Every finding on record at Gastonia Health & Rehab Center

Based on record review, observation and interviews with resident, staff, Cardiology Clinic receptionist and the Medical Director, the facility failed to schedule a cardiology appointment for heart monitor placement for 1 of 3 residents reviewed for quality of care (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (ischemic stroke which happens when blood flow to part of the brain is blocked), atherosclerotic heart disease (condition where the arteries that supply blood to the heart become narrowed or blocked because of plaque buildup) and vascular dementia (type of dementia caused by reduced blood flow or damage to blood vessels in the brain).The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired and required substantial/maximal assistance with most activities of daily living.A review of the hospital Discharge summary dated [DATE] indicated Resident #1 was admitted on [DATE] for acute altered mental status and garbled speech and was found to have an acute ischemic left middle cerebral artery stroke. Neurology consult dated 7/9/26 indicated that the appearance of the stroke on Magnetic Resonance Imaging was concerning for the embolic (blood vessel was blocked by a blood clot) etiology. Neurology recommended 30-day heart monitor on discharge. Resident #1 was discharged back to the facility on 7/10/26 with a referral to the Cardiology Clinic for placement of a telemetry monitor (device that continuously monitors a person's heart rhythm). The referral did not specify an appointment date and time and there were no instructions to make an appointment for a certain date or time frame. The discharge summary did not include any information about the heart monitor being delivered to the facility.A phone interview with Nurse #6 on 8/17/26 at 1:34 PM revealed she was an agency nurse, and she re-admitted Resident #1 to the facility on 7/10/26. Nurse #6 stated that she did not read the entire discharge summary for Resident #1, and all she did was reconcile the medication orders with the Medication Administration Record. Nurse #6 stated she did not remember anything about Resident #1 requiring a heart monitor or needing a cardiology appointment set up. Nurse #6 explained that she was told by the Director of Nursing (DON) to leave the discharge paperwork in a file folder behind the nurses' desk, so she left the discharge paperwork in the file folder behind the nurses' desk. Nurse #6 indicated that nursing management would give the referrals to the Transportation Aide who would schedule any appointments that needed to be set up. Nurse #6 reported that she assumed the DON would have communicated with the medical providers about Resident #1's hospital discharge summary and orders.A review of Resident #1's medical record indicated a physician's order dated 7/10/26 that read: Ensure heart monitor is plugged up at all times. This order was scheduled to be done twice a day on the day shift and night shift, and was entered into Resident's #1's medical record by the Director of Nursing.Resident #1's Medication Administration Records (MAR) for July and August 2026 indicated the above order dated 7/10/26 to: Ensure heart monitor is plugged up at all times. It was documented as having been checked and signed off twice a day from 7/10/26 to 8/17/26 by nurses and medication aides.A History and Physical note dated 7/14/26 by the Medical Director indicated Resident #1 with a history of prior strokes presented for follow-up after a recent left middle cerebral artery stroke. At the time of hospital presentation, speech was impaired. She currently denied right-sided weakness and denied dizziness or blurry vision. A 30-day heart monitor was recommended on discharge with cardiology follow-up. Reviewed inpatient workup with negative echocardiogram (test that uses sound waves to create pictures of the heart). Plan to proceed with recommended 30-day cardiac monitor and cardiology follow-up to evaluate for occult arrhythmia (hidden or intermittent abnormal heart rhythm) as a potential stroke mechanism.Further review of Resident #1's medical record indicated no order for a 30-day cardiac monitor and cardiology follow-up to evaluate for occult arrhythmia.During an interview with Resident #1 on 8/17/26 at 11:12 AM, she stated that she currently did not have a heart monitor.An observation was made of Resident #1 on 8/17/26 at 2:09 PM with Nurse #1. Nurse #1 was interviewed during the observation and confirmed that Resident #1 did not ever have a heart monitor. Nurse #1 reported that she had been working at the facility for a month and a half, and had not observed Resident #1 with a heart monitor. Nurse #1 stated that she notified the Director of Nursing (DON) about Resident #1 not having a heart monitor, but she couldn't remember when and the DON told Nurse #1 that she was working on getting Resident #1 a heart monitor. Nurse #1 stated that she saw on Resident #1's MAR about ensuring the heart monitor was plugged in, and she signed off on her MAR even though she knew that Resident #1 did not have a heart monitor.A phone interview with the former Admissions Director on 8/17/26 at 3:17 PM revealed that prior to Resident #1 being re-admitted to the facility on [DATE], she had coordinated with the case manager at the hospital about the heart monitor. The former Admissions Director stated that the case manager told her that the heart monitor was going to be delivered to the facility on the same day when Resident #1 came back to the facility. She reported that she made sure this was communicated to the Administrative team, and she told the Receptionist to watch out for it and give it to the nurse when it was delivered. The former Admissions Director stated that she did not know what happened after that, and she did not know that the heart monitor was never delivered to the facility. She revealed that she did not follow up to make sure the heart monitor was delivered to the facility and she had assumed that the DON would follow up and ensure that the heart monitor was delivered.Attempts were made to interview the Case Manager, but they were not successful.An interview with the Transportation Aide on 8/17/26 at 11:53 AM revealed she was responsible for transporting the residents to medical appointments as well as scheduling and following up on them. During the interview, the Transportation Aide looked through her appointment calendar and did not see any appointment that was scheduled for Resident #1 to be seen at the Cardiology Clinic. She stated that Resident #1 had not been to see a cardiologist since the Transportation Aide starting doing transports in June 2026. She reported that she never received any referral for Resident #1 to see a cardiologist. The Transportation Aide further stated that the nurses usually gave her referrals or discharge summaries if she needed to schedule a resident for an outside medical appointment.A phone interview with the Cardiology Clinic receptionist on 8/17/26 at 12:58 PM revealed there had been no appointment made for Resident #1 at their clinic, and that Resident #1 was never seen by a cardiologist at their clinic. The receptionist stated that the resident would have to be seen by a cardiologist before a 30-day heart monitor could be set up as outpatient.A phone interview with the Medical Director on 8/17/26 at 5:49 PM revealed he wanted to proceed with the recommendation by neurology for Resident #1 for a heart monitor. The Medical Director explained that the heart monitor was supposed to detect any atrial fibrillation not normally caught with a routine electrocardiogram, and any problems with the heart that could have caused the clot which caused Resident #1's stroke. He stated the 30-day heart monitoring was not emergent for Resident #1 and ideally, she would have come back to the facility with the heart monitor from the hospital. The Medical Director indicated it was usually hard to coordinate that, so the facility would have to set up an appointment with the cardiologist to get the heart monitor set up for Resident #1. The Medical Director stated that he was aware Resident #1 did not have a heart monitor, but he assumed that the facility was setting up an appointment with the cardiologist to get the heart monitor set up. He stated that he did not write an order for the cardiology follow up, but he told the DON on 7/14/26 to proceed with the recommendation from neurology.An interview with the Director of Nursing (DON) on 8/17/26 at 2:42 PM revealed Resident #1's order for the heart monitor was based on a recommendation when Resident #1 came back from the hospital on 7/10/26. The DON stated that the former Admissions Director told her and the administrative team that the Cardiology Clinic was supposed to send the heart monitor together with Resident #1 when she was re-admitted to the facility. However, the heart monitor was never delivered, and as far as the DON knew, nobody had followed up. The DON stated that she should have followed up on Resident #1's heart monitor. She reported that none of the nurses had told her that the heart monitor was not in place for Resident #1. The DON shared that the former Admissions Director recently stopped working at the facility, but the former Admissions Director was responsible for coordinating with the hospital about appointments that needed to be set up. The DON stated that she reviewed the hospital discharge summary, but she missed following up on the cardiology consult to get the heart monitor for Resident #1. She was responsible for reviewing orders and discharge summaries and if there were any appointments that needed to be set up, she forwarded this information to the Transportation Aide who would schedule the appointments. The DON stated she entered the order on 7/10/26 for Resident #1's heart monitor because they thought the heart monitor would come from the hospital just as what the former Admissions Director reported to her.A follow-up interview with the DON on 8/17/26 at 4:39 PM revealed she just found out that the heart monitor for Resident #1 was never delivered to the facility. The DON stated that none of the nurses or medication aides had reported to her that Resident #1 did not have a heart monitor. She stated that the nurses probably assumed that she knew the heart monitor was not in place. She explained that around 7/10/26, she was the only Administrative nurse, and she was the only nurse reviewing all the discharge summaries for newly admitted and readmitted residents. The DON indicated that she most likely missed following up on the order for the cardiology consult and the heart monitor. The DON stated that the facility needed to have a better system with following up on appointments that they needed to make for the residents. She further stated that it was not an excuse, but at that time, she was trying to keep up with everything because she was the only nurse in charge. The DON shared that they should have set up an appointment for Resident #1 to be seen by a cardiologist who would have set up the heart monitor and go over the instructions on what to do with it while Resident #1 was at the facility.An interview with the Administrator on 8/17/26 at 4:46 PM revealed the former Admissions Director informed her that when Resident #1 came back from the hospital on 7/10/26, neurology had recommended a heart monitor for Resident #1. The Administrator stated that the case manager at the hospital informed the former Admissions Director that the Cardiology Clinic was going to send them the heart monitor, but it never arrived at the facility. The Administrator indicated that Resident #1 did not have a follow-up appointment scheduled with the Cardiology Clinic. The Administrator stated that she knew the heart monitor was not in place, but she thought they were waiting for it to arrive, and they could have intervened sooner. She shared that any nurse could have followed up on the heart monitor order by calling the Cardiology Clinic or asking a nurse manager to help with obtaining the heart monitor.

Based on record review and staff interviews, the facility failed to maintain accurate medical records related to a heart monitor for 1 of 3 residents (Resident #1) reviewed for medical record accuracy. Resident #1's heart monitor was documented in place from 7/10/26 to 8/17/26 despite it not being applied to the resident.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (condition where the arteries that supply blood to the heart become narrowed or blocked because of plaque buildup).A review of Resident #1's medical record indicated a physician's order dated 7/10/26 that read: Ensure heart monitor is plugged up at all times. (Plugged up meant plugged up to the outlet in the wall and charged). This order was in place after Resident #1 was re-admitted to the facility on [DATE]. This order was scheduled to be checked twice a day on the day shift and night shift, and was entered into Resident's #1's medical record by the Director of Nursing.Resident #1's Medication Administration Records (MAR) for July 2026 and August 2026 revealed an order for: Ensure heart monitor is plugged up at all times. It was documented as having been checked and signed off twice a day from 7/10/26 to 8/17/26. Nurse #1 signed off on the order on 7/13/26, 7/15/26, 7/20/26, 7/21/26, 7/22/26, 7/27/26, 7/28/26, 7/30/26, 7/31/26, 8/4/26, 8/10/26, 8/14/26 and 8/17/26. Nurse #2 signed off on the order on 7/11/26, 7/12/26, 8/5/26, 8/8/26 and 8/9/26. Nurse #3 signed off on the order on 7/29/26 and 8/12/26. Nurse #4 signed off on the order on 7/16/26, 7/23/26, 8/1/26, 8/2/26, 8/6/26 and 8/16/26. Nurse #5 signed off on the order on 7/28/26, 8/1/26, 8/15/26 and 8/16/26.An interview with Nurse #1 on 8/17/26 at 2:09 PM revealed she had provided care to Resident #1 since 7/10/26 on the day shift from 7:00 AM to 7:00 PM. Nurse #1 explained the heart monitor was not available, but she had signed off on the heart monitor being plugged in each day she had worked. Nurse #1 stated that she notified the Director of Nursing (DON) about the heart monitor not being available, but she could not remember when, and the DON told Nurse #1 she was working on getting Resident #1 a heart monitor.A phone interview with Nurse #2 on 8/17/26 at 3:52 PM revealed she documented about ensuring Resident #1's heart monitor was plugged up on day shift on 7/11/26, 7/12/26, 8/5/26, 8/8/26 and 8/9/26. Nurse #2 stated that she saw the heart monitor order on Resident #1's MAR, but she did not physically check if Resident #1 had a heart monitor. Nurse #2 stated she did not remember making a note in Resident #1's medical record that the heart monitor was not available. The above dates were the only dates in the MAR for Nurse #2.A phone interview with Nurse #3 on 8/17/26 at 4:12 PM revealed he was assigned to Resident #1 on day shift on 7/29/26 and 8/12/26. Nurse #2 explained Resident #1 did not have a heart monitor. Nurse #3 stated that he should not have documented in Resident #1's MAR about ensuring that the heart monitor was plugged up because it was not available. The above dates were the only dates in the MAR for Nurse #3.A phone interview with Nurse #4 on 8/17/26 at 4:15 PM revealed she provided care to Resident #1 on day shift on 7/16/26, 7/23/26, 8/1/26, 8/2/26, 8/6/26 and 8/16/26. Nurse #4 stated that on 8/16/26, she questioned the order for a heart monitor for Resident #1 and asked the night shift nurse what the order meant. Nurse #4 reported the night shift nurse told her that she did not know what the order to plug in the heart monitor meant. Nurse #4 stated she was not sure and confused about the order regarding ensuring the heart monitor was plugged up because Resident #1 did not have one. She further stated she meant to ask Resident #1's family member who was visiting but the family member left before she could even ask her about Resident #1's heart monitor. Nurse #4 stated another nurse told her that the order meant that she was supposed to check on Resident #1's vital signs and that was what she did and then she signed off on the order on the MAR. The above dates were the only dates in the MAR for Nurse #4.A phone interview with Nurse #5 on 8/17/26 at 5:27 PM revealed she was assigned to Resident #1 on the night shift from 7:00 PM to 7:00 AM on 7/28/26, 8/1/26, 8/15/26 and 8/16/26. Nurse #5 explained Resident #1 did not have a heart monitor. Nurse #5 stated she signed off on the order to make sure the heart monitor was plugged up, but she had questioned the order to another night shift nurse, but she could not remember who, because she could not find the heart monitor. The above dates were the only dates in the MAR for Nurse #5. An observation made of Resident #1 on 8/17/26 at 2:09 PM revealed that Resident #1 did not have a heart monitor.An interview with the Director of Nursing (DON) on 8/17/26 at 4:39 PM revealed the nurses should have followed up on the heart monitor order instead of just signing off that it was completed. The DON stated they should have clarified it with her if they were unsure about the order. She further stated that even with medication orders, she always told the nurses not to mark it as unavailable, but to call the on call provider and get clarification. The DON added the nurses should not have been signing off on Resident #1's heart monitor order if it was not in place.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for residents with new mental health diagnoses for 6 of 6 residents (Resident #8, Resident #9, Resident #18, Resident #19, Resident #22, and Resident #42) reviewed for PASRR.The findings include:a. Review of Resident #8's medical record revealed PASRR level I was completed on 3/06/24 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, bipolar disorder, and major depressive disorder.There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. b. Review of Resident #9's medical record revealed PASRR level I was completed on 2/03/25 prior to admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #9 was admitted to the facility on [DATE].The electronic medical record revealed Resident #9 was diagnosed with anxiety disorder and major depressive disorder with psychotic symptoms on 10/30/25.There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. c. Review of Resident #18's medical record revealed PASRR level I was completed 9/08/23 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #18 was admitted to the facility on [DATE] and readmission on [DATE].Review of Resident #18's medical record also revealed her current active diagnoses included psychotic disorder (diagnosed on [DATE]) and anxiety disorder (diagnosed on [DATE]).There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. d. Review of Resident #19's medical record revealed PASRR level I was completed 8/13/18 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #19 was admitted to the facility on [DATE].Review of Resident #19's medical record also revealed his current active diagnosis included coronary artery disease, hypertension, end stage renal disease, type 2 diabetes, malnutrition, major depressive disorder (diagnosed on [DATE]), bipolar disorder (diagnosed on [DATE]), and anxiety disorder (diagnosed on [DATE]).There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. e. Review of Resident #22's medical record revealed PASRR level I was completed 7/28/19 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #22 was admitted to the facility on [DATE] and readmission on [DATE].Review of Resident #22's medical record also revealed her current active diagnoses included schizoaffective disorder (diagnosed on [DATE]) and major depressive disorder (diagnosed on [DATE]).There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. f. Review of Resident #42's medical record revealed PASRR level I was completed 3/07/24 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #42 was admitted to the facility on [DATE] and readmission on [DATE]. Review of Resident #42'a medical record also revealed his current active diagnoses included major depressive disorder (diagnosed on [DATE]) and psychotic disorder (diagnosed on [DATE]).There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. An interview on 12/17/25 at 11:55 AM with the Social Worker (SW) revealed she had begun working at the facility in August 2025 and was responsible for completing PASRR paperwork for residents. She stated she was aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission, when they received a new mental health diagnosis, or had a significant change. The SW stated that since she had begun her position at the facility she had been focused on making sure PASRR paperwork was being completed for any new admissions or residents that had received any new diagnosis but had not had time to go back and review residents with mental health diagnosis that were admitted prior to her starting at the facility or residents that had been readmitted . She revealed she did not have a good reason as to why the sampled residents did not have an evaluation for a Level II PASRR completed but after reviewing their mental health diagnoses, Level II PASRR evaluations should have been completed.During an interview on 12/18/25 at 12:55 PM with the Administrator, he communicated he had just started his position at the facility in October 2025. He revealed he was not aware of who was responsible for completing PASRR level II prior to his employment but since he started his position in October the responsibility of the requests for Level II PASRR evaluations was the Social Worker. The Administrator revealed he was not aware of the sampled resident's diagnosis or that they did not have a PASRR level II evaluation completed and did not know why a PASRR level II evaluation request had not been submitted. He stated that his understanding was that a PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis and that according to the sampled resident's diagnoses a PASRR level II should have been completed.

Based on record review, review of the Nurse Aide Registry forms, and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide Registry to ensure that 1 of 37 Nursing Assistants (NA) that were employed at the facility remained listed on the on the NC Nurse Aide Registry with an active Nurse Aide I recertification (NA#1).The findings included:NA #1 was hired by the facility on [DATE] to work with residents in need of care and treatment. Review of NA #1's personnel file indicated that NA #1's Nurse Aide Certification had expired on [DATE]. A review of the staffing schedule sheets from [DATE] to [DATE] revealed NA #1 had worked with an expired Nurse Aide Certification during the timeframe of schedules reviewed. On [DATE] the Administrator was notified that NA#1's Nurse Aide Certification had expired on [DATE], and NA #1's timecard for [DATE] was requested. Review of NA #1's timecard for [DATE] revealed NA #1 had worked the following days and time at the facility after her Nurse Aide Certification had expired on [DATE]: [DATE] 7:30 AM to 7:30 PM [DATE] 7:45 AM to 7:15 PM [DATE] 8:45 AM to 7:30 PM During an interview on [DATE] at 12:13 PM the Human Resources (HR) Director stated she recalled she had verbally informed the Former Scheduler that NA #1's certification would expire on [DATE] but could not recall the specific date the notification was made. The HR Director stated she was responsible for notifying the scheduler when an NAs certification was going to expire. During a telephone interview on [DATE] at 2:35 PM the Former Scheduler stated normally HR Director would notify her if a NAs certification was going to expire. The Former Scheduler did not recall if she had been notified that NA #1's Nurse Aide Certification was getting ready to expire. The Former Scheduler stated when she received notification that a NAs certification was going to expire, she would notify the employee and if the NAs certification was not renewed the NA would be removed from the schedule until the NAs certification was active. During an interview on [DATE] at 12:21 PM the Director of Nursing (DON) stated she expected the NAs Nurse Aide Certification to be active and for the NA to be removed from the schedule if their Nurse Aide Certification expired. The DON stated the HR Director was responsible for notifying the scheduler when a NAs certification was going to expire. The scheduler would notify the employee, if the certification was not renewed the NA would be removed from the schedule until the certification was active. The DON stated there was not documented communication regarding NA #1's certification expiration and so verifying it was renewed had not occurred. During an interview on [DATE] at 12:37 PM the Administrator stated he expected all NAs to have active Nurse Aide Certification and if their certification expired for the NA to be removed from the schedule. The Administrator stated the HR director was responsible for notifying the scheduler when a NAs certification was going to expire. The Administrator stated there was only verbal communication that NA #1's NA certificate was going to expire, and no one verified that it was renewed.

Based on observation, record review, and resident, staff, manufacturer 's representative, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to: a.) supervise Resident #1 during a shower when Nurse Aide (NA) #1 turned away from Resident #1 to gather supplies on 09/18/25 and Resident #1 fell from the shower chair to the shower room floor. No pain or injury was noted from this incident; b.) provide a safe transfer for Resident #1 when NA #1 was transferring the resident from the bed to wheelchair using the mechanical lift. During the transfer and while Resident #1 was suspended approximately 4 to 5 feet from the floor, the lift tilted to one side and the resident fell while still in the sling onto the floor on her back. Then the mechanical lift fell on top of Resident #1 with the lift bar striking her on the top of her head. Resident #1 was evaluated at the hospital and diagnosed with a left calcaneal fracture (fracture of the heel bone) and a left anterior talus (the bone in the foot that connects the ankle to the leg) fracture and returned to the facility with a leg immobilizer and non-weight bearing orders pending orthopedic evaluation; c.) transfer Resident #1 safely when NA #5 and NA #6 had to manually stabilize the mechanical lift when the left back lift wheel lifted off the floor while the resident was suspended in the lift sling. Two additional staff assisted in completing the transfer safely with no injuries to the resident. It was observed after the transfer, the brand of lift sling used for the transfer was not the same brand as the mechanical lift utilized by the facility which does not align with the manufacturer's recommendations; and d.) transfer Resident #1 out of bed with the mechanical lift using a lift sling that was the same brand as the brand of mechanical lift utilized by the facility. In addition, an interview revealed the NAs were responsible for determining the sling size a resident required for mechanical lifts. This deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). The findings included:1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, decreased mobility, osteoarthritis, diabetes mellitus, morbid obesity, and non-Alzheimer's dementia.A Care Area Assessment summary dated 12/02/24 revealed Resident #1 was at risk for falls due to her dementia, incontinence, medications, lack of mobility, and functional decline in her activities of daily living (ADL). The summary indicated interventions were in place and updated, changed and/or added as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with no behaviors and no impairment of upper or lower extremities and used wheelchair for mobility. The assessment also revealed the resident was dependent for toileting, bathing, dressing and transfers, and required substantial to maximal assistance with personal hygiene, bed mobility, and partial to moderate assistance with mobility in her wheelchair. In addition, the resident's weight was documented as 304 pounds.An activity of daily living care plan dated 07/24/25 revealed Resident #1 had an ADL self-care performance deficit related to limited mobility. The goal was for Resident #1 to have needs met with staff assistance as needed. The interventions included two staff assistance with bed mobility and with care while in bed, required assist bars to aid in bed mobility, required two staff assist with mechanical lift and encourage the resident to use call bell for assistance.A falls care plan dated 07/24/25 revealed Resident #1 was at risk of falls characterized by history of falls/injury, multiple risk factors related to: dementia, confusion, medication use, incontinence, poor safety awareness and psychiatric disorder. The goal was to minimize falls with injuries through the next review. The interventions included fall prevention program per facility routine, encourage resident to get out of bed for meals as she agrees and/or wishes, bed in lowest position and fall risk assessments quarterly and as needed.a. During an interview with Resident #1 on 10/08/25 at 2:25 PM she revealed that on 09/18/25, NA #1 and NA #2 transferred her from her wheelchair into a bariatric shower chair. The resident stated she was not all the way back in the chair so NA #1 requested assistance from Nurse #3 to reposition the resident in the shower chair. Resident #1 further stated she could tell that she was not positioned all the way back in the chair and said it was a different chair than she was used to because her feet did not touch the floor in the chair. She explained that the other bariatric chair allowed her to keep her feet on the floor and gave her a sense of balance while in the shower chair. Resident #1 indicated she told NA #1 that she was in the wrong shower chair because her feet did not touch the floor and said NA #1 told her she was okay in the chair she was in. Resident #1 stated NA #1 turned away from her to get supplies and the shower chair started to tip but NA #1 was able to turn back around and catch her and the chair before she fell. Resident #1 further stated NA #1 turned away from her again to get supplies and this time Resident #1 said the chair tipped forward and she fell out of the chair onto the floor on her left side hitting her left arm and shoulder on the shower floor. Resident #1 stated NA #1 tried to grab her right arm to stop her from falling but was unable to stop the fall. Resident #1 said she screamed as she was falling and then NA #1 screamed for help and three additional staff members came in the shower room. Resident #1 stated NA #1, NA #2, Nurse #3, and the Speech Therapist (ST) got her up with the lift and back in her wheelchair and then transferred her back to bed. Resident #1 further stated she had not gone out to the hospital after the fall because she had been assessed as having no injury from the fall. Resident #1 further indicated after the fall in the shower room she had two persons come in to provide her care.A telephone interview was conducted with NA #1 on 10/10/25 at 11:12 AM. She was assigned to care for Resident #1 on the 7:00 AM to 7:00 PM shift on 09/18/25. NA #1 stated Resident #1's first fall with her happened right after lunch time on 09/18/25 when she had the resident in the shower room. She and NA #3 had transferred the resident via mechanical lift into the shower chair from her wheelchair in the shower room and NA #3 left the shower room to care for her assigned residents. Resident #1 scooted forward in the shower chair to get her feet on the floor. NA #1 said she turned her back to the resident to get some supplies and the resident started going forward in the shower chair towards the floor. NA #1 went behind the resident and gently sat her down on the floor. NA #1 stated the resident screamed and she screamed for help. Nurse #3 and NA #2 and NA #3 came into the shower room. She stated NA #2 left the shower room to get the mechanical lift and NA #3 went to get the vital signs machine. NA #2 asked the Speech Therapist (ST) to come in and assist with getting Resident #1 up off the shower room floor and into her wheelchair with the lift. NA #1 stated she, NA #2, Nurse #3 and the ST got Resident #1 up with the lift and safely transferred her to her wheelchair and then transferred her from her wheelchair to her bed. An interview on 10/08/25 at 12:20 PM with NA #2 revealed she recalled Resident #1's fall on 9/18/25 in the shower room. NA #2 stated she heard the resident scream and went into the shower room, and she was on the floor curled up in a ball lying on her left side crying in the corner shower stall. She said the shower chair was being lifted back up by NA #1. NA #2 stated Resident #1 told her she fell out of the shower chair onto her left side, and the shower chair hit her on the back of the head as she was falling to the floor. NA #2 further stated Nurse #3 assessed Resident #1 on the floor of the shower room before they moved her and determined that she had no visible injuries. NA #2 indicated once the resident was assessed she, NA #1, Nurse #3 and the ST transferred Resident #1 from the floor to her wheelchair using the mechanical lift and then took her to her room and transferred lifted her from the wheelchair to the bed. An interview on 10/08/25 at 1:24 PM with the Speech Therapist (ST) revealed he was in the hallway on 09/29/25 and NA #2 asked if he could assist with getting Resident #1 up off the shower floor with the mechanical lift. The ST stated he was used to being asked to assist with residents because he was a big guy and could move residents that others were not able to move. He stated when he entered the shower room the resident was on the shower room floor lying on her left side. The ST assisted other staff (could not recall whom but said there were 3 other staff in the room) with getting the mechanical lift sling properly aligned under the resident and then assisted with lifting her from the floor to her wheelchair in the mechanical lift. The ST further stated Resident #1 was coherent and able to follow directions when he assisted with using the mechanical lift to move her from the floor to her wheelchair and then transferring Resident #1 back to bed she was not crying or complaining of any pain. Review of a fall report completed on 09/18/25 at 3:25 PM by Nurse #3 who was assigned to care for Resident #1 during the 7:00 AM to 7:00 PM shift revealed the following: During shower, staff reported the resident was moving in an attempt to re-adjust self in shower chair, causing the shower chair to tilt forward. The resident began to slide requiring staff to lower her to floor and call for help. The inter-disciplinary team met following the fall and reviewed the fall based on the information provided by NA #1 that the resident was in the shower and attempted to reposition and slipped off the shower chair. The intervention put into place was for two-persons assistance in the shower. The resident was recorded as being at risk for falls related to morbid obesity, delusional disorder, hallucinations, unsteady gait, and abnormal posture. The resident's care plan was updated, notifications completed, and plan of care was to continue. A nurse progress note dated 09/18/25 and written by Nurse #3 revealed that during shower resident attempted to re-adjust self in shower chair and chair tilted. Staff had to lower the resident to ground and call for help per staff. A second nurse progress note dated 09/18/25 and written by Nurse #3 was an addendum to previous fall note that resident had no injury noted, vitals were obtained, unit manager, emergency contact and physician were notified of resident's fall.A telephone interview on 10/08/25 at 5:07 PM, with Nurse #3 revealed 09/18/25 was her first day working at the facility and she was sitting at the desk charting and NA #1 opened the door to the shower room and asked for help in repositioning Resident #1 in the shower chair. Nurse #3 stated she helped try to reposition the resident in the chair but said the resident did not seem to be comfortable in the shower chair and kept saying that she was in the wrong chair and she was used to the other shower chair. Nurse #3 stated she asked NA #1 if they needed to switch her chair and NA #1 said no that Resident #1 was fine in the chair she was in. Nurse #3 said she left the shower room and said maybe five or so minutes later she heard a boom and then screaming. Nurse #3 further stated she ran back into the shower room and Resident #1 was on the floor and NA #1 and NA #2 were in the shower room and by the time she got in there the shower chair was sitting upright and away from the resident. She said by this time there were several staff in the shower room and NA #2 went to get the lift and NA #3 went to get the vital signs machine. Nurse #3 stated Resident #1 told her in the shower room that she had fallen out of the shower chair on her left side and hit her arm and shoulder on the shower floor but said that she was not injured just shook up. Nurse #3 assessed the resident on the shower room floor and then she, NA #1, NA #2 and the Speech Therapist (ST) lifted the resident off the floor and into her wheelchair using the mechanical lift and then they transferred Resident #1 from the wheelchair back to bed. Nurse #3 explained that she reported the incident to Unit Manager #1, Director of Nursing (DON), called the emergency contact for the resident, called the physician, and completed a fall report and charted the incident. She stated Unit Manager #1 told her that was all she needed to do following the fall.During a telephone interview with NA #3 on 10/09/25 at 11:26 AM she revealed she recalled the day Resident #1 fell in the shower room. She stated she was not in the shower room at the time of the fall but had assisted NA #1 with getting Resident #1 from her wheelchair to the shower chair that day in the shower room. NA #3 recalled the resident kept complaining about being in the wrong chair. She stated the resident was in a bariatric shower chair and she didn't understand what the resident was referring to about being in the wrong chair but said NA #1 told her she was fine in the chair that she was in. NA #3 stated that after Resident #1 fell, she had gotten the vital signs machine and checked her vitals while the nurse assessed Resident #1. NA #3 further stated after she checked Resident #1's vital signs she left the room with the machine and continued with care of her residents.An observation of the shower room on 10/08/25 at 2:47 PM with NA #2 revealed there were three shower chairs and one shower bed in the shower room. Two of the three shower chairs were bariatric chairs. The bariatric chairs were placed side by side and the blue trimmed bariatric chair was approximately two inches higher than the white bariatric chair. The blue trimmed chair had a step stool that slid out from under the seat of the chair at the base that allowed for a resident who was ambulatory to step onto the stool and into the chair. The blue trimmed chair also had a blue cushion on the seat and the arms of the chair and the seat of the chair were approximately two inches higher than the arms and seat on the white bariatric chair and the back of the chair extended higher than the back of the white bariatric chair.An interview with the Director of Nursing (DON) on 10/09/25 at 1:25 PM revealed that after Resident #1's fall in the shower room, the interdisciplinary team held a huddle (short meeting held to share information, problem solve and manage resident safety). She stated in addition an interdisciplinary team meeting was held and it was determined that given the resident's size it would be safer for her and the staff if there were two staff present for her showers. The root cause of her fall in the shower room was determined to be that only one staff member was with her in the shower room and now they were going to implement two staff persons for her shower. The DON stated she was not aware Resident #1 had a preference for the shorter shower chair so she could keep her feet on the floor. She said she would update her care plan for the preference of the shorter shower chair.b. During an interview with Resident #1 on 10/08/25 at 2:25 PM she revealed that on 09/29/25 NA #1, who had let her fall in the shower room a few days prior, tried to transfer her from the bed to her wheelchair by herself using the mechanical lift and she fell to the floor and the lift fell on top of her with the top of the lift (boom) hitting her on the top of her head. Resident #1 stated she screamed as the lift was falling with her in the sling and said when she hit the floor her left ankle and back started hurting and her head started hurting where the lift had hit her on top of her head. Resident #1 said it was scary, and she was still scared to be transferred using the mechanical lift. Resident #1 stated when Nurse #2 came into the room, the nurse said one of the straps had come loose and was laying across her. Resident #1 said no one else had ever tried to get her up with the mechanical lift by themselves. Resident #1 explained she had gone to the hospital and had returned later in the evening on the same day. She said she had followed up with the orthopedic doctor in his office, and he had put a boot on her left lower leg to stabilize the fracture in her foot. A telephone interview on 10/08/25 at 11:11 AM with NA #1 confirmed she had attempted to transfer Resident #1 using a mechanical lift without additional staff assistance on 09/29/25. She stated Resident #1 had fallen to the floor along with the lift during the transfer. NA #1 recalled Resident #1 was being transferred to her wheelchair to go to the dining room for lunch. NA #1 stated she had requested assistance from NA #4 who was also working on the hall to assist her, but said NA #4 had been in the shower room giving a shower to another resident. NA #1 stated NA #2 was in another resident room providing care, so she had asked Nurse #1 for assistance because they had been instructed to always have 2-person assist when using the mechanical lift. She said Nurse #1 was busy with medications and treatments of other residents. NA #1 explained she positioned Resident #1 in her sling and made the decision to go ahead and transfer the resident by herself. NA #1 indicated after she had gotten Resident #1 positioned in the sling, she made sure the sling straps were all positioned correctly, and the clasps locked in place and then proceeded with the transfer. She recalled Resident #1's bed was in a low position, and she didn't have to lift her any higher and used the lift to move her horizontally off the bed. Resident #1 was suspended approximately 4 to 5 feet from the floor and as NA #1 moved the lift towards her wheelchair, the lift tilted, and Resident #1 fell onto the floor on her back. The lift fell on top of her with the lift bar striking her on the top of her head. NA #1 stated somehow the lift struck her on the forehead as it was falling and she had a big bump on her forehead. NA #1 restated she was instructed to always have 2-person assist when using the mechanical lift and she made the wrong decision to go ahead and transfer Resident #1 without waiting for help.An interview on 10/08/25 at 9:47 AM with NA #2 revealed on 9/29/25 she passed NA #1 in the hallway and saw her go into Resident #1's room and said about 10 minutes later she heard a boom and screaming. NA #2 stated she ran into Resident #1's room and Resident #1 was lying on the floor and the resident said, She dropped me. NA #2 stated that the lift pad was not properly positioned under the resident to provide adequate support and noted that the leg strap between the resident's legs was not crisscrossed as required. NA #2 stated the lift was lying on top of the resident and Resident #1 told her the lift bar had hit her on the top of her head. NA #2 indicated the lift had somehow hit NA #1 on her forehead and she had a knot on her forehead from the lift. NA #2 stated NA #1 left the room to get ice to place on her head and NA #2 went and got the Director of Rehabilitation while Nurse #2 assessed the resident on the floor. NA #2 stated Resident #1 was crying and complaining of left ankle pain, pain on the top of her head and lower back pain. NA #2 explained that Resident #1 was transferred from the floor back to bed with the mechanical lift by the Director of Nursing, Director of Rehabilitation and herself with leg strap crisscrossed between her legs and she was transferred back to bed without incident. NA #2 went on to explain that all the staff knew that a mechanical lift required two staff members and said that NA #1 never asked her for assistance in getting Resident #1 up out of bed and into her wheelchair.An interview with Nurse #1 on 10/08/25 at 10:41 AM revealed that on 09/29/25 she was at the nurses' station and heard a loud bang and screaming. She went into Resident #1's room and saw the resident on the floor on her back with the lift on top of her and the lift wheels in the air. She stated about that time Nurse #2 who was assigned to care for Resident #1 during the 7:00 AM to 7:00 PM shift came in and she and two other NAs (could not recall who they were) disconnected the lift pad from the lift and moved the mechanical lift off the resident. Nurse #1 stated she left the room to call Emergency Medical Services (EMS) and call the provider while Nurse #2 assessed the resident. Nurse #1 stated she got the paperwork ready for Resident #1 to go to the hospital and then returned to the room. The DON, NA #2, Nurse #2, and the Director of Rehabilitation transferred the resident off the floor and back to bed with the mechanical lift. Nurse #1 stated Resident #1 was crying and complaining of pain in her left ankle and back. She stated the Nurse Practitioner was in the building and came to the room to assess the resident and was going to order x-rays, but EMS arrived, and she gave orders for the resident to go out to the hospital for evaluation and treatment.Review of a fall report completed on 09/29/25 at 11:40 AM by Nurse #2 revealed the interdisciplinary team reviewed the fall. The staff member's action was negligent and unsafe. Immediate investigation, audits, orders completed and initiated. Intervention for two persons assistance with all care needs and transfers. Referral to physical therapy.A nurse progress note dated 09/29/25 at 11:40 AM written by Nurse #2 read in part, Resident was in mechanical lift transferring to wheelchair. Staff was using the mechanical lift and resident dropped to floor, mechanical lift turned over and landed on top of resident. Assessment left ankle pain, back pain and headache. Nurse Practitioner in building notified and order received to transfer to emergency room (ER).A second progress note dated 09/29/25 at 12:31 PM written by Nurse #2 read in part, Resident was transferred to the hospital by EMS for evaluation and treatment, after having a fall. NP ordered to transfer resident by EMS.During a telephone interview with Nurse #2 on 10/08/25 at 11:22 AM Nurse #2 stated she was assigned to care for Resident #1 on 09/29/25 during the 7:00 AM to 7:00 PM shift. She stated she was at her cart pulling medications for another resident when she heard someone hollering so she went down the hall and happened to look in Resident #1's room and saw her lying on the floor with the mechanical lift lying on top of her chest. Nurse #2 stated the legs of the lift were closed and NA #1 was pacing around in the room saying, Oh my gosh, I have dropped her. Nurse #2 stated she and another NA (could not recall whom) took the straps of the lift sling out of the lift bar and got the mechanical lift off the resident. Nurse #2 stated she was assessing the resident, and Resident #1 was screaming with pain in her left foot and said when she assessed her left foot, she could see it was swelling. She stated Nurse #1 who was also in the room went out to call EMS and start Resident #1's paperwork so she could be transferred to the hospital. Nurse #2 stated she, NA #2, the DON and the Director of Rehab used the mechanical lift and got Resident #1 back into the bed. She further stated when they had gotten the resident back to bed the NP came in the room and was going to assess the resident, but EMS walked in right after and they took over and transported the resident to the hospital. Nurse #2 stated NA #1 was in the room to answer questions EMS had about the resident's fall and said after EMS left with the resident, NA #1 left the room with the DON.An interview with the Director of Rehabilitation on 10/08/25 at 12:29 PM revealed he came into the room on 09/29/25 to assist with getting Resident #1 off the floor and into her bed. He stated he assisted DON and NA #2 in getting the sling properly positioned under the resident and lifting her from the floor onto her bed. The Director of Rehab stated Resident #1 was tearful and complaining that her left ankle was hurting. He further stated they had done an evaluation of her after her first fall and were planning to pick her up for physical therapy but said she came back from the hospital with orders to be non-weight bearing so they were waiting until she could bear weight on her left foot and leg.A physician progress note dated 09/29/25 written by the facility's Nurse Practitioner (NP) indicated [Resident #1] seen for acute visit at facility request due to recent fall while being transferred to wheelchair via mechanical lift. Resident with complaints of left ankle pain and headache where lift hit her on the head. EMS arrived while this provider was assessing resident. Acute status post fall while being transferred to wheelchair via mechanical lift. Resident reports lift hit her on the head and resident requires escalation to next level of care hospitalization for further evaluation and treatment.A telephone interview with the facility's NP on 10/09/25 at 4:12 PM revealed she had been at the facility on 09/29/25 when Resident #1 fell from the mechanical lift. She stated a staff member (could not remember whom) came and asked her to see the resident because she had fallen from the lift and was complaining of left foot pain, back pain and a headache. The NP stated she went into the room and was assessing the resident and was going to order x-rays when EMS walked in the room. She said once EMS walked in, she stepped aside and gave them the scene and ordered for the resident to be sent to the local hospital emergency department (ED) for evaluation and treatment.Resident #1's hospital records revealed the resident presented to the emergency department (ED) at the local hospital on [DATE] after falling about 5 feet from a mechanical lift and the lift fell on top of her but denied loss of consciousness. Resident #1 complained of lumbar back pain, left leg pain, and severe left foot pain. Resident was found to have possible acetabular (socket-shaped bone that forms the hip joint) fracture, a left calcaneal fracture (fracture of the heel bone) and a left anterior talus (the bone in the foot that connects the ankle to the leg) fracture. The fracture was discussed with orthopedic surgery who did not recommend acute surgical intervention and recommended follow up with a local orthopedic practice. It was documented that a lot of her symptoms were exacerbated by movement which was consistent with musculoskeletal strain/sprain from the fall. The ED physician considered hospitalization but on re-evaluation the resident appeared well, so she discharged back to nursing home with immobilizer and orders to follow up with orthopedics.Review of a physician progress note dated 09/30/25 by the Medical Director revealed in part, the resident was seen following fall and visit to the local hospital ED. The resident was evaluated in the ED where she was informed of fractures in her foot and a possible fracture in her leg. She had not yet had a follow-up with an orthopedic specialist. The resident complained of significant pain, particularly in her lower back, and said she had been taking acetaminophen which had provided some relief but indicated it was not sufficient to manage her pain efficiently. The plan was for orthopedic evaluation required to confirm the fracture and decide on treatment plan, follow up required to confirm fractures in the left foot following fall, and prescription written for oxycodone for stronger pain relief.During a telephone interview with the Medical Director of the facility on 10/10/25 at 11:12 AM he revealed he had not been at the facility the day of Resident #1's fall but said the NP had been there and ordered her to be sent out to the local hospital. The Medical Director stated he evaluated the resident on 09/30/25 in the facility and said he understood she was in the mechanical lift and something happened with the lift, and she fell about five feet to the floor in her room. He stated he reviewed the ED notes and x-rays and scans completed on Resident #1 at the hospital and found the resident was having some pain that was not relieved by her acetaminophen. He ordered some stronger pain medication to be given every 8 hours as needed for pain and ordered follow-up with an orthopedic specialist as soon as possible. The Medical Director further stated the resident had not ambulated in over a year and while it was unfortunate she had been dropped from the lift, he didn't expect her to be able to ever ambulate again.Review of a consultation report dated 10/01/25 with an orthopedic specialist revealed in part the resident was seen and x-rays performed and the resident was diagnosed with left mildly displaced calcaneus (heel bone) fracture extending into the anterior talus joint (joint that connects the tibia and fibula to the ankle) and lumbar spine degenerative disc disease with right-sided radiculopathy (condition caused by compression or irritation of a nerve root where it exits the spine or pinched nerve). Recommendations included immobilization of the left foot and ankle in a tall walker boot, physical therapy and progression to touch down weight bearing if able to progress with therapy. Also recommended follow-up with orthopedics in three weeks for x-rays and to check progression.An interview with the Director of Nursing (DON) on 10/09/25 at 1:25 PM revealed she was called in to assist at the time of Resident #1's fall on 09/29/25 by NA #2. She stated she and Nurse #2 evaluated Resident #1 while she was still on the floor and she complained of lower back pain, left foot pain and her head hurting where the mechanical lift hit the top of her head. The DON said she, Nurse #2, NA #2 and the Director of Rehabilitation transferred the resident with the mechanical lift from the floor back to bed and the resident told them she felt better now that she was in bed off the floor. The DON stated the NP was in the building and came in to assess the resident and shortly after EMS arrived and the NP gave orders to send Resident #1 out to the local hospital ED for evaluation and treatment. She stated Resident #1 was transported out to the hospital by EMS. The DON further stated NA #1 was immediately suspended after she talked with her and found out she had transferred the resident without a second staff member. She stated Resident #1 returned to the facility from the hospital on the evening of 09/29/25 and had a follow up appointment at the orthopedic specialist's office on 10/01/25. The DON further stated there had been no other incidents since 09/29/25 with mechanical lifts. The DON indicated the NAs were responsible for determining the sling size a resident required for mechanical lifts. She explained that each sling had a weight capacity on the tag inside the sling and the NAs measured the resident from the base of their spine to the top of their shoulder with a tape measure to determine if the sling was an appropriate fit for the resident. She further explained that a large sling had a maximum weight capacity of 500 pounds and an extra-large sling had a maximum weight capacity of 850 pounds and the extra-large sling was the one used for Resident #1. According to the DON the root cause of Resident #1's fall on 09/29/25 was only one staff member transferring the resident in the mechanical lift. c. Review of the manufacturer's information for the brand of mechanical lift used by the facility revealed it had a lift capacity of 600 pounds. There was also a placard on the mechanical lift that indicated the weight capacity as 600 pounds. In addition, the manufacturer's recommendations stated the following: Slings are made specifically for use with the mechanical patient lifts. For the safety of the patient, DO NOT intermix slings and patient mechanical lifts of different manufacturers. According to the manufacturer's recommendations the slings for the brand of mechanical lift at the facility come in sizes extra-small through extra extra-large and come with their own identification information on the label. The information on the label included model reference number, type of sling, size, date of manufacture, care instructions, weight capacity and an identification picture of the sling. The extra-small through large slings had a weight capacity of 500 pounds. The extra-large sling had a weight capacity of 550

Based on observation, record review, and resident and staff interviews, the facility failed to provide incontinence care to a resident prior to her wetting through her brief, turn sheet, and bed sheet for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atrial fibrillation, diabetes mellitus, decreased mobility, osteoarthritis and non-Alzheimer's dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with no behaviors and no impairment of her upper or lower extremities and used a wheelchair for mobility. The assessment also revealed the resident was dependent for toileting, required 2 persons assistance with toileting and was incontinent of both bladder and bowel.A urinary incontinence care plan last revised on 10/14/25 revealed Resident #1 was incontinent of urine. The goal was for Resident #1 to receive assistance with toileting, be maintained comfortable, clean and dry and free from skin breakdown. The interventions included providing incontinence care as needed and monitoring peri-area for redness, irritation, skin excoriation and breakdown.An activity of daily living self- care performance deficit care plan last revised on 10/14/25 revealed Resident #1 required assistance with all ADL related to limited mobility. The goal was for Resident #1's needs to be met with staff assistance as needed. The interventions included encourage Resident #1 to use bell to call for assistance, and 2 persons assist with bed mobility and with all care while resident is in bed.An observation of incontinence care on 10/14/25 at 10:30 AM, revealed Resident #1 was being assisted with a brief change by Nurse Aide (NA) #5 and NA #6. When NA #5 and NA #6 pulled back Resident #1's bed covers, the bed sheet was visibly wet under the resident. NA #5 pulled back the resident's brief and it was saturated from the front of the brief to the back of the brief with urine and the inside of the brief had begun to bunch up. NA #6 cleaned the resident from front to back and then NA #5 and NA #6 assisted the resident to turn on her side so NA #6 could clean her back side. NA #6 then placed a clean brief under the resident and she and NA #5 turned the resident to get the brief placed on her and get the soiled brief off the resident. When NA #5 threw the soiled brief in the trash can it made a loud thud. NA #5 and NA #6 then placed clothing on the resident so she could get up in her wheelchair. Once the resident had been transferred to her wheelchair there was a visible wet spot on the turn sheet and the bed sheet under it was visibly wet with urine as well. NA #7 came in and stripped the wet turn sheet and bed sheet from the bed.An interview on 10/14/25 at 10:55 AM with Resident #1 revealed she had not been provided incontinence care since 1:30 AM on 10/14/25 until she received it at 10:30 AM. Resident #1 stated NA #8 who was caring for her during the 7:00 PM to 7:00 AM shift had come in and told her that she would be back to change her brief around 6:00 AM but said NA #8 never came back to change her. Resident #1 further stated NA #7 who was assigned to care for her during the 7:00 AM to 7:00 PM shift on 10/14/25 had come into her room and told her she would be back with another NA to change her but said she never came back before NA #5 and NA #6 came in to get her ready to get up in the wheelchair and they had changed her brief. Resident #1 stated they usually changed her two to three times during the night because she urinated frequently but said they had only changed her once after midnight at 1:30 AM. Resident #1 indicated she knew she was wet because when she woke up sometime between 5:30 AM and 6:00 AM she felt her wet sheet against her leg and it was cold. The resident further indicated she had eaten her breakfast in bed in her wet brief but said she was more concerned with eating because her blood sugar had been low earlier at 6:00 AM. A telephone interview on 10/14/25 at 3:20 PM with NA #8 who was assigned to care for Resident #1 during the night shift on 10/14/25 revealed she had not changed Resident #1 after 1:30 AM. She stated it had been a busy night and she had gone to change the resident around 6:00 AM and the resident was shaking and told NA #8 she thought her blood sugar was low and asked her to get the nurse. NA #8 stated she was going back to change Resident #1 around 6:30 AM to 6:45 AM and said her coworker had left shift early and was not available to assist her so she had reported off to 1st shift (could not recall who she reported off to) that Resident #1 needed to be changed. NA #8 further stated Resident #1 should have been changed one additional time during the night but said it was difficult when there were only 2 NAs working to get both NAs in one room to change the resident. NA #8 indicated she had not asked the nurse for assistance because she had been busy with other tasks but said that she probably should have asked her to assist and changed the resident.An interview on 10/14/25 at 11:10 AM with NA #5 and NA #6 revealed they were not assigned to care for Resident #1 but said they had been asked to lift her out of bed into her wheelchair by Unit Manager #1. NA #5 and NA #6 both stated when they went into the room to get her ready for the lift, they found her wet through her brief and turn sheet and onto her bed sheet, so they had provided her with incontinence care prior to lifting her in the mechanical lift into her wheelchair. Both NAs stated they were not assigned to care for the resident but had been asked to get her up, so they had changed her prior to getting her up in the wheelchair.An interview on 10/14/25 at 2:08 PM with NA #7 who was assigned to care for Resident #1 during the 7:00 AM to 7:00 PM shift revealed she was working her way towards Resident #1 but had not gotten to her before NA #5 and NA #6 had changed her to get her up in her wheelchair. NA #7 stated Resident #1 had told her that she had not been changed since 1:30 AM and said the resident should have been changed twice more during the night shift. NA #7 stated she had to wait until there was another NA available to help her change Resident #1 and said Unit Manager #1 had pulled an NA from the rehabilitation floor to come assist with Resident #1's care and getting her up in the wheelchair. NA #7 further stated no one had reported off to her that the resident had not been changed but once during the night but said the resident had told her and she was waiting for another staff member's assistance to get her changed.An interview with Unit Manager #1 on 10/14/25 at 3:35 PM revealed she was not aware that Resident #1 had gone from 1:30 AM to 10:30 AM on 10/14/25 without being provided incontinence care. She stated no one had asked her for assistance and said she assisted with care to residents all the time. Unit Manager #1 stated NA #7 was an agency NA and probably was waiting until one of the other NAs was free to assist. Unit Manager #1 further stated it was their expectation that residents be rounded on every 2 to 3 hours and checked and changed as needed. She said that no resident should go from 1:30 AM to 10:30 AM without being checked and changed several times. The Director of Nursing (DON) was not available for interview.

Based on observations, record review and staff interviews, the facility failed to develop comprehensive individualized care plans in activities of daily living (ADL) for 1 of 4 residents (Resident #47). Findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #47's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition and displayed no moods or rejection of care. He was coded for partial assistance with oral hygiene. Resident #47's care plan dated 6/30/24 had a problem category for ADL Functional Status related to weakness and limited mobility. Approaches included assisting with activities of daily living, dressing, grooming, toileting, feeding and oral care. There was no denture care noted on the care plan. Resident #47 was not interviewable. An interview with Nurse #1 conducted in conjunction with an observation of Resident #47 on 10/22/24 at 12:49 PM revealed she was unaware if Resident #47 had dentures. She stated if he had dentures, they should be on his care plan so the Nursing Assistants were aware they should provide denture care. Nurse #1 asked Resident #47 if he had dentures and the resident removed the upper plate but did not remove the lower plate. The upper plate was coated with food debris and had black areas between the teeth. She stated the Nursing Assistants should remove his dentures every night to be cleaned, placed in a cup to soak during the night, and they should be placed back in his mouth every morning before breakfast. An interview on 10/23/24 at 4:42 PM with the MDS Nurse revealed she was aware Resident #47 had dentures. She stated his denture should have been included in his care plan. The MDS Nurse stated it was human error and she had overlooked his dentures when she developed his care plan. An interview on 10/23/24 at 11:22 AM with the Director of Nursing stated Resident #47 should receive oral, or denture care every morning and evening. She stated that he required assistance with his dentures which included cleaning and soaking them, but he could put them in and take them out of his mouth. She also stated that she was aware he had dentures based on his admission assessment, but it should have been on his care plan. An interview on 10/23/24 at 5:19 PM with the Administrator revealed she expected the care plan to be comprehensive and accurate.

Based on observations, record review and staff interviews, the facility failed to provide oral care for 1 of 4 dependent residents reviewed for activities of daily living (Resident #47). Findings included: Resident # 47 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #47's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition. He was coded for partial staff assistance with oral hygiene. He was coded for no behaviors or rejection of care. Resident #47's care plan dated 6/30/24 had a problem category for ADL Functional Status related to weakness and limited mobility. Approaches included assisting with activities of daily living to include oral care. There was no other oral care or denture care noted on the care plan. Resident #47 was not interviewable. An interview with Nurse #1 conducted in conjunction with an observation of Resident #47 on 10/22/24 at 12:49 PM revealed she was unaware if Resident #47 had dentures. She stated if he had dentures, they should be on his care plan so the Nursing Assistants (NA) were aware they should provide oral denture care. Nurse #1 asked Resident #47 if he had dentures and the resident removed the upper plate but did not remove the lower plate. The upper plate was coated with debris and had black areas between the teeth. She stated the Nursing Assistants should remove his dentures every night, they should be cleaned, placed in a cup to soak during the night and they should be placed back in his mouth every morning before breakfast. An interview on 10/23/24 at 1:05 PM with Nursing Assistant (NA) #5 revealed she had been assigned to provide care for Resident #47 on the 7 PM to 7 AM shift which started at 7 PM on 10/21/24 and ended at 7 AM on 10/22/24. She stated she was frequently assigned to provide care for him. She stated she was unaware if he had dentures and had not provided oral care for him when she was assigned to him on 10/21/24 into 10/22/24 or any other night. She stated on 10/21/24 night shift she had not removed his dentures or provided him oral or denture care. She stated that she was able to tell if a resident had dentures by looking in their mouth, but she had not looked at his teeth and was unable to state if he had dentures. She was unable to clarify if he required assistance with oral or denture care. An interview on 10/22/24 at 3:28 PM with NA #6 revealed she was assigned to provide care for Resident #47 sometimes and was assigned to provide care for him on 10/22/24 on the 7 AM to 7 PM shift. She stated she did not know if he had dentures and had not provided oral care for him that morning. She stated she usually asked the resident if they had dentures or looked in the nightstand for the denture cup. NA #6 stated Resident #47 required assistance with oral care and residents should be given oral care in the morning and at bedtime. An interview on 10/23/24 at 11:22 AM with the Director of Nursing revealed she was aware Resident #47 had not received oral care on 10/21/24 and 10/22/24. She stated he should receive oral or denture care every morning and evening. She stated that Resident #47 required assistance with his dentures which included cleaning and soaking them, but he could put them in and take them out of his mouth. She also stated that she was aware he had dentures based on his admission assessment. An interview on 10/23/24 at 5:19 PM with the Administrator revealed she expected Resident #47 to received oral care every morning and evening. She stated that dentures should be included on the resident's care plan to ensure staff were aware when residents have dentures, so they provide proper care. She felt lack of staff education had resulted in Resident #47 not receiving adequate oral hygiene.

Based on observations and staff interviews the facility failed to remove an unidentified resident's medications, failed to remove loose and unsecure pills and failed to remove debris of paper shavings and rubber bands from medication cart (medication cart #2) and failed to remove loose and unidentified pills and debris of paper shavings and rubber bands from medication cart (medication cart #1) for 2 of 2 medication carts reviewed for medication storage. The findings included: a. On 10/23/24 at 3:12 PM an observation was made of medication cart #2 along with Nurse #1. Stored in the narcotic drawer was a resident's personal weekly medication container that contained no resident name or information that had 6 pills in the Thursday's slot, 7 pills in the Friday's slot and 7 pills in the Saturday's slot. The medication cart also had 21 loose and unidentifiable pills in the bottom of the drawers along with debris of paper shavings and rubber bands. An interview was conducted with Nurse #1 on 10/23/24 at 3:12 PM. The Nurse explained that the medication container was in the narcotic box when she accepted the keys to the medication cart that morning and when she asked the nurse who reported off to her who's medications they were, the nurse did not know. Nurse #1 stated she should dispose of the medications because they were unidentifiable, and she did not know who they belonged to. The Nurse also explained that every nurse was responsible for keeping the medication carts clean but that was the first time in a long time she was on medication cart #2 and did not have time to clean the medication cart. b. An observation was made on 10/23/24 at 3:39 PM of medication cart #1 along with Nurse #2. The cart yielded 4 loose and unidentifiable pills in the bottom of the drawers as well as debris of paper shavings and rubber bands. During an interview with Nurse #2 on 10/23/24 at 3:39 PM the Nurse explained that the night shift was responsible for keeping the medication carts clean and orderly. She indicated the loose pills should be discarded since she did not know who they belonged to. An interview was conducted with the Director of Nursing on 10/23/24 at 3:50 PM who explained that she thoroughly cleaned and organized both medication carts about a month ago. She stated there should not be any unidentified medications stored on the medication carts and each nurse should keep their medication carts clean and orderly. The DON also stated each nurse was responsible for keeping the medication carts clean and orderly

Based on record review and resident and staff interviews the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident (Resident #1). Resident # 1 reported she started to cry, was scared, was upset the aide was hurting her. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included muscle weakness, hypertension, lack of coordination, and renal failure. Diagnoses further revealed Resident #1 had a fracture to the right tibia dated 06/30/23 with orders to wear a brace. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required two plus assist with transfers. The MDS further revealed Resident #1 was not coded for behaviors. Resident #1's care plan revised on 05/05/23 revealed Resident #1 had limited physical mobility due to weakness. The goal was for Resident #1 to remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions included to provide gentle range of motion as tolerated with daily care, provide supportive care and assistance with mobility as needed, and requires mechanical lift with two staff assist for transfers. Resident #1's care plan revised on 07/09/23 revealed Resident #1 required the use of an immobilizer to lower right extremity. The goal was for Resident #1 to be free of pain or discomfort through the next review. Interventions included providing verbal prompts. Review of the facility initial allegation report dated 08/25/23 revealed on 08/25/23 at 5:50 PM Resident #1 stated to the MDS Coordinator NA #1 hit her on the right side of the temple. The report further revealed a skin assessment was completed by the MDS Coordinator and there was no evidence of abuse. Review of the investigation completed by the Administrator on 08/31/23 related to Resident #1's incidents revealed the following: -NA #1's written statement dated 08/25/23 revealed NA #1 and NA #2 went into Resident #1's room to provide care and Resident #1 started to fuss and state she was going somewhere else. NA #1 further revealed while she and NA #2 were lifting her into bed and Resident #1 tried to sit up and the resident stated leave me alone and get out. NA #1 indicated she told Resident #1 she needed to check her brief and Resident #1 stated no, I do not want you in here. NA #1 revealed she just wanted to make sure Resident #1 was not wet and started to remove Resident #1's brace on her right leg. Resident #1 started to slap at NA #1, and NA #1 indicated she grabbed Resident #1's right hand and placed it on her chest to keep her from hitting her. The statement revealed NA #1 was taking off Resident #1's right leg brace and Resident #1 balled up her fist and hit NA #1 multiple times. NA #1 stated she got Resident #1's right leg brace and pants off and told Resident #1 that she had to do her job and care for her. The statement indicated Resident #1 stated to get out and not come back and NA #1 indicated she would not return after getting Resident #1 properly positioned into bed. The statement further revealed NA #1 left the room and reported to Nurse #1 Resident #1's aggressive behaviors. The statement indicated later Resident #1's call light was on and NA #1 returned to Resident #1's room and the resident was upset and asked NA #1 to leave again. -NA #2's written statement dated 08/25/23 revealed she witnessed NA #1 put Resident #1 in the bed and Resident #1 stated NA #1 was hurting her. NA #2 further revealed in the statement NA #1 continued to do care and Resident #1 started to swing at her and NA #1 hit Resident #1's right hand and right leg which was in a brace. The statement indicated Resident #1 wanted NA #1 to get out of the room and NA #1 stated she wasn't going anywhere. NA #2 said both NA #1 and Resident #1 were cussing at each other. -Nurse #1's written statement dated 08/25/23 revealed during late evening medication pass Resident #1 wanted to make sure that NA #1 wasn't her NA. The statement further revealed Nurse #1 asked the resident what had happened, and Resident #1 revealed NA #1 moved her right bad leg after Resident #1 had told her not to move it a certain way. Resident #1 indicated NA #1 told her that she was her caregiver, and she would do whatever needed to be done and proceeded to move her right leg. Resident #1 indicated to Nurse #1 that she had hit NA #1. The statement further revealed Nurse #1 spoke to NA #1 and NA #1 reported she did not hit the resident and NA #1 moved her hand close to Resident #1's body after being hit by the resident. -Statement written by the MDS Coordinator dated 08/25/23 revealed at 5:50 PM NA #1 revealed Resident #1 had struck at the NA several times. The statement further revealed the MDS Coordinator went, and interviewed Resident #1 and the resident stated, the NA was moving me and hit my broken leg and told NA #1 that it hurts and don't touch it and to leave me alone. Resident #1 stated NA #1 indicated she was the resident's caregiver, and she was going to help her. The statement further revealed Resident #1 admitted to hitting NA #1 after NA #1 hit her on the temple. The MDS Coordinator notified the Administrator at 5:54 PM and left a voice mail and also contacted the Director of Nursing (DON) and Social Worker (SW). A phone interview with NA #1 on 09/07/23 at 10:20 AM revealed on 08/25/23 NA #1 entered Resident #1's room with NA #2 around 1:30 PM after the resident had returned from dialysis. NA #1 indicated Resident #1 told her she was tired and wanted to be put into bed. NA #1 further revealed they used a mechanical lift and assisted Resident #1 into bed. While assisting Resident #1 into bed NA #1 stated Resident #1 was stating I am leaving and going somewhere else. NA #1 revealed she got Resident #1 into her bed and started to remove her leg brace on her right leg to assist with care and Resident #1 stated to get out and leave me alone. NA #1 revealed Resident #1 began to strike at her and she grabbed her right hand and held it down on her chest. NA #1 indicated Resident #1 continued to state, leave me alone and get out. NA #1 revealed she let go of Resident #1's right hand and the resident began to hit NA #1 with a balled fist. NA #1 indicated she grabbed Resident #1's right arm again and held it down to her chest to restrain her from hitting her. NA #1 further revealed she continued to give care by taking off her right brace and pants. NA #1 indicated Resident #1 complained about her right leg brace being removed. NA #1 indicated Resident #1 was dry and she left the room with NA #2. NA #1 indicated she reported Resident #1's behaviors of hitting to Nurse #1 and Nurse #1 indicated she would report it to upper management on Monday. NA #1 revealed she continued to work on the floor until about 5:50 PM and reported to the MDS Coordinator Resident #1 had shown aggressive behaviors towards NA #1. NA #1 indicated shortly after speaking to the MDS Coordinator she was pulled into the conference room and was suspended for further investigation and was not allowed back in the facility. NA #1 indicated Resident #1 was not normally aggressive and does not feel like she was restraining her. NA #1 stated she had been educated to walk away if a resident became aggressive or combative but felt like she needed to complete Resident #1's care before leaving the room even though the resident had asked her to leave. An interview with NA #2 on 09/07/23 at 10:35 AM revealed on 08/25/23 after lunch she assisted NA #1 with Resident #1 getting into bed. NA #2 further revealed while lifting Resident #1 in the mechanical lift Resident #1 started to complain the lift was hurting her leg and wanted to be put down. NA #2 indicated NA #1 stated she was not putting the resident back down because the resident wanted to get back in the bed. NA #2 and NA #1 got Resident #1 into the bed and Resident #1 stated to NA #1 you are hurting me, and I want you to get out of my room. NA #1 stated I am not going anywhere because I am your caretaker. NA #2 revealed Resident #1 became more agitated and started to slap at NA #1 and NA #1 slapped Resident #1's right hand out of the way and pushed on Residents #1's right fractured leg that was in a brace. NA #2 indicated Resident #1 began to cry in pain and stated again for NA #1 to get out of her room. NA #2 revealed Resident #1 began to hit again at NA #1 and NA #1 took both hands and held them to her chest. NA #2 stated Resident #1 was very upset and continued to tell NA #1 to get out of her room. NA #2 indicated she pushed NA #1 off of Resident #1 and told NA #1 to get out of the room immediately. NA #2 indicated NA #1 stated she wasn't going any damn where that she was caring for the resident. NA #2 stated she told her to leave again, and NA #1 left the room mad. NA #2 revealed she stayed in the room with Resident #1 to calm her down and complete care of the resident. An interview conducted with Resident #1 on 09/07/23 at 11:50 AM revealed on 08/25/23 NA #1 and NA #2 assisted her into the bed and NA #1 was being rough and hurting her. Resident #1 further revealed she stated to NA #1 honey, you are hurting me. Resident #1 stated NA #1 pushed on her hurt right leg and stated she was the caregiver and was going to do what she wanted. Resident #1 further revealed she started to cry and was scared so she started to slap at NA #1 to get her off and asked her to leave. Resident #1 revealed NA #1 took both her hands and held them to her chest and eventually let go. Resident #1 indicated she did not recall if she received care or not because she was so upset. Resident #1 indicted NA #2 did not say anything or intervene until NA #1 had left the room. An interview conducted with the MDS Coordinator dated 09/07/23 at 12:00 PM revealed on 08/25/23 at 5:50 PM she was about to leave, and NA #1 stopped her and indicated Resident #1 was having aggressive behaviors. The MDS coordinator further revealed she went and spoke to Resident #1 and Resident #1 indicated NA #1 hit her right leg and her right temple and had hurt her. The MDS Coordinator stated Resident #1 had indicated NA #1 continued to be rough with her right leg and did not want her back in her room. The MDS coordinator revealed she contacted the Administrator and removed NA #1 off the floor immediately. It was further revealed the MDS coordinator assisted interviewing alert and oriented residents and completing skin audits with other residents who were cognitively impaired An interview conducted with Nurse #1 on 09/07/23 at 1:45 PM revealed on 08/25/23 after dinner she was completing a medication pass and observed Resident #1 looking at her strange and seemed to be scared. Resident #1 stated to Nurse #1 she wanted to make sure she was not NA #1 because NA #1 was rough with her and didn't want NA #1 to take care of her. Nurse #1 further revealed nobody had reported to her the incident or Resident #1's behaviors. Nurse #1 revealed the MDS Coordinator came to the resident's room right after she had spoken to Resident #1. An interview conducted with the Administrator on 09/07/23 at 4:30 PM revealed on 08/25/23 the MDS Coordinator called her about 6:30 PM and revealed Resident #1 reported NA #1 had hit her. The Administrator further revealed she instructed the MDS Coordinator to pull NA #1 off the floor immediately and came to the facility to complete an investigation. The Administrator revealed she received statements from all staff involved and interviewed Resident #1. The Administrator further revealed Resident #1 stated NA #1 had hurt her while putting her into the bed and had hit her right hand and leg. The Administrator indicated adult protective services, law enforcement, the state, and family were notified immediately. The Administrator indicated she completed a thorough investigation and completed in services, interviews with alert and oriented residents, skin audits with other residents, and started audits of care. The Administrator revealed nursing staff had been educated to walk away if a resident was being combative or aggressive. The Administrator further revealed NA #1 and NA #2 should have walked away from Resident #1 when she asked, and NA #2 should have reported immediately to upper management concerns of abuse. The Administrator was notified of immediate jeopardy on 09/08/23 at 9:00 AM. The corrective action plan for noncompliance dated 08/30/23 was as follows: On 8/25/2023 at approximately 5:50pm CNA (Certified Nursing Assistant) #1 informed Nurse #1 (MDS Nurse) that Resident #1 had hit her. Nurse #1 at approximately 5:50PM immediately notified NHA (Nursing Home Administrator) and interviewed Resident #1, who stated that she did indeed hit CNA #1 because she (CNA #1) had hurt her leg and had hit her on her hand and her leg with an open hand. The incident occurred between 2:30pm-3:00pm. On 8/25/2023 at around 6:25pm the Administrator interviewed Resident #1: Resident #1 indicated that CNA #1 and CNA #2 were transferring resident to bed, via mechanical lift and CNA #1 bumped Resident #1 foot on the foot board, which caused pain to her leg. Resident #1 stated she told CNA #1 to get out, but CNA #1 continued to take care of her, so Resident #1 hit CNA #1. Resident #1 indicated when she hit CNA #1, CNA #1 in turn hit Resident #1 on her left side of waist and left leg. Resident #1 denied any injury or pain at that time. On 8/25/2023, between 6:45-7:00pm, CNA #2 was interviewed by the Administrator. Administrator asked CNA #2 why she did not immediately report the abuse to Administrator. CNA #2 stated that she did not report right away because she was pulled away to help with another resident. After assisting other residents, CNA #2 stated she forgot to go back and report to the charge nurse. Upon interview with Administrator CNA #2 was re-educated to immediately report abuse to the facility Abuse Coordinator, the Administrator. On 8/25/2023, Nurse #1 removed CNA #1 from resident care area and placed her in the conference room between 6:00pm-6:05pm as soon as Administrator was made aware. On 8/25/2023, at approximately 6:00PM alleged perpetrator CNA #1 and witness CNA #2 were suspended pending an investigation. On 8/25/2023, staff working on the skilled unit were interviewed regarding abuse allegation, if they were aware of any abuse, neglect or exploitation of residents, or if they were aware of any concerns in this regard in the building at this time. Staff working on this unit (100 Hall) provided written statements regarding this allegation and day. All staff were educated regarding abuse allegation, if they were aware of any abuse, neglect or exploitation of residents, or if they were aware of any concerns. On 8/25/2023, APS and local Police Department were notified. On 8/25/2023, Investigation was initiated and NCDHHS was notified via fax by Administrator at approximately 6:30PM. Administrator immediately reported to NCDHHS after interviewing CNA #1 and CNA #2. On 8/25/2023, Administrator notified resident's daughter. B. How corrective action will be accomplished for resident(s) having potential to be affected by same issue needing to be addressed: On 8/28/2023, skin assessments were completed on all non-interviewable residents on resident #1 ' s unit (100 Hall). No other residents were identified. On 8/28/2023, interviews were completed on all residents cognitively intact on Resident #1's unit (100 Hall). No other residents were identified. On 8/28/2023, interviews were completed on residents cognitively intact on 100 Hall. No other residents were identified. Social Services Director completed interviews with alert and oriented residents with a BIMS (brief interview for mental status) of 12-15 which reflected residents to be cognitively intact. No one reported any abuse allegations. Residents on the skilled unit with a BIMS greater than 12 received education from the Social Services Director regarding abuse, neglect and exploitation and to report this to the Administrator immediately. Questions that were asked are as follow: 1. Do you feel afraid, or humiliated at any time here at the facility? 2. Has anyone said mean things to you? 3. Has anyone hit you or handled you roughly? 4. Has anyone made you feel uncomfortable or touched you inappropriately? 5. Have you seen or heard of any residents being treated like the above mentioned? C. What measure will be put in place or systemic changes made to ensure that the identified issue does not occur in the future? On 8/25/2023, Director of Nursing/Designee started verbal education, to include Dietary, Housekeeping, Therapy, Maintenance, Licensed Nurses, Certified Nursing Assistants, all non-licensed administration personnel, including agency staff on the following: reporting Abuse, Neglect and Exploitation. The facility will not tolerate abuse, neglect, and mistreatment, exploitation of residents and misappropriation of resident's property by anyone. The abuse policy includes the following: Protection of the Resident and Reporting. The abuse policy was included in staff re-education. Facility lesson plan that was delivered included Stopping when a Resident Says Stop, and Protecting Residents from Abuse. Staff were not allowed to work until education was received, which was provided by Charge Nurse and Director of Nursing. Education was directed to each individual department and whom they should report to including during off hours. All staff report up to their supervisor and if their supervisor is not available, report to Charge Nurse. Charge Nurse will contact the Abuse Coordinator. The Abuse Coordinator is the Administrator, contact numbers are posted throughout the facility. This education was completed on 8/28/2023. On 8/28/2023, this education was added to the facility orientation program for all new hires. This includes any new agency staff. This education will be presented during orientation by the Director of Nursing/Designee. The NHA/Designee will track education 5 times weekly to ensure new staff, including agency staff do not work before receiving education. D. Indicate how facility plans to monitor its performance to make sure that solution was achieved and sustained: To monitor and maintain ongoing compliance starting on 8/28/2023 ,when the HR Director was notified, Human Resource Director/Designee will randomly interview 3 employees weekly x 12 weeks to ensure understanding of abuse/neglect/timely reporting/what to do if they witness or hear abuse, which includes ensuring the safety of residents, protection of residents, stopping the abuse, reporting immediately to NHA/supervisor. The Administrator/Designee starting 8/28/2023, will be responsible to report results of all audits to the QAPI (Quality Assurance Performance Improvement) committee for review and revision monthly x 3 months or longer if deemed so by QAPI committee. Alleged Date of Compliance 8/30/23 Validation of the past non-compliance immediate jeopardy corrective action plan was conducted in the facility on 09/13/23. Interviews with alert and oriented residents were reviewed with no concerns noted. Skin assessments of cognitively impaired residents were reviewed with no concerns noted. The education plan conducted along with staff signature sheets to verify completion and understanding of the education were reviewed with no concerns. The education plan included the different types of abuse. The abuse education was verified to be included in the new hire orientation for staff and was included in the orientation for agency staff utilized at the facility. Audits of care were reviewed with no concerns. The staff interviewed were able to verbalize the educational points of recognizing abuse. The corrective action plan was validated for past non-compliance effective 08/30/23.

Based on record review, and resident and staff interviews, the facility failed to follow their abuse policy for protection and reporting. Nurse Aide (NA) #2 failed to protect the resident from further abuse and immediately report abuse to the Administrator. This deficient practice affected one of one resident reviewed for abuse (Resident #1). The findings included: A review of the facility policy and procedure titled North Carolina Resident Abuse, with a revised date of 10/03/22 read in part facility staff must immediately report all such allegations to the Administrator/ Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. In the section Protect the Resident, the policy read in part, If the resident is injured as a result of the alleged or suspected incident, the facility should take immediate action to treat the resident. A.) staff should report all incidents immediately to their direct supervisor. Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included muscle weakness, hypertension, lack of coordination, and renal failure. Diagnoses further revealed Resident #1 had a fracture to the right tibia dated 06/30/23 with orders to wear a brace. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. Review of the facility initial allegation report dated 08/25/23 revealed on 08/25/23 at 5:50 PM Resident #1 stated to the MDS Coordinator NA #1 hit her on the right side of the temple. An interview conducted with Resident #1 on 09/07/23 at 11:50 AM revealed on 08/25/23 NA #1 and NA #2 assisted her into the bed and NA #1 was being rough and hurting her. Resident #1 further revealed she stated to NA #1 honey, you are hurting me. Resident #1 stated NA #1 pushed on her hurt right leg and stated she was the caregiver and was going to do what she wanted. Resident #1 further revealed she started to cry and was scared so she started to slap NA #1 to get her off and asked her to leave. Resident #1 revealed NA #1 took both her hands and held them to her chest and eventually let go. Resident #1 indicated she did not recall if she received care or not because she was so upset. Resident #1 indicted NA #2 did not say anything or intervene until NA #1 had left the room. A phone interview with NA #1 on 09/07/23 at 10:20 AM revealed on 08/25/23 NA #1 entered Resident #1's room with NA #2 around 1:30 PM after the resident had returned from dialysis. NA #1 indicated Resident #1 indicated she was tired and wanted to be put into bed. NA #1 further revealed they used a mechanical lift and assisted Resident #1 into bed. NA #1 revealed she got Resident #1 into her bed and started to remove her leg brace on her right leg to assist with care and Resident #1 stated to get out and leave me alone. NA #1 revealed Resident #1 began to strike at her and she grabbed her right hand and held it down on her chest. NA #1 indicated Resident #1 continued to state, leave me alone and get out. NA #1 revealed she let go of Resident #1's right hand and the resident began to hit NA #1 with a balled fist. NA #1 indicated she grabbed Resident #1's right arm again and held it down to her chest to restrain her from hitting her. NA #1 further revealed she continued to care for the resident by taking off her right brace and pants. NA #1 indicated Resident #1 complained about her right leg brace being removed. NA #1 indicated Resident #1 was dry and left the room with NA #2. NA #1 indicated she reported Resident #1's behaviors of hitting to Nurse #1 and Nurse #1 indicated she would report it to upper management on Monday. NA #1 revealed she continued to work on the floor until about 5:50 PM and reported to the MDS Coordinator Resident #1 had shown aggressive behaviors towards NA #1. NA #1 indicated she felt like an upper management staff should be advised of Resident #1's aggressive behaviors. NA #1 indicated shortly after speaking to the MDS Coordinator she was pulled into the conference room and was suspended for further investigation and was not allowed back in the facility. NA #1 indicated Resident #1 was not normally aggressive and does not feel like she was restraining her. NA #1 stated she had been educated to walk away if a resident became aggressive or combative but felt like she needed to complete Resident #1's care before leaving the room even though the resident had asked her to leave. An interview with NA #2 on 09/07/23 at 10:35 AM revealed on 08/25/23 after lunch she assisted NA #1 with Resident #1 into getting into bed. NA #2 further revealed while lifting Resident #1 in the mechanical lift Resident #1 started to complain the lift was hurting her leg and wanted to be put down. NA #2 indicated NA #1 stated she was not putting the resident back down because the resident wanted to get back in the bed. NA #2 and NA #1 got Resident #1 into the bed and Resident #1 stated to NA #1, you are hurting me, and I want you to get out of my room,. NA #1 stated, I am not going anywhere because I am your caretaker. NA #2 revealed Resident #1 became more agitated and started to slap NA #1 and NA #1 slapped Resident #1's right hand out of the way and pushed on Residents #1's right fractured tibia that was in a brace. NA #2 indicated Resident #1 began to cry in pain and stated again for NA #1 to get out of her room. NA #2 revealed Resident #1 began to hit again at NA #1 and NA #1 took both hands and held them to her chest. NA #2 stated Resident #1 was very upset and continued to tell NA #1 to get out of her room. NA #2 indicated she pushed NA #1 off Resident #1 and told NA #1 to get out of the room immediately. NA #2 indicated NA #1 stated she wasn't going any damn where that she was caring for the resident. NA #2 stated she told her to leave again, and NA #1 left the room mad. NA #2 revealed she stayed in the room with Resident #1 to calm her down and to complete care of the resident. NA #2 indicated she did not report to anybody once she left the room because therapy needed her to assist with another resident. NA #2 revealed she identified that NA #1 was being abusive towards Resident #1 and NA #1 had continued to work on the floor until later in the evening around 6:00 PM. NA #2 indicated Resident #1 was rarely aggressive and regrets not intervening sooner. NA #2 stated she was educated to walk away from residents if residents are aggressive or combative and to report abuse to upper management immediately. An interview conducted with the MDS Coordinator dated 09/07/23 at 12:00 PM revealed on 08/25/23 at 5:50 PM she was about to leave, and NA #1 stopped her and indicated Resident #1 was having aggressive behaviors. The MDS coordinator further revealed she went and spoke to Resident #1 and Resident #1 indicated NA #1 hit her right leg and temple and had hurt her. The MDS Coordinator stated Resident #1 had indicated NA #1 continued to be rough with her right leg and did not want her back in her room. The MDS coordinator revealed she contacted the Administrator and removed NA #1 off the floor immediately. An interview conducted with Nurse #1 on 09/07/23 at 1:45 PM revealed on 08/25/23 after dinner she was completing a medication pass and observed Resident #1 looking at her strange and seemed to be scared. Resident #1 stated to Nurse #1 she wanted to make sure she was not NA #1 because NA #1 was rough with her and she didn't want NA #1 to take care of her. Nurse #1 further revealed nobody had reported to her the incident or Resident #1's behaviors. Nurse #1 revealed the MDS Coordinator came to the resident's room right after she had spoken to Resident #1. An interview conducted with the Administrator on 09/07/23 at 4:30 PM revealed on 08/25/23 the MDS Coordinator called her about 6:30 PM and revealed Resident #1 reported NA #1 had hit her. The Administrator further revealed she instructed the MDS Coordinator to pull NA #1 off the floor immediately and came to the facility to complete an investigation. The Administrator revealed she received statements from all staff involved and interviewed Resident #1. The Administrator further revealed Resident #1 stated NA #1 had hurt her while putting her into the bed and had hit her right hand and leg. The Administrator indicated adult protective services, law enforcement, the state, and family were notified immediately. The Administrator indicated she completed a thorough investigation and completed in services, interviews with alert and oriented residents, skin audits with other residents, and started audits of care. The Administrator revealed nursing staff had been educated to walk away if a resident is being combative or aggressive. The Administrator further revealed NA #1 and NA #2 should have walked away from Resident #1 when she asked, and NA #2 should have reported immediately to upper management the concerns of abuse. The Administrator was notified of immediate jeopardy on 09/08/23 at 9:00 AM. The facility submitted the following corrective action plan: A. How corrective action will be accomplished for resident(s) found to have been affected: On 8/25/2023 at approximately 5:50pm CNA (Certified Nursing Assistant) #1 informed the Nurse #1 (MDS Nurse) that Resident #1 had hit her. Nurse #1 immediately at approximately 5:50PM notified NHA (Nursing Home Administrator) and interviewed Resident #1, who stated that she did indeed hit CNA #1 because she (CNA #1) had hurt her leg and had hit her on her hand and her leg with an open hand. The incident occurred between 2:30pm-3:00pm. On 8/25/2023 at around 6:25pm the Administrator interviewed Resident #1: Resident #1 indicated that CNA #1 and CNA #2 were transferring resident to bed, via mechanical lift and CNA #1 bumped Resident #1 foot on the foot board, which caused pain to her leg. Resident #1 stated she told CNA #1 to get out, but CNA #1 continued to take care of her, so Resident #1 hit CNA #1. Resident # 1 indicated when she hit CNA #1, CNA #1 in turn hit Resident #1 on her left side of waist and left leg. Resident #1 denied any injury or pain at that time. On 8/25/2023, between 6:45-7:00pm, CNA #2 was interviewed by the Administrator. Administrator asked CNA #2 why she did not immediately report the abuse to Administrator. CNA #2 stated that she did not report right away because she was pulled away to help with another resident. After assisting other resident, CNA #2 stated she forgot to go back and report to charge nurse. Upon interview with Administrator CNA #2 was re-educated to immediately report abuse to the facility Abuse Coordinator, the Administrator. On 8/25/2023, Nurse #1 removed CNA #1 from resident care area and placed her in the conference room between 6:00pm-6:05pm as soon as Administrator was made aware. On 8/25/2023, at approximately 6:00PM alleged perpetrator CNA #1 and witness CNA #2 were suspended pending an investigation. On 8/25/2023, staff working on the skilled unit were interviewed regarding abuse allegation, if they were aware of any abuse, neglect or exploitation of residents, or if they were aware of any concerns in this regard in the building at this time. Staff working on this unit (100 Hall) provided written statements regarding this allegation and day. All staff were educated regarding abuse allegation, if they were aware of any abuse, neglect or exploitation of residents, or if they were aware of any concerns. On 8/25/2023, APS and the local Police Department were notified. On 8/25/2023, Investigation was initiated and NCDHHS was notified via fax by Administrator at approximately 6:30PM. Administrator immediately reported to NCDHHS after interviewing CNA #1 and CNA #2. On 8/25/2023, Administrator notified resident's daughter. B. How corrective action will be accomplished for resident(s) having potential to be affected by same issue needing to be addressed: On 8/28/2023, skin assessments were completed on all non-interviewable residents on resident #1 ' s unit (100 Hall). No other residents were identified. On 8/28/2023, interviews were completed on all residents cognitively intact on resident #1 ' s unit (100 Hall). No other residents were identified. On 8/28/2023, interviews were completed on residents cognitively intact on 100 Hall. No other residents were identified. Social Services Director completed interviews with alert and oriented residents with a BIMS (brief interview for mental status) of 12-15 which reflected residents to be cognitively intact. No one reported any abuse allegations. Residents on the skilled unit with a BIMS greater than 12 received education from the Social Services Director regarding abuse, neglect and exploitation and to report this to the Administrator immediately. Questions that were asked are as follow: 1. Do you feel afraid, or humiliated at any time here at the facility? 2. Has anyone said mean things to you? 3. Has anyone hit you or handled you roughly? 4. Has anyone made you feel uncomfortable or touched you inappropriately? 5. Have you seen or heard of any residents being treated like the above mentioned? C. What measure will be put in place or systemic changes made to ensure that the identified issue does not occur in the future? On 8/25/2023, Director of Nursing/designee started verbal education, to include Dietary, Housekeeping, Therapy, Maintenance, Licensed Nurses, Certified Nursing Assistants, all non-licensed administration personnel, including agency staff on the following; reporting Abuse, Neglect and Exploitation. The facility will not tolerate abuse, neglect, and mistreatment, exploitation of residents and misappropriation of resident ' s property by anyone. The abuse policy includes the following: Protection of the Resident and Reporting. The abuse policy was included in staff re-education. Facility lesson plan that was delivered included Stopping when a Resident Says Stop, and Protecting Residents from Abuse. Staff were not allowed to work until education was received, which was provided by Charge nurse and Director of Nursing. Education was directed to each individual department and whom they should report to including during off hours. All staff report up to their supervisor and if their supervisor is not available, report to charge nurse. Charge Nurse will contact the Abuse Coordinator. The Abuse Coordinator is the Administrator, contact numbers are posted throughout the facility. This education was complete on 8/28/2023. On 8/28/2023, this education was added to the facility orientation program for all new hires. This includes any new agency staff. This education will be presented during orientation by the Director of Nursing/designee. The NHA/designee will track education 5 times weekly to ensure new staff, including agency staff do not work before receiving education. D. Indicate how facility plans to monitor its performance to make sure that solution are achieved and sustained: To monitor and maintain ongoing compliance starting on 8/28/2023, when the HR Director was notified, Human Resource Director/designee will randomly interview 3 employees weekly x 12 weeks to ensure understanding of abuse/neglect/timely reporting/what to do if they witness or hear abuse, which includes ensuring the safety of residents, protection of residents, stopping the abuse, reporting immediately to NHA/supervisor. The Administrator/designee starting 8/28/2023, will be responsible to report results of all audits to the QAPI (Quality Assurance Performance Improvement) committee for review and revision monthly x 3 months or longer if deemed so by QAPI committee. Alleged Date of Compliance 8/29/23 Validation of the past non-compliance immediate jeopardy plan of correction was conducted in the facility on 09/13/23. The facility's current Abuse Policy and Procedure was reviewed along with facility reported incidents in the last thirty (30) days to ensure timely reporting with no concerns noted. The education plan was reviewed along with staff signature sheets to verify completion and understanding of the education with no concerns. Interviews with staff across all departments and disciplines were conducted and staff were able to verbalize the steps they should take if they witness or suspect any type of abuse. The staff were able to verbalize they must first stop the abuse and stay with the resident providing protection from the abuse and then immediately report the abuse to the Administrator or on weekends to the Manager on Duty or Charge Nurse. The staff understood and were able to verbalize the perpetrator was to be placed on one-on-one supervision immediately for the protection of other residents. The education plan was verified to be part of the orientation program for all newly hired staff. The Administrator was able to verbalize her reporting requirements and time frames after becoming aware of any witnessed or suspected abuse in the facility. The plan of correction was validated for past non-compliance effective 08/29/23.

Based on observations, record reviews, resident, family member, visitor, and staff interviews, the facility failed to lower a resident's bed before leaving the resident alone after care for 1 of 3 residents reviewed for falls. Resident #3's bed was left in the high position and the resident rolled off the air mattress onto the floor and sustained a laceration to her right forehead measuring 3 centimeters (cm) by 1 millimeter (mm) that required 6 sutures to repair and an acute right comminuted (a bone that is broken in at least 2 places), non-displaced (broken bone that retains proper alignment) femoral neck fracture that was conservatively managed (no surgical intervention). The findings included: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, malnutrition, and aphasia. Review of Resident #3's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely impaired cognitive skills for daily decision making and short-term and long-term memory problems. The MDS also revealed Resident #3 required extensive total assistance with all activities of daily living and impairment on both sides of her upper and lower extremities. Resident #3 had no falls since prior assessment dated [DATE]. Review of Resident #3's care plan dated 07/30/23 revealed a focus area for the resident being at risk for falls characterized by a history of falls, injury and or multiple risk factors related to bladder and bowel incontinence, dementia, and impaired cognition. The interventions included educate resident/family regarding preventative fall interventions and safety devices as appropriate, implement preventative fall interventions and devices, maintain call bell within reach and educate resident to use call bell, maintain resident's needed items within reach, PT/OT/SLP to screen and treat as necessary per physician order and (effective 8/8/23) when resident is in bed and not receiving care, bed in low position. Review of the unwitnessed fall report written by Nurse #3 and Nurse #4 dated 08/07/23 revealed Resident #3 was found lying on the floor on her right side on the left side of the bed. The resident was unable to give a description as to how she had fallen out of bed. She was noted to have a gash in her forehead and a cool compress was applied to the gash. Vital signs were obtained and the physician and family were notified of the fall. An order was received to send the resident out to the hospital for evaluation and treatment. The predisposing factors included confusion (the resident was oriented to person only), gait imbalance and impaired memory. A head-to-toe assessment revealed pain at a level of 3 out of 10 for which the resident refused pain medication, respirations even and unlabored, apical pulse was 107 with regular rhythm and pedal pulses were present on the right and left. Review of witness statements attached to the facility's fall report revealed the fall was unwitnessed and the resident was seen on the floor by Visitor #1 who was there to see her family member. Visitor #1 immediately alerted Nurse #3 that the resident was on the floor and the nurse went in the room and assessed the resident and assisted in getting her back to bed via mechanical lift. The resident was sent out to the hospital via Emergency Medical Services (EMS). Review of an Intradisciplinary Department Team note revealed they had discussed Resident #3's fall on 08/07/23 and the intervention put into place was for her bed to be in low position when the resident was in bed. Review of the hospital records dated 08/07/23 revealed Resident #3 presented to the emergency department of the local hospital in stable condition with a 3 centimeter (cm) by 1 millimeter (mm) diagonal laceration to the right forehead which required 6 sutures. X-ray of her pelvis revealed an acute right femoral neck fracture and the computerized tomography (CT) scan of the pelvis revealed an acute right comminuted, non-displaced intertrochanteric fracture of the right hip. An orthopedic surgeon was consulted while the resident was in the emergency department and the surgeon and family member who was the responsible party made the decision not to treat the fracture surgically but to manage it conservatively with pain medication and follow up with orthopedics. The resident was returned on 08/08/23 to the facility with new orders for pain medication and to follow up with orthopedics in 1 to 2 weeks. A phone interview on 09/07/23 at 9:43 AM with Visitor #1 who had seen the resident on the floor revealed she came to the facility on [DATE] at 9:30 PM and was talking with Nurse #3 in the hallway and looked to her left and saw Resident #3 lying on the floor and stated she said to the nurse oh my gosh you've got one down. Visitor #1 stated she noticed the bed was in a high position and the nurse immediately went into the room and yelled for assistance. Visitor #1 further stated she walked down to her family member's room and relieved NA #3 so she could assist the Nurse with Resident #3. A phone interview on 09/07/23 at 10:53 AM with NA #3 who was assigned to Resident #3 on the evening of her fall revealed she was in another resident's room providing assistance when Visitor #1 came in and relieved her and said Nurse #3 needed her in Resident #3's room. NA #3 stated she had been in Resident #3's room about 30 minutes earlier and had changed her brief and got her ready for bed. NA #3 further stated she couldn't remember what position her bed was in when she left the room. She indicated she was not sure how the resident fell out of bed but had a sheet on her air mattress and that along with the air mattress could have attributed to her fall. NA #3 stated she was aware the resident's bed was now supposed to be in low position when in the bed and she was supposed to be positioned in the center of the bed with fall mats placed on either side of the bed. NA #3 stated all staff had been in-serviced on the resident's positioning after her fall. A phone interview on 09/07/23 at 12:15 PM with Nurse #3 who was assigned to Resident #3 on the evening of her fall revealed when she was alerted by Visitor #1 and went into Resident #3's room she found her lying on the floor on her right side on the left side of her bed. Nurse #3 stated Resident #3 had a gash in her forehead where she had hit the floor or hit something on the way down to the floor. She further stated NA #3 and NA #6 had just been in her room to change her and get her ready for bed. Nurse #3 said she thought NA #3 and NA #6 had positioned the resident too close to the edge of her bed and felt like she either wiggled or the air mattress forced her off the bed. She indicated when she went into the room the bed was not in a low position but was in a higher position for the NAs to change her brief. Nurse #3 further indicated Resident #3 was sent out to the hospital because she had a deep gash in her forehead and they later learned she had broken her hip with the fall. Nurse #3 stated she had been in-serviced after the fall about positioning the resident in the center of the bed and putting her bed in low position when she was in bed and placing fall mats down on either side of the bed. Several attempts were made to contact Nurse #4 without success. Several attempts were made to contact NA #6 without success. An interview on 09/07/23 at 2:34 PM with the Assistant Director of Nursing (ADON) revealed she was familiar with Resident #3's fall. She stated the resident was found lying on her right side on the left side of the bed. The ADON further stated she felt like the resident had been positioned too close to the edge of the bed and either through her movement in the bed or movement of the air mattress, the resident fell out of bed. She indicated Resident #3 was able to move some in bed and able to straighten one of her legs out and wiggle in the bed. The ADON indicated the interventions put into place following Resident #3's fall were to make sure the air mattress was on the right setting, bed in low position when Resident #3 was in the bed and make sure resident is positioned in the center of the bed and fall mats placed on either side of the bed. A phone interview on 09/07/23 at 3:00 PM with the former Director of Nursing (DON) revealed she recalled Resident #3's fall and said she came in the following day and the only conclusions she came to was the sheet on the air mattress and the Resident being positioned too far to the edge of the bed caused her fall or the air mattress settings along with the sheet on the mattress caused her to fall. The former DON stated the resident did move sometimes in the bed and either a positioning problem or problem with the air mattress settings had attributed to her fall. She further stated the resident was able to move some in the bed and was able to straighten out one of her legs and either by doing that or movement from the air mattress she had fallen out of the bed. The former DON explained she had completed a 4-step fall with fracture plan and had in serviced all NAs, Patient Care Assistants (PCAs) and licensed staff on positioning of the resident and her bed and had completed monitoring of residents with fall precautions in place. She stated when she left her position at the facility the monitoring was to continue with the ADON. A phone interview on 09/07/23 with Resident #3's family member and responsible party revealed she had visited Resident #3 on Monday, 09/04/23 at 2:45 PM and she found her in the bed and the bed was in waist high position and the resident was not positioned in the center of the bed but was again positioned on the edge of the bed. The family member stated she told NA #4 who was assigned to the resident but said the bed remained in the same position during her visit. The family member stated she then went to the Administrator with her concerns of the staff not positioning the resident correctly while in bed because she was afraid of her falling out of bed again. She further stated the Administrator told her she would re-educate the staff. A phone interview on 09/11/23 at 11:57 AM with NA #4 revealed he had been assigned to care for the resident on 09/04/23 during the 7:00 AM to 3:00 PM shift. NA #4 did not recall what position the bed was in on that day but said typically the bed was to the floor when the resident was in the bed. He stated Resident #3 leans to the left when in bed and usually ends up on the edge of the bed from leaning. NA #4 further stated he typically raises her bed to change her but makes sure it is lowered before leaving the room but said he could not recall the position of the bed on 09/04/23. NA #4 stated all the staff had been in serviced on positioning the resident in the middle of the bed and ensuring her bed was in low position when she was in the bed. Observation of Resident #3 on 09/07/23 at 9:30 AM revealed resident lying on her left side on the edge of the left side of her bed with half of her pillow hanging off the bed. The resident had her eyes closed with her covers pulled up over her and her air mattress on. Her bed was noted to be in waist high position and was not in low position (close to the floor) as indicated in her care plan. There were no staff in the room at the time providing care. An interview on 09/07/23 with NA #5 who was assigned to Resident #3 on the 7:00 AM to 3:00 PM shift revealed the only time she raised the resident's bed was when she fed the resident in her room or when changing her brief. She stated she always tried to put the resident's bed back down before leaving the room but must have forgotten to do that today after feeding her. NA #5 further stated she knew the bed was supposed to be in low position when the resident was in it and the resident positioned in the middle of her bed. She said they had been in serviced on positioning of the bed and the patient after her fall. A phone interview on 09/11/23 at 3:57 PM with NA #2 revealed she had not been assigned to Resident #3 on 09/07/23 but had lowered the resident's bed to the floor and placed the fall mats on either side of her bed. She stated when she had gone into the room the bed was in waist high position and the fall mats were not at her bedside so she lowered the bed and placed the fall mats down. NA #2 stated they had been in serviced more than once regarding the resident's bed being in low position while she was in it and her being positioned in the middle of the bed with fall mats on either side of her bed. NA #2 stated the resident was able to move one of her legs and tended to lean to her left side while in bed and often wiggled over to the edge of the left side of her bed. An interview on 09/07/23 at 4:58 PM with the Administrator revealed she had talked with Resident #3's family member after her visit on 09/04/23 and her concerns about Resident #3 still not being positioned correctly in bed. The Administrator stated that she, the DON and the ADON had met with the family member and assured her they would re-educate staff about the bed being positioned low when the resident was in bed and the resident being positioned in the center of the bed. The Administrator was made aware of the observation made earlier in the day on 09/07/23 of the resident still not being positioned in the center of the bed and the bed not being positioned in low position and she stated they would have to do more one-on-one education with the staff. Review of a 4-step fall with fracture plan (a 4-step plan including assessment of the fall, identification of other vulnerable residents, interventions to prevent fall from happening again and monitoring for ongoing compliance) dated 08/08/23 revealed on 08/07/23 a head to toe assessment, pain assessment, fall assessment were all completed, the Medical Director (MD) and responsible party for the resident were notified of the fall and an order received to transfer the resident to the hospital for evaluation and treatment. Residents with the potential to be affected were identified by the Director of Nursing (DON)/Designee and all residents were reviewed to ensure the care needs were reflected accurately on the Kardex and care plans with a completion date of 08/14/23. To prevent this from happening again the DON/Designee educated Nurse Aides (NAs), Patient Care Assistants (PCAs) and licensed staff on positioning of residents in bed, managing settings on the air mattress and making sure the settings are correct on the air mattress. The staff was also shown how to find the Kardex information on the kiosk and this education will be presented to new staff in the new hire orientation. This education was completed on 08/14/23. To monitor and maintain ongoing compliance the DON/Designee completed an observation audit weekly for 4 weeks then monthly for 2 months to ensure that residents were being cared for appropriately per the plan of care and the results will be presented to the QAPI committee for review and revisions as needed. The audits attached were reviewed with no concerns except Resident #3 was not included in the audits each week and month. The compliance date for the plan was 08/14/23. This was determined not to be past non-compliance because the resident was observed on 09/07/23 in the bed with the bed in waist high position and the resident was observed on the edge of the bed with her pillow hanging halfway off the bed instead of being positioned in the middle of the bed. During the observation there was no staff member in the room with Resident #3. NA #5 was assigned to Resident #3 on 09/07/23 and stated she had been educated to lower the bed after providing care and had forgotten to do so before she left the room. Review of the auditing tools for the 4-step action plan revealed Resident #3 was not consistently included in the weekly and monthly. As a result, the facility remains out of compliance for supervision to prevent accidents.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 02/17/22 and 07/12/23. This failure was for two deficiencies that were originally cited in the areas of Nutrition/Hydration Status Maintenance (F692) and Infection Prevention and Control (F880) and were subsequently recited on the current complaint investigation and revisit survey of 09/13/23. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F692: Based on observations, record review, resident, and staff interviews, the facility failed to follow a physician order for a nutritional supplement for 1 of 3 sampled residents reviewed for nutrition (Resident #2). During the recertification and complaint investigation survey conducted on 07/12/23, the facility failed to follow a physician's order for a nutritional supplement for a Hospice resident and provide the supplement in the flavor that the resident preferred and could swallow for 1 out of 1 resident. F880: Based on observations, record reviews, and staff interviews, the facility failed to follow their COVID-19 Testing Guidance within their Policy and Procedure when the staff failed to provide testing of residents and staff after a positive COVID-19 test was obtained on a symptomatic resident (Resident #5) on 09/02/23 at 1:30 AM. During the recertification and complaint investigation survey conducted on 02/17/22 the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when staff members working on the 100-hall failed to wear eye protective gear while providing care to residents for 5 out of 10 staff members. During an interview on 09/07/23 at 4:58 PM with the Administrator, she reported her quality assurance (QA) team met monthly and included the Medical Director, department heads, administrative staff, the Nurse Practitioner, and the Regional Dietician and Pharmacist by phone. She reported they currently had Process Improvement Plans (PIPs) addressing the deficiencies of the previous complaint investigations and recertification surveys and had made significant changes but still had work to be done. She further reported they were currently working on PIPs on recruitment and retention to hire their own staff instead of relying on agency staff which would help alleviate some of the issues they were having with nursing, PIP on nutritional supplements which they would need to implement a more significant focus on going forward and infection prevention and control which would need more focused approach. She stated they had hired a new Director of Nursing that would be starting on 09/25/23 and they were sending the Assistant Director of Nursing to SPICE training in November of this year. The Administrator further stated the PIPs in place would be ongoing and monitored extensively to ensure ongoing and future compliance.

Based on observations, record reviews, and staff interviews, the facility failed to follow their COVID-19 Testing Guidance within their Policy and Procedure when the staff failed to provide testing of residents and staff after a positive COVID-19 test was obtained on a symptomatic resident (Resident #5) on 09/02/23 at 1:30 AM. The findings included: Review of the facility's COVID Testing Guidance under section Testing Summary - under the column Testing Trigger - newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts/Broad Based approach. Under the column Staff/Healthcare Personnel (HCP), the guidance read, Test all staff, regardless of vaccination status, facility-wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). If negative, test again 48 hours later, and if negative 48 hours after the second test. In general, testing should continue every 3-7 days until 14 days have passed without any new cases. Under the column Residents, the guidance read, Test all residents, regardless of vaccination status, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility). If negative, test again 48 hours later and, if negative, 48 hours after the second test. In general, testing should continue every 3-7 days until 14 days have passed without any new cases. The Administrator stated on 09/07/23 at 8:45 AM there was one positive case of COVID-19 in the building and the resident remained on transmission-based contact precautions. She further stated Resident #5 had tested positive after exhibiting symptoms of cough and congestion and the test was completed on 09/02/23 at 1:30 AM. The Administrator indicated Resident #5's roommate - Resident #6 had been tested but her results were negative. Observation on 09/07/23 at 09:45 AM of Resident #5's room revealed signage on the door indicating Transmission Based Contact Precautions and instructions for personal protective equipment (PPE) to be worn inside the room. A bin was observed outside the room with all needed PPE contained in the bin. Review of the vaccine status of staff revealed 50 of the 72 staff were fully vaccinated or 69%. Review of the vaccine status of residents revealed 27 of 45 residents were fully vaccinated or 60%. During a follow up interview on 09/07/23 at 5:15 PM with the Assistant Director of Nursing (ADON) who also served as the Infection Preventionist (IP) revealed the facility had only done testing on Resident #5 and Resident #6 for COVID-19. She stated they had not done contact tracing for Resident #5 and they had not done broad based testing of residents and staff because it was her understanding from her Regional Nurse Consultant, they only tested residents and staff that were exhibiting symptoms. The ADON/IP further stated she had not tested any of the residents or staff because none were exhibiting symptoms of COVID-19. She indicated she was aware of their COVID-19 Policy and Procedure but was following instruction from her Regional Nurse Consultant. During a follow-up phone interview on 09/08/23 at 11:45 AM with the ADON/IP information was requested regarding their COVID-19 guidance and specifically their testing guidance, test results for Residents #5 and #6. The ADON/IP again stated they still had not done contact tracing or broad-based testing of the residents and staff. Several attempts were made to interview the Nurse who had tested the two residents with no success. During a follow-up phone interview on 09/08/23 at 12:00 PM with the Administrator and the Clinical Quality Specialist, explained the concern regarding infection control due to staff and residents not being tested after a symptomatic resident tested positive and contact tracing was not initiated. Referred them back to their testing guidance and once reviewed, they both agreed they should have done contact tracing or broad-based testing of the residents and staff. During a phone interview on 09/11/23 at 10:58 AM with the Regional Nurse Consultant, he revealed he had not told the ADON/IP that she only had to test residents and staff who had symptoms once a COVID-19 positive result was obtained. He stated she had misunderstood initial testing with symptoms and testing after a positive test is obtained. He further stated he would talk with the ADON/IP and make sure she understood the testing guidelines outlined in their policy and procedure and they would immediately begin testing residents and staff.

Based on observations, record review, resident, and staff interviews, the facility failed to follow a physician order for a nutritional supplement for 1 of 3 sampled residents reviewed for nutrition (Resident #2). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. A care plan dated 05/25/23 had a focus area for increased nutrition/hydration due to poor by mouth intake. The goal was for the resident to be adequately nourished within limits of her end stage illness. Interventions included providing supplements per order. An annual Minimum Data Set, dated dated dated [DATE] revealed Resident #2 was cognitively intact. The resident was coded as receiving a therapeutic diet. Resident #2 was not coded for weight loss or weight gain. A Physician order dated 12/01/22 read, Nutritional supplement three times a day 90 milliliters three times daily, offer non-vanilla flavor, unable to swallow vanilla. Resident #2's Medication Administration Record (MAR) dated September 2023 revealed a physician order dated 12/01/22 which read, Nutritional supplement three times a day 90 milliliters three times daily, offer non-vanilla flavor, unable to swallow vanilla. The order was listed for 9:00 AM, 1:00 PM and 5:00 PM. On 09/07/23 Nurse #2 documented she had administered the supplement to Resident #2 at 9:00 and 1:00 PM. An observation was conducted on 09/07/23 at 11:31 AM of the 100-hall nourishment room. The observation revealed 3 vanilla flavored nutritional supplement drinks in the refrigerator. On 09/07/23 at 10:16 AM an interview was conducted with Resident #2. She stated she did not receive her morning nutritional supplement because Nurse #1 had not asked. The interview revealed she did not like the vanilla flavor the facility often provided and that was all the nurses had been offering to her. She stated she would like to try the chocolate or strawberry flavor. She stated staff had not asked her to try another flavor they just assumed because she did not like vanilla that she would refuse for the day. On 09/07/23 at 3:24 PM an interview was conducted with the Dietary Manager. During the interview she stated the facility had several different flavors of nutritional supplements such as strawberry, chocolate and vanilla. She stated the supplements were provided to the residents by the nurses on the hall unless specified on the dietary card. The Dietary Manager reviewed Resident #2's dietary card and stated the kitchen did not send her supplement out with the meal tray, the nurses on the hall provided it to her. On 09/07/23 at 3:45 PM an interview was conducted with Nurse #2. During the interview she stated she knew Resident #2 had orders for a Nutritional Supplement but was in a hurry and did not give it to her at 9:00 AM or 1:00 PM and the documentation on the MAR was an error. Nurse #2 stated she thought that vanilla was the only flavor in the facility anyway and Resident #2 often refused. The interview revealed Nurse #2 had not asked Resident #2 if she would like to try another flavor or if she wanted to take her supplement on 09/07/23. On 09/07/23 at 4:09 PM an interview was conducted with the Registered Dietitian (RD). She stated she normally prescribed a nutritional supplement to residents that she felt needed additional calories in between meals. The interview revealed she wanted the nurses on the halls to provide the residents with the supplemental drinks she ordered to ensure the residents did not have a weight loss. The RD stated Resident #2's weight was between 97 pounds to 103 pounds, and she wanted her to maintain that weight. She stated she was unaware the resident had not been receiving the nutritional supplement as ordered. On 09/07/23 at 5:10 PM an interview was conducted with the Administrator. She stated Nurse #2 should have given the resident the supplement as ordered or at least have asked if she wanted to take it for the day. She stated since the last survey this concern was in the plan of correction book assigned for the Assistant Director of Nursing (ADON) to ensure an audit was conducted weekly. She stated she did not know how the problem was still occurring. On 09/07/23 at 5:30 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated she had been conducting weekly audits of nurses on the medication cart administering nutritional supplements. She stated she knew Resident #2 had not received her nutritional supplement on several days and thought the only flavor of the nutritional supplement the facility had was vanilla. The ADON stated she didn't know she could go to the kitchen and get another flavor per the resident's request.

Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #40) reviewed with indwelling catheters. The findings included: Resident #40 was admitted to the facility on [DATE]. Resident #40 was currently being followed by Hospice and had an indwelling urinary catheter for comfort. A review of Resident #40's care plan dated 03/21/2023 revealed a focus area for indwelling urinary catheter. The interventions included check tubing for kinks each shift, and position catheter bag and tubing below the level of the bladder and provide a privacy cover. A review of Resident #40's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required extensive to total assistance with all activities of daily living (ADL) except eating and had an indwelling urinary catheter. A review of the physician orders for Resident #40 dated 07/01/23 revealed an order for an indwelling urinary catheter size 16 French with a 5 cubic centimeter (cc) bulb (the part of the catheter used to prevent the catheter from sliding out of the urinary bladder) for comfort in a Hospice patient. There were orders to change the catheter every 4 weeks on Monday, catheter care every shift and as needed for preventive measures and an order to drain the catheter every shift and as needed. An observation was conducted of Resident #40 on 07/10/23 at 10:47 AM. Resident #40 was observed sitting in a chair in her room with her urinary catheter bag with a privacy cover that was open on the bottom hanging on the outside of her trash can and the bottom of the bag was touching the floor and the tubing to empty the catheter bag was in direct contact with the floor surface. An observation was conducted of Resident #40 on 07/11/23 at 4:45 PM. Resident #40 was observed sitting in a chair in her room with her urinary catheter bag hanging on the outside of her trash can and the tubing and bottom of the bag were in direct contact with the floor surface. An interview was conducted on 07/12/23 at 11:04 AM with Nursing Assistant (NA) #1 which revealed she was assigned to care for Resident #40 from 7:00 AM to 7:00 PM. She stated she had placed Resident #40's catheter on the side of her chair but that she often moved it to the outside of her trash can because she moved from her chair to her recliner during the day. NA #1 indicated she had been educated to keep a catheter bag off the floor due to infection control and prevention of urinary tract infection. She further stated when the bag was hooked to her chair, the bag and tubing did not touch the floor. An observation was conducted of Resident #40 on 07/12/23 at 11:33 AM. Resident #40 was observed sitting in a chair in her room with her urinary catheter bag hanging on the outside of her trash can and the tubing and bottom of the bag were in direct contact with the floor surface. An interview was conducted with Nurse #1 on 07/12/23 at 11:04 AM in Resident #40's room. Nurse #1 stated she was assigned to care for Resident #40 from 7:00 AM to 7:00 PM on 07/12/23. Nurse #1 observed the resident's urinary catheter bag and tubing resting on the floor. She stated she had seen the bag on the floor and knew it shouldn't be touching the floor but the resident liked to hook it to her trash can. Nurse #1 indicated it was concerning to her that the catheter bag and tubing were in contact with the floor because this placed the resident at greater risk for urinary tract infections. Nurse #1 proceeded to move the catheter bag and tubing and hooked it on the bottom of the chair so the tubing and bag were no longer in contact with the surface of the floor. She further stated she would talk with NA #1 to make sure she kept the bag and tubing off the floor. An interview was conducted with the Director of Nursing (DON) on 07/12/23 at 2:17 PM and she revealed it was her expectation that catheter bags and tubing be placed below the level of the resident's bladder and that they both clear the floor to prevent the resident contracting a urinary tract infection. An interview was conducted with the Administrator on 07/12/23 at 3:30 PM and she revealed that it was her expectation that a urinary catheter bag and tubing be kept below the level of the urinary bladder and off the floor. She added a catheter bag should never be in contact with the floor.

Based on observations, record review, resident and staff interview the facility failed to follow a physician order for a nutritional supplement for 2 of 2 sampled residents reviewed (Resident #20 and Resident #7). The findings included: 1. Resident #20 was admitted into the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was alert and oriented. The resident was coded as receiving a therapeutic diet. Resident #20 was not coded for weight loss or weight gain. A care plan dated 05/25/23 had a focus area for increased nutrition/hydration due to poor by mouth intake. The goal was for the resident to be adequately nourished within limits of her end stage illness. Interventions included providing supplements per order. Resident #20's Medication Administration Record (MAR) dated July 2023 revealed a physician order dated 12/01/22 which read, Nutritional supplement three times a day 90 milliliter's three times daily. On 07/12/23 Nurse #1 documented Resident #20 had refused the supplement at 9:00 AM. On 07/12/23 at 8:55 AM an observation was conducted of Nurse #1 administering medication to Resident #20. During the observation Nurse #1 did not provide Resident #20 with the nutritional supplement. Nurse #1 was observed documenting refusal for the ordered supplement. On 07/12/23 at 11:16 AM an interview was conducted with Resident #20. She stated she did not refuse to take her morning nutritional supplement, but Nurse #1 had not asked. The interview revealed she did not like the vanilla flavor the facility often provided and wanted to try chocolate or strawberry instead. She stated staff had not asked her to try another flavor they just assumed because she did not like vanilla that she would refuse for the day. On 07/12/23 at 11:28 AM an interview was conducted with the Dietary Manager. During the interview she stated the facility had several different flavors of nutritional supplements such as strawberry, chocolate and vanilla. She stated the supplements were provided to the residents by the nurses on the hall unless specified on the dietary card. The Dietary manager reviewed Resident #20's dietary card and stated the kitchen did not send her supplement out with the meal tray, the nurses on the hall provided it to her. On 07/12/23 at 2:30 PM an interview was conducted with Nurse #1. During the interview she stated she knew Resident #20 didn't like the vanilla nutritional supplement, so she went ahead and documented refused. Nurse #1 stated she thought that was the only flavor in the facility. The interview revealed Nurse #1 had not asked Resident #20 if she would like to try another flavor or if she wanted to take her supplement on 07/12/23. On 07/12/23 at 1:46 PM an interview was conducted with the Registered Dietitian (RD). She stated she normally prescribed a nutritional supplement to residents that she felt needed additional calories in between meals. The interview revealed she wanted the nurses on the halls to provide the residents with the supplemental drinks she ordered to ensure the residents did not have a weight loss. On 07/12/23 at 2:10 PM an interview was conducted with the Director of Nursing (DON). She stated she had been working with the nurses on orders. She stated Nurse #1 should have given the resident the supplement as ordered or at least have asked if she wanted to take it for the day. 2. Resident #7 was admitted into the facility on [DATE]. A quarterly MDS dated [DATE] revealed Resident #7 was moderately cognitively impaired. The resident was coded as not having a weight loss or weight gain. A care plan dated 03/22/23 had a focus area for increased nutrition/hydration due to a history of significant weight loss. The goal was for Resident #7 to remain free of significant weight changes through the next review. Interventions included providing supplements per orders. On 07/12/23 at 8:58 AM an observation was conducted of Nurse #1 administering Resident #7's medication. During the observation Nurse #1 was not observed administering Resident #7's ordered nutritional supplement. An observation was conducted of Resident #7's breakfast tray sitting on her bedside table. The resident did not have a nutritional supplement on the tray. Resident #7's Medication Administration Record (MAR) dated July 2023 revealed a physician order dated 05/21/23 which read, Nutritional supplement two times a day 90 milliliter's. On 07/12/23 Nurse #1 documented she had administered the prescribed supplement at 8:00 AM. On 07/12/23 at 2:30 PM an interview was conducted with Nurse #1. During the interview she stated she documented she had given Resident #7 her nutritional supplement because she thought it had come out on her breakfast tray. When the surveyor stated the tray had been observed with no supplement Nurse #1 stated she didn't know why it wasn't on there she thought the resident had received it. On 07/12/23 at 11:28 AM an interview was conducted with the Dietary Manager. She stated the supplements were provided to the residents by the nurses on the hall unless specified on the dietary card. The Dietary manager reviewed Resident #7's dietary card and stated the kitchen did not send her supplement out with the meal tray, the nurses on the hall provided it to her. On 07/12/23 at 1:46 PM an interview was conducted with the Registered Dietitian (RD). She stated she normally prescribed a nutritional supplement to residents that she felt needed additional calories in between meals. The interview revealed she wanted the nurses on the halls to provide the residents with the supplemental drinks she ordered to ensure the residents did not have a weight loss. On 07/12/23 at 2:10 PM an interview was conducted with the Director of Nursing (DON). She stated she had been working with the nurses on orders. The interview revealed Nurse #1 should have given Resident #7 the boost supplement during the medication pass.

Based on observations, record review, resident interview, and staff interviews the facility failed to maintain a continuous supply of supplemental oxygen for 1 of 1 resident reviewed for oxygen therapy (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) with exacerbation and abnormalities of breathing. A physician order dated 07/03/23 revealed Resident #246 was ordered supplemental oxygen at 2 liters per minute continuously every day and night shift. The admission evaluation dated 07/05/23 revealed Resident #246 was alert and oriented and required one person assist for majority of activities of daily living (ADL). The admission evaluation further revealed Resident #246 was coded for oxygen use. An observation and interview conducted with Resident #246 on 07/10/23 at 11:50 AM revealed Resident #246 was sitting in her bed with oxygen running through nasal cannula. Resident #246 stated she had told staff on 07/10/23 at 7:00 AM during breakfast that her oxygen tank was empty, and she was unable to go to the dining room for meals and attend activities. It was observed the oxygen tank on her wheelchair was empty by the gauge. Resident #246 indicated staff had not been back into the room to put a new tank on her wheelchair. During the observation of Resident #246 she did not report being short of breath or appear to have signs or symptoms of respiratory distress. An observation and interview was conducted with the Director of Nursing (DON) on 07/10/23 at 12:05 PM. The DON observed Resident #246's oxygen tank on her wheelchair was empty. Resident #246 explained to the DON that she had told staff it was empty while staff had passed tray at an estimated time of 7:00 AM. The DON indicated the tank was empty and should have been replaced immediately once staff was made aware. An interview conducted with Nurse Aide (NA) #3 on 07/11/23 at 2:50 PM revealed on 07/10/23 around 7:00 AM she had assisted passing out breakfast trays and delivered Resident #246's meal. NA #2 further revealed Resident #246 had reported to her and NA #4 her oxygen tank on her wheelchair was empty. NA #3 stated the tank was empty and advised NA #4 to change her tank out. An interview conducted with NA #4 on 07/11/23 at 3:05 PM revealed he assisted NA #3 with passing trays around 7:00 AM. NA #4 further revealed Resident #246 had stated her oxygen tank was empty on her wheelchair. NA #4 indicated he was busy passing trays and had forgotten to get a new tank. An interview conducted with Nurse #2 on 07/12/23 at 2:35 PM revealed she was not aware Resident #246's oxygen tank was empty. Nurse #2 further revealed oxygen tanks were supposed to be checked each shift and Resident #246's tank should have been changed when she had reported to nursing staff. Nurse #3 indicated Resident #246 had enjoyed being out in the dining room for meals and to attend activities. Nurse #3 stated Resident #246 was ordered to have oxygen continuously and when she is not getting oxygen, she was short of breath. A follow up interview with the DON on 07/12/23 at 2:20 PM revealed oxygen tanks were supposed to be checked every shift and anytime nursing staff were in the resident's room. The DON indicated Resident #246 needed to remain on oxygen continuously and her oxygen tank should have never been empty. An interview with the Nurse Practitioner (NP) on 07/12/23 at 2:30 PM revealed Resident #246 had history of chronic obstructive pulmonary disease and respiratory issues that required her to be on oxygen continuously. The NP further revealed Resident #246 was a newer admit, but assumed she would be short of breath without oxygen.

Based on record reviews, responsible party, staff, and Nurse Practitioner interviews, the facility failed to notify the physician of the deterioration of a stage 2 decubitus ulcer (also known as a bed sore that is an injury to the skin and underlying tissues resulting from prolonged pressure on the area) to a stage 4 decubitus ulcer with tunneling and [CONDITION(S)]. The facility also failed to notify the Responsible Party (RP) of the development and deterioration of a pressure ulcer. This was for 1 of 3 residents (Resident #106) reviewed for notification of changes. Immediate jeopardy began on [DATE] when Resident #106 was observed by staff with a deteriorated pressure ulcer with tunneling of the wound and staff failed to notify the physician. The resident was hospitalized on [DATE] when she was unresponsive and was diagnosed with a stage 4 decubitus ulcer with tunneling and [CONDITION(S)] and died in the hospital on [DATE]. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example 1b was cited a scope and severity level of D. The findings included: 1. Resident #106 was admitted to the facility on [DATE]. Resident #106's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was moderately cognitively impaired. 1a. An interview on [DATE] at 5:30 PM with Nurse #1 assigned to Resident #106 on [DATE] revealed she observed Resident #106's bottom and described she had several different areas on her bottom and coccyx with one area that resembled a blister with fluid in it. Nurse #1 said she had done the dressing on Resident #106 on [DATE], [DATE], [DATE] and [DATE] and said the wound had progressively gotten redder and was larger than when it was first noted on [DATE]. Nurse #1 indicated she had not contacted the physician or Nurse Practitioner (NP) to notify them of the wound's progression after [DATE]. A Nurse Practitioner (NP) progress note dated [DATE] revealed the resident was being seen for follow up visit for evaluation of buttocks breakdown. Integumentary (includes the skin and all its layers) was noted as being positive for poor healing of wounds. The wounds were described in the notes as multiple denuded areas with top layer of skin sheared off over bilateral upper/posterior thighs, buttocks, and coccyx. An interview on [DATE] at 11:49 AM with Nurse Aide (NA) #2 revealed she had taken care of Resident #106 on [DATE] and had asked the Director of Nursing (DON) to come into her room to look at the residents wound. NA #2 stated the wound was red with some bleeding in some areas and there were areas of black on the wound. The NA stated she could not remember the wound having a foul odor but said it could have and she just didn't remember. NA #2 stated the wound looked worse than the last time she had seen it and taken care of the resident on [DATE]. An interview on [DATE] at 6:42 PM with the Director of Nursing (DON) revealed she had been at the facility on [DATE]. The DON stated she had been asked by the NA (could not recall her name) taking care of the resident on [DATE] to come into the room and look at her wounds while she was performing incontinence care. The DON stated she went into the room and looked at the wounds on her buttocks and coccyx and stated the pressure ulcer had worsened and appeared as though the wound was tunneling. The DON indicated she placed a note in the provider book for the NP to see the resident on her next rounds. The DON explained the NP was at the facility 3 days per week and available by phone as needed but said she had not called her when she noticed the wound had worsened but had opted to place a note in the provider book. A nursing progress noted dated [DATE] written at 6:38 PM by Nurse #5 revealed Resident #106 was observed not in her baseline orientation this morning. Not able to respond to commands, not able to stick her tongue out. No grasp reflex. Not her usual self. DON notified for comparison to normal baseline. Directed from DON to call family and ask if they wanted resident sent out. Family member requested send to emergency department for further evaluation. On call contacted. NP gave order to send to ED (emergency department) to rule out possible [CONDITION(S)] (TIA)/stroke. Vital signs ,d+[DATE], 105, 99.0, 97% and blood sugar 127. Resident #106's hospital admission notes revealed she was admitted to the local hospital on [DATE] through the emergency department (ED) to the ICU (Intensive Care Unit). The resident was evaluated for generalized weakness and altered metal status. The resident had a decubitus ulcer that was undergoing treatment at the facility where she resided. The resident was diagnosed with acute kidney injury, [CONDITION(S)], [CONDITION(S)], lactic acidosis, [CONDITION(S)], and sacral wound. The resident had a large foul-smelling decubitus ulcer that would likely require surgical evaluation and possibly debridement. They placed a urinary catheter in the ED and gave her bolus fluids, intubated her per the responsible party's (RP) request and admitted her for further management and stabilization to the critical care unit. The resident was initiated on broad-spectrum antibiotics for her [CONDITION(S)], and it was suspected the wound was the source of her infection. The critical care physician shared with the RP the resident needed surgical intervention for the wound but given her overall condition it was suspected she would not survive surgery, so the family member decided not to actively treat her but to extubate her, provide her with fluids, and make her comfortable. The resident died in the hospital on [DATE] at 4:30 PM. Her death according to the hospital records was attributed to severe [CONDITION(S)]. A phone interview with the Nurse Practitioner (NP) on [DATE] at 3:12 PM revealed she saw the resident on [DATE] and she had multiple denuded areas of sheared skin on her buttocks and coccyx area. She stated she expected the nurses to have notified her of the worsening of the wound and she would have re-evaluated her wounds and possibly ordered a urinary catheter to be placed. According to the NP, had she known the wound had gotten worse she would have referred Resident #106 to the wound physician. An interview on [DATE] at 6:42 PM with the DON revealed she couldn't explain why the physician or NP had not been notified of her worsening decubitus ulcer but stated she expected all changes especially any worsening changes to be communicated to the NP or physician. An interview on [DATE] at 7:32 PM with the Administrator revealed she expected skin changes and wound changes to be discussed with the NP or physician. The nursing home Administrator was notified of Immediate Jeopardy on [DATE] at 9:43 AM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility has identified that the use of Staffing Agency personnel led to a breakdown in the system for reporting skin issues and notification of the resident's Attending Physician. The use of multiple Staffing Agency personnel resulted in a failure to report skin issues by the agency CNAs and Agency Nurses. These issues led to a delay in Resident #106's wound deterioration being evaluated by the provider. The Director of Nursing was not aware that the Nurse Practitioner had not been notified of the worsening of the wound. She placed a note in the provider book for the Nurse Practitioner, but she had not notified the Nurse Practitioner by phone. Nurse #1 also placed a note in the provider book but had not notified the Nurse Practitioner by phone. The missing note from Nurse #1 and the Director of Nursing that were placed in the provider book have not been found. Resident #106 is no longer a resident at [NAME] Place and therefore, no interventions are needed for Resident # 106. [NAME] Place has identified that all residents have the potential to be affected by this practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility has designated an Administrative Licensed Practical Nurse as the individual that will be completing all notifications to the Attending Physician and contract wound doctor concerning wounds. This Administrative Licensed Practical Nurse has been inserviced on [DATE] by an outside facility consultant concerning notifying the attending physician and contract wound doctor about any changes to wounds. The Director of Nursing and two Nurse Managers were also inserviced by the outside facility consultant on the same topic on [DATE]. If the Administrative Licensed Practical Nurse is not working at the time that a worsening of the wound is noted, the Floor nurse will be responsible for notifying the Attending Physician. An outside facility consultant has inserviced all Nurses that are working on [DATE] on first shift (7am-7pm) on the proper protocol for notifying the Attending Physician concerning changes in condition and worsening of wounds. These inservices included the Director of Nursing, Nurse Managers, and Administrative Licensed Practical Nurse as participants. The Director of Nursing will continue to inservice all staff [DATE] - [DATE] to ensure that all staff have received inservicing on the proper protocols. Any new agency staff that may be coming to the facility in the future will be inserviced at the start of their shift to ensure that they are aware of the facility's protocol. Nurses that have not been inserviced by [DATE] will receive the inservice prior to working on the floor. All CNAs working on [DATE] have been inserviced by the outside facility consultant on what skin changes they need to watch for and to report these to the unit nurse. These inservices included the Director of Nursing as a participant. The Director of Nursing will continue to inservice all staff [DATE] - [DATE] to ensure that all staff have received inservicing on the proper protocols. Any new agency staff that may be coming to the facility in the future will be inserviced at the start of their shift to ensure that they are aware of the facility ' s protocol and what to do in the event that a skin issue appears during their shift. CNAs that have not been inserviced by [DATE] will receive the inservice prior to working on the floor. Date of alleged Immediate Jeopardy Removal: [DATE]. Person responsible for the implementation is the Administrator. On [DATE] the facility's credible allegation was validated through record reviews, staff, and resident interviews. The facility provided education through an outside facility consultant to all nurses on the proper protocol for notifications to the attending physician, nurse practitioner and wound physician any changes to skin integrity or current wounds. A nurse had been designated as the wound nurse and she will be completing all notifications to the providers concerning skin changes and changes in wounds. The nurse has been inserviced by an outside facility consultant concerning when notifications should be made to all providers. The Director of Nursing, Nurse Managers and all Administrative nurses were included in the inservice by the facility consultant. The facility provided signed education sheets on the new system for notification of changes to providers and responsible parties. Interviews conducted with the wound nurse, and administrative nurses validated their responsibilities for notifying the providers of any skin or wound changes in residents. The nurses interviewed were able to explain with accuracy their responsibilities for notifying providers of changes. Nursing assistants were interviewed and described the changes in skin integrity they were expected to watch for when providing resident care and who to report the skin changes to during their shift. The Director of Nursing (DON) will continue to inservice new staff, and new agency staff on the proper protocol for reporting skin changes and what to do in the event of a skin change in residents. The facility provided signed education sheets for the nursing assistants working outlining the skin changes and who they were to report the changes to on their shift. The nursing assistants interviewed were able to explain with accuracy what skin changes were to be reported and to whom they were to be reported. The Director of Nursing was interviewed and was able to describe in detail the new system for reporting changes to ensure changes are identified and reported timely to the providers and responsible parties of the residents. The DON explained she or her designee verified the sheets that identified skin changes and then verified they were reported, and a progress note had been completed. The Administrator was interviewed and described in detail her education with the Nurse Practitioner (NP), Facility Medical Director and Wound physician regarding notification of changes in skin and wounds and their responsibilities for collaboration regarding wounds and notifications to the residents and responsible parties if wounds worsen and their management plan. A resident identified by the facility as alert and oriented with a wound was interviewed and reported she and her son were kept informed by the nurse and Wound Physician of the progress of her stage II wound. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. 1b. An interview on [DATE] at 5:30 PM with Nurse #1 assigned to Resident #106 on [DATE] revealed she observed Resident #106's bottom and described she had several different areas on her bottom and coccyx with one area that resembled a blister with fluid in it. Nurse #1 said she had done the dressing on Resident #106 on [DATE], [DATE], [DATE] and [DATE] and said the wound had progressively gotten redder and was larger than when it was first noted on [DATE]. Nurse #1 stated she had not notified Resident #106's responsible party (RP) of the skin changes or the worsening wound on Resident #106's buttocks and coccyx. A Nurse Practitioner (NP) progress note dated [DATE] revealed the resident was being seen for follow up visit for evaluation of buttocks breakdown. Integumentary was noted as being positive for poor healing of wounds. The wounds were described in the notes as multiple denuded areas with top layer of skin sheared off over bilateral upper/posterior thighs, buttocks, and coccyx. An interview on [DATE] at 11:49 AM with Nurse Aide (NA) #2 revealed she had taken care of Resident #106 on [DATE] and had asked the Director of Nursing (DON) to come into her room to look at the residents wound. NA #2 stated the wound was red with some bleeding in some areas and there were areas of black on the wound. NA #2 stated the wound looked worse than the last time she had seen it and taken care of the resident on [DATE]. An interview on [DATE] at 6:42 PM with the Director of Nursing (DON) revealed she had been at the facility on [DATE]. The DON stated she had been asked by the NA (could not recall her name) taking care of the resident on [DATE] to come into the room and look at her wounds while she was performing incontinence care. The DON stated she went into the room and looked at the wounds on her buttocks and coccyx and stated the pressure ulcer had worsened and appeared as though the wound was tunneling. Additionally, the DON stated she had not notified Resident #106's responsible party (RP) of the wound changes and stated she could not remember why she had not notified the RP of the changes but said she should have notified her when the wound had worsened. A phone interview on [DATE] with Resident #106's family member revealed she was the responsible party (RP) for the resident. The RP stated she had visited the resident at the facility on [DATE] and was not told the resident had any skin breakdown. The RP indicated she was not aware of Resident #106's worsening decubitus ulcer until she was notified by the hospital emergency department physician that the resident had a stage IV decubitus ulcer with tunneling and severe [CONDITION(S)]. The RP further indicated she should have been notified and kept apprised of the resident's wound and treatment and progress of the wound. An interview on [DATE] at 6:42 PM with the DON revealed she couldn't explain why Resident #106's skin changes had not been reported to the responsible party (RP) and why the RP had not been notified of the worsening condition of the resident's wound. The DON stated the RP should have been notified of the skin changes and the wound worsening as soon as it had occurred. An interview on [DATE] at 7:32 PM with the Administrator revealed she expected responsible parties and any interested family members to be notified of any and all changes in residents.

Based on observations, record reviews, staff, Nurse Practitioner, and Wound Physician interviews, the facility failed to complete skin assessments as ordered, effectively assess, and monitor a pressure ulcer, and ensure treatments were ordered by the Nurse Practitioner in accordance with the treatment plan (Resident #106). Resident #106 was hospitalized on [DATE] with a stage 4 pressure ulcer (full-thickness skin and tissue loss) with tunneling (passageway of tissue destruction under the skin surface). The facility also failed to provide pressure ulcer care as ordered by the physician (Resident #44). This was for 2 of 3 residents reviewed for pressure ulcers (Residents #106 and #44). Immediate jeopardy began on 12/19/21 when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition. The immediate jeopardy was removed on 02/13/22 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity level of D. The findings included: 1. Resident #106 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #106's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was moderately cognitively impaired and required extensive assistance of 2 staff with bed mobility, transfers and toileting. The MDS further revealed Resident #106 was always incontinent of bowel and bladder and at risk for developing pressure ulcers but had none at present. The MDS indicated Resident #106 had a pressure reducing device on her bed. There were no documented behaviors reflected in the MDS. Resident #106's care plan dated 10/07/21 revealed a plan of care for pressure ulcers. The care plan stated Resident #106 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was noted with a history of pressure ulcers. She was incontinent of bladder and bowel. Staff assists with toileting and peri care frequently and as needed (prn). She required extensive to total assistance with activities of daily living (ADL) and transfers. Resident #106 was at risk for skin breakdown. The interventions included provide supplemental nutritional support, monitor labs as ordered, weekly skin assessments per facility protocol, encourage good nutritional intake, maintain pressure reduction mattress to bed, provide incontinence care frequently and as needed, monitor skin daily during morning care and treatments as ordered. There was no documented care plan for refusal of care. Resident #106's skin assessment dated [DATE] read in part no issues with skin, skin warm, dry and intact. Further review of the record revealed there was no evidence of any skin assessments completed, signed, and dated from 10/18/21 through 12/07/21. Resident #106's skin assessment dated [DATE] read in part resident would not let nurse check skin that isn't visible. States she had no open areas on her body. No skin issues observed on skin visible. The note was signed by Nurse #2 who had attempted the skin assessment. There were no progress notes or documentation that indicated Nurse #2 attempted the skin assessment later that day. Resident #106's nursing progress note dated 12/09/21 at 4:33 AM, read in part, weekly nursing evaluation completed. Resident would not let nurse check skin that isn't visible, resident stated she has no open areas on her body. No skin issues/abnormalities observed on visible skin during nursing evaluation. Resident remains stable, no s/s distress or discomfort, continues scheduled pain medication with no breakthrough pain. Written by Nurse #5 as part of the weekly nursing evaluation. An interview on 02/02/22 at 11:41 AM with Nurse Aide (NA) #1 revealed she had taken care of Resident #106 on 12/09/21 and reported to Nurse #2 that her skin was red on her buttocks and coccyx area, and she had several areas that looked raw and were red. She stated there were areas on the back of her legs and her bottom and coccyx area. NA #1 stated this was the first day she had noticed her buttocks being red. An interview on 02/03/22 at 5:30 PM with Nurse #1 assigned to Resident #106 on 12/09/21 revealed she had been called into the shower room by the Nurse Aide (could not recall her name) caring for the resident on 12/09/21 to look at her bottom. Nurse #1 stated she went into the shower room to see Resident #106's bottom and described the resident was moaning and groaning and said she had several different areas on her bottom and coccyx with one area that resembled a blister with fluid in it. Nurse #1 further stated she followed the standing orders and completed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not aware she was supposed to complete a wound assessment on Resident #106 and said no one had shown her how to do that at the facility. Nurse #1 indicated she had placed a note in the provider book for the Nurse Practitioner to see the resident on her next round. Nurse #1 said she had done the dressing on the resident several times and stated her wound was not getting better and had gotten worse. Nurse #1 indicated the resident was noncompliant with turning and repositioning to offload her buttock and coccyx area and wouldn't allow the staff to assist her in turning and repositioning. She further indicated the resident had refused her meals several times and refused to get up out of bed to assist in offloading her buttocks and coccyx. Nurse #1 stated she had tried to talk the resident into repositioning and tried to talk her into getting up in her chair but Resident #106 still refused to get up. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse area to back of upper leg with wound cleanser, pat dry and apply absorbent foam dressing and change every 3 days and as needed until resolved. Cleanse area to coccyx with wound cleanser, pat dry, apply absorbent foam dressing and change every 3 days and as needed until resolved. Complete weekly skin assessments. A Nurse Practitioner (NP) progress note dated 12/10/21 revealed the resident was being seen for follow up visit for evaluation of buttocks breakdown. Integumentary (includes the skin and all its layers) was noted as being positive for poor healing of wounds. The wounds were described in the notes as multiple denuded (stripped of covering) areas with top layer of skin sheared off over bilateral upper/posterior thighs, buttocks, and coccyx. Resident #106 was diagnosed by the NP with non-pressure chronic ulcer of buttock limited to breakdown on skin. The plan was to continue to cleanse area with wound cleanser and apply bordered foam dressing daily and as needed. Notify if areas worsen or stall in healing process. The contingency plan was consider temporary indwelling urinary catheter if skin condition declines. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview with the Nurse Practitioner (NP) on 02/01/22 at 3:12 PM revealed she saw the resident on 12/10/21 and she had multiple denuded areas of sheared skin on her buttocks and coccyx area. During the conversation with the NP, she referred to the wound as a pressure wound not a non-pressure chronic ulcer of the buttocks as she had noted in her progress notes on 12/10/21. She stated she had written in Resident #106's treatment plan on her progress note dated 12/10/21 to clean the areas with wound cleanser and apply antibiotic cream and cover with a foam dressing daily and as needed. The NP acknowledged that she had not written orders for the treatment in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP described Resident #106 as arousable but said she didn't communicate a lot with her. She described her appetite as waxing and waning and said she was immobile during the time she had her wounds and was not motivated to offload while in the bed and was refusing to turn while in the bed and refusing to get up. The NP said given her comorbidities and overall generalized decompensated condition she stated Resident #106's wounds were unavoidable, and she also said she would have expected her wounds to have gotten worse. The NP indicated the wounds could have been a source of her pain, but the resident had been diagnosed with chronic pain. The NP further indicated although she would have anticipated her wounds to have gotten worse given her overall poor health, she would have expected the nurses to have notified her of the worsening of the wound and she would have re-evaluated her wounds and possibly ordered a urinary catheter to be placed. According to the NP she had not referred Resident #106 to the wound physician because she had previous experience with wounds and worked in a wound clinic and felt while the wound was a stage II she could manage and treat it but stated had she known the wound had gotten worse she would have referred Resident #106 to the wound physician. Review of Resident #106's Treatment Administration Record (TAR) for December 2021 revealed the following order: Cleanse area to coccyx with wound cleanser, pat dry, apply Allevyn (foam dressing that removes fluid faster than regular dressings) and change every 3 days and as needed until resolved. Effective date of the order was 12/09/21. The TAR from 12/9/21 through 12/18/21 revealed that treatments were provided as ordered every 3 days on 12/09/21, 12/12/21, 12/15/21, and 12/18/21. There were no PRN treatments documented as provided. The medical record revealed no evidence of any pressure ulcer assessments completed for Resident #106's stage II pressure ulcer after the NP's evaluation on 12/10/21. Further review of the medical record revealed no evidence wound measurements were obtained after the pressure ulcer was first identified on 12/9/21. An interview on 02/02/22 at 11:49 AM with Nurse Aide (NA) #2 revealed she had taken care of Resident #106 on 12/19/21 and had asked the Director of Nursing (DON) to come into her room to look at the residents wound. NA #2 stated the wound was red with some bleeding in some areas and there were areas of black on the wound. The NA stated she could not remember the wound having a foul odor but said it could have and she just didn't remember. NA #2 stated the wound looked worse than the last time she had seen it and taken care of the resident on 12/15/21. An interview on 02/03/22 at 6:42 PM with the Director of Nursing (DON) revealed she had been at the facility on 12/19/21. The DON stated she had been asked by the NA (could not recall her name) taking care of the resident on 12/19/21 to come into the room and look at her wounds while she was performing incontinence care. The DON stated she went into the room and looked at the wounds on her buttocks and coccyx and stated the pressure ulcer had worsened and appeared as though the wound was tunneling. She said she called the Unit Manager at home to ask her about the wound and care of the wound. The DON indicated she did the wound care as ordered and had placed a note in the provider book for the NP to see the resident on her next rounds. The DON further indicated she should have completed an assessment of the wound but had not done so and could not remember why she had not documented her observation of the wounds. She said she should have completed a wound assessment with measurements for the NP to review on her next rounds at the facility. The DON explained the NP was at the facility 3 days per week and available by phone as needed. The facility was unable to locate the note that was placed in the provider book by the DON on 12/19/21. A nursing progress note dated 12/21/21 written at 7:15 AM by Nurse #2 revealed NA came to get nurse to show wounds on bottom. No dressings on bottom. Two (2) absorbent foam dressings placed on buttocks. Wound communication put in provider book. The note was placed in the provider book for the NP to see the resident on her next rounds in the facility. A phone interview was attempted on 02/02/22 at 11:30 AM, 02/03/22 at 9:26 AM, and 02/03/22 at 3:31 PM with Nurse #2 with no return call. The facility was unable to locate the note that was placed in the provider book by Nurse #2 on 12/21/21. A nursing progress noted dated 12/22/21 written at 6:38 PM by Nurse #5 revealed Resident #106 was observed not in her baseline orientation this morning. Not able to respond to commands, not able to stick her tongue out. No grasp reflex. Not her usual self. DON notified for comparison to normal baseline. Directed from DON to call family and ask if they wanted resident sent out. Family member requested send to emergency department for further evaluation. On call contacted. NP gave order to send to ED (emergency department) to rule out possible [CONDITION(S)] (TIA)/stroke. Vital signs 107/65, 105, 99.0, 97% and blood sugar 127. A phone interview was attempted on 02/02/22 at 11:31 AM, 02/03/22 at 9:28 AM and 02/03/22 at 3:33 PM with Nurse #5 with no return call. Resident #106's hospital admission notes revealed she was admitted to the local hospital on 12/22/21 through the emergency department (ED) to the ICU (Intensive Care Unit). The resident was evaluated for generalized weakness and altered metal status. The resident had a decubitus ulcer that was undergoing treatment at the facility where she resided. The resident was diagnosed with acute kidney injury, [CONDITION(S)], [CONDITION(S)], lactic acidosis, respiratory failure, and sacral wound. The resident had a large foul-smelling decubitus ulcer that would likely require surgical evaluation and possibly debridement. She was admitted her for further management and stabilization to the critical care unit. The resident was initiated on broad-spectrum antibiotics for her [CONDITION(S)], and it was suspected the wound was the source of her infection. A phone interview was attempted with the attending hospital physician on 02/03/22 at 11:30 AM, 02/03/22 at 2:00 PM and 02/03/22 at 4:00 PM with no return call. An interview on 02/03/22 at 6:42 PM with the DON revealed there should have been weekly skin assessments documented for Resident #106 especially since she had developed a stage II decubitus ulcer on 12/09/21. She stated she contributed some of the breakdown to the agency staff in the building. The DON further stated she was planning to implement bedside rounding so the nurses were looking at the residents while giving report. She indicated they had already revamped their 24-hour reporting sheets to include labs and x-ray reports so the nurses would be aware of any pending labs or reports. The DON further indicated since they were using so much agency, she had started bringing them in on meetings monthly and had included them on group texts. The DON said she couldn't explain why Resident #106's weekly skin assessments had not been done and stated there were always opportunities to view a resident's skin during incontinence care, showers, baths and when dressing. She also said the nurses should have asked for assistance with the skin assessments if they were unable to get the resident to allow them to look at her skin. The DON stated she realized they were going to need to provide additional education to the NAs and the nurses about skin assessments and wound care. She further stated she was planning to ask the wound doctor if he could provide some education to the NAs and the nurses regarding wounds. According to the DON, she expected skin assessments to be completed by the nurses, orders for wound care to be written by the providers and wound care to be done by the nurses as ordered by the physician. Additionally, the DON stated they would be doing some education with the Nurse Practitioner regarding the process for writing orders. The DON stated their normal process for verbal or written orders were for them to be written on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the NP notes were not immediately available in the resident's record so she would need to write any orders she wanted carried out in the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Administrator on 02/03/22 at 7:32 PM revealed she had just taken over the building as the Administrator in the middle of December 2021. She stated she quickly found out there were systems that were not in place that needed to be in place. She indicated she expected skin assessments and wound care to be done as ordered and stated it should have been done all along for the residents. The nursing home President and owner was notified of Immediate Jeopardy on 02/10/22 at 5:05 PM Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility has identified that the use of Staffing Agency personnel and the actions of the Nurse Practitioner led to a breakdown in the system for reporting skin issues, initiating treatments, effectively assessing, and monitoring identified skin issues, and notification of the resident's Attending Physician as well as the failure to complete weekly skin assessments. The use of multiple Staffing Agency personnel resulted in weekly skin assessments not being completed by Agency nurses and in a failure to report skin issues by the agency CNAs. [NAME] Place has also identified that the Nurse Practitioner failed to actually write the order to change the dressing from every three days to daily or to notify facility staff of her desire to change the order. The Nurse Practitioner included in her progress noted of 12/10/2021 the change in order but failed to write an order as is the facility's system or to notify anyone in Nursing of the need to change the order. The Nurse Practitioner also failed to follow the wound herself and therefore failed to note that a change in dressing order had not been done. The facility does not receive the Nurse Practitioner's dictated progress notes until a full week to two weeks after the note is dictated and was not aware of the Nurse Practitioner's order to change the frequency of the wound dressing. These issues led to Resident #106's wound order not being changed and to the deterioration of the wound not being noted timely. The Director of Nursing was not aware that the Nurse Practitioner had not been notified of the worsening of the wound and was not aware that skin assessments, wound assessments, or measurements had not been done. The Director of Nursing did not complete these tasks herself because she thought the floor staff had completed them. The missing note from the provider book has not been found. Resident #106 is no longer a resident at [NAME] Place and therefore, no interventions are needed for Resident # 106. [NAME] Place has identified that all residents have the potential to be affected by this practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility has designated an Administrative Licensed Practical Nurse as the individual that will be completing all skin assessments, wound dressing changes, and notifications to the Attending Physician. This Administrative Licensed Practical Nurse has been inserviced on 02/11/2022 and assisted the Director of Nursing and two Nurse Managers in completing skin audits and order audits for all residents on 02/11/2022. An outside facility consultant conducted the inservice of the Administrative Licensed Practical Nurse and also inserviced the Director of Nursing and two Nurse Managers as well. The results of the audit showed that all residents receiving wound treatments are currently receiving the correct treatment and that no new skin issues exist. The facility has also inserviced all staff that are working on 02/11/2022 on first shift (7am-7pm) on the proper protocol for notifying the Unit Nurse, Administrative Licensed Practical Nurse, Nurse Managers, or Director of Nursing of any skin breakdown or skin integrity issues. The unit nurses have been inserviced on the proper way to assess, document, and notify the physician of any skin issues that may be brought to their attention by the CNAs. CNAs were inserviced on what to do to prevent pressure ulcers, notifying the nurse of resident refusals of turning and repositioning, notifying nurses of resident refusals to get out of bed, and what skin changes they need to watch for and to report these to the unit nurse. These inservices were conducted by an outside facility consultant and included the Director of Nursing as a participant. The Director of Nursing will continue to inservice all staff 02/11/2022 - 02/12/2022 to ensure that all staff have received inservicing on the proper protocols. Any new agency staff that may be coming to the facility in the future will be inserviced at the start of their shift to ensure that they are aware of the facility's protocol and what to do in the event that a skin issue appears during their shift. The Nurse Practitioner has been inserviced by the facility Administrator on the proper protocol for writing orders and notifying the Nursing Staff of any change in orders. She has also been informed that she is to follow all wounds on a weekly basis or more often if needed and is to report off to the Director of Nursing and Administrator any changes in wounds or wound orders. This report will be made in writing. The facility Administrator has contacted the Wound Physician, the Attending Physician, and Attending Nurse Practitioner on 02/11/2022 and has informed each of them of the protocol for writing orders and notifying the staff of any change in orders. All residents that have wounds will also now be referred to the facility's contract wound service by the Administrative Licensed Practical Nurse for follow up and treatment even if they are managed care clients. Any current resident with wounds will be referred to the contract wound service on 02/11/2022 if they are not already being seen by this service. The Administrative Licensed Practical Nurse will accompany the wound physician on their visits to ensure that any dressing changes are properly ordered and entered into the resident's chart. In the event that the Administrative Licensed Practical Nurse is not available to conduct skin assessments, do dressing changes, or to accompany the wound physician, one of the Nurse Managers will fulfill those duties. Date of alleged Immediate Jeopardy Removal: 2/13/2022. Person responsible for the implementation is the Administrator. On 02/17/22 the facility's credible allegation was validated through record reviews, staff, and resident interviews. The facility provided education documentation for all staff on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on the new system for completing skin assessments. The education provided detailed how all new admissions, readmissions would have an initial, weekly, and as needed skin assessments completed by the nurse. Interviews conducted with the nursing staff validated skin assessments were assigned to each resident and were flagged on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Assistants were interviewed and described the new system of describing any changes in the residents' skin on their shower sheets and demonstrated a copy of the sheet and how they were taught to mark any changes in the resident's skin. The Director of Nursing (DON) was interviewed and described the way the new system to ensure skin assessments were completed. She reported all skin assessments were assigned in the electronic medical record (EMR) on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained she or her designee were responsible for reviewing the assessments daily to ensure all skin assessments had been thoroughly completed. The DON explained she or her designee verified the sheets were completed in detail and not just checked as done. The Administrator was interviewed and described in detail her education with the Nurse Practitioner (NP), Facility Medical Director and Wound Physician regarding referral of all wounds to the Wound Physician and collaboration between the NP, Medical Director and Wound Physician regarding resident wounds. A resident identified by the facility as alert and oriented with a wound was interviewed and reported his skin was assessed weekly by the nurse and nurse aide during his showers and he was followed by the Wound Physician for his decubitus ulcer. The credible allegation for the immediate jeopardy removal was validated on 02/17/22 with a removal date of 02/13/22. 2. Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Area Assessment for Pressure Ulcer on the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 had limited mobility and required extensive to total assist with activities of daily living and transfers. She was admitted with an existing pressure ulcer and fracture. She utilized a pressure reduction mattress. Resident #44 was at risk for skin breakdown. A review of Resident #44's Weekly Skin assessment dated [DATE] indicated a rash to the right shoulder, redness to left chest underneath breast area, a shear wound to the left buttock and a purple discoloration to the distal side of the left heel. Resident #44's Wound Assessment Report dated 12/16/21 indicated a new pressure ulcer to the left heel was identified on 12/15/21. It was described as unstageable due to slough/eschar (dead tissue) with the following measurements: length-1.8 cm (centimeters), width-1.8 cm and depth-0 cm. The most recent quarterly MDS assessment dated [DATE] indicated Resident #44 was cognitively intact, required extensive physical assistance with all activities of daily living and had impairment on one side of the upper extremities. She had one unstageable pressure ulcer due to slough/eschar present and continued to have a pressure reducing device for bed. Resident #44's care plan reviewed on 12/17/21 indicated the following interventions under pressure ulcers: refer to wound specialist as needed, treatments as ordered, weekly skin assessment per facility protocol and maintain pressure reduction mattress. A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . a. An observation of pressure ulcer care on Resident #44 was made on 2/2/22 at 9:41 AM of Nurse #3. Nurse #3 cleaned the wound to the left heel with a gauze soaked with wound cleanser. She applied a mixture of an antimicrobial gel and [MEDICATION(S)] ointment to the surface of the wound using a cotton swab applicator. Nurse #3 covered the wound with a [MEDICATION(S)] gauze, applied a foam heel cup and wrapped it with a bandage roll. The pressure ulcer to the side of the left heel had the following approximate measurements: length-1 cm, width-1cm, depth-0.5 cm. The wound bed was clean with 80% granulation tissue observed surrounded by rough and peeling edges. A phone interview with Nurse #3 on 2/2/22 at 1:10 PM revealed she got confused with the order for Resident #44's left heel pressure ulcer. Nurse #3 explained that she followed a printout with step-by-step directions and items needed to perform the treatment. The printout included a [MEDICATION(S)] gauze but when she verified the order in the electronic medical record after she performed the procedure, she saw the order did not include the use of a [MEDICATION(S)] gauze. Nurse #3 further stated she called the Unit Manager to ask her if it was acceptable to use a [MEDICATION(S)] gauze instead of a regular gauze which was specified in the order. The Unit Manager told her that she was going to check with the wound doctor and clarify the order for Resident #44's left heel pressure ulcer. An interview with the Unit Manager (UM) on 2/2/22 at 3:00 PM revealed she frequently rounded with the wound doctor whenever he came to the facility. The UM confirmed that the last time the wound doctor assessed Resident #44's left heel pressure ulcer, he changed the treatment order from using a [MEDICATION(S)] gauze to [MEDICATION(S)] ointment and regular gauze because the wound needed more debridement and he preferred using [MEDICATION(S)] for this purpose. The treatment orders were located in the electronic medical record, but the UM also made a book of printouts that had step by step instructions to help the nurses when they performed wound care. The UM reported that Nurse #3 had asked her about the [MEDICATION(S)] gauze after she did Resident #44's treatment to her left heel pressure ulcer and told her she got confused because the printout still had a [MEDICATION(S)] gauze listed as one of the items needed but she failed to read the instructions that only included a regular gauze. The UM stated she told Nurse #3 she should have looked at the Treatment Administration Record in the electronic medical record and not relied on the printout. The UM also stated Nurse #3 should have used a regular gauze instead of a [MEDICATION(S)] gauze. An interview with the wound doctor on 2/3/22 at 10:44 AM revealed he had been following Resident #44 for over 2 months and had been treating her left heel pressure ulcer. It started as a deep tissue injury with unstageable necrosis which he debrided and eventually advanced the staging to stage 4 due to exposure of fascia 2-3 weeks after it was first identified. At some point he had ordered the use of [MEDICATION(S)] gauze because the wound was too dry, and it needed moisture, but he discontinued it on 1/24/22 and changed the treatment to an antibiotic gel and [MEDICATION(S)] ointment because it needed debridement. The wound doctor stated Nurse #3 probably did not pick up on the change in the treatment and used [MEDICATION(S)] gauze instead of a regular gauze which might not have been harmful, but it added a lot of moisture to the wound and could cause maceration of the surrounding skin tissue. The wound doctor also stated he expected the nurses to follow his orders and instructions when providing pressure ulcer care to Resident #44. An interview with the Director of Nursing (DON) on 2/3/22 at 6:22 PM revealed Nurse #3 should not have relied on the printout and should have looked at the order on the electronic medical record before doing Resident #44's dressing change. The DON stated she had addressed the issue with the UM and instructed her to do away with the book or at least make a copy of the current order and continually update it to reflect the current treatment orders. b. A review of Resident #44's Treatment Administration Record (TAR) for January 2022 indicated the treatment order for Resident #44's left heel was left blank on 1/15/22 and 1/31/22. An interview with Nurse #4 on 2/3/22 at 2:20 PM reve [TRUNCATED]

Based on record review, staff, Nurse Practitioner, and Physician interviews, the facility failed to provide care and treatment to a wound in accordance with accepted professional standards of practice, resulting in one resident's wound becoming infected and infested with maggots and requiring hospitalization . This was evidenced in 1 of 1 sampled resident reviewed for maggots (Resident #5). Immediate Jeopardy began on 10/30/18 when Resident #5 was found with maggots in the uncovered wound over his left ear. Immediate Jeopardy was removed on 11/16/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There were no documented wound assessments completed for Resident #5 from his admission of 01/29/18 until his discharge of 10/30/18. Review of the physician order [REDACTED].#5 should have a non-adhesive dressing applied to the wound over his left ear every three days. Review of the nurse's notes for Resident #5 revealed the following: 02/28/18 - 11:48 AM Resident observed picking at area above left ear. Blood noted dripping down side of head. Area cleansed, and dry dressing applied. Resident continues to pick at area. 03/01/18 - Dressing to left ear is not present and new one applied. Review of the Nurse Practitioner (NP) progress notes dated 03/13/18 revealed Resident #5 had a [MEDICAL CONDITION] of the scalp removed with a wound and continued to remove dressing from the wound over his left ear. He refused to leave the dressing over suspected area of [MEDICAL CONDITION] above his left ear. He was having some minimal drainage. Will continue to monitor, as potentially this is a risk to other residents if his drainage ends up in places that another patient will touch. There were no signs and symptoms of infection at this time, but he is certainly high risk related to this. He and his family have opted for no further workup or treatment related to this at this time. Review of the NP Progress Note dated 05/31/18 revealed Resident #5 was seen due to nursing report that he had some green drainage from the wound on the left side of his head this AM. He has had this wound for several months after an excision related to [MEDICAL CONDITION]. He continues to pick at the wound and it has not healed because of this. Nursing continues to try to cover it several times a day, but he continues to remove and pick at it. Plan - He continues to pick at this lesion. Will likely continue to be open. Nursing will continue to try to dress this, but he will continue to remove. No signs and symptoms of infection noted today. Continue to monitor, high risk for infection given his hands always being in it. Review of the nurse's note dated 08/13/18 11:35 AM revealed Resident #5's dressing to left ear completed this am. Noted odorous greenish/tan drainage on soiled dressing. Acute sheet completed for PEC for further instruction. Review of the NP's Progress Note dated 08/14/18 revealed Resident #5 was seen today for nursing concern about the wound above his left ear. She reports that he has had some greenish/tan odorous drainage. This is a persistent wound removal of [MEDICAL CONDITION]. Since he has had this done, he has not kept his dressing on this and has been frequently picking at it which has worsened it. Nursing has devised a way it seems at this point to keep the dressing on so that he is not able to touch it, which will certainly help with healing. I do not see any signs or symptoms of infection that would warrant antibiotics at this point. Change the dressing to a dry dressing that is to be changed daily as this may help with the odor since it was only changed every 3 days before. Continue to monitor as he has high risk for infection. Review of the physician orders [REDACTED].#5's revealed a new order for the dressing to left ear to be changed every day with a dry dressing. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS further revealed Resident #5 was receiving dressing changes with no wound type checked on the MDS. Review of the care plan dated 10/23/18 revealed Resident #5 was care planned for removing the dressing from his left ear and picking at the area. The goal was for the staff to reapply the dressing as needed. The interventions were as follows: weekly skin assessments per facility protocol. Assist resident to reposition/shift weight frequently when up in wheelchair to reduce risk for redness or impairment at pressure points. Keep skin clean and dry. Keep nails clean and trimmed, rough edges filed. Review of the facility Treatment Record for 10/2018 revealed all treatments were checked as being completed as ordered. Review of the nurse's note dated 10/30/18 at 12:29 PM revealed it was reported by night shift RN that resident had maggots noted in left ear wound. The Nurse Practitioner (NP) was in and looked at wound. Order to send to the emergency room for evaluation and treatment possible surgical debridement. The responsible party was notified, and resident was transported via non-emergent transport. Review of the nurse's note dated 11/02/18 at 2:26 PM as an Addendum with no late entry date documented revealed the following: Late entry: At about 5:00 AM the Nurse Aide (NA) told this writer that resident took dressing off his wound. During application of new dressing, foreign bodies were noted in the wound. Wound was cleaned, and 2 foreign bodies removed. Note left in physician's book for NP who is due in facility this AM. Review of the hospital records dated 10/30/18 through 11/02/18 revealed Resident #5 was seen in the emergency room (ER) for evaluation of a wound infection. The Plan of Care revealed the following statement from the ER physician, I am concerned for this patient's well-being as I do not believe that all of his maggots appeared just today. They were likely there before today. I believe that he warrants hospitalization today for aggressive wound care and intravenous antibiotics. Medical Decision Making and Plan of Care revealed there was an infestation by maggots and wound infection. The patient had numerous, very large maggots in his wound which runs very deep. It does still appear to be superficial to the skull however. Did not believe imagining was indicated but certainly extensive blood work was warranted including blood cultures. Review of the hospital discharge summary dated 11/02/18 revealed this [AGE] year-old male who presented from skilled assisted living facility with a wound infection was noted to have a wound over his left ear that had been chronic and biopsied in the past and was noted to [MEDICAL CONDITION]. He was noted to have maggots around his left ear wound. He was given intravenous antibiotics and admitted to the hospital. He was transitioned to by mouth antibiotics prior to discharge. A wound consult was placed, and it was recommended that the patient be placed on twice a day/as needed wound care with Dakins solution, a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION] then cover with a moist gauze dressing. Resident #5 was discharged from the hospital to a different skilled nursing facility on 11/02/18. An interview conducted with Nurse Aide #1 on 11/14/18 at 3:11 PM revealed if she was working with Resident #5 and his dressing wasn't on she would let the nurse know and they would replace it. She stated Resident #5 constantly picked at the wound and removed his dressing often. An interview conducted on 11/14/18 at 10:42 AM with Nurse #1 revealed she cared for Resident #5 from the time he was admitted to the day he was discharged to the hospital. She stated Resident #5 was admitted with a wound above his left upper ear and they were changing his dressing every three days. She stated they did not do weekly wound assessments or measurements on Resident #5's wound because it wasn't a pressure wound. She stated Resident #5 would pick at his wound under his dressing and take his dressing off. She stated when she observed the greenish/tan odorous drainage on 08/14/18 she notified the NP and who wrote an order to change the dressing every day. Nurse #1 stated they would clean the wound with wound cleanser and cover with a dry dressing once a day. She stated Resident #5 didn't remove his dressing every day, it was more when he was anxious and she wasn't aware of any interventions in place to keep him from picking at his wound or removing the dressing. Nurse #1 further stated she had never observed maggots in Resident #1's wound until the morning he was sent out to the hospital to have them removed. An interview conducted on 11/16/18 at 9:40 AM with Nurse #3 revealed she had changed Resident #5's dressing on 10/27/18, 10/28/18, and 10/29/18 and had not observed maggots or any signs or symptoms of infection in his wound. Nurse #3 stated his wound always had an odor and she didn't notice any difference in the odor or observe any flies in the building the three days she changed his dressing before he was sent to the hospital. She further she they did not do weekly wound assessments on his wound because it wasn't a pressure ulcer. Interview conducted on 11/14/18 at 2:24 PM with Nurse #2 revealed he was working the 11:00 PM to 7:00 AM shift on 10/30/18 when the NA told him Resident #5 had taken off his dressing over his left ear. Nurse #2 stated he went in to replace the dressing and as he was cleaning it with wound cleanser he saw 2 maggots, which he removed from the wound. He stated he covered the wound with the dressing and put a note in the physician's book for the NP to see him later that morning. Nurse #2 further stated he never had to replace Resident #5's wound dressing during the night and that was the first time he had observed Resident #1's wound. Interview conducted on 11/14/18 2:54 PM with the facility Nurse Practitioner stated Resident #5 had a chronic wound over his left ear from [MEDICAL CONDITION] being removed. She stated the family didn't want to pursue any [MEDICAL CONDITION] or [MEDICAL CONDITION] for [MEDICAL CONDITION] but did want treatment for [REDACTED]. She stated she never considered a wound consult for Resident #5 because he picked at the wound all the time and she didn't think a wound consult would benefit him. The NP stated she had not assessed Resident #5's wound in about 2 months when she was asked to look at it on 10/30/18. She stated the wound had maggots in it that morning and she wrote an order for [REDACTED].#5 picking at his wound and removing his dressing. An interview conducted on 11/15/18 at 3:11 PM with the facility Physician revealed maggots in wounds came from flies laying eggs on the wound. He stated they started growing within 8 to 12 hours and the bigger they were the longer they had been present in the wound. An interview conducted on 11/16/18 at 10:30 AM with the Director of Nursing revealed it was her expectation that there should have been documentation of weekly wound assessments by the treatment nurse and floor nurse completed for Resident #5's wound over his left ear. She stated any odor or change in the wound should have been documented on the wound assessments. On 11/14/18 at 5:12 PM the Administrator and Corporate Vice President were notified of Immediate Jeopardy. On 11/16/18 the facility provided a credible allegation of Immediate Jeopardy removal that included: Immediately after learning of the incident the following interventions were put into place by the Director of Nursing and the Corporate Quality Assurance Nurse: 1. Resident #5 was sent to the hospital for evaluation and treatment of [REDACTED]. The facility nursing staff had noted that the resident #5 had maggots in the wound. Per the resident's family's request, he did not return to the facility. 2. On (MONTH) 30, (YEAR) the Quality Assurance nurse completed a thorough skin assessments on all residents with wounds and noted that no other residents' wounds showed any evidence of foreign bodies, infection, or neglect by nursing staff. 3. The Director of nursing and Quality Assurance nurse interviewed nursing staff between (MONTH) 31st and (MONTH) 1, (YEAR) concerning this resident's wound to determine when the last wound treatment was done and when it was first noted that resident #5 had removed the dressing at some point between the late evening of (MONTH) 29th and early morning (MONTH) 30, (YEAR). Staff interviews showed that the dressing was noted to be intact through the day on (MONTH) 29, (YEAR) and into the evening/night on (MONTH) 29, (YEAR). Staff had noted that the dressing was intact during all rounds made on the resident up until the 5am round when the dressing was noted to be removed. Statements from staff also spoke to the week prior to (MONTH) 30th (YEAR) and resident #5 was noted not to have maggots in the wound prior to 5am on (MONTH) 30th (YEAR). The facility had an order to change the dressing daily and to use dry dressings on the [MEDICAL CONDITION] lesion. There were no orders for any ointments due to resident's propensity to pick at the wound and eat scabbed material from the wound. Other than staff intervening and redirecting resident #5 when he was noted to be picking and eating at the dressing/wound, no other interventions were in place Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To be Affected By The Same Deficient Practice: Immediately after learning of the incident the following interventions were put into place by the Director of Nursing and the Corporate Quality Assurance Nurse: 1. On (MONTH) 31, (YEAR) the Quality Assurance nurse completed a thorough skin assessments on all residents with wounds and noted that no other residents' wounds showed any evidence of foreign bodies, infection, or neglect by nursing staff. 2. On (MONTH) 2, (YEAR) the facility signed a contract with a wound services physician in order to get a designated wound care physician contracted to take over the treatment and prescribing of wounds in the facility. The wound physician had been contacted on (MONTH) 31, (YEAR). 3. All nurses and aides were in-serviced by the Director of Nursing on what a change in condition is and who should be notified in the event of a change in condition on (MONTH) 1, (YEAR). Aides were in-serviced by the Director of Nursing on (MONTH) 1, (YEAR) that they should notify the nurse on the unit of any change in a resident's condition including dressings that are not intact or in need of being changed. The nurses will be in-serviced on (MONTH) 15, (YEAR) by the Director of Nursing that they should notify the physician, the director of nursing and the family of any change in condition of residents and non-compliance with wound care or removing dressing. For the nurses and aids not present on (MONTH) 15, (YEAR) they will be in-serviced by the Director of Nursing as they report to work to ensure they are re-educated before they begin their shift. 4. All wound orders were audited and reviewed by the Director of Nursing and the Corporate Quality Assurance nurse on (MONTH) 14, (YEAR) to ensure treatments are being done as ordered and that all dressings were intact. This audit will be reviewed with the wound physician on (MONTH) 21, (YEAR). 5. All residents who are known to exhibit the behavior of non-compliance with wound care will be re-assessed by the Interdisciplinary Team to ensure that appropriate interventions are in place and appropriate interventions will be put in place by (MONTH) 16, (YEAR). For any intervention that is found to be out of place it will be re-initiated immediately, and staff will be re-trained on the importance of maintaining intervention. For resident's with severely impaired cognition, interventions will be developed based upon the individual resident's behavior to ensure that a severely impaired cognitive resident's wound dressing remains intact at all times. All alert and oriented residents will receive education by (MONTH) 16, (YEAR) regarding possible negative outcomes of non-compliance with dressing changes and leaving dressings intact. All nurses will be in-serviced on (MONTH) 15, (YEAR) on the procedure for the behavior communication form. This form will allow staff to write in the date, residents name, behaviors noted and what interventions they initiated at that time and whether those interventions were effective. For the nurses and aids not present on (MONTH) 15, (YEAR) they will be in-serviced by the Director of Nursing as they report to work to ensure they are re-educated before they begin their shift. Address What Measures Will Be Put Into Place Or Systemic Changes Made To Ensure That The Deficient Practice Will Not Recur: 1. All nursing staff will be in-serviced by the Director of Nursing before the start of their shift on (MONTH) 15, (YEAR) on how to complete and document on a behavior communication form all noted behaviors including non-compliant behavior. For any nurse or aide that is not present on (MONTH) 15, (YEAR), they will receive an in-service as they report to work before the start of their shift by the Director of Nursing. Staff will turn in the behavior communication forms to the Director of Nursing once they have completed them. All housekeeping, laundry, dietary, maintenance and administrative staff will be educated on the importance of reporting behaviors to the unit nurse by (MONTH) 15, (YEAR).All new hires will be educated during their initial orientation on the communication of behaviors including non-compliant behavior before they are released to work on the floor. 2. For any resident with non-compliant behaviors noted on the behavior communication form, the Interdisciplinary team will review interventions weekly that are in place to ensure that these interventions are effective in ensuring the resident remains free from non-compliance to as the high of a degree as possible. For resident's with severely impaired cognition, interventions will be developed based upon the individual resident's behavior to ensure that a severely impaired cognitive resident's wound dressings remain intact at all times. 3. The Director of Nursing will inspect each wound in the facility to ensure that the wound is free of foreign bodies, signs of infection, and neglect. These rounds will begin (MONTH) 15, (YEAR). For any wound that shows a negative change in condition the Director of Nursing will also review residents' medical records to ensure that the physician was notified of the change in condition. 4. The Director of Nursing's observations will be recorded on a Quality Assurance form and will be presented to the interdisciplinary team each week for review and discussion to ensure that wounds remain free of signs of neglect on (MONTH) 15, (YEAR). Indicate How The Facility Plans To Monitor It's Performance To Make Sure That Solutions Are Sustained. The Facility Must Develop A Plan For Ensuring That Correction Is Achieved And Sustained: 1. The Quality Assurance Committee, QAPI Committee and the Medical Director and Wound Physician have been apprised of this plan and commit their support to assisting the facility with achieving and sustaining compliance with this alleged citation. The QAPI Committee was notified on (MONTH) 11, (YEAR). 2. The Director of Nursing's weekly wound assessment rounds and audit of charts to ensure notification of physician due to change in resident wound condition will be presented at monthly QA meetings and quarterly to the QAPI Committee for evaluation to determine if the system is adequate and if determined it is not, they will devise and re-implement a system to ensure the alleged deficient practice does not occur again. 3. The review done by the interdisciplinary team on all residents with non-compliant behavior will be presented to the QA committee monthly and the QAPI committee quarterly. Date of Compliance is (MONTH) 16, (YEAR). The Administrator will be responsible for implementing this plan of correction. Immediate Jeopardy was removed on 11/16/18 at 12:26 PM when facility staff were interviewed and demonstrated they had been trained on the topics of abuse and neglect, change in condition, and report of change in condition.

Based on record review, Nurse Practitioner, Physician, and staff interviews, the facility neglected to assess and maintain a clean covered wound and neglected to implement effective interventions to prevent a resident from picking at a wound to prevent maggot infestation for 1 of 1 resident reviewed with having maggots in a wound (Resident #5). In addition the facility neglected to provide ordered assistive equipment for 1 of 1 resident reviewed for assistive devices (Resident #2). Immediate Jeopardy began on 10/30/18 when maggots were found in Resident #5's wound above his ear. Immediate Jeopardy was removed on 11/16/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) for example #2. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses of hypertension, unspecified dementia without behavioral disturbance, [MEDICAL CONDITION], muscle weakness, and depression. There was no [DIAGNOSES REDACTED].#5. There were no documented wound assessments completed for Resident #5 from his admission of 01/29/18 until his discharge of 10/30/18. Review of the skin assessment dated [DATE] revealed Resident #5 had an open area/blister to left side of head. Review of the physician order [REDACTED].#5 should have a non-adhesive dressing applied to the wound over his left ear every three days. Review of the nurse's notes for Resident #5 revealed the following: 02/28/18 - 11:48 AM Resident observed picking at area above left ear. Blood noted dripping down side of head. Area cleansed, and dry dressing applied. Resident continues to pick at area. 03/01/18 - Dressing to left ear is not present and new one applied. Review of the Nurse Practitioner (NP) progress notes dated 03/13/18 revealed Resident #5 had a [MEDICAL CONDITION] of the scalp removed with a wound and continued to remove dressing from the wound over his left ear. He refused to leave the dressing over suspected area of [MEDICAL CONDITION] above his left ear. He was having some minimal drainage. Will continue to monitor, as potentially this is a risk to other residents if his drainage ends up in places that another patient will touch. There were no signs and symptoms of infection at this time, but he is certainly high risk related to this. He and his family have opted for no further workup or treatment related to this at this time. Review of the NP Progress Note dated 05/31/18 revealed Resident #5 was seen due to nursing report that he had some green drainage from the wound on the left side of his head this AM. He has had this wound for several months after an excision related to [MEDICAL CONDITION]. He continues to pick at the wound and it has not healed because of this. Nursing continues to try to cover it several times a day, but he continues to remove and pick at it. Plan - He continues to pick at this lesion. Will likely continue to be open. Nursing will continue to try to dress this, but he will continue to remove. No signs and symptoms of infection noted today. Continue to monitor, high risk for infection given his hands always being in it. Review of the nurse's note dated 08/13/18 11:35 AM revealed Resident #5's dressing to left ear completed this am. Noted odorous greenish/tan drainage on soiled dressing. Acute sheet completed for the physician for further instruction. Review of the NP's Progress Note dated 08/14/18 revealed Resident #5 was seen today for nursing concern about the wound above his left ear. She reports that he has had some greenish/tan odorous drainage. This is a persistent wound removal of [MEDICAL CONDITION]. Since he has had this done, he has not kept his dressing on this and has been frequently picking at it which has worsened it. Nursing has devised a way it seems at this point to keep the dressing on so that he is not able to touch it, which will certainly help with healing. I do not see any signs or symptoms of infection that would warrant antibiotics at this point. Change the dressing to a dry dressing that is to be changed daily as this may help with the odor since it was only changed every 3 days before. Continue to monitor as he has high risk for infection. Review of the physician orders [REDACTED].#5's revealed a new order for the dressing to left ear to be changed every day with a dry dressing. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS further revealed Resident #5 had behavioral symptoms toward others 1 to 3 days during the assessment period and was receiving dressing changes with no wound type checked on the MDS. Review of the care plan dated 10/23/18 revealed Resident #5 was care planned for removing the dressing from his left ear and picking at the area. The goal was for the staff to reapply the dressing as needed. The interventions were as follows: weekly skin assessments per facility protocol. Assist resident to reposition/shift weight frequently when up in wheelchair to reduce risk for redness or impairment at pressure points. Keep skin clean and dry. Keep nails clean and trimmed, rough edges filed. Review of the facility Treatment Record for 10/2018 revealed all treatments were checked as being completed as ordered. Review of the nurse's note dated 10/30/18 at 12:29 PM revealed it was reported by night shift nurse that resident had maggots noted in left ear wound. The NP was in and looked at wound. Order to send to emergency room for evaluation and treatment possible surgical debridement. RP notified, and resident transported via non-emergent transport. Review of the nurse's note dated 11/02/18 at 2:26 PM as an Addendum with no late entry date documented revealed the following: Late entry: At about 5:00 AM the NA told this writer that resident took dressing off his wound. During application of new dressing, foreign bodies were noted in the wound. Wound was cleaned, and 2 foreign bodies removed. Note left in physician's book for NP who is due in facility this AM. Review of the hospital records dated 10/30/18 through 11/02/18 revealed Resident #5 was seen in the emergency room (ER) for evaluation of a wound infection. The Plan of Care revealed the following statement from the ER physician, I am concerned for this patient's well-being as I do not believe that all of his maggots appeared just today. They were likely there before today. I believe that he warrants hospitalization today for aggressive wound care and intravenous antibiotics. Medical Decision Making and Plan of Care revealed there was an infestation by maggots and wound infection. The patient had numerous, very large maggots in his wound which runs very deep. It does still appear to be superficial to the skull however. Did not believe imagining was indicated but certainly extensive blood work was warranted including blood cultures. Review of the hospital discharge summary dated 11/02/18 revealed this [AGE] year-old male who presented from skilled assisted living facility with a wound infection was noted to have a wound over his left ear that had been chronic and biopsied in the past and was noted to [MEDICAL CONDITION]. He was noted to have maggots around his left ear wound. He was given intravenous antibiotics and admitted to the hospital. He was transitioned to by mouth antibiotics prior to discharge. A wound consult was placed, and it was recommended that the patient be placed on twice a day/as needed wound care with Dakins solution, a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION] then cover with a moist gauze dressing. An interview conducted on 11/14/18 at 10:42 AM with Nurse #1 revealed she cared for Resident #5 from the time he was admitted to the day he was discharged to the hospital. She stated Resident #5 was admitted with a wound above his left upper ear and they were changing his dressing every three days. She stated Resident #5 would pick at his wound under his dressing and take his dressing off. She stated when she observed the greenish/tan odorous drainage on 08/14/18 she notified the NP and who wrote an order to change the dressing every day. Nurse #1 stated they would clean the wound with wound cleanser and cover with a dry dressing once a day. She further stated Resident #5 didn't remove his dressing every day, it was more when he was anxious. She stated she wasn't aware of any interventions in place to keep him from picking at his wound or removing the dressing. Nurse #1 further stated she had never observed maggots in Resident #1's wound until the morning he was sent out to the hospital to have them removed. Interview conducted on 11/14/18 at 2:24 PM with Nurse #2 revealed he was working the 11:00 PM to 7:00 AM shift on 10/30/18 when the NA told him Resident #5 had taken off his dressing over his left ear. Nurse #2 stated he went in to replace the dressing and as he was cleaning it with wound cleanser he saw 2 maggots, which he removed from the wound. He stated he covered the wound with the dressing and put a note in the physician's book for the NP to see him later that morning. Nurse #2 further stated he never had to replace Resident #5's wound dressing during the night and that was the first time he had observed Resident #1's wound. Interview conducted on 11/14/18 2:54 PM with the facility Nurse Practitioner stated Resident #5 had a chronic wound over his left ear from [MEDICAL CONDITION] being removed. She stated the family didn't want to pursue any [MEDICAL CONDITION] or [MEDICAL CONDITION] for [MEDICAL CONDITION] but did want treatment for [REDACTED]. She stated she never considered a wound consult for Resident #5 because he picked at the wound all the time and she didn't think a wound consult would benefit him. The NP stated she did not expect staff to do weekly measurements or weekly documentation of Resident #5's wound. The NP stated she had not assessed Resident #5's wound in about 2 months when she was asked to look at it on 10/30/18. She stated the wound had maggots in it that morning and she wrote an order for [REDACTED].#5 picking at his wound and removing his dressing. An interview conducted with Nurse Aide #1 on 11/14/18 at 3:11 PM revealed if she was working with Resident #5 and his dressing wasn't on she would let the nurse know and they would replace it. She stated Resident #5 constantly picked at the wound and removed his dressing often. An interview conducted on 11/15/18 at 3:11 PM with the facility Physician revealed maggots in wounds came from flies laying eggs on the wound. He stated they started growing within 8 to 12 hours and the bigger they were the longer they had been present in the wound. An interview conducted on 11/16/18 at 9:40 AM with Nurse #3 revealed she had changed Resident #5's dressing on 10/27/18, 10/28/18, and 10/29/18 and had not observed maggots or any signs or symptoms of infection in his wound. Nurse #3 further revealed she didn't do weekly measurements or skin assessments for Resident #5's wound above his ear since it wasn't being treated as a pressure area. An interview conducted on 11/16/18 at 10:30 AM with the Director of Nursing revealed it was her expectation that there should have been documentation of weekly skin assessments completed for Resident #5's wound over his left ear. On 11/14/18 at 5:12 PM the Administrator and Corporate Vice President were notified of Immediate Jeopardy. On 11/16/18 the facility provided a credible allegation of Immediate Jeopardy removal that included: Immediately after learning of the incident the following interventions were put into place by the Director of Nursing and the Corporate Quality Assurance Nurse: 1. Resident #5 was sent to the hospital for evaluation and treatment of [REDACTED]. The facility nursing staff had noted that resident #5 had maggots in the wound. Per the resident's family's request, he did not return to this facility 2. On (MONTH) 30, (YEAR) the Quality Assurance nurse completed a thorough skin assessments on all residents with wounds and noted that no other residents' wounds showed any evidence of foreign bodies, infection, or neglect by nursing staff. 3. The Director of nursing and Quality Assurance nurse began interviewing nursing staff concerning these residents' wounds to determine when the last wound treatment was done and when it was first noted that the resident #5 had removed the dressing from the wound. Staff had noted that the dressing was intact during all round made on the resident up until the 5am round on (MONTH) 30th when the dressing was noted to be missing. The facility had an order to change the dressing daily and to use dry dressings on the [MEDICAL CONDITION] lesion. There were no orders for ointments or other treatments due to resident #5's propensity to pick at the wound and to eat the scabs and other material from the wound. Other than staff intervening and re-directing this resident when he was noted to be picking at the wound, no other interventions were in place as the resident's cognitive status prevented him from being able to understand the need for leaving the wound alone. An in-house investigation began immediately on (MONTH) 31, (YEAR) and neglect was not suspected. A 24 -hour initial report was not sent in due to neglect not being suspected. Statements from staff collected during the (MONTH) 30th interviews that were done by the Director of nursing, show that staff were aware of the resident removing the dressing and that they would intervene when he was observed doing so. Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To be Affected By The Same Deficient Practice: Immediately after learning of the incident on (MONTH) 30, (YEAR) the following interventions were put into place by the Director of Nursing and the Corporate Quality Assurance Nurse: 1. The facility already has developed and implemented written policies and procedures that prohibit and prevent abuse, neglect and exploitations of residents and misappropriation of resident property. Annually and as needed, in-services are completed, and an acknowledgement is signed by all staff in the facility. 2. All staff, including PRN staff were in-serviced by the Social worker and Vice President on abuse and neglect of residents on (MONTH) 9, (YEAR) to ensure that all staff have an understanding of what constitutes neglect and what to do when neglect is suspected. On (MONTH) 1, (YEAR) all nurses and aides were in-serviced by the Director of Nursing on what a change in condition is and who should be notified in the event of a change in condition. Aides were in-serviced on (MONTH) 15, (YEAR) by the Director of Nursing that they should notify the nurse of any change in a resident's condition including dressings that are not intact or are in need of changing. The nurses were in-serviced on (MONTH) 15, (YEAR) by the Director of Nursing that they should notify the physicians, Director of nursing and the family in any change in condition of a resident. Any nurse or aide not present on (MONTH) 15, (YEAR) will receive an in-service by the Director of Nursing as they report to work before beginning their shift. All new hires will receive training on abuse and neglect, change in condition, and reporting change in condition during initial classroom orientation that is conducted prior to new staff being assigned to work the floor. 3. All residents were interviewed by the social worker on (MONTH) 9, (YEAR) to ensure they feel safe in the facility, if they feel anyone has harmed them, and if they feel they are receiving good care. All residents reported feeling safe and they feel the care provided to them is good. No resident reported any harm. 4. On (MONTH) 30th the Quality assurance nurse completed a thorough skin assessment on all residents with wounds that included visually looking at the wounds to ensure that basic care and cleanliness had been provided and dressing changes and treatments were completed as ordered. Address What Measures Will Be Put Into Place Or Systemic Changes Made To Ensure That The Deficient Practice Will Not Recur: 1. All neglect policies, practices, procedures and protocols were reviewed with all staff including any PRN staff on (MONTH) 9, (YEAR). This was done through in-servicing that was conducted by the facility social worker and the facility Vice President. All new hires will receive in-servicing and training on neglect policies, practices, procedures and protocols during their initial classroom orientation prior to being assigned to work the floor. 2. All wounds will be assessed by the Director of Nursing on (MONTH) 15, (YEAR). All wounds will be assessed by the Director of Nursing and the new wound physician on a weekly basis to ensure neglect and infections are not present. 3. On (MONTH) 15, (YEAR), The Director of Nursing will review the behavior communication form and audit all charts of residents documented to have non-compliant behaviors to ensure nurses notes include the behaviors documented on the communication form and that interventions have been put in place. For residents with severely impaired cognition, interventions will be developed based upon the individual resident's behavior to ensure that severely impaired cognitive residents do not suffer from neglect due to non-compliant behaviors. Indicate How The Facility Plans To Monitor It's Performance To Make Sure That Solutions Are Sustained. The Facility Must Develop A Plan For Ensuring That Correction Is Achieved And Sustained: 1. The Quality Assurance Committee, QAPI Committee and the Medical Director and Wound Physician have been apprised of this plan and commit their support to assisting the facility with achieving and sustaining compliance with this alleged citation. The QAPI Committee was notified on (MONTH) 11, (YEAR). 2. The Director of Nursing's weekly wound assessment rounds and audit of charts to ensure documentation, notification of physician due to change in resident wound conditions will be presented at monthly QA meetings and quarterly to the QAPI Committee for evaluation to determine if the system is adequate and if determined it is not, they will devise and re-implement a system to ensure the alleged deficient practice does not occur again. 3. The review done by the interdisciplinary team on all residents with non-compliant behavior will be presented to the QA committee monthly and the QAPI committee quarterly. 4. All policies, procedures and protocols pertaining to neglect will be reviewed quarterly by the QAPI Committee for the next 3 quarters and annually thereafter for appropriateness in preventing neglect. Date of compliance (MONTH) 16, (YEAR) The Administrator will be responsible for implementing this plan of correction. Immediate Jeopardy was removed on 11/16/18 at 12:26 PM when facility staff were interviewed and demonstrated they had been trained on the topics of abuse and neglect, change in condition, and report of change in condition. 2. Resident #2 was admitted to the facility 08/24/17 with diagnosed including: [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely impaired for cognition and required supervision with eating. Resident #2's care plan for nutrition last updated 11/01/18 revealed she was to receive a nosey cup with meals. (A nosey cup is a cup with a u shaped cut out on one side that allows the person using it to drink without bending their neck or tilting their head.) Review of Resident #2's Physician orders [REDACTED]. Observation of Resident #2 on 11/13/18 on 12:32 PM revealed she was feeding herself and her nectar thickened beverages were in regular drinking glasses. There was no nosey cup observed on Resident #2's meal tray. Observation of Resident #2 on 11/15/18 at 8:12 AM revealed she was eating breakfast with her nectar thickened liquid beverages in their original container. There was no nosey cup observed on Resident #2's meal tray. An interview with the Dietary Manager on 11/15/18 at 8:39 AM revealed the kitchen was responsible for putting nosey cup on residents' trays and she was not sure why Resident #2 did not receive a nosey cup on her tray. An interview with the Speech Therapist on 11/16/18 at 9:55 AM revealed he did not make the recommendation for Resident #2 to receive a nosey cup because the Speech Therapist that worked at the facility before him made the recommendation but he agreed with the recommendation and felt it was helpful for Resident #2 to be able to drink needed fluids. An interview with the Director of Nursing (DON) on 11/16/18 at 9:55 AM revealed she was aware that Resident #2 had not been receiving the nosey cup on her meal tray. The DON did not offer any reason as to why she did follow up to see why Resident #2 did not receive the nosey cup. The DON stated if the Physician ordered the nosey cup Resident #2 should receive the nosey cup. An interview with the Administrator on 11/16/18 at 1:18 AM revealed she expected Physician orders [REDACTED].