Every finding on record at Glenwood Health & Rehabilitation

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening Resident Review (PASRR) was completed for a resident with a diagnosis of a serious mental illness for 2 of 3 residents reviewed for PASRR (Resident #80 and Resident #87).The findings included: a. A review of the medical record revealed a Level I PASRR was completed for Resident #80 on 11/05/19 but did not include his active diagnoses of mental illness. The Level I PASRR determination letter noted Resident #80 did not to meet the federal definition for mental illness and was assigned a PASRR number with no expiration. Resident #80 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and delusional disorder. A review of the medical record revealed no evidence a Level II PASRR evaluation was completed for Resident #80. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact, exhibited no behaviors or rejections of care, had active diagnoses including depression, anxiety disorder and psychotic disorder (other than schizophrenia), and she was receiving anti-anxiety and anti-depressant medications. The MDS indicated Resident #80 was not currently considered by the state Level II PASRR authority to have a serious mental illness or intellectual disability. b. A review of the medical record revealed a Level I PASRR was completed for Resident #87 on 3/23/23 but did not include her active diagnoses of mental illness. The Level I PASRR determination letter noted Resident #87 did not to meet the federal definition for mental illness and was assigned a PASRR number with no expiration. Resident #87 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD). A review of the medical record revealed no evidence that a Level II PASRR evaluation was completed for Resident #87. The admission MDS dated [DATE] indicated Resident #87 was cognitively intact, exhibited no behaviors or rejections of care, had an active diagnosis of PTSD and he was receiving anti-anxiety and anti-depressant medications. The MDS indicated Resident #87 was not currently considered by the state Level II PASRR authority to have a serious mental illness or intellectual disability. An interview was conducted with the Director of Social Services on 7/10/26 at 9:34 AM revealed she assumed the role of Director of Social Services in January 2026 and was responsible for ensuring a Level I PASRR was completed for residents prior to admission to the facility. She indicated the hospital case managers usually completed the Level I PASRR prior to admission however she reviewed the Level I screen in the North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) to ensure it was completed during the most recent hospitalization and included any diagnoses of mental illness. She stated when Resident #80 and Resident #87 were admitted to the facility the Former Director of Social Services was responsible for this and should have completed new Level I PASRR screens for Resident #80 and Resident #87 to include their diagnoses of mental illness and submitted them for review. Attempts made to contact the Former Director of Social Services on 7/09/26 at 12:53 PM and 7/10/26 at 10:09 AM were unsuccessful. An interview conducted with the Administrator on 7/10/26 at 11:30 AM indicated the Director of Social Services was responsible for ensuring a Level I PASRR was completed for all residents prior to admission and reviewing the Level I PASRR screens completed by the hospital to ensure it was submitted for review during the most recent hospitalization and included the resident's diagnoses of mental illness. The Administrator stated the Former Director of Social Services should have completed new Level I PASRR screens for both Resident #80 and Resident #87 and submitted them for review.

Based on record review, observations, and staff interviews, the facility failed to maintain a medication error rate of less than 5%, as evidenced by the administration of medications that were ordered and manufactured to be administered whole after they were crushed prior to administration. This resulted in 2 medication errors out of 25 medication administration opportunities, for a medication error rate of 8% for 1 of 3 residents (Resident #77) observed during the medication pass.The findings included: Resident #77 was admitted to the facility on [DATE] with diagnoses that included heart failure.Review of the Physician's Orders in Resident #77's electronic medical record revealed an active physician order dated 11/30/25 for Potassium Chloride Crystals Extended-Release Oral Tablet 20 mEq, administer one tablet by mouth once daily for low potassium. The order further instructed, Do not chew or crush.Review of the Physician's Orders in Resident #77's electronic medical record revealed an active physician order dated 06/17/26 for Metoprolol Succinate Extended-Release oral tablet release 24-hour 25 milligram (mg) administer one tablet by mouth daily for hypertension.On 07/07/26 at 8:45 AM an observation and interview were conducted with Nurse #1. Nurse #1 was observed preparing medications for Resident #77. Nurse #1 removed one tablet labeled Potassium Chloride Crystals Extended-Release Oral Tablet 20 mEq and one tablet labeled Metoprolol Succinate Extended-Release 25 mg. The surveyor asked Nurse #1 how Resident #77 took her medications. Nurse #1 stated she planned to place the potassium tablet in a separate medication cup and crush the remaining medications. Nurse #1 was then observed placing both the Potassium Chloride Extended-Release tablet and the Metoprolol Extended-Release tablet into the same medication cup and crushing both medications. Nurse #1 proceeded to Resident #77's bedside, asked the resident to state her name, and after Resident #77 stated her first name, administered the crushed medications.An interview with Nurse #1 on 07/07/26 at 10:05 AM revealed she was unaware the physician's order for Potassium Chloride instructed that the medication should not be chewed or crushed. Nurse #1 further stated she did not realize the Metoprolol 25 mg was an extended-release medication and should not be crushed. She explained she had previously received education regarding medications that should not be crushed but became nervous while being observed by the surveyor and made a mistake.An interview with the Director of Nursing (DON) on 07/09/26 at 11:22 AM revealed Nurse #1 should have compared the medication package to the physician's orders, reviewed the physician's instructions not to crush the Potassium Chloride, and recognized that extended-release medications should not be crushed.

Based on record review, observations, and staff, Pharmacist, and Medical Director interviews, the facility failed to ensure a resident was free of significant medication errors when extended-release medications that were ordered to be administered whole were crushed prior to administration for 1 of 3 residents (Resident #77) observed during the medication pass. Findings included: Resident #77 was admitted to the facility on [DATE] with diagnoses that included heart failure.Review of the physician's orders in Resident #77's electronic medical record revealed an active physician order dated 11/30/25 for Potassium Chloride Crystals Extended-Release Oral Tablet 20 milliequivalents (mEq), administer one tablet by mouth once daily for low potassium. The order further instructed, Do not chew or crush.Review of the physician's orders also revealed an active physician order dated 06/17/26 for Metoprolol Succinate Extended-Release 24-hour oral tablet 25 milligrams (mg), administer one tablet by mouth once daily for hypertension.On 07/07/26 at 8:45 AM, an observation and interview were conducted with Nurse #1 during the medication pass for Resident #77. Nurse #1 was observed preparing the resident's scheduled medications. Nurse #1 removed one Potassium Chloride Crystals Extended-Release Oral Tablet 20 mEq and one Metoprolol Succinate Extended-Release 25 mg tablet. The surveyor asked Nurse #1 how Resident #77 normally took her medications. Nurse #1 stated she planned to place the Potassium Chloride tablet into a separate medication cup and crush the remaining medications. Nurse #1 was then observed placing both the Potassium Chloride Extended-Release tablet and the Metoprolol Succinate Extended-Release tablet into the same medication cup and crushing both medications. Nurse #1 proceeded to Resident #77's bedside, asked the resident to state her name, and after Resident #77 stated her first name, administered the crushed medications.On 07/07/26 at 10:05 AM, an interview was conducted with Nurse #1. Nurse #1 stated she was unaware the physician's order for Potassium Chloride instructed the medication should not be chewed or crushed. Nurse #1 further stated she did not realize the Metoprolol 25 mg was an extended-release medication and should not be crushed. Nurse #1 explained she had previously received education regarding medications that should not be crushed but became nervous while being observed during the medication pass and made a mistake.On 07/08/26 at 8:18 AM an interview was conducted with the facility Pharmacist. The Pharmacist stated Resident #77 had active physician orders for Metoprolol Succinate Extended-Release 25 mg and Potassium Chloride Crystals Extended-Release 20 mEq. The Pharmacist explained extended-release medications should never be crushed because crushing destroys the extended-release delivery system, resulting in the medication being released immediately rather than gradually over the intended dosing interval. The Pharmacist stated crushing these medications altered their intended release characteristics and could affect medication absorption and therapeutic effectiveness.On 07/09/26 at 11:22 AM, an interview was conducted with the Director of Nursing (DON). The DON stated Nurse #1 should have compared the medication packaging with the physician's orders, followed the physician's instruction not to crush the Potassium Chloride tablet, and recognized that Metoprolol Succinate Extended-Release should not be crushed. The DON stated medications should be administered according to the physician's orders and manufacturer recommendations.On 07/09/26 at 1:29 PM, an interview was conducted with the Medical Director. The Medical Director stated crushing extended-release medications was not appropriate because doing so altered the intended release characteristics of the medications and could increase gastric irritation. The Medical Director stated he did not believe Resident #77 experienced actual harm because the facility was monitoring the resident's potassium level and blood pressure; however, crushing the medications was not the appropriate method of administration.

Based on observations, record review, Nurse Practitioner (NP), Speech Language Pathologist (SLP) and staff interviews, the facility failed to implement an effective system to ensure that a severely cognitively impaired resident with a diagnosis of dysphagia received the correct food texture (mechanical soft) as ordered by the physician (Resident #32). On 7/6/26, Resident #32 was observed in her bed sitting upright with her lunch tray in front of her on her overbed table. The lunch plate revealed a whole, soft dinner roll, ground turkey chili with beans over cream of rice, and whole asparagus spears. Resident #32 was observed trying to pick up the asparagus spears with her right hand and attempted to chew one spear but was unsuccessful in eating any of the asparagus. On 7/7/26 during the breakfast meal, an observation revealed Resident #32 in bed, sitting upright with her breakfast tray in front of her on her overbed table. The tray revealed one large slice of thick cut bacon and a whole, un-mashed hard-boiled egg. The whole hard-boiled egg was observed to have a small area with teeth indentation. This deficient practice occurred for 1 of 1 resident reviewed for correct diet textures (Resident #32). The findings included: A review of Resident #32's hospital speech therapy dysphagia treatment note dated 5/27/26 revealed she was seen for suspicion for oropharyngeal dysphagia (difficulty moving food and liquids from your mouth into your throat and esophagus). The note indicated Resident #32 was edentulous (lacking any natural teeth) and her dentures were not available. The note further indicated Resident #32's behaviors were consistent with that of cognitive related dysphagia associated with advanced cognitive decline. The SLP noted Resident #32 exhibited oral holding (keeping food, liquid, or saliva in the mouth, cheeks, or floor of the mouth instead of swallowing it) with prolonged anterior to posterior transit (longer than normal for food or liquid to move from the front of the mouth to the back of the tongue during the oral phase of a swallow) when given a meal trial of puree (a smooth, pudding-like consistency requiring no chewing) solids and thin liquids. The note revealed there were no overt clinical signs and symptoms of aspiration (accidentally breathing food or liquid down the windpipe and into the lungs instead of the esophagus) and no globus sensation (a feeling of lump, tightness, or something stuck in the throat when no physical blockage was present). The SLP recommended an eating technique of slow rate, small bites and sips of liquids and monitoring for fatigue intermittent and periodic monitoring for supervision and medication to be given one at a time and as tolerated. A review of Resident #32's hospital Discharge summary dated [DATE] indicated she had a physician's order for pureed texture diet. Resident #32 was admitted to the facility on [DATE] with diagnoses which included oropharyngeal phase dysphagia, moderate protein-calorie malnutrition, cirrhosis of the liver, and a non-ruptured cerebral aneurysm. A review of Resident #32's physician's orders revealed an order for a regular diet, puree texture with thin liquids consistency for dysphagia dated 5/29/26. Resident #32's admission Minimum Data Set (MDS) dated [DATE], revealed she was severely cognitively impaired. She required setup assistance when eating. The MDS indicated Resident #32 had a swallowing disorder and was on a mechanically altered diet. The MDS further revealed Resident #32 complained of difficulty or pain with swallowing. The MDS indicated Resident #32 had no concerns with oral or dental status, and she was not edentulous (completely lacking or missing all natural teeth). The MDS also indicated Resident #32 was not coded for broken or loosely fitting full or partial dentures (the section was left blank). A review of a speech therapy treatment encounter note dated 6/4/26 and written by the SLP revealed Resident #32 was seen for skilled speech therapy for addressing swallowing function. The SLP presented Resident #32 with mechanical soft diet texture meal and thin liquids via straw. The note indicated SLP assessed for signs and symptoms of aspiration and noted prolonged time with mastication (chewing) with mechanical soft texture. Resident #32 reported some difficulty chewing soft foods and SLP educated Resident #32 on taking small bites, eating slowly and spitting out food if not able to chew. The note indicated Resident #32 gave good understanding of education and there were no overt signs or symptoms of aspiration with any consistency. An additional review of Resident #32's physician's orders revealed an upgraded regular diet, mechanical soft texture, and thin liquids consistency dated 6/5/26. Resident #32's care plan, last revised on 6/8/26, revealed a focus area for the risk of malnutrition, dehydration or weight loss and requiring a mechanically altered diet due to dysphagia. Interventions included a mechanically altered diet as ordered, Registered Dietitian (RD) consult as needed, record meal percentage intake, and speech therapy as ordered. A review of a speech therapy treatment encounter note dated 6/24/26 and written by the SLP revealed Resident #32 was seen for skilled speech therapy addressing cognitive communication deficit. The note indicated Resident #32 required extra time for processing and to respond to simple questions regarding feelings and pain and followed simple one step commands with mild verbal and visual cues. The note indicated Resident #2 required a soft and bite size diet (mechanical soft) with thin liquids. A review of Resident #32's speech therapy discharge summary signed by the SLP on 7/1/26 revealed it was recommended for Resident #32 to remain on a mechanical soft consistency diet with thin liquids with a request for referral to additional speech therapy if changes in swallowing function occurred. The discharge summary also indicated Resident #32 required Minimal to Close supervision when eating upon discharge from speech therapy on 6/24/26. The speech therapy discharge summary suggested using compensatory strategies and positions while eating for Resident #32 after discharge. These strategies included general swallow techniques and precautions, alternation of liquids and solids, bolus size (a small, rounded mass of chewed food) modifications and have Resident #32 remain upright in posture during meals and additionally remain upright for more than 30 minutes after meals. A telephone interview with the SLP occurred on 7/23/26 at 3:30 PM. She explained Resident #32's discharge summary for speech therapy indicated she needed distant supervision for safety. She stated Resident #32 could be left in her room while eating by herself with staff stopping by to check on her during the meal. The SLP stated there was not a set time frame for staff to check on Resident #32 while eating. She stated she directly communicated with nursing staff regarding eating strategies for all residents including Resident #32. The SLP indicated intermittent reminders from nursing staff to utilize eating strategies would equate to distant supervision while Resident #32 was eating her meals. An observation of Resident #32 was conducted on 7/6/26 at 2:19 PM. She was observed in her bed, wearing her dentures and sitting upright with her lunch tray in front of her on her overbed table. The lunch plate revealed a whole, soft dinner roll, ground turkey chili with beans over cream of rice, whole cooked asparagus spears. Resident #32 was observed trying to pick up the cooked asparagus spears with her right hand to chew one spear but was unsuccessful in eating any of the asparagus. Resident #32 had consumed approximately half of the whole, soft dinner roll and had not consumed any of the ground turkey chili with beans over the cream of rice. The meal ticket present on Resident #32's tray revealed a mechanical soft G regular and thin liquids and it listed turkey chili (ground) cream of rice, asparagus (ground), dinner roll (pureed), sherbert, coffee or hot tea and beverage of choice. An interview and observation conducted with Nurse Aide (NA) #1 on 7/6/26 at 2:24 PM revealed she delivered Resident #32's lunch tray earlier. She stated she was new to the facility and did not know Resident #32 required a mechanical soft diet and that her lunch tray had the incorrect food textures. The State Surveyor accompanied NA #1 to the kitchen at 2:26 PM to return Resident #2's lunch tray and replace it with foods with a mechanical soft texture. The Dietary Manger confirmed a new tray would be delivered to Resident #32. NA#1 delivered the correct tray to Resident #32's room. An additional observation of Resident #32's meal tray occurred on 7/7/26 at 10:06 AM during the breakfast meal. Resident #32 was observed lying in bed, wearing her dentures, sitting upright with her breakfast tray in front of her on her overbed table. A large slice of thick cut bacon and a whole, un-mashed hard-boiled egg was observed on the tray. The whole hard-boiled egg was observed to have a small area with teeth indentation on it. Resident #32 had consumed the bowl of hot cereal (oatmeal) and approximately 25% of the slice of bread. Resident #32's breakfast meal ticket indicated a mechanical soft diet and thin liquids with selections which included hot cereal, a ground hard-boiled egg, a ground turkey sausage link, a slice of bread, jelly and margarine, coffee or hot tea, choice of juice, and milk. NA #1 followed the State Surveyor into the room and removed the tray out of Resident #32's room at the request of the State Surveyor. The State Surveyor requested of NA #1 a correct diet texture tray to be delivered to Resident #32.An interview with NA #1 on 7/9/26 2:40 PM revealed she was new to the facility and did not know certain foods on the meal tray needed to be ground when a mechanical soft texture was listed on the meal ticket, she was only aware that the meat portion should be cut up. NA #1 stated she was supposed to check the meal trays for the correct diet and texture when they came out of the kitchen in case the kitchen made a mistake and stated Resident #32's meals had been wrong during the lunch meal on 7/6/26 and the breakfast meal on 7/7/26. A follow-up telephone interview with NA #1 on 7/23/26 at 3:43 PM revealed she did check on Resident #32 during her meals to make sure she was not having any concerns with eating or swallowing her meals and to encourage her to eat. She stated there was no time frame for checking in with Resident #32 during her meals, but she did encourage her to take a bite of her food or take a sip of her drink during her meals. On 7/7/26 at 10:20 AM, the State Surveyor alerted the Administrator of the incorrect diet textures for two observed meals for Resident #32. The Administrator stated he was not aware of the incorrect tray delivered to Resident #32 for the lunch meal on 7/6/26 or the breakfast meal on 7/7/26 and explained he would immediately work with the Dietary Manager, kitchen staff and nursing about the concern. A review of a dietary progress note written by the RD dated 7/8/26 at 11:53 AM revealed Resident #32 had a past medical history of dysphagia and moderate protein-calorie malnutrition. The note indicated Resident #32 was ordered a regular diet with a mechanical soft texture and regular, thin consistency for liquids. Resident #32's meal intakes ranged from 50-100% with liquid protein for wound healing and was also ordered a house supplement at bedtime with intake typically being 100%. A telephone interview with the RD on 7/9/26 at 10:40 AM was conducted. She stated Resident #32 required a mechanical soft textured diet for her diagnosis of dysphagia. The RD explained she had the expectation a mechanical soft diet would be served correctly which included ground meats and proteins and any resident needing a mechanical soft diet would be at risk for adverse outcomes. She reiterated that the facility did not offer a mechanical soft ground textured diet, which was incorrectly indicated on Resident #32's meal ticket on 7/6/26 and somehow was mistakenly printed out from meal ticket software program. The RD stated she was not sure why the ticket reflected a diet not offered at the facility. An interview was conducted with the Dietary Manager on 7/9/26 at 9:59 AM. The Dietary Manager stated Resident #32's ticket at the lunch meal on 7/6/26 was incorrect and the facility did not offer a mechanical soft ground diet (indicated by the letter G on the ticket), they only offered mechanical soft, meaning the dinner roll did not need to be pureed and the turkey chili did not need to be ground. She did not know why the ticket was incorrect and did not know how long it reflected the incorrect food texture for Resident #32. The Dietary Manager stated Resident #32's tickets were updated in their system after the lunch meal on 7/6/26 to mechanical soft. She indicated she was not aware the asparagus spears should have been cut or chopped up for a mechanical soft texture. The Dietary Manager stated Resident #32's breakfast meal tray on 7/7/26 was incorrect and the bacon should not have been on the tray, a ground turkey sausage link was supposed to be on the tray. The Dietary Manager stated the hard-boiled egg should have been mashed up by kitchen staff or by NA #1. A follow-up interview with the Dietary Manager and the Regional Director of Operations for Dining Services occurred on 7/27/26 at 10:39 AM. The Dietary Manager stated Resident #32's meal ticket on 7/6/26 had the letter G on it, a diet texture not offered at the facility. The Dietary Manager stated she entered the diets into the meal ticket system but did not know how the letter G was on the ticket for Resident #32. She assumed it was put into the system by error as a typo and the computer system generated a diet not offered at the facility. The Dietary Manager stated the G was most likely added by mistake and she did not know by who. She stated the meals on 7/6/26 and 7/7/26 were set up by the cook in the kitchen who scooped out the food onto the plate while a Dietary Aide called out the meal and diet texture on the ticket. An additional Dietary Aide would take the plate and place it on the serving cart to be delivered to residents' rooms. The Dietary Manager stated on 7/6/26, Resident #32's lunch meal should have had a mechanical soft texture, and she was not aware cooked asparagus should have been chopped or ground up to be compatible with a mechanical soft texture. She explained all residents on a mechanical soft texture diet in the facility did not receive chopped or ground asparagus during the lunch meal on 7/6/26. The Dietary Manger stated Resident #32's meal ticket indicting pureed bread was missed due to the Dietary Aides reading the top of the ticket that indicated a mechanical soft texture and most likely, the puree note next to the bread was ignored. She explained on a mechanical soft diet texture, Resident #32 was able to have a regular, soft dinner roll and a pureed texture was not needed. The Dietary Manager stated Resident #32 most likely received one slice of thick cut bacon for the breakfast meal on 7/7/26 as the slices were a larger size. She stated bacon cannot be made into a mechanical soft texture, so ground turkey sausage should have been on Resident' #32's plate for her breakfast. The Dietary Manager explained other residents on a mechanical soft diet texture received ground turkey sausage the morning of 7/7/26. She stated the bacon served was actually turkey bacon and she assumed one of the Dietary Aides made a mistake by placing the turkey bacon on the plate instead of the ground turkey sausage. The Dietary Manager indicated she was not aware that a hard-boiled egg needed to be mashed up or ground before it left the kitchen to be compatible with a mechanical soft texture diet. She explained all residents who received a mechanical soft diet for the breakfast meal on 7/7/26 were served a whole hard-boiled egg, not mashed up. A review of the Dietary Staff schedule revealed Dietary Aide #1 worked 7/6/26 and 7/7/26 from 7:00 AM until 2:30 PM. Dietary Aide #2 worked on 7/6/26 from 7:00 AM until 2:30 PM. A combined interview with Dietary Aide #1 and Dietary Aide #2 occurred on 7/27/26 at 12:44 PM. Dietary Aide #1 stated Resident #32's lunch meal on 7/6/26 and breakfast meal on 7/7/26 were incorrect and the kitchen staff made a mistake by not giving Resident #32 the correct texture diet and food selections indicated on the ticket. Dietary Aide #1 and Dietary Aide #2 explained when trays were prepared in the kitchen, one of the Dietary Aides would call out the information on the ticket, the [NAME] scooped the food onto the plate, then the next Dietary Aide would check the plate before the tray went on the meal cart. An interview with the SLP on 7/9/26 at 10:28 AM revealed Resident #32 was admitted to the facility originally with a pureed diet and was upgraded on 6/5/26 to a mechanical soft texture diet. She stated Resident #32 was able to safely eat breads and they did not need to be pureed. The SLP stated asparagus spears were not typically considered a soft vegetable and should have been ground up before being served to Resident #32. She stated the hard-boiled egg should have been mashed up by the NA if not by kitchen staff. The SLP also stated bacon was not on a mechanical soft diet, but the turkey sausage could be ground up or sliced to the appropriate texture. She indicated Resident #32 finished her recent speech therapy on 6/24/26 and was not upgraded to a regular texture diet and still had minimal dysphagia. An interview with Unit Manager #1 on 7/8/26 at 3:29 PM revealed Resident #32 needed set up assistance from staff. She stated NAs were expected to pass out the meal trays to all residents and they were to check the meal tickets on the tray to ensure each resident received the correct meal and diet. Unit Manager #1 stated if the NAs noticed any mistakes with the food texture or food selections on the tray not matching the ticket on the tray, she would expect them to go back to the kitchen and get the correct meal. She was unsure why NA #1 did not notice the meal trays at both lunch on 7/6/26 and breakfast on 7/7/26 were the incorrect diet texture. An interview with the NP occurred on 7/27/26 at 1:21 PM. She stated she had the expectation that facility staff should serve the correct diet and texture to Resident #32 and all other residents. She indicated nursing staff, including NAs were trained to double-check tickets and meals for the correct diets and textures. The NP stated that ultimately, the meal tray for Resident #32 should have had the correct mechanical soft diet texture for her to eat. A telephone interview with the Director of Nursing (DON) on 7/10/26 at 10:49 AM was conducted. She had the expectation NA #1 and all other NAs to understand different diets and textures and to review the meal tickets to make sure the meal trays had the correct diet and texture before giving them to Resident #32 and all other residents. A follow-up interview with the DON on 7/27/26 at 2:16 PM revealed training for new NAs upon hire was three days on the job training after orientation with another trained NA, but more training was available if the NA requested it. The DON stated she expected the incorrect diet texture during the lunch meal served to Resident #32 on 7/6/26 and incorrect diet texture during the breakfast meal on 7/7/26 to have been caught by NA #1. The DON stated NA #1 was trained to review meal tickets for accuracy before serving them to residents. A telephone interview was conducted with the Administrator on 7/10/26 at 10:57 AM. He stated had the expectation Resident #32 should have been served the correct diet and consistency by staff.

Based on observations and staff interviews, the facility failed to label and date open food items and discard items that were beyond their expiration date in 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator in the kitchen. The findings included: An observation of the facility's kitchen completed on 5/12/25 at 10:31 AM revealed a small plate with six slices of tomato with no use by date and a carton of whole milk with a use by date of 4/14/25 located in the facility's reach-in refrigerator. Additional observations at this time of the facility's walk-in fridge revealed an open and undated package of diced ham, two open and undated packages of sliced ham, an open and undated package of sliced turkey breast, a pan of cooked alfredo pasta that was open and undated, an open and undated pan of sliced pork, and open and undated bag of white and orange shredded cheese, and open and undated package of sliced American cheese, and 16 premade peanut butter and jelly and ham and cheese sandwiches that were dated to be used by 4/05/25. During an interview with the Dietary Manager on 5/15/25 at 11:43 AM, she reported that she had been on vacation for 4 days prior to 5/13/25. She stated while she was out, the staff cooks oversaw the kitchen, and she reported that the cooks were aware of the facility's processes and procedures on how to store open or leftover food items. She stated she expected her staff to place an open date, along with a use by date that was no longer than seven days from the day of opening. The Dietary Manager reported she had no idea how the 16 premade sandwiches and the expired carton of milk were missed as she checked the refrigerators daily for out-of-date food. An interview with the Administrator on 05/12/25 at 11:33 AM revealed the Dietary Manager had been on vacation and reported that food items that are opened should be dated and stored appropriately, and expired food should be removed and disposed of.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with new mental health diagnoses for 2 of 3 residents (Resident #18 and #61) reviewed for PASRR. The findings include: 1. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. PASRR level I was completed on 6/12/23 prior to Resident #18's admission with a recommendation to resubmit paperwork for a PASRR level II if Resident #18 received a new mental health diagnosis or if there was a significant change in condition. The electronic medical record revealed Resident #18 was diagnosed with bipolar disorder on 10/15/24 and major depressive disorder on 12/17/24. No PASRR level II was completed. An interview on 5/14/25 at 2:00 PM with Social Worker (SW) #1 revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II and their paperwork required them to be reviewed every 30 or 60 days or if a resident had a change in condition. SW #1 revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission or for residents who had received a new mental health diagnosis. SW #1 stated based on Resident #18's mental health diagnosis, a PASRR level II should have been completed. During an interview on 5/15/25 at 12:20 PM with the Administrator she revealed 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. She stated based on Resident #18's mental health diagnosis, PASRR level II should have been completed 2. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. PASRR level I was completed on 10/21/19 prior to Resident #61's admission with a recommendation to resubmit paperwork for a PASRR level II if Resident #61 received a new mental health diagnosis or if there was a significant change in condition. The electronic medical record revealed Resident #61 was diagnosed with bipolar disorder on 10/29/24 and major depressive disorder on 11/05/24. No PASRR level II was completed. An interview on 5/14/25 at 2:00 PM with Social Worker (SW) #1 revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II and their paperwork required them to be reviewed every 30 or 60 days or if a resident had a change in condition. SW #1 revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission or for residents who had received a new mental health diagnosis. SW #1 stated based on Resident #61's mental health diagnosis, a PASRR level II should have been completed. During an interview on 5/15/25 at 12:20 PM with the Administrator she revealed 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. She stated based on Resident #61's mental health diagnosis, PASRR level II should have been completed.

Based on observations, record review and staff and Resident interviews, the facility failed to obtain an order for the size of a urinary catheter and change the catheter as ordered for 1 of 1 resident (Resident #87) reviewed for urinary catheters. The findings included: a. Resident #87 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy (a blockage or hinderance in the flow of urine from the kidneys through the ureters and into the bladder, and then out through the urethra). Review of Resident #87's Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and had an indwelling urinary catheter. Review of Resident #87's physician orders dated 4/04/25 revealed an order to change urinary catheter in the facility every 28 days. There was no order for the size of urinary catheter. Review of Resident #87's Medication Administration Record for 4/2025 indicated the Resident's urinary catheter was changed last on 4/04/25 by Nurse #4. An interview was conducted with Nurse #4 on 5/14/25 at 5:02 PM. The Nurse explained that she had to change Resident #87's urinary catheter on 4/04/25 and there was no order for the size of the catheter, but Nurse #2 told her to use the same size of catheter that she removed from Resident #87 which was a size 16 French. Nurse #4 stated she had no problem changing the urinary catheter. During an interview with Nurse #2 on 5/14/25 at 3:45 PM the Nurse explained that she did not know what size catheter Resident #87 has ordered but she helped Nurse #4 gather the supplies for the catheter change on 4/04/25 and Nurse #4 told her that there was no order for a specific catheter size so Nurse #2 told Nurse #4 to use the same size catheter that she removed from Resident #87. During an interview with the Unit Manager on 5/15/25 at 9:00 AM the Unit Manager stated there should be an order for the size of the urinary catheter. An interview was conducted with the Medical Director on 5/14/25 at 11:51 AM who explained that there should be a specific order for the size of urinary catheter. On 5/15/25/at 11:42 AM during an interview with the interim Director of Nursing (DON), the DON stated her expectation was for there to be an order for the size of the urinary catheter and if there was no order then Nurse #4 should have obtained an order for the size of the catheter. The DON indicated an order for a size 16 French catheter had already been obtained from the physician. b. Resident #87 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy (a blockage or hinderance in the flow of urine from the kidneys through the ureters and into the bladder, and then out through the urethra). Review of Resident #87's Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and had an indwelling urinary catheter. Review of Resident #87's physician orders dated 4/04/25 revealed an order to change urinary catheter in the facility every 28 days in the evening. Review of Resident #87's 4/2025 Medication Administration Record revealed the last urinary catheter change was on 4/04/25. Review of Resident #87's Medication Administration Record (MAR) for 5/2025 revealed the catheter change was scheduled for 5/02/25. The scheduled change was initialed by a Medication Aide #1. An interview was conducted with Medication Aide (MA) #1 on 5/14/25 at 3:28 PM. The MA explained that if she initialed the MAR for the catheter change it was a mistake because that was not in her scope of practice to change urinary catheters. The MA stated it was the nurse's responsibility to change the urinary catheters. On 5/14/25 at 3:40 PM an interview was conducted with Resident #87. The Resident stated the last time his urinary catheter was changed was about a month ago and it was time for it to be changed again. He stated it was uncomfortable, but he tolerated it well. An interview was conducted with Nurse #2 on 5/14/25 at 3:45 PM. The Nurse confirmed that she worked on 5/02/25 from 3:00 PM to 7:00 PM but she did not change Resident #87's urinary catheter. Nurse #2 indicated she did not know that the catheter was scheduled to be changed. During an interview with Nurse #3 on 5/14/25 at 4:33 PM the Nurse confirmed that he worked on 5/02/25 from 7:00 PM to 11:00 PM on the hall that Resident #87 resided. The Nurse explained that he was not aware that Resident #87 was scheduled for a urinary catheter change during that shift and therefore he did not change the Resident's catheter. Nurse #3 stated the MA did not let him know that the Resident was due for a catheter change. An interview was conducted with the Unit Manager on 5/15/25 at 9:00 AM who explained that it was the responsibility of the nurse on duty to look at the residents' MARs to know what they needed to do during the shift and not the MAs responsibility to let the nurses know. The Unit Manager stated if Resident #87 was scheduled for a catheter change on 5/02/25 then there was no reason why the catheter should not have been changed. During an interview with the Medical Director (MD) on 03/14/25 at 11:51 AM the MD indicated if there was an order for a resident's catheter to be changed then his expectation was for the catheter to be changed per that order. An interview was conducted with the interim Director of Nursing (DON) on 05/15/25 at 11:32 AM. The DON explained that Resident #87's catheter should have been changed as scheduled and she would see that it was changed on 05/15/25.

#2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, sleep apnea, and chronic respiratory failure. Review of Resident #46's quarterly Minimum Data Set assessment revealed she was cognitively impaired. Resident #46 was dependent on others for the completion of her activities of daily living and received oxygen therapy while admitted to the facility. Review of Resident #46's physician orders revealed the following physician order dated 12/22/25: - Rinse or replace oxygen filters on concentrator weekly and as needed. Remove concentrator from machine. Rinse filter with running water and allow to air dry before returning to concentrator. Every night shift, every Sunday. An observation completed of Resident #46's oxygen concentrator on 05/12/25 at 12:00 PM revealed it to be set to 2 liters per minute and had copious amounts of gray matter on the intake filter. An additional observation of Resident #46's oxygen concentrator on 05/14/25 at 2:17 PM revealed the concentrator to continue to be set to 2 liters per minute with additional gray and white matter on the intake filter. Review of Resident #46's medication administration record revealed Nurse #5 was the nurse responsible for ensuring that Resident #46's oxygen concentrator filter was cleaned on Sunday, 05/11/25 overnight. An interview with Nurse #5 on 05/15/25 at 2:17 PM via telephone revealed she had worked on Resident #46's hall on 03/11/25 and would have been responsible for cleaning Resident #46's oxygen concentrator filter. She indicated that she was busy that evening and was not certain she had time or stopped to change or clean Resident #46's oxygen concentrator filter. She verified that the order to clean the filter did show up on the medication administration record so she would see it when she was passing medications. During an interview with the Director of Nursing on 05/15/25 at 12:00 PM, she reported it was only her second day serving in the role of Director of Nursing and she was unsure about the facility's process for ensuring oxygen concentrators and filters were clean but indicated they should be clean and free from dust and debris. An interview with the Administrator on 05/15/25 at 12:01 PM revealed that oxygen concentrators and filters should be cleaned every Sunday on the overnight shift each week. He stated the order to clean the oxygen concentrators and filters should show up on the medication administration record and should be completed. She stated she expected her staff to clean the intake and filter to ensure it was free from dust and debris. Based on observations, record reviews, and staff interviews, the facility failed to post cautionary oxygen signage on 1 of 2 oxygen storage rooms where full portable oxygen cylinders were stored. The facility also failed to maintain a clean oxygen concentrator filter for 1 of 5 residents reviewed for respiratory care (Resident #46). Findings included: 1. Observations of oxygen storage closet #1 located on the 300 hall on 05/14/25 at 10:48 AM, 1:34 PM, and 3:58 PM revealed closet #1 had a laminated sign labeled full tanks. There was no cautionary oxygen signage noted on the door. There were 48 full oxygen tanks stored in closet #1. An interview with the Interim Director of Nursing on 05/15/25 at 8:43 AM revealed that oxygen storage areas should be labeled with cautionary no smoking signage.

b. On 05/13/25 at 9:45 AM the Wound Nurse prepared to perform wound care on Resident #61 who had an Enhanced Barrier Precaution sign on his door. The sign indicated wearing gloves and a gown for high contact resident care activities which included wound care. The Wound Nurse washed her hands and applied her gloves then prepared the work field on the over bed table. She then positioned Resident #61 on his right side to expose the stage IV pressure ulcer on his left ischium (hip bone) which had no dressing on it. The Wound Nurse cleansed the wound then removed her gloves and applied clean gloves without washing her hands. The Wound Nurse then applied the ordered treatment and covered the wound with a border dressing to complete the wound care. The Wound Nurse did not don a gown per the Enhanced Barrier Precautions. An interview was conducted with the Wound Nurse on 05/14/25 at 2:34 PM. The Wound Nurse explained that she was aware of the Enhanced Barrier Precautions sign that was posted on Resident #61's door but she thought she only had to wear the gown if the wound had the potential to splash drainage on her. She stated she had been educated on infection control but that was her understanding of Enhanced Barrier Precautions. During an interview with the interim Director of Nursing (DON) on 05/14/25 at 2:49 PM the DON explained that Enhanced Barrier Precautions (gowns and gloves) were to be utilized on all wound care and the Wound Nurse should have washed her hands after she removed her gloves and before she donned new gloves to continue the procedure. The DON also stated the Wound Nurse should have worn a gown during the procedure as the sign directed. Based on observations, record reviews and staff interviews, the facility failed to implement their infection control policy when the Wound Nurse did not apply a gown when performing wound care for Resident #83 and Resident #61. In addition, the Wound Nurse failed to perform hand hygiene before applying clean gloves during wound care on Resident #61. This occurred for 1 of 2 staff members observed for infection control practices (Wound Nurse). Findings included: Review of the facility's undated infection control policy for Hand Hygiene revealed the staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub also known as alcohol-based hand rub. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of the facility's Enhanced Barrier Precautions (EBP) dated 03/24 revealed it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident activities. 2. Initiation of Enhanced Barrier Precautions: i. Wound care. a. On 05/14/25 at 9:38 AM the Wound Care Nurse prepared to perform wound care to Resident #83 who had an Enhanced Barrier Precaution sign on door. The sign indicated staff should don gloves and a gown for high contact resident care activities which included wound care. The Wound Nurse performed hand hygiene, and donned gloves. The Wound Nurse did not don a gown per the Enhanced Barrier Precautions. Resident #83 was positioned to perform wound care to lower right leg. The dressing to area removed and had a small amount of drainage. The Wound Nurse performed hand hygiene, then donned new gloves. The wound site was cleansed with normal saline, ordered treatment was applied, and new 6 inch by 6-inch bordered gauze dressing applied to wound. The Wound Nurse discarded trash, removed gloves, and performed hand hygiene to complete the wound care. An interview with the Wound Nurse on 05/14/25 at 9:54 AM after wound care observation revealed she recently had been educated on EBP. She stated she believed the gown would only need to be worn if the wound was infected. She was not aware that a gown was needed during routine wound care.

Based on record reviews, and facility staff, Physician Assistant (PA) and Medical Director interviews, the facility failed to immediately notify the PA when Resident #1 had an acute change in condition after a fall. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. The PA was not notified until 4:50 PM on 03/26/25 of the acute change in condition. The PA ordered bloodwork, urinalysis with culture and sensitivity, and a chest x-ray for reports of lethargy. On 03/27/25 at 9:58 AM Resident #1's family came to the facility and found him unresponsive and called Emergency Medical Services (EMS) and Resident #1 was transported to the Emergency Department (ED) and diagnosed with a huge left subdural hematoma with a midline shift (shifting of brain past its center). Resident #1 was transitioned to Hospice services and passed away on 03/31/25. This affected 1 of 3 residents reviewed for notification. Immediate Jeopardy began on 03/26/25 when the medical provider was not immediately notified that Resident #1 had an acute significant change in condition. Immediate Jeopardy was removed on 04/05/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, history of pulmonary embolism, history of cerebral infarction with hemiplegia and traumatic brain injury. Review of a physician order dated 02/28/25 read; apixaban (anticoagulant) 5 milligrams (mg) via gastrostomy tube two times a day for atrial fibrillation. A review of Resident #1's Medication Administration Record (MAR) for 02/2025 and 03/2025 indicated the Resident had received an anticoagulant medication apixaban 5 mg via gastrostomy tube twice a day for atrial fibrillation. The MARs indicated Resident #1 received the anticoagulant as ordered since his admitted [DATE]. An incident report dated 03/25/25 at 2:00 PM and written by Nurse #1 revealed Resident #1 was in bed after lunch when Nurse #1 was called to the Resident's room and upon arrival Resident #1 was lying on the floor next to his bed. Resident #1 stated he rolled over and he did not know what he was trying to do. A head-to-toe assessment was done, and Resident #1 was moving all extremities without any problems. The Resident complained of back pain which he does most of the time and was given some pain medication for pain. No injuries were noted, and Resident #1 was assisted back to bed using the total lift. Neurologic checks were initiated, and all vital signs were within the normal limits. Staff were to do frequent rounding and ensure correct positioning while in bed. During an interview with Nurse #1 on 04/02/25 at 2:40 PM the Nurse confirmed that she worked the 7:00 AM shift on 03/27/25 after his fall on 03/25/25. Nurse #1 explained that when she returned to work on 03/27/25 for the 7:00 AM shift, Nurse #3 informed her that Resident #1 was lethargic, but she did not think to ask how long he had been lethargic. Nurse #1 explained that she went to assess Resident #1, and he was sleeping and when she tried to wake him up, the Resident would not wake up and he was lethargic. She stated she reviewed his progress notes which indicated he had labs drawn and a urine sample and a chest x-ray was due to be done. Nurse #1 reported that the Unit Manager (UM) asked her how Resident #1 was doing that day and Nurse #1 informed her that he was lethargic, and the UM stated that the Resident had labs drawn the day before. Nurse #1 reported that while she was passing her morning medications the radiology technician arrived to obtain a chest x-ray. Shortly after that, Resident #1's family came to visit and informed her that Resident #1 was not acting like himself and was aware that he had a fall on 03/25/25 and stated that Resident #1 had a history of two brain bleeds. The Nurse informed the family of the labs that were ordered, and the chest x-ray had been done but the family insisted that Resident #1 be transferred to the hospital, so Nurse #1 notified the PA and was given an order to transfer Resident #1 to the hospital. On 04/02/25 at 12:55 PM and 04/03/25 at 10:45 AM interviews were conducted with Nurse Aide (NA) #1 who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25 on a different assignment, but she went to check on Resident #1 because he had fallen on 03/25/25 and found him to be lethargic and basically not responding as his usual self. The NA stated that she helped NA #2 get Resident #1 out of the bed for therapy around mid-morning and the Resident was limp like a rag doll and lethargic and that was a change in the Resident since the day before. NA #1 reported that she went and got the Physical Therapy Assistant (PTA) and reported how the Resident was acting since the fall on 03/25/25 and they both put Resident #1 back in the bed. An interview was conducted with Nurse Aide #2 on 04/03/25 at 10:15 AM who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25. The NA explained that she had only worked with Resident #1 one time before 03/26/25, and he was alert and conversed with her about having a daughter with her name. NA #2 reported that when she went in to care for Resident #1 on that morning (03/26/25) around breakfast, she knew immediately that he was acting differently from their previous encounter because the Resident's response was slower, and he was not conversing with her like he normally did. NA #2 continued to explain that around 10:00 AM NA #1 helped her get Resident #1 out of bed for therapy and NA #1 went to inform therapy of how Resident #1 was acting and therapy and NA #1 put the Resident back to bed. NA #2 reported that she went to notify Nurse #2 of Resident #1's condition and Nurse #2 went to his room to assess him. NA #2 explained that Resident #1 acted the same throughout the rest of the shift when she went into care for him. During an interview with the Physical Therapy Assistant (PTA) on 04/02/25 at 11:45 AM the PTA explained that she had worked with Resident #1 since his admission, and he was able to participate in therapy. She reported that on the morning of 03/26/25 NA #1 came and got her to go to Resident #1's room because the Resident had a fall out of bed the day before (03/25/25) and they had gotten him out of bed for his therapy session, but he was not behaving like his normal behavior. The PTA stated she went into Resident #1's room and could see that he was lethargic and not responding to her as he normally did, and she and NA #1 put the Resident back to bed. The PTA explained that she reported her concern to Nurse #2 and the Nurse informed her that no one reported to her that Resident #1 had a fall. The PTA continued to explain that she periodically checked on Resident #1 throughout the rest of the shift and he barely made eye contact with the PTA. She indicated the Resident made groaning and moaning sounds while he was sleeping. Interviews were conducted with Nurse #3 on 04/02/25 at 9:20 PM and 04/04/25 6:55 AM. The Nurse confirmed that she worked with Resident #1 on 03/25/25 through 03/26/25 for the 7:00 PM to 7:00 AM shift and 7:00 PM to 7:00 AM for 03/26/25 through 03/27/25. Nurse #3 explained that she received in the report on 03/25/25 that Resident #1 sustained a fall from the bed and the neurologic checks were on going. Nurse #3 continued to explain that she reported off to Nurse #2 on the morning of 03/26/25 and informed the Nurse that Resident #1 had a fall and that his neurologic checks were on going and had been stable throughout the night and she documented it on the 24-hour report sheet. Nurse #3 stated when she came on duty at 7:00 PM on 03/26/25 she checked on the residents and found that Resident #1 was lethargic. Nurse #3 was then told by the UM that labs, urine and a chest x-ray had been ordered for Resident #1 and that she had to collect the urine and have it ready for the lab to pick up. The Nurse stated she obtained the urine, and the lab phlebotomist came in around 4:00 AM in the morning to obtain the Resident's labs so that just left the chest x-ray which she reported to Nurse #1 when she gave her report that morning. Nurse #3 continued to explain that Resident #1 slept all night, and she was able to perform the neurologic checks except the grips because he was sleeping. The Nurse indicated the Resident's vital signs were stable. Nurse #3 reported if it had been during the day she would have called the provider, but she knew the provider had already been informed of Resident #1's condition and his lab work was pending. Interviews were conducted with Nurse #2 on 04/02/25 at 11:30 AM and 04/03/25 at 11:35 AM. Nurse #2 confirmed that she worked with Resident #1 on 03/26/25 from 7:00 AM to 3:00 PM and it was the first time she had worked with the Resident. Nurse #2 stated between 8:00 AM and 8:30 AM a therapy staff (PTA) member informed her that Resident #1 had a fall the previous day (03/25/25) and was not acting like himself and she went to assess him. Nurse #2 stated Resident #1 would open his eyes when she called his name, but he would not respond to her. The Nurse indicated that she obtained the Resident's vital signs which were within normal limits and completed a change in condition assessment and reported the change in condition to the UM after the UM got out of a meeting which was around 10:30 AM and the UM informed Nurse #2 that she would call the PA. The Nurse explained that they received orders for some blood work, urine and a chest x-ray. When Nurse #2 was asked why she did not call the PA herself the Nurse indicated that she was not familiar with Resident and wanted to report the Resident's condition to her Unit Manager. A review of a Change in Condition Assessment completed by Nurse #2 on 03/26/25 at 2:35 PM revealed Resident #1 was drowsy, lethargic and very less responsive. Blood Pressure 115/62, Pulse 64, Respirations 18 and Temperature 97.7 via forehead and recent oxygenation 95%. Decreased level of consciousness (sleepy, lethargic). The assessment indicated the PA, and the responsible party were notified. A review of Resident #1's physician orders on 03/26/25 written around 5:40 PM indicated orders for a Complete Blood Count with Differential (CBC/Diff) in AM, Urine for Urinalysis and Culture and Sensitivity (UA/C&S) if indicated and a Chest X-Ray (CXR) for cough were obtained. The orders were written by the Unit Manager. Interviews were conducted with the Unit Manager on 04/02/25 at 5:00 PM and 04/03/25 at 10:45 AM. The UM explained that she was notified of Resident #1's fall by Nurse #1 on 03/25/25 shortly after the fall happened and was told that the Resident did not sustain any injuries from the fall. The UM continued to explain that the next day on 03/26/25 at approximately 4:30 PM after she got out of the Risk Management meeting, Nurse #2 informed her that Resident #1 had a change in condition and was lethargic and she was going to document a change in condition and call the responsible party. The UM stated that she stepped into Resident #1's room and laid eyes on him but the Resident did not appear to her to be lethargic. She indicated that she did not complete an assessment on Resident #1. The UM continued to explain that since she had to call the PA about other residents, she decided to call the PA at that time and reported that Resident #1 had a change in condition and was lethargic. The UM stated she received orders for lab work, urine for culture and sensitivity and a chest x-ray which she put in the computer. The UM reported that Nurse #3 was to collect the urine, and the phlebotomist was to obtain the blood when they made their next round to the facility. The UM indicated Resident #1's vital signs were stable, and they were trying to rule out infection. Review of a progress note made by Nurse #1 on 03/27/25 at 10:52 AM indicated Resident #1 continued to appear lethargic, family at the facility at the time, requested Resident #1 to be sent out to ED for more evaluation. The PA was notified, and an order was received. Resident #1 left with EMS at around 10:19 AM. Vital Signs: 133/94, T97.3, R18, P112, 02 saturation 97% on room air. A review of Resident #1's hospital records dated 03/27/25 revealed Resident #1 arrived at the ED with a history of intracranial hemorrhage, altered mental status and subdural hematoma. The Resident received apixaban 5 mg twice a day. Resident #1's vital signs rose to 212/108, 124, 40 but remained negative for fever. The Glasco Coma Scale (GCS) (a neurological assessment tool used to measure a person's level of conscientious especially in traumatic brain injury) was a 3 meaning the lowest possible level of consciousness and is usually associated with the deep coma or death meaning the person is wholly unresponsive. The computed tomography (CT) results of the brain revealed a huge left subdural hematoma measuring 15.1 centimeters (cm) in length, thickness of 3.4 cm and height of 9.7 cm. This results in severe compression of the left hemisphere with 1.5 cm midline shift. There is developing right side hydrocephalus (a buildup of fluid deep within the cavities of the brain). The report indicated the Resident's family was consulted on his condition and because of his condition the family opted to provide comfort measures only and to consult Hospice services. Interviews were conducted with the Physician Assistant on 04/02/25 at 2:15 PM and 04/03/25 at 12:45 PM. The PA explained that she was at the facility on 03/25/25 and was informed that the Resident sustained a fall and assessed Resident #1 late that same night. The PA reported that the UM called her the next day on 03/26/25 around 4:50 PM when the Resident had a change in condition. When the PA was asked if she was notified that Resident #1 was lethargic, the PA stated she could not remember the exact verbiage that the UM used in describing the Resident's change in condition, but she felt that she needed to obtain labs, urine and a chest x-ray to diagnose the issue. The PA reported that the next morning on 03/27/25 she was notified by Nurse #1 that Resident #1's family was at the facility and wanted him sent to the hospital and she gave the Nurse an order to send Resident #1 out to the hospital. During an interview was conducted with the Director of Nursing (DON) on 04/03/25 at 2:40 PM. The DON explained that she was aware that Resident #1 had a fall on 03/25/25 and that he had no injuries from the fall. The DON stated that she did not know that Resident #1 had a change in condition on the morning of 03/26/25 and indicated that when the change in condition occurred the PA should have been notified at that time. An interview was conducted with the Medical Director on 04/04/25 at 4:15 PM. The Medical Director stated that he was notified of Resident #1's situation by the PA and was aware of the events that led to the Resident being sent to the hospital. The Medical Director stated that given Resident #1's complex medical history, the facility should have notified the PA as soon as they noticed a change in the Resident's condition and sent Resident #1 to the hospital. He indicated that the outcome might not have changed but the facility should have sent him out. The Administrator was notified of Immediate Jeopardy on 04/03/25 at 4:40 PM. The facility implemented the following Credible Allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to immediately notify the Medical Provider when Resident #1 had a change in condition on 03/26/25 at approximately 8:30 AM. Resident #1 had a fall on 03/25/25 at approximately 2:00 PM and was assessed by the nursing staff to have no injuries and was transferred back to bed. On 03/26/25 at 8:30 AM Resident #1 had a change in condition as described by staff as having a decreased level of consciousness, unable to be awakened, lethargic slow to respond, much different than his baseline. The Medical Provider was not notified until 4:50 PM on 03/26/25 and gave orders for blood work, urinalysis, and chest x-ray. On 03/27/25 Resident #1's family came to visit and found him unresponsive and called Emergency Medical Services (EMS). Resident #1 was transferred to the emergency room and diagnosed with a large subdural hematoma with midline shift. Resident #1 was transferred to hospice and passed away on 03/31/25. On 4/3/25, the DON re-educated the nurse on the notification policy and process to include immediately notifying the Medical Provider when a resident has a change in condition. On 4/3/25, the DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall within the last 72 hours to ensure timely notification to the Medical Provider if a change in resident condition occurs. Two residents were identified and no concerns identified. On 4/4/2025, the facility reviewed all residents with changes in condition in 24 hours to ensure immediate notification to the Medical Provider occurred. Six residents were identified, and the Medical Provider was notified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. On 4/3/25, the Administrator, Director of Nursing (DON), [NAME] President of Risk and Quality Assurance (VPRQA), Nurse Consultant, Physician Assistant and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to immediately notify the Medical Provider when Resident #1 had a change in condition. Root cause analysis determined that the facility failed to have effective systems in place and monitoring measures to ensure that a licensed nurse understood the seriousness of their responsibility to notify the Medical Provider when a resident experiences a change in condition post-fall, especially those on anticoagulants. On 4/3/2025, the Director of Risk of Quality Management, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the notification and fall policy. No updates were made. Effective 4/3/25, the Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention Policies. Education includes the licensed nurse's responsibility to immediately notify the Medical Provider of any resident's change in condition, especially post-fall, with a history of stoke and pulmonary embolism on an anticoagulant. Certified Nursing Assistants will immediately communicate to the licensed nurses any change in Residents condition. The Director of Nursing will ensure all newly hired licensed nurses and Certified Nursing Assistants will be educated during orientation and contracted staff educated prior to taking their assignment. Effective 4/3/25, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 04/05/25 On 04/08/25 the credible allegation of Immediate Jeopardy removal with a removal date of 04/05/25 was validated by onsite verification through staff interviews, record reviews, and education reviews. The staff interviewed included members of administration, licensed nurses and nursing assistants. The staff interviews were related to the facility's policy and procedures for notification of changes in condition, specifically how to identify changes in conditions and notification the providers upon changes in conditions. The management team reported new procedures in monitoring for changes in conditions in order to notify the providers. The licensed nurses reported their responsibility to assess residents when changes in conditions occur so that timely notification can be made to the providers, and the nurse aides voiced their responsibility in notifying the nurses of changes in the residents' conditions as soon as possible. The education of Notification provided for the staff was evident through staff interviews and education attendance records. The Immediate Jeopardy removal date of 04/05/25 was validated.

Based on record reviews, Emergency Medical Services (EMS) records, facility staff, Emergency Department (ED) Physician, Physician Assistant (PA) and Medical Director interviews, the facility failed to recognize the severity of an acute change in condition after a fall for Resident #1. Resident #1 had a past medical history that included atrial fibrillation with anticoagulation, recent pulmonary embolism, recent COVID-19, history of traumatic brain injury (TBI), history of hemiplegia (paralysis on one side of body) following a cerebral infarction, and history of previous subdural hematoma. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. At 4:50 PM on 03/26/25 the Unit Manager (UM) notified the PA that Resident #1 was lethargic and received orders for bloodwork, urinalysis, culture and sensitivity, and a chest x-ray. On 03/27/25 at 9:58 AM Resident #1's family came to the facility and found him unresponsive and called Emergency Medical Services (EMS) and Resident #1 was transported to the Emergency Department (ED) and diagnosed with a huge left subdural hematoma with a midline shift (shifting of brain past its center). Resident #1 was transitioned to Hospice services and passed away on 03/31/25. This affected 1 of 3 residents reviewed for change in condition. Immediate Jeopardy began on 03/26/25 when Resident #1 was noted to have had an acute significant change in condition and was not evaluated or transferred to a higher level of care until 03/27/25. Immediate Jeopardy was removed on 04/05/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, history of pulmonary embolism, history of cerebral infarction with hemiplegia and traumatic brain injury. Review of a physician order dated 02/28/25 read; Apixaban 5 milligrams (mg) via gastrostomy tube two times a day for atrial fibrillation. A review of Resident #1's care plan dated 02/28/25 indicated the Resident received an anticoagulant medication related to a diagnosis of atrial fibrillation. The goal that Resident #1 will be free from adverse side effects of the anticoagulation medication would be attained by utilizing interventions such as administering the anticoagulation medication as ordered and monitoring for side effects specifically for bleeding since Resident #1 has a history of gastrointestinal bleed. Further Review of Resident #1's care plan revealed no active care plan for falls prior to the fall on 03/25/25. A review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. The Resident was coded as requiring substantial to maximal assistance with most activities of daily living except eating. It was documented that he had no falls since admission and received an anticoagulant. A review of Resident #1's Medication Administration Record (MAR) for 02/2025 and 03/2025 indicated the Resident had received an anticoagulant medication apixaban 5 mg via gastrostomy tube twice a day for atrial fibrillation. The MARs indicated Resident #1 received the anticoagulant as ordered since his admitted [DATE]. An incident report dated 03/25/25 at 2:00 PM and written by Nurse #1 revealed Resident #1 was in bed after lunch when Nurse #1 was called to the Resident's room and upon arrival Resident #1 was lying on the floor next to his bed. Resident #1 stated he rolled over and he did not know what he was trying to do. A head-to-toe assessment was done, and Resident #1 was moving all extremities without any problems. The Resident complained of back pain which he does most of the time and was given some pain medication for pain. No injuries were noted, and Resident #1 was assisted back to bed using the total lift. Neurologic checks were initiated, and all vital signs were within the normal limits. Staff were to do frequent rounding and ensure correct positioning while in bed. A nursing progress note written by Nurse #1 on 03/25/25 at 3:34 PM indicated Resident #1 was alert and able to make his needs known. The Resident was in bed after lunch when Nurse #1 was called to Resident #1's room (by Nurse Aide (NA) #1) and upon arrival the Resident was lying on the floor next to his bed. When Resident #1 was asked what he was trying to do, the Resident responded that he did not know what he was trying to do. A head-to-toe assessment was completed with Resident #1 being able to move all his extremities without any problems. No injuries noted. The Resident was transferred to bed via a total lift and 2 person assist (Nurse #1 and NA #1). Resident #1 complained of back pain and a pain medication was given and was effective. Neurologic checks were initiated, and the Resident's vital signs were within normal limits. A review of the neurologic checks with vital signs indicated the checks were initiated on 03/25/25 at 2:00 PM and continued through 03/27/25 at 9:00 AM. One neurologic check assessment dated [DATE] at 7:45 PM was not documented. The documented neurologic checks indicated the vital signs were within normal limits and the grips were present and the upper and lower motor function of the extremities were present. A review of the Physician Assistant progress note dated 03/25/25 revealed Resident #1 was assessed after sustaining a fall earlier in the day of 03/25/25. No injuries or cognition changes were reported. The neurologic exam was at baseline and no acute distress was appreciated. The Resident was status post recent complicated hospitalization with a history of atrial fibrillation, cerebral vascular accident with residual left hemiparesis, pulmonary embolism and recent gastrointestinal bleed. Medications include apixaban 5 mg two times a day. Vital signs 119/76, 73, 18, 97.6 and oxygen saturation of 96%. Assessment Plan: continue post fall measures and neuro checks per the facility policy and continue to monitor for bleeding. Nursing will continue to monitor changes and inform the provider as needed. During an interview with Nurse #1 on 04/02/25 at 2:40 PM the Nurse confirmed that she worked from 7:00 AM to 7:00 PM on 03/25/25. The Nurse explained that she was notified that Resident #1 was on the floor in his room by NA #1. Nurse #1 went to the Resident's room to find him lying on the floor and when the Nurse asked Resident #1 how he got on the floor, he stated that he guessed he turned over, but he could not remember. The Resident complained of back pain, and she gave him some pain medication that was effective. The Nurse continued to explain that they (Nurse #1 and NA #1) got Resident #1 back in the bed using the total lift. Nurse #1 stated she asked the Resident if he hit his head, and he made a remark of something funny which was his normal demeanor. She indicated she specifically looked for injuries on his head because it was an unwitnessed fall and there were no visible injuries. The Nurse reported she initiated neurologic checks, and they were within normal limits. Nurse #1 explained that she continued the neurologic checks throughout the rest of the shift and the neurologic checks remained within normal limits and Resident #1 was alert and talkative, which was his normal demeanor. The Nurse indicated that she reported off to Nurse #3 at the change of shift. Nurse #1 continued to explain that when she returned to work on 03/27/25 for the 7:00 AM shift, Nurse #3 informed her that Resident #1 was lethargic, but she did not think to ask how long he had been lethargic. Nurse #1 explained that she went to assess Resident #1, and he was sleeping and when she tried to wake him up, the Resident would not wake up and he was lethargic. She stated she reviewed his progress notes which indicated he had labs drawn and a urine sample and a chest x-ray was due to be done. Nurse #1 reported that the UM asked her how Resident #1 was doing that day and Nurse #1 informed her that he was lethargic, and the UM stated that the Resident had labs drawn the day before. Nurse #1 reported that while she was passing her morning medications the radiology technician arrived to obtain a chest x-ray. Shortly after that, Resident #1's family came to visit and informed her that Resident #1 was not acting like himself and was aware that he had a fall on 03/25/25 and stated that Resident #1 had a history of two brain bleeds. The Nurse informed the family of the labs that were ordered, and the chest x-ray had been done but the family insisted that Resident #1 be transferred to the hospital, so Nurse #1 notified the PA and was given an order to transfer Resident #1 to the hospital. On 04/02/25 at 12:55 PM and 04/03/25 at 10:45 AM interviews were conducted with Nurse Aide (NA) #1 who confirmed she worked from 7:00 AM to 3:00 PM on 03/25/25. The NA explained that after lunch she answered the call light for Resident #1's room and found Resident #1 lying on the floor on his left side between his bed and his roommate's bed. The roommate had pushed the call light for Resident #1. NA #1 continued to explain that she asked Resident #1 if he was hurt or if he hit his head during the fall and the Resident told her no and she saw no visible signs of injury or bleeding from Resident #1. NA #1 informed the Resident that she was going to get Nurse #1 which she did and after Nurse #1 assessed Resident #1 they used the total lift to put him back in bed. NA #1 reported that she checked on Resident #1 one more time before she went off shift and asked him what he was trying to do when he fell and the Resident responded, I don't know, dancing I guess. The NA explained that it was Resident #1's usual demeanor to joke with the staff. NA #1 continued to explain that she worked from 7:00 AM to 3:00 PM on 03/26/25 but she worked on a different assignment, but she went to check on Resident #1 and found him to be lethargic and basically not responding as his usual self. The NA stated that she helped NA #2 get Resident #1 out of the bed for therapy around mid-morning and the Resident was limp like a rag doll and lethargic and that was a change in the Resident since the day before. NA #1 reported that she went and got the Physical Therapy Assistant (PTA) and reported how the Resident was acting since the fall on 03/25/25 and they both put Resident #1 back in the bed. An interview was conducted with Nurse Aide #2 on 04/03/25 at 10:15 AM who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25. The NA explained that she had only worked with Resident #1 one time before 03/26/25, and he was alert and conversed with her about having a daughter with her name. NA #2 reported that when she went in to care for Resident #1 on that morning (03/26/25) around breakfast, she knew immediately that he was acting differently from their previous encounter because the Resident's response was slower, and he was not conversing with her like he normally did. NA #2 continued to explain that around 10:00 AM NA #1 helped her get Resident #1 out of bed for therapy and NA #1 went to inform therapy of how Resident #1 was acting and therapy and NA #1 put the Resident back to bed. NA #2 reported that she went to notify Nurse #2 of Resident #1's condition and Nurse #2 went to his room to assess him. NA #2 explained that Resident #1 acted the same throughout the rest of the shift when she went into care for him. During an interview with the Physical Therapy Assistant (PTA) on 04/02/25 at 11:45 AM the PTA explained that she had worked with Resident #1 since his admission, and he was able to participate in therapy. She reported that on the morning of 03/26/25 NA #1 came and got her to go to Resident #1's room because the Resident had a fall out of bed the day before and they had gotten him out of bed for his therapy session, but he was not behaving like his normal behavior. The PTA stated she went into Resident #1's room and could see that he was lethargic and not responding to her as he normally did, and she and NA #1 put the Resident back to bed. The PTA explained that she reported her concern to Nurse #2 and the Nurse informed her that no one reported to her that Resident #1 had a fall. The PTA continued to explain that she periodically checked on Resident #1 throughout the rest of the shift and he barely made eye contact with the PTA. She indicated the Resident made groaning and moaning sounds while he was sleeping. Interviews were conducted with Nurse #3 on 04/02/25 at 9:20 PM and 04/04/25 6:55 AM. The Nurse confirmed that she worked with Resident #1 on 03/25/25 through 03/26/25 for the 7:00 PM to 7:00 AM shift and 7:00 PM to 7:00 AM for 03/26/25 through 03/27/25. Nurse #3 explained that she received in the report on 03/25/25 that Resident #1 sustained a fall from the bed and the neurologic checks were on going. When the Nurse went into assess Resident #1, he was alert and talkative and informed her that he had a fall before she asked the Resident about the fall. The Nurse indicated that every time she went into assess Resident #1, he spoke with her and his neurologic checks and vital signs were within normal limits and remained within normal limits throughout the rest of the shift. Nurse #3 continued to explain that she reported off to Nurse #2 the morning of 03/26/25 and informed the Nurse that Resident #1 had a fall and that his neurologic checks were on going and she documented it on the 24-hour report sheet. Nurse #3 stated when she came on duty at 7:00 PM on 03/26/25 she checked on the residents and found that Resident #1 was lethargic. Nurse #3 was then told by the Unit Manager (UM) that labs, urine and a chest x-ray had been ordered for Resident #1 and that she had to collect the urine and have it ready for the lab to pick up. The Nurse stated she obtained the urine, and the lab phlebotomist came in around 4:00 AM in the morning to obtain the Resident's labs so that just left the chest x-ray which she reported to Nurse #1 when she gave her report that morning. Nurse #3 continued to explain that Resident #1 slept all night, and she was able to perform the neurologic checks except the grips because he was sleeping. The Nurse indicated the Resident's vital signs were stable. Nurse #3 reported that she was able to connect his external tube feeding, medicate him through his gastrostomy tube, clean the gastrostomy tube site and disconnect the external tube feeding without waking him but that was not unusual for the Resident because he could be a hard sleeper. Nurse #3 reported if it had been during the day she would have called the provider, but she knew the provider had already been informed of Resident #1's condition and his lab work was pending. Interviews were conducted with Nurse #2 on 04/02/25 at 11:30 AM and 04/03/25 at 11:35 AM. Nurse #2 confirmed that she worked with Resident #1 on 03/26/25 from 7:00 AM to 3:00 PM and it was the first time she had worked with the Resident. Nurse #2 explained that she did not receive in report from Nurse #3 that Resident #1 had fallen but she did receive other information about the Resident. Nurse #2 stated after that between 8:00 AM and 8:30 AM a therapy staff (PTA) member informed her that Resident #1 had a fall and was not acting like himself and she went to assess him. Nurse #2 stated Resident #1 would open his eyes when she called his name, but he would not respond to her. The Nurse indicated that she obtained the Resident's vital signs which were within normal limits and completed a change in condition assessment and reported the change in condition to the UM after the UM got out of a meeting which was around 10:30 AM and the UM informed Nurse #2 that she would call the PA. The Nurse explained that they received orders for some blood work, urine and a chest x-ray and Nurse #2 called the Resident's responsible party twice but had to leave a message on the cell phone and she did not know if the responsible party called back because she left off shift around 3:00 PM. When Nurse #2 was asked why she did not call the PA herself the Nurse indicated that she was not familiar with Resident and wanted to report the Resident's condition to her Unit Manager. A review of a Change in Condition Assessment completed by Nurse #2 on 03/26/25 at 2:35 PM revealed Resident #1 was drowsy, lethargic and very less responsive. Blood Pressure 115/62, Pulse 64, Respirations 18 and Temperature 97.7 via forehead and recent oxygenation 95%. Decreased level of consciousness (sleepy, lethargic). The assessment indicated the PA, and the responsible party were notified. A review of Resident #1's physician orders on 03/26/25 written around 5:40 PM indicated orders for a Complete Blood Count with Differential (CBC/Diff) in AM, Urine for Urinalysis and Culture and Sensitivity (UA/C&S) if indicated and a Chest X-Ray (CXR) for cough were obtained. The orders were written by the Unit Manager. Interviews were conducted with the Unit Manager on 04/02/25 at 5:00 PM and 04/03/25 at 10:45 AM. The UM explained that she was notified of Resident #1's fall by Nurse #1 on 03/25/25 shortly after the fall happened and was told that the Resident did not sustain any injuries from the fall. Nurse #1 initiated the neurologic checks which included vital signs as per protocol for post falls. The UM continued to explain that the next day on 03/26/25 at approximately 4:30 PM after she got out of the Risk Management meeting, Nurse #2 informed her that Resident #1 had a change in condition and was lethargic and she was going to document a change in condition and call the responsible party. The UM stated that she stepped into Resident #1's room and laid eyes on him but the Resident did not appear to her to be lethargic. She indicated that she did not complete an assessment on Resident #1. The UM continued to explain that since she had to call the PA about other residents, she decided to call the PA at that time and reported that Resident #1 had a change in condition and was lethargic. The UM stated she received orders for lab work, urine for culture and sensitivity and a chest x-ray which she put in the computer. The UM reported that Nurse #3 was to collect the urine, and the phlebotomist was to obtain the blood when they made their next round to the facility. The UM indicated Resident #1's vital signs were stable, and they were trying to rule out infection. During an interview with NA #3 on 04/04/25 at 11:40 AM the NA confirmed that she worked with Resident #1 on 3:00 PM to 11:00 PM on 03/26/25. The NA explained that she remembered Resident #1 being quiet and refusing his supper. She indicated that he would only answer her questions with one-word responses and slept most of the shift. NA #3 stated she had not worked with Resident #1 enough to determine if it was his normal demeanor, so she did not think it was abnormal to report his behavior. An interview was conducted with Nurse #4 on 04/03/25 at 8:15 AM who confirmed that she worked with Resident #1 on 03/26/25 from 3:00 PM to 7:00 PM. The Nurse explained that she only worked with the Resident that day and was unfamiliar with his usual demeanor. The Nurse stated she did not get in report that he had a fall, or she would have completed the neurologic checks. Nurse #4 reported that the Resident would answer her questions and allowed her to give him his enteral feeding. The Nurse stated if she had known or suspected that Resident #1 had a change in condition she would have notified the provider on call. An interview was conducted with Nurse Aide #5 on 04/03/25 at 10:30 AM. The NA confirmed that she worked with Resident #1 on 03/26/25 3:00 PM through 03/27/25 to 7:00 AM. The NA explained that she noticed that Resident #1 was not acting like his normal self on the evening of 03/26/25 and reported it to Nurse #3 who was working with her that night. The Nurse informed her that Resident #1 had a fall the day before and they had notified the PA and were given orders for lab work. NA #5 stated that she was able to check and reposition Resident #1 throughout the night and basically sleep through it all which was unusual because the Resident would normally grunt and moan when she turned him. Review of a progress note made by Nurse #1 on 03/27/25 at 10:52 AM indicated Resident #1 continued to appear lethargic, family at the facility at the time, requested Resident #1 to be sent out to ED for more evaluation. The PA was notified, and an order was received. Resident #1 left with EMS at around 10:19 AM. Vital Signs: 133/94, T97.3, R18, P112, 02 saturation 97% on room air. A review of the EMS records dated 03/27/25 revealed they were dispatched to the facility at 10:01 AM and arrived at the facility at 10:10 AM to find Resident #1 lying in the bed unresponsive, hot to touch and breathing approximately 40 times a minute. They were advised by facility staff that he had fallen 2 days prior but could not indicate how the Resident fell as it was noted that the Resident was paralyzed from previous cerebral vascular accidents. The family was also at bedside and advised that the Resident was normally alert and verbal and could carry a conversation, so they called EMS because the Resident was unresponsive. His temperature was obtained at 100.6 axillary, and intravenous access was established, and a fluid bolus was given. The Resident remained unresponsive throughout the transport. A review of Resident #1's hospital records dated 03/27/25 revealed Resident #1 arrived at the ED with a history of intracranial hemorrhage, altered mental status and subdural hematoma. The Resident received apixaban 5 mg twice a day. Resident #1's vital signs rose to 212/108, 124, 40 but remained negative for fever. The Glasco Coma Scale (GCS) (a neurological assessment tool used to measure a person's level of conscientious especially in traumatic brain injury) was a 3 meaning the lowest possible level of consciousness and is usually associated with the deep coma or death meaning the person is wholly unresponsive. The computed tomography (CT) results of the brain revealed a huge left subdural hematoma measuring 15.1 centimeters (cm) in length, thickness of 3.4 cm and height of 9.7 cm. This results in severe compression of the left hemisphere with 1.5 cm midline shift. There is developing right side hydrocephalus (a buildup of fluid deep within the cavities of the brain). The report indicated the Resident's family was consulted on his condition and because of his condition the family opted to provide comfort measures only and to consult Hospice services. An interview was conducted with the ED Physician on 04/04/25 at 10:20 PM. The ED Physician explained Resident #1 was brought to the ED by EMS who reported he had a fall one to one and a half days prior and had a decreased level of consciousness. He stated the Resident's vital signs were not terrible, but his blood pressure was 208/100 and his pulse was 124. The ED Physician continued to explain that the CT results showed a huge intracranial hemorrhage of a subdural hematoma that had a midline shift and after discussion with the family about the probable prognosis the family opted for Hospice services where he was sent that same day. The ED Physician reported that he saw no signs of injuries to account for the subdural hematoma, but it would not be uncommon for there not to be visible signs. He stated his opinion was that the hematoma was acute, but he could not be sure when it started because everyone was different and it could have even been before the fall. He indicated it could have been a slow bleed and when it crossed the midline shift was when Resident #1 started having a decreased level of consciousness. The ED Physician was asked if he thought Resident #1's recent diagnosis of COVID-19 affected his outcome and the ED Physician stated probably not. Interviews were conducted with the Physician Assistant on 04/02/25 at 2:15 PM and 04/03/25 at 12:45 PM. The PA explained that she was at the facility on 03/25/25 and was informed that the Resident sustained a fall and assessed Resident #1 late that same night. She reported that Resident #1 had an extensive complicated history with multiple comorbidities and recently contracted COVID-19 which made his condition worse since he had a neurological condition. The PA continued to explain that when she assessed the Resident, she did not order anything but to continue the facility's protocol for post fall neurologic checks. The PA reported that the UM called her the next day on 03/26/25 around 4:50 PM when the Resident had a change in condition. When the PA was asked if she was notified that Resident #1 was lethargic, the PA stated she could not remember the exact verbiage that the UM used in describing the Resident's change in condition, but she felt that she needed to obtain labs, urine and a chest x-ray to diagnose the issue. The PA reported that the next morning on 03/27/25 she was notified by Nurse #1 that Resident #1's family was at the facility and wanted him sent to the hospital and she gave the Nurse an order to send Resident #1 out to the hospital. The PA stated she now knew that Resident #1 had a subdural hematoma which could show up in 72 hours after a fall with head injury and as soon as the facility noticed a change in condition, they called the PA for guidance. The PA stated it was possible that Resident #1 could have had a slow hemorrhage from a previous bleed. During an interview was conducted with the Director of Nursing (DON) on 04/03/25 at 2:40 PM. The DON explained that she was notified of Resident #1's fall shortly after it happened but could not remember who notified her, but they told her that there were no injuries, and he did not hit his head. The DON reported that they talked about Resident #1 in the Risk Management meeting, and she specifically looked at his neurologic checks that were being done and there were no problems that she could determine. The DON stated that she always tried to follow up with the residents after falls and on Wednesday 03/26/25 she went into see Resident #1 who was in bed and asked him how he fell , and the Resident told her that he did not know how he fell and that he was not having any pain that he did not usually have. The DON reported that the next thing she knew was that Resident #1 was being sent to the emergency department on 03/27/25 at the family's request. The DON stated she did not know that Resident #1 had a change in condition on 03/26/25. On 04/03/25 at 3:10 PM an interview was conducted with the Administrator. The Administrator explained that the facility followed the fall protocol and conducted neurologic checks with vital signs and the neurologic checks were stable until Resident #1 had a change in condition on 03/26/25. At that time the Physician Assistant was notified, and orders were received for labs, urine and a chest x-ray which were pending when the family insisted that Resident #1 be sent to the hospital. She indicated that when families insist on the residents to be sent to the hospital the facility accommodated the request. The Administrator acknowledged Resident #1's hospital admission diagnosis of a huge left subdural hematoma with a midline shift and indicated it could have been growing since the Resident's last traumatic brain injury. An interview was conducted with the Medical Director on 04/04/25 at 4:15 PM. The Medical Director stated that he was notified of Resident #1's situation by the PA and was aware of the events that led to the Resident being sent to the hospital. The Medical Director stated that given Resident #1's complex medical history, the facility should have sent Resident #1 to the hospital when they noticed a change in his condition. He indicated that the outcome might not have changed but the facility should have sent him out. The Administrator was notified of Immediate Jeopardy on 04/03/25 at 4:40 PM. The facility implemented the following Credible Allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to recognize the severity of a change in condition for Resident #1 who sustained a fall from bed on 03/25/25 at approximately 2:00 PM. Resident #1 had a past medical history significant for history of stroke, recent pulmonary embolism, recent COVID-19, atrial fibrillation, and traumatic brain injury, who was prescribed Apixaban (anticoagulant) 5 milligram (mg) via gastrostomy tube twice a day for atrial fibrillation. In the morning hours of 03/26/25 at approximately 8:30 AM, Resident #1 was noted by staff with a change in condition as described by staff as having a decreased level of consciousness, not easily aroused, lethargic slow to respond, much different than his baseline. On 3/26/25 at approximately 4:50 PM the Unit Manager notified the Physician Assistant (PA), and orders obtained for blood work, urinalysis, and Chest Xray. Vital signs and neurological checks remained stable throughout the night. On 03/27/25 at approximately 9:58 AM Resident #1 became non-responsive and Emergency Medical Services (EMS) was called by the licensed nurse and family as ordered by the Physician Assistant. Resident #1 was diagnosed with sepsis and a left subdural hematoma and transferred and placed on Hospice services where he passed away on 03/31/25. On 4/3/25, the DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall within the last 72 hours to ensure timely recognition and response occurred if the resident experienced a change in condition. Two residents were identified and no concerns identified. On 4/4/2025, the DON and Unit Managers reviewed all residents with changes in condition in 24 hours to ensure immediate notification to the Medical Provider occurred. Six residents were identified and assessed, and the Medical Provider was notified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. On 4/3/25, the Administrator, Director of Nursing (DON), [NAME] President of Risk and Quality Assurance (VPRQA), Nurse Consultant, PA and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to recognize the severity of a change in condition for Resident #1. Root cause analysis determined that the facility failed to have effective systems in place and monitoring measures to ensure timely response and notification is made to a medical provider for proper intervention up to and including transfer to a higher level of care. On 4/3/2025, the Director of Risk and Quality Assurance, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the change in condition and fall policy. No changes were made. Effective 4/3/25, the Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention policies. Education includes recognizing the severity of a change in condition status post fall to include post fall assessment changes for 72 hours, changes in level of consciousness, and altered mental status away from baseline. Upon licensed nurse's assessment recognizing the severity of the residents change in condition away from baseline post fall, the Medical Provider will be immediately notified. Certified Nursing Assistants wil[TRUNCATED]

Based on resident and staff interviews, and record reviews, the facility failed to protect a resident's right to be free from physical abuse when a Nursing Assistant woke a resident from his sleep to provide incontinent care against his will and held the resident's arms while the resident was fighting for 1 of 3 sampled residents (Resident #2). A skin tear to the resident's left lower forearm was noted after this incident. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, pacemaker, type II diabetes mellitus with chronic kidney disease, and major depressive disorder. A review of the 09/26/2024 provider progress notes on Resident #2 revealed major depression with psychosis with psychiatric features, moderate depression with psychosis, intermittent unfounded accusations toward staff and facility with paranoid ideations, and that [NAME] wanted to kill him. Psychotherapy and evaluation and aggression with paranoid ideations were pending official notes. Lamictal (a drug used for bipolar I disorder maintenance) and trazodone (a drug used for depression) were reviewed. Lamictal dosing was switched to nighttime dosing due to daytime fatigue. A Discharge (end of Prospective Payment System [PPS] Part A Stay) Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 was cognitively intact and had skin tears. Resident #2 care plan dated 10/19/2024 stated that he had a skin tear to the right hand. A review of the physician orders revealed that the right hand had a skin tear on 10/09/2024 with orders renewed on 10/22/2024 to clean right hand with wound cleanser. Apply xeroform. Cover with dry dressing every day shift for wound healing. Then an order started on 10/22/2024 to Clean left wrist skin tear with wound cleanser and apply xeroform. Cover with dry dressing every day shift for wound healing. The initial psychiatric assessment dated [DATE] denied a history of abuse without symptoms of Post Traumatic Stress Disorder. The report stated that Resident #2 denied recent abuse, history of traumatic events, no suicidal or homicidal ideations, no audio verbal hallucinations, or guilt. Diagnoses of bipolar and insomnia were documented by the Psychiatric Nurse Practitioner. A daily skilled assessment authored by Nurse #5 at 10:48 AM on 10/21/2024 revealed that Resident #2 did not have any unhealed pressure ulcers or injuries, yet he did have a skin tear. It was documented that there was no change in his skin integrity. Nursing Assistant (NA) #8's written statement on 10/22/2024 was reviewed and revealed that the employee entered Resident #2's room earlier that morning at approximately 5:45 AM, introduced himself and explained that he was going to change him. NA #8 explained that the resident was immediately aggressive and began throwing his hands. NA #8 stated that Resident #2 reportedly pulled back, and NA #8 left the room to allow the resident to cool down. He went back in 15 minutes, reintroduced himself, cleaned the resident and asked if Resident #2 needed anything else. Resident #2 reportedly thanked him and replied that he didn't think he needed anything more. NA #8 wrote that he told the resident he was welcome and exited the room. At 2:16 PM on 04/02/2025, NA #8 was interviewed and stated that Resident #2 doesn't like to be woken from sleep. If he was awakened, he would become violent. Resident #2 tended to jump and get violent. NA #8 reported that when he awakened Resident #2 after NA #8 identified himself, Resident #2 refused care. NA #8 stated that when he touched Resident #8 to turn him, the resident started swinging his arms. NA #8 reported that Resident #8 could be aggressive and abusive both verbally and physically. NA #8 allowed the resident to cool down and reported to the nurse about Resident #2's refusal. NA #8 did not recall which nurse reportedly told him to go back and try to care for the resident again. NA #8 reported going back again to Resident #2 who seemed mildly cooperative. NA #8 was interviewed by phone at 1:05 PM on 04/03/2025. He stated that he didn't know anything about Resident #2 having skin tears. NA #8 stated that he did not recall twisting his arms or doing anything to cause Resident #2 any harm. He explained that when he changed Resident #2 around 6:00 AM, the resident was wet and soiled with bowel movement (BM). NA #8 remembered the BM, because he recalled Resident #2 was on metformin, an antidiabetic drug, and was having issues with his bowels. During an interview with Resident #2 at 1:55 PM on 04/02/2025, he reported that NA #8 was trying to change me when I didn't need it. I resisted. He twisted my hands, and his long fingernails went into my skin. He nipped my skin with my fingernails. I told him he better not do that again. He didn't mean to hurt me. He was trying to get his job done. He changed me. I told them to keep him out of my room. It's better for us to stay apart. I didn't want to hurt him, and he didn't want to hurt me. Just the situation just gets out of hand. An interview with Resident #2 at 4:23 PM on 04/02/2025 revealed that he didn't think the situation we talked about with NA #8 changing him was abuse. Resident #2 reported that he didn't think so, but he should have stopped when I resisted. I didn't need changing. Nurse #8's written statement dated 10/25/2024 revealed that no observations from NA #8 were reported to him on the night shift of 10/21/2024. Nurse #8 worked on the same hallway as NA #8 was assigned. Nurse #8 was not able to be interviewed. A review of Nurse #7's written statement dated 10/24/2024 about her interview with Resident #2 revealed that the resident reported NA #8's grabbing him while he was sleeping thus startling him. The nurse observed 2 skin tears on Resident #2 at both the hand and wrist. The resident reported that he jacked away from him. Resident #2 reportedly told her that he felt his injuries were not intentional. Resident #2 thought that NA #8 had a history of being rough with him. Nurse #7, a former Unit Manager who worked on dayshift, was unable to be interviewed. A review of a change in condition assessment on 10/22/2024 at 3:36 PM authored by Nurse #5 revealed that Resident #2 had a skin tear on the right hand and a skin tear on the left lower arm. Documentation revealed that the nurse was notified by Resident #2's family representative about an incident with the night NA. The Director of Nursing (DON) was interviewed at 3:55 PM on 04/03/2025 and stated she expected the NAs to provide care and communicate with the nurse. She revealed that a complete round must be done on every resident including a resident like Resident #2. During an interview at 2:34 PM on 04/03/2025 with the Administrator, she revealed that the NAs must explain to the nurse when a resident refuses care. Then the NA must report on why the resident was still resistant if applicable. A resident's history of behavior like Resident #2 is not a reason to not see about his care. She reported that the expectation has been set for every resident to be rounded on and clean. Each resident's brief must be opened and cleaned if needed. She expected the NAs to complete a round on every resident prior to leaving.

Based on record review, staff, news article review, North Carolina Board of Nursing Investigator, power of attorney, and detective interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to immediately initiate protective measures to safeguard residents from misappropriation of property and complete a thorough investigation when they received a report from local law enforcement of misappropriation of resident property. On 05/18/23 the facility received a call from Detective #1 informing them that Nurse #1 had been involved in a traffic stop and was in possession of Resident #156's driver's license, social security card, and debit card. There was a high likelihood that Nurse #1 misappropriated the property of other residents leading to the loss of financial resources for residents who resided at the facility at the time of Nurse #1's employment. The facility also failed to thoroughly investigate an allegation of abuse (Resident #28). This deficient practice was for 2 of 3 residents reviewed for allegations of abuse, neglect, and misappropriation of property. Immediate jeopardy began on 05/18/23 when the facility was made aware by law enforcement that Nurse #1 was found to be in possession of Resident #156's driver's license, social security card, and debit card and failed to immediately implement measures to protect other residents from misappropriation of property. Immediate jeopardy was removed on 01/30/24 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. Example #2 is being cited at a lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy). The finding included: Review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 10/22/23 read in part: Investigation of Alleged Abuse, Neglect, and Exploitation- an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations included: identify staff responsible for the investigation, exercising caution in handling evidence that could be used in criminal investigation, investigating different types of alleged violations, identifying, and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or misappropriation has occurred, the extent, and cause. Providing complete and thorough documentation of the investigation. Further review of the policy titled, Abuse, Neglect, and Exploitation revised on 10/22/23 read, Protection of Resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. 1. Review of an Initial Allegation Report from the facility to the Department of Health and Human Services (DHHS) for an allegation of misappropriation of property dated 05/18/23 read in part, Administrator received a call from Detective #1 indicating Nurse #1 had been stopped by police and Nurse #1 was in possession of Resident #156's social security card and driver's license. The report was signed by the Administrator. An email dated 05/18/23 from Detective #1 to the Administrator indicated when Nurse #1 was stopped by law enforcement she was found to have the driver's license and social security card for Resident #156 in her possession along with multiple other bank cards for other elderly people. She has been charged for other cards which were in her possession. Detective #1 was interviewed via phone on 01/25/24 at 8:41 AM and explained that Nurse #1 was stopped by a patrol officer in the county and the officer was able to charge Nurse #1 on the spot because she had charges of intercepting a mail truck and stole something from an elderly person that lived nearby that she claimed to be their caretaker. Detective #1 stated that after the patrol officer charged Nurse #1, she had received the case because she had so many stolen cards in her possession including those of Resident #156. She explained that she was able to locate the victims and had forwarded cases to surrounding counties that she had stolen cards from so the individual counties could press charges against Nurse #1. Detective #1 stated she had worked diligently to report Nurse #1 to the board of nursing because I did not want her near old people. An online news article from the county where the facility was located was posted on 5/21/23 and indicated on 5/16/23 Nurse #1 was charged with multiple offenses to include seven counts of taking a financial transaction card. Review of Investigation Report from the facility to DHHS dated 05/25/23 read in part, facility interviews with staff to include agency staff and resident interviews did not reveal any additional concerns. Nurse #1 was no longer being utilized in the facility. The police were still investigating and the agency that Nurse #1 was with was notified as well. Education to the staff on abuse, but not limited to misappropriation of property was conducted with the facility to include agency staff. The board of nursing will also be made aware of the incident. The report was signed by Former Director of Nursing (DON) #1. An attempt to interview Former DON #1 was made by phone on 01/26/24 at 9:25 AM and again at 5:29 PM without success. The investigation folder provided by the facility regarding the incident initially contained the Initial Report and the Investigation report. The facility later provided signature sheets of education completed on 05/18/23 and 05/19/23 regarding abuse, neglect, misappropriation of funds and a submission of complaint to the North Carolina Board of Nursing on 05/26/23 about Nurse #1. No other investigation items were provided from the facility including statements from other residents and/or staff. The North Carolina Board of Nursing Investigator was interviewed by phone on 01/30/24 at 8:22 AM. She stated that they had received a public complaint regarding Nurse #1 on 05/19/223 alleging the theft of credit cards then on 05/25/23 Detective #1 called and informed them that Nurse #1 had been arrested for being in possession of illegal drugs and stolen credit cards from various other towns. The investigator stated that she called the facility and spoke to Former DON #1 who reported that Nurse #1 had only worked 2 shifts at the facility. The investigator further explained that Nurse #1 had gone to trial and was convicted of 2 felonies. Resident #156's Power of Attorney (POA) was interviewed via phone on 01/25/24 at 2:46 PM who stated that Resident #156 had told him that his driver's license, social security care, and debit card were missing, and he needed to go the bank to get it replaced. The POA stated that he could not recall exactly when they went to the bank, but he guessed it was late March 2023 or early April 2023. When they got to the bank, they went over the charges on his account that Resident #156 was not aware of and did not authorize which were reoccurring charges to a taxi services, online shopping services, and a gas station in nearby county. He revealed the charges started in February 2023 and recurred until the card was cancelled in April. He added that no one from the facility had contacted him regarding the incident. An initial interview with the Administrator on 01/24/24 at 12:30 PM revealed that she had not done anything regarding the incident, and no investigation was completed on the incident with Nurse #1 because she had been told by her staff that she had never been their employee. A facility document titled Timecard Detail Report for 02/19/23 through 03/04/23 indicated that Nurse #1, an agency nurse, clocked into the facility on [DATE] at 7:30 PM and clocked out at 7:07 AM and on 02/24/23 she had clocked in at 11:07 PM and clocked out at 7:07 AM. A follow-up interview was conducted with the Administrator on 01/25/24 at 11:59 AM. She stated that she had received a call from a local detective (5/18/23) letting her know that Nurse #1 had been pulled over and had in her possession credit cards, driver's license, and social security from several elderly folks including one of the facility's residents (Resident #156). She explained that they ran an employee report from the previous 60 days in the facility and Nurse #1 had not worked in the facility, so they reported it to the State Survey agency and to the North Carolina Board of Nursing and that was it. The Administrator confirmed that they had not spoken to any of the other residents but did some education on misappropriation. When asked to explain why further investigation was not conducted the Administrator reported the facility believed Nurse #1 obtained Resident #156's driver's license, social security card, and debit card during a hospitalization he had in April of 2023. The Administrator was notified of Immediate Jeopardy on 01/25/24 at 1:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to fully implement their abuse policy when the facility failed to interview all staff, other residents, or family members when the facility received a credible allegation of misappropriation by Nurse #1 of Resident #156's driver's license, social security card, and debit card on 5/18/23. On 5/18/23, the facility Administrator was notified by a Detective from the Iredell County sheriff's office related to an ongoing investigation concerning Nurse #1 who was stopped on a traffic violation and was found to have in her possession several people's bank cards to include Resident #156's driver's license, social security card, and bank card. Resident #156 was interviewed by the Detective and again by the Director of Nursing (DON) on 5/18/23 which revealed that the resident was aware that the identified items were missing but he just thought that he lost or misplaced the items. Resident #156 reported to the Detective and the DON that he had cancelled the bank card and was not worried about the driver's license or the social security card. Resident #156 also reported to the DON on 5/18/23 that he had not reported the missing items to the staff. Review of the resident's medical record revealed that Resident #156 was his own responsible party and had a BIMS (Brief Interview Mental Status) of 15 (Highest). In addition, the Detective revealed that all of the identified people who had missing possessions recently had home health care or a hospital stay. Review of the medical records revealed that Resident #156 was recently in the hospital on 4/12/23 - 4/17/23. Resident #156 was unsure if he might have lost his wallet during his recent hospitalization . The Administrator reviewed the facility's grievance book on 5/18/23 which revealed no entries related to missing possessions to include social security cards, driver's licenses and debit cards for resident #156 or any current or former resident/responsible party. No other resident items were identified by the Detective that belonged to current and/or former facility residents. The Administrator was unable to identify any other staff except for Nurse #1. This incident appears to be an isolated incident. After review of the findings, it was determined that the facility failed to interview all the facility staff, the interviewable current residents and the non interviewable resident's responsible parties in the facility to ensure that no other residents may have been affected. On 5/18/23, education was initiated related to Abuse and Neglect to include misappropriation of resident funds and Preventing Elder Abuse by the Director of Nursing and the Unit Managers that included all facility staff which includes licensed nurses, certified nursing assistants, administrative staff, social service, business office, housekeeping/laundry, dietary, therapy, agency staff, weekend staff and prn staff. All current residents who prefer not to lock/secure their valuable personal items are at risk as a result of this deficient practice. On 1/26/24 an audit was initiated by the Unit Managers to identify current residents who prefer not to lock/secure their valuable personal items. o 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 Administrator and the Director of Nursing were educated on 1/26/24 by the Chief Nursing Officer related to ensuring that Abuse investigations include interviews of all staff, interviewable residents, and non-interviewable resident responsible parties when allegations of misappropriation of resident property occur and per facility policy provide complete and thorough records of documentation of the investigation. Starting 1/26/24, the Staff Development Coordinator (SDC) will complete interviews of the interviewable current residents to ensure resident concerns related to misappropriation of resident funds/ property to include driver's license, social security card, and debit cards have been identified and addressed. Starting 1/26/24, the Staff Development Coordinator, Unit Managers, and Nursing supervisors will complete interviews of the facility staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary, housekeeping/laundry, therapy staff, maintenance, administrative staff, business office, social services, weekend staff, agency and prn staff to ensure all reports of resident Abuse/Neglect to include misappropriation of resident's property have been reported and follow up completed if needed. Starting 1/26/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, therapy, social services, business office, weekend staff, CNA, and CMA receive the Abuse and Neglect education to include misappropriation of a resident's property. The SDC and/or DON will complete this education for new hires and prn staff to ensure that they receive the training before they return to work. Effective 1/30/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. A credible allegation of immediate jeopardy removal was conducted on 02/01/24. Education that was completed at the time the facility was made aware of the incident was reviewed along with the education that was currently used to educate all staff on abuse, neglect, and misappropriation. Interviews with residents and staff that were conducted were reviewed and no other significant findings were noted. The letter that was sent to families about misappropriation and the availability of lock boxes was also reviewed. Administrative interviews with the Administrator and Director of Nursing revealed that they had been educated by the Chief Nursing Officer on completing a thorough investigation and retaining proper documentation of the investigation per facility policy. Interviews across all departments revealed that they had been educated on abuse, neglect, and misappropriation of resident property. The staff were able to verbalize what misappropriation was, who to report to, and options the residents had to safeguard their belongings. The immediate jeopardy removal date of 01/30/24 was validated. 38515 2. Review of an Initial Allegation Report from the facility to the Department of Health and Human Services (DHHS) for an allegation of resident abuse dated 10/12/22 revealed the facility was made aware of an allegation of resident-to-resident abuse on 10/11/22 when Resident #28 reported Resident #46 touched her without her permission. Review of the facility's 5 working day read in part, the investigation reveal[ed] that Resident #[28] reported that Resident #[46] touched her inappropriately on her breast. Resident #[46] was interviewed and admitted to touching Resident #[28] and reported to social services that he would no do this again. Resident #[28] was placed on 1 to 1 monitoring by staff with a new room change. Resident #[28] continues to be observed for changes in mood and behavior with none observed. Both residents' care plans were reviewed and revised as needed. Resident #28 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, dementia without behaviors, anxiety disorder, and major depressive disorder. Review of Resident #28's quarterly Minimum Data Set, dated dated dated [DATE] which was prior to the alleged incident revealed her to be cognitively impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #46 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with mood disturbances, anxiety disorder, and history of stroke. Review of Resident #46's quarterly Minimum Data Set assessment dated [DATE] which was prior to the alleged incident revealed him to be cognitively impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Review of the facility's collective investigations of facility reportable incidents revealed this allegation to not have any additional investigation provided other than the 24 hour and 5 working days reports. There were no written statements from staff, or the residents involved. There were also no skin checks or other information regarding the complete and thorough investigation of the allegation. Review of Resident #46's progress notes revealed a note dated 10/11/22 at 1:05 PM, written by Social Worker #1 that read, Social Services was made aware of resident inappropriate touching behavior towards a resident. Spoke with resident, nurse, and family. Resident recognized and admit[ted] to inappropriate behavior and informed social services that this behavior will not happen again. [Medical Director] mad aware. An interview with Social Worker #1 on 01/25/24 at 2:34 PM revealed she had no recollection of the event. After reviewing her note dated 10/11/22, she reported Resident #46 had inappropriately touched another resident. She spoke with Resident #46 about the incident and stated Resident #46 reported he recognized it was inappropriate and would not do it again. Social Worker #1 stated she did not know what the inappropriate touching behavior was and stated she could not define what type of behavior would cause her document inappropriate touching behavior. Social Worker #1 reported having no further information than what was in her progress note. An interview with Resident #28 on 01/25/24 at 9:16 AM revealed she had no recollection of the event and stated she felt safe. An interview with Resident #46 on 01/24/24 at 2:37 PM revealed he had no recollection of the event. He stated he did not know Resident #28 and stated he had never touched anyone inappropriately. An interview with DON #3, who was the Director of Nursing at the time the incident occurred, was attempted by phone on 01/25/24 at 4:47 PM, but unsuccessful. An interview with Administrator #3 who was the Administrator at the time of the incident, was completed on 01/25/24 at 5:01 PM. It was revealed that he had no other information to provide to the investigation other than what was in the file at the facility. He stated if there were any written statements or skin checks, they would have been in the folder with the report given to the Division of Health Service Regulation. Administrator #3 also reported he would have sent his complete investigation, which included written statements with his 5 working day report. An interview Administrator #1 on 01/26/24 at 4:14 PM, she reported all facility reportable incidents should have a thorough and complete investigation. She stated the incident between Resident #28 and Resident #46 happened before she arrived and she could not speak to why the investigation was not thorough and complete.

Based on record review, news article review, North Carolina Board of Nursing Investigator, staff, power of attorney, and detective interviews the facility failed to assure that a resident's (Resident #156) property was safeguarded, and that staff did not misappropriate the resident's property. Nurse #1 was found to have in her possession Resident #156's driver's license, social security card, and debit card without his permission or knowledge and was alleged to have made unauthorized charges on the debit card which included reoccurring charges to a taxi services, online shopping services, and a gas station in a nearby county (Gastonia). The unauthorized charges started in February 2023 and recurred until the card was cancelled in [DATE] for an undisclosed amount of money. The reasonable person concept was applied for this deficient practice in that a reasonable person would have the high likelihood of being upset about the loss of financial resources, the invasion into one's personal financial status, and increased anxiety over the risk of identity theft. The deficient practice was discovered for 1 of 3 residents reviewed for abuse, neglect, and misappropriation of resident property. Immediate Jeopardy began on [DATE] when Nurse #1 first worked in the facility and likely misappropriated Resident #156's documents, including his driver's license, social security card, and bank debit card. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #156 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (chronic degenerative disorder), heart disease, and congestive heart failure. Resident #156 expired on [DATE]. Review of Resident #156's medical record revealed no record of inventory of his personal belongings that he had in his possession upon admission to the facility, or during any part of his stay. Further review of Resident #156's history of stay revealed that he had been hospitalized on [DATE] and readmitted to the facility on [DATE] and remained in the facility until [DATE]. He was again hospitalized on [DATE] and readmitted on [DATE] and remained in the facility until his passing on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #156 was cognitively intact and had no behaviors. A facility document titled Timecard Detail Report for [DATE]-[DATE] indicated that Nurse #1 an agency nurse clocked into the facility on [DATE] at 7:30 PM and clocked out at 7:07 AM and on [DATE] she had clocked in at 11:07 PM and clocked out at 7:07 AM. Review of the Iredell Free News website article titled [County Sherriff's Office] ICSO Felony Arrests [NAME] ,d+[DATE] [2023] revealed Nurse #1, on [DATE], was charged with seven counts of taking a financial transaction card, possession of methamphetamine, maintaining a dwelling or vehicle for sale or use of controlled substances and a misdemeanor drug offense. An email dated [DATE] from Detective #1 to the Administrator read, as discussed, the detective was emailing about the incident with Resident #156 and the theft of his North Carolina Driver's License, his social security card, and his bank debit card. The detective spoke with Resident #156 via phone, and the resident advised he did not report the documents stolen because with his declining health and issue with memory he thought maybe he just lost it or hid it and could not remember where he put it. Resident #156 further stated he closed the debit card once he realized it was gone and did not worry about the license or social security card because he was in the nursing home, and he did not need it at the time. The detective explained when Nurse #1 was stopped by a police officer, she was found to have both the driver's license and social security card for Resident #156 in her possession along with multiple other bank cards for other elderly people. Nurse #1 was charged for other cards which were in her possession. During the investigation it was discovered all of the alleged victims had been in and out of hospitals, have had to have home health care, and the detective had been attempting to identify how all of the patients (alleged victims) may have been linked (to Nurse #1) and that was how she found Resident #156 and the facility. Resident #156's license and card were in the evidence locker at the county sheriff's office and would be held until after Nurse #1's trial. The items could be picked up when the trial was complete. (This could be several years.) Detective #1 was interviewed via phone on [DATE] at 8:41 AM and explained Nurse #1 was stopped by a patrol officer in the county. The detective said the officer was able to charge Nurse #1 on the spot because she had charges of intercepting a mail truck and was alleged to have stole something from an elderly person that lived nearby that she claimed to be their caretaker. Detective #1 stated after the patrol officer charged Nurse #1, she had received the case because Nurse #1 had so many stolen cards in her possession. She explained she was able to locate the victims and had forwarded cases to surrounding counties where Nurse #1 had stolen cards from so the individual counties could press charges against Nurse #1. Detective #1 added in addition to intercepting the mail truck, Nurse #1 was also the subject of a medication theft of another nursing home in another county. Nurse #1 was working through an agency and was accepting jobs in numerous other counties and had last resided in [NAME]. Detective #1 stated she located a phone number for Resident #156 and talked to him via phone and as far as he knew no money had been taken and that was why the resident had not reported it to the staff. She explained to Resident #156 his cards were in the safe at the county courthouse. Detective #1 stated she had worked diligently to report Nurse #1 to the board of nursing because I did not want her near old people. Detective #1 also confirmed that Nurse #1 was not in the Iredell County jail at the time of interview. Resident #156's power of attorney (POA) was interviewed via phone on [DATE] at 2:46 PM who stated Resident #156 had told him his driver's license, social security card, and debit card were missing, and he needed to go the bank to get it replaced either in late [DATE] or early [DATE]. He further explained Resident #156 did not drive at the time, and he transported Resident #156 wherever he needed to go. When they got to the bank, they went over the charges on his account that Resident #156 was not aware of and did not authorize which were reoccurring charges to a taxi services, online shopping services, and a gas station in nearby county (Gastonia) and the charges started in February 2023 and reoccurred until the card was cancelled in April2023. Resident #156 explained to the bank he just wanted a replacement card and not to close the account because his mind was failing, and he did not want to learn new account numbers. The POA stated the bank replaced Resident #156's debit card and he gave it to the POA to keep in his possession so this would not happen again. The POA stated the bank did an investigation and did replace some of the money that had been taken. He added no one from the facility had contacted him regarding the incident and stated Resident #156 was very sick and it was easy for someone to come along and take something. The POA stated they had not reported the missing documents, or the alleged fraudulent charges, to the facility because they did not know if the fraudulent charges were made by a facility employee. An attempt to speak to the agency that Nurse #1 worked for was attempted on [DATE] at 10:30 AM. An attempt to speak to Nurse #1 was made on [DATE] via phone at 8:34 AM and again on [DATE] via phone at 5:31 PM and was unsuccessful. The North Carolina Board of Nursing Investigator was interviewed via phone on [DATE] at 8:22 AM. She stated that they had received a public complaint regarding Nurse #1 on [DATE] alleging the theft of credit cards then on [DATE] Detective #1 called and informed them that Nurse #1 had been arrested for being in possession of illegal drugs and stolen credit cards from various other towns. The investigator stated that she called the facility and spoke to Former DON #1 who reported that Nurse #1 had only worked 2 shifts at the facility. The investigator further explained that Nurse #1 had gone to trial and was convicted of 2 felonies. She also explained that the Board of Nursing recommendation was to suspend Nurse #1's nursing license. However, they could not do that without her acknowledgment and thus far she has made no acknowledgement of their attempts to notify Nurse #1 of the action. The Investigator added that they would take it to a hearing and after the hearing they could formally suspend Nurse #1's nursing licenses. There was no date scheduled for the hearing, but the Investigator stated she hoped by the spring of 2024 they would have date. An attempt to interview Former DON #1 was made on [DATE] at 9:25 AM and again at 5:29 PM without success. The Administrator was interviewed on [DATE] at 11:59 AM. She stated she had received a call from a local detective letting her know Nurse #1 had been pulled over and had in her possession credit cards, driver's license, and social security cards from several elderly folks including one of our residents (Resident #156) on [DATE]. She explained they ran an employee report from the previous 60 days in the facility and Nurse #1 had not worked in the facility, and it was reported it to the State Survey agency and to the North Carolina Board of Nursing. The Administrator confirmed they had not spoken to any of the other residents but did some education on misappropriation and stated, there is no way to safeguard his own personal belongings he was alert and oriented. The Administrator was notified of Immediate Jeopardy on [DATE] at 1:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to assure that a resident's property was safeguarded, and that staff did not misappropriate the resident's property (driver's license, social security card, and debit card) without the resident's permission or knowledge. On [DATE], the facility Administrator was notified by a Detective from the Iredell County Sheriff's office of an ongoing investigation concerning Nurse #1 who was stopped on a traffic violation and was found to have in her possession several people's bank cards to include Resident #156's driver's license, social security card, and bank card. Resident #156 was interviewed by the Detective and again by the Director of Nursing (DON) on [DATE] which revealed that the resident was aware that the identified items were missing but he just thought that he lost or misplaced the items. Resident #156 reported to the Detective and the DON that he had cancelled the bank card and was not worried about the license or the social security card. Resident #156 also reported to DON that he had not reported the missing items to the staff. Review of the resident's medical record revealed that Resident #156 was his own responsible party and had a BIMs of 15 (Highest). Review of the admission agreement, section 9 regarding Personal Possessions, indicated that Resident #156 was aware that he could secure his personal property with the facility but preferred to secure his own personal property. In addition, the Detective revealed that all of the identified people who had missing possessions recently had home health care, or a hospital stay. Review of the medical records revealed that Resident #156 was recently in the hospital on [DATE] - [DATE]. Resident #156 was unsure if he might have lost his wallet during his recent hospitalization The Administrator reviewed the resident grievances and there were no additional concerns noted of the current and/or discharged residents related to missing possessions including social security cards, driver's licenses and debit cards. No other resident property was identified by the Detective that belonged to current and/or former facility residents. Review of the findings revealed, however, that the facility failed to provide ongoing education/reminders to all facility staff, interviewable residents and non interviewable resident responsible parties of the facility options to secure resident property. These include lock boxes, the facility safe and utilizing the resident trust system (banking). On [DATE], education was initiated related to Abuse and Neglect to include misappropriation of resident property and Preventing Elder Abuse by the Director of Nursing and the Unit Managers that included all facility staff (licensed nurses, certified nursing assistants, administrative staff, social service, business office, housekeeping/laundry, dietary, therapy, agency staff, weekend staff and prn staff). All current residents who prefer not to lock/secure their valuable personal possessions are at risk as a result of this deficient practice. On [DATE] an audit was initiated by the Unit Managers to identify current residents who prefer not to lock/secure their valuable personal items. The identified residents that preferred not to lock/secure their belongings were made aware that lock boxes and/or resident trust fund accounts were available. o 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 administrator and the Director of Nursing were educated on [DATE] by the Chief Nursing Officer on misappropriation of resident possessions to include the facility options to secure resident possessions such as lock boxes and resident trust accounts. Starting [DATE], the education will be initiated by the Staff Development Coordinator and the Unit Managers to all staff, interviewable residents, and non interviewable resident families. The Administrator will be starting to distribute and mail the letters by [DATE] to the residents and/or resident's responsible parties that include education related to resident lock boxes and resident trust accounts to aid in safeguarding resident possessions. Starting [DATE], the Staff Development Coordinator (SDC) will complete education on misappropriation of resident property which includes facility options to secure resident possessions such as lock boxes and resident trust accounts to the facility staff which includes licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary, housekeeping/laundry, therapy staff, maintenance, administrative staff, business office, social services, weekend staff, agency and prn staff. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, therapy, social services, business office, weekend staff, CNA, and CMA receive the Abuse and Neglect education to include misappropriation of resident funds that include facility options to secure resident possessions. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the ongoing education is completed. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. A credible allegation of immediate jeopardy removal was conducted on [DATE]. Review of all alert and oriented resident interviews regarding any misappropriation of property were reviewed and education provided to resident, staff, and family was reviewed explaining what misappropriation was, who to report it to, and ways the facility had to safeguard the resident's belongings and personal effects. Interviews with staff across all departments revealed that they had received the education on misappropriation and were able to verbalize what misappropriation was, who to report to, and way that the facility had in place to store resident's belongings. The immediate jeopardy removal date of [DATE] was validated.

Based on staff interviews the facility failed to employ a qualified director of food and nutrition services. The findings included: An interview was conducted with the Interim Dietary Manager #1 (DM) on 1/25/24 at 2:17 PM and revealed that he had taken over as the Dietary Manager this week. He stated that the food service company that employed him sent him to this facility on 01/22/24 (Monday) to assume the Dietary Manager position. He stated the previous DM #2 was out sick this week, but she had been working as the DM for this facility for about 8-9 months. DM #1 stated he had worked in the food industry for about [AGE] years, and he confirmed he had a dietary manger certification. However, he stated he and his organization were aware DM #2 did not have a Dietary Manager certification and he was unsure how long he would be in this current role. He stated DM #2 would be working in the facility as a dietary aide for now. In a phone interview on 1/30/24 with DM #2, she stated she had been working at the facility since March 2023. DM #2 stated she did not have her Dietary Manager certification, or a Serve Safe certification. She stated she was aware she was supposed to have a certification in her role as a Dietary Manager, but her organization had not enrolled her in a certification program, and she was not able to pay for it on her own. The Registered Dietician (RD) was interviewed via phone on 01/25/24 03:50 and she stated she worked full time but not at this facility. She explained that she visited the facility once a week and would attend the Interdisciplinary Team meeting when she could. The Administrator was interviewed on 01/24/24 at 6:15 PM and she confirmed that DM #2 had been working at the facility for about a year and was employed through an outside food service agency. The Administrator also confirmed the RD did not work full-time at the facility. She said the RD came to their facility once a week. In a follow-up interview with the Administrator which was conducted on 02/01/24 she stated she could not specifically recall being notified of DM #2's lack of any certification.

Based on observations, record review, video footage review, staff, and Nurse Practitioner interviews the facility failed to redirect and implement effective interventions to prevent a severely cognitively impaired resident with a history of wandering and exit seeking behaviors and wore a wander guard (alarm used to prevent resident from exiting the building) from exiting the building unsupervised (Resident #155). The facility also failed to effectively supervise and remain with a resident with dementia and had a history of wandering and wore a wander guard who was observed by the Receptionist to exit the building (Resident #95). This deficient practice affected 2 of 2 residents reviewed for accidents. The findings included: 1. Review of a facility policy titled, Elopements and Wandering Residents dated 11/23/23 read, Elopement occurs when a resident leaves the premises or safe area without authorization (i.e an order for discharge or leave of absence) and /or any necessary supervision to do so. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g internal alert code). Resident #155 was admitted to the facility on [DATE]. His diagnoses included Huntington's Chorea (inherited condition where nerve cells break down over time and cause uncontrolled movements) unspecified psychosis, dementia, major depressive disorder, Alzheimer's disease, restlessness, and agitation. Review of a wandering assessment completed on 12/01/22 revealed a score of 2 which was low risk to wander. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #155 was severely impaired for daily decision making and wandered 1 to 3 days during the assessment reference period. The MDS further indicated Resident #155 required one person assistance in locomotion on and off the unit. No restraints or alarms were used during the assessment reference period. Review of a progress note dated 12/06/22 at 12:19 AM read, patient very restless, walking up and down the hallway with an unsteady gait. Patient was redirected multiple times to use his chair or ask for help when needing things. Patient did not express understanding and repeatedly walked the halls without his wheelchair before he went to sleep. A care plan initiated on 12/14/22 read, Resident #155 is a wanderer/elopement risk (packing clothes and wanting to go home) related to impaired safety awareness. A social services assessment dated [DATE] indicated that Resident #155's family had reported that while they had him at home, they had found Resident #155 outside going through their cars. A Situation, Background, Assessment, and Recommendation (SBAR) dated 12/17/22 read; Resident #155 was anxious and packed up belongings and stated his family was picking him up and became agitated when told family was not coming to get him today. Provider notified and one time order of Clonazepam (antianxiety) 1 milligram (Mg) and hold the scheduled dose at 9:00 PM. If still anxious after 11:00 PM give Clonazepam 0.5 mg. Review of a progress note dated 12/20/22 at 2:19 PM read, resident observed propelling himself in wheelchair in hallway with belongings. Resident stated that he wants to go home. Resident was redirected by staff and assisted back to room He also refused care from staff and refused to don clean clothes. His family was called and notified that patient wants to go home. Family will visit on Thursday. (12/21/22) The note was electronically signed by Nurse #14. Review of a progress note dated 12/22/22 at 10:15 AM read, Resident noted with behavior of his packing belongings and attempting to go home. Call to family made. Will place wander guard today and family agreed and stated that resident called him 3-4 times a day requesting to go home. Family indicated that they reassured him that they would visit soon. This note was electronically signed by previous Director of Nursing (DON) #1. Review of a physician order dated 12/22/22 read; wander guard to left leg, check function and placement every shift. A wandering assessment completed on 12/22/22 indicated a score of 12 high risk to wander. Revision of care plan on 12/22/22 stated wander guard in place to left ankle. Interventions included address wandering behavior by walking with resident, redirect from inappropriate areas, engage in diversional activity, administer, and monitor medications, assess for fall risk, assist resident to bed or chair when fatigued, create a rest station in hallway for resident, distract from wandering by offering pleasant diversion, ensure proper fitting of clothes and shoes, and ensure that the area that resident wanders in is safe. Review of the Treatment Administration Record (TAR) dated January 2023 revealed that Resident #155's wander guard was checked every shift for placement. Review of a progress note dated 12/28/22 at 2:12 PM read, Resident #155 refuses care and continues to go to the front door wanting to go home. The note was electronically signed by Nurse #13. Review of progress note dated 12/29/22 at 11:30 AM read, per staff Resident #155's family visited over the weekend, and he was very adamant about wanting to go home and sitting in main lobby. At times residents blocks the front door, not allowing visitors to enter or exit. Refusing to return to room for care or meals. Receiving max encouragement from staff, requiring several re-approaches. The note was electronically signed by previous DON #1. Review of a progress note dated 01/19/23 at 9:15 PM read, Staff reported resident was outside in the parking lot area on facility grounds in his wheelchair. Resident was assisted by a staff member and this nurse and was taken to his room. He was alert and oriented. No acute distress, respirations even and unlabored. Skin assessment completed with no injuries or bruising. Resident was placed on one-on-one supervision. Resident put back to bed and was resting at that time. Family and DON updated. The note was electronically signed by Nurse #2. An observation of the parking lot of the facility was conducted on 01/24/24 at 2:00 PM revealed the area that was identified by Medication Aide (MA) #1 as being the location that she found Resident #155 at on 01/19/23 was on an incline approximately 10 feet from the main residential street which dead ended into the parking lot with a direct turn to the right. Resident #155 was at the direct turn right into the facility on an incline surrounded by woods and homes. The area was approximately 222 feet from the front door of the facility where Resident #155 exited from. MA #1 was interviewed on 01/23/24 at 4:02 PM. She stated that from what she could recall she was sitting in the assisted living hall that is adjoined to the skilled facility and was charting when she heard the wander guard alarm go off. MA #1 stated she looked at the alarm panel on the wall directly above her head and saw that it was the front door alarm. MA #1 stated she got up after a brief pause to see if any of the staff closer to the front were going to respond and proceeded to run through the facility to the front door and walked outside to see why the alarm was sounding. MA #1 stated she saw Resident #155 in his wheelchair headed up the incline at the exit of the facility near the main road. MA #2 stated she was afraid Resident #155 was going to get up the hill or someone was going to come over the hill and hit him. MA #1 stated she ran to Resident #155 who was dressed in a gown and asked him if they could go back into the facility because it was cold outside. She stated Resident #155 was agreeable and allowed her to push him back to the building where they went to the assisted living door and banged on the door and Nurse #2 came and let them in. She added that Nurse #2 returned Resident #155 to his room, and she resumed her charting. MA #1 could not recall if Resident #155 had on footwear or what it was if he did. Nurse #2 was interviewed on 01/23/24 at 3:37 PM and stated she vaguely recalled the event with Resident #155 as it had been over a year since it occurred. She stated she was the charge nurse the night the resident exited the facility. Nurse #2 stated she was not very familiar with Resident #155 but thought she recalled him being a wandering patient. Nurse #2 stated that she completed a skin assessment, and he had no injury and she immediately put Resident #155 on one-on-one supervision and notified the management team. Weather.com, an online weather source indicated that on 01/19/23 the weather in the county where the facility was located had a high temperature of 63 and a low temperature of 45. Review of video footage from 1/19/23 revealed Resident #155 sitting in his wheelchair at the front desk of the facility messing with papers with the exit door directly across from the front desk approximately 8 feet between the desk and the front door. An unknown staff member was observed to walk by Resident #155 two times without redirecting Resident #155 away from the exit door. Resident #155 was observed to be dressed in a short sleeve t-shirt with a gown either on his lap or on over the t-shirt with black hard sole shoes on. After 1-2 minutes Resident #155 went to the front door of the facility directly across from the front desk and pushed on the door three times and it did not open. Resident #155 was then observed to lift the plastic cover to the emergency door unlock switch and switched it down unlocking the first of two doors. Once Resident #155 flipped the emergency switch down, he pushed the first door and it opened and he propelled himself out the first door and then out the second door and propelled himself towards the right through the parking lot. Approximately 4 minutes after Resident #155 exited the front door MA #1 was seen responding to the door. No other staff were seen in the video footage besides the unidentified staff member and MA #1. The video had a date stamp of 01/19/23 on it. Nurse #13 was interviewed via phone on 01/23/24 at 3:04 PM. Nurse #13 confirmed she was taking care of Resident #155 on 01/19/23 when he exited the facility. Nurse #13 explained that she had gone to the vending machine that night to get a snack and was standing outside the vending machine area looking at the windows at the front of the facility and saw a staff member pushing a resident in a wheelchair. She explained she had no idea it was Resident #155. She stated she really thought nothing about it, she just assumed the staff member had taken the resident out for some reason. After Nurse #13 finished her snack, she returned to the unit and Nurse #2 brought Resident #155 to the unit and said he got out the front door and Nurse #13 said how did that happened I just told Nurse Aide (NA) #5 to put him in the bed because he had been yawning and appeared sleepy. Nurse #2 explained that she worked at the facility through an agency and was not very familiar with Resident #155 but was aware that he tried to get out of the facility often and wore a wander guard bracelet that she had to check for working order when she worked on third shift. Nurse #13 stated that when Nurse #2 brought Resident #155 back to the unit she did a skin assessment and documented in the record and completed an incident report. She added that she had also notified the Administrator and Medical Doctor about Resident #155 getting outside to the parking lot. An attempt to speak to NA #5 was made on 01/23/24 at 5:16 PM and was unsuccessful. A handwritten statement from NA #5 dated 01/19/23 read, I was working on 600 hall from 3-11 and was assigned to care for Resident #155. When the dinner trays had been collected my evening care was done, I communicated with my nurse to let her know that I was taking my 30-minute break. I went to grab some food and when I came back, I seen other NA at the nurse's station. So, I went down the hall and sat down to watch the hall. At that time med aide was pushing Resident #155 in wheelchair saying he was outside. Former DON #3 was interviewed via phone on 01/23/24 at 5:17 PM. She stated that she worked at the facility from September 2022 to May 2023. She recalled that Resident #155 was only at the facility for a short time because the family could not take care of him. Resident #155 was exit seeking and had a wander guard in place. Former DON #3 explained that initially upon admission Resident #155 did not wander but as he stayed and progressed in therapy, he realized that his family was not coming to pick him up and he began to exit seek and liked to sit up front by the front door and talk to the staff that were coming and going. She explained one night after everyone had left up front, he lifted the cover on the emergency door switch and switched it off and then proceeded out the door and went to the far right of the parking lot but did not make it to the main road. She stated, I don't believe he wanted to leave the facility I believe he just wanted some fresh air. Former DON #3 stated that she cannot recall who called her, but someone called her and told her that Resident #155 had gotten out to the parking lot, and she came in and interviewed all the staff, put someone up front to monitor the door that night, and put Resident #155 on one-on-one supervision. She further stated that she began education on elopement with all the staff and got the next shift as they came in for work and the Assistant Director of Nursing (also known as Former DON #2) at the time helped with the investigation. In addition to the education and interviews they contacted a company to come out and add additional screamer alarms and install alarms that were key enabled instead of a switch. She also stated she thought the Nurse Practitioner (NP) had assessed Resident #155 the next day and no injuries were noted. Former DON #2 was interviewed via phone on 01/24/24 at 2:32 PM who confirmed that at the time that Resident #155 eloped she was the ADON, and she heard about the elopement the following morning when she came to work. She stated that Resident #155 did not make it off the property because MA #1 had heard the alarm and went and looked for him and found him and returned him to the facility. She stated she assisted with the education to help Former DON #3 out. Former DON #2 stated that Resident #155 would exit seek more during the times when his family had not come to visit and so we had to put a wander guard on him but generally the aides were easily able to redirect him back to the unit with no issues. The Administrator was interviewed on 01/24/24 at 10:45 AM, she stated she received a call on 01/19/23 from Nurse #2 about Resident #155 getting outside to the parking lot. She stated she instructed Nurse #2 to do a head-to-toe assessment and place him on one-on-one supervision. The Administrator stated she did not come to the facility that night because she knew that she could review the video footage the next morning when she came to work. She explained that when she came in the next morning, she reviewed the video footage, and it showed that Resident #155 lifted the cover to the emergency door switch and flipped to the off position which disabled the door lock, and he opened the door and exited through the first door and because he had a wander guard on the alarm sounded. MA #1 came to the door and walked outside to check the perimeter and found him in his wheelchair. Nurse #2 completed a head count the night before and everyone was accounted for. The Administrator stated that they called the door company to come out and do an assessment of the door system and put the push button screamer alarms on the exit doors at the front, assisted living door, and kitchen door. The ancillary doors screamers were added that can only be disabled with a key that are kept on the medication cart key ring. She added that they educated everyone on the elopement process, what to do if there was an elopement, who to notify, check the residents, update care plan, and how we announce the elopement. The Administrator stated they had conducted a root cause analysis of the situation and determined the root cause to be the emergency switch was easily accessible to the residents, so the facility had the switch removed and push button screamers added to the exit doors. She went on to say that since then they had been monitoring the wander guard system weekly but had not been monitoring the screamer alarms that were installed as a result of the root cause analysis. The Administrator stated that MA #1 did great and did exactly what she was supposed to. On 01/20/23 we had a sister facility that had a memory unit and agreed to take Resident #155 so with family permission Resident #155 was discharged from the facility. The NP was interviewed via phone on 01/23/24 at 6:12 PM who stated she recalled Resident #155 and did recall being notified that he had gotten outside of the facility one night. She stated she evaluated him the next day and it was an uneventful assessment, and basically, he wanted to go home. The NP stated she was aware that Resident #155 had Huntington's Chorea and was doing well initially but was aware of some behavioral changes he had since his admission. She clarified that she saw and evaluated Resident #155 first thing in the morning when he was his sharpest as far as mental state. She further explained that Resident #155 liked to sit in the front lobby and appeared to be watching people come and go, maybe, learning how to get out of the building but to her knowledge this was the only occurrence. The NP stated that no resident should be outside unattended in the parking lot for safety reasons. Review of a physician order dated 01/20/23 read ok to discharge to memory care unit. 38515 #2. A facility policy titled, Elopements and Wandering Residents dated 11/23/23 read, Elopement occurs when a resident leaves the premises or safe area without authorization (i.e an order for discharge or leave of absence) and /or any necessary supervision to do so. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g internal alert code). Resident #95 admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, psychophysiologic insomnia, and repeated falls. A physician's order dated 11/08/23 read, wander [alarm] in place on left ankle and ensure placement of wander [alarm] on left ankle every shift for wandering. A physician's order dated 11/09/23 read, ensure function of wander [alarm] every day, one time a day for function of device. A progress note dated 11/08/23 at 11:17 AM read, Wander [alarm] placed on resident's left ankle. Resident #95's care plan, last reviewed on 11/09/23 revealed a care plan area for The resident is an elopement risk/wanderer related to impaired safety awareness. Interventions included address wandering behavior by walking with resident; redirect resident from inappropriate areas; engage in diversional activity. A wandering assessment completed on 11/13/23 revealed a score of 12 out of 15 which was high risk to wander. Resident #95's quarterly Minimum Data Set assessment dated [DATE] revealed he had moderately impaired cognition with no psychosis, behaviors, or rejection of care. Resident #95 was coded with wandering behaviors occurring 1-3 days during the lookback period. Resident #95 was also coded with having had 2 or more falls since his admission. Resident #95 was coded as using a wander or elopement alarm daily. Review of a progress note dated 12/01/23 at 10:27 PM read in part, Resident encouraged to lay down and rest because he has been walking/wandering around majority of shift. This note was electronically signed by Wound Nurse #1. An interview with Wound Nurse #1 on 01/23/24 at 2:30 PM revealed she had started noting Resident #95's behaviors when she started getting complaints from other residents about Resident #95 wandering in and out of their rooms. She stated she had never observed any exit seeking behaviors. Wound Nurse #1 reported she had heard Resident #95 had exited the building to the courtyard but had no knowledge of him leaving the front of the building. Review of facility provided incident logs revealed Resident #95 with an elopement on Sunday, 12/03/23. A review of historical weather data via www.weather.com revealed the high on 12/03/23 in Mooresville, NC was 72 degrees Fahrenheit with a low of 55 degrees Fahrenheit and the skies were partly cloudy. Review of video footage dated Sunday, 12/3/23 when Resident #95 exited without supervision from the building revealed him to be in gray sweatpants, gripper socks with no shoes, and a red t-shirt. Resident was observed on video to walk up to the door, pause for a second, then push the door open and move into the -vestibule before opening the outside door and walking out of the facility. Receptionist #1 was observed to follow Resident #95 out of the front door and catch up to him several feet from the front door. It appeared that Receptionist #1 attempted to redirect Resident #95 back into the building, but he refused and proceeded to continue to walk to the left, down the sidewalk. Receptionist #1 was observed to not follow Resident #95 but walked back into the facility, put in a numerical code to unlock the front door, and then walk towards the front desk and out of view of the camera. After 5-10 seconds, she was observed to walk back in front of the front desk moving to the left and out of vision of the camera. An interview with Receptionist #1 on 01/23/24 at 2:53 PM revealed she remembered Resident #95 walking out of the front door. She reported she was working at the front desk on 12/03/23 when Resident #95 walked up to the front door, pushed it open, and walked out. She stated Resident #95 wore a wander [alarm] and that the front door normally locked and alarmed if he tried to open it, but that this time, the door did not lock, and the alarm did not sound. Receptionist #1 stated she immediately got up and followed Resident #95 out the front door and took his arm and tried to redirect him back into the facility. She stated Resident #95 said, No!, yanked away from her and started walking down the sidewalk towards the side of the building. Receptionist #1 reported she ran back into the building, tried contacting the nurses' station via phone and received no answer, so she started walking back to the nurses' station to notify someone that Resident #95 was out of the building. She stated on her way back to the nurse's station she saw Nurse Aide (NA) #5 and called out to her that Resident #95 was outside of the building. She reported NA #7 ran out the side door and was able to get Resident #95 back into the building. Receptionist #1 reported she did not know where NA #7 found Resident #95 or which door they reentered as she went back to the front desk after she notified NA #7 that Resident #95 was outside of the building. During an interview with the Administrator on 01/23/24 at 12:47 PM, she verified that Resident #95 had exited the facility without supervision on Sunday, 12/03/23. Review of a progress note dated 12/04/23 at 10:07 PM read, Residents' vital [within normal limits]. All medications tolerated. Resident encouraged to resident and ask for assistance. Resident wanders around unit and is redirected as needed. Will continue to monitor. This note was electronically signed by Wound Nurse #1. During a follow-up interview with Receptionist #1 on 01/24/24 at 2:27 PM, she reported she had not received any elopement training, that she did not know if there was a code she should have called when she saw Resident #95 leave the facility, and that she had been told to notify a nurse if a resident exited the building. She also reported Resident #95 was wearing pajama pants, a short sleeve t-shirt and gripper socks with no shoes. An interview with NA #7 on 01/23/24 at 3:13 PM revealed she was assigned to Resident #95's hall that day and that Resident #95 had an energy level of 10 on 12/03/23. She reported Resident #95 wore a wander guard and that he was not safe to be outside of the building without close supervision. She reported shortly after breakfast, she was notified by Receptionist #1 that Resident #95 had gotten outside of the building, so she ran through the side door of the facility to go look for him. NA #7 stated there was no alarm sounding so no one knew Resident #95 had exited the building. She reported that when she exited the side door of the building, she did not immediately see him. She stated there were a few housekeepers in the side parking lot who pointed further down the side of the facility and told her he had continued that direction. She reported she immediately began running further down the side of the building and saw Resident #95 walking away from her. She called out for him to stop at which point, NA #7 stated Resident #95 looked back at her and began running from her. NA #7 stated she was finally able to catch up to him around the back of the building and Resident #95 reportedly told her that if he had his tennis shoes on, she would never have caught him. NA #7 stated she was successfully able to bring Resident #95 back into the facility through a back door on the 200 hall. She reported Resident #95 was wearing sweatpants, a t-shirt, and gripper socks with no shoes. NA #7 also stated that Resident #95's feet were wet from walking through water puddles on the ground from rain from the night before. An observation of Resident #95's suspected path of travel with NA #7 revealed he ambulated a total of 494 feet from the front door before he was intercepted and returned to the building. The path Resident #95 took included paved sidewalk, uneven ground, and parking lot with Resident #95 being 15-25 feet from the building. The facility was in a residential area surrounded by homes and a large, wooded area that was accessible by an old farm road by the side parking lot. An interview with Housekeeper #1 on 01/24/24 at 12:28 PM revealed she was working 12/03/23 when Resident #95 exited without supervision from the facility. She reported she remembered the incident because she had taken her 15-minute break and was sitting in her car which was parked near the side of the building near the side door when she noticed Resident #95 walking past her vehicle, down the side of the building. She stated there was no staff member with Resident #95 and she knew he should not have been outside without close supervision. She stated she started to exit her vehicle when she heard NA #7 calling Resident #95's name. She reported she did not say anything to NA #7 because Housekeeper #2, who was also outside at the time, called out to NA #7, pointed in the direction Resident #95 was headed and told her he had gone that direction (towards the back of the facility). An interview with Housekeeper #2 on 01/24/24 at 12:52 PM revealed she was sitting in her vehicle which was parked on the side of the building near the side entrance and was on her break, on Sunday, 12/03/24 when Resident #95 caught her eye as he walked past the front of her car. She stated her immediate thought was why is he out here without anyone. Housekeeper #2 noted that she observed Resident #95 walk through water puddles that were on the ground from rain the previous night, so she got out of her car to try to redirect him back into the building but when she got out of her car, she saw NA #7 exit the side door of the building so she called out to her and told NA #7 which direction Resident #95 was headed. Housekeeper #2 reported NA #7 was successfully able to locate Resident #95 and assist him back into the facility. An interview with the Maintenance Director on 01/24/24 at 11:58 AM revealed he checked the wander alarm system weekly on Fridays. He stated there were 3 exterior doors that were equipped with the wander alarm system, the front door, the side door near the facility's kitchen, and the door to the assisted living side of the building. He reported he was informed that Resident #95 had exited the building on Sunday 12/03/23 when he arrived to work on Monday, 12/04/23 when the door did not lock or alarm as it was designed to do when a resident who was wearing a wander alarm bracelet approached the door. He stated when he tested Resident #95's wander alarm on 12/04/23 it worked as it should, with the door locking and the alarm sounding. He reported he also checked the functionality of the other wander alarms on the residents in the facility that used them and found no issues. The Maintenance Director reported he contacted the wander alarm system company, and they came and extended the distance from the front door that would trigger the door to lock and alarm. An observation and trial with the wander alarm system on the front door on 01/24/23 at 3:47 PM revealed the door failed to lock and alarm in time when walking at a brisk pace allowing the surveyor to successfully exit the facility before the door locked and alarmed. Additional trials at slower speeds resulted in the door locking and the alarm sounding, which prevented the surveyor from exiting the facility. An interview with the Administrator on 01/25/24 at 12:36 PM revealed she was familiar with the incident with Resident #95 and was made aware. She reported she did not consider the incident an elopement and insisted that someone from her staff always had their eyes on him from when he exited the front door to when he was brought back into the building. She reported her investigation concluded there was a failure with the wander alarm system that prevented the front door from locking fast enough when Resident #95 approached the front door which allowed Resident #95 to open the door and exit the building. The Administrator reported she felt Receptionist #1 did exactly what she should have when she followed Resident #95 out of the building, attempted to redirect him, then returned and requested additional assistance, which in turn, left Resident #95 outside. The Administrator stated that they called the door company to come out and do an assessment of the door system and they moved the signal receiver further from the front door to aide in locking the door before a resident with a wander guard could reach the door.

Based on observations, record reviews, staff and consultant pharmacist interviews the facility failed to: 1) label medications with the minimum information required, including the first and last name of the resident on 1 of 7 medication (med) carts observed (300 Distal); 2) store medications in accordance with the pharmacy storage instructions on 3 of 7 med carts (100 Even, 200 and ,d+[DATE] Split); 3) failed to remove lose and unsecure pills/capsules from 6 of 7 med carts (300 Distal, 100 Even, 300 Proximal, 200 Hall, ,d+[DATE] Split and 600 Hall) and 4) failed to remove expired medication from the refrigerator in 1 of 2 med rooms (100 Hall) reviewed for medication storage. The findings included: The medication storage information sheet from the facility's pharmacy dated ,d+[DATE] revealed Humulin R insulin expired within 28 days of opening. 1. On [DATE] at 2:41 PM an observation was conducted on 300 Distal med cart with Nurse #3. Stored on the med cart was a vial of Humulin R insulin that had no resident's name or opening date. At the time of the observation on [DATE] at 2:41 PM Nurse #3 noted the insulin vial and stated there was no resident's name or open date on the vial to determine who it belonged to or when it was opened therefore it should be discarded. The Nurse indicated that she did not know how long the insulin could be kept on the med cart after it was opened. The Nurse explained that all nurses were responsible for keeping the medication carts clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly which meant they should make sure all medications had the residents' name and open dates on them to determine when the medications should be discarded. At 4:55 PM on [DATE] an interview was conducted with the Consultant Pharmacist who explained that open Humulin R insulin should be discarded after 28 days of opening the vial and each insulin vial should have the resident's name on it. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications have a resident's name and an open date if indicated for that medication to determine the expiration date for the medication. The DON indicated the unit managers should provide oversight for the nurses. 2. The medication storage information sheet from the facility's pharmacy dated ,d+[DATE] revealed Miacalcin Nasal Spray (used to treat osteoporosis) should be stored in the upright position. a. An observation was made of the 100 Even med cart on [DATE] at 2:54 PM along with Nurse #4. The observation revealed Resident #87's Miacalcin Nasal Spray was stored horizontally in the med cart. An interview was conducted with Nurse #4 on [DATE] at 2:54 PM. The Nurse indicated that she was not aware that Miacalcin Nasal Spray should be stored in the upright position and that each nurse should make sure the medication carts were clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. At 4:55 PM on [DATE] an interview was conducted with the Consultant Pharmacist who explained that Miacalcin Nasal Spray should be stored in the upright position. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. The DON indicated the unit managers should provide oversight for the nurses. The medication storage information sheet from the facility's pharmacy dated ,d+[DATE] revealed Ipratropium / Albuterol inhalation solution (duoneb) vials should remain in the foil pouch and discard in 14 days after opening. b. An observation was conducted on [DATE] at 3:28 PM of 200 med cart along with Nurse #6. The observation revealed an undated open foil pouch containing 9 vials of duoneb solution belonging to Resident #37. An interview was made with Nurse #6 on [DATE] at 3:28 PM who explained it was each nurse's responsibility to keep the med carts clean and orderly. The Nurse indicated that she did not know the specific storage instructions for open and undated foil pouches for duoneb solutions. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. At 4:55 PM on [DATE] an interview was conducted with the Consultant Pharmacist who explained that duonebs should remain in the foil pouch after opening and should be discarded in 14 days. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. The DON indicated the unit managers should provide oversight for the nurses. c. An observation of ,d+[DATE] Split med cart was made on [DATE] at 3:42 PM along with Nurse #7. The observation yielded an open and undated foil pouch of duonebs containing 3 vials belonging to Resident #3 and an open and undated foil pouch of duonebs containing 3 vials belonging to Resident #111. An interview was conducted with Nurse #7 on [DATE] at 3:42. The Nurse explained it was each nurse's responsibility to keep the med carts clean and orderly. She indicated she did not know how long the duonebs could stay in the foil pouches after opening. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. At 4:55 PM on [DATE] an interview was conducted with the Consultant Pharmacist who explained that duonebs should remain in the foil pouch after opening and should be discarded in 14 days. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. The DON indicated the unit managers should provide oversight for the nurses. d. An observation was made of the 600 med cart on [DATE] at 3:58 AM along with Nurse #8. The observation yielded 2 open and undated foil pouches of duonebs belonging to Resident #43. An interview was conducted with Nurse #8 on [DATE] at 3:58 PM who explained that it was each nurse's responsibility to keep the med carts clean and orderly. The Nurse indicated that she did not know how long the pouches could be used after opening. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. At 4:55 PM on [DATE] an interview was conducted with the Consultant Pharmacist who explained that duonebs should remain in the foil pouch after opening and should be discarded in 14 days. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were stored according to the pharmacy recommendations. The DON indicated the unit managers should provide oversight for the nurses. 3a. 1. On [DATE] at 2:41 PM an observation was conducted on 300 Distal med cart with Nurse #3. The observation yielded 2 white, loose and unsecured pills in the bottom of the med cart drawer. At the time of the observation on [DATE] at 2:41 PM Nurse #3 noted the 2 pills and stated she could not identify the pills or who they belonged to. The Nurse explained that all nurses were responsible for keeping the medication carts clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. b. An observation was made of the 100 Even med cart on [DATE] at 2:54 PM along with Nurse #4. The observation revealed 17.5 loose and unsecure pills of different shapes, sizes and colors in the bottom of the med cart. An interview was conducted with Nurse #4 on [DATE] at 2:54 PM at the time of the observation. The Nurse explained that she could not identify all the pills because they were not in the medication cards that they were delivered in. The Nurse stated that all nurses were responsible for keeping the med carts clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. c. An observation was made on the 300 Proximal med cart on [DATE] at 3:21 PM along with Nurse #5. The observation yielded 5.5 pills of different colors, shapes and sizes in the bottom of the med cart drawer. The pills were loose and unsecure. During an interview with Nurse #5 on [DATE] at 3:21 PM the Nurse explained that the pills should be secured in a medication card labeled with the resident's name and the name of the pill. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. d. An observation was conducted on [DATE] at 3:28 PM of 200 med cart along with Nurse #6. The observation revealed 35 loose and unsecured pills/capsules in the bottom of the med cart drawer. An interview was made with Nurse #6 on [DATE] at 3:28 PM who explained it was each nurse's responsibility to keep the med carts clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. e. An observation of ,d+[DATE] Split med cart was made on [DATE] at 3:42 PM along with Nurse #7. The observation yielded 8 loose and unsecure pills of different shapes and sizes in the bottom of the med cart. An interview was conducted with Nurse #7 on [DATE] at 3:42. The Nurse explained it was each nurse's responsibility to keep the med carts clean and orderly. On [DATE] at 4:16 PM during an interview with Unit Manager (UM) #1 the UM explained all nurses were responsible for keeping the medication carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. f. An observation was made of the 600 med cart on [DATE] at 3:58 AM along with Nurse #8. The observation yielded 22 loose and unsecured pills/capsules of different shapes and sizes in the bottom of the med cart drawer. An interview was conducted with Nurse #8 on [DATE] at 3:58 PM who explained that it was each nurse's responsibility to keep the med carts clean and orderly. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses. The medication storage information sheet from the facility's pharmacy dated ,d+[DATE] revealed Aplisol (solution that aids in the detection of infection with tuberculosis) expired in 30 days after opening. On [DATE] at 9:57 AM an observation was made of the 100 Hall med room along with Nurse #9. The observation yielded 2 vials of Aplisol solution that were open and undated. The date on the prescription package was [DATE]. An interview was conducted with Nurse #9 on [DATE] at 9:57 AM. The Nurse indicated she did not know how long the Aplisol solution could remain in the refrigerator after opening and stated regardless the vials should have been dated when opened. An interview was made with UM #1 on [DATE] at 10:11 AM. The UM stated she did not know how long the Aplisol solution could remain in the refrigerator after opening. During an interview with the Director of Nursing (DON) on [DATE] at 11:49 AM the DON explained that it was each nurses' responsibility to ensure the med carts were clean and orderly which meant they should make sure the medications were secure and in a medication card labeled with the resident's name. The DON indicated the unit managers should provide oversight for the nurses.

Based on observations, staff, and resident interviews, and test tray observation the facility failed to serve food that was palatable in temperature and appearance for 3 of 8 residents reviewed for food (Resident #42, Resident #65, and Resident #107). The findings included: 1a. Resident #42 was admitted to the facility on [DATE] with diagnoses that included moderate protein calorie malnutrition, and history of pressure ulcer of left lower back. Review of a physician order dated 02/29/20 read, regular diet, regular texture, and regular thin consistency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 was cognitively intact and required set up assistance only with feeding. An observation and interview were conducted with Resident #42 on 01/25/24 at 2:01 PM. Resident #42 had just returned to her room from the dining room. As Resident #42 was going down the hallway to her room she was overheard telling her next-door neighbors that were on the hall, don't get excited for lunch it was awful. Resident #42 proceeded to her room and stated that the food today was awful and the only thing she ate was the carrots they were warm but definitely not hot. The noodles were just plain noodles, were cool and were stuck in the pile that had been plated in the kitchen, there was no sauce or anything on them and I don't like fish. 1b. Resident #65 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, and iron deficiency anemia. Review of a physician order dated 08/28/23 read, regular diet, regular texture, and regular thin consistency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #65 was cognitively intact and required extensive assistance of two person staff for eating. An observation and interview with Resident #65 were conducted on 01/25/24 at 12:23 PM. Resident #65 was eating lunch in the main dining room and had her lunch tray in front of her. She was taking small bites of fish; she stated it tasted awful, but she was hungry. She added that the food definitely could have been warmer but she was hungry so she ate the fish and noodles, but the carrots were so mushy and cold she could not eat them. An observation and interview with Resident #65 were conducted on 01/26/24 at 12:49 PM. Resident #65 was propelling herself out of the dining room towards her room, she stated she had eaten a few bites of turkey but did not touch her sweet potato. Resident #65 stated it was not all that warm and stated she was still hungry. The surveyor asked Resident #65 if the staff warmed up her sweet potato and put some butter on it would she eat it, she replied yes I am still hungry. The staff were asked to heat up Resident #65's sweet potato and add some butter and Resident #65 was observed sitting in the dining room taking bites of her sweet potato. 1c. Resident #107 was admitted to the facility on [DATE]. During an initial interview with Resident #107 on 01/22/24 at 2:33 PM, he reported the food was often cold and tasted terrible and that he had his spouse bring him protein shakes so he did not have to eat the food from the kitchen. A review of Resident #107's admission Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact with no psychosis or behaviors. Review of Resident #107's physician orders revealed an order dated 01/25/24 read, regular diet, regular texture, and regular thin consistency with unsweetened beverages and condiments. A follow-up interview with Resident #107 on 01/25/24 at 2:19 PM revealed he received a lunch meal and that it was not good. Resident #107 reported the fish was dry and tough and the noodles were cold and were stuck together. Resident #107 stated the carrots were ok but tasted like they were just served from the can. He stated he ate less than half of his meal before he sent it back and drank one of the protein shakes his spouse had brought him. An interview with Dietary Manager (DM) #2 was conducted on 02/01/24 at 2:43 PM who stated that she had worked in the dietary department for 2 years and generally she had no complaints about temperature of food. She stated she often had complaints about food being too salty or having too much pepper, but she had spoken to the cooks and the issue had been reported to have gotten better per the residents in resident council. DM #2 stated that she regularly attended resident council and addressed any food issues that were raised during the meeting. DM #2 was not present at the time the test tray was completed but stated a lot of temperatures issues may come from the trays sitting on the hall too long. She stated that DM #1 was taking over the kitchen next week and they would have to work together to find a solution to the cold temperature issues. DM #1 was interviewed on 02/01/24 at 3:17 PM who stated that he was assuming the manager role this upcoming week and the first thing he was going to do was implement a tray cart delivery log so they knew what time and temperature the food was when it left the kitchen and then what time it arrived at the unit. DM #1 stated that while being at the facility on 02/01/24 he had addressed numerous grievances and 75% of them were about temperature. He planned to enforce recipe compliance and when DM #1 received food complaints he planned on taking the cook with him to talk to the resident so the cook could hear firsthand issues with the food they had cooked. DM #1 stated part of his role was to build a team so that they can serve good hot food to the residents. 2. An observation of the lunch tray line service was conducted on 01/25/24 at 12:00 PM. A test tray was requested for the 600 unit. Each plate was noted to be in the warmer until time of use and then an insulated dome lid and bottom were used with each plate before being plated with food and put on the covered cart to be delivered to the unit. The menu for the day was fish fillet, buttered noodles, and carrots along with a piece of cake for dessert. The food on the steam table was observed to have visible steam coming off it. The test tray was plated at 12:15 PM and was placed on the cart for delivery to the 600 unit. The 600-hall cart left the kitchen at 12:19 PM and arrived at the 600-hall unit at 12:24 PM. At 12:36 PM two staff members were observed to begin passing tray on the 600 hall. The test tray was sampled at 12:46 PM along with the Regional Director of Operations of the contract dietary agency. When the lid was lifted off the tray there was no visible steam but there was visible condensation on the inside of the dome lid. The tray was served with no tarter sauce for the fish fillet and had to be requested. The fish fillet was room temperature at best but had good flavor. The buttered noodles had really good flavor and were warm but definitely not hot. The carrots were served in a separate bowl on the tray and were definitely the hottest part of the meal. They lacked seasoning but salt and pepper was present for use on the tray. The Regional Director of Operation for the contract dietary agency was interviewed on 01/25/24 at 1:00 pm who also sampled the test tray and stated the food had good flavor but was at best room temperature. She stated that the tray could have definitely been warmer. She explained that the current Dietary Manager was out sick, and they had asked her to come to the facility and help out. She added they were sending a fill in dietary manager over to the facility later that that day. An interview with Dietary Manager (DM) #2 was conducted on 02/01/24 at 2:43 PM who stated that she had worked in the dietary department for 2 years and generally she had no complaints about temperature of food. She stated she often had complaints about food being too salty or having too much pepper, but she had spoken to the cooks and the issue had been reported to have gotten better per the residents in resident council. DM #2 stated that she regularly attended resident council and addressed any food issues that were raised during the meeting. DM #2 was not present at the time the test tray was completed but stated a lot of temperatures issues may come from the trays sitting on the hall too long. She stated that DM #1 was taking over the kitchen next week and they would have to work together to find a solution to the cold temperature issues. DM #1 was interviewed on 02/01/24 at 3:17 PM who stated that he was assuming the manager role this upcoming week and the first thing he was going to do was implement a tray cart delivery log so that we know what time and temperature the food was when it left the kitchen and then what time it arrived at the unit. DM #1 stated that while being at the facility on 02/01/24 he had addressed numerous grievances and 75% of them were about temperature. He planned to enforce recipe compliance and when DM #1 received food complaints he planned on taking the cook with him to talk to the resident so the cook could hear firsthand issues with the food they had cooked. DM #1 stated part of his role was to build a team so that we can serve good hot food to the residents.

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 complaint investigations that occurred on 01/14/22, 09/20/22 and the recertification and complaint investigations that occurred on 04/15/21 and 07/15/22. This failure was for seven deficiencies that were originally cited in the areas of Resident Assessment (F641), Quality of Life (F677), Quality of Care (F689), Pharmacy Services (F761), Resident Rights (F550 & F584) and Comprehensive Resident Centered Care Plan (F661) and were subsequently recited on the current recertification and complaint survey on 02/01/24. The continued failure of the facility during five federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F550: Based on record reviews, and resident and staff interviews, the facility failed to treat residents in a dignified manner when staff spoke to a resident in a disrespectful manner. The resident expressed feelings of anger, upset, and disrespect. This affected 1 of 3 residents reviewed for dignity and respect (Resident #74). During the recertification and complaint survey completed on 07/15/22 the facility failed to treat a resident in a dignified manner by not responding to a call light and meeting the resident's request which led to the resident's brief and bed being wet with urine requiring an entire bed change. The resident stated this made her feel unwanted, belittled, and uncared for by everyone except her family or 1 of 2 residents reviewed for dignity. During the complaint survey completed on 01/14/22 the facility failed to maintain resident's dignity by not providing incontinence care which made the resident feel miserable and embarrassed and failing to assist a resident with toileting that resulted in the resident being incontinent of bowel making her feel embarrassed and ashamed for 2 of 3 residents reviewed for dignity and respect. During the complaint survey completed on 04/15/21 the facility failed to promote a dignified dining experience by standing over 1 of 2 residents reviewed for dining (Resident #21). F584: Based on resident and staff interviews the facility failed to unclog a clogged toilet for 1 of 1 resident room (room # 319) reviewed for providing a clean, sanitary, and homelike environment. During the recertification and complaint survey completed on 07/15/22 the facility failed to maintain walls in good repair in 1 of 5 resident's rooms on 1 of 4 halls. During the complaint survey completed on 01/14/22 the facility failed to have bath linens available for resident use on 4 of 4 halls. During the complaint survey completed on 04/15/21 the facility failed to clean sticky bedroom flooring in a residents' room for 1 of 19 rooms. The facility failed to repair walls with exposed metal dented L shaped corner brackets and chipped drywall for 3 of 19 rooms. The facility failed to repair peeling and cracked laminate on nightstands for 2 of 19 rooms. The facility failed to remove a broken toilet seat riser with visible sharp metal railing and 4 plastic pointed brackets that had been bolted to the commode seat for 1 of 19 rooms. These observations occurred on 2 of 4 halls. F641: Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice, diagnoses, and range of motion for 2 of 31 sampled residents (Resident #16 and Resident #60) reviewed. During the recertification and complaint survey completed on 07/15/22 the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 3 residents reviewed for indwelling catheter, 1 of 5 residents reviewed for unnecessary medication, and 1 of 1 resident reviewed for hospice. F661: Based on record review and staff interviews the facility failed to complete a discharge summary recapitulation of stay fully and accurately for 1 of 3 residents reviewed for discharges (Resident #155). During the recertification and complaint survey completed on 07/15/22 the facility failed to complete a comprehensive discharge summary that included a recapitulation of stay for 1 of 1 resident reviewed for discharge. F677: Based on observations, record review, family, resident, and staff interviews the facility failed to trim a female resident's chin hairs and toenails (Resident #34) for 1 of 3 residents reviewed for activities of daily living. During the recertification and complaint survey completed on 07/15/22 the facility failed to provide incontinence care before the resident wet through her brief and bed linens and provide assistance to maintain personal hygiene for 2 of 5 resident reviewed for activities of daily living. During the complaint survey completed on 01/14/22 the facility failed to perform incontinence care for 2 of 3 dependent residents sampled for activities of daily living. During the complaint survey completed on 04/15/21 the facility failed to clean dependent residents' fingernails and failed to trim a dependent residents' toenails. This affected 2 of 11 residents investigated for activities of daily living. F689: Based on observations, record review, video footage review, staff, and Nurse Practitioner interviews the facility failed to redirect and implement effective interventions to prevent a severely cognitively impaired resident with a history of wandering and exit seeking behaviors and wore a wander guard (alarm used to prevent resident from exiting the building) from exiting the building unsupervised (Resident #155). The facility also failed to effectively supervise and remain with a resident with dementia and had a history of wandering and wore a wander guard who was observed by the Receptionist to exit the building (Resident #95). This deficient practice affected 2 of 2 residents reviewed for accidents. During the complaint survey completed on 09/20/22 the facility failed to prevent a cognitively impaired resident from exiting the facility without supervision for 1 of 3 residents reviewed for supervision to prevent accidents. The resident was severely cognitively impaired, and he exited the front door of the facility in his wheelchair and traveled approximately one quarter mile down the road to a neighborhood where he climbed into a car and was apprehended by local law enforcement using K-9 dogs for suspicion of breaking into a car. The resident was taken to the local emergency room for treatment of dog bites. The facility was unaware the resident had exited the facility until local law enforcement arrived at the facility to confirm his identity and notify the facility that the resident had been taken to the emergency room for treatment. The resident sustained bruises and puncture wounds to his extremities from dog bites. During the recertification and complaint survey completed on 07/15/22 the facility failed to protect a resident from falling from the bed to the floor during personal care for 1 of 3 resident reviewed for supervision to prevent accidents. During the complaint survey completed on 01/14/22 the facility failed to provide supervision to prevent a cognitively impaired resident from wandering into resident room and sitting on her bed reviewed for privacy. This occurred for 1 of 1 sampled resident reviewed for accidents. F761: Based on observations, record reviews, staff and consultant pharmacist interviews the facility failed to: 1) label medications with the minimum information required, including the first and last name of the resident on 1 of 7 medication (med) carts observed (300 Distal); 2) store medications in accordance with the pharmacy storage instructions on 3 of 7 med carts (100 Even, 200 and 200/600 Split); 3) failed to remove lose and unsecure pills/capsules from 6 of 7 med carts (300 Distal, 100 Even, 300 Proximal, 200 Hall, 200/600 Split and 600 Hall) and 4) failed to remove expired medication from the refrigerator in 1 of 2 med rooms (100 Hall) reviewed for medication storage. During the recertification and complaint survey completed on 07/15/22 the facility failed to remove expired medications from 2 of 3 medication carts and 2 of 2 medication rooms. The facility also failed to remove unopened insulin pens for 1 of 3 medications carts reviewed. During the complaint survey completed on 01/14/22 the facility failed to secure an unattended medication cart for 1 of 5 observed medication carts. During the complaint survey completed on 04/15/21 the facility failed to remove lose and unsecure pills/capsules, failed to remove debris of paper shavings and rubber bands, failed to remove 2 unopened insulin vials, and failed to remove an opened and undated insulin pen (delivered 12/26/21) from 3 of 5 medication carts reviewed for medication storage. During an interview with Administrator #1 on 02/01/24 at 3:02 PM, she reported her quality assurance (QA) team met monthly and included the Medical Director, unit managers, administrative staff, and even some direct care staff. Administrator #1 indicated she did not know why there was an identified pattern of repeat deficiencies and reported the identified deficiencies would be included in their quality assurance process moving forward.

Based on record reviews, and resident and staff interviews, the facility failed to treat residents in a dignified manner when staff spoke to a resident in a disrespectful manner. The resident expressed feelings of anger, upset, and disrespect. This affected 1 of 3 residents reviewed for dignity and respect (Resident #74). The findings included: Resident #74 was admitted to the facility on [DATE]. Review of Resident #74's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #74's cognition was intact was independent for bathing. An interview conducted with Resident #74 on 01/26/24 at 10:20 AM revealed early one morning of October 2023 the resident was in the shower room taking a shower when Nurse Aide (NA) #6 came into the shower room. Resident #74 further revealed NA #6 yelled at him and stated that he should not be in the shower room and refused to give her name. Resident #74 stated he had to tell the NA to leave the shower room for privacy. Resident #74 left the shower room once he dried off and went directly to the Nurse #17 on the hall to get the NA's name and to tell the Nurse about the incident. Resident #74 indicated he spoke to the Nurse and the Business Office Manager (BOM) regarding the incident, but no one ever resolved the situation. Resident #74 indicated NA #6 comes into his room to gather laundry and trash bags sometimes. Resident #74 revealed he felt angry, upset, and disrespected that the NA yelled at him, and that the facility continued to let the NA have communication with the resident. An interview conducted with Nurse #17 on 01/26/24 at 10:30 AM revealed Resident #74 came to her visibly upset in October that NA #17 had been rude to the resident. Nurse #1 indicated she did not witness the conversation but could hear NA #17 being loud at the Resident. Nurse #17 further revealed Resident #74 indicated he was taking a shower and NA #17 yelled at him and he could not be in the shower room and had to leave. Nurse #17 revealed Resident #74 was independent for bathing and was allowed to shower at his convenience. Nurse #17 indicated she gave Resident #74 the NA #6's name and reported the incident to the Administrator. An interview conducted with the BOM on 01/26/24 at 12:35 PM revealed she had a conversation with Resident #74 in October and the resident revealed NA #6 had yelled at him for being in the shower room. The BM further revealed she reported it to the prior Director of Nursing but does not recall what happened after that. A phone interview was conducted with NA #6 on 01/26/24 at 12:50 PM revealed in October she had entered the shower room and Resident #74 was giving himself a shower. NA #6 further revealed she asked Resident #74 why he was in the shower because it was not his scheduled shower day and asked how long it would be. The NA indicated resident #74 was upset and told her to leave the shower room. NA #6 stated she did not rush Resident #74 and did not speak to him in a disrespectful manner. The NA revealed she reported the incident to Unit Manager #2 (UM), and nobody had talked to her about the incident. An interview conducted with the Unit Manager #2 (UM) on 01/26/23 at 2:35 PM revealed she did not recall any incident with Resident #74. UM #2 further revealed NA #1 had never reported any incident with Resident #74. An interview conducted with the Administrator on 01/26/24 at 3:50 PM revealed she was not aware of the incident until today. The Administrator revealed Resident #74 was independent and was able to shower in the shower room at any time that was appropriate. The Administrator indicated she expected staff to always wear a badge and to treat all residents with dignity and respect.

Based on observation, record review, staff, resident, Local Law Enforcement, and Medial Director interview the facility failed to prevent a cognitively impaired resident from exiting the facility without supervision for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was severely cognitively impaired, and he exited the front door of the facility in his wheelchair and traveled approximately one quarter mile down the road to a neighborhood where he climbed into a car and was apprehended by local law enforcement using K-9 dogs for suspicion of breaking into a car. Resident #1 was taken to the local emergency room for treatment of dog bites. The facility was unaware Resident #1 had exited the facility until local law enforcement arrived at the facility to confirm his identity and notify the facility that Resident #1 had been taken to the emergency room for treatment. Resident #1 sustained bruises and puncture wounds to his extremities from dog bites. The finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: numerous fractures to upper and lower extremities and pelvis, cerebral infarction (stroke), [CONDITION(S)] (difficulty talking), cognitive communication deficit (difficulty with thinking), and [CONDITION(S)]. A wandering assessment was completed on 08/24/22 and indicated that Resident #1 was at low risk for wandering. Review of an admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #1 was severely cognitively impaired and required limited assistance with mobility on the unit. The MDS further indicated that Resident #1 had no wandering behaviors during the assessment reference period. An interdisciplinary note dated 09/08/22 read in part, Resident #1 expressing wanting to go home now. Family lives out of state. Asked family to let the facility know of a date for discharge so they could plan appropriately. Resident #1 is wanting to discharge. A wandering assessment was completed on 09/08/22 and revealed that Resident #1 was high risk for wandering. A physician order dated 09/08/22 read; wanderguard (device that resident wears and sounds alarm if they go near an exit door) placed on left ankle with expiration date of March 2024. Monitor placement and skin integrity every shift. Check strap to ensure it is secure but loose enough to get one finger behind strap. Review of a physician order dated 09/10/22 read: check wanderguard device every shift for placement and function. Review of a care plan dated 09/09/22 read in part; Resident #1 is an elopement risk related to impaired safety awareness. The interventions included: ensure that the area the resident wanders in is safe and wanderguard to left ankle. A nursing note dated 09/10/22 read; Medical Director (MD) notified of elopement and resident status. Review of the facility's daily schedule dated 09/10/22 indicated that Nurse #1, Nurse Aide (NA) #1, NA #2, and NA #3 were assigned to work the unit where Resident #1 resided. Review of a Disposition Summary from the local emergency room (ER) dated 09/10/22 read in part: discharged ordered to nursing home. Condition stable, Diagnoses bitten by dog multiple puncture wounds, fall on same level, contusion of right elbow. The summary further read: this resident was found by the police trying to break into a vehicle. Apparently, he is a resident at a local nursing facility who left the residence and started wandering through the town. When the police tried to confront the patient, it was initially felt that he was breaking into the car. He was initially held at gunpoint and when the patient resisted, the police dog was initiated to restrain the patient. The patient was bitten by the dog several times. He ended up falling at some point. He did have injury to the right side of his head, shoulder, and elbow. He does have bites to his right knee, left leg as well as left buttock. Also has scratches to his lower back. Patient does have a history of [CONDITION(S)] however he presents today with confusion. Resident #1 was prescribed [MEDICATION(S)] (antibiotic) 875 milligrams (mg)/125 mg by mouth every 12 hours for 10 days and returned to the facility, A weekly skin review dated 09/10/22 revealed that Resident #1 had new skin issues that included an abrasion to left elbow, bruise right cheek and shoulder and puncture areas to bilateral lower extremities was completed by the Director of Nursing (DON). An observation and interview were conducted with Resident #1 on 09/19/22 at 3:29 PM. Resident #1 was up in his wheelchair in his room. Resident #1's room was approximately 50 feet from the front exit door. He was observed to have a dressing that was clean and intact to his right elbow. Resident #1 recalled the events of 09/10/22 and stated, it was just a mistake. He stated he went out the front door in his wheelchair and no alarm sounded and no one told me I couldn't go and indicated he was looking for a ride home. Resident #1 stated that his family lived out of state, and he was going to live with them but then the cops showed up and they turned the dogs on me but the bite marks were healing well. Resident #1 stated that he had a (wanderguard) bracelet on his left ankle and indicated he had it on 09/10/22 when he exited the facility in his wheelchair out the front door. Medication Aide #1 was interviewed on 09/19/22 at 12:58 PM who stated that she was working on the other side of the building on 09/10/22 and around 10:00 AM to 10:15 AM was talking to the Director of Nursing (DON) on the phone about a staffing issue. The DON had asked to speak to the nurse, so Medication Aide #1 stated she walked to the nursing station with the DON on the phone and when she got to the nursing station the local law enforcement officer was at the station telling the staff that they had found Resident #1 outside in a nearby neighborhood and had taken him to the local ER for treatment. Medication Aide #1 stated that when she arrived for work at 6:30 AM she had to walk past Resident #1's room to get her to assigned unit and he was resting in his bed at that time. Medication Aide #1 confirmed that she had not heard any door alarm sound that morning and had no idea that Resident #1 had exited the facility until the local law enforcement came to the facility and reported it. The Maintenance Assistant was interviewed on 09/19/20 at 1:11 PM and confirmed that he checked the wanderguard system weekly. He stated he took a wanderguard bracelet with the signaling device on it to each of the doors equipped with the wanderguard device to ensure that the door locked, and the alarm sounded as it should. Once the weekly check was completed the Maintenance Assistant stated he logged the check into his computer. He stated that he had checked the wander guard system several times during the week of 09/04/22 including Friday 09/09/22 and each door that was equipped with the wanderguard system worked as they should. The Maintenance Assistant stated that after Resident #1 had gotten out of the facility they contacted a repair man to come and look at the wanderguard system and after looking at the system and front door where Resident #1 exited from they determined that there was a 1-inch gap in the center of the door that was a dead spot and did not pick up the signal to lock the door and sound the alarm. He indicated that the repair man adjusted the range to cover the spot and then tested it again and it was operating properly again. Review of an invoice from the Door System repair company dated 09/13/22 read in part; checked the door at the front entrance with a transmitter to see how it would pick up; found a space of about one inch in the center of the door that is a dead spot; adjusted the range on the antennas to cover this spot. tested again to make sure the door is operating properly. Set the time schedule from 9:00 am to 7:00 PM as requested. Service call taken 09/13/22. Nurse #1 was interviewed on 09/19/22 at 5:00 PM via phone who confirmed that she arrived to work on 09/10/22 around 6:45 AM. She stated when she got report that day Resident #1 was in his room in his wheelchair. She continued to say that around 8:00 AM to 8:30 AM a member of the housekeeping staff came to tell her that Resident #1's bathroom sink was clogged and not to use it until it could be repaired. Nurse #1 stated she walked to Resident #1's room at that time and he was in his wheelchair right outside of his room. Nurse #1 stated that at around 10:00 AM she got a call that she had a family emergency and had to leave the facility. She stated that she counted the cart with Medication Aide #1 and reported off and left the facility. She stated that on her way out of the facility she saw local law enforcement at the nursing station but had no idea what was going on. Nurse #1 confirmed that she did not hear any door alarm sound that morning and was unaware that Resident #1 had exited the facility. The facility was unable to provide contact information for Nurse Aide (NA) #1. A handwritten statement from NA #1 and dated 09/10/22 read in part; I was doing baths and was unaware of the alert resident that escaped. The statement was signed by NA #1. Nurse #2 was interviewed on 09/19/22 via phone at 5:05 PM and confirmed that she was working on 09/10/22 but not on the unit where Resident #1 resided. She stated that around 10:00 AM one of her residents was sitting up near the main nurse's station and she decided to go and check on the resident and as she rounded the corner there were 3 local law enforcement officers at the main nursing station talking to the staff. One of the police officers wanted to verify Resident #1's date of birth so Nurse #2 stated that she went to the nearest computer and verified that the date of birth that Resident #1 gave to the police officers matched his medical record. The police officers stated to Nurse #2 that Resident #1 was at the local ER, but they needed more information before they could treat him. Nurse #2 stated she spoke to the DON who was on the phone and got permission to fax information over to the ER. She stated that she faxed over the usual documents to the ER and then called the charge nurse at the ER to verify they were received. Nurse #2 confirmed that she was not aware that Resident #1 had exited the facility on 09/10/22 until the local law enforcement officers came to the facility. NA #3 was interviewed on 09/19/22 via phone at 5:19 PM and confirmed that she worked on 09/10/22 on the unit where Resident #1 resided. She explained that 09/10/22 was her first day back in the facility in over a month. In report she was told that Resident #1 was independent but needed some assistance. NA #3 stated that when she arrived to work that day at around 7:00 AM Resident #1 was already up and dressed and in his wheelchair in his room. She stated that breakfast trays came to the unit around 8:00 AM and we passed out trays including Resident #1's. NA #3 stated around 9:00 AM they were collecting the breakfast trays and Resident #1 was sitting in his wheelchair just outside of the door to his room. She stated that around 10:00 AM the local law enforcement officers came to the facility and told the staff they had found Resident #1 in a nearby neighborhood. They indicated that a neighbor had called the police because Resident #1 had gotten into a car. The local law enforcement stated to the staff that Resident #1 was able to tell the law enforcement officer his name and they had taken him to the local ER. NA #3 stated she left her shift at 3:00 PM that day and Resident #1 had not returned to the facility from the ER. NA #3 confirmed that she had not heard any door alarm sound that morning and did not know that Resident #1 had exited the facility that day. NA #2 was interviewed on 09/19/22 via phone at 5:39 PM and confirmed that she was working on the unit where Resident #1 resided on 09/10/22. She stated that while they passed-out breakfast trays on the unit Resident #1 was sitting in his wheelchair. Once Resident #1's breakfast tray was delivered he continued to sit in his wheelchair in the hallway right outside of his room and eat his meal. NA #2 stated that around 9:00 AM they began collecting the breakfast trays and Resident #1 remained in his wheelchair in the hallway. About an hour or so later NA #2 stated she was taking soiled linen to the soiled utility room across from the nursing station and overheard the local law enforcement officer telling the staff that they had found Resident #1 outside and had taken him to the ER. NA #2 stated that she was aware Resident #1 had a wanderguard on one of his ankles and had seen him near the exit doors in the past, but he was always easily redirected and would generally follow her back to the unit. NA #2 stated that it was not uncommon for Resident #1 to go into the courtyard during the day, so she did not find it unusual when she did not see him sitting in the hallway after breakfast trays had been collected. NA #2 stated that she had not heard any door alarm sound that morning and did not know that Resident #1 had exited the facility that morning. She added that she worked until 11:00 PM that night and was there when Resident #1 returned from the hospital, and he remained in his room for the rest of her shift. The local Law Enforcement Officer was interviewed via phone on 09/19/22 at 2:52 PM and confirmed that they had received a call that a man had gotten into a car in a nearby neighborhood on 09/10/22. The local law enforcement officer stated that Resident #1 was actively and passively resisting arrest and he was finally arrested and taken to the local hospital. He stated that was all the information he could share as the incident was still under investigation. The DON was interviewed on 09/19/22 at 12:20 PM and confirmed that she had gotten a call from Medication Aide #1 on 09/10/22 at approximately 10:00 AM. During that call Medication Aide #1 had taken the phone to the nursing station and during that time was informed that Resident #1 had gotten outside of the facility and wandered into a nearby neighborhood and crawled into the back seat of car. The owners of the car did not know Resident #1, so they called the local police. Apparently before the local police showed up Resident #1 had gotten out of the back seat of the car and wandered to another house and was standing between a boat and a car and he refused to comply with the local police, and they used the K-9 dogs to apprehend Resident #1 and they took him to the local ER for treatment. The DON stated after she was told of what happened she immediately came over the facility. The DON stated she called Resident #1's family and made them aware of the situation and began the investigation while she waited for Resident #1 to return to the facility from the ER. She indicated that Resident #1 was assessed upon admission for wandering and posed no risk but on 09/08/22 when the team began discussing discharge plans with Resident #1, he was adamant that he was going home now. The DON stated she reassessed him and he was now a high risk for wandering and a wanderguard was placed on his left ankle. The DON stated that during the investigation they learned that the alarm either had not sounded or sounded but with a delay so they immediately locked the front door and had receptionist at the door until the door could be looked at and/or repair. She stated that the door technician came last week and had found a dead spot on the door and repaired it. The DON stated that they had completed an investigation, had the door repaired, and educated all the staff on the elopement process and what to do if a resident eloped. The education included updating the elopement binders with resident information at the front door and at each nursing station. The DON further stated the doors were checked daily for 7 days and then weekly as before. The Administrator was interviewed on 09/19/22 at 1:43 PM and confirmed that he was notified that Resident #1 had eloped on 09/10/22. He stated he immediately came to the facility and began the investigation along with the DON. The Administrator stated that he tested the front door alarm about 25-30 times using the wanderguard bracelet that Resident #1 had on and was able to walk through the door 2 times without it alarming or locking. He stated that the door was locked, and receptionist was placed at the front door 24 hours a day until the door was repaired on 09/13/22. The Medical Director was interviewed on 09/19/22 at 4:34 PM and confirmed that she was notified of Resident #1's elopement on 09/10/22. She stated that Resident #1 had a history of a stroke and when she first met him, he was able to follow instructions but was unable to verbalize very much. However, she stated she saw Resident #1 on 09/13/22 and he was much improved and was able to carry on a good conversation. She stated that she educated Resident #1 on the importance of communicating with staff when he desired to leave the facility. The Medical Director stated that with the damage to Resident #1's brain from the stroke he should not be outside alone for a long period of time. She did say that he was appropriate to leave the facility with friends or family but again should not be left alone unattended for a long period of time. The Administrator was notified of the Immediate Jeopardy on 09/20/22 at 10:09 AM. The facility provided the following the following corrective action plan with completion date of 09/13/22: Based on record review, staff interviews, and observation, the facility failed to prevent a resident from exiting the facility unsupervised, propelling himself in wheelchair and getting into a neighbor's car. According to statements from staff on 9/10/22, at approximately 8:00 am, resident was observed sitting in hallway outside lobby doors and NA#1 redirected him back to his room. NA's #2 and #3 observed resident sitting in his doorway eating breakfast at approximately 8:45 am. According to the statement from resident #1, he ate his breakfast and exited the front door at approximately 9:15 am, and he got into the backseat of a neighbor's car. At approximately 9:45 am, Police received a call that resident was standing in the driveway of another neighbor between the car and boat. Police attempted to apprehend resident #1 utilizing K9 assistance and they had him transported to local hospital. Resident #1 returned to facility at approximately 3:45 pm. Resident #1 was assisted into bed, placed on every 15-minute checks and wander guard replaced. Licensed Nurse completed head to toe skin assessment and observed bruises and puncture areas to upper and lower extremities, abrasions to right elbow and right shoulder, bruise to right cheek. Vital signs WNL. No additional exit seeking or wandering behaviors noted. Wandering assessment, incident report and care plan updated accordingly for Resident #1, as well as notifications to family and Medical Director with follow up order to refer to psych services. On 9/10/22, the facility conducted an Ad Hoc QA meeting with key department heads to discuss incident, review facility elopement policy and to initiate a performance improvement plan based on root cause analysis. Root cause analysis determined that front door wander guard receiver was intermittently malfunctioning. Device technician notified and appointment set up for emergency service, front door code changed, front doors to remain locked 24 hours a day, receptionist 24 hours a day. Effective 9/10/22, Resident #1 will remain on every 15minute checks with wander guard in place until further indicated by the IDT and Medical Director. On 9/10/22, the facility completed 100% census verification and Elopement drill to ensure residents safety. All residents accounted for and safe. Elopement drills were conducted on each shift on 09/10/22. On 9/10/22, DON assessed all residents with wander guards for placement and proper function. No concerns identified. On 9/10/22, the facility updated the Wandering Risk Assessments on current facility residents. Those identified at risk for elopement were reviewed for appropriate care plan and wander guard orders where indicated. The Director of Nursing updated the Elopement Risk Binder to contain resident profiles and photographs, current Wandering Risk Assessment and placed at nurses ' station and receptionist desk. A copy of the Wandering/Elopement Policy and Elopement Drill Documentation tool also in place in front of binders for quick response reference in the event of a missing resident. On 9/10/22, the facility provided elopement education with all current facility and agency staff. Education included response to alarming doors and providing supervision for cognitively impaired residents with wandering and exit seeking behaviors to prevent unsupervised exits from the facility. Education also included proper response in the event of a missing resident. Facility and agency staff will not be permitted to work until receiving education. The ADON/Staff Development Coordinator will include the facility and agency orientation process and checklists. The ADON is responsible for tracking the education of the staff. Effective 9/10/22, the facility DON and/or Administrator will conduct quality improvement audits to determine the continued safety of the residents as to prevent unsupervised exiting of the facility Monitoring will be completed weekly for four weeks. This audit will consist of: 1. Understanding the elopement policy and response to a missing resident 2. Ensuring Elopement binders are at each nursing station and are up to date 3. If resident is on 1:1, every 15, or every 30-minute checks, there will be appropriate documentation in place. 4. Residents with wander guards have corresponding orders on the eMar to check placement and functionality and the wander guard is care planned. 5. Daily door checks x 7 days and then weekly door checks x 4 weeks The results of the monitoring will be discussed in weekly Risk meeting and during monthly QAPI meeting with the IDT. Changes made to the plan as necessary to maintain compliance with resident safety. Root cause was temporarily addressed on 9-10-22 when the front door was reprogrammed to remained locked 24 hours a day. Root cause was fully resolved on 9-13-22 when the technician identified the reason the door failed and completed repairs/adjustments to ensure proper function going forward. Accordingly, the facility returned to full compliance on 9-13-22. The Corrective Action Plan was validated on 09/20/22 and concluded the facility had implemented an acceptable corrective action plan on 09/13/22. The facility provided education and training on the facility's elopement policy and procedures, placed elopement binders at each nursing station and the front desk, ensured all components of the wanderguard system and door alarm were functioning and ensured staff knew how to respond to an elopement and door alarms. In addition, all residents who were at high risk for wandering were identified using the wandering risk assessment and ensured all had a care plan with interventions in place. The root cause analysis that was completed on 09/10/22 was reviewed as was the monitoring tools for 09/10/22, 09/12/22, and 09/19/22 for door inspections including the doors equipped with the wanderguard system. Staff interviewed along with education sign in sheets revealed that all staff had been trained and were aware where the elopement binders were located, how and when to complete wandering risk assessments, and how to respond to door alarms or a reported elopement. The corrective action plan was reviewed in an ad hoc QAPI meeting on 09/10/22.

Based on record review, resident, family, and staff interview the facility failed to treat a resident in a dignified manner by not responding to a call light and meeting the resident's request which led to the resident's brief and bed being wet with urine requiring an entire bed change. The resident stated this made her feel unwanted, belittled, and uncared for by everyone except her family or 1 of 2 residents reviewed for dignity (Resident #72). The findings included: Resident #72 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of one staff member for toileting and was always incontinent of bladder. Review of the facility daily assignment sheet for 07/09/22 for 3:00 PM to 11:00 PM revealed that Nurse Aide (NA) #3, NA #10, and NA #11 were assigned on the unit where Resident #72 resided. An interview was conducted with Resident #72's family member on 07/11/22 at 1:58 PM who stated on 07/09/22 she received a video call from Resident #72 at 9:08 PM. She stated that Resident #72's call light was on, and she needed to be changed. She stated that Resident #72 stated that she had turned the call light about 20 minutes prior to calling the family member and had reported that the last time she had received incontinent care was at 1:30 PM. The family member stated that while on the video call with Resident #72 a staff member who she could not recall their name came in and when Resident #72 stated she needed to be changed the staff member stated that she was not assigned to Resident #72 that shift and then exited the room. The family member stated that about 10 minutes later another staff member came into the room to provide incontinent care but by that time Resident #72, her brief, and bed were all wet and needed to be changed. Resident #72 was interviewed via video call on 07/11/22 at 2:25 PM and stated on 07/09/22 she had remained in bed all day. She stated that the staff had woken her up at 5:30 AM to provide incontinent care and then again at 1:30 PM. Resident #72 stated that she did not see the staff again until around 9:15 PM when a staff member came in to answer her call light that had been a while but when she told the staff member, she needed to be changed the staff member stated that she was not assigned to take care of Resident #72 that shift and then left the room. Resident #72 stated that about 10 minutes later a new staff member came in to provide incontinent care to her. She stated by that time she was wet and so was her bed and everything had to be changed which made her feel unwanted and uncared for except for her family. Resident #72 stated that it was quite belittling for the staff to have to change not only her but her entire bed as well. NA #4 was interviewed on 07/11/22 at 5:57 PM and confirmed that she had cared for Resident #72 on first shift (7:00 AM to 3:00 PM) on 07/09/22. She stated that when she arrived for her shift, she checked Resident #72 who was dry and then she checked her again around 11:00 AM and she was still dry. NA #4 stated that she provided incontinent care to Resident #72 around 1:30 PM before she left for the day. She added she was slightly wet, but her bed was dry so, she only had to change her brief. Nurse Aide (NA) #3 was interviewed on 07/12/22 at 2:33 PM and reported she was working on 07/09/22 from 3:00 PM to 11:00 PM and had answered Resident #72 ' s call light because her assigned NA was on break. NA #3 state that she answered the call light at approximately 9:30 PM and was not sure who was assigned to care for Resident #72 because that was her first day in the facility in 2 years. NA #3 stated that when she answered her call light Resident #72 was on the phone with her family member and was wet and needed to be changed. She stated that her bed was also wet and needed to be changed, they were not saturated but I did not want to leave them soiled. NA #3 did not know which staff member had previously answer Resident #72's call light or how long the call light had been on. NA #10 was interviewed on 07/13/22 at 11:02 AM and confirmed that she worked 07/09/22 from 3:00 PM to 11:00 PM on the unit where Resident #72 resided but stated she did not provide any care to her. She stated she answered her call light around dinner time, and she wanted a cup of ice and that was given to her, she did not mention needing incontinent care at that time. NA #11 was interviewed on 07/13/22 at 1:19 PM and confirmed she worked on 07/09/22from 3:00 PM to 11:00 PM on the unit where Resident #72 resided. She stated she was assigned to sit with another resident on that unit and did not provide any care to Resident #72 during that shift. The Regional Nurse Consultant was interviewed on 07/15/22 at 1:18 PM. She stated that the facility staff were to round on each resident before and after meals, at bedtime and as needed. She stated that Resident #72 should have been checked before and after her evening meal and again at bedtime and if her call light was on then as requested.

Based on observations, record review, resident, and staff interview the facility failed to honor a resident choice to have two showers a week (Resident #131) and failed to keep a resident's wheelchair beside his bed per his choice (Resident #47) for 2 of 3 resident reviewed for choices. The findings included: 1. Resident #131 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Social Service assessment dated [DATE] revealed Resident #131 was cognitively intact. Review of the facility's shower schedule revealed Resident #131 was scheduled for showers on Wednesday and Friday on first shift. Review of Resident #131's documentation report for bathing dated July 2022 indicated that on first shift on Wednesday 07/06/22 Nurse Aide (NA) #4 documented a partial but did not specify if it was a bed bath or shower and on Friday 07/08/22 NA #5 documented a bed bath. An observation and interview were conducted with Resident #131 on 07/11/22 at 10:28 AM. Resident #131 was resting in bed dressed in a pajama top and bottom. Resident #131's hair was standing up in spots and appeared almost wet with oil and the bottom of her feet were black with dirt. She stated that her showers were scheduled for Wednesday and Friday morning, but she had not had a shower since she admitted on [DATE]. She stated she asked a staff member this morning for a shower, and they told her it was not her shower day, but she did not know who the staff member was. Resident #131 stated she had an appointment on Friday, and she wanted to be sure she had a shower before her appointment. An observation and interview were conducted with Resident #131 on 07/12/22 at 11:08 AM. Resident #131 was resting in bed dressed in a pajama top and bottom. Resident #131's hair was standing up in spots and appeared almost wet with oil and the bottom of her feet were black with dirt. She again stated she had asked for a shower yesterday and did not get it. NA #5 was interviewed on 07/13/22 at 7:59 AM and confirmed that she cared for Resident #131 on Wednesday 07/06/22. She stated that Resident #131 had just admitted to the facility the day before and she did not have any clothes with her. She stated she set her up with a wash basin and wash cloth so she could wash her face. NA #5 stated that Resident #131 did not have a shower that day, but she did not know why, she stated maybe there was a shower team or maybe she had not been added to the shower sheet yet but again did not know why Resident #131 did not have a shower that day. NA #5 stated that their assignment sheet indicated who was scheduled for a shower that day and if there was no shower team then the NAs on the hall were responsible for completing the scheduled showers. NA #4 was interviewed on 07/13/22 at 10:28 AM and confirmed that she cared for Resident #131 for the first time on Friday 07/08/22. NA #4 stated that she did not give Resident #131 a shower on Friday 07/08/22 and she was not sure if there was a shower team or not. She stated that recently they have been lucky and had a shower team often but did not recall if they had one on 07/08/22. NA #4 stated that there was a paper at the nurse's station that told them who was scheduled for a shower each day, but she could not recall why Resident #131 did not get one on 07/08/22. NA #1 was interviewed on 07/14/22 at 2:04 PM who confirmed that she cared for Resident #131 on 07/11/22 and 07/12/22. She stated that on 07/11/22 Resident #131 did ask for a shower but it was not her scheduled shower day and was told her that her scheduled shower day was on Wednesday, and she seemed ok with that. The Director of Nursing (DON) was interviewed on 07/15/22 at 12:41 PM. The DON stated that showers were scheduled based upon room or by resident preference and should be given as scheduled. If the resident requested a shower on a non-scheduled shower day, then it should be given by the staff as requested by the resident. 2. Resident #47 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #47 was moderately cognitively impaired and required one person assistance with transfers. The MDS further indicated that Resident #47 had no falls since the previous assessment. Review of Resident #47's care plan revealed no care plan intervention to keep his wheelchair in the bathroom or out of his reach. An observation and interview were conducted with Resident #47 on 07/11/22 at 12:31 PM. Resident #47 was sitting on the side of the bed. He stated that his wheelchair was in the bathroom because he had fallen a while ago and the staff kept it in the bathroom away from me. Resident #47 stated he could get from his bed to his wheelchair, but they kept his chair in the bathroom and I have to use my call bell but sometimes it takes an hour for anyone to help me. He stated he would like the wheelchair beside his bed so he can get to it when he wanted too. An observation of Resident #47 was made on 07/13/22 at 7:55 AM. Resident #47 was resting in bed with his bedside table next to him. His wheelchair was not beside his bed it was in the bathroom in his room. Nurse Aide (NA) #6 was interviewed on 07/13/22 at 8:58 AM who confirmed she was familiar with Resident #47. She stated that they kept his wheelchair in the bathroom because he was a fall risk and would try to get up in it, so we place the wheelchair in the bathroom. NA #7 was interviewed on 07/13/22 at 8:59 AM who confirmed she was familiar with Resident #47. She stated that his wheelchair was kept in his bathroom because he was a fall risk and for space. NA #7 stated that in the past Resident #7 had fallen so we put his wheelchair in the bathroom for safety. NA #4 was interviewed on 07/13/22 at 10:37 AM. NA #4 stated that Resident #47 can get up to his wheelchair whenever he wanted to, but we must assist him. She stated that they kept his wheelchair in the bathroom to keep him from falling. Nurse #15 was interviewed on 07/13/22 at 3:48 PM. Nurse #15 stated that if Resident #47 was moving around in the bed she would get him up to his wheelchair. She stated a month or so ago Resident #47 got up and walked out to the hallway and fell . Nurse #15 stated she was unaware of why his wheelchair was kept in the bathroom because Resident #47 could get from his bed to wheelchair and vice versa. Nurse #15 stated she kept Resident #47's bed in low position and again if he was up on the side of bed, she would aide him into his wheelchair so he could roll around for bit then he would be ready to go back to bed. NA #8 was interviewed on 07/14/22 at 3:06 PM. She stated that she gave Resident #37 a shower today and he transferred very easily and could get into his wheelchair if it was kept beside his bed. She added he was able to get into the shower chair with stand by assistance. An observation and interview with Resident #47 were conducted on 07/14/22 at 3:08 PM. Resident #47 was sitting on the side of the bed and again stated that he wanted his wheelchair, but it was in the bathroom, and he could not walk over there to get it. He stated, I want it here by my bed. Nurse #2 was interviewed on 07/14/22 at 3:13 PM who stated that they try to keep Resident #47 away from his wheelchair because he tires to get in it, and I she thought he had fallen in the past, so we keep his chair out of reach. The Director of Nursing (DON) was interviewed on 07/15/22 at 2:05 PM. The DON stated that Resident #47 should be able to have his wheelchair at beside per his choice.

Based on record review, resident, family, and staff interviews the facility failed to provide incontinence care before the resident wet through her brief and bed linens (Resident #72) and provide assistance to maintain personal hygiene (Resident #131) for 2 of 5 resident reviewed for activities of daily living. The finding included: Resident #72 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of one staff member for toileting and was always incontinent of bladder. Review of the facility daily assignment sheet for 07/09/22 for 3:00 PM to 11:00 PM revealed that Nurse Aide (NA) #3, NA #10, and NA #11 were assigned on the unit where Resident #72 resided. An interview was conducted with Resident #72's family member on 07/11/22 at 1:58 PM who stated on 07/09/22 she received a video call from Resident #72 at 9:08 PM. She stated that Resident #72's call light was on, and she needed to be changed. She stated that Resident #72 stated that she had turned the call light about 20 minutes prior to calling the family member and had reported that the last time she had received incontinent care was at 1:30 PM. The family member stated that while on the video call with Resident #72 a staff member who she could not recall their name came in and when Resident #72 stated she needed to be changed the staff member stated that she was not assigned to Resident #72 that shift and then exited the room. The family member stated that about 10 minutes later another staff member came into the room to provide incontinent care but by that time Resident #72, her brief, and bed were all wet and needed to be changed (via the video call). Resident #72 was interviewed via video call on 07/11/22 at 2:25 PM and stated on 07/09/22 she had remained in bed all day. She stated that the staff had woken her up at 5:30 AM to provide incontinent care and then again at 1:30 PM. Resident #72 stated that she did not see the staff again until around 9:15 PM (time on her tablet device) when a staff member came in to answer her call light that had been a while but when she told the staff member, she needed to be changed the staff member stated that she was not assigned to take care of Resident #72 that shift and then left the room. Resident #72 stated that about 10 minutes later a new staff member came in to provide incontinent care to her. She stated by that time she was wet and so was her bed and everything had to be changed. NA #4 was interviewed on 07/11/22 at 5:57 PM and confirmed that she had cared for Resident #72 on first shift (7:00 AM to 3:00 PM) on 07/09/22. She stated that when she arrived for her shift, she checked Resident #72 who was dry and then she checked her again around 11:00 AM and she was still dry. NA #4 stated that she provided incontinent care to Resident #72 around 1:30 PM before she left for the day. She added she was slightly wet, but her bed was dry so, she only had to change her brief. Nurse Aide (NA) #3 was interviewed on 07/12/22 at 2:33 PM and reported she was working on 07/09/22 from 3:00 PM to 11:00 PM and had answered Resident #72's call light because her assigned NA was on break. NA #3 stated that she answered the call light at approximately 9:30 PM and was not sure who was assigned to care for Resident #72 because that was her first day in the facility in 2 years. NA #3 stated that when she answered her call light Resident #72 was on the phone with her family member and was wet and needed to be changed. She stated that her bed was also wet and needed to be changed, they (sheets) were not saturated but I did not want to leave them soiled. NA #3 did not know which staff member had previously answer Resident #72's call light or how long the call light had been on. NA #10 was interviewed on 07/13/22 at 11:02 AM and confirmed that she worked 07/09/22 from 3:00 PM to 11:00 PM on the unit where Resident #72 resided but stated she did not provide any care to her. She stated she answered her call light around dinner time, and she wanted a cup of ice and that was given to her, she did not mention needing incontinent care at that time. NA #11 was interviewed on 07/13/22 at 1:19 PM and confirmed she worked on 07/09/22from 3:00 PM to 11:00 PM on the unit where Resident #72 resided. She stated she was assigned to sit with another resident on that unit and did not provide any care to Resident #72 during that shift. The Regional Nurse Consultant was interviewed on 07/15/22 at 1:18 PM. She stated that the facility staff were to round on each resident before and after meals, at bedtime and as needed. She stated that Resident #72 should have been checked before and after her evening meal and again at bedtime and if her call light was on then as requested. 2. Resident #131 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Social Service assessment dated [DATE] revealed Resident #131 was cognitively intact. Review of the facility's shower schedule revealed Resident #131 was scheduled for showers on Wednesday and Friday on first shift. Review of Resident #131's documentation report for bathing dated July 2022 indicated that on first shift on Wednesday 07/06/22 Nurse Aide (NA) #4 documented a partial but did not specify if it was a bed bath or shower and on Friday 07/08/22 NA #5 documented a bed bath. An observation and interview were conducted with Resident #131 on 07/11/22 at 10:28 AM. Resident #131 was resting in bed dressed in a pajama top and bottom. Resident #131's hair was standing up in spots and appeared almost wet with oil and the bottom of her feet were black with dirt. She stated that her showers were scheduled for Wednesday and Friday morning, but she had not had a shower since she admitted on [DATE]. She stated she asked a staff member this morning for a shower, and they told her it was not her shower day, but she did not know who the staff member was. Resident #131 stated she had an appointment on Friday, and she wanted to be sure she had a shower before her appointment. An observation and interview were conducted with Resident #131 on 07/12/22 at 11:08 AM. Resident #131 was resting in bed dressed in a pajama top and bottom. Resident #131's hair was standing up in spots and appeared almost wet with oil and the bottom of her feet were black with dirt. She again stated she had asked for a shower yesterday and did not get it. NA #5 was interviewed on 07/13/22 at 7:59 AM and confirmed that she cared for Resident #131 on Wednesday 07/06/22. She stated that Resident #131 had just admitted to the facility the day before and she did not have any clothes with her. She stated she set her up with a wash basin and wash cloth so she could wash her face. NA #5 stated that Resident #131 did not have a shower that day, but she did not know why, she stated maybe there was a shower team or maybe she had not been added to the shower sheet yet but again did not know why Resident #131 did not have a shower that day. NA #5 stated that their assignment sheet indicated who was scheduled for a shower that day and if there was no shower team then the NAs on the hall were responsible for completing the scheduled showers. NA #4 was interviewed on 07/13/22 at 10:28 AM and confirmed that she cared for Resident #131 for the first time on Friday 07/08/22. NA #4 stated that she did not give Resident #131 a shower on Friday 07/08/22 and she was not sure if there was a shower team or not. She stated that recently they have been lucky and had a shower team often but did not recall if they had one on 07/08/22. NA #4 stated that there was a paper at the nurse's station that told them who was scheduled for a shower each day, but she could not recall why Resident #131 did not get one on 07/08/22. NA #1 was interviewed on 07/14/22 at 2:04 PM who confirmed that she cared for Resident #131 on 07/11/22 and 07/12/22. She stated that on 07/11/22 Resident #131 did ask for a shower but it was not her scheduled shower day and was told her that her scheduled shower day was on Wednesday, and she seemed ok with that. The Director of Nursing (DON) was interviewed on 07/15/22 at 12:41 PM. The DON stated that showers were scheduled based upon room or by resident preference and should be given as scheduled. If the resident requested a shower on a non-scheduled shower day, then it should be given by the staff as requested by the resident.

Based on observations, record review, resident, and staff interview the facility ' s Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 4/15/21 and the complaint investigation completed on 01/14/22. This was for four repeat deficiencies in the area of advance directives, home like environment, medication storage, and food storage that were originally cited on 04/15/21 during a recertification and complaint survey and for three repeat citations in the area of respect and dignity, grievances, and activities of daily living that were originally cited on 01/14/22 during a complaint investigation. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The finding included: This citation is cross referred to: F550: Based on record review, resident, family, and staff interview the facility failed to treat a resident in a dignified manner by not responding to a call light and meeting the resident's request which led to the resident's brief and bed being wet with urine requiring an entire bed change. The resident stated this made her feel unwanted, belittled, and uncared for by everyone except her family or 1 of 2 residents reviewed for dignity (Resident #72). During the complaint investigation of 01/14/22 the facility failed to maintain a resident's dignity by not providing incontinence care which made the resident feel miserable and embarrassed (Resident #1) and failing to assist a resident with toileting that resulted in the resident being incontinent of bowel making her feel embarrassed and ashamed (Resident #4) for 2 of 3 resident reviewed for dignity and respect. F565: Based on Resident Council Meeting Minutes, resident and staff interviews, the facility failed to resolve dietary grievances that were reported in the Resident Council meetings (1/14/2022, 1/17/2022, 3/10/2022, and 3/31/2022). During the complaint investigation of 01/14/22 the facility failed to communicate the resident councils concerns with the nursing department, failed to respond to and provide resolution to grievances filed during the resident council for 2 of 10 months of minutes reviewed. F578: Based on record review and staff interview the facility failed to maintain accurate advance directives throughout the medical record (Resident #47, Resident #131, Resident #22) for 3 of 5 residents reviewed for advance directives. During the recertification survey of 4/15/21 the facility failed to maintain accurate advance directives throughout the medical record for 1 of 15 residents reviewed for advance directives. F584: Based on observations and staff interviews, the facility failed to maintain walls in good repair in 1 of 5 resident's rooms (room [ROOM NUMBER]) on 1 of 4 halls (200 hall). During the recertification survey of 04/15/21 the facility failed to clean sticky bedroom flooring in a resident room for 1 of 19 rooms. The facility failed to repair walls with exposed metal dented L shaped corner brackets and chipped drywall for 3 of 19 rooms. The facility failed to repair peeling and cracked laminate on nightstands for 2 of 19 rooms. The facility failed to remove a broken toilet seat riser with visible sharp metal railing and 4 plastic pointed brackets that had been bolted to the commode seat for 1 of 19 rooms. These observations occurred on 2 of 4 halls. F677: Based on record review, resident, family, and staff interviews the facility failed to provide incontinence care before the resident wet through her brief and bed linens (Resident #72) and provide assistance to maintain personal hygiene (Resident #131) for 2 of 5 resident reviewed for activities of daily living. During the complaint investigation of 01/14/22 the facility failed to perform incontinence care for 2 of 3 dependent residents sampled for activities of daily living. F761: Based on observations, record review, and staff interview the facility failed to remove expired medications from 2 of 3 medication carts (100 hall cart and 200 hall cart) and 2 of 2 medication rooms (front medication room and back medication room). The facility also failed to remove unopened insulin pens for 1 of 3 medications carts (100 hall cart) reviewed. During the recertification of 04/15/21 the facility failed to remove lose and unsecure pills/capsule, failed to remove debris of paper shaving and rubber bands, failed to remove 2 unopened and undated insulin pen from 3 of 5 medication carts reviewed for medication storage. F812: Based on observations and staff interview the facility failed to label and date opened food and discard outdated food for 2 of 2 nourishment rooms (300 and 600 Hall) and failed to ensure dietary staff wore hair restraints that fully covered their hair while working in the kitchen. During the recertification survey of 04/15/21 the facility failed to properly label open food items in 1 of 1 freezer, 1 of 1 refrigerator, and 1 of 2 nourishments rooms. The facility also failed to date, and discard expired thicken water from 1 of 1 reach in refrigerator. F880: Based on observation, record review, and staff interview the facility failed to disinfect a glucometer (used to check a resident's blood glucose level) after use per the manufacture's recommendations which resulted in the potential for cross contamination for 2 of 2 residents (Resident #39 and Resident 25). During the complaint investigation of 01/14/22 the facility failed to follow the CDC guidance regarding appropriate Personal Protective Equipment (PPE) for counties of high county transmission rates when 2 of 4 nurses administered medications to 3 of 3 residents without donning eye protection and 1 of 3 Nurse Aides failed to wear eye protection while providing patient care. The facility further failed to follow infection control guidelines when 1 of 1 wound care personnel failed to remove gloves and perform hand hygiene during 2 of 3 wound observations. During the recertification survey of 04/15/21 the facility failed to develop and implement a policy to follow guidelines established by the Center for Disease Control and Prevention (CDC) dated 11/20/20 which indicated personal protective equipment (PPE) to include a gown, gloves, face mask, and eyewear were to be worn when in resident care areas for new admission who under quarantine resident with an unknown COVID-19 status reside for 3 of 3 staff observed on the new admission quarantine unit and prevent a contracted phlebotomist from wearing gloves in the hallway when she was observed at the central nurses station for 1 of 1 contracted staff observed in a common area who were observed for infection control practices. The Administrator was interviewed on 07/15/22 at 11:19 AM. The Administrator stated he had been at the facility for 2 days and was getting to meet the residents and staff. He stated that the facility's Quality Assurance committee met monthly and included the Administrator, Director of Nursing, Assistance Director of Nursing, Unit Manager, Social Worker, Maintenance Director, Dietary Director, Business office Manager, Housekeeping Manager, Medical records clerk, Medical Director, and pharmacist. The Administrator stated that sometimes he had to go back to the drawing board and fix the QAPI program to identify areas of weakness so that they facility could began to repair the system. He stated if the QAPI system was broken in this facility he would reach out for assistance at getting it back on track so the team could start repairing the broken systems. He stated he started achieving compliance yesterday when he met with the team and told them his expectations and why compliance was important. The Administrator stated that they must prioritize the broken systems starting with quality of life and work from there.

Based on observations, record review, and facility staff and resident interviews, the facility failed to maintain resident's dignity by not providing incontinence care which made the resident feel miserable and embarrassed (Resident #1) and failing to assist a resident with toileting that resulted in the resident being incontinent of bowel making her feel embarrassed and ashamed (Resident #4) for 2 of 3 residents reviewed for dignity and respect. The findings included:dignity 1. Resident #1 was admitted to the facility on [DATE]. Review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was cognitively intact and required total assistance with bed mobility, transfers, toileting, and personal hygiene. Resident was always incontinent of both bladder and bowel. Review of Resident #1's care plan dated 12/1/2021 revealed a focus area for bladder incontinence related to immobility. Interventions included providing peri care after each incontinent episode and checking resident #1 every two hours and assist with toileting as needed. An interview conducted with Resident #1 on 1/10/22 at 10:36 AM revealed that on 12/19/21 her brief was wet with urine and used call bell for assistance with incontinence care at 4:30 PM. Resident #1 stated at 4:30 PM Nurse Aide (NA)#1 entered the room, and informed Resident #1 that she would be right back. Resident #1 further stated that the NA #1 did not return until 10:10 PM. She was told by NA #1 that she had to wait because she was the only NA for the entire facility for the rest of the night. Resident #1 stated it made her feel miserable and embarrassed when she had to sit in a wet brief. The interview revealed she knew the exact times of the incident because she had been looking at the clock. An interview conducted with NA #1 on 1/10/22 at 3:26 PM revealed that she was the only NA assigned to the 100 hall and the 300 halls with over fifty (50) residents on 12/19/2021 during second shift. She stated that she was not able to perform every two (2) hour incontinence rounds. She further stated that Resident #1 had to wait more than three (3) hours to have incontinence care performed on 12/19/2021 during second shift. An interview conducted with Director of Nursing (DON) on 1/11/22 at 2:45 PM revealed it was expected for incontinence care to be completed every two hours. She stated she was not aware Resident #1 had not been changed, and that she had to wait for over 3 hours for incontinence care on 12/19/2021. She further stated that she was not aware the NA was the only one working on 12/19/2021. The DON stated, It was not acceptable for a resident to wait that long before being changed. An interview conducted on 1/11/22 at 2:45 PM with the Administrator revealed he expected for nursing staff to be providing incontinence care as needed to the residents. The interview revealed staff were expected to not turn off a resident call light unless care had been provided. 2. Resident #4 was admitted on [DATE] and recently readmitted to the facility on [DATE]. A review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact for daily decision making with no recorded instances of rejecting care. Resident #4 required extensive assistance with transfer, personal hygiene and was totally dependent on others for toilet use. Resident #4 was coded as always incontinent of bladder and frequently incontinent of bowel. During an interview with Resident #4 on 01/04/22 at 10:21 AM, she stated this morning, she woke up and turned her call light on a little after 7:00 AM and needed to go to the bathroom. She explained no staff came into the room until around 8:15 AM after her breakfast had arrived. Resident #4 reported by that time, she had already had a bowel movement and was in the middle of eating her breakfast. She asked the aide to return because she did not want to have to eat a cold breakfast. Resident #4 stated it was embarrassing and very unpleasant to have to eat breakfast with a dirty brief and felt ashamed. She reported she could recognize when she needed to have a bowel movement but could hold it for over an hour and she needed assistance getting in and out of bed and to the bathroom. Resident #4 reported was changed at 9:45 AM and knew this because she had looked at the clock in her room. During an interview with Nurse Aide #2 on 01/10/22 at 2:43 PM she reported she was not on the schedule to work on first shift but had called the facility to see if they needed any additional help and was asked to come in. She reported when she arrived at the facility around 9:00 AM she noticed that Resident #4's call light was on. She reported when she went into the room, she told Resident #4 that she would return after breakfast since Resident #4's meal tray had already been served and she was in the middle of eating. Nurse Aide #2 reported Resident #4 was agreeable to that and stated she changed Resident #4 a little before 10:00 AM. She stated she did not know if anyone had checked on her prior to her arriving at the facility. An interview with the Director of Nursing on 01/10/22 at 4:39 PM revealed there were 3 call outs that morning and that a resident should not have to wait from 7:00 AM to 10:00 AM before being assisted with toileting. The Director of Nursing reported if breakfast was being served or if the assigned nurse aide was otherwise indisposed, another staff member including nurses and other nurse aides, should make themselves available to provide incontinence care to resident who have had a bowel movement.

Based on record review, resident and staff interviews the facility failed to perform incontinence care for 2 of 3 dependent residents sampled for activities of daily living (Resident #1 and Resident #4). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was cognitively intact and required total assistance with bed mobility, transfers, toileting, and personal hygiene. Resident was incontinent of both bladder and bowel. Review of Resident #1's care plan dated 12/1/2021 revealed a focus area for bladder incontinence related to immobility. Interventions included providing peri care after each incontinent episode and checking Resident #1 every two hours and assist with toileting as needed. An interview conducted with Resident #1 on 1/10/22 at 10:36 AM revealed that on 12/19/21 her brief was wet with urine and used call bell for assistance with incontinence care at 4:30 PM. Resident #1 stated at 4:30 PM Nurse Aide (NA)#1 entered the room, and informed Resident #1 that she would be right back. Resident #1 further stated that the NA #1 did not return until 10:10 PM. She was told by NA #1 that she had to wait because she was the only NA for the entire facility for the rest of the night. Resident #1 stated it made her feel miserable and embarrassed when she had to sit in a wet brief. The interview revealed she knew the exact times of the incident because she had been looking at the clock. An interview conducted with NA #1 on 1/10/22 at 3:26 PM revealed that she was the only NA assigned to the 100 hall and the 300 halls with over fifty (50) residents on 12/19/2021 during second shift. She stated that she was not able to perform every two (2) hour incontinence rounds. She stated that she answered the call light at 4:30 PM but was not able to perform incontinence care until approximately 4 hours later, and she confirmed Resident #1 was sitting in a brief soiled with urine. An interview conducted with Director of Nursing (DON) on 1/11/22 at 2:45 PM revealed it was expected for incontinence care to be completed every two hours. She stated she was not aware Resident #1 had not been changed, and that she had to wait for over 3 hours for incontinence care on 12/19/2021. She further stated that she was not aware the NA was the only one working on 12/19/2021. The DON stated, it was not acceptable for a resident to wait that long before being changed. An interview conducted on 1/11/22 at 2:45 PM with the Administrator revealed she expected for nursing staff to be providing incontinence care as needed to the residents. The interview revealed staff were expected to not turn off a resident call light unless care had been provided. She indicated that was unacceptable for Resident #1 to lay soiled for over 3 hours. 2. Resident #4 was admitted on [DATE] and recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact for daily decision making with no recorded instances of rejecting care. Resident #4 required extensive assistance with transfer, personal hygiene and was totally dependent on others for toilet use. Resident #4 was coded as always incontinent of bladder and frequently incontinent of bowel. A review of Resident #4's care plan dated 09/14/21 revealed a care plan area for: The resident has an Activities of Daily Living (ADL) self-care performance deficit related to a decline in medical status. Interventions included: the resident requires supervision to extensive assistance by staff for toileting. During an interview with Resident #4 on 01/10/22 at 10:21 AM, she reported she had turned her call light on upon waking up this morning around 7:00 AM due to having to go to the bathroom for a bowel movement. She explained no staff came into the room until around 8:15 AM after her breakfast had arrived. Resident #4 reported by that time, she had already had a bowel movement and was in the middle of eating her breakfast. She asked the aide to return because she did not want to have to eat a cold breakfast. Resident #4 went on to explain she could recognize when she needed to have a bowel movement but could not hold it for over an hour and she needed assistance getting in and out of bed and to the bathroom. Resident #4 reported she was changed at 9:45 AM and knew this because she had looked at the clock in her room. During an interview with Nurse Aide #2 on 01/10/22 at 2:43 PM she reported she was not originally scheduled to work but was asked to come in to fill a hole in the schedule after a call out. She reported when she arrived to the facility, she noticed Resident #4's call light was on. She reported when she entered the room, she noted Resident #4 was eating her breakfast. She asked if Resident #4 would like for her to return after her breakfast and Resident #4 reported she would. Nurse Aide #2 reported she returned to the room and provided incontinence care to Resident #4 a little before 10:00 AM. Nurse Aide #2 stated she did not know if anyone had seen Resident #4's call light or checked on her prior to her arriving to the facility. During an interview with the Director of Nursing on 01/10/22 at 4:39 PM, she verified there were multiple call outs this morning and that other staff were called in to fill the vacancies. The Director of Nursing reported no residents should have to wait 3 hours to be changed and that she expected call lights to be answered within 10-15 minutes.

Based on observations, record review, resident, and staff interview the facility failed to provide sufficient nursing staff that resulted in incontinence care not being provided for 2 of 3 residents (Resident #1 and Resident #4) and have sufficient staff to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to have sufficient staff to complete a quarterly Minimum Data Set (MDS) assessment (Resident #2), a discharge assessment (Resident #1 and Resident #3) and a comprehensive Minimum Data Set Assessment within the required timeframe for 1 of 2 residents (Resident #4). In addition, the facility failed to develop a comprehensive care plan for a resident known to wander for 1 of 1 resident reviewed (Resident #5). Findings Included: This tag was cross referenced to: F677: Based on record review, resident and staff interviews the facility failed to perform incontinence care for a dependent resident for 2 of 3 residents sampled for activities of daily living (Resident #1 and Resident #4). F550: Based on observations, record review, and facility staff and resident interviews, the facility failed to maintain resident's dignity by not providing incontinence care which made the resident feel miserable and embarrassed (Resident #1) and failing to assist a resident with toileting that resulted in the resident being incontinent of bowel making her feel embarrassed and ashamed (Resident #4) for 2 of 3 residents reviewed for dignity and respect. F684: Based on observations, record review, resident and staff interviews, the facility failed to follow physicians' orders for a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . F636: Based on record review and facility staff interviews, the facility failed to complete a comprehensive Minimum Data Set Assessment within the required timeframe for 1 of 2 residents (Resident #4). F638: Based on record review and staff interviews the facility failed to complete a quarterly minimum data set (MDS) assessment with 92 days of the previous quarterly MDS assessment (Resident #2) and failed to complete discharge assessments within 14 days of the assessment reference date (Resident #1 and Resident #3). This affected 3 of 4 residents reviewed (Resident #1, Resident #2, and Resident #3). F656: Based on observations, record review, and staff interviews, the facility failed to develop a comprehensive care plan for a resident with a known history of wandering for 1 of 2 residents reviewed for accidents (Resident #5). An interview was conducted with NA #1 on 1/10 /2022 at 3:26 PM. NA #1 stated that on her unit they usually had 4 NAs through the week and only 2 NAs on the weekend. She stated that sometimes on the weekend the unit would have 1 NA to care for 37 residents. She stated, we do the best we can. NA #1 indicated because of the lack of staff; her residents did not get incontinent care for an extended period. NA #1 stated they have a lot of complaints about patient care but there was just not enough of us to do everything that needed to be done. An interview was conducted with NA #2 on 1/11/2022 at 9:30 AM. NA # 2 stated she had worked at the facility a little over 3 months and staffing is very bad. She stated that most of the time she works the 300 halls, which is the heaviest hall for total care patients. She stated on the weekends sometimes the hall only had one maybe two NAs and she was only able to provide incontinence care to her residents 1 time during her shift. NA #2 stated that she refused to work any extra weekends due to the fact she would be the only NA and it would be too much. She further stated that the administration staff offers no help or support. An interview was conducted with NA #3 on 1/11/2022 at 9:42 AM. NA #3 stated that she is staffed through agency and had been at the facility about 4 months. She stated the facility had no permanent NAs on staff. She stated sometimes her unit had 4 NAs, but at times the unit had two or three NAs. NA #3 added, if we have four nurse aides on the entire unit that is good day. She added that on the weekends her unit had only one NA. NA #3 stated that the residents would get better care if we had more staff on the units, she stated that on days when the unit had 2 NAs the residents would go for long periods of time before getting incontinence care. An interview was conducted with Nurse #1 on 1/11/2022 at 12:41 PM. Nurse #1 stated that she is agency staffed. She stated staffing is terrible. Honestly it should not happen, but we have one NA on the hall. Nurse #1 stated that it was unacceptable for residents to be soiled for long periods of time. She stated that showers were not consistently being completed because there was not enough staff. An interview was conducted with Nurse #2 on 1/11/2022 at 1:34 PM. Nurse #2 stated that is normally the wound nurse, but she will work the nurse's cart when the facility had call outs. She stated that when she worked weekends, she had 37 residents to administer medications and perform wound treatments on her hall. Nurse #2 stated that the NAs had twenty plus residents and were unable to perform incontinence wounds every two- hours. She further stated that the facility had a lot of call outs from both Nurses and NAs. An interview was conducted with the Director of Nursing (DON) on 1/11/2022 at 10:47 AM. The DON stated that she expected the facility to maintain a level of staff to meet the needs of the residents. She added that the facility utilized six different staffing agencies, they had job fairs, and had numerous advertisements for job openings. She added that she had a lot more agency staff in the facility than permanent staff. The DON stated that they usually did not work with one NA on the hall because she would put a nurse on the hall to perform patient care before she would let one NA work the hall alone. She further added that on the weekends the manager on call would come in and work if they had any call outs. An interview was conducted with the Administrator on 1/11/2022 at 2:45 PM. The Administrator stated she had not been at the facility long enough to assess the staffing issue within the building. She stated she would expect that there was enough staff to meet the safety and welfare needs of the residents.

Based on record reviews and staff, Respiratory Therapist and Medical Director (MD) interviews the facility failed to notify the Physician for clarification when a resident (Resident #1) was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. In addition, Nurse Manager #1 did not contact the Physician when they were not able to reach the Respiratory Therapist on [DATE] for assistance with setting up the [CONDITION(S)]. The morning of [DATE] Nurse #2 was approached by Resident #1's family member who asked why the non-invasive mechanical ventilator was not being used. Nurse #2 did not attempt to contact the Physician or Respiratory Therapy for assistance. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 1 resident reviewed for notification of changes. The findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital discharge summary dated [DATE] revealed he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital discharge orders dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed the orders did not include [CONDITION(S)] settings. An interview conducted on [DATE] at 12:25 PM with Nurse #1 revealed he was working the evening Resident #1 was admitted into the facility. He stated the resident came after 3:00 PM on [DATE] and he received report from Emergency Medical Services (EMS) who stated that the resident's oxygen level would decrease very quickly when off of supplemental oxygen. EMS services had Resident #1 on a non-rebreather mask when he entered the facility and Nurse #1 kept the mask on for a short period in case his oxygen levels decreased. Nurse #1 stated he then changed the resident to a nasal cannula on 4 liters of supplemental oxygen. He stated Resident #1 wore the nasal cannula at 4 Liters the entire time he was working until 11:00 PM. He stated he was not aware that the family member with Resident #1 had brought in a non- invasive mechanical ventilator. He stated the Nurse Manager assisted him with the admission. The interview revealed Nurse Manager #1 had assessed the resident and obtained vital signs. Review of a nursing progress note dated [DATE] at 7:11 PM written by Nurse Manager #1 revealed Resident #1 had arrived at the facility from the hospital. Resident #1 was documented as being on 4 liters of supplemental oxygen and would be using a [CONDITION(S)] at night. Nurse Manager #1 documented she had contacted Respiratory Therapy to come an evaluate the residents [CONDITION(S)]. Resident #1 was noted to be alert and oriented to person, place, and time. No vital signs were included in the initial assessment of Resident #1. Review of a nursing progress note dated [DATE] at 6:02 PM written by the Nurse Manager #1 revealed she had contacted Respiratory Therapy and spoke with the respiratory therapy company Staff Member #1 who said they would have someone come evaluate Resident #1's [CONDITION(S)]. The note did not reveal the exact time the call was placed. Review of a nursing progress note dated [DATE] at 10:13 PM written by the Nurse Manager #1 revealed she had called Respiratory Therapy and spoke with the respiratory therapy company Staff Member #2 who stated an on-call RT (Respiratory Therapist) would contact them again regarding Resident #1's [CONDITION(S)]. The note did not reveal the exact time the call was placed. An interview conducted on [DATE] at 2:02 PM with Nurse Manager #1 revealed she was working during the evening shift when Resident#1 was admitted on [DATE]. She stated Nurse #1 was the hall nurse, but she assisted him with the admission. She stated Resident #1 was alert, oriented and talking with no respiratory distress. The interview revealed Resident #1 was wearing a nasal cannula with 4 liters of supplemental oxygen. She stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she hadn't heard anything back from the company, so she went into the room around 9:30 PM and Resident #1 stated he used his Non-invasive mechanical ventilator machine at home. Nurse Manager #1 stated she then took the machine from his bag and laid it onto his bed. She stated the machine was in pieces and she did not know how to put it together or turn it on. She stated she did not contact the Physician when the RT company did not respond. The interview revealed Resident #1 went to sleep without the non-invasive mechanical ventilator machine on the night of [DATE] and had not shown signs of respiratory distress. An interview conducted on [DATE] at 9:15 AM with Nurse #6 revealed she was taking care of Resident #1 on [DATE] following Nurse #1 at 11:00 PM. She stated she knew he did not have his [CONDITION(S)] in place, so she had checked his oxygen saturation level shortly after she took over at 11:00 PM and it was good. The interview revealed she could not remember the exact oxygen saturation level but stated it was greater than 92% on 4 liters of supplemental oxygen via nasal cannula. She stated Resident #1 did not seem like he was in any type of respiratory distress and did not mention his [CONDITION(S)] machine. She stated she did not call the Physician because she knew Nurse Manager #1 had contacted the Respiratory Therapy company and thought someone was coming to set up Resident #1's machine. An interview conducted on [DATE] at 12:06 PM with Nurse #2 revealed she took over care for Resident #1 at 7:00 AM on [DATE]. She stated in report Nurse #6 stated the facility had received a new admission (Resident #1) and the hospital had sent the incorrect [CONDITION(S)] machine with the resident. The nurse told Nurse #2 the resident had issues with [CONDITION(S)]. Nurse #2 stated the resident's family member was in the room during the shift on [DATE]. She stated the family member came to her around 8:45 AM asking why the residents non-invasive mechanical ventilator machine was not hooked up and she stated she told the family member that it was her understanding that another nurse had called respiratory therapy, and someone was supposed to come set up his machine. Nurse #2 stated she went into the resident's room when she was administering his morning medication and saw his non-invasive mechanical ventilator machine laying on his bed. Nurse #2 stated Resident #1 was experiencing labored breathing and was very anxious at that time, but she did not check his oxygen saturation level. After administering the breathing treatment, she stated the resident was able to calm down. Nurse #2 stated the resident was sitting at a 90-degree angle in the bed due to difficulty breathing. She stated the Medical Director was able to get in touch with the Respiratory Therapist (RT) who entered the building around 5:00 PM on [DATE] to see Resident #1. She stated when the RT checked Resident #1's oxygen saturation level it was 85% (normal oxygen saturation level greater than 92%) on 4 liters via nasal cannula. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1's non-invasive mechanical ventilator machine was to be worn at night and as needed during naps. The order included the settings for non-invasive mechanical ventilator machine to deliver the [CONDITION(S)] ventilation. An interview conducted on [DATE] at 3:10 PM with the Medical Director (MD) revealed she had seen Resident #1 in his room on [DATE] at 9:00 PM. She stated she had an interaction with Nurse #2 earlier in the day regarding his non-invasive mechanical ventilator machine and was informed it had not been set up. She stated she immediately called the RT and the RT answered the phone right away and said she would be on her way to the facility. She stated she was told the nurse had tried to contact RT and was unsuccessful but stated she had no issues getting ahold of them and them responding. The interview revealed she had not been informed of Resident #1's non-invasive mechanical ventilator not being set up prior to Nurse #2 telling her while she was in the facility. The interview revealed for anyone who required the use of a non-invasive mechanical ventilator machine, not being on it could have a serious negative impact. That was why when she found out he needed his machine initiated she wanted it on as soon as possible. The interview revealed Resident #1 had been using the machine at home prior to admission in the hospital. She stated nobody had contacted her the night prior stating they couldn't get a RT to come initiate his machine. The interview revealed when she saw Resident #1 at 9:00 PM he had his non-invasive mechanical ventilator mask on and was lying in bed. She stated she stopped the machine for 2 minutes to speak to him and he started breathing at an abnormally fast rate with his lips pursed. The MD stated Resident #1 did not do well off of the non-invasive mechanical ventilator machine. She stated during the 10 minutes she was in his room the resident did not move his arms or try to move his arms. The MD stated she was notified [DATE] that Resident #1 was found with a nebulizer mask on his face and had expired. She stated she felt he had expired from [CONDITION(S)] (lack of oxygen). The interview revealed she did not feel comfortable saying that his death was ultimately due to not receiving his non-invasive mechanical ventilator machine timely. An interview conducted with the Respiratory Therapist (RT) on [DATE] at 12:45 PM she stated she was contacted on [DATE] around 4:00 PM by the MD to initiate Resident #1's non-invasive mechanical ventilator machine. The RT stated when she arrived on [DATE] around 4:30 PM to the facility Resident #1's oxygen saturation level was ,d+[DATE] % on 4 liters of oxygen. She stated she had to use two pulse oximeters on his fingers to obtain a reading and his heart rate was 125. Resident #1 was observed by the RT to be short of breath and lying like a statue. The RT stated she asked Resident #1 if he was afraid to move and he responded with a yes due to being afraid to overexert himself. She stated after the Non-invasive mechanical ventilator machine was set up his heart rate was 68 beats per minute with an oxygen saturation level of 92%. The facility Administrator was not available for interview during the time of the investigation. The facility provided the following Corrective Action Plan with the correction date of [DATE]: 1) Immediate Action for Resident Affected: · Resident #1 expired on [DATE]. Physician and Responsible Party was notified on [DATE]. · On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed via conference call with facility Interdisciplinary Team (IDT) and Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and Vice President of Clinical Services (VPCS) to discuss initial findings of event and to initiate immediate action plans based on immediate findings. 2) Identification of Others: · On ,d+[DATE] and [DATE], an audit was completed by the Director of Nursing of all current residents utilizing Non-Invasive Ventilator (NIV) which include bi-level positive airway pressure (Bi-Pap), continuous positive airway pressure (C-Pap) and non-invasive ventilation average volume assured pressure support-auto E-Pap (NIV/AVAPS-AE, brands such as trilogy) devices to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 identified for order clarification. There was no harm or adverse effects to Resident #2 and resident remains stable on current NIV settings. · On [DATE], the Physician was notified by the Director of Nursing of orders needing clarification for Resident #2 ' s NIV/AVAPS-AE (Non-Invasive Ventilation) device. Resident #2 orders revised and implemented on [DATE] by the Director of Nursing and care plan revised on [DATE]. · On [DATE], the respiratory therapist completed a review (and revision as appropriate) of current residents on NIV devices to ensure settings were accurate based upon physician orders. No further recommendations made. · On [DATE], all new admissions from ,d+[DATE]-[DATE] will be reviewed by the Director of Nursing/designee to ensure any resident requiring NIV devices per hospital discharge summary have appropriate orders to include settings and frequency of use. No additional residents were identified for correction. · On [DATE], the VPCS and contracted District Director of Respiratory Therapy reviewed and revised policy Non-Invasive Ventilation: IV/AVAPSA-E feature to reflect and further clarify licensed nurses and Respiratory Therapists roles and responsibilities in the management of Bi-Pap, C-Pap and APAPS-AE NIV (brands such as Trilogy) devices. 3) Education/Systemic Change · On [DATE], the VPCS provided education to the facility Administrator, DON and RDCS on the updated policy Non-Invasive Ventilation: IV/AVAPSA-E feature to include that effective immediately the facility shall no longer accept NIV/AVAPS-AE devices (brands such as trilogy) On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed by the IDT and RDCS, RDO and VPCS a comprehensive corrective action plan was developed based on root cause analysis to address F580, F695, F726, and F835. · By [DATE], all licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing (DON)/ designee on ensuring that the physician is notified of any delay in implementing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will not be allowed to work until education completed. · By [DATE], all licensed nursing staff including agency staff will be educated by the Director of Nursing/designee related to the admission process including verification and transcription of orders and immediately contacting the physician if clarifications are needed. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], the unit clerk and all licensed nursing staff including agency staff will be educated by the Director of Nursing /designee regarding the notification process which includes calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. In addition, if the resident is in any acute distress, he/she will immediately be sent to the emergency room for further evaluation. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · Effective [DATE], each nursing station will have the contact information for the contracted Respiratory Therapy company prominently posted. Respiratory therapy services are available after hours and on weekends. · By [DATE], the Admission Director will be educated by the Administrator/ designee on ensuring the respiratory therapist, unit clerk, and supply personnel are notified prior to admission when residents require NIV devices. Education also included for admissions to no longer accept NIV/AVAPS-AE, brands such as trilogy effective [DATE]. The Admissions Director was also educated by the DON on [DATE] on C-PAP, Bi-PAP, and AVAPS-AE (Trilogy type) devices to identify the differences in the settings associated with these types of devices. The DON will maintain education records to validate staff competency for current and newly hired facility Admission staff. Staff will not be allowed to work until education completed. · Effective [DATE], the Admission Director or Director of Nursing will ensure that the contracted respiratory therapy company will be notified at least 24 hours prior to an admission with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . · By [DATE], the Admission Director and licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing on ensuring that ordered equipment/or devices are available with required setting and frequency orders when residents are admitted to the facility. The DON will maintain education records to validate staff competency for current and newly hired facility Admissions staff and facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Licensed Nurses, Admissions Director, Medical Director and Social Services were educated by the Administrator on the facility clinical capabilities grid which specifies the care services provided by the facility to determine admission approval. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses, Admissions staff, Medical Director and Social Services staff. Staff will not be allowed to work until education completed. · Effective [DATE], the facility will no longer accept NIV/ AVAPS-AE devices (brands such as trilogy) in the facility. The Admission Director received education on [DATE]. · By [DATE], Licensed Nurses including agency licensed nurses will be educated on the facility policy revision date [DATE] Non-Invasive Ventilation: IV/AVAPSA-E feature to include competencies on the use of all NIV devices, required ongoing respiratory assessment documentation related NIV and oxygen therapy by the Respiratory Therapist and Director of Nursing. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Certified Nurse Aides (CNA) including agency CNA will be educated by the Director of Nursing on the care of NIV residents including notifying the Licensed Nurses of any issues with the NIV including alarms, remaining with the resident until licensed nurse responds and not manipulating machine in any way. The DON will maintain education records to validate staff competency for current and newly hired facility and agency CNAs. Staff will not be allowed to work until education completed. Staff will not be allowed to work until education completed. · Effective [DATE], all education for above will be included in the orientation process to include new hire facility licensed nurses, agency licensed nurses, CNAs, and admission staff. These staff will not be allowed to work until education completed. · Effective [DATE], new admission paperwork and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing management was informed of review process during Ad Hoc QAPI meeting on [DATE] by the Administrator. 4) Monitoring Process: · Beginning [DATE], 1) nursing management will review/audit new admission paperwork during morning clinical report to ensure the accuracy and timely implementation of physician s orders for Bi-Pap and C-Pap NIV devices and notification to physician of any order discrepancies for clarification. Any discrepancies will be communicated to the physician for clarification and/or correction and 2) the Administrator/designee will review/audit nursing education files for new hires and agency staff to ensure staff competence of Bi-Pap and C-Pap NIV devices. Staff will not be allowed to work until education complete. · Results of the audits will be documented on the Quality Improvement Data Collection Sheet and maintained in the plan of correction binder in the Administrator's office. · On [DATE], the QAPI Committee was notified by the Administrator of delegation of QA monitoring responsibilities. The results of the monitoring will be discussed in the monthly QAPI committee meeting for at least three months, overseen by the Administrator, Director of Nursing, and the Medical Director. The interdisciplinary team will recommend revisions to the plan as indicated to maintain substantial compliance. · Beginning [DATE], the RDCS and/or the RDO will review results of facility audits and QAPI minutes monthly for three months to ensure ongoing compliance with accuracy and timely implementation of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility alleges compliance on [DATE] The Corrective Action Plan was validated on [DATE] and concluded the facility implemented an acceptable corrective action plan on [DATE]. The facility amended the notification process to include calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. The Corrective Action Plan was reviewed during QAPI meeting held on [DATE]. The weekly monitoring logs residents requiring a [CONDITION(S)]/ [CONDITION(S)] were reviewed from [DATE] to [DATE] with no concerns identified. Review of the nursing staff in-service sheets on non-invasive mechanical ventilator training revealed the nursing staff had initialed as receiving the in-service training. Interviews conducted with nursing staff from first, second and third shifts revealed they had received the in-service as stated by the facility. The staff verified they had received in-servicing on notification, abuse, neglect, change of condition and use of a [CONDITION(S)]/[CONDITION(S)] machine.

Based on record reviews and staff, Respiratory Therapist, Medical Director (MD) and clinical respiratory provider interviews the facility failed to provide necessary respiratory care and services to a resident with a compromised respiratory status who was dependent on bilevel positive airway pressure ([CONDITION(S)]). Resident #1 was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. The facility failed to clarify orders for the [CONDITION(S)] on admission or involve respiratory therapy and as a result the [CONDITION(S)] machine was not set up until the evening of [DATE]. In addition, the facility failed to complete and document on-going comprehensive assessments of the resident's respiratory status and ensure Resident #1 had continuous oxygen. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 resident reviewed for respiratory care. The findings included: Resident #1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's hospital discharge summary dated [DATE] revealed he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's hospital discharge orders dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed the orders did not include [CONDITION(S)] settings, orders for oxygen therapy or any orders for a nebulizer treatment. Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted on [DATE] at 2:51 PM with the Admissions Coordinator for the facility revealed she had seen Resident #1 in the hospital. She stated she was unaware that he used a non-invasive mechanical ventilator machine but knew he had orders for a [CONDITION(S)]. She stated she usually read the hospital discharge summary but did not see where it talked about his non-invasive mechanical ventilator machine. She stated the facility was not supposed to admit residents with a non-invasive mechanical ventilator machine. She stated they had another resident on a non-invasive mechanical ventilator machine and wasn't sure why he was admitted . An interview conducted on [DATE] at 12:25 PM with Nurse #1 revealed he was working the evening Resident #1 was admitted into the facility. He stated the resident came after 3:00 PM on [DATE] and he received report from Emergency Medical Services (EMS) who stated that the resident's oxygen level would decrease very quickly when off supplemental oxygen. EMS services had Resident #1 on a non-rebreather mask when he entered the facility and Nurse #1 kept the mask on for a short period in case his oxygen levels decreased. Nurse #1 stated he then changed the resident to a nasal cannula on 4 liters of supplemental oxygen. He stated Resident #1 wore the nasal cannula at 4 Liters the entire time he was working until 11:00 PM. He stated he was not aware that the family member with Resident #1 had brought in a non- invasive mechanical ventilator. He stated the Nurse Manager assisted him with the admission. The interview revealed Nurse Manager #1 had assessed the resident and obtained vital signs. A nursing progress note dated [DATE] at 6:02 PM written by the Nurse Manager #1 revealed she had contacted Respiratory Therapy and spoke with the respiratory therapy company Staff Member #1 who said they would have someone come evaluate Resident #1's [CONDITION(S)]. The note did not reveal the exact time the call was placed. A nursing progress note dated [DATE] at 10:13 PM written by the Nurse Manager #1 revealed she had called Respiratory Therapy and spoke with the respiratory therapy company Staff Member #2 who stated an on-call RT (Respiratory Therapist) would contact them again regarding Resident #1's [CONDITION(S)]. The note did not reveal the exact time the call was placed. An interview conducted on [DATE] at 2:02 PM with Nurse Manager #1 revealed she was working during the evening shift when Resident#1 was admitted on [DATE]. She stated Nurse #1 was the hall nurse, but she assisted him with the admission. She stated Resident #1 was alert, oriented and talking with no respiratory distress. The interview revealed Resident #1 was wearing a nasal cannula with supplemental oxygen at 4 liters. She stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she hadn't heard anything back from the company, so she went into the room around 9:30 PM and Resident #1 stated he used his non-invasive mechanical ventilator machine at home. Nurse Manager #1 stated she then took the machine from his bag and laid it onto his bed. She stated the machine was in pieces and she did not know how to put it together or turn it on. She stated she did not contact the Physician when the RT company did not respond. The interview revealed Resident #1 went to sleep without the non-invasive mechanical ventilator machine on the night of [DATE] and had not shown signs of respiratory distress. Resident #1's vital signs revealed an oxygen saturation level documented on [DATE] at 1:07 AM by Nurse #6 of 96% (normal range for oxygen saturation level is greater than 92%) on room air. An interview conducted on [DATE] at 9:15 AM with Nurse #6 revealed she was taking care of Resident #1 on [DATE] following Nurse #1 at 11:00 PM. She stated she knew he did not have his [CONDITION(S)] in place, so she had checked his oxygen saturation level shortly after she took over at 11:00 PM and it was good. The interview revealed she could not remember the exact oxygen saturation level but stated it was greater than 92% on 4 liters of supplemental oxygen via nasal cannula. She stated Resident #1 did not seem like he was in any type of respiratory distress and did not mention his [CONDITION(S)] machine. She stated she did not call the Physician because she knew Nurse Manager #1 had contacted the Respiratory Therapy company and thought someone was coming to set up Resident #1's machine. Nurse #6 stated the vital signs she entered on [DATE] at 1:07 AM should have indicated oxygen via nasal cannula. Nurse #6 confirmed the flow meter was set at 4 L/min. Resident #1's vital signs revealed an oxygen saturation level documented on [DATE] at 10:57 AM by Nurse #2 of 94% receiving supplemental oxygen via nasal cannula. An interview conducted on [DATE] at 12:06 PM with Nurse #2 revealed she took over care for Resident #1 at 7:00 AM on [DATE]. She stated in report Nurse #6 stated the facility had received a new admission (Resident #1) and the hospital had sent the incorrect [CONDITION(S)] machine with the resident. The nurse told Nurse #2 the resident had issues with [CONDITION(S)]. Nurse #2 stated the resident's family member was in the room during the shift on [DATE]. She stated the family member came to her around 8:45 AM asking why the residents non-invasive mechanical ventilator machine was not hooked up and she stated she told the family member that it was her understanding that another nurse had called respiratory therapy, and someone was supposed to come set up his machine. Nurse #2 stated she went into the resident's room when she was administering his morning medication and saw his non-invasive mechanical ventilator machine laying on his bed. Nurse #2 stated Resident #1 was experiencing labored breathing and was very anxious at that time, but she did not check his oxygen saturation level. After administering the breathing treatment, she stated the resident was able to calm down. Nurse #2 stated the resident was sitting at a 90-degree angle in the bed due to difficulty breathing. She stated the Medical Director was able to get in touch with the Respiratory Therapist (RT) who entered the building around 5:00 PM on [DATE] to see Resident #1. She stated when the RT checked Resident #1's oxygen saturation level it was 85% (normal oxygen saturation level greater than 92%) on 4 liters via nasal cannula. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1's non-invasive mechanical ventilator machine was to be worn at night and as needed during naps. The order included the settings for non-invasive mechanical ventilator machine to deliver the [CONDITION(S)] ventilation Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .,d+[DATE].5 milligrams/3 milliliters inhale orally via nebulizer every 4 hours for shortness of breath. The review revealed the nebulizer solution was not administered for the 12:00 AM dose. Nurse #3 documented Resident #1 was sleeping. Review of a nursing progress note dated [DATE] at 12:00 AM written by Nurse #3 revealed Resident #1 was administered [MEDICATION(S)] (a medication used to treat high blood pressure) tablet 30 milligrams via feeding tube. The note stated Resident #1 was receiving oxygen via his non-invasive mechanical ventilator machine. Around 1:50 AM Resident #1 was found with his nebulizer mask on and unresponsive. The non-invasive mechanical ventilator mask was immediately reapplied, and his oxygen saturation level checked with no reading. CPR was initiated at 1:55 AM and 911 was called. EMS arrived to the facility at 2:00 AM and Resident #1 was pronounced as expired at 2:07 AM. An interview conducted on [DATE] at 12:21 PM with Nurse #3 revealed she received report from Nurse #2 on [DATE] at 7:00 PM for Resident #1. She stated the RT was not in the building when she received report, but Nurse #2 took her into the room and tried to show her how to use the non-invasive mechanical ventilator machine. She stated Resident #1 had taken the mask off to eat supper so when she and Nurse #2 entered the room Nurse #2 reapplied the residents mask since he had finished his supper meal. She stated she went into the room at 8:30 PM to check the resident's blood sugar and administer his medications via his feeding tube. The interview revealed she returned to the room around 9:00 PM looking for humidification for the resident's oxygen and he was still on the non-invasive mechanical ventilator machine. Nurse #3 stated at midnight she went into the room to administer the resident's medication and he was in no respiratory distress. She stated she administered his blood pressure medication via feeding tube, the resident was awake at the time she was in the room. Nurse #3 stated the resident had a breathing treatment ordered for midnight however she didn't administer it because she didn't want to touch his non-invasive mechanical ventilator mask. Nurse #3 stated around 1:30 AM she walked by Resident #1's room and saw he did not have his non-invasive mechanical ventilator mask on but had his nebulizer mask on with no supplemental oxygen hooked to it and no other tubing hooked. The resident just had the nebulizer mask on his face. She stated when she walked in the room, she did not see him breathing and checked for a pulse. She yelled for another nurse to call 911 and come into the room, and they initiated cardiopulmonary resuscitation (CPR) but were unable to revive the resident. Nurse #3 stated Resident #1's nebulizer mask had been on his bedside dresser and the resident must have reached over, took his Non-invasive mechanical ventilator mask off and replaced it with his nebulizer treatment mask himself. She stated she did not hear an alarm coming from the non-invasive mechanical ventilator machine, but she believed it was on. Nurse #3 stated she had received no training regarding a non-invasive mechanical ventilator machine before or after the incident. She stated nobody had asked her anything about the incident. Resident #1's vital signs revealed an oxygen saturation level documented on [DATE] at 1:29 AM by Nurse #3 of 95% receiving supplemental oxygen via nasal cannula. A follow-up interview conducted on [DATE] at 3:24 PM with Nurse #3 revealed Resident #1's vital signs must have been entered by mistake. She stated at 1:29 AM his oxygen saturation level was not 95%. An interview conducted on [DATE] at 9:10 AM with Nurse #4 revealed she was working on the 300 hall on the morning of [DATE]. She stated Nurse #3 calmly went up to Nurse Manger #2 and stated Resident #1 was unresponsive. Nurse Manger #2 then ran to call a code. Nurse #4 responded with Nurse #5 to the room while Nurse #3 stayed at the nurse's station to call EMS. She stated when she entered the room Resident #1 was laying in the bed and felt cold to the touch. She stated he had a nebulizer mask on, but the tubing was incorrect and not connected to the nebulizer machine. She did not hear the nebulizer machine running. Resident #1 had no supplemental oxygen on. Nurse #4 stated she and Nurse #5 felt for a pulse but neither nurse could feel one. She stated Nurse #3 had said she thought she felt a pulse when she reported it to Nurse Manager #2, so they began to initiate CPR. She stated they performed CPR unit EMS arrived. The interview revealed she saw the non-invasive mechanical ventilator machine, but it looked like it hadn't been on the resident stating it along with the mask was on his bedside dresser and didn't remember seeing it turned on. She stated she had to place oxygen on him via nasal cannula prior to initiating CPR. The interview revealed that afterwards the nurses were discussing what had happened and Nurse #3 stated to her she had been scared to touch his non-invasive mechanical ventilator machine and that's why she hadn't administered his 12:00 AM breathing treatment. She stated in the past she knew non-invasive mechanical ventilator machines had an alarm if they became disconnected from a resident. The interview revealed she had not heard any alarms coming from Resident #1's room during the shift. An interview conducted on [DATE] at 9:41 AM with Nurse Manager #2 revealed Nurse #3 came to her and said she had a resident who was unresponsive. Nurse Manager #2 stated she ran into his room with Nurse #4 and Nurse #5. She stated she told Nurse #3 to call EMS, the resident's family and to get his paperwork together. She stated when she entered the room Resident #1 was laying on his back lifeless. The interview revealed she could not feel a pulse and there was no rise or fall to his chest. Resident #1 was not wearing supplemental oxygen, nor did she see his non-invasive mechanical ventilator machine. She stated the resident was cool to the touch. Nurse Manager #2 obtained the AED (Automated External Defibrillator) while Nurse #4 initiated CPR. The nurses continued CPR until EMS arrived and pronounced the resident expired at 2:07 AM. She stated she did not hear any alarms coming from his room or hear the nebulizer machine running. A voicemail was left for Nurse #5 who worked on [DATE] during third shift with no return phone call. A voicemail was left for the third shift Nurse Aide working on [DATE] with no return phone call. Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). An interview conducted on [DATE] at 3:10 PM with the Medical Director (MD) revealed she had seen Resident #1 in his room on [DATE] at 9:00 PM. She stated she had an interaction with the hall nurse earlier in the day regarding his non-invasive mechanical ventilator machine and was informed it had not been set up. She stated she immediately called RT in which the RT answered the phone right away and said she would be on her way to the facility. She stated she was told the nurse had tried to contact RT and was unsuccessful but stated she had no issues getting ahold of them and them responding. The MD stated she was originally told that the facility did not accept residents on non-invasive mechanical ventilator machines, but they had two residents on them. The interview revealed for anyone who required the use of a non-invasive mechanical ventilator machine, not being on it could have a serious negative impact. That was why when she found out he needed his machine initiated she wanted it on as soon as possible. The interview revealed Resident #1 had been using the machine at home prior to admission in the hospital. She stated nobody had contacted her on [DATE] stating they couldn't get a RT to come initiate his machine. The interview revealed when she saw Resident #1 at 9:00 PM he had his non-invasive mechanical ventilator mask on and was lying in bed. She stated she stopped the machine for 2 minutes to speak to him and he started breathing at an abnormally fast rate with his lips pursed. The MD stated Resident #1 did not do well off of the non-invasive mechanical ventilator machine. She stated during the 10 minutes she was in his room the resident did not move his arms or try to move his arms. The MD stated she was notified that Resident #1 was found with a nebulizer mask on his face and had expired. She stated she felt he had expired from [CONDITION(S)] (lack of oxygen). The interview revealed she did not feel comfortable saying that his death was ultimately due to not receiving his non-invasive mechanical ventilator machine timely. An interview conducted with the Respiratory Therapist (RT) on [DATE] at 12:45 PM revealed she was contacted on [DATE] around 4:00 PM by the MD to initiate Resident #1's non-invasive mechanical ventilator machine. The RT stated when she arrived around 4:30 PM to the facility Resident #1's oxygen saturation level was ,d+[DATE] % on 4 liters of oxygen. She stated she had to use two pulse oximeters on his fingers to obtain a reading and his heart rate was 125. Resident #1 was observed by the RT to be short of breath and lying like a statue. The RT stated she asked Resident #1 if he was afraid to move and he responded with a yes due to being afraid to overexert himself. She stated after the non-invasive mechanical ventilator machine was set up his heart rate was 68 beats per minute with an oxygen saturation level of 92%. The RT stated she educated Nurse #2 on use of the machine and had asked her to demonstrate how to use it. She stated she asked the nurse to educate the oncoming nurses because she knew the facility staff was not familiar with use of a non-invasive mechanical ventilator machine. The RT stated she stayed in the facility and placed her notes and orders into the Point Click Care system as she always did and left the building. The next day the RT contacted the Director of Nursing to ask how Resident #1 was and was told he had expired during the night. She stated she was told he was found with a nebulizer mask on his face and knew he had orders for a breathing treatment at midnight. She stated she immediately thought the nurse on duty had not hooked his supplemental oxygen up with his nebulizer treatment when she administered it. The RT stated when she logged into the system, she saw the nurse had documented she did not administer the breathing treatment because the resident was asleep. The RT stated it didn't make sense to her because she had seen the resident prior and felt he could not have changed the mask himself. She stated with his breathing he wouldn't have lasted 2 minutes without the use of supplemental oxygen and the non-invasive mechanical ventilator machine should have been alarming if it had been removed. She stated the only way it wouldn't have been was if someone had silenced it and Resident #1 wouldn't have been able to reach it on his bedside dresser. She stated following the incident she was asked to have a meeting with the Director of Nursing and Corporate team where she told them the nurses were not educated to care for a resident with a non-invasive mechanical ventilator machine. She stated she was asked to provide a 4-day in-service to staff following the incident on the weekend. A follow-up interview conducted on [DATE] at 11:15 AM with the Respiratory Therapist revealed the settings were for the [CONDITION(S)] mode of the non-invasive mechanical ventilator machine. She stated she always wrote for [CONDITION(S)] to be on at night and as needed for naps because they could not be on longer than 12 hours consistently. The RT stated she had spoken with the resident's family member who told her he was wearing it more frequently at home since he had become sick. The Respiratory Therapist stated she had told the facility to not accept residents without [CONDITION(S)] settings included on their hospital discharge summary, but that Resident #1 came to the facility without an order including his [CONDITION(S)] settings. She stated she remembered when she was setting up the machine and showing Nurse #2 how to use the machine it kept alarming, and she was having to press the silence button because it was not yet on his face. She stated once it was on his face someone would have had to of hit the silence button for the machine to stop alarming. The Respiratory Therapist stated the facility did not have a policy prior to [DATE] for accepting admissions on a non-invasive mechanical ventilator machine. The interview revealed the RT felt Resident #1 was still in an acute condition and needed close monitoring. On [DATE] at 1:30 PM an interview was conducted with the District Manager from the Respiratory Therapy company. She stated she was notified by the facility that they could not get in touch with the RT company after Resident #1 had expired, so she had the corporate team pull all of the call logs from the dates of [DATE] and [DATE]. She stated the facility had contacted the agency on [DATE] at 2:24 PM for a different resident in which the RT responded and was not notified about Resident #1. She stated prior to that the company was contacted on [DATE]. The interview revealed the company had no record of the facility contacting them regarding Resident #1 except for when the Medical Director had directly called the RT on her cell phone at 4:30 PM no prior calls were seen on the call log. She stated the RTs only have 10 minutes to respond after they obtain a call. An interview conducted on [DATE] at 4:54 PM with the Director of Nursing (DON) revealed the facility had a policy that allowed them to accept non-invasive mechanical ventilator residents as long as the machine remained on the [CONDITION(S)] setting. The DON stated Resident #1 came from the hospital with orders for a [CONDITION(S)] as needed. She stated Nurse Manager #1 called the Respiratory Therapy company using number located at the nurse's desk twice during her shift, but nobody responded. She stated the Nurse Manager said she had spoken to someone, but she felt that the call was routed to a different region incorrectly by the company. She stated if the order is as needed then Respiratory Therapy initiates the machine. When asked if it was normal for a resident to have to wait a day and a half for initiation of a non-invasive mechanical ventilator machine, she stated no that was not normal. She stated she had asked Nurse #3 what happened to Resident #1 and did not question it any farther. The interview revealed the facility had started an in-service on non-invasive mechanical ventilator machines after the incident for 4 days taught by the Respiratory Therapist and the District Manager of the RT company. A follow up interview conducted on [DATE] at 4:36 PM with the Director of Nursing revealed she did not always communicate with the Admissions Coordinator regarding new admissions in the facility. She stated she was unaware Resident #1 required a [CONDITION(S)] or non-invasive mechanical ventilator machine. The DON stated she had not seen Resident #1's hospital discharge summary. The interview revealed she would have expected the Admissions Coordinator to communicate to her if a resident required a [CONDITION(S)] or non-invasive mechanical ventilator machine. She stated residents don't always have orders prior to entering the facility. The interview revealed the Admissions Coordinator should have notified Respiratory Therapy prior to Resident #1's arrival into the facility. She stated when the facility becomes aware of a resident needing [CONDITION(S)] they notify Respiratory Therapy and obtain a [CONDITION(S)] machine that was kept in the facility for resident use. The DON stated she learned about the resident needing a [CONDITION(S)] on [DATE] after he was in the facility it was her understanding the nurses had attempted to contact Respiratory Therapy on [DATE] and that they were coming to set up his non-invasive mechanical ventilator machine. The facility Administrator was not available for interview during the time of the investigation. An interview was conducted on [DATE] at 10:45 AM with a representative from a clinical respiratory provider specializing in ventilator therapy. He explained [CONDITION(S)] was static therapy which was non-reactive to any change in patient needs. On the other hand, AVAPS-AE (Average Volume Assured Pressure Support- Auto EPAP) mode automatically adjusts ventilation to patients' breathing patterns, to meet their changing needs over time. The interview revealed the system was a higher level of support but not life sustaining. The non- invasive mechanical ventilator could set end expiratory pressure and had a flow tracking function to sense if the resident was still exhaling air in order to prevent a next breath from being delivered prematurely. He stated there was no way to disable the low pressure alarm if the patient was disconnected from the device, however staff could silence the alarm by pushing the button on the front of the machine, but it would only stop the alarm for one minute. He stated if the machine was unplugged there was a battery back-up and explained when the battery got down to 20 minutes of run time remaining a more aggressive alarm would begin to sound and at 10 minutes remaining time an even louder alarm would sound that cannot be silenced using the alarm silence button. He stated the only way there would be no alarm is if the machine was turned off. An interview conducted on [DATE] at 10:30 AM with Family Member #1 revealed she was in the facility on [DATE] at the front desk due to the facility on ly allowing one person to see Resident #1. Resident #1 was being quarantined as a new admission. She stated Family Member #2 was in the room with the resident. She stated she stopped the Director of Nursing (DON) in the hall and was asking her why Resident #1 had gone the night prior without his [CONDITION(S)] machine and also had no breathing treatments. The interview revealed the family was on high alert because Resident #1 was so weak and had been extremely short of breath the day before on [DATE] and on [DATE]. She stated she left the facility, but Family Member #2 stayed in the facility until 6:00 PM with Resident #1. She stated at 1:30 AM she received a call from Nurse #3 stating Resident #1 was unresponsive, so she called Family Member #2 and they began to drive to the facility. She stated she received a second call shortly after stating Resident #1 had expired. Family Member #1 stated Nurse #3 told her she had just given him his medication and then found him stating he had changed his mask. Family Member #1 confirmed with Family Member #2 that Resident #1 was short of breath on [DATE] prior to the Respiratory Therapist entering the building and applying his non-invasive mechanical ventilator machine. Family Member #1 stated Resident #1's non-invasive mechanical ventilator mask had to be applied for him prior to entering the hospital and while in the hospital. She stated she stated that Resident #1 could not remove his mask by himself in the weak state he was in. The facility provided the following Corrective Action Plan with the correction date of [DATE]: 1) Immediate Action for Resident Affected: · Resident #1 expired on [DATE]. Physician and Responsible Party was notified on [DATE]. · On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed via conference call with facility Interdisciplinary Team (IDT) and Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and Vice President of Clinical Services (VPCS) to discuss initial findings of event and to initiate immediate action plans based on immediate findings. 2) Identification of Others: · On ,d+[DATE] and [DATE], an audit was completed by the Director of Nursing of all current residents utilizing Non-invasive Ventilator (NIV) which include bi-level positive airway pressure (Bi-Pap), continuous positive airway pressure (C-Pap) and non-invasive ventilation average volume assured pressure support-auto E-Pap (NIV/AVAPS-AE, brands such as trilogy) devices to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 identified for order clarification. There was no harm or adverse effects to Resident #2 and resident remains stable on current NIV settings. · On [DATE], the Physician was notified by the Director of Nursing of orders needing clarification for Resident #2 ' s NIV/AVAPS-AE (Non-invasive Ventilation) device. Resident #2 orders revised and implemented on [DATE] by the Director of Nursing and care plan revised on [DATE]. · On [DATE], the respiratory therapist completed a review (and revision as appropriate) of current residents on NIV devices to ensure settings were accurate based upon physician orders. No further recommendations made. · On [DATE], all new admissions from ,d+[DATE]-[DATE] will be reviewed by the Director of Nursing/designee to ensure any resident requiring NIV devices per hospital discharge summary have appropriate orders to include settings and frequency of use. No additional residents were identified for correction. · On [DATE], the VPCS and contracted District Director of Respiratory Therapy reviewed and revised policy Non-invasive Ventilation: IV/AVAPSA-E feature to reflect and further clarify licensed nurses and Respiratory Therapists roles and responsibilities in the management of Bi-Pap, C-Pap and APAPS-AE NIV (brands such as Trilogy) devices. 3) Education/Systemic Change · On [DATE], the VPCS provided education to the facility Administrator, DON and RDCS on the updated policy Non-invasive Ventilation: IV/AVAPSA-E feature to include that effective immediately the facility shall no longer accept NIV/AVAPS-AE devices (brands such as trilogy) On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed by the IDT and RDCS, RDO and VPCS a comprehensive corrective action plan was developed based on root cause analysis to address F580, F695, F726, and F835. · By [DATE], all licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing (DON)/ designee on ensuring that the physician is notified of any delay in implementing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will not be allowed to work until education completed. · By [DATE], all licensed nursing staff including agency staff will be educated by the Director of Nursing/designee related to the admission process including verification and transcription of orders and immediately contacting the physician if clarifications are needed. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], the unit clerk and all licensed nursing staff including agency staff will be educated by the Director of Nursing /designee regarding the notification process which includes calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and

Based on record reviews and staff, Respiratory Therapist and Medical Director (MD) interviews the facility failed to ensure nursing staff could demonstrate competency to provide for and to meet the respiratory care needs of a resident with a compromised respiratory status. Resident #1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 resident reviewed for competent nursing staff. The findings included: This tag is cross referred to: F 580: Based on record reviews and staff, Respiratory Therapist and Medical Director (MD) interviews the facility failed to notify the Physician for clarification when a resident (Resident #1) was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. In addition, Nurse Manager #1 did not contact the Physician when they were not able to reach the Respiratory Therapist on [DATE] for assistance with setting up the [CONDITION(S)]. The morning of [DATE] Nurse #2 was approached by Resident #1's family member who asked why the non-invasive mechanical ventilator was not being used. Nurse #2 did not attempt to contact the Physician or Respiratory Therapy for assistance. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 1 resident reviewed for notification of changes. F 695: Based on record reviews and staff, Respiratory Therapist, Medical Director (MD) and clinical respiratory provider interviews the facility failed to provide necessary respiratory care and services to a resident with a compromised respiratory status who was dependent on bilevel positive airway pressure ([CONDITION(S)]). Resident #1 was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. The facility failed to clarify orders for the [CONDITION(S)] on admission or involve respiratory therapy and as a result the [CONDITION(S)] machine was not set up until the evening of [DATE]. In addition, the facility failed to complete and document on-going comprehensive assessments of the resident's respiratory status and ensure Resident #1 had continuous oxygen. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 resident reviewed for respiratory care. The facility provided the following Corrective Action Plan with the correction date of [DATE]: 1) Immediate Action for Resident Affected: · Resident #1 expired on [DATE]. Physician and Responsible Party was notified on [DATE]. · On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed via conference call with facility Interdisciplinary Team (IDT) and Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and Vice President of Clinical Services (VPCS) to discuss initial findings of event and to initiate immediate action plans based on immediate findings. 2) Identification of Others: · On ,d+[DATE] and [DATE], an audit was completed by the Director of Nursing of all current residents utilizing Non-invasive Ventilator (NIV) which include bi-level positive airway pressure (Bi-Pap), continuous positive airway pressure (C-Pap) and non-invasive ventilation average volume assured pressure support-auto E-Pap (NIV/AVAPS-AE, brands such as trilogy) devices to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 identified for order clarification. There was no harm or adverse effects to Resident #2 and resident remains stable on current NIV settings. · On [DATE], the Physician was notified by the Director of Nursing of orders needing clarification for Resident #2 s NIV/AVAPS-AE (Non-invasive Ventilation) device. Resident #2 orders revised and implemented on [DATE] by the Director of Nursing and care plan revised on [DATE]. · On [DATE], the respiratory therapist completed a review (and revision as appropriate) of current residents on NIV devices to ensure settings were accurate based upon physician orders. No further recommendations made. · On [DATE], all new admissions from ,d+[DATE]-[DATE] will be reviewed by the Director of Nursing/designee to ensure any resident requiring NIV devices per hospital discharge summary have appropriate orders to include settings and frequency of use. No additional residents were identified for correction. · On [DATE], the VPCS and contracted District Director of Respiratory Therapy reviewed and revised policy Non-invasive Ventilation: IV/AVAPSA-E feature to reflect and further clarify licensed nurses and Respiratory Therapists roles and responsibilities in the management of Bi-Pap, C-Pap and APAPS-AE NIV (brands such as Trilogy) devices. 3) Education/Systemic Change · On [DATE], the VPCS provided education to the facility Administrator, DON and RDCS on the updated policy Non-invasive Ventilation: IV/AVAPSA-E feature to include that effective immediately the facility shall no longer accept NIV/AVAPS-AE devices (brands such as trilogy) On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed by the IDT and RDCS, RDO and VPCS a comprehensive corrective action plan was developed based on root cause analysis to address F580, F695, F726, and F835. · By [DATE], all licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing (DON)/ designee on ensuring that the physician is notified of any delay in implementing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will not be allowed to work until education completed. · By [DATE], all licensed nursing staff including agency staff will be educated by the Director of Nursing/designee related to the admission process including verification and transcription of orders and immediately contacting the physician if clarifications are needed. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], the unit clerk and all licensed nursing staff including agency staff will be educated by the Director of Nursing /designee regarding the notification process which includes calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. In addition, if the resident is in any acute distress, he/she will immediately be sent to the emergency room for further evaluation. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · Effective [DATE], each nursing station will have the contact information for the contracted Respiratory Therapy company prominently posted. Respiratory therapy services are available after hours and on weekends. · By [DATE], the Admission Director will be educated by the Administrator/ designee on ensuring the respiratory therapist, unit clerk, and supply personnel are notified prior to admission when residents require NIV devices. Education also included for admissions to no longer accept NIV/AVAPS-AE, brands such as trilogy effective [DATE]. The Admissions Director was also educated by the DON on [DATE] on C-PAP, Bi-PAP, and AVAPS-AE (Trilogy type) devices to identify the differences in the settings associated with these types of devices. The DON will maintain education records to validate staff competency for current and newly hired facility Admission staff. Staff will not be allowed to work until education completed. · Effective [DATE], the Admission Director or Director of Nursing will ensure that the contracted respiratory therapy company will be notified at least 24 hours prior to an admission with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . · By [DATE], the Admission Director and licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing on ensuring that ordered equipment/or devices are available with required setting and frequency orders when residents are admitted to the facility. The DON will maintain education records to validate staff competency for current and newly hired facility Admissions staff and facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Licensed Nurses, Admissions Director, Medical Director and Social Services were educated by the Administrator on the facility clinical capabilities grid which specifies the care services provided by the facility to determine admission approval. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses, Admissions staff, Medical Director and Social Services staff. Staff will not be allowed to work until education completed. · Effective [DATE], the facility will no longer accept NIV/ AVAPS-AE devices (brands such as trilogy) in the facility. The Admission Director received education on [DATE]. · By [DATE], Licensed Nurses including agency licensed nurses will be educated on the facility policy revision date [DATE] Non-invasive Ventilation: IV/AVAPSA-E feature to include competencies on the use of all NIV devices, required ongoing respiratory assessment documentation related NIV and oxygen therapy by the Respiratory Therapist and Director of Nursing. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Certified Nurse Aides (CNA) including agency CNA will be educated by the Director of Nursing on the care of NIV residents including notifying the Licensed Nurses of any issues with the NIV including alarms, remaining with the resident until licensed nurse responds and not manipulating machine in any way. The DON will maintain education records to validate staff competency for current and newly hired facility and agency CNAs. Staff will not be allowed to work until education completed. Staff will not be allowed to work until education completed. · Effective [DATE], all education for above will be included in the orientation process to include new hire facility licensed nurses, agency licensed nurses, CNAs, and admission staff. These staff will not be allowed to work until education completed. · Effective [DATE], new admission paperwork and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing management was informed of review process during Ad Hoc QAPI meeting on [DATE] by the Administrator. 4) Monitoring Process: · Beginning [DATE], 1) nursing management will review/audit new admission paperwork during morning clinical report to ensure the accuracy and timely implementation of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any discrepancies will be communicated to the physician for clarification and/or correction and 2) the Administrator/designee will review/audit nursing education files for new hires and agency staff to ensure staff competence of Bi-Pap and C-Pap NIV devices. Staff will not be allowed to work until education complete. · Results of the audits will be documented on the Quality Improvement Data Collection Sheet and maintained in the plan of correction binder in the Administrator ' s office. · On [DATE], the QAPI Committee was notified by the Administrator of delegation of QA monitoring responsibilities. The results of the monitoring will be discussed in the monthly QAPI committee meeting for at least three months, overseen by the Administrator, Director of Nursing, and the Medical Director. The interdisciplinary team will recommend revisions to the plan as indicated to maintain substantial compliance. · Beginning [DATE], the RDCS and/or the RDO will review results of facility audits and QAPI minutes monthly for three months to ensure ongoing compliance with accuracy and timely implementation of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility alleges compliance on [DATE]. The Corrective Action Plan was validated on [DATE] and concluded the facility implemented an acceptable corrective action plan on [DATE]. The facility amended the notification process to include calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. The Corrective Action Plan was reviewed during QAPI meeting held on [DATE]. The weekly monitoring logs residents requiring a [CONDITION(S)]/ [CONDITION(S)] were reviewed from [DATE] to [DATE] with no concerns identified. Review of the nursing staff in-service sheets on non-invasive mechanical ventilator training revealed the nursing staff had initialed as receiving the in-service training. Interviews conducted with nursing staff from first, second and third shifts revealed they had received the in-service as stated by the facility. The staff verified they had received in-servicing on notification, abuse, neglect, change of condition and use of a [CONDITION(S)]/[CONDITION(S)] machine.

Based on record reviews and Respiratory Therapist, Medical Director (MD) and Administrative staff interviews the facility failed to provide oversight for effective admission procedures and decisions, and systems for effective and necessary delivery of care for a resident with a compromised respiratory status and dependency on [CONDITION(S)] ventilation using a non-invasive mechanical ventilator. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 residents reviewed for Administration. The findings included: This tag is cross referred to: F 580: Based on record reviews and staff, Respiratory Therapist and Medical Director (MD) interviews the facility failed to notify the Physician for clarification when a resident (Resident #1) was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. In addition, Nurse Manager #1 did not contact the Physician when they were not able to reach the Respiratory Therapist on [DATE] for assistance with setting up the [CONDITION(S)]. The morning of [DATE] Nurse #2 was approached by Resident #1's family member who asked why the non-invasive mechanical ventilator was not being used. Nurse #2 did not attempt to contact the Physician or Respiratory Therapy for assistance. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 1 resident reviewed for notification of changes. F 695: Based on record reviews and staff, Respiratory Therapist, Medical Director (MD) and clinical respiratory provider interviews the facility failed to provide necessary respiratory care and services to a resident with a compromised respiratory status who was dependent on bilevel positive airway pressure ([CONDITION(S)]). Resident #1 was admitted on [DATE] with orders for a bilevel positive airway pressure ([CONDITION(S)]) that did not include the settings or frequency for the non-invasive mechanical ventilator. The facility failed to clarify orders for the [CONDITION(S)] on admission or involve respiratory therapy and as a result the [CONDITION(S)] machine was not set up until the evening of [DATE]. In addition, the facility failed to complete and document on-going comprehensive assessments of the resident's respiratory status and ensure Resident #1 had continuous oxygen. Review of Resident #1's Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 resident reviewed for respiratory care. F 726: Based on record reviews and staff, Respiratory Therapist and Medical Director (MD) interviews the facility failed to ensure nursing staff could demonstrate competency to provide for and to meet the respiratory care needs of a resident with a compromised respiratory status. Resident #1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 ' s Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen). This failure affected 1 of 2 resident reviewed for competent nursing staff. The facility provided the following Corrective Action Plan with the correction date of [DATE]: 1) Immediate Action for Resident Affected: · Resident #1 expired on [DATE]. Physician and Responsible Party was notified on [DATE]. · On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed via conference call with facility Interdisciplinary Team (IDT) and Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and Vice President of Clinical Services (VPCS) to discuss initial findings of event and to initiate immediate action plans based on immediate findings. 2) Identification of Others: · On ,d+[DATE] and [DATE], an audit was completed by the Director of Nursing of all current residents utilizing Non-invasive Ventilator (NIV) which include bi-level positive airway pressure (Bi-Pap), continuous positive airway pressure (C-Pap) and non-invasive ventilation average volume assured pressure support-auto E-Pap (NIV/AVAPS-AE, brands such as trilogy) devices to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 identified for order clarification. There was no harm or adverse effects to Resident #2 and resident remains stable on current NIV settings. · On [DATE], the Physician was notified by the Director of Nursing of orders needing clarification for Resident #2's NIV/AVAPS-AE (Non-invasive Ventilation) device. Resident #2 orders revised and implemented on [DATE] by the Director of Nursing and care plan revised on [DATE]. · On [DATE], the respiratory therapist completed a review (and revision as appropriate) of current residents on NIV devices to ensure settings were accurate based upon physician orders. No further recommendations made. · On [DATE], all new admissions from ,d+[DATE]-[DATE] will be reviewed by the Director of Nursing/designee to ensure any resident requiring NIV devices per hospital discharge summary have appropriate orders to include settings and frequency of use. No additional residents were identified for correction. · On [DATE], the VPCS and contracted District Director of Respiratory Therapy reviewed and revised policy Non-invasive Ventilation: IV/AVAPSA-E feature to reflect and further clarify licensed nurses and Respiratory Therapists roles and responsibilities in the management of Bi-Pap, C-Pap and APAPS-AE NIV (brands such as Trilogy) devices. 3) Education/Systemic Change · On [DATE], the VPCS provided education to the facility Administrator, DON and RDCS on the updated policy Non-invasive Ventilation: IV/AVAPSA-E feature to include that effective immediately the facility shall no longer accept NIV/AVAPS-AE devices (brands such as trilogy) On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed by the IDT and RDCS, RDO and VPCS a comprehensive corrective action plan was developed based on root cause analysis to address F580, F695, F726, and F835. · By [DATE], all licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing (DON)/ designee on ensuring that the physician is notified of any delay in implementing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will not be allowed to work until education completed. · By [DATE], all licensed nursing staff including agency staff will be educated by the Director of Nursing/designee related to the admission process including verification and transcription of orders and immediately contacting the physician if clarifications are needed. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], the unit clerk and all licensed nursing staff including agency staff will be educated by the Director of Nursing /designee regarding the notification process which includes calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. In addition, if the resident is in any acute distress, he/she will immediately be sent to the emergency room for further evaluation. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · Effective [DATE], each nursing station will have the contact information for the contracted Respiratory Therapy company prominently posted. Respiratory therapy services are available after hours and on weekends. · By [DATE], the Admission Director will be educated by the Administrator/ designee on ensuring the respiratory therapist, unit clerk, and supply personnel are notified prior to admission when residents require NIV devices. Education also included for admissions to no longer accept NIV/AVAPS-AE, brands such as trilogy effective [DATE]. The Admissions Director was also educated by the DON on [DATE] on C-PAP, Bi-PAP, and AVAPS-AE (Trilogy type) devices to identify the differences in the settings associated with these types of devices. The DON will maintain education records to validate staff competency for current and newly hired facility Admission staff. Staff will not be allowed to work until education completed. · Effective [DATE], the Admission Director or Director of Nursing will ensure that the contracted respiratory therapy company will be notified at least 24 hours prior to an admission with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . · By [DATE], the Admission Director and licensed nursing staff including agency licensed nurses will be educated by the Director of Nursing on ensuring that ordered equipment/or devices are available with required setting and frequency orders when residents are admitted to the facility. The DON will maintain education records to validate staff competency for current and newly hired facility Admissions staff and facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Licensed Nurses, Admissions Director, Medical Director and Social Services were educated by the Administrator on the facility clinical capabilities grid which specifies the care services provided by the facility to determine admission approval. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses, Admissions staff, Medical Director and Social Services staff. Staff will not be allowed to work until education completed. · Effective [DATE], the facility will no longer accept NIV/ AVAPS-AE devices (brands such as trilogy) in the facility. The Admission Director received education on [DATE]. · By [DATE], Licensed Nurses including agency licensed nurses will be educated on the facility policy revision date [DATE] Non-invasive Ventilation: IV/AVAPSA-E feature to include competencies on the use of all NIV devices, required ongoing respiratory assessment documentation related NIV and oxygen therapy by the Respiratory Therapist and Director of Nursing. The DON will maintain education records to validate staff competency for current and newly hired facility and agency licensed nurses. Staff will not be allowed to work until education completed. · By [DATE], Certified Nurse Aides (CNA) including agency CNA will be educated by the Director of Nursing on the care of NIV residents including notifying the Licensed Nurses of any issues with the NIV including alarms, remaining with the resident until licensed nurse responds and not manipulating machine in any way. The DON will maintain education records to validate staff competency for current and newly hired facility and agency CNAs. Staff will not be allowed to work until education completed. Staff will not be allowed to work until education completed. · Effective [DATE], all education for above will be included in the orientation process to include new hire facility licensed nurses, agency licensed nurses, CNAs, and admission staff. These staff will not be allowed to work until education completed. · Effective [DATE], new admission paperwork and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing management was informed of review process during Ad Hoc QAPI meeting on [DATE] by the Administrator. 4) Monitoring Process: · Beginning [DATE], 1) nursing management will review/audit new admission paperwork during morning clinical report to ensure the accuracy and timely implementation of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any discrepancies will be communicated to the physician for clarification and/or correction and 2) the Administrator/designee will review/audit nursing education files for new hires and agency staff to ensure staff competence of Bi-Pap and C-Pap NIV devices. Staff will not be allowed to work until education complete. · Results of the audits will be documented on the Quality Improvement Data Collection Sheet and maintained in the plan of correction binder in the Administrator ' s office. · On [DATE], the QAPI Committee was notified by the Administrator of delegation of QA monitoring responsibilities. The results of the monitoring will be discussed in the monthly QAPI committee meeting for at least three months, overseen by the Administrator, Director of Nursing, and the Medical Director. The interdisciplinary team will recommend revisions to the plan as indicated to maintain substantial compliance. · Beginning [DATE], the RDCS and/or the RDO will review results of facility audits and QAPI minutes monthly for three months to ensure ongoing compliance with accuracy and timely implementation of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility alleges compliance on [DATE] The Corrective Action Plan was validated on [DATE] and concluded the facility implemented an acceptable corrective action plan on [DATE]. The facility amended the notification process to include calling the respiratory therapy company customer service number to notify the Respiratory Therapist of all new admission requiring NIV devices and any other respiratory needs of current residents. If the respiratory therapy company does not respond within 10 minutes, the facility will reattempt x 1, if no response the MD will be immediately contacted for further orders. The Corrective Action Plan was reviewed during QAPI meeting held on [DATE]. The weekly monitoring logs residents requiring a [CONDITION(S)]/ [CONDITION(S)] were reviewed from [DATE] to [DATE] with no concerns identified. Review of the nursing staff in-service sheets on non-invasive mechanical ventilator training revealed the nursing staff had initialed as receiving the in-service training. Interviews conducted with nursing staff from first, second and third shifts revealed they had received the in-service as stated by the facility. The staff verified they had received in-servicing on notification, abuse, neglect, change of condition and use of a [CONDITION(S)]/[CONDITION(S)] machine.

Based on observations, record review, resident and staff interview the facility failed to protect a resident's right to be free from physical abuse for 2 of 3 sampled residents reviewed for abuse (Residents #2 and #3). Resident #1 slapped Resident #2 on the left side of his face. Resident #1 also turned Resident #3 over backwards while she was seated in her wheelchair and placed a sock over her mouth and attempted to tie it around her head when she began to holler for help. This resulted in Resident #3 hitting her head on the floor and experiencing back and neck pain. Resident #3 also expressed being very uncomfortable that Resident #1 was in the facility. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was cognitively impaired and had no behaviors during the assessment reference period. The MDS further indicated that Resident #1 was independent with walking in room and on the corridor. Resident #1 had no impairment to her bilateral upper and lower extremities and used walker for ambulation. An observation of Resident #1 was made on 01/12/21 at 11:03 AM. Resident #1 was sitting next to her bed with a staff member sitting with her and they were observed to be coloring. 1 a. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that Resident #2 was cognitively intact and required extensive assistance with toileting. The MDS further revealed that Resident #2 had no behaviors, rejection of care, wandering or [MEDICAL CONDITION] during the assessment reference period. Review of a 24-hour initial allegation report dated 12/07/20 read in part, Resident #1 was reported to have entered Resident #2's bathroom in response to him hollering for assistance and slapped Resident #2 on the left side of the face. No injury was identified at the time. The report was completed by the Administrator. Review of an Investigation report dated 12/14/20 read in part, on 12/07/20 Resident #1 was having a normal baseline day. She has a [DIAGNOSES REDACTED]. Resident #2 was in the restroom and needed staff assistance, without turning on his call bell he began to yell for staff to come and assist him. Resident #1 entered Resident #2's bathroom in response to his yelling and open hand slapped Resident #2 on the left side of his face. Staff overheard the altercation and immediately intervened. Resident #1 was escorted out of the room. Resident #2 had a head to toe assessment completed and no injury, no redness, no bruising was noted. Emotional and psychosocial support was provided to both residents for the next 72 hours with no acute issues or needs identified. Resident #1 was placed on 1:1 supervision immediately following the incident until the Nurse Practitioner (NP) evaluated her on 12/09/20 and agreed it was safe to stop the 1:1 supervision due to no further combative or aggressive behaviors and no wandering. The NP also reviewed Resident #1's medications and no changes were made. A urinalysis was ordered for Resident #1 which had no acute findings. During this process a referral was made to acute psychiatric unit. The summary was signed by the Director of Nursing (DON) and the Administrator. Review of a nurses note, written by Nurse #3, dated 12/09/20 at 2:59 PM read, spoke with NP regarding reevaluating resident (Resident #1) due to 1:1 supervision due to aggression with another resident. She stated she had, resident does not recall the incident and no behaviors reported from staff since the 1:1 supervision so the 1:1 supervision may be stopped. Her medications were evaluated. An observation was made of Resident #2 on 01/12/21 at 5:45 PM. Resident #2 was resting in bed and was covered with a blanket. There was no visible bruising or redness noted to Resident #2's face. 1 b. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS dated [DATE] indicated Resident #3 was cognitively intact and required extensive assistance with activities of daily living. The MDS further indicated Resident #3 had an impairment to one upper extremity and impairment to bilateral lower extremities. Review of an incident report for Resident #3, dated 12/10/20 at 8:15 PM read in part, heard Resident #3 yelling out found her in room in her wheelchair tipped over on the floor, Resident #3's lower body half in chair upper half on the floor. Resident #3 stated, I did hit my head, but it does not hurt. No injury visible. Resident #3 also stated she was in her closet putting away clothes and Resident #1 wanted her to take her name off her clothes when she said no Resident #1 grabbed her wheelchair and tipped her over. The report was prepared by Nurse #1. Review of a nurses note, written by the Supervisor (Nurse #2), dated 12/10/20 at 8:42 PM read, this nurse was summoned to Resident #3's room where she was observed tilted backward on the floor in her wheelchair. She was observed to have socks draped around her shoulders. Resident #3 stated that Resident #1 wrapped the socks around her neck and mouth as if to try and smother her. Staff assisted Resident #3 into an upright position, she had no physical complaint. DON aware of situation. Resident #1 was immediately placed on 1:1 supervision. The note was electronically signed by the Supervisor (Nurse #2). Review of a care plan created 12/11/20 read in part, Resident #1 may be at risk of hitting the other resident. The goal of the care plan read, Resident #1 will not hit or injury any other resident through the next re-evaluation date. The interventions included: 1:1 supervision, assist her in avoiding resident or situations that may incite outburst, coordinate care to help resident maintain control of her behavior, educate resident to alternative ways of dealing with anger, and intervene if she shows signs of hostility or anger. An observation and interview were conducted with Resident #3 on 01/12/21 at 11:52 AM. Resident #3 stated that on 12/10/20 she was in her room with whom she shared with Resident #1. She was putting a big bag of stuff in her closet and was using her reacher and she dropped it. Resident #3 stated she grabbed her other reacher and opened her closet. Resident #1 grabbed her arm and took the reacher out of her hand and began pulling Resident #3 backward in her wheelchair towards her bed. Resident #3 stated she was attempting to roll forward but could not, so she asked Resident #1 if she had a hold of her wheelchair and Resident #1 stated no. Resident #3 explained that Nurse #1 came in to administer medications to Resident #1 and saw what was going on and instructed Resident #1 to let go of the wheelchair and she did. Resident #3 stated she then rolled forward towards her bed and Nurse #1 exited the room and shut the door. Resident #3 stated she began to lay her night clothes on the end of her bed that included her socks and Resident #1 got up and began tilting her wheelchair backwards by the handles. She instructed Resident #1 to quit because she was afraid, she was going to drop her on the floor. All the sudden Resident #1 tilted the wheelchair backwards and let go and the chair fell to the floor with the front wheels up in the air. Resident #3 stated she was hanging on as tightly as possible to the handles so she would not fall out of the chair. She explained that she hit her head on the floor, but her head did not hurt. She added that her back and neck were killing her. Resident #3 stated that the clock on the wall directly in front of her read 8:30 PM and she knew that her Nurse Aide (NA) was in the shower room with another resident and was not due to return to the room until 9:30 PM so she hollered for help. Resident #3 stated that when she started to holler for help Resident #1 took the sock off the end of her bed and tried to tie it around her mouth and head. She stated she could feel Resident #1 trying to tie it at the back of her head but she kept telling Resident #1 to stop and as Resident #1 reached for the other sock she was able to yank the sock off of her mouth. Nurse #1 opened the room door and entered the room not long after she began yelling. Nurse #1 stated what are doing in the floor. Resident #3 stated that Nurse #1 the made sure she was ok and sat my wheelchair back upright. Resident #3 explained that the staff took her blood pressure which was 190 over something and my oxygen level was 100% so I was breathing fine. Resident #3 stated that they took her out in the hallway and again checked her out and I told them that she did not trust Resident #1 anymore and felt very uncomfortable with her being in the facility and actually did not go to bed that night. She added that they had someone sit with Resident #1 for the rest of the night and the next day they sent her to the hospital. Resident #3 stated that Resident #1 was back in the facility, but she had not had any contact with her since the incident on 12/10/20 but she still felt very uncomfortable with Resident #1 in the building and just did not trust Resident #1 anymore. She explained that she tolerated Resident #1 on a day to basis like when she would be sweet one minute and the next minute would curse at her or when she would stand in front of her door and not let me out. However Resident #1 had never physically harmed her before and she was certainly not expecting what occurred on 12/10/20 to occur. She stated Resident #1 did not know better and she was ok with that but after the incident on 12/10/20 she just could not trust her and was still uncomfortable knowing that she was in the facility An interview was conducted with the NP on 01/12/21 at 3:35 PM The NP stated she was familiar with Resident #1 and #2 and #3. She indicated Resident #1 had a [MEDICAL CONDITION] and all of a sudden had an anger or psychotic type break. She stated that on 12/07/20 she struck Resident #2 who was yelling and cursing. The NP stated she evaluated Resident #1 that day and believed she was a threat to others, so the facility placed Resident #1 on 1:1 supervision. The NP stated that on 12/09/20 she reevaluated Resident #1 and spoke to the staff that were providing 1:1 supervision and she had no behaviors of any type since the 12/07/20 incident. She added that prior to the 12/07/20 incident Resident #1 was stubborn and head strong but had never displayed those aggressive type of behaviors before and added that Resident #1 had enough of her left mentally to know what she wanted. The NP stated that at the time she believed she was no longer a threat to others and stopped her 1:1 supervision on 12/09/20. Following the incident on 12/07/20 and discontinuing the 1:1 supervision on 12/09/20 the NP stated she was off for a couple of weeks and when she returned was aware that an incident occurred but was not sure what the incident was. At the time on 12/09/20 she did not believe that Resident #1 was appropriate or required a more control environment like a locked unit but after learning about what occurred between Resident #1 and #3 it would be a good recommendation to have Resident #1 in a more control environment for the safety of other residents. She added that Resident #1 always had a stubborn streak but was easily redirected and Resident #3 would always say things like you don't know what it is like living with her but never reported any aggressive behaviors and never any physical contact with Resident #1. Resident #1 would from time to time resist care but with some redirection would always do what was needed. The NP added that Resident #1 also suffered from Alzheimer's dementia and that coupled with a [MEDICAL CONDITION] those residents don't always stabilize and would further decline with age and medical changes. She did add that there was nothing acute medically going on with Resident #1 to explain her sudden outburst of striking out at other residents but again reiterated that type of behavior was very uncharacteristic of Resident #1 and she certainly would not have predicted this type of aggressive behavior towards Resident #3 or any resident or she would have continued the 1:1 supervision. An interview was conducted with Nurse #1 on 01/13/21 at 5:11 PM. Nurse #1 confirmed that she worked on 12/10/20 and was caring for Resident #1 and #3. She stated she was working on her evening medication pass and heard a commotion coming from their room. When Nurse #1 opened the door she observed Resident #1 had tipped Resident #3's wheelchair over and was holding onto the handles. Nurse #1 stated she instructed Resident #1 to let go of the handles and she got angry and called me a liar. Nurse #1 stated she had to show Resident #1 that she did indeed have a hold of Resident #3's wheelchair hands and she said oh and let go and she went and laid down on her bed. Nurse #1 stated she stepped out into the hallway and got on the loudspeaker and called for staff. Nurse #1 stated that when she stepped out of the room to get some help Resident #1 was lying on her bed and Resident #3 was tipped over in wheelchair and she knew she needed to get someone in the room to help. Nurse #1 could not recall who responded but she did recall the Supervisor (Nurse #2) coming to the room. She stated that the first thing they did was assess Resident #3 to makes sure she was not injured, and she was able to move all extremities. After determining Resident #3 had no injuries we set her back upright in her wheelchair and Resident #1 remained lying on her bed. She added that she immediately placed Resident #1 on 1:1 supervision after she returned to the room from calling for help and once Resident #3 was up, and the things had calmed down she did return to her medication pass but Resident #3 did not go to bed that night. Nurse #1 stated she did not know about the incident with the sock until 2 days later but Resident #1's behavior was very uncharacteristic for her and really surprised Nurse #1 nor did she know of the incident that Resident #3 spoke of when Resident #1 was holding onto her chair. She added she had never witnessed Resident #1 do anything like this before and was shocked. Normally Resident #1 was pleasantly confused and she generally was in their room at medication time and anytime that she was needed but generally the NAs would do the routine checks on both Resident #1 and #3 as they did with all the resident on the unit. Nurse #1 stated that when she entered the room when she heard Resident #3 yelling that was the first time, she had been in their room that day. Nurse #1 stated that maybe Resident #3 got her nights mixed up. Nurse #1 also stated she contacted the DON, the family, and the on-call provider to notify them of the incident as well. An interview was conducted with NA #1 on 01/13/21 at 5:30 PM. NA #1 confirmed that she routinely cared for Resident #1 and was caring for Resident #1 and #3 on 12/10/20. She stated that normally Resident #1 was pleasantly confused and would wander from time to time on the unit. NA #1 had never witnessed any type of aggressive behavior from Resident #1 before and was shocked when she learned about the incident between Resident #1 and #3 on 12/10/20. She stated she was in the shower room when the incident occurred, but when she came out of the shower room, she was assigned the 1:1 supervision of Resident #1 for the remainder of her shift. NA #1 stated that she immediately took Resident #1 for a walk throughout the facility and we sat down in the dining room where she could see out of the glass windows. She stated that after about 10-15 minutes Resident #1 began getting agitated and stated people were trying to kill her. NA #1 stated she attempted to redirect the conversation and when that was not effective she took Resident #1 to view the Christmas trees that were in the facility and we sat around the tree which did not get her mind off people trying to kill her. She added I repeatedly told Resident #1 that no one was trying to kill her, NA #1 added she had never seen Resident #1 like this before. She continued the 1:1 supervision until the end of her shift and another staff member came to relieve her of the duty. NA #1 was not aware of any special interventions or observations that were in place prior to the incident on 12/10/20 because Resident #1 had never had those type of behaviors so day to day she would just routinely check on her and Resident #3 in their room because they did like to keep the door shut. An interview was conducted with the Supervisor (Nurse #2) on 01/13/21 at 6:38 PM. The Supervisor reported that on 12/10/20 she responded to Resident #1 and #3's room because of an overhead page. She stated when entered the room she found Resident #3 backwards on the floor with her front wheelchair wheels up in the air. She stated when she walked into the room Resident #1 was lying on her bed and Resident #3 was near the bottom of her bed with her feet in the air on her back in her wheelchair. The Supervisor stated they assisted Resident #3 upright and began questioning her if she was hurt or not. Resident #3 denied any injuries and was able to move all extremities. As the Supervisor she stayed in the room to talk with Resident #3 and noticed that she had socks draped over her shoulders, she stated that Resident #3 reported that Resident #1 had placed them around her mouth but was not able to tighten them. She added that Resident #1 was placed on 1:1 supervision and remained that way through the end of her shift. The Supervisor stated she was not familiar with Resident #1 or her past; she had seen her around the facility but had never seen her act out aggressively towards any resident or staff before. She added that the on-call provider, the DON, and the family were all notified of the incident. An observation and interview were conducted with Resident #1 on 01/14/21 at 11:03 AM. Resident #1 was dressed and had a staff member sitting with her and they were listening to music. Resident #1 denied knowing Resident #2 or #3 and did not recall ever slapping anyone, tipping a wheelchair over or placing a sock around Resident #3's mouth and head. Resident #1 stated, I have never seen anything like that here before. She could also not recall her recent hospitalization and stated, did I go to the hospital? An interview was conducted with the DON on 01/15/20 at 2:16 PM The DON stated that on 12/07/20 Resident #1 slapped Resident #2 in response to him hollering and cursing. She stated following the incident Resident #1 was placed in 1:1 supervision after being evaluated by the NP. She stated that Resident #2 had no injury or redness from being slapped by Resident #1. The DON stated that following that incident they asked all resident if they felt safe in the facility including Resident #3 and they all reported they felt very safe in the facility. After 2 days of no further behaviors or aggressions the NP once again evaluated Resident #1 and reviewed her medication and believed she was no longer a threat to others or herself and the 1:1 supervision was stopped with no additional orders obtained. In addition to the 1:1 supervision Resident #1's medications were reviewed, and a urinalysis was done and nothing acute was going on. Then on 12/10/20 Nurse #1 called and reported that Resident #1 had tipped Resident #3's wheelchair over backwards. The DON stated she inquired about the resident and made sure they were both okay. Nurse #1 reported that she had already initiated 1:1 supervision with Resident #1 and once they assessed Resident #3 were able to turn her wheelchair back upright. The DON stated after she got off the phone with Nurse #1, she called back to circle back through the events and make sure they had done everything that needed to be done. The DON stated that Resident #1's actions were definitely out of character and with her impulsivity and paranoia we again placed her in 1:1 supervision. She added I think her actions definitely had the potential to be harmful and we were very lucky that Resident #3 was not physically harmed. Both times the DON spoke to Nurse #1 via phone the sock incident never came up, the DON stated she learned about that the next day when she was reading the progress note and went to talk to the Supervisor (Nurse #2). The DON stated as reported by Resident #3 the sock incident would be a form of abuse. The staff were educated on a monthly basis about abuse and how to identify and handle potential occurrences of abuse and were once again reeducated after the incident on 12/07/21. The DON stated that the staff were trained to first protect the resident that was being abused and then report to the Nurse, Supervisor, Administrator, or herself. She again confirmed that initially she did not see the issue as abuse but after learning of the sock incident that would definitely be a form of abuse, she added that the following day after the incident they were able to get Resident #1 admitted to an acute care psychiatric unit for treatment. The DON stated since the event on 12/10/20 she frequently checked on Resident #3, offered her talk therapy and chaplain services and she declined both. An interview was conducted with the Administrator on 01/15/21 at 4:54 PM. The Administrator stated that on 12/07/20 Resident #1 struck Resident #2 which was very out of character for her and the team was very taken back by her behavior, so they placed her on 1:1 supervision. A couple of days later the NP again revalued Resident #1 and with no further behaviors or aggressive indicators the decision was made to stop the 1:1 supervision. The NP also evaluated her medications, but no changes were made, and no further orders were obtained. The Administrator stated that they had already began the process of getting Resident #1 into an acute psychiatric unit, but a bed was not available at that time. Then on 12/10/20 she was called by the Supervisor and notified of the incident where Resident #1 turned over Resident #3's wheelchair with her still in the chair. Initially the Administrator stated she was not aware of the incident with the sock until the next day but when investigating she could not confirm or deny that the incident had occurred. The Administrator stated that she did not think in Resident #1's state of mind she was trying to be abusive, she believed it was all reactionary on Resident #1's part. The Administrator stated that she did go and speak to Resident #3 and she was more upset that Resident #1 was still in the facility which was a legitimate concern as it was a concern for her as well. She added that they were able to get Resident #1 into an acute psychiatric unit on 12/11/20. She added if Nurse #1 would have reported the sock issue it certainly would have led us down the abuse path, but we discussed as a team and with our corporate consultants to make sure we were doing what we needed to be doing. If Nurse #1 had noticed the socks draped around Resident #3 shoulders or had then been marks on Resident #3's face, then yes I would certainly say this was abuse. When Resident #1 returned from the hospitalization she remained on 1:1 supervision and Resident #3 had seen Resident #1 was back in the facility and on the same unit she was very upset, so we had to make a room change for Resident #1. The Administrator specified that Resident #1 was generally docile but, I don't trust her at this point. The Administrator stated that Resident #3 was still very concerned with Resident #1 being in the building and they were providing frequent reassurance to Resident #3 that a staff member was always with her and would be watching her to make sure nothing else occurred. The facility provided a plan of correction with a correction date of 12/14/20. The plan of correction included: Resident to Resident Altercation: - On 12/07/20 Resident #1 went into Resident #2's bathroom. Resident #2 was yelling loudly instead of using call light. Resident #1 slapped Resident #2 on the side of the face. Nursing staff immediately escorted Resident #1 out the bathroom she was cooperative but confused. -A nursing assessment was completed on Resident #2 to find no injury, no redness, or no bruising. -Emotional and psychosocial support was provided to Resident #2 with no acute issues or needs identified. -Resident #1 was placed on one on one observation until further notice. -All interviewable residents were interviewed for safety. A skin check was completed on all non interviewable residents for any signs or symptoms of abuse. -Nurse Educator immediately initiated training on abuse and management of difficult residents to all staff and agency staff on 12/08/20. -On 12/09/20 The NP assessed Resident #1. The behavior of 12/07/20 was not usual behavior for this resident and she had never displayed aggression in the past. The NP deemed Resident #1 to be cleared from one on one observation. -On 12/10/20 Resident #1 was in an altercation with Resident #3 who was her roommate. This altercation resulted in Resident #1 turning Resident #3 backward in her wheelchair. This was a continuation of Resident #1's new behaviors. -Following the incident Resident #1 was again placed on one on one observation until discharged to a psychiatric hospital for evaluation and treatment. -On 12/11/20 in morning meeting the 24 hour clinical report was reviewed and discovered a nurses note written by the Supervisor and additional details of socks wrapped around Resident #3's neck were discovered. -The Supervisor was called and brought into the facility for further investigation. Her statement was obtained and counseling provided. - Nurse #1 was re-interviewed and continued to deny seeing the stocking. The DON interviewed Resident #3 and emotional support provided. - The Nurse Educator completed training on abuse and management of difficult residents to all staff and agency staff on 12/14/20. Residents Interviewed that may have been affected: -On 12/08/20 the Social Worker interviewed interviewable residents. The residents verbalized that they felt safe and reported no issues with other residents. -Skin Checks were completed on all non interviewable residents for signs of abuse on 12/09/20. -New Admission interviews continue on all new admissions and will continue to ensure their comfort and satisfaction. Implementation of changes to prevent resident to resident reoccurrence: -Nurse Educator or designee will ensure all new hires or new agency staff are trained on abuse policy and management of difficult residents. -The Social Worker or designee will meet with random interviewable residents monthly and report findings to QAPI. QAPI will evaluate the need for frequency. -Upon Resident #1's readmission from the psychiatric hospital she remains on one on one observation. -The DON will audit the 24 hour report daily Monday through Friday and review for residents exhibiting any type of aggressive behavior to identify early reporting and interventions. Monitoring through QAPI to ensure performance and corrective actions sustained:-Nurse Educator or designee will ensure all new hires or new agency staff are trained on abuse policy and management of difficult residents. -The Social Worker or designee will meet with random interviewable residents monthly and report findings to QAPI. QAPI will evaluate need for frequency. -New Admission interviews will continue on all new admissions to ensure their comfort and satisfaction. The corrective action plan was reviewed in addition to documents and audits which confirmed that inservice education had been completed by 12/04/20, 24-hour reports had been reviewed for resident behaviors and the Social Worker or designee had completed interviews with interviewable residents. The full body skin assessments completed on 12/09/20 for the five residents that were not interviewable and resided on Resident #1's were reviewed. Resident #1 was observed with a staff member one on one on 01/12/21 and 01/14/21. During the onsite investigation conducted on 01/12/21 and 01/14/21 staff were able to verbalize recent abuse training and education. The action plan was validated on 02/16/21.

Based on record review, Physician Assistant and staff interviews, the facility failed to transfer a dependent resident using a mechanical lift with 2-person assist. This action resulted in the resident hitting his stump on the arm of the wheelchair which caused a staple to come out, opening and bruising his incision site for 1 of 3 resident's reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's discharge Minimum Data Set ((MDS) dated [DATE] revealed he was alert and oriented. Resident #1 required extensive, two-person assistance with most activities of daily living (ADL) and was dependent upon staff for transfers. Review of a grievance dated 4/06/20 revealed Resident #1 was transferred from the bed to his wheelchair without use of a mechanical lift. The grievance stated Resident #1 had told the Nurse Aide (NA) to use a lift pad because [MEDICAL TREATMENT] needed it to transfer him. The NA disregarded the resident's request causing the resident to have to return from [MEDICAL TREATMENT] to the facility to be placed on a lift pad. The findings of the investigation revealed Resident #1 was sent back to the facility from the [MEDICAL TREATMENT] center due to not having a lift pad under him. The investigation revealed the facility had a resident roster which showed how each resident was supposed to be transferred. Resident #1's resident roster showed he was supposed to be a mechanical lift for transfers. The NA was removed from the schedule and the agency company was notified. Review of Resident #1's undated resident roster revealed he required a mechanical lift with two staff members assistance for transfers and was to have a mechanical lift pad under him when going to the [MEDICAL TREATMENT] center. Review of a facility reported incident dated 4/10/20 revealed NA #1 assisted Resident #1 into his wheelchair for [MEDICAL TREATMENT] on 4/6/20. Resident #1 stated, I tried to explain to NA #1 what needed to be done. NA #1 lifted Resident #1 up and placed him in his wheelchair hitting his stump on the side of the wheelchair. The report revealed the facility discovered the resident was not properly transferred from the bed to his wheelchair as indicated on the resident roster. Resident #1 had attempted to direct NA #1 on how to transfer him and the importance of a lift pad for [MEDICAL TREATMENT] use. Resident #1's incision located on his left stump area opened up due to the incident and a staple was absent requiring the resident to see a surgeon on 4/7/20. On 8/11/20 at 5:01 PM an interview was conducted with Resident #1. He stated on 4/6/20 he had dressed himself independently and was sitting on the side of his bed waiting on a two staff member assistance to his wheelchair. Resident #1 stated NA #1 came into his room alone and told him he was going to transfer him to the wheelchair. Resident #1 stated he told NA #1 he needed to use a mechanical lift with another staff member assistance. NA #1 stated to him he didn't need to use a mechanical lift and proceeded to put his arms under Resident #1's shoulders to lift him onto the wheelchair. Resident #1 stated his left stump hit the arm of the wheelchair causing pain and his stump area to bleed. The interview revealed Resident #1 had told another staff member about the incident prior to leaving for [MEDICAL TREATMENT] however he could not recall what staff member he told. On 8/11/20 at 1:33 PM an interview was conducted with NA #1. During the interview he stated he was getting Resident #1 ready for [MEDICAL TREATMENT] on 4/6/20 and assisting him to transfer into his wheelchair. NA #1 stated his role was to make sure Resident #1 did not fall forward so he had placed his arms on the resident's shoulders. The interview revealed NA #1 did not go get a mechanical lift to transfer Resident #1 he instead decided to assist the resident himself. He stated he didn't know Resident #1 required a mechanical lift transfer and wasn't aware of what a resident roster was. NA #1 stated the resident had not hit his leg on the wheelchair arm and had never complained of pain during or after the transfer, so he did not notify the nurse. He stated Resident #1 did not complain of pain until he returned from [MEDICAL TREATMENT]. On 8/11/20 at 3:30 PM an interview was conducted with [MEDICAL TREATMENT] Nurse #1. She stated she was very familiar with Resident #1 and on 4/6/20 he told her NA #1 had transferred him incorrectly and hit his left stump area on the arm of his wheelchair. She stated she was concerned regarding the allegation from Resident #1 and had called the facility to tell them what had happened. The interview revealed she had spoken with someone from the facility however could not recall their name. She stated if a resident who required a mechanical lift transfer was sent to the [MEDICAL TREATMENT] clinic from a facility without a lift pad, they would send the resident back to the facility to get a lift pad prior to dialyzing the resident. The interview revealed Resident #1 had come to [MEDICAL TREATMENT] without a lift pad and was sent back to the facility. On 8/11/20 at 2:01 PM an interview was conducted with Wound Nurse #1. She stated on 4/6/20 Resident #1 had returned from [MEDICAL TREATMENT] when she was alerted by another staff member to go look at his left below knee amputation stump. She stated when she entered the room Resident #1 told her NA #1 had lifted him into his wheelchair incorrectly and hit his stump area on the arm of the wheelchair. The interview revealed NA #1 had not reported the incident to the hall nurse and a 4-6-hour time frame had occurred from when the incident happened until she assessed it. She stated she unwrapped the ace bandage which had a dried red substance on the outside of the wrap and opened the dressing to find staples hanging out of the incision. The interview revealed she notified administrative staff and put a treatment plan in place. She stated she called the vascular surgeon. On 8/12/20 at 8:00 AM an interview was conducted with the Director of Nursing (DON). She stated after Resident #1 returned from [MEDICAL TREATMENT] on 4/6/20 the wound nurse had observed changes to the wound and notified her. The interview revealed Resident #1 was upset with NA #1 who had gotten him ready for [MEDICAL TREATMENT] that morning. Resident #1 had stated to her he tried to explain to NA #1 what needed to be done but the NA was not listening. Resident #1 explained to her NA #1 picked him up and put him in the wheelchair. Resident #1 went on to state his stump was bumped on the wheelchair during the transfer which resulted in the facility calling the surgeon. She stated following the incident the unit managers on the hall conducted audits of resident transfers daily, weekly and then monthly. On 8/11/20 at 1:27 PM an interview was conducted with the Administrator. She stated Resident #1 was alert and oriented. The interview revealed Resident #1 had told NA #1 how to transfer him however NA #1 ignored the resident completely and transferred him without using a mechanical lift which was the proper way. She stated when they conducted an interview with NA #1, he stated to them he had used a one man assist to transfer Resident #1 into his wheelchair and stated he didn't know where to find the resident rosters. The interview revealed NA #1 had received training on resident rosters and had signed the training form. Following the incident, NA #1 was removed from the facility. She stated staff had conducted 100% education on abuse, transferring residents and reviewing the resident rosters. The interview revealed the facility had incorporated transfers and falls into their April 2020 Quality Assurance and process improvement meeting and into their morning clinical interdisciplinary team meeting. She stated the Unit Manager had conducted transfer audits which were completed 5 times a week for the first 2 weeks, then once a week for the following 2 weeks and was currently conducting monthly audits. Review of the transfer lift audits initiated on 4/20/20 revealed staff had conducted audits 5 times a week for 2 weeks, then once a week for the following 2 weeks and had conducted monthly audits for the months of July and August 2020. On 8/12/20 at 9:25 AM an interview was conducted with the Nurse Practitioner (NP). She stated Resident #1 had a [DIAGNOSES REDACTED]. The interview revealed Resident #1's wound had dehisced, and he was saying it had opened up due to the trauma of being hit which she stated was possible. On 8/12/20 at 10:10 AM an interview was conducted with Unit Manger #1. She stated following the incident the facility conducted 100% education to all staff members regarding resident transfers. The interview revealed once the in-servicing was completed on 4/20/20 she conducted transfer audits 5 times a week for the first 2 weeks, then once a week for the following 2 weeks and was currently conducting monthly audits. Review of the hospital records dated 4/8/20 revealed Resident #1 had experienced an incident at the nursing facility where he had trauma to his left below knee amputation when being transferred to a chair which caused his stump to dehisce. On 8/13/20 at 4:20 PM an interview was conducted with the Surgeons Physician Assistant. She stated Resident #1 had a bilateral [MEDICAL CONDITION] as a result of [MEDICAL CONDITION]. She stated following the surgery he was placed into the nursing home for rehabilitation therapy. The interview revealed when Resident #1 was seen on 4/7/20 by the Surgeon he told the Surgeon the wound had opened due to being hit on the wheelchair during a transfer with a Nurse Aide. She stated upon examination the wound was open and bruised. The interview revealed the wound was not opened prior to the incident on 4/6/20. She stated the resident was alert and oriented, able to describe exactly what had happened and was hard to disregard however she did not witness the incident and could only speak for what she saw on 4/7/20 when she examined the resident. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: 1. Resident #1 was assessed by the Wound Nurse on 04/06/20. The surgeon was notified of the status of the incision site. A Physician appointment was scheduled for 4/07/20. The nursing assistant that transferred Resident #1 independently on 04/06/20 was counseled on 04/06/20 and a request was made to the staffing agency that he not return to the facility. Resident #1 was counseled by the Social Worker regarding the incident on 04/06/20. 2. All nursing staff (licensed nurses and nursing assistants) were re-educated on resident transfers and proper procedure with a return demonstration. All agency nursing staff (licensed nurses and nursing assistants) were re-educated on resident transfers and proper procedure with a return demonstration (prior to working at the facility). All nursing staff (licensed nurses and nursing assistants) were re-educated on where to locate the appropriate method of transfer for residents in the Resident Roster (which contained individual care needs for residents) and individual care plans. The re-education and return demonstration began on 04/20/20 through 04/23/20. 3. Quality improvement monitoring was initiated 04/27/20 after all training was completed to conducted audits 5 times a week for 2 weeks, then once a week for the following 2 weeks and had conducted monthly audits for the months of July and August 2020. 4. The results of the monitoring would be reported at the monthly Quality Assurance and Performance Improvement (QAPI) meeting until such time as substantial compliance had been achieved. The facility's corrective actions were verified on 8/11/20 by record review, observations and interviews with residents and staff. The record of Resident #1 was reviewed. Resident #1 was assessed by the Surgeon on 04/07/20. The physician and family member were informed of the incident and Resident #1 was immediately provided with treatment. The DON investigated the incident. The 24 hour and 5-day report were sent to the State Agency on 04/06/20. The nursing assistant involved in the 04/06/20 incident was counseled, and a request was made to the staffing agency for her not to be sent again to the facility. The investigation was substantiated and closed on 04/10/20. In-service records were reviewed with training started on 04/20/20 through 04/23/20. All staff signed attendance sheets with in-services addressing safe resident transfers and use of the resident roster. All newly hired employees, nursing staff and agency staff working since 04/06/20 had received training and a system was in place to ensure all new facility staff and agency staff were properly trained and demonstrated return demonstration on use of all lifts. During the survey interviews were conducted with dependent residents regarding assistance provided by staff when utilizing lifts for transfers. No issues were identified with interviews. An observation was unable to be obtained due to no residents requring transfer assist using a mechanial lift while the surveyor was in the building. During the survey nurses and nursing assistants (both facility and agency staff) were interviewed and verified they received in-service on transferring residents with a lift with emphasis on always having two staff present. Nursing assistants stated they reviewed the resident roster before every shift to identify any changes with transfer requirements for residents they were assigned to care for. On 08/11/20 at 2:30 PM the facility's plan for past noncompliance was validated by the following. Review of in-service training records revealed staff from all shift and disciplines had been in-serviced on 04/20/20 through 04/23/20 regarding safe resident transfers. Beginning at 3:00 PM on 08/11/20 multiple interviews were conducted with staff in different departments/shifts. These interviews validated staff had undergone training during the month of April regarding safe resident transfers.

Based on observation, record review, family, hospital Medical Doctor, Detective and staff interviews the facility failed to protect a resident from a significant injury of unknown origin for 1 of 3 residents sampled (Resident #1). Resident #1 was discovered to have a bruise to his right arm and chest and was sent to the emergency room where it was discovered he also had a right chest wall hematoma (a collection of blood outside the blood vessels), right lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma), and a mild superior endplate compression fracture of T12 ([MEDICATION NAME] spine). Immediate Jeopardy began on 05/25/18 when the staff was dressing Resident #1 for bed and discovered a dark purple bruise to his right upper arm and chest. The immediate jeopardy is present and on-going. The findings included: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired and required extensive assistance of 2 staff members with bed mobility, transfers, and dressing. Further review of the MDS revealed that Resident #1 received no anticoagulants (blood thinners) during the assessment period. Review of a care plan revised on 05/22/18 read in part, Resident #1 required limited to extensive assistance for activities of daily living due to cognitive loss/dementia. The goal of the care plan read in part, Resident #1's care needs would be anticipated and met to maintain highest practicable level of functioning. The interventions included: geri sleeves to bilateral arms and transfers require extensive assistance utilizing a gait belt and 1 to 2 person assistance. (MONTH) use sit to stand lift if needed. Review of an Initial Allegation Report dated 05/25/18 at 6:30 PM revealed that Resident #1 had an injury of unknown source that included a bruise to right side rib area and right upper/inner arm. The report indicated that injury had been reported to the local law enforcement agency on 05/25/18. The accused employees were listed as Nursing Assistant (NA) #1, #2, and #3. Review of a 5-working day report dated 06/01/18 read in part, Resident #1 had been investigated for resident abuse for purple bruising to right upper extremity and medial side with purple bruising to right lateral chest. The report indicated that the incident had been reported to local law enforcement. The 5-working day report included brief statements from NA #1, #2, and #3. The conclusion read in part, other residents on the unit were interviewed and none had issues with the staff. Skin assessments completed on the unit with no further injuries observed. All staff assigned to Resident #1 on 05/25/18 were interviewed and none of the staff were aware that Resident #1 had bruising to right inner arm and chest region. Resident #1 was a 1-2 person assist with pivot transfers. His skin was frail and he wore thickened arm protectors to decrease the risk of bruising. The incident was reported to the family and to the Medical Doctor (MD). There was no indication of abuse in this case No cause of the bruise/injury was identified. An interview was conducted with Resident #1's family member on 06/06/18 at 9:48 AM. The family member stated that she had visited him on 05/24/18 up until 6:30 PM and witnessed him getting ready for bed. The family member stated that at that time Resident #1 had no bruising and was his usual self. She stated that on 05/25/18 at approximately 6:30 PM she received a phone call from the facility telling her that they had found some bruising to Resident #1's right arm and chest area. The family member stated she immediately went over to the facility to see the bruising for herself. She added that when she saw the bruising which she described as dark purple around his right arm extending over to his right side and rib cage and she also noted a large protrusion to Resident #1's right chest area. She stated that she asked the facility what had happened and they replied, we don't know what happened. The family member stated she contacted the local law enforcement at around 6:45 PM and they responded to the facility and they asked what had happened to Resident #1. The family member stated she directed the law enforcement questions to the facility and again they replied, we don't know what happened. The interview further revealed local law enforcement then called Emergency Medical Services (EMS) and Resident #1 was transferred to the local hospital. Review of a Chest scan obtained in the hospital on [DATE] revealed the following: right anterior chest wall pectoralis hematoma (bleeding under the skin), ill-defined left upper lobe opacity may represent lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma), and mild superior endplate compression fracture of T12 ([MEDICATION NAME] spine). An interview was conducted with the local law enforcement Detective on 06/07/18 1:30 PM. The Detective who was assigned to the case stated that on 05/25/18 one of his officers responded to the call made from Resident #1's family member from the facility. He responded to the facility and was made aware from the family something had happened to her family member. The Detective stated that when the officer saw the bruises and the staff was unable to tell him what happen to Resident #1 he called EMS to transport him to the hospital. The Detective stated he responded to the ER and observed the bruises and was surprised by the appearance of the dark bruises and the extent of the bruises. He added that he briefly spoke to the ER doctor and obtained some pictures but that was all that he had time to do. He added that he would be going back over to the facility to talk to the staff at some point but had not had time to do so. Review of the facility's daily assignment sheet dated 05/25/18 revealed that NA #4 cared for Resident #1 from 11:00 PM on 05/24/18 to 7:00 AM on 05/25/18. The assignment sheet also revealed that NA#2 cared for Resident #1 on 05/25/18 from 7:00 AM to 11:00 AM, NA #3 cared for Resident #1 from 11:00 AM to 3:00 PM, NA #1 care for Resident #1 from 3:00 PM to 5:00 PM and NA #5 cared for Resident #1 from 5:00 PM until he was sent to the emergency room (ER) for evaluation. An interview was conducted with NA #4 on 06/06/18 at 11:33 AM. NA #4 confirmed that she cared for Resident #1 from 11:00 PM on 05/24/18 to 7:00 AM on 05/25/18 and that she routinely cared for him and was familiar with his needs. She stated that night Resident #1 was his usual self and sometime in the morning hours she bathed Resident #1 and got him dressed for the day. NA #4 stated that when she bathed Resident #1 on the morning on 05/25/18 he had no bruises at all on his right arm or chest area. She added that he had a small bruise to his left-hand area but the nurse was already aware of that area. NA #4 did not recall any protrusion from Resident #1's right chest area but confirmed that there was no bruising to his right arm or chest area. She stated if she would have seen any new bruising she would have reported it to the nurse and had no knowledge of how the bruises occurred. An interview was conducted with NA #2 on 06/06/18 at 11:26 AM. NA #2 confirmed that she cared for Resident #1 on 05/25/18 from 7:00 AM until 11:00 AM. She also added that was the first time she had ever taken care of Resident #1 and she clearly remembered the morning of 05/25/18, stating it was crazy that morning, there was only 2 of us on the hall and I did not know any of the residents and I knew I had to get 4 people up for breakfast. NA #2 stated that she grabbed NA #6 and asked her to help get Resident #1 up to his wheel-chair. NA #2 stated that in report NA #4 had reported that Resident #1 required 2 person assist with transfers and that he had already been bathed and dressed and just needed to be transferred to his chair. NA #2 stated that she entered Resident #1's room that morning and made sure his brief was dry by just sliding the top of his pants down and he was dry so she stated she pulled his pants up and her and NA #6 used a gait belt and pivoted Resident #1 to his chair. She stated that she did not see any bruising to his right arm or chest but added he was already bathed and dressed when she arrived for duty and he had a shirt on and his geri sleeve was on his right arm so the arm and chest were not visible to her. She added it was one quick movement to his chair and was very easy to transfer. NA #2 stated that after they placed Resident #1 in his chair she did not render anymore care to him because she left at 11:00 AM and NA #3 took over her assignment. She added she had no knowledge of how the bruises occurred. An interview was conducted with NA #6 on 06/08/18 at 9:50 AM. NA #6 stated that she rarely worked with Resident #1 but vaguely recalled assisting NA #2 on 05/25/18 with sitting him on the side of the bed and then pivoting Resident #1 to his chair. NA #6 stated shortly after she assisted NA #2 with transferring Resident #1 to his chair she was moved to different assignment and was not in Resident #1 ' s room anymore that day. She added that she did not see any bruising to Resident #1's right arm or chest but he was dressed and had on a geri sleeve so she did not visualize his skin, she was just assisting with a transfer. She added she had no knowledge of how the bruises occurred. An interview was conducted with NA #3 on 06/06/18 at 11:45 AM. NA #3 confirmed that he came to work on 05/25/18 at 11:00 AM and was responsible for Resident #1. He stated that when he arrived at 11:00 AM Resident #1 was already up in his chair and was taken to the dining room for lunch. NA #3 stated that after lunch someone returned Resident #1 to his room and he and NA #7 began their last round to change everyone and lay them down for the afternoon. He added that after he and NA #7 had laid down another resident and exited the room he entered Resident #1's room to lay him down and change him. However, NA #3 stated that when he entered Resident #1's room the curtain was pulled and he could see Resident #1's feet in the bed and his chair was empty beside the bed. NA #3 also stated that he saw NA #2 and who he believed to be NA #6 behind the curtain changing Resident #1. He added that when he saw the 2 other staff members in the room tending to Resident #1 he exited the room and again met up with NA #7 to continue their round. NA #3 stated that he was in Resident #1's room less than 30 seconds and never visualized his skin and had no knowledge of how the bruises occurred. An interview was conducted with NA #7 on 06/06/18 at 12:00 PM. NA #7 confirmed that she was working on the unit where Resident #1 resided on 05/25/18. She stated that after lunch she and NA #3 started the last round on the unit and had just exited another residents room and NA #3 stated he was going to go and lay down Resident #1. She stated that very shortly after he went to Resident #1's room he returned and stated Resident #1 was already in the bed. NA #7 stated she does not know who placed Resident #1 in the bed that afternoon and when NA #3 returned to her and stated that Resident #1 was already in the bed they continued with providing care to the other residents. She added that she had no knowledge of how the bruises occurred. An interview was conducted with NA #1 on 06/08/18 at 11:13 AM. NA #1 confirmed that on 05/25/18 she had worked on a different unit from 7:00 AM to 3:00 PM and at 3:00 PM she transferred to the unit where Resident #1 resided. She stated that when she arrived at the unit at 3:00 PM there was no staff present to give her report and so she started her round to change people and get them ready for supper. NA #1 stated that at approximately 3:40 PM she went to Resident #1's room to provide incontinent care to him and he was resting in the bed, with no pants on and his brief was soaked. She stated she provided incontinent care to Resident #1 and placed pants on him and then transferred him to the wheel-chair by herself with no gait belt. NA #1 stated she did not notice any bruises to his arms or chest area but stated she only had to change his brief and apply cloths to his lower half. She stated she had no knowledge of the how the bruises occurred. She added that when she left her shift at 5:00 PM Resident #1 was sitting in his wheelchair beside his bed waiting for supper. An interview was conducted with NA #5 on 06/06/18 at 3:50 PM. NA #5 confirmed that she arrived for her shift on 05/25/18 at 5:00 PM and relieved NA #1. She added that Resident #1 was pushed in his wheelchair to the dining room for supper and she fed him. NA #5 stated that Resident #1 was his usual self and had no signs of pain or discomfort. She added that Resident #1 had on a short sleeve shirt and geri sleeve that came up to his elbow with jogging pants. She stated that he ate 100% of the meal and he was taken back to his room and at approximately 5:30-6:00 PM she began to undress Resident #1 for bed and noticed the dark purple bruise to his arm and chest area. NA #5 stated that he also had a large protrusion to his right chest area that had light purple bruising surrounding it. NA #5 stated that she had cared for Resident #1 on the evening of 05/24/18 as well and when she dressed him for bed there was no bruising to his right arm or chest area and the large protrusion was not there. She stated she had no knowledge of what happened to Resident #1. NA #5 stated that when she discovered the bruises she immediately reported it to Nurse #1. An interview was conducted with Nurse #1 on 06/06/18 at 3:22 PM. Nurse #1 confirmed that she worked with Resident #1 on 05/25/18. She stated that after supper NA #5 had taken Resident #1 to his room to get him ready for bed and when she removed his shirt noted some purple bruising to his right arm and chest area and came and reported it. Nurse #1 stated she went to look at the bruises and when she saw them she went and got the Nursing Supervisor (NS) and the Director of Nursing (DON) and they came to the room and looked at the bruises. Nurse #1 stated that she asked NA #5 to remove the geri sleeve from his right arm and noticed a lot of facial grimacing from Resident #1 when his right arm was touched. Nurse #1 stated that the bruises were not present the night before when she had worked and she could tell by the color of the bruises that they were new bruises. Nurse #1 added that he had a knot on his right chest area and she stated, I thought something was broken in there. Nurse #1 stated she has no knowledge of how the bruises occurred. An interview was conducted with NA #8 on 06/07/18 at 5:38 PM. NA #8 stated that on 05/25/18 she reported for her shift between 10:30 AM and 11:00 AM and was working on the same unit Resident #1 resided. She added that between 4:00 PM and 5:00 PM she was in the break room having a snack and NA #3 and NA #1 were in there talking. NA #8 stated she heard NA #3 state, man we dropped Resident #1 and I asked them did you not use the lift and NA #3 replied no we used top and bottom. NA #8 further stated that she asked them did you tell the nurse and NA #3 stated no we did not say anything we just picked him up and put him back in the bed. She stated later there was commotion outside of Resident #1's room and she heard them talking about bruises and she stated to the NS that maybe you should talk to NA #3 and NA #1 and NS told NA #8 to mind your own business. NA #8 stated after that she returned to her assignment and did not say anything else about what she had heard and been told. An interview was conducted with the NS on 06/06/18 at 4:12 PM. The NS stated that on 05/25/18 sometime after dinner Nurse #1 came to me and stated she needed to me to come and look at Resident #1. The NS stated that when she entered his room and Nurse #1 pointed to the right mid arm and a knot on his right chest and there was bruising below his right breast over to his side. She added the bruise to his mid arm looked bluish and looked like a new bruise and when his right arm was moved you could see changes in his facial expression so the staff were instructed to be very careful with him when they were moving him. The NS stated that Resident #1's family was notified and they came to the facility and they called the local law enforcement and they called EMS to take Resident #1 to the ER. She stated that before the local law enforcement arrived at the facility the Medical Doctor (MD) was notified of the new bruising and STAT (now) orders were given for x-rays. When the local law enforcement decided to call EMS the MD was again notified that Resident #1 was going to the ER. The NS stated she honestly had no idea how the bruises occurred and stated Resident #1 did not move enough to cause those injuries to himself but added it was very well possible that he was dropped. The NS also stated that NA #8 was asking questions about what happened and trying to get involved in the situation and I told her she needed to mind her business and get back to work but she never reported to me that she had heard NA #3 and NA #1 talking about dropping Resident #1. An interview was conducted with the DON on 06/08/18 at 1:09 PM. The DON stated that on 05/25/18 Nurse #1 called me to come and look at Resident #1. She stated that when she entered his room his shirt had been removed and I witnessed dark purple bruising to his right inner arm and light bruising to right lateral chest. NA #5 reported to me that the bruises had not been present the evening before. The DON stated she advised Nurse #1 to call the MD and request an X-ray to rule out any fracture due to how frail Resident #1 was. She added that she then left the facility but had to return shortly after that because the family was there and was upset. When she returned to the facility the family was at bedside and EMS was preparing to take Resident #1 to the local hospital and she updated the Administrator that the family was upset and that Resident #1 was going to the hospital. The DON stated that she had no knowledge of how the bruises occurred and no one that she had spoken to had any knowledge of how the bruises occurred. She added that Resident #1 was not able to move enough to harm himself and that believed something happened but the staff was not being forth coming. An observation of Resident #1 was made in the local hospital on [DATE] at 3:50 PM. Resident #1 was resting in bed with eyes open, he was alert and incoherently verbal. There was extensive dark purple bruising noted from the right upper chest area down to his right hip area, the bruising extended across the abdomen but had turned to a yellow color across the abdomen. The right upper arm also contained purple bruising that extended approximately 3 inches around the upper arm. Resident #1 was turned on his left side and dark purple bruising was visible to the right side extending to the back of Resident #1. He was observed to have a large protrusion to the right chest area. Resident #1 was noted to have facial grimacing while being assisted with turning and repositioned but was unable to voice his pain level. An interview was conducted with the hospital Medical Doctor (HMD) on 06/08/18 at 10:42 AM. The HMD stated that another MD admitted Resident #1 to the hospital on [DATE] and he took over his case on 05/30/18. The HMD stated that when he first met and examined Resident #1 he believed that moving Resident #1 in the bed could not have caused his injuries but stated a transfer may have caused the bruising. The HMD further explained that after they performed a chest scan that revealed a chest wall hematoma (a collection of blood outside the blood vessels) and lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma) he determined that bumping into something could not have caused the lung contusion. The HMD stated it would take a pretty strong force to cause the lung contusion and he believed from his injuries it appeared that Resident #1 may have been dropped. He added that he sees lung contusions a lot in motor vehicle accidents or in the elderly who have fallen out of bed and are not cognitively aware to put their hands down to break the fall. The HMD also stated that the protrusion on Resident #1's right chest was suspected to be a pectoral muscle tear but to confirm that he would need to perform a more extensive test and Resident #1 was not physically appropriate for that test. The HMD stated that the dark purple bruises indicated that his injuries were new or acute and that when the bruises start to turn yellow that indicates that they were beginning to heal. He added that it would be hard to say if his injuries were life threatening due to Resident #1's age and over-all health but initially he would say no. An interview was conducted with the Administrator on 06/08/18 at 11:36 AM. The Administrator stated that he was notified on 05/25/18 that Resident #1 was discovered to have bruises around his right arm and chest area and by the time he arrived back at the facility Resident #1 had been transported to the ER. The Administrator obtained a copy of the police report but it contained no photographs so his knowledge of the bruises was reported to him by the DON. He added that by the reports of the bruises he would assume that Resident #1 was either dropped or someone man handled him but our investigation did not conclude what happened to Resident #1 or how he acquired the injuries in the facility. The Administrator stated that someone in the facility knew what happened and they needed to come forward and report it, he added that he had an open-door policy and he always encouraged the staff to come to him. The acting Administrator was notified of the immediate jeopardy on 06/20/18 at 10:22 AM.

Based on observation, record review, family, hospital Medical Doctor, Detective, and staff interviews the facility failed to implement their abuse policy and procedures to protect residents from abuse during and after the investigation, failed to thoroughly investigate an injury of unknown origin, and failed to report the injury to the State Survey Agency within 2 hours for 1 of 3 residents sampled (Resident #1). Resident #1 was discovered to have a significant bruising with injury to his right chest area and right upper/inner arm and the facility was not able to determine the cause of the injuries. The resident was admitted to the hospital for evaluation and treatment of [REDACTED]. Immediate Jeopardy began on 05/25/18 when the staff was dressing Resident #1 for bed and discovered a dark purple bruise to his right upper arm and chest. The facility began the investigation but failed to protect the residents from further harm and did not try to ascertain the extent of his injuries or explore what may have caused the injury. The immediate jeopardy is present and on-going. The findings included: A review of the facility's Abuse Prohibition policy revised on 03/01/18 read in part, upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the Center Executive Director (CED/Administrator) or designee will perform the following: initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries if indicated, causative factors, and interventions to prevent further injury. The CED will also report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property not later than 2 hours after the allegation is made if the event results in serious bodily injury. The policy further read, the center will protect patients from further harm during an investigation. Further review of the policy read, the employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired and required extensive assistance of 2 staff members with bed mobility, transfers, and dressing. Review of an Initial Allegation Report dated 05/25/18 at 6:30 PM, completed by the Administrator revealed that Resident #1 had an injury of unknown source that included bruises to right side ribs and right upper/inner arm. The report indicated that the injury had been reported to the local law enforcement agency on 05/25/18 at 6:45 PM. The accused employees were listed as Nursing Assistant (NA) #1, #2, and #3. The form further indicated that it had been faxed to the State Survey Agency on 05/25/18 at 9:46 PM. Review of a 5-working day report dated 06/01/18 read in part, Resident #1 had been investigated for resident abuse for purple bruising to right upper extremity and medial side with purple bruising to right lateral chest. The report indicated that the incident had been reported to local law enforcement. The 5-working day report included brief statements from NA #1, #2, and #3. The conclusion read in part, other residents on the unit were interviewed and none had issues with the staff. Skin assessments completed on the unit with no further injuries observed. All staff assigned to Resident #1 on 05/25/18 were interviewed and none of the staff were aware that Resident #1 had bruising to right inner arm and chest region. Resident #1 was a 1-2 person assist with pivot transfers. His skin was frail and he wore thickened arm protectors to decrease the risk of bruising. The incident was reported to the family and to the Medical Doctor (MD). There was no indication of abuse in this case. No cause of the bruise/injury was identified. The 5-working day report was faxed to the State Survey agency on 06/01/18 at 1:49 PM. Review of the daily assignment schedule for 05/25/18 revealed that NA #4 cared for Resident #1 from 11:00 PM on 05/24/18 to 7:00 AM on 05/25/18, NA #2 cared for Resident #1 from 7:00 AM to 11:00 AM on 05/25/18, NA #3 cared for Resident #1 from 11:00 AM to 3:00 PM on 05/25/18, NA #1 cared for Resident #1 from 3:00 PM to 5:00 PM on 05/25/18, and NA #5 cared for Resident #1 from 5:00 PM until he discharged to the emergency room (ER) on 05/25/18. An interview was conducted with NA #1 on 06/08/18 at 11:13 AM. NA #1 confirmed that she had cared for Resident #1 on 05/25/18. She stated that on 05/30/18 the Director of Nursing (DON) had asked her for a written statement about what had occurred with Resident #1 on 05/25/18 and she had done so. She added that she continued to work her regularly scheduled assignment with no change to her scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with NA #2 on 06/06/18 at 11:26 AM. NA #2 confirmed that she cared for Resident #1 on 05/25/18. She stated that on 05/28/18 the DON had asked her for a written statement about what had occurred with Resident #1 on 05/25/18 and she had done so. She added that she continued to work her regularly scheduled assignment with no change to her scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with NA #3 on 06/06/18 at 11:45 AM. NA #3 confirmed that he cared for Resident #1 on 05/25/18. He stated that on 05/31/18 the DON had asked him for a written statement about what had occurred with Resident #1 on 05/25/18 and he had done so. He added that he continued to work his regularly scheduled assignment with no change to his scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with NA #4 on 06/06/18 at 11:33 AM. NA #4 confirmed that she cared for Resident #1 from 11:00 PM on 05/24/18 to 7:00 AM on 05/25/18 and that she routinely cared for him and was familiar with his needs. NA #4 stated that the DON did not speak to her about the bruises discovered on Resident #1 and she was not asked to write a statement. She added that she continued to work her regularly scheduled assignment with no change to her scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with NA #5 on 06/06/18 at 3:50 PM. NA #5 confirmed that she cared for Resident #1 on 05/25/18 from 5:00 PM until his was discharged to the hospital. She stated that after she discovered the dark purple bruises to Resident #1 and reported it to Nurse #1 the DON had asked her what happened but she was not asked to write a statement. She added that she continued to work her regularly scheduled assignment with no change to her scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with NA #8 on 06/07/18 at 5:38 PM. NA #8 stated that on 05/25/18 she reported for her shift between 10:30 AM and 11:00 AM and was working on the same unit Resident #1 resided. She added that between 4:00 PM and 5:00 PM she was in the break room having a snack and NA #3 and NA #1 were in there talking about how they had dropped Resident #1 and they had not reported it they just picked him up and put him back to bed. She stated later there was commotion outside of Resident #1's room and she heard them talking about bruises and she stated to the Nursing Supervisor (NS) that maybe you should talk to NA #3 and NA #1 and the NS told NA #8 to mind your own business. NA #8 stated after that she returned to her assignment and did not say anything else about what she had been told and heard and no one ever questioned her about the incident and she was not asked to give a statement. She added that she continued to work her regularly scheduled assignment with no change to her scheduled duties and had no knowledge of how Resident #1 acquired the bruise/injury of unknown origin. An interview was conducted with the NS on 06/06/18 at 4:12 PM. The NS stated she honestly had no idea how the bruises occurred and stated Resident #1 did not move enough to cause those injuries to himself but added it was very well possible that he was dropped. The NS also stated that NA #8 was asking questions about what happened and trying to get involved in the situation and I told her she needed to mind her business and get back to work but she never reported to me that she had heard NA #3 and NA #1 talking about dropping Resident #1. An interview was conducted with Resident #1's family member on 06/06/18 at 9:48 AM. She stated that on 05/25/18 at approximately 6:30 PM she received a phone call from the facility telling her that they had found some bruising to Resident #1's right arm and chest area. The family member stated she immediately went over to the facility to see the bruising for herself. She added that when she saw the bruising which she described as dark purple around his right arm extending over to his right side and rib cage and she also noted a large protrusion to Resident #1's right chest area. She stated that she asked the facility what had happened and they replied, we don't know what happened. The family member stated she contacted the local law enforcement at around 6:45 PM and they responded to the facility and they asked what had happened to Resident #1. The family member stated she directed the law enforcement questions to the facility and again they replied, we don't know what happened. The interview further revealed local law enforcement then called Emergency Medical Services (EMS) and Resident #1 was transferred to the local hospital. An observation of Resident #1 was made in the local hospital on [DATE] at 3:50 PM. Resident #1 was resting in bed with eyes open, he was alert and incoherently verbal. There was extensive dark purple bruising noted from the right upper chest area down to his right hip area, the bruising extended across the abdomen but had turned to a yellow color across the abdomen. The right upper arm also contained purple bruising that extended approximately 3 inches around the upper arm. Resident #1 was turned on his left side and dark purple bruising was visible to the right side extending to the back of Resident #1. He was observed to have a large protrusion to the right chest area. Resident #1 was noted to have facial grimacing while being assisted with turning and repositioned but was unable to voice his pain level. An interview was conducted with the hospital Medical Doctor (HMD) on 06/08/18 at 10:42 AM. The HMD stated that another MD admitted Resident #1 to the hospital on [DATE] and he took over his case on 05/30/18. The HMD stated that when he first met and examined Resident #1 he believed that moving Resident #1 in the bed could not have caused his injuries but stated a transfer may have caused the bruising. The HMD further explained that after they performed a chest scan that revealed a chest wall hematoma (a collection of blood outside the blood vessels) and lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma) he determined that bumping into something could not have caused the lung contusion. The HMD stated it would take a pretty strong force to cause the lung contusion and he believed from his injuries it appeared that Resident #1 may have been dropped. He added that he sees lung contusion a lot in motor vehicle accidents or in the elderly who have fallen out of bed and are not cognitively aware to put their hands down to break the fall. The HMD also stated that the protrusion on Resident #1's right chest was suspected to be a pectoral muscle tear but to confirm that he would need to perform a more extensive test and Resident #1 was not physically appropriate for that test. The HMD stated that the dark purple bruises indicated that his injuries were new or acute and that when the bruises start to turn yellow that indicates that they were beginning to heal. He added that it would be hard to say if his injuries were life threatening due to Resident #'s age and over-all health but initially he would say no. Review of a Chest scan obtained in the hospital on [DATE] revealed the following: right anterior chest wall pectoralis hematoma (bleeding under the skin), ill-defined left upper lobe opacity may represent lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma), and mild superior endplate compression fracture of T12 ([MEDICATION NAME] spine). An interview was conducted with the local law enforcement Detective on 06/07/18 1:30 PM. The Detective who was assigned to the case stated that on 05/25/18 one of his officers responded to the call made from Resident #1's family member from the facility. He responded to the facility and was made aware from the family something had happened to her family member. The Detective stated that when the officer saw the bruises and the staff was unable to tell him what happen to Resident #1 he called EMS to transport him to the hospital. The Detective stated he responded to the ER and observed the bruises and was surprised by the appearance of the dark bruises and the extent of the bruises. He added that he briefly spoke to the ER doctor and obtained some pictures but that was all that he had time to do. He added that he would be going back over to the facility to talk to the staff at some point but had not had time to do so. An interview was conducted with the DON on 06/08/18 at 1:09 PM. The DON confirmed that she conducted the investigation of Resident #1's bruise/injury of unknown origin. She indicated she started with the staff that cared for him on 05/25/18 and then proceeded from there with the full investigation. The DON confirmed that she listed NA #1, #2, and #3 on the initial and 5-working day report because they were on the schedule and cared for Resident #1 on 05/25/18. She confirmed that none of the accused individuals were suspended or reassigned on 05/25/18 or during the investigation. She further confirmed that all 3 accused staff members provided care to other residents in the days following the bruise/injury of unknown origin. The DON stated that she provided verbal reeducation for staff immediately on proper transfer and she believed that was protecting the residents. She added that she was unable to determine what caused Resident #1's bruise/injury but stated something happened and someone knows what happened and they need to come forward. The DON stated that she should have suspended the accused individuals until she could determine that no abuse had occurred to make sure all the residents were protected. She added that she had not reached out to the hospital to determine the extent of Resident #1's injuries and confirmed that she based her investigation on the 3 individuals that cared for Resident #1 on 05/25/18 but acknowledged that she did not talk to everyone that provided care to him that day and she should have. An interview was conducted with the Administrator on 06/08/08 at 11:36 AM. The Administrator stated that he was informed of Resident #1's bruising on 05/25/18 at approximately 6:45 PM and by the time he arrived back at the facility Resident #1 had been sent to the emergency room (ER) so he had not visualized Resident #1. He stated that when he returned to the facility he had to gather the needed information and at that point he faxed the initial allegation report to the State Survey Agency and confirmed that it was outside of the 2-hour window but stated he reported it as quickly as he could. He added that he also had not seen any pictures that had been taken by the family or the local law enforcement. The Administrator stated that he delegated the investigation to the DON but did not see or review the investigation until the DON had faxed the 5-working day report to the State Survey Agency on 06/01/18. The Administrator stated that when he reviewed the investigation after it had been reported to the State Survey Agency he believed that the investigation was lacking in areas and could have been more through but at that time the report had already been faxed to the agency so he signed off on the report. He further stated that to his knowledge no one that was caring for Resident #1 on 05/25/18 when the injury occurred were suspended or placed on leave pending the investigation. He acknowledged that they remained working in the facility on 05/25/18 and in the days, that followed. The Administrator stated that he expected the DON or anyone conducting investigations to follow the facility policy and thoroughly investigation each allegation of bruise/injury of unknown origin. He added that with the extent of Resident #1's injuries he would say he was man-handled or dropped but could not rule out abuse and the results of the facility's investigation left him with unanswered questions. He added that because he did not conduct the investigation he could not say how the residents were protected and would have to ask the DON. The Administrator stated that he expected the DON or anyone conducting investigations to follow the facility policy and protect the residents from further harm during the investigation period. The Administrator added that he planned to reopen the investigation and conduct the investigation himself to determine how Resident #1 acquired his injuries while in the facility. A review of the reopened investigation was made on 06/20/18. The investigation contained statements from the DON, NA #1, NA #2, NA #3, NA #5, NA #7, NA #9, Nurse #1, NS, and Nurse #2 but contained no date of when the investigation was completed. The conclusion of the investigation read in part, to the best of our ability we have obtained new statements from the interested parties involved and as of today we cannot isolate the cause of the bruises. We feel the individuals that were involved with the care of Resident #1 are not necessarily being forthcoming with events of the day in question. All of these individuals are agency staff and were suspended from duty on 06/08/18 and will not return to the building. Review of a daily assignment sheet dated 06/20/18 indicated that NA #3 was scheduled to work from 7:00 AM to 3:00 PM. Review of NA #3's time card confirmed that he had worked on 06/20/18 from 7:15 AM to 3:01 PM, further review of his time card indicated that he had worked on 06/11/18, 06/12/18, 06/13/18, 06/14/18, and 06/15/18. Review of time card for NA #1 and #2 revealed that they had clocked out on 06/08/18 and had not returned to the facility to work. An interview was conducted with the Clinical Quality Specialist (CQS) on 06/20/18 at 6:00 PM. The CQS stated that the Administrator had reopened the investigation on 06/08/18 and concluded the investigation on 06/14/18. The CQS confirmed that NA #3 had worked on 06/20/18 and provided care to the residents. She indicated that the Administrator was currently on vacation and unavailable for interview but had communicated to her that his investigation had revealed no definitive cause of the bruises but he had decided that NA #1 and NA #2 could not return to the facility to work for reasons other than the investigation. The CQS indicated that the Administrator had determined that NA #3 had not done anything wrong and allowed him to return to duty. She could not answer as to why the Administrator's conclusion of his investigation indicated that the involved parties would not be returning to the facility or what basis was made for allowing NA #3 to return to duty. The acting Administrator was notified of the immediate jeopardy on 06/20/18 at 10:22 AM.

Based on observation, record review, family, hospital Medical Doctor, Detective and staff interview the facility Administration failed to provide leadership and oversight to protect a resident from a significant injury of unknown origin and conduct a thorough investigation to determine the cause, failed to implement their abuse policies to protect the residents during and after the investigation, and failed to report the significant injury to the state survey agency within 2 hours for 1 of 3 residents sampled (Resident #1). Resident #1 was discovered by facility staff to have significant bruising to his upper torso which the origin was unknown. The resident was sent to the hospital for evaluation and treatment and was diagnosed with [REDACTED]. Immediate jeopardy began on 05/25/18 when the staff discovered Resident #1 had a significant bruise/injury to his upper torso and the facility's administration did not interview all staff involved (NA #4 and NA #8), they did not reach out to the hospital to determine the extent of his injuries, and they failed to obtain vital information from NA #8 that had knowledge of an incident. The facility's administration also failed to protect the residents during and after the investigation by allowing the accused individuals to continue to provide care to the residents in the facility The immediate jeopardy is present and on-going. The findings included: 1. This tag is cross referred to F600: Based on observation, record review, family, hospital Medical Doctor, Detective and staff interviews the facility failed to protect a resident from a significant injury of unknown origin for 1 of 3 residents sampled (Resident #1). Resident #1 was discovered to have a bruise to his right arm and chest and was sent to the emergency room where it was discovered he also had a right chest wall hematoma (a collection of blood outside the blood vessels), right lung contusion (a type of hematoma in which blood has escaped from ruptured capillaries usually due to trauma), and a mild superior endplate compression fracture of T12 ([MEDICATION NAME] spine). 2. This tag is cross referred to F607: Based on observation, record review, family, hospital Medical Doctor, Detective, and staff interviews the facility failed to implement their abuse policy and procedures to protect residents from abuse during and after the investigation, failed to thoroughly investigate an injury of unknown origin, and failed to report the injury to the State Survey Agency within 2 hours for 1 of 3 residents sampled (Resident #1). Resident #1 was discovered to have a significant bruising with injury to his right chest area and right upper/inner arm and the facility was not able to determine the cause of the injuries. The resident was admitted to the hospital for evaluation and treatment of [REDACTED]. A follow up interview was conducted with the Administrator on 06/08/18 at 7:01 PM. The Administrator again stated that he felt like the investigation that the Director of Nursing (DON) had conducted was not thorough and he had decided to reopen the investigation and had already conducted several interviews and obtained additional statements. He added that at the time the 5-working day report had already been sent to the State Survey Agency and it was over and done with and we were moving on. The Administrator stated that once he learned of the significant injuries Resident #1 sustained he felt like he needed to try and figure out what happened but he certainly expected the DON or anyone he delegated to conduct the investigation would do a thorough investigation and determine a cause and protect the residents at the same time and clearly that was not done with this incident. The Administrator also stated he would expect the reporting of the incident to be completed within the 2-hour time frame. The acting Administrator was notified of the immediate jeopardy on 06/20/18 at 10:22 AM

Based on observation, record review, resident, and staff interviews, the facility failed to follow physician orders [REDACTED].#110) reviewed for wound care. The resident experienced pain during the removal of the incorrect dressing that was applied to a wound. Findings included: Resident #110 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #110's most recent quarterly minimum data set ((MDS) dated [DATE] revealed she was cognitively intact and had some behavioral symptoms not directed toward others. The resident required extensive assistance of 1 staff with dressing, toileting, personal hygiene and bathing. Review of Resident #110's care plan dated 12/21/17 revealed she was care planned for exhibiting or being at risk for alterations in comfort related to the wound to her lower extremity and her chronic pain. The goal was that the resident would achieve an acceptable level of pain control for the next 90 days with a target date of 03/27/18. Interventions included in part: 1. Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors, 2. Utilize pain scale, 3. Advise resident to request pain medication before pain becomes severe, and 4. Encourage and assist resident to eliminate additional stressors or sources of discomfort. Review of a physician order [REDACTED]. Apply [MEDICATION NAME] cream from the hospital stay to all wounds daily. Use ABD pads (which are non-adherent) to ankle to cover all wounds. Two layer compression wrap to be changed daily. Wound Care Clinic (WCC) may use [MEDICATION NAME] if patient does not have cream with her. Review of Resident #110's pain medication orders revealed there were no orders for pain medication to be given prior to her dressing change. An interview on 01/03/18 at 9:42 AM with Resident #110 revealed she had been at the facility for approximately 3 years. The resident stated that she had a wound on her right leg below her knee due to venous ulcer and had had the wound for 2 years. She stated that she had been to the wound clinic yesterday and the physician had debrided her wound and showed a picture on her phone of the wound. The resident stated she was also being seen at the pain clinic and she had told the physician she was having pain with the dressing changes and stated the physician wanted her to stay on the current pain regimen for at least 6 weeks before she changed the orders. She stated that she had complained about pain during the dressing changes but had been told they were giving her all the medication she had ordered for pain. The resident stated she just had to get through the dressing change and try to tolerate the pain. The resident acknowledged she had not asked them to stop the dressing change because she knew it had to be done and she knew they would not give her anything additionally for the pain. An observation of Resident #110's dressing change on 01/04/18 at 4:20 PM revealed the resident had been pre-medicated by Nurse #2 for the procedure at 3:25 PM. The 2nd shift nurse supervisor and Nurse #1 were in the room and getting their supplies ready for the dressing change. The supervisor washed her hands and donned her gloves and started cutting the dressing away from the wound and the resident had tolerated it well. The cut part of the dressing which was Kerlix was removed by the supervisor. Upon removal of the rest of the dressing, the supervisor and Nurse #1 ascertained that the wrong dressing had been applied to the resident's wound on 01/03/18 when the nurse had changed it on second shift. The orders were written for a non-adherent dressing to be applied to the wound and gauze which is adherent had been applied to the wound instead. The nurses cleaned the excess cream from the skin surrounding the wound and some from the wound itself. Nurse #1 using aseptic technique applied a thin layer of [MEDICATION NAME] cream on the wound, rubbing from top to bottom. The nurse then applied 5 non-adherent abdominal (ABD) pads to cover the wound completely and wrap around the ankle. The 2 step compression was then layered over the ABD pads and taped in place and the dressing was covered with a stockinette. Nurse #1 stated the dressing came in a kit which contained the 2 compression dressings and the stockinette. The nurse stated there was a supply of the kits in the clean utility room and a kit was kept in the treatment cart. The supervisor and Nurse #1 went back into the resident's room and continued to try to remove the dressing and the resident continued to cry out, with a grimaced face and had tears rolling down her cheeks. The supervisor asked the resident at 4:35 PM if she wanted her scheduled dose of pain medication and the resident stated no, she wanted to wait until the dressing change was done. The supervisor continued to try to remove the dressing that was saturated but it was stuck to the wound bed and the resident continued to cry in pain. At 5:20 pm the supervisor went out of the room to get the Director of Nursing (DON) for her to try to remove the dressing. The supervisor stated she had not seen Resident #110 cry out in this much pain. The DON came into the room, saturated the dressing again and attempted to loosen the dressing and the resident again cried out in pain, was grimacing and had tears rolling down her face. The DON stated to Resident #110 why don't you take your additional pain medication and the resident agreed at 5:30 pm to take the medication. The DON stated to the resident why are you acting like this? You don't usually cry out in pain like this, what is different? The resident stated to the DON I don't know what is different it just hurts and the nurse put too much medicine on it last night when she changed it and it hurts. The DON kept trying to get the dressing off and finally was able to remove the top dressing but the wound bed dressing was still attached. At 5:30 PM, the supervisor returned with Resident #110's pain pill and asked the nurses if they would wait to give the pill a chance to kick in before they continued with the dressing change. The supervisor and Nurse #1 stated they would return in 20 to 30 minutes to continue with the dressing change. At 5:23 PM an interview with Resident #110 revealed the pain associated with the dressing change was much worse today than previously. She stated there was always some pain associated with the dressing change but the dressing had not been sticking to the wound like it had this time. She stated that she had usually yelled in pain but not like this and stated that it had not previously hurt this bad. At 5:53 PM the supervisor and Nurse #1 returned to the resident's room to try to remove the dressing again. The supervisor started working with the dressing after saturating it again and the resident again cried out in pain so the supervisor stopped. Nurse #1 stated she would try to remove the dressing and started working with the dressing and after a while was finally able to remove the rest of the dressing. Resident #110 continued to cry during the removal of the dressing but stated the medication had helped a little bit. The wound had a circular area at the top and then a larger wider open area down to the ankle. The wound bed had granulating tissue but there was an excess of cream on the skin and on the wound that had not been absorbed. Upon the dressing being removed the supervisor and Nurse #1 ascertained that the wrong dressing had been applied to the resident's wound on 01/03/18 when the second shift nurse had changed it. The orders were written for ABD pads (which are non-adherent) to be applied to the wounds and gauze (which is adherent) had been applied to the wound instead. The nurses cleaned the excess cream from the skin surrounding the wound and some from the wound itself. Nurse #1 using aseptic technique applied a thin layer of [MEDICATION NAME] cream on the wound, and applied 5 ABD pads to cover the wound completely and wrap around the ankle. The 2 step compression was then layered over the ABD pads and taped in place and the dressing was covered with a stockinette. Nurse #1 stated the dressing came in a kit which contained the 2 compression dressings and the stockinette. The nurse stated there was a supply of the kits in the clean utility room. An interview on 01/05/18 at 10:01 AM with the wound care clinic physician revealed they had been battling Resident #110's wound for some time and had tried various treatments and had finally seen some improvement with the wound. The physician stated he had just debrided the wound on 01/02/18 and changed her orders for her dressing to a non-adherent dressing. He stated that gauze on a wound after debridement would legitimately cause pain with the removal of the dressing. The physician also stated the pain she had with the removal of the gauze dressing demonstrated why you would have used and why he had ordered a non-adherent dressing. The wound care physician stated he expected the facility to follow the orders he had written for dressing changes to the extent possible. He also stated that trying to follow the orders as much as possible would be advantageous for Resident #110. An interview on 01/05/18 at 11:55 AM with the Medical Director revealed that he expected when he wrote an order for [REDACTED]. An interview on 01/05/18 at 12:03 PM with the facility's Nurse Practitioner revealed that she expected when she wrote an order for [REDACTED]. An observation on 01/05/18 at 1:18 PM of the clean utility room revealed there were 6 kits for Resident #110's dressing available for use. An interview on 01/05/18 at 3:21 PM with Nurse #3 revealed she had done the dressing on 01/03/18 for Resident #110 on second shift. She stated she had followed the physician order [REDACTED]. Nurse #3 reviewed the MAR and realized the orders for the dressing had been changed on 01/02/18 by the wound care physician and stated that she had not followed the new orders for wound care which took effect on 01/02/18. Nurse #3 stated she had looked at the old orders and followed them instead of the new orders. An interview on 01/05/18 at 3:33 PM with the Director of Nursing (DON) revealed her expectation was for the nurses to follow physician orders [REDACTED]. An interview on 01/05/18 at 6:50 PM with the DON and Administrator revealed the Administrator expected the nurses to follow the physician orders [REDACTED].

Based on observation, record review, resident, staff, and physician interviews, the facility failed to provide effective pain management during a dressing change for 1 of 1 resident (Resident # 110) reviewed for wound care. Findings included: Resident #110 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #110s most recent quarterly minimum data set ((MDS) dated [DATE] revealed she was cognitively intact and had some behavioral symptoms not directed toward others. The resident required extensive assistance of 1 staff with dressing, toileting, personal hygiene and bathing. Resident #110 used a walker or wheelchair for locomotion and was always continent of urine and occasionally incontinent of stool. Review of Resident #110s care plan dated 12/21/17 revealed she was care planned for exhibiting or being at risk for alterations in comfort related to the wound to her lower extremity and her chronic pain. The goal was that the resident would achieve an acceptable level of pain control for the next 90 days with a target date of 03/27/18. Interventions included in part: 1. Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors, 2. Utilize pain scale, 3. Advise resident to request pain medication before pain becomes severe, and 4. Encourage and assist resident to eliminate additional stressors or sources of discomfort. Review of a physician order [REDACTED]. Apply [MEDICATION NAME] cream from the hospital stay to all wounds daily. Use ABD pads (which are non-adherent) to ankle to cover all wounds. Two layer compression wrap to be changed daily. Wound Care Clinic (WCC) may use [MEDICATION NAME] if patient does not have cream with her. Review of Resident #110s pain medication orders revealed there were no orders for pain medication to be given prior to her dressing change. An interview on 01/03/18 at 9:42 AM with Resident #110 revealed she had been at the facility for approximately 3 years. The resident stated that she had a wound on her right leg below her knee due to venous ulcer and had had the wound for 2 years. She stated that she had been to the wound clinic yesterday and the physician had debrided her wound and showed a picture on her phone of the wound. The resident stated she had been dealing with the treatment for 2 years and the physician numbed it at the wound clinic before changing her dressing, but they had not done that at the facility. The resident stated the dressing changes were painful but her pain pill helped after the dressing changes. The resident stated she was also being seen at the pain clinic and she had told the physician she was having pain with the dressing changes and stated the physician wanted her to stay on the current pain regimen for at least 6 weeks before she changed the orders. She stated that she had complained about pain during the dressing changes but had been told they were giving her all the medication she had ordered for pain. The resident stated she just had to get through the dressing change and try to tolerate the pain. The resident acknowledged she had not asked them to stop the dressing change because she knew it had to be done and she knew they would not give her anything additionally for the pain. Observation of Resident #110s dressing change on 01/04/18 at 4:20 PM revealed the resident had been pre-medicated by Nurse #2 for the procedure at 3:25 PM. The supervisor using aseptic technique started cutting the dressing away from the wound and the resident had tolerated it well. The supervisor had begun to remove the dressing and the resident started yelling that it was hurting, crying, visibly grimacing with tears running down her face. The supervisor was asked to stop and Nurse #2 stated I will continue to try to remove the dressing, and they were both asked to step out in the hall. The supervisor stated the resident always had pain with the dressing change, but not usually this bad and stated they were usually able to talk to her and continue with the dressing change. The supervisor stated Resident #110 had been on the same pain regimen for approximately 6 weeks and it had not controlled her pain and the resident usually complained of pain during the dressing change. The supervisor stated Resident #110 had been on [MEDICATION NAME] 4 milligrams (mg) at 5:00 PM scheduled and [MEDICATION NAME] 4 mg as needed (prn) times one dose daily and had still had pain with her dressing changes. The supervisor stated they had contacted the pain clinic for additional orders for dressing changes and the physician had not wanted to change the resident's orders. The supervisor stated the pain clinic physician wanted the resident to remain on the current pain regimen at least 6 weeks and it had been approximately 4 weeks. The supervisor also stated the Nurse Practitioner and attending physician at the facility had not wanted to write any additional orders for pain since the pain clinic was managing her pain medication. The supervisor and Nurse #1 went back into the resident's room and continued to try to remove the dressing and the resident continued to cry out, with a grimaced face and had tears rolling down her cheeks. The supervisor asked the resident at 4:35 PM if she wanted her scheduled dose of pain medication and the resident stated no, she wanted to wait until the dressing change was done. The supervisor continued to try to remove the dressing that was saturated but it was stuck to the wound bed and the resident continued to cry in pain. At 5:20 pm the supervisor went out of the room to get the Director of Nursing (DON) for her to try to remove the dressing. The supervisor stated she had not seen Resident #110 cry out in this much pain. The DON came into the room, saturated the dressing again and attempted to loosen the dressing and the resident again cried out in pain, was grimacing and had tears rolling down her face. The DON stated to Resident #110 why don't you take your additional pain medication and the resident agreed at 5:30 pm to take the medication. The DON stated to the resident why are you acting like this? You don't usually cry out in pain like this, what is different? The resident stated to the DON I don't know what is different it just hurts and the nurse put too much medicine on it last night when she changed it and it hurts. The DON kept trying to get the dressing off and finally was able to remove the top dressing but the wound bed dressing was still attached. At 5:30 PM, the supervisor returned with Resident #110's pain pill and asked the nurses if they would wait to give the pill a chance to kick in before they continued with the dressing change. The supervisor and Nurse #1 stated they would return in 20 to 30 minutes to continue with the dressing change. At 5:23 PM an interview with Resident #110 revealed the pain associated with the dressing change was much worse today than previously. She stated there was always some pain associated with the dressing change but the dressing had not been sticking to the wound like it had this time. She stated that she had usually yelled in pain but not like this and stated that it had not previously hurt this bad. At 5:53 PM the supervisor and Nurse #1 returned to the resident's room to try to remove the dressing again. The supervisor started working with the dressing after saturating it again and the resident again cried out in pain so the supervisor stopped. Nurse #1 stated she would try to remove the dressing and started working with the dressing and after a while was finally able to remove the rest of the dressing. Resident #110 continued to cry during the removal of the dressing but stated the medication had helped a little bit. The wound had a circular area at the top and then a larger wider open area down to the ankle. The wound bed had granulating tissue but there was an excess of cream on the skin and on the wound that had not been absorbed. Upon the dressing being removed the supervisor and Nurse #1 ascertained that the wrong dressing had been applied to the resident's wound on 01/03/18 when the second shift nurse had changed it. The orders were written for ABD pads (which are non-adherent) to be applied to the wounds and gauze (which is adherent) had been applied to the wound instead. The nurses cleaned the excess cream from the skin surrounding the wound and some from the wound itself. Nurse #1 using aseptic technique applied a thin layer of [MEDICATION NAME] cream on the wound, and applied 5 ABD pads to cover the wound completely and wrap around the ankle. The 2 step compression was then layered over the ABD pads and taped in place and the dressing was covered with a stockinette. Nurse #1 stated the dressing came in a kit which contained the 2 compression dressings and the stockinette. The nurse stated there was a supply of the kits in the clean utility room. An interview on 01/05/18 at 10:01 AM with the wound care clinic physician revealed they had been battling Resident #110's wound for some time and had tried various treatments and had finally seen some improvement with the wound. The physician stated he had just debrided the wound on 01/02/18 and changed her orders for her dressing to a non-adherent dressing. He stated that the resident had a low pain tolerance and they were actually anesthetizing the wound prior to her dressing change at the wound clinic. The physician stated he expected Resident #110 would need a little something prn for pain prior to her dressing being done at the facility. He stated that gauze on a wound after debridement would legitimately cause pain with the removal of the dressing. The physician also stated the pain she had with the removal of the gauze dressing demonstrated why you would have used and why he had ordered a non-adherent dressing. An interview on 01/05/18 at 11:55 AM with the Medical Director revealed that he expected when he wrote an order for [REDACTED]. An interview on 01/05/18 at 12:03 PM with the facility's Nurse Practitioner revealed that she expected when she wrote an order for [REDACTED]. An observation on 01/05/18 at 1:18 PM of the clean utility room revealed there were 6 kits for Resident #110's dressing available for use. An interview on 01/05/18 at 3:21 PM with Nurse #3 revealed she had done the dressing on 01/03/18 for Resident #110 on second shift. She stated she had followed the physician order [REDACTED]. Nurse #3 reviewed the MAR and realized the orders for the dressing had been changed on 01/02/18 by the wound care physician and stated that she had not followed the new orders for wound care. Nurse #3 stated she had looked at the old orders and followed them instead of the new orders. An interview on 01/05/18 at 3:33 PM with the Director of Nursing (DON) revealed she felt like Resident #110 was being dramatic during her dressing change and stated the resident was crying out when she wasn't even touched. The DON stated that she had never seen the resident cry out to that level during a dressing change. She stated to her knowledge the dressing was the same process and there had been no difference yesterday. The DON stated she had even come in on weekends and done the dressing before so it was not a strange or new person who had done the dressing. The DON revealed her expectation was for the nurses to follow physician orders [REDACTED]. An interview on 01/05/18 at 6:50 PM with the DON and Administrator revealed the Administrator would have expected the resident's pain to be managed during her dressing change.