Every finding on record at Clear Creek Nursing & Rehabilitation Center

Based on observations and staff interviews, the facility failed to store, label and date food in 1 of 1 freezer and 1 of 1 walk-in cooler and failed to remove produce with signs of spoilage in the walk-in cooler. These practices had the potential to affect food served to residents.Findings Include:a. During an initial kitchen tour of the walk-in cooler, conducted with the Dietary Manager on 05/11/2026 at 10:25 AM, the following concerns were identified:- Two packages of strawberries were stored in their original packaging. Four strawberries in one package were observed covered with a white, fuzzy substance. The second package contained one visibly spoiled strawberry.- One pack of blueberries was stored in its original packaging. Five blueberries were observed covered with a white, fuzzy substance. - Thirty-eight yellow squash stored in a box was observed wilted and brown in color.- One box containing 30 oranges stored in a box was observed. Five oranges were observed covered with a white, fuzzy substance.- One box containing loose mushrooms was observed with dark brown and wilted mushrooms. - Ten yellow zucchini were observed in a box wilted and brown in color. - Four unopened packs of lettuce in their original packaging were observed dark brown in color and mushy, with liquid present inside the bags. - Three unopened packs of thyme in their original packaging were observed dark brown in color and mushy, with liquid present inside the bags. b. During an initial kitchen tour of the walk-in freezer, conducted with the Dietary Manager on 05/11/2026 at 10:43 AM, the following concerns were identified:- One bag of open french fries had been removed from the original packaging and placed in an unlabeled resealable plastic bag exposed to air, with no open date.- Twelve packs of open and exposed hamburger meat had been removed from the original packaging and placed in an unlabeled resealable plastic bag, with no open date and visible ice crystals present.- One bag of hush opened puppies was stored in its original packaging with no open date.- One bag of 35 opened and exposed chicken breasts was stored in its original packaging, on the top shelf, with no open, and visible ice crystals present.- Two packages of unopened gluten-free bread were stored in its original packaging labeled with an open date of 12/04/2024.- Two packages of open and exposed pancakes were stored in its original packaging with no open date.On 05/11/2026 at 1:45 PM, an interview was conducted with the Dietary Manager. The Dietary Manager stated the kitchen audit was to be completed by the Kitchen Manager on 5/11/2026 and was rotated between himself and the Kitchen Manager. The Dietary Manager revealed produce was commonly delivered spoiled by the food company utilized by the facility and would spoil quickly because the quality of the food did not last long. The Dietary Manager stated all food items stored in the walk-in cooler and freezer should have been labeled and dated when opened, labeled and dated when removed from the original packaging, and discarded once expired. The Dietary Manager further stated food items that were wilted or had a visible white, fuzzy substance should have been discarded. The Dietary Manager stated he and the Kitchen Manager were responsible for completing the cleaning and audits of the kitchen due to the kitchen being short staffed.On 05/11/2026 at 12:00 PM, an interview was conducted with the Kitchen Manager. The Kitchen Manager stated all food items stored in the walk-in cooler and freezer should have been labeled and dated when opened, labeled and dated when removed from the original packaging, and discarded once expired. The Kitchen Manager further stated any food items that were wilted or had a visible white, fuzzy substance should have been discarded. The Kitchen Manager reported she was scheduled to complete her audit and clean the walk-in cooler and freezer on 05/11/2026 but had not yet had the opportunity to do so. She stated audits were completed weekly and rotated between herself and the Dietary Manager. The Kitchen Manager explained the audit process included checking food items for expiration dates, labeling and dating, and identifying spoiled food items. The Kitchen Manager stated when spoiled or expired food items were identified during the audit process, the items were discarded. The Kitchen Manager indicated that during the previous week's audit, wilted and visibly moldy food items had been identified and discarded.On 05/11/2026 at 1:15 PM, an interview was conducted with the Cook's Assistant. The Cook's Assistant reported the Kitchen Manager and Dietary Manager completed weekly audits and kitchen cleaning of the freezer, cooler, and dry storage areas. The Cook's Assistant stated the Kitchen Manager and Dietary Manager consistently educated staff on kitchen expectations and proper cleaning procedures, including properly labeling and dating food items, discarding expired or spoiled food, rotating food items, and maintaining cleanliness of storage areas; however, staff did not always follow expectations. The Cook's Assistant stated she attempted to help in the kitchen and discarded food items that were no longer good, but other kitchen employees did not always do the same.On 05/14/2026 at 3:59 PM, an interview was conducted with the Administrator. The Administrator stated that all food items should be stored properly, labeled with an open date and expiration date, and monitored through daily audits. The Administrator further stated the expectation was for staff to complete routine audits and clean the kitchen and storage areas regularly to ensure food safety standards were maintained.

Based on observations, record review, and resident, staff, Dietary Manager, and Registered Dietitian (RD) interviews, the facility failed to provide food that accommodated a documented allergy to pineapple for 1 of 4 residents reviewed for nutrition (Resident #61).Findings included: Resident #61 was admitted to the facility on [DATE]. Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors. Resident #61's electronic health record revealed an undated area on the clinical dashboard listed food allergies as pineapple and tree nuts and listed the severity as unknown. A review of Resident #61's care plan document which was last reviewed on 3/9/26, stated at the bottom of the document, the resident's food allergies included pineapple and tree nuts. There was no separate care plan for the allergy.A review of a history and physical note written by the Internal Medicine Nurse Practitioner, dated 4/10/26 indicated Resident #61 had documented food allergy of pineapple with the reaction of abdominal pain. The menu posted in the dining room on 5/14/26 showed the dessert for lunch to be pineapple upside-down cake.A lunch tray observation was conducted with Resident #61 on 5/14/26 at 1:00 PM. Resident #61 was sitting in the dining area with her meal tray. Her meal tray ticket stated allergy to pineapple and tree nuts. Resident #61 was eating a piece of cake with pineapple topping. The resident stated, I don't know what is on this cake, so I am a little hesitant to eat it because I have allergies. The State surveyor intervened and alerted Nurse #7 who then removed the dessert from Resident #61's tray. Nurse #7 informed resident #61 the cake contained pineapple and asked the resident if she felt okay. Resident #61 stated she felt fine and she could not remember what happened when she ate pineapple as it had been too long ago since she last had it, but she thought it upset her stomach.On 5/14/26 at 1:05PM an observation and interview was conducted with Nurse #7. She was obtaining Resident #61's vital signs and stated she had telephoned the facility provider who gave her a verbal order to administer Benadryl 25mg capsule immediately and then every 8 hours as needed for allergic reaction for Resident #61 which she stated she had administered.An observation was made in the dining room on 5/14/26 at 1:10PM when Nurse #7 asked the three Nurse Aides (NAs) who helped serve the meal trays for that lunch meal and if any of them had served Resident #61 the cake. All three NAs (NA #3, #5, and #6) denied serving Resident #61 the cake. Nurse #7 told the three NAs the cake contained pineapple and Resident #61 was allergic to pineapple. Nurse #7 told the NAs they needed to read the resident's dietary tickets before serving them their food. During an interview with the Dietary Manager on 5/14/26 at 1:15PM he revealed he expected all staff who handed out meal trays to read each resident's dietary ticket to be made aware of any allergies or food preferences. The Dietary Manager stated the kitchen sent out the desserts for the dining room on a separate tray and it was up to the staff handing the desserts out to look at the dietary tickets before giving them to the residents. An interview was conducted with the RD on 5/14/26 at 1:20PM and she stated it would have been the responsibility of the NAs to read the dietary tickets and give the residents the correct desserts.During an interview with the Director of Nursing (DON) in the presence of the Administrator on 5/14/26 at 1:57PM, the DON stated she had been made aware that Resident #61 was given pineapple during lunch and that she had since spoken to all staff members present regarding food allergies and the importance of reading the dietary tickets.

Based on observation and staff interviews, the facility failed to label an in-use insulin pen with the opened and expiration date information for 1 of 4 medication carts (200-hall medication cart). The findings included:An observation was conducted of the 200-hall medication cart with Nurse #5 on 5/14/26 at 12:47 PM. The observation revealed one opened and in use Lantus Solostar insulin pen not labeled with an opened or expiration date. The insulin pen was stored in a clear zippered bag labeled with the resident's name and prescribing information. Nurse #5 was interviewed during the cart observation and stated insulin pens were supposed to be dated with the date they were opened. She further stated insulin pens should be discarded 28 days after being opened. Nurse #5 stated she was unsure when the Lantus insulin pen was opened or why the insulin pen was not dated.On 5/14/26 at 3:47 PM the Director of Nursing (DON) was interviewed and stated she expected nursing staff to label insulin pens with the date they were opened and discard them 28 days after the opened date.The Administration was interviewed on 5/14/26 at 3:48 PM and stated he expected staff to label and date medications when opened.

Based on record review, observation, and staff interviews, the facility failed to change the pressure ulcer dressing as ordered for 1 of 3 residents reviewed for pressure ulcers (Resident #11). The findings included:Resident #11 was readmitted on [DATE] with diagnoses which included pressure ulcer of the sacral (triangular bones located below the lumbar spine) area (stage 4), neurocognitive disorder with Lewy Bodies, abnormal posture, and chronic obstructive pulmonary disease. Resident #11 was admitted to hospice care on 12/26/25.The care plan revised 6/26/25 revealed Resident #11 had an ulceration or interference with structural integrity of layers of skin of the sacral area caused by pressure related to friction, incontinence of bowel and/or bladder, and immobility. The goal was Resident #11's pressure ulcer would not worsen through review. Interventions included administer medications as ordered, administer treatments as ordered, utilize enhanced barrier precautions, turn and reposition the resident routinely, cleanse perineal area well with each incontinence episode, and ensure special mattress (air mattress) was in place and functioning properly.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was cognitively intact. Further review of the MDS indicated Resident #11 was dependent on staff for toileting, personal hygiene, showering, dressing, and rolling left and right. The MDS also indicated she was always incontinent of bowel and bladder. The MDS further revealed Resident #11 had a stage 4 pressure ulcer at the time of the review. There was no indication of rejection of care.Review of a physician order written on 1/20/26 for Resident #11 instructed staff to clean her sacral wound every day shift (7:00AM to 7:00PM) with normal saline, pat dry, place calcium alginate (highly absorbent wound dressing) to wound bed, and cover with bordered dressing.Review of Resident #11's wound flow sheet dated 5/9/26 stated the sacral wound measured 2 centimeters (cm) x 0.8cm x 0.7cm. There was no tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), undermining (destruction of tissue or ulceration extending under the skin edges), or odor present. The wound was noted to have a scant amount of serous (thin, watery, clear) drainage present, and it was described as having 75% to 100% beefy red granulation tissue (pink-red moist tissue that fills an open wound, when it starts to heal). Review of Resident #11's Treatment Administration Record (TAR) for May 2026 revealed the sacral wound treatment was not documented as completed on 5/10/26 and 5/11/26. An observation Nurse #6 providing wound care for Resident #11 was completed on 5/12/26 at 11:30 am and revealed a pressure wound to the sacrum, with beefy red granulation tissue. The observation further revealed the dressing was dated 5/9/26 and Nurse #6 stated the old dressing was dated 5/9/26 as he removed it. There was no odor noted. There was no active drainage to the wound bed, and the old dressing had scant yellow drainage noted. Nurse #6 completed the wound care and dressing change per the physician's order. An interview was conducted on 5/13/26 at 10:45AM with Nurse #7. She stated she worked with Resident #11 on 5/10/26 and 5/11/26. Nurse #7 revealed that she should have completed the dressing changes to the resident's sacral wound but stated she did not complete the wound care and dressing change because she was busy those days and missed them when going through her tasks on the TAR. Nurse #7 apologized and said that she had completed the resident's sacral dressing change on May 9th but understood it was supposed to be a daily dressing change. Nurse #7 stated she needed to do a better job looking at the TAR, so she would not miss dressing changes in the future.Review of Resident 11's wound flow sheet dated 5/13/26 revealed she had a stage 4 pressure ulcer to the sacrum, which measured 2 cm x 0.8 cm x 0.7 cm. An interview with the Wound Care Nurse on 5/13/26 at 11:00AM revealed that she was new to her role and had completed Resident #11's sacral wound dressing change for the first time that morning. The Wound Care Nurse stated Resident #11's sacral wound was with 100% granulated tissue and stated it measured much smaller in size than it had been previously documented in the prior months. She said there was no indication of infection noted. An interview was conducted on 5/14/26 4:46PM with the Director of Nursing (DON). The DON was not aware Resident #11's pressure wound treatment had not been completed on 5/10/26 and 5/11/26. The DON stated her expectation would be for all treatments to be administered according to physician's order and stated it was not acceptable to not complete the dressing change, no matter the reason.An interview was conducted with the Administrator on 5/14/26 at 5:15PM. The Administrator was not aware that Resident #11's sacral wound dressing change hadn't been completed on 5/10/26 and 5/11/26. The Administrator stated his expectation would be that all treatments were completed as ordered.

Based on record review and interviews with staff, the facility failed to ensure the medical record was complete regarding documentation of wound care for 1 of 3 residents reviewed for pressure ulcers (Resident # 11).The findings included:Review of Resident #11's Treatment Administration Record (TAR) revealed that in March 2026, nurse's initials were missing for the sacral dressing change order on March 1st, 4th, 5th, 11th, 15th, 20th, 21st, and 22nd.Review of the TAR for April 2026 for Resident #11, revealed it was missing nurse's initials for the sacral dressing change on April 4th, 5th, 12th, 18th, 19th, and 21st.Review of Resident 11's TAR for May 2026 revealed it was missing nurse's initials on May 2nd, 3rd, 4th, 6th, 7th, 10th, and 11th.An interview was conducted with Nurse #6 on 3/13/26 at 3:30PM. He stated that he worked on May 3rd, 4th, and 7th, and stated that he completed the dressing changes for Resident #11 on those days. Nurse #6 stated that he was very busy on those days and did all the medications and treatments. Nurse #6 reported he got too busy at times to get everything charted. Nurse #6 further stated on April 5th, 2026, and March 15th and 22nd, 2026 he was certain he completed the sacral dressing changes for Resident #11. He explained he knew he completed the dressing changes because when he worked he 'always completed all of his work'. Nurse #6 reported he must have been too busy on those dates to sign the TAR. On 5/14/26 at 11:19AM, a telephone interview was conducted with Nurse #8. She stated she was familiar with Resident #11 but no longer worked for the facility. Nurse #8 stated that if she was scheduled to work, she knew she would have completed the wound care for Resident #11 because she 'always did her work'. Specifically, regarding her missing initials for March 4th, 5th, 11th and 20th, 2026 Nurse #8 stated she was sure she completed the dressing changes and probably just forgot to sign the TAR on those days. A telephone interview was conducted on 5/14/26 at 12:21PM with Nurse #10. She revealed she worked on April 12th, 2026, with Resident #11 and stated that another nurse (Nurse #12) completed the sacral dressing change for Resident #11 that day because Nurse #12 had the required supplies to complete the dressing change.An interview with Nurse #1 on 5/14/26 at 1:00PM revealed that she remembered working with Resident #11, on April 19th and May 2nd, 2026, but stated that another nurse (Nurse #11) split the shift with her and Nurse #11 was the nurse who completed the sacral dressing changes for both of those dates. Nurse #1stated that she worked from 7:00AM to 3:00PM and then Nurse #11 worked from 3:00PM to 7:00PMDuring a telephone interview conducted on 5/14/26 at 1:41PM, Nurse #11 stated that on April 19th and May 2nd of 2026 she remembered completing the sacral dressing changes for Resident #11. She said it was very busy and she missed getting them signed off on the TAR.During a telephone interview with Nurse #12 on 5/14/26 at 2:04PM, she stated that she may have completed Resident #11's dressing change for Nurse #10, because she commonly does other nurses dressing changes, but stated she doesn't usually sign the TAR herself when the task was not assigned to her. Nurse #12 further explained that occasionally she completed dressing changes for other nurses but stated she was busy with her own stuff too. Nurse #12 indicated she would normally tell the nurse who was assigned the dressing change that it was completed, and she would have expected that nurse to sign the TAR. Nurse #12 stated she could not recall the specifics of the date of April 12th, 2026, because she works 120 to 130 hours per week and can't remember what she did last week. Nurse #12 stated, I probably did, but I can't say for sure. Multiple attempts were made during the investigation to interview Nurse #9, but she did not return the call and no longer works for the facility. The dates Nurse #9 worked that were missing her initials in Resident #11's TAR included March 21st and April 4th and 18th, 2026.An interview was conducted with the Director of Nursing (DON) on 5/14/26 at 4:46PM. She stated that if a nurse completed a dressing change, then it was expected that they would have documented the completion in the TAR. The DON stated it was not acceptable to leave the TAR blank, and they needed to be consistently documenting their tasks. An interview was conducted with the Administrator on 5/14/26 at 5:15PM. He stated he would expect all staff to document properly.

Based on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 4 of 6 monthly Resident Council Meetings. The Resident Council had concerns during resident council meetings that revealed no follow up resolutions (09/19/24, 11/14/24, 12/11/24, and 01/16/24.) The findings included: On 09/19/24 the Resident Council Meeting Minutes noted music not being played during meals, getting assistance to go to the beauty shop, and residents wants DNR above their bed. The Resident Council Follow-Up for 09/19/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 11/14/24 the Resident Council Meeting Minutes noted call lights were not being answered. The Resident Council Follow-Up for 11/14/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 12/11/24 the Resident Council Meeting Minutes noted call lights were not being answered and residents had issues with different nursing staff. The Resident Council Follow-Up for 12/11/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 01/16/24 the Resident Council Meeting Minutes noted sink and toilet issues, missing laundry, resident rooms needing painting, nursing staff being loud at night, and call lights not being answered. The Resident Council Follow-Up for 01/16/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. Interviews conducted with Resident #4, Resident #13, Resident #49, and Resident #61 during the Resident Council Meeting on 03/20/25 at 11:00 AM revealed there had been no resolution with the ongoing concerns that were addressed during the resident council meetings. The residents further revealed the issues were still a concern and the Activity Director (AD) did not discuss resolutions at resident council meetings. An interview conducted with the Activity Director (AD) on 03/20/25 at 12:05 PM revealed he had completed grievances and gave them to department heads to follow up on. The AD further revealed once the department heads completed grievance that they were sent to the Administrator and Social Worker. The AD stated he had failed to document resolutions on resident council minutes, but had reported to the resident council residents how concerns were being addressed. An interview conducted with the facility Social Worker (SW) on 03/20/25 at 12:30 PM revealed when grievances are completed during resident council minutes they are signed off by the Administrator and brought to her to be stored. The SW further revealed she had not received any resident council grievances since August 2024. An interview conducted with the Administrator on 03/20/25 at 1:00 PM revealed he was not aware if grievances were being completed and resolved from Resident Council meetings. The Administrator further revealed he expected concerns to be addressed and documentation to be included within the Resident Council minutes.

Based on observations, record review and staff interviews, the facility staff failed to perform hand hygiene during meal service for 1 of 4 staff observed (Nursing Assistant #2) and failed to follow Enhanced Barrier Precautions (EBP) and apply personal protective equipment (PPE) prior to providing enteral feeding to a resident with a gastrostomy tube (G-tube) for 1 of 1 staff observed (Nurse #4) and failed to perform hand hygiene or apply new gloves during a dressing change to a G-tube for 1 of 1 observation for G-tube dressing changes (Nurse #1). The deficient practice occurred for 3 of 8 staff members reviewed for infection control practices. The findings included: The facility Handwashing Policy with a revision date of 4/2023 was reviewed and read, in part: Personnel should wash their hands after contact with body fluids, equipment or articles contaminated with body fluids; after removing gloves; before and after touching wounds; between resident contacts, when otherwise indicated to avoid transfer of microorganisms, and between tasks and procedures; an alcohol-based hand sanitizer may be used for handwashing unless the hands are visibly soiled. 1. The 300-400 hall dining room was observed on 3/17/25 at 12:31 PM. Nursing Assistant (NA) #2 was observed to be passing out meals to the residents. NA #2 was observed to cut food up for a resident, remove lids from drinks, and assist the resident to pick up the utensils. NA #2 was then observed to return to the counter and pick up another meal and deliver it to another resident without performing hand hygiene. NA #2 was observed to deliver multiple meals to residents in the dining room without performing hand hygiene between each delivery. NA #2 was observed again on 3/18/25 at 12:37 PM delivering meals to residents in room [ROOM NUMBER]. NA #2 was observed to assist Bed A resident to sit up in bed, she adjusted the over-the-bed tray and assisted the resident to remove lids from her drinks. NA #2 returned to the dining room and did not perform hand hygiene before she picked up another tray to deliver to Bed B in room [ROOM NUMBER]. NA #2 did not perform hand hygiene after assisting the resident with her tray, bed, and over-the-bed table. NA #2 was stopped as she headed to the meal service area to pick up another tray and asked about hand hygiene. NA #2 went to the wall mounted hand sanitizer and reported she was aware she should have used hand sanitizer between the delivery of each meal, but she did not think about it during the meal service because she was trying to get the food to the residents as quickly as possible. The Director of Nursing (DON) was interviewed on 3/20/25 at 10:44 AM. The DON reported there was no supervision during the meal service to monitor if staff were performing hand hygiene. The DON reported NA #2 was very task oriented and was focused on getting meals to residents as quickly as possible and did not think to perform hand hygiene. 2. The facility Enhanced Barrier Precautions policy with a revision date of 6/13/2024 was reviewed, and read, in part: EBP are used in conjunction with Standard Precautions to reduce the risk of MDRO transmission (multi-drug-resistant organisms, primarily bacteria that is resistant to one or more classes of antimicrobial agents [antibiotics] making infections caused by the bacteria difficult to treat) during high-contact resident care activities. Included with use of both gowns and gloves. EBP are meant to be in place for the duration of the resident's stay, or until .discontinuation of an indwelling medical device occurs .EBP apply to residents with any of the following: . presence of indwelling medical devices with or without the presence of an MDRO infection or colonization .Resident care activities that are considered high contact include, but are not limited to .device care or use: .feeding tube . (Instructions included) perform hand hygiene with alcohol-based handrub or wash with soap and water before entering and after leaving the room; Wear gloves and a gown for the following high-contact resident care activities .device care .feeding tube .take off and dispose gloves .gown .(and use) alcohol-based handrub or wash with soap and water . An observation of Resident #3's room was conducted on 3/18/25 at 12:30 PM. A sign with EBP instructions was posted on her door and a caddy with PPE was on the door, including gloves, gowns, and face masks. The EBP sign directed staff to perform hand hygiene, apply gloves and a gown when providing care to Resident #3. Nurse #4 was observed on 3/18/25 at 12:41 PM to enter Resident #3's room to provide G-tube feeding. Nurse #4 was observed to perform hand hygiene with hand sanitizer and apply gloves. Nurse #4 did not apply a gown. Nurse #4 went to Resident #3's beside and explained it was time for her G-tube feeding. Nurse #4 pulled the covers down and was removing the abdominal binder when she was stopped and asked to come to the door to read the EBP sign. Nurse #4 read the sign for EBP and reported she was going to complete the G-tube feeding without the gown because she was rushing to get the feeding completed. Nurse #4 removed her gloves, performed hand hygiene, and applied a gown to complete the G-tube feeding. Nurse #4 explained that she was aware of the EBP and PPE use, but she didn't think to apply it. The Director of Nursing was interviewed on 3/18/25 at 3:52 PM and she reported she was not aware Nurse #4 did not apply appropriate PPE to provide a G-tube feeding to Resident #3, and she expected all staff to read the signs on the doors and apply the appropriate PPE for resident care. 50415 3. According to the facility's infection control policy subsection titled Enhanced Barrier Precautions dated 4/03 and revised 6/13/24, personal protective equipment (PPE) including a gown and gloves was to be worn during high contact care for a resident with an indwelling medical device such as a feeding tube. On 3/19/25 at 10:06 AM Nurse #1 donned a gown and gloves at the doorway of Resident #100's room due to the resident being on enhanced barrier precautions. Nurse #1 was observed as she provided a dressing change of the (PEG) percutaneous endoscopic gastrostomy tube (a thin, flexible tube inserted through the skin and into the stomach) insertion site. After cleansing the insertion site and applying a clean dressing, Nurse #1 removed her gloves and took a pen out of her pocket. Without performing hand hygiene or donning a clean pair of gloves, she then used her bare left hand and stabilized the newly applied dressing against the resident's stomach and wrote her initials and date on the tape of the dressing. Nurse #1 was interviewed immediately upon exiting the room. She stated that she knew the resident was on enhanced barrier precautions, but she did not want to touch her pen with the gloves she had been wearing. She stated that she should have had a pen readily available and changed gloves to write the date on the dressing instead of using her bare hand. The Director of Nursing (DON) was interviewed on 3/19/25 at 10:42 AM, and she stated that Nurse #1 should have followed the instructions for the facility's policy on enhanced barrier precautions. The Nurse Practitioner was interviewed on 3/19/25 at 11:46 AM, and she stated that she expected the staff to follow written orders for a resident placed on enhanced barrier precautions when providing care to the residents. On 3/20/25 at 2:00 PM the Administrator was interviewed. He stated he expected the facility's staff to follow the infection control policy when providing care to all residents.

Based on record reviews and staff interviews, the facility failed to maintain psychiatric progress notes in the electronic medical record (Residents #21, # 31, #37 and #90), and to accurately document the completion of an order on the medication administration record (Resident #36). This deficient practice occurred for 5 of 5 residents (Resident #21, # 31, #36, #37 and #90) reviewed for accurate medical records. The findings included: 1a. Resident #21 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbances. A physician order for Resident #21 dated 10/24/24 ordered psychiatric services for evaluation and treatment. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicted Resident #21 had severe cognitive impairment and received antipsychotic, antianxiety and antidepressant medications. A review of Resident #21's electronic medical record (EMR) did not include any psychiatric progress notes. A request for psychiatric progress notes was made to the Administrator and hard copies of the visit notes were printed by the facility for 12/19/24, 1/2/25, 1/24/25, and 2/21/25. 1b. Resident #31 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and anxiety disorder. A physician order for Resident #31 dated 8/14/23 ordered psychiatric services consult. A psychiatric progress note dated 4/8/24 indicated Resident #31 was to have follow-up in four weeks. A review of Resident #31's EMR did not include any psychiatric progress notes after 4/8/24. An annual MDS assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and received antianxiety and antidepressant medications. A request for psychiatric progress notes was made to the Administrator and hard copies of the visit notes were printed by the facility for 7/18/24, 9/2/24, 10/3/24, 11/7/24, 12/5/24, 1/2/25, 1/30/25, 3/1/25 and 3/14/25. 1c. Resident #37 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, insomnia, anxiety disorder and dementia. A psychiatric progress note dated 4/26/24 indicated Resident #37 was to have follow-up in four weeks. A review of Resident #37's EMR did not include any psychiatric progress notes after 4/26/24. A quarterly MDS assessment dated [DATE] indicated Resident #37 had severe cognitive impairment and received antianxiety and antidepressant medications. A request for psychiatric progress notes was made to the Administrator and hard copies of the visit notes were printed by the facility for 7/5/24, 8/2/24, 9/2/24, 10/3/24, 10/31/24, 11/21/24, 12/19/24, 1/16/25, 2/21/25 and 3/13/25. 1d. Resident #90 was admitted to the facility 10/2/24 with diagnoses including Alzheimer's disease and anxiety. A physician order for Resident #90 dated 12/18/24 ordered a psychiatry evaluation. The significant change MDS assessment dated [DATE] assessed Resident #90 to be severely cognitively impaired and he received antipsychotic medications. A care area assessment dated [DATE] documented Resident #90 was receiving psychotropic medications, and he was seen by psychiatric services. Review of Resident #90's EMR revealed no psychiatric progress notes. A request for psychiatric visit notes was made to the Administrator and hard copies of the visit notes were printed dated 12/20/24, 1/23/25, 2/21/25, and 3/14/25. The Social Worker was interviewed on 3/19/25 at 12:56 PM and stated that the psychiatric provider visited the facility weekly and provided progress notes by email to the Social Worker and Director of Nursing (DON). She stated the facility policy was for them to be printed off so the physician could review the progress notes before they were uploaded to the EMR. She was unable to explain why Residents #21, #31,#37 and #90 were missing psychiatric progress notes in their EMR. The Social Worker had been out of the facility from December 2024 to March 16, 2025. An attempt to interview the previous Social Worker was made on 3/20/25 at 10:10 AM and was unsuccessful. She had been employed at the facility from December 2024 to March 2025. An interview occurred with the Medical Records Clerk on 3/20/25 at 10:51 AM. She explained there was a process for psychiatric progress notes where the physician reviewed them and then they would have been uploaded to Residents #21, #31, #37 and #90 EMRs. She was unable to explain why there were missing psychiatric progress notes in their EMR. The DON was interviewed on 3/20/25 at 12:33 PM and could not explain why the psychiatric progress notes were not part of Residents #21, #31, #37 and #90's EMR as they should be. On 3/20/25 at 11:49 AM, the Administrator was interviewed. He had begun employment at the facility in January 2025. The Administrator was unable to explain why the psychiatric progress notes for Residents #21, #31, #37 and #90 were not in their EMR as they should be. 49160 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included history of stage 3-4 pressure ulcer. Resident #36 had a physician order dated 03/11/25 that read; discontinue the indwelling urinary catheter on 03/15/25. Resident #36's medication administration record (MAR) indicated the indwelling urinary catheter was removed on 3/15/25 by Nurse #6. Further review of Resident #36's medical record revealed there were no orders to reinsert the indwelling urinary catheter. An observation conducted on 3/17/25 at 10:21 AM revealed Resident #36 was lying in bed resting and had an indwelling urinary catheter draining to a bedside drainage bag. A phone interview with Nurse #6 on 3/20/25 at 8:04 AM indicated she was the 3rd shift (11pm-7am) nursing supervisor on 3/14/25 to 03/15/25. She indicated she did not recall seeing an order to remove Resident #36's indwelling urinary catheter on 3/15/25 nor did she remove the catheter. Nurse #6 was unable to explain why it was documented on the MAR that she completed the order to remove Resident #36's indwelling urinary catheter. An interview was conducted with the Director of Nursing (DON) on 3/20/25 at 11:05 AM. The DON revealed she was not aware Resident #36's indwelling urinary catheter was not removed on 3/15/25 per the physician's order. The DON stated if Nurse #6 did not remove Resident #36's indwelling catheter on 3/15/25 then she should not have documented on the MAR that the order was completed.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was made after a resident was given new mental health diagnoses for 1 of 3 residents (Resident #71) reviewed for PASRR. The findings include: Review of Resident #71's medical record revealed the resident was originally admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with depression on 04/20/23, delusional disorder on 12/4/23, and insomnia on 12/04/24. Review of Resident #71's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident was not coded for a level II PASRR. During an interview on 03/19/25 at 1:00 PM with the Social Worker (SW) she revealed a PASRR level II referral should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. It was further revealed by the SW Resident #71 should have been assessed for a possible level II and the facility failed to do so. The SW indicated she was not aware that Resident #71 did not have level II PASRR determination. During an interview on 03/20/25 at 1:00 PM with the Administrator he revealed PASRR level II referrals should be completed in a timely manner upon the admission of a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. The Administrator stated he was not aware Resident #71 had not been assessed for a possible PASRR level II.

Based on record review and staff interviews, the facility failed to complete a performance review every 12 months for 2 of 5 Nurse Aides (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance evaluations (NA #2 and NA #3). The findings included: a. A review of NA #3's employment file revealed a hire date of 8/27/21. There was no record a performance review was completed for NA #3 from January 2024 to present. A phone interview conducted with NA #3 on 3/21/25 at 10:22 AM indicated she did not recall that a performance review had been completed at any time during her employment at the facility. b. A review of NA #2's employment file revealed a hire date of 5/30/23. There was no record a performance review was completed for NA #2 from January 2024 to present. A phone interview with NA #2 on 3/21/25 at 10:02 AM indicated she did not recall that a performance review had been completed since she was hired by the facility in 2023. A phone interview conducted with the Staff Development Coordinator (SDC) on 3/21/25 at 10:50 AM revealed she started working as the facility's SDC in August of 2024. The SDC stated the NA annual performance reviews were a part of the facility's online education program and email notifications were sent to the NAs when the performance review was due, and she received the email as well. The SDC stated she provided reminders to the NAs when the performance review was due, but the NA was responsible for printing the review, having it completed by a nurse and then providing a copy of the review for her to keep on file. The SDC revealed she did not recall receiving email notifications that NA #2 and NA #3 were due for a performance review and was unable to explain why there was no record that a performance review was completed for NA #2 and NA #3 every 12 months as required. Attempts made to contact the former SDC were unsuccessful. A phone interview with the Director of Nursing on 3/21/25 at 11:21 AM indicated the SDC was responsible for monitoring the completion of the NA performance reviews and NA performance reviews should be completed every 12 months. A phone interview with the Administrator on 03/21/25 at 11:21 AM revealed NAs should have a performance review every 12 months and the SDC was responsible for overseeing and making sure that the reviews were completed.

Based on observations, record review, and family member and staff interviews, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #72). The findings included: Resident #72 was admitted to the facility 1/18/25 with diagnoses including chronic lung disease and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #72 to have oxygen therapy. A physician order dated 1/18/25 read (for) cyanosis or dyspnea: oxygen at 2 liters per minute, notify the provider. A care plan dated 1/21/25 addressed Resident #72's potential for breathing issues related to his lung disease and specified to administer oxygen at 2 liters per minute by nasal canula. Review of the physician orders for Resident #72 revealed no order for oxygen therapy. The significant change MDS dated [DATE] assessed Resident #72 to not have oxygen therapy. Resident #72 was observed on 3/17/25 at 2:16 PM. Resident #72 had an oxygen concentrator running at the bedside, delivering 2.5 liters of oxygen by nasal cannula. The Responsible Party was interviewed at the time of the observation, and he reported Resident #72 required oxygen all the time because of his lung disease and he had been receiving oxygen therapy since he was admitted to the facility. Resident #72 was observed on 3/19/25 at 12:50 PM. The oxygen concentrator was running at the bedside, delivering 3 liters of oxygen by nasal cannula. The Nurse Practitioner was interviewed on 3/19/25 at 10:32 AM and she reported she was aware Resident #72 was using oxygen, but did not know there was not an active order for oxygen therapy. Nurse #4 was interviewed on 3/19/25 at 12:55 PM and she checked the physician orders for oxygen for Resident #72 and was unable to find an order for oxygen. Nurse #4 reported Resident #72 should have a physician order for oxygen and the order for oxygen would give instructions for the flowrate, as well as changing the nasal cannula and oxygen tubing. The Director of Nursing was interviewed on 3/20/25 at 10:55 AM and she reported she was not aware there was no order for oxygen for Resident #72 and there should be an order with the flowrate and orders to change the tubing and nasal cannula. The DON explained initiating oxygen therapy was a nursing judgement, but the physician needed to be notified to write an order.

Based on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to remove an indwelling urinary catheter per the physician's order and failed to keep a urinary catheter drainage bag and tubing from touching the floor to reduce the risk of infection for 1 of 4 residents reviewed for urinary catheters (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included history of stage 3-4 pressure ulcer. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was moderately cognitively impaired and was coded for having an indwelling urinary catheter. The care plan dated 01/02/25 revealed Resident #36 had an indwelling urinary catheter due to a stage 4 sacral wound and the interventions included providing catheter care per the physician orders. Resident #36 had a physician order dated 03/11/25 that read; discontinue the indwelling urinary catheter on 03/15/25. The order was entered by Nurse #3. Resident #36's medication administration record (MAR) indicated the indwelling urinary catheter was removed on 03/15/25 by Nurse #6. a. An observation conducted on 03/17/25 at 10:21 AM revealed Resident #36 was lying in bed resting and had an indwelling urinary catheter draining to a bedside drainage bag. An interview with Nurse #3 on 03/19/25 at 12:20 PM revealed on 03/11/25 a member of the nurse management team, she did not recall their name, asked her to obtain a physician's order to remove Resident #36's indwelling urinary catheter. Nurse #3 stated she called the Nurse Practitioner and obtained an order to remove Resident #36's indwelling urinary catheter on 03/15/25. Nurse #3 indicated she entered the order into the electronic medical record, but she was not Resident #36's assigned nurse on 03/15/25 and was unsure if the urinary catheter was removed. A phone interview with Nurse #6 on 03/20/25 at 8:04 AM indicated she was the 3rd shift (11pm-7am) nursing supervisor on 03/14/25 to 03/15/25. She indicated she did not recall seeing an order to remove Resident #36's indwelling urinary catheter on 03/15/25 nor did she remove the catheter. Nurse #6 was unable to explain why it was documented on the MAR that she completed the order to remove Resident #36's indwelling urinary catheter. During an interview with Nurse #5 on 03/20/25 at 9:03 AM she indicated she was Resident #36's assigned nurse on 3/17/25. Nurse #5 revealed a nurse, she did not recall her name, informed her that Resident #36 had an order to remove Resident #36's indwelling urinary catheter on 03/15/25 that was not completed. Nurse #5 stated she removed Resident #36's indwelling urinary catheter on 03/17/25 at approximately 10:30 AM. An interview conducted with the Nurse Practitioner (NP) on 03/19/25 at 10:16 AM revealed she received a phone call from the facility on 03/11/25 requesting an order to remove Resident #36's urinary catheter because there was not a supporting diagnosis for the use of the catheter. The NP indicated she ordered Resident #36's indwelling urinary catheter to be removed on 03/15/25. The NP stated she was unaware the order was not completed, and the catheter should have been removed on 03/15/25 as ordered. During an interview with the Director of Nursing (DON) on 03/20/25 at 11:05 AM she revealed Resident #36 had an indwelling urinary catheter in place to assist with healing of a sacral wound. The DON indicated the interdisciplinary care team decided wound healing was not considered to be a supporting diagnosis for the use of an indwelling urinary catheter, so they requested an order from the NP to remove the catheter. The DON indicated she was not aware Resident #36's indwelling urinary catheter was not removed on the order date and that it should have been removed on 03/15/25 as ordered. An interview conducted with the Administrator on 03/20/25 at 1:30 PM indicated an order to remove an indwelling urinary catheter should have been completed on the date the physician ordered it to be removed. b. An observation conducted on 03/17/25 at 10:21 AM revealed Resident #36 was lying in bed resting and had an indwelling urinary catheter draining to a bedside drainage bag. The catheter tubing and bedside drainage bag were observed lying on the floor beside the bed. An interview with Nurse #5 on 03/17/25 at 10:51 AM indicated she was assigned to Resident #36 and entered her room around 10:30 AM to remove the indwelling urinary catheter. She stated the catheter tubing and bedside drainage bag were lying on the floor beside the bed. Nurse #5 indicated the Nurse Aides (NA) were responsible for emptying the bedside drainage bags and usually emptied them at the end of each shift. Nurse #5 was unsure if the drainage bag lying on the floor was last emptied by the 3rd shift NA or the 1st shift NA, but stated it should have been secured under the bed frame and not touching the floor. A phone interview with NA #5 on 03/20/25 at 1:53 PM revealed she was the 3rd shift NA assigned to Resident #36 on 03/16/25. NA #5 stated she emptied Resident #36's bedside drainage bag around 6:00 AM on 03/17/25 prior to the end of her shift and then secured the drainage bag under the bed frame to ensure it was not touching the floor. NA #5 stated when she left Resident #36's room the urinary catheter tubing and bedside drainage bag were not touching the floor. Several attempts were made to contact NA #4, assigned to Resident #36 on 1st shift on 03/17/25, were unsuccessful. An interview conducted with the Director of Nursing on 03/20/25 at 11:05 AM revealed indwelling urinary catheter tubing and bedside drainage bags should be secured under the bed frame when a resident was in bed and not touching the floor. The DON indicated catheter tubing and drainage bags should not be lying on the floor because of the increased risk of infection. During an interview with the Administrator on 03/20/25 at 1:30 PM he stated urinary catheter tubing and drainage bags should not be lying on the floor due to the increased risk for infection.

Based on record review, resident/ family and staff interviews, the facility failed to protect a resident's right to be free from verbal and mental abuse when Nurse Aide #4 and Social Worker confronted Resident #2 in her room and intimidated her into not submitting a grievance. Nurse Aide #4 refused to provide incontinent care for Resident #2 by taking her to her room and yelling at her by stating she could poop in her diaper like everyone else does then slammed the door as she left. Nurse Aide #4 yelled at Resident #2 who requested incontinent care, by stating I am not your CNA and will never be your CNA no more in life. These actions caused Resident #2 to feel intimidated, devalued, deprived of care, ignored, depressed, without control of her life, trapped, upset, and as if she did something wrong. This occurred for 1 of 1 resident reviewed for abuse. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses inclusive of Parkinson's disease, depression, and neurogenic bladder. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was cognitively intact and dependent on staff assistance with toileting, showering, lower body dressing and putting footwear on / off. She was independent with eating and required set up with oral hygiene. Resident had a suprapubic catheter and was incontinent of bowel habits. a. During an interview on 11/13/23 at 3:43 PM Resident #2 revealed on 10/30/23 (incident #1) Nurse Aide (NA) #4 and the Social Worker came into her room and confronted her about Resident #2's plan to submit a grievance about NA #4 refusing to provide incontinent care when asked. Resident #2 further revealed she was grilled by the Social Worker and felt intimidated by their presence until she finally decided that she would not file a grievance against NA #4 and did not receive further discussion from any staff member about the issue. Resident #2 stated that NA #4 accused her of lying on her and trying to get her fired, then stated she never heard her (Resident #2) ask for assistance to the bathroom. Resident #2 responded to the SW and NA #4 that perhaps NA #4 did not hear her request for assistance in using the bathroom. During an interview on 11/14/23 at 3:57 PM, the Social Worker (SW) indicated that a few weeks prior (early November 2023) that another staff member (former Admissions Director) informed her that Resident #2 reported that NA #4 told her she didn't have time assist her with incontinent care. Therefore, she took herself to the restroom, attempted to toilet herself and fell on the floor. The SW further indicated she brought NA #4 into Resident #2's room to discuss the matter together and that was not her normal practice when attempting to resolve a matter between a resident and staff member. She stated she redirected NA #4 not to say anything while they were in the Resident's room. Her intention was not to intimidate Resident #2 by bringing NA #4 into the room and did not realize that Resident #4 felt badgered into not filing a grievance. During an interview on 11/15/23 at 8:39 AM, NA #4 revealed, during the same week of the incident that took place on 10/30/23, she told Resident #2 that she would no longer work with her or speak to her after the incident that took place on 10/30. NA #4 stated she believed Resident #2 lied on her by stating she asked her to take her to the bathroom and NA #4 refused by ignoring the Resident. NA #4 then stated, because of that she did not work with her since 10/30/23, although she was assigned to that hall and Resident #2 as a permanent assignment. NA #4 did indicate that she and the SW went to Resident #2's room to discuss the incident that took place on 10/30 and did not intend to intimidate her into not filing a grievance. NA #4 further stated that the SW did not submit a grievance because Resident #2 agreed that her request to be taken to the bathroom may not have been heard by NA #4. During an interview on 11/16/23 at 11:52 AM, the DON revealed she was unaware Resident #2 was confronted in her room by the SW and NA #4 and that Resident #2 felt intimidated and badgered into not filing a grievance on NA #4. Her expectation was for Resident's rights to be respected and free from abuse according to the facility's abuse policy. During a follow-up interview on 11/17/23 at 9:30 AM, Resident #2 indicated that she felt trapped, devalued, and as if she did something wrong, when the SW and NA #4 came into her room and confronted her about the incident that took place on 10/30/23. She further indicated she was very depressed that night and wondered if the SW ever filed the grievance. b. During an interview on 11/13/23 at 3:55 PM, Resident #2 revealed (incident #2) on 10/31 or 11/1/23 while she was in the dining room, she asked her assigned NA#4 for assistance with going to the rest room and was ignored. She then asked NA #4 a second time and NA #4 grabbed her wheelchair and hurriedly pushed her down the hall to her room and told her she could poop in her diaper like everyone else does. Resident #2 told her I don't poop in my pants, and I don't wear diapers and that I needed to go to the rest room. NA #4 then stated it won't be me then left out the room and slammed the door. Resident #2 was able to self-propel her wheelchair out of her door and approach the hall nurse who had another NA provide incontinent care. Resident #2 further revealed she felt degraded and without control of her life because she needed to use the restroom and could not get help from her assigned aide. Resident #2 stated later that day NA #4 told her that she would no longer speak to her or work with her and that was NA #4's choice. Resident #2 stated she was very upset and reported the incident to her son via telephone on 11/2/23. She stated her son was also upset and contacted the Administrator to discuss the matter and was promised the incident would be addressed. She also stated she reported the incident to Nurse #5 when she returned from days off and was encouraged to report the incident to the SW. However, she did not feel comfortable reporting another issue to the SW. During an interview on 11/14/23 at 3:40 PM, NA #7 indicated she may have heard Resident #2 was told she had to wait and go to the bathroom on herself but could not recall who the NA was. During a telephone interview on 11/15/23 at 8:45 AM, NA #4 revealed that although she was assigned to Resident #2 the week of 10/30, she did not recall taking her to her room on 10/31 or 11/1 and did not refuse to give her incontinent care or tell her that she could go in her diaper like everyone else. NA #4 stated she worked 10/30- 11/1 and was off 11/2 & 11/3, then worked the weekend of 11/11 & 11/12 and was permanently assigned to Res #2 on the 300 hall. During a phone interview on 11/15/23 at 6:17 PM, Resident #2's family member revealed the Resident left him a voice mail message on 11/1, that she had something to tell him and to call her back. When he called her back, she told him that NA #4 took her into her room, told her she could poop in her pants and left her there. The family member stated he was very upset and contacted the Administrator who told him that he would take care of it. During an interview on 11/15/23 at 10:51 AM, Nurse #5 revealed that at the beginning of November 2023, when she returned from days off, Resident #2 reported to her that NA #4 told her to go to the bathroom in her brief like others do. Nurse #5 stated she believed the Resident's report to be credible and informed the SW that Resident #2 needed to talk to her about possibly filing a grievance. Nurse #5 further revealed that Resident #2 does not normally have a bowel movement in her brief and normally uses the toilet with staff assistance. Nurse #5 also stated that one day when Resident #2 accidentally had a bowel movement in her brief, she was tearful and mortified. During a follow-up interview on 11/15/23 at 1:59 PM, the SW indicated she was not made aware that Resident #2 had an additional conflict with NA #4 regarding being told to poop in her pants. She further stated that neither staff nor Resident #2 made her aware of it. Therefore, she did not file a grievance on the Resident's behalf. During an interview on 11/17/23 at 12:25 PM, the Speech Therapist indicated she did hear NA #4 tell Resident #2 while she was in the hallway near dining room that Resident #2 could poop in her pants. The Speech Therapist further indicated that she submitted a 24-hour internal report about the incident but could not recall if she submitted it on 10/30 or 10/31/23. During an interview on 11/16/23 at 11:52 AM, the DON revealed NA #4 was permanently assigned to 300 hall residents that included Resident #2 and NA #4 worked 10/30, 10/31, 11/1 and was on days off 11/2 & 11/3. She had no knowledge of the incident #2, where Resident #2 described as being taken back to her room and being told to poop in her pants. Her expectation was for the treatment of all residents to be free from all forms of abuse. During an interview on 11/15/23 at 6:01 PM, the Administrator indicated that he was not aware of the incident that occurred on 10/31 or 11/1, involving NA #4's refusal to provide incontinent care by telling Resident #2 that she could poop in her pants. He further indicated that he was not aware if a grievance was submitted. During a follow-up interview on 11/16/23 at 4:17 PM the Administrator revealed that he did not speak to Resident #2's family member about the incident that occurred on 10/31 or 11/1and that they only addressed the incident that occurred on 10/30/23. c. During an interview on 11/13/23 at 4:25 PM Resident #2 revealed (incident #3) that on 11/12/23 she needed incontinent care because her catheter was leaking. She asked NA #6 if she was her assigned nurse aide and was told that NA #4 was assigned to her. Resident #2 asked the hall nurse (Nurse #6) if she knew who her assigned nurse aide was. Nurse #6 agreed to find out and have an aide provide care. A short time later, NA #4 came into her room and stated that she would assist her with incontinent care. The following morning, Resident #2 complained to the Administrator and spoke with the DON about not knowing who her assigned nurse aide was for the past two days. During a phone interview on 11/15/23 at 8:50 AM, NA #4 revealed in reference to incident #3 that took place on 11/12/23, she never spoke to or provided care to Resident #2 on 11/12/23 because she switched assignments with other aides on that weekend, when she was assigned to the Resident #2. She also did not discuss changing her assignment with the hall nurse or DON and that it was not uncommon for nurse aides to switch assignments. She stated that she did tell Resident #2 that she did not have to speak to her or be her nurse aide and that was her (NA #4's) choice. Therefore, she switched assignments with other aides. During an interview on 11/16/23 at 10:43 AM, Nurse #6 indicated she did not know that Resident #2's assigned NA #4 had switched with NA #6 because she did not want to care for the Resident. She further indicated she reassured Resident #2, that she would find out and send her in to provide care. Nurse #6 stated that NA#4 told her about Resident #2's leaking catheter and that she switched assignments with NA #6. She did not hear NA #4 refuse to care for Resident #2. However, Nurse #6 stated she did assure that the Resident received care from another aide. During an interview on 11/15/23 at 6:06 PM, the DON revealed that on the morning of 11/13/23 Resident #2 reported to her that she did not receive care from her assigned NA #4 over the past weekend and that she needed incontinent care. The DON further revealed she started an investigation and interviewed both nurse aides (#4 & #6). NA #4 was suspended after NA #6 provided a written statement that she witnessed (on 11/12/23) NA #4 yell out I will never be your CNA no more in life! The DON stated that a 24-hour report was completed and sent to the State. The DON stated that Resident #2 did receive care from another aide (NA #6). The DON further stated that she expected residents to be free from all forms of abuse to include verbal and mental abuse. She also stated that nursing staff have had recent in-services on the abuse policy.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 05/26/22, the complaint investigation survey completed on 7/13/23, and the complaint investigation survey completed on 08/11/23. This was for five repeat deficiencies originally cited in the areas of freedom from abuse and neglect, develop/implement abuse policies, activities of daily living provided for dependent residents, development of comprehensive care plans, infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 11/17/23. The continued failure of the facility during four federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F600: Based on record review, resident/ family and staff interviews, the facility failed to protect a resident's right to be free from verbal and mental abuse when Nurse Aide #4 and Social Worker confronted Resident #2 in her room and intimidated her into not submitting a grievance. Nurse Aide #4 refused to provide incontinent care for Resident #2 by taking her to her room and yelling at her by stating she could poop in her diaper like everyone else does then slammed the door as she left. Nurse Aide #4 yelled at Resident #2 who requested incontinent care, by stating I am not your CNA and will never be your CNA no more in life. These actions caused Resident #2 to feel intimidated, devalued, deprived of care, ignored, depressed, without control of her life, trapped, upset, and as if she did something wrong. This occurred for 1 of 1 resident reviewed for abuse. During the complaint investigation survey of 08/11/23, the facility failed to protect a resident's right to be free from employee verbal abuse. F607: Based on record review and review of the facility's policy entitled Abuse and Neglect, and resident and staff interviews, the facility failed on 2 occasions to implement its own policy to immediately report an incident of abuse or neglect to the Administrator. This affected 1 of 1 resident reviewed for abuse (Resident #2). During the complaint investigation survey of 08/11/23, the facility failed suspend an employee immediately after an allegation of abuse. F656: Based on observations, resident interviews, staff interviews, and record review the facility failed to develop an individualized person-centered comprehensive care plan in the area of visual impairment (Resident #14). This deficient practice was for 1 of 1 resident whose comprehensive care plans were reviewed. During a recertification and complaint survey of 05/26/22, the facility failed to develop a comprehensive care plan for a resident related to non-pressure skin issues. F677: Based on record review, observations, and interviews with the resident, staff and the Hospice Nurse, the facility failed to provide a dependent resident with nail care and facial hair trim to 1 of 4 residents (Resident #68) reviewed for assistance with activities of daily living. During a complaint investigation survey of 7/13/23, the facility failed to provide incontinence care to a resident dependent on staff for activities of daily living. F880: Based on staff interviews and record reviews the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 84 of 84 residents in the facility. During a recertification and complaint survey of 05/26/22, the facility failed to implement infection control practices when 3 nurses did not disinfect multi-use blood glucose meters after use. The administrator stated in an interview on 11/17/23 at 12:35 PM that the facility's QAA Committee met every month and as needed with all department managers, the Pharmacist and Medical Director. He stated that trends were identified using a corporate template and discussed at each meeting to identify any changes in monitoring that were needed. The Administrator stated that a Performance Improvement Plan was implemented for each deficiency from prior surveys and the status of audits were discussed at each monthly QAA Committee meeting. The Administrator stated that he attributed repeat deficiencies to staff turnover and new management staff. He stated that the facility continued to discuss and monitor concerns with abuse, care plans, nail care, and infection control in QAA Committee meetings, but that new concerns had not been identified. He stated that he could not say for sure why concerns were identified in these areas for this survey, but that these areas were still included in orientation for new staff.

Based on staff interviews and record reviews the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 84 of 84 residents in the facility. The finding included: The Infection Control Plan dated 09/25/2023 and the Facility assessment dated [DATE] revealed services offered by the facility included infection prevention and control with identification and containment of infections, prevention of infections, and tracking and monitoring infections. The Infection Preventionist conducts surveillance of all infections among residents including tracking and analysis of outbreaks of infections. During the Entrance Conference with the Administrator on 11/13/2023 at 9:30 AM, he revealed that the facility's designated Infection Preventionist was the Wound Care Nurse. An interview with the Wound Care Nurse on 11/16/2023 at 10:01 AM revealed she had not performed any duties related to Infection Prevention and Control since she resigned from the Director of Nursing (DON) position on 07/31/2023. She further revealed the current DON was responsible for the facility's Infection Control Program. During an interview with the DON on 11/16/2023 at 3:40 PM, she stated she had occupied the DON position since 08/29/2023 and did not realize she was the facility's designated Infection Preventionist (IP). The DON also stated she was not performing infection surveillance and did not have any tracking forms. She explained she had not tracked or analyzed any infections in the facility since her arrival in August 2023. She also indicated antibiotics were discussed in the weekly interdisciplinary meetings. The discussion included the indication for use and the start and stop date of each antibiotic ordered for a resident. An interview with the Administrator on 11/16/2023 at 3:55 PM revealed he thought the Wound Nurse was still acting as the facility's Infection Preventionist. He was not aware the DON was responsible for the Infection Prevention and Control Program. The Administrator explained the IP nurse was responsible for infection surveillance and he was unaware the wound nurse was not tracking and analyzing the resident's infections. He stated he expected infection surveillance to be completed on all identified resident infections.

Based on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection and Control Program. This had the potential to affect 84 of the 84 residents at the facility. The findings included: During the Entrance Conference with the Administrator on 11/13/2023 at 9:30 AM, he revealed the facility's designated Infection Preventionist was the facility's wound care nurse. An interview with the wound care nurse on 11/16/2023 at 10:01 AM revealed she had not performed any duties related to Infection Prevention and Control since she resigned from the Director of Nursing (DON) position on 07/31/2023. The wound nurse stated she had attended the Statewide Program for Infection Control and Epidemiology (SPICE) and was SPICE trained. She further revealed the current DON was responsible for the facility's Infection Control Program. She also stated she had provided a hand off of Infection Prevention and Control information to the current DON when she exited the DON position in July 2023. During an interview with the DON on 11/16/2023 at 3:40 PM, she stated she had occupied the DON position since 08/29/2023 and did not realize she was the facility's designated Infection Preventionist. The DON also revealed she had not taken the Statewide Program for Infection Control and Epidemiology (SPICE) training and she was not currently registered to take the class. She also indicated she had not received any specialized training in Infection Control. An interview with the Administrator on 11/16/2023 at 3:55 PM revealed he thought the wound nurse was still acting as the facility's Infection Preventionist. He was not aware the DON was responsible for the Infection Prevention and Control Program.

Based on record review, observations, and interviews with residents, staff and the Nurse Practitioner, the facility failed to assess the ability of residents to self-administer medications for 4 of 6 residents observed with medications at the bedside (Residents #30, #52, #25 and #237). The findings included: 1. Resident #30 was admitted to the facility on [DATE] with diagnoses that included anemia, chronic kidney disease and liver cirrhosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 was cognitively intact, and was independent with most activities of daily living. A review of Resident #30's medical record indicated no documentation that Resident #30 was assessed for self-administration of medications. Resident #30 did not have a physician's order for self-administration of medications. A review of Resident #30's Medication Administration Record for November 2023 indicated an active physician's order for Vitamin D3 125 micrograms (5000 international units) - give one tablet by mouth one time a day for supplementation. During an initial observation of Resident #30 in his room on 11/13/23 at 10:17 AM, Resident #30 was sitting up by the side of his bed with his head down and asleep. There was a bottle of red liquid labeled as sore throat oral anesthetic spray, a bottle labeled as Vitamin B12 5000 micrograms (mcg) and another green bottle of pills on the windowsill. There was also a bottle of nasal spray, and a bottle of ear drops on top of Resident #30's bedside table. An interview with Resident #30 on 11/13/23 at 12:41 PM revealed he took one pill from green bottle and one pill from the Vitamin B12 bottle once a day every morning. Resident #30 stated that the green bottle of pills was just vitamins. During the interview, he pulled out a bag of Epsom salts from inside his closet and stated that he used the Epsom salts to soak his feet at night. He further stated that he did all activities of daily living independently and rarely had to request assistance from staff. Another observation of Resident #30's room on 11/14/23 at 12:24 PM revealed the same medications previously observed on 11/13/23 were still at Resident #30's bedside. The green bottle of pills was observed to be Vitamin D3. An interview with Nurse #1 on 11/14/23 at 2:38 PM revealed she had not noticed any of the medications that Resident #30 kept at his bedside. Nurse #1 stated that she always administered his medications at the dining table whenever he ate his breakfast, and she did not usually go to his side of the room. During the interview with Nurse #1, another observation and interview with Resident #30 revealed the green bottle of pills was Vitamin D3 125 mcg (5000 IU), and the Vitamin B12 was 5000 mcg. Both bottles were on Resident #30's windowsill along with a bottle of medicated relief lotion and a bottle of throat spray. Resident #30 stated that he seldom used the throat spray anymore, but he often rubbed the medicated relief lotion to his hands and arms whenever they hurt. Resident #30 also showed a saline nasal spray which was on top of his bedside table and stated that he used this to irrigate his ears. He further revealed a bottle of earache drops which he used whenever his ears hurt. Resident #30 stated that he had brought all of these medications from home, and he was used to using them when he was at home. Nurse #1 stated she did not know whether Resident #30 was assessed for medication self-administration and that she would have to look at his medical record. An interview with Nurse #2 on 11/15/23 at 9:48 AM revealed she had taken care of Resident #30, but she had not noticed any of the medications that he kept at the bedside. Nurse #2 stated Resident #30 was usually out in the hallway, and he always came to the nurses' station or to the medication cart whenever he was ready to take his medications. Nurse #2 stated she did not usually go into Resident #30's room. An interview with Medication Aide (MA) #1 on 11/15/23 at 2:23 PM revealed she had not noticed Resident #30's medications at the bedside. MA #1 stated that Resident #30 was always at the dining table whenever she gave his morning medications. An interview with Nurse #3 on 11/16/23 at 10:11 AM revealed she normally did not look in Resident #30's room and she usually gave his medications while he was eating breakfast. Nurse #3 stated she noticed that Resident #30 had a lot of stuff in his room that he had ordered online and even if she noticed his medications, she knew it would have been an argument trying to keep him from having medications at the bedside. Nurse #3 stated that if Resident #30 wanted to self-administer medications, the doctor would need to write an order that he was capable of administering his own medication and an assessment would need to be completed. Nurse #3 further stated she was not aware whether Resident #30 had a doctor's order, or an assessment was completed regarding medication self-administration. An interview with Nurse Aide (NA) #1 on 11/16/23 at 10:11 AM revealed Resident #30 often refused assistance from staff and did most of his activities of daily living by himself. NA #1 stated she still went into Resident #30's room just to check if he needed anything but she did not notice any of the medications that Resident #30 kept at his bedside. An interview with the Unit Manager (UM) on 11/14/23 at 2:58 PM revealed she was not aware that Resident #30 had been administering medications which he kept at the bedside and that she had no idea how Resident #30 had obtained his medications. The UM stated she was not sure whether Resident #30 had been assessed for medication self-administration. She also stated that the residents should be assessed first if they could safely administer medications to themselves before they were allowed to keep medications at the bedside. An interview with the Nurse Practitioner (NP) on 11/16/23 at 2:57 PM revealed she was not aware of Resident #30 self-administering his medications at the bedside. The NP stated that if the staff asked her that Resident #30 wanted to self-administer medications, she would let him as long as he was competent and he was assessed to safely administer medications to himself. The NP stated she did not consider Resident #30 receiving two doses of Vitamin D3 significant and taking over-the-counter medications without a physician's order harmful to him. However, Resident #30 should have been assessed first if it was safe for him to self-administer his medications. An interview with the Director of Nursing (DON) on 11/17/23 at 8:46 AM revealed she was not aware that Resident #30 had been taking medications by himself at the bedside. The DON stated when she found out, she asked a nurse to do a self-administration assessment and he failed so they had to remove all his medications at the bedside and give them to his family member. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, and was independent with most activities of daily living. A review of Resident #52's medical record indicated no documentation that Resident #52 was assessed for self-administration of medications. Resident #52 did not have a physician's order for self-administration of medications. A review of Resident #52's Medication Administration Record for November 2023 indicated an active physician's order for Fluticasone Propionate nasal suspension - 1 spray in both nostrils in the morning for allergy signs/symptoms and allergic rhinitis. During an initial observation of Resident #52 in his room on 11/13/23 at 12:40 PM, Resident #52 was lying in bed asleep with his head covered up with a blanket. There was a bottle of Fluticasone nasal spray enclosed in an orange container on top of his bedside table. There was another spray bottle with a red cap labeled as Afrin nasal spray on top of his side table. An interview with Resident #52 on 11/13/23 at 3:30 PM revealed he used the Afrin nasal spray at night whenever his nose got stopped up. Resident #52 explained that he used a BiPAP machine at night and it was hard to use it whenever his nose was stopped up. (A BiPAP machine is a machine that supplies pressurized air into the airways and is also called positive pressure ventilation because the device helps to open the lungs with this air pressure.) Resident #52 stated the Fluticasone nasal spray was for his allergies and he only used it once in a while. He further stated he did not need it as much as he used to when he first got admitted to the facility. Another observation of Resident #52's room on 11/14/23 at 12:24 PM revealed the Afrin and the Fluticasone nasal sprays were still available at his bedside. An interview with Nurse #1 on 11/14/23 at 2:38 PM revealed she had seen Resident #52's Fluticasone nasal spray at the bedside. Nurse #1 stated that Resident #52 preferred to administer this medication to himself, and he wanted to keep this nasal spray at his bedside. However, Nurse #1 stated that she had not noticed the Afrin nasal spray and did not know how Resident #52 obtained it. Nurse #1 stated she did not know whether Resident #52 was assessed for medication self-administration and that she would have to look at his medical record. An interview with Nurse #2 on 11/15/23 at 9:48 AM revealed she had taken care of Resident #52, but she had not noticed any of the nasal sprays that he kept at the bedside. Nurse #2 stated Resident #52 usually sat in his wheelchair by the side of his bed, and he normally asked for his breathing treatments whenever he had complaints of difficulty breathing. Nurse #2 stated she couldn't remember seeing Resident #52's nasal sprays at the bedside. An interview with Medication Aide (MA) #1 on 11/15/23 at 2:23 PM revealed she had noticed Resident #52's Fluticasone nasal spray which was on his bedside table, but she left it alone because he had another Fluticasone nasal spray which they kept inside the medication cart. MA #1 stated she did not remember seeing an Afrin nasal spray on his side table. An interview with Nurse #3 on 11/16/23 at 10:11 AM revealed she had not noticed any of the nasal sprays that Resident #52 kept at his bedside. Nurse #3 stated that Resident #52 had another bottle of Fluticasone spray in the medication cart which she usually gave to him in the mornings. Nurse #3 stated that if Resident #52 wanted to self-administer medications, the doctor would need to write an order that he was capable of administering his own medication and an assessment would need to be completed. Nurse #3 further stated she was not aware whether Resident #52 had a doctor's order, or an assessment was completed regarding medication self-administration. An interview with Nurse Aide (NA) #1 on 11/16/23 at 10:11 AM revealed she often went into Resident #52's room to check on him but she did not notice any of the nasal sprays that Resident #52 kept at his bedside. An interview with the Unit Manager (UM) on 11/14/23 at 2:58 PM revealed she was not aware that Resident #52 had been administering medications which he kept at the bedside and that she had no idea how Resident #52 had obtained his medications. The UM stated she was not sure whether Resident #52 had been assessed for medication self-administration. She also stated that the residents should be assessed first if they could safely administer medications to themselves before they were allowed to keep medications at the bedside. An interview with the Nurse Practitioner (NP) on 11/16/23 at 2:57 PM revealed she was not aware of Resident #52 self-administering his medications at the bedside. The NP stated that if the staff asked her that Resident #52 wanted to self-administer medications, she would let him as long as he was competent and he was assessed to safely administer medications to himself. An interview with the Director of Nursing (DON) on 11/17/23 at 8:46 AM revealed she was not aware that Resident #52 had been taking medications by himself at the bedside. The DON stated she was not sure how Resident #52 obtained the nasal sprays he kept at his bedside, but he should have been assessed for medication self-administration. 45358 3. Resident #25 was admitted to the facility on [DATE] with diagnoses inclusive of heart failure, stage 2 chronic kidney disease, pulmonary hypertension and peripheral vascular disease. The quarterly MDS assessment dated [DATE] indicated Resident #25 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. He was independent with eating and was totally dependent on bathing. A review of Resident #25's medical record indicated there was no assessment or physician's order for self-administration of medications. A review of Resident #25's Medication Record for November 2023 revealed an active physician's order for ammonium lactate lotion and natural tears eye ointment. The Medication Record did not reveal an order for the following over-the-counter medications: nasal spray, peptide collagen, calcium antacids, or joint pain relief rub roll-on. During an initial observation of Resident #25's room on 11/13/23 at 10:48 AM revealed prescribed ammonium lactate lotion and prescribed natural tears eye ointment and a container of collagen peptide powder next to snacks on a built-in shelf. Additionally, nasal spray, calcium antacids container, and joint pain relief rub roll on were observed on nightstand. An interview with Resident #25 on 11/13/23 at 10:55 AM indicated he used the ammonium lactate lotion, natural tears eye ointment, nasal spray, calcium antacids and joint pain relief rub roll on as needed. He further indicated a nursing aide would also use the lotion and joint pain relief on his legs. He no longer used the collagen peptide powder because he did not believe it helped with his knees. During a follow-up observation to Resident #25's room on 11/14/23 at 2:30 PM, the same medications that were observed on 11/13/23 on Resident #25's nightstand and built-in shelf near his snacks. During a follow-up observation to Resident #25's room on 11/15/23 at 10:10 AM, all medications had been removed from the room. During an interview on 11/15/23 at 10:17 AM, Nurse #5 revealed that the Scheduler did a sweep of Resident #25's room and removed all medications. She further revealed she usually removed any over-the-counter medications brought in by the Resident's daughter. However, she did not notice the medications in his room when she recently administered his medications. She also stated Resident #25 did not have an order to self-administer medications and the medications should not have been in his room. During an interview on 11/15/23 at 10:06 AM, Nurse #6 indicated she was assigned to Resident #25 on 11/12/23, administered his scheduled medications and did not recall seeing medicated lotion, eye drops, joint pain relief roll on, or nasal spray in his room. During an interview on 11/15/23 at 2:27 PM, the Scheduler revealed he usually performed a monthly sweep of all resident rooms to inventory supplies that were ordered and distributed to residents. He further revealed he removed medications from Resident #25's room as instructed. During an interview on 11/16/23 at 11:22 AM, the DON indicated she was recently informed of over-the-counter medications in resident rooms who had no physician orders for self-administration. Her expectation was for basic nursing rules to be followed as it related to residents being screened to self-medicate and have a documented physician's order. She further indicated there has since been a sweep of resident rooms, in search of and removal of medications from resident rooms where residents did not have an assessment or physician's order to self-medicate. During an interview on 11/16/23 at 3:15 PM, the NP revealed Resident #25 had not been assessed to self-administer medications at bedside and she did not feel he was capable of self-administering medications safely. 4. Resident #237 was admitted to the facility on [DATE] with diagnoses inclusive of sepsis, osteoarthritis, hypertension, and asthma. An admission MDS assessment dated [DATE] indicated Resident #237 was cognitively intact and required extensive assistance with bed mobility, transfers, and toileting. He also required supervision with eating. A review of Resident #237's medical record indicated there was no assessment or physician's order for self-administration of medications. A review of Resident #237's Medication Record for November 2023 revealed an active physician's order for cream-clotrimazole betamethasone. During an interview on 11/13/23 at 10:30 AM, Resident #237 indicated he did not know how long the medicine cup of white cream had been on his bedside table. He further indicated he believed the cream was used on his buttocks by the nurse. During an interview and observation on 11/13/23 at 10:35 AM, Nurse #1 revealed she had not left the medicine cup of white cream in Resident #237's room and that it may have been left there by the 3rd shift nurse. She removed the medicine cup from the Resident's room and agreed to find out what type of medication was in the medication cup. During an interview on 11/15/23 at 10:00 AM, Nurse #6 indicated she could not recall if she left a medication cup of clotrimazole on Resident #237's bedside table. She further indicated she applied it as prescribed, during her 7a-7p shift on 11/12/23 per her initials on the MAR and that the Resident did not have a physician's order to self-administer medications. She also stated that it was not her practice to leave medications at bedside if a resident was not assessed to self-administer medications. During an interview on 11/16/23 at 11:08 AM, the DON revealed the cup of medicated cream should have been caught if staff were doing rounds as expected. She further revealed that she was not sure which shift nurse left the medicine cup in Resident #237's room, since the MAR indicated it was administered at least twice before the Surveyor observed it on the bedside table. Her expectation was for medications not be left in resident rooms whereas the resident was not assessed and/or there was no physician's order in place for self-administration.

Based on observations, interviews with residents (Residents #23, #27, #36, #38, #47, #50, #58, #74, and #140) and staff and record review, the facility failed to provide privacy for 5 months during Resident Council meetings. The findings included: A review of Resident Council meeting minutes from June 2023 to November 2023 revealed Residents #23, #27, #36, #38, #47, #50, #58, #74, and #140 attended Resident Council meetings routinely. The minutes did not record concerns voiced by residents regarding the location of their meetings. An observation of the activity area on the 500/600 hall occurred on 11/13/23 at 12:15 PM. The activity area was observed with a vending machine and refrigerator. The area was an open space that was adjacent to the open dining room and nurse's station. The area was not enclosed for privacy. An interview with the Activity Director (AD) occurred on 11/13/23 at 1:18 PM. The AD stated that he had arranged for the Resident Council meeting with the Surveyor to be held in the 500/600 hall activity area. He confirmed that this space did not afford privacy and stated, This is where the Residents always meet for Resident Council. The Surveyor requested a private space. The AD stated that there were two other activity areas that were typically used for activities, but these areas were not large enough to hold large resident activities. When the Surveyor inquired about the Community Room, the AD stated that the Community Room had not been used for Resident Council meetings before, but it was large enough to hold Resident Council meetings. The AD stated that he would discuss it with the Administrator and follow up. The AD returned at 1:30 PM and stated that the Resident Council meeting with the Surveyor would be held in the Community Room to afford privacy. A Resident Council meeting was held on 11/15/23 at 2:00 PM with nine Residents (Residents #23, #27, #36, #38, #47, #50, #58, #74, and #140) identified by the AD with intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 or higher. The AD placed a sign outside the Community Room that recorded Resident Council Meeting in Progress, Please Do Not Disturb. During the meeting the Social Worker (SW) opened the door to the Community Room, entered the room, looked around the room, said Excuse me, I apologize, and exited the room. When asked if this interruption to their meeting bothered them, Resident #23 stated Well yes, we would like to have our privacy. All the Residents expressed they agreed. The Residents stated that the Resident Council meetings were arranged by the AD and were held in the 500/600 hall activity area but did not give them privacy. The Residents stated staff frequently interrupted meetings/activities to use the vending machine and refrigerator stored in the activity area and sometimes the nurse was on the hall with a medication cart administering medications to residents. The Residents stated they were told that was the only space large enough to accommodate everyone. The SW was interviewed on 11/17/23 at 9:15 AM and stated she had been the SW at the facility for the past three years. The SW stated she entered the Community Room on 11/15/23 during the Resident Council meeting to look for another surveyor. The SW stated that she did not see the sign posted which indicated that a Resident Council meeting was in progress, she stated I was not focused on that, I was looking for the surveyor. The SW stated she was not aware that staff should not interrupt resident meetings. The SW also stated that Resident Council meetings were held in the activity area of the 500/600 hall and there was a vending machine and a refrigerator that staff used. The SW stated that sometimes staff have come in to use the refrigerator or vending machine while the residents were having a meeting. The SW stated that the 500/600 hall activity area did not afford residents privacy during their meetings. The Administrator stated in an interview on 11/17/23 at 12:48 PM that he had been the Administrator at the facility since June 2023 and that during those five months, Resident Council meetings were always held in the 500/600 hall activity area. The Administrator stated that staff should not interrupt Resident Council meetings and that he would move the Resident Council meetings to the Community Room to give the Residents privacy during their meetings.

Based on record review, observations and staff interviews, the facility failed to discard expired medications and date opened insulin vials and eye drops in 1 of 2 medication rooms (300 hall/400 hall medication room) and 3 of 5 medication carts (300 hall/400 hall medication cart, 600 hall medication cart and 500 hall medication cart). The findings included: 1. An observation of the 300 hall/400 hall medication room with Nurse #5 on 11/15/23 at 11:38 AM revealed an opened vial of Tuberculin marked with an open date of 10/2/23. The vial was stored in the medication room refrigerator and was available for use. During the observation, Nurse #5 stated that the opened Tuberculin vial was only good for 28 days after opening and should have been discarded. She also stated that the Tuberculin vial was normally used by the night shift nurse for newly admitted residents. (Tuberculin, also known as purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis.) An interview with the Unit Manager (UM) on 11/17/23 at 8:03 AM revealed the Director of Nursing was responsible for checking the medication rooms for expired medications. The UM stated that she did not even have a key to the medication rooms, but the nurses were supposed to make sure there were no expired medications in the medication rooms. The UM stated that the opened vial of Tuberculin was only good for 28 days and should have been discarded after that. An interview with the Director of Nursing (DON) on 11/17/23 at 8:46 AM revealed the nurses were responsible for checking the medication rooms and expired medications should be removed. The DON stated the opened Tuberculin vial only lasted for 28 days and should have been discarded after that. 2. a. An observation of the 300 hall/400 hall medication cart with Nurse #5 on 11/15/23 at 11:42 AM revealed an opened Latanoprost eye drop bottle which was not marked when it was opened. There was a sticker on the bottle that indicated it expired 6 weeks after opening. The eye drop bottle was available for use in the top drawer of the medication cart. (Latanoprost is a medication used to treat glaucoma.) During the observation, Nurse #5 stated the bottle of Latanoprost eye drops should have been dated when it was opened because it was only good for 6 weeks after opening. She further shared that the night shift nurse normally gave it which was why she did not notice it. b. An observation of the 600 hall medication cart with Medication Aide (MA) #2 on 11/16/23 at 11:06 AM revealed an opened vial of Insulin glargine, an opened vial of Insulin lispro and an opened bottle of Latanoprost eye drop in the top drawer of the medication cart and available for use. Both opened vials of Insulin glargine and Insulin lispro had stickers that indicated they expired 28 days after opening. (Insulin glargine and Insulin lispro are different types of insulin used to treat diabetes.) The opened bottle of Latanoprost eye drops had a sticker that indicated it expired 6 weeks after opening. During the observation, MA #2 stated she did not know anything about the insulins because she did not give them and the Latanoprost eye drop was given by the night shift nurse. MA #2 stated she knew all medications should be dated when first used but she was not sure about the expiration dates after the medications were opened. An interview with Nurse #6 on 11/16/23 at 11:18 AM revealed she oversaw MA #2 and was responsible for the insulins on the 600 hall medication cart. Nurse #6 stated she did not notice the undated vials of insulin and Latanoprost eye drops but the nurses need to put a date whenever those were opened. c. An observation of the 500 hall medication cart with Nurse #6 on 11/16/23 at 11:19 AM revealed two containers of Hydrocortisone 1%/barrier cream/antifungal cream marked with expiration dates of 3/16/23 and 3/23/23. Both containers were available for use in the fourth drawer of the medication cart. (Hydrocortisone cream is a medicated lotion, ointment or solution that treats eczema and other skin conditions.) There was also a bottle of Antacid tablets marked with an expiration date of 8/23 which was available for use in the third drawer of the medication cart. (An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion or an upset stomach.) During the observation, Nurse #6 stated that she did not notice the expired medications in the medication cart because she didn't give any of those to her residents, but they should have been discarded after they expired. An interview with the Unit Manager (UM) on 11/17/23 at 8:03 AM revealed the nurses were supposed to check the medication carts daily whenever they used them. All insulins and Latanoprost eye drops should be dated when first opened and all expired medications should be discarded. The UM stated the pharmacy consultant had just checked the medication carts this week and she was not sure why she did not catch any of these. An interview with the Director of Nursing (DON) on 11/17/23 at 8:46 AM revealed the nurses were responsible for checking the medication carts and they should be doing this daily. The DON stated expired medications should be removed from the medication carts and all insulins and eye drops should be dated when they are opened.

Based on observations, interviews with residents and staff and record review, the facility failed to provide supplemental oxygen (O2) per physician (MD) order for 2 of 2 sampled residents reviewed for respiratory care (Residents #69 and #14). The findings included: 1. Resident #69 readmitted to the facility on [DATE]. Diagnoses included dementia, pneumonia, and anxiety disorder. A Nurse Practitioner (NP) progress note dated 9/11/23 documented the NP assessed Resident #69 on re-admission. The Resident denied cough, and shortness of breath. Her lungs were clear, bilaterally, without wheezes, rales, rhonchi, and her breathing was non-labored. A NP progress note dated 9/15/23 recorded nursing reported to the NP that Resident #69 experienced decreased 02 saturations (a measure used to determine oxygen levels in the blood). The NP assessed Resident #69 as alert, in no acute distress, vital signs (VS) within normal limits and her lungs with diffuse wheezes noted. The NP ordered a STAT (immediately) chest Xray. Review of a chest Xray dated 9/15/23 revealed pneumonia to bilateral lungs. The NP was notified. Levaquin and Rocephin (antibiotics) and to monitor O2 saturations were prescribed. A significant change [NAME] Data Set assessment dated [DATE] assessed Resident #69 with adequate hearing, impaired vision, use of corrective lenses, ability to be understood, ability to understand, and intact cognition. A September 2023 care plan identified Resident #69 at risk for side effects of medication prescribed for her diagnosis of anxiety. Interventions included: to monitor VS and provide medications per MD order. Review of electronic MD orders and Medication Administration Records (MAR) for September 1, 2023 - November 17, 2023, revealed the following: - A standing MD order for the diagnosis of cyanosis (skin with bluish/greyish color that indicates inadequate oxygen levels in the blood) or dyspnea (shortness of breath) to provide supplemental O2 at 2 liters per minute (LPM), via nasal cannula (NC) and to notify the provider. Review of the September 1, 2023 - November 17, 2023, MARs revealed this order was not an active MD order and was not included on the MARs. - An active MD order dated 9/10/23 with a stop date of 11/1/23 recorded take VS every shift for readmission. The VS results, which included O2 saturations, were documented on the September, October, and November 2023 MARs. - An active MD order dated 9/29/2023 recorded to change O2 tubing, humidified water, and nebulizer tubing out every Sunday night, sign, and date tubing, on every night shift every Sunday for infection control. The nurses recorded their initials on the September, October, and November 2023 MARs. Resident #69's September 2023 - October 2023 MAR recorded O2 saturations with a range of 84-98%. The electronic medical record documented O2 saturations with the use of supplemental O2 via NC on the following days: - Thirteen days in September 2023 (9/11/23 - 9/15/23, 9/17/23 - 9/28/23, and 9/30/23) - Twenty-seven days in October 2023 (10/1/23 - 10/4/23, 10/8/23 - 10/15/23, and 10/17/23 - 10/31/23) An observation of Resident #69 in her room in bed occurred on 11/14/23 at 9:31 AM. Resident #69 fed herself breakfast and received supplemental 02 from a concentrator via NC at 4 LPM; she denied difficulty breathing. An observation of Resident #69 occurred on 11/14/23 at 10:41 AM; she was in her room in bed with supplemental 02 from a concentrator via NC at 4 LPM. An observation of Resident #69 occurred on 11/15/23 at 10:45 AM with Nurse #2. Resident #69 was lying in bed with 02 via NC at 2 LPM, and a humidifier bottle with a small amount of water. Resident #69 kept moving her O2 tubing in/out of her nose. Nurse #2 asked Resident #69 if she was getting enough O2, she replied Not really. Nurse #2 checked the flow of O2 and stated that she could feel the O2, but that the tubing might be clogged so she would change the O2 tubing and place a new humidifier bottle. Nurse #2 checked Resident #69's O2 saturations and stated, It's fluctuating between 91 - 92%. An interview with Nurse #2 occurred on 11/15/23 during the observation at 10:45 AM. Nurse#2 stated that she was familiar with Resident #69 and was her Nurse on the 7A-7P shift. Nurse #2 described Resident #69 with increased anxiety with difficulty breathing shortly after re-admission to the facility. Nurse #2 stated, So we used the supplemental oxygen at 2 LPM continuous per standing order. Nurse #2 reviewed the November 2023 MAR for Resident #69 and stated she was not sure which nurse transcribed the standing order for supplemental O2 because she did not see the standing order as an active order, but that she was aware that Resident #69 should receive continuous O2 at 2 LPM per standing order. A phone interview with Nurse #8 occurred on 11/16/23 at 10:42 AM. Nurse #8 stated she was the Nurse for Resident #69 on the 7P - 7A shift. Nurse described Resident #69 with a lot of anxiety that's triggered if she feels like she's not breathing the way she should. Nurse #8 stated Resident #69 received supplemental O2 at 2 LPM shortly after her readmission from the hospital. Nurse #8 stated Resident #69 had not expressed difficulty breathing to her but received O2 at 2 LPM per the standing order. Nurse #8 stated she was unsure which nurse implemented the order for O2. An interview with Nurse #6 occurred on 11/16/23 at 6:05 PM. Nurse #6 stated that she assessed Resident #69 on 10/20/23 with low O2 saturations and notified the NP. Nurse #6 stated O2 was already in place via NC at 2 LPM. Nurse #6 stated she received a verbal MD order from the NP to increase O2 to 3 LPM and monitor. Nurse #6 stated that when a nurse started an MD order, the nurse contacted the MD/NP to obtain the MD order. The MD order was either written or verbal and the nurse transcribed the order by entering/activating the MD order in the computer which added the MD order to the MAR. Nurse #6 stated she could not tell which nurse initiated the MD order for O2 for Resident #69 because the MD order was not on the MAR. Nurse #6 stated she thought she returned the O2 rate to 2 LPM once the Resident's O2 saturations stabilized, but she was not certain. An interview with the Unit Manager (UM) occurred on 11/15/23 at 11:23 AM. The UM stated that she was the UM in the facility since October 2023. The UM stated that a discussion regarding MD orders for all new admissions or re-admissions occurred during morning department manager meetings. She stated that the nurses had access to two sets of standing orders, one set from the MD and one set from the corporate office. The UM described the MD orders for supplemental 02, as one that recorded 02 at 2 LPM, but did not give an option to titrate the O2 up/down, and the second order from the corporate office gave the option to write in the 02 range which would require the nurse to contact the MD to clarify the order. The UM stated both orders would require the nurse to contact the MD. The UM stated that the nurse should contact the MD to obtain an order if they wanted to have the option to titrate the 02. The UM stated that titrating O2 was not left to the discretion of the nurse and the order had to be activated by the nurse so that the order would populate on the MAR. The UM stated that supplemental 02 was a medication and should be on the MAR as an order. The UM reviewed the September 2023 - November 2023 MAR for Resident #69 and stated that the MAR did not include an order for supplemental O2. An interview with the Director of Nursing (DON) occurred on 11/15/23 at 11:44 AM. The DON stated she was not aware of why a nurse would change the 02 rate if there was a standing MD order to provide O2 at 2 LPM. The DON stated that if the nurse did not obtain a MD order to titrate the 02, the nurse did not have the discretion to do so. The DON stated that it was difficult to determine which nurse initiated the O2 standing order because the nurse did not activate the order so that it would populate on the MAR, but that the MD order should be on the MAR and followed. The DON stated that it was possible that the nurse may have wanted to assess if Resident #69 responded better to an increase in 02 to discuss this with the MD, but then once the nurse completed the assessment, the 02 rate should have been adjusted back per the MD order until an MD order to titrate the O2 rate up was obtained. An interview with the Administrator occurred on 11/15/2023 at 10:20 AM and he stated that he expected nursing to obtain and follow all physician's orders as written. An interview with the NP occurred on 11/16/23 at 3:47 PM. The NP stated that she did recall getting a phone call from a nurse about Resident #69 having low O2 saturations in the last month or so, but that this had occurred more than once. The NP stated the last call she received the nurse said that she applied O2 at 2 LPM, but that the Resident's O2 saturations were coming up slowly. The NP stated she advised the nurse to increase the O2 to 3 LPM until the Resident became stable which brought her O2 saturations up to 92%. The NP stated she was aware that Resident #69 received O2 at 2 LPM due to her diagnosis of pneumonia and fluctuating O2 saturations. The NP stated she expected Resident #69 would need supplemental O2 continuously, but she would expect the nurse to return the O2 to 2 LPM after the Resident became stable and to notify the MD/NP if an MD order was needed to titrate the O2 up for further clarification of the order. 48006 2. Resident #14 was admitted to the facility on [DATE]. Resident #14 had diagnoses which included chronic respiratory failure with hypoxia with dependence on supplemental oxygen. Review of the electronic medical record revealed a physician order for Resident #14 dated 11/09/2022 which read in part: oxygen at 2 liters per minute via nasal cannula (NC) related to chronic respiratory failure with hypoxia. A review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact with no documented behaviors. Resident #14's MDS indicated she was receiving oxygen therapy. Review of the care plan dated 10/30/2023 revealed Resident #14 had the potential for actual ineffective breathing pattern related to history of chronic respiratory failure with hypoxia requiring supplementary oxygen. The interventions included administer oxygen as ordered and observed for signs and symptoms of respiratory complications. Observations were completed of Resident #14 on 11/13/2023 at 11:32 AM, 11/13/2023 at 3:55 PM, 11/14/23 at 9:16 AM, and 11/14/2023 at 5:11 PM. During each of the observations Resident #14 was observed in bed with her nasal cannula in her nostrils. The oxygen concentrator was set at 3 liters per minute, and Resident #14 was observed to not be in distress. Review of Resident #14's oxygen saturation (a measure of oxygen in the body) levels revealed: 11/13/2023 - 98% (Normal level = 95%-100%) 11/14/2032 - 95% (Normal level = 95%-100%) 11/15/2023 - 94% (Normal level = 95%-100%) An interview was completed with Resident #14 on 11/14/2023 at 2:45 PM. Resident #14 stated she has been on oxygen since she had been at the facility. She further stated, I get short of breath if I don't have it on. She further stated the nursing staff takes care of her oxygen. An interview was completed on 11/15/2023 at 9:10 AM with Resident #14's nursing assistant (NA #3). NA #3 stated she does not do anything with the oxygen machine or the settings. NA #1 further stated she did make sure the tubing was in place in the nose and would notify the nurse if the resident refused to wear it or if the resident was not breathing good. An interview was completed on 11/15/2023 at 09:16 AM with Nurse #7. Nurse #7 stated Resident #14 was on 2 liters of oxygen. She further stated she received that information during shift report. She also stated she saw the oxygen concentrator was set on 3 liters on 11/14/2023 but it slipped her mind to verify the setting with the physician's order. Nurse #7 explained Resident #14 could not change her oxygen settings independently due to her immobility. An observation was completed with Nurse #6 on 11/15/2023 at 9:20 AM. Nurse #6 stated Resident #14's oxygen concentrator setting was set at 3 liters per minute. Review of a nursing note dated 11/15/2023 at 9:45 AM revealed Nurse #6 contacted the Medical Provider and obtained an order for oxygen 3 liters per minute per nasal cannula. An interview was completed on 11/15/2023 at 9:50 AM with the Director of Nursing (DON). The DON stated the nurses should review the physician's order, ensure the in-room concentrator was at the correct ordered liter. An interview was conducted with the Administrator on 11/15/2023 at 10:20 AM. The Administrator stated he expected nursing to follow all physician's orders as written. An interview was conducted on 11/16/2023 at 2:25 PM with the Nurse Practitioner (NP). The NP stated she expected the nursing staff to follow physician's orders for oxygen therapy including the correct flow rate.

Based on record reviews, staff, Responsible Party text communication (RP), Nurse Practitioner (NP), physician (MD), and Urology Physician Assistant (PA) interviews, the facility failed to implement the Urology Physician's orders dated 6/9/23 for prophylactic antibiotic treatment for recurrent urinary tract infections (UTI) and to discontinue a medication to treat an overactive bladder. The facility also failed to ensure staff were trained on the correct procedure to collect a urine specimen and ensure the laboratory was notified there was a specimen for pick up. The deficient practice affected 1 of 3 residents reviewed for urinary tract infections (Resident #1). Resident #1 was sent to the emergency department on 7/13/23 due to being found unresponsive, upon examination in the emergency room Resident #1 required hospital admission in the intensive care unit (ICU) for sepsis (a life-threatening emergency to the body's response to an infection) secondary to a Urinary Tract Infection. The immediate jeopardy began on 6/9/23 when a medical provider (PA) ordered antibiotic therapy was not started and the medication for an overactive bladder was not discontinued per physician order for Resident #1. The immediate jeopardy was removed on 8/5/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had no rejection of care. The assessment indicated she was totally dependent for toileting and personal hygiene and was frequently incontinent of bowel and bladder. According to the MDS assessment, Resident #1 did not have a catheter, had no behaviors or delusions, and did not receive any antibiotic therapy during the review period. A review of a nurse's note dated 5/26/23 at 6:47 PM written by Nurse #1 revealed Resident #1 was transferred to the emergency room at the request of Resident #1's RP for signs and symptoms of a UTI. Review of the hospital discharge summary dated 5/29/23 revealed Resident #1 had a urinalysis that was turbid (unclear and murky in clarity) in appearance and positive for protein and white blood cells during her hospitalization ; however, had no bacterial growth on culture. During her hospitalization , she was treated with intravenous Cefazolin 2000 mg in the emergency room and then on Cipro IV, however, when the urine culture showed no growth, the antibiotics were discontinued, and Resident #1 was anticipated to return to baseline as her Blood Urea Nitrogen (BUN) and creatinine (kidney function labs) had returned to normal and she was tolerating a nutritional diet. Discharge instructions included the following: An indwelling catheter was placed on 5/26/23 and left intact to Resident #1's bladder on discharge, fluids were encouraged and Resident #1's urology appointment was to be rescheduled by Resident #1's RP due to original appointment was cancelled due to hospitalization . A physician's order dated 5/29/23 indicated Resident #1 was to have an indwelling catheter for a neurogenic bladder related to a disease of the brain and spinal cord and change it monthly and as needed for occlusion, obstruction, or obstruction closed system compromise. A nurse progress note dated 6/2/23 at 2:20 AM written by Nurse #7 indicated the nurse had gone into the room to administer medication for Resident #1 around 9:00 PM on 6/1/23 and the catheter was pulled out with the bulb was still intact. The on-call provider gave orders to leave the catheter out of the bladder that shift due to the bulb being intact when it was pulled out then re-insert. A nurse progress note dated 6/2/23 at 10:47AM written by the Director of Nursing (DON) indicated the in-house NP gave instructions that Resident #1's catheter could remain out until her urology appointment on 6/9/23 if she was voiding without difficulty. The note also indicated Oxybutynin, medication to treat overactive bladder, was to be discontinued at that time. A review of the Medication Administration Record dated June 2023 revealed Oxybutynin was discontinued on 6/2/23. Review of the quarterly MDS assessment dated [DATE] indicated Resident #1 was moderately impaired for cognition and had no rejection of care. The assessment indicated she was totally dependent for toileting and personal hygiene and was always incontinent of bowel and bladder. It further indicated Resident #1 had no rejection of care, no delusions, or hallucinations, and received no antibiotics during the review period. The MDS assessment referenced Resident #1 had a catheter intact during the reference period. A review of the Medication Administration Record dated June 2023 indicated Oxybutynin 5 mg TID (3 times a day) was restarted on the evening of 6/5/23 for overactive bladder. Resident #1's urinary care plan dated 6/7/23 revealed the following interventions: Resident #1 had an indwelling catheter intact and at risk for infection with interventions that included: observe for signs and symptoms of UTI: fever, flank pain, nausea, vomiting, dysuria, hematuria, change in color, consistency, and odor with notification of the physician as indicated. It also included obtain labs as ordered and notify the physician of abnormal findings. A telephone interview with Resident #1's RP on 7/24/23 at 3:00 PM revealed she scheduled an appointment for Resident #1 for a follow-up with the urology office on 6/9/23. A review of Urology office notes dated 6/9/23 indicated Resident #1 was seen by the Urology PA for a UTI without hematuria, blood in the urine, and urinary retention. The note indicated: Since Resident #1 was non-ambulatory and voided (elimination of urine) in a brief, the plan would be to rotate prophylaxis antibiotic treatment every 6 months and consider stopping the course should a time occur where Resident #1 regained her ability to ambulate to the bathroom. It further indicated a scan of Resident #1's bladder indicated she retained 211 cubic centimeters (cc) of urine and felt the urge when she needed to void. Details of the note included: Resident #1 was alert and oriented x 4 and had previously been under the care of a different urology provider where she was on a yearlong course of prophylaxis antibiotics which aided her in no recurrent UTIs while on the 1-year treatment course. The note indicated an order was placed for the following: Urine test using a dipstick to determine pH, nitrate, protein, glucose, ketones, leucocytes, and blood in the urine. A review of the Urology Consultation Report form dated 6/9/23 revealed Resident #1 was seen by the local Urology office for recurrent UTI's with encephalopathy which included orders provided by the physician to: Continue holding Oxybutynin and start Macrobid 50 milligrams (mg) daily for 6 months. The consult form did not indicate it was reviewed by a nurse or a medical provider. A review of Resident #1's physician's orders dated June 2023 revealed Macrobid 50 mg was not transcribed on 6/9/23. It further revealed no orders transcribed for Oxybutynin to be discontinued or held on 6/9/23. Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Macrobid was not provided daily beginning on 6/9/23 as ordered. It further revealed an order for Oxybutynin dated 6/5/23 was not held nor discontinued on 6/9/23 and Resident #1 continued to receive Oxybutynin the remainder of the month of June. A review of the nurses' shift to shift report sheet dated 6/9/23 indicated Resident #1 had an appointment with the urology office at 8:15 AM but no further details were contained related to Resident #1. A telephone interview with Nurse #1 conducted on 8/2/23 at 9:59 AM revealed he was an agency nurse who had been employed to work the 500 hall on day shift (7A-7P) on 6/9/23. Nurse #1 stated he was familiar with Resident #1 and recalled she had been prone to recurrent UTI's, did have an indwelling catheter, but it was discontinued in June. Nurse #1 stated he recalled Resident #1 returning from her urology appointment on 6/9/23 with a consult form returned; however, he could not recall if he reviewed the orders provided by the urology office on that date. Nurse #1 stated he placed the consultation form in the box designated for the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for review. Nurse #1 stated he could not recall if he provided report of the orders from the urology appointment to the oncoming nurse that evening and was unsure if the DON or ADON carried out the orders listed on the consultation form. Nurse #1 stated he had been taught how to enter orders into the electronic medical record but had not been taught to transcribe orders from consultation forms before approved by the in-house medical provider. An interview with the ADON on 8/2/23 at 10:22 AM revealed she was not aware Resident #1's physician's orders had not been transcribed on Friday 6/9/23 per a urology consult sheet until a complete chart review was conducted from 7/25/23 through 8/1/23 which revealed Resident #1 had not received her prophylaxis antibiotic treatment and her Oxybutynin had not been discontinued. The ADON stated she or the DON obtain consultation forms from the box at the nurses' station daily (Monday- Friday) and they were reviewed during morning clinical meetings. She indicated all orders should have been transcribed by Nurse #1 when they were received on 6/9/23. She reported she was not certain how review of this consultation report for Resident #1 dated 6/9/23 was overlooked during clinical review and orders were not transcribed as recommended. An interview with NA #1 on 7/25/23 at 11:51 AM revealed she worked on the 500 hall from 7:00 PM-7:00 AM and explained Resident #1 had incontinence of her bowel and bladder and during the last month she was in the facility, she frequently reported Resident #1's increase in odor and mucous in her urine visualized during incontinence care to the nurses. NA #1 indicated she had reported the hallucinations to Nurse #2 and was told not to be concerned the hallucinations were because of Resident #1 having recurrent UTIs. She was unable to verify what dates she had made reports to Nurse #2, but verified she worked on the 500 hall unit with Nurse #2 on the following dates: 6/14, 6/18, 6/19, 6/27, 6/28, 7/1, 7/3, 7/11, and 7/12. NA #1 stated prior to her hospitalization in May 2023, Resident #1 was able to make all her needs known and actively engage in decision making. A telephone interview with NA #2 on 7/25/23 at 1:11 PM revealed she worked the 500 hall from 7:00 PM-7:00 AM. NA #2 stated when she started in June 2023, Resident #1 would communicate most of her needs with staff and had no abnormal behaviors; however, within a couple week of working with Resident #1, her ability to communicate her needs clearly had declined and she was reaching for things or people not present. NA #2 indicated she had notified Nurse #2 and another nurses (she could not recall name or specific dates reported) about the changes in behaviors but was told Resident #1 was having the hallucinations due to a UTI. A telephone interview with Nurse #2 conducted on 7/26/23 at 5:00 PM revealed she was the routine nurse who worked on the 500 hall on night shift (7:00 PM -7:0 AM). Nurse #2 verified she worked on the night of 6/9/23. Nurse #2 stated she recalled Resident #1 was followed by urology but was unable to recall if Nurse #1 reported the recommendations provided by urology on 6/9/23 and she was unaware Resident #1 did not receive medications as recommended by the urology office following that visit. Nurse #2 stated Resident #1 was alert and oriented x 2, had been able to make her needs known at that time, and was able to assist in some of her activities of daily living (ADLs) at the time, she did not recall Resident #1 having any hallucinations or complaints of symptoms of UTI on that shift. Nurse #2 also indicated she could not recall if NA #1 and NA #2 notified her of Resident #1's hallucinations, increase urine odor or the discharge and mucous observed during incontinence care. A provider progress note written by the NP dated 6/15/23 indicated Resident #1 was assessed to be alert, oriented with some confusion. The note further indicated recent urology notes were reviewed and per urology oxybutynin was to be discontinued and Macrobid 50mg daily for 6 months due to recurrent UTI's was ordered. A telephone interview with the NP on 7/27/23 at 10:30 AM revealed she had seen Resident #1 and reviewed her medical record on 6/15/23; however, she was unaware the recommendations by urology had not been transcribed into her medical record and were not implemented. The NP stated the orders provided on the urology consultation should have been initiated on the day of the appointment. A telephone interview with Resident #1's RP on 7/24/23 at 3:00 PM revealed she notified the facility through text message communication on 6/23/23 that Resident #1 had been experiencing hallucinations by seeing cats and dogs on the ceiling. Resident #1's RP stated she did not get a response back from the ADON at the time and was not sure until several days later that Resident #1 had a UTI and was started on antibiotic therapy on 6/29/23. A review of photographed text messages between Resident #1's Responsible Party (RP) and the ADON which included date and time stamps revealed on 6/23/23 at 2:47 PM, Resident #1's RP made the facility aware Resident #1 was hallucinating by seeing dogs and cats on the ceiling and requested she be assessed for a UTI. An interview with the ADON on 7/25/23 at 3:45 PM revealed she frequently engaged in communication via text with Resident #1's RP, but no longer kept the text communication feed on her cellphone. The ADON stated she did recall being made aware Resident #1 had experienced hallucinations and she contacted the provider (she could not recall if she spoke with the MD or NP on that date). The ADON indicated she received orders to obtain a urine specimen for a urinalysis with culture and sensitivity for Resident #1 on 6/23/23 and entered the orders into the medical record. The ADON stated the hall nurse was made aware of the new orders at the time. A review of the physician's orders revealed the following orders: A physician's order dated 6/23/23 indicated obtain a urinalysis with culture and sensitivity x 1 without a reason indicated. A review of the nurses' shift to shift report sheet dated 6/23/23 indicated Resident #1 had a urine specimen located in the fridge. A telephone interview with Nurse #3 on 8/4/23 at 11:29 AM revealed she was an agency nurse employed by the facility to work on day shift (7A-7P) on the 500 hall on 6/23/23. Nurse #3 stated she was notified of the new orders for urinalysis for Resident #1. Nurse #3 indicated Resident #1 was up in her chair at the time and she requested staff place her back to bed to obtain the specimen. Nurse #3 explained she had the NA's (names unknown) place Resident #1 on a bed pain to void. She then, transferred the collected urine from the used bed pan into a cup and from that into a vacuum sealed tube available at the facility. Nurse #3 stated she placed the specimen in the fridge but did not contact the laboratory to make them aware the urine needed to be picked up. She stated she did not know the lab did not pick up specimens on the weekend without being notified. Nurse #3 explained when she obtained the specimen on 6/23/23, she noticed the specimen appeared abnormal and the urine had a strong odor and was a yellowish-white thick substance and contained mucous but did not contact the medical provider for further orders. A laboratory report revealed a urinalysis was collected on 6/23/23 at an unknown time and received by the laboratory company on 6/26/23 at 12:23 PM. It further revealed the results were sent to the facility on [DATE] which indicated the specimen contained 2 bacteria which included: enterococcus faecalis and streptococcus anginous. A review of the physician's order revealed an additional order dated 6/26/23 that indicated obtain a urinalysis with culture and sensitivity x 1 for urinary retention. A telephone interview with Nurse #3 on 8/4/23 at 11:29 AM revealed she was made aware when she returned to work on 6/26/23 that the urine specimen she collected on 6/23/23 had not been picked up by the lab and was collected using the incorrect collection method and therefore had to be recollected on 6/26/23. Nurse #2 explained she recalled NAs on the unit alerting her that Resident #1 had visual hallucinations and would begin talking to things that weren't seen by staff, but she had assessed her to have confusion and therefore did not alert the medical provider of the reported hallucinations. A review of the physician's order revealed an order dated 6/29/23 that indicated Resident #1 was to receive Macrobid 100 mg twice daily for 7 days for a UTI. A provider note written by the facility MD dated 6/29/23 indicated urology notes were noted and the plan was to continue with urology and urology orders. A review of the MAR dated June and July 2023 revealed Resident #1 received Macrobid 100 mg twice daily which began on the evening of 6/29/23 and was completed on the morning of 7/6/23. An appointment was scheduled by Resident #1's RP for a follow-up with the urology office on 7/12/23. A review of the Urology Report of Consultation form dated 7/12/23 revealed Resident #1 was seen by the local Urology office for Altered Mental Status (AMS) and returned the form to the facility with recommendations which indicated: Catheter sample, collect tonight and fax results to the urology office. Start Ciprofloxacin (Cipro) 500 mg twice daily for 10 days. Following Cipro, start Macrobid 50 mg daily and stop Oxybutynin. The consult form additionally revealed a clarification was made by Nurse #4 for a stop date for the Macrobid. A fax written order from the Urology office dated 7/12/23 at 2:58 PM was attached which included a prescription for the Cipro 500 mg twice daily. A review of Urology office notes dated 7/12/23 indicated Resident #1 was seen by the PA for recurrent UTI's and significant AMS with a plan to start antibiotic treatment and request and I&O (in and out) catheterization to collect the urine sample. It further detailed review of the medication reconciliation revealed Resident #1 had continued Oxybutynin and had not started on prophylaxis antibiotic therapy for recurrent UTI's as previously ordered. Additional orders were placed for Ciprofloxacin 500 mg twice daily for 10 days then resume prophylaxis antibiotic therapy Macrobid 50 mg daily for 6 months and discontinue Oxybutynin. An interview with Nurse #4 on 7/25/23 at 12:20 PM revealed she worked the 500 hall on 7/12/23 from 7:00 AM-7:00 PM shift. Nurse #4 recalled Resident #1 returning from a urology appointment on 7/12/23 with new orders to obtain a urine specimen for a culture and sensitivity and medication changes to include an antibiotic and stop Oxybutynin. Nurse #4 stated she called the urology office for clarification of the antibiotic order because it did not include a stop date; however, she did not collect the urine specimen on her shift nor start the antibiotics as ordered. Nurse #4 explained she reported the new orders to the night shift nurse (Nurse #2) at the change of shift. A telephone interview with Nurse #2 on 7/26/23 at 5:00 PM revealed she worked on the 500 hall on 7/12/23 to 7/13/23 on the 7:00 PM-7:00 AM shift. Nurse #2 indicated she collected the urine specimen around 9:00 - to 11:00 PM on 7/12/23 and placed it in the refrigerator for pick-up by the lab for the next morning. Nurse #2 stated she obtained the urine specimen via I &O catheterization. A nurses note written by Nurse #2 dated 7/12/23 at 9:52 PM indicated a urine specimen was collected from Resident #1 and sent to the laboratory. The specimen was described as white, thick, and contained mucous. A review of the MAR dated July 2023 revealed Resident #1 received one dose of oral Ciprofloxacin 500 mg on 7/12/23 at 8:00 PM. A telephone interview with Nurse #5 on 7/25/23 at 12:50 PM revealed she was an agency nurse who was assigned to work the 500 hall on 7/13/23 during day shift (7:00 AM-7:00 PM). Nurse #5 stated she obtained shift report from Nurse #2 who had not indicated any concerns with Resident #1 and began administering her morning medications as usual. Nurse #5 stated around 8:30 AM on the morning of 7/13/23, she entered Resident #1's room to administer her medications and found her to be unresponsive to verbal or tactile stimuli. Nurse #5 stated Resident #1's breathing was sporadic (8-10 breaths per minute), and her skin was slightly pale with her mouth being cyanotic, blue, and her tongue being very dry in nature. She attempted to obtain vital signs and perform a sternal rub without success. Nurse #5 explained she continued to attempt to obtain vital signs and an oxygen saturation and called for the assistance of staff to come to the room for assistance. After a few minutes, the ADON and Medication Aide #1 arrived to the unit to assist Nurse #5. Nurse #5 stated when she obtained an oxygen saturation in the 70 % range, MA #1 retrieved an oxygen tank and a rebreather mask and the ADON began a facetime call with the NP who provided orders to send Resident #1 to the hospital via EMS for further evaluation. Nurse #5 stated Resident #1 had not shown any responsiveness when paramedics arrived and was transported to the local hospital. An interview with MA #1 on 7/25/23 at 2:25 PM revealed he arrived to the 500 hall unit to assist Nurse #5 and was asked to retrieve an oxygen tank and a rebreather mask for Resident #1. He stated he could not recall if he attempted to obtain vitals on Resident #1 on the morning of 7/13/23, but explained he took the robo- nurse (portable multi-use machine used to obtain vital signs) and a manual blood pressure cuff and stethoscope to Nurse #5 and printed out discharge/transfer paperwork for Resident #1's discharge with EMS. MA #1 said he could not recall Resident #1's appearance on the morning of 7/13/23 other than her being unresponsive. An interview with the ADON on 7/25/23 at 3:45 PM revealed she was called to the room of Resident #1 on the morning of 7/13/23 in the early morning although she could not recall a time. The ADON stated when she arrived, Resident #1 was unresponsive to verbal and tactile stimuli according to Nurse #5 who was at the bedside. The ADON stated she immediately facetimed the NP who assessed Resident #1 and provided orders to transfer her to the hospital for evaluation. The ADON stated she notified Resident #1's RP via telephone and then Resident #1 was discharged with EMS. A telephone interview with the NP on 7/31/23 at 10:48 AM revealed she was familiar with Resident #1 and aware she had a diagnosis of recurrent UTI's. The NP indicated she was aware Resident #1 had been seen by urology and was aware of the mediation changes but had not been made aware the orders were not initiated on 6/9/23. The NP stated all orders from the consult sheets were expected to be transcribed and started as ordered. The NP further explained that she became aware of changes in condition for Resident #1 on 6/23/23 by the ADON and provided orders to obtain a urine specimen for culture and sensitivity. She was not aware the specimen was not sent to the lab until 6/26/23 and therefore delayed treatment for Resident #1 until 6/29/23. The NP also explained that she would expect a provider to be notified immediately if there was a delay in collection of a lab, delay in processing, and of any abnormalities of the urine specimen that were obvious on collection. A telephone interview with the MD on 7/31/23 at 10:15 AM revealed he was somewhat familiar with Resident #1. The MD indicated most concerns related to Resident #1 were handled through the NP. He stated he was not made aware orders were not transcribed from the urology consult sheet and initiated as ordered nor was he made aware of the delays in collection and processing of the urine specimen collected on 6/23/23 which delayed treatment of a UTI. The MD stated he would expect to be notified immediately of all changes in a resident's medical condition and expected orders to be carried out as prescribed. Due to being unable to interview by phone, the Urology PA provided the following documentation for the surveyor: By the facility not following recommendations to collect a urine specimen and begin treatment Resident #1 incurred risk of untreated UTI's which included worsening infection to the point of urosepsis and significant decline in health with possible mortality. A review of emergency room notes dated 7/13/23 revealed Resident #1 arrived at the hospital via EMS after she had presented with Altered Mental Status (AMS) status and unresponsiveness, low oxygen saturation of 79% which required 15 liters oxygen via nasal cannula to stabilize, and hypotensive with systolic blood pressure in the 80's. Resident #1 was febrile with a temperature of 101.8 degrees Fahrenheit. Resident #1 required hospital admission in the ICU due to the medical providers evaluation which indicated a high probability of imminent or life-threatening deterioration due to coma and lactic acidosis. The note also read admitted due to severe sepsis believed to be secondary to UTI, acute kidney injury, hypercalcemia, and AMS. The Administrator, Assistant Director of Nursing, and Regional Nurse Consultant were notified of the immediate jeopardy on 8/3/23 @ 11:15 AM. The facility provided the following plan for IJ removal. Recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance. Resident #1 was alert with moderately impaired cognition. Diagnoses include encephalopathy, altered mental status, history of urinary tract infections (UTIs), neuromuscular dysfunction of the bladder, multiple sclerosis, muscle weakness, generalized anxiety, and major depressive disorder. On 6/9/23, Resident #1 was seen by the urologist with a new order to start Macrobid 50 mg once a day for 6 months and continue holding oxybutynin. When the resident returned to the facility from the appointment, the assigned nurse (Nurse #1) did not review the consult sheet and was not aware of the new orders from the urologist. The Macrobid 50 mg was never started, and the oxybutynin was not put on hold due to Nurse #1 not understanding the process for checking consult sheets. On 6/23/23, the resident's sister notified the Assistant Director of Nursing (ADON) that Resident #1 was hallucinating. The ADON contacted the Nurse Practitioner (NP), and a new order was received for a urinalysis (UA) and culture and sensitivity (C&S). The resident's urine was collected on 6/23/23, but the nurse did not notify the lab company that the UA was collected. The lab company picked up the urine on 6/26/23 and it resulted on 6/29/23. The NP reviewed the results on 6/29/23, and Macrobid was ordered and administered for 7 days. On 7/12/23, the resident attended a urology appointment scheduled by her sister. Per the urology consult sheet on 7/12/23, the resident was experiencing altered mental status. Resident #1 was sent back to the facility from the urology appointment with new orders for a UA, start Cipro 500 mg bid x 10 days, start Macrobid 50 mg daily after the Cipro is completed and stop the oxybutynin. The Cipro was started on 7/12/23 at 8:00 pm, the oxybutynin was discontinued, and the UA was collected per the provider's order. On 7/13/23, Resident #1 was unresponsive, had decreased blood pressure and heart rate, and was sent to the emergency room per physician's order, where she was diagnosed with severe sepsis secondary to UTI. All residents could be affected by the deficient practice. On 8/3/23, the Staff Development Coordinator (SDC) conducted education with all alert and oriented residents with a BIMs of 13 and higher regarding signs and symptoms of a UTI, reporting signs and symptoms of a UTI, and prevention of UTIs. On 8/3/23, the Unit Manager (UM) will assess all residents with a history of UTIs to ensure all residents with active signs and symptoms are being treated per the physician's order. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The UM will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/3/23, the SDC will interview all nurses and nursing assistants, in person or via telephone, regarding residents with a change in condition to include signs and symptoms of a UTI. After 8/4/23, anyone that has not been interviewed will be educated prior to the next scheduled shift. The purpose of the interviews is to ensure all residents with a change in condition, including a UTI, have been identified with notification to the physician. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The UM will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/3/23, the Facility Nurse Consultant (FNC) will review all resident's progress notes in the past 30 days for documented signs and symptoms of UTIs. The purpose of the audit is to ensure the physician was contacted and orders were followed for all residents identified with UTI symptoms. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The Assistant Director of Nursing will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/1/23, the FNC began an audit of all consults x 30 days, the UM will complete the review of all consult sheets, including urology consults for the past 30 days, to ensure new orders received, including antibiotics, are processed, and implemented as ordered by the consulting physician. The UM will contact the provider for any identified orders that were not implemented. The audit will be completed by 8/4/23. On 8/3/23, the Assistant Director of Nursing (ADON) and Unit Manager (UM) will review all lab orders, including urinalysis for the past 30 days to ensure the lab was collected, picked up by the lab company, and results received timely. The ADON and UM will contact the provider for any identified delays in labs noted. The audit will be completed by 8/4/23. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring. On 8/3/23, the Staff Development Coordinator initiated an in-service with all nursing assistants, nurses, and agency staff, regarding: 1. Signs and symptoms of UTIs include but are not limited to urinary urgency, burning urination, frequent urinating, cloudy urine, red, bright pink, or cola-colored urine, strong-smelling urine, or pelvic pain. 2. In the elderly, signs and symptoms of UTI can be any subtle change. It is important to recognize and report all acute changes in condition observed to prevent the risk of severe symptoms. 3. Signs and symptoms of sepsis include but are not limited to changes in mental status, shivering, shallow breathing, decrease in blood pressure, and lethargy. 4. Prevention of UTIs including, offering fluids per fluid requirements, and following infection control techniques during incontinent care. On 8/3/23, the Staff Development Coordinator initiated an in-service with all nurses, including agency nurses, regarding: 1. It is the nurse's responsibility to review consult sheets upon the resident return to the facility from an appointment for new and discontinued orders and ensurin[TRUNCATED]

Based on record review, resident, Family member, and staff interview, the facility failed to protect a resident right to be free from employee to resident verbal abuse for 1 of 2 residents investigated for abuse (Resident #2). Resident #2 reported needing assistance with toileting when a Nurse Aide (NA #6) entered her room and NA #6 refused to assist her with incontinence care stating she didn't have time. Resident #2 alleged later that same evening NA #6 returned to her room to place her on the bed pan and verbalized threats while shaking her hand at the resident in a manner which made the resident feel deflated, defeated, tearful, and insignificant. She also stated she was afraid to ask for anything else because she was concerned NA #6 would retaliate against her. The findings included: Resident #2 was readmitted to the facility on [DATE] for rehabilitation services with diagnoses that included displaced avulsion fracture of tuberosity of left calcaneus (a piece of the calcaneus is pulled off when the Achilles tendon splits away from the bone) and retention of urine (difficulty urinating or emptying the bladder). A 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact, required extensive assistance for toileting and personal hygiene, and had occasional incontinence of bladder. A review of the Initial Allegation Report dated 8/1/23 revealed on 7/31/23, the facility was made aware of the incident involving Resident #2 and Nurse Aide (NA) #6. The report indicated the allegation of neglect completed by the former Assistant Director of Nursing (ADON) was made that NA #6 had refused to address the needs of Resident #2 who needed to use a bed pan. Review of Investigation Report dated 8/8/23 competed by the Administrator for abuse and neglect revealed the incident occurred on 7/31/23 at 5:45 PM when NA #6 entered Resident #2's room, walked over and turned the call light off without assisting the resident. Resident #2's [family member] informed NA #6 that Resident #2 needed to get on a bed pan and had been waiting. NA #2 told both Resident #2 and Resident #2's family member I don't have time for that. [Family member} then stood up and asked when will you have time 5 minutes? 10 minutes? NA #2 left the room. At approximately 6:00 PM, [Family member) leaves Resident #2's room and both he and NA #6 are overheard in the hallway and Nurse #6 attempted to intervene and speak with the [family member] to understand what occurred. [Family member] tells Nurse #6 what occurred then went to the Accounts Receivable (A/R) Manager's office to speak with the Assistant Director of Nursing (ADON). At approximately 6:15 PM, NA #6 re-entered Resident #2's room while the [family member] was in the A/R Manager's office and placed Resident #2 on the bed pan. At approximately 6:20 PM, the ADON spoke with the [family member] and the [family member] expressed the same concerns and wanted NA #2 terminated due to her attitude. On 8/1/23 at approximately 9:30 AM, the [family member] filed a formal concern with the social worker and provided a written letter with full details of the allegation of abuse and neglect. The facility did not substantiate the allegations of abuse or neglect in their investigation. A telephone interview with NA #6 on 8/8/23 at 2:20 PM revealed that she was currently on suspension pending an investigation involving Resident #2 which occurred on 7/31/23. NA #6 stated on the evening of 7/31/23 around 5:00 PM she noticed Resident #2's light was on while she was handing out supper trays, but wanted to make sure Resident #2 was not having an emergency so she entered her room carrying another residents' supper tray and when she saw Resident #2 was not in acute distress she turned off her light and began to exit the room before she noticed Resident #2's [family member] sitting in the corner of the room and he told her Resident #2 had been waiting awhile to be helped onto the bed pan. NA #6 admitted she was in the middle of serving meal trays at the time and did not have time to assist her and she would have to wait until she had time. NA #6 explained as she began to leave the room, Resident #2's [family member] stood from the chair and asked how long it would take before she was able to provide Resident #2 the care she had requested, 5 min? 10 min? 20 min? NA #6 stated she told both Resident #2 and her [family member] that she was busy and did not have time then left the room where Resident #2's [family member] followed out the door continuing to demand she provide care to Resident #2. NA #6 stated he made a derogatory comment then left the unit and she was unsure where he had gone. NA #6 indicated she provided care to all residents every 2 hours, and she does not skip residents to provide care to another quicker unless there is an emergency such as a fall. NA #6 said she finished passing the trays and returned to place Resident #2 on the bed pan as she had requested before her [family member] returned to the unit. NA #6 stated she told Resident #2 that her [family member] should not treat her like that then exited the room. NA #6 said she was in Resident #2's room approximately 5-10 minutes to place her on the bed pan but denied shaking her hands at Resident #2 while in the room. NA #6 said as she exited the room to find Nurse #6 to tell her what had occurred when Resident #2's [family member] approached her in the hallway and continued to make demeaning and derogatory comments towards her and within minutes, Nurse #6 and NA #7 approached her and Resident #2's [family member] and intervened in the interaction. NA #6 stated Nurse #6 told her to go to the nurses' station and she indicated she did as she was told and went to the nurses' station while Nurse #6 spoke to Resident #2's [family member]. An interview with Resident #2 on 8/8/23 at 10:10 AM revealed she was sitting up in her wheelchair with a boot on one foot and the other foot wrapped in a bandage with bilateral feet propped up on her leg rest. Resident #2 stated she recalled the incident on 7/31/23 which involved NA #6. Resident #2 indicated on the evening of 7/31/23, around supper time, she had turned her light on for assistance with getting on the bed pan, but after no one arrived to assist her, she called her [family member] to see if he could get her some assistance. Resident #2 stated her [family member] lived 5-10 minutes from the facility and came to the facility to get her some assistance. She explained when her [family member] arrived, she had still not been assisted and her [family member] verified the call light was working before NA #6 entered her room carrying a meal tray. Resident #2 stated NA #6 walked over to the call light system and turned it off without asking what she needed. Resident #2 told NA #6 she needed to get on the bed pan and needed assistance, but NA #6 told her she didn't have time to deal with her and she would have to wait her turn. Resident #2 explained that her [family member] stood up and asked how much longer it would be . 5 min? 10 min? Resident #2 stated NA #6 told Resident #2 and the [family member] she was busy and didn't have time to deal with them and she did not have to answer to them and stormed out of the room mumbling something under her breath. Resident #2 indicated her [family member] became upset with NA #6's actions and left the room to go find the nursing director, but while the [family member] was gone, NA #6 returned to her room to put her on the bed pan. Resident #2 explained after NA #6 got her on the bed pan, and she was still in her personal space, NA #6 shook her clinched hands (closed fist) at her and stated I don't have time to deal with you and I will not have your [family member] putting his fingers in my face and if she needed to pee that bad, she should have made her company leave before supper, then she left the room hastily. Resident #2 stated the interaction on the evening of 7/31/23 made her feel deflated, defeated, tearful, insignificant, like I am this big (holding up two fingers close together), and afraid to ask for anything else because she was concerned NA #6 would retaliate against me. Resident #2 stated she had not seen NA #6 since that night she was neglected and spoken to with disrespect and had no further concerns with care since the night of 7/31/23. A telephone interview with Resident #2's [family member] on 8/8/23 at 11:34 AM revealed that he was contacted by Resident #2 on 7/31/23 around 4:45PM stating she needed assistance with using the bed pan and could not get staff assistance after turning on her call light. The [family member] stated he when he arrived around 5:00 PM, Resident #2 had not received assistance, so he verified that the call light system was working and on. The [family member] said he and Resident #2 waited a few additional minutes before NA #6 entered Resident #2's room holding another resident's meal tray. The [family member] said NA #6 walked over to the wall and turned the call light off without asking Resident #2 how she could assist her. The [family member] indicated before NA #6 could exit the room, he told her Resident #2 needed help getting on the bed pan and had been waiting awhile to which NA #6 replied she did not have time for Resident #2. The [family member] explained that he felt that was not an acceptable response and he asked NA #6 how much longer Resident #2 would have to wait? (5 min, 10 min, 20 min). The [family member] stated at that time, NA #6 stated I don't have time for this and I don't have to answer to you, I don't need this job bad enough for this then she turned and walked out of the room mumbling something (unclear for interpretation) under her breath. The [family member] explained he stood up and followed NA #6 out of Resident #2's room and told her she needed to lose the attitude and be more respectful of the patients and do her job like she was hired to do, or she should lose her job. The [family member] stated he and NA #6 had a brief exchange of harsh words before he left the unit to go to locate the ADON. The [family member] stated when he rounded the corner from the unit headed towards the front lobby, he located the A/R Manager who asked how she could assist him. The [family member] indicated he told the A/R Manager what had occurred in the room and how NA #6 was disrespectful to Resident #2 and wanted to speak to the ADON. The [family member] said the A/R Manager called the ADON on the telephone because she had left for the day and the ADON told the A/R Manager she could not handle the concern now and would have to call him back in 15-20 minutes when she was finished completing whatever she was doing at the time of the call. The [family member] stated he left the A/R Manager's office and headed back towards Resident #2's room to wait for the ADON to call him. As he was approaching Resident #2's room, he noticed NA #6 exit Resident #2's room with a smirk grin on her face. The [family member] stated when he and NA #6 met in the hallway, they again began to exchange negative words when she told him she didn't need his attitude and he told her, he had reported her, and she needed to lose her job for how she treated the patients. The [family member] admitted he said some derogatory comments towards NA #6 for the way she treated Resident #2 as Nurse #6 and NA #7 approached them in the hallway to diffuse the interaction. The [family member] said Nurse #6 told NA #6 to go to the office and shut the door which she repeatedly refused until Nurse #6 told her she was being insubordinate and again told her to go in the nurses' station until she could talk to the [family member]. The family member said NA #6 entered the nurses' station; however, when he began telling Nurse #6 what happened, NA #6 stood in the hallway hollering back down the hallway towards him and Nurse #6 and she again told NA #6 to go in the office and shut the door and she complied. The family member finished telling Nurse #6 what happened and returned to Resident #2's room where he was told NA #6 had made threats toward Resident #2 when she returned to the room to place her on the bed pan while he was gone. The family member acknowledged he was even more upset and when the ADON returned his call approximately 30 minutes later, he told her what happened and that he wanted NA #6 terminated immediately. He stated he was angry and could not recall if he used the words abuse/neglect but did tell the ADON how the NA spoke to his mom and refused to provide care which should have been known as such. He said the ADON told him that NA #6 was not on shift the following day and she would handle the concern on the following morning (8/1/23) when she arrived at the facility. The family member verified he stayed with Resident #2 for a while that evening to help Resident #2 feel safe and said NA #6 did not return to assist Resident #2 before the end of the shift when he left for the night. The following morning, the family member stated he brought a letter outlining the concerns with NA #6 to the facility and filed a formal complaint with the Social Worker where he explained that Resident #2 had been neglected and verbally abused on 7/31/23. An interview on 8/8/23 at 1:35 PM with the A/R Manager revealed Resident #2's family member approached her office on the evening of 7/31/23 around supper time (she was unable to recall the exact time) looking for the nursing supervisor to make her aware of his concerns with a staff member. The A/R Manager stated she asked what occurred because she thought she might could assist him initially since the ADON had already left the facility for the day. Resident #2's family member told her that a staff member had refused to provide care for Resident #2 and spoke to both Resident #2 and him in a rude manner. She called the ADON on the telephone to make her aware of Resident #2's family member's concerns, but when she reached her, the ADON told her she was busy and would need to call the RP back in 15-20 minutes. The A/R Manager stated the family member left her office and returned to the unit where Resident #2 resided, and she had no further interaction with him that evening. An interview with Nurse #6 on 8/8/23 at 3:25 PM revealed she was assigned to the 300 unit where Resident #2 resided on 7/31/23. Nurse #6 stated she was not present when interactions occurred between NA #6 and Resident #2 occurred; however, she intervened when she overheard NA #6 and Resident #2's [family member] arguing in a loud and harsh tone. Nurse #6 stated she attempted to separate them by instructing NA #6 to go to the nurses' station while she spoke with Resident #2's [family member]. Nurse #6 stated she had to repeat herself several times before NA #6 followed her instructions and went to the nurses' station. Nurse #6 stated Resident #2's [family member] explained to her that NA #6 had refused to provide care to Resident #2 when requested and spoke to her disrespectfully. Nurse #6 explained Resident #2's [family member] told her the ADON was supposed to return his call and he was going to report NA #6 to get the matter handled. An unsigned or dated typed witness statement from NA #7 indicated on 7/31/23, around 5:15 PM, she overheard NA #6 and Resident #2's [family member] speaking loudly so she stopped feeding another resident and went to the hallway to intervene. The statement indicated NA #7 stepped between NA #6 and Resident #2's [family member] when Nurse #6 told NA #6 to go the nurses' station. NA #7 stated she went in Resident #2's room to assist her off the bed pan and while in the room, Resident #2 told her NA #6 had fussed at her about her [family member] when he had left the room. Multiple attempts to contact Nurse Aide (NA #7) were made without success. An interview with the Social Worker (SW) on 8/8/23 at 3:45 PM revealed Resident #2's [family member] came to her office on the morning of 8/1/23 and presented her with a formal complaint letter detailing how he felt Resident #2 had been neglected and abused by NA #6 on 7/31/23. She stated she listened to all his concerns and wrote each up on a formal grievance form. The SW stated after she read the letter, she immediately informed the Administrator of the concerns presented by Resident #2's [family member]. The SW stated she had no further interaction with Resident #2's [family member]. An interview with the ADON on 8/9/23 at 8:53 AM revealed was no longer employed at the facility but she received a phone call from the A/R Manager after she left the faciity on [DATE] informing her Resident #2's family member had some concerns with a staff member. The ADON verified she told the A/R Manager she could not handle the concern at the time and would have to call him back. The ADON stated she finished completing what she was doing and then called Resident #2's [family member] back. The ADON explained when she spoke with Resident #2's [family member], he informed her that NA #6 had refused to help Resident #2 and had an attitude with both him and Resident #2 and he wanted NA #6 terminated. The ADON acknowledged she was more concerned if someone provided the incontinence care before the end of the shift to Resident #2 than his concern with how she was treated at the time and did not think about it being neglect or abuse until the following day when Resident #2's [family member] arrived at the facility and filed a formal complaint with the SW. She indicated she could not recall if Resident #2's [family member] had used the words abuse or neglect on 7/31/23 during their conversation, but she felt since it was close to the end of the shift, she could handle the concern the next morning. An interview with the Administrator on 8/8/23 at 1:00 PM revealed he learned of the confrontation between NA #6, Resident #2, and Resident #2's [family member] on 8/1/23 when the SW informed him Resident #2's [family member] had filed a formal complaint with her alleging abuse and neglect. He indicated the letter was attached to the complaint, but it was given to the ADON to handle. He stated the ADON had been handling the investigation until her last day (8/4/23) and he took over the investigation at that time. The Administrator did not substantiate the allegations because he felt the concern was more to do with the family member's behavior than NA #6's actions.

Based on observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #6 from a resident care assignment after NA #6 shook her clinched hands (closed fist) at her and stated, I don't have time to deal with you and if she needed to pee that bad, she should have made her company leave before supper. Resident #2 reported the interaction on the evening of 7/31/23 made her feel deflated, defeated, tearful, insignificant, like I am this big (holding up two fingers close together), and afraid to ask for anything else because she was concerned NA #6 would retaliate against me. NA #6 continued to provide care to other residents in the facility after the incident until the end of her shift at 7:00 pm. This was for 1 of 3 residents reviewed for abuse (Resident #87) . The findings included: A review of the facility policy titled: Abuse, Neglect, or Misappropriation of Resident Property revised 10/15/22 indicated the facility shall take whatever steps are necessary to prevent further acts of abuse, neglect, misappropriation of property, drug diversion, or fraud while the investigation is in progress. Employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. The resident will be examined for any signs of injury as appropriate and emotional support will be provided as needed. Resident #2 was readmitted to the facility on [DATE] for rehabilitation services with diagnoses that included displaced avulsion fracture of tuberosity of left calcaneus (a piece of the calcaneus is pulled off when the Achilles tendon splits away from the bone) and retention of urine (difficulty urinating or emptying the bladder). A 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact, required extensive assistance for toileting and personal hygiene, and had occasional incontinence of bladder. Review of Investigation Report dated 8/8/23 competed by the Administrator for abuse and neglect revealed the incident occurred on 7/31/23 at 5:45 PM when NA #6 entered Resident #2's room, walked over and turned the call light off without assisting the resident. Resident #2's [family member] informed NA #6 that Resident #2 needed to get on a bed pan and had been waiting. NA #2 told both Resident #2 and Resident #2's family member I don't have time for that. [Family member} then stood up and asked when will you have time 5 minutes? 10 minutes? NA #2 left the room. At approximately 6:00 PM, [Family member) leaves Resident #2's room and both he and NA #6 are overheard in the hallway and Nurse #6 attempted to intervene and speak with the [family member] to understand what occurred. [Family member] tells Nurse #6 what occurred then went to the Accounts Receivable (A/R) Manager's office to speak with the Assistant Director of Nursing (ADON). At approximately 6:15 PM, NA #6 re-entered Resident #2's room while the [family member] was in the A/R Manager's office and placed Resident #2 on the bed pan. At approximately 6:20 PM, the ADON spoke with the [family member] and the [family member] expressed the same concerns and wanted NA #2 terminated due to her attitude. On 8/1/23 at approximately 9:30 AM, the [family member] filed a formal concern with the social worker and provided a written letter with full details of the allegation of abuse and neglect. The facility did not substantiate the allegations of abuse or neglect in their investigation. An interview with Resident #2 on 8/8/23 at 10:10 AM revealed on the evening of 7/31/23, around supper time, she had turned her light on for assistance with getting on the bed pan, but after no one arrived to assist her, she called her [family member] to see if he could get her some assistance. Resident #2 stated her [family member] lived 5-10 minutes from the facility and came to the facility to get her some assistance. She explained when her [family member] arrived, she had still not been assisted and her [family member] verified the call light was working before NA #6 entered her room carrying a meal tray. Resident #2 stated NA #6 walked over to the call light system and turned it off without asking what she needed. Resident #2 told NA #6 she needed to get on the bed pan and needed assistance, but NA #6 told her she didn't have time to deal with her and she would have to wait her turn. Resident #2 explained that her [family member] stood up and asked how much longer it would be . 5 min? 10 min? Resident #2 stated NA #6 told Resident #2 and the [family member] she was busy and didn't have time to deal with them and she did not have to answer to them and stormed out of the room mumbling something under her breath. Resident #2 indicated her [family member] became upset with NA #6's actions and left the room to go find the nursing director, but while the [family member] was gone, NA #6 returned to her room to put her on the bed pan. Resident #2 explained after NA #6 got her on the bed pan, and she was still in her personal space, NA #6 shook her clinched hands (closed fist) at her and stated I don't have time to deal with you and I will not have your [family member] putting his fingers in my face and if she needed to pee that bad, she should have made her company leave before supper, then she left the room hastily. Resident #2 stated the interaction on the evening of 7/31/23 made her feel deflated, defeated, tearful, insignificant, like I am this big (holding up two fingers close together), and afraid to ask for anything else because she was concerned NA #6 would retaliate against me. Resident #2 stated she had not seen NA #6 since that night she was neglected and spoken to with disrespect and had no further concerns with care since the night of 7/31/23. A telephone interview with Resident #2's family member on 8/8/23 at 11:34 AM revealed that he was contacted by Resident #2 on 7/31/23 around 4:45 PM stating she needed assistance with using the bed pan and could not get staff assistance after turning on her call light. The family member stated he when he arrived around 5 PM, Resident #2 had not received assistance, so he verified that the call light system was working. The family member stated he and Resident #2 waited a few additional minutes before NA #6 entered Resident #2's room holding another resident's meal tray. The family member said NA #6 walked over to the wall and turned the call light off without asking Resident #2 how she could assist her. The family member indicated before NA #6 could exit the room, he told her Resident #2 needed help getting on the bed pan and had been waiting awhile to which NA #6 replied she did not have time for Resident #2. When asked how much longer it would be for assistance, NA #6 stated I don't have time for this and I don't have to answer to you, I don't need this job bad enough for this then she turned and walked out of the room mumbling something (unclear for interpretation) under her breath. The family member explained he reported the incident to the Accounts Receivable Manager and had an additional confrontation with NA #6 on his way back to Resident #2's room. Nurse #6 and NA #7 intervened and Resident #2's family member reported the actions of NA #6 to Nurse #6 before he returned to Resident #2's room where he was told by Resident #2 that NA #6 had made threats toward her when she returned to the room to place her on the bed pan while he was gone, and it made her feel defeated and not valued and she was afraid to ask for further assistance. A review of NA #6's time record dated 7/25/23 through 8/5/23 indicated NA #6 worked from 7:00 AM through 7:09 PM on 7/31/23. An interview with NA #6 on 8/8/23 revealed she worked the 300 hall on day shift (7A-7P) on the 300 hall and was assigned to Resident #2. NA #6 stated she went in to make sure Resident #2 was not having an emergency and she needed assistance getting on the bed pan. NA #6 explained she told Resident #2 she did not have the time to provide the assistance and she would have to wait. NA #6 stated she was placed on suspension in the late afternoon on 8/1/23 by the ADON who stated she had been accused of abuse and neglect. NA #6 stated she recalled the confrontation between herself, Resident #2, and Resident #2's [family member] on the evening of 7/31/23 but was not sent home from duty on that shift. NA #6 stated Nurse #6 had her go in the nurses' station while she spoke with Resident #2's [family member], but then told her to care for the other residents on the unit and assigned NA #7 to care for Resident #2 until night shift arrived at 7 PM. NA #6 explained she stayed after her shift because she thought a member of Administration would need to speak with her, but when no one called or arrived at the facility she left on her own accord since her shift was over. An interview on 8/8/23 at 1:35 PM with the Accounts Receivable (A/R) Manager revealed Resident #2's family member approached her office on the evening of 7/31/23 around supper time (she was unable to recall the exact time) looking for the nursing supervisor to make her aware of his concerns with a staff member. The A/R Manager stated she asked what occurred because she thought she might could assist him initially since the ADON had already left the facility for the day. Resident #2's family member told her that a staff member had refused to provide care for Resident #2 and spoke to both Resident #2 and him in a rude manner. She called the ADON on the telephone to make her aware of Resident #2's family member's concerns, but when she reached her, the ADON told her she was busy and would need to call the family member back in 15-20 minutes. She indicated she was not involved in how manners were handled and left that to the ADON to handle. The A/R Manager stated the family member left her office and returned to the unit where Resident #2 resided, and she had no further interaction with him that evening. An interview with Nurse #6 on 8/8/23 at 3:25 PM revealed she was assigned to the 300 unit on 7/31/23. Nurse #6 stated she was not present when interactions occurred between NA #6 and Resident #2 but spoke with Resident #2's [family member] who explained to her that NA #6 had refused to provide care to Resident #2 when requested and spoke to her disrespectfully. Nurse #6 explained Resident #2's [family member] told her the ADON was supposed to return his call and he was going to report NA #6 to get the matter handled. Nurse #6 confirmed following the interaction, she instructed NA #6 to care for the other residents on the unit but not to return to Resident #2's room to provide any care unless instructed by her but did not send her home or call the ADON or Administrator since Resident #2's [family member] was already anticipating a call from the ADON. A telephone interview with the ADON on 8/9/23 at 8:53 AM revealed she was no longer employed at the facility but recalled being notified of the incident that occurred between NA #6, Resident #2, and Resident #2's [family member] on 7/31/23. The ADON stated she had already left for the day when she received a phone call from the Accounts Receivable Manager who told her Resident #2's [family member] wanted to speak to her urgently. The ADON explained she was busy at the moment and would have to call Resident #2's [family member] back in 15 minutes or so. The ADON stated she finished what she was doing and then called Resident #2's [family member]. During the telephone conversation between the ADON and Resident #2's [family member], the ADON stated Resident #2's [family member] telling her NA #6 had refused care to Resident #2 and told Resident #2 she didn't have time. The ADON acknowledged she told Resident #2's [family member] that since NA #6 was not scheduled to be on duty on the following day, she would handle his concerns on the next day when she arrived at work. The ADON said she did not call the facility to instruct Nurse #6 to send NA #6 home for the day, she did not call to speak with NA #6 to suspend her on 7/31/23 and did not contact the Administrator to notify him of the allegation on the evening she was made aware of Resident #2's [family member] concerns. The ADON explained her main concern on the night of 7/31/23 was did Resident #2 get the incontinence care provided at some point before the end of the shift by a member of the nursing staff and did not even think about it being abuse at the time. An interview with the Administrator on 8/8/23 at 1:00 PM revealed the facility began an investigation once Resident #2's [family member] arrived at the facility the following morning (8/1/23) filing a formal grievance with the social worker which alleged abuse/neglect. He stated a FRI was not initiated on 7/31/23 because the facility did not consider this incident as abuse until Resident #2's [family member] use this verbiage in the formal grievance process. The Administrator did not see the incident as abuse and felt the ADON handled the situation appropriately.

Based on record review, observations, resident, and staff interviews, the facility failed to maintain a resident's dignity by not providing incontinence care. Resident #3 stated she felt frustrated and mad. This occurred for 1 of 3 residents reviewed for dignity (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact with refusal of care occurring 1 to 3 days during the assessment period. She required extensive assistance with bed mobility, transfers, and toilet use. She was always incontinent of bowel and bladder. During a continuous observation on 7/11/23 from 11:38 am to 12:51 pm, an interview was conducted with Resident #3 who was sitting up in a wheelchair in her room. Resident #3 requested the surveyor to turn her call light on because she stated that she was wet and needed her brief changed. Resident #3 looked at the clock on the wall, discussing how long it would take staff to answer the call light. At 11:51 am, Resident #3's call light remained on while Nurse Aide (NA) #1 and NA #3 were observed passing by the room without answering the call light. At 11:49 am, Therapist #1 walked past the call light without answering it. At 11:54 am, another nurse aide was observed walking past the call light twice while delivering water to other rooms in the hall. At 12:37 pm, NA #1 walked into Resident #3's room and asked the resident what she needed. Resident #3 stated, I'm wet and I need to be changed. NA #1 turned off the call light and stated to Resident #3 that she had to get linen and would be back to clean up the resident. At 12:45 pm, Therapist #2 entered Resident #3's room and asked Resident #3 how she was doing and if she needed anything. Resident #3 stated she was wet and needed to be cleaned up. Therapist #2 turned on the call light and left the room. At 12:51 pm, NA #2 and NA #3 entered Resident #3's room. At this time, there was a strong odor of urine which could be smelled from the hallway. Resident #3 stated to NA #2 and NA #3 that she was wet and needed to be changed. NA #2 assisted the resident to the bathroom by wheelchair. They placed a clean brief and pants on Resident #3. Resident #3 was assisted back to her wheelchair. NA #2 stated she was making rounds and NA #3 was assisting her. NA #3 stated Resident #3 had refused a shower at 11:00 am and he had agreed to help with her care but was not aware Resident #3 had turned on her call light. A follow-up interview on 7/11/23 at 1:00 pm with Resident #3 revealed she had refused to take a shower at 11:00 am but she did not refuse incontinence care. At 11:00 am, she was already wet and needed to be changed. Resident #3 stated she looked at the clock on the wall which was how she kept up with the time. Resident #3 stated it made her frustrated when the staff let her sit in a wet brief. She stated, It makes me frustrated when they leave me sitting so long without helping me, they know I can't do it myself. An interview with NA #2 on 7/11/23 at 1:10 pm revealed she was assigned to care for Resident #3. NA #2 stated that NA #3 had assisted her with rounds so they could get finished quicker. NA #2 stated she had offered a shower at 11:00 am to Resident #3 who refused so she left the room. She stated that she was not aware the resident needed incontinence care at that time, and she did not ask Resident #3 if she needed to be changed. An interview on 7/11/23 at 2:40 pm with Nurse #2 revealed she had asked NA #2 to make sure she completed care rounds with Resident #3 since she had refused care at 11:00 am. Nurse #2 stated she did not know Resident #3 did not receive incontinence care at 11:00 am. An interview on 7/11/23 at 1:46 pm with NA #1 revealed when she went in to answer Resident #3's call light, she couldn't remember what Resident #3 had wanted but she thought Resident #3 had asked for some water. NA #1 stated she got tied up giving the other residents water and she didn't come back to Resident #3's room. NA #1 stated she wasn't assigned to Resident #3 and only answered her call light, but she couldn't remember Resident #3 requesting to be changed. A follow-up interview on 7/11/23 at 2:55 pm with Resident #3 revealed when NA #1 came to her room to answer her call light, she had asked to be changed because she was soaking wet and that she never asked for some water from NA #1. Resident #3 demonstrated increased anger during the interview by wringing her hands, her face turned red, and she began to stutter. She said, I have trouble getting my words out when I get mad. She added, They knew I was wet. An interview was conducted on 7/12/23 at 11:05 am with the Director of Nursing (DON). The DON stated that anyone could answer the call lights. The DON stated Resident #3 should not have waited more than an hour before she was provided incontinence care. She also stated that whoever answered Resident #3's call light should have provided incontinence care to her or should have gotten another staff member to do it if they were doing another task at that time.

Based on observation, record review, resident interviews, staff interviews and nurse practitioner interview, the facility failed to respond to a resident's complaint of pain for 1 of 3 sampled residents reviewed for pain management (Resident #26). The findings included: Resident #26 was readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #26's significant change Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, she had clear speech and could make her needs understood and understood others. The MDS also specified the resident received as needed pain medication for pain. Resident #26's care plan updated with the significant change MDS identified a focus area for potential pain, acute/chronic pain related to [MEDICATION NAME] spine. The identified goal noted resident will voice a level of minimal pain daily through next review date. A review of Resident #26's physician's orders [REDACTED]. 5mg in the morning for arthritis, and 9/15/19 Tylenol 325mg (2 tablets) two times a day for pain. An observation was made on 1/21/2020 at 12:23 PM of Resident #26 lying on her back in bed. During the interview, she reported experiencing pain and she had informed a nurse aide of the need for pain medication. Resident #26 stated her pain was located in her back. She rated the pain as a seven on a scale of 1 to 10 with 10 being the worse. On 1/21/2020 at 12:40 PM, Resident #26 reported the pain had increased a little and no one came to administer pain medication. Again, she rated the pain as seven. Resident #26 also stated, the nurses take their time giving pain medicine. On 1/21/2020 at 1:02 PM. Resident #26 was observed sitting up in bed with the head of the bed raised and not able to raise her arm to eat the lunch meal placed on the bedside table over her lap. Resident #26 stated the pain in her back was so that she was not able to feed herself. Resident #26 displayed facial grimacing during this observation. Resident #26 reported she had not received pain medication requested and was unable to eat due to discomfort in her back. Resident #26 stated she informed everyone that came into the room to let the nurse know (she) needed something for pain. During an interview with Nurse Aide (NA) #1 on 1/21/2020 at 3:02 PM, she reported Resident #26 had requested pain medication twice during the day shift (7:00 AM - 3:00 PM). NA#1 stated Resident #26 was reassigned to her after mid-morning when another nurse aide was no longer needed on the hall. NA#1 stated Resident #26 had requested pain medication during lunch. NA#1 stated she forgot to inform the nurse at this time. NA #1 reported the second time Resident #26 requested pain medication was prior to the end of the day shift (7:00 AM - 3:00 PM) and before she left the facility for an appointment at the change of shift from day to evening shift (3:00 PM). NA #1 stated Nurse #1 was informed of Resident #26's request for pain medication and Nurse #1 walked past and stated, okay. A review of Resident #26's medication administration (MAR) indicated Resident #26 received scheduled [MEDICATION NAME] 7. 5mg and Tylenol 325mg (2 tablets) on the morning of 1/21/2020. Nurse #1 administered the medication to Resident #26. On 1/21/2020 at 3:34 PM, an interview was conducted with Nurse #1. During the interview, Nurse #1 stated a nurse aide had not informed her of Resident #26's request for pain medication during the day shift or prior to Resident #26 leaving the facility for an orthopedic appointment. Nurse #1 reported she administered scheduled morning medication to Resident #26. Nurse #1 stated Resident #26 did not report pain during this time. The Director of Nursing (DON) was interviewed on 1/21/2020 at 4:48 PM. During the interview, the DON reviewed Resident #26's as needed orders for pain. The DON stated nurses should assess every resident for pain due to the population in the facility. She also stated a pain assessment should take place at minimum every shift. The DON expressed her expectation for nurse aides to report to the nurses the name of residents who report pain and request pain medication. The DON suggested a task on the Medication Administration Record [REDACTED]. The DON acknowledged Resident #26's MAR indicated [REDACTED]. On 1/21/20 at 05:09 PM, after returning from an orthopedic appointment to evaluate her pain, Resident #26 reported she did not receive pain medication before she left the facility. She reported she had a cortisone shot during the appointment that has helped to relieve her pain. Review of an orthopedic consultation note dated 01/21/2020 revealed Resident #26 was seen for follow up of her extremely arthritic left shoulder. It was noted she recently had surgery on her back to remove a tumor in her spinal cord based on computerized tomography (CT) scan findings at her last visit. Resident #26 reported she had been in significant pain in her left arm. On examination revealed pseudo paralysis of her left arm. Resident #26 received an injection of cortisone (steroid hormone) and a local anesthetic agent. The consultation note recommended a follow up in 4 to 5 months. During an interview with the Nurse Practitioner (NP) on 1/24/2020 at 11:38 AM, she stated Resident #26 has pain a lot of the time. The NP also stated a report of pain should be a priority for the nursing staff. The NP reported the indication of a pain assessment was a task initiated by the facility.

Based on observations, record reviews, staff, visitors, family, Nurse Practitioner and Medical Doctor interviews the facility failed to notify a resident's responsible party and Medical Doctor that the resident began having facial droop, slurred speech and drooling which resulted in a stroke. The facility also failed to notify a resident's responsible party of an antibiotic which was ordered to treat a urinary tract infection [MEDICAL CONDITION] for 1 of 3 residents reviewed for change in condition (Resident #1). Immediate Jeopardy began on 05/11/18 when Resident #1 began to exhibit right side facial droop, slurred speech and drooling. Nurse #1 did not assess the resident's change in condition and therefore did not report the change in condition to her medical provider or responsible party. Immediate Jeopardy was removed on 05/31/18 at 5:53 PM when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place for reporting a resident's change in condition were effective. The findings included: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that she was cognitively impaired and required limited assistance with her activities of daily living (ADLs). The MDS further indicated that she had clear speech and was usually understood by others. On 05/29/18 at 6:30 PM an interview was conducted with a Restorative Aide (RA) who stated that on 05/11/18 at approximately 1:00 PM she was weighing Resident #1 when she noticed she was not acting like herself. The RA stated Resident #1's speech was slurred and muffled so she pushed her to Nurse #1 and informed the Nurse of what she had observed of Resident #1 and the Nurse indicated she was aware of Resident #1's condition and the Nurse pushed Resident #1 towards her room. An interview was conducted with Visitor #1 on 05/29/18 at 3:40 PM who stated she was a daily visitor to the facility and was familiar with how Resident #1 normally acted. Visitor #1 stated that on 05/11/18 at approximately 2:45 PM she noticed Resident #1 was rolling herself around in her wheelchair using her legs and flailing her arms in the air and hollering but nothing she said made sense. The Visitor stated Resident #1's mouth was drawn to one side (she could not remember which side) and she was drooling. Visitor #1 stated to Nurse #1 that she thought Resident #1 was having a stroke and Nurse #1 told Visitor #1 they were taking care of it. On 05/29/18 at 4:10 PM an interview was conducted with Visitor #2 who stated she too was a daily visitor to the facility and knew the behaviors of Resident #1. The Visitor stated she arrived at the facility around 5:00 PM on 05/11/18 and observed Resident #1 in her wheelchair making all kinds of noises but her speech was not making sense. Visitor #2 further stated that Resident #1 was slurring her speech, had facial droop and was drooling. The Visitor stated she looked around and could not find a staff member to report her concern to so she went toward the front lobby but on her way to the lobby she saw two therapy staff in the therapy gym and went to report her concerns to them. Visitor #2 stated after she told them of her observation of the slurred speech, drooling and facial droop that Resident #1 was having, they immediately went to check on her themselves. An interview was conducted with PT #1 and PT #2 on 05/29/18 at 5:30 PM. PT #1 stated that on 05/11/18 at approximately 5:30 PM Visitor #2 came into the therapy gym and reported to them that Resident #1 had slurred speech, facial droop and was drooling. Both PT #1 and PT #2 went to check on Resident #1 and found her to have the same symptoms that Visitor #2 reported to them. PT #1 and PT #2 went to report their observation to Nurse #1 who stated, Resident #1 was seen by the Nurse Practitioner (NP) earlier that day and was being treated for [REDACTED]. On 05/29/18 at 4:34 PM an interview was conducted with the NP who stated that on the morning of 05/11/18 she was asked by Nurse #1 to evaluate Resident #1 because something was wrong with her. The NP stated she went to evaluate Resident #1 and she was not her normal spry self. Then she reviewed her urinalysis (analysis of urine) which indicated Resident #1 had a UTI so she ordered an antibiotic for her. The NP stated that Resident #1 did not show any signs or symptoms of a stroke for example slurred speech, facial droop or drooling or she would have sent her to the emergency room . The NP further stated she was in the facility until around 5:00 PM and at no time was she alerted to any other changes in Resident #1. On 05/29/18 at 5:20 PM an interview was conducted with Nurse #1 who indicated that throughout the day staff and visitors informed her of Resident #1's slurred speech, facial droop, and drooling but she felt they were the effects of the UTI that the NP diagnosed her with earlier that day. Nurse #1 admitted she did not call Resident #1's responsible party (RP) nor did she notify the NP/MD of Resident #1's right side facial droop, slurred speech or drooling. An interview was conducted with Nurse Aide #1 on 05/30/18 at 12:54 PM. NA #1 stated she took care of Resident #1 on 05/11/18 on first and second shifts. She stated that Resident #1 was not acting like herself, her speech was slurred and she was drooling from one side of her mouth. The NA stated she reported her observation to Nurse #1 and was told that Resident #1 had already been evaluated by the NP and was being treated for [REDACTED].#1 stated that she put Resident #1 in the bed per her usual routine and when she left her shift at 11:00 PM on 5/11/18 Resident #1 was resting in bed with her eyes closed. An interview was conducted with NA #2 on 05/30/18 at 11:54 AM, she confirmed that she worked third shift on 05/11/18 and stated that Resident #1 rested in bed the entire night and she did not notice anything different with her. The NA stated she rendered incontinent care to Resident #1 at approximately 5:00 AM on 05/12/18 and during the interaction she did not notice any unusual behavior or anything out of the normal for Resident #1. She stated that if she had noticed anything abnormal with Resident #1, she would have notified the nurse. An interview was conducted with Nurse #2 on 05/31/18 at 12:50 PM who confirmed he worked third shift on 05/11/18 and was responsible for Resident #1. The Nurse stated that during report he was notified that Resident #1 had not been acting like herself but had been evaluated by the NP and was started on an antibiotic for a UTI. Nurse #2 stated that the resident rested throughout the night and he never had to interact with her that night. He added that NA #2 did not report any abnormal observations of Resident #1 that evening and it was a normal night for Resident #1. An interview was conducted with Nurse #3 on 05/31/18 at 1:01 PM who confirmed she worked first shift on 05/12/18 and was responsible for Resident #1. The Nurse stated that approximately 10:00 AM Resident #1's RP approached her and asked her to check the resident's vital signs because something wrong with her. Nurse #3 stated that she had not seen Resident #1 prior to the family asking her to check her vital signs but when she went to obtain Resident #1's vital signs she did not notice any drooling or facial droop. Nurse #3 stated she asked Resident #1 to smile and she did then she asked her to raise both arms in the air which she did as well. Nurse #3 stated that her assessment revealed no change in Resident #1 from her baseline but the RP requested for her to be sent to the emergency room (ER) for evaluation so she sent her out. An interview was conducted with Resident #1's RP on 05/29/18 at 2:17 PM who stated that she arrived at the facility on 05/12/18 at approximately 10:15 AM to take Resident #1 out for a few hours and was waiting on the staff to get her dressed. The RP stated Visitor #1 came in and informed her of what she had witnessed the day before with Resident #1. The RP stated that when Nurse #3 pushed Resident #1 into the dining area she saw her for the first time that day and noticed her mouth was drawn to the right side. The RP stated she asked Resident #1 if she was okay and she stated she was not okay. The RP stated she then asked Nurse #3 if Resident #1 was okay that she looked like she had a stroke and Nurse #3 told her she looked that way that morning. The RP stated she insisted Resident #1 be sent to the ER for evaluation and they did. The RP explained that she was not notified of Resident #1's change in condition, having a UTI or that she had been started on an antibiotic nor had she been informed of her having facial droop, slurred speech or drooling until the morning she was sent to the ER. An interview was conducted with the Director on Nursing (DON) on 05/30/18 at 3:30 PM who stated that on the morning of 05/12/18 she had arrived at the facility and was informed that Resident #1's RP was there and felt that she was having a stroke. The DON stated she immediately went to check on Resident #1 but initially could not tell if anything was wrong with her until Resident #1 tried to speak then she knew something was not right with Resident #1. The DON also stated she was not aware that Resident #1 started having facial droop and drooling after the NP evaluated her on the morning of 05/11/18. The DON added if Resident #1's symptoms were reported to the nursing staff then they should have been reported to her as well. On 05/30/18 at 12:10 PM an interview was conducted with the Medical Doctor (MD) who stated that if Resident #1 began to display facial droop, drooling and slurred speech on 05/11/18, that those were all classic signs of a stroke, and should have been reported to the NP who was in the building so the resident could be reevaluated immediately and sent to the emergency room . The MD continued to state that Resident #1 had returned to her baseline neurologically and physically and had done well while working with therapy. He added that when Resident #1 presented to the ER, her scan of her brain was abnormal and indicated a stroke but could not determine how old. The MD added that because we could not identify when the stroke occurred or how old it was along with Resident #1's advanced age she would not have qualified for the treatment of [REDACTED]. Review of the Discharge Summary from the hospital dated 05/16/18 indicated Resident #1 had presented to theER on [DATE] and the scan of her head revealed punctate age indeterminate lunar (stroke) in the right basal ganglia and right thalamus (parts of the brain). Her readmitting [DIAGNOSES REDACTED]. An observation was made of Resident #1 on 05/30/18 at 12:10 PM where she was sitting in her wheelchair in the common area. She was calm and no facial droop or drooling was noted. An observation was made of Resident #1 on 05/31/18 8:00 AM where she was sitting at the breakfast table waiting to be served her meal. She was calm and pleasant and no drooling or facial droop was evident. On 05/30/18 at 4:51 PM the administration was notified of Immediate Jeopardy. The facility provided the following credible allegation of removal on 05/31/18 at 4:15 PM: 1. The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited On 5/30/18, Clear Creek Nursing and Rehabilitation Center was placed into Immediate Jeopardy at 5:00 PM for failing to provide Quality of Care. The process that led to the deficiency was determined to be the facility's failure to notify the family/physician/nurse practitioner of Resident #1's change of condition when the resident showed signs of facial drooping and drooling. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited On 5/10/18, the MDS nurse's Care Plan - General Note indicated Resident #1 was at baseline and did not indicate Resident #1 with facial drooping or other change in condition. On 5/11/18 earlier in the day before 11 AM, Nurse #1 did observe Resident #1's change in clarity of speech, but did not see any facial drooping or drooling, and then called the nurse practitioner to verify the nurse practitioner would be at the facility on 5/11/18. Nurse #1 is a licensed practical nurse (LPN) and it is not in the scope of practice for an LPN to assess. On 5/11/18 at approximately 11:46 AM, the physician extender nurse practitioner (NP) note indicated Resident #1 was seen by the NP. The NP note indicated Patient seen for acute care. Meds, labs, notes reviewed .alert, confused .UA reviewed, + for leukocytes, positive for [MEDICATION NAME] .patient refuses PO medications, give [MEDICATION NAME] 1 Gram IM q 24h x 3 doses, give with [MEDICATION NAME]. The NP note did not indicate Resident #1 with right facial drooping. On 5/11/18 at approximately 1:00 PM, the restorative aide noticed Resident #1's speech was not clear while weighing her and took the resident to Nurse #1. On 5/11/18, at approximately 1:00 PM, the restorative aide witnessed Nurse #1 looking at Resident #1 and watched Nurse #1 transport Resident #1 to the nurse station for observation. Nurse #1 did not document an assessment in the electronic health record. Not recognizing there was a change of condition, LPN #1 did not notify a registered nurse (RN), nurse practitioner (NP), or physician (MD) to re-assess Resident #1 in the afternoon as the day progressed on 5/11/18. On 5/11/18 at approximately 2:45 PM, a different resident's family member reported that she attempted to approach Nurse #1 regarding Resident #1. Nurse #1 stated she could not recall this specific visitor interaction. On 5/11/18 after 5:00 PM, the therapist reported to Nurse #1 that Resident #1 was exhibiting slouched posture, drooling and slurred speech. Nurse #1 stated the NP assessed the resident in the morning and Resident #1 was on antibiotic therapy for a urinary tract infection. On 5/11/18 at approximately 6:00 PM, Nurse #1 administered an antibiotic injection for Resident #1. At that time, Nurse #1 did not note observing facial drooping or drooling. On 5/11/18 at the 7 PM shift change, Nurse #1 reported to medication aide (MA) #1. Nurse #1 and MA #1 did not report to a registered nurse (RN) Resident #1's change in condition (right facial drooping, drooling, and continued slurred speech) for assessment, failing to follow established policy. On 5/12/18 at approximately 10:08 AM, registered nurse (RN) #1 assessed Resident #1. The assessment revealed Resident #1 had a change in condition (right facial drooping). RN #1 contacted Resident #1's physician/nurse practitioner provider. The provider gave an order to send Resident #1 to the emergency department (ED) for evaluation. RN #1 also contacted Resident #1's resident representative (RR)/daughter. RN #1 sent Resident #1 to the ED as ordered by the provider. The RR met Resident #1 at the ED. The resident representative/daughter reported to ED physician that Resident #1 was at baseline on 5/10/18. The resident representative/daughter also reported noticing right facial drooping on the morning of 5/12/18. On 5/12/18 through 5/16/18, the ED physician evaluation, including laboratory and radiology test results indicated no evidence that Resident #1 had a [MEDICAL CONDITIONS], Workup here so far has been normal except the fact that she has been hypertensive, was also started on antibiotics for her urinary tract infections yesterday. On 5/12/18, physician orders [REDACTED].#1 back to the facility with no medications ordered. The discharge [DIAGNOSES REDACTED]. Resolved [DIAGNOSES REDACTED]. On 5/16/18, Resident #1 returned to the facility with discharge instruction for hospice evaluation. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements On 5/30/18, the minimum data set (MDS) RN and wound nurse RN assessed each resident. The RN assessment of each resident included taking vital signs, pain, and mental status for change in condition. The purpose of the assessments was to protect Resident #1 and other residents in similar situations. The findings of the assessments: no current facility residents have a new/previously unidentified change in condition requiring additional assessment or physician/NP/resident representative notification. On 5/30/18, the director of nursing (DON) initiated a re-education with all nursing staff to include nursing assistants (NAs), MAs, LPNs, and RNs. The re-education covered the topic of Notification. Notification of changes, Notification of MD/NP and RP. When alerted of a change in a resident, complete an assessment and document. Reporting changes include bruises of unknown origin . On 5/30/18, the facility administrator and DON consulted with the regional vice president (RVP) and corporate RN facility consultant. The RVP and corporate consultant re-educated the administrator and DON. The re-education covered the topics of Quality of Care and the requirements for Notification of Changes. In addition, the RVP and corporate consultant reviewed with the administrator and DON topics of: 1) Change in Condition policy, 3) failure to assess for change of condition resulting from failure to follow established policy, and 4) the importance of addressing resident/family concerns related to Quality of Care. On 5/30/18, the corporate consultant initiated a 100% audit of the nurse progress notes from 5/1/18 through 5/30/18. The purpose of the audit was to identify any needed resident assessment for Resident #1 or other resident at risk of a change of condition that has not been assessed and addressed through physician/NP provider notification and RR notification. Any resident needing assessment will be assessed by a RN and notifications made to the care provider and RR. 4. The title of the person responsible for implementing the acceptable plan of correction. The administrator will be implementing and is responsible for implementing the acceptable plan of correction. Immediate Jeopardy was removed on 05/31/18 at 5:53 PM when interviews with nursing staff revealed they had been educated on when to report a resident's change in condition as well as who to report the change in condition to.

Based on observations, record reviews, staff, visitor, family, Nurse Practitioner, and Medical Doctor interviews the facility failed to assess a resident that exhibited signs and symptoms of [MEDICAL CONDITION] (stroke). This resulted in a delayed hospital evaluation and possible treatment for [REDACTED].#1). Immediate jeopardy began on 05/11/18 when Resident #1 began to exhibit signs and symptoms of a stroke that included slurred speech, right side facial droop, and drooling. Nurse #1 was notified by various staff and visitors that Resident #1 was exhibiting slurred speech, right sided facial droop, and drooling and did not assess Resident #1. Immediate jeopardy was removed on 05/31/18 at 5:53 PM when the facility provided and implemented an acceptable allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place for assessing a resident with a change in condition are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was cognitively impaired and required limited assistance with activities of daily living. The MDS further revealed that Resident #1 had clear speech and was usually understood by others. Review of a Nurse Practitioner (NP) progress noted dated 05/11/18 at 11:46 AM read, Resident #1 was seen for acute care. Medications, laboratory values, and notes were reviewed. Staff noted that Resident #1 has had change in mental status and was having difficulty speaking. Resident #1 was very confused and was not interacting with me when assessed. Her assessment revealed Resident #1 was calm and pleasant but confused. Review of a urinalysis (analysis of the urine) revealed it was positive for leukocytes (a cell that could indicate a urinary tract infection) and [MEDICATION NAME] (a cell that could indicate a urinary tract infection). The assessment and plan read, Urinary tract infection [MEDICAL CONDITION]: Resident #1 refuses to take medications by mouth. Give [MEDICATION NAME] (antibiotic) 1 gram (gm) intramuscular (IM) every day for 3 days. An interview was conducted with the NP on 05/29/18 at 4:34 PM. The NP stated that on 05/11/18 Nurse #1 stated something was wrong with Resident #1. The NP stated she went to see Resident #1 and evaluated her and reviewed her laboratory values. The laboratory values indicated that she had a UTI and she was not her usual spry or jovial self. The NP stated at the time she evaluated Resident #1 she had no slurred speech or any other signs that indicated she may be having [MEDICAL CONDITION] stroke or she would have sent Resident #1 to the hospital. She indicated that her assessment and review of her medical record indicated that Resident #1 had a UTI and she was placed on [MEDICATION NAME] for 3 days. The NP also confirmed that she was not alerted to any other changes that transpired with Resident #1 that day. An interview was conducted with the Restorative Aide (RA) on 05/29/18 at 6:30 PM. The RA stated that on 05/11/18 she was doing weights in the facility. While weighing Resident #1 at approximately 1:00 PM the RA noted that Resident #1 was not acting like herself, she was agitated her speech was slurred and muffled. The RA indicated that she pushed Resident #1 in her wheelchair to Nurse #1 and informed her that her speech was slurred and she was not acting like herself. She stated Nurse #1 indicated that she was aware of Resident #1's condition and pushed Resident #1 back towards her room. An interview was conducted with Visitor #1 on 05/29/18 at 3:40 PM. Visitor #1 indicated she arrived at the facility on 05/11/18 at approximately 2:45 PM and noticed Resident #1 rolling around the halls hollering but nothing she said made any sense. She further indicated that Resident #1 was flailing her arms around in the air and was drooling and her mouth was drawn to one side but she could not recall which side. Visitor #1 stated she saw Nurse #1 and stated to her I think Resident #1 is having a stroke. Visitor #1 stated that Nurse #1 replied we are taking care of it and that was it. Visitor #1 stated that later in the day she told Visitor #2 that something was wrong with Resident #1. Visitor #1 stated she did not see Nurse #1 go and check on Resident #1 during her time in the facility. An interview was conducted with Visitor #2 on 05/29/18 at 4:10 PM. Visitor #2 stated that she arrived at the facility on 05/11/18 at approximately 5:00 PM and was informed by Visitor #1 that something was wrong with Resident #1. Visitor #2 stated that she observed Resident #1 in her wheelchair and was making all kinds of noises but her speech was slurred and she couldn't talk. Visitor #2 stated she went to look for someone to help Resident #1 and found Physical Therapist (PT) #1 and #2 and asked them to check on Resident #1. An interview was conducted with PT #1 and PT #2 on 05/29/18 at 5:30 PM. PT #1 stated that on 05/11/18 at approximately 5:30 PM Visitor #2 came to the therapy gym and stated that Resident #1 had slurred speech, she had facial droop and was drooling. PT #1 indicated that she grabbed PT #2 and they went to check on Resident #1 and found her to exhibit the same symptoms described by Visitor #2. PT #1 stated that they went to Nurse #1 to inform her of Resident #1's condition. PT #1 stated that Nurse #1 stated that she was aware of Resident #1's condition and she had been seen by the NP earlier that day and was being treated for [REDACTED].#2 stated she again informed Nurse #1 of her concern with Resident #1's facial droop and again Nurse #1 stated she was aware. Both PT #1 and PT #2 did not see Nurse #1 assess Resident #1 and after they informed Nurse #1 of their concerns they returned to the therapy gym to complete their work. An interview was conducted with Nurse #1 on 05/29/18 at 5:20 PM. Nurse #1 indicated that on 05/11/18 in report she was informed that the NP needed to evaluate Resident #1 because she was not acting like herself. Nurse #1 stated that she did not see or interact with Resident #1 that morning because she was passing medication and Resident #1 was not prescribed any medications. Nurse #1 stated around lunch time the RA brought Resident #1 to me stated that she was not acting like herself and her speech was slurred. Nurse #1 indicated she was aware of her slurred speech and that the NP had seen her and ordered her an antibiotic for a UTI. Nurse #1 indicated that later in the day two PTs had come and stated that Resident #1 was not acting like herself and was exhibiting slurred speech, facial droop, and drooling. Nurse #1 stated that she replied to PT #1 and #2 that she had already been assessed and she was being taken care of. Nurse #1 stated that she did not think she needed to go and assess Resident #1 because the NP had already assessed her earlier in the day. A follow up interview was conducted with Nurse #1 on 05/31/18 at 10:26 AM. Nurse #1 confirmed again that she had not assessed Resident #1 for a change in condition and did not ask any other nurse to assess Resident #1. She acknowledged that the RA, Visitor #1, PT #1 and #2 had reported their concerns to her about Resident #1's slurred speech, facial droop, and drooling but she believed that they were all effects from her UTI. Nurse #1 stated that after the RA brought Resident #1 to her earlier that day she did not see Resident #1 again until 6:00 PM when she went to administer her ordered antibiotic injection and at that time she did not notice any change to her condition. An interview was conducted with Nursing Assistant (NA) #1 on 05/30/18 at 12:54 PM. NA #1 confirmed that she took care of Resident #1 on 05/11/18 on 1st and 2nd shift. She stated that Resident #1 was not acting like herself and her speech was slurred and she was drooling from one side of her mouth. NA #1 stated that she alerted Nurse #1 and was told that Resident #1 had already been evaluated by the NP and was being treated for [REDACTED].#1 stated that she placed Resident #1 in the bed per her usual routine and when she left her shift at 11:00 PM on 05/11/18, Resident #1 was resting in bed with her eyes closed. An interview was conducted with NA #2 on 05/30/18 at 11:54 AM. NA #2 confirmed that she worked 3rd shift on 05/11/18 and stated that Resident #1 rested in bed the entire night and she did not notice anything different with her. NA #2 stated that she rendered incontinent care to Resident #1 at approximately 5:00 AM on 05/12/18 but during that interaction she did not notice any usual behavior or anything out of the normal with Resident #1. She added that if she would have noticed any abnormal behavior she would have alerted the nurse. An interview was conducted with Nurse #2 on 05/31/18 at 12:50 PM. Nurse #2 confirmed that he was working 3rd shift on 05/11/18 and was responsible for Resident #1. Nurse #2 stated that during report he was notified that Resident #1 had not been acting like herself but had been evaluated by the NP and was on antibiotic for UTI. Nurse #2 stated that Resident #1 rested throughout the night and he never had to interact with Resident #1 that night. He added that NA #2 did not report any unusual behavior that evening and it was a normal night for Resident #1. An interview was conducted with Nurse #3 on 05/31/18 at 1:01 PM. Nurse #3 confirmed that she worked 05/12/18 on 1st shift and was responsible for Resident #1. Nurse #3 stated that approximately 10:00 AM Resident #1's family approached her and asked that Resident #1's vital signs be checked because there was something wrong with her. Nurse #3 stated that she had not seen Resident #1 prior to the family asking for her to check Resident #1's vital sings. Nurse #3 stated that when she went to obtain Resident #1's vital signs she did not notice any drooling or facial droop. She stated that she asked Resident #1 to smile and she did and she asked Resident #1 to lift both her arms in the air and she was able to do that. Nurse #3 stated that her assessment revealed no change in Resident #1 from her baseline but the family requested that Resident #1 be sent to the emergency room (ER) for evaluation and so she sent her out. An interview was conducted with Resident #1's family on 05/29/18 at 2:17 PM. The family member stated that she had visited Resident #1 on 05/10/18 and found her to be in her usual state of health. The family member stated that she came to the facility on [DATE] at approximately 10:15 AM and was sitting in the dining room waiting on the staff to get her family member dressed. She added that Visitor #1 came in and informed the family member of what she had witnessed on 05/11/18 with Resident #1. The family member stated that when Nurse #3 pushed her family member into the dining room and she observed her for the first time that day she instantly noticed her mouth was drawn to the right side and she stated she asked Resident #1 if she was okay and Resident #1 stated no I am not okay. Resident #1's family member stated to Nurse #3 is my family member ok she looks like she has had a stroke and Nurse #3 replied she looked like that this morning. Resident #1 stated she informed Nurse #3 she wanted her family member sent out to the ER for evaluation and they did. An interview was conducted with NA #3 on 05/31/18 at 1:24 PM. NA #3 confirmed that she was working on 05/12/18 on 1st shift. NA #3 stated that Resident #1's family asked her to go and look at Resident #1. NA #3 stated that the instant she saw her she noticed her face was drawn to the right side and she looked like someone who had a stroke. NA #3 stated that she summoned the Director of Nursing (DON) to come and look at Resident #1 and she had her sent to the ER for evaluation. An interview was conducted with the DON on 05/30/18 at 3:30 PM. The DON stated that on the morning of 05/12/18 she arrived at the facility and NA #3 informed her that Resident #1's family member was in the facility and thought Resident #1 was having a stroke. The DON stated she immediately proceeded to go and check on Resident #1 and initially by looking at her could not tell anything was wrong but when Resident #1 started to speak she knew something was not right. The DON stated that Resident #1's speech was very slurred and she asked if the medics were on the way. She added that Nurse #3 stated that they were on the way to the facility and Resident #1 was transported to the ER for evaluation. The DON stated she was not aware that on 05/11/18 sometime after Resident #1 was evaluated by the NP she began to have facial droop and drooling and if these symptoms were reported to the nursing staff they should have contacted her. An interview was conducted with the Medical Doctor (MD) on 05/30/18 at 12:10 PM. The MD stated that if Resident #1 began to display facial droop, drooling, and slurred speech those were all classic signs of a stroke. The MD stated that if these symptoms were reported to the nursing staff on 05/11/18 the NP who was in the building should have been made aware so Resident #1 could have been reevaluated and sent immediately out to the ER. The MD stated that Resident #1 had returned to her baseline neurologically and physically and had done well while working with therapy. He added that when Resident #1 presented to the ER her scan of her brain was abnormal and indicated a stroke but could not determine how old. The MD added that because we could not identify when the stroke occurred or how old it was along with Resident #1's advanced age she would not have qualified for the treatment of [REDACTED]. Review of the discharge summary from the hospital dated 05/16/18 indicated that Resident #1 had presented to theER on [DATE] and scan of her head revealed punctate age indeterminate lacunar infarcts (stroke) in the right basal ganglia and right thalamus (parts of the brain). Her readmitting [DIAGNOSES REDACTED]. An observation was made of Resident #1 on 05/30/18 at 12:10 PM. Resident #1 was sitting in her wheelchair in the common area. She was calm and no facial droop or drooling was noted. An observation was made of Resident #1 on 05/31/18 at 8:00 AM. Resident #1 was sitting at the breakfast table waiting to be served her meal. She was calm and pleasant and no facial droop or drooling was noted. Credible Allegation 5/31/18, 4:15 PM F684 1. The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited On 5/30/18, Clear Creek Nursing and Rehabilitation Center was placed into Immediate Jeopardy at 5:00 PM for failing to provide Quality of Care. The process that lead to the deficiency was determined to be the facility ' s failure to assess for change of condition when the licensed practical nurse (LPN, Nurse #1) did not report to a registered nurse (RN) for re-assessment of Resident #1 after receiving reports of the resident showing signs of facial drooping and drooling. The nurse recognized the resident ' s change in condition and believed the nurse practitioner addressed the resident ' s needs by performing an assessment and prescribing an antibiotic for the [DIAGNOSES REDACTED]. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited On 5/10/18, the MDS nurse's Care Plan - General Note indicated Resident #1 was at baseline and did not indicate Resident #1 with facial drooping or other change in condition. On 5/11/18, earlier in the day before 11 AM, Nurse #1 did observe Resident #1's change in clarity of speech and did not see any facial drooping or drooling earlier in the day and did call the nurse practitioner. Nurse #1 is a licensed practical nurse (LPN) and it is not in the scope of practice for an LPN to assess. Not recognizing there was a change of condition, LPN #1 did not notify a registered nurse (RN), nurse practitioner (NP), or physician (MD) to re-assess Resident #1 in the afternoon as the day progressed on 5/11/18. On 5/11/18 at approximately 11:46 AM, the Physician Extender nurse practitioner (NP) note indicated Resident #1 was seen by the NP. The NP note indicated Patient seen for acute care. Meds, labs, notes reviewed .alert, confused .UA reviewed, + for leukocytes, positive for [MEDICATION NAME] .patient refuses PO medications, give [MEDICATION NAME] 1-gram IM q24h x 3 doses, give with [MEDICATION NAME]. The NP note did not indicate Resident #1 with right facial drooping. On 5/11/18 at approximately 1:00 PM, the restorative aide noticed Resident #1's speech was not clear while weighing her and took the resident to Nurse #1. The restorative aide witnessed Nurse #1 looking at Resident #1 and watched Nurse #1 transport Resident #1 to the nurse station for observation. Nurse #1 did not document an assessment in the electronic health record. On 5/11/18 at approximately 2:45 PM, a different resident's family member reported that she attempted to approach Nurse #1 regarding Resident #1. Nurse #1 stated she could not recall this specific visitor interaction. On 5/11/18 after 5:00 PM, the therapist reported to Nurse #1 that Resident #1 was exhibiting slouched posture, drooling and slurred speech. Nurse #1 stated the NP assessed the resident in the morning and Resident #1 was on antibiotic therapy for a urinary tract infection. On 5/11/18 at approximately 6:00 PM, Nurse #1 administered an antibiotic injection for Resident #1. At that time, Nurse #1 did not note observing facial drooping or drooling. On 5/11/18 at the 7 PM shift change, Nurse #1 reported to medication aide (MA) #1. Nurse #1 and MA #1 did not report to a registered nurse (RN) Resident #1's change in condition (right facial drooping, drooling, and continued slurred speech) for assessment, failing to follow established policy. On 5/12/18 at approximately 10:08 AM, registered nurse (RN) #1 assessed Resident #1. The assessment revealed Resident #1 had a change in condition (right facial drooping). RN #1 contacted Resident #1's physician/nurse practitioner provider. The provider gave an order to send Resident #1 to the emergency department (ED) for evaluation. RN #1 also contacted Resident #1's resident representative (RR)/daughter. RN #1 sent Resident #1 to the ED as ordered by the provider. The RR met Resident #1 at the ED. The resident representative/daughter reported to the ED physician that Resident #1 was at baseline on 5/10/18. The resident representative/daughter also reported noticing right facial drooping on the morning of 5/12/18. On 5/12/18 through 5/16/18, the ED physician evaluation, including laboratory and radiology test results indicated no evidence that Resident #1 had a [MEDICAL CONDITIONS], Workup here so far has been normal except the fact that she has been hypertensive, was also started on antibiotics for her urinary tract infections yesterday. On 5/12/18, physician orders [REDACTED].#1 back to the facility with no medications ordered. The discharge [DIAGNOSES REDACTED]. Resolved [DIAGNOSES REDACTED]. On 5/16/18, Resident #1 returned to the facility with discharge instruction for hospice evaluation. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements On 5/30/18, the minimum data set (MDS) RN and wound nurse RN assessed each resident. The RN assessment of each resident included taking vital signs, pain, and mental status for change in condition. The purpose of the assessments was to protect Resident #1 and other residents in similar situations. The findings of the assessments: no current facility residents have a new/previously unidentified change in condition requiring additional assessment or physician/NP notification. On 5/30/18, the director of nursing (DON) initiated a re-education with all nursing staff to include nursing assistants (NAs), MAs, LPNs, and RNs. The re-education covered the topic of Notification. Notification of changes, Notification of MD/NP and RP. When alerted of a change in a resident, complete an assessment and document. Reporting changes include bruises of unknown origin . On 5/30/18, the facility administrator and DON consulted with the regional vice president (RVP) and corporate RN facility consultant. The RVP and corporate consultant re-educated the administrator and DON. The re-education covered the topics of Quality of Care and the requirements for Notification of Changes. In addition, the RVP and corporate consultant reviewed with the administrator and DON topics of: 1) Change in Condition policy, 3) failure to assess for change of condition resulting from failure to follow established policy, and 4) the importance of addressing resident/family concerns related to Quality of Care. On 5/30/18, the corporate consultant initiate a 100% audit of the nurse progress notes from 5/1/18 through 5/30/18. The purpose of the audit was to identify any needed resident assessment for Resident #1 or other resident at risk of a change of condition that has not been assessed and addressed through physician/NP provider notification and RR notification. Any resident needing assessment will be assessed by a RN and notifications made to the care provider and RR. 4. The title of the person responsible for implementing the acceptable plan of correction. The administrator will be implementing and is responsible for implementing the acceptable plan of correction. Immediate jeopardy was removed on 05/31/18 at 5:53 PM when interviews with nursing staff revealed that they had been educated on conducting assessments when a change of condition was reported. The education also included if the nurse was unable to assess the resident that the expectation was that they report to a nurse that could assess the resident.

Based on observations, staff and hospice nurse interviews, and record review, the facility failed to provide the appropriate size of wheel chair for proper body alignment for 1 of 4 sampled residents who required assistance with positioning (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an occupational therapy discharge summary dated 05/03/17 revealed Resident #48 received an assessment to determine a seating system to increase comfort, provide safety and decrease agitated behaviors. Resident #48's wheel chair was changed to a brand specific tilt chair with a 4-quadrant gel cushion. Review of Resident #48's quarterly Minimum Data Set ((MDS) dated [DATE] revealed an assessment of short-term and long-term memory problems. The MDS indicated Resident #48 required the extensive assistance of one person with bed mobility and transfers. Review of the care plan dated of 03/14/18 revealed Resident #48 required the assistance of one person with transfers. There was no documentation of a chair type. Review of Resident #48's resident care guide dated 03/21/18 and posted inside Resident #48's closet revealed required equipment included the brand specific tilt chair with a 4- quadrant gel cushion when out of bed. Observation on 04/15/18 at 9:07 AM revealed Resident #48 seated in a wheelchair on a pommel cushion. (A pommel cushion is a cushion with an upward projecting protuberance at the front.) Resident #48's toe tips reached the floor. The wheel chair did not contain leg rests. Resident #48 moved both legs knee to chest. Observations on 04/15/18 at 9:64 AM and 10:19 AM revealed Resident #48 seated on the pommel cushion in the wheelchair. Observation at 10:48 AM on 04/15/18 revealed Resident #48 with both legs on the right side of the pommel cushion center. Both legs dangled off the chair. Observations on 04/16/18 at 8:49 AM revealed Resident #48 seated on the pommel cushion in the wheelchair. Observations at 9:23 AM, 9:44 AM, and 10:56 AM on 04/16/18 revealed Resident #48 seated in the same position; the pommel cushion overlapped the wheel chair seat approximately 2 inches. Interview on 04/16/18 at 2:38 PM with Nurse Aide (NA) #1 revealed Resident #48 used the wheel chair and pommel cushion every day when out of bed. NA #1 explained Resident #48 required total assistance with locomotion and moved her legs frequently over the center of the pommel cushion. Interview with Nurse #2 on 04/16/18 at 4:00 PM revealed Resident #48 used the wheel chair with pommel cushion daily. Nurse #2 reported she was not aware of another tilt chair with 4-quadrant gel cushion for Resident #48's use. Interview on 04/17/18 at 8:41 AM with NA #2 revealed Resident #48 used the wheel chair and pommel cushion every day when out of bed. Observations on 04/17/18 at 8:50 AM revealed Resident #48 seated on the pommel cushion in the wheelchair. Observations at 9:43 AM on 04/17/18 revealed Resident #48 seated in the same position; the pommel cushion overlapped the wheel chair seat approximately 2 inches. Resident #48 placed both hands on the protuberance in the center of the pommel cushion. Interview with the rehabilitation director (RD) at 10:08 AM on 04/17/18 revealed Resident #48 received a discharge from therapy with the direction to use the brand specific tilt chair and 4-quadrant gel cushion. Upon observation of Resident #48 seated in the wheel chair on the pommel cushion, the RD announced the wheel chair was not at the correct height for Resident #48. The RD explained the pommel cushion should not overlap the edge of the wheel chair. The RD suggested the hospice staff might have switched out the chairs. Interview with the Director of Nursing (DON) on 04/17/18 at 10:44 AM revealed Resident #48 should be properly positioned and could not provide a reason the recommended chair and cushion was not used. Telephone interview with the hospice nurse on 04/17/18 at 12:09 PM revealed Resident #48 probably received a new chair when hospice services began (MONTH) (YEAR). The hospice nurse explained the hospice relied on facility staff to assess positioning needs such as wheel chair height and cushions since Resident #48 was usually in bed during hospice visits.

Based on observations, staff interviews and record review, the facility failed to care plan a resident ' s increased risk of skin tears that included goals and interventions for skin tear prevention for 1 of 3 residents (Resident #3) reviewed for skin impairment. Findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Progress notes for 3/31/15 3:47 PM indicated Resident #3 had been admitted with skin tears to top of his left wrist, right hand and right wrist. Review of the 4/7/15 Admission Minimum Data Set (MDS) indicated Resident # 3 was severely cognitively impaired with no behaviors or rejection of care. The MDS revealed the resident required extensive assistance for transfer, dressing, toilet use, and personal hygiene. Progress notes for 4/10/15 at 9:32 AM indicated Resident #3 had sustained a skin tear to his right elbow during a transfer from bed to the wheelchair. The nurse documented Resident #3 was resistive to care during activities of daily living and transfers. There were no interventions or plan initiated to prevent Resident #3 from sustaining skin tears. On 4/10/15 at 11:59 AM progress notes indicated the treatment nurse noticed skin tears to Resident #3 ' s right forearm while assessing Resident #3 ' s other areas. The nurse documented Resident #3 had very fragile skin. The intervention documented was observation to see if the resident ' s medications needed adjustment. There was no documentation that indicated the nurse had reviewed the resident ' s medication. Review of a nursing progress note for 4/18/15 at 11:24 AM indicated the RP brought to the nurse ' s attention an open area to the resident's left shin area. The nurse documented she assessed the area, cleansed the area with normal saline and applied a [MEDICATION NAME] dressing. No measures were put into place to prevent further skin tears. Review of the care plan did not reveal any identification that Resident #3 had a problem with skin tears and included no interventions for prevention of skin tears. NA #2 was interviewed on 6/30/15 at 1:21 PM. The NA stated she cared for Resident #3 each day she worked which was usually 5 times per week and added it was not unusual for the resident to get skin tears. NA #2 when she transferred Resident #3 she tried to make sure the path was clear to avoid having any object hit his skin. The NA stated instructions for caring for residents were found on the care guides located at the nurse ' s station. NA #2 reviewed Resident #3 ' s care guide and acknowledged the care guide did not include information about residents who are at risk for skin tears During an interview with Nurse #1 on 6/30/15 at 2:30 PM, she stated the facility ' s wound care protocols covered the treatment of [REDACTED]. An interview was held with the Director of Nursing (DON) and MDS Nurse #1 on 7/1/15 at 1:30 PM. The DON stated she expected Resident #3 ' s skin tears to be addressed on the care plan. The DON reviewed the care plan and stated she did not see a care plan identifying skin tears as a problem for Resident #3, did not identify interventions for skin tear prevention and did not identify the resident ' s current wound identified as caused by a skin tear. The DON reviewed the care guide, identified to be used by the NAs for caring for residents and stated the resident's risk of skin tears and interventions for skin tear prevention was not identified on the care guides for Resident 3. The MDS nurse stated she had no explanation why the skin tear on the left shin or interventions to prevent skin tears had not been addressed or Resident #3 ' s care plan or care guide.

Based on observations, staff interviews, interviews with a family member and record review, the facility failed to place interventions for prevention of skin tears for 1 of 1 resident (Resident #3) reviewed for skin tears, whose skin tear resulted in an unstageable wound. Findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Progress notes for 3/31/15 3:47 PM indicated Resident #3 had been admitted with skin tears to top of his left wrist, right hand and right wrist. Review of the 4/7/15 Admission Minimum Data Set (MDS) indicated Resident # 3 was severely cognitively impaired with no behaviors or rejection of care. The MDS revealed the resident required extensive assistance for transfer, dressing, toilet use, and personal hygiene. Progress notes for 4/10/15 at 9:32 AM indicated Resident #3 had sustained a skin tear to his right elbow during a transfer from bed to the wheelchair. The nurse documented Resident #3 was resistive to care during activities of daily living and transfers. There were no interventions or plan initiated to prevent Resident #3 from sustaining skin tears. On 4/10/15 at 11:59 AM progress notes indicated the treatment nurse noticed skin tears to Resident #3 ' s right forearm while assessing Resident #3 ' s other areas. The nurse documented Resident #3 had very fragile skin. The intervention documented was observation to see if the resident ' s medications needed adjustment. There was no documentation that indicated the nurse had reviewed the resident ' s medication. Review of a nursing progress note for 4/18/15 at 11:24 AM indicated the RP brought to the nurse ' s attention an open area to the resident's left shin area. The nurse documented she assessed the area, cleansed the area with normal saline and applied a [MEDICATION NAME] dressing. No measures were put into place to prevent further skin tears. On 5/5/15, a Flow-sheet of Non-Ulcer Skin Conditions indicated Resident #3 had a left shin, lower leg, medium skin tear with no skin flap. The skin tear was described as red and yellow discoloration with defined edges. The treatment documented indicated the skin tear should be cleaned with wound cleanser and hydrogel (a treatment that provides moisture to the wound bed and aides in healing) applied. The dressing was documented as changed every 3 days and as needed. On 6/3/15, the Flow-sheet of Non-Ulcer Skin Conditions indicated Resident #3 had a left shin skin tear with no flap, yellow discoloration, with defined wound edges. The nurse noted the resident was seen by the wound care specialist (WCS) weekly. Noted was a new physician's order [REDACTED]. Wound/Skin/Treatment notes for 6/11/15 at 6:57 PM were reviewed and indicated Resident #3 was evaluated by the WCS on 6/10/15 and found the wound to the left anterior mid shin as improved. The wound measured 1.6 centimeters (cm) x 0.7 cm with 100% necrotic (dead) tissue. Debridement was performed. [MEDICATION NAME] was continued as the treatment. On 6/16/15, the Flow-sheet of Non-Ulcer Skin Conditions noted a left lower leg skin tear measuring 1.8 cm x 1.9 cm x 0.2 with no exudate. Under comments, the nurse had written the area would be cleansed with wound cleanser, patted dry, Santyl applied and cover with dry protective dressing daily and as needed until healed. On 6/19/15 at 11:27 AM, the nurse noted Resident #3 was seen by the WCS for skin tear on left anterior mid shin measuring 1.8 cm x 0.9 cm x 0.2 cm. The skin tear was described as having yellow necrotic tissue present. Review of the care plan did not reveal any identification that Resident #3 had a problem with skin tears and included no interventions for prevention of skin tears. A wound care observation was completed on 6/30/15 at 9:24 AM. Nurse #1 and Nursing Assistant (NA) #1 worked with Resident #3 to complete the treatment. Resident #3 was observed with an open wound on his left lower leg that was approximately 2.54 cms. The wound bed appeared to be 50% to 75% yellow tissue. Nurse #1 stated the resident ' s family member discovered the wound, but the facility had been on it since discovery. She stated she was unaware of the origin of the wound. Nurse #1 added the WCS saw Resident #3 every Wednesday. The family member was interviewed on 6/30/15 at 9:40 AM. She stated another family member was the one that discovered the wound. She added the open wound was seen on Resident #3 ' s lower leg as he sat in the wheelchair. His pants rose above the wound and that ' s when it was observed. The family member had no idea how the wound had occurred. NA #2 was interviewed on 6/30/15 at 1:21 PM. The NA stated she cared for Resident #3 each day she worked which was usually 5 times per week. NA #2 stated she was unaware how Resident #3 received the skin tear on his lower leg, but added it was not unusual for the resident to get skin tears. She added when she transferred Resident #3 she tried to make sure the path was clear to avoid having any object hit his skin. NA #2 stated she was off duty when the lower leg skin tear was found. She added the day before discovery, when she worked, she was sure the resident had no skin tear on his leg. The NA stated instructions for caring for residents were found on the care guides located at the nurse ' s station. The care guide, the NA stated, did not include information about residents who are at risk for skin tears During an interview with Nurse #1 on 6/30/15 at 2:30 PM, she stated the facility ' s wound care protocols covered the treatment of [REDACTED]. The nurse was unaware how the skin tear on Resident #3 ' s skin had occurred. NA #3 was interviewed on 7/1/15 at 10:03 AM. She was unaware how the left lower leg skin tear had occurred. An interview was held with the Director of Nursing (DON) and MDS Nurse #1 on 7/1/15 at 1:30 PM. The DON stated she expected Resident #3 ' s skin tears to be addressed on the care plan. The DON reviewed the care plan and stated she did not see a care plan identifying skin tears as a problem for Resident #3, did not identify interventions for skin tear prevention and did not identify the resident ' s current wound identified as caused by a skin tear. The DON reviewed the care guide, identified to be used by the NAs for caring for residents and stated the resident's risk of skin tears and interventions for skin tear prevention was not identified on the care guides for Resident 3. The MDS nurse stated she had no explanation why the skin tear on the left shin or interventions to prevent skin tears had not been addressed or Resident #3 ' s care plan or care guide. A telephone interview with Nurse #2 was conducted on 7/2/15 at 10:47 AM. The nurse acknowledged she had written the note dated 4/18/15 at 11:24 AM about the open area on Resident #3 ' s left shin. Nurse #2 stated she had not known about the area prior to that day. The nurse stated she had observed the resident's family member placing an antibiotic ointment on the resident's leg and asked what she was doing. Nurse #2 added she had not received reports about the skin tear to Resident 3 ' s left shin from the NA or during report. The nurse stated on first observation, the wound was a small red area that looked superficial. Nurse #3 added she had reported the area to the treatment nurse. Nurse #2 stated she had questioned NA #2 and the NA had told her the area was not there during the resident's bath.