Every finding on record at Davie Nursing and Rehabilitation Center

Based on observations the facility failed to discard expired beverages, label and date open food items, remove food items with signs of spoilage, and maintain a clean and sanitary floor in 1 of 1 walk-in cooler; label and date food items in 1 of 1 walk-in freezer; maintain a clean and sanitary ice machine for 1 of 3 ice machines (kitchen ice machine); failed to implement their infection control policies when Dietary Aide #1 failed to perform hand hygiene after handling dirty dishes and before touching clean items in the kitchen; label and date opened food items in 1 of 3 reach-in coolers; and discard expired beverages in 1 of 1 dry storage room. These failures had the potential to affect food served to residents. Findings included:1. An initial observation of the walk-in cooler on 09/29/25 at 09:27 AM revealed the following:a. dried white stains and scattered debris across the entire floorb. an opened and undated 46-ounce box of thickened orange juice sitting on a shelfc. an opened and undated 46-ounce box of thickened apple juice with a best-by date of 09/15/25 sitting on a shelfd. an opened and undated 46-ounce box of thickened cranberry juice sitting on a shelfe. a bag of salad mix with an open date of 09/18/25 and a use-by date of 09/24/25. [NAME] discoloration was noted on the lettuce. An interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed all opened food items to be labeled and dated. She stated all food and beverage items should be used or discarded on or before the expiration date. The Dietary Manager stated it was the responsibility of all kitchen staff to label and date food and beverage items and to check for expiration dates. She stated the floor in the walk-in cooler should be clean. An interview with the Administrator on 10/02/25 12:45 PM revealed he expected dietary staff to comply with the regulations for food storage and kitchen cleanliness. 2. An observation of the walk-in freezer on 09/29/25 at 09:35 AM revealed the following:a. an undated bag of potato wedges sitting on a shelfb. an opened and undated bag of potato wedges sitting on a shelfc. an undated bin of pre-packaged waffles and pancakes sitting on a shelfAn interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed food items should be labeled and dated. She stated it was the responsibility of all kitchen staff to label and date food items. An interview with the Administrator on 10/02/25 at 12:45 PM revealed he expected dietary staff to comply with the regulations for food storage. 3. A observation of both vents of the ice machine located in the kitchen on 09/29/25 at 09:39 AM revealed a build-up of gray debris. An interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed the maintenance department was responsible for cleaning the ice machine vents. An interview with the Maintenance Director on 10/01/25 at 03:50 PM revealed his assistant cleaned the ice machine once a week and it was last cleaned 5 or 6 days ago. An interview with the Administrator on 10/02/25 12:45 PM revealed he expected dietary staff to comply with the regulations for kitchen cleanliness.4. An observation of Dietary Aide #1 on 09/29/25 from 09:45 AM through 09:49 AM revealed she loaded the dish washer rack with a dirty plate, walked over to the dish washer rack containing clean cup lids, picked up 4 clean cup lids and placed them on a kitchen shelf, walked to the dish washer rack containing clean plate covers, and picked up 3 plate covers and placed them on a rack in the dish room. Dietary Aide #1 did not perform hand hygiene after touching a dirty plate and before touching clean items in the kitchen. When an attempt to interview Dietary Aide #1 about hand hygiene on 09/29/25 at 09:49 AM was made, Dietary Aide #1 walked off. An interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed she expects staff to perform hand hygiene when going from dirty to clean tasks. An interview with the Administrator on 10/02/25 12:45 PM revealed he expected dietary staff to comply with the regulations for hand hygiene.5. An observation of the reach-in cooler on 09/29/25 at 09:52 AM revealed an undated bowel of potato salad sitting on a shelfAn interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed all opened food items to be labeled and dated and it was the responsibility of all kitchen staff to label and date food items. An interview with the Administrator on 10/02/25 12:45 PM revealed he expected dietary staff to comply with the regulations for food storage. 6. An observation of the dry storage room on 09/29/25 at 09:56 AM revealed two 46-ounce boxes of thickened apple juice with a best-by date of 09/15/25 sitting on a shelf. An interview with the Dietary Manager on 09/30/25 at 11:12 AM revealed all beverage items should be used or discarded on or before the expiration date. The Dietary Manager stated it was the responsibility of all kitchen staff to check for expiration dates. An interview with the Administrator on 10/02/25 at 12:45 PM revealed he expected dietary staff to comply with the regulations for food storage.

Based on observations, record reviews, and resident and staff interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen (Resident #3, #7, and #13) and failed to maintain a clean oxygen concentrator (Resident #55) for 4 of 4 residents reviewed for respiratory care (Resident #3, Resident #7, Resident #13, and Resident #55).The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and heart failure. Review of Resident #3's physician orders dated 12/26/24 revealed oxygen at 2 liters per minute via oxygen tank or 3 liters per minute via oxygen concentrator continuously via a nasal cannula. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact and received oxygen therapy. An observation and interview were conducted on 09/29/25 at 12:39 PM of Resident #3 sitting in her wheelchair by her bed. The Resident explained that she had required oxygen since she was admitted to the facility. There was no cautionary oxygen signage posted near the Resident's room or in her environment. An observation was made of Resident #3 sitting in the doorway of her room and wearing oxygen via the nasal cannula on 10/01/25 at 11:00 AM. There was no oxygen cautionary sign posted near the Resident's room or in her environment. An interview conducted with Nurse #1 was conducted on 10/01/25 at 3:18 PM. The Nurse acknowledged there were no oxygen cautionary signs posted by the Resident's door and explained that since the facility was a smoke free facility, they only had to post the oxygen cautionary sign on the front door entrance. During an interview with the Director of Nursing (DON) on 10/02/25 at 9:45 AM the DON explained that they only posted the oxygen cautionary signage on the front door entrance because the facility was smoke free. An interview was conducted with the Administrator on 10/02/25 at 10:30 AM. The Administrator explained that it was his understanding that if the facility was smoke free that they did not have to post the oxygen cautionary signs on each residents' door with oxygen and by posting the signage on the front door would suffice for the regulation. 2. Resident #7 was admitted to the facility 03/28/24 with diagnoses that included heart failure and chronic obstructive pulmonary disease. Review of Resident #7's physician orders revealed an order dated 03/28/25 for oxygen at 2 liters per minute via nasal cannula. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she received oxygen therapy. An observation was made on 09/29/25 at 11:41 AM of Resident #7 lying in bed sleeping and wearing oxygen via a nasal cannula and delivered by a concentrator. There was no oxygen cautionary sign posted near the Resident's room or in her environment. On 10/01/25 at 8:43 AM an observation was made of Resident #7 sitting up in bed and eating breakfast. The Resident was wearing oxygen via the nasal cannula being delivered by the oxygen concentrator. There was no oxygen cautionary sign posted near the Resident's door or in her environment. An interview conducted with Nurse #1 on 10/01/25 at 3:18 PM. The Nurse acknowledged there were no oxygen cautionary signs posted by the Resident's door and explained that since the facility was a smoke free facility, they only had to post the oxygen cautionary sign on the front door entrance. During an interview with the Director of Nursing (DON) on 10/02/25 at 9:45 AM the DON explained that they only posted the oxygen cautionary sign on the front door entrance because the facility was smoke free. An interview was conducted with the Administrator on 10/02/25 at 10:30 AM. The Administrator explained that it was his understanding that if the facility was smoke free that they did not have to post the oxygen cautionary signs on each residents' door with oxygen and by posting the signage on the front door would suffice for the regulation. 3. Resident #13 was admitted to the facility on [DATE] with diagnoses that included heart failure. Review of Resident #13's physician orders dated 05/27/24 revealed an order for oxygen at 2 liters per minute via nasal cannula. Review of Resident #13's annual Minimum Data Set (MDS) assessment 08/12/25 revealed the Resident was cognitively intact and he received oxygen therapy. On 09/29/25 at 11:30 AM an observation was made of Resident #13 lying in bed sleeping wearing a nasal cannula and oxygen was being delivered at 2 liters per minute. There was no oxygen cautionary sign posted near the Resident's door or in his environment. An observation was made of Resident #13 on 10/01/25 at 8:50 AM lying in bed and wearing oxygen delivered via a nasal cannula. There was no oxygen cautionary sign posted near the Resident's door or in his environment. An interview conducted with Nurse #1 on 10/01/25 at 3:18 PM. The Nurse acknowledged there were no oxygen cautionary signs posted by the Resident's door and explained that since the facility was a smoke free facility, they only had to post the oxygen cautionary sign on the front door entrance. During an interview with the Director of Nursing (DON) on 10/02/25 at 9:45 AM the DON explained that they only posted the oxygen cautionary sign on the front door entrance because the facility was smoke free. An interview was conducted with the Administrator on 10/02/25 at 10:30 AM. The Administrator explained that it was his understanding that if the facility was smoke free that they did not have to post the oxygen cautionary signs on each residents' door with oxygen and by posting the signage on the front door would suffice for the regulation. 4. Resident #55 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of Resident #55's physician orders revealed the following orders: 4/01/25- Oxygen: Clean oxygen concentrator and filter, change tubing once per week. Special Instructions: Wipe down concentrator, remove filter, clean, and air dry, once a day shift on Sundays.7/21/25- Oxygen: Administer oxygen via nasal cannula continuously at 4 liters per minute, every shift. Review of Resident #55's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #55 to be cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident was coded as receiving oxygen therapy while admitted as a resident. An observation of Resident #55's oxygen concentrator on 09/29/25 at 11:57 AM revealed the intake filter on Resident #55's oxygen concentrator to be caked with gray dust and debris. An interview with Resident #55 on 09/29/25 at 12:01 PM revealed she used oxygen on a continuous basis. Resident #55 also reported that she did not know who was responsible for cleaning the oxygen concentrator nor had she observed any staff members cleaning the oxygen concentrator. Another observation of Resident #55's oxygen concentrator on 10/01/25 at 3:13 PM revealed it continued to have gray dust and debris caked on the intake filter. Review of facility provided staffing schedules with hall assignments revealed Nurse #6 was assigned to Resident #55 on 09/28/25, the Sunday prior. Multiple attempts to reach Nurse #6 via telephone call on 10/01/25 and 10/02/25 were unsuccessful. An interview with the Director of Nursing on 10/02/25 at 12:40 PM revealed oxygen concentrator cleaning was the responsibility of the facility maintenance department and the Director of Maintenance. The Director of Nursing reported she did expect her hall nurses to monitor the oxygen concentrators and report to the maintenance department any oxygen concentrators that needed to be cleaned. An observation of Resident #55's oxygen concentrator was completed on 10/02/25 at 12:43 PM with the Director of Nursing. After observing Resident #55's oxygen concentrator the Director of Nursing stated that Resident #55's oxygen concentrator did not appear clean and that there should not be visible gray dust and debris coming out of the intake filter. An interview with the Maintenance Director on 10/02/25 at 1:05 PM revealed the maintenance department was responsible for ensuring that intakes and intake filters were clean and free from dust and debris on resident oxygen concentrators. He stated he tried to check the oxygen concentrators every week or if he is notified by hall staff that one needs cleaning. Regarding Resident #55's oxygen concentrator, the Maintenance Director stated it must have been missed on his weekly check. An interview with the Administrator on 10/02/25 at 2:40 PM revealed he expected his staff to follow the regulations regarding cleanliness of oxygen concentrators and indicated that oxygen concentrators in the facility should be clean and free from dust and debris in the intake and filter.

Based on observation and staff interviews, the facility failed to discard 7 doses of expired COVID-19 vaccines and one bottle of expired eye drops in accordance with manufacturer's expiration date and storage guidelines for 2 of 2 medication storage rooms (South Wing and North Wing).A review of manufacturer's package insert indicated that after thawing Spikevax (Moderna COVID-19 vaccine 2024-2025 formula), it should be refrigerated with temperature between 2 to 8 Celsius (C) (36 F to 46 Fahrenheit (F)) for up to 60 days, or until the expiration date printed on the carton, whichever comes first. A review of manufacturer's package insert revealed an unopened bottle of Latanoprost eye drop should be stored under refrigeration at 2 to 8 C or (36 to 46 F). Once the bottle was opened for use, it could be stored at room temperature up to 25 C (77 F) for up to 6 weeks. a. During a medication storage audit conducted on [DATE] at 12:38 PM, an opened carton of COVID-19 vaccine containing 7 doses of unused Spikevax 2024-2025 formula injectable suspension was found in the refrigerator of South Wing medication storage room and they were ready to be used. Each dose of COVID-19 vaccine contained 0.5 milliliter (ml) of the formula. A label stated Discard unused portion after the expiration date of [DATE] was found on the carton. A review of the manufacturer's expiration date printed on the carton confirmed these vaccines were expired on [DATE]. The carton did not have a date indicating when the vaccines were thawed. An interview was conducted with Nurse #2 on [DATE] at 12:42 PM. She stated all the medications in the medication storage rooms were supposed to be checked by the third shift nurse at least once per week on Sunday. She could not explain what had happened and acknowledged that all the expired COVID-19 vaccines should be discarded. b. Resident #14 was admitted to the facility on [DATE] with diagnoses including glaucoma. A review of physician's order dated [DATE] revealed Resident #14 had an order to receive one (1) drop of Latanoprost 0.005% for both eyes once daily at bedtime. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #14 with severe impairment in cognition. The medication administration records for September and [DATE] indicated Resident #14 had received Latanoprost as ordered before bedtime during the past 2 months. During a medication storage check conducted on [DATE] at 1:02 PM, one bottle of Resident #14's Latanoprost ophthalmic solution with the strength of 0.005% that was opened on [DATE] was found in the refrigerator of North Wing medication storage room and it was ready to be used. An interview was conducted with Nurse #3 on [DATE] at 1:05 PM. She could not explain why the expired Latanoprost that opened on [DATE] was stored in the refrigerator in medication storage room. She stated once Latanoprost was opened and being used, it should be stored in room temperature and discarded after 42 days. She stated Resident #14 had another bottle of Latanoprost that was opened on [DATE] and stored in the medication cart. Nurse #3 denied she had ever used the expired Latanoprost for Resident #14 so far. An immediate observation of 100 Hall medication cart confirmed Resident #14 had another bottle of Latanoprost opened on [DATE]. During an interview conducted with the Director of Nursing (DON) on [DATE] at 1:18 PM, she explained one of the nurses who checked the refrigerator in the morning saw the expired Latanoprost and thought it was opened on [DATE]. She expected nursing staff to follow manufacturer's guideline when storing Latanoprost and Spikevax and added both expired eye drops and vaccines should be discarded. An interview was conducted on [DATE] with the Administrator. He stated it was his expectation for nursing staff to follow facility's medication storage policy and manufacturer's guidelines to discard the expired latanoprost and COVID-19 vaccines.

Based on observations and staff interviews, the facility failed to ensure 1 of 1 Nurse Aides (NA #1) followed the Special Droplet Contact Precautions signage posted on the door of a resident's room (Resident # 47) by not donning and doffing Personal Protective Equipment (PPE) while entering 1 of 1 resident rooms on transmission-based precautions (TBP). The findings included: The Special Droplet Contact Precautions (SDCP) signage, with a revised date of 02/09/22, noted staff should follow the instructions listed on the signage before entering the resident's room which included: all healthcare personnel must: 1) clean hands before entering and when leaving the room, 2) wear a gown when entering room and remove before leaving, 3) wear N95 or higher level respirator before entering the room and remove after exiting, 4) wear protective eyewear (face shield or goggles), and 5) wear gloves when entering room and remove before leaving. A review of staff training revealed NA #1 received training on the facility's Infection Control policy and completed the PPE Skills Competency review on 08/06/24. A progress note and physician order dated 08/05/24 revealed the Nurse Practitioner assessed Resident #47 for a sore throat and cough. An order was written for throat lozenges and Combined Droplet/Contact Precautions/Isolation related to pending respiratory viral panel results. Resident was tested for influenza, respiratory syncytial virus, and corona virus. An observation on 08/06/24 at 9:46 AM of the 400-hall revealed NA #1 entered room [ROOM NUMBER], which had SDCP signage posted on the room door and a PPE cart outside of it, without sanitizing her hands or donning any personal protective equipment (PPE) per the instructions on the signage. An interview was conducted with NA #1 on 08/06/24 at 9:47 AM as she exited room [ROOM NUMBER] without required PPE. When asked about the instructions on the SDCP signage on room [ROOM NUMBER] she stated the Assistant Director of Nursing (ADON) told her she could enter any room that had precaution signage without PPE on as long as she did not touch a resident to provide care. She stated she was hired through an agency, and she never wore all PPE at any other facility unless she was providing direct care. NA #1 questioned this surveyor Are you going to fine them for me not wearing PPE? That's messed up. NA #1 then donned a gown, gloves, and mask and reentered room [ROOM NUMBER]. She did not wear a face shield or googles when she reentered room [ROOM NUMBER]. An interview was conducted with Nurse #1 on 08/06/24 at 9:53 AM. Nurse #1 stated earlier, on the morning of 08/06/24, NA # 1 had requested to wear a surgical mask instead of the N95 respirator prior to entering rooms with SDCP signage posted. Nurse #1 stated she asked the Director of Nursing (DON) about NA #1's request to wear a surgical mask and the DON replied No, an N95 respirator is required for droplet precautions. Nurse #1 stated she educated NA #1 on the required PPE, including the N95 respirator, for rooms with SDCP signage posted. Nurse #1 said she informed NA #1 the required PPE was to protect both residents and staff from respiratory illnesses. She stated she told NA #1 the signage posted on the outside of the room for any resident on TBP listed the required PPE and instructions. On 08/06/24 at 10:00 AM NA #1 opened the door of room [ROOM NUMBER] and asked Nurse #1 if she could leave after she finished her assignment. She told Nurse #1 she was hired through agency, and she was not going to wear all the PPE to enter the rooms posted with SDCP the rest of the day. She stated she felt as if this surveyor had intentionally allowed her to initially enter the room without PPE. Nurse #1 sent a text to the DON and asked for her assistance. An interview was conducted with the DON on 08/06/24 at 10:02 AM outside of room [ROOM NUMBER]. She stated NA #1 was aware of the PPE required for rooms posted with SDCP signage. She stated NA #1 would be relieved of her assignment upon exit from room [ROOM NUMBER]. On 08/06/24 at 11:05 AM an interview was conducted with NA #2 and she stated full PPE is required for rooms with droplet precaution signage. She stated the SDCP signage contained instructions and outlined which PPE was required before entering a room of a resident on TBP. NA #2 stated she received infection control training when she was hired [AGE] years ago and was required to complete yearly competencies on infection control. An interview was conducted with the ADON on 08/06/24 at 2:28 PM. She stated she is the facility Infection Preventionist. She stated for rooms with SDCP signage an N 95 mask, face shield or appropriate googles, gown and gloves are required prior to entry for any reason. She stated she had not educated NA #1 that she could enter a room with SDCP signage without PPE if she was not going to make any contact with the resident. She stated infection control policy education was provided to all facility and agency during orientation and a yearly training competency. She stated the training included the PPE required for each type of precaution. She stated all staff are required have infection control and PPE training prior their first assignment on a hall. She stated NA #1had received the infection control and PPE training that morning, 08/06/24, before she started working on the floor. The ADON stated NA #1 was specifically educated on the two signs (droplet, enhanced barrier) that were active on her assigned hall. She stated she explained to NA #1 if she forgot the difference between the two precautions to read the signage outside [NAME] door, and it would direct her to the proper PPE required prior to entering the room. The ADON added NA #1 was directed to leave the facility when she exited room [ROOM NUMBER] that morning. On 08/06/24 at 2:45 PM a follow up interview was conducted with the DON and she stated NA #1 should have had utilized the required PPE indicated on the SDCP signage. She stated she had received a message from Nurse #1 asking if the NA #1 could wear a surgical mask in place of an N 95 respirator and she told her No, not if it is an isolation room. She said she told Nurse #1 to inform NA #1 that an N 95 respirator was required to enter a room with SDCP signage. The DON stated all staff, including agency NAs, are trained on PPE and the infection control policy and procedures policy when hired and yearly thereafter.

Based on record review and staff interviews the facility failed to follow up on x-ray results for 1 of 1 resident reviewed for providing care according to professional standards (Resident #1). The findings included: Review of progress note dated 06/07/24 completed by Nurse #1 revealed Resident #1 voiced left hip pain stating something popped when she was turned by Nurse Aides (NAs) providing incontinence care. The note further revealed the on-call provider was contacted and gave an order for an x-ray to be completed of Resident #1's left hip. Review of Resident #1's orders revealed on 06/07/24 the on-call provider ordered an x-ray of the residents left hip. Review of progress note date 06/08/24 completed by Nurse #1 revealed the facility received a call from the mobile x-ray company stating a repeat left hip x-ray would need to be completed as the films from last evening were unclear and rejected by the radiologist. Review of the x-ray results completed on 06/08/24 revealed Resident #1 sustained a left mildly displaced femoral neck fracture (upper part of the thigh bone). The note further revealed diffused osteopenia is present. The results were sent electronically to the facility at 7:16 PM the same day. An interview with Nurse Aide (NA) #1 on 06/17/24 at 2:05 PM revealed on 06/07/24 during 1st shift she and another NA went to change Resident #1. NA #1 indicated Resident #1 often refused care but allowed the NAs to give incontinence care. NA #1 stated when the NAs rolled the resident on her side the resident stated she felt a pop and that her hip hurt. NA #1 indicated they immediately went and got Nurse #1 to assess the resident. An interview with NA #2 on 06/17/24 at 1:45 PM revealed she cared for Resident #1 on 06/08/24 (7:00 AM- 3:00 PM) and 06/09/24 7 AM-3 PM and 11:00 PM- 7:00 AM). NA #2 further revealed Resident #1 did not complain or show any signs of pain during her shifts. NA #2 indicated Resident #1 often refused care and was often confused. An interview with NA #3 on 06/17/24 at 2:45 PM revealed she had cared for Resident #1 on 06/08/24 (11:00 PM- 7:00 AM) and the resident did not complain or show any signs of pain. NA #3 indicated Resident #1 often refused care and often seems confused. A phone interview conducted with Nurse #1 on 06/17/24 at 10:55 AM revealed she had cared for Resident #1 on 06/07/24 and 06/08/24 during day shift 7:00 AM to 7:00 PM. Nurse #1 further revealed on 06/07/24 two NAs had cared for Resident #1 and reported to the nurse that Resident #1 had complained of pain in her left hip. Nurse #1 indicated she assessed Resident #1 and found no irregularities of the left hip but contacted the on-call provider due to the resident complaining of pain and a mobile x-ray was ordered. Nurse #1 stated Resident #1's x-ray was obtained after the Nurses shift ended at 7:00 PM. Nurse #1 revealed on 06/08/24 she was notified Resident #1's x-rays completed on 06/07/24 were inconclusive, and x-ray were obtained again on 06/08/24. Nurse #1 stated she communicated to Nurse #2 at shift change that Resident #1 had received a follow up x-ray and results were pending. A phone interview conducted with Nurse #2 revealed she cared for Resident #1 on 06/08/24 from 7:00 PM to 7:00 AM. Nurse #2 further revealed Nurse #1 communicated to her at shift change that Resident #1 had an x-ray completed and results were pending. Nurse #2 stated she failed to follow up and look for the x-ray results in the system. Nurse #2 indicated she had also failed to communicate to the next Nurse #3 on shift that Resident #1 had received an x-ray and results were pending. Nurse #2 revealed she had been educated to communicate resident information and to follow up on orders but had failed to do so on 06/08/24. Review of progress note dated 06/10/24 completed by the Director of Nursing (DON) revealed upon findings Resident #1's x-ray showed a mild displaced, impacted left femoral neck fracture. The note further revealed the Medical Director (MD) was notified and Resident #1 was ordered to be sent to the hospital for evaluation and treatment. Review of orthopedic consult note from the hospital dated 06/10/24 revealed Resident #1 had a closed left hip fracture. The note further revealed the fracture was a fragility fracture with osteoporosis. Review of hospital progress notes revealed Resident #1 was admitted on [DATE] with left hip pain. The note further revealed resident #1 sustained a closed left hip fracture. On 06/11/24 Resident #1 received hip arthroplasty to the left hip. Resident #1 was discharged back to the facility on [DATE]. An interview conducted with the Nurse Practitioner (NP) on 06/17/24 at 10:35 AM revealed Resident #1 had rheumatoid arthritis, was immobile for 5 plus years, had contractures, and took several immunosuppressant drugs that caused Resident #1's bones to be brittle with low density. The NP further revealed Resident #1 was on palliative care due to her diagnoses and pain management. The NP indicated she would have expected nursing staff to receive x-ray results and contacted a provider. The NP stated even though the facility delayed sending Resident #1 the resident had no negative outcome. An interview conducted with the Director of Nursing (DON) on 06/17/24 at 11:30 AM revealed she was not in the building until 06/10/24 when she found Resident #1's x-rays had not been found in the system by nursing staff. The DON further revealed she had educated Nursing staff to always follow up with residents if they had been sent or if any results were pending. The DON indicated results are sent to the charting system that Nursing staff can obtain. The DON stated nursing staff failed to communicate and follow up on Resident #1's x-rays results. The facility received Resident #1's x-ray results on 06/08/24 but failed to review them until 06/10/24. The facility provided the following corrective action plan with a completion date of 6/11/24. Allegation background: On 6/7/24 Nurse Aide #1 certified nurse aide, and Nurse Aide #4 certified nurse aide were providing care to Resident #1. - They heard a pop during care, staff reported the change in condition to Nurse #1. - Nurse went to resident's room to assess resident and notified the on-call provider and obtained an order for an X-ray. - Nurse informed resident's family member of the change in condition and new orders for x-ray. - Resident #1 is a [AGE] year-old female who is a long-term resident in the facility. - She has a diagnosis of rheumatoid arthritis, heart failure, obesity, and long-term use of steroids related to arthritis. - She has been bed bound for several years. X-ray results resulted on 6/8/24 at 7:16 PM, results were not reported to the provider until 6/10/24. Timeline: - 6/7/24 Contracted imaging provider came to the facility and obtained x-rays on the resident - 6/8/24 at 6:15 PM contracted imaging provider notified the facility nurse that x ray results were unclear and rejected by the radiologist and they would be back to re-take the x ray. - 6/8/24 at 6:49 PM contracted imaging provider was back in the facility and obtained repeat x-ray. - 6/8/24 at 7:16 PM x-ray results were sent to the facility. - 6/10/24 at 10:00 AM resident was reviewed in clinical morning meeting with Director of Nursing and identified a positive X-ray for femur fracture. - 6/10/24 at 10:54 AM Assistant Director of nursing notified Medical Director of the positive results with new orders to send resident to hospital for further evaluation. Resident #1's family member was notified of the positive results from x-ray and new orders to send to hospital. Resident #1 was assessed by the hospital and sent for surgery to repair the fracture. Upon discovery of the occurrence, facility implemented the following quality insurance measures: - 6/10/24 Medical Director was notified of positive x-ray results and resident was transferred to the hospital for evaluation and treatment. - She was admitted to the hospital and on 6/11/24 underwent left hip hemi arthroplasty. - Orthopedic provider diagnosed resident with a fragility fracture of the femur related to osteoporosis. - She was readmitted to the facility on [DATE]. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: - On 6/10/24 the Director of Nursing or designee reviewed all x ray results for the past seven days to ensure the results were called into the provider. - No other issues were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: All licensed nurses including agency staff were educated 6/10/24 on timely notification to the provider for positive x-ray results. The system failure was a lack of understanding of the new electronic medical records system and nurse was not aware to check portal for diagnostic results. Nurses including agency staff were re-educated by DON/Designee on proper communication between nurses and shifts and where to look for these reports. Nurses including agency staff were re-educated by DON/Designee to check for results every shift. Licensed Nurses including agency staff were also educated by DON/designee that if diagnostic results were pending, that they are to report to on coming shift and the oncoming shift was to check portal for results. The education was provided in-person and via phone with all Licensed nurses including agency with understanding of education confirmed by nurses reiterating the content of the education. All newly hired licensed nurses to receive education during orientation. To monitor and maintain ongoing compliance - Beginning 6/16/24 the Director of Nursing or designee will review 3 resident charts per week for timely notification of positive diagnostic results to the provider. - Audits will continue for 8 weeks. Results of the audit will be reported to the QAPI committee by the Director of Nursing or designee. If concerns are identified with audits, the IDT team will meet to make adjustments to the QAPI. Alleged date of completion for the corrective action plan is 6/11/24. The corrective action plan was validated on 06/27/24 as evidenced by staff interviews, review of education sign sign in sheets and audits. Staff education was initiated on (6/10/24) regarding timely notification to provider for positive Xray results. Licensed nursing staff from multiple shifts were interviewed and stated they were educated to check the portal of the electronic medical records for diagnostic results every shift and pending diagnostic results were to be reported to the oncoming shift and oncoming shift was to check the portal for results. The completion date of 6/11/24 was validated.

Based on staff interviews and record reviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 1/27/22. This was for 1 deficiency that was cited for Accuracy of Assessments (F641) cited on 1/27/22 and recited on the current recertification and complaint survey of 4/13/23. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag is cross referenced to: F641- Based on staff interviews and record reviews, the facility failed to accurately code significant weight loss, cognitive status, mood, and medications received on the Minimum Data Set (MDS) assessments for 3 of 23 residents (Residents #24, #1 and #48) reviewed for MDS accuracy. During the recertification and complaint survey of 1/27/22, the facility failed to accurately code the Pre-Admission Screening and Resident Review (PASRR) on the comprehensive MDS assessment for 1 of 3 residents reviewed for PASRR. An interview with the Administrator on 4/13/23 at 3:33 PM revealed the QAA committee met monthly. Some of the issues reviewed during the monthly meetings were identified through quality measures, trends with grievances, previous survey results and corporate established standards. The Administrator shared the facility had a high volume of admissions and discharges which required numerous MDS assessments and that may have contributed to the inaccurate coding on the MDS assessments.

Based on staff interviews and record reviews, the facility failed to accurately code significant weight loss, cognitive status, mood, and medications received on the Minimum Data Set (MDS) assessments for 3 of 23 residents (Residents #24, #1 and #48) reviewed for MDS accuracy. 1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus type II and acute kidney failure. A review of the quarterly Minimum Data Set (MDS) for Resident #24, dated 2/20/2023, was conducted. Next to the question, for significant weight loss, had the Resident lost 5% or more in the last month or 10% or more in the last 6 months, the answer was no. A review of the electronic medical record revealed Resident #24 weighed 270.0 pounds (lbs.) on 1/2/2023 and 252.8 lbs. on 2/4/2023. The Resident had lost 17.2 lbs. and 15.7% of his body weight. An interview was conducted with the MDS Nurse #1 on 4/12/2023 at 11:42 a.m. The MDS nurse reviewed the electronic medical record for Resident #24 and stated the Resident had lost 17.2 lbs. from 1/2/2023 and 2/4/2023. She added the weight loss was prior to the assessment date for the quarterly MDS dated [DATE] and the response that the Resident had not experienced 5% weight loss was inaccurate. 37983 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) and mood interview should be conducted with Resident #1; however, the interviews were coded with dashes which indicated the resident's cognitive status and mood state were not assessed. The Social Worker (SW) and MDS Nurse #1 were interviewed on 4/12/23 at 2:35 PM. The SW shared she was responsible for the completion of the cognition and mood sections of the MDS assessment and Resident #1 was able to be interviewed for the sections. The SW verified she completed the cognition and mood sections, but she had missed the assessment reference date deadline to interview Resident #1 and coded dashes (not assessed) for the resident interviews. The SW added she wasn't sure why she missed completing the interviews with Resident #1 and said there may have been a lot going on that day or she may have been overwhelmed with responsibilities and hadn't completed the resident interviews on time. MDS Nurse #1 clarified if the resident interviews were not conducted by the ARD, then staff coded the interviews as not assessed. During an interview with the Administrator on 4/13/23 at 3:30 PM, he stated MDS Nurse #1 should have reviewed the SW's coding and verified the assessment was accurate and complete. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia and generalized anxiety disorder. The physician orders were reviewed for January 2023 and February 2023 and revealed no orders for an anti-depressant medication. The quarterly MDS assessment dated [DATE] and completed by MDS Nurse #1 revealed Resident #48 received an anti-depressant medication seven of seven days during the look back period. On 4/12/23 at 2:41 PM, an interview was completed with MDS Nurse #1. She verified she completed Resident #48's MDS assessment. She said when she coded medications on the MDS, they were coded per drug classification and not how they were used. She explained she thought she might have mistakenly coded another medication (Memantine) as an anti-depressant and added the coding error was an oversight. During an interview with the Administrator on 4/13/23 at 3:27 PM, he said there might have been some confusion with how MDS Nurse #1 viewed medications on the facility's computer system which resulted in the coding error.

Based on observations, record review, staff and physician interviews, the facility failed to 1. Assess and initiate a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. A review of Resident #294 ' s hospital discharge summary dated 10/22/2021 revealed a stage 3 pressure ulcer to the sacrum that was present on admission and excoriation to the buttocks. Instructions for wound care were to off-load, apply a foam absorbent dressing and barrier cream. The facility admitted Resident #294 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan dated 10/22/2021 did not include a focus area of pressure ulcer presence. A nurse ' s note dated 10/22/2021 at 7:30 PM by Nurse #3 revealed Resident #294 arrived at his room. Sacral wound present. Dressings malodorous to right elbow and sacrum upon arrival, drainage present on both wounds. An admission skin assessment dated [DATE] by Nurse #3 revealed a sacral wound present and an open wound to the right elbow. No other description was recorded. The assessment did not include the appearance of Resident #294 ' s buttocks. On 01/27/2022 at 2:50 PM, Nurse #3 was interviewed. She stated she was new to the facility and was working on 10/22/2021 when Resident #294 was admitted . She stated she did a head-to-toe assessment and saw that Resident #294 had a pressure ulcer to his sacrum. She stated he did not have a pressure ulcer to his buttocks. She stated she was told by the First Shift Supervisor not to worry about staging the wound and that was why she didn ' t describe it further in her documentation. She added she did not know why she did not put the treatment orders in place. A nurse ' s note dated 10/24/2021 at 5:20 PM by the Director of Nursing revealed Resident #294 had skin impairment and the physician was notified. No orders were given. A physician ' s progress note dated 10/25/2021 at 1:30 PM indicated presence of a sacral wound. Plan was to continue wound care as ordered and wound physician to follow. Continue to offload pressure as much as resident will allow. A nurse ' s note dated 10/25/21 at 3:57 PM by the Social Worker read resident discharged home today per his own choice. Resident #294 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #294 ' s Treatment Administration Record for October 2021 did not include wound care orders. On 01/27/2022 at 8:46 AM, the Treatment Nurse was interviewed. She stated if a resident came in late on Friday and she has already left, the hall nurse or supervisor does the assessment. They are to do a head-to-toe assessment and document the wounds appearance. She would do the measurements on Monday when she returned to work. The admitting nurse should also put the treatment orders in. She stated Resident #294 was agitated and refused to allow her to assess his wound on Monday, 10/25/2021 because he wanted to leave so she never saw his wound. On 01/27/2022 at 2:31 PM, the Director of Nursing was interviewed. She stated when a resident is admitted , the admitting nurse should do a head-to-toe assessment, take off all old dressings, look at all wounds, documents and replace dressings. Documentation should include what the wounds look like including size and appearance. The admitting nurse doesn ' t have to stage the wound, that can be done by the Treatment Nurse the following day. She stated admitting nurse was expected to implement orders from the discharge summary. She didn ' t know why that didn ' t get done for Resident #294. On 01/27/2022 at 3:05 PM, the First Shift Supervisor was interviewed. She stated she came on duty after Nurse #3 on 10/25/2021 and got report on Resident #294. She stated she observed the dressing to the resident ' s sacrum and did not note any foul odor. She stated she lifted the dressing to the sacrum and observed the wound and saw an open area. The wound dressing did not have a large amount of drainage. She added she did not change the dressing at that time because it had a foam dressing in place, and she didn ' t know what the orders were. She stated she did not put the treatment orders in because she thought Nurse #3 did it already. On 01/27/2022 at 4:43 PM, the Second Shift Supervisor was interviewed. She stated she worked on 10/22/2021 when Resident #294 was admitted , and she was training Nurse #3. Nurse #3 did the assessment and she put in the orders. She stated Nurse #3 came to her and asked her what to do about the resident ' s wound and she told her to use the foam dressing that was ordered. Nurse #3 went to get the supplies and she changed the dressing. She stated she observed the wound also and the wound dressing was soiled on admission. She stated the resident had an open sacral wound and no other wounds on his bottom, but he did have some excoriation to his buttocks. The Second Shift Supervisor added she was on call the following day, 10/23/2021 and she went to the facility to check on things. She stated she saw Resident #294 to check on him because she knew he was being difficult and wanting to leave the day before. She stated the wound dressing was intact, but he had a bowel movement and would not allow her to change the dressing; she stated he started yelling at her and using racial slurs. She stated he was very uncooperative and didn ' t want to stay in the facility. She did not know why the orders for the treatment did not get implemented. On 01/27/2022 at 5:21 PM, an interview was conducted with the Wound Care Physician. He stated he did not see Resident #294 because he left against medical advice. He stated the order from the hospital discharge summary for the foam dressing would have been okay to leave on a wound for several days, changing when it was soiled. He did not have a concern about the foam dressing staying in place until the wound care nurse could assess the area on Monday.

Based on record review and staff interview, the facility failed to ensure a resident assessment for a Level II PASRR (Preadmission Screening and Resident Review) was completed for 1 of 3 sampled residents (Resident #65) reviewed for Level II PASRR. Findings included: Review of Resident #65's admitting Minimum Data Set (MDS) dated [DATE] revealed that Resident #65 had been admitted to the facility from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASRR Level I Determination Notification letter dated 6/9/2021 revealed that No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's PASRR Level 1 Screen paper application dated 6/9/2021 revealed that the previous facility indicated that he had no mental health diagnoses. In an interview on 1/25/22 at 3:00 PM, the Social Worker stated that Resident #65 was admitted to the facility from the hospital and the facility had scanned in his PASRR Determination Notification letter that stated he did not need a Level 2 upon admission. She stated that she was unaware of the possibility that the previous facility may have completed the initial PASRR application incorrectly and added that she does not routinely check the letters for accuracy. In an interview on 1/26/22 at 2:30 PM the Administrator stated he was unaware that the facility could be accountable for incorrect data being entered by another facility resulting in a Level 2 not being completed for a resident prior to him or her be admitted to the facility. He added that the facility will begin screening for this with every current resident and new admission.

Based on observation, record reviews and staff interviews the facility failed to ensure Resident #63 was positioned upright in bed while eating during 1 of 2 dining observations. The findings included: Resident #63 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly assessment dated [DATE] indicated Resident #63 was cognitively impaired with a communication deficit and required extensive assistance with eating due to coughing/choking during meals. The care plan dated 12/15/21 revealed Resident #63 was at risk for nutritional/hydration alterations. Interventions included: Monitor for signs and symptoms of aspiration; speech therapy screen, when necessary; and encourage adequate fluid intake. On 1/27/22 at 9:01 a.m., Resident #63 was observed reclined in her bed with the head of the bed raised at an approximate angle of 40 degrees. The resident was attempting to feed herself from her meal tray which was on the overbed table positioned across her lap but raised so that the resident had to reach up to reach the food items on the meal tray. A return visit to Resident #63's room was made on 1/27/22 at 9:05 a.m., accompanied by Supervisor Nurse #1 who observed and acknowledged Resident #63 was not positioned correctly in her bed while feeding herself. She confirmed the nursing assistant (NA) should have raised the head of the resident's bed upright and repositioned the resident so she could look down at the food items on the meal tray. Supervisor Nurse #1 removed the overbed table and explained to the resident she needed to reposition her so that she (Resident #63) could see the food on her tray, but she would need staff assistance. Supervisor Nurse #1 left the resident's room and returned with NA #5 who assisted the nurse with repositioning the resident and raising the head of the bed at an approximate 85-degree angle. Throughout this process the nurse educated NA #5 on the risk of Resident #63 aspirating on a food item when eating in a reclined position. Before exiting the room, Supervisor Nurse #1 also instructed the NA#5 to sit in the chair next to the bed and assist the Resident #63 with completing her breakfast. During an interview on 1/27/22 at 9:15 a.m., NA #5 stated once she set up Resident #63's meal tray on the overbed table in front of her, she (NA) felt the was ok to feed herself because the resident could reach the food items on her meal tray. When asked if she (NA#5) had been educated about this resident's care, the NA#5 responded, I don't remember. During an interview on 1/27/22 at 9:28 a.m., Supervisor Nurse #1 revealed Resident #63 recently returned from the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that upon NA#5's arrival for duty that morning, she was educated about the care needed for Resident #63.

Based on observations, record review and staff and wound physician interviews, the facility failed to follow a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: The facility admitted Resident #3 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #3 required extensive assistance with bed mobility, dressing, toileting and hygiene. The resident was dependent for transfers and bathing, was non-ambulatory and incontinent of bowel and bladder. Resident #3 had 5 venous or arterial ulcers and received dressings to feet. The care plan included a focus area of actual skin impairment to left proximal foot. Interventions included treatments as ordered. Resident #3 ' s January 2022 physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound assessment dated [DATE] by the wound care physician revealed a full thickness arterial wound to Resident #3 ' s left proximal, lateral foot. The area measured 4.8 x 2 x 0.2 and had 100 % granulation tissue. The dressing treatment plan was to continue calcium alginate and wrap with kerlix and ace wrap for 15 days. On 01/26/2022 at 10:28 AM, an observation of Resident #3 ' s wounds was conducted by the Treatment Nurse. The Treatment Nurse removed the ace wrap and kerlix to Resident #3 ' s left foot. A dry dressing was observed over the left proximal wound with moderate reddish-brown drainage. The wound bed was observed to be beefy red and there was a small, blackened area noted. The wound was cleaned then the Treatment Nurse was observed to put medi-honey (a wound gel for dry to moderately exuding wounds) on the wound and cover the wound with an abdominal pad, wrapped it with kerlix and an ace wrap. On 01/27/2022 at 8:41 AM, an interview was conducted with the Treatment Nurse. When asked about the treatment provided to Resident #3 ' s left proximal foot, she stated the wound care physician must have changed the order and she was unaware medi-honey was not the order for the left proximal foot. On 01/27/2022 at 9:48 AM, a second interview was conducted with the Treatment Nurse who stated she checked Resident #3 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did check orders before she provided care but must have gotten confused. She added the resident has 3 areas on his left foot and they all have different orders for treatments. On 01/27/2022 at 1:36 PM, an interview was conducted with the wound care physician. He was away from his computer and could not recall Resident #3 ' s orders but stated medi-honey was used to add moisture to wounds. He stated the Treatment Nurse should have applied the correct treatment per the orders to Resident #3 ' s wound but the application of medi-honey would not have caused any harm to the resident.

Based on observations, resident representative interview, staff interviews and record reviews, the facility failed to treat residents in a dignified manner during dining by standing over a resident while assisting the resident with eating (Resident #60); and when a staff member entered a resident's room (Resident #80) without knocking or asking permission to enter for 2 of 8 residents reviewed for dignity. 1. Resident #60 was admitted to the facility on [DATE]. The significant change assessment dated [DATE] indicated Resident #60 was severely cognitively impaired. The care plan dated 1/24/22 revealed Resident #60 was at risk for nutritional/hydration alterations. Interventions included: provide assistance with meals as needed to encourage intake. During a dining observation on 01/24/22 at 01:49 p.m., Nursing Assistant (NA#4) was assisting Resident #60 with feeding while standing over him as he reclined in his bed which was in a lowered position. NA#4 revealed she usually sat in a chair (pointed to a chair next to the roommate's bed) when feeding Resident #60. Throughout the dining observation, NA#4 continued to stand while assisting the resident with feeding in his room. During an interview on 01/27/22 at 09:41 a.m., Supervisor Nurse #1 stated that NA#4 should not have been feeding the resident while standing over him. 2. Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set assessment dated [DATE] revealed Resident #80 had moderately impaired cognition. She required extensive assistance with eating. On 1/24/22 at 12:36 PM Nurse Aide (NA) #3 was observed when she delivered a meal tray to Resident #80. The door to the room was open. NA #3 entered the resident's room without knocking on the door or announcing her presence. NA #3 provided assistance with eating to Resident #80 and at 12:53 PM removed the resident's tray and exited the room. At 12:56 PM, NA #3 obtained a nutritional supplement for Resident #80, then re-entered her room and dropped off the supplement without knocking on the door or announcing her presence. NA #3 returned to the room a third time, at 12:57 PM and provided a straw to the resident. She entered Resident #80's room without knocking on the door or announcing her presence. An interview was completed with NA #3 on 1/24/22 at 1:05 PM, during which she stated prior to entering a resident's room staff were supposed to knock on the door. NA #3 shared sometimes she just walked into a resident's room if the door was open and announced her presence as she walked into the room. She acknowledged she should have knocked on Resident #80's door before she entered her room. Resident #80's representative was interviewed by phone on 1/25/22 at 9:23 AM. He thought in a traditional home environment Resident #80 would want a visitor to knock on her door before they entered her home or room. During an interview with the Director of Nursing (DON) on 1/27/22 at 9:41 AM, she explained when staff entered a resident's room they should either knock on the door or announce their presence before they entered the room. The DON said the facility routinely completed inservices with staff relating to resident rights and dignity and NA #3 should have knocked on the door or announced her presence before she entered Resident #80's room.

Based on observation, resident interview, staff interviews and record review, the facility's interdisciplinary team failed to assess and document the ability of a resident to self-administer medications for 1 of 1 resident (Resident #46) who was observed to have medications at bedside. Findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively intact. Physician (MD) orders were reviewed and included an order dated 1/4/22 for [MEDICATION(S)] (a multi-vitamin), one capsule by mouth, one time a day at the bedside, and an order dated 1/4/22 for Prevagen (a supplement to help with memory), one capsule by mouth, one time a day at the bedside. Further review of the medical record revealed no assessments were completed for the self-administration of medications. An observation and interview were conducted with Resident #46 on 1/24/22 at 10:48 AM. A bottle of PresserVision, and a bottle of Prevagen were observed to be placed within the resident's reach on the overbed table. During an interview with Resident #46, she stated she wanted to have the medications at her bedside, had permission to self-administer the medications and the facility had completed an evaluation of her to self-administer the medications. On 1/27/22 at 9:16 AM a phone interview was completed with Nurse #5. She entered the orders in the electronic health record for Resident #46 to self-administer medications of [MEDICATION(S)] and Prevagen. She explained if a resident wanted medications kept at bedside there was a self-administration of medications form that was completed by the nurse before the medications were left at the bedside. Typically, the nurse notified the MD of the resident's request to self-administer medications, obtained the order and completed the assessment. Nurse #5 said she had not completed the self-administration of medication assessment because she thought either the MD or nurse practitioner (NP) had completed the form. During interviews with the Director of Nursing (DON) on 1/26/22 at 11:25 AM and on 1/27/22 at 9:35 AM, she explained if a resident requested medications be kept at the bedside, the facility assessed the resident's competence to self-administer medications and obtained an order from the MD for medications to be kept at bedside. The DON said the NP had assessed Resident #46 and validated the resident was competent to have medications at bedside but did not properly document. Since there was no assessment documented, Nurse #5 should have completed the assessment to self-administer medications after she received the order from the NP.

Based on staff interviews and record review, the facility failed to accurately code the Pre-Admission Screening and Resident Review (PASRR) on the comprehensive Minimum Data Set (MDS) assessment for 1 of 3 residents (Resident #28) reviewed for PASRR. Findings included: Resident #28 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The North Carolina Medicaid Uniform Screening Tool (a computer program used to apply for PASRR numbers) was reviewed with the facility Social Worker (SW) on 1/26/22 at 9:25 AM and specified Resident #28 had a level two PASRR determination that was effective 3/12/20. The comprehensive MDS assessment dated [DATE] did not indicate Resident #28 had a level two PASRR determination. During an interview with the SW on 1/26/22 at 11:18 AM, she reported she coded the PASRR on the MDS assessments. She explained she routinely looked in the miscellaneous section in the resident's electronic health record (EHR) for PASRR information which was where PASRR determination notices were scanned into the chart. The SW said the PASRR determination notice was not uploaded into the EHR so she didn't see that Resident #28 had a level two PASRR determination. On 1/27/22 at 9:45 AM an interview was completed with the Administrator. He said the facility staff missed a step in the coding process and the PASRR determination notice was not scanned into the computer system. He added the corporate office assisted with training and monitoring related to MDS accuracy.

Based on observations, resident interview, staff interview and record review, the facility failed to renew an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively intact. She needed supervision to extensive assistance with activities of daily living (ADLs). She was coded as having no skin issues and she received application of ointments/medications other than to feet. The care plan, updated 12/9/21, revealed focused areas of ADLs and skin. Interventions included, Resident will have the ability to perform or be assisted with hygienic measures, such as proper hand washing, and administer medications as ordered by physician. Physician (MD) orders were reviewed and included an order dated 12/9/21 for [MEDICATION(S)] powder (an anti-fungal medication), 100,000 unit/gram, apply to redness topically in the evening for yeast. The order for the [MEDICATION(S)] powder was discontinued on 12/18/21. Observations and interviews were conducted with Resident #46 on 1/24/22 at 10:48 AM and on 1/26/22 at 1:50 PM. A bottle of anti-fungal powder was observed to be placed within the resident's reach on the overbed table. During an interview with Resident #46, she stated the facility gave her the anti-fungal powder over six months ago and explained she applied the powder when she experienced moisture on her skin or if she felt raw. She said she had permission to self-administer the powder which she used on an as needed basis and the last time she used it was three weeks ago. During an interview with the Director of Nursing (DON) on 1/27/22 at 9:35 AM, she stated Resident #46 had skin impairment and yeast and the Nurse Practitioner (NP) placed her on [MEDICATION(S)] powder. The DON thought the skin issues resolved and the powder was discontinued. The DON explained staff should have removed the powder from Resident #46's room when the order was discontinued or if the resident felt she still needed it then staff should have obtained a new order for the resident to use the powder as needed.

Based on observation, staff interviews, and record review, the facility failed to implement their policy for doffing personal protective equipment (PPE) and Centers for Disease Control and prevention (CDC) COVID 19 guidelines, when 1 of 1 staff member (Nursing Assistant #1) failed to remove PPE including a gown and gloves prior to exiting a residents room, who was on enhanced droplet precautions. This failure occurred during the COVID-19 pandemic. The findings included: The CDC guidance on Using PPE updated on 8/19/20 included instructions on how to take off PPE that included removing gloves and gown prior to exiting a resident's room. The facility's COVID-19 Personal Protective Equipment: Doffing step by step policy and procedure dated 4/10/20 included exiting patient room after removing gown and gloves. A facility in-service on proper PPE donning and doffing with return demonstration was conducted on 12/1/20 and had NA #1's signature. A tour of the 100 hall was conducted on 12/7/20 at 9:20 AM. NA#1 was observed exiting a resident's room that had a sign posted on the door for enhanced droplet precautions. NA#1 exited the room while still wearing a gown and gloves. NA #1 was observed walking down the hall before NA #2 reminded her to remove her gown and gloves. An interview was conducted on 12/7/20 at 11:40 AM with NA #1. She stated she knew gown and gloves were to be removed prior to exiting a resident's room, but she forgot she had the gown and gloves still on when she exited the resident's room. An interview was conducted with Nurse #1 on 12/7/20 at 9:25 AM. Nurse #1 stated the 100 hall had residents on enhanced droplet precautions due to their previous roommates testing positive for COVID and their roommate subsequently being moved to the facility's COVID Unit. Nurse #1 added gowns and gloves had to be removed prior to exiting resident rooms on enhanced droplet precautions. An interview was conducted with the Director of Nursing (DON) on 12/7/20 on 9:40 AM. The DON stated the staff was re-educated last week on proper PPE donning and doffing. The DON added PPE (gowns and gloves) were to be removed prior to exiting a resident's room.

Based on resident and staff interviews and record review, the facility failed to refer a resident, who was hospitalized for [REDACTED].#19) reviewed for PASARR. Findings included: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had a level I PASARR number upon initial admission. Resident #19 discharged to the hospital on [DATE] due to a decline in her psychiatric condition. She was re-admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED].-admission. The facility completed a psychiatric evaluation on 5/20/19 which explained Resident #19 was admitted to the hospital 5/8/19 and was discharged back to facility on 5/16/19 due to [MEDICAL CONDITION] and paranoia. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was cognitively intact. She reported mood symptoms that included having little interest in things and feeling tired/little energy. Resident #19 received antipsychotic and antidepressant medications for 7 of 7 days during the MDS look back period. A care plan for delusional behavior was updated 1/14/20 and an intervention included, Refer to psychiatrist and/or psychologist as needed. On 2/11/20 at 9:55 AM Resident #19's current PASARR number was provided by the facility social worker (SW) and revealed a level I PASARR number. On 2/11/20 at 9:10 AM an interview was completed with the SW. She reported the Admissions office verified PASARR numbers prior to a resident's admission to the facility. She stated she was unaware that a level II PASARR needed to be completed when a resident was identified with a mental illness diagnosis. The Admissions Coordinator (AC) was interviewed on 2/11/20 at 9:35 AM. She stated she was the facility's social worker in (MONTH) 2019 when Resident #19 was transferred to the hospital. She said the resident had received psychiatric services in the facility for about two weeks yet on 5/8/19 was delusional and endorsed suicidal ideation with a plan. The facility immediately sent Resident #19 to the emergency department and the resident was admitted to the hospital for psychiatric care. The AC stated when the resident returned to the facility she had not completed a level II PASARR referral and added she had not done level II referrals when a resident was identified with a mental illness diagnosis. She said, Honestly, I didn't know I should have done one. During an interview with Resident #19 on 2/13/20 at 9:31 AM, she recalled in (MONTH) 2019 she had thoughts of harming herself and was sent to the hospital. While in the hospital Resident #19 stated her psychiatric medications were adjusted and she felt better. She acknowledged that since her return to the facility she had seen a therapist weekly for psychotherapy and had felt well. On 2/12/20 at 2:15 PM an interview was completed with the Administrator. He reported the SW was responsible for completing level 2 PASARR referrals. He said the SW was new to the facility and recently had received education from the corporate office regarding the level 2 PASARR process.

Based on record review, and staff, nurse practitioner, and physician interviews the facility failed to prevent a significant medication error by not administering a resident's anticoagulant medication (Xarelto) on two consecutive days and failed to notify the on-call nurse practitioner or physician of the missed doses because of the resident's altered mental status for 1 of 3 residents' (Resident #85) closed charts reviewed. Findings included: Resident #85 was admitted to the facility on [DATE] following a hospitalization for left radius and left hip open reduction internal fixation (ORIF) after sustaining a fall at home. Review of Resident #85's Admission Minimum (MDS) data set [DATE], progress notes, and assessments revealed that Resident #85 had cognitive deficit but was alert and able to make needs known and required a one-two-person extensive assistance with activities of daily living. Her [DIAGNOSES REDACTED]. Review of progress notes, diagnostic results, and physician's orders [REDACTED].#85 had noted left lower leg swelling, the on-call nurse practitioner was notified, and a physician's orders [REDACTED]. The ultrasound was completed on 1/16/20, the results of evidence of a rather extensive left lower extremity [MEDICAL CONDITIONS] was reported to the on-call provider, and orders were placed for Xarelto Tablet 15 milligrams (MG) (Rivaroxaban) 15 mg by mouth every 12 hours for Left Lower Extremity [MEDICAL CONDITION] for 21 Days on 1/16/20. Review of Resident #85's Medication Administration Record [REDACTED]. During an interview with Nurse #2 on 2/11/20 at 05:02 PM she stated that Resident #85 was not alert enough to take her medications on 1/18/20 and 1/19/20 at 8:00 PM, she did not administer her ordered medications, including Xarelto, and did not notify the physician or on-call nurse practitioner of the missed doses. During an interview with Nurse Practitioner #1 on 2/11/20 at 04:02 PM she stated that she had seen Resident #85 daily during the week of 1/13/20 through 1/17/20 due to nausea/vomiting, critical labs reported, and the lower left extremity [MEDICAL CONDITION] that was found on 1/16/20 via ultrasound. When asked if she would expect staff to notify a provider of missed doses of Xarelto and mental status changes, she stated that if there was a change in condition where Resident #85 was not alert enough to take her medications and/or missed doses of ordered medications that the on-call provider should have been notified of the change. When asked about Resident #85's missed doses of Xarelto ordered to treat her [MEDICAL CONDITION], she stated that it would increase the risk of a negative outcome for the resident if not taken as ordered. During an interview with the Director of Nursing on 2/12/20 at 11:05 AM when asked about Resident #85's missed doses of medications on 1/18/20 and 1/19/20 at 8:00 PM, she stated that she became aware of the situation shortly after and had started/implemented a Quality Assurance plan to address it. She stated that it was her expectation that a nurse practitioner or physician is notified of missed medication doses, especially the high-risk medications like Xarelto. Education was given to all staff to notify and document resident status changes and failure to receive ordered medications for any reason. During an interview with Physician #1 on 2/12/20 at 3:07 PM, when asked if the nursing staff should have contacted the on-call provider regarding Resident #85's cognitive status change and missed doses of Xarelto, she stated yes. When asked what negative outcomes could have occurred due to Resident #85 not receiving her Xarelto as ordered, she stated possible worsening of the resident's current blood clot and other blood clots were a possibility.

Based on staff interviews and record review the facility failed to accurately code the active diagnoses section (section I) on the Minimum Data Set (MDS) assessment for 2 of 5 residents (Resident #7 and Resident #19) reviewed for unnecessary medications. Findings included: 1. Resident #7 was admitted to the facility on [DATE]. Cumulative diagnoses included, in part, anxiety disorder and depression. A psychiatry note dated 10/21/19 stated Resident #7 had a [DIAGNOSES REDACTED]. In a note dated 10/23/19, the facility nurse practitioner indicated Resident #7 had a past medical history of [REDACTED]. The quarterly MDS assessment dated [DATE] revealed Resident #7 received an anti-depressant medication for 7 of 7 days during the lookback period. Additionally, no diagnoses were checked under the psychiatric/mood disorder portion of section I. On 2/12/20 at 11:29 AM an interview was completed with MDS Nurse #1. She said when she coded diagnoses on the MDS assessment she reviewed physician (MD) notes and if the MD note indicated an active psychiatric [DIAGNOSES REDACTED]. She added that if a resident took a medication for depression or anxiety of if a resident was seen by psychiatric services in the facility then she kept the [DIAGNOSES REDACTED]. She explained that both anxiety and depression diagnoses should have been coded on the MDS based upon the psychiatry note and thought she must have missed coding it when she completed the quarterly MDS assessment. During an interview with the Administrator on 2/13/20 at 10:33 AM, he revealed when a MDS assessment was completed it went through a triple check process among the business office, MDS office and therapy office and they made sure everything was appropriately checked. The Administrator said he wasn't sure why the diagnoses coding was missed on the MDS assessment. 2. Resident #19 was admitted to the facility on [DATE]. Cumulative diagnoses included, in part, anxiety disorder, depression and post-traumatic stress disorder ([MEDICAL CONDITION]). A psychiatry note dated 12/2/19 stated Resident #19 had a [DIAGNOSES REDACTED]. In a note dated 12/11/19, the facility nurse practitioner included [MEDICAL CONDITION] in the list of diagnoses for Resident #19. The comprehensive MDS assessment dated [DATE] revealed Resident #19 received anti-depressant and anti-psychotic medications for 7 of 7 days during the lookback period. The diagnoses of anxiety and depression were checked under the psychiatric/mood disorder portion of section I, however, [MEDICAL CONDITION] was not checked. On 2/12/20 at 2:40 PM an interview was completed with MDS Nurse #2. She said when she coded diagnoses on the MDS assessment she reviewed physician (MD) notes and the medical diagnoses list. She explained she typically included all psychiatric diagnoses when she coded section I because, the resident can fluctuate. She indicated Resident #19 had multiple psychiatric diagnoses and said she missed coding the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. During an interview with the Administrator on 2/13/20 at 10:33 AM, he revealed when a MDS assessment was completed it went through a triple check process among the business office, MDS office and therapy office and they made sure everything was appropriately checked. The Administrator said he wasn't sure why the diagnoses coding was missed on the MDS assessment.

Based on staff interview and medical record review, the facility failed to provide a CMS- (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare part A skilled services to two of four residents (Resident #36 and Resident #183) reviewed for SNF Beneficiary Protection Notification. Findings included: 1. Resident #36 was admitted on [DATE] and currently resided in the facility during the review. A review of the SNF Beneficiary Protection Notification records for Resident #36 revealed Medicare Part A skilled service start date was 08/21/19 and ended on 09/03/19. The services were terminated because Resident #36 had achieved the highest practical level according to therapy. Form CMS- was not provided to Resident #36 or their Responsible Party (RP). During an interview on 02/12/20 at 3:28 PM, the Business Office Manager (BOM) confirmed she did not provide the SNF/ABN, form CMS- to Resident #36, or the resident's RP. Her interpretation of when to issue the form was if the resident chose to continue with therapy services after being discharged then she provided a SNF/ABN, form CMS- . If the resident chose not to continue with therapy services, she only provided the CMS- form. The BOM stated going forward both forms would be provided for residents who remained in the facility to ensure if therapy services were to continue Medicare A may not pay making the resident responsible. During an interview on 02/13/19 at 3:07 PM, the Administrator understood that both forms needed to be provided to the resident or the resident's responsible party. He stated that he was unaware that the BOM did not know this and that going forward, he would make sure it was clear that when a resident remained in the facility and was discharged from Medicare Part A services with remaining days both the CMS- and CMS- forms were provided to either the resident or their RP. 2. Resident #183 was admitted on [DATE] and was not residing in the facility during the review. A review of the SNF Beneficiary Protection Notification records for Resident #183 revealed Medicare Part A skilled service start date was 09/11/19 and ended on 09/24/19. The services were terminated because Resident #183 had achieved the highest practical level according to therapy. Form CMS- was not provided to Resident #183 or their Responsible Party (RP). During an interview on 02/12/20 at 3:28 PM, the Business Office Manager (BOM) confirmed she did not provide the SNF/ABN, form CMS- to Resident #183 or the resident's RP. Her interpretation of when to issue the form was if the resident chose to continue with therapy services after being discharged then she provided a SNF/ABN, form CMS- . If the resident chose not to continue with therapy services, she only provided the CMS- form. The BOM stated going forward both forms would be provided for residents who remained in the facility to ensure if therapy services were to continue Medicare A may not pay making the resident responsible. During an interview on 02/13/19 at 3:07 PM, the Administrator understood that both forms needed to be provided to the resident or the resident's responsible party. He stated that he was unaware that the BOM did not know this and that going forward, he would make sure it was clear that when a resident remained in the facility and was discharged from Medicare Part A services with remaining days both the CMS- and CMS- forms were provided to either the resident or their RP.

Based on observations, record reviews, resident, staff and Medical Doctor (MD) interviews, the facility failed to manage and treat complaints of pain for 2 of 3 sampled residents (Residents #8 and #10) reviewed for pain. The facility failed to manage Resident #8's pain during pressure ulcer dressing changes which resulted in the resident experiencing severe pain and anxiety. The facility also failed to administer pain medication to Resident #10 who had a recent knee surgery and was undergoing therapy which resulted in the resident experiencing pain during her therapy sessions. Findings included: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of his care plan dated 06/18/19 revealed he was care planned for pain and the potential for pain related to [MEDICAL CONDITION], decreased mobility, abdominal cramping, declining wound care and incontinent care due to pain. The goal was for the resident to express pain level within satisfactory limits. The interventions included administer pharmacological interventions as indicated per physician and monitor the effectiveness, assess for verbal and nonverbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increase anxiety, assess need to medicate prior to procedures, implement non-pharmacological interventions to release the pain like distraction techniques, relaxation and breathing exercises, music therapy and repositioning, Nurse Practitioner (NP) to review pain medication regime, provide education to resident and family, and provide rest periods to promote relief, sleep and relaxation. A review of Resident #8's quarterly Minimum Data Set ((MDS) dated [DATE] revealed he was cognitively intact for daily decision making and required extensive assistance with all activities of daily living (ADL) except eating. The resident was frequently incontinent of urine and always incontinent of bowel. The resident was admitted with pressure ulcers to the right malleolus (bony prominence of the side of the ankle) and heel that was unstageable, right calf that was unstageable, left heel that was unstageable, left calf that was unstageable and sacrum that was a stage 3. He occasionally had pain at a level of 7 and took pain medication daily. A review of the physician orders [REDACTED]. 1. Apply [MEDICATION NAME] solution to right malleolus and heel wound, clean with wound cleanser and cover with foam dressing and wrap with kerlix one time a day for wound care (wound care initiated on 06/14/19). 2. Apply [MEDICATION NAME] solution to left heel wound, clean with wound cleanser and cover with foam dressing and wrap with kerlix one time a day for wound care (wound care initiated on 06/14/19). 3. Apply [MEDICATION NAME] solution to right calf wound topically, clean with wound cleanser and apply padded dressing one time a day for wound care (wound care initiated on 06/14/19). 4. Apply [MEDICATION NAME] solution to left calf wound topically, clean with wound cleanser and apply padded dressing one time a day for wound care (wound care initiated on 06/14/19). 5. [MEDICATION NAME] tablet 250 milligrams (mg) crush and apply to sacrum wound topically two times a day for wound infection for 14 administrations, clean with wound cleanser and apply Dakin's soaked gauze with [MEDICATION NAME] to wound bed and apply ABD pad two times a day for wound care (wound care initiated on 06/14/19, [MEDICATION NAME] initiated on 07/17/19). 6. [MEDICATION NAME] Capsule 75 mg - give 1 capsule two times a day for pain (initiated on 06/12/19 and scheduled at 8:00 AM and 8:00 PM). 7. [MEDICATION NAME] Tablet 0.25 mg by mouth two times a day for anxiety and [MEDICAL CONDITION] (initiated on 06/14/19 and scheduled at 8:00 AM and 8:00 PM). 8. [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for pain (initiated on 06/14/19 and last dose given at 6:54 PM on 7/22/19). Observation on 07/23/19 at 9:52 AM of Resident #8's wound care revealed the wound care was done by the Wound Certified Medication Aide (CMA) with the Wound Nurse in the room, along with a Nurse Aide (NA) to assist in holding the resident. Resident #8 was sweating and said, wait and let me get ready and was taking deep breaths and wanted to count to 3 before being moved for the dressing changes. The staff counted with the resident and turned him on the count of 3. He was sweating and asked the Wound CMA to wait a minute while he prepared himself for the dressing changes. She explained that she was going to start with his heels and calves. When his boots were removed, and his leg was lifted to remove the old dressing on his left leg he yelled out oh, oh, oh. The Wound Nurse told him she was not going to lift his leg up any more but was going to hold it, so the Wound CMA could remove his old dressing. The Wound Nurse moved her hand to hold his foot and he yelled don't touch my foot there, it hurts and his face was grimaced, and he was sweating. When asked by the surveyor about his pain level Resident #8 stated it was an 8 out of 10. The Wound CMA asked if he was ok to continue with the wound care and Resident #8 told her to go ahead and get it over with. The Wound CMA cleaned the wounds with wound cleanser, painted with [MEDICATION NAME] and applied a thick foam adhesive dressing to his heel. The wounds were eschar but the area around the wound bed was blanchable and firm. The Wound CMA moved to his right leg and the Wound Nurse raised it to allow her to remove the old dressing and Resident #8 yelled out again in pain and stated, don't raise my leg so high - it hurts. Again, his face was grimaced, and he was sweating. The CMA proceeded with cleaning the heel and posterior calf with wound cleanser and painted them with [MEDICATION NAME] and the heel was covered with a thick foam dressing and the posterior calf was cleaned, painted with [MEDICATION NAME] and covered with a [MEDICATION NAME] island dressing. The wounds on the right heel and posterior calf were eschar and the surrounding tissue was blanchable and firm. Resident #8's boots were placed back on and adjusted. The Wound CMA then moved to the head of the bed and gently removed the pillow from underneath his left arm and gently placed it on his chest. Resident #8 during this time stated oh, oh, be gentle and stated he had a lot of nerve pain in his left arm that made it hard for him to move in the bed. He stated ok, ok wait and let me get ready before you turn me. Resident #8 was grimacing and sweating and asked the staff to wait and then on a count of 3 turn him on his right side. The staff counted to 3 and as he was turned he was yelling out about his feet and not to lift them too high and to hold them in place, so the Wound Nurse was attempting to hold his feet. The Wound CMA started taking off the old dressing and cleaned the wound gently with wound cleanser and the resident yelled out again and when asked by the surveyor the resident stated his pain was an 8 out of 10. The Wound CMA placed Dakin's (a diluted solution of bleach) soaked gauze with crushed [MEDICATION NAME] (an antibiotic medication) on it directly on the wound bed and added more Dakin's soaked gauze at the request of the resident. Resident #8 stated it felt better with the additional gauze on it. The Wound CMA then placed an abdominal pad (ABD) over the wound and taped it in place. The CMA and NA along with the Wound Nurse helped the resident turn back onto his back and again he yelled out my leg, my leg and the Nurse held his legs as he turned back over. The Wound CMA gently placed the pillow back under his arm and Resident #8 was grimacing and sweating. The CMA cleaned up her supplies and discarded the trash and left the room. The Wound Nurse stated she was going to find his Nurse to get him some pain medication. An interview on 07/23/19 at 10:00 AM with Resident #8 revealed he had acute Guillain Barre syndrome and it had affected the myelin sheath (insulation around nerve that facilitates the transmission of nerve impulses) around his nerves and caused him to have severe nerve pain. He stated it started on 03/23/19 when he struggled to stand up and fell and had to go to the hospital. He stated he was transferred to the facility for rehab and to be close to his family member. Resident #8 said he had terrible pain and anxiety with his dressing changes since being at the facility and stated it causes him to sweat and hold his breath. He stated he would like to get his pain medication before his dressing change so it was not so painful. According to Resident #8 the wounds were present when he was admitted , and he had been having daily dressing changes since admission and it was always painful and stressful for him due to the pain. He stated his pain medication was only ordered for twice daily and it was just not working for his pain especially during his dressing changes. Resident #8 said he was supposed to see the doctor today and he was going to ask about getting his pain medication administered before his dressing changes. The resident stated as long as he was still in the bed and no one was touching him he was able to tolerate the pain but stated when someone started touching him and moving him the pain started to increase. According to the resident anytime anyone touched him or moved him the pain increased. Resident #8 said he was waiting for his pain medication along with his 7/23/19 morning meds and stated he had not received any of his medications this morning. An interview on 07/23/19 at 4:10 PM with the Wound CMA revealed she had been doing wounds for some time. She stated Resident #8 was always in excruciating pain and had lots of anxiety during his dressing change. The Wound CMA stated since she had to have help in holding the resident during the wound care, she had to coordinate it with his NA because it took 2 people to move him and one to hold him while the dressing changes were done. She stated when Resident #8 stated his pain level was an 8 out of 10 she should have stopped and asked his Nurse to give his pain medication or offered an intervention to alleviate his pain. The Wound CMA stated the pain and anxiety the resident had during the observed wound care was no different than usual for him. She said anytime he was moved he was yelling out in pain and the only time his pain had been tolerable was if he is still in the bed and no one was touching him. The Wound CMA stated she had not addressed his pain during dressing changes with the nurse or the physician. She stated she was not aware the resident had not had his morning medications prior to his dressing change and stated she should have asked his nurse. An interview on 07/23/19 at 12:00 PM with the Director of Nursing (DON) revealed he would have expected the Wound CMA or Wound Nurse to have stopped the dressing change and had his Nurse to have administered Resident #8 his pain medication. He stated he would expect them to give the medication time to work and then resume the wound care. The DON stated he would have expected the Wound CMA and Wound Nurse to have stopped and found some way to give an intervention to have alleviated Resident #8's pain. He stated he was not aware of the resident's high level of pain and signs of anxiety until it was brought to his attention by the surveyor. According to the DON, it was unacceptable for a resident to have this much pain during dressing changes. The DON was not aware Resident #8 had not received his morning medications on 07/23/19, including his pain medication, prior to his dressing change taking place and stated he would follow up with his nurse to find out what had happened. An interview on 07/23/19 at 1:40 PM with the Medical Director (MD) revealed she had a long conversation with Resident #8 and his family member. The MD agreed that his pain needed to be controlled during his dressing changes and stated she had offered the option of using [MEDICATION NAME] but stated the family member was concerned about the resident being too sedated and developing an addiction. The MD stated she had compromised and doubled his current pain medication and written an order for [REDACTED]. The MD stated she was concerned about his pain level with movement and stated she was going to work with the staff to get his pain better controlled so he could tolerate being moved and turned and positioned without so much pain. An interview on 07/23/19 at 2:10 PM with Nurse Aide (NA) #1 revealed she had taken care of Resident #8 quite often. She stated he had a lot of pain and anxiety with dressing changes but also had pain any time they moved or positioned him. NA #1 said she often tried to coordinate with the Wound CMA, so she could get his bed bath done at the same time of his dressing change so he only had to be moved once for care. An interview on 07/23/19 at 3:00 PM with Nurse #1, who was Resident #8's nurse on first shift on 07/23/19, revealed she had not given the resident his morning medications, including his pain and antianxiety medications, prior to his dressing change. She stated she was not aware they were doing his wound care and had not given him his morning [MEDICATION NAME] 75 mg or [MEDICATION NAME] 0.25 mg prior to his dressing change. Nurse #1 said she did not get the keys from the night nurse until 8:00 AM which put her behind and stated it was hard to catch up once you started behind. According to Nurse #1 Resident #8 had not received his morning medications on 07/23/19 until 10:50 AM. A review of Resident #8's medical record on 07/23/19 revealed new orders written on 07/23/19 as follows by the Medical Director (MD): 1. Give [MEDICATION NAME] 0.25 milligrams (mg) - 1 tablet by mouth 3 times daily for anxiety or [MEDICAL CONDITION]. 2. Give [MEDICATION NAME] 5-325 mg - 2 tablets by mouth daily 30 minutes before dressing change to wounds. 3. Give [MEDICATION NAME] capsule 150 mg by mouth one time a day for [MEDICAL CONDITION] (initiated on 07/23/19 and scheduled at 8:00 AM). A review of Resident #8's Medication Administration Record [REDACTED]. An observation of Resident #8's wound care on 07/24/19 at 3:50 PM revealed the resident only yelled out once when his leg was moved and once while the Wound Medical Doctor (MD) debrided his wound but otherwise he tolerated it well. When the resident called out and moved slightly during debridement the Wound MD stopped and stated he would debride more of the wound later. During this wound care observation Resident #8 was not sweating and was not holding his breath as he had done on 07/23/19 during his wound care. An interview on 07/24/19 at 4:15 PM with the Wound Medical Doctor (MD) revealed Resident #8's wounds looked better today than last week. The Wound MD stated he performed further debridement of the sacral wound on 07/24/19 after numbing the area with [MEDICATION NAME] and Resident #8 tolerated it well. The Wound MD stated he was not aware of Resident #8's pain with dressing changes but stated he understood the Medical Director had written new orders for pain management and stated the resident tolerated his wound care and debridement well on 07/24/19. An interview on 08/08/19 at 1:00 PM with the Minimum Data Set (MDS) Coordinator revealed she was familiar with Resident #8 and stated she had completed his care plan for pain. The MDS Coordinator stated she was not sure what if any of the non-pharmacological measures to decrease the resident's pain had been implemented. She went on to say that she usually had not followed up with nursing until the next review was done unless there was a problem. The MDS Coordinator stated the care plan was accessible to the nursing staff and assumed they followed up on the interventions. An interview on 08/08/19 with the Nurse Practitioner (NP) revealed Resident #8 had been evaluated several times for pain. The NP stated he had been evaluated 2 weeks ago by both she and the MD on the same day and they had discussed his care several times. She stated he was complicated but thought he was doing better now that he received pain medication prior to his dressing changes. Resident #10 seemed to be progressing with therapy now that he had better pain relief and seemed to be in better spirits now. The NP stated she and the MD discussed stronger medication being utilized for the resident but stated he and his family member were concerned about him not being able to participate in therapy and stated they were concerned about addiction related to their experience with another family member. She stated they were continuing to evaluate Resident #10's pain medication and would increase it as needed. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed Resident #10 was cognitively intact and required one-person assistance with most activities of daily living (ADL). Resident #10 was noted to have a surgical incision located on her left knee. On 7/24/19 at 3:10 PM an interview was conducted with Resident #10. Resident #10 stated she had been in the facility for two weeks following a left knee replacement. She stated she had been experiencing pain at a level of 10 on a 0 to 10 scale while working with physical therapy however had not received any pain medication. The interview revealed Resident #10 had asked the nurses for pain medication and was told she did not have anything ordered. Resident #10 stated she knew this information was incorrect because she had seen a prescription for [MEDICATION NAME] pain medication written for her while she was at an Orthopedic appointment on 07/22/19. She stated she handed the prescription to Nurse #1. Multiple attempts were made to contact Nurse #1 and were not successful. Review of Resident #10's medical record revealed no report of the Orthopedic appointment progress note dated 07/22/19. Review of Resident #10's Medication Administration Record [REDACTED]. The order was discontinued on 07/19/19. The review revealed no order for pain medication initiated on 07/22/19 for Resident #10. Review of Resident # 10's medical record revealed a prescription which had been scanned into point click care by the facility on 07/24/19. The prescription dated 07/22/19 read, [MEDICATION NAME] 5/325 milligrams (mg) by mouth every 6 hours as needed for pain. On 07/24/19 at 3:30 PM an interview was attempted with Nurse #3. The surveyor was unable to leave a voicemail due to her voice mailbox being full. The facility attempted to make contact with Nurse #3 with no success. On 07/24/19 at 3:48 PM an interview was conducted with Nurse #9. Nurse #9 stated she was taking care of Resident #10 during this shift. She stated Resident #10 did not have anything ordered for pain. Nurse #9 stated the protocol once a resident returned from an appointment was for the nurse on duty to enter the orders into point click care and fax the prescription to the pharmacy. On 07/24/19 at 3:35 PM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #10 did have a prescription for pain medication dated 07/22/19 that had not been put into the system as a physician order [REDACTED]. The interview revealed the order should have been placed onto Resident #10's MAR by 07/22/19 so she could receive pain medication as needed. The DON stated his expectations were for the nurses to receive the prescriptions from the physicians and enter the orders into the system or call the physicians to clarify the orders if they have questions and to fax the prescription to the pharmacy. The interview revealed it was unacceptable for Resident #10 to go two days without receiving pain medication. On 08/08/19 at 1:30 PM an interview was conducted with the Occupational Therapist (OT). The OT stated Resident #10 did have some pain while participating in therapy but stated it had not prevented her from being able to complete her therapy. She stated if Resident #10 had complained of pain due to therapy she would have taken her to the nurse and requested the resident receive her medication. On 08/08/19 at 2:35 PM an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated Resident #10 had some pain during therapy but stated it had not prevented her from participating and reaching her goals. She stated looking back at the resident's physical therapy notes it had been documented on all but 2 days the resident was having knee pain. Resident #10 as the PTA recalled stated she was having knee pain as more of a comment than a concern or complaint but stated it had been documented she was having knee pain during therapy. The PTA stated usually if a resident is unable to complete therapy due to pain, they take them to their room and notify their nurse they need pain medication. She stated she had not had to do that with Resident #10 and stated she had participated in her therapy daily.

Based on observations, record review, staff, resident, and Medical Director interviews the facility failed to ensure that a resident who was transported on external public transportation van was safely transferred from the [MEDICAL TREATMENT] center back to the facility. When the van returned to the facility the resident was on the floor and the facility failed to thoroughly investigate and determine root cause of the incident. This affected 1 of 2 residents who received [MEDICAL TREATMENT] services (Resident #33). Immediate jeopardy began on 12/27/17 when the external public transportation driver entered the facility and stated to the staff that he needed assistance in getting Resident #33 off the floor of the van. Following the incident, the facility staff failed to thoroughly investigate the incident and to determine the root cause of the incident on the van that involved Resident #33. Immediate jeopardy was removed on 04/20/18 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective for thoroughly investigating incidents and determining root cause of the incident. The findings included: Review of a facility contract titled Public Transportation Agreement dated 07/12/17 read in part, the contractor (external public transportation company) will follow the approved safety plan. All drivers are drug tested and criminal background checks done prior to hiring. A copy of the external public transportation company's safety plan was obtained and outlined the hiring process and training process that included defensive driving (which included distracted driving education and no cell phone use policy), emergency procedures, and behind the wheel training. Resident #33 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #33 had long and short-term memory problems but was independent with daily decision-making skills. Resident #33 required total assistance of 2 people for transfers. Review of a nurses note dated 12/27/17 at 2:00 PM signed by the Director of Nursing (DON) read in part, the external public transportation van driver came to the nurse's station and stated that Resident #33 was on the floor of the van. He stated that she must have slid out of her wheel chair during transport. The DON and Environmental Services Director (ESD) went to the van to observe the resident and 911 was called for assessment and transport. Resident #33 was alert however lethargic. The external public transportation van driver was unable to vocalize how long she had been in the floor of the van during the transport however stated that there were cameras in the van that would show that. The external public transportation van driver, DON and ESD stayed with Resident #33 until Emergency Medical Services (EMS) arrived to assist in transferring. EMS assisted resident to her wheelchair and then down the lift and to the EMS stretcher. EMS then transported Resident #33 to the hospital. Resident #33's family was notified of the transport and the external public transportation company's security officer called. He stated they would be completing the investigation on the end of external public transport company and monitoring the camera recordings. Nurse practitioner (NP) was notified. Resident #33 was unable to verbalize what happened or how long she had been in floor. An interview was conducted the external public transportation company's security officer on 04/18/18 at 11:20 AM. He stated that he could not comment on the incident that it was a personnel issue and the external public transportation company's director had the full details of the investigation. An interview was conducted with the Public Transportation Director (PTD) on 04/19/18 at 11:18 AM. The PTD stated that he returned to work on 01/02/18 and learned of the incident. He further stated that they immediately began to investigate the incident and watched the video footage and made the determination of what they believed happened. He stated that the investigation led us to believe that Resident #33 was picked up at [MEDICAL TREATMENT] an was enroute to the facility. Resident #33 appeared to have a medical issue which appeared to be a [MEDICAL CONDITION]. The driver continued to the facility. While traveling the contracture of Resident #33's muscles caused her head to go back and she pushed her hips forward and slid under the seat belt to the floor with her back against the wheelchair. The driver arrived at the facility and opened the door and discovered Resident #33 on the floor of the van and entered the facility to get some help. The facility staff contacted EMS and Resident #33 was transported to the hospital. The PTD stated they interviewed the driver, however the video footage told us what we needed to know. The driver was terminated because he did not respond appropriately to a medical emergency. The PTD state that drivers received education on lift position procedure, defensive driving, blood and air borne pathogens, first aid, cardiopulmonary resuscitation, automatic external defibrillator use, special needs children, car seat booster seat security, emergency procedure and evacuation, customer sensitivity, call center issues, use of the push to talk phones, inclement weather, and vehicle fueling procedures. He added that after the 39-hour class room training the drivers were put with more seasoned drivers for however long it took them to get acclimated to the process which generally took 2-5 days depending on the experience level of the driver. The PTD stated that the driver never indicated why did not pull over, he stated he did not see her in his mirror that was located directly above his head. The PTD stated that when he reviewed the video footage he was able to ascertain why he did not see Resident #33 in his mirror. An observation of the video footage from the external public transportation van was made on 04/19/18 at 4:06 PM. The video footage was splint 4 ways with each camera having a different angle. One camera was pointed directly to the front of the van, one on the rear of the van, one camera was directly on Resident #33 and one camera was directly on the driver. On 12/27/17 at 12:32 PM the driver was noted to push Resident #33 onto the van and secure her 4-point straps to the floor of the van and apply the seat belt which came over her left shoulder across her abdomen and fastened to the floor behind her right side. The driver began to drive towards the facility at 12:36 PM and at 12:37 PM Resident #33 was observed to begin to violently twitch, her hands appear to become rigid and she threw her head back and her hips slide forward. The driver was observed to pick up his cell phone and proceeded to make a personal call at 12:37 PM, never checking his mirror or speaking to Resident #33. As the van proceeded down the road with each bump, Resident #33 who was now unconscious with her head back, her hips inched closer to the front of the wheelchair seat and at 12:39 PM Resident #33 slipped from the wheelchair to the floor of the van. The seat belt still secured but was now resting across her chest. The driver remained on the phone with no knowledge of what was happening behind him, he again never checked his mirror or spoke to Resident #33. At 12:41 PM Resident #33 regained consciousness and lifted her head, she appeared disoriented and tried to lift her arm. Resident #33 was heard coughing and appeared to be trying to pull her shirt down over her abdomen. The driver again never checked his mirror and remained on his cell phone. At 12:47 PM the driver returned to the facility parking lot backed the van into the space and placed the van in park. The driver remained in his seat continuing his conversation on the phone and had yet to observe Resident #33 on the floor of the van. He finally exited the van and proceeded to the rear door and opened the door. He rode the lift gait up to the van and reached for Resident #33's wheelchair, at which time he realized Resident #33 was not in the wheelchair, he then hung up his phone. At 12:50 PM the driver loosened the seat belt and attempted to pick up Resident #33 and when he could not, he exited the van and proceed to enter the nursing facility. Resident #33 was still on the floor of the van and the seat belt was now resting against the right side of her neck and was looped under her left arm. The driver returned at 12:56 PM and completely removed the seat belt from Resident #33. The facility staff arrived at the van at 12:58 PM, the DON was heard speaking to the driver. At 1:00 PM the ESD entered the van and got down on the floor with Resident #33 and states are you feeling ok and Resident #33 stated NO. The DON then asked Resident #33 are you a diabetic? and bent down to Resident #33 and checked a pulse in her right wrist. The DON was then overheard stating I can't touch her she is on your property, she then dialed a number on her cell phone and was heard asking when EMS would be there and stated, this is an emergency and indicated Resident #33 was pale. At 13:06 EMS arrived on the scene and entered the van and began to assess Resident #33, she was then placed in her wheelchair and exited the van using the rear lift. Once outside the van the EMS workers placed Resident #33 on the stretcher and into the back of the ambulance. At 1:16 PM the driver entered the van and left the parking lot while the EMS van was still parked in the facility parking lot. An follow up interview was conducted with the PTD on 04/18/18 at 5:00 PM. The PTD stated that driver was terminated for violating the cell phone policy and not pulling over and contacting emergency personnel when a medical emergency occurred. The PTD verified that the external public transportation driver had received the education on the lift position procedure, defensive driving, blood and air borne pathogens, first aid, cardiopulmonary resuscitation, automatic external defibrillator, special needs children, car seat booster seat security, emergency procedure and evacuation, customer sensitivity, call center issues, HR, use of the push to talk phones, inclement weather, and vehicle fueling procedures on 08/17/17. An interview was conducted on 04/18/18 11:42 AM with the current external public transportation driver. The driver of the public transportation van stated that when she was hired she had to complete an online course that included emergency procedures and how to respond to them. The driver explained that they were trained that if there was an emergency or an accident they were to pull over to a safe place and call 911 and to notify our dispatch. The driver stated that it was never appropriate to drive around with a patient on the floor of the van. She also stated that she was not the driver involved in the incident with Resident #33 but she was aware of it. She added that she ensured Resident #33 was always visible in her mirror and she would often talk to her during the commute to make sure she was ok and certainly did not talk on her cell phone while driving the van. An interview was conducted with Resident #33 on 04/18/18 at 5:50 PM. Resident #33 stated she did not recall the incident on the van at all, she had no idea she had fallen. Resident #33 recalled being in the hospital and stated she has not had any recent [MEDICAL CONDITION]. Resident #33 stated she really liked her van driver now and she felt very secure in the van. An interview with the ESD was conducted on 04/18/18 12:54 PM. The ESD stated that on 12/27/17 he was called to go outside to meet the DON at the public transportation van. He stated when he walked onto the van he found Resident #33 sitting on her butt in front of her wheel chair. Resident #33 was very sleepy and would not say much. The ESD stated he asked the driver what happed and he stated, I am trying to get a hold of my supervisor. He added that the DON called EMS and they came and picked her up and put her back in the wheelchair and then transferred her to the stretcher and took her to the hospital. The ESD stated that it appeared that she had slid out from under the seat belt. The ESD stated that he did not have anything to do with the public transportation company, and stated we believe they have the ability to do what they need to do. He added that he had never ridden with the drivers of the external public transportation company before and did not verify any training or safe driving practices. He stated that when Resident #33 returned from the hospital he added anti tippers to both the front and back of her wheelchair and tilted her seat back a bit to alter her center of gravity since she was a bilateral [MEDICAL CONDITION]. An interview was conducted with the DON on 04/19/18 at 9:10 AM. The DON stated that on 12/27/17 the public transportation driver walked to the nursing station and stated that he needed someone to come and help because he had a resident on the floor of the van. She stated when she entered the van Resident #33 was sitting on her butt in front of her wheelchair and did not look like her usual self but had no obvious injury and was not complaining of any pain. She added she had already called EMS. She stated the driver indicated he did not know what happened when he pulled in the parking lot this was what he found. The driver kept insisting that we needed to get Resident #33 up and he was informed that EMS would be there shortly to get her up. The DON stated the driver refused to answer any questions or to provide a statement about the incident. EMS arrived and placed Resident #33 back in her wheelchair and down the lift and then transferred her to the stretcher and they took her to the hospital. After the driver left the facility the DON stated she contacted the transportation company and left a message and the safety officer returned her call and was informed about the incident. The following day the public safety officer called the facility and stated to the DON that the driver had not driven since the incident and he had reviewed the video and it appeared that Resident #33 had [MEDICAL CONDITION] activity and the fall occurred before pulling into the parking lot. She added that they were later informed that the driver had been terminated for his actions that day and when she requested a copy of the investigation the request was denied. The DON stated that the driver should have immediately pulled over and called 911. She added that she had not seen the video footage and was not aware of any modification that were made to the van or the manner in which Resident #33 was transported. She added that she had not witnessed any further transported with Resident #33 and stated, she was not the expert on that. She added that Resident #33 had no injury from her fall but did return to the facility on [MEDICAL CONDITION] medication and has had no further [MEDICAL CONDITION] activity. An follow up interview was conducted with the DON on 04/20/18 at 3:45 PM. The DON stated that she had been thinking a lot about what she could have done diffidently and stated she should have reported the driver for neglect and proceeded to determine the root cause of the incident which should have included being more persistent about obtaining the full details of the investigation from the external public transportation company and watching the video footage. An interview was conducted with the Administrator on 04/19/18 08:57 AM. The Administrator stated that primarily the facility used the external public transportation van to bring Resident #33 from [MEDICAL TREATMENT] He stated that the facility van was tied up with other residents and for consistency the facility used the external public transportation company. The Administrator stated the contract company was responsible for training and safe driving. He added that he had never been out to [MEDICAL TREATMENT] to watch them load and unload Resident #33 but at times seen them here at the facility and never had concerns with the staff or the way they unload or load a resident. The Administrator, DON, and Regional Director of Clinical Operations were notified of the immediate jeopardy on 04/19/18 at 2:58 PM. The facility provided an acceptable credible allegation of compliance on 04/20/18. F689 Accidents Credible Allegation of Compliance · The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: o On 12-27-2017, upon return of Resident #33 from [MEDICAL TREATMENT], the contract transportation driver notified facility staff that Resident #33 was on floor of their van and needed assistance at which time the Director of Nursing (DON) and Environmental Services Director immediately responded to the van and noted Resident #33 sitting on floor of van in front of wheelchair. The Environmental Service Director reports that at the time he entered the van, Resident #33's wheelchair was secure. The external contracted transportation company driver stated to facility staff that the he had already removed the seat belt from resident #33. At the time of the event, DON did not recall wheelchair securement and the external contracted transportation driver stated that resident #33 slid under the seatbelt onto the floor. No obvious injuries were noted. Emergency Medical Services (EMS) was contacted via 911. The DON repeatedly asked the contract transportation driver about the details of this occurrence, but he would only state that he did not hear anything. Once EMS arrived, they assisted Resident #33 to her wheel chair and exited the van via the lift. EMS then transferred resident to stretcher and resident was then placed into ambulance. The DON again asked the contract transportation driver for details of this occurrence, but he refused to provide any information. The driver also refused to contact his supervisor. The driver then left the facility parking lot in the external contracted transportation van. The facility staff did not inspect the public transportation van. The DON immediately contacted the driver's Supervisor to report occurrence. The public transportation supervisor then informed the DON that there were cameras on the van and that he would review the video. He also stated that this driver would not drive again until this investigation was complete. The DON followed up with the public transportation supervisor on 12-29-2017. He relayed the information regarding the review of the video. He stated that it appeared that the resident may have had a [MEDICAL CONDITION]. The facility requested to view the video and the request was denied; therefor, the facility staff has not viewed the video. As reported by the Supervisor, the actions of Resident #33 during her [MEDICAL CONDITION] could have contributed to the resident sliding from her wheel chair. o On (MONTH) 3, (YEAR), the DON placed a follow up call to the public transportation Supervisor and she was informed that the driver was no longer employed. At the time of the incident, the facility was made aware that the driver was terminated as a result of his actions on (MONTH) 27, (YEAR). The facility was only informed that the employee's actions resulted in termination. Root cause analysis completed by facility on 1-3-2018, determined that this was caused by the external contracted transportation driver ' s failure to follow the external contracted transportation's policy on emergency procedures by not supervising or monitoring Resident #33 during transport to ensure the resident remained safe. · The procedure for implementing the acceptable plan of correction for the specific deficiency o Regional Director of Clinical Services provided education on root cause analysis and thorough investigation of incidents/accidents to prevent re-occurrences on 4-20-2018 to Administrator, DON, and Assistant Director of Nursing. All incidents involving a resident, regardless if the incident occurs on or off of facility property, must be thoroughly investigated. o All external transports are suspended as of 4-19-2018 for at least the next two (2) weeks until facility can determine safety of our residents during transports in which our facility will require documentation/evidence of training and competency. The facility will not utilize external contracted transportation company until contract is updated to include the thorough investigation including all facts of any accident involving a facility resident and the facility will have the right to see all evidence relating to the accident. The Administrator will collaborate with contracted transportation company to obtain a list of drivers that will be providing services to our facility in order to perform initial competencies for current drivers and any new hires prior to residents being transported. In the meantime, residents will be transported with the facility van other than emergency transports. o For resident #33, resident's wheel chair was modified by facility's physical therapist and environmental services director on 1-11-2018. For those residents who have amputations and/or physical challenges, facility occupational/physical therapy will do an evaluation of their wheelchairs to determine if alterations/modifications need to be made in order to ensure safety during transport. Two other residents with amputations were evaluated by Physical Therapist on 4-20-2018 which required no modifications in order to ensure safe transports. o In the event of an accident related to external contracted transportation, facility administrator/DON will collaborate with external contracted transportation in order to investigate to determine root cause of event. In the event of an accident related to external contracted transportation, Administrator/DON will notify supervisor that their services will be suspended until investigation is completed and corrective action taken. o On 4-20-2018, Administrator re-educated the transportation staff on proper wheelchair securement, seatbelt application, reporting requirements, what to do if there is an accident or if a resident has a medical emergency during transport, loading, and unloading of residents into facility van. In the event of an accident in the facility transportation van, the administrator and DON will be notified immediately and all other transports by facility transportation van will be suspended. Staff will be suspended until an investigation is completed in order to determine root cause and the corrective action is put into place. · 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. o To ensure safety of our residents during transports on facility transport van, Administrator will perform direct observation of transport aid and validate that the transport aid is competent by utilizing the Competency: Securing Wheelchair and Resident in Van form which includes Wheelchair Securement, Securing Passenger, Releasing Wheelchair, and Releasing Passenger onloading and unloading of residents weekly x 4, then monthly x 3, and will be completed annually on current transportation staff. In addition, for new transportation hires, initial competencies will be completed to ensure safety during transport and at least annually thereafter. The Administrator will collaborate with contracted transportation company to obtain a list of drivers that will be providing services to our facility in order to perform initial competencies by utilizing the Competency: Securing Wheelchair and Resident in Van form which includes Wheelchair Securement, Securing Passenger, Releasing Wheelchair, and Releasing Passenger onloading and unloading of residents for current drivers and any new hires prior to residents being transported. The competencies will be performed quarterly thereafter by the Administrator. To ensure safety of our residents during external contracted transportation, the Administrator will perform initial competencies for all drivers on proper onloading and securing of residents properly. · The title of the person responsible for implementing the acceptable plan of correction. o The Administrator Immediate jeopardy was removed on 04/20/18 when interviews with administrative and transportation staff revealed that they had been educated on reporting and thoroughly investigating incidents and determining root cause for each incident that occurred.

Based on observations, record review, and staff interviews the facility's administration failed to identify the root cause of an incident that occurred on external public transportation van and then failed to make any process, systemic, or contractual changes with the company and allowed the resident to continue to be transported by the company. This affected 1 of 2 residents that received [MEDICAL TREATMENT] services (Resident #33). Immediate jeopardy began on 12/27/17 after an incident occurred on the external public transportation van and the facility failed to discern the root cause of the incident, failed to make any process or contractual changes, failed to make any changes to the safety plan and continued to use the external public transportation company to transport Resident #33. Immediate jeopardy was removed on 04/20/18 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective for investigating incidents to determine root cause and making subsequent changes to ensure the incident does not happen again. The findings included: This tag is cross referred to F689: Based on observations, record review, staff, resident, and Medical Director interviews the facility failed to ensure that a resident who was transported on external public transportation van was safely transferred from the [MEDICAL TREATMENT] center back to the facility. When the van returned to the facility the resident was on the floor and the facility failed to thoroughly investigate and determine root cause of the incident. This affected 1 of 2 residents who received [MEDICAL TREATMENT] services (Resident #33). An interview with the Environmental Service Director (ESD) was conducted on 04/18/18 12:54 PM. The ESD stated that to his knowledge following the incident the driver was terminated and the facility continued to use the external public transportation company to transport Resident #33 back from [MEDICAL TREATMENT]. He stated, we believe they have the ability to do what they need to do. He stated that when Resident #33 returned from the hospital he tilted her seat back a bit to alter her center of gravity since she was a bilateral [MEDICAL CONDITION] but that was the extent of it. An interview was conducted with the Director of Nursing (DON) on 04/19/18 at 9:10 AM. The DON stated that following the incident the driver was terminated and she believed that was appropriate action and continued to use the external public transportation company. She added that to her knowledge no systemic or contractual changes had been made. The DON also stated that she was unable to discern the cause of the incident because her request for the full detail of the investigation was denied and she believed that once the driver was terminated that was sufficient action to continue the use of the services. An interview was conducted with the Administrator on 04/19/18 08:57 AM. The Administrator stated that primarily the facility used the external public transportation van to bring Resident #33 back from [MEDICAL TREATMENT]. The Administrator stated the contract company was responsible for training and safe driving and he had not provided any oversight to the external public transportation company. The Administrator went on to say that following the incident, the facility did not determine the root cause of the incident and they had not made any contractual, systemic, or process changes. He stated they continued to use the external public transportation company to transport Resident #33 back from [MEDICAL TREATMENT] because the driver had been terminated and he felt like that was appropriate action and continued to use their services to transport Resident #33. The Administrator, DON, and Regional Director of Clinical Operations were notified of the immediate jeopardy on 04/19/18 at 2:58 PM. On 04/20/18 the facility provided an acceptable credible allegation of compliance. F835 ADMINISTRATION- Corrective Action Plan for Immediate Jeopardy Removal Submission of the corrective action plan for immediate jeopardy removal is not an admission that a deficiency exists or that one was cited correctly. This corrective action plan is submitted to meet requirements established by state and federal law. · The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: o On 12-27-2017, upon return of Resident #33 from [MEDICAL TREATMENT], the contract transportation driver notified facility staff that Resident #33 was on floor of their van and needed assistance at which time the Director of Nursing (DON) and Environmental Services Director immediately responded to the van and noted Resident #33 sitting on floor of van in front of wheelchair. The Environmental Service Director reports that at the time he entered the van, Resident #33's wheelchair was secure. The external contracted transportation company driver stated to facility staff that the he had already removed the seat belt from resident #33. At the time of the event, DON did not recall wheelchair securement and the external contracted transportation driver stated that resident #33 slid under the seatbelt onto the floor. No obvious injuries were noted. Emergency Medical Services (EMS) was contacted via 911. The DON repeatedly asked the contract transportation driver about the details of this occurrence, but he would only state that he did not hear anything. Once EMS arrived, they assisted Resident #33 to her wheel chair and exited the van via the lift. EMS then transferred resident to stretcher and resident was then placed into ambulance. The DON again asked the contract transportation driver for details of this occurrence, but he refused to provide any information. The driver also refused to contact his supervisor. The driver then left the facility parking lot in the external contracted transportation van. The facility staff did not inspect the public transportation van. The DON immediately contacted the driver's Supervisor to report occurrence. The public transportation supervisor then informed the DON that there were cameras on the van and that he would review the video. He also stated that this driver would not drive again until this investigation was complete. The DON followed up with the public transportation supervisor on 12-29-2017. He relayed the information regarding the review of the video. He stated that it appeared that the resident may have had a [MEDICAL CONDITION]. The facility requested to view the video and the request was denied; therefore, the facility staff has not viewed the video. As reported by the Supervisor, the actions of Resident #33 during her [MEDICAL CONDITION] could have contributed to the resident sliding from her wheel chair. o On (MONTH) 3, (YEAR), the DON placed a follow up call to the public transportation Supervisor and she was informed that the driver was no longer employed. At the time of the incident, the facility was made aware that the driver was terminated as a result of his actions on (MONTH) 27, (YEAR). The facility was only informed that the employee s actions resulted in termination. Despite requesting additional information about the cause of the incident, the facility was only informed that the employee's actions resulted in termination, thereby leading the facility to believe that the employee had some culpability for the episode. Thus, because the individual had been terminated, the facility elected to continue using this company to transport residents. The facility's administration did not make additional attempts to obtain more information about this incident and continued using this company to transport residents. So, administration failed to conduct a thorough investigation to determine how the incident occurred and how to possibly prevent a reoccurrence. Root cause analysis completed by facility on 1-3-2018, determined the facility's administration believed the facility did not need to complete a thorough investigation of this incident, which involved Resident #33, since the transport van involved was not the facility's property. · The procedure for implementing the acceptable plan of correction for the specific deficiency o Regional Director of Clinical Services provided education on root cause analysis and thorough investigation of incidents/accidents to prevent re-occurrences on 4-20-2018 to Administrator, DON, and Assistant Director of Nursing. All incidents involving a resident, regardless if the incident occurs on or off of facility property, must be thoroughly investigated. o All external transports are suspended as of 4-19-2018 for at least the next two (2) weeks until facility can determine safety of our residents during transports in which our facility will require documentation/evidence of training and competency. The facility will not utilize external contracted transportation company until contract is updated to include the thorough investigation including all facts of any accident involving a facility resident and the facility will have the right to see all evidence relating to the accident. The Administrator, with corporate oversight and direction, will collaborate with contracted transportation company to obtain a list of drivers that will be providing services to our facility in order to perform initial competencies for current drivers and any new hires prior to residents being transported. In the meantime, residents will be transported with the facility van other than emergency transports. o In the event of an accident related to external contracted transportation, facility administrator/DON, with corporate oversight, will collaborate with external contracted transportation in order to investigate to determine root cause of event. In the event of an accident related to external contracted transportation, Administrator/DON will notify supervisor that their services will be suspended until investigation is completed and corrective action taken. o On 4-20-2018, Administrator re-educated the transportation staff on proper wheelchair securement, seatbelt application, reporting requirements, what to do if there is an accident or if a resident has a medical emergency during transport, loading, and unloading of residents into facility van. In the event of an accident in the facility transportation van, the administrator and DON will be notified immediately and all other transports by facility transportation van will be suspended. Staff will be suspended until an investigation is completed in order to determine root cause and the corrective action is put into place. · 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. o To ensure safety of our residents during transports on facility transport van, Administrator will perform direct observation of transport aid and validate that the transport aid is competent weekly x 4, then monthly x 3, and will be completed annually on current transportation staff. The Regional Director of Clinical Services will oversee at least one of these audits per period specified to ensure they are being performed correctly. In addition, for new transportation hires, initial competencies will be completed to ensure safety during transport and at least annually thereafter. The Administrator, with corporate oversight, will collaborate with contracted transportation company to obtain a list of drivers that will be providing services to our facility in order to perform initial competencies for current drivers and any new hires prior to residents being transported. The competencies will be performed quarterly thereafter by the Administrator. To ensure safety of our residents during external contracted transportation, the Administrator will perform initial competencies for all drivers on proper onloading and securing of residents properly. Regional Director of Clinical Services provided education on root cause analysis and thorough investigation of incidents/accidents to prevent re-occurrences on 4-20-2018 to Administrator, DON, and Assistant Director of Nursing. Regional Director of Operations or Regional Director of Clinical Services will audit one investigation weekly x 4 and monthly x 3, if applicable, to ensure investigations are being conducted correctly. o Monitoring results will be discussed in monthly QAPI as information is available from results of audits of investigation root cause analysis of investigation of incidents/accidents. In addition to ensure sustained compliance, after completion of the four-month monitoring of the investigation of accidents, Regional Director of Clinical Services will complete one random review of accident investigations per month for the next six months. In addition, Regional Director of Operations or Regional Director of Clinical Services will audit training and competencies for completion on new hires related to internal and external transport van drivers. · The title of the person responsible for implementing the acceptable plan of correction. o Regional Director of Operations and Regional Director of Clinical Services Immediate jeopardy was removed on 04/20/18 after interviews with the Regional Director of Clinical Services, Administrator, DON, and Assistant DON had been educated on the process of identifying the root cause of the incident and making appropriate changes to prevent reoccurrence.

Based on staff, physician and family interviews and record review the facility neglected to seek medical intervention when it was reported that a resident had been drinking fluids but had no urine output for 8 hours and complained of not feeling well. The resident's family requested Emergency Medical Services (EMS) and the resident was admitted to Intensive Care Unit (ICU) diagnosed with [REDACTED].#28). Immediate jeopardy began on 01/31/16 when Resident #28 had no urine output and the facility neglected to seek medical treatment or intervention for this change in condition. Immediate jeopardy was removed on 03/24/16 when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognition but had clear speech and able to make herself understood; she required extensive assistance with activities of daily living but was able to feed herself with setup from staff; and had an indwelling urinary catheter. The MDS also specified the resident received as needed pain medication and was not on Hospice. Resident #28 had a care plan for her urinary catheter updated on 01/26/16 that specified the bag was to be emptied every shift and to provide catheter care as ordered. The care plan goal was that the resident would not experience catheter relates issues such as failure to drain. Resident #28 received a therapeutic, mechanically altered diet with regular liquids. On 01/31/16 review of Resident #28's urine output revealed the Resident went 24 hours with no urine output. No documentation was made in the medical record on 01/31/16 that an assessment had been completed for no urine output or that the physician had been contacted. On 02/01/16 review of Resident #28's urine output revealed the Resident #28 went 24 hours and only had 50ml of urine. No documentation that an assessment had been completed for the decreased urine output or that the physician had been contacted. On 02/02/16 at 5:00 PM a nurse's entry made by the nurse supervisor specified the family of Resident #28 was visiting and reported that the resident was not acting right and demanded the resident be sent to the Emergency Department. Resident #28's blood pressure was 95/54 and temperature was 99.4 degrees Fahrenheit, heart rate was 115 beats per minute and resting respirations were 34. The resident was noted to have 0 ml in Foley catheter bag. The Emergency Medical Services (EMS) run report dated 02/02/16 at 6:15 PM specified Resident #28 was somnolent and had a fever of 100.3 degrees Fahrenheit. The Resident was given 200ml of normal saline intravenously. EMS documented the resident had thick discolored urine in catheter bag but did not specify how much. On 02/02/16 Resident #28 was transported to the Emergency Department (ED). Review of the ED notes dated 02/02/16 specified the resident presented with [MEDICAL CONDITION] and in septic shock due to urinary tract infection [MEDICAL CONDITION]. In the ED they attempted to get a urine specimen but documented that there was not enough urine. Resident #28 was also diagnosed with [REDACTED]. In the ED, Resident #28's urinary catheter was changed and the hospital was able to obtain reddish pussy urine. Resident #28 was admitted to the Intensive Care Unit (ICU). Resident #28 was discharged from the hospital on [DATE] to another facility with a fair potential for rehab. On 3/21/16 at 1:10 PM a family member of Resident #28 was interviewed on the telephone and reported that the family visited twice daily. The family member explained that on 02/02/16 around 4:30 PM she visited the resident and the resident was not her usual self. She explained that the resident was very lethargic and did not engage in conversation with the family as she usually did. The family member added that she attempted to get a nurse and the nurse told her that she was on a medication pass. The family member located a nurse supervisor and asked that the resident be transported to the ED. The family stated that since the hospitalization and time in ICU the resident's cognition was not the same. On 3/22/16 at 10:15 AM Nurse #4 was interviewed and stated she was the nurse assigned to Resident #28 on 02/02/16 from 7 AM to 3 PM. The Nurse explained the resident slept the majority of the shift and was refusing all intake and this was unusual for the resident because would usually at least accept bites of food. Nurse #4 reported that she did not complete an assessment on Resident #28 that included checking her catheter or assessing her abdomen because the shift had been very busy and the resident did not appear to be in distress. Nurse #4 stated that by the end of the shift she estimated the resident drank a combined total of 60 - 120ml of water during the shift. Nurse #4 explained that at the end of the shift nurse aide #2 reported to her that Resident #28's catheter bag was empty. The nurse stated that this was concerning to her because the Resident had been drinking fluids and the physician would need to be called. During the shift the nurse aide had obtained vitals on the resident and according to Nurse #4 the vitals were okay. The nurse stated that it was the end of her shift when she became aware of the no urine output and she passed the concern along in report and expected that Nurse #3 follow-up by assessing the resident and contacting the physician. Nurse #4 stated that she did not call the physician earlier in the shift because there was nothing to call about. Nurse #4 added that she wished the nurse aide had reported earlier in the shift the poor urine output. The nurse also stated that she had been in the resident's room a few times during the shift but had not visualized the catheter bag because it was on the other side of the bed and she had not assessed Resident #28's catheter or abdomen. On 03/22/16 at 10:30 AM Nurse #3 was interviewed on the telephone and reported that she was assigned to care for Resident #28 on 02/02/16 from 3 PM to 11 PM. The nurse explained that the shift was very hectic because when she arrived for her shift she was notified that a pharmacy consultant would be following her on her medication pass. The nurse stated that she was not given any concerns in report about her residents and therefore did not conduct an initial round on her residents to check them. Nurse #3 reported that it was her usual practice to make a brief round to spot check her residents. Nurse #3 stated that she was not told in report that Resident #28 had gone 8 hours with no urine output. Nurse #3 proceeded to explain that she was completing her medication pass when family of Resident #28 arrived. She added that moments later the nurse supervisor asked the nurse to assess Resident #28 because she was not acting right. Nurse #3 stated she had to finish administering the medications already prepared before she could attend to Resident #28. Nurse #3 estimates she waited 5 to 10 minutes before responding to concern about the resident. Nurse #3 stated that this was around 4:30 - 5 PM and that when she went into Resident #28's room it was the first time since her shift had started that she had visualized the resident. Nurse #3 reported that when she went into the room the resident was not her usual self, less alert and her response was very slow. Nurse #3 did not know how long the resident had been in that condition. The nurse also was not aware of how much urine was in the catheter bag and did not have time to fully assess because the family was insistent on calling 911. The nurse aide assigned to Resident #28 on 02/02/16 from 3 PM to 11 PM was no longer employed at the facility unable to be interviewed. On 03/22/16 at 1:00 PM the nurse supervisor was interviewed and reported that she was working on 02/02/16 and did not recall any concerns being reported that day about Resident #28. The nurse supervisor explained that around 5 PM the resident's family came and expressed concern that the resident was not acting right and wanted the resident sent to the ED. She added that she reported the concern to Nurse #3 who was busy completing a medication pass. And added that since Nurse #3 was busy she went to the room to check on Resident #28. The nurse supervisor reported that the family was concerned that the resident wouldn't speak but when the nurse supervisor called the resident's name, the resident was able to turn her head and respond. She stated that she glanced at the catheter bag and noted that it was empty. The nurse supervisor added that after the incident she became aware that the resident had gone a few days without having much urine output. She explained that no urine output in 8 hours would be a flag and the physician would need to be called. The nurse stated that prior to the incident the resident had not been declining in health. The nurse supervisor explained the process for documenting and monitoring fluid intake and urine output for residents with urinary catheters. She stated that the nurse aides were responsible for measuring and documenting the total amount of urine in the catheter bag into the computer. She went on to add that if a concern was noted with the urinary output such as being less than usual or change in appearance or not urine output the nurse aide would report the concern to the nurse. The nurse supervisor stated that the nurse aides were aware and educated to be accurate with their documentation. On 03/22/16 at 4:10 PM the Director of Nursing (DON) was interviewed and reported that she would expect nurse aides to report concerns of no urine output to the nurse and for the nurse to follow-up with that concern by assessing the resident to determine if the physician needed to be contacted. The DON explained that an assessment would include checking the catheter to make sure it was patent (able to flow) and look for signs of a change such as distended abdomen newness of pain. She added that if concerns were identified the nurse would be expected to call the physician. On 03/23/16 at 8:48 AM the physician was interviewed on the telephone and explained that if a resident was having no urine output the nurse would be expected to assess the catheter and if unable to provide explanation for the no urine output then contact the physician. The physician stated that the need to contact the physician would rely on nursing judgement and a clinical assessment with data to support a change in the resident's condition. On 03/23/16 at 3:45 PM NA #4 was interviewed and reported that on 02/02/16 she reported for her 3 PM to 11 PM shift and was told by NA #2 that Resident #28 was not acting right and was sick and the nurses were aware. The NA went on to explain that she checked on the resident frequently that shift and the resident only wanted to sleep which was not usual for her and that she obtained vitals on the resident and the resident slept through getting her vitals taken. The NA recalled that the resident's vitals were okay. NA #4 stated that during the shift she asked the nurse supervisor if she knew what was wrong with Resident #28 and the nurse supervisor stated she was not aware anything was wrong with the resident. The NA added that around 5 PM she left the hall to help with the evening meal in the dining room and when she came back the resident had been transported to the ED. On 03/22/16 at 4:30 PM the Administrator was notified of immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 03/24/16. The following interventions were put into place to remove the immediate jeopardy. F-224 Neglect/Failure to assess resident to identify status change 1. Resident #28 no longer resides in the facility. Resident was transferred to hospital 2/2/16 and did not return to this facility upon discharge from hospital. The alleged deficient practice included a change in condition/overall status of the resident related to decrease output and mental changes which were not immediately assessed and identified and reported to the MD. 2. All residents have the potential to be affected by this alleged deficient practice. On 3/22 and 3/23 all residents were observed by Licensed nursing staff to determine if they experienced a significant change in status in their physical or mental status. Any resident observed with a significant change in status was further assessed utilizing the Change in status assessment tool which is a comprehensive assessment of body systems, medications, vital signs, labs and functional status as well as documentation of the resident's Physician (MD) and Responsible Party (RP) notification. Licensed nursing staff also in-serviced on the use of the Change in status assessment form and the utilization of the 24 hour shift report as communication tools to report and document resident status changes on March 22 thru March 23 by the Director of Nursing. All residents with catheters were assessed by licensed nurses on March 22, 2016 to identify any change in status utilizing the Change in Status Assessment which includes a complete assessment of the resident including pain, lab, and system review as well as documentation of MD/RP notification. Care plans were updated for the patients with catheters to include notification of the MD when decreased output or any other status changes occur including chills, pain, change in color consistency, and odor of urine, mental status change. 3. Licensed Nurses were in-serviced March 22, 2016 thru March 23rd prior to their next scheduled shift to work by the Director of Nursing/designee regarding neglect related to failure to complete an assessment and provide care when a resident has a change in status including follow up when Nursing Assistant (NA) staff report a change in resident condition. The Nursing assistants (NA) were in-serviced by Director of Nursing March 22, 2016 thru March 23rd on what constitutes and how to identify a significant change in resident condition including, but not limited to the following: no urinary output, change in color or consistency of the urine, mental status changes, nausea, vomiting, and pain and the need for immediate notification of the Licensed Nurse when they identify a change in the resident's status. Licensed nurses and NAs who have not completed in-service will be required to complete in-service prior to their next scheduled shift to work. They will not be allowed to work until they have completed the in-services. 4. The facility will utilize the 24 Hour shift to shift report as a communication tool to document status changes. The nurse will document any changes that occur during their shift and verbally communicate changes in status of residents from this tool during shift to shift report at shift change. For verification both nurses will be required to record their initials beside each residents name and information on the report as proof of receiving and giving report of status changes. Director of Nursing/Designee will monitor compliance by review of the 24 Hour report. Immediate Jeopardy was removed on 03/24/16 at 2:30 PM when the facility provided evidence of additional training provided to the nursing staff that proved they were aware of the new system for monitoring, assessing and reporting changes in a resident's condition.

Based on staff and physician interviews and record review the facility failed to notify the physician when a resident ' s condition changed. The resident had decreased urine output, increase in pain and complained of being sick for 1 of 3 sampled residents (Resident #28). Resident #28 was diagnosed with [REDACTED]. Immediate jeopardy began on 01/31/16 when Resident #28 had no urine output and was not assessed for a change in condition and the physician was not contacted. Immediate jeopardy was removed on 03/24/16 when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognition but had clear speech and able to make herself understood; she required extensive assistance with activities of daily living and had an indwelling urinary catheter. A review of Resident #28's total daily fluid intake with meals and total urine output (measured in milliliters and documented by the nurse aides) revealed: Date Fluid in Urine out 1/31/16 720ml 0ml 2/01/16 440ml 50ml 2/02/16 0ml 0ml On 01/31/16 review of Resident #28's urine output revealed the Resident went 24 hours with no urine output. No documentation was made in the medical record on 01/31/16 that an assessment had been completed for no urine output or that the physician had been contacted. On 02/01/16 review of Resident #28's urine output revealed the Resident #28 went 24 hours and only had 50ml of urine. There was no documentation that an assessment had been completed for the decreased urine output or that the physician had been contacted. Further review of the medical record revealed: - On 02/02/16 at 1:25 AM the resident complained of pain and was given [MEDICATION NAME] by Nurse #2. - On 02/02/16 at 3:15 AM the resident complained of pain and was given Tylenol by Nurse #2. - On 02/02/16 at 6:37 AM the resident continued to complain of pain and was given [MEDICATION NAME] again by Nurse #2. There was no documentation in the medical record that Nurse #2 had assessed Resident #28 and had not contacted the physician regarding the Resident's continued complaints of pain. On 02/02/16 at 5:00 PM a nurse's entry made by the nurse supervisor specified the family of Resident #28 was visiting and reported that the resident was not acting right and demanded the resident be sent to the Emergency Department. Resident #28's blood pressure was 95/54 and temperature was 99.4 degrees Fahrenheit, heart rate was 115 beats per minute and resting respirations were 34. The resident was noted to have 0 ml in urinary catheter bag. The Emergency Medical Services (EMS) run report dated 02/02/16 at 6:15 PM specified Resident #28 was somnolent and had a fever of 100.3 degrees Fahrenheit. The Resident was given 200ml of normal saline intravenously. EMS documented the resident had thick discolored urine in catheter bag but did not specify how much. On 02/02/16 Resident #28 was transported to the Emergency Department (ED). Review of the ED notes dated 02/02/16 specified the resident presented with [MEDICAL CONDITION] and in septic shock due to urinary tract infection [MEDICAL CONDITION]. In the ED they attempted to get a urine specimen but documented that there was not enough urine. Resident #28 was also diagnosed with [REDACTED]. In the ED, Resident #28's urinary catheter was changed and the hospital was able to obtain reddish pussy urine. Resident #28 was admitted to the Intensive Care Unit (ICU). Resident #28 was discharged from the hospital on [DATE] to another facility with a fair potential for rehab. On 02/05/16 Nurse #2 documented a late entry for 02/02/16 that Resident #28 was able to make her needs known, the nurse aide (NA) reported resident complained of pain all over and was medicated with [MEDICATION NAME]. The entry specified the Resident was alert and verbal and noted to be heavily covered up. Urinary catheter noted with cloudy urine approximately 100cc (cubic centimeters) output. At 3:15 AM resident continued to complain of pain. Resident was noted to be slightly diaphoretic (sweating) and temperature in room was elevated. Resident appears in no distress. On 03/21/16 at 4:00 PM Nurse #2 was interviewed on the telephone and stated that she was assigned to work 02/01/16 at 11 PM to 02/02/16 until 7 AM which was a double shift (16 hours) for her. The nurse explained that she did not routinely work the hall with Resident #28 and was not overly familiar with the resident. The nurse recalled the night she was assigned to Resident #28 and her numerous complaints of pain. The nurse stated that she asked the nurse aides about the resident's complaints of pain and they reported to her that the resident always complained of pain and that it was normal for her. The nurse explained that when a resident complained of pain she would administer pain medication if ordered, wait 30-60 minutes to assess effectiveness of the pain medication. She added that if the pain was not resolved she would contact the physician. She stated that in the case of Resident #28 she did not call the physician because she did not feel anything was wrong with the resident and at the end of her shift (7 AM) the 2 doses of [MEDICATION NAME] and 1 dose of Tylenol (650milligrams) appeared to be effective because the resident was no longer complaining of pain. The nurse added that Resident #28's urine output had been poor during the same shift and the nurse aides reported that the resident's intake had been poor. The nurse explained that she wasn't concerned with the low urine output since the resident's intake was poor and that during night residents urinated less. Review of Resident #28's Medication Administration (MAR) record for January 2016 and February 2016 revealed the resident received as needed pain medication less than daily expect on 02/02/16 she received 3 doses of as needed pain medication. On 3/22/16 at 10:15 AM Nurse #4 was interviewed and stated she was the nurse assigned to Resident #28 on 02/02/16 from 7 AM to 3 PM. The Nurse explained the resident slept the majority of the shift and was refusing all intake and this was unusual for the resident. Nurse #4 explained that at the end of the shift nurse aide #2 reported to her that Resident #28's catheter bag was empty. The nurse stated that this was concerning to her because the Resident had been drinking fluids and the physician would need to be called. The nurse stated that it was the end of her shift when she became aware of the no urine output and she passed the concern along in report and expected that Nurse #3 follow-up by assessing the resident and contacting the physician. Nurse #4 stated that she did not call the physician earlier in the shift because there was nothing to call about. Nurse #4 stated that if the nurse aide had reported sooner the resident had no urine output then she would have checked on the resident and contacted the physician. On 03/22/16 at 10:30 AM Nurse #3 was interviewed on the telephone and reported that she was assigned to care for Resident #28 on 02/02/16 from 3 PM to 11 PM. The nurse explained that the shift was very hectic because when she arrived for her shift she was notified that a pharmacy consultant would be following her on her medication pass. The nurse stated that she was not given any concerns in report about her residents or Resident #28. The nurse stated she did not assess Resident #28 or contact the physician because she was not aware the resident had gone 8 hours with no urine output and/or was complaining of being sick. On 03/22/16 at 4:10 PM the Director of Nursing (DON) was interviewed and reported that she would expect nurse aides to report concerns of no urine output to the nurse and for the nurse to follow-up with that concern by assessing the resident to determine if the physician needed to be contacted. The DON explained that an assessment would include checking the catheter to make sure it was patent (able to flow) and look for signs of a change such as distended abdomen newness of pain. She added that if concerns were identified the nurse would be expected to call the physician. On 03/23/16 at 8:48 AM the physician was interviewed on the telephone and explained that if a resident was having no urine output the nurse would be expected to assess the catheter and if unable to provide explanation for the no urine output then contact the physician. The physician stated that the need to contact the physician would rely on nursing judgement and a clinical assessment with data to support a change in the resident's condition. On 03/22/16 at 4:30 PM the Administrator was notified of immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 03/24/16. The following interventions were put into place to remove the immediate jeopardy. F-157 Failure to notify MD of status change 1. Resident #28 no longer resides in the facility. Resident was transferred to hospital 2/2/16 and did not return to this facility upon discharge from hospital. The alleged deficient practice included a change in condition/overall status of the resident related to decrease output and mental changes which were not immediately assessed and identified and reported to the MD. 2. All residents have the potential to be affected by the alleged deficient practice. On 3/22/16 and 3/23/16 all residents were observed by licensed nursing staff to determine if they had a significant change in their physical or mental status. Any resident observed with a significant change in their physical or mental status was further assessed utilizing the Change Status Assessment. This assessment is a comprehensive assessment including all body systems, vital signs, medications and labs and functional status as well as documentation of the resident's Physician (MD) and Responsible Party (RP) notification. All residents with a catheter have been assessed by licensed nurses March 22 thru March 23, 2016 using the Nursing Change in Status Assessment tool 3/22 & 23, 2016 to identify any changes in status utilizing the Nursing change in status form. The Care plans for patients with catheters have been revised by the licensed nurse on March 23rd, 2016 to include notification of MD for decreased output or any identified status changes including pain, chill, change in color, consistency of urine or mental status changes. 3. Licensed Nurses will be in-serviced March 22, 2016 thru March 23rd prior to their next scheduled shift to work by the Director of Nursing/Designee on notifying the resident ' s MD and RP when a resident experiences a significant change in status including assessment of residents with catheters utilizing the Change of status assessment which includes assessment of output each shift and notification of MD and RP when decreased output or other identified status changes occur including pain, chills change in color consistency of urine or mental status changes. Licensed nursing staff also in-serviced on the use of the Change in status assessment form and the utilization of the 24 hour shift report as communication tools to report and document resident status changes on March 22-23 by the Director of Nursing. The Nursing assistants (NA) were in-serviced by Director of Nursing March 22, 2016 thru March 23rd on what constitutes and how to identify a significant change in resident condition including, but not limited to the following: no urinary output, change in color or consistency of the urine, mental status changes, nausea, vomiting, and pain and the need for immediate notification of the Licensed Nurse when they identify a change in the resident ' s status. Licensed nurses or NAs not yet in-serviced will be required to complete the in-service prior to working their next scheduled shift. They will not be allowed to work until they have completed the in-services. 4. Individual nurses identified in the alleged deficient practice were in-serviced by the Director of Nursing on March 22 on completion of the change of status assessment which becomes a part of the electronic medical record and includes notification of the MD and RP when a change is identified. The identified NA has been in-serviced the Director of Nursing March 23 on what constitutes a significant change in resident status and on immediate notification of the Licensed Nurse for any identified change in the resident occurs including no urinary output, change in color, consistency, or odor of urine, mental status changes, nausea, vomiting, vital signs or anything they see as a change in the patient. The facility will utilize the 24 Hour shift to shift report as a communication tool to document status changes. The nurse will document any changes that occur during their shift and verbally communicate changes in status of residents from this tool during shift to shift report at shift change. For verification both nurses will be required to record their initials beside each residents name and information on the report as proof of receiving and giving report of status changes. Director of Nursing/Designee will monitor compliance by review of the 24 Hour report. Immediate Jeopardy was removed on 03/24/16 at 2:30 PM when the facility provided evidence of additional training provided to the nursing staff that proved they were aware of the new system for notifying the physician of a resident's change in condition.