Every finding on record at Eden Rehabilitation and Healthcare Center

Based on record review, and staff, Friend #1, Friend #2, Family Member, Home Health Nurse, Adult Protective Services Social Worker, hospital Social Worker, Nurse Practitioner, and Primary Care Physician interviews, the facility failed to ensure a safe and orderly discharge for a resident that had severe cognitive impairment, incontinent of bowel and bladder, required assistance with all activities of daily living, and was not capable of managing her medications prescribed for diabetes, hypertension, hypothyroidism, pain and depression. Resident #1 was discharged to her apartment where she lived alone with friends (Friend #1 and Friend #2) who indicated they were unable to provide the 24-hour level of care the resident required. Resident #1's Family Member was not included in the discharge planning process and was not notified of the discharge by the facility. The discharge on [DATE] (Good Friday) occurred without confirmation of 24-hour support, necessary services or appropriate resources including durable medical equipment (DME) to ensure the resident's health, safety, and well-being could be maintained. The facility contacted home health on 4/2/26 and the home health service provider notified the facility it would be 24 to 48 hours from the date if the referral before a home health worker would be able to conduct an at home visit for Resident #1. The facility Social Worker contacted Adult Protective Services on 4/3/26 to report their concern the friends may not have been able to provide the 24-hour level of care the resident required and may have been at risk of harm. On 4/3/26 the friends were able to get Resident #1 into her apartment, provide a meal, change her, put her to bed but no medications were given. There were no arrangements made for the provision of care until one of the friends returned the next day. On 4/4/26 Friend #1 visited and found the resident very soiled due to incontinence and located a neighbor to clean up Resident #1. Friend #1 fixed Resident #1 a meal, did not administer any medications, and left in the evening. On Easter Sunday, 4/5/26, a home health nurse conducted an at home visit and found the resident to be in bed, soiled with incontinence from urine and bowel, unable to get out of bed, even with assistance, unable to answer the door, unable to vacate the premises in the event of emergency, and had not received her prescribed medications, including insulin since she had been discharged from the facility on 4/3/26. The home health nurse checked Resident #1's blood sugar and contacted the resident's Primary Care Physician about her blood sugar level history and administered insulin. The only DME present was the wheelchair that was delivered to the facility on 4/3/26. On 4/7/26, an APS worker made an in home visit to Resident #1 and found the resident to be in bed, soiled with incontinence from urine and bowel, unable to get out of bed, even with assistance, unable to answer the door, unable to vacate the premises in the event of emergency, and had not been consistently receiving her prescribed medications since the resident was discharged from the facility on 4/3/26. Resident #1 was unable to press the button on her medical alert necklace or call 911 for assistance on the phone. Based on the APS worker's assessment an order for provision emergency service order was obtained from the district court judge for Resident #1 to be transferred to the hospital on 4/7/26 and was admitted with a urinary tract infection. The deficient practice occurred for 1 of 3 residents reviewed for discharge (Resident #1).Immediate jeopardy began on 4/3/26 when Resident #1 was discharged from the facility to home without the necessary 24-hour support and services the resident required to ensure her well-being and safety. Immediate jeopardy was removed on 4/10/26 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity (D) (no actual harm with a potential for minimal harm that is not immediate jeopardy) for the facility to complete employee staff training and monitoring to ensure interventions put into place are effective.The findings included:Review of the hospital Discharge summary dated [DATE] revealed Resident #1's admission date to the hospital was 2/28/26. Further review revealed Resident #1 was documented as having lived alone and had not been taking medication for several weeks. Resident #1's primary care physician requested a wellness check from the police, and the resident was found down on the floor by a friend (Friend #1). Resident #1 was taken to the emergency room at the local hospital and later transferred to University of North Carolina (UNC) hospital for trauma evaluation. Resident #1 found to have a stroke, altered mental status with a recent diagnosis of dementia, stroke symptoms related to altered mental status, diabetes, and medication non-compliance. The assessment and plan documented by the hospital was for Resident #1 to be discharged to a skilled nursing facility for medication management and therapy services.A telephone interview was conducted on 4/8/26 at 1:26 PM with Resident #1's Primary Care Physician (PCP) from the community who stated there had been concerns about the resident's ability to continue to live alone due to decline in health and cognition based on missed appointments and change in health status during office visits. He stated he had called the police to do a wellness check (could recall date) which initiated the original hospital admission on [DATE]. He indicated that a wellness check had been done for the resident at her home, where she was found down on the floor by a family friend (Friend #1), and had not been taking her medication for several weeks. He indicated several attempts had been made to reach the resident's Family Member and/or other support to assist with the resident's care prior to her admission to the hospital and the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, stroke, communication deficit, diabetes, hypothyroidism, hyperlipidemia, anemia, osteoarthritis, hypertension, and dementia.Review of Resident #1's facility admission paperwork revealed Friend #1 signed the admission paperwork on 3/16/26.Review of the face sheet revealed Friend #1 was listed as 1st emergency contact, Friend #2 was the 2nd emergency contact and the family member as emergency contact #3. There was no responsible party listed on the face sheet.A telephone interview was conducted on 4/8/26 at 11:10 AM with Friend #1 who was listed as the 1st emergency contact person and stated Resident #1 lived alone and he and other friends were stopping by Resident #1's apartment to assist with basic things like shopping, cooking, or taking her to appointments. Resident #1 was able to take care of her personal needs, administer her own medication and handle her own financial affairs before she went to the hospital. Friend #1 stated he and Friend #2 visited Resident #1 at different times of the day to help as much as they were able. He indicated several friends were stopping by the apartment to check on the resident and taking her to appointments, doing the best they could to assist. He stated during a visit in February he found the resident on the floor and he called 911. He explained Resident #1 had a stroke and was not taking her medications. Friend #1 indicated he and Friend #2 came to the facility to assist with getting Resident #1 admitted . Friend #1 stated he signed all the paperwork for the admission as a friend and not the legally responsible person. Friend #1 stated Resident #1's Family Member was not actively involved prior to Resident #1's hospital admission and was not available to assist once the resident was admitted to the facility. A telephone interview was conducted on 4/9/26 at 8:25 AM with Friend #2 who was present with Friend #1 when Resident #1 was admitted to the facility. Friend #2 was listed in the medical record as emergency contact #2. Friend #2 stated she had previously assisted Resident #1 with intermittent home care supports prior to Resident#1's hospitalization and continued to visit during Resident #1's nursing home stay. Friend #2 stated she did not participate in a discharge planning meeting. She stated the admission Director and Social Worker (SW) mentioned financial responsibility and discharge plans when Resident #1 was admitted but nothing was finalized at the time. She stated the admission Director and SW asked if she would be the guardian and assist with the Medicaid application. She informed the facility admission Director and the SW that she was unable to provide 24-hour care for Resident #1 in the home and could not assume responsibility for making legal or healthcare decisions on behalf of Resident #1.Resident #1's care plan dated 3/17/26 included a focus area for activities of daily living (ADL) self-care performance deficit related to stroke. The goal indicated that the resident will improve current level of function in ADL. Interventions included Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. The resident requires maximum assistance by staff with bathing/showering as necessary. Bed mobility: The resident requires supervision to partial assistance by staff to turn and reposition in bed as necessary. Dressing: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Eating: The resident requires assistance from staff to eat. Personal hygiene/Oral care: The resident requires supervision to partial assistance staff for personal hygiene and oral care. Side rails: Quarter rails up as per physician order for safety during care provision, to assist with bed mobility. Toilet use: The resident is dependent on staff for toileting. Transfer: The resident requires partial to maximum assistance by staff to move between surfaces as necessary. A care plan dated 3/20/26 indicated the resident has diabetes. The resident will have no complications related to diabetes. Diabetes medication as ordered by doctor. Observe for side effects and effectiveness of diabetic medications. Observe for any signs/symptoms of hyperglycemia (high blood sugar), including increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep rapid breathing), acetone breath (smells fruity), stupor, and coma. Observe for any signs and symptoms of hypoglycemia (low blood sugar) including sweating, tremor, increased heart rate, pallor (paleness of the skin), nervousness, confusion, slurred speech, lack of coordination, and staggering gait. Observe for compliance with diet and document any problems. Offer substitutes for foods not eaten. Further review of Resident #1's care plans dated 3/20/26 revealed a person-centered care plan was not developed with goals and interventions for discharge planning that included identification of responsible caregivers, coordination of services to be provided for Resident #1's activities of daily living, limited psychosocial support, and financial need. An interview was conducted on 4/8/26 at 9:30 AM with the admission Director who stated Friend #1 and Friend #2 were listed as primary contact person #1 and primary contact person #2 and the resident's family member was listed as contact #3 for Resident #1. She indicated Friend #1 and Friend #2 were present when Resident #1 was admitted . Friend #1 assisted and signed the paperwork for Resident #1 during the admission process. She stated she had reached out to the resident's Family Member to assist with the paperwork on 3/16/26; however, he was not responsive to taking over the responsibility of Resident #1's decision making or financial responsibilities. The admission Director stated she had spoken with the friends about obtaining guardianship and applying for Medicaid on admission. She indicated both declined, indicating they were unable to handle or manage Resident #1's 24-hour care. The admission Director stated she was not at the care plan/discharge planning meeting 3/20/26. She was informed by the SW that during the care plan meeting on 3/20/26 community placement had been discussed with Friend #1 and the interdisciplinary team for Resident #1 to return home. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had severe cognitive impairment and needed assistance with transfers, bed mobility, and activities of daily living. The MDS indicated Resident #1 received insulin injections and had impaired range of motion to bilateral lower extremities. The Participation in Assessment and Goal Setting section of the MDS was not completed. Frequently incontinent of bowel and bladder.Review of the Social Service Progress note for Resident #1, dated 3/20/26, revealed an admission care plan meeting was held on 3/20/26 with Friend #1, Social Work, and the Rehabilitation (Rehab) Director. The discharge plan at the time was probable long-term care. SW advised the friend that the resident would need a guardian if the resident's Family Member was not able to participate in care decisions from [another state]. The Business Office Manager had made contact with the resident's Family Member in [another state]. The resident's Family Member stated that he planned to travel to this area in the next month. The admission Director requested that the resident Family Member present the Power of Attorney (POA) documents as soon as possible. The Medical Orders for Scope of Treatment (MOST) form had been uploaded. There was no power of attorney established.The Discharge Planning Review form for Resident #1, dated 3/20/26, which was completed by the SW documented the following Section A: Anticipated length of stay-short term care, as stated by friends, expects to be discharged to the community, the resident lived alone, family support and primary caregivers indicated friends check in daily. Overall discharge potential revealed discharge to home with friends' assistance. Home health and durable medical equipment will be ordered as needed. A telephone interview was conducted on 4/8/26 at 8:17 PM with the SW who stated Resident #1 was admitted to the facility with the assistance of friends. She indicated she did not reach out to resident's Family Member who was listed as a contact person for his input on Resident #1's care or discharge plans at the time of admission. The SW explained the admission Director had spoken with the Family Member on admission about Resident #1's placement and financial concerns. She stated Friend #1 and Friend #2 were asked (date not provided) about seeking guardianship and assisting with the Medicaid application by the Business Office Manager and SW and the friends declined stating they did not want the responsibility of making decisions for Resident #1. The SW indicated the admission Director handled the initial paperwork and financial review. The SW explained Friend #1 signed and assisted with the paperwork on behalf of Resident #1. The SW further stated the discharge plan was discussed, on 3/20/26 and 3/31/26, but acknowledged the care plan was not updated to reflect finalized arrangements.The facility Physician assessment dated [DATE] indicated the chief complaint was fasting blood sugar follow-up evaluation. Resident #1 was being seen for diabetes, she was able to make her needs known and had no complaints. It was noted Resident #1 had a history of hypertension, diabetes, osteoarthritis, hypothyroidism, and peripheral neuropathy, and was presenting for follow-up after recent hospitalization 2/28/26 to 3/16/26 for right basal ganglion intraparenchymal hemorrhage (stroke). Physical exam revealed Resident #1 had no acute respiratory distress, cardiovascular rate and rhythm without murmurs, no edema of lower extremities, gastrointestinal sounds were soft with bowel sounds present. Nontender and non-distended abdomen. She was alert and oriented times two (no details in the assessment). Plan and assessment revealed diabetes with hyperglycemia: uncontrolled; fasting blood sugar from low to 100 mid 100s so no longer having hypoglycemia, continue insulin glargine, metformin and monitor fasting blood sugar. Order hemoglobin A1c (a blood sugar test of the blood which measures average blood sugars of the past 2-3 months) 3 months after last value, diabetes with diabetic neuropathy controlled, continue gabapentin. Hypertension associated with diabetes controlled with valsartan.The facility Physician was unavailable for interview.Review of the Notice of Medicare Non-Coverage (NOMNC) a document which informs the resident, or responsible party, that the insurance provider and/or health plan determined that Medicare (including Medicare replacement plans) probably won't pay for Skilled Nursing Facility services after the provided date. The resident, or responsible party, may have to pay for any services received after the listed date. The letter included information about the resident's or responsibly party's right to appeal the decision, how to ask for immediate appeal and what happens next. Due to Resident #1's cognitive impairment, Friend #2 was contacted on 3/31/26 by the SW who obtained verbal consent for the NOMNC form. The form documented that skilled nursing facility services last covered date was 4/2/26 and the beneficiary liability (amount the resident or responsible party would be billed for) was expected to begin on 4/3/26 the day after last covered date of 4/2/26. The Social Worker was the only person that signed the form for verbal consent.The insurance company and/or benefits manager were unavailable for interview.A Social Service progress note written by the SW dated 3/31/26 revealed the SW issued NOMNC to Friend #2 who had been assisting Resident #1 for many years because the resident does not have family nearby. Resident #1's Family Member has a history of having very little contact with Resident #1. Resident #1 was cognitively impaired and did not understand intent of NOMNC. The NOMNC documented the last covered date was going to be 4/2/26. Representative (Friend #2) did not wish to appeal and had requested discharge.A telephone interview was conducted on 4/8/26 at 8:17 PM with the facility's SW. The SW stated she stated she contacted Friend #2 on 3/31/26 and gave verbal notice of the discharge plan and date. She stated Friend #2 was informed Resident #1 was being discharged due to coverage of benefits being stopped by insurance. The SW explained that Friend #1 and Friend #2 stated there was no one in the home that could provide 24-hour care. Friend #1 and Friend #2 visited several times during Resident #1's stay and informal conversations were held during these visits. Friend #1 and Friend #2 had given the impression to the SW that friends could get 24-hour assistance for Resident #1 in the home through family and friends, therefore, the discharge was moved forward. The SW stated when the education on the appeal process was offered to Friend #1 on 4/3/26 and with Friend #2 verbally on the phone on 3/31/26 she indicated understanding and declined. The SW further stated they still decided to take the resident home.An interview was conducted on 4/8/26 at 9:30 AM with the admission Director who stated the SW was responsible for reviewing the discharge plan with the resident and/or resident responsible person which would include the financial, medical and community plan of care at the meeting. The admission Director stated when the SW received the non-coverage letter from the insurance company Resident #1's friends (Friend #1 and Friend #2) were contacted and informed of the end of coverage day by the SW. She stated the SW informed Friend #2 on 3/31/26 the end of coverage date was 4/3/26. She further stated she had asked Friend #1 and Friend #2 at the time of admission about obtaining guardianship and applying for Medicaid and both declined. Resident #1 did not have any additional financial coverage to stay beyond the Medicare covered days. She indicated the SW stated she had spoken with the friends about the appeals process when they were informed of the non-coverage notice and the friends declined. A telephone interview was conducted on 4/9/26 at 8:25 AM with Friend #2 who stated she received a call from the facility Social Worker on 3/31/26 informing her that Resident #1 would be discharged on 4/3/26 due to insurance coverage ending in the next few days. The Friend stated she was unaware of Resident #1's finances other than her Medicare benefits, therefore was unable to make a financial decision about payment for an extension of stay. Friend #2 stated she felt pressured to take Resident #1 home and reported she was not provided with clear information regarding the appeal process when it was discussed or that she had the option to refuse to take the resident home. She indicated she contacted Friend #1 and informed him of the discussion held with the SW and both did not know their options and told the facility SW they would attempt to find additional family and friends who could assist with care following discharge, however, they indicated they were unable to provide 24-hour care or remain overnight in the home themselves.A telephone interview was conducted on 4/8/26 at 11:10 AM with Friend #1 who stated he and Friend #2 told the admission Director and the Social Worker that they did not want to be responsible for making healthcare or financial decisions for Resident #1 when they were asked to be the guardian and fill out the Medicaid application. Friend #1 stated he and Friend #2 had visited Resident #1 in the facility a few times and continued to tell the SW worker that Resident #1 could not take care of herself, or live by herself, and they would only be able to stop by to assist with basic things Resident #1 needed like they did before she went to the hospital. Friend #1 stated he informed the facility admission Director, SW and Rehab Director that he was unable to provide the 24-hour care Resident #1 needed because he was physically unable and could not stay overnight in the home with resident. He further stated he did inform the facility staff that he and other friends would stop to assist Resident #1 as much as possible but would not be providing the 24-hour care Resident #1 needed. He stated he could not recall the date he received the call, but Friend #2 received a call from the facility SW on 3/31/26 who informed them that the resident no longer had insurance coverage and needed to be picked up and returned home by 4/3/26.The Nurse Practitioner (NP) discharge summary note for Resident #1, dated 4/1/26, read in part: Resident #1 was seen for discharge and complaint of vision changes. Past medical history was significant for but not limited to hypertension, hyperlipidemia, diabetes, osteoarthritis, neuropathy and hypothyroidism. Resident #1's prior hospitalization was for a right basal ganglia intraparenchymal hemorrhage (stroke). Resident #1 did well during her stay, she was working with physical therapy and participated in activities. Resident #1 had some fluctuation in blood sugar, requiring some changes in her regimen. Resident #1 A1c (measures average blood glucose levels over the last two to three months) during stay was 11.4 (goal for a person with diabetes is below 7%). The resident's most recent blood sugar after adjustment in medications was noted to be 124. Resident #1 was being discharged on aspirin, valsartan, gabapentin, zetia, levothyroxine, atorvastatin, fluoxetine, metformin, insulin glargine, and Humalog insulin. A therapy note documented some self-reported vision changes this morning during therapy. Resident #1 was sitting at her bedside, in her wheelchair, reported that she feels well, and denied any pain or vision changes. The NP documented the resident reported she had an ongoing issue with some blurry vision when participating in strenuous activities. The note documented that the resident had no additional acute complaints. The resident's discharge condition: Resident #1 average risk for readmission over the next 3-6 months related to multiple comorbidities and associated risks. Discharge medications: the resident's medications were appropriate; duration of all medications supplied to resident/staff based on facility protocol. Resident #1 needed to follow-up with her primary care physician within 1 to 2 weeks for further refills and medication management. The resident was being discharged to home with home health physical therapy and any appropriate durable medical equipment and keep follow-up appointments. Nursing and rehab therapy to discuss medication instructions and therapy restrictions with Resident #1 and family.A telephone interview was conducted on 4/8/26 at 2:15 PM with the NP who stated she assessed Resident #1 on 4/1/26 in preparation for discharge. She indicated the SW had informed her (unable to recall exact day she was informed) that Resident #1's end of coverage date was 4/3/26 due to exhaustion of benefits and the friends (Friend #1 and Friend #2) had requested the discharge. The NP stated Resident #1 had multiple health concerns following her recent hospitalization for a stroke and poor medication management. The NP stated Resident #1 did have some periods of confusion but was able to answer some basic questions about her general health and Resident #1 did not express any specifics about her discharge home. The NP indicated Resident #1 did have some blood sugar level concerns that resulted in a medication adjustment. She stated based on the therapy assessment Resident #1 had made some progress. She further stated Resident #1 would need 24-hour care and medication monitoring in the home. The NP indicated a discussion was held with the SW and the Nursing Manager a few days prior to discharge to discuss Resident #1's need for 24-hour care, home health, physical therapy, and nursing services in the home. The NP was not involved in the discussion. She stated the SW informed her that a discussion was held with the friends that were listed on the contact sheet about Resident #1's 24-hour medical needs. Based on the discussion with SW the friends had been informed of the appeals process and declined, therefore, the discharge plan proceeded. The NP added the Social Worker contacted Adult Protective Services (APS) as a back-up to ensure Resident #1 received the home care services she needed. The Occupational Therapy Discharge summary dated [DATE] revealed Resident #1's goals included Resident #1 would her improve ability to complete toilet/commode transfers with supervision or touching assistance with ability to right self-to achieve/maintain balance, improve ability to safely and efficiently perform lower body dressing with supervision or touch assistance with the use of adaptive equipment in order to facilitate ability to live in environment with the least amount of supervision and assistance. Resident #1 would improve her ability to safely and efficiently bathe self, including washing, rinsing and drying self with supervision or touch assistance. Resident #1 would increase ability to stand supported for 5 minutes in order to increase participation with activities of daily tasks. Resident #1 would complete all activities of daily living self-care tasks with set-up assistance with ability to right self- achieve/maintain balance. Resident #1 would improve ability to safely and efficiently maintain perineal hygiene, adjust clothes before/after voiding or have a bowel movement with setup or cleanup assistance in order to facilitate independence with toileting task. Functional assessment revealed Resident #1 required substantial/maximum assistance with shower/baths, lower body dressing, putting on and removal of footwear, toileting/hygiene, transfers, and bed mobility. The assessment summary indicated Resident #1 made progress with skilled therapy but insurance ended. Discharge recommendations were for an elevated toilet seat, 3 in 1 commode, assistance with activities of daily living, grab bars, home health services, in-home aide, and a hand reacher. The Physical Therapy Discharge summary dated [DATE] revealed Resident #1's goals included Resident #1 would improve her ability to safely transfer from lying to sitting on the end of bed with setup assistance in order to participate in activities of daily living and prepare for transfer activities. Resident #1 would improve bilateral lower extremities muscle strength in order to increase ability to safely transfer position from sitting in a chair, wheelchair or on the side of the bed with standby assistance. Resident #1 would improve ability to safely and efficiently transfer to and from a bed or wheelchair with standby assistance with ability to right self to achieve/maintain balance. Resident #1 would safely ambulate 50ft with contact guard assistance, using 2 wheeled-walker, demonstrating safe balance in order to increase independence with functional mobility within the facility. Resident #1 would increase her ability to stand supported for minutes in order to increase participation with activities of daily living tasks and functional mobility. Resident #1 discharged home due to exhausted benefits. Resident #1 discharged home with support from others. Functional skills assessment revealed Resident #1 required supervision or touch assistance with sit/lying down position, partial/moderate assistance with chair to bed transfers, toilet transfers, car transfers, and walking 10 to 50 feet with supervision or touch assistance. Assessment and summary of skilled services and recommendation revealed Resident #1 made functional gains in response to therapy services that included therapeutic exercise of bilateral lower extremities, bed mobility, transfer training to increase out of bed activities, and balance training for fall prevention. The summary indicated Resident #1 would need home health services, assistive devices for safe functional mobility and 24-hour care.The Speech Therapy Discharge summary dated [DATE] revealed Resident #1's progress and response to treatment was completed due to insurance denial and Resident #1 returning to prior living arrangements. Resident #1 participated in cognitive activities and practice of cognitive-communication strategies in order to improve effective communication and enhance cognitive function with minimal progress noted due to extent of cognitive deficits. An interview was conducted on 4/8/26 at 11:36 AM with the Rehab Director who stated the resident was seen for therapy services from 3/16/26 through 3/31/26. The SW informed therapy that Resident #1 received the NOMNC non-coverage letter on 3/31/26, the last covered day was 4/2/26, and the resident would be discharged on 4/3/26. He stated he was not part of the discussion of the discharge plan on admission; his first communication about the discharge plan was at the 3/31/26 meeting. He stated the therapy department completed an assessment My Plan for Success form on 3/26/26 and the form was used by therapy staff to determine the individual discharge needs in the home setting. The form included assessment of transition location, mobility, transfers, food and liquid consistency, supervision and assistance needed for meal preparation, grooming and bathing assistance, communication goals, and resident goals. He further stated a discharge planning meeting was held on 3/31/26 with the facility interdisciplinary team (Social Worker, Dietary Manager, Nursing Unit Manager, Activity Director) and Friend #1, who was present at the meeting. Resident #1 was cognitively impaired and unable to effectively communicate her needs or participate in the discharge planning discussion. The Rehabilitation Director reported Friend #1 stated he was unable to provide 24-hour care for Resident #1 but indicated he, along with other friends and family, would attempt to assist in arranging 24-hour coverage and care for the resident following discharge. The Rehabilitation Director stated Resident #1 had made some progress in therapy; however, the resident had not achieved sufficient independence to complete personal care tasks without 24-hour assistance. The Rehabilitation Director stated Resident #1 could have benefitted from additional servic

Based on record review and staff interview, the facility failed to ensure a resident with severe cognitive impairment, no established legal decision maker for financial or healthcare decisions, and no payor source when Medicare skilled benefit days were exhausted was assisted with pursuit of a legal decision maker (guardianship) and the completion of a Medicaid application for 1 of 3 residents reviewed for discharge planning (Resident #1).The findings included:Resident #1 was admitted on [DATE] with diagnoses that included anxiety, depression, communication deficit and dementia.Review of the clinical record did not specify a responsible party, guardian, or power of attorney for Resident #1. The admission Minimum Data Assessment (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired.Resident #1's care plan initiated on 3/20/26 did not include interventions addressing lack of a legal decision maker or assistance with completion of a Medicaid application.The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment. The discharge was coded as return not anticipated. The discharge location was to home/community.A review of Resident #1's medical record from admission on [DATE] through discharge on [DATE] revealed the following information. Resident #1's payor source on admission was a Medicare managed care plan that covered a limited number of days in skilled nursing care under Medicare Part A. Resident #1 exhausted the Medicare Part A coverage benefits on 4/3/26. There was no additional payor source identified for Resident #1. There was no evidence assistance was provided with the completion of a Medicaid application for Resident #1. Additionally, there was no evidence that the facility had made any efforts to refer the resident for a guardianship evaluation or any other interventions to assist the resident with establishing a legal decision maker or additional financial coverage. During an interview on 4/8/26 at 9:30 AM with the admission Director she revealed Resident #1 did not have an established legal representative. She stated during the resident's stay at the facility she discussed guardianship and a Medicaid application with friends of the resident that assisted with Resident #1's admission. Friend #1 signed the admission paper and declined assuming responsibility for Resident #1's decision making. She further stated Resident #1 did not have any additional financial coverage to stay at the facility beyond the Medicare covered days. The admission Director further stated that the responsibility for addressing the need for initiating guardianship and completion of the Medicaid application was referred to the Social Worker who was responsible for this task. The admission Director confirmed that to her knowledge no Medicaid application or guardianship referral had been initiated or completed on behalf of Resident #1.During an interview on 4/8/26 at 8:17 PM with the Social Worker (SW) she stated the facility was aware Resident #1 did not have a legal representative available to assist with financial decisions, medical decisions or other legal matters. The Social Worker indicated she was made aware that Resident #1 did not have a legal representative by the admission Director and the friends of Resident #1 who assisted the resident when she was admitted to the facility. She acknowledged that Resident #1 was unable to make informed decisions financially and medically due to cognitive impairment. The SW confirmed that Resident #1's need for guardianship and Medicaid application assistance had been discussed with the admission Director (no date was provided of when the discussion was); however, no referral for guardianship was made and no assistance with the Medicaid application was provided for Resident #1. The SW indicated the resident was discharging within a few days of the discussion with the admission Director and she ran out of time. An interview was conducted on 4/13/26 at 9:30 AM with the Administrator who stated there was a breakdown in communication and coordination between the two departments. The Administrator indicated the previous policy and procedure did not specify the role and responsibilities of the admission Director and Social Worker to initiate the process for guardianship for cognitively impaired individuals who had no legal decision maker or for completion of a financial application for Medicaid and/or other payor sources.

Based on record review, observation, and staff interviews, the facility failed to label and date food and discard expired food from two nourishment refrigerators reviewed for food storage (400 hallway and 500 hallway nourishment refrigerators). These practices had the potential to affect food served to residents.Findings included:a. On 2/16/26, at 1:35 PM, an observation with the Dietary Manager of nourishment refrigerator #1 (400 hallway) revealed that the refrigerator contained a gallon-size clear plastic bag with a sandwich, a 4-ounce juice carton, and a snack bag with no name or date on them; a peanut butter and jelly sandwich in a plastic bag with no name or date; a takeout box containing pinto beans and seasoned rice with the date [DATE]th - 15th written on it; food wrapped in aluminum foil with no name or date; an opened 16-ounce soda bottle with no name or date; and a takeout 20-ounce coffee cup with no name or date. b. On 2/16/26, at 1:42 PM, an observation with the Dietary Manager of nourishment refrigerator #2 (500 hallway) revealed a small plastic container with homemade food that had no label indicating the resident's name or date; a gallon-size plastic container with homemade food with no resident name and the date 2/5 - 2/9 written on it; and a grocery bag containing a box of fried chicken with no name or date. During an interview on 2/16/26, at 1:37 PM, the Dietary Manager stated that the nursing staff were responsible for labeling and dating food brought in by visitors for residents. He explained that food could be stored in the refrigerator for seven days before being discarded. He further stated that either he or the dietary staff checked the nourishment refrigerators daily when restocking snacks and drinks and discarded any expired food.During an interview on 2/18/26, at 1:30 PM, the Director of Nursing (DON) stated that all nursing staff (nurses and nurse aides) were responsible for labeling and dating any food brought in by family for residents before placing it in the nourishment refrigerator. She explained that food should be discarded within seven days and that no personal staff food should be placed in the nourishment refrigerator. She added that the dietary staff were responsible for ensuring all food was discarded after seven days.During an interview on 2/18/26, at 2:00 PM, the Administrator stated that residents' food should be labeled and dated before being placed in the nourishment refrigerators. She emphasized that staff should follow policy related to residents' food brought in by their families and that dietary staff should ensure all expired food was discarded.

Based on observations, manufacturer instructions review, and staff interviews, the facility failed to date opened multi-dose pen injectors of insulin and failed to remove expired multi-dose pen injectors of insulin from 1 of 5 medication administration carts ( 500-hall).Findings Included: On 2/16/26 at 1:25 PM, an observation of the 500-hall medication cart with Nurse #1 revealed 2 open and undated multi-dose vials of Lantus insulin pens injectors. Review of the manufacturer's instructions indicated to discard Lantus insulin multi-dose vial 28 days after opening. In the second drawer of the 500-hall medication cart, there were: one opened Lispro insulin multi-dose pen injector, marked as expired on 2/10/26, one opened Aspart Flex insulin pen injector, marked as expired on 1/15/26, and one opened Glargine insulin multi-dose pen injector, marked as expired on 2/9/26.On 2/16/26 at 1:30 PM, during an interview, Nurse #1 indicated the nurses who worked on the medication carts were responsible for discarding open and undated multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medication vials. The nurse acknowledged she had not checked the date of opening or expiration date on insulin pen injectors in her medication administration cart at the beginning of her shift. Nurse #1 confirmed she had not administered open and undated or expired medications during her shift. On 2/16/26 at 1:55 PM, during an interview, the Director of Nursing indicated that the nurses were responsible for checking the date of opening and the expiration dates of the medications in the medication administration carts at the beginning of the shift. She expected that no expired items be left in the medication carts.

Based on record review, and Legal Guardian, and staff interviews, the facility failed to communicate with the Resident's Legal Guardian regarding resident's abdominal pain and the resident's refusal to go to the hospital. This occurred for 1 of 3 sampled residents reviewed for the surrogate to exercise the resident's rights (Resident #1). Findings included: Resident #1 was admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, diabetes mellitus type (2), dementia, and hypomagnesemia (a condition characterized by abnormally low levels of magnesium in the blood. Symptoms may include muscle cramps, weakness, and irregular heart rhythms). Review of Resident #1's facility face sheet dated 1/18/22 revealed a social worker from local Department of Social Services (DSS) was appointed as his Legal Guardian and included contact information. Resident #1's face sheet indicated the Legal Guardian was the Power of Attorney (POA) for the resident. During an interview on 6/10/25 at 10:28 AM, Nurse #1 indicated she was assigned to Resident #1 on 5/26/25 from 7:00 AM to 3:00 PM. Nurse #1 stated at around 10:00 AM, Resident #1 was brought to the nurse by the activity staff. The Nurse #1 indicated the resident was complaining of stomach pain during activities. Nurse further stated Resident#1 was complaining of pain on the right side of his stomach. The pain was reported as a mild pain with a pain scale of 4. Nurse #1 indicated she asked the resident if he would like to go to the hospital for further evaluation and he agreed. Nurse #1 further indicated she had called the Nurse Practitioner (NP) and during the assessment and conversation with the NP, she had asked Resident #1 if he would like to go to the hospital for further evaluation. Nurse #1 stated the resident had initially agreed to go to the hospital, but later during the telephone conversation she (Nurse #1) had with the NP, Resident #1 refused to go to the hospital. This was conveyed to the NP and labs and x-rays for the abdominal area were ordered at the facility. Nurse #1 stated Resident #1 was alert and oriented, able to communicate his needs, and make his own decisions. She indicated due to those reasons; she did not call or inform the Legal Guardian about resident's refusal to go to the hospital. During a telephone interview on 6/11/25 at 9:30 AM, Nurse #2 indicated she worked the 3:00 PM to 11:00 PM shift on 5/26/25 and the 7:00 AM to 3:00 PM shift on 5/27/25 and she was assigned to Resident #1 on both days. Nurse #2 further stated during the shift change report on 5/26/25, the outgoing nurse (Nurse #1) had reported that Resident #1 had complained of abdominal pain earlier that day. The resident initially agreed to go to the hospital and later refused. Labs and x-rays were ordered by the provider prior to her shift on 5/26/25. Resident #1 did not complain of severe abdominal pain during the shift. Nurse #2 stated Resident #1 had x-rays completed after supper and the x-ray results arrived later that night. The on-call provider was notified about the x-ray results which indicated possible ileus, and the on-call provider gave orders for the resident to be nothing by mouth (NPO) for 24 hours and later a liquid diet until seen by the facility provider. Nurse #2 indicated around breakfast time on 5/27/25, she was on the medication cart, administering medication for another resident in the hallway, when she heard Resident #1 moan in pain. Nurse #2 indicated she notified the Nurse Practitioner (NP), and orders were received to send the resident to the emergency room (ER). Nurse #2 indicated she notified the Legal Guardian on 5/27/25 about the resident transfer to the ER. Nurse #2 further indicated on 5/27/25, she did inform the Legal Guardian that the resident had complained of abdominal pain on 5/26/25 and did not want to go to the hospital. During a telephone interview on 6/10/25 at 10:31 AM, the residents' Legal Guardian stated prior to the admission to the facility, Resident #1 had a stroke resulting in intellectual disability and being unable to make his own medical decision. In August 2021 the court appointed him, a DSS Social Worker, as Resident #1's Legal Guardian. The Legal Guardian indicated on 5/27/25, Nurse #2 had notified him about Resident #1 being in excruciating pain and was sent to the emergency room. The Legal Guardian stated it was also reported to him on 5/27/25 by Nurse #2 that the resident had complained of abdominal pain the day before (5/26/25) and did not want to go to emergency room (ER). The Legal Guardian indicated he was unsure why the facility had not called him on 5/26/25. During a follow-up telephone reinterview on 6/10/25 at 4:53 PM, the Legal Guardian stated the facility had his number and could have contacted him, The Legal Guardian indicated if he did not respond immediately, the staff could leave a message for him, which he would see and respond later. The facility also had an after-hours number and could leave a message on the after-hours number and would be checked later. The Legal Guardian stated had the facility notified the Legal Guardian on 5/26/25, the Guardian would have spoken to Resident #1, and the resident would have gone to the hospital to get evaluated. The Legal Guardian indicated Resident #1 had always listened to Legal Guardian and followed the advice of the Legal Guardian regarding his medical care. During an interview on 6/10/25 at 10:46 AM the Nurse Practitioner indicated she received a call from the facility (date unknown) regarding Resident #1 complaining of right-side abdominal pain. The NP stated she could hear the nurse questioning and assessing the resident over the phone. The NP stated she could hear the resident deny any issues of nausea/ vomiting. The resident was heard over the phone reporting to the nurse that the pain was not severe. The NP indicated during the telephone conversation and assessment of the resident the nurse had asked the resident if he would like to go to the hospital for further evaluation. The resident had declined going to the hospital. The nurse notified the NP about the resident's refusal. The NP indicated labs and x-rays were ordered. The NP stated the resident's vital signs were reported to be normal. The resident reported minor pain on the right side of the abdomen. During an interview on 6/11/25 at 2:00 PM, the Director of Nursing (DON) stated Resident #1 was alert and oriented and was able to make his needs known. However, the resident was not capable of making medical decisions. The resident reported mild stomach pain on 5/26/25 and orders were obtained for labs and x-rays of the abdominal. An x-ray was completed on 5/26/25 and report indicated the resident had a possible ileus. DON indicated on 5/26/25 the assigned nurse should have contacted the Legal Guardian and had not contacted him. The DON stated on 5/27/25, around the time of their morning meeting, the resident's condition changed, and he was in severe pain. Nurse #2 had already contacted the Nurse Practitioner and was in the process of calling the ambulance to send the resident to the ER per providers' s order. The resident's Legal Guardian was also notified. During an interview on 6/11/25 at 2:00 PM, the Administrator indicated Resident #1 was admitted to the facility from a group home with a Legal Guardian appointed by the court. The Administrator indicated the resident's medical care was always discussed with the Legal Guardian. The Legal Guardian would attend the resident's care plan meeting and would listen to the resident. The Administrator acknowledged Resident #1's medical decisions were made by the Legal Guardian. The Administrator confirmed that the Legal Guardian was not contacted on 5/26/25 by the facility staff. The Administrator indicated the best practice would have been to ask the Legal Guardian if the resident needed to be sent to the hospital on 5/26/25, however at that time it was not a medical emergency. On 5/26/25, the resident had complained about abdominal pain, which was mild throughout the day. The resident was casually asked if he would like to go to hospital on 5/26/25 for further evaluation, which he refused. The Administrator indicated on 5/27/25 the resident had a change in condition; he was immediately sent to the ER for further evaluation.

Based on observations and staff interviews, the facility failed to (1a) remove expired medication from hall 3 medication cart, (1b) discard loose pills from hall 1,2, and 4 medication carts, and (1c) failed to date an open vial of lidocaine (local anesthetic) found in hall 4's medication cart for 4 of 5 medication carts reviewed for medication storage. The findings included: 1a. Observation of Hall 3 medication cart occurred on [DATE] at 10:31am with Nurse #3. The following item was found: -Bisacodyl (laxative) 5 milligrams (mg) bottle expired in [DATE]. During an interview with Nurse #3 on [DATE] at 10:33am, Nurse #3 stated she was unaware the medication had expired. She explained the night shift nurses were responsible for checking the medication carts for expired medication. b. Observation of the medication cart for halls 1 and 2 occurred on [DATE] at 10:48am with Nurse #4. The following item was found: - one small pink round pill was loose in the top drawer of the medication cart. Nurse #4 was interviewed on [DATE] at 10:50am. The nurse stated she was unaware of the pill being loose in the drawer and stated if she had known she would have disposed of the pill. c. During an observation of hall 4's medication cart on [DATE] at 11:08am with Nurse #2, the following items were found: - one oblong white pill was loose in the top drawer of the medication cart. - one round off white pill was also loose in the top drawer of the medication cart. - one 10 cubic centimeter (cc) vial of lidocaine 1% was found to be open with no open date documented. An interview with Nurse #2 occurred on [DATE] at 11:11am. Nurse #2 explained she did not see the loose pills in the drawer, and she had not administered the lidocaine, so she was unaware the vial had been opened but not dated. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at 11:45am. ADON explained that the third shift nurses were responsible for cleaning the medication carts, checking for expired medication and ensuring medications had an open date if needed. She also explained that the nurses assigned to a medication cart were also responsible for checking expiration dates, checking for any loose pills, and open dates if needed. The ADON stated the nurses were aware of their duties and said she could not explain why the above issues were found.

Based on observation, staff interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) when a nurse aide provided catheter care for Resident #200 and did not wear a gown for 1 of 1 staff members observed for infection control practices. Findings included: The facility policy for Enhanced Barrier Precautions dated 2024 read in part that they required the use of gown and gloves for high-contact resident care activities in the resident's room when doing device care or use of urinary catheter. The physician order dated 11/08/24 to use indwelling catheter with closed drainage system due to neuromuscular dysfunction of bladder. Another order included for enhanced barrier precautions related to indwelling catheter every shift and to provide catheter cleansing and perineal hygiene every shift and as needed if soiled. An observation for the urinary catheter care was done on 11/13/24 at 3:48 PM. NA #1 washed her hands in the bathroom and collected her water in a basin with soap and towels for the catheter care. She wore her gloves during the entire urinary catheter care but did not wear any gown during the process. Interview with NA #1 on 11/13/24 at 5:07 PM stated she forgot to wear her gown during the catheter care, and she only realized after she was done cleaning. She stated she should have worn a gown as part of the enhanced barrier precautions. Interview with Director of Nursing (DON) on 11/15/24 at 10:50 am stated that nurses doing close personal care for resident with EBP would wear a gloves and gowns when doing catheter care. Interview with Administrator on 11/15/24 at 11:55 am stated that nursing staff should wear gloves and gowns when doing catheter care.

Based on observation, staff interview, and record review the facility failed to secure the indwelling urinary catheter to reduce tension for 1 of 2 residents (Resident #200) reviewed for urinary catheter. Findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder, and calculus of ureter. The physician order dated 11/08/24 was to use an indwelling catheter with closed drainage system due to neuromuscular dysfunction of bladder. The physician order dated 11/08/24 included to use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. The order included to rotate site of securement as needed and check the securement every shift. Documentation on his care plan noted 11/9/24 for the resident had Indwelling urinary catheter related to neurogenic bladder. The approaches included to position catheter bag and tubing below the level of the bladder and away from entrance room door and to place secure tape on leg for catheter security. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was severely cognitively impaired. He was coded to have an indwelling urinary catheter and was always incontinent of bowel. An observation on 11/12/24 at 3:14 pm showed Resident #200 indwelling catheter was not secured on his leg. There was a tape on the catheter tubing but was loose and the tape was not attached to the leg for securement. The resident was in bed and the catheter tube was visible when observed on the right side of his bed. It was also noted that the urine color in the tubing was dark colored with some sediment. Observation of catheter care on 11/13/24 at 3:48 pm noted that the urinary catheter tube was not secured to Resident #200's leg. Nurse Aide (NA #2) stated that it was loose and not secured to resident's leg. NA #2 further stated that she didn't know anything about the securement and did not know what to do with it. The tape was dated 11/11/24. Interview with Nurse #5 on 11/13/24 at 3:57 pm stated that the Wound Nurse was the one to check the securement device daily. Interview with the Wound Nurse on 11/14/24 at 9:58 am stated that she checked Resident #200's securement device for his catheter tubing at 7:00 am this morning and it was intact at that time. She stated that the nurse on the floor also checks the securement devices. The Wound Nurse further stated the securement devices comes off easily. Interview with the DON on 11/15/24 at 10:50 am stated that all residents with indwelling urinary catheter should have a securement device attached. She stated the nurses should check them every shift.

Based on record review, observations, resident and staff interviews, the facility failed to provide adaptive eating utensils to a resident who required light weight utensils with a rubber grip. This occurred for 1 of 1 resident (Resident #28) reviewed for accommodation of needs. The findings included: Resident #28 was admitted to the facility on [DATE] with multiple diagnoses that included multiple sclerosis and muscle weakness. Physician order dated 4-9-24 revealed Resident #28 was to receive a divided plate, a special cup (a cup with 2 handles and a lid), and built-up utensils. Resident #28's care plan with a revision date on 7-21-24 revealed the resident had nutritional problems or the potential for nutritional problems related to multiple sclerosis. The goal for Resident #28 involved her maintaining adequate nutritional status. The interventions included Resident #28 having a lightweight fork with a rubber grip handle. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact, had upper extremity impairment on one side, and required set up/clean up assistance with eating. Observation of Resident #28's lunch meal occurred on 11-12-24 at 12:20pm. Resident #28's meal ticket had that she was to receive light weight rubber handles utensils with meals. The observation revealed Resident #28 had received weighted utensils with a rubber grip, however, when the surveyor picked up the utensils by the handle, the weight of the utensils was heavy. Resident #28 was interviewed on 11-12-24 at 12:21pm. Resident #28 was sitting in a small dining room with one other resident. The resident stated she was not able to eat with the utensils because they are too heavy for me, and I cannot hold them. She said no staff had checked on her since bringing her tray, so she was not able to tell anyone about the utensils. During an interview with the Dietary Manager on 11-12-24 at 12:25pm, the Dietary Manager came to where Resident #28 was eating. He reviewed Resident #28's meal ticket and confirmed the resident was to receive light weighted utensils with her meals. The Dietary Manager picked up Resident #28's utensils and stated, oh no these are the heavy weighted utensils. Resident #28 told the Dietary Manager she could not eat with heavy weighted utensils, so she was not going to eat. The Dietary Manager did not respond to Resident #28 but stated there was a new Dietary Aide on the tray line and must have gotten confused between the heavy weighted and light weight utensils and then the Dietary Manager left the room. Continuous observation of the dining room where Resident #28 was sitting occurred on 11-12-24 from 12:28pm to 12:59pm. The observation revealed no staff member had entered the dining room to bring Resident #28 the proper utensils. Resident #28 was observed to be eating crackers during this time and not her meal. Nursing Assistant (NA) #1 was interviewed on 11-12-24 at 1:01pm. NA #1 explained prior to giving a resident their meal tray, she will read the meal ticket to ensure the resident received the correct meal. She stated she had not read Resident #28's meal ticket today and was unaware the resident needed light weight rubber grip utensils. The NA said she did see there were special utensils on the tray but did not know they were not the right ones. NA #1 stated if Resident #28 had told her the utensils were not right, she would have gone to the kitchen to retrieve the right utensils. NA #1 confirmed that she had not checked on Resident #28 after providing the resident with her tray. An interview with Dietary Aide #1 occurred on 11-12-24 at 2:06pm. The Dietary Aide explained she had been working at the facility for 3 weeks and she was still in training. She stated she was taught to get a meal ticket from the pile of tickets, place the ticket on the tray, read the ticket to see if there are special needs in silverware or cups, and then wrap the silverware in a napkin. Dietary Aide #1 stated she was aware Resident #28 received light weighted utensils and that she just grabbed the wrong utensils. A follow-up interview was conducted with the Dietary Manager on 11-13-24 at 1:17pm. The Dietary Manager confirmed he had not provided Resident #28 the lightweight utensils on 11-12-24 after he had discovered the resident had the wrong utensils. He explained he did not provide the utensils because Resident #28 had told him she was not going to eat cold food. The Dietary Manager stated he should have asked Resident #28 if she would like her food heated and provided the lightweight utensils but said, I didn't think about it. During an interview with the Administrator on 11-13-24 at 12:59pm, The Administrator stated she would have wanted the Dietary Manager to bring Resident #28 the light weighted utensils so she could eat but said the Dietary Manager explained to her Resident #28 said she was not going to eat because her food was cold.

Based on record review and staff interviews the facility failed to post accurate Registered Nurse (RN) staffing information for 51 of 103 days reviewed for posted nurse staffing (8/12/24, 8/14/24, 8/15/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/25/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/25/24, 9/26/24, 9/30/24, 10/1/24, 10/5/24, 10/7/24, 10/9/24, 10/10/24, 10/14/24, 10/15/24, 10/17/24, 10/23/24, 10/24/24, 10/26/24, 10/28/24, 10/29/24, 10/30/24, 11/6/24, 11/7/24, 11/8/24, 11/11/24, 11/12/24). The findings included: The daily posted nurse staffing sheets were reviewed from August 2024 through November 2024 and revealed the following: -August 2024 did not have any RN documented as working for all 3 shifts on the following days: 8/12/24, 8/14/24, 8/15/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/25/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24. -September 2024 did not have any RN documented as working for all 3 shifts on the following days: 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/25/24, 9/26/24, 9/30/24. -October 2024 did not have any RN documented as working for all 3 shifts on the following days: 10/1/24, 10/5/24, 10/7/24, 10/9/24, 10/10/24, 10/14/24, 10/15/24, 10/17/24, 10/23/24, 10/24/24, 10/26/24, 10/28/24, 10/29/24, 10/30/24. -November 2024 did not have any RN documented as working for all 3 shifts on the following days: 11/6/24, 11/7/24, 11/8/24, 11/11/24, 11/12/24. An interview with the Office Assistant occurred on 11/13/24 at 12:19pm. The Office Assistant confirmed she was responsible for completing the daily posted nurse staffing sheets. She explained she was provided with the schedule for the day by the Scheduler and from the schedule she completed the daily posted nurse staffing sheet. The Office Assistant stated that when she was not available to complete the daily posted nurse staffing sheets, the manager on duty was responsible for the completion of the daily posted nurse staffing sheet. The Office Assistant stated she was trained in completing the daily posted nurse staffing sheet by the Scheduler and that she was aware there needed to be a RN in the building at least 8 hours a day. The Office Assistant explained if there was not a RN listed on the daily posted nurse staffing sheet then there was a salaried RN in the building such as the Staff Development Coordinator, Assistant Director of Nursing, and/or the Minimum Data Set Nurse. She said she was told by the Scheduler that a salaried RN could not be counted on the daily posted nurse staffing sheet. The Scheduler was interviewed on 11/13/24 at 12:37pm. The Scheduler confirmed she had trained the Office Manager in completing the daily posted nurse staffing sheets. She stated she was aware a RN had to be present in the building for at least 8 hours a day but said she was not informed that a salaried RN could be placed on the daily posted nurse staffing sheets. During an interview with the Director of Nursing (DON) on 11/13/24 at 12:44pm, the DON discussed that there was no process in place to check the daily posted nurse staffing sheets. She explained she looked at the assignment sheets every day but not the daily posted nurse staffing sheets. The DON stated she would want to see on the daily posted nurse staffing sheets the census, how many LPN's, how many RNs, and how many Nursing Assistant's were working on each shift. She also stated she was aware a RN needed to be in the building at least 8 hours a day. The DON explained that a salaried RN had not been typically placed on the daily posted staffing sheets because they were not working on the halls. An interview with the Administrator occurred on 11/13/24 at 12:51pm. The Administrator stated she would want to see on the daily posted nurse staffing sheets the date, census, and how many hours per discipline. She explained she had used the daily posted nurse staffing sheets as who was providing hands on care to the residents not who was present in the building. The Administrator stated there had been a RN in the building every day at least 8 hours each day.

Based on observation, record review and staff interviews the facility failed to monitor temperatures for 1 of 2 medication refrigerators (300/500 Hall medication refrigerator). The findings included: Review of the medication storage policy labeled Medication Storage in the Facility and last updated 5/1/22 read in part The facility should maintain a temperature log in the storage area to record temperatures at least once a day. An observation was conducted of the 300/500 Hall medication refrigerator on 07/25/23 at 03:25 PM. Review of the temperature log for the month of July revealed the temperatures had not been recorded for 7/3/23, 7/8/23, 7/9/23, 7/18/23, 7/21/23, 7/22/23, 7/23/23, 7/24/23. An attempt to conduct an interview on 7/26/23 with the night shift nurse was unsuccessful. An interview was conducted with the Director of Nursing on 07/27/23 at 11:20 AM. The DON stated the refrigerator temperature checks were assigned to the night shift nurse. An interview was conducted with the Administrator on 07/27/23 at 11:27 AM. The Administrator stated she expected that medication refrigerators temperatures would be monitored at least once a day.

Based on observations, staff interviews and record review, the facility failed to maintain accurate documentation in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: On 01/13/22 at 8:30 AM Nurse #1 was observed administering medications to Resident #61. Nurse #1 was logged into the electronic health record (EHR), and in the resident's MAR, under Nurse #2's name. Review of Nurse #2's time clock information, provided by human resources (HR), revealed Nurse #2 had clocked out of her shift on 01/13/22 at 7:43 AM. An interview was conducted with Nurse #1 on 01/13/22 at 8:30 AM. The nurse stated she did not have a login due to a 30-day inactivity lockout rule for EHR access. Nurse #1 explained she had to wait for the HR Manager to arrive before she could get her login reset for the EHR. Review of a document titled: Agency Access Staff Information, indicated Nurse #1's EHR access was reset on 01/13/22 at 8:58 AM. Review of residents' (Resident #31, Resident #55 and Resident #65) MARs on 500 Hall revealed 9:00 AM medications were documented on 01/13/22 with Nurse #2's EHR login. 1. Review of Resident #31's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications included: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. 2. Review of Resident #55's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications included: calcium + vitamin D3, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. [MEDICATION(S)] was scheduled for 08:00 AM and documented with Nurse #2's initials. 3. Review of Resident #65's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications included: aspirin and multivitamin. [MEDICATION(S)] and [MEDICATION(S)] were scheduled for 8:00 AM and documented with Nurse #2's initials. An interview was conducted with the director of nursing (DON) on 01/13/22 at 9:00 AM. She stated most of the time nurses let her know if they had issues logging into the EHR. The DON explained nurses administering medications should do so under their own name. Nurse #1 Should not have given medications under another nurse's login. An interview was conducted with the HR manager on 01/13/22 at 10:25 AM. She explained she had access to fix EHR logins for nurses. The DON and assistant director of nursing (ADON) were able to reset logins as well. HR stated Nurse #1 requested a login reset on 01/13/22, and it was reset. In a follow up interview with the DON on 01/13/22 at 10:38 AM, she stated there was an afterhours process in place for any EHR access issues. Afterhours, the DON would be notified of EHR access issues. She would contact information technology (IT) to assist with issue resolution as needed. An interview was conducted with Nurse #3 (unit manager) on 01/13/22 at 10:55 AM. She explained she was made aware Nurse #1 did not have access to the EHR and sent the nurse to HR to have her access reset. Nurse #1 informed Nurse #3 she had not documented medication administrations under another nurse's name. Nurse #3 stated there was a process in place to ensure nursing staff had EHR access and all nurses had their own logins. Nurse #3 stated Nurse #1 should not have used another nurse's login to access the EHR. An interview was conducted with Nurse #2 on 01/13/22 at 11:29 AM. Nurse #2 stated she thought she had logged out of the EHR before leaving the facility. She revealed her typical process was to log out of the EHR when she was done with her shift. Nurse #2 explained the controlled substance count was correct when Nurse #1 assumed ownership of the medication administration cart. Nurse #2 voiced she had not known anyone to access the EHR under her login information.

Based on observation and staff interviews the facility failed to keep kitchen's exhaust range hood clean to prevent food from potentially being contaminated while being prepared. The range hood which was located directly above food preparation equipment was observed to have areas of chipping and peeling paint and rusted areas. Findings include: Observations on 1/8/20 at 11:40 AM, of the kitchen's range hood system revealed the range hood was positioned directly over food preparation equipment including; a tilt skillet, food warmer and a stove. Observations of the inside of range hood revealed the inside was painted and it contained areas that were brown in color which appeared to be rust. An area on the range hood's interior that was approximately one foot wide by one foot high and directly over the kitchen's tilt skillet had cracked and chipped paint. The paint was peeling and hanging loosely from the hood. A half foot circular area on the range hood's interior that was above a food warmer also had chipped paint. The outside area of the range hood was also observed. The area was painted and had brown colored areas which appeared to be rust. During an interview on 1/8/20 at 12:00 PM, the cook stated she had not observed the paint chipping on the kitchen's range hood and had not placed any work orders for maintenance regarding the hood system. During an interview on 1/8/20 at 12:17 PM, the district dietary manager stated he was unsure why the kitchen's range hood was painted and was unaware of the paint chipping and rusted areas of the hood system. He stated the entire range hood needed to be replaced. During an interview on 1/8/20 at 1:55 PM, the maintenance director indicated that the facility had a contract with external service company to clean the kitchen's range hood vents and this service was last performed in (MONTH) 2019. He indicated he was unaware that the range hood was painted and unaware of the paint chipping and rust areas on the range hood system. During an interview on 1/9/20 at 5:02 PM, the administrator indicated the kitchen's range hood system was painted long ago and was unsure why it was painted. The administrator stated the facility will remove any loose paint and rust from the range hood and be working to replace the entire range hood.

Based on resident and staff interviews and review of resident council meeting minutes, the facility failed to address and resolve ongoing grievances about food that were reported at resident council meetings for 6 of 9 residents who were reviewed for grievances. (Resident #90, #45, #61, #84, #79 and #26). The findings included: The resident council minutes dated 10/8/19 and 11/9/19 documented continued resident concerns about the food they were being served at meals which included: Meal carts were left on the hall for a while before meals were passed, the food was not as hot as it could be, tired of rice and green peas, water sitting on top of oatmeal, okra mushy, don ' t put sugar on vegetables, pinto and lima beans are hard, food preferences were not being honored and the barbeque beef (pork) tips were not good. On 11/13/19 the Administrator, Director of Nursing, the previous Dietary Manager (DM) and Activities Director had a follow up meeting with the residents of the resident council. The minutes from this meeting revealed the previous DM indicated the resident food concerns would be addressed with the cooks and an educational session with the cooks would be scheduled to address their food issues. Additionally, the DM announced that he would meet with residents 1 on 1 to review their food preferences. Further review of the resident council minutes revealed there was no monthly resident council meeting scheduled in (MONTH) 2019. An interview with the members of the Resident Council was conducted on 1/08/20 at 10:35 AM. A total of 9 residents, who regularly attended the facility ' s monthly resident council meeting, were present at this meeting. The meeting revealed six of the nine residents present had ongoing concerns with foods being served cold at meals, meal delivery being slow, foods being served with sugar, food quality needing to improve and the same meal selection week after week for the past two months. Multiple residents reported once the meal carts were delivered to the halls, the food would sit in the cart for a long period of time, which resulted in the food being served cold at all three meals. In addition, six members of the resident council reported administration and the previous dietary manager stated they would resolve their food concerns, but they were unaware of what action was taken to resolve the issues. The residents stated the food continued to be served cold and there were no changes in the quality of the food or the selection of food choices. The residents added there had been no individual discussions held with them by dietary or administration about the changes or resolution to their food concerns. Individual interviews with residents, who attend the resident council interview on 1/08/20, and were identified as alert and oriented revealed the following: During an interview on 1/8/20 at 12:30 PM, Resident #90 stated food selection is the same week after week. Resident #90 further stated the DM had not came to her to discuss her food preferences, and the meal today was luke warm. She stated there were a ton of people in the dining room to help with the meal service today, but other days we had to wait till they get to the cart which is often on the hall for 20 minutes after it was delivered. Resident #90 stated the residents shouldn ' t have to keep asking staff to reheat their food. During an interview on 1/8/20 at 12:35 PM, Resident #45 stated even when staff were asked to warm up the food by the time the food returns it was at the same temperature as it left, or the food was dried out. Resident #45 stated the DM had not asked her about her food preferences. Resident #45 added, I end up eating what is served because it would take too long to get the meal back. During an interview 1/8/20 at 1:00 PM, Resident #61 stated she had reported her food concerns during resident council meetings about the quality of food, food temperature and limited selection in the choice of foods being served. She explained the same foods continue to be served in the same quality. Resident #61 stated there was a meeting and staff informed us what they were going to do to change things, but we have not seen any changes. Resident #61 reported she had not seen anyone from administration or dietary to review her food preferences or ask any specific questions about the quality of the food. During an interview on 1/8/20 at 1:15PM, Resident #84 stated, in resident council meetings she reported about the food being served sweet, cold and no changes in the meal selection two months ago. Resident #84 further stated the food selection process had not changed, foods continued to be served sweet and cold. Resident #84 reported no one from dietary or administration had spoken with her about her food preferences or changes in the dietary process. Resident #84 indicated they told us there would be some changes, but no changes had not occurred at this time. During an interview on 1/8/20 at 1:20 PM, Resident #79 reported the problems with food temperatures and quality of food had been discussed in resident council meetings many times. Resident #79 stated the food was often served cold. Resident #79 reported she was tired of asking staff to reheat the food and wanted to know why, food was not being served hot when it left the kitchen. Resident #79 added the residents had been told changes would occur in dietary, but no one had spoken with her directly about her food preferences. Resident #79 reported the food concerns had not really been resolved within the resident group since everyone was still talking about the problems with the food. During an interview on 1/8/20 at 3:00 PM, Resident #26 stated there had been several discussions in the resident council about the food temperatures, food quality and food choices. Resident #26 stated we get what we get and no one reviewed my food preferences with me. The staff said they told us they were going to do all those food changes in the last meeting, but we are still served the same old rice, peas and some dried meat. Interview on 1/8/20 at 1:45 PM, the Administrator stated a follow up meeting was held with the residents on 11/13/19 to discuss the resident council concerns with dietary. The administrator explained, during the meeting the previous dietary manager presented the potential resolution for the identified food concerns. The Administrator stated in part the administrative team did test trays on the halls and a tray delivery assessment. The assessment revealed the cause of cold food was the delay in tray delivery once the carts were delivered. The Administrator confirmed she nor the dietary staff had followed up on the other concerns that was identified by the group. The administrator also confirmed there were no follow-up documented/recorded discussions held with residents individually or collectively about their dietary concerns.

Based on record review and staff interview the facility failed to accurately code the minimum data set (MDS) for therapeutic diet for 1 of 4 residents reviewed for nutrition (Resident #40) and failed to code hospice services for 1 of 1 resident reviewed for hospice (Resident #65). Findings Included: 1. Resident #40 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. A quarterly MDS dated [DATE] for Resident #40 identified he was on a mechanically altered diet; therapeutic diet was marked as no. An interview on 1/9/20 at 3:25 pm with MDS Nurse #1 revealed the Dietary Manager (DM)was responsible for completing Section K of the MDS. She explained the DM that completed Section K of the 11/13/19 MDS no longer worked at the facility. She stated the DM should have coded therapeutic diet for Resident #40 and she would need to do a correction. 2. Resident #65 admitted to the facility on [DATE] with a history of malignant neoplasm of the esophagus and brain, [MEDICAL CONDITION], congested heart failure, hypertension, and type 2 diabetes. Significant change in status of the Minimum data set ((MDS) dated [DATE] revealed Resident #65 was cognitively intact. Further review of the MDS did not identify resident was receiving hospice services. The Hospice Physician certification of terminal illness dated 11/20/19 and signed by attending physician on 11/20/19 revealed Resident #65 had a life expectancy of less than 6 months. On 1/9/20 at 12:53 PM an interview was conducted with Nurse #2. She stated Resident #65 was receiving hospice services. An interview was conducted on 1/9/20 at 3:00 PM with MDS Nurse #1. She stated Resident #65 admitted to hospice services on 11/20/19 , and a significant change in status MDS assessment with a reference date of 12/2/19 was completed due to resident admitting to hospice services. She verified special treatments, procedures, and programs (section O) of the MDS did not identify resident was receiving hospice services. She stated it was an error and she would do a modification. On 1/9/20 at 4:19 PM an interview with the Director of Nursing was conducted and she stated the process was the MDS assessment should be coded accurately.

Based on record review and staff interview the facility failed to revise a care plan to reflect significant weight loss for 1 of 4 residents reviewed for nutrition (Resident #40). Findings Included: Resident #40 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A care plan dated 6/21/18 for Resident #40 stated he was at risk for potential nutritional problems and weight fluctuations related to therapeutic, mechanically altered diet; [DIAGNOSES REDACTED]. An update dated (MONTH) (YEAR) stated significant weight loss in one month and to begin supplements. Review of the weight record for Resident #40 identified the following weights:138.5 pounds (lbs.) on 12/30/19 and 148.5 lbs. on 11/25/19. This reflected a 6.67% weight loss in 1 month. An interview on 1/8/20 at 3:45 pm with the Registered Dietitian (RD) revealed Resident #40 had a significant weight loss and was refusing most meals, supplements and medications. An interview on 1/9/20 at 3:25 pm with MDS Nurse #1 revealed the last time Resident #40 ' s care plan was reviewed was 11/12/19. She explained the Dietary Manager (DM) had signed the care plan which indicated it had been reviewed and was current. MDS Nurse #1 stated the DM that had reviewed the care plan on 11/12/19 no longer worked at the facility. She stated the resident ' s nutrition care plan did need to be updated with his current nutritional status. An interview on 1/9/20 at 3:41 pm with the Director of Nursing (DON) revealed it was her expectation that care plans were updated to reflect the current health status of the resident.

Based on observations, resident, staff and Nurse Practitioner interviews and record reviews, the facility failed to provide foot care and arrange podiatry services for 2 of 2 dependent residents with thick long curled toenails( Resident #27 and Resident #22) reviewed for foot care. The findings included: 1.Resident #27 was admitted on [DATE]. The [DIAGNOSES REDACTED]. The quarterly Minimum Data Set((MDS) dated [DATE] indicated Resident #27 had cognitive impairment and required total assistance with activities of daily living. Care plan dated 11/1/19 identified the problem as Resident #27 had activities of daily living (ADL) self-care performance deficit related to dementia, muscle weakness, unsteadiness on feet, abnormal posture. The goal included Resident #27 would maintain current level of function. The interventions included Resident #27 required total assistance from staff to provide bath/shower as necessary and sponge bath when a full bath or shower cannot be tolerated. Staff would gather and provide needed supplies, observe/document/report PRN any signs or symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation to nursing. Staff would cut long toe nails, observe/document foot care needs and refer to podiatrist/foot. Review of the podiatry schedule from (MONTH) 2019 through (MONTH) 2019, revealed Resident #27 was scheduled to be seen on 6/11/19 and 10/2/19, there was no consultation report or notation in chart Resident #27 had been seen. Review of skin assessments dated 12/25/19 and 1/1/20, revealed there was no documentation of the condition of Resident #27 ' s toenails. Observation on 01/06/20 4:00 PM, Resident #27 ' s toenails on his feet were extra-long pass the toe bed. They were very thick yellow/brown and curled. The toenails had large amounts of brown matter, scaly and jiggered. Observation1/7/20 at 8:30 AM, Resident #27s toenail remained in the same condition and had not been cleaned or cut/trimmed. The toenails were thick and more than an inch longer the toenail bed. Resident presented that the toe area was sensitive to touch as he would not allow blanket to cover feet. Observation on 1/7/20 at 2:30 PM, there was no change in the condition of Resident #27 ' s toenail. Staff had provided personal care for the resident several times but did not address the condition of the toenails. Resident #27 had been observed yelling when staff touched his feet. Resident #27 just pulled his feet to the side. Observation on 1/8/20 at 8:00 AM, Resident #27 was in room lying in bed and feet were exposed from the covers and there were no changes in the condition of his toenails on both feet. Interview on 1/8/20 at 9:34 AM, NA#3 stated they were told that residents who were diabetic, the aides were not to cut the toe nails, but should report the condition of the toe nails to nursing. The diabetic residents toe nails would be done by the podiatrist. NA#3 reported when the resident ' s toe nails were observed the nails getting to long, sharp or change of condition it should be reported to the nursing staff so the resident could be scheduled for podiatrist. The NA#3 stated she had worked with Resident #27 on a regular basis and the toenails had been in the current condition for several months. NA #3 state the condition of the toenails had been reported to nursing, but she was uncertain when the podiatry appointment had been schedule. Observation on 1/8/20 at 9:45 AM, NA #2 with permission from Resident #27 removed the resident's sock and the toe nails condition was unchanged. The resident feet were very sensitive to touch. He was cooperative in allowing the staff to remove the socks but did not want staff to touch his feet, Resident #27 stated his feet hurt. NA #2 stated diabetic residents ' toenails were cut by the podiatrist. The aides were expected to report to nursing when the toe nails needed to be cut by the podiatrist. Interview on 1/8/20 at 9:50 AM, the Scheduler stated the podiatrist visits the facility every three months and any diabetic resident would be added to the schedule when nursing reported a resident needed podiatry services. The Scheduler indicated any resident seen/refused would be documented in the chart as well as the referral form. Review of the schedule form indicated Resident #27 had been scheduled for 6/11/19 and 10/2/19, there was no documentation to indicate whether the resident had been seen or services provided. Interview on 1/8/20 at 10:00 AM, the Director of Nursing(DON) stated the podiatrist was scheduled every 3 months and it was expected that any diabetic residents who needed podiatry service be added to the schedule. The Nurse Aides were responsible for reporting to nursing when diabetic resident ' s toenails were extremely, long/sharp and needed podiatry trim/cut. DON added due to the complexity of diabetic footcare needs, podiatry was more appropriate to cut the toenails rather than nurses/nurse aide. The DON indicated there was no back up system in place for missed appointments or refusal of services The Administrator confirmed the expectation/responsibility of nurse aides/nursing and added the nurses should notify the nurse practitioner of any residents that needed toenail/footcare in between scheduled appointment to ensure residents did not get missed. The Administrator added if a resident refused or missed an appointment the NP would be notify for intermittent foot care. Interview on 1/8/20 at 10:30 AM, the Nurse Practitioner(NP) stated during her visits she did not do routine full body checks and would not have checked a resident ' s toenail unless nursing reported there was a concern or a need for referral to podiatry. The NP added any resident could be seen for toenail care in between podiatry visits if the toenails were growing very long, had thick/long sharp edges and needed to be cut/trim before three months. In addition, staff would need too informed her when a diabetic resident needed a referral for podiatry services. The NP added she was unaware of Resident #27 toenails needed to be cut/trim. 2. Resident #22 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] indicated Resident #22 had some cognitive deficits. The MDS coded Resident #22 totally dependent on staff for all activities of daily living. Care plan dated 10/23/19 identified the problem as Resident #22 had activities of daily living (ADL) self-care performance deficit r/t pelvic fracture (healed) & pain and [MEDICAL CONDITION] to right side, right foot drop. The goal included Resident #22 would maintain or improve current level of function. The interventions included Resident #22 required total assistance from staff to provide bath/shower as necessary and sponge bath when a full bath or shower cannot be tolerated. Staff would gather and provide needed supplies, observe/document/report PRN any signs or symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation to nursing. Staff would cut long toe nails, observe/document foot care needs and refer to podiatrist/foot. Review of the podiatry schedule from (MONTH) 2019 through (MONTH) 2019, revealed Resident #22 was scheduled to be seen on 6/11/19, but had not been seen or rescheduled. The podiatrist return visit was 10/2/19 and Resident #22 was not seen or scheduled. Observation on 01/07/20 at 10:14 AM, Resident #22 was lying in bed with feet hanging out from under covers, bilateral toenails long and sharp. Resident #22 stated she needed and wanted her toes nails cut. She stated she thought staff would do them during care, but they had not been done in a month or so. Resident #22 ' s left ankle and foot was very swollen. Observation on 1/7/20 at 2:45 PM, Resident #22 was lying in bed with feet exposed all the toenails on both feet were very long, thick, yellowing and brown matter underneath, with some swelling around the ankles. Resident #22 stated she had told staff during her care that her toenails needed to be clipped and was told she had to be scheduled to see the podiatrist. The resident added that her toenails have gotten caught up in the covers or poked through her socks at times. I could not tell you the last time when my toenails were cut. Occasionally they would hurt when my shoes were put on. Observation on 1/8/20 at 9:30 AM, Resident #22 was seated in wheelchair with socks/shoes on, Nurse Aide #2 removed the shoes and sock and the toenails on both feet had not been cut/trimmed and remained in the same condition. The big toe on each foot was poking through the sock. Resident #22 stated that her toenails had been in this condition for several months, staff knew they were very long, and no-one cut them. NA #2 observed the condition of the toenails and confirmed that all toe nails were very long , thick and more than an inch beyond each toe. NA #2 stated diabetic residents toe nails were cut by the podiatrist. The aides were expected to report to nursing when the toe nails needed to be cut by the podiatrist. Interview on 1/8/20 at 9:34 AM, NA#3 stated they were told that residents who were diabetic, the aides were not to cut the toe nails, but should report the condition of the toe nails to nursing. The diabetic residents toe nails would be done by the podiatrist. NA#3 reported when the resident ' s toe nails were observed the nails getting to long, sharp or change of condition it should be reported to the nursing staff so the resident could be scheduled for podiatrist. The NA#3 stated she had worked with Resident #22 on a regular basis and the toenails had been in the current condition for several months. NA #3 state the condition of the toenails had been reported to nursing, but she was uncertain when the podiatry appointment had been schedule. Interview on 1/8/20 at 9:50 AM, the Scheduler stated the podiatrist visits the facility every three months and any diabetic resident would be added to the schedule when nursing reported a resident needed podiatry services. The Scheduler indicated any resident seen/refused would be documented in the chart as well as the referral form. Review of the schedule form indicated Resident #22 had been scheduled for 6/11/19 but was not seen due to another appointment. Further review of the referral form, the podiatrist had visited the facility on 10/2/19 and Resident #22 had not been seen or rescheduled. Additional review of the chart revealed there had not been any consultation notes of the resident being seen in the past 6 months. Interview on 1/8/20 at 10:00 AM, the Director of Nursing(DON) stated the podiatrist was scheduled every 3 months and it was expected that any diabetic residents who needed podiatry service be added to the schedule. The Nurse Aides were responsible for reporting to nursing when diabetic resident ' s toenails were extremely, long/sharp and needed podiatry trim/cut. DON added due to the complexity of diabetic footcare needs, podiatry was more appropriate to cut the toenails rather than nurses/nurse aide. The DON indicated there was no back up system in place for missed appointments or refusal of services. The Administrator confirmed the expectation/responsibility of nurse aides/nursing and added the nurses should notify the nurse practitioner of any residents that needed toenail/footcare in between scheduled appointment to ensure residents did not get missed. The Administrator added if a resident refused or missed an appointment the NP would be notify for intermittent foot care. Interview on 1/8/20 at 10:30 AM, the Nurse Practitioner(NP) stated during her visits she did not do routine full body checks and would not have checked a resident ' s toenail unless nursing reported there was a concern or a need for referral to podiatry. The NP added any resident could be seen for toenail care in between podiatry visits if the toenails were growing very long, had thick/long sharp edges and needed to be cut/trim before three months. In addition, staff would need too informed her when a diabetic resident needed a referral for podiatry services. The NP added she was unaware of Resident #22 toenails needed to be cut/trim.

Based on record review, staff and family interviews, the facility failed to monitor blood sugar level for 1 of 3 residents with diabetes mellitus (Resident #1). Findings included: Resident #1 admitted on [DATE]. Review of discharge Minimum Data Set assessment, dated 3/18/18, revealed his moderately impaired cognition. Resident ' s [DIAGNOSES REDACTED]. He was always continent for bladder and occasionally incontinent for bowel. The resident received antidepressant, anticoagulants and diuretics. Review of Resident 1 ' s plan of care, dated 3/1/18, revealed he had diabetes mellitus. The goal was to have no complications related to diabetes. The interventions were to observe/document/report any symptoms and signs of [DIAGNOSES REDACTED] (low blood sugar) and infection to any open areas. Review of physician's order [REDACTED]. Review of physician's order [REDACTED]. Review of physician's order [REDACTED].– (MONTH) (YEAR) did not reveal the order to check blood sugar. Review of Resident 1 ' s Medication Administration Record [REDACTED]– (MONTH) (YEAR) did not reveal blood sugar checking procedures. Review of Resident 1 ' s laboratory data revealed the results of basic metabolic panel (BMP – blood test), dated 2/16/18, and signed by Physician #1, indicated high blood glucose level. Review of Resident 1 ' s laboratory data revealed the results of BMP, dated 3/3/18, and signed by Physician #1, indicated high blood glucose level and high level of HgbA1C. Review of Resident 1 ' s vital signs record for (MONTH) – (MONTH) (YEAR) did not reveal blood sugar results. On 6/6/18 at 1:45 PM, during an interview, Nurse #1 indicated that Resident #1 had [DIAGNOSES REDACTED]. There was no order for blood sugar check for this resident. On 6/6/18 at 2:26 PM, during the phone interview, Physician #1 indicated that Resident #1 had type two, non-insulin dependent diabetes mellitus with the history of [DIAGNOSES REDACTED] (low blood sugar). He received the treatment with [MEDICATION NAME] and the staff did not report hypoglycemic episodes during his stay in the facility. Physician #1 confirmed that he forgot to order the routine blood sugar check. He was aware of two blood tests with abnormal but not critically high blood glucose level. Physician #1 mentioned that it would be beneficiary for Resident #1 to have his blood sugar results few times a week. On 6/7/18 at 9:41 AM, during the phone interview, Physician #2 indicated that his expectation to have blood sugar monitoring for residents with diabetes mellitus in the facility. For Resident #1 it would be appropriate to order blood sugar check 2-3 times a week, as long as he was stable. Physician #2 was aware of two non-critically high blood glucose results. On 6/7/18 at 10:00 AM, during an interview, the Director of Nursing indicated that Resident #1 had type two diabetes mellitus and did not receive insulin. He did not have the order for blood sugar check. There were two laboratory test results, indicated high blood glucose, signed by Physician #1 with no new orders. On 6/7/18 at 10:20 AM, during an interview, the Administrator, indicated that she expected the staff to follow the physician's order [REDACTED].

Based on observation and facility staff interviews, the facility failed to discard expired food from the dry storage, reach in refrigerator, nourishment refrigerator, walk-in refrigerator and walk-in freezer and failed to properly store food in the walk in freezer. Findings included: 1a. An observation of the bread rack in dry storage on 10/23/17 at 3:30 PM revealed the 2 loaves of whole wheat bread with best by date 10/12/17, 2 loaves of whole wheat bread with best by date 10/19/17, 2 loaves of king thin bread with best by date 10/19/17, 7 packs of hot dogs buns with best by date 10/19/17 indicated on them. The bread rack also contained 4 loaves of opened king thin bread with best by date of 10/19/17 and 2 packs of opened hot dog buns opened with best by date 10/19/17 with no opened date or use by date label on them. b. Observation of the reach in refrigerator on 10/23/17 at 3:35 PM revealed a clear plastic container with a label Cream of Mushroom, Use by date: 10/22/17, a clear plastic container with yellowish liquid with a label Cream of chicken, Use by date: 10/22/17, an aluminum container with a plastic cover with a label Cabbage, Use by date 10/19/17, a plastic container containing a purple jelly like food with a label Grape Jelly, Use by date 10/3/17, Wholesome farm liquid eggs pasteurized - 64 ounce carton with label Use by date 10/20/17, and an 8 ounce (oz.) milk carton with expiration date 10/1/17 indicated on it . Observation also revealed a plastic container with salad mix with a label 10/22/17. Label did not indicate a use by or preparation date. During an interview with the dietary aide (DA) # 1 on 10/23/17 at 3:37 PM, dietary aide indicated that all left over foods were labelled with a use by date which was usually 2-3 days from the date of preparation. She stated that the food was used within the date indicated on the label. She further stated that the food was to be discarded when not used within the use by date indicated on them. c. Observation of the walk in refrigerator on 10/23/17 at 3:40 PM revealed a container on the top rack containing 4 whole wilting purple cabbage heads and a Ziploc bag containing a half cut purple cabbage with Date opened -9/20/17 and use by date - 9/23/17 written on it. Observation also revealed a transparent container with white mushy food and a label Applesauce, date - 10/14/17. d. Observation of the walk in freezer on 10/23/17 at 3:45 PM revealed an aluminum pan with silver foil with a label to be frozen - turkey tet, dated 4/3/17, 2 cardboard boxes labeled southern style chicken pureed shaped meat with binders - 24/ 3 oz. with expiration date 3/27/15. Observation also revealed one cardboard box labeled country style green beans - 24/3.2 oz. with expiration date 2/20/15. During an interview with the DA # 1 on 10/23/17 at 3:37 PM, dietary aide indicated that she was unaware that the food had expired in 2015 and unsure who placed these boxes in the freezer and why it was not discarded earlier. During an interview with the Dietary Manager (DM) on 10/25/17 at 12:01 PM, the DM indicated that that the boxes in the freezer were an error on his part. He indicated that that while checking the emergency supply, instead of discarding the expired pureed food, he had placed it in the freezer and was to discard them later. e. Observation of nourishment refrigerator in hallway 200 on 10/26/2017 at 8:33 AM, revealed a blue plastic bag with label indicating resident name and date 9/26/17. Observation of the plastic bag when opened by the staff revealed a clear plastic box with brown colored food that looked like home cooked food with some meat and vegetables. During an interview with Assistant Director of Nursing (ADON) on 0/26/2017 at 9:50 AM, she indicated that the Nursing aides (NA) were assigned to clean the nourishment refrigerator. She further stated that all resident's food were labeled and dated. She also stated that store purchased, sealed food, unopened with an expiration date was stored more than a month. f. Observation of the walk in freezer on 10/23/17 at 3:45 PM revealed ice on a cardboard labeled muffin bulk stored on the rack beneath the freezer compressor. The DM #1 indicated that the water must have dripped out of the compressor. During an interview with DM on10/26/2017 at 10:00 AM, he indicated that it was his expectation that every Monday, the bread guy pulls out the old bread before storing fresh bread on the rack. He also indicated that all staff should label opened containers and leftovers with a preparation date and a use by date. He further stated that leftover food should be used or discard based on the date indicated on the label. He also indicated that all expired food should the discarded immediately. He stated that the freezer would be serviced to prevent ice formation. During an interview on 10/26/2017 at 10:54 AM, the Administrator stated that it was her expectation that staff use proper labeling and discard expired products immediately and appropriately. She also indicated that a staff member was now assigned as a designated staff for nourishment refrigerator and that the refrigerator will be checked on regular basis and foods disposed as needed.

Based on record review, observations and facility staff interviews, the facility ' s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the [DATE] recertification survey to correct a deficiency in the area of dietary (F371), which was subsequently recited on [DATE] on the recertification. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. The Findings Included: This tag is cross referenced to: F371 Based on observation and facility staff interviews, the facility failed to discard expired food from the dry storage, reach in refrigerator, nourishment refrigerator, walk-in refrigerator and walk-in freezer and failed to properly store food in the walk in freezer. An interview with the Administrator on [DATE] at 1:42 PM revealed the facility had a Quality Assurance and Performance Improvement (QAPI) program in place. Administrator indicated that the QAA (Quality Assurance Agency) committee consisted of herself, Director of Nursing, Minimum Data Set coordinator, Medical Director, Business Office Manager, Dietary Manager, All Department heads and the Admissions Coordinator. She indicated that team met during daily stand up meeting, monthly reviews and quarterly assessment. She indicated that the team discussed on-going issues, has an audit program, tracked and trended the problem and planned training and education process based on the trends.

Based on record review, staff and physician interviews, the facility failed to notify the physician of a change in condition for one (1) of two (2) sampled residents (Resident #1) when Resident #1 complained of abdominal pain, exhibited nausea and vomiting and was noted to have no bowel sounds when examined by nursing staff. Immediate jeopardy began on 12/04/2010 and was identified on 07/07/2011 at 11:20 AM. Immediate Jeopardy was removed on 07/07/2011 at 6:39 P.M., when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 had a hospitalization [DATE]-[DATE] with [DIAGNOSES REDACTED]. Hospital discharge summary dated 11/30/2010 stated Resident #1 developed an ileus (obstruction of the bowel) during his hospitalization probably secondary to pneumonia. He was treated with large doses of [MEDICATION NAME] (laxative), eventually improved and his bowels were moving regularly on discharge from the hospital. Physician orders [REDACTED].(by mouth) every for (4) hours for pain. Lexi-Comp's Geriatric Dosage Handbook 12th edition indicated that constipation was a side effect of the medication. A care plan dated 09/28/2010 indicated Resident #1 had a potential for alteration in bowel function with episodes of constipation related to medication. Approaches included: encourage fluids, observe for bowel pattern to ensure adequate bowel elimination and notification of physician as indicated. A review of the Bladder and Bowel report sheet for 11/26/2010 through 12/8/2010 revealed Resident #1 had a documented bowel movement on 12/1/2010 and 12/4/2010. Complete Blood \count (CBC) results obtained on 12/2/2010 indicated a white cell count of 13.8 On 12/04/2010 at 06:00 AM., nursing notes stated Resident #1 was experiencing some chronic constipation. An enema was given at 01:00 AM. with no results. The nurse's note indicated Resident #1 had vomited undigested food three times and staff attempted to give Resident #1 warm prune juice, but Resident #1 could not keep it down. Vital signs were temperature- 97.4, pulse-72, respirations-20 and blood pressure 168/87. On 12/04/2010 at 1:30 PM., nursing notes indicated Resident #1 said he had not used the bathroom for three days. Resident #1 vomited liquid one time. He was given an enema and a medium soft stool was noted after the enema was given. The documentation indicated Resident #1's abdomen was distended and firm to touch with complaints of pain when his stomach was touched. No bowel sounds were heard in any areas of the stomach after the bowel movement. Vital signs were temperature-99.6, pulse-75, respirations-18 and blood pressure 121/70. On 12/05/2010 at 12:30 PM., nursing noted stated Resident #1 was coughing, spitting up frothy brown sputum and only took liquids for breakfast. He complained of nausea and stomach pain. His abdomen was distended and firm to touch and hypoactive bowel sounds were noted in all areas of the stomach. Vital signs were temperature-97.1, pulse-68, respirations-16 and blood pressure 140/72. At 4:00 PM., Resident #1 had nausea and vomiting. Vital signs were temperature-99.1 axillary, pulse-67, respirations-24 and blood pressure 132/64. On Monday, 12/6/2010 at 05:45 AM., nursing notes stated "Resident #1 appears to be having some hydration problems. His PO (oral) intake had decreased and he's had episodes of nausea/vomiting over 48 (forty-eight) hours. His abdomen is somewhat distended. On 12/4 and 12/5 he experienced severe constipation. Enemas given x 2 and effective. Currently he's taking [MEDICATION NAME] 80 mg. BID (twice daily) and [MEDICATION NAME] 300 mg. His urine is a dark/amber tome without foul odor. 12/5/10 he experienced an elevated temp. (temperature) which was treated with Tylenol and ice chips." On 12/6/2010 at 7:09AM, Resident #1's physician was notified via fax. Information noted on the fax stated "Resident #1's oral intake decreased. Due to dysphagia, he's on thickened liquids which he does not like. The last 48 (forty-eight) hours, he's had episodes of nausea/vomiting. 12/5-12/5 severe constipation. Treated with enema x 2 (effective). 12/5 temp (temperature) elevated. Urine dark/amber. Skin turgor poor. Currently taking [MEDICATION NAME] 80 mg. BID, [MEDICATION NAME] 300 mg. qd (daily)." Resident #1's physician ordered a complete blood count (CBC) with differential and a complete metabolic panel (CMET). On 12/6/2010, CBC results indicated a white cell count of 19.1 (normal 4.0-10.5). This was increased from the result received four days earlier. On 12/6/2010 at 9:40 PM., nursing notes stated Resident #1 complained of nausea and was given [MEDICATION NAME] 25 mg. intramuscularly (IM). Vital signs were temperature-97.9, pulse-65, respirations-24 and blood pressure 115.62. On 12/7/2010 at 1:30 PM., vital signs were temperature 97.1, pulse-72, respirations-20 and blood pressure 156/103. Resident #1 continued to spit up frothy sputum, complained of feeling bad and refused breakfast. No bowel movement was noted. At 8:45 PM., Resident #1 vomited yellowish liquid and was given [MEDICATION NAME] with no further vomiting noted. A Quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 received pain medication as needed. The assessment stated Resident #1 experienced occasional mild pain that affected day to day activities and sleep. Constipation was not indicated on the assessment. On 12/8/2010 at 06:00 AM., nursing notes stated Resident #1 vomited liquid that was phlegm in appearance. Vital signs were temperature 99.5, pulse-71, respirations-28 and blood pressure 95/51. At 11:00 AM., vital signs were temperature-97.4, pulse-76, respirations-26 and blood pressure-108-59. He had vomited twice that morning and had been unable to eat breakfast. Morning medications were vomited. Resident #1 was moaning. His abdomen was distended and very hard. Resident #1's physician was notified and he was sent to (name) hospital at 10:00 AM. Resident #1 was admitted to (name) hospital on [DATE] with a [DIAGNOSES REDACTED]. The Hospital discharge summary dated 12/15/2010 included a discharge [DIAGNOSES REDACTED]. X-rays done on admission revealed a high-grade small bowel obstruction with free intraperitoneal air consistent with perforation. Nurse #3 worked night shift (11:00 PM.-07:00 AM.) and provided care for Resident #1 on 12/4, 12/6, 12/7 and 12/8/2010. On 07/6/2011 at 3:15 PM., she stated it was not abnormal for Resident #1 to complain of stomach pain and/or become constipated due to pain medication. Nurse #3 said she received reports of Resident #1 being constipated and nausea and vomiting. Nurse #3 stated, on 12/04/2010 at 01:00 AM., Resident #1's abdomen was distended and hard. She listened to his abdomen and noted very little bowel sounds. She could not press on Resident #1's abdomen because he complained of pain and that was "different" for him. She said she checked the rectum and felt a solid mass of stool. Constipation was the first thing that came to her mind and Resident #1 was given an enema per standing orders for constipation. Nurse #3 stated she did not notify the physician on 12/4/2010 at 6:00 AM. because Resident #1 had vomited only one time and the standard protocol was to monitor for twenty-four (24) to seventy-two (72) hours before faxing/calling the physician. Nurse #2 worked evening shift (3:00 PM.-11:00 PM.) and provided care for Resident #1 on 12/4, 12/5 and 12/6/2010. On 07/6/2011 at 3:35 PM., she stated Resident #1 had complaints of leg pain nausea and vomiting on his return from the hospital on [DATE]. Nurse #2 stated the physician would be notified by telephone or fax if nausea and vomiting continued for more than one day. Nurse #2 stated she did not notify the physician regarding the nausea and vomiting because Resident #1 was not vomiting every shift. Nurse #4 worked day shift (07:00 AM.-3:00 PM.) and provided care for Resident #1 on 12/6 and 12/8/2010. On 07/6/2011 at 4:35 PM., she stated she notified the physician on 12/6/2010 that Resident #1 vomited almost everything that was given him and the family was concerned about Resident #1's condition. Nurse #4 stated she could not remember if she also notified the physician about Resident #1's distended abdomen, complaints of abdominal pain or the absence of bowel sounds on 12/4/2010. Nurse #4 stated she was aware that Resident #1 had a [DIAGNOSES REDACTED]. This would be documented in the nursing notes or on the daily skilled nursing sheets. Nurse #4 stated Resident #1 displayed signs of increased pain on 12/8/2010. She stated Resident #1 was moaning loudly and began vomiting. She notified the physician at that time and Resident #1 was transferred to the hospital. On 07/6/2011 at 5:30 PM., the interim Director of Nursing stated any change in resident condition would be documented on the 24 hour report sheet. The report sheets for December 2010 had been shredded but she would expect any information that had been on the 24 hour report sheet to be documented in the resident's chart. The interim Director of Nursing stated nursing staff followed a flip chart to determine what to do in certain situations. She obtained the flip chart from the nurse's desk, referred to the "constipation" section and stated it informed nursing staff on what to document and not when and/or who to notify in any situation. When asked regarding the nursing notes written on 12/4/2010 at 1:30 PM., the interim Director of Nursing stated, she would expect the nursing staff to notify the administrative nurse on call who was available at all times for further help in assessment. She stated, with nausea, vomiting, constipation and no bowel sounds, she would expect the physician to be notified at that time. Nurse #1 worked day shift (07:00 AM.-3:00 PM.) and provided care for Resident #1 on 12/4, 12/5 and 12/7/2010. On 07/7/2011 at 8:55 AM., Nurse #1 stated Resident #1's abdomen was distended and no bowel sounds were heard when she examined him on 12/4/2010 at 1:30 PM. She did not notify the physician because Resident #1's abdomen "was always distended and tender to touch. It was normal for him to have diminished or no bowel sounds." Nurse #1 stated the physician had always been aware that Resident #1's abdomen was distended. She said she would have notified the physician for pain medication if Resident #1 had continued profusely vomiting, had an elevated temperature, was in severe pain and/or not voiding. She indicated as long as Resident #1 was voiding and not vomiting, she had no concerns. On 07/7/2011 at 7:10 PM., Resident #1's physician stated it was not normal for Resident #1 to have a distended abdomen, abdominal pain or diminished/ no bowel sounds. He said he would expect to be notified if there was any question of pain, potential for blockage, vomiting, fecal material in the vomitus, tender or distended abdomen and absence or hyperactive bowel sounds. Resident #1's physician stated that a complete bowel obstruction and perforation was a lot different that an ileus and it was miraculous that Resident #1 survived. The physician stated, if he had been called on 12/4/2010 and told the information noted in the nursing notes (nausea and vomiting, abdomen distended and firm, complaints of abdominal pain, no bowel sounds), he would have told the facility to transfer the resident to the hospital for evaluation. The Administrator was notified of the Immediate Jeopardy on 07/07/2011 at 11:20 AM. The facility presented a credible allegation of compliance on 07/07/2011 at 6:39 PM. which included: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 transferred to the hospital on December 8, 2010 at 10:00am related to acute changes in his clinical status. This resident was admitted to the hospital with [REDACTED]. On July 6, 2011 the facility's interim Director of Nursing began an investigation into the facts surrounding the resident's discharge on December 8, 2010. The investigation continued until July 7, 2011. This investigation included details regarding the discharge of Resident #1 on December 8, 2010. Director of Nursing and Staff Development Coordinator provided one-to-one education in regards to communicating with supervisors regarding notification of change in condition, including incidents of constipation, nausea, and vomiting, and completion of change of condition forms, InterAct II (Interventions to reduce acute care transfers), when to report to the MD/PA/NP, and following the chain of command. On July 7, 2011, the Staff Development Coordinator initiated education for all licensed nurses regarding notification of change in condition and assessment of a resident specifically related to constipation, nausea, and vomiting, and assessments in relation to change of condition and reporting and will be completed by July 12, 2011 to include those staff on vacation and work only weekends. On July 7, 2011, all available Certified Nursing Assistants were educated on communicating with supervisors regarding change in condition including incidents of constipation and completion of Change of Condition forms and will be completed by July 12, 2011 to include those staff on vacation and work weekends only. An impromptu meeting of the Quality Assessment and Assurance including the Nursing Home Administrator, Director of Nursing, Staff Development Coordinator, Resident Care Management Director, and Medical Director was conducted at the Brian Center of Eden on July 7, 2011 at 12:50pm to implement a plan of action regarding the alleged deficient practice. Starting the week of July 11, 2011 the facility Quality Assessment and Assurance Committee will meet weekly for a period of three weeks to review actions associated with notification of change in resident status. Going forward, the Quality Assessment and Assurance Committee, to include the Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Unit Coordinator, Resident Care Management Director, and MDS Coordinator) will meet monthly or as needed. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: Residents who exhibit acute changes in condition requiring intervention, such as constipation, have the potential to be affected by the alleged deficient practice. On July 7, 2011, the Director of Nursing began a review of the current residents who have had an acute change in condition requiring notification. On July 7, 2011, the Director of Nursing audited the corresponding documentation in the medical records of these residents to determine that a nursing assessment was done and interventions were implemented, and communicated to the appropriate parties. Two residents were noted with skin tears and the interventions were as follows: treatment initiated, MD and RP notification, identification of the underlying cause with correction. Appropriate notification and treatments initiated and completed for both residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On July 7, 2011, facility initiated reinforcement of the facility's practice for the Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Resident Care Management Director, and MDS Coordinator) to review on a daily basis, Monday through Friday, those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms are documented, interventions were initiated, and the attending physician was contacted as appropriate by reviewing the 24 hour reports, change of condition forms, Bowel records, and telephone orders. Adjustments to the plan of care and Care Assignment Sheets will be made based on these reviews and the input of medical professionals. On July 7, 2011, the facility initiated a mechanism to account for weekend review of the 24-hour report, incidents and changes in condition by the manager on duty and/or charge nurse. The Director of Nursing or Administrator will be called to discuss findings and initiate further action as appropriate. The Quality Assessment and Assurance Committee will monitor the process daily Monday thru Friday for a period of 4 weeks, then weekly for a period of 4 weeks, then randomly as deemed necessary by the Quality Assessment and Assurance Committee. On July 7, 2011, the Regional Clinical Director, the Director of Nursing, and the Staff Development Coordinator conducted training with all scheduled licensed nurses regarding what constitutes a nursing assessment, post-change of condition assessment, use of Interact II tools as guidelines for assessment components, and timely intervention including calling 911 if initial assessment indicates a life threatening event and physician involvement for identified acute changes in resident condition. The Interact II tool is used for the identification of change in condition, communication of those changes and continuity of care. The Director of Nursing, Resident Care Management Director, or Staff Development Coordinator will provide all licensed nursing staff education prior to being allowed to work. This education will be included in the facility's new hire orientation. Beginning July 7, 2011, scheduled Certified Nursing Assistants were educated regarding notification of the Nurse when a resident experiences a change in condition, including but not limited to constipation, nausea, and vomiting. Certified Nursing Assistants will be provided this education via the Director of Nursing, Resident Care Management Director, or Staff Development Coordinator prior to being allowed to work. In addition, on July 7, 2011 the facility's grand rounds process, which includes Director of Nursing, Resident Care Management Director and/or Staff Development Coordinator, increased the frequency of the grand rounds to at least three times per week for the next four weeks to include observations, discussion with four randomly chosen licensed nurses regarding residents with the potential to have acute changes in condition, identified residents with acute changes in condition, physician involvement as appropriate, and interventions being implemented to address the resident's need. The Director of Nursing and Regional Clinical Director conducted grand rounds on July 7, 2011. Residents were reviewed to assess for additional needs and interventions. The Director of Nursing and Regional Clinical Director also reviewed the documentation in the medical records of these residents to ensure identification of acute changes of condition and notification of physician. Necessary follow-up was completed and there are no outstanding concerns. Additional measures put into place to ensure the alleged deficient practice does not recur include: The Interdisciplinary Team (IDT) will review bowel reports on a daily basis Monday through Friday during the IDT meeting to ensure any change in condition is identified. Appropriate interventions and notifications will be made based on these reviews. The Director of Nursing, RCMD, and/or Staff Development Coordinator will review 24-hour reports daily, Monday through Friday, to identify any change in resident's condition. Additionally, the licensed nurses will be educated annually on nursing assessment, post-change of condition assessment, use of Interact II tools as guidelines for assessment components, and timely intervention including calling 911 if initial assessment indicates a life threatening event and physician involvement for identified acute changes in resident condition to ensure continued compliance. Indicate how the facility plans to monitor its performance to make sure solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system of the facility: On July 7, 2011, the Quality Assessment and Assurance Committee (QA&A), including the facility Administrator, Human Resources Coordinator, Director of Nursing, Resident Care Management Director, MDS(Minimum Data Set) Coordinator, Maintenance Director, Social Worker, Activities Director, Therapy Program Manager, Medical Records Coordinator, and Dietary Manager to discuss the acute episode experienced by Resident #1 on December 4, 2011. The Committee also has reviewed this acute episode with the facility ' s Medical Director. On July 7, 2011, the Committee has reviewed the education materials provided to the licensed nursing staff regarding identification of change in condition, nursing assessment, and initiation of interventions based on assessment findings. The Administrator and/or Director of Nursing will review data obtained during reviews and report patterns/trends to the QA&A Committee weekly for four weeks and monthly thereafter. The QA&A Committee will evaluate the effectiveness of the above plan, and will add additional interventions based on negative outcomes identified to ensure continued compliance. Immediate Jeopardy was removed on 07/07/2011 at 6:39 PM. Interviews with licensed nursing staff confirmed they had received in-servicing on nursing assessment, use of InterAct II tools as guideline for assessment and when/ whom to notify for acute changes in resident condition. Documentation was provided by the facility that in-servicing began on 07/07/2011 and copies were provided of the tools that would be used as a guideline for assessment.

Based on medical record review, staff and physician interviews, the facility failed to continue to assess and monitor new onset of abdominal pain with associated nausea and vomiting, distended abdomen and absence of bowel sounds for one (1) of two (2) sampled residents (Resident #1) which resulted in hospitalization for small bowel obstruction with perforation. Immediate jeopardy began on 12/04/2010 and was identified on 07/07/2011 at 11:20 AM. Immediate Jeopardy was removed on 07/07/2011 at 6:39 PM. when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 had a hospitalization [DATE]-[DATE] with [DIAGNOSES REDACTED]. Hospital discharge summary dated 11/30/2010 stated Resident #1 developed an ileus (obstruction of the bowel) during his hospitalization probably secondary to pneumonia. He was treated with large doses of [MEDICATION NAME] (laxative), eventually improved and his bowels were moving regularly on discharge from the hospital. Physician orders [REDACTED].(by mouth) every for (4) hours for pain. Lexi-Comp's Geriatric Dosage Handbook 12th edition indicated that constipation was a side effect of the medication. A care plan dated 09/28/2010 indicated Resident #1 had a potential for alteration in bowel function with episodes of constipation related to medication. Approaches included: encourage fluids, observe for bowel pattern to ensure adequate bowel elimination and notification of physician as indicated. A review of the Bladder and Bowel report sheet for 11/26/2010 through 12/8/2010 revealed Resident #1 had a documented bowel movement on 12/1/2010 and 12/4/2010. On 12/04/2010 at 06:00 AM., nursing notes stated Resident #1 was experiencing some chronic constipation. An enema was given at 01:00 AM. with no results. Resident #1 had vomited undigested food three times. Nursing staff attempted to give Resident #1 warm prune juice but Resident #1 could not keep it down. Vital signs were temperature- 97.4, pulse-72, respirations-20 and blood pressure 168/87. On 12/04/2010 at 1:30 PM., nursing notes stated Resident #1 said he had not used the bathroom for three days. Resident #1 vomited liquid one time. He was given an enema and a medium soft stool was noted after the enema was given. Resident #1's abdomen was distended and firm to touch with complaints of pain when his stomach was touched. No bowel sounds were heard in any areas of the stomach after the bowel movement. Vital signs were temperature-99.6, pulse-75, respirations-18 and blood pressure 121/70. On 12/5/2010 at 12:30 PM., nursing notes stated Resident #1 was coughing and spitting up frothy brown sputum and only took liquids for breakfast. Hypoactive bowel sounds were noted in all areas of the stomach. His abdomen was distended and firm to touch. Resident #1 complained of nausea and of stomach pain. [MEDICATION NAME] 25 milligrams (mg) was administered by mouth. Vital signs were temperature-97.1, pulse-68, respirations-16 and blood pressure 140/72. On 12/5/2010 at 4:00 PM., nursing notes stated Resident #1 had nausea and vomiting one time. [MEDICATION NAME] 25 mg. suppository and Tylenol suppository was given. Vital signs were temperature-99.1 axillary, pulse-67, respirations-24 and blood pressure 132/64. On 12/6/2010 at 05:45 AM., nursing notes stated "Resident #1 appears to be having some hydration problems. His PO (oral) intake had decreased and he's had episodes of nausea/vomiting over 48 (forty-eight) hours. His abdomen is somewhat distended. On 12/4 and 12/5 he experienced severe constipation. Enemas given x 2 and effective. Currently he's taking [MEDICATION NAME] 80 mg. BID (twice daily) and [MEDICATION NAME] 300 mg. His urine is a dark/amber tome without foul odor. 12/5/10 he experienced an elevated temp. (temperature) which was treated with Tylenol and ice chips." On 12/6/2010 at 9:40 PM., nursing notes stated Resident #1 complained of nausea and [MEDICATION NAME] 25 mg.intramuscularly (IM) was given and noted to be effective. Vital signs were temperature-97.9, pulse-65, respirations-24 and blood pressure 115/62. On 12/7/2010 at 1:30 PM., vital signs were temperature 97.1, pulse-72, respirations-20 and blood pressure 156/103. Resident #1 continued to spit up frothy sputum and complained of feeling bad. No bowel movement was noted. Breakfast was refused but liquids were consumed well. On 12/7/2010 at 8:45 PM., nursing notes stated Resident #1 vomited yellowish liquid. Only twenty-five (25) per cent of the meal was consumed. [MEDICATION NAME] 25 mg. was given with no further vomiting noted. Vital signs were temperature-97.4, pulse-76, respirations-26 and blood pressure 134/56. A Quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 received pain medication as needed. The assessment stated Resident #1 experienced occasional mild pain that affected day to day activities and sleep. Constipation was not indicated on the assessment. On 12/8/2010 at 06:00 AM., nursing notes stated Resident #1 vomited liquid that was phlegm in appearance. Vital signs were temperature-99.5, pulse-71, respirations-28 and blood pressure 95/51. On 12/8/2010 at 11:00 AM., nursing notes stated vital signs were temperature-97.4, pulse-76, respirations-26 and blood pressure-108/59. Resident #1 had vomited twice that morning and had been unable to eat breakfast. Morning medications were vomited. Resident #1 was moaning. Abdomen was distended and very hard. Resident #1's physician was notified and Resident #1 was sent to (name) hospital at 10:00 AM. Resident #1 was admitted to (name) hospital on [DATE] with a [DIAGNOSES REDACTED]. Hospital discharge summary dated 12/15/2010 included a discharge [DIAGNOSES REDACTED]. X-rays done on admission revealed a high-grade small bowel obstruction with free intraperitoneal air consistent with perforation. Nurse #3 worked night shift (11:00 PM.-07:00 AM.) and provided care for Resident #1 on 12/4, 12/6, 12/7 and 12/8/2010. On 07/6/2011 at 3:15 PM., she stated it was not abnormal for Resident #1 to complain of stomach pain and/or become constipated due to pain medication. Nurse #3 said she received reports of Resident #1 being constipated and nausea and vomiting. Nurse #3 stated, on 12/04/2010 at 01:00 AM., Resident #1's abdomen was distended and hard. She listened to his abdomen and noted very little bowel sounds. She could not press on Resident #1's abdomen because he complained of pain and that was "different" for him. She said she checked the rectum and felt a solid mass of stool. Constipation was the first thing that came to her mind and Resident #1 was given an enema per standing orders for constipation. Nurse #3 stated she did not notify the physician on 12/4/2010 at 6:00 AM. because Resident #1 had vomited only one time and the standard protocol was to monitor for twenty-four (24) to seventy-two (72) hours before faxing/ calling the physician. Nurse #2 worked evening shift (3:00 PM.-11:00 PM.) and provided care for Resident #1 on 12/4, 12/5 and 12/6/2010. On 07/6/2011 at 3:35 PM., she stated Resident #1 had complaints of leg pain nausea and vomiting on his return from the hospital on [DATE]. Nurse #2 stated the physician would be notified by telephone or fax if nausea and vomiting continued for more than one day. Nurse #2 stated she did not notify the physician regarding the nausea and vomiting because Resident #1 was not vomiting every shift. Nurse #4 worked day shift (07:00 AM.-3:00 PM.) and provided care for Resident #1 on 12/6 and 12/8/2010. On 07/6/2011 at 4:35 PM., she stated she notified the physician on 12/6/2010 that Resident #1 vomited almost everything that was given him and the family was concerned about Resident #1's condition. Nurse #4 stated she could not remember if she also notified the physician about Resident #1's distended abdomen, complaints of abdominal pain or the absence of bowel sounds on 12/4/2010. Nurse #4 stated she was aware that Resident #1 had a [DIAGNOSES REDACTED]. This would be documented in the nursing noted or on the daily skilled nursing sheets. Nurse #4 stated Resident #1 displayed signs of increased pain on 12/8/2010. She stated Resident #1 was moaning loudly and began vomiting. She notified the physician at that time and Resident #1 was transferred to the hospital. On 07/6/2011 at 5:30 PM., the interim Director of Nursing stated any change in resident condition would be documented on the 24 hour report sheet. The report sheets for December 2010 had been shredded but she would expect any information that had been on the 24 hour report sheet to be documented in the resident's chart. The interim Director of Nursing stated nursing staff followed a flip chart to determine what to do in certain situations. She obtained the flip chart from the nurse's desk, referred to the "constipation" section and stated it informed nursing staff on what to document and not when and/or who to notify in any situation. When asked regarding the nursing notes written on 12/4/2010 at 1:30 PM., the interim Director of Nursing stated, she would expect the nursing staff to notify the administrative nurse on call who was available at all times for further help in assessment. She stated, with nausea, vomiting, constipation and no bowel sounds, she would expect the physician to be notified at that time. Nurse #1 worked day shift (07:00 AM.-3:00 PM.) and provided care for Resident #1 on 12/4, 12/5 and 12/7/2010. On 07/7/2011 at 8:55 AM., Nurse #1 stated Resident #1's abdomen was distended and no bowel sounds were heard when she examined him on 12/4/2010 at 1:30 PM. She did not notify the physician because Resident #1's abdomen "was always distended and tender to touch. It was normal for him to have diminished or no bowel sounds." Nurse #1 stated the physician had always been aware that Resident #1's abdomen was distended. She said she would have notified the physician for pain medication if Resident #1 had continued profusely vomiting, had an elevated temperature, was in severe pain and/or not voiding. She indicated as long as Resident #1 was voiding and not vomiting, she had no concerns. On 07/07/2011 at 7:10 PM., Resident #1's attending physician stated Resident #1 required close monitoring for eating, bowel movements and complaints of pain. He expected nursing staff to assess Resident #1 routinely for vomiting, fecal material in vomitus, abdominal tenderness, distended abdomen and absence or hyperactive bowel sounds The Administrator was notified of the Immediate Jeopardy on 07/07/2011 at 11:20 AM. The facility presented a credible allegation of compliance on 07/07/2011 at 6:39 PM. which included: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 transferred to the hospital on December 8, 2010 at 10:00am related to acute changes in his clinical status. This resident was admitted to the hospital [DIAGNOSES REDACTED]. On July 6, 2011 the facility's interim Director of Nursing began an investigation into the facts surrounding the resident's discharge on December 8, 2010. The investigation continued until July 7, 2011. This investigation included details regarding the discharge of Resident #1 on December 8, 2010. Director of Nursing and Staff Development Coordinator provided one-to-one education in regards to resident assessment and communicating with supervisors regarding change in condition, including incidents of constipation, nausea, and vomiting, and completion of change of condition forms, InterAct II( Interventions to reduce acute care transfers), when to report to the MD/PA/NP, and following the chain of command. On July 7, 2011, the Staff Development Coordinator initiated education for all licensed nurses regarding assessment of a resident specifically related to constipation, nausea, and vomiting, and assessments in relation to change of condition and reporting and will be completed by July 12, 2011 to include those staff on vacation and work only weekends. On July 7, 2011, all available Certified Nursing Assistants were educated on communicating with supervisors regarding change in condition including incidents of constipation and completion of Change of Condition forms and will be completed by July 12, 2011 to include those staff on vacation and work weekends only. An impromptu meeting of the Quality Assessment and Assurance including the Nursing Home Administrator, Director of Nursing, Staff Development Coordinator, Resident Care Management Director, and Medical Director was conducted at the Brian Center of Eden on July 7, 2011 at 12:50pm to implement a plan of action regarding the alleged deficient practice. Starting the week of July 11, 2011 the facility Quality Assessment and Assurance Committee will meet weekly for a period of three weeks to review actions associated with notification of change in resident status. Going forward, the Quality Assessment and Assurance Committee, to include the Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Unit Coordinator, Resident Care Management Director, and MDS Coordinator) will meet monthly or as needed. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: Residents who exhibit acute changes in condition requiring intervention, such as constipation, have the potential to be affected by the alleged deficient practice. On July 7, 2011, the Director of Nursing began a review of the current residents who have had an acute change in condition requiring notification. On July 7, 2011, the Director of Nursing audited the corresponding documentation in the medical records of these residents to determine that a nursing assessment was done and interventions were implemented, and communicated to the appropriate parties. Two residents were noted with skin tears and the interventions were as follows: treatment initiated, MD and RP notification, identification of the underlying cause with correction. Appropriate notification and treatments initiated and completed for both residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On July 7, 2011, facility initiated reinforcement of the facility's practice for the Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Resident Care Management Director, and MDS Coordinator) to review on a daily basis, Monday through Friday, those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms are documented, interventions were initiated, and the attending physician was contacted as appropriate by reviewing the 24 hour reports, change of condition forms, Bowel records, and telephone orders. Adjustments to the plan of care and Care Assignment Sheets will be made based on these reviews and the input of medical professionals. On July 7, 2011, the facility initiated a mechanism to account for weekend review of the 24-hour report, incidents and changes in condition by the manager on duty and/or charge nurse. The Director of Nursing or Administrator will be called to discuss findings and initiate further action as appropriate. The Quality Assessment and Assurance Committee will monitor the process daily Monday thru Friday for a period of 4 weeks, then weekly for a period of 4 weeks, then randomly as deemed necessary by the Quality Assessment and Assurance Committee. On July 7, 2011, the Regional Clinical Director, the Director of Nursing, and the Staff Development Coordinator conducted training with all scheduled licensed nurses regarding what constitutes a nursing assessment, post-change of condition assessment, use of Interact II tools as guidelines for assessment components, and timely intervention including calling 911 if initial assessment indicates a life threatening event and physician involvement for identified acute changes in resident condition. The Interact II tool is used for the identification of change in condition, communication of those changes and continuity of care. The Director of Nursing, Resident Care Management Director, or Staff Development Coordinator will provide all licensed nursing staff education prior to being allowed to work. This education will be included in the facility's new hire orientation. Beginning July 7, 2011, scheduled Certified Nursing Assistants were educated regarding notification of the Nurse when a resident experiences a change in condition, including but not limited to constipation, nausea, and vomiting. Certified Nursing Assistants will be provided this education via the Director of Nursing, Resident Care Management Director, or Staff Development Coordinator prior to being allowed to work. In addition, on July 7, 2011 the facility's grand rounds process, which includes Director of Nursing, Resident Care Management Director and/or Staff Development Coordinator, increased the frequency of the grand rounds to at least three times per week for the next four weeks to include observations, discussion with four randomly chosen licensed nurses regarding residents with the potential to have acute changes in condition, identified residents with acute changes in condition, physician involvement as appropriate, and interventions being implemented to address the resident's need. The Director of Nursing and Regional Clinical Director conducted grand rounds on July 7, 2011. Residents were reviewed to assess for additional needs and interventions. The Director of Nursing and Regional Clinical Director also reviewed the documentation in the medical records of these residents to ensure identification of acute changes of condition and notification of physician. Necessary follow-up was completed and there are no outstanding concerns. Additional measures put into place to ensure the alleged deficient practice does not recur include: The Interdisciplinary Team (IDT) will review bowel reports on a daily basis Monday through Friday during the IDT meeting to ensure any change in condition is identified. Appropriate interventions and notifications will be made based on these reviews. The Director of Nursing, RCMD, and/or Staff Development Coordinator will review 24-hour reports daily, Monday through Friday, to identify any change in resident's condition. Additionally, the licensed nurses will be educated annually on nursing assessment, post-change of condition assessment, use of Interact II tools as guidelines for assessment components, and timely intervention including calling 911 if initial assessment indicates a life threatening event and physician involvement for identified acute changes in resident condition to ensure continued compliance. Indicate how the facility plans to monitor its performance to make sure solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system of the facility: On July 7, 2011, the Quality Assessment and Assurance Committee (QA&A), including the facility Administrator, Human Resources Coordinator, Director of Nursing, Resident Care Management Director, MDS(Minimum Data Set) Coordinator, Maintenance Director, Social Worker, Activities Director, Therapy Program Manager, Medical Records Coordinator, and Dietary Manager to discuss the acute episode experienced by Resident #1 on December 4, 2011. The Committee also has reviewed this acute episode with the facility's Medical Director. On July 7, 2011, the Committee has reviewed the education materials provided to the licensed nursing staff regarding identification of change in condition, nursing assessment, and initiation of interventions based on assessment findings. The Administrator and/or Director of Nursing will review data obtained during reviews and report patterns/trends to the QA&A Committee weekly for four weeks and monthly thereafter. The QA&A Committee will evaluate the effectiveness of the above plan, and will add additional interventions based on negative outcomes identified to ensure continued compliance. Immediate Jeopardy was removed on 07/07/2011 at 6:39 PM. Interviews with licensed nursing staff confirmed they had received in-servicing on nursing assessment, use of InterAct II tools as guideline for assessment and when/ whom to notify for acute changes in resident condition. Documentation was provided by the facility that in-servicing began on 07/07/2011 and copies were provided of the tools that would be used as a guideline for assessment.