The Physician stated he had seen a lot of COVID patients and afterwards the patient would hang in there for a little bit and then go downhill. The Physician stated he was not notified the resident was not consuming the supplements and was not notified of the resident's weight loss. The Physician further stated anytime a resident was not eating this could certainly contribute to the development of a pressure ulcer. The Physician continued and stated the resident had excoriation of the sacrum on admission but he was not able to see the area very well. The Physician stated when in the hospital a culture was not done of the resident's pressure ulcer and there was no debridement done. The Physician further stated her urine culture was correlated to her [CONDITION(S)] and when in the ED she was in congestive heart failure. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review revealed a nurse note dated [DATE] that indicated Resident #34 was readmitted from another facility on [DATE]. A record review revealed an admission skin referral form dated [DATE] that indicated Resident #34 had a stage III pressure ulcer to sacrum with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had severe cognitive impairment, was totally dependent on staff with one person assist for all Activities of Daily Living (ADLS). Resident #34 was incontinent of bowel and bladder, had a stage 3 pressure ulcer upon admission. A review of the resident care plan updated [DATE] revealed a problem of ulceration or interference with structural integrity of layers of skin caused by pressure related to incontinence and immobility with a goal of Stage III to sacrum . now a Stage IV would show positive healing with reduction in size of pressure ulcer through next review. The interventions included treatment as ordered by physician, monitor wound vac and alert nurse if not operating. A review of the medical record revealed Resident #34 was seen by wound clinic on [DATE] and returned to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Treatment Administration Record (TAR) revealed an order to monitor wound vac at 125mmhg to sacrum stage IV pressure ulcer dated [DATE]. Further review of the TAR revealed that staff had been monitoring the wound vac each shift. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a grievance form dated [DATE] revealed that a concern was identified with wound vac dressing changes. The grievance stated that the initial dressing was the same dressing that the resident appeared to the wound clinic with on [DATE]. An interview was conducted with the wound doctor on [DATE] at 10:21 AM. The physician stated Resident #34 was seen in the wound clinic on [DATE] and a wound vac order was placed. He stated that it was not uncommon for skilled nursing facilities to not have wound vacs available on day of the order. The wound doctor stated when Resident #34 returned to the wound clinic on [DATE] the wound vac had been placed. The doctor stated there had been no deterioration of the wound. An interview was conducted with the wound nurse on [DATE] at 3:49 PM. The wound nurse stated that Resident #34's wound vac was initiated on [DATE]. The wound nurse stated she had changed the wound vac on the next scheduled day [DATE]. The wound nurse stated when she went to change the wound vac on [DATE], she knew it had to be changed three times a week, so she set the wound vac changes for Monday, Wednesday, Friday. The wound nurse stated she had put the wound vac order in a little late because she was just learning. An interview was conducted with the DON on [DATE] at 4:25PM. The DON stated she was not aware of any issues with the residents dressing when he went out to the wound clinic on [DATE]. The DON stated that the Wound Nurse was responsible for changing the wound vac dressing. The DON stated resident returned from the wound clinic on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that she knew the wound nurse had changed the wound vac on [DATE] because the resident had gone to the shower and the wound vac dressing was completed afterwards by the wound nurse and she assisted. The DON further stated that on [DATE], the facility placed the wound vac dressing on resident because the wound clinic did not have the supplies.

Based on record review and staff and resident interviews, the facility failed to provide adequate supervision when repositioning a resident in the bed during care, resulting in the resident falling off the bed and sustaining an injury to her right arm for 1 of 4 residents (Resident #67) reviewed. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses that included hypertension and arthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #67 was cognitively intact and required extensive assistance with 1 person physical assistance for bed mobility. A review of Resident #67's Care Plan dated 1/4/21, with a focus are of Activities of Daily Living care, revealed interventions to include bed mobility, one person assist. Review of a nursing note dated 1/25/21 stated Nurse #2 was called to the room by NA #1 to find the resident was face down on the floor between the bed and the wall at 11:15AM. Review of the fall report completed by Nurse #4 on 1/25/21 revealed Resident #67 had swelling and a small laceration to forehead. A small pool of blood was noted under head. Review of a nursing note, by Nurse #4, dated 1/25/21 stated while receiving AM care, resident was turned to wash backside. In the process of turning resident rolled out of bed and fell approximately 3 feet to the floor. Resident landed face down. NA #1 called out for help. Resident was yelling out. Stated pain 7/10 to head, neck, and arms. Pressure applied to forehead. Dr. notified. 911 called. Review of the Witness statement dated 1/25/21 by NA #1 stated I went in the room to provide AM care. I turned the water on. I went to the resident and removed her gown. I unlocked the bed and pulled out from the wall and relocked it. I rolled resident to her left side. Resident was using the headboard to hold herself. I turned away from resident to get the water and heard the resident yell. I unlocked the bed to help reposition her and moved the bed and she fell to the floor. I yelled for help and moved the bed completely away from her as she was on the floor. Review of the physician note dated 1/29/21 revealed Resident #67 required a foam cast to right arm due to a fracture of the distal end of the right humerus. During an interview with Resident #67 on 4/27/21 at 11:48AM, she revealed she had fallen from the bed onto the floor. She further stated this occurred when NA #1 was providing care. Resident #67 stated she had broken her arm. During an interview on 4/29/21 at 3:35PM with NA #1, she stated she had no recollection of the incident. A subsequent interview with NA #1 on 4/29/21 at 3:50PM revealed she was not familiar with Resident #67. During an interview with Nurse #2 on 4/29/21 at 4:00PM revealed she had been called to Resident #67's room. When she arrived, the resident was on the floor. NA #1 stated the resident had fallen face first from the bed. The resident was yelling out in pain. Nurse #2 stated she assessed Resident #67. The PCP was notified and 911 was called. Resident was transported to the hospital. NA stated she had turned away from resident to get supplies, the resident was calling out, NA moved bed to re-position resident and resident fell from bed. An interview with the Director of Nursing (DON) on 4/29/21 revealed NA #1 had difficulty with recall. The DON stated NAs were to place residents in the center of the bed during care and were not to leave the resident unattended during care. The Corporate Compliance Nurse (CCN) #1 stated, on 4/29/21, that following this incident, all nursing assistant staff, 20 of 20, were re-educated on turning and positioning resident and safe handling and movement of residents. She further stated all nursing assistant staff were audited during the training to include observation and presentation. CCN #1 stated further random audits were conducted on a weekly basis to observe 10 nursing assistants, across all shifts, to ensure turning and positioning of residents was done correctly. She further stated NA #1 was re-trained on turning and positioning residents and safe handling and movement of residents. NA #1 was part of the random audits for 4 weeks, conducted by the Director of Nursing and the Unit Managers. The facility provided the corrective actions dated 1/25/21, taken by the facility for tag F689 as follows: The corrective action for the alleged deficient practice was accomplished by: Resident #67 was provided an assessment on 1/25/21. Resident #67 was observed to have small laceration with uncontrolled bleeding and swelling to the forehead and pain to the upper body. The Primary Care Physician was notified with orders to transfer resident to Emergency Department of local hospital for assessment. Resident's responsible party was notified by the licensed nurse of incident and transfer. Residents with the potential to be affected by alleged deficient practice: The Unit Managers conducted an audit on 1/25/21 of 100% of all residents to ensure residents were positioned properly in bed. This audit identified no additional concerns. Systemic Changes: On 1/25/21, 100% Resident Care Audit on turning and positioning in bed with return demonstration was initiated by the Director of Nursing with all nursing assistants. This audit was to ensure staff used appropriate technique with turning and positioning during care and to ensure residents were positioned in the center of the bed following care. The Unit Managers and Staff Facilitator will address all areas of concern identified during the audit to include education to staff and/or repositioning resident when indicated. Return demonstrations was completed by 1/29/21. On 1/25/21, the Director of Nursing (DON) initiated an in-service with all nursing assistants (NAs) to include NA #1 in regard to the Turning and Positioning with emphasis on positioning resident in the center of the bed during and following care to prevent falls/injury. In-service was completed by 2/2/21. All newly hired NAs would be in-serviced by the Staff Facilitator during orientation in regard to Turning and Positioning. QAPI: Ad Hoc QAPI was held on 1/25/21 and Performance Improvement Plan (PIP) was developed and accepted by the Inter-Disciplinary Team (IDT) on 1/26/21. Quality Assurance Monitoring occurred once a week for 4 weeks to include an audit by the Staff Facilitator and Unit Manager utilizing the Resident Care Audit - Turning and Positioning. The audit ensured staff used proper technique for turning and positioning and that residents were positioned in the center of the bed during and following care. The Staff Facilitator addressed all concerns identified during the audit which included repositioning the resident and re-education of the Staff. The DON reviewed and initialed the Resident Care Audits - Turning and Positioning weekly for 4 weeks to ensure completion and that all areas of concern were identified. The DON forwarded the results of the Resident Care Audit Turning and Positioning Tool to the Executive QA Committee monthly for 1 month. The Executive QA Committee met monthly for 1 month and reviewed the Resident Care Audit Turning and Position Tool to determine trends and/or issues that may have needed further interventions put into place and to determine the need for further and/or frequency of monitoring. As part of the validation process of 4/29/21, it was verified that that audits were completed on all residents. It was further confirmed and reviewed that all nursing assistants were in-serviced on turning and positioning residents. The Quality Assurance monitoring was corroborated and validated. Date of Correction Action Completion. Final Compliance date 2/26/21 was verified and accepted Observations from 4/26/21 - 4/29/21 revealed residents were turned and positioned properly during incontinence care and wound care. The observations further revealed residents were positioned in the center of the bed following care.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition by failing to clean 2 of 2 ice machines and failed to clean the reach-in freezer filter grill. The findings included: A review of the Dietary Policy Manual (Revised on 2/9/16) Under Cleaning Procedures; Ice Making Machines. Exterior: reads as: Clean heavily soiled surfaces with a mild cleaning solution, then rinse with clear water and air dry. Observation on 4/26/21 at 2:53 PM the 300-hall ice machine was observed to have lime build up under the lid frame and rust was visible on the hinge screws. No debris or rust was observed in the ice. A second observation on 4/29/21 at 10:03 AM revealed the 300-hall ice machine to be in the same condition. On 4/29/21 At 10:28 AM the dining room ice machine was observed to have lime build up under the lid frame and dust particles on top of the door. No debris or rust was observed in the ice. During the meal observation on 4/28/21 at 11:40 AM the 3-door freezer filter grill was observed. The freezer filter grill was observed to have a thin layer of grease and debris on the front of the grill. During a second observation with the Dietary Manager on 4/29/21 at 10:22 AM revealed the freezer filter grill to be in the same condition. In an interview on 4/29/21 at 10:23 AM the Dietary Manager confirmed the freezer filter grill needed to be cleaned. She stated the maintenance man cleaned the ice machines and she would have staff clean the reach in freezer grill immediately. In an interview on 4/29/21 at 10:30 AM the maintenance man revealed he cleaned the ice machines once a month, however he was unable to provide a date when they were last cleaned. In an interview on 4/29/21 at 10:39 AM the Administrator stated if an area was listed to be cleaned then she expected the kitchen staff to clean it.

Based on record review and staff interview the facility failed to have a Registered Nurse (RN) in the building for 8 hours a day, 7 days a week for 1 day of 3 months reviewed. The findings included: The nurse staffing sheets were reviewed for January, February and March 2021. On Saturday 1/9/21 there was not a RN scheduled to work. An interview was conducted with the Director of Nursing (DON) on 4/29/21 at 4:56 PM. The DON stated she did not have RN coverage in the building on 1/9/21. The DON further stated she was out with COVID-19 and returned to work on 1/11/21 and a RN from a sister facility was covering but was not in the building and they had an interim administrator at the time.

Based on observations, interviews with staff and Resident #1's physician and record review, the facility failed to stop a treatment and assess exhibited signs and symptoms of pain for 1 of 3 sampled residents (Resident #1) whose wound treatment was observed. Findings included: Resident #1 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Wound Ulcer Flow-Sheet dated 11/14/16 indicated a suspected deep tissue injury measuring 1.5 centimeters (cms) by 1 cm was found on the resident's sacrum. The pressure ulcer was assessed and a treatment started. On 11/21/17, the nurse documented on the Wound Ulcer Flow-Sheet, that Resident #1 had experienced pain during the dressing change to the pressure ulcer. Tylenol was given and the nurse added the Tylenol had been effective in relieving the resident's pain. The 12/5/16 Wound Ulcer Flow-Sheet, completed by a nurse, indicated the pressure ulcer was tender with dressing changes. The 1/9/17 Annual Minimum Data Set (MDS) indicated Resident #1 had short and long term memory impairment with severely impaired cognitive skills for daily decision making. His speech was assessed as unclear and rarely understood. Resident #1 was identified as requiring extensive to total assistance with all activities of daily living. His sacral pressure ulcer was coded as a Stage III. The MDS indicated the Resident #1 received both scheduled and as needed pain medication during the assessment period. The MDS included a staff assessment of Resident #1's pain which indicated the resident's pain was identified through non-verbal sounds such as crying, whining, gasping, moaning or groaning and facial expressions such as grimaces and winches. There was no identification of protective body movements or postures suggestive of hitting. Review of the care plan, initiated on 1/5/17 and most recently reviewed on 1/17/17 indicated the resident had pain due to his sacral pressure ulcer. Resident #1's goal was to be pain free through the next review date using the following interventions: acknowledge the presence of pain and discomfort, administer pain medication as needed and ordered, anticipate the resident's need for pain relief and respond appropriately and document and report complaints and non-verbal signs of pain. A pain assessment, completed on 1/9/17, by a facility nurse indicated the resident was unable to report pain due to being non-verbal. The resident was described as having occasional moan and groan, low level speech with a negative or disapproving quality, sad, frightened, and frowning facial expression, tense, fidgeting body language, but since the resident was non-verbal there was no need to console. A pressure ulcer treatment was observed on 1/25/17 at 9:40 AM. The resident was lying quietly in bed. Nursing Assistant (NA) #1 removed the wedges from underneath the resident and positioned him on his right side. Resident #1 had no moans, groans or other indications of pain during the removal of the wedges and the positioning on his right side. When the treatment nurse removed the outer dressing, Resident #1 yelled and continued to moan and groan until the removal had been completed. When the dressing removal had been completed, Resident #1 was observed to lie quietly without signs and symptoms of pain. When the treatment nurse starting cleaning the pressure ulcer, Resident #1 again began to moan and groan and yell. The surveyor intervened and asked if the resident had been pre-medicated prior to the treatment. The treatment nurse answered, No and continued the treatment. After cleaning the wound had been completed, the resident lay quietly until the treatment nurse started packing the wound. Again, the resident moaned, groaned and yelled out. When the nurse completed the treatment, Resident #1 again lay quietly without signs and symptoms of pain. Review of the January Medication Administration Record [REDACTED]. At 9:55 AM on 1/25/17, the treatment nurse documented in progress notes that during wound care, a noted area of white at the center of the wound appeared to be a bone sheath. She noted the resident had received Tylenol per schedule at 8:00 AM. The treatment nurse also documented that during wound care, Resident #1 yelled when the wet saline gauze touched his skin and when the moist packing was inserted into the wound bed. She added there had been no signs of discomfort when the wound care was completed. The nurse documented she notified the physician about the change in the wound's appearance (observation of bone), requested a change in treatment and requested a change in pain medication. NA #1 was interviewed on 1/25/17 at 12:06 PM. She stated at times, when she assisted with wound care, the resident yelled out during treatment; adding during the treatment this morning, Resident #1 seemed to be in pain as he yelled, moaned and groaned when the dressing was removed, when the wound was cleaned and packed, but had not yelled or struck out at her when she turned and positioned the resident. The NA also stated the resident's moans and groans had ended when the treatment ended. On 1/25/17 at 3:50 PM, the treatment nurse (TN) was interviewed. She stated the resident received regularly scheduled Tylenol each morning during the 8:00 AM medication pass. She stated she had been taught to stop treatments if a resident was uncomfortable. The treatment nurse stated when Resident #1 was in pain, he became aggressive. Since he had not hit at her this morning, she had not thought he was in pain. The treatment nurse acknowledged the resident only yelled when she touched him, but thought that was due to the products used to clean the wound being cold. She stated she had not asked the resident if he was in pain or requested pre-medication prior to the dressing change. The Director of Nursing (DON) was interviewed on 1/26/17 at 11:20 AM. The DON stated she expected nurses to stop treatments and try to figure out what was causing residents to yell during treatment. She acknowledged he had received Tylenol during the 8:00 AM medication pass, but since he yelled each time the treatment nurse touched the pressure ulcer, she had not considered the Tylenol effective for Resident #1's pain. The DON added she would have expected the nurse to assess the root cause of the resident's pain. If a symptom of pain for Resident #1 was hitting, she would have expected to find that on the care plan. The DON stated pain assessments were completed on admission and quarterly, but were not routinely completed for residents on pain medication. A telephone interview with Resident #1's primary care physician (PCP) was held on 1/26/17 at 2:00 PM. The PCP stated he would have expected the nurse to stop the treatment for [REDACTED].#1 received pain medication prior to dressing changes. The PCP stated Resident #1's wound had improved since the dead tissue had been removed about a month ago, which probably made the resident more sensitive to pain, resulting in the need for better pain control.