Every finding on record at Greenville Health and Rehabilitation Center

Based on record review and interviews with staff, Physicians and Nurse Practitioners (NP), the facility failed to notify and consult with a medical provider for new onset and continued vomiting and when bolus tube feedings (liquid formula is administered through a feeding tube into the stomach in larger volumes over a short period) were held for a severely cognitively impaired resident with a diagnosis of traumatic brain injury (disruption in normal brain function caused by an external mechanical force) who received all fluid and caloric intake through tube feedings. Resident #145 had an acute vomiting episode on [DATE] (Friday) before 6:00 AM, and the 6:00 AM bolus feeding was held. The medical provider was not notified of the vomiting or that the bolus tube feeding was being held. The resident had a second vomiting episode on [DATE] before 10:00 PM, and the 10:00 PM bolus tube feeding was held. Nurse #2 contacted the on-call medical provider, and a kidney, ureters, and bladder (KUB) x-ray was ordered at 10:42 PM. Resident #145 vomited on [DATE] before the scheduled 10:00 AM bolus tube feeding and a medical provider was not notified of the vomiting or the bolus tube feeding being held. The x-ray was completed during the 3:00 PM to 11:00 PM shift on [DATE] and the results were received at 1:00 AM on [DATE] (Sunday) and a medical provider was not informed of or consulted regarding the results. The KUB results included abundant fecal material seen within the distal large bowel loops (outer, peripheral loops of the colon) and up to 0.5 centimeters (cm) dilated rectum in keeping with constipation and possible fecal retention (stool becomes hard and stuck in the rectum). Abundant air was seen within up to 9.7 cm dilated large bowel loops and small bowel loops, which may have represented obstipation (severe form of constipation when the patient cannot pass fecal material or gas) and/or ileus (temporary slowing or obstruction of the digestive tract. If untreated, ileus can lead to intestinal perforation, infection, or tissue death, making prompt medical attention essential). Resident #145 vomited on [DATE] before the scheduled 10:00 AM bolus tube feeding and a medical provider was not notified of the vomiting or the bolus tube feeding being held. The KUB results were not called to a medical provider on [DATE] but were reviewed by NP #1 at 1:55 PM on [DATE]. NP #1 ordered an aggressive bowel regimen for three days including lactulose (prescription laxative) daily, a suppository daily, and an herbal laxative syrup twice daily. On [DATE] Resident #145 vomited twice during the evening shift from 3:00 PM to 11:00 PM, anti-nausea medication was administered, and the 6:00 PM bolus tube feeding was held. A medical provider was not notified of the vomiting or the bolus tube feeding being held. Then on [DATE], Nurse #5 documented at 8:20 PM that the resident vomited five times and contacted the on-call medical provider. The on-call medical provider asked for the KUB results but did not have access to the radiology report. The 10:00 PM bolus tube feeding was held on [DATE] and an injection used to prevent and treat nausea and vomiting was prescribed every six hours for two days. The nurse documented on [DATE] at 7:03 AM that the resident tolerated the 2:00 AM and 6:00 AM bolus tube feedings; however, he vomited afterward and had to be cleaned up. The medical provider was not notified of the vomiting. On [DATE] at 10:00 AM the nurse held the 10:00 AM bolus tube feeding and the medical provider was not notified. Later in the shift the nurse noted Resident #145 was sweating profusely, had labored breathing, and his skin was clammy but warm to the touch. His oxygen saturation was noted to be 79% (normal range 95 to 100%). The Physician was notified and ordered oxygen and for Resident #145 to be sent to the hospital for an evaluation. Emergency Medical Services (EMS) was contacted and was at the bedside at 12:20 PM and Resident #145 was found unresponsive, tachypneic (abnormally rapid and shallow breathing), clammy, cyanotic (a bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) and in obvious distress. His blood pressure (BP) was 98/64 (normal range <120 and <80), pulse 188 (normal range 60 to 100 bpm), respirations 46 (normal range 12 to 20), blood sugar 119 (normal range 70 to 140), pupils were 8 millimeters and nonreactive (fixed or nonreactive pupils are a serious neurological sign that requires immediate medical evaluation). The oxygen level in his blood was very low and a non- rebreather mask (oxygen mask that delivers high concentrations of oxygen) with oxygen at 15 liter per minute was applied at 12:26 PM. EKG (electrocardiogram) results noted subventricular tachycardia (SVT which is a type of arrhythmia where the heart beats too fast, originating in the upper chambers (atria) or the atrioventricular (AV) node). Cardioversion was attempted three times but was not successful (cardioversion involves delivering a controlled electric shock to the heart to restore a normal rhythm) and a chemical cardioversion was attempted and was not successful. At 12:38 PM assisted ventilations using a bag valve mask (BVM) with oxygen at 25 liters per minute was initiated. Vital signs at 12:44 PM included BP 64/44 (severely low blood pressure), pulse 180, respirations 29 and blood oxygen saturation was 75%. An intravenous (IV) drip of epinephrine (vasoconstrictor which can stimulate the heart and increase blood flow to the brain and other organs) was initiated at 12:46 PM with no improvement of blood pressure noted. EMS left the facility at 12:48 PM with Resident #145 and advised the Emergency Department (ED) of medical red which means the patient has conditions that required immediate medical attention to have a chance of survival. While enroute to the ED at 12:49 PM vital signs included BP 25/19 (critically low blood pressure), pulse 169, respirations 23, and blood oxygen saturation of 73%. His temperature was 103.1 degrees Fahrenheit at 1:00 PM, which was noted as an indication of sepsis. In the ED Resident #145 was unresponsive and in obvious respiratory distress with grunting and retractions (the chest [NAME] in when a person tries to breathe in). ED triage vital signs at 1:04 PM included BP 75/21 (hypotensive), pulse 182, respirations 26 and blood oxygen saturation of 75%. The physical exam noted the resident was in acute distress, had dark brown gastric contents oozing from mouth and nose, pupils were dilated and minimally reactive, sweating heavily, tachycardic, had abdominal distention and rhonchi (continuous, low-pitched, coarse lung sounds caused by partial obstruction of the larger airways, often due to mucus or secretions) was noted when lung sounds were assessed. Resident #145 required urgent intubation for airway protection which was complicated by copious amounts of gastric regurgitation in the airway and was suctioned extensively before the second attempt at intubation was successful. Resident #145 was started on three vasoconstrictors used to treat life-threatening low BP and became bradycardic (heart rate of less than 60 beats per minute) and received a dose of atropine (used to treat bradycardia) just prior to cardiac arrest. Resident #145 arrested a total of four times, and he underwent four rounds of Cardiopulmonary Resuscitation (CPR) and spontaneous circulation was restored each time. He was transferred to the Cardiac Intensive Care Unit (ICU) in guarded condition. The physician in the Cardiac ICU documented an orogastric tube (OGT) was placed in the ED and was placed to suction when Resident #145 arrived in the Cardiac ICU. Bright red blood was observed from the OGT and despite continuous suction Resident #145's abdomen continued to increase in size. The CT (computed tomography) scans noted concerns for a small bowel obstruction and impacted stool in the rectum. Attempts were made to manually remove the impacted stool from the rectum but were unable to reach a large portion of the stool. Acute Care Surgery was consulted by the Cardiac ICU physician due to acute abdomen and concluded Resident #145 had multisystem organ failure and was not a surgical candidate. Despite aggressive medical interventions Resident #145 died on [DATE] at 12:21 AM. The Death Certificate dated [DATE] revealed that Resident #145's primary cause of death was sepsis (a systemic infection bacteria that could quickly progress to septic shock and multi organ failure) secondary to probable aspiration pneumonia. The deficient practice occurred for 1 of 2 residents reviewed for tube feeding management (Resident # 145).Immediate jeopardy began on [DATE], when nursing staff failed to notify and consult with a medical provider regarding the results of the KUB and Resident #145's continued vomiting. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.Findings included: Resident #145 was a [AGE] year-old male who was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury (TBI), protein calorie malnutrition, gastrostomy status (means a person has a surgically placed gastrostomy tube/feeding tube that provides direct access to the stomach for nutrition, fluids, or medication), dysphagia (difficulty swallowing), and quadriplegia. On [DATE] a physician's order was entered for bolus tube feeding six times a day with one can of Nutren 2.0 (tube feeding formula) 240 milliliters (mL) via the gastrostomy tube after placement was confirmed. Hold for residuals (the volume of formula or stomach contents that remain in the stomach after a feeding) greater than 200 mL. After 2 hours recheck and if the residuals remain greater than 200 mL, notify the physician and make sure the resident had a recent bowel movement if the tube feeding was held. Review of Resident #145's medical record from [DATE] through 7/2025 revealed no documentation of any vomiting episodes. Nursing staff schedules revealed Nurse #1 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. A nursing progress note dated [DATE] at 7:18 AM by Nurse #1 revealed that Resident #145 vomited twice with a light brown milky substance like the tube feeding. The resident position was high bed [NAME] (the bed is elevated 60 to 90 degrees) lying on the bed. He did not have shortness of breath. The oxygen saturation measured 97% (normal range 95 to 100%), and the 6:00 AM tube feeding was held. Nurse #1 would continue to monitor Resident #145. The [DATE] Medication Administration Record (MAR) revealed that Resident #145 did not receive the 6:00 AM bolus tube feeding on [DATE] due to vomiting. There was no documentation in Resident #145's medical record that showed Nurse #1 contacted a medical provider when the 6:00 AM bolus tube feeding was held on [DATE] or about the vomiting episode. Nurse #1 was interviewed via telephone on [DATE] at 8:15 AM and confirmed she was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. She revealed that she did not notify a provider by phone when she held the bolus tube feeding on [DATE] at 6:00 AM. Nurse #1 stated that she recorded Resident #145's vomiting episode in the provider notification book (a central communication binder for all updates, alerts, and/or instructions between nurses and providers) located at the nurses' station. Nurse #1 felt that this was the appropriate action after Resident #145's first vomiting episode rather than contacting a provider directly. She indicated that she was unsure if a provider saw her documentation on [DATE]. Nursing staff schedules revealed Nurse #2 was assigned to the resident on [DATE] from 3:00 PM until 11:00 PM. At 10:05 PM on [DATE], Nurse #2 included a note on the [DATE] MAR that coincided with the 10:00 PM bolus tube feeding administration that read: vomiting x1. A nursing progress note dated [DATE] at 10:51 PM by Nurse #2 revealed that Resident #145 had one vomiting episode. The substance appeared as clear content with yellow content of the resident's tube feeding. Resident #145 was stable with no facial grimacing noted. The abdominal area had hypoactive bowel sounds and was distended/bloated. The on-call provider was contacted, and they ordered Zofran 4 mg (milligrams) every 8 hours for three days for nausea and vomiting. A KUB of the abdomen was also ordered related to nausea and vomiting. Resident #145's last bowel movement was on [DATE] and was large in appearance. An on-call provider note dated [DATE] completed by Nurse Practitioner #2 revealed that Resident #145's vital signs at the time of notification from Nurse #2 at 10:42 PM included temperature of 97.2 degrees Fahrenheit (normal range 97 to 99 degrees Fahrenheit), BP of 113/82, pulse of 100 beats per minute, respiration rate per minute was 20, and the oxygen saturation measured 94%. The resident was stable, at normal baseline, and smiling. Resident #145 had a vomiting episode, and the last feeding for the evening shift scheduled for 10:00 PM was held. The vomiting content appeared clear and had some yellow content, which was the same color as the tube feeding he received. Residual measured 30 mL. The abdomen was bloated with hypoactive bowel sounds, and his last large bowel movement was on [DATE]. Nurse Practitioner #2 recommended Zofran as needed and a KUB of the abdomen due to the vomiting episode reported by Nurse #2. Multiple attempts were made to interview Nurse Practitioner #2 by phone, but she was unable to be reached during the investigation and no longer worked with the facility.A Change in Condition Evaluation dated [DATE] by Nurse #2 indicated that Resident #145 had a nausea/vomiting episode with a distended abdomen and no pain. The change in condition started during the night of [DATE]. There were no changes in mental or functional status noted. The on-call provider ordered a KUB of abdomen and anti-nausea medicine every eight hours for three days. Nurse #2's contact information was not available; she no longer worked at the facility and was unable to be contacted for interview during the investigation.Nursing staff schedules revealed Nurse #4 was assigned to the resident on [DATE] from 7:00 AM until 3:00 PM. The [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding was held on [DATE] by Nurse #4 due to vomiting that resembled his tube feeding formula. There was no documentation in Resident #145's medical record that Nurse #4 contacted a medical provider when the 10:00 AM bolus tube feeding was held on [DATE] or about the vomiting episode. Nursing staff schedules revealed Nurse #3 was assigned to the resident on [DATE] from 3:00 PM until 11:00 PM. A nursing note dated [DATE] at 11:09 PM by Nurse #3 revealed that the KUB was completed during the evening shift and results were pending. Nurse #3's contact information was not available; she no longer worked at the facility and was unable to be contacted for interview during the investigation.The Radiology Results Report for Resident #145's KUB was received by the facility on [DATE] at 1:00 AM. The results showed abundant fecal material seen within the distal large bowel loops and up to 0.5 centimeters (cm) dilated rectum in keeping with constipation and possible fecal retention. Abundant air was seen within up to 9.7 cm dilated large bowel loops and small bowel loops, which may have represented obstipation and/or ileus. The radiologist recommended review of the KUB results and an appropriate follow up evaluation was clinically warranted. A computed tomography (CT) scan, or more detailed x-ray, was recommended to be considered by the facility. According to the results report, Nurse Practitioner #1 reviewed the KUB results on [DATE] at 1:55 PM. Nursing staff schedules revealed Nurse #7 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. There was no documentation in Resident #145's medical record that Nurse #7 contacted a medical provider with the results of the KUB during the 11:00 PM to 7:00 AM shift. Multiple attempts were made to interview Nurse #7 by phone, but she was unable to be reached during the investigation and no longer worked at the facility.The [DATE] MAR revealed on [DATE] Resident #145 received the 2:00 AM and 6:00 AM bolus tube feedings given by Nurse #1.At 6:26 AM on [DATE], Nurse #1 included a note that coincided with the August MAR for as needed Zofran administration that read: vomit x 1 this shift, large amount of large brown substance that appears to be (the tube) feeding. Nursing staff schedules revealed Nurse #4 was assigned to Resident #145 on [DATE] from 7:00 AM to 3:00 PM. The [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding on [DATE] was held by Nurse #4 due to a vomiting episode prior to the feeding. A nursing progress note dated [DATE] at 3:49 PM by Nurse #4 revealed that Resident #145 vomited once which resembled the tube feeding during the day shift. The morning feeding was held, and Resident #145 tolerated the afternoon feeding. No further vomiting episodes were noted. Vital signs were measured and included temperature of 95.5 degrees Fahrenheit, pulse of 88 beats per minute, and blood pressure of 110/70. There was no documentation in Resident #145's medical record that Nurse #4 contacted a provider when the 10:00 AM bolus tube feeding was held on [DATE] or about the vomiting episode. Nurse #4 was interviewed via telephone on [DATE] at 4:00 PM. She revealed that Resident #145's temperature measurement of 95.5 degrees Fahrenheit included in the [DATE] at 3:49 PM nursing progress note was a data entry error. Nurse #4 explained if Resident #145 displayed a temperature of 95.5, she would first recheck the temperature and if still measured 95.5 degrees Fahrenheit she would notify the provider immediately and follow orders. Nurse #4 stated that it was facility protocol for nursing staff to contact the provider after a vomiting episode for any resident. She could not recall the details of Resident #145's vomiting episode on [DATE] during her shift. Nurse #4 indicated that she could not recall if she contacted the provider or not when the 10:00 AM tube feeding bolus was held on [DATE]. The physician orders for Resident #145 revealed that Nurse Practitioner #1 entered orders on [DATE] at 2:11 PM and included Lactulose solution (prescription laxative used to treat chronic constipation) via gastrostomy tube one time a day for constipation for three days, Bisacodyl suppository (fast acting laxative used to relieve occasional constipation) insert one suppository rectally one time a day for constipation for three days, and Senna oral syrup (herbal laxative used to relieve occasional constipation) give via gastrostomy tube two times a day for bowel regulation for three days.Review of the medical record revealed Nurse Practitioner #1 did not document a progress note on [DATE]. Nurse Practitioner #1 was interviewed via telephone on [DATE] at 12:50 PM. She revealed she had not worked at the facility since [DATE]. Nurse Practitioner #1 stated that if Resident #145's KUB x-ray results were received over the weekend, then the nurse on duty who received it should have contacted the on-call provider with the results. She could not recall the details of Resident #145's vomiting episodes or the KUB results and indicated she needed Resident #145's medical record in front of her to answer further questions. NP #1 then ended the call noting a current medical problem. Nursing staff schedules revealed Nurse #3 was assigned to Resident #145 on [DATE] from 3:00 PM until 11:00 PM.A nursing progress note dated [DATE] at 10:37 PM by Nurse #3 revealed that Resident #145 vomited twice during the evening shift from 3:00 PM to 11:00 PM. The as needed Zofran was given, and the 6:00 PM bolus tube feeding was held.The [DATE] MAR revealed that Resident #145's 6:00 PM bolus tube feeding was held on [DATE] by Nurse #3. There was no documentation in Resident #145's medical record that Nurse #3 contacted a provider when the 6:00 PM tube feeding bolus was held on [DATE] or about vomiting twice earlier during the evening shift on [DATE].Nursing Staff schedules revealed Nurse #5 was assigned to Resident #145 from 3:00 PM until 11:00 PM on [DATE]. A nursing progress note dated [DATE] at 8:20 PM by Nurse #5 revealed that Resident #145 vomited five times during the evening shift. His abdomen was distended, and the vomit substance appeared to be yellow. The on-call provider was notified and ordered Phenergan 25 mg intramuscular every six hours for two days for nausea and vomiting. An on-call provider note dated [DATE] completed by Nurse Practitioner #3 revealed that Resident #145's vital signs at the time of notification from Nurse #5 at 8:20 PM included temperature of 97.8 degrees Fahrenheit, blood pressure of 134/76, pulse of 76 beats per minute, respiration rate per minute was 18, and the oxygen saturation measured 96%. Resident #145 had a vomiting episode, and the contents were yellow and appeared to be stomach acid. His abdomen was distended. The as needed Zofran was administered at 7:30 PM but was not effective, and Resident #145 had vomited twice since then. Nurse Practitioner #3 asked Nurse #5 if the KUB results ordered by Nurse Practitioner #2 on [DATE] were available for her to review and asked what was given to Resident #145 due to the x-ray results. Nurse #5 told Nurse Practitioner #3 about the bowel regimen of Lactulose, Bisacodyl suppository, and Senna liquid ordered by Nurse Practitioner #1 on [DATE]. Phenergan (antihistamine used to prevent and treat nausea and vomiting) intramuscular every six hours as needed for two days for nausea/vomiting was recommended. Nurse Practitioner #3 was contacted via telephone for an interview on [DATE] at 4:18 PM; however, she no longer worked at the facility and refused to answer any questions related to Resident #145. Nurse Practitioner #4 was interviewed via telephone on [DATE] at 3:21 PM after reviewing Resident #145's medical record. She revealed that she was the current Nurse Practitioner Supervisor for the facility on-call providers. Nurse Practitioner #4 stated that based on her own opinion she would not have held the bolus tube feeding after Resident #145 first vomited on [DATE] until bowel sounds were assessed. NP #4 indicated when NP #2 was notified on [DATE] in the evening that it was the second vomiting episode and had only 30 mL of residuals, then she would not have held the 10:00 PM bolus tube feeding. The on-call providers would not automatically receive the KUB results unless notified. NP #4 explained on [DATE] during the evening shift, Nurse Practitioner #3 asked for the KUB results, but the KUB results were not included in the resident's chart and could not be seen presently. After reviewing the KUB results, Nurse Practitioner #4 stated that she would have implemented a more aggressive bowel regimen just as Nurse Practitioner #1 did on [DATE]. However, she would be more reserved about holding the bolus tube feedings in general due to reduced caloric intake and possible blood sugar issues. The [DATE] MAR revealed that Resident #145's 10:00 PM bolus tube feeding was held on [DATE] by Nurse #5. Multiple attempts were made to interview Nurse #5 by phone, but she was unable to be reached during the investigation and no longer worked at the facility.Nursing Staff schedules revealed Nurse #1 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. A nursing progress note dated [DATE] at 7:03 AM by Nurse #1 revealed that Resident #145 was alert and responsive, tolerated the bolus feedings at 2:00 AM and 6:00 AM during the overnight shift, and vomited once. He was bathed and the linens were changed. There was no documentation in Resident #145's medical record that showed Nurse #1 contacted a provider when Resident #145 vomited once during the overnight shift from 11:00 PM on [DATE] until 7:00 AM on [DATE]. During a follow-up interview with Nurse #1 on [DATE] at 9:37 AM, she revealed that during the overnight shift from 11:00 PM on [DATE] through 7:00 AM on [DATE] when Resident #145 vomited, she did not contact the provider and only recorded the episode in the provider communication book because it had occurred towards the end of her shift and it was not an out of the ordinary occurrence.Nursing Staff schedules revealed Nurse #4 was assigned to Resident #145 on [DATE] from 7:00 AM to 3:00 PM.The [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding was held on [DATE] by Nurse #4. There was no documentation in Resident #145's medical record that Nurse #4 contacted a provider when the 10:00 AM bolus tube feeding was held on [DATE]. A nursing progress note dated [DATE] at 12:34 PM by Nurse #4 revealed that Physician #3 was in the facility making rounds to address Resident #145's continued nausea and vomiting unrelieved by as needed Zofran. Resident #145 was sweating excessively and had labored breathing. His skin was clammy and warm to the touch. Oxygen saturation was noted to be 79% on room air. Orders were received from Physician #3 for 2 liters of oxygen via nasal cannula and were implemented. Physician #3 then placed the order for Resident #145 to be sent to the emergency department (ED) for altered mental status and change of condition. Emergency Medical Services (EMS) arrived and assumed care of the resident. Nurse #4 was interviewed via telephone on [DATE] at 4:00 PM. Nurse #4 stated that it was facility protocol for nursing staff to contact the provider after a vomiting episode for any resident. She could not recall the details of Resident #145's vomiting episode on [DATE] during her shift. Nurse #4 indicated that she could not recall if she contacted the provider or not when the 10:00 AM tube feeding bolus was held on [DATE]. Review of the medical record revealed Physician #3 did not document a progress note on [DATE]. On [DATE] at 4:08 PM Physician #3 was interviewed via telephone. He revealed that the last time he evaluated Resident #145 was on [DATE]. He never had any interaction with Resident #145 after that date. Physician #3 stated that no nursing staff came to him on [DATE] while he was in the facility and told him there was an emergency with Resident #145. He could not recall if any nursing staff asked him to come to Resident #145's room to assess him or if he ordered two liters of oxygen or to send Resident #145 to the ED. Physician #3 stated that if he sent any resident to the ED, he would have written a progress note of his evaluation and the reason for sending the resident to the hospital. The EMS Report dated [DATE] revealed that 911 was contacted at 12:10 PM for a resident with difficulty breathing, EMS was dispatched at 12:12 PM, arrived at the facility at 12:16 PM, and was at the bedside at 12:20 PM. Resident #145 was found unresponsive, tachypneic, clammy, cyanotic and in obvious distress. At 12:20 PM his BP was 98/64, pulse 188, respirations 46, blood sugar 119, pupils were 8 millimeters and nonreactive, and a Glascow Coma Scale of 6 (GCS- clinical tool used to assess a patient's level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully alert)). A GCS of 6 indicates a lack of responsiveness suggesting a patient is in critical condition with a severe disruption in nervous system function and often associated with the need for airway protection. The oxygen level in his blood was very low and a non- rebreather mask with oxygen at 15 liter per minute was applied at 12:26 PM. EKG results noted subventricular tachycardia. Cardioversion was attempted three times but was not successful and a chemical cardioversion was attempted and was not successful. At 12:38 PM assisted ventilations using BVM with oxygen at 25 liters per minute was initiated. Vital signs at 12:44 PM included BP 64/44, pulse 180, respirations 29 and blood oxygen saturation was 75%. An intravenous (IV) drip of epinephrine was initiated at 12:46 PM with no improvement of blood pressure noted. EMS left the facility at 12:48 PM with Resident #145 and advised the ED of medical red. While enroute to the ED at 12:49 PM vital signs included BP 25/19, pulse 169, respirations 23, and blood oxygen saturation of 73%. His temperature was 103.1 degrees Fahrenheit at 1:00 PM, which was noted as an indication of sepsis. The report noted Resident #145's care was transferred to the ED.The ED provider note dated [DATE] indicated when Resident #145 arrived at the ED EMS reported to the ED physician Resident #145 had been vomiting in the days prior, was unresponsive when they arrived at the facility, and SVT was noted on the EKG. In the ED he was unresponsive and in obvious respiratory distress with grunting and retractions. ED triage vital signs at 1:04 PM included BP 75/21, pulse 182, respirations 26 and blood oxygen saturation of 75%. The physical exam noted the resident was in acute distress, had dark brown gastric contents oozing from mouth and nose, pupils were dilated and minimally reactive, sweating heavily, tachycardic, had abdominal distention and rhonchi was noted when lung sounds were assessed. Resident #145 required urgent intubation for airway protection which was complicated by copious amounts of gastric regurgitation in the airway and was suctioned extensively before the second attempt at intubation was successful. Resident #145 was then started on epinephrine, levophed and vasopressin which are all vasoconstrictors used to treat life-threatening low BP. He became bradycardic and received a dose of atropine (used to treat bradycardia) prior to PEA arrest (Pulseless Electrical Activity which means the heart stops and the patient is in cardiac arrest) and CPR (cardiopulmonary resuscitation) was started immediately and there was a return of spontaneous circulation prior to a second cardiac arrest. CPR was started again and a return of spontaneous circulation was achieved a second time. During goals of care discussions with Resident #145's family member it was requested the resident remain a full code. In all Resident #145 underwent four rounds of CPR. The ED provider documented that due to Resident #145's hemodynamic instability and critical condition the Cardiac Intensive Care Unit (ICU) was consulted, and he was admitted in guarded condition.The Cardiac Critical Care (ICU) admission noted dated [DATE] indicated Resident #145 had CT scans completed and was brought to the Cardiac ICU. The physician further noted had been vomiting the days prior and the facility had sent a KUB report which showed distended bowel loops. It was noted the resident was hemodynamically unstable with high and difficulty maintaining oxygen saturation on the ventilator. An orogastric tube (OGT) was placed in the ED and was placed to suction when Resident #145 arrived in the Cardiac ICU. Bright red blood was observed from the OGT and despite continuous suction Resident #145's abdomen continued to increase in size. The CT scans noted concerns for a small bowel obstruction and impacted stool in the rectum. Attempts were made to manually remove the impacted stool from the rectum but were unable to reach a large portion of the stool. Acute Care Surgery was consulted by the Cardiac ICU physician due to acute abdomen and concluded Resident #145 had multisystem organ failure and was not a surgical candidate. A goal of care meeting was held with Resident #145's family member and his code status was changed to DNR (Do Not Resuscitate). Despite aggressive medical interventions Resident #145 died on [DATE] at 12:21 AM.The Death Summary and Certificate Information from the hospital dated [DATE] revealed that Resident #145 expired at 12:21 AM. The final disease resulting in death was documented as multi-system organ failure and circulatory shock due to aspiration pneumonia. The Death Certificate dated [DATE] revealed that Resident #145's primary cause of death was sepsis secondary to probable aspiration pneumonia.Physician #1 was interviewed via telephone on [DATE] at 12:59 PM. She revealed that she was the interim Medical Director in [DATE], and her last day at the facility was [DATE]. Physician #1 indicated that she did not see any residents [NAME][TRUNCATED]

Based on record review and interviews with staff, Physicians and Nurse Practitioners (NP), the facility failed to identify the seriousness of new onset and continued vomiting, complete and document ongoing comprehensive nursing assessments of the residents condition or identify the urgent need for medical attention for a severely cognitively impaired resident with a diagnosis of traumatic brain injury who received all fluid and caloric intake through bolus tube feedings six times a day. Resident #145 had an acute vomiting episode on [DATE] and the 6:00 AM bolus feeding was held. Nursing staff provided three scheduled bolus tube feedings on [DATE] before the 10:00 PM bolus tube feeding was held due to vomiting. The on- call provider was contacted and notified Resident #145's abdominal area had hypoactive bowel sounds and was distended/bloated. The on-call provider ordered a kidney, ureters, and bladder (KUB) x-ray at 10:42 PM and Zofran (antiemetic). On [DATE] Resident #145 vomited before the bolus tube feeding was due at 10:00 AM and the feeding was held. The KUB was completed during the 3:00 to 11:00 PM shift on [DATE] and the results were received at 1:00 AM on [DATE] (Sunday) which showed abundant fecal material seen within the distal large bowel loops (outer, peripheral loops of the colon) and up to 0.5 centimeters (cm) dilated rectum in keeping with constipation and possible fecal retention (stool becomes hard and stuck in the rectum). Abundant air was seen within up to 9.7 cm dilated large bowel loops and small bowel loops, which may have represented obstipation (severe form of constipation when the patient cannot pass fecal material or gas) and/or ileus (temporary slowing or obstruction of the digestive tract. If untreated, ileus can lead to intestinal perforation, infection, or tissue death, making prompt medical attention essential). All scheduled bolus tube feedings were provided after 10:00 AM on [DATE] until [DATE] when the resident vomited and the 10:00 AM and the feeding was held. The KUB results were not reviewed by a medical provider until NP #1 on [DATE] at 1:55 PM who ordered an aggressive bowel regimen for three days including lactulose daily, a suppository daily, and an herbal laxative syrup twice daily. NP #1 did not assess Resident #145 on [DATE]. Despite continued vomiting episodes and KUB results which noted abundant fecal retention and possible ileus nursing staff continued to provide the bolus tube feedings except when the resident vomited. The 2:00 PM bolus tube feeding was provided on [DATE] and when Resident #145 vomited twice during the evening shift the 6:00 PM tube feeding was held. Resident #145 was provided with all scheduled bolus tube feeding after 6:00 PM on [DATE] until the resident vomited five times and the 10:00 PM on [DATE] was held. Then on [DATE], Nurse #5 documented at 8:20 PM that the resident vomited five times and contacted the on-call medical provider. The nurse documented his abdomen was distended, and the vomited substance appeared to be yellow. The on-call medical provider asked for the KUB results but did not have access to the radiology report. The 10:00 PM bolus tube feeding was held on [DATE] and an injection used to prevent and treat nausea and vomiting was prescribed every six hours for two days. The 2:00 AM and 6:00 AM bolus tube feedings were provided however, the resident vomited after the 6:00 AM feeding. The nurse held the 10:00 AM bolus tube feeding on [DATE] and later in the shift the nurse noted Resident #145 was sweating profusely, had labored breathing, and his skin was clammy but warm to the touch. His oxygen saturation was noted to be 79% (normal range 95% to 100%). The Physician was notified and ordered oxygen and for Resident #145 to be sent to the hospital for an evaluation. Emergency Medical Services (EMS) was contacted and was at the bedside at 12:20 PM and Resident #145 was found unresponsive, tachypneic (abnormally rapid and shallow breathing), clammy, cyanotic (a bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) and in obvious distress. His blood pressure (BP) was 98/64 (normal range <120 and <80), pulse 188 (normal range 60 to 100), respirations 46 (normal range 12 to 20), blood sugar 119 (normal range 70 to 140), pupils were 8 millimeters and nonreactive (fixed or nonreactive pupils are a serious neurological sign that requires immediate medical evaluation). The oxygen level in his blood was very low and a non- rebreather mask (oxygen mask that delivers high concentrations of oxygen) with oxygen at 15 liter per minute was applied at 12:26 PM. EKG (electrocardiogram) results noted subventricular tachycardia (SVT which is a type of arrhythmia where the heart beats too fast, originating in the upper chambers (atria) or the atrioventricular (AV) node). Cardioversion was attempted three times but was not successful (cardioversion involves delivering a controlled electric shock to the heart to restore a normal rhythm) and a chemical cardioversion was attempted and was not successful. At 12:38 PM assisted ventilations using a bag valve mask (BVM) with oxygen at 25 liters per minute was initiated. Vital signs at 12:44 PM included BP 64/44 (severely low blood pressure), pulse 180, respirations 29 and blood oxygen saturation was 75%. An intravenous (IV) drip of epinephrine (vasoconstrictor which can stimulate the heart and increase blood flow to the brain and other organs) was initiated at 12:46 PM with no improvement of blood pressure noted. EMS left the facility at 12:48 PM with Resident #145 and advised the Emergency Department (ED) of medical red which means the patient has conditions that required immediate medical attention to have a chance of survival. While enroute to the ED at 12:49 PM vital signs included BP 25/19 (critically low blood pressure), pulse 169, respirations 23, and blood oxygen saturation of 73%. His temperature was 103.1 degrees Fahrenheit at 1:00 PM, which was noted as an indication of sepsis. In the ED Resident #145 was unresponsive and in obvious respiratory distress with grunting and retractions (the chest [NAME] in when a person tries to breathe in). ED triage vital signs at 1:04 PM included BP 75/21 (hypotensive), pulse 182, respirations 26 and blood oxygen saturation of 75%. The physical exam noted the resident was in acute distress, had dark brown gastric contents oozing from mouth and nose, pupils were dilated and minimally reactive, sweating heavily, tachycardic, had abdominal distention and rhonchi (continuous, low-pitched, coarse lung sounds caused by partial obstruction of the larger airways, often due to mucus or secretions) was noted when lung sounds were assessed. Resident #145 required urgent intubation for airway protection which was complicated by copious amounts of gastric regurgitation in the airway and was suctioned extensively before the second attempt at intubation was successful. Resident #145 was started on three vasoconstrictors used to treat life-threatening low BP and became bradycardic (heart rate of less than 60 beats per minute) and received a dose of atropine (used to treat bradycardia) just prior to cardiac arrest. Resident #145 arrested a total of four times, and he underwent four rounds of Cardiopulmonary Resuscitation (CPR) and spontaneous circulation was restored each time. He was transferred to the Cardiac Intensive Care Unit (ICU) in guarded condition. The physician in the Cardiac ICU documented an orogastric tube (OGT) was placed in the ED and was placed to suction when Resident #145 arrived in the Cardiac ICU. Bright red blood was observed from the OGT and despite continuous suction Resident #145's abdomen continued to increase in size. The CT (computed tomography) scans noted concerns for a small bowel obstruction and impacted stool in the rectum. Attempts were made to manually remove the impacted stool from the rectum but were unable to reach a large portion of the stool. Acute Care Surgery was consulted by the Cardiac ICU physician due to acute abdomen and concluded Resident #145 had multisystem organ failure and was not a surgical candidate. Despite aggressive medical interventions Resident #145 died on [DATE] at 12:21 AM. The Death Certificate dated [DATE] revealed that Resident #145's primary cause of death was sepsis (a systemic infection caused by bacteria that could quickly progress to septic shock and multi organ failure) secondary to probable aspiration pneumonia. The deficient practice occurred for 1 of 2 residents reviewed for tube feeding management (Resident # 145).Immediate jeopardy began on [DATE], when the facility failed to complete ongoing thorough nursing assessments for Resident #145 after a significant change and recognize the seriousness of the KUB results and seek a medical evaluation at a higher level of care. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.Findings included: Resident #145 was a [AGE] year-old male who was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury (TBI), protein calorie malnutrition, gastrostomy status (means a person has a surgically placed gastrostomy tube/feeding tube that provides direct access to the stomach for nutrition, fluids, or medication), dysphagia (difficulty swallowing), and quadriplegia. Resident #145's care plan initiated on [DATE] and last revised on [DATE] revealed that he was full code status. Resident #145's care plan had a focus added on [DATE] and last revised on [DATE] that indicated he was at risk for complications related to the need for tube feeding secondary to severe dysphagia. Interventions included administer tube feedings and flushes as ordered, head of bed elevated during feedings per order; pause feedings during personal care as indicated, observe for signs and symptoms of aspiration or aspiration pneumonia and notify the provider as indicated, resident was NPO, Registered Dietitian consult as needed and residual checks per order. A physician order for nothing by mouth (NPO) was added on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #145 had adequate hearing and vision, no speech, rarely/never understood/understands, and was severely cognitively impaired. He was not coded for any behavior or vomiting and was totally dependent on staff for all activities of daily living (ADL). Resident #145 was 72 inches tall, weighed 206 pounds, and all fluid and calorie intake were received through tube feeding. Review of Resident #145's medical record from [DATE] through 7/2025 revealed no documentation of any vomiting episodes. The Documentation Survey Report for [DATE] revealed on [DATE] Resident #145 had a large bowel movement at 11:48 AM and a medium bowel movement at 9:08 PM. On [DATE] a physician's order was entered for bolus tube feeding six times a day with one can of Nutren 2.0 (tube feeding formula) 240 milliliters (mL) via the gastrostomy tube after placement was confirmed. Hold for residuals (the volume of formula or stomach contents that remain in the stomach after a feeding) greater than 200 mL. After 2 hours recheck and if the residuals remain greater than 200 mL, notify the physician and make sure the resident had a recent bowel movement if the tube feeding was held. Nursing staff schedules revealed Nurse #1 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. A nursing progress note dated [DATE] (Friday) at 7:18 AM by Nurse #1 revealed that Resident #145 vomited twice with a light brown milky substance like the tube feeding. The resident position was high bed [NAME] (the bed is elevated 60 to 90 degrees) lying on the bed. He did not have shortness of breath. The oxygen saturation measured 97% (normal range 95 to 100%), and the 6:00 AM tube feeding was held. Nurse #1 would continue to monitor Resident #145. The [DATE] Medication Administration Record (MAR) revealed that Resident #145 did not receive the 6:00 AM bolus tube feeding on [DATE] due to vomiting. There was no physician order to hold the 6:00 AM bolus tube feeding on [DATE], and Nurse #1 added details about the vomiting episode in the provider communication book. There was no documentation in Resident #145's medical record that Nurse #1 completed a comprehensive nursing assessment after the morning vomiting episode on [DATE] including lung sounds, bowel sounds, and a full set of vital signs other than oxygen saturation. Nurse #1 was interviewed via telephone on [DATE] at 8:15 AM. She revealed that after each vomiting episode on [DATE], [DATE], and [DATE], she checked Resident #145's lung and bowel sounds and all vital signs, especially oxygen saturation, and added all details to the provider's communication book. Nurse #1 stated that she also checked the residuals before each bolus tube feeding, and they were never above 200 mL. Nursing staff schedules revealed Nurse #2 was assigned to the resident from 3:00 PM until 11:00 PM on [DATE]. At 10:05 PM on [DATE], Nurse #2 included a note on the [DATE] MAR that coincided with the 10:00 PM bolus tube feeding administration that read: vomiting x1. The [DATE] Medication Administration Record (MAR) revealed that an order was entered at 10:49 PM for Zofran oral tablet 4 milligrams (mg) via gastrostomy tube every 8 hours as needed for nausea and vomiting until [DATE] at 11:59 PM. Resident #145 received Zofran 4mg at 10:15 PM on [DATE]. A nursing progress note dated [DATE] at 10:51 PM by Nurse #2 revealed that Resident #145 had one vomiting episode. The substance appeared as clear content with yellow content of the resident's tube feeding. Resident #145 was stable with no facial grimacing noted. The abdominal area had hypoactive bowel sounds and was distended/bloated. The on-call provider was contacted, and they ordered Zofran 4 mg (milligrams) every 8 hours for three days for nausea and vomiting. A KUB of the abdomen was also ordered related to nausea and vomiting. Resident #145's last bowel movement was on [DATE] and was large in appearance. An assessment of lung sounds was not documented. In the vital signs section of Resident #145's medical record, Nurse #2 recorded the following vital signs on [DATE] at the corresponding times:Blood pressure 113/82 at 11:54 PMPulse 100 at 11:54 PMOxygen saturation 94% at 10:42 PMAn on-call provider note dated [DATE] completed by Nurse Practitioner #2 revealed that Resident #145's vital signs at the time of notification from Nurse #2 at 10:42 PM included temperature of 97.2 degrees Fahrenheit (normal range 97 to 99 degrees Fahrenheit), blood pressure of 113/82, pulse of 100 beats per minute, respiration rate per minute was 20, and the oxygen saturation measured 94%. The resident was stable, at normal baseline, and smiling. Resident #145 had a vomiting episode, and the last feeding for the evening shift scheduled for 10:00 PM was held. The vomiting content appeared clear and had some yellow content, which was the same color as the tube feeding he received. Residual measured 30 mL. The abdomen was bloated with hypoactive bowel sounds, and his last large bowel movement was on [DATE]. Nurse Practitioner #2 recommended Zofran as needed and a KUB of the abdomen due to the vomiting episode reported by Nurse #2. Multiple attempts were made to interview Nurse Practitioner #2 by phone, but she was unable to be reached during the investigation and no longer worked with the facility.A Change in Condition Evaluation dated [DATE] by Nurse #2 indicated that Resident #145 had a nausea/vomiting episode with a distended abdomen and no pain. The change in condition started during the night of [DATE]. There were no changes in mental or functional status noted. The on-call provider ordered a KUB of abdomen and anti-nausea medicine every eight hours for three days. Nurse #2's contact information was not available, and she was unable to be contacted during the investigation and no longer worked at the facility. Nursing staff schedules revealed that Nurse #4 was assigned to the resident on [DATE] from 7:00 AM until 3:00 PM. The [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding was held on [DATE] by Nurse #4 due to vomiting that resembled his tube feeding formula. Resident #145 received Zofran 4 mg at 9:38 AM on [DATE].There was no physician order to hold the 10:00 AM bolus tube feeding on [DATE].There was no documentation in Resident #145's medical record that showed Nurse #4 completed a comprehensive nursing assessment after the morning vomiting episode on [DATE] including lung sounds, bowel sounds, and a full set of vital signs. Nursing staff schedules revealed that Nurse #3 was assigned to the resident on [DATE] from 3:00 PM until 11:00 PM. A nursing note dated [DATE] at 11:09 PM by Nurse #3 revealed that the KUB was completed during the evening shift and results were pending. Nurse #3's contact information was not available, and she was unable to be contacted during the investigation and no longer worked at the facility. The Radiology Results Report for Resident #145's KUB was received by the facility on [DATE] at 1:00 AM. The results showed abundant fecal material seen within the distal large bowel loops and up to 0.5 centimeters dilated rectum in keeping with constipation and possible fecal retention. Abundant air was seen within up to 9.7 cm dilated large bowel loops and small bowel loops, which may have represented obstipation and/or ileus. The radiologist recommended review of the KUB results and an appropriate follow up evaluation was clinically warranted. A computed tomography (CT) scan, or more detailed x-ray, was recommended to be considered by the facility. Nurse Practitioner #1 reviewed the KUB results on [DATE] at 1:55 PM.The Documentation Survey Report for [DATE] revealed that Resident #145 had a medium bowel movement at 2:59 PM [DATE]. Nursing staff schedules revealed that Nurse #7 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. There was no documentation in Resident #145's medical record that showed Nurse # 7 contacted a provider when the KUB results were received by the facility at 1:00 AM on [DATE]. Multiple attempts were made to interview Nurse #7 by phone, but she was unable to be reached during the investigation and no longer worked with the facility.Nursing staff schedules reviewed revealed that Nurse #1 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. The [DATE] MAR revealed on [DATE] Resident #145 received the 2:00 AM and 6:00 AM bolus tube feedings given by Nurse #1. At 6:26 AM, Nurse #1 included a note that Resident #145 had a vomiting episode with a large amount of brown substance that appeared to be the tube feeding. Further review of the MAR revealed Resident #145 received Zofran 4 mg at 6:26 AM on [DATE]. There was no documentation in Resident #145's medical record that Nurse #1 completed a comprehensive nursing assessment after the morning vomiting episode on [DATE] including lung sounds, bowel sounds, and a full set of vital signs. Nurse #1 was interviewed via telephone on [DATE] at 8:15 AM. She revealed that after each vomiting episode on [DATE], [DATE], and [DATE], she checked Resident #145's lung and bowel sounds and all vital signs, especially oxygen saturation, and added all details to the provider's communication book. Nurse #1 stated that she also checked the residuals before each bolus tube feeding, and they were never above 200 mL. Nursing staff schedules revealed that Nurse #4 was assigned to Resident #145 on [DATE] from 7:00 AM to 3:00 PM. The [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding on [DATE] was held by Nurse #4 due to vomiting prior to the bolus tube feeding administration. There was no physician order to hold the 10:00 AM bolus tube feeding on [DATE].A nursing progress note dated [DATE] at 3:49 PM by Nurse #4 revealed that Resident #145 vomited once which resembled the tube feeding during the day shift. The morning feeding was held, and Resident #145 tolerated the afternoon feeding. No further vomiting episodes were noted. Vital signs were measured and included temperature of 95.5 degrees Fahrenheit, pulse of 88 beats per minute, and blood pressure of 110/70. There was no documentation in Resident #145's medical record that Nurse #4 completed a comprehensive nursing assessment after the morning vomiting episode on [DATE] including lung sounds, bowel sounds, and oxygen saturation. Nurse #4 was interviewed via telephone on [DATE] at 4:00 PM. She revealed that Resident #145's temperature measurement of 95.5 degrees Fahrenheit included in the [DATE] at 3:49 PM nursing progress note was a data entry error. Nurse #4 stated that she could not recall if she had assessed lung sounds; however, bowel sounds were assessed. She indicated it was common practice for her to check lung sounds after an emesis episode. However, Nurse #4 could not recall the details of Resident #145's vomiting episodes during her shifts.The physician orders for Resident #145 revealed that Nurse Practitioner #1 entered orders on [DATE] at 2:11 PM and included Lactulose solution (prescription laxative used to treat chronic constipation) via gastrostomy tube one time a day for constipation for three days, Bisacodyl suppository (fast acting laxative used to relieve occasional constipation) insert one suppository rectally one time a day for constipation for three days, and Senna oral syrup (herbal laxative used to relieve occasional constipation) via gastrostomy tube two times a day for bowel regulation.There was no documentation in Resident #145's medical record that Nurse Practitioner #1 completed a full evaluation after the KUB results were received on [DATE] at 1:00 AM and prior to ordering the aggressive bowel regimen that included lactulose, Bisacodyl suppository, and senna liquid on [DATE] at 2:11 PM. Nurse Practitioner #1 was interviewed via telephone on [DATE] at 12:50 PM. She revealed that she had not worked at the facility since [DATE]. Nurse Practitioner #1 stated that if Resident #145's KUB x-ray results were received over the weekend, then the nurse on duty who received it should have contacted the on-call provider with the results. She could not recall the details of Resident #145's vomiting episodes or the KUB and indicated she needed Resident #145's medical record in front of her to answer further questions. NP #1 then ended the call noting a current medical problem.Nursing staff schedules revealed that Nurse #3 was assigned to Resident #145 on [DATE] from 3:00 PM until 11:00 PM.The Documentation Survey Report for [DATE] revealed that Resident #145 had a small bowel movement at 6:55 PM on [DATE]. A nursing progress note dated [DATE] at 10:37 PM by Nurse #3 revealed that Resident #145 vomited twice during the evening shift. The as needed Zofran was given, and the 6:00 PM bolus tube feeding was held.The [DATE] MAR revealed that Resident #145's 6:00 PM bolus tube feeding was held on [DATE] by Nurse #3. Resident #145 received Zofran 4 mg at 4:39 PM on [DATE].There was no physician order to hold the 6:00 PM bolus tube feeding on [DATE].There was no documentation in Resident #145's medical record that showed Nurse #3 completed a comprehensive nursing assessment after the vomiting episode during the evening shift on [DATE] including lung sounds, bowel sounds, and a full set of vital signs. Nursing Staff schedules revealed Nurse #5 was assigned to Resident #145 from 3:00 PM until 11:00 PM on [DATE]. A nursing progress note dated [DATE] at 8:20 PM by Nurse #5 revealed that Resident #145 vomited five times during the evening shift. His abdomen was distended, and the vomit substance appeared to be yellow. The on-call provider was notified and ordered Phenergan 25 mg intramuscular every six hours for two days for nausea and vomiting. A comprehensive nursing assessment including vital signs, and an assessment of bowel sounds, or lung sounds was not documented in the progress note. An on-call provider note dated [DATE] completed by Nurse Practitioner #3 revealed that Resident #145's vital signs at the time of notification from Nurse #5 at 8:20 PM included temperature of 97.8 degrees Fahrenheit, blood pressure of 134/76, pulse of 76 beats per minute, respiration rate per minute was 18, and the oxygen saturation measured 96%. Resident #145 had a vomiting episode, and the contents were yellow and appeared to be stomach acid. His abdomen was distended. Resident #145 had vomited twice since then. Nurse Practitioner #3 asked Nurse #5 if the KUB results ordered by Nurse Practitioner #2 on [DATE] were available for her to review and asked what was given to Resident #145 due to the x-ray results. Nurse #5 told Nurse Practitioner #3 about the bowel regimen of Lactulose, Bisacodyl suppository, and Senna liquid ordered by Nurse Practitioner #1 on [DATE]. Phenergan (antihistamine use to prevent and treat nausea and vomiting) intramuscular every six hours as needed for two days for nausea/vomiting was recommended. Nurse Practitioner #3 was contacted via telephone for an interview on [DATE] at 4:18 PM; however, she no longer worked at the facility and refused to answer any questions related to Resident #145. Resident #145's physician orders revealed that the Phenergan injection solution 25 mg/mL inject 25 mg intramuscularly every six hours as needed for nausea and vomiting for two days was entered on [DATE] at 8:42 PM.The [DATE] MAR revealed on [DATE] Resident #145's 10:00 PM bolus tube feeding was held by Nurse #5 and Phenergan injection was administered at 10:45 PM. There was no physician order to hold the 10:00 PM bolus tube feeding on [DATE].Multiple attempts were made to interview Nurse #5 by phone, but she was unable to be reached during the investigation and no longer worked at the facility.Nursing staff schedules revealed that Nurse #1 was assigned to Resident #145 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. A nursing progress note dated [DATE] at 7:03 AM by Nurse #1 revealed that Resident #145 was alert and responsive, tolerated the bolus feedings at 2:00 AM and 6:00 AM during the overnight shift, and vomited once. He was bathed and the linens were changed. There was no documentation in Resident #145's medical record that showed Nurse #1 completed a comprehensive nursing assessment after the vomiting episode during the overnight shift from 11:00 PM on [DATE] until 7:00 AM on [DATE] including lung sounds, bowel sounds, and a full set of vital signs. She also did not document the amount of the residuals. Nurse #1 was interviewed via telephone on [DATE] at 8:15 AM. She revealed that after each vomiting episode on [DATE], [DATE], and [DATE], she checked Resident #145's lung and bowel sounds and all vital signs, especially oxygen saturation, and added all details to the provider's communication book. Nurse #1 stated that she also checked the residuals before each bolus tube feeding, and they were never above 200 mL. Nursing staff schedules revealed that Nurse #4 was assigned to Resident #145 on [DATE] from 7:00 AM to 3:00 PMThe [DATE] MAR revealed that Resident #145's 10:00 AM bolus tube feeding was held on [DATE] by Nurse #4. There was no physician order to hold the 10:00 AM bolus tube feeding on [DATE].A nursing progress note dated [DATE] at 12:34 PM by Nurse #4 revealed that Physician #3 was in the facility making rounds to address Resident #145's continued nausea and vomiting unrelieved by as needed Zofran. Resident #145 was excessively sweating and had labored breathing. His skin was clammy and warm to the touch. Oxygen saturation was noted to be 79% on room air. Orders were received from Physician #3 for 2 liters of oxygen via nasal cannula and were implemented. Physician #1 then placed the order for Resident #145 to be sent to the emergency department (ED) for altered mental status and change of condition. Emergency medical services (EMS) arrived and assumed care of the resident. Lung sounds, abdomen was not assessed, bowel sounds, no BP, pulse or respirations documented. Nurse #4 was interviewed via telephone on [DATE] at 4:00 PM. Nurse #4 stated that it was facility protocol for nursing staff to contact the provider after a vomiting episode for any resident. She could not recall the details of Resident #145's vomiting episode on [DATE] during her shift. Nurse #4 indicated that she could not recall if she contacted the provider or not when the 10:00 AM tube feeding bolus was held on [DATE]. During a follow-up interview with Nurse #4 on [DATE] at 1:53 PM, she revealed that she could not recall the details of [DATE] or the resident on that date. Review of the medical record revealed Physician #3 did not document a progress note on [DATE]. On [DATE] at 4:08 PM Physician #3 was interviewed via telephone. He revealed that the last time he evaluated Resident #145 was on [DATE]. He never had any interaction with Resident #145 after that date. Physician #3 stated that no nursing staff came to him on [DATE] while he was in the facility and told him there was an emergency with Resident #145. He could not recall if any nursing staff asked him to come to Resident #145's room to assess him or if he ordered two liters of oxygen or to send Resident #145 to the ED. Physician #3 stated that if he sent any resident to the ED, he would have written a progress note of his evaluation and the reason for sending the resident to the hospital. The EMS Report dated [DATE] revealed that 911 was contacted at 12:10 PM for a resident with difficulty breathing, EMS was dispatched at 12:12 PM, arrived at the facility at 12:16 PM, and was at the bedside at 12:20 PM. Resident #145 was found unresponsive, tachypneic, clammy, cyanotic and in obvious distress. At 12:20 PM his BP was 98/64, pulse 188, respirations 46, blood sugar 119, pupils were 8 millimeters and nonreactive, and a Glascow Coma Scale of 6 (GCS- clinical tool used to assess a patient's level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully alert)). A GCS of 6 indicates a lack of responsiveness suggesting a patient is in critical condition with a severe disruption in nervous system function and often associated with the need for airway protection. The oxygen level in his blood was very low and a non- rebreather mask with oxygen at 15 liter per minute was applied at 12:26 PM. EKG results noted subventricular tachycardia. Cardioversion was attempted three times but was not successful and a chemical cardioversion was attempted and was not successful. At 12:38 PM assisted ventilations using BVM with oxygen at 25 liters per minute was initiated. Vital signs at 12:44 PM included BP 64/44, pulse 180, respirations 29 and blood oxygen saturation was 75%. An intravenous (IV) drip of epinephrine was initiated at 12:46 PM with no improvement of blood pressure noted. EMS left the facility at 12:48 PM with Resident #145 and advised the ED of medical red. While enroute to the ED at 12:49 PM vital signs included BP 25/19, pulse 169, respirations 23, and blood oxygen saturation of 73%. His temperature was 103.1 degrees Fahrenheit at 1:00 PM, which was noted as an indication of sepsis. The report noted Resident #145's care was transferred to the ED.The ED provider note dated [DATE] indicated when Resident #145 arrived at the ED EMS reported to the ED physician Resident #145 had been vomiting in the days prior, was unresponsive when they arrived at the facility, and SVT was noted on the EKG. In the ED he was unresponsive and in obvious respiratory distress with grunting and retractions. ED triage vital signs at 1:04 PM included BP 75/21, pulse 182, respirations 26 and blood oxygen saturation of 75%. The physical exam noted the resident was in acute distress, had dark brown gastric contents oozing from mouth and nose, pupils were dilated and minimally reactive, sweating heavily, tachycardic, had abdominal distention and rhonchi was noted when lung sounds were assessed. Resident #145 required urgent intubation for airway protection which was complicated by copious amounts of gastric regurgitation in the airway and was suctioned extensively before the second attempt at intubation was successful. Resident #145[TRUNCATED]

Based on record review, observation, staff, Nurse Practitioner, Respiratory Therapist and Medical Director interviews, the facility failed to reconcile conflicting information regarding the resident's oxygen flow rate following readmission from the hospital, for 1 of 3 residents reviewed for respiratory services (Resident #32).Findings included:Resident #32 was readmitted to the facility on [DATE], following hospitalization from 7/2/2026 through 7/6/2026 for acute-on-chronic respiratory failure and pneumonia. Diagnoses included chronic respiratory failure, tracheostomy (trach) (an opening in the neck that leads directly into the windpipe) status, quadriplegia (paralysis or severe weakness in both arms and both legs), dysphagia (difficulty swallowing food or liquids), and recurrent pneumonia.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had severe cognitive impairment and was coded as receiving continuous oxygen therapy and tracheostomy care.A care plan dated 5/25/2026 read, respiratory interventions included providing humidified oxygen as ordered, performing routine tracheostomy care, suctioning the tracheostomy as needed, monitoring respiratory status and oxygen saturation, maintaining tracheostomy equipment, and observing for increased secretions or signs of respiratory distress.Review of a physician order dated 7/6/2026, showed an active order for humidified oxygen to tracheostomy: 3 liters (L) every shift for tracheostomy use. This was entered by the admission Nurse as a verbal Order from the Medical Director.Review of Medication Administration Record (MAR) dated July 2026 showed a physician order entered 7/6/2026 for humidified oxygen to trach: 3 liters (L) every shift for Trach use. The MAR documented the order was signed as administered by the evening shift nurse on 7/6/2026, by both day and evening nurses on 7/7/2026 through 7/14/2026, and by the day shift nurse on 7/15/2026.A review of Nurse Practitioner (NP) #2 note dated 7/9/2026 revealed a recommendation that Resident #32 continue with tracheostomy and supplemental oxygen via tracheostomy collar at 6 liters per minute.On 7/15/2026 at 2:05 pm, Nurse #6, assisted by the Assistant Director of Nursing (ADON), was observed performing tracheostomy care on Resident #32. It was observed that Resident #32 breathed through a tracheostomy. A plastic trach collar was placed over the tracheostomy and connected to oxygen tubing, allowing oxygen to flow directly into the resident's airway to support breathing. Oxygen saturation (measurement of how much oxygen is in the blood) measured 97% prior to tracheostomy care and 98% following replacement of the inner cannula and completion of tracheostomy care. After completion of tracheostomy care, Nurse #6 noted that the oxygen concentrator was set at 10 liters. When asked why the oxygen concentrator was set at 10 liters, Nurse #6 stated it was ordered at 10 liters to keep oxygen saturation above 90%. Nurse #6 was unable to locate a physician order authorizing oxygen at 10 liters.On 7/15/2026 at 2:49 pm the Respiratory Therapist was observed to enter Resident #32's room. When asked if he was aware that Resident #32 was on 10 liters of oxygen the Respiratory Therapist questioned 10? and immediately went to Resident #32's oxygen concentrator. The Respiratory Therapist stated that sometimes the nurses would bump the oxygen up, but he did not recommend 10 liters. The Respiratory Therapist turned the oxygen flow down from 10 liters to 6 liters. He stated that the goal was to maintain oxygen levels above 91% and while he does not recommend 10 liters, it would not cause Resident #32 too much harm with him having a tracheostomy.An interview was conducted with the Director of Nursing (DON) on 7/15/2026 at 3:21 pm. The DON stated that when Resident #32 left for the hospital, he was on 6 to 10 liters of oxygen via tracheostomy. She stated that staff were very familiar with Resident #32 and would have immediately recognized that 3 liters was not enough oxygen for Resident #32. The DON stated that the nursing staff should have contacted the NP for new orders.On 7/15/2026 at 3:56 pm the Medical Director stated he was not sure why Resident #32 would have been on 10 liters of oxygen. The Medical Director stated that NP #2 may have given an order for 10 liters of oxygen but he wouldn't have recommended it. The Medical Director stated that 10 liters would not have caused any harm since Resident #32 had a tracheostomy. When asked about the verbal order for 3 liters of oxygen the Medical Director stated that he did not recall giving the order but that may have just been a standing order. The Medical Director stated NP #2 was more familiar with this patient and the recommended liters of oxygen that should be ordered.An interview with NP #2 on 7/16/2026 at 3:35 pm revealed she verbally ordered oxygen at 6 to 10 liters per minute on 7/9/2026 due to Resident #32 respiratory status after hospitalization. NP #2 could not recall which nurse she gave the verbal order to. NP #2 stated the verbal order of 6 to 10 liters of oxygen per minute should have been entered into the electronic medical record by either herself or the receiving nurse; however, the order may not have been entered. NP #2 confirmed the active written physician order for humidified oxygen at 3 liters per minute did not reflect the oxygen therapy she intended the resident to receive following readmission.In an interview with the Administrator on 7/17/2026 at 11:53 am she stated that she expected staff to administer oxygen per physician orders. She stated that if the nurse felt that there was a change needed, they should notify the Medical Director or NP for assessment and to obtain new orders. The Administrator stated that NP #2 sometimes entered her orders and sometimes she gave a verbal order with the expectation that the nurse would enter the order. The Administrator believed that in this situation, NP #2 gave a verbal order and the nurse did not enter the order.

Based on record review, observation, and staff interviews, the facility failed to maintain an accurate medical record for the administration of supplemental oxygen for 1 of 3 residents reviewed for respiratory services (Resident #32).Resident #32 was readmitted to the facility on [DATE].Review of a physician order dated 7/6/2026, showed an active order for humidified oxygen to tracheostomy: 3 liters (L) every shift for tracheostomy use.Review of Medication Administration Record (MAR) dated July 2026 showed a physician order entered 7/6/2026 for humidified oxygen to trach: 3 liters (L) every shift for tracheostomy use. The MAR documented the order was signed as administered by Nurse #6 for the dayshift on 7/15/2026. On 7/15/2026 at 2:05 pm, Nurse #6, assisted by the Assistant Director of Nursing (ADON), was observed performing tracheostomy care on Resident #32. After completion of tracheostomy care, Nurse #6 noted that the oxygen concentrator was set at 10 liters. When asked why the oxygen concentrator was set at 10 liters, Nurse #6 stated it was ordered at 10 liters to keep oxygen saturation above 90%. Nurse #6 was unable to locate a physician order authorizing oxygen at 10 liters. Nurse #6 acknowledged that she did sign off on the MAR on 7/15/2026 which said humidified oxygen to trach: 3L every shift for Trach use. Nurse #6 stated that she did not pay attention to the amount, only that Resident #32 was receiving humidified oxygen to tracheotomy.An interview was conducted with the Director of Nursing (DON) on 7/15/2026 at 3:21 pm. The DON stated that she would expect nurses to pay more attention to orders and when signing off on those orders in the MAR.In an interview with the Administrator on 7/17/2026 at 11:53 am she stated that she expected staff to verified oxygen orders before documenting that oxygen was being administered at the correct rate.

2. Resident #85 was re-admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain). A review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had functional limitation in range of motion on both sides of his upper and lower extremities. He required substantial/maximal assistance to roll left and right in bed. Resident #85 was always incontinent of bladder. He had no falls since his re-entry to the facility. On 6/2/25 at 3:37 PM a review of an unsigned incident report provided by the Director of Nursing (DON) dated 10/9/24 at 7:12 PM revealed at 3:30 PM on 10/9/24 staff was assisting Resident #85 with incontinence care, Resident #85 rolled out of bed face down sustaining a small skin tear on his forehead. Resident #85's family member was at his bedside, and Emergency Medical Services (EMS) was called. On 6/5/25 at 3:45 PM a telephone interview with Nurse #5 indicated she responded to Nurse Aide (NA) #4's call for assistance with Resident #85 on 10/9/24. She stated when she entered Resident #85's room, he was lying on the floor on the left side of his bed which was positioned approximately 3 feet from the floor. She reported she completed vital signs and a head to toe assessment of Resident #85 and observed a small bleeding cut on his forehead. Nurse #5 went on to say Resident #85 was sent to the hospital for evaluation. She stated NA #4 reported to her that while she had been providing Resident #85 with incontinence care, he fell off the bed. Nurse #5 reported she did not recall receiving any in-service education after this incident regarding ensuring residents were positioned in the center of the bed and turning residents towards yourself rather than away from yourself when providing care. Multiple attempts at telephone interview with NA #4 were unsuccessful. NA #4 no longer worked at the facility. A review of Resident #85's hospital record for his admission to the hospital on [DATE] revealed in part Resident #85 presented to the emergency room at approximately 3:30 PM on 10/9/24 after falling face down while being turned at the facility. He had a small cut on his forehead. Diagnostic imaging studies of his head, spine, wrists, hands and knees did not reveal any abnormalities. Resident #85 returned to the facility on [DATE]. On 6/2/25 at 3:37 PM an interview with Resident #85's family member indicated there was an instance within the last year where Resident #85 fell out of bed when someone was turning him. She stated she was outside his room at the time, and while she did not witness the incident, she saw Resident #85 on the floor in front of his bed after he fell. She reported he was not complaining of any pain, but he had a small cut on his forehead from his glasses, and she asked that he be sent to the hospital. She indicated she was not aware of any other injuries from the incident. On 6/4/25 at 9:07 AM an interview with the Director (DON) indicated she was not the DON at the time of Resident #85's fall from bed during care on 10/9/25. She stated Nurse #6, who no longer worked at the facility, was the DON at the time of the fall. She went on to say there was an incident report regarding the fall, but she did not have an investigation file for the incident. A review of a Post Fall Investigation report dated 10/12/24 at 5:51 PM completed by Nurse #6 revealed in part Resident #85 had a fall in his room on 10/9/24. There was no additional information related to what steps were taken to investigate this fall. On 6/4/25 at 10:51 AM a telephone interview with Administrator #2 indicated he was the facility's Administrator on 10/9/24. He stated he did not recall Resident #85 having a fall from bed during care. He reported this would have been a serious incident, and an investigation would have been done. Administrator #2 stated residents should not fall out of bed when staff were providing care to them. On 6/4/25 at 2:27 PM a telephone interview with Nurse #6 indicated she had been the DON at the facility on 10/9/24 when Resident #85 fell out of bed during care. She stated an investigation had been conducted but she did not know where the investigation file would be. She reported the investigation revealed NA #4 had been providing Resident #85 with incontinence care by herself, did not have Resident #85 positioned in the middle of the bed, and turned Resident #85 away from herself during the care. Nurse #6 stated Resident #85 had rolled off the left side of his bed face first onto the floor. She went on to say Resident #85 sustained a small cut to his forehead and had been sent to the hospital for evaluation. On 6/5/25 at 3:34 PM a telephone interview with the Medical Director indicated she was Resident #85's facility physician. She stated all residents should receive care in a safe manner and Resident #85 should not have experienced a fall from bed during the provision of care. On 6/6/25 at 11:33 AM an interview with the Administrator indicated she was not the Administrator on 10/9/24. She stated she had looked, but did not have an investigation file for Resident #85's fall incident on that date. She reported residents should receive care in a safe manner and should not experience a fall from bed during the provision of care. Based on observation, record review, and interviews with family, staff, physician, Nurse Practitioner (NP), Medical Director, and the Director of Rehabilitation, the facility failed to prevent a resident with severe cognitive impairment and exit seeking behaviors from exiting the facility without supervision. On Saturday, 5/31/25, the Receptionist observed an elderly male (Resident #76) exit the facility behind a male resident who was discharging from the facility and a female family member who was moving that resident out. She did not recognize the elderly male as Resident #76, and she believed he was part of the discharging resident's family. Later that morning, as Nurse Aide (NA) #1 was driving in the community, she saw an individual who she thought looked like a resident walking without staff accompaniment approximately 0.7 miles away from the facility. She contacted the facility by phone, provided a description of the resident and staff who were working realized Resident #76 was missing. There was a high likelihood of serious harm, injury, or death for Resident #76 as the area he traversed included a well-travelled State Highway immediately outside of the facility's parking lot and multiple intersecting roads including a 4-lane intersection that was a major thoroughfare through the city. In addition, the facility failed to provide care in a safe manner when Resident #85 rolled out of bed during care and sustained a small cut to his forehead. These deficient practices affected 2 of 6 residents reviewed for accidents (Resident #76 and Resident #85). Immediate Jeopardy began on 5/31/25 when Resident #76 exited the facility without supervision. Immediate jeopardy was removed on 6/6/25 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 level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 was cited at scope and severity level of D. The findings included: 1. Resident #76 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, and anxiety disorder. A review of the elopement risk tool assessment dated [DATE] revealed Resident #76 was at low risk for elopement. A review of the care plan dated 4/28/25 revealed a focus area for Resident #76 being at risk for falls related to cognitive impairment, poor balance, and poor safety awareness and a focus area for Resident #76 being at risk for complications related to cognitive impairment with interventions that included reorienting resident as needed to person, place, time, and location. There was also a focus area also for the resident being at risk for adverse reactions related to the use of antipsychotics secondary to the diagnosis of delirium and dementia related behaviors. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #76 had severe cognitive impairment and no wandering or behavioral symptoms. He was assessed as needing moderate assistance walking 10 feet. He received antipsychotic medication and Physical Therapy services. Resident #76 found it very important to go outside to get fresh air when the weather was good. An interview with the Director of Rehabilitation on 6/4/25 at 1:41 PM revealed Resident #76 was provided with physical therapy services from 4/29/25 through 5/28/25. At the time of discharge from physical therapy, he walked 600 feet with supervision for safety. The nursing progress note written by Nurse #1 dated 5/30/25 at 10:23 PM revealed Resident #76 was exit seeking, became confused and started yelling at staff and forgot how to get back to his room. Once the resident was back in his room he began to calm down. Telephone interviews with Nurse #1 were conducted on 6/3/25 at 4:15 PM and 6/11/25 at 10:15 AM. She revealed she worked on 5/30/25 from 3:00 PM until 11:00 PM. She went on to say Resident #76 attempted to leave the facility on 5/30/25 at approximately 3:40 PM. She stated the resident was exit seeking, became confused and started yelling at staff and walking to the front exit door. Nurse #1 then placed herself between Resident #76 and the front exit door until the DON was able to redirect him and walk with him back to his room. She stated this was the first time she had witnessed his exit seeking behavior. Nurse #1 indicated she was an agency nurse and had not worked with Resident #76 often. The Director of Nursing (DON) was in the facility at the time Resident #76 exhibited exit seeking behaviors on 5/30/25. Nurse #1 reported that the DON asked Nurse #1 to call Resident #76's family to see if they would come and sit with him. The family did not answer her call. Resident #76 was in his room with a roommate, who was cognitively intact, and she (Nurse #1) checked on him often throughout her shift. Nurse #1 stated she did report Resident #76's exit seeking behaviors to the oncoming nurse. An interview with the DON was held on 6/3/25 at 4:30 PM, she revealed she did not recall Resident #76 exhibiting exit seeking behavior, but she felt he was only upset on 5/30/25. She stated Resident #27 said, I don't want to go to the pea patch. The DON then went with Nurse #1 to take the resident to his room. She added that she did not ask Nurse #1 to call the family as the facility provided one-to-one service if needed. A telephone interview with Nurse Aide (NA) #1 was conducted on 6/3/25 at 3:20 PM. She revealed on 5/31/25 she had left the facility via her car during her break and while she was enroute back to the facility she saw whom she thought might be a resident walking on the sidewalk towards a fast-food restaurant. She called the facility at 9:11 AM and spoke with the Receptionist to let her know his location and described the clothes he was wearing. She indicated at that point the Receptionist identified the resident as Resident #76. Nurse Aide #1 then turned the car around and sat with Resident #76 until Nurse #2 and the Receptionist arrived to pick him up. Resident #76 was wearing black pants, a purple T-shirt and tennis shoes. He was kneeling on one knee when she saw him. Nurse Aide #1 stated he appeared very tired but not overheated. He was easily redirected into the Receptionist's car. A telephone interview was conducted with the Receptionist on 6/3/25 at 3:30 PM. She indicated that prior to working as the Receptionist, she was an NA at the facility. She revealed there were several discharges at the facility on 5/31/25, the date Resident #76 exited the facility without staff supervision. A male resident was moving out with the assistance of a female family member. The Receptionist stated she observed the male resident and the female family member exiting the facility with an elderly male behind them and did not realize that this elderly male was a resident at the facility. She explained she thought Resident #76 was part of that resident's family. The resident was wearing black pants and a purple t-shirt and walked out behind the family members of the discharged resident. The Receptionist reported that she could not recall what time this happened. The Receptionist stated she went to get Resident #76 with Nurse #2 after NA #1 contacted the facility and the resident seemed very tired but not overheated. She stated Resident #76 was severely cognitively impaired and the road he was walking on was a highly traveled main thoroughfare from downtown Greenville, NC to Falkland, NC. The door that Resident #76 used to exit was the front entrance door to the building which was unlocked every morning at 8:00 AM until 8:00 PM. She added that the facility did not utilize a wander guard system. Follow-up interviews with the Receptionist on 6/4/25 at 10:20 AM and 6/11/25 at 9:30 AM indicated the admission Nurse would verbally tell the receptionists if there was a resident that they should be on the lookout for exit seeking behaviors. She revealed there was no photo book at the reception desk to identify residents at risk for elopement. The nursing note dated 5/31/25 at 9:15 AM written by Nurse #2 revealed Resident #76 was off the premises of the facility and was returned to the facility with no injuries. An interview with Nurse #2 on 6/3/25 at 2:15 PM revealed she gave Resident #76 his medication on 5/31/25 at 8:30 AM which was the last time she saw him prior to learning of the unsupervised exit. The Receptionist notified her at approximately 9:11 AM that Nurse Aide #1 had called the facility to make them aware of a resident was walking down the road. The facility staff were unaware Resident #76 was not in the facility. She went on to say she (Nurse #2) remembered Resident #76 coming to the nurse's station prior to this day and said he wanted to go see his family. Nurse #2 went with the Receptionist at approximately 9:15 AM to pick him up and he was located on a grassy area between the sidewalk and a restaurant. Resident #76 was found kneeling on one knee, wearing black pants and a purple t-shirt. When they returned to the facility, Nurse #2 assessed him and identified no injuries noted. A follow up telephone interview was conducted with Nurse #2 on 6/11/25 at 8:45 AM. She revealed she did not know, nor did anyone tell her that Resident #76 had been exit seeking on 5/30/25, the day prior to the elopement on 5/31/25. She went on to say she did not know Resident #76 well enough to know if he would have been safe outside without facility staff supervision, but she felt the road he walked along would have been dangerous for him. A telephone interview was conducted on 6/11/25 at 8:50 AM with NA #11. He stated he worked on 5/31/25 from 7:00 AM to 3:00 PM. He indicated 5/31/25 was his first shift working with Resident #76 and he was unaware the resident had exit seeking behaviors on 5/30/25. He also stated he last saw Resident #76 when breakfast was served but did not know the time. He was not aware Resident #76 was out of the facility prior to NA #1 calling the facility to alert the staff. According to the Global Positioning System (GPS) traffic application, the location Resident #76 was found to be approximately 0.7 miles from the facility. On 6/4/25, beginning at approximately 11:45 AM, the Surveyor walked approximately 0.7 miles from the facility to the location where Resident #76 was picked up by the staff on 5/31/25. The walk revealed the resident would have to walk through the facility's parking lot that contained loose gravel and multiple potholes. Directly outside of the facility's parking lot was a well-traveled 4 lane divided State Highway, NC 43, with a speed limit of 45 miles per hour. The highway had a sidewalk. Resident #76 would then have had to cross over the following intersections: a 2-lane entrance to an apartment complex; a 4-lane intersection at [NAME] Arlington Blvd., a major thoroughfare through the city with a traffic light and a crosswalk; an apartment complex entrance road and exit road; and a gated driveway entrance and exit to an assisted living facility. Along the route there were 2 large ditches on the side of the sidewalk: one ditch approximately 3 feet deep partially covered by brush/bush-like vegetation and one ditch approximately 12 feet deep containing water and rock. There was a large volume of traffic observed during this walk. The weather underground website shows it was 66 degrees Fahrenheit in Greenville on 5/31/25 at 9:15 AM. An interview with the Medical Director was conducted on 6/4/25 at 11:07 AM. She stated the facility reported the elopement with no injuries on 5/31/25. She went on to say something failed and there were always risks of injury when someone eloped from a facility. During a follow up interview with the Medical Director on 6/11/25 at 9:05 AM she revealed the Nurse Practitioner was more familiar Resident #76 and indicated she would be able to provide further resident specific information. An interview with the NP on 6/11/25 at 9:10 AM revealed Resident #76 had dementia. She indicated she could not say whether or not Resident #76 was safe to be outside of the facility without supervision, but she did say it was concerning. She stated the roads in the area were dangerous. She reported there was not any medical reason that would have triggered the new exit seeking behavior for Resident #76. In follow-up interviews with the Director of Nursing on 6/4/25 at 2:30 PM and 6/11/25 at 10:30 AM she indicated there was a receptionist at the front desk daily Monday through Sunday from 8:00 AM until 8:00 PM. She reported that the facility did not utilize a wander guard system. She stated prior to 5/30/25, there was no system in place to identify residents that were unsafe to exit the facility unsupervised. She revealed there should have been a picture of anyone with a high risk of elopement at the reception desk to prevent a resident at risk from going outside without supervision. She stated she felt the road Resident #76 traversed would not be a safe walk for someone with cognitive issues. She went on to say it was a well-traveled road with a high volume of vehicles daily. An interview with the Administrator on 6/4/25 at 4:25 PM revealed there should have been a sign on the door asking families to check with a nurse prior to letting a resident out of the facility to prevent residents from exiting the building. She went on to say a photo book should have been created to let the staff know any resident at risk for elopement. These books should have been at all 3 nurses' stations and at the reception desk. During a follow-up telephone interview with the Administrator on 6/11/25 at 10:51 AM she stated there were not any residents at risk of elopement prior to Resident #76's elopement on 5/31/25, therefore there was not a system in place to identify residents at risk. She revealed she felt the road Residents #76 was walking on was dangerous and that it was well traveled road with a high volume of vehicles daily. The facility provided a corrective action plan that was not acceptable to the State Agency as it did not address the issue of the Receptionist not being able to distinguish between residents and visitors and not being aware of what residents were safe to be outside without supervision. It additionally did not address how the facility would ensure staff were aware of residents who were at risk for wandering and exit seeking. On 6/4/25 at 8:40 AM the Administrator was notified of immediate jeopardy. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non-compliance: Resident #76 was admitted on [DATE] with a diagnosis of muscle wasting, muscle weakness, dysphagia, anxiety disorder, abnormalities of gait and mobility and unspecified dementia. On 4/28/2025, an initial elopement assessment was completed by the Unit Manager that resulted in the resident being at low risk for elopement (referring to the act of an older adult leaving a safe environment without supervision). On 5/30/2025, a progress note written by the hall nurse identified Resident #76 as exit seeking. He was given a snack and drink, and he returned to his room to watch TV with his roommate. The hall nurse notified the Director of Nursing. He had no further behavior throughout the shift. At approximately 9:00 a.m. on 5/31/2025, Resident #76 was identified by a staff member driving by and thought she recognized the resident walking on the sidewalk about 0.7 miles from the facility. The resident at that time had not been reported as missing. The staff member that spotted him kept him in eyesight and stayed with him and called the facility. She spoke with the Receptionist and together they realized he was resident at the facility. The Receptionist alerted the nurse and together they immediately went and brought Resident #76 back to the facility. The Receptionist is a certified nursing assistant, however, has not worked as one in this facility since 5/19/2022 and was unfamiliar with the newer residents. The Receptionist observed Resident #76 exit the facility with other individuals who were visiting the facility, but she did not identify that he was a resident and therefore did not stop the resident from exiting. A full skin assessment was performed by the hall nurse on 5/31/2025 with no negative findings. The Responsible Party (RP) and physician were notified by the hall nurse, and new orders were obtained for urinalysis and a psychiatry consultation. The urinalysis resulted negative on 5/31/2025. The psychiatry visit was completed on 6/2/2025 with no new orders. Resident #76 was placed on one-on-one supervision until further notice while the social worker / discharge planner work with the family members to find a memory care unit. On 5/31/2025 the Administrator met with the Assistant Director of nursing, floor nurse and Receptionist and determined staff did not intervene with the resident's exit seeking behavior, nursing staff did not follow up on exit seeking behaviors the night prior to the elopement, and there was no wandering book at the front desk or nursing stations with residents with exit seeking behaviors pictures. The floor nurses completed a 100% head count of all residents; all were present and accounted for. On 5/31/2025, the Director of Nursing (DON) initiated an audit of resident progress notes to include Resident #76 for the past 14 days. The audit was completed with no other residents' issues identified. On 5/31/2025, the Assistant Director of Nursing (ADON) completed an audit of all wandering assessments to ensure assessments were completed accurately and to ensure all residents who triggered as at risk were care planned for wandering risk. No other residents were identified. 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: On 5/31/2025, the Administrator & ADON initiated an in-service with all nurses regarding initiating an intervention if residents are exhibiting wandering behaviors or statements about seeking exit and notify the DON/ADON. On 5/31/2025 an in-service was also initiated by the ADON & Administrator with all staff, including agency staff, regarding not assisting any person known or unknown outside of the facility without checking with nursing staff to ensure the resident is safe to be outside unsupervised. The DON created on 6/4/2025 wandering books for all nurses' stations and the front desk with pictures and resident demographics for any resident identified to be an elopement risk. The Activity Director has placed pictures of residents from the wandering book on the bulletin board in the employee dining room to assist staff in identifying residents with exit seeking behaviors. The DON started all staff in-services on 6/5/2025 on the wandering books at the nurses' stations and the front desk and the notification board in the employee break room. Any new residents identified with exit seeking behaviors will be added to the wandering books and bulletin board along with being added to the Kardex used by the certified nursing assistants for charting care given. The Minimum Date Set (MDS) nurse will update the Kardex as residents are identified to be exit seeking. This in-service will be completed by 6/5/2025 and any staff who are not in serviced will be in serviced prior to their next shift. The ADON will be responsible for updating the wandering books at the nurses' station and front desk and updating the bulletin board in the employee dining room. The nursing staff that identifies the exit seeking behaviors will complete the Elopement Assessment in the electronic medical record as directed by the DON/ADON upon notification. The Regional Clinical Director in serviced the DON/ADON on 6/5/2025 on steps to direct the nursing staff upon any notification of exit seeking behaviors, these steps will include completing an Elopement Assessment. The ADON will then notify the MDS nurse to update the Kardex. All in-services will be completed by 6/5/2025. The Staff Development Coordinator (SDC) and Scheduler will be responsible for tracking staff needing an in-service prior to working. All in-services will be added to the orientation for all new staff to be completed by the SDC. A sign was placed on the front door on 6/4/2025 by the Administrator to alert any visitors or other family members not to assist anyone outside and to seek help from the receptionist. The Social Worker has drafted a letter to the families of current residents to remind them not to assist residents outside without checking with the nursing staff or the receptionist. This letter will be post marked 6/5/2025 and will be mailed on 6/5/2025 by the Social Worker. Alleged date of immediate jeopardy removal: 6/6/2025 Onsite validation of the immediate jeopardy removal plan was completed on 6/6/25 as follows: Review of the facility documentation revealed the facility completed an audit of resident progress notes for the past 14 days. Review of the facility education materials and sign-in sheets were reviewed to confirm that education was provided as indicated in the removal plan. Interviews were conducted on 6/6/25 with facility staff to confirm that education was received regarding elopement risk residents. Observed the elopement risk photo binders located on all 3 nurses' stations and at the reception desk. Observed the signs posted on the interior and exterior of the front door asking all visitors to check with a nurse prior to assisting residents outside. Observed the residents' photos at risk for elopement that were posted in the staff break room. Reviewed evidence of the letters that were sent to the families of current residents asking them not to assist residents outside without checking with a nurse or the receptionist. The facility's immediate jeopardy removal date of 6/6/25 was validated.

Based on observation and interviews with staff, the facility failed to secure a packaged terminal air conditioner (PTAC) unit to the wall on 1 of 5 resident halls reviewed for the environment (Resident #280's room). The findings included: An observation of Resident #280's room on 6/3/25 at 8:20 AM revealed a packaged terminal air conditioner (PTAC) unit which is a self-contained heat and air conditioning unit was not secured to the wall. An area of outdoor grass was visible through the approximately ½ inch gap. An interview and observation of the PTAC unit in Resident #280's room was conducted on 6/4/25 at 10:50 AM with the Maintenance Director, he revealed the unit was coming away from the wall due to a screw missing which created an approximately ½ inch gap between the unit and the wall which allowed for the grass outside to be visible. The Maintenance Director stated he was not aware of this needed repair as no one had reported it to him. An interview with the Administrator was conducted on 6/6/25 at 8:40 AM. At that time, she revealed the department managers were tasked to conduct room inspections daily. These inspections should have found the unit missing a screw and coming away from the wall and been reported to the Maintenance Director for repair.

Based on record review and staff interviews, the facility failed to file a grievance on behalf of a resident when the resident reported a grievance verbally to the Social Worker (SW) related to multiple items missing from her belongings after returning from a short hospital stay. The missing items were not located. This deficient practice affected 1 of 1 resident reviewed for grievances Resident #93). Findings included: A review of the facility policy titled Service Concerns/Grievances dated 3/1/25 indicated that nursing staff, Social Work and Discharge Planners or any other team member receiving questions or issues of concern regarding care and/or services are to immediately respond at the point of service in an effort to satisfactorily resolve issues of concern. The policy stated the patient had the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. Resident #39 was readmitted to facility on 10/15/24 with a diagnosis of non-Alzheimer's dementia. A review of Resident #39's medical record revealed she was sent to the hospital on 4/27/25 and returned on 5/5/25 and was discharged on 5/23/25. A review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed she was moderately cognitively impaired. During an interview with the SW on 6/4/25 at 1:12 PM she revealed Resident #39 was admitted to the hospital from the facility on 4/27/25. The SW stated that she packed Resident #39's belongings and put them in storage on facility grounds on 4/28/25. When Resident #39 returned from the hospital on 5/5/25 her belongings were returned to her and put away in her room by staff. The SW was unable to state which staff put the items away. The SW further stated that Resident #39 told her on more than one occasion between the dates of 5/5/25 and her discharge on [DATE] that she was missing a small suitcase, a pair of shoes, and two cotton nightgowns. The SW indicated she remembered the suitcase, as she had packed items in it to go to storage. The SW indicated she did not tell other staff Resident #39 reported missing items to her. The SW revealed she did not file a grievance on behalf of Resident #39, nor did she look for the items, as she was waiting for the resident to provide her with a written list including sizes. The SW indicated she would have been responsible for locating the items and that the items were never located. The SW further stated she should have written a grievance on behalf of Resident #39 given her cognitive status and to ensure her concerns were followed up on. Attempts to reach Resident #39 by telephone were unsuccessful. In an interview with the Administrator on 6/4/25 at 1:30 PM she stated she was not aware Resident #39 was missing a small suitcase, a pair of shoes and two cotton nightgowns. She further stated the SW should have made a list of the missing items for Resident #39 given her cognitive status. The Administrator revealed she did not think a grievance should have been filed right away, but rather after the missing items were not located after a week or so.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of high risk drug class medications. This was for 1 of 5 residents reviewed for unnecessary medications (Resident #30). Findings included: Resident #30 was admitted to the facility on [DATE]. A review of Resident #30's admission Minimum Data Set (MDS) assessment dated [DATE] revealed coding that Resident #30 received anticoagulant (blood thinning) medication during the look-back period of the assessment. A review of Resident #30's Medication Administration Record (MAR) for February 2025 did not reveal any documentation indicating a physician's order for anticoagulant medication or that anticoagulant medication was administered to Resident #30 in February 2025 since her admission to the facility. On 6/6/25 at 8:35 AM an interview with MDS Nurse #2 indicated she coded the high risk drug class medication section of Resident #30's MDS assessment dated [DATE]. She stated although Resident #30 had not taken any anticoagulant medication in the look back period of this assessment since her admission to the facility, she had received heparin (a blood thinning medication) in the hospital in the 2 days prior to her admission. She reported it was her understanding that the anticoagulant medication Resident #30 received in the hospital should be reflected on Resident #30's MDS assessment dated [DATE]. On 6/6/25 at 8:51 AM an interview with the Director of Nursing indicated it was her understanding that the anticoagulant medication Resident #30 received in the hospital prior to her admission to the facility should be reflected on Resident #30's MDS assessment dated [DATE]. She reported that resident's MDS assessments should be accurate. On 6/6/25 at 10:00 AM an interview with the Administrator indicated everyone understood that the high risk drug class section of a resident's MDS assessment should be coded based on a 7 day look back period which included any of these medications a resident received outside the facility during a 7 day look back period. She reported MDS assessments should be coded accurately.

Based on observations, record review and staff interviews, the facility failed to develop a comprehensive care plan for a resident in the areas of bed rails (Resident #94) and for the use of a Continuous Positive Airway Pressure (CPAP) machine for one resident (Resident #63). This was for 2 of 24 residents reviewed for comprehensive care plans. Findings included: 1. Resident #94 was admitted to the facility on [DATE]. A review of Resident #94's comprehensive care plan dated 11/3/24 revealed she did not have a care plan that included the use of bilateral quarter length side rails. Resident #94's quarterly Minimum Data Set (MDS) dated [DATE] revealed bed rails were not used as a restraint. An observation was conducted on 6/3/25 at 12:43 PM in Resident #94's room. The resident was lying in bed with bilateral quarter length side rails in the raised position. In an interview with Resident #94 on 6/3/25 at 12:43 PM, she stated she had always had the side rails on her bed. An interview with the admission Nurse was conducted on 6/5/25 at 2:03 PM. She stated she did the admission side rail assessment for Residents #94. The admission Nurse reviewed the side rail assessment during the interview and revealed that it was marked as not using bilateral quarter length side rails which was not correct. She was unsure why she had marked it as such. In an interview with MDS Nurse #2 on 6/5/25 at 1:46 PM she stated the care plan was updated by MDS coding and any other department in the facility such as nursing, activities or dietary. MDS Nurse #2 further stated MDS coding for side rails comes from the side rail assessment completed by nursing and MDS Nurse's do not go to the residents' room to observe for side rails. An observation and interview was conducted with the Director of Nursing (DON) on 6/3/25 at 2:31 PM. Resident #94 was lying in bed with bilateral quarter length side rails in the raised position. The DON stated Resident #94 should have had a care plan that included the use of bilateral quarter length side rails. In an interview with the Administrator on 6/3/25 at 3:07 PM, she stated Residents #94 should have had a care plan that included the use of bilateral quarter length side rails since the side rails were on the bed. The Administrator further stated she was only aware that the comprehensive care plan was developed automatically based on nursing assessments and other departments can add to it. 2. Resident #63 was admitted to the facility on [DATE]. Resident #63's hospital Discharge summary dated [DATE] indicated she brought her CPAP machine from home and used it nightly in the hospital. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #63 indicated she was cognitively intact and required no CPAP machine usage. An interview with the admission Nurse was conducted on 6/5/25 at 2:03 PM. She stated she did the admission nursing assessments for Resident #63. The admission Nurse indicated she was unaware the resident had a CPAP machine. The admission Nurse stated she did go into the resident's room when she completed the assessment but she did not notice the CPAP machine A review of Resident #63's comprehensive care plan dated 3/24/25 revealed she did not have a care plan that included nightly use of a CPAP machine. On 6/2/25 at 1:15 PM an interview with Resident #63 and an observation of her room was conducted. The resident had a CPAP machine next to her bed, and she stated she brought it with her from the hospital when she was admitted to the facility. Resident #63 further stated it was her personal CPAP machine that she had brought to the hospital before coming to the facility. Resident #63 indicated she used it every night for sleep apnea (when a person has breathing interruptions in their sleep). In an interview with MDS Nurse #2 on 6/5/25 at 1:46 PM, After that, the care plan was updated by MDS coding and any other department in the facility such as nursing, activities or dietary. MDS Nurse #2 further stated MDS coding for side rails comes from the side rail assessment completed by nursing and MDS Nurse's do not go to the residents' room to observe for a CPAP machine. An interview with the Unit Manager (UM) #1 and NA #1 was conducted on 6/5/25 at 1:59 PM. They both stated Resident #63 brought the CPAP machine with her from the hospital and wore it nightly. They indicated she put it on and took it off independently. In an interview with the Administrator on 6/3/25 at 3:07 PM she stated Resident #63 should have had a care plan for the use of the CPAP machine. The Administrator further stated she was only aware that the comprehensive care plan was developed automatically based on nursing assessments and other departments can add to it.

Based on observation, record review, and staff and Wound Care Nurse Practitioner (NP) interviews, the facility failed to obtain a provider order for and implement the recommended pressure relief measure of a heel protection boot for 1 of 1 resident reviewed for a non-pressure related heel wound (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of a Wound Care NP progress note for Resident #62 dated 2/25/25 at 10:50 PM revealed Resident #2 had a new non-thermal blister to his left heel. A review of Resident #62's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired and he had one open lesion on the foot. Resident #62 required moderate assistance with sit to lying position, lying to sitting on the side of the bed, and sit to stand position. Resident #62 was maximal assistance with putting and taking off footwear. Resident #62 was moderate assistance with lower body dressing and setup with upper body dressing. He was moderate assistance with bathing and personal hygiene. A review of a Wound Care NP's progress note for Resident #62 dated 4/21/25 at 9:31 AM revealed Resident #61's left heel wound was an arterial ulcer. A review of a Wound Care NP's progress note for Resident #62 dated 5/13/2025 at 6:14 PM revealed the recommendation to float Resident #62's left heel while in bed using a soft protective boot. Review of the medical record and physician orders view of Resident #62's orders did not reveal a provider order for a protective boot for Resident #62's left heel. On 6/2/25 at 11:00 AM an observation of Resident #62 revealed him to be lying on his back in bed. Resident #62's bilateral heels were observed to be in contact with his mattress. No protective boot was observed on his left heel. On 6/4/25 at 1:30 PM an observation of Resident #62 revealed him to be lying on his back in bed. Resident #62's bilateral heels were observed to be in contact with his mattress. No protective boot was observed on his left heel. On 6/5/2025 at 2:42 PM an observation of Resident #62's left heel wound was conducted with the facility's Treatment Nurse. This wound was observed to appear clean, with no foul odor, and no drainage was present. An interview completed with the Treatment Nurse at the time of the observation revealed she had been the treatment nurse at the facility for a month and was familiar with Resident #62's left heel wound. She reported the wound was improving. Treatment Nurse stated when she and the Wound Care NP did wound care together the Wound NP informed her of her reccomendation. On 6/05/2025 at 3:29 PM an interview with Nurse Aide (NA) #6 revealed Resident #62 had been in his current room for a couple of months and since Resident #62 had been in his current room she had not placed a protective boot on Resident #62. In an interview on 6/5/2025 at 2:02 PM the Wound Care NP stated when she made a recommendation, the report was sent via e-mail to the Director of Nursing (DON). The DON then printed the report and gave a copy to the facility's treatment nurse. The facility's treatment nurse was then responsible for obtaining a facility provider's order for the recommendation. On 6/5/2025 at 3:18 PM an interview with the DON indicated after each visit, the Wound Care NP e-mailed her a report. She stated this report did not include the Wound Care NP's recommendations. The DON reported these recommendations were provided to the Treatment Nurse at the time of visit with each resident. She went on to say the Wound Care NP would verbally communicate her recommendations to the DON before the Wound Care NP exited the building. The DON stated she was not aware of the recommendation for a soft protection boot for Resident #62's left heel. She reported that if this wasn't part of the conversation she had with the Wound Care NP when she exited the building after seeing Resident #62, or on the e-mail report, then it would have gotten missed. On 6/5/2025 at 3:49 PM an interview with the Administrator indicated the Wound Care NP's recommendation for Resident #82 to have a soft protection boot to his left heel had gotten missed.

Based on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to ensure infection control standards were followed when Nurse #8 did not remove soiled gloves, perform hand hygiene, and don sterile gloves during tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) care for a resident and also failed to change the tracheostomy ties per the Physician's order (Resident #33). In addition, the facility failed to obtain a Physician's order for the use of a Continuous Positive Airway Pressure (CPAP) machine for one resident (Resident #63). This deficient practice affected 2 of 2 residents reviewed for respiratory care (Resident #33 and Resident #63). The findings included: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included tracheostomy status. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was severely cognitively impaired and was coded as receiving tracheostomy care. Resident #33's current comprehensive care plan dated 8/22/24 revealed a problem of being at risk for complications secondary to tracheostomy. Interventions included tracheostomy care per physician orders. a.) An observation of tracheostomy care was conducted with Nurse #8 on 6/4/25 at 10:51 AM. Nurse #8 washed her hands with soap and water, set up the tracheostomy care supplies on the bedside table. She then opened the container that held sterile supplies and donned sterile gloves. Nurse #8 then opened the sterile drape, placed it on the resident's chest and set the new sterile split sponge on the drape. She proceeded to remove the soiled split sponge from behind the phalange of the tracheostomy cannula with her left hand, then removed the soiled inner cannula from the tracheostomy with both hands by holding the phalange in place with her left hand and removing the inner cannula with her right. She then opened the sterile inner cannula and placed it in the tracheostomy using both hands. Nurse #8 poured sterile water in a sterile cup, opened a sterile cotton swab, dipped it in the sterile water and cleaned around the outside of the tracheostomy with it. Next, Nurse #8 wet a sterile gauze with the sterile water, squeezed out the excess water with her right hand, cleaned around the tracheostomy with her right hand and dried it with a dry sterile gauze with her right hand and then placed sterile split sponge behind tracheostomy phalange with both hands. In an interview with Nurse #8 on 6/4/25 at 11:05 AM she stated she was an agency Nurse, and this was her second day at the facility. She indicated she was trained in infection control practices and tracheostomy care before being allowed to work at the facility. Nurse #8 further stated she did not remove her soiled gloves, perform hand hygiene and don sterile gloves during tracheostomy care because she was nervous and forgot. In an interview with the Infection Preventionist on 6/4/25 at 11:09 AM, she stated Nurse #8 should have removed her soiled gloves, washed her hands with soap and water, then donned new sterile gloves before touching the sterile items needed for tracheostomy care. The Director of Nursing (DON) was interviewed on 6/4/25 at 11:15 AM. The DON stated Nurse #8 should have removed the soiled gloves, washed her hands with soap and water and donned sterile gloves before moving on to the sterile part of tracheostomy care. This was to prevent introducing disease causing bacteria into the respiratory tract of the resident via his tracheostomy. The Administrator was interviewed on 6/4/25 at 11:19 AM. She indicated that in order to prevent bacteria from entering the tracheostomy, Nurse #8 should have removed her soiled gloves, washed her hands with soap and water, then donned sterile gloves to complete the tracheostomy care. On 6/5/25 at 3:12 PM, the Nurse Practitioner (NP) was interviewed. She stated proper infection control practices such as hand hygiene between dirty and sterile procedure is important to cut down on the chance of bacteria getting into the resident's lungs through the tracheostomy and causing illness. The NP indicated Nurse #8 should have removed the soiled gloves, washed her hands with soap and water, then donned new sterile gloves. b.) Resident #33's physician orders an order tracheostomy ties daily written on 6/3/25. An observation of tracheostomy care and interview was conducted with Nurse #8 on 6/4/25 at 10:51 AM. During tracheostomy care, which included replacing the used inner cannula with a new one, changing a used split gauze for a new one, and cleaning around the tracheostomy site, Nurse #8 did not change Resident #33's tracheostomy ties. The ties appeared to have a dried yellow substance near the tracheostomy site. Nurse #8 removed her gown and gloves, performed hand hygiene and exited the resident's room. During the interview Nurse #8 stated she forgot to change the tracheostomy ties when doing tracheostomy care. In an interview with the Director of Nursing (DON) on 6/5/25 at 11:15 AM she stated Resident #33 had been a resident at the facility for several years. The DON indicated she expected Nurse #8 to have followed the physicians order to change the tracheostomy ties. An interview was conducted with the Administrator on 6/5/25 at 3:40 PM. The Administrator indicated she expected that Nurse #8 would have followed the physicians order to change the tracheostomy ties. 2. Resident #63 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, diabetes mellitus II and muscle wasting. There was no diagnosis for sleep apnea (interruptions in breathing while asleep requiring the use of a CPAP machine.) The hospital Discharge summary dated [DATE] for Resident #63 revealed documentation that the resident brought her CPAP machine to the hospital from home, used it nightly, and was encouraged to take it to the facility with her at discharge. An interview with the Admissions Nurse was conducted on 6/5/25 at 2:03 PM. She stated she did the admission nursing assessments for Resident #63. She indicated she was unaware the resident had a CPAP machine as she did not see the documentation in the hospital discharge summary. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. The MDS was not coded for the use of a CPAP machine. Resident #63's Physician's orders for the months of March, April, May and June 2025 revealed there was no order written for use of the CPAP machine. An observation and interview were conducted on 6/2/25 at 1:15 PM in Resident #63's room. The resident had a CPAP machine next to her bed, and she stated she brought it with her from the hospital when she was admitted to the facility. Resident #63 further stated it was her personal CPAP machine that she had brought to the hospital before coming to the facility. Resident #63 indicated she used it every night for sleep apnea (a condition where a person has breathing interruptions in their sleep). In an interview with Nurse Aide (NA) #1 on 6/5/25 at 1:59 PM she stated Resident #63 used the CPAP machine nightly and that she brought it with her when she was admitted . She indicated she was familiar with Resident #63 and would see her wearing her CPAP mask when the NA arrived each morning. In an interview with Unit Manager (UM) #1 on 6/5/25 at 1:59 PM she stated Resident #63 used the CPAP machine nightly and she brought it with her when she was admitted . UM#1 reviewed Resident #63's physicians orders and stated there was no order for use of the CPAP machine. UM #1 indicated that use of a CPAP machine should have a physician's order. In an interview with the Administrator on 6/3/25 at 3:07 PM she stated Resident #63 should have had orders for use of the CPAP machine.

Based on observations, record review and staff interviews the facility failed to attempt alternative interventions, assess for entrapment risk, review the risks and benefits of the use of side rails, and/or obtain consent from the resident or resident representative prior to installing bilateral quarter length side rails (Resident #94 and Resident #172). In addition, the facility failed to attempt alternative interventions prior to installing bilateral quarter length side rails (Resident #63). This deficient practice affected 3 of 3 residents reviewed for side rails (Resident #94, Resident #172, and Resident #63). Findings included: 1. Resident #94 was admitted to the facility on [DATE] with diagnoses that included dementia, arthritis and heart failure. Resident #94's Minimum Data Set (MDS) revealed she required partial to moderate assistant with bed mobility and that she had impairment to both lower extremities. The MDS indicated Resident #94 was moderately cognitively impaired. Resident #94's comprehensive care plan dated 11/3/24 revealed she did not have a care plan that included the use of side rails. Resident #94's bed side rail tool, dated 1/23/25 and completed by the admission Nurse, indicated the resident did not use side rails, risks versus benefits and consent were not completed, and there was no assessment for entrapment risk. The bed side rail tool revealed no alternative interventions were tried before the installation and use of bilateral quarter length side rails. An interview with the admission Nurse was conducted on 6/5/25 at 2:03 PM. She stated she did the admission side rail assessment for Resident #94. The admission Nurse reviewed the assessment during the interview and revealed it was marked that the resident did not use bilateral quarter length side rails which she confirmed was not correct. The admission Nurse indicated she could not remember if the side rails were on the bed at the time of her assessment. The admission Nurse further stated review of risks and benefits, consent, and entrapment risk would not have been completed unless Resident #39 was approved for use of bilateral quarter length side rails. She was unsure why she had marked Resident #39 as not using side rails and was unaware alternative interventions needed to be tried and documented before the installation and use of side rails. An observation was conducted on 6/3/25 at 12:43 PM in Resident #94's room. The resident was lying in bed with bilateral quarter length side rails in the raised position. In an interview with Resident #94 on 6/3/25 at 12:43 PM, she stated she had always had the side rails on her bed and she used them to assist staff to help her roll over or to sit on the side of the bed. In an interview with the Director of Nursing (DON) on 6/3/25 at 2:22 PM she reviewed Resident #94's bed side rail tool assessment and stated that it indicated she did not use side rails. A follow-up observation and interview was conducted with the DON on 6/3/25 at 2:31 PM. Resident #94 was lying in bed with bilateral quarter length side rails in the raised position. The DON stated Resident #94's bed side rail tool should have indicated she did use side rails, an entrapment risk evaluation should have been completed, risks vs benefits should have been reviewed, and consent should have been received. She further stated she was unaware alternative interventions needed to be tried and documented before the installation and use of bilateral quarter length side rails. In an interview with the Administrator on 6/3/25 at 3:07 PM, she stated Residents #94 should have had an accurate bed side rail tool to include the use of bilateral quarter length side rails. The Administrator further stated she was unaware alternative interventions to bilateral quarter length side rails needed to be tried and documented before the installation and use of side rails. 2. Resident #172 was admitted to the facility on [DATE] with diagnoses that included acquired loss of left leg below the knee. Resident #172's admission nursing assessment dated [DATE] indicated he was cognitively intact. Resident #172's Minimum Data Set (MDS) was not available. Resident #172's bed side rail tool dated 5/29/25 and completed by the admission Nurse indicated the resident did not use side rails, entrapment risk was not evaluated, risks and benefits were not discussed and consent was not obtained from the resident or his responsible party. The bed side rail tool did not have alternative interventions listed before the installation and use of the side rails. An interview with the Admissions Nurse was conducted on 6/3/25 at 2:07 PM. She stated she did the admission side rail assessment for Resident #172. The admission Nurse reviewed the assessment during the interview and revealed it was marked that the resident did not use bilateral quarter length side rails which she confirmed was not correct. The admission Nurse indicated she could not remember if the side rails were on the bed at the time of her assessment. The admission Nurse further stated review of risks and benefits, consent, and entrapment risk would not have been completed unless Resident #172 was approved for use of bilateral quarter length side rails. She was unsure why she had marked Resident #172 as not using side rails and was unaware alternative interventions needed to be tried and documented before the installation and use of side rails. An observation was conducted on 6/2/25 at 11:30 AM in Resident #172's room. The resident was sitting on the side of his bed with bilateral quarter length side rails in the raised position. In an interview with Resident #172 on 6/2/25 at 11:30 AM he stated the side rails had been on the bed since his admission. In an interview with the Director of Nursing (DON) on 6/3/25 at 2:15 PM she reviewed Resident #172's bed side rail tool assessment and stated that it indicated he did not use side rails. A follow-up observation and interview was conducted with the DON on 6/3/25 at 2:29 PM. Resident #172 was sitting on the side of the bed with bilateral quarter length side rails in the raised position. The DON stated Resident #172's bed side rail tool should have indicated he did use side rails, an entrapment risk evaluation should have been completed, risks vs benefits should have been reviewed, and consent should have been received. She further stated she was unaware alternative interventions needed to be tried and documented before the installation and use of bilateral quarter length side rails. In an interview with the Administrator on 6/3/25 at 3:07 PM, she stated Resident #172 should have had an accurate bed side rail tool completed to include the use of bilateral quarter length side rails. The Administrator further stated she was unaware alternative interventions to bilateral quarter length side rails needed to be tried and documented before the installation and use of side rails. 3. Resident #63 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, diabetes mellitus II and muscle wasting. Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required partial/moderate assistance with bed mobility. The MDS further revealed she had impairment of both upper and lower bilateral extremities. Resident #63's bed side rail tool dated 3/20/25 and completed by the admission Nurse did not include documentation regarding the use of alternative interventions before the installation of side rails. The updated care plan for Resident #63 dated 4/2/25 included a focus of short term care: the resident requires assistance with activities of daily living (ADL). The goal was for the resident to improve their ADL functionality through the next review. Interventions included half length bed side rails. An interview with the admission Nurse was conducted on 6/5/25 at 2:03 PM. She stated she completed the bed side rail tool for Resident #63. She indicated she was unaware alternative interventions needed to be tried and documented prior to the installation and use of bilateral quarter length side rails. An observation of Resident #63 was conducted on 6/2/25 at 10:50 AM. The resident was lying in bed with bilateral quarter side rails in the raised position. A follow up observation and interview was conducted with Resident #63 on 6/3/25 at 1:25 PM. The resident was lying in bed with bilateral quarter side rails in the raised position. Resident #63 indicated she used the side rails to assist her when rolling over or repositioning in bed and they had been in place since her admission. In an interview with the Administrator on 6/3/25 at 3:07 PM she stated she was unaware alternative interventions were required to be tried and documented before the installation and use of bilateral quarter length side rails.

Based on record review and staff interviews, the facility failed to document the completion of wound treatments provided to a resident. This was for 1 of 3 residents (Resident #85) reviewed for pressure ulcers. Findings included: A review of Resident #85's physician's orders revealed an order dated 6/5/25 with an order start date of 6/5/25 at 7:00 AM indicated to cleanse Resident #85's posterior (further back position) scrotal (a muscular skin covered sack in front of the pelvis covering the testicles) skin tear with soap and water, pat dry, apply collagen particles (a protein that provides support and strength to skin) covered by a thin layer of zinc oxide paste (a medicated cream), and apply bordered gauze (an absorptive dressing) daily and as needed. An additional physician's order dated 6/5/25 with an order start date of 6/5/25 at 12:00 PM indicated to cleanse his right groin (the area where the thigh and abdomen meet) abrasion (a superficial injury to the skin) with wound cleanser, apply calcium alginate with silver (an antimicrobial dressing) and leave open to air three times daily and as needed. On 6/6/25 at 11:00 AM a review of Resident #85's medical record and June 2025 Treatment Administration Record (TAR) did not reveal any documentation indicating that his right groin abrasion or scrotal skin tear wound treatments had been completed on 6/5/25. On 6/6/25 at 11:21 AM an interview with the Wound Care Nurse indicated she completed all Resident #85's right groin abrasion and posterior scrotal skin tear treatments on 6/5/25 as ordered by his physician. She stated she could not say why she had not documented the completion of these treatments in Resident #85's medical record or on Resident #85's TAR for that date, but she should have. In an interview on 6/6/25 at 11:30 AM the Director of Nursing (DON) stated Resident #85's medical record should accurately reflect the wound treatments provided to him by the Wound Care Nurse on 6/5/25. On 6/6/25 at 11:33 AM an interview with the Administrator indicated the Wound Care Nurse should have documented the wound treatments she provided to Resident #85 on 6/5/25 to ensure his medical record was complete and accurate.

Based on observation, record review, and staff and Nurse Practitioner(NP) interviews, the facility failed to ensure infection control standards were followed when Nurse #3 dropped a residents medication on the top of the medication cart, picked it up with her bare fingers, placed it in the medication cup and gave the medications to the resident. This was for 1 of 11 staff members reviewed for infection control practices (Nurse #3). Findings included: An observation was conducted on 6/4/25 at 8:35 AM during medication pass. Nurse #3 was preparing several medications for a resident when she popped a pill out of the back of the bubble pack and it missed the medication cup and landed on the top of the medication cart. Nurse #3 picked the pill up off the medication cart with her bare fingers and placed it in the medication cup. She stated Ooops, I probably shouldn't have done that. Oh well. Nurse #3 then gave the medications to the resident. She had last performed hand hygiene before starting to prepare the medications for this resident. She had touched 5 bottles of stock medications, 3 bubble pack cards and the drawer handles of the cart while preparing the medications for this resident. She was not observed to clean the top of the medication cart at any time during the medication pass observation. In an interview with Nurse #3 on 6/4/25 at 8:45 AM she stated she knew she should have thrown the pill away after it touched the top of the medication cart and she touched it with her bare hands as that would have been proper infection control procedure. She further stated she didn't know why she continued to put it in the cup and give it to the resident. During an interview with the Infection Preventionist on 6/4/25 at 11:45 AM, she stated Nurse #3 should have thrown the pill away after picking it up from the top of the medication cart with her bare hands. She revealed both the medication cart and her hands could have transmitted a disease causing organism to the resident. On 6/5/25 at 3:12 PM, the NP was interviewed. She stated Nurse #3 should have thrown the pill away after it touched the top of the medication cart and she picked it up with her bare hands. The NP revealed that people's hands are the number one way bacteria and viruses are passed from person to person, either from the person themselves or after touching a contaminated surface such as the top of the medication cart. In an interview with the Director of Nursing on 6/4/25 at 11:50 AM she stated Nurse #3 should have thrown the pill away after it touched the top of the medication cart. She further stated that Nurse #3's hands, or the top of the medication cart, could have been contaminated and that could have been passed to the resident via the pill. An interview with the Administrator and the Director of Clinical Services was conducted on 6/4/25 at 11:55 AM. The Director of Clinical Services stated they did not have a policy directly related to the deficiency of touching a pill with bare hands that had been on top of the medication cart and then giving it to a resident. The Administrator indicated that it would be common nursing practice to throw the pill away and get a clean one for the resident, and that is what she would have expected Nurse #3 to have done.

Based on record review and staff interviews, the facility failed to maintain documentation of grievances and evidence of the result of all grievances for 7 of 7 months reviewed. Findings included: Review of the facility policy dated 1/23/2020 titled Grievances read in part: (4) The Administrator will maintain a file for tracking and referencing grievances received and responses provided for a period of 3 years. A review of the grievance logs from June 2024 to January 2025 revealed all logs from June 2024 to January 2025 were unavailable. In a telephone interview with previous Administrator #2 on 1/28/25 at 2:40 PM he stated when he left employment at the facility two weeks ago the grievance log binder was on the shelf behind the desk in the Administration office. In an interview with current Administrator #1 on 1/28/25 at 3:30 PM she stated she had been unable to locate the grievance log binder for the time period of June 2024 to January 2025. She stated she would continue to search for it. In a follow-up interview with Administrator #1 on 1/30/25 at 11:00 AM she stated she still had not located the missing grievance log binder covering the time frame of June 2024 to January 2025. She was aware complete grievance logs including the result of the grievance investigation were to be maintained for three years or longer.

Based on record review, and staff interviews and Pharmacist interviews, the facility failed to provide care according to professional standards when Nurse #1 borrowed medication from Resident #6 to administer to Resident #5. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses that included diabetes with neuropathy (nerve pain). Physician orders dated 10/19/24 for Resident #6 revealed an order for gabapentin (a medication used to treat nerve pain) 100 milligrams (mg) to be administered once a day. The admission Minimum Data Set (MDS) assessment for Resident #6 dated 10/22/24 revealed she was cognitively intact. Resident #6 was no longer at the facility and was not available for interview. Resident #5 was admitted to the facility on [DATE] with diagnoses that included pain of lower extremities. Physician orders dated 10/19/24 for Resident #5 revealed an order for gabapentin 100 mg to be administered 3 times a day for pain. The admission Minimum Data Set (MDS) assessment for Resident #5 dated 10/22/24 revealed he was moderately cognitively impaired. Review of the Medication Administration Record (MAR) for Resident #5 for the month of October 2024 revealed the ordered gabapentin 100mg had been signed off as administered by Nurse #1 on 10/19/24 at 9:00 am and 2:00 pm. Resident #5 was no longer at the facility and was not available for interview. During an interview with Administrator #2 on 1/29/25 at 11:43 am he stated he was the Administrator in October of 2024 and recalled that Resident #5's family member had a concern that Nurse #1 borrowed 2 pills of gabapentin (not sure of the dosage) from Resident #6 and administered them to Resident #5. He stated Nurse #1 told the facility she borrowed the gabapentin from Resident #6 to administer to Resident #5 because gabapentin was not in the ADS. Administrator #2 stated Nurse #1 should not have borrowed the gabapentin and should have called the on-call pharmacist if the gabapentin was not available. In a telephone interview with Nurse #1 on 1/29/25 at 7:25 pm she stated she borrowed 2 capsules of gabapentin 100 mg from Resident #6 and administered the capsules to Resident #5 on 10/19/24, one capsule at 9:00 am and one capsule at 2:00 pm, for a total of 2 capsules borrowed and administered. Nurse #1 stated she borrowed the gabapentin because Resident #5 was a new admission, his medication supply had not yet come in, and the gabapentin was not available in the automated dispensing system (a pharmacy device designed to provide secure surplus medication storage on patient care units). She further stated that she should have called the on-call pharmacist to have the gabapentin called into the back-up pharmacy but did not. Nurse #1 stated she did not know she could not borrow medications from one resident to give to another resident. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9:55 am. The DON stated Administrator #2 told her on 10/21/24 that Nurse #1 borrowed 2 gabapentin 100 mg capsules from Resident #6 and administered them to Resident #5 on 10/19/24. The DON further indicated she completed an investigation that revealed Nurse #1 borrowed 2 gabapentin 100 mg capsules for Resident #5 on 10/19/24 because he was newly admitted , and his medication supply had not yet arrived from the pharmacy. The DON stated the facility had a process in place to ensure residents did not miss any doses of prescribed medications while they waited for the pharmacy to deliver their medications. She stated Nurse #1 should not have borrowed medications from Resident #6 but should have first attempted to obtain the needed medication from the on-site automated dispensing system and if it was not available to call the on-call pharmacist to have the medication called in to a local pharmacy for delivery to the facility. During an interview with the Regional Director Clinical Consultant on 1/29/25 at 10:15 am she stated she was contacted by Administrator #2 on 1/22/24 and asked to assist with an investigation where Nurse #1 borrowed gabapentin from Resident #6 and administered it to Resident #5. The Regional Director Clinical Consultant stated she assisted the DON in the completion of the investigation and formulated a plan of correction on borrowing medications and the use of the back-up medication system. She further indicated that the nurse had borrowed the gabapentin for Resident #5 because a family member had demanded that it be administered right away, and the medication was not available in the automated dispensing system. During an interview with the Pharmacist on 1/30/25 at 10:00 am he stated Resident #5 was admitted to the facility on the evening of 10/18/24 and his order for gabapentin 100 mg was received in the pharmacy on 10/19/24 at 12:31 am, was filled and sent out to the facility for the next night's delivery on 10/20/24. The interview revealed Nurse #1 should not have borrowed medications from Resident #6 to administer to Resident #5. The Pharmacist went on to explain Nurse #1 should have obtained the medication from the automated dispensing system and if it was not available, she should have called the on-call pharmacist, and the medication would have been called into a local back-up pharmacy for the medication to be delivered to the facility. The facility provided the following corrective action plan with a completion date of 10/24/2024: Address how the facility will correct the deficiency as it relates to the individual. Nurse #1 was suspended by the Administrator on 10/21/2024 pending investigation. The Administrator submitted a report to North Carolina Department of Health and Human Services (NCDHHS). Medications for Resident #5 were delivered on 10/19/2024. Medications were replaced for Resident #6 by the facility at the facility's cost. Address how the facility will act to protect residents in similar situations. A 100% admissions audit for the last 14 days (October 8-22) was performed by the Regional Director of Clinical Services on 10/22/2024 for medication delivery within 24 hours of admission. All residents admitted in the last 14 days had all ordered medications on the medication cart. Address what measures will be put into place or systemic changes made to ensure that the problem does not recur. All licensed nurses and medication aides were educated by the Staff Development Coordinator and DON on using the automated dispensing system (a pharmacy device designed to provide secure surplus medication storage on patient care units) for medications and never borrowing medications from one resident to give to another resident on 10/22/2024 and 10/23/2024. The DON ensured all licensed nurses had access to the automated dispensing system on 10/21/2024. Indicate how the facility will monitor its performance to make sure that solutions are sustained. The DON or Unit Manager will audit all new admissions to verify that medications were received within 24 hours of admission as they are admitted to the facility. These audits will occur 5 times a week for 2 weeks then 3 times a week for 2 weeks to ensure compliance has been achieved. The plan of correction must provide dates when corrective action will be completed: Compliance date: 10/24/2024 The facility's corrective action plans date of compliance of 10/24/24 was verified on 1/30/2025 by review of the following: Interviews and record review verified Resident #6's gabapentin was replaced on 10/25/24 by the facility at the facility's expense. Record review revealed a 100% admissions audit was completed 10/8/24 through 10/22/24 to ensure new admission medications were received. Interviews with Nurses revealed they were educated on how to obtain medications for new admissions and not to borrow medications from one resident to administer to another. Record reviews and interviews confirmed audits were performed 5 times a week for 2 weeks and then 3 times a week for 2 weeks to ensure compliance was achieved. The compliance date of 10/24/2024 was validated.

Based on record review and staff interviews, the facility failed to have a complete and accurate Medication Administration Record (MAR) for 1 of 3 residents (Resident #11) reviewed for record accuracy. Findings included: Resident #11 was admitted to the facility on [DATE]. Resident #11's Physician's orders included: - Administer enteral feed Jevity 1.5, 237 milliliters (mls) (1 carton) twice a day at 5:00 AM and 11:00 PM with an order date of 10/23/24. - Flush feeding tube every 6 hours at midnight, 6:00 AM, noon and 6:00 PM with 150 mls of free water with an order date of 10/23/24. Resident #11's December 2024 MAR revealed the enteral feed had not been documented as given or refused on: -12/10/24 at 5:00 AM by Nurse #2 -12/19/24 at 5:00 AM by Nurse #3 -12/24/24 at 5:00 AM by Nurse #4 -12/26/24 at 6:00 AM by Nurse #2 The December 2024 MAR further revealed the 150 mls of free water was not documented as given or refused on: -12/10/24 at 6:00 AM by Nurse #2 -12/12/24 at 6:00 AM by Nurse #4 -12/19/24 at 6:00 AM by Nurse #3 -12/24/24 at 6:00 AM by Nurse #4 -12/26/24 at 6:00 AM by Nurse #2 In a telephone interview on 1/28/25 at 3:10 PM with Nurse #3 she stated she forgot to sign the MAR after giving the enteral feed and 150 ml free water flush to Resident #11 on 12/19/24. She further stated she was aware all medications should have been signed off in the MAR as soon as they were given. In a telephone interview on 1/28/25 at 6:40 PM with Nurse #4 she stated she must have forgotten to sign the MAR after giving the 150 ml free water flush on 12/12/24 and the enteral feed and free water flush to Resident #11 on 12/24/24. Nurse #1 revealed she was aware all medications were to be signed off in the MAR as soon as they were given. In a telephone interview on 1/29/25 at 9:27 AM with Nurse #2 she stated she must have forgotten to sign the MAR on 12/10/24 and 12/26/24 after giving the enteral feed and 150 ml free water flush as well as after giving the free water flush on 12/12/24 to Resident #11. Nurse #2 revealed she was aware all medications needed to be signed off in the MAR as soon as they were given. An interview with the Director of Nursing (DON) was conducted on 1/29/25 at 9:40 AM. The DON stated all medications were to be signed off in the MAR as soon as they were given. She further stated that if a medication was not given, the Nurse was to use one of the codes available in the MAR to indicate why it was not given. There should not have been empty spaces in the MAR where it should have been signed off by the Nurse. In an interview with Administrator #1 on 1/29/25 at 9:50 AM she revealed all medications were to be signed off in the MAR as soon as possible, and available coding was to be used if medication was not given. The signature space for the medication should never be left empty. She stated all new hires including agency staff are educated regarding signing the MAR.

Based on record review and interviews with facility staff and the Nurse Practitioner (NP), the facility failed to ensure there was effective communication during shift to shift report between facility nursing staff to avoid a lapse between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for quality of care. The findings included: A review completed of Resident #1's hospital lab results dated 10/30/24 revealed on 10/29/24 her hemoglobin was 8.4 (normal values 12.0-16.0) and her hematocrit was 27.7 (normal values 35.0-47.0). Resident #1 was admitted to the facility on [DATE] with diagnoses that included heart disease, anemia, a viral infection of the liver causing inflammation and swelling of the liver, diabetes, parathyroid disease, history of a stroke, and hypertension A progress note dated 11/1/24 at 2:43pm stated the facility's NP was in the facility and notified Resident #1 having episodes of vomiting. The NP gave an order to have a STAT CBC lab drawn and notify the provider as soon as the lab results were available for review. A telephone interview was completed on 11/12/24 at 3:30pm with the facility's NP. The NP stated she was in the facility on 11/1/24 completing resident visits. The NP stated during her visit she reviewed Resident #1's hospital records for her 10/22/24-10/30/24 stay and spoke to the Resident's assigned nurse on that day. The NP stated it was in her medical opinion the Resident's diagnosis of liver disease resulted in her ongoing anemia and abnormal lab results. The NP stated that because of Resident #1's abnormal lab values during her hospital stay and multiple health diagnoses, she ordered STAT labs to be completed. The NP stated she requested the facility contact her or the provider on-call when the lab results were received. The NP stated she did not receive a call from the facility nor was there a notation that the on-call provider received a telephone call regarding the lab results. An interview was completed on 11/12/24 at 11:09am with Minimum Data Set (MDS) Nurse Coordinator. The Nurse stated the NP was in the facility on 11/1/24 and ordered stat labs for Resident #1. The Nurse stated she called the lab at approximately 2:43pm to place the STAT lab order. The MDS Coordinator stated she notified the Resident's assigned 7am-3pm Nurse of the STAT lab order and entered a progress note in Resident #1's medical record regarding the order. A telephone interview was completed on 11/12/24 at 12:00pm with Nurse #2. The Nurse stated she was assigned to Resident #1 during the 7am-3pm shift on 11/1/24. Nurse #2 revealed she was unable to recall if she had notified the oncoming 3pm-11pm nurse of the pending STAT labs or written it on the 24-hour Report Sheet. Nurse #3 stated it was her routine to alert the oncoming nurse of pending labs during shift report. Nurse #2 stated she informed the NP she felt Resident #1's jaundice had increased since she worked with her the day before. An interview was completed on 11/12/24 at 4:30pm with Nurse #5. The Nurse stated she was assigned to Resident #1 during the 3pm-11pm shift on 11/1/24. Nurse #5 revealed she did not recall Nurse #2 notifying her of pending STAT labs for Resident #1. Nurse #5 stated she did not recall seeing a 24-hour Report Sheet alerting Resident #1 had pending labs. Lab results dated 11/1/24 revealed the lab phlebotomist (medical professional who draws blood) obtained the blood sample on Resident #1 at 6:10pm on 11/1/24. The laboratory received the blood sample at 7:15pm from the phlebotomist and the result of the CBC lab was received at the laboratory at 7:35pm. The CBC results were as follows: hemoglobin 5.5 and hematocrit 17.8. The laboratory noted these values to be at a critical level. A telephone interview was completed on 11/12/24 at 1:43pm with Nurse #4. The Nurse stated she was assigned to Resident #1 during the 11pm-7am shift on 11/1/24. Nurse #4 stated she did not recall the 3pm-11pm nurse notifying her Resident #1 had pending STAT labs. Nurse #4 stated she did not recall seeing Resident #1 had pending labs on the 24-hour report sheet. A telephone interview was completed on 11/12/24 at 3:20pm with the facility's contracted laboratory's Regional Service Representative. The Representative stated the hospital laboratory, and the facility contracted laboratory attempted to contact the facility multiple times on 11/1/24 and 11/2/24 of Resident #1's critically low lab values without success. The 5 day stay MDS assessment dated [DATE] revealed Resident #1 was cognitively impaired. A progress note dated 11/3/24 at 4:03pm stated Resident #1's responsible party (RP) requested to have the Resident sent to the hospital for evaluation due to Resident #1 not being at her normal baseline. The note stated Resident #1's vital signs were as follows: blood pressure: 106/62, pulse: 70 beats per minute, and respirations were 20 breaths per minute. The note stated the nurse called Resident #1's name, she opened her eyes and looked toward the nurse. Emergency Services were alerted and Resident #1 was transferred to the hospital for evaluation and treatment at approximately 3:15pm. A review of Resident #1's hospital history and physical note dated 11/3/24 revealed Resident #1 arrived at the emergency department at approximately 3:39pm was alert to person but not time or place. Her vital signs were as follows: blood pressure: 127/74, pulse: 82 beats per minute, and respirations: 16 breaths per minute. The CBC lab was completed and at approximately 4:03pm Resident #1's hemoglobin had decreased to 4.2 and her hematocrit had decreased to 13.4. A progress note dated 11/4/23 stated the STAT labs obtained on 11/1/24 for Resident #1 did not populate into Resident #1's electronic medical record from the laboratory company. An interview was completed on 11/12/24 at 11:15am with the Director of Nursing (DON). The DON stated on 11/4/24 it was discovered the facility had not received results from STAT labs completed on Resident #1 on 11/1/24. The DON stated when lab results were completed the results were populated into the resident's electronic medical record and the laboratory called with critically low lab values. The DON stated due to the results not populating into Resident #1's electronic medical record, the assigned nurse was not aware of the critically low results. The DON stated the facility did not receive calls from the lab regarding the critically low results. The DON stated nurses communicated a resident's acute issues and pending labs during shift report and by writing them on a 24-hour Report Sheet that was kept at the nurses' station. The DON revealed she was unaware if Resident #1's pending STAT labs were communicated shift to shift between the Resident's assigned nurses. The DON stated she was unable to locate a 24-hour Report Sheet alerting oncoming nurses of Resident #1's pending labs. A follow-up interview was completed on 11/13/24 at 2:56pm with the DON. The DON stated the failure of Resident #1's assigned nurses to communicate Resident #1's pending labs shift to shift resulted in the labs not being addressed timely. An interview was completed on 11/13/24 at 3:15pm with the facility's Administrator. The Administrator stated it was his expectation nursing staff communicate shift to shift of any pending labs to be completed and results waiting to be received. The facility provided the following corrective action plan with a date of 11/4/24 to begin monitoring and a completion date of 11/7/24. Problem: Communication between nurses shift to shift. Immediate Response-what was done at the time. The Resident is no longer at the facility. How to Identify other residents. All residents have the potential to be affected. 24-hour report sheets were reviewed by the DON on 11/5/24 for the last 14 days to ensure all acuities reported were followed up on. What Measures were put in place to prevent reoccurrence. Licensed nurses and medication aides were in-serviced by the Regional Director of Clinical Services and the Administrator on 11/5/24-11/6/24 on communication during verbal shift to shift report with the oncoming shift and written communication on the 24-hour report to include all acuities. How to monitor to ensure the problem does not reoccur. The DON or Unit Manager will monitor 24-hour reports daily 5 times per week for 4 weeks. Then 3 times per week for 4 weeks and finally 2 times per week for 2 weeks to ensure all acuities have been reviewed and followed up on. The results will be reported to the monthly Quality Committee meeting (11/20/24) for review and discussion to ensure substantial compliance. Once the Quality Assurance Committee determines the problem no longer exists, then the review will be completed on a random basis. Alleged date of compliance: 11/7/24 Onsite validation was completed on 11/13/24 through staff interviews, observations, and record reviews. Inservice was confirmed to be provided on lab tracking and Provider notification of lab results. Staff were interviewed to validate the in-service was completed on shift-to-shift communication. A review of 24-hour report sheets for 11/8/24, 11/10/24, and 11/11/24 revealed no concerns. A review of the 24-hour Report Audit-DON Monitoring tool was reviewed for 11/7/24, 11/9/24, and 11/10/24 revealed no concerns. An interview was completed on 11/13/24 at 2:47pm with Nurse #6. The Nurse stated when she received a lab order or noted any acute concerns with a resident during her shift, she notified the oncoming nurse and entered any new orders and acute concerns on the 24-hour Report Sheet. The Nurse confirmed she had received education regarding communication between nursing staff shift to shift. An interview was completed on 11/13/24 at 2:50pm with Nurse #7. The Nurse verified he had received education regarding shift-to-shift communication and completing the 24-hour Report Sheet with any acute concerns or labs pending on residents. The facility's corrective action plan was validated to be completed as of 11/7/24.

Based on record review and interviews with facility staff, Nurse Practitioner (NP), and the facility's contracted laboratory company, the facility failed to ensure there was effective communication between facility staff and the lab company to avoid a lapse of multiple days between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results timely. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for laboratory services. The findings included: A progress note dated 11/1/24 at 2:43pm stated the facility's NP was in the facility and notified Resident #1 having episodes of vomiting. The NP gave an order to have a STAT CBC lab drawn and notify the provider as soon as the lab results were available for review. Lab results dated 11/1/24 revealed the lab phlebotomist (medical professional who draws blood) obtained the blood sample on Resident #1 at 6:10pm on 11/1/24. The laboratory received the blood sample at 7:15pm from the phlebotomist and the result of the CBC lab was received at the laboratory at 7:35pm. The CBC results were as follows: hemoglobin 5.5 and hematocrit 17.8. The laboratory noted these values to be at a critical level. A progress note dated 11/4/23 stated the results from STAT labs obtained on Resident #1 on 11/1/24 did not populate into Resident #1's electronic medical record from the laboratory company. An interview was completed on 11/12/24 at 11:09am with Minimum Data Set (MDS) Nurse Coordinator. The Nurse stated the NP was in the facility on 11/1/24 and ordered stat labs for Resident #1. The Nurse stated she called the lab at approximately 2:43pm to place the STAT lab order. The MDS Coordinator stated she notified the Resident's assigned 7am-3pm Nurse of the STAT lab order. The Nurse stated on 11/4/24 she discovered Resident #1's STAT lab results were not in her electronic medical record. The Nurse stated the lab results are normally populated into the electronic medical record by the lab once the results are in. The Nurse stated she contacted the lab on 11/4/24 to make it aware Resident #1's lab results did not populate into her electronic medical record. An interview was completed on 11/12/24 at 11:15am with the Director of Nursing (DON). The DON stated on 11/4/24 it was discovered the facility had not received results from STAT labs completed on Resident #1 on 11/1/24. The DON stated when lab results were completed the results were populated into the resident's electronic medical record and the laboratory called with critically low lab values. The DON stated due to the results not populating into Resident #1's electronic medical record, the assigned nurse was not aware of the critically low results. The DON stated the facility did not receive calls from the lab regarding the critically low results. The DON revealed she was unaware if Resident #1's pending STAT labs were communicated shift to shift between the Resident's assigned nurses. The DON stated she normally reviewed all pending labs daily, including weekends, to assure the facility had received the results and notified the provider. The DON stated she was unable to say why she did not review Resident #1's labs to ensure the results were received and the provider notified. The DON stated MDS Coordinator Nurse and herself are now reviewing, printing, and assuring medical providers are contacted regarding resident's lab results daily. A telephone interview was completed on 11/12/24 at 12:00pm with Nurse #2. The Nurse stated she was assigned to Resident #1 during the 7am-3pm shift on 11/1/24. Nurse #2 revealed she was unable to recall if she notified the oncoming 3pm-11pm nurse of the pending STAT labs. Nurse #3 stated it was her routine to alert the oncoming nurse of pending labs during shift report. A telephone interview was completed on 11/12/24 at 1:43pm with Nurse #4. The Nurse stated she was assigned to Resident #1 during the 11pm-7am shift on 11/1/24. Nurse #4 stated she did not recall receiving a phone call from the laboratory regarding Resident #1's critically low hemoglobin and hematocrit. The Nurse stated she was unable to recall if the 3pm-11pm nurse alerted her to Resident #1's pending STAT labs. A telephone interview was completed on 11/1/24 at 3:20pm with the facility's contracted laboratory's Regional Service Representative. The Representative stated at approximately 7:32pm on 11/1/24 the hospital laboratory contacted the facility by phone to notify Resident 1's nurse of a critically low lab result. The Representative stated a facility staff member answered the phone and revealed to the laboratory employee there was no Resident by the name of Resident #1 residing in the facility. The hospital laboratory attempted to contact the facility once more at approximately 5:22am on 11/2/24 without success. On 11/2/24 at approximately 6:01am the hospital laboratory contacted the facility's contract laboratory company regarding the inability to communicate to the facility Resident #1's critically low lab result. On 11/2/24 at approximately 6:08am the contracted lab attempted to contact the facility without success. The Representative stated there were no further attempts made by the contracted laboratory to notify the facility of the critically low lab result. A telephone interview was completed on 11/12/24 at 3:30pm with the facility's NP. The NP stated she was in the facility on 11/1/24 completing resident visits. The NP stated during her visit she reviewed Resident #1's hospital records for her 10/22/24-10/30/24 stay and spoke to the Resident's assigned nurse on that day. The NP stated that because of Resident #1's abnormal lab values during her hospital stay and multiple health diagnoses, she ordered STAT labs to be completed. The NP stated she requested the facility contact her or the provider on-call when the lab results were received. The NP stated she did not receive a call from the facility nor was there a notation that the on-call provider received a telephone call regarding the lab results. An interview was completed on 11/12/24 at 4:30pm with Nurse #5. The Nurse stated she was assigned to Resident #1 during the 3pm-11pm shift on 11/1/24. Nurse #5 revealed she did not recall Nurse #2 notifying her of pending STAT labs for Resident #1. The Nurse revealed she did not receive a telephone call from the laboratory regarding the lab results for Resident #1. A follow-up interview was completed on 11/13/24 at 2:56pm with the DON. The DON stated the failure of the lab results to populate into the Resident's electronic medical record and the failure of communication between the laboratory and the facility caused the lab to not be addressed timely. An interview was completed on 11/13/24 at 3:15pm with the facility's Administrator. The Administrator stated it was his expectation lab results are received and follow up on timely. The facility provided the following corrective action plan with a date of 11/4/24 to begin monitoring and a completion date of 11/5/24. Problem: On 11/1/24 the Resident had an episode of vomiting. The NP assessed the Resident and ordered STAT labs to be drawn that day. The facility's contracted laboratory obtained the labs and sent them to the hospital laboratory. At approximately 7:32pm the hospital laboratory called and reportedly was told there was no resident in the facility by the Resident's name. On 11/2/24 at 5:22am the hospital laboratory called the facility, and no one answered. On 11/2/24 at approximately 6:01am the hospital laboratory called the facility's contracted laboratory to notify them of the unsuccessful attempts to notify the facility. On 11/2/24 at approximately 6:08am the contracted laboratory called the facility and there was no answer. There were no further calls made to the facility. On 11/3/24 the Resident's RP noticed a change in the Resident's condition and requested for her to be sent out to the emergency department. The assigned nurse assessed the Resident, obtained vital signs, called emergency services, and sent the Resident to the emergency department. Immediate Response-what was done at the time. The Resident is no longer at the facility. How to identify other residents. On 11/4/24 the Minimum Data Set (MDS) Coordinator and DON reviewed all labs for the last 30 days to ensure there were no critical results that had not been reported or followed up on. On 11/4/24 the MDS Coordinator emailed the contracted laboratory in regard to lab results not populating in electronic medical records. What measures were put in place to prevent reoccurrence. One 11/4/24 and 11/5/24 the DON educated the MDS Coordinator, Unit Manager, Wound Nurse, and Charge Nurse on the process of accessing lab results each morning for review and follow-up. How to monitor to ensure the problem does not reoccur. The DON or MDS Coordinator will assess lab results daily and complete a lab tracking tool daily for 12 weeks. The results will be presented in the clinical meeting to ensure all lab results have been reported and have received follow-up. The results will be reported to the monthly Quality Committee meeting (11/20/24) for review and discussion to ensure substantial compliance. Once the Quality Assurance Committee determines the problem no longer exists, then the review will be completed on a random basis. Alleged date of compliance: 11/5/24 Onsite validation was completed on 11/13/24 through staff interviews, observations, and record reviews. Inservice was confirmed to be provided on lab tracking and Provider notification of lab results. Staff were interviewed to validate the in-service was completed on lab tracking and Provider notification. A review of education conducted with the MDS Nurse Coordinator regarding steps to take when a facility Provider orders labs. A review of labs ordered on residents on 11/7/24, 11/8/24, and 11/9/24 revealed no concerns. A review of the Lab Monitoring Tracker audit tool for 11/5/24, 11/6/24, and 11/724 revealed no concerns. An interview was completed on 11/13/24 at 9:30am with the MDS Nurse Coordinator. The Nurse revealed every day she reviewed labs ordered by the facility's Providers, printed all lab results for that day and ensured the Provider was notified of the results. An interview was completed on 11/13/24 at 2:47pm with Nurse #6. The Nurse stated when she received an order for a STAT lab during her shift, she contacted the laboratory to place an order for the lab, completed a progress note in the resident's medical record regarding the order, and when the lab was not collected prior to the end of her shift, she notified the oncoming nurse. The facility's corrective action plan was validated to be completed as of 11/5/24.

Based on observations, staff, Podiatrist, and resident interviews and record review the facility failed to ensure a resident was free from injury while being loaded into the transportation van for 1 of 6 residents reviewed for accidents. Resident #72's right foot became caught between the van ramp and hydraulic lift platform and she sustained an avulsion to her right great toe (forcible tearing off of skin), the skin was unable to be sewn together, x-ray results showed the toe had a minimally displaced fracture (Resident #72). Findings included: Resident #72 was admitted to the facility on [DATE]. Her active diagnoses included coronary artery disease, heart failure, end stage renal disease, and diabetes. Resident #72's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. She was independent with sit to stand function and chair/bed to chair transfers. She was documented to receive dialysis. Review of a nursing note dated [DATE] noted as late entry for [DATE] revealed Resident #72 was being loaded to be transported to dialysis by the Transport Driver and Resident #72 moved her foot up too far while the lift was in motion. Resident #72's right great toe was caught on the lift gate as she was being lifted into the transport vehicle. She sustained a laceration on her right great toe. Wound care was provided by this nurse (Staff Development Coordinator) and the Corporate Nurse Consultant. There was minimal bleeding at that time, pressure bandage applied so resident could go to dialysis, and Resident #72 stated the toe was not hurting anymore. Review of a nursing note dated [DATE] noted as late entry for [DATE] revealed Resident #72 returned from dialysis. The dressing to her right great toe was noted to be bloody. The wound was cleansed, and a pressure dressing applied. Resident #72 complained of pain from touch. As needed pain medication was offered, and on a follow-up assessment it was noted the bandage was soaked with blood. The physician was notified, 911 called, and the transfer was paperwork completed. Report was given to Emergency Medical Services on arrival and then transported to the hospital for further evaluation. Review of the hospital discharge summary dated [DATE] for Resident #72 revealed the physician documented upon initial examination; Resident #72 did appear to have a laceration but upon further inspection there was no large area to sew however there was avulsed (forcible tearing off of skin) skin removed to the toe. X-ray showed a minimally displaced fracture to the right great toe metatarsal. Due to the open fracture, Resident #72 was given Keflex (a type of cephalosporin antibiotic that treats bacterial infections) in the emergency department and sent back to the facility with a prescription for 5 days. The laceration was repaired after washing with soap and water and irrigation. Steri-Strips were used. The right great toe was wrapped in sterile gauze and Coban (a self-adhering, elastic bandage). Resident #72 was advised to follow up with her regular doctor in the next couple of days for wound check and resident was agreeable to the plan. During an interview on [DATE] at 2:57 PM Resident #72 stated in [DATE] the Transport Driver was taking her to dialysis and she was in the van lift as he began to operate the lift. She stated he had placed her feet flat on the lift instead of on the wheelchair footrests. As the lift went up, she screamed out in pain. Her right great toe had been caught in the lift as she was going up. She shouted, put it down, put it down, and he heard her and let the lift down. The Corporate Nurse Consultant must have heard her yell from inside and she came out and asked what was wrong. Resident #72 told her that her toe got caught in the lift of the van. The Corporate Nurse Consultant got down on her knees to check Resident #72's toe and got someone to bring her ointment and gauze. The Corporate Nurse Consultant treated the toe and got her fixed up so she could go to dialysis. Resident #72 went to dialysis because she told them she still wished to go, and she was not hurting. When she got up to leave dialysis the toe started to bleed again. The dialysis nurse treated the toe and she returned to the facility. The toe started to bleed when she returned, and the nurse was concerned and sent Resident #72 to the hospital for evaluation of the toe. She stated at the hospital she discovered her right great toe was broken, and the toenail was damaged and killed the toenail. She concluded her toe had healed but the toenail died . She stated she had been unable to wear shoes for some time which was why she did not have any on during the incident. During an interview on [DATE] at 10:15 AM the Podiatrist stated he had seen Resident #72 today for an exam and reviewed her right great toe as well. She was seen last by podiatry in [DATE] and since then she had several missed appointments due to resident refusals and today was the first she had been seen by podiatry since 2022. He stated upon review of her right great toe, the toenail looked dystrophic (thick and crumbly and discolored due to past trauma). The toe itself had proper alignment with no obvious signs of injury. He stated based on his review this morning the toenail probably would not regrow. It is likely to remain dystrophic, however the toe itself was healed and did not impact her daily life. During an interview on [DATE] at 12:16 PM the Transport Driver stated he remembered the incident with Resident #72 in [DATE]. He further stated he was taking Resident #72 to dialysis, and he placed her on the lift for the transport van. He then positioned the resident on the lift and one step he had to perform each transport was looking to see if the resident's feet were on the wheelchair footrests. He stated everything was good and she was positioned correctly with her feet on the footrests of the wheelchair. He stated he was standing on her right side, by the lift where he was supposed to stand and had the lift control in his hand and began to raise her up as he watched the lift. He stated he was responsible for observing the closing back ramp which would prevent the resident from rolling back and off the ramp as he was trained. Because of this and the resident's size, he did not see that she removed her right foot from her footrest and placed it on the lift with her right great toe under the yellow ramp which folds down to the van entrance as the lift elevated to the floor of the van. As the ramp made it to the highest elevation, Resident #72 said, Oh, my feet! He stopped the lift immediately and then lowered the lift. Resident #72 then told him her foot was in pain, so he called for nursing assistance and two nurses came and checked Resident #72. Following their treatment of the resident's right great toe he was told she could go to dialysis. He raised the lift fully without the resident to ensure the lift was working properly and no issues were found. With the two nurses observing him, he again put the resident on the same lift, and he had no issues as the resident was placed on the van and taken to dialysis. Later he was informed Resident #72 had to go to the hospital for her right great toe. He then had to watch a training video regarding the van and the lift. Training was also given by a staff member after the video training. He was then monitored for multiple weeks after the incident by a staff member and there were no issues with any of his transports. During an interview on [DATE] at 11:37 AM the Corporate Nurse Consultant stated she was one of the first staff to respond from the facility to Resident #72's incident in the van. She further stated there was a call overhead for nursing assistance at the front of the building. She was in the building that day and she went to respond. Resident #72 was at the front of the building in her wheelchair with the Transport Driver. Resident #72's right great toe was bleeding. She had yellow non-skid socks on with no shoes and she removed the sock as the Staff Development Coordinator came to her and then went to collect wound supplies. At the time she did not complain of pain, and the Corporate Nurse Consultant did not know how much the resident could feel her feet due to her diabetic history. She held pressure at the tip of her toe, cleaned the wound, and dressed it. Resident #72 said she wanted to proceed to dialysis and have the doctor look at it there. They then had the Transport Driver do a return demonstration for the Staff Development Coordinator and herself. He did everything as he should and used the correct process. When they interviewed the resident, Resident #72 stated she had moved her foot as the lift was going up and felt a pinch. Resident #72 could not wear shoes before the incident due to edema. The Corporate Nurse Consultant stated at no time did she recall Resident #72 say to her that the transport driver had put her feet on the lift floor instead of the wheelchair footrests or had issues with the lift. Even though they did not find any issues with the Transport Driver's return demonstration, he was monitored afterword, given education as well as watching the van driver training in order to complete a plan of correction since there was an injury. Resident #72 often preferred to not use her wheelchair footrests and would slide down in her wheelchair with her feet on the floor to feel more comfortable. During an interview on [DATE] at 12:01 AM the Staff Development Coordinator stated she was the unit manager for Resident #72's hall at the time of the incident in [DATE]. She further stated a page for nursing to come to the front was heard overhead and she and the Corporate Nurse Consultant responded to the page. She saw that Resident #72's sock had blood on it, so she went to get supplies while the Corporate Nurse Consultant remained with Resident #72. She returned and the Corporate Nurse Consultant and herself dressed Resident #72's wound. At the time the wound was barely bleeding, and Resident #72 showed no signs of pain and denied pain as well. Resident #72 was given the option to not go to dialysis, but she stated she wanted to go and was not in discomfort. They asked Resident #72 how her foot became injured, and she told them that the yellow flap which flipped down hit her toe as she was going up. She did not say she was positioned incorrectly or that she moved as far as the Staff Development Coordinator could recall. She stated the Transport Driver indicated to them that she would often move her feet after he had correctly positioned her and would move her feet out of the wheelchair footrests onto the lift gate. She stated because Resident #72 wanted to go to dialysis, the Corporate Nurse Consultant and herself observed him operating the lift and he did it correctly. Resident #72 did not remove her feet from the wheelchair footrests. The Staff Development Coordinator stated they then monitored the Transport Driver loading residents on the lift for several weeks following the incident for a plan of correction, and each time she was assigned to observe him operating the lift on the van, he did it correctly. She stated she could not remember what they found in the hospital once the resident agreed to go to the hospital following her toe being injured on the lift as it was a long time ago. During observation on [DATE] at 12:40 PM the Transport Driver was observed demonstrating the lift of the van used during the incident in [DATE] and the lift operated correctly. During an interview on [DATE] at 7:27 AM the Director of Nursing stated she was notified of the incident with the van on the evening of [DATE]. She stated upon investigation, it came to her attention that Resident #72 did not wish to use the leg rests on her wheelchair and the van driver was unable to visualize her entire body during the lift process. Because Resident #72 could move her legs herself, she was able to remove her feet from the leg rest on her wheelchair during the lift process with the hydraulic lift. This resulted in her putting her foot down on the lift with her toe under the yellow ramp which folds down to the van entrance as the lift goes up. Because he could not visualize her entire body during the lift process, Resident #72 sustained a cut to her right great toe and a fracture to her right great toe. In response to this incident the Transport Driver was asked to provide a demonstration of how he had lifted Resident #72, and this was when she discovered the space where the resident could place her foot and the van driver could not see it. She stated they reeducated the Transport Driver to no longer utilize the hydraulic lift with Resident #72. She stated Resident #72 was then transported by a different transport service with a platform ramp. Due to her weight they had to send two staff members everywhere she was transported, and she went to dialysis three days a week. Because of the requirement of multiple staff, they then changed to a different transport company who could transport her via bariatric stretcher. The transport driver was given education regarding safe transportation as well as in-house training. The Transport Driver was then monitored for approximately 6 weeks and the results were reported to QAPI monthly. During an interview on [DATE] at 8:35 AM the Administrator stated on [DATE] Resident #72 was being transported to dialysis. The Transport Driver placed her on the lift and had given her instructions about the placement of her feet during the lift operation. As the lift was going up to the height of the van entrance, she moved her foot, and her right great toe was far enough forward to get pinched by the yellow ramp which folds down to the van entrance. The Transport Driver responded immediately and lowered the lift. He stated he did not know if the Transport Driver could see Resident #72's toe or not during the lift process but because she moved her foot right as the lift was reaching the van height, her toe was pinched by the lift against the van ramp causing a laceration and toe fracture to her right great toe. He stated they reevaluated how she would go on future transports and identified that the Transport Driver had had issues with Resident #72 maintaining safe positioning during lift operation and Resident #72 had acknowledged to the Administrator that the Transport Driver had given her instructions for safe positioning prior to the incident but that she moved her foot which resulted in the facture on [DATE]. Due to this information, it was decided the resident would transport via either platform ramp or stretcher only and no longer use the hydraulic lift. The facility provided and implemented the following corrective action plan with a completion date of [DATE]. Problem Identified: On [DATE], [Resident #72] was being loaded onto the facility van by the facility's van driver when she moved her foot sustaining a laceration to the great toe. Address how corrective action will be accomplished for resident(s) found to have been affected: [Resident #72]'s foot was assessed, cleaned and dressed by the nurse consultant and unit manager. [Resident #72] requested to proceed to her scheduled dialysis appointment following wound care. This was completed on [DATE]. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: A review of facility transports for the last 30 days revealed no other injuries during the unloading or loading process by the van driver were found. This was completed on [DATE]. On [DATE] a return demonstration by the van driver revealed the correct procedure was followed. Address what measures will be put in place and systemic changes made to ensure that the identified issue does not occur in the future: The van driver was educated by the [Maintenance Director] on [DATE] regarding safe loading and unloading of passengers. The van driver completed Transportation in Healthcare/Van driver training in Relias on [DATE]. On [DATE], transportation mode changed from hydraulic lift to a manual ramp. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Starting [DATE] the DON or unit manager will observe the loading or unloading of 1 resident daily Monday through Friday x 2 weeks, then one resident 3x/week x 2 weeks and 1 resident weekly x 4 weeks to ensure the correct procedure is followed. Results of the DON's transportation audits will be reviewed in the facility Quality Assurance and Performance Improvement meeting monthly until compliance is achieved starting [DATE]. The corrective action plan was validated on [DATE]. Interviews and observations confirmed the transport driver was educated about the safe loading and unloading of passengers and van safety. Monitoring tools, staff education, and Performance Improvement Plan were reviewed. The corrective action was verified as completed on [DATE].

Based on observations, staff and resident interviews and record review the facility failed to maintain a resident's dignity when incontinent care for a bowel movement was not provided when requested prior to the meal causing the resident to feel nasty while trying to eat (Resident #71), and when a staff member spoke in a loud stern harsh voice causing the residents to feel bad and upset (Residents #48 & #18) for 3 of 5 residents reviewed for dignity. The findings included; 1. Resident #71 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, hypertension, and chronic pancreatitis. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #71 had no behaviors, required extensive assistance with toileting, was frequently incontinent of urine, and always incontinent of bowel. The care plan with a review date of 3/6/23 revealed Resident #71 had urinary and bowel incontinence so was at risk for infection or skin condition. The interventions included assist with perineal cleaning as needed. On 3/6/23 at 1:19 PM Resident #71 stated he had an incontinent bowel movement and was still waiting to be changed. Resident #71 added he told the Nursing Assistant (NA) when his meal tray was passed. On 3/6/23 at 1:21 PM NA #8 reported she passed the lunch meal tray to resident #71 and he told her he was soiled. NA #8 said she informed Resident #71 it was facility protocol not to provide incontinent care while passing meal trays. She added she was not sure the last time he had received incontinent care because he was not on her room assignment. On 3/6/23 at 1:22 PM NA #9 reported she was assigned to provide care for Resident #71 during the 7:00 AM to 3:00 PM shift and she last provided incontinent care to him at around 9:30 AM. On 3/6/23 at 1:29 PM the Director of Nursing said if meal trays were being passed and a resident needed incontinent care the NA should remove the meal tray from the room then provide the incontinent care. After the incontinent care was provided and the NA performed hand hygiene the meal tray could then be provided to the resident. On 3/6/23 at 1:45 PM NA #9 stated she provided incontinent care for Resident #71, and he had a loose bowel movement. During an additional interview with Resident #71 on 3/7/23 at 11:35 AM he said it made him feel nasty to try to eat while being soiled and not getting changed prior to eating. 44890 2. Resident #48 was admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis and paraplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and was dependent on staff assistance with activities of daily living (ADL). Review of the plan of care for activity preference dated 10/2/2019 listed Resident #48 preferred independent and self-directed leisure activities with an intervention for: staff will encourage active conversation with me while they are in my room. An observation and interview with Resident #48 occurred on 03/07/2023 at 02:35 P.M. Resident was observed to be laying on an air mattress and the lights were off on the control unit at the foot of the bed. Resident #48 stated that his call bell device was not working and the facility gave him a tap bell to ring. He further stated that his air mattress must have come unplugged when they weighed him in bed this morning. Resident #48 tapped his bell for assistance with the mattress. Resident #48 stated that Nurse #8 was the dayshift nurse. He further stated that Nurse #8 treated him like he was in the army and doesn't know how to talk to residents. Resident #48 indicated that Nurse #8 yelled and argued with him when he asked Nurse #8 questions. He stated that Nurse #8 would say, I am the nurse and I know what I am doing. Resident #48 stated that, Nurse #8 gets me upset and makes me feel bad. Resident #48 further stated that they don't speak to each other. He indicated that if he needed something or had an issue he would wait until he saw another nurse ask them to help him. Resident #48 stated that he was not happy with the way Nurse # changed his catheter so he had asked Nurse #5 to change it. Resident #48 stated that the facility had offered to move him to another hall and that he had refused. He further stated that this was his home, and he didn't see why he was the one who should have to move. Resident #48 indicated that Nurse #8 should have to move off the unit not him. He further stated that Nurse #8 always won and was still the nurse on the unit. Nurse #8 was asked to come to Resident #48's room by this surveyor on 03/07/2023 at 02:50 P.M. Nurse #8 stated that he had not heard the tap bell. He further stated that the mattress was not plugged in and he plugged it into the unit and left the room. Nurse #8 did not speak or look at Resident #48 when he was in the room. An interview with Nurse #5 was completed on 03/08/2023 at 07:20 A.M. Nurse #5 stated that Resident #48 and Nurse #8 do not get along. She further stated that she had changed Resident #48's catheter change time to night shift so she could do it for him, because he did not want Nurse #8 to change it. Nurse #5 indicated that Resident #48 had not told her Nurse #8 yelled at him. She further stated that she had not told anyone in administration. An interview with the Director of Life Enhancement occurred on 03/08/2023 at 07:54 A.M. She stated that Resident #48 told her that he didn't like Nurse #8 because of his attitude and that he doesn't listen to him. The Director of Life Enhancement indicated that Resident #48 and Nurse #5 don't get along. An interview with Unit Manager #2 was completed on 03/08/2023 at 4:09 P.M. Unit Manager #2 stated that was a time period when Resident #48 refused to accept medications from Nurse #8. She further stated that she had given Resident #48 his medications during that time. Unit Manager #2 indicated that the prior administration had been aware of the issues between Resident #48 and Nurse #8. An interview with the Central Supply Coordinator occurred on 03/08/2023 at 04:18 P.M. The Central Supply Coordinator stated that Nurse #8 was very militant in his interactions with others. She further stated that Nurse #8 treats everyone like they are in the military. An interview with the Staff Development Coordinator was completed on 03/08/2023 at 4:24 P.M. She stated that when she interviewed Resident #48 today, he told her Nurse #8 made him feel bad when he talked loudly and argued with him. An interview with the Administrator and the Director of Nursing (DON) occurred on 03/09/2023 at 11:36 A.M. The Administrator stated that she had been unaware of any issues between Nurse #8 and Resident #48. She further stated that Nurse #8 was suspended pending further investigation and that the facility had filed a 24-hour report with the State. The DON stated that now that the facility was aware of the allegations, they were taking care of the issue. A telephone interview with Nurse #8 was completed on 03/13/2023 at 2:49 P.M. Nurse #8 stated that he and Resident #48 had a very respectful relationship. He further stated that he was respectful to Resident #48 and in return Resident #48 was respectful to him. Nurse #8 stated that to his knowledge we don't have a communication problem. 3. Resident #18 was admitted to the facility on [DATE] with diagnosis to include unspecified asthma and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and was not hard of hearing. An interview with Resident #18 was completed on 03/06/2023 at 11:58 A.M. Resident #18 stated that Nurse #8 yelled at him sometimes and made him feel bad. He stated that he was not a child and should not be treated like one. An interview with Nurse #5 was completed on 03/08/2023 at 07:20 A.M. Nurse #5 stated that Resident #18 told her he was upset because Nurse #8 had talked to him like a child when he asked about his inhaler. She further stated that she told Resident #18 he had a breathing treatment and an inhaler that were ordered as needed. An interview with the Central Supply Coordinator occurred on 03/08/2023 at 04:18 P.M. The Central Supply Coordinator stated that Nurse #8 was very militant in his interactions with others. She further stated that Nurse #8 treats everyone like they are in the military. An interview with the Staff Development Coordinator was completed on 03/08/2023 at 4:24 P.M. She stated that when she interviewed Resident #18 today, he told her Nurse #8 made him feel bad when he spoke loudly to him. An interview with the Administrator and the Director of Nursing (DON) occurred on 03/09/2023 at 11:36 A.M. The Administrator stated that Nurse #8 was suspended pending further investigation. She further stated that Resident #18 had not complained about Nurse #8 making him feel like a child or speaking to him in a loud voice. A telephone interview with Nurse #8 was conducted on 03/13/2023 at 2:49 P.M. Nurse #8 stated that to his knowledge he did not have a communication issue with Resident #18. He further stated that he always talked respectful to Resident #18.

Based on record review and staff, family and Physician interviews, the facility failed to notify the Responsible Party of two newly identified wounds (buttocks and heel) and failed to notify the Physician of one newly identified wound (heel) which resulted in lack of treatment, ongoing assessment, and worsening of a wound for 1 of 3 residents reviewed for notification of condition change (Resident #65). Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan was reviewed and noted as last updated on 12/6/2016. The Care Plan revealed a problem of a risk for Pressure Ulcers related to impaired mobility with the goals listed as no areas of skin breakdown through the next review. Interventions included daily observation of skin with routine care, float heels on pillows at all times and monitor the eschar (a dry dark scab like area) on right heel and notify the doctor if any change noted. The most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #65 was cognitively intact and required the assistance of 1 person for all Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. The MDS indicated Resident #65 was at risk for pressure ulcers and no pressure ulcers were present on assessment. Skin Inspection Report assessments dated 3/8/2017 and 3/15/2017 completed by Unit Manager (UM) #1 indicated Resident #65's skin was intact. A review of the nursing notes revealed a note dated 3/20/2017 at 2:05 AM written by Nurse # 5. The note reported a quarter sized open area was observed on the right buttocks, barrier cream was applied and the area would be reported to the oncoming nurse. Further review of the nursing notes revealed a note dated 3/22/2017 at 1:53 PM written by UM #1. The note reported an open area was observed on Resident #65's right buttocks, barrier cream was applied and the Physician was notified. No new orders were obtained from the Physician. A physician's orders [REDACTED].#65's medical record. The order specified Resident #65 be sent to the Emergency Department (ED) to be evaluated for increased temperature and altered mental status. Hospital records were reviewed and revealed Resident #65 was admitted to the hospital with [REDACTED]. A Skin Assessment note dated 3/27/2017 at 4:16 PM from the ED revealed Resident #65 had a fluid filled DTI noted on the left heel which measured 4 centimeter in length by 6 centimeter in width and several small areas on the right buttocks which appeared to be from shearing. A telephone interview was conducted with Resident #65's Responsible Party (RP) on 4/26/2017 at 2:12 PM. The RP stated she visited the resident often and visited the resident at the facility on 3/24/2017. The RP stated she was at the Emergency Department (ED) with Resident #65 on 3/27/2017. The RP further stated the resident was observed to have a pressure sore on his buttock and a dark, bloody looking area on his heel. The RP reported she was unaware of these areas until the observation in the ED. An interview was conducted on 4/27/2017 at 10:35 AM with the MDS nurse. The MDS nurse reported she assessed Resident #65 on 3/6/2017 for his quarterly MDS assessment and observed a small purple, bruise-like area on his right heel. The MDS nurse stated she thought she reported the area to the staff nurse but could not remember which nurse or if she reported it. The MDS nurse stated she did not notify the Physician or the RP of the area. A telephone interview was conducted with Nurse #5 on 4/27/2017 at 11:10 AM. Nurse #5 recalled the area on Resident #65's buttock which was discovered on the 11PM to 7AM shift. Nurse #5 stated since the area was small with no drainage she applied barrier cream. Nurse #5 also stated she did not notify families or Physicians during the night shift unless it was a serious situation. Nurse #5 indicated she would give the information to the oncoming nurse for follow up. Nurse #5 stated she did not recall if she passed the information on to the oncoming nurse regarding the open area on Resident #65's buttock. An interview was conducted with the Physician on 4/27/2017 at 11:30 AM. The Physician stated he recalled Resident #65 and was aware of the open area on the buttock. The Physician reported the wound physician normally assessed the facility residents' wounds and he reviewed the orders and recommendations. The Physician indicated he did not recall notification of any skin issues with Resident #65's heel. An interview was conducted with UM #1 on 4/27/2017 at 1:35 PM. UM #1 indicated she usually called the RP after she called the Physician when a change in condition is noted. UM #1 also indicated she would document when the Physician and RP were notified. UM #1 stated she observed a small purple bruise-like area on Resident #65's heel on his weekly skin assessments on 3/8/2017 and 3/15/2017 but did not consider it a wound since it was not open and she did not notify anyone or document the observation. UM #1 further stated she recalled assessing the area on Resident #65's buttock and notifying the Physician but could not remember if the RP was notified. An interview was conducted with UM #2 on 4/27/2017 at 3:00 PM. UM #2 reported she assessed the area on Resident #65's right lower buttock on 3/22/2017 and completed the Skin Inspection Report. UM #2 reported she did not complete a full body assessment at that time and only looked at the area on the buttock. UM #2 stated she did not notify the Physician or the RP. An interview was conducted with the facility Administrator on 4/27/2017 at 4:15 PM. The Administrator stated the facility expectation was for any resident change of condition to be thoroughly assessed. The Administrator further stated the expectation included the condition change assessment be reported to the Physician and the RP with documentation to include the condition change, any new orders or treatments and notification.

Based on observation, staff and resident interviews and record review, the facility failed to accurately assess a resident's skin status for 1 of 3 residents reviewed for Pressure Ulcers (Resident #65). Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan was reviewed and noted as last updated on 12/6/2016. The Care Plan revealed a problem of a risk for Pressure Ulcers related to impaired mobility with a goal of no new areas of skin breakdown through the next review. Interventions included daily observation of skin with routine care, float heels on pillows at all times and monitor the eschar (a dry dark scab like area) on right heel and notify the doctor if any change noted. The Skin Inspection Report Assessments dated 2/22/2017 and 3/1/2017 completed by Unit Manager (UM) #1 indicated Resident #65's skin was intact. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #65 was cognitively intact and required the assistance of 1 person for all Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. The MDS indicated Resident #65 was at risk for pressure ulcers and no pressure ulcers were present on assessment. Review of the clinical record further revealed Resident #65 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Hospital records were reviewed and revealed Resident #65 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A Skin Assessment note dated 3/27/2017 at 4:16 PM from the Emergency Department revealed Resident #65 had a fluid filled Deep Tissue Injury noted on the left heel which measured 4 centimeter in length by 6 centimeter in width. An interview was conducted on 4/27/2017 at 10:35 AM with the MDS nurse. The MDS nurse reported she assessed Resident #65 for his quarterly MDS assessment and observed a small purple, bruise-like area on his right heel. The MDS nurse stated the documentation in the Quarterly MDS dated [DATE] was an error oversight and the heel area was not eschar as documented on the Care Plan. The MDS nurse reported the 3/6/2017 skin assessment was incorrect. An interview was conducted with UM #1 on 4/27/2017 at 2:30 PM. UM #1 stated she completed a full body assessment on Resident #65 for the Skin Inspection Report on 3/8/2017 and 3/15/2017 and documented the skin was intact. UM #1 stated she saw a small dark purple area on Resident's #65's heel on both dates but did not recall which heel. UM #1 further stated since the area was not open she did not consider it a problem and did not document it or report the area. UM #1 could not recall if Resident #65's heels were floated or if he wore a heel protector to the right foot. On 4/27/2017 at 4:15 PM an interview was conducted with the Administrator. The Administrator stated the facility expectation was the MDS assessments to be completed thoroughly and all of the MDS information to be accurate.

Based on staff interviews and record review, the facility failed to accurately code section M (skin conditions) of the Minimum Data Set (MDS) assessment to reflect a deep tissue injury (DTI) on the resident's heel which resulted in lack of treatment and progression in the size of the wound for 1 of 3 residents reviewed for Pressure Ulcers (Resident #65). Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan last updated on 12/6/2016 was reviewed. The Care Plan revealed a problem of a risk for Pressure Ulcers related to impaired mobility with a goal of no new areas of skin breakdown through the next review. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #65 was cognitively intact and required the assistance of 1 person for all Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. The MDS indicated Resident #65 was at risk for pressure ulcers and no pressure ulcers were present on assessment. The Skin Inspection Report Assessments dated 3/8/2017 and 3/15/2017 completed by Unit Manager (UM) #1 indicated Resident #65's skin was intact. Review of the clinical record further revealed Resident #65 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Hospital Emergency Department records were reviewed and revealed Resident #65 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A Skin Assessment note dated 3/27/2017 at 4:16 PM from the Emergency Department revealed Resident #65 had a fluid filled Deep Tissue Injury (DTI) noted on the left heel which measured 4 centimeters in length by 6 centimeters in width. An interview was conducted on 4/27/2017 at 10:35 AM with the MDS nurse. The MDS nurse reported she assessed Resident #65 on 3/6/2017 for the quarterly MDS assessment. The MDS nurse stated she completed a skin assessment on Resident #65 on 3/6/2017 and observed a small purple, bruise-like area on his heel. The MDS nurse stated the documentation of the skin assessment she entered in the Quarterly MDS dated [DATE] was not accurate. The MDS Nurse further reported Resident #65 had an identified suspected DTI on the heel during the 3/6/2017 physical assessment for the Quarterly MDS assessment which she failed to document. The MDS nurse reported the 3/6/2017 skin assessment information was inaccurate as she did not indicate Resident #65 was observed to have a suspected DTI on 3/6/2017. The MDS nurse did not give an explanation for the inaccuracy. An interview was conducted with UM #1 on 4/27/2017 at 2:30 PM. UM #1 stated she completed a full body assessment on Resident #65 for the Skin Inspection Report on 3/8/2017 and 3/15/2017 and documented the skin was intact. UM #1 stated she saw a small dark purple area on Resident's #65's heel on both dates but did not recall which heel. UM #1 further stated since the area was not open she did not consider it a problem and did not document it or report the area. On 4/27/2017 at 4:15 PM an interview was conducted with the Administrator. The Administrator stated the facility expectation was the MDS assessments to be completed thoroughly and all of the MDS information to be accurate.

Based on record review and responsible party and staff interviews, the facility failed to provide a comprehensive wound assessment, initiate treatment and monitor a newly identified Suspected Deep Tissue Injury (DTI) to the left heel resulting in worsening of the DTI. The facility also failed to assess a wound caused by shearing and delayed treatment for 2 days after the wound was discovered and failed to thoroughly complete a skin assessment for 1 of 3 residents reviewed for pressure ulcers (Resident #65). Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Care Area Assessment (CAA) for Pressure Ulcer dated 6/10/2016 noted Resident #65 required extensive assistance for bed mobility and spent time up in his wheelchair almost daily which put Resident #65 at an increased risk for Pressure Ulcers. The Care Plan was reviewed and noted as last updated on 12/6/2016. The Care Plan revealed a problem of a risk for Pressure Ulcers related to impaired mobility with the goals listed as no areas of skin breakdown through the next review. Interventions included daily observation of skin with routine care, float heels on pillows at all times and monitor the eschar (a dry dark scab like area) on right heel and notify the doctor if any change noted. The most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #65 was cognitively intact and required the assistance of 1 person for all Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. The MDS indicated Resident #65 was at risk for pressure ulcers and no pressure ulcers were present on assessment. a) Nursing notes were reviewed from 1/1/2017 through 3/27/2017 with no entries which reported skin issues with Resident #65's heels. The Physician order [REDACTED]. The Medication Administration Record [REDACTED]. There were 10 shifts from 3/1/2017 to 3/26/2017 without initials. The MAR indicated [REDACTED]. Five of those shifts were without initials from 3/1/2017 to 3/26/2017. The Skin Inspection Report Assessments dated 3/8/2017 and 3/15/2017 completed by Unit Manager (UM) #1 indicated Resident #65's skin was intact. A physician's orders [REDACTED].#65 to the Emergency Department (ED) to be evaluated for increased temperature and altered mental status was noted in the medical record. Hospital records were reviewed and revealed Resident #65 was admitted to the hospital with [REDACTED]. A Skin Assessment note dated 3/27/2017 at 4:16 PM from the ED revealed Resident #65 had a fluid filled DTI noted on the left heel which measured 4 centimeter in length by 6 centimeter in width. A telephone interview was conducted with the Responsible Party (RP) of Resident #65 on 4/26/2017 at 2:12 PM. The RP was present during the resident's ED visit on 3/27/2017. The RP reported Resident #65's heel had a dark purple bloody looking area and there was an area on his sacrum that was open. The RP reported she visited Resident #65 often and did not recall his heels being floated and did not recall the resident had heel protectors. An interview was conducted on 4/27/2017 at 9:25 AM with Nursing Assistant (NA) #2. NA #2 reported Resident #65 was on the assignment she worked daily. NA #2 stated she was unaware of any skin problems on Resident #65's heels. NA #2 stated she applied socks to Resident #65's feet daily after a bath. NA #2 reported the resident's heels were floated sometimes and did not recall if a heel protector was applied to the right foot daily. NA #2 also reported she worked with Resident #65 on 3/26/17 and did not recall any issues with his heels when he was bathed. NA #2 indicated Resident #65 was discharged to the hospital prior to her day shift on 3/27/2017. The NA on duty for the night shift when Resident #65 was transported to the hospital no longer worked at the facility and was unavailable for interview. An interview was conducted with the MDS nurse on 4/27/2017 at 10:35 AM. The MDS nurse reported she completed an assessment on Resident #65 on 3/6/2017 for the quarterly review and discovered a small dark purple area to his heel. The MDS nurse stated she thought it was the right heel but was unable to recall. The MDS nurse stated it was not eschar as indicated on the Care Plan and the information she added to the Care Plan was an error oversight. The MDS nurse said she informed the nurse on duty during day shift on 3/6/2017 of the area observed on Resident #65's heel but could not recall the nurse. The MDS nurse further stated the resident was in a wheelchair almost daily and recalled times the resident's heels were not floated and the heel protector not applied. An interview was conducted with Nurse #4 on 4/27/2017 at 11:45 AM. Nurse #4 stated she was the nurse on duty on the day shift on 3/6/2017. Nurse #4 stated no recollection no recollection of any skin issues reported by the MDS nurse. Nurse #4 reported being unaware of any issues with pressure areas on Resident #65's heels. Nurse #4 reported she thought the resident's heels were floated and recalled the resident wearing heel protectors at times. An interview was conducted with Unit Manager (UM ) #1 on 4/27/2017 at 2:30 PM. UM #1 stated she completed a full body assessment on Resident #65 for the Skin Inspection Report on 3/8/2017 and 3/15/2017 and documented the skin was intact. UM #1 stated she saw a small dark purple area on Resident's #65's heel on both dates but did not recall which heel. UM #1 further stated since the area was not open she did not consider it a problem and did not document it or report the area. UM #1 could not recall if Resident #65's heels were floated or if he wore a heel protector to the right foot. An interview was conducted with the facility Administrator (Adm) on 4/27/2017 at 4:15 PM. The Adm stated the facility followed the Pressure Ulcer Prediction, Prevention and Treatment Pathway provided by a healthcare consulting firm. A copy was reviewed and indicated a head to toe skin assessment was to be conducted weekly and any changes in the overall skin condition of a resident was to be assessed thoroughly, reported to the Physician, treatment obtained and family notified. The Adm also provided documentation of Common Wound Treatment Modalities and stated the facility followed the Treatment Modalities for wounds. The Modalities contained descriptions of wounds, treatments and frequency of treatments. The Modalities included a Suspected Deep Tissue Injury and listed the description as a purple or maroon localized area of discolored intact or blood filled blister. The recommended treatment was listed as pressure relief or [MEDICATION NAME] dressing (a non-breathable transparent wound dressing). The treatment also included to monitor the area daily for worsening condition or drainage. The Adm stated the facility expectation was the pathway would be followed as well as the treatment modalities. The Adm indicated the treatment modality for a Suspected Deep Tissue Injury specified the area should be monitored daily for changes. The Adm further stated the expectation was for all skin issues to be identified on the weekly body assessments and to be classified accurately and reported to the Physician immediately for treatment orders. b) Review of the nursing notes revealed a note dated 3/20/2017 at 2:05 AM written by Nurse #5 which indicated a quarter sized open area was noted on the right buttock of Resident #65. The note reported barrier cream was applied and the area would be reported to the oncoming nurse. Further review revealed a nursing note dated 3/22/2017 at 1:53 PM signed by Unit Manager (UM) #1 revealed UM #1 was notified of an open area to Resident #65's right buttock by Nursing Assistant (NA) #2. The note indicated barrier cream was applied, the Physician was notified and no new orders were given. A review of the Treatment Administration Record for March 2017 revealed an order for [REDACTED]. A review of the Skin Inspection Report for 3/22/2017 revealed the skin status of Resident #65 was not intact. The information was entered by UM #2. A physician's orders [REDACTED].#65 to the Emergency Department (ED) to be evaluated for increased temperature and altered mental status was noted in the medical record. A Skin Assessment note dated 3/27/2017 at 4:16 PM from the Emergency Department revealed Resident #65 had a Stage 3 pressure ulcer on the sacrum which measured 1 centimeter in length by 1 centimeter in width and several small areas on the right buttocks which appeared to be from shearing. An interview was conducted on 4/27/2017 at 9:25 AM with NA #2. NA #2 reported Resident #65 was on the assignment she worked daily. NA #2 stated she discovered the open area to Resident #65's lower right buttock during bathing on the morning of 3/22/2107. NA #2 reported it was quarter sized and looked like the skin was just scraped off a little. NA #2 stated she covered the resident and immediately reported to the Nurse #4 who was the hall nurse on that day. NA #2 said she was instructed to cover the area with barrier cream. NA #2 stated she covered the area with barrier cream every day after that until the resident went to the hospital. NA #2 also stated she worked with Resident #65 the day before he was admitted to the hospital and recalled the area was still there and looked the same. A telephone interview was conducted with Nurse #5 on 4/27/2016 at 11:10 AM. Nurse #5 indicated she recalled the NA reporting Resident #65 had an area on the lower right buttock and also recalled assessing the area. Nurse #5 stated the area was small and open and looked like it was just the top layer of skin so she applied barrier cream. Nurse #5 stated if a small skin area is noted during the night shift, she will report it to the oncoming nurse to follow up with the Physician and the family. Nurse #5 could not recall if she included the skin area in report with the oncoming nurse and stated sometimes if it was a really busy night she may have forgotten if she did not write it down. An interview was conducted with Nurse #4 on 4/27/2017 at 11:45 AM. Nurse #4 stated she was the nurse for the day shift on 3/20/2017 for Resident #65. Nurse #4 reported there was no mention of any skin issues for Resident #65 from the night nurse. Nurse #4 stated she was made aware of an area to Resident #65's buttocks on the morning of 3/22/2017 and reported it to UM #1 as soon as it was reported. Nurse #4 stated UM #1 assessed the wound and wrote the order to apply barrier cream every shift. An interview was conducted with UM #1 on 4/27/2017 at 2:30 PM. UM #1 stated she recalled being informed of the wound on Resident #65's buttocks. UM #1 further stated the wound was assessed and was a small open area which was superficial with no depth and was pink. UM #1 also stated the wound was not measured but it was about quarter sized. UM #1 recalled the Physician was notified and agreed with the barrier cream for treatment. UM #1 indicated all new wounds were assessed by the Wound Physician every Tuesday and Resident #65 was on the list for the Wound Physician on 3/28/2017 but Resident #65 was admitted to the hospital on [DATE]. An interview was conducted with UM #2 on 4/27/2017 at 3:00 PM. UM #2 stated she assessed the wound on 3/22/2017 and it was a quarter sized open area to the right buttocks with no drainage and appeared pinkish red with no drainage. UM #2 further stated she only assessed the lower right buttocks of Resident #65. UM #2 said she completed the documentation in the Skin Inspection Report but did not measure the wound. UM #2 also stated Resident #65 was on the Wound Physician list for 3/28/2017 but discharged to the hospital on [DATE]. An interview was conducted with the facility Administrator (Adm) on 4/27/2017 at 4:15 PM. The Adm stated the facility followed the Pressure Ulcer Prediction, Prevention and Treatment Pathway provided by a healthcare consulting firm. A copy was reviewed and indicated a head to toe skin assessment was to be conducted weekly and any changes in the overall skin condition of a resident was to be assessed thoroughly, reported to the Physician, treatment obtained and family notified. The Adm also provided documentation of Common Wound Treatment Modalities and stated the facility followed the Treatment Modalities for wounds. The Modalities contained descriptions of wounds, treatments and frequency of treatments. The Modalities included description of a Stage 2 wound as a partial thickness loss of dermis (second layer of skin) with a red, pink wound bed with the treatment listed as [MEDICATION NAME] film dressing to be changed every 3-7 days and as needed. The Adm stated the facility expectation was the pathway would be followed as well as the treatment modalities. The Adm further stated the expectation was for all skin issues to be identified on the weekly body assessments and to be classified accurately and reported to the Physician immediately for treatment orders.

Based on staff and family interviews and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place for pressure sores (tag F314) following the annual recertification survey of 08/13/2015, the complaint investigation of 04/15/2016, the annual recertification survey of 06/09/2016 and the current recertification survey of 04/24/2017. Also the facility failed to maintain implemented procedures and monitor the interventions put into place for notification of the responsible party and physician (tag 157) during the annual recertification survey of 06/09/2016 and the current recertification survey of 04/24/2017. The re-citation of F314 and F157 during the last year of federal survey history showed a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross-referenced to: 1. F314 Pressure Ulcers: Based on record review and staff interviews, the facility failed to provide a comprehensive wound assessment, initiate treatment and monitor a newly identified Suspected Deep Tissue Injury (DTI) to the left heel resulting in worsening of the DTI. The facility also failed to assess a wound caused by shearing and delayed treatment for 2 days after the wound was discovered and failed to thoroughly complete a skin assessment for 1 or 3 residents reviewed for pressure ulcers (Resident #65). Review of the facility's survey history revealed F314 was cited during the facility's 08/13/2015 annual recertification survey, during a 04/15/2016 complaint investigation, during the 06/09/2016 annual recertification survey and was re-cited during the current 04/24/2017 annual recertification/ complaint survey. 2. F157 Notify of Changes: Based on record review and staff and family interviews, the facility failed to notify the Responsible Party of two newly identified wounds and failed to notify the Physician of one newly identified wound for 1 of 3 residents reviewed for notification of condition change (Resident #65). Review of the facility's survey history revealed F157 was cited during the facility's 06/09/2016 annual recertification survey and re-cited during the current 04/24/2017 annual recertification/complaint survey. In an interview on 04/28/2017 at 05:13 pm, the Administrator acknowledged understanding of the reciting of F314 and F157 during the recertification/complaint survey of 04/24/2017.

Based on observations, record review and staff interviews, the facility failed to prevent neglect of 1 of 1 sampled residents (Resident #7) as evidenced by not providing hand hygiene of the left hand. The facility failed to assess Resident #7's left hand and failed to prevent the development of a stage 2 pressure ulcer to the fifth digit on the left hand. The facility also failed to monitor and/or assess prevention/protection measures to protect the skin integrity of the severely contracted left hand. Findings included: Resident #7 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident #7 also had a history of [REDACTED]. The undated "NURSING INSTRUCTIONS" cardex for Resident #7 noted contractures of the left arm and hand. There was no mention of splinting or protective devices. The "RESTORATIVE NURSING" section was blank. The Quarterly Minimum Data Set (MDS) assessment of 08/06/14 documented Resident #7 was not cognitively intact and required extensive to total assistance for all activities of daily living. It was noted that he had the presence of a stage 3 pressure ulcer with no measurements documented. The Quarterly Minimum Data Set (MDS) assessment of 10/30/14 indicated Resident #7 had severely impaired cognition. He required extensive to total assistance for all activities of daily living. He had a history of [REDACTED].#7 had a functional limitation in range of motion on one side of the upper extremity and on both sides of the lower extremity. Resident #7's care plan, last reviewed on 11/12/14, identified several problem areas which included: . a problem with being at risk for skin breakdown due to hemi/para/[MEDICAL CONDITION] with onset date of 04/23/14. The goal was to remain free from skin breakdown through the next review date. Approaches included keeping the skin clean and dry as well as observing the skin daily. Any abnormalities were to be reported to the nurse. . a problem (with onset date of 05/12/14) with being at high risk for the development of pressure ulcers and the resident had a stage 3 pressure ulcer to the left thumb. Approaches included a daily observation of the skin with routine care and a full skin evaluation weekly with the bath/shower. The problem was reviewed on 11/12/14 and it was noted to continue the POC (plan of care). . a problem with onset date of 08/13/14 with impaired physical mobility, limited range of motion and a potential for worsening contractures. Interventions included PT (physical therapy), OT (occupation therapy) screen/evaluation as indicated. Another intervention was to encourage to participate in range of motion exercises daily and to encourage to utilize the right static hand splint. There was no mention of prevention measures for the left hand. A daily therapy note of 09/01/14 noted that Resident #7 was supine in bed with a left static hand splint in place. The therapist removed the splint and would replace it tomorrow after passive stretching. It was noted that passive stretch had been completed on the left hand to increase range of motion in order to decrease finger flexion contractures. The therapy discharge summary of 09/17/14 indicated Resident #7 had received treatment for [REDACTED]. A physician's telephone order of 09/17/14 noted that Resident #7 was discharged from occupation therapy and had met the maximum rehabilitation potential. It was noted that nursing was to continue with restorative care for orthotic placement. A physical therapy (PT) screen of 10/21/14 noted Resident #7 had no changes in his contractures and PT was not indicated. An occupation therapy (OT) screen of 11/26/14 indicated the quarterly assessment was conducted with Resident #7. It was noted that he presented with no functional deficits or focus for skilled OT at this time. The December 2014 treatment administration record for Resident #7 included no orders for any treatment that included washing the left hand. There was no January 2015 treatment record found in his active chart. A physician's progress note of 01/15/15 documented to continue with routine wound care, dressing and splinting. A contracture risk review dated 01/16/15 written by Nurse #6 for Resident #7 documented that a contracture risk care plan was in place. It was noted on the review that a score of 6 or higher indicated was at risk. Resident #7 had a score of 11. It was noted that Resident #7 had joint pain and a history of [MEDICAL CONDITIONS] as predisposing factor for contracture development. A physician's progress note of 01/18/15 made no mention of any contracture management for Resident #7. A re-admission therapy screen of 01/22/15 noted Resident #7 displayed no current focus for services. The most recent Quarterly Minimum Data Set (MDS) assessment of 01/23/15 noted Resident #7 required extensive to total care with all activities of daily living. It was documented that he had limitation in range of motion on both sides in both upper and lower extremities. He was identified as at risk for pressure ulcers. Resident #7 was observed resting in bed on 02/02/14 at 9:40 AM. There was a distinct foul odor noted in the room and the odor smelled strongest when next to Resident #7's bed. Resident #7 was observed resting in bed on 02/02/15 at 11:45 AM. His left hand was noted to be tightly clenched in the shape of a ball with the thumb pressed underneath the fingers and protruding out the opposite side of the hand. The left arm was clenched tightly against his chest. There was no splinting or protection noted in the left hand. Resident #7 was observed resting in bed while being fed by staff (NA #6) on 02/02/15 at 1:15 PM. The odor remained in the room and no visible splinting/protection devices were noted in either of his hands. The treatment nurse was observed feeding Resident #7 on 02/02/15 at 5:58 PM. There was no visible splinting/protection devices in place to either of his hands. Resident #7 was observed resting in bed on 02/03/15 at 8:45 AM. The right hand was underneath the bed covers but the left hand was visible. There was no protective device noted in his left hand. The odor was still detected. Resident #7 was observed resting in bed on 02/04/15 at 9:15 AM. There was no visible splinting or protection measure in place to either of his hands. The odor was still present. A bed bath was observed beginning at 9:20 AM on 02/04/15. NA #7 washed, rinsed and dried the right arm and hand. He washed the outer surface of the left contracted hand but made no attempt to open it to wash inside. As NA #7 was completing the bath, he reported that he didn't attempt to open the left hand due to pain on the part of the resident. When questioned about the ability to open the left hand, he attempted to move the fingers very gently away from the palm of the hand. He was able to extend the fingers just enough to allow slight washing of the inside of the hand. There was a very distinct foul odor detected as he began to gently extend the fingers from atop the thumb which was positioned across the palm of the hand extending out the far side of the hand. He washed, rinsed and dried the left hand very gently and carefully. NA #7 was interviewed after the observation on 02/04/15 at 9:50 AM. He stated he hadn't worked with Resident #7 in a while but didn't remember any splinting devices for his hands. He stated there was a distinct odor when he washed the left hand. He reported that he would tell the nurse about the odor. During an observation of Resident #7, on 02/04/15 at 12:50 PM, the left hand was noted to have a clean dressing in place. During an interview with the treatment nurse on 02/04/15 at 1:00 PM, she stated NA #7 had asked her to look at Resident #7's hand. She stated the hall nurse had also reported to her that Resident #7 was experiencing pain in the left hand and asked her to assess it. The treatment nurse stated she noticed an odor when she washed the left hand today. She also reported she had placed gauze between his fingers and a gauze roll inside the hand followed by wrapping the hand with rolled gauze. She added that while she was washing the left hand, she found a stage 2 pressure ulcer to the inside of the left pinky finger where it was pressed against the fourth digit (ring finger). She commented that the hall nurses completed weekly skin checks. The treatment nurse added that Resident #7 had a history of [REDACTED]. She remarked that she would speak with the physician about possibly obtaining an order for [REDACTED].#7's left hand prior to discovery of the stage 2 pressure ulcer. A wound assessment of 02/04/15 for the left little finger of Resident #7's left hand noted a stage 2 pressure ulcer. The open wound measured 0.5 centimeters by 0.5 centimeters by 0.2 centimeters with 100% granulation tissue noted. It was noted that Resident #7 experienced pain with the treatment. It was documented in the notes section of this assessment that the hall nurse had notified her of the breakdown to resident's left hand. The treatment nurse also documented that the area was painful to touch with a scant amount of drainage. She washed Resident #7's left hand with soap and water and applied (brand name) ointment to the wound. She covered the area with a dry dressing and placed a gauze hand roll into the palm of the left hand with gauze placed between his fingers and secured the dressing with rolled gauze. She also documented that she had notified the family. The treatment nurse also documented she had paged the physician for treatment orders. A screen from the therapy department of 02/04/15 noted that Resident #7 was screened due to left upper extremity contracture. It was noted that the resident's [DIAGNOSES REDACTED] was severe with pain noted as a 9 on a scale of 1-10 during passive range of motion. It was noted that there had been attempts in the past to address his contracture. No services could address the tone in the left hand without surgical intervention at this time. A physician's telephone order of 02/04/15 at 12:00 PM noted to wash Resident #7's left hand with soap and water daily. It noted to clean the wound to the left pinky fingers with normal saline and apply (brand name) ointment with a dry dressing daily. Another physician's telephone order of 02/04/15 noted to insert a gauze hand roll to the left hand daily until assessed by therapy. It also noted to insert gauze between the fingers on the left hand daily until assessed by therapy. During an interview with Nurse #2 who worked on Resident #7's hall, on 02/05/15 at 9:58 AM, she stated Resident #7 had been transferred to her hall about a month ago from another hall in the facility. She stated she had worked with him previously and he had a history of [REDACTED]. Nurse #2 reported that she had gone into his room yesterday during rounds to reposition him and while turning him he complained about pain in his left hand. She stated the open area was discovered at that time. The rehabilitation manager was interviewed on 02/05/15 at 10:05 AM. She stated Resident #7 had been evaluated. She stated Resident #7 did have a splint to his left hand at one time but he developed a wound from it and the splint was stopped until the area healed. She commented that once the area healed, the contracture had worsened to the point that splinting couldn't be done. The manager stated when he was discharged from therapy he was to have a wash cloth for protection to the left hand or a hand roll. The manager also stated that the recommendation upon discharge was for the thumb to be amputated or a tendon release to help relax the fingers but both were refused. She stated he should have been discharged to the restorative program for splinting of both hands. The manager reported that when Resident #7 was discharged from therapy the orders were not written properly and Resident #7 was never referred to restorative for his splinting needs. The treatment nurse and the acting Director of Nurses (DON) were observed providing treatment to Resident #7 on 02/05/15 at 10:50 AM. The treatment nurse reported Resident #7 had been pre-medicated for pain about 20 minutes ago. She removed the old dressing and began to wash the left hand with soap and water. There was a very distinct foul odor detected as the fingers were gently separated. The DON held the hand while the treatment nurse maneuvered to wash inside the severely contracted hand. The fingers were contracted on top of each other overlapping the thumb making it difficult for her to wash them. The treatment nurse was not able to use the wash cloth to cleanse inside the palm of the hand due to the inability to extend the fingers far enough to get the wash cloth inside. The treatment nurse moistened dry gauze with water and utilized a q-tip to gently wash inside the hand. Once she had washed the hand, she dried the inside of his hand with dry gauze and a clean q-tip. There was an approximate dime size open area to the little "pinky" finger that had white raised edges and a sunken dark pink center. The treatment nurse applied the (brand name) ointment using a q-tip. She placed folded gauze between each finger and a gauze hand roll into the palm of the left hand. She wrapped the hand with rolled gauze. The treatment administration record for Resident #7 indicated that as of 02/05/15 the left hand was to be washed with soap and water. The wound to the left "pinky" finger was to be cleansed with normal saline, (brand name) ointment was to be applied and there was to be a gauze hand roll placed in the left hand. On 02/05/15 at 10:20 AM, an interview was conducted with Nurse #4 who was identified as being responsible for the restorative program. She stated Resident #7 was not currently on restorative caseload. She reported that he did have a splint in the past to the left hand but he developed a wound from the splint and it was discontinued. Nurse #4 reported that Resident #7 had been in the restorative program in the past for passive range of motion and splinting. She also reported that when a resident was in restorative any splinting needs would be included on the resident's cardex so all staff would be aware of his needs. Nurse #7 reported that when Resident #7 was discharged from therapy last September 2014 he was not referred back to restorative for splinting or contracture management services. NA #7 reported on 02/05/15 at 11:20 AM that he had informed the treatment nurse on 02/04/15 about the odor noted in Resident #7's left hand yesterday. He stated if he found any issues with a resident's skin he would report it to the nurse. On 02/05/25 at 11:40 AM, Nurse #4 stated that the rehabilitation manager had updated Resident #7's care plan today. She reported that she would ask therapy to evaluate the appropriateness of splinting for Resident #7. Nurse #2 and Nurse #5 were interviewed on 02/05/15 at 2:15 PM. Nurse #2 stated skin checks were completed by the second shift nurses and if a new area was discovered it was assessed and the appropriate treatment started. Nurse #5 stated that the skin checks had been discontinued when the new management came and the nurse aides were given the responsibility to do the skin checks during showers. Nurse #5 stated the aide was to report any skin changes found to the nurse for evaluation. NA #9 was interviewed on 02/05/15 at 2:25 PM. She stated she was unsure as to whether Resident #7 had splinting devices or not. She stated she had worked with him in the past and thought restorative had applied splints but she wasn't sure which hand they were placed in. The restorative aide (RA) who had worked with Resident #7 was interviewed on 02/05/15 at 3:07 PM. She stated she had worked with him for passive range of motion to his left lower extremity but had never worked with him in regards to splinting of the upper extremity. Nurse #6 was interviewed about the contracture risk review form on 02/05/15 at 4:00 PM. She stated she was new at the facility and it was just a form that needed to be completed when a resident was admitted or readmitted to the facility. She wasn ' t sure what happened to it once it was completed. Nurse #1 was interviewed on 02/05/15 at 4:10 PM. She stated that she had been in Resident #7's room and there was a definite odor detected to his left hand. She stated that the aides should have been placing a rolled up wash cloth in Resident #7's left hand on a daily basis to protect his hand. Resident #7's care plan was updated on 02/05/15 to include a problem with impaired physical mobility, limited range of motion and potential for worsening contractures. Interventions included therapy screens/evaluations as indicated, encourage to participate in range of motion exercises, and utilize a right palmar splint to decrease risk of further contracture. His care plan also identified a problem with having a high risk for the development of pressure ulcers (onset date of 05/12/14) and had a stage 2 pressure ulcer to the fifth digit of the left hand. There was a handwritten note that documented "updated 2/5/15". A handwritten note of 02/05/15 indicated to cleanse the site with normal saline, apply (brand name) ointment and cover with a dry dressing. It was noted in the approach section that the skin was to be observed daily with routine care and a full skin evaluation was to be done weekly with the bath and/or shower.

Based on observations, record review and staff interviews, the facility failed to assess the skin integrity of the left hand and also failed to prevent the development of a pressure ulcer to the fifth digit (left little finger) of the contracted left hand for 1 of 3 sampled residents (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident #7 had a history of [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment of 08/06/14 noted that Resident #7 had a stage 3 pressure ulcer with slough. There were no measurements documented. The Quarterly Minimum Data Set (MDS) assessment of 10/30/14 indicated Resident #7 had severely impaired cognition. He required extensive to total assistance for all activities of daily living. He had a history of [REDACTED]. Resident #7's care plan identified several problem areas which included a problem with being at risk for skin breakdown due to hemi/para/[MEDICAL CONDITION] with an onset date of 04/23/14. The goal was to remain free from skin breakdown through the next review date. Approaches included keeping the skin clean and dry as well as observing the skin daily. Any abnormalities were to be reported to the nurse. This problem was last reviewed on 11/12/14. Another area (with onset date of 05/12/14) identified a problem of being at high risk for the development of pressure ulcers due to having a stage 3 pressure ulcer to the left thumb. This problem was last reviewed on 11/12/14 and it was noted to continue with the plan of care. There were no treatment orders noted on the December 2014 treatment administration record for Resident #7 in regards to routine washing of the left hand. There was no January 2015 treatment administration rcord found in Resident #7's chart. The most recent Quarterly Minimum Data Set (MDS) assessment of 01/23/15 noted Resident #7 required extensive to total care with all activities of daily living. Resident #7 was observed resting in bed at 11:45 AM on 02/02/15. A very foul odor was detected in his room. A bed bath was observed beginning at 9:20 AM on 02/04/15. As NA #7 was completing the bath, he reported that he didn't attempt to open the left hand due to pain on the part of the resident. When questioned about the ability to open the left hand, he attempted to move the fingers very gently away from the palm of the hand. He was able to extend the fingers just enough to allow slight washing of the inside of the hand. There was a very distinct foul odor detected as he began to gently extend the fingers from atop the thumb which was positioned across the palm of the hand extending out the far side of the hand. He washed, rinsed and dried the left hand very gently and carefully. NA #7 was interviewed following the observation at 9:55 AM on 02/04/15. He reported that he had not worked with Resident #7 in a while as he floated from hall to hall. When questioned about hygiene care of the left hand, he stated the treatment nurse was responsible for washing the hand on a daily basis. NA #7 confirmed that there was a definite odor detected upon washing the hand and he would report it to the nurse. A physician's telephone order of 02/04/15 at 12:00 PM indicated to wash the left hand with soap and water daily. It was noted to clean the wound to the left pinky finger with normal saline, apply (brand name ointment) ointment and cover with a dry dressing daily. It was also noted to insert a gauze hand roll into the left hand and insert gauze between the fingers on the left hand daily until assessed by therapy. During an observation of Resident #7, on 02/04/15 at 12:50 PM, the left hand was noted to have a gauze wrapped around the entire surface of the hand. During an interview with the treatment nurse on 02/04/15 at 1:00 PM, she stated NA #7 had asked her to look at Resident #7's hand. She stated the hall nurse had also reported to her that Resident #7 was experiencing pain in the left hand and asked her to assess it. The treatment nurse stated she noticed an odor when she washed the left hand today. She also reported she had placed gauze between his fingers and a gauze roll inside the hand followed by wrapping the hand with rolled gauze. She added that while she was washing the left hand, she found a stage 2 pressure ulcer to the inside of the left pinky finger where it was pressed against the fourth digit (ring finger). She commented that the hall nurses completed weekly skin checks. The treatment nurse added that Resident #7 had a history of [REDACTED]. She remarked that she would speak with the physician about possibly obtaining an order for [REDACTED].#7's left hand daily, she responded that she had not been washing his hand on a routine basis but now that the pressure ulcer was present she would be providing daily treatment which included hand washing. A wound assessment of 02/04/15 for the left little finger of Resident #7's left hand noted a stage 2 pressure ulcer. The open wound measured 0.5 centimeters by 0.5 centimeters by 0.2 centimeters with 100% granulation tissue noted. It was noted that Resident #7 experienced pain with the treatment. It was documented in the notes section of this assessment that the hall nurse had notified her of the breakdown to resident's left hand. The treatment nurse also documented that the area was painful to touch with a scant amount of drainage. She washed Resident #7's left hand with soap and water and applied (brand name) ointment to the wound. She covered the area with a dry dressing and placed a gauze hand roll into the palm of the left hand with gauze placed between his fingers and secured the dressing with rolled gauze. She also documented that she had notified the family. The treatment nurse also documented she had paged the physician for treatment orders. During an interview with Nurse #2 who worked on Resident #7's hall, on 02/05/15 at 9:58 AM, she stated Resident #7 had been moved to her hall about a month ago from another hall. She stated she had worked with him previously and he had a history of [REDACTED]. Nurse #2 reported that she had gone into his room yesterday during rounds to reposition him and while turning him he complained about pain in his left hand. She stated the open area was discovered at that time. The treatment nurse and the acting Director of Nurses (DON) were observed providing wound treatment to Resident #7 on 02/05/15 at 10:50 AM. The treatment nurse reported Resident #7 had been pre-medicated for pain about 20 minutes ago. She removed the old dressing and began to wash the left hand with soap and water. There was a very distinct foul odor detected as the fingers were gently separated. The DON held the hand while the treatment nurse maneuvered to wash inside the severely contracted hand. The fingers were contracted on top of each other overlapping the thumb making it difficult for her to wash them. The treatment nurse was not able to use the wash cloth to cleanse inside the palm of the hand due to the inability to extend the fingers far enough to get the wash cloth inside. The treatment nurse moistened dry gauze with water and utilized a q-tip to gently wash inside the hand. Once she had washed the hand, she dried the inside of his hand with dry gauze and a clean q-tip. There was an approximate dime size open area to the little "pinky" finger that had white raised edges and a sunken dark pink center. The treatment nurse applied the (brand name) ointment using a q-tip. She placed folded gauze between each finger and a gauze hand roll into the palm of the left hand. She wrapped the hand with rolled gauze. The treatment administration record for Resident #7 indicated that as of 02/05/15 the left hand was to be washed with soap and water. The wound to the left "pinky" finger was to be cleansed with normal saline, (brand name) ointment was to be applied and there was to be a gauze hand roll placed in the left hand. NA #7 reported on 02/05/15 at 11:20 AM that he had informed the treatment nurse on 02/04/15 about the odor noted in Resident #7's left hand. He stated if he found any issues with a resident's skin he would report it to the nurse. NA #7 commented that he had not worked with this resident in a while due to being a floater about the facility. Nurse #2 and Nurse #5 were interviewed on 02/05/15 at 2:15 PM. Nurse #2 stated skin checks were completed by the second shift nurses and if a new area was discovered it was assessed and the appropriate treatment started. Nurse #5 stated that the skin checks had been discontinued when the new management came and the nurse aides were given the responsibility to do the skin checks during showers. Nurse #5 stated the aide was to report any skin changes found to the nurse for evaluation. Nurse #1 was interviewed on 02/05/15 at 4:00 PM. She stated that nurse aides were expected to observe the resident's skin during showers and complete a skin sheet if any areas of concern were identified. Nurse #1 reported the nurse would then assess the skin concern and provide appropriate treatment. She added that she had been in Resident #7's room and there was a definite odor detected to his left hand. During an interview with the acting Director of Nurses (DON), on 02/05/15 at 5:45 PM, she stated the nurse aides should be reporting any issues with a resident's skin to the nurses. She stated there was a definite foul odor detected when the left hand was washed during wound care. The DON added that the floor nurses were responsible for completing weekly skin checks. There were no skin checks found for the month of January/February 2015. Resident #7's updated care plan of 02/05/15 identified a problem with being at high risk for the development of pressure ulcers due to the development of a stage 2 pressure ulcer to the fifth digit on the left hand. A handwritten note of 02/05/15 indicated to cleanse the site with normal saline, apply triple antibiotic ointment and cover with a dry dressing. It was noted in the approach section that the skin was to be observed daily with routine care and a full skin evaluation was to be done weekly with the bath and/or shower.

Based on medical record reviews and staff interviews the facility failed to contact the physician to clarify admission orders [REDACTED]. The facility failed to contact the physician timely on 10/06/10 for an elevated FSBS level timely for 1 of 3 residents. (Resident #1) The findings include: Resident #1 was admitted to the facility on [DATE] around 2:15 PM (according to the nurses ' notes) with the [DIAGNOSES REDACTED]. Review of the hospital discharge report dated 10/11/10 revealed admission [DIAGNOSES REDACTED]. The resident slowly transitioned off his insulin pump and placed on [MEDICATION NAME] with prandial (given with or after meals) [MEDICATION NAME] (insulin) to accompany his [MEDICATION NAME] tube feedings and supplemental insulin. The discharge instructions revealed: nurses must adhere to insulin administration in relation to tube feeds as follows: "Checks FSBS (finger stick blood sugar) every tube feed give insulin based on FSBS before the tube feed." Interview with Nurse #1 on 10/27/10 at 11:30 AM revealed she tried to contact the physician to obtain the orders (for the [MEDICATION NAME] and FSBS check and parameters) or the resident, but he did not return the call. She informed Nurse #2 (the next shift nurse) to continue to contact the physician to get the orders for this resident. She further revealed she knew the resident needed these orders from the report and the hospital records she received. She stated" I placed the orders of the medications (including [MEDICATION NAME]) I had from the hospital discharge summary on the MAR (medication administration record) and explained to Nurse #2 (2nd shift nurse) to get these other orders (for [MEDICATION NAME] and FSBS and parameters) for the resident." Interview with Nurse #2 on 10/27/10 at 3:40 PM revealed she attempted to call the doctor during her shift (on 10/01/10), but he did not respond. She indicated she did not follow up with the doctor. Review of the MAR indicated [REDACTED]. There were nurses' initials on 10/2, 10/3 10/4 and 10/5 indicating [MEDICATION NAME] was administered on those days. There were no nurses' initials on 10/01/10. Review of the MAR indicated [REDACTED]. There were initials of the nurses indicating Glucerna was initiated on 10/01/10 at midnight. Review of the MAR indicated [REDACTED]. Review of the Nurses' Notes for 10/02/10 and 10/03/10 revealed no documentation the physician was notified of the elevated FSBS levels on 10/02/10 and 10/03/10. Interview with Nurse #3 (the 11-7 shift) on 10/27/10 at 6:30 PM she stated" I reviewed the chart and did not see any other orders to monitor his (resident's) blood sugars, so I initiated the 6:00 AM FSBS on 10/02/10 since he (resident #1) was receiving [MEDICATION NAME] at bedtime." She further stated" he (the resident) was not symptomatic on Saturday morning (10/02/10) and I would only call the doctor if it (FSBS level) was over 400". Attempts to contact Nurse #4 (worked on 11-7 shift on 10/3/10) were not successful. Review of the Physician order [REDACTED].#1. The order read "[MEDICATION NAME] R 8 units TID before meals, FSBS TID before meals." Review of the Physician order [REDACTED].#1 "[MEDICATION NAME] R 8 units sq TID before meals, FSBS TID before meals". Review of the MAR indicated [REDACTED]. Interview with Nurse #1 on 10/27/10 at 12 noon revealed that when she came back to work on 10/04/10, she realized that orders for [MEDICATION NAME] and FSBS check or parameters for treating his elevated FSBS levels were not obtained. Nurse #1 revealed she contacted the physician to obtain the orders on 10/04/10 and transcribed it to the MAR. She further indicated she told the next shift nurse (Nurse #2) during report about the new orders. She also revealed she placed the information on the 24 hour report (A reporting system used by the nurses to be made aware of new admissions, acute residents' condition and changes to their care). Interview with Nurse #2 at 10/27/10 at 3:40 PM revealed she was unaware of the new orders written by Nurse #1 on 10/04/10 for the resident's FSBS or [MEDICATION NAME] to be initiated that evening at the evening meal. During an interview with the director of nursing (DON) on 10/27/10 at 1 50 PM revealed her expectation was that admission orders [REDACTED]. She further indicated if the nurse was unable to contact the physician the medical director should have been contacted. The nurse should have relayed this information during report to the next shift nurse and the next shift nurse should have tried to obtain the necessary orders. The DON indicated her expectation was that the administrative staff should have been made aware of the problem of obtaining orders also. Attempts to contact Resident#1 physician and the medical director were unsuccessful. Review of the MAR indicated [REDACTED]. FSBS readings were documented as: 403 mg/dl on 10/05/10 at 6:00 AM, 126 mg/dl at 11:30 AM, 122 mg/dl on 3:00 PM, Review of Nurses' Note revealed no documentation to attempt to contact the physician with the elevated FSBS readings on 10/02/10, 10/03/10 and 10/05/10. Review of the MAR indicated HI". The resident received his scheduled 8 units of [MEDICATION NAME] R at that time. Review of Nurses' Notes dated 10/06/10 read "FSBS HI at 6:20 AM. Physician on call for doctor paged." Review of Nurses' Notes dated 10/06/10 revealed the physician returned the call at 6:40 AM and ordered additional 4 units of [MEDICATION NAME] to equal 12 units. The physician ordered to recheck FSBS at 11:30 AM and call him back for further adjustment if FSBS was still elevated. Review of Nurses' Notes dated 10/06/10 at 11:30 AM revealed FSBS continued to read HI, the doctor was paged to him make aware. The nurse was waiting for a response. Review of Nurses' Notes dated 10/06/10 at12 pm revealed the doctor was paged again three times to make him aware of FSBS, but there was no response. Review of Nurses' Notes dated 10/06/10 at 1:00 PM revealed the nurse called the doctor ' s office to make him aware of the elevated FSBS. The nurse was instructed the doctor was on vacation and to keep paging until the on call doctor responded. Review of Nurses' Notes dated 10/06/10 (no time) revealed VS (vital signs) were 97.1 (temperature), 66 (pulse), 18 (respiration), 124/60 (blood pressure). Nurse #1 called the medical director of the facility and received orders for "12 units regular insulin NOW, recheck in 2 hrs. Pt is showing no s/s (signs and symptoms) of distress." Review of Nurses' Notes dated 10/06/10 at 3:35 PM revealed FSBS was checked and was still registering " HI " on FSBS machine. Nurse #2 used a different machine to check the resident FSBS and it was 498 mg/dl. The nurse paged the doctor 6 times, waiting for response. Review of Nurses' Notes dated 10/06/10 at 5:00 PM revealed Nurse #2 paged the doctor a total of 14 times, with no response. The nurse notified the medical director for facility, at 4:45 PM and made him aware of situation. The medical director ordered to send the resident to the hospital emergency room for evaluation. The resident left at 5:00 PM via EMS stretcher and ambulance. The RP (responsible party) was notified at 4:55 PM. Review of Nurses' Notes dated 10/07/10, revealed a Late Entry for 10/06/10 at 1:40 PM. The nurse received orders from doctor/medical director to give 12 units regular insulin sq NOW and to recheck FSBS in 2 hours, and continue to monitor for distress. Interview with Nurse #1 on 10/27/10 at 12:48 PM revealed she monitored the resident and he was not showing symptoms of distress. She indicated he was not restless or lethargic which were signs to look for with a resident with [MEDICAL CONDITION]. Interview with the Director of Nursing on 10/27/10 at 11:45 AM revealed her expectation was the nurse should not have to continually page the doctor. She indicated 3 or 4 calls should be enough if, no response from the doctor then the nurses should know to call the medical director or her. She stated "(Nurse #2) is a new nurse and she did call me for direction after she could not reach the doctor".

Based on record review and staff interviews the facility failed to clarify physician admission order for insulin and blood sugar check; failed to monitor the resident's elevated blood sugar and failed to notify the physician timely of a resident's elevated blood sugar for 1 of 3 residents. (Resident #1) The findings include: Resident #1 was admitted to the facility on [DATE] around 2:15 PM (according to the nurses notes) with the [DIAGNOSES REDACTED]. Review of "Patient Transfer Form" dated 10/1/10 revealed "see D/C (discharge) summary (from the hospital)" was hand written under the section titled "Diet, Drugs and other Therapies". Review of the hospital discharge summary dated 10/01/10 listed, under discharge medication, "[MEDICATION NAME] (long acting insulin) 100 units/ml subcutaneous solution, give 18 units at bedtime". "Instructions to nursing home" read: "please monitor patient's FSBS (finger stick blood sugar) regularly as he is prone to [DIAGNOSES REDACTED]." On page two of the hospital discharge summary, Nurse# 1's handwritten note read "FSBS orders, was getting [MEDICATION NAME] R 8-10 units scheduled TID (three times a day) FSBS TID & HS(hour of sleep)". Interview with Nurse#1 on 10/27/10 at 11:30 AM revealed she tried to contact the physician to obtain the orders (for the [MEDICATION NAME] and FSBS check) for the resident, but he did not return the call. She informed Nurse#2 (the next shift nurse) to continue to contact the physician to get the orders for this resident. She further revealed she knew the resident needed these orders from the report and the hospital records she received. She stated "I placed the orders of the medications (including [MEDICATION NAME]) I had from the hospital discharge summary on the MAR (medication administration record) and explained to Nurse #2 (2nd shift nurse) to get these other orders (for [MEDICATION NAME] and FSBS) for the resident." Interview with Nurse #2 on 10/27/10 at 3:40 PM revealed she attempted to call the doctor during her shift (on 10/01/10), but he did not respond. Review of the MAR indicated [REDACTED]. There were nurses' initials on 10/2, 10/3 10/4 and 10/5 indicating [MEDICATION NAME] was administered on those days. There were no nurses' initials on 10/01/10. Review of the MAR indicated [REDACTED]. There were initials of the nurses indicating Glucerna was initiated on 10/01/10 at midnight. Review of the MAR indicated [REDACTED]. Review of the Nurses' Notes for 10/02/10 and 10/03/10 revealed no documentation the physician was notified of the elevated FSBS levels on 10/02/10 and 10/03/10. Interview with Nurse# 3 (the 11-7 shift) on 10/27/10 at 6:30 PM she stated "I reviewed the chart and did not see any other orders to monitor his (resident ' s) blood sugars, so I initiated the 6:00 AM FSBS on 10/02/10 since he (resident #1) was receiving [MEDICATION NAME] at bedtime." She further stated "he (the resident) was not symptomatic on Saturday morning (10/02/10) and I would only call the doctor if it was over 400". Attempts to contact Nurse #4 (worked on 11-7 shift on 10/3/10) were not successful. Review of the Physician order [REDACTED].#1. The order read "[MEDICATION NAME] R 8 units TID before meals, FSBS TID before meals." Review of the Physician order [REDACTED].#1 "[MEDICATION NAME] R 8 units sq TID before meals, FSBS TID before meals". Review of the MAR indicated [REDACTED]. Interview with Nurse #1 on 10/27/10 at 12 noon revealed that when she came back to work on 10/04/10, she found out that orders for [MEDICATION NAME] and FSBS check were not obtained. Nurse #1 revealed she contacted the physician to obtain the orders for [MEDICATION NAME] and FSBS check on 10/04/10 and transcribed it to the MAR. She further indicated she told the next shift nurse (Nurse #2) during report about the new orders. She also revealed she placed the information on the 24 hour report (A reporting system used by the nurses to be made aware of new admissions, acute residents' condition and changes to their care). Interview with Nurse #2 at 10/27/10 at 3:40 PM revealed she was unaware of the new orders written by Nurse #1 on 10/04/10 for the resident's FSBS or [MEDICATION NAME] to be initiated. Review of the MAR indicated [REDACTED]. FSBS readings were documented as: 403 mg/dl on 10/05/10 at 6:00 AM, 126 mg/dl at 11:30 AM, 122 mg/dl on 3:00 PM. Review of Nurses' Note revealed no documentation to attempt to contact the physician with the elevated FSBS readings on 10/02/10, 10/03/10 and 10/05/10. Review of the MAR indicated HI". The resident received his scheduled 8 units of [MEDICATION NAME] R at that time. Review of Nurses' Notes dated 10/06/10 read "FSBS HI at 6:20 AM. Physician on call for doctor paged." Review of Nurses' Notes dated 10/06/10 revealed the physician returned the call at 6:40 AM and ordered additional 4 units of [MEDICATION NAME] to equal 12 units. The physician ordered to recheck FSBS at 11:30 AM and call him back for further adjustment if FSBS was still elevated. Review of Nurses' Notes dated 10/06/10 at 11:30 AM revealed FSBS continued to read HI, the doctor was paged to him make aware. The nurse was waiting for a response. Review of Nurses' Notes dated 10/06/10 at12 pm revealed the doctor was paged again three times to make him aware of FSBS, but there was no response. Review of Nurses' Notes dated 10/06/10 at 1:00 PM revealed the nurse called the doctor's office to make him aware of the elevated FSBS. The nurse was instructed the doctor was on vacation and to keep paging until the on call doctor responded. Review of Nurses' Notes dated 10/06/10 (no time) revealed VS (vital signs) were 97.1 (temperature), 66 (pulse), 18 (respiration), 124/60 (blood pressure). Nurse #1 called the medical director of the facility and received orders for "12 units regular insulin NOW, recheck in 2 hrs. Pt (patient) is showing no s/s (signs and symptoms) of distress." Review of Nurses' Notes dated 10/06/10 at 3:35 PM revealed FSBS was checked and was still registering "HI" on FSBS machine. Nurse #2 used a different machine to check the resident FSBS and it was 498 mg/dl. The nurse paged the doctor 6 times, waiting for response. Review of Nurses' Notes dated 10/06/10 at 5:00 PM revealed Nurse #2 paged the doctor a total of 14 times, with no response. The nurse notified the medical director for facility, at 4:45 PM and made him aware of situation. The medical director ordered to send the resident to the hospital emergency room for evaluation. The resident left at 5:00 PM via EMS stretcher and ambulance. The RP (responsible party) was notified at 4:55 PM. Review of Nurses' Notes dated 10/07/10, revealed a Late Entry for 10/06/10 at 1:40 PM. The nurse received orders from doctor/medical director to give 12 units regular insulin sq NOW and to recheck FSBS in 2 hours, and continue to monitor for distress. Interview with Nurse #1 on 10/27/10 at 12:48 PM revealed she monitored the resident and he was not showing symptoms of distress. She indicated he was not restless or lethargic which were signs to look for with a resident with [MEDICAL CONDITION]. Interview with the Director of Nursing on 10/27/10 at 11:45 AM revealed her expectation was the nurse should not have to continually page the doctor. She indicated 3 or 4 calls should be enough if, no response from the doctor then the nurses should know to call the medical director or her. She stated " (Nurse #2) is a new nurse and she did call me for direction after she could not reach the doctor". Review of the EMS (emergency medical services) report dated 10/06/10 at 5 PM revealed the resident opened his eyes, with no speech. The report documented a finger stick was done with a " HIGH " reading. He was transported to the hospital. Review of the hospital discharge report dated 10/11/10 revealed admission [DIAGNOSES REDACTED]. The resident's blood sugar was 500 milligram per deciliter (mg/dl) on admission. He was started on an insulin drip in ? normal saline because of [MEDICAL CONDITION], and low levels of sodium in the blood. Potassium was added to the intravenous fluid. The resident slowly transitioned off his insulin pump and placed on [MEDICATION NAME] with prandial (given with or after meals) [MEDICATION NAME] (insulin) to accompany his [MEDICATION NAME] tube feedings and supplemental insulin. The discharge instructions revealed: nurses must adhere to insulin administration in relation to tube feeds as follows: "Checks FSBS (finger stick blood sugar) every tube feed give insulin based on FSBS before the tube feed." Review of the resident's Minimum Data Set of 10/11/10 revealed the resident was coded to have short and long problems and was severely impaired in daily decision making. The resident was non verbal and had difficulty making his needs known. He required extensive assistance from staff for all activities of daily living and was incontinent of bowel and bladder.