Every finding on record at Highland House Rehabilitation and Healthcare

Based on observations, resident, and staff interviews, the facility failed to maintain two bathroom floors and door frames in good repair and to ensure one of the bathrooms was free of odor which affected 3 residents (Resident #51, Resident #65, and Resident #10) on 1 of 3 halls reviewed for clean, comfortable and homelike environment (A hall).Findings included:1a. On 3/9/26 at 3:45 PM an observation of the shared bathroom floor in Resident #51 and Resident #65's room, which was on the A hall, was conducted. A very strong odor of urine was noted upon entering the resident room. A grayish discoloration was noted on almost all the cream Vinyl Composite Tile (VCT) flooring, especially at the edges of each square tile. The VCT appeared aged, scuffed, scratched, and had no evidence of finish or wax. The floor close to the base of the toilet was noted to be wet. The far-right corner floor from the bathroom door appeared to have three cut tile pieces placed on top of the original floor to patch it and did not create a smooth cleanable finish and edge. In addition, the bathroom door frame was noted to have multiple areas of peeling paint, exposing brown metal.A quarterly admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #51 as cognitively intact.An interview was conducted with Resident #51on 3/9/26 at 3:47 PM and he stated he did not use the bathroom because he was incontinent, but he could smell the odor from his bed which was by the window and was further from the bathroom door than the other bed in the same room. Resident #51 stated he did not like the smell at all because it was not pleasant. He further stated that he had not reported the issue to the facility staff because anyone who came to his room could smell it. The resident was unable to identify how long it had been since he first noticed the odor.An annual MDS dated [DATE] coded Resident #65 as cognitively intact.During an interview with Resident #65 on 3/10/26 at 2:56 PM he reported that he used the toilet in his room independently and when asked how he felt about the condition of the bathroom or how long the bathroom had smelled like that he said he did not know.During an interview on 3/10/26 at 1:05 PM with NA #4 she stated that Resident #65 used the toilet in his room all the time and she had noted the floor to be wet sometimes and had a bad smell. NA #4 further stated she did not report this to anyone because anyone that came to the room could smell the odor and see the condition of the bathroom floors.1b. On 3/9/26 at 3:55 PM an observation of Resident #10's bathroom, which was on the A hall, was conducted. The bathroom floor, which consisted of cream colored VCT was noted to have black and gray discoloration on most of the floor. The VCT appeared aged, scuffed, scratched, and had no evidence of finish or wax. The lower portions of the bathroom door frames on both sides of the bathroom were noted to have paint peeling off exposing brown metal.A quarterly admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #10 as cognitively intact.An interview was conducted with Resident #10 on 3/10/26 at 12:48 PM she stated she used the bathroom in her room, but she did not like how it looked and it made her feel bad. She stated that housekeeping staff cleaned it and sometimes she tried to clean it too to make it look better. Resident #10 stated she had discussed the condition of the bathroom with the Administrator about 2 to 3 months ago and the Administrator had told her that the facility would try to wax it and buff it to make it look better.During an interview on 3/12/26 at 8:22 AM with Housekeeping Aide #1 she reported she worked 5 days a week and was assigned the resident rooms and bathrooms on the A hall. She further explained on the days she was not working; Housekeeping Aide #2 was assigned to clean A hall resident rooms and resident bathrooms. Housekeeping Aide #1 verbalized she had noted water on the floor and an odor in Resident #51 and Resident #65's bathroom when she went in to clean the bathroom and that the Housekeeping Supervisor was aware.Attempts to interview Housekeeping Aide #2 were unsuccessful.During an interview on 3/10/26 at 12:58 PM with Regional Maintenance Manager he stated that the toilet (closet) flange (pipe fitting that connects the toilet to the drain line, secures it to the floor and seals out sewer gas using wax ring) in Resident #51's room was broken. He explained that when the flange which was supposed to create a seal was broken it made the water back up when the toilet was flushed, the floor would get wet. He indicated it should have been fixed and that they were going to start working on it later that day. He stated he learned about the bathroom concern from the former Maintenance Director and facility Administrator but could not recall the exact dates.An interview was conducted on 3/11/26 at 2:05 PM with the Housekeeping Supervisor. He stated they had tried to clean the floors in Resident #51 and Resident #10's bathrooms but the floor discoloration could not be solved by cleaning but needed replacement. He explained that they had tried a floor cleaning process that involved enzymes, scrubbing, and stripping to try and clean the bathroom floors, but it did not succeed in resolving the discoloration of the tiles. An observation of the door frames was conducted with the Housekeeping Supervisor during the interview. He stated that they were going to repaint the door frames when they fixed the bathroom floors. A follow up interview was conducted on 3/13/26 at 10:30 AM with the Housekeeping Supervisor and District Housekeeping Manager. They reported that water would sometimes seep up through the bathroom floor tiles in Resident #51 and Resident #65's bathrooms when someone stepped on the bathroom floor.During an interview on 3/10/26 at 2:10 PM with the Administrator she stated she was aware of the situation in Resident #10 and Resident #51/Resident #65's bathrooms since December 2025. She stated she noticed the bathroom floors were discolored when she was doing her rounds. The Administrator stated her expectation was the facility should have a plan to address any repairs and renovations that were needed to fix the bathroom floors and bathroom door frames. During a follow-up interview with the Administrator on 3/12/26 at 2:05 PM she verbalized that her expectation was for the facility to identify any environmental problems in the facility and address them. The Administrator added she thought one of the residents who used the bathroom in Resident #51's bathroom urinated on the floor which the facility staff would clean when they were aware that happened and they were working on replacing the bathroom floor tiles.

Based on record review and interviews with resident and staff, the facility failed to protect the residents' right to be free from misappropriation for 3 of 6 residents (Residents #60, #10, and #45) reviewed for misappropriation of property. Resident #60's Oxycodone (narcotic pain medication) was misappropriated and Resident #10's and Resident #45's Healthcare Spending Cards (health insurance cards with monthly monetary benefits that can be utilized for purchasing approved food items and over-the-counter products) were taken by the Activities Assistant without their knowledge and used for her own personal purchases.Findings included: The facility's abuse policy which was revised on 12/2024 was reviewed and the policy stated misappropriation was the deliberate misplacement, exploitation or wrongful use of the resident's money or belongings. The abuse policy further stated the residents have the right to be free of misappropriation of their property. 1. Resident #60 was admitted to the facility on [DATE]. A review of Resident #60's electronic medical record (EMR) revealed his physician's order of Oxycodone HCl 10 milligrams every 4 hours as needed for pain was initiated on 12/04/2025. A Packing Slip Proof of Delivery form from the facility's contracted pharmacy was provided for review by the facility. The form was not signed by a receiving nurse but indicated 180 tablets of Oxycodone 10 milligrams were delivered to the facility on [DATE]. An interview with Nurse #3 was conducted on 03/12/2026 at 10:32 AM. She worked from 7:00 AM to 7:00 PM on 12/21/2025. Around 6:30 PM she was at the nurse's station completing her paperwork when Nurse #4 walked up to her and stated she was her relief for the next shift. She told Nurse #4 that another nurse was scheduled, and she stated she had called out and she was her replacement. Nurse #4 was not familiar to her but that was not odd to her because they used a lot of agency nurses. Nurse #4 also stated she did not need a long report because she usually worked that hall and was familiar with the residents. They counted the cart to include Resident #60's Oxycodone 10 milligram tablets and narcotic sheets and there were 103 tablets left. She gave Nurse #4 the keys, the Nurse took possession of the cart and walked down the hall with the cart. She finished her documentation and left the facility. On 12/22/2025 she came in for her 7:00 AM to 7:00 PM shift and Nurse #5 stated that Resident #60 did not have any Oxycodone. Nurse #3 told Nurse #5 when she left the evening prior there were 103 tablets. Nurse #3 indicated she did not count the cart with Nurse #5 and went to get the Director of Nursing (DON). Attempted three calls to Nurse #4 for an interview and left telephone voice messages but she did not return the telephone messages. Attempted three calls to Nurse #5 for an interview and left telephone voice messages but she did not return the telephone messages. A review of Nurse #5's statement dated 12/22/2025 revealed she was asked to switch carts and counted with Nurse #4. The count and numbers for narcotic medications matched with what she called out. However, she did not see any medications for Resident #60. During an interview with the Quality Assurance (QA) Nurse on 03/13/2026 at 11:22 AM she stated the DON was out sick and could not be reached by phone. The QA Nurse indicated she was a part of the investigation of the missing medications. she stated Nurse #4 had worked at the facility as an agency nurse but was not on the schedule on 12/21/2025. Nurse #4 counted medications with Nurse #3 on 12/21/2025 for the 7:00 PM to 7:00 AM shift and all the narcotic medications and narcotic sheets were accounted for. Nurse #4 complained of a stomachache and counted with Nurse #5 and left the facility within an hour of her having the cart. The morning of 12/22/2025 Nurse #3 reported that Nurse #5 stated Resident #60 did not have any narcotic medication, but when she left the previous evening there were 103 tablets. Nurse #5 stated she did count the narcotics with Nurse #4, and the medication and narcotic sheets were accounted for but there were no medications or narcotic sheets for Resident #60. The DON discovered the narcotics were missing with the narcotic sheets and an investigation began. They called the police and made the initial allegation report. They assessed Resident #60 and he was pain free and contacted the provider for an emergency prescription. Resident #60 did not miss any medications. The QA Nurse further stated they could not say for sure who took the missing narcotics, but it was missing and staff were educated. 2a. Resident #10 was admitted to the facility on [DATE]. Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. The facility's investigation report dated 9/23/25 completed by the Regional [NAME] President of Operations for an allegation of misappropriation of property for Resident #10 indicated the facility became aware of the allegation on 9/16/25 when the resident reported her Healthcare Spending Card was unable to be located. Law enforcement and Adult Protective Services were notified. The Activity Assistant was the accused staff member and she was terminated on 9/16/25. The investigational summary submitted with the investigation report revealed the facility substantiated the allegation of misappropriation of property and that the Healthcare Spending Card was used without the resident's awareness by the Activities Assistant. The resident stated the wallet was stored in the bottom drawer of her nightstand and the investigation indicated that when staff searched the resident's room, the Healthcare Spending Card could not be located. The resident's insurance provider confirmed the card had been used at a local retail store for a transaction of $95.00 on 9/15/25 at approximately 4:00 pm. The Activities Assistant reported the resident had given her permission to take and use the card to purchase items for the resident. The Activities Assistant stated she returned the card and cash to the resident, explaining that approximately $50.00 represented her portion of the items purchased on the card. Interview with the resident revealed that the resident denied giving the Activities Assistant permission to take or use the card and denied awareness that the Activities Assistant had possession of the card. The resident also denied having received $50.00 cash from the Activities Assistant. Resident #10 was interviewed on 3/12/2026 at 8:15 am. Resident #10 indicated she recalled the incident in September 2025 when her Healthcare Spending Card was utilized without her permission. She explained that in the past, the Activities Director and Activities Assistant helped her with shopping online for food and personal items using her Healthcare Spending Card. Resident #10 reported that she discovered on 9/16/25 that her card was missing and she reported the missing card to the Unit Manager #1. Resident #10 stated the Regional [NAME] President of Operations reported to her that the Activities Assistant took her Healthcare Spending Card and used the card at a local store, spending $95.00. Resident #10 reported that the Activities Assistant informed her on 9/16/25 the purchases were made because her (the Activities Assistant's) children were hungry. Resident #10 denied having received $50.00 cash from the Activities Assistant. Resident #10 stated she felt disappointed in the Activities Assistant and expressed concern that a similar incident could occur again. Resident #10 further stated the facility reimbursed the amount of the unauthorized purchase into her resident trust account. Unit Manager #1 was no longer employed by the facility and was unavailable for interview. b. Resident #45 was admitted to the facility on [DATE]. Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. An initial report dated 9/23/25 completed by the Regional [NAME] President of Operations for an allegation of misappropriation of property for Resident #45 indicated the facility became aware of the allegation on 9/23/25. Resident #45's Healthcare Spending Card was misplaced sometime around 9/4/25. When unable to be located, the card was cancelled and a new card was requested. On 9/23/25 transactions on the card were obtained and indicated the Healthcare Spending Card was used after it was identified as missing. The accused was noted to be a former employee (the Activities Assistant). The incident was reported to law enforcement. The investigation summary dated 9/23/25 related to the allegation of misappropriation of property for Resident #45 revealed that during the investigation into Resident #10's allegation of misappropriation of property the facility identified that Resident #45's Healthcare Spending Card had been used without the resident's permission. It was determined during the investigation that in-store transactions occurred on 8/12/25 in the amount of $106.06, 9/4/25 in the amount of $212.38, and on 9/8/25 in the amount of $18.57 using Resident #45's Healthcare Spending Card for a total of $337.01. Resident #45 was interviewed on 3/12/2026 at 8:36 am. Resident #45 stated that her Healthcare Spending Card had previously been misplaced and she reported the misplaced card to the Activities Assistant. She was unable to recall the date this occurred. Resident #45 stated the Activities Assistant helped her with canceling the misplaced Healthcare Spending Card and ordering a replacement card. Resident #45 reported Social Worker (SW) #2 explained to her that her card had previously been used for in-store purchases before and after the card was identified as misplaced. Resident #45 stated her Healthcare Spending Card had been used without her permission. Resident #45 indicated she never made any in-store purchases on the card. Resident #45 further indicated the last time she used her card for an on-line purchase was sometime in early September 2025 with the help of the Activities Assistant. Resident #45 further stated she was upset regarding the situation and felt the Activities Assistant should be held accountable for using her card without her permission. Resident #45 reported that because of the incident she kept her personal items secured in a lockbox and stated the key to the lockbox was kept around her neck. Resident #45 further stated the facility discontinued assisting residents with online shopping because of this incident and residents now participate in scheduled shopping trips outside the facility to obtain personal items. Resident #45 further stated the facility reimbursed the amount of the unauthorized purchases into her resident trust account. Multiple attempts were made to contact the Activities Assistant and were unsuccessful. The police reports for the misappropriation of property allegations that occurred in September 2025 for Residents #10 and #45 were requested but were not received during the survey. The police department was contacted via phone on 3/13/26 at 1:58 pm and an email address was given for the officer on record. A message via email was sent to the officer on 3/13/26 and no response was received. The Activities Director was interviewed on 3/12/2026 at 9:26 am. The Activities Director stated that residents previously participated in online shopping every Thursday, which was facilitated by the Activity Department. The Activities Director explained that the Activities Assistant used a tablet computer to assist residents with online shopping and purchases. The Activities Director stated that Healthcare Spending Card were not to be used unless the resident was present during the transaction. The Activities Director explained that the Activities Assistant would help the resident select items from the tablet computer that they wanted to purchase and pay for the items with the Healthcare Spending Card with the resident present. The Activities Director indicated after the incident related to the Activities Assistant using Resident #10's Healthcare Spending Card occurred, the Activities Assistant reported that she went to a store after hours for Resident #10 and had the resident's permission to use her Healthcare Spending Card. The Activities Director stated that Resident #10 later reported to the Regional [NAME] President of Operations that she did not give the Activities Assistant permission to use her Healthcare Spending Card. The Activities Director stated the Activities Assistant also helped Resident #45 with online shopping but did not admit to her (the Activities Director) that she used Resident #45's Healthcare Spending Card. The Activities Director further stated that following the incident the facility discontinued the online shopping process. The Activities Director reported that residents now participated in scheduled shopping outings to local stores to purchase their own items. She further stated that residents who were unable to attend the outings would contact their responsible parties or representatives to assist them with obtaining personal items. The Activities Director explained the facility now provided personal lock boxes with their own key for the residents to store their Healthcare Spending Card, other credit/debit cards, personal items, and cash. A phone interview was conducted on 3/13/26 at 12:02 pm with the Business Office Manager. The Business Office Manager stated Resident #10 and Resident #45 were reimbursed for the money identified as not being spent for purchases by the facility. An interview was conducted on 3/12/26 at 10:15 am with the Regional [NAME] President of Operations, who was serving as the Interim Administrator at the time of the misappropriation of property allegations for Residents #10 and #45. The Regional [NAME] President of Operations explained she was made aware of the initial misappropriation of property allegation for Resident #10 by Unit Manager #1 on 9/16/25. She explained that she conducted the facility's investigation and during the investigation it was identified that Resident #45 also had an allegation of misappropriation of property related to the Activities Assistant utilizing the resident's Healthcare Spending Card. The Regional [NAME] President of Operations stated that law enforcement was notified on 9/16/25 for the incident involving Resident #10 and on 9/23/25 for the incident involving Resident #45. The Regional [NAME] President of Operations stated the police department informed her on 9/25/25 the cases for Resident #10 and Resident #45 would be linked and the Activities Assistant was charged with 3 felonies. The Regional [NAME] President of Operations further stated the Activities Assistant resigned via email on 9/16/25. She reported that a background check had been completed for the Activities Assistant prior to employment, and the facility had no prior concerns related to criminal activity. The Regional [NAME] President of Operations stated that the Activities Assistant should not have taken the Healthcare Spending Cards belonging to Resident #10 and Resident #45. The Regional [NAME] President of Operations stated each resident with Healthcare Spending Cards, cash, or other personal items were given a personal lock box to store their personal belongings with their own key after the incidents happened. The Regional [NAME] President of Operations further stated the Director of Social Services had a master key for the lock boxes secured in her office. During an interview conducted on 3/12/26 at 10:15 am, the Administrator stated her expectation was that all staff follow the facility's policy related to misappropriation of resident property. The facility provided a corrective action plan that was not accepted by the State Agency.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of falls and restraints for 3 of 20 residents reviewed for MDS accuracy (Resident #54, #100, and #6). The findings included: Resident #54 was admitted into the facility on [DATE] with diagnosis of epilepsy. Resident #54's medical record indicated he had a fall with on 1/5/26 resident was observed on the floor sitting on his buttocks. A nursing progress note dated 1/11/26 specified Resident #54 was lying on his right side on a fall mat with no injury noted. A nursing progress note dated 1/14/26 revealed Resident #54 was seen trying to get up out of the wheelchair and slide to the ground on his buttocks with no injury noted. And a nursing progress note dated 1/17/26 revealed Resident #54 was observed on the floor beside his wheelchair but was unable to state what had happened with no injury noted. Resident #54's discharge MDS dated [DATE] specified since admission/entry or reentry or prior assessment the resident had no falls with no injury, 1 fall with injury and no falls with major injury. An interview was conducted on 3/10/26 at 9:50 AM with the MDS Coordinator who confirmed she completed Resident #54's discharge MDS. She indicated that she was aware Resident #54 had multiple falls and he continued to be a fall risk. A review of the discharge MDS dated [DATE] that indicated Resident #54 had no falls with no injury was reviewed with the MDS Coordinator and the MDS Coordinator revealed the discharge MDS was incorrectly coded for falls. She stated she was unsure of how the coding error occurred. An interview conducted with the Administrator on 3/10/26 at 10:30 AM revealed she expected all MDS assessments to be accurate and timely. 2. Resident #100 was admitted into the facility on 1/9/2026 with diagnoses of cerebrovascular accident and muscle weakness. Resident #100's medical record indicated he had 2 falls on 1/12/26. A nursing progress note dated 1/12/26 at 9:00 AM revealed Resident #100 was observed on the floor sitting on his buttocks, the fall was witnessed, resident stated he was not hurt. Resident #100 stated he was trying to get out of bed there was no injury noted. On 1/12/26 at 2:45 PM a nursing progress note specified Resident #100 was observed lying on his back, the Resident stated he was trying to get out of the chair. There was no injury noted. Resident #100's admission Minimum Data Set (MDS) dated [DATE] indicated there had been no falls since admission. An interview was conducted on 3/10/26 at 9:50 AM with the MDS Coordinator who confirmed she had completed Resident #100's admission MDS. A review of the admission MDS dated [DATE] that indicated Resident #100 had no falls since admission was reviewed with the MDS Coordinator. The MDS Coordinator revealed the admission MDS was incorrectly coded for falls. She stated she was unsure of how the coding error occurred. An interview conducted with the Administrator on 3/10/26 at 10:30 AM revealed she expected all MDS assessments to be accurate and timely. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and vascular dementia. Review of Resident #6's physician orders did not include orders for physical restraints. Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively impaired. The MDS further revealed she was coded for a trunk restraint used less than daily. During an interview on 3/11/26 at 12:33 PM with the MDS Coordinator, she stated Resident #6 did not have a restraint, as there were no restraints used in the facility. She further stated that indicating Resident #6 had a restraint on the MDS was an oversight on her part. In an interview with the Regional Nurse Consultant on 3/12/26 at 12:07 PM she stated her expectation was that the MDS should be coded correctly, but sometimes buttons were pushed inadvertently. An interview was conducted with the Administrator on 3/12/26 at 12:20 PM. She stated her expectation was that all MDS assessments were completed accurately.

Based on record review, and interviews with staff, contracted Transportation Aide, and Medical Director, the facility failed to reschedule an eye appointment for 1 of 3 residents reviewed for vision services (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with the last readmission on [DATE]. His diagnoses included type 2 diabetes, glaucoma, and coronary artery disease.A physician progress note dated 1/26/26 indicated that Resident #9 was being referred to an outpatient ophthalmologist due to bilateral eye burning.A physician order dated 1/27/26 indicated a referral to ophthalmology (a medical specialty that focuses on comprehensive eye and vision care) at an outpatient facility.A physician order dated 1/27/26 indicated Refresh Tears Ophthalmic Solution 0.5 %. Instill 1 drop in both eyes four times a day for dry eyes. A physician order dated 1/27/26 indicated Tylenol extra strength oral tablet 500 milligram (mg). Give 1 tablet by mouth every 8 hours as needed (PRN) for pain.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment. He was coded as having adequate vision and no corrective lenses. He was coded as not having had pain and had not received scheduled or as needed pain medication or non-medication intervention for pain. A patient transport requisition form completed by Medical Supplies Personnel indicated Resident #9 had an eye appointment at an outpatient office on 2/13/26 at 8:10 AM and was to be ready for transportation at 7:10 AM.An interview was conducted on 3/11/26 at 9:30 AM with the Transportation Aide from a contracted transportation company. She explained that she picked up Resident #9 on 2/13/26 from the facility and drove him to his eye appointment at an outpatient office. When they arrived at the outpatient office, the Transportation Aide signed Resident #9 in and left him there for his appointment. She stated that staff from the outpatient office called her approximately 15 minutes after she had left letting her know that she needed to come and pick up Resident #9 because he could not be seen by the provider without someone accompanying him. The Transportation Aide stated that she called the facility and asked if someone was going to sit with Resident #9 at the outpatient office for his appointment and she was informed (she could not recall who she had talked to over the phone) that there was no one who was going to accompany him. She explained that she drove back to the outpatient office to pick up Resident #9 to take him back to the facility. When the Transportation Aide arrived at the outpatient office, she was informed that Resident #9 was having a medical emergency and an ambulance had been called to transport him to the Emergency Department (ED). She notified the facility by phone that Resident #9 was being transferred to the hospital. The Transportation Aide verbalized that she picked Resident #9 later that day from the ED and took him back to the facility.A review of Resident #9's medical records revealed no evidence that Resident #9's eye appointment that was originally scheduled for 2/13/26 had been rescheduled.During an interview on 3/10/26 at 2:15 PM with Medical Supplies Personnel she stated that she kept a calendar and transportation requisition forms for all residents that had appointments, but she did not have any records of an upcoming scheduled eye appointment for Resident #9.The Medication Administration Records from 1/28/26 through 3/10/26 for Resident #9 indicated the following:- Refresh Tears were administered 4 times per day as ordered.- PRN Tylenol 500 mg was administered once on 2/12/26 at 5:51 PM for a pain level of 4 out of 10 (on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain possible). - Pain assessments were conducted on all three shifts (7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM) with a recorded pain level of 0 on all assessments aside from the 3:00 pm to 11:00 pm shift on 2/12/26 (when PRN Tylenol was administered). Attempts to engage Resident #9 in a conversation about his vision and eye appointments were unsuccessful on 3/9/26 at 1:12 PM and 3/13/26 at 9:30 AM.During an interview on 3/13/26 at 10:00 AM with the Unit Manager for the hall Resident #9 resided on, she stated that Resident #9 was transferred to the ED from the eye clinic on 2/13/26 due to a medical emergency and did not receive ophthalmology services on that day. The Unit Manager indicated that she had called the eye clinic to schedule Resident #9's appointment but she could not recall the exact date of the call and that she was waiting for a call back and then she would reschedule the appointment. She stated that Resident #9 was not in any distress when he left the faciity on 2/13/26, and she did not think he needed to be accompanied for the appointment. He had an order for eye drops four times a day for dry eyes and as needed Tylenol for pain which nurses administered as ordered and Resident #9 had not continued to complain of burning or pain in eyes.Attempts to interview the Director of Nursing (DON) who was out of the facility during the survey were unsuccessful.During an interview on 3/12/26 at 12:10 PM with the Medical Director she stated that she expected the facility to schedule residents for any specialty referrals she ordered and to reschedule any missed appointments to ensure residents received the medical services they needed. The Medical Director stated that she had referred Resident #9 to ophthalmology due to burning in both eyes and she had ordered eye drops to relieve the eye dryness and burning until he was seen by the ophthalmologist for specialized treatment. An interview was conducted on 3/12/26 at 2:05 PM with the Administrator. She stated that her expectation was for the facility to reschedule any residents' missed appointments in a timely manner and that the nursing staff that received the order or unit manager would schedule the appointments. The Administrator stated that the facility would send staff to accompany a resident who was not able to communicate their needs or if the doctor's office requested someone to accompany the resident. She further stated that if the facility thought that Resident #9 was not able to communicate his needs, they would have sent someone with him. She explained that the 2/13/26 appointment was Resident #9's first scheduled appointment at that ophthalmologist.

Based on record review, and staff, Wound Physician Assistant and Medical Director interviews the facility failed to initiate wound treatment for 4 days upon admission for a resident who was admitted with a pressure ulcer. This was for 1 of 3 residents reviewed for pressure ulcers (Resident #114). Findings included:Resident #114 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and pressure ulcer of sacral region.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #114 was cognitively severely impaired. She was dependent on staff with oral and personal hygiene, bathing/showers, rolling left and right in bed and transfers. She had impairment on both sides of the upper and lower extremities. She was coded for one unstageable pressure ulcer that was present on admission.An admission skin assessment dated [DATE] indicated pressure ulcer to sacral area was covered with clean dry dressing and no bleeding or drainage was noted on the dressing. The assessment did not include measurements of the wound.A review of Resident #114's medical records did not reveal wound care orders or any documentation of sacral wound treatment on 4/25/25, 4/26/25, 4/27/25 and 4/28/25.A review of Resident #114's April Treatment Administration Record (TAR) revealed an order dated 4/28/25 that indicated cleanse sacrum with wound cleanser and pat dry. Apply primary treatment of medical grade honey and cover with dry protective dressing every day shift for Stage 3 pressure injury. This treatment was checked on the TAR as completed on 4/29/25. The order was discontinued on 4/29/25.A physician order dated 4/29/25 indicated consult wound care specialist to treat and evaluate Resident #114 as indicated for wound care.A physician order dated 4/29/25 indicated cleanse sacrum with wound cleanser and pat dry. Apply Santyl (topical enzyme medication) to wound bed and quarter strength [antimicrobial cleanser] moistened gauze and cover with dry protective dressing every day shift for unstageable pressure injury. This treatment was checked on the TAR as completed starting 4/29/25 onward.A review of the facility's standing orders last revised 6/25/24 had a section titled routine pressure ulcer care that indicated: (a) May treat stage 1 and 2 wounds and skin tears according to facility wound guide policy or nursing home policy recommendation. (b) Stage 3 and 4 wounds as ordered by medical doctor or wound care specialist.An interview was conducted with the former Wound Treatment Nurse on 3/11/26 at 1:15 PM. The Wound Treatment Nurse reported that she was not at the facility when Resident #114 was admitted to the facility. She explained that if a resident was admitted when she (Wound Treatment Nurse) was not at the facility the admitting nurse would complete a skin assessment, complete wound assessment, and implement orders from the discharge summary or standing orders and if there were no orders the admitting nurse would need to reach out to the provider to ask for wound care orders.Attempts to interview the nurse who had admitted Resident #114 to the facility on 4/24/25 were unsuccessful.An interview was conducted on 3/11/26 at 2:22 PM with the Corporate Nurse Consultant. She reported that she could not locate the orders implemented or the documentation indicating that Resident #114's sacral wound treatment was completed between 4/24/25 and 4/28/25 and so she could not say whether it was done or not and that she expected orders to have been implemented when Resident # 114 was admitted and treatment completed as ordered.During an interview on 3/11/26 at 3:45 PM with the Wound Physician Assistant (PA) he indicated that a different PA had completed Resident #114's initial wound evaluation on 4/29/25 and that he could give an overview based on the documentation. The PA reported that Resident#114's wound was evaluated weekly starting 4/29/25 by a wound provider during her stay at the facility. He stated that from the documentation in Resident #114's medical records there was no indication that the facility staff had reached out to the consulting company regarding Resident #114's wound care orders prior to the evaluation on 4/29/25. He further stated that there was no significant deterioration of Resident #114's wound when he compared the hospital wound measurements on 4/7/25 and the wound measurements completed by the former Wound PA on 4/29/25 at the facility.Resident #114's sacral wound measurements at the hospital on 4/7/25 were noted as follows: Length: 5 centimeters (cm), Width: 6 cm, Depth: 0.1 cm and size(area): 30 square centimeters.Resident #114's sacral wound measurements at the facility on 4/29/25 were noted as follows: Length: 4 centimeters (cm), Width: 8.4 cm, Depth: 0.4 cm and size(area): 33.6 square centimeters.During an interview on 3/12/26 at 12:10 PM with the Medical Director, she stated that she expected nurses to reach out to her if they did not have wound care orders in the discharge summary or if they could not use the standing orders to ensure that treatments were completed correctly. She stated that there was always a provider on call available 24 hours a day and that the nurse who admitted Resident #114 should have called when he realized the resident had a wound and there were no wound treatment orders.During an interview on 3/12/16 at 2:05 PM with the Administrator, she stated that she expected nurses to complete skin assessments on residents upon admission and contact the physician for wound care orders if there were no orders in the discharge documents or if they needed clarification.

Based on observation, record review, and resident and staff interviews, the facility failed to secure smoking materials (cigarettes/lighters) for 1 of 3 residents reviewed for smoking (Resident #47).Findings included:Review of the facility resident smoking policy effective 02/2026 revealed that all resident smoking materials are maintained in a secure area (lock box) at the nursing station when not in use.Resident #47 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) followed by hemiplegia, hemiparesis, aphasia and dysphagia, vascular dementia with mood disturbance and anxiety.The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively intact. The MDS also indicated the resident required assistance with several activities of daily living, including eating (supervision/setup), upper body dressing (dependent), and required limited to extensive assistance for other self-care activities. The MDS further indicated he was coded for tobacco use.Review of smoking evaluation dated 03/02/2026 revealed Resident #47 was an independent, safe smoker and his preference to smoke independently at the times of his choice was honored.A observation of Resident #47 on 3/10/2026 at 12:19 PM revealed Resident #47 sitting in a day room eating candy. When asked if he had any smoking materials Resident #47 nodded yes and showed a lighter and two cigarettes rolled up in the bottom of his shirt.An interview with Nurse #1 on 03/10/2026 at 12:36 PM revealed she did not give Resident #47 any smoking materials. Nurse #1 stated she did not know where the cigarettes or the lighter came from. Nurse stated that she did not know the smoking policy as this was her first time working this hall. She stated that she normally worked on a different hall that did not have smokers.An interview with Nurse #2 on 03/10/2026 at 12:40 PM revealed that she worked with Resident #47 and was aware that he did not turn his lighter in once he finished smoking. She further stated that there were no designated smoking times and the smoking residents were allowed to smoke whenever they wished. She stated that this made it difficult for nursing staff to track when residents were smoking. Nurse #2 stated that once a resident returned from smoking, the resident was supposed to give their lighter and cigarettes to his or her nurse. Nurse #2 stated that she knew that this was not the case with Resident #47 as he liked to keep his lighter since he went out so frequently. Nurse #2 stated that the smoking materials were located in a lock box behind the nurses' station that any of the nursing staff could access.In an interview with Administrator on 03/10/2026 at 12:55 PM the Administrator stated that there were three residents grandfathered in who were allowed to smoke cigarettes in the designated area on facility property. Cigarettes were kept in a locked box at nurses' station at Hall A. Nurses were supposed to confiscate lighters after a resident finished smoking. She stated that she was not aware that residents were not turning in their lighters. She stated that residents may be keeping the lighters until they finish smoking for the day. When asked for clarification on if residents should turn in lighters at the end of the day or at the end of a smoking session, she stated that residents have been allowed to make that determination. She stated that some of the residents were hardcore smokers and they go out so often it is easier for them to keep track of the lighter rather than turn it in every time.

Based on record review and interviews of the staff, a family member, and the resident, the facility failed to honor a dependent resident's preference for a shower and provided a bed bath instead (Resident #62). This deficient practice affected 1 of 3 sampled residents. Findings included: Resident #62 was admitted to the facility on [DATE] with the diagnosis of stroke. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #23 documented her cognition was moderately impaired. She was able to make herself understood and understands and had not refused care. The resident required substantial assistance for bathing, dressing, and personal care. There was a care plan dated 12/5/24 for Resident #62 that included an activities of daily living (ADL) deficit which required assistance with bathing. Resident #62's Nursing Assistant (NA) Kardex documented she was to receive showers on Wednesday and Saturday on evening shift. A review of Resident 62's ADL sheets for 11/23/24 through 12/20/24 documented the resident had a bed bath every day and had refused 2 showers. The Administrator provided the 11/23/24 through 12/20/24 activities of daily living for showers documented the list of NA signatures for Resident #62's scheduled shower dates which revealed NO, N/A (not applicable) and REFUSED on the Kardex. NA Kardex shower documentation for Resident #62 was as follows: o 11/23/24 NA #3 NO o 11/27/24 NA #6 REFUSED o 11/30/24 NA #2 NO o 12/4/24 NA #2 N/A o 12/7/24 NA #1 NO o 12/11/24 NA #8 REFUSED o 12/14 NA #2 N/A o 12/18/24 NA #2 N/A o 12/20/24 NA #2 N/A On 12/19/24 at 10:53 am Resident #62's bathing and shower record for 11/23/24 through 12/20/24 was reviewed with the Administrator. The NAs documented the showers were not done by response of NO, N/A and two refusals. On 12/16/24 at 3:01 pm an interview was conducted with Resident #62's family member. He stated the resident was mostly non-verbal but could nod her head for yes and no. He stated the resident was not getting showers 2 times a week and she wanted her showers. On 12/16/24 at 2:40 pm Resident #62 was interviewed using yes and no questions. The resident had responded with a head nod of no when asked if she had received her shower. On 12/19/24 at 9:00 am an interview was conducted with Resident #62. She answered yes/no head nod. The resident nodded that she had not received her showers. On 12/19/24 at 9:18 am Nurse #4 was interviewed. Nurse #4 stated she was not aware Resident #62 had not received her showers and she was not informed the resident had refused care. On 12/19/24 at 9:32 an interview was conducted with NA #7. NA #7 stated she was very familiar with Resident #62. The resident was scheduled twice a week Wednesday and Saturday on evening shift for her showers. The NA stated evening shift does not always provide the shower and the NA tried to fit in showers on day shift that were not completed on evening shift. The NA stated there were a couple of residents that had reported to the NA they had not received their showers on evening shift as scheduled. On 12/19/24 at 12:24 PM an interview was unsuccessful with NA #3. On 12/19/24 at 11:58 am NA #1 was interviewed. NA #1 stated she knew the resident well. The resident had already gotten a bed bath on day shift which was received in report and documented NO in the Kardex the shower was not given on evening shift. She was not aware the resident desired showers. On 12/19/24 at 12:29 pm NA #6 was interviewed. NA #6 stated she was assigned to Resident #62 on evening shift a couple of occasions. The NA asked the resident if she wanted a shower and the resident pointed to her leg and nodded her head yes to pain. NA #6 reported the resident's pain to the nurse. The resident refused once due to pain. NA #6 stated a shower would be given even if a resident had a bed bath the same day. NA #6 stated If an NA documented N/A or NO the shower was not given. On 12/19/24 at 2:40 pm NA #8 was interviewed. NA #8 stated that Resident #62 refused one shower. He also stated that he would offer a shower even if the resident had received a bed bath on the same day. Staff was required to offer. On 12/19/24 at 5:03 pm an interview was conducted with NA #2. NA #2 stated that she remembered Resident #62. She stated that if her documentation for the resident's Kardex in the kiosk was NO or N/A then the care was not provided.

Based on record review and interview of the resident and staff, the facility failed to complete and provide a written grievance when a resident reported an error on his facility trust fund account statement. This deficient practice affected 1 of 4 residents reviewed for grievances (Resident #24). Findings included: Resident #24 was admitted on [DATE] with the diagnosis of chronic obstructive pulmonary disease. On 12/16/24 at 11:05 am Resident #24 was interviewed. He stated that the facility took over $600 from his facility trust fund account without notifying him way back in April 2024. He noticed on his April 2024 statement the money was taken. The resident stated he notified the business office sometime in April 2024 of the error and he had not been reimbursed. The business office member had not completed a grievance and there was no resolution. On 12/17/24 at 10:32 am an interview was conducted with the Business Office Manager. She stated that back in April 2024 Resident #24 was billed for a second patient monthly liability for February 2024 in error. She also stated the resident reported this to the business office and a grievance was not completed and the Administrator was not notified. On 12/17/24 at 11:53 am the Administrator was interviewed. The Administrator stated she spoke to Resident #24 (12/17/24). The resident informed her money was owed to him and that he had reported the concern to the Business Office Manager months ago. The Administrator stated she spoke to the Business Office Manager and corporate to resolve the concern (12/17/24). The Administrator stated the Business Officer Manager had not completed a written grievance form when the concern was reported.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessment in the area of feeding tubes for 1 of 23 residents reviewed for MDS accuracy (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease. The quarterly MDS, dated [DATE], indicated Resident #6 was moderately cognitively impaired and had a feeding tube while at the facility. An interview was conducted with Nurse #5 on 12/17/24 at 12:12 P.M. Nurse #5 stated that Resident #6 did not have a feeding tube and had never had one while he was at the facility that she was aware of. An interview was conducted with the MDS Coordinator on 12/17/24 at 3:01 P.M. The MDS Coordinator explained Resident #6 did not have a feeding tube. She further explained the nutrition section of Resident #6's 10/15/24 quarterly MDS assessment had been completed by the Assistant Dietary Manager. An interview was conducted with the Assistant Dietary Manager on 12/18/24 at 12:15 P.M. The Assistant Dietary Manager explained she had mistakenly marked Resident #6 as having had a feeding tube on his 10/15/24 quarterly MDS assessment due to human error. An interview was conducted with the Director of Nursing (DON) on 12/19/24 at 11:55 A.M. The DON stated it was her expectation that the MDS assessment was coded accurately.

Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with newly evident mental health diagnosis for 1 of 2 sampled residents reviewed for PASRR. (Resident #3) The findings included: The North Carolina Department of Health and Human Services (NCDHHS) PASRR determination letter dated 02/01/2023 revealed a level I screen and a PASRR number that remained valid for the individual's stay and no further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis of mental illness. Resident #3 was readmitted to the facility on [DATE] with diagnoses including vascular dementia, with psychotic disturbance. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #3 coded as cognitively intact. A review of the diagnosis list revealed a diagnosis of bipolar II disorder, 04/11/2024. An interview with the Social Worker (SW) was conducted on 12/17/2024 at 10:10 AM. The SW stated he oversaw submitting PASRRs for determinations and when a resident had a new mental health diagnosis the facility submitted a PASRR application for a level II screen. Resident #3 had a new mental health diagnosis since her first determination letter and a new PASRR application was supposed to be submitted when she was diagnosed with bipolar II disorder on 04/11/2024. A PASRR level II screen should have been submitted after the new diagnosis but wasn't due to an oversite. An interview with the Administrator was conducted on 12/17/2024 at 10:38 AM. The Administrator stated Resident #3 did have a negative PASRR level I and did have new mental health diagnoses. The SW who oversaw the PASRRs should have submitted a new PASRR application at the time of a new mental health diagnoses, but it was not done. The Administrator also stated the SW will work with psych closer to get the new diagnoses as it happens so he will not miss any PASRR screenings.

Based on observation, record review, and interview of the resident and staff, the facility failed to provide a dependent resident nail care (Resident #23). This deficient practice affected 1 of 3 sampled residents. Findings included: Resident #23 was admitted to the facility on [DATE] with the diagnosis of adult failure to thrive. The care plan for Resident #23 included an activity of daily living deficit. The intervention was for staff to provide bathing, dressing, and all personal care. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #23 documented her cognition was moderately impaired. She was able to make herself understood and understands. The resident required substantial assistance for bathing, dressing, and personal care. On 12/16/24 at 12:30 pm Resident #23 was observed and interviewed. The resident was alert and able to clearly make her needs known. The resident stated she wanted her nails cleaned and trimmed; she could not do this by herself. The resident's nails were long, uneven, jagged, and had black soil underneath with more on the right hand than the left. The staff had not offered nail care, and she had not thought to ask. She has a bed bath each morning during weekdays. On 12/16/24 at 1:22 pm an observation of incontinence care with Resident #23 and NA #5 was completed. The resident had long, uneven and jagged nails with black soil underneath. A concurrent interview was completed with NA #5. She stated she was the assigned NA and was only providing incontinent care and meal set up. The NA commented that the resident's nails were cut during bathing, and the hospice NA was providing the bathing and would provide nail care. The NA observed the long, dirty nails and stated she had not offered the resident nail care today and had not known why. The NA stated she was aware the facility staff were responsible for cleaning and/or cutting the resident's nails. On 12/16/24 at 1:22 pm an interview was conducted with Nurse #2. He stated the facility NAs were responsible for nail care if the hospice NA had not provided nail care during bathing. On 12/19/24 at 11:50 am an interview was conducted with NA #7. She stated that the NAs were responsible for nail care which was completed during bathing or showers and when requested. On 12/19/24 at 1:40 pm an interview was conducted with the Administrator. The Administrator stated she was not aware Resident #23's nails needed care. The facility was responsible for nail care if not completed by hospice staff during bathing.

Based on record review and interviews of the resident, staff, and Department of Social Services, the facility failed to manage a resident's facility trust fund account when a billing discrepancy was discovered regarding the resident's patient monthly liability (PML) for February 2024. This deficient practice affected 1 of 1 resident reviewed for personal funds (Resident #24). Findings included: Resident #24 was admitted on [DATE]. Resident #24's RTF statement documented Resident #24 had a deduction from his Resident Trust Fund (RTF) for his February 2024 PML. A document from the Department of Social Services (DSS), clarified the amount due to the facility for February 2024 skilled nursing was for the full month and was not prorated, as it should have been for 2 days, starting 2/27/24. On 12/16/24 at 11:05 am Resident #24 was interviewed. He stated the facility charged over $600 from his skilled nursing facility (SNF) resident trust fund (RTF) account without notifying him back in April 2024. He noticed on his April 2024 RTF statement the money was withdrawn. The resident stated he notified the business office sometime in April 2024 of the error and he still had not been reimbursed. According to the resident, the business office member's answer repeatedly was they were working on it. On 12/17/24 at 10:32 am an interview was conducted with the Business Office Manager. The Business Office Manager stated when Resident #24 moved from adult care to SNF care nursing on 2/27/24, he was billed for the entire month of February 2024 for skilled nursing PML instead of 2 days prorated. This mistake was not identified until April 2024 when the Business Officer Manager first started the position. The corporate business office was working on correcting the mistake since it was first identified in April. The resident complained to the Business Office Manager a couple of months after April that he was due money. The resident believed he was due approximately $600 from the mistake. The error had not been corrected and the resident had still not been refunded. The Business Office Manager stated the Administrator was not made aware. The Business Officer Manager provided a copy of an email to DSS staff dated 7/18/24 requesting an answer whether the facility should take the entire month's PML for February for the SNF stay from Resident #24 starting 2/27/24 for that time or partial? The DSS staff responded the facility could bill for the SNF stay from 2/27/24 to 5/31/24. The Business Office Manager provided a copy of an email to the corporate billing office, dated 7/31/24, informing the office Resident #24's DSS case correction was completed. The corporate office could bill PML for 2/27/24 through 5/31/24 for his SNF stay. On 12/17/24 at 11:53 am the Administrator was interviewed. The Administrator stated she spoke to Resident #24 (on 12/17/24). The resident informed her money was owed to him and he had reported the concern to the Business Office Manager months ago. The Administrator stated she spoke to the Business Office Manager and corporate today (12/17/24). The facility was communicating via email regarding the billing discrepancy and money due to the resident but had not acted upon the reimbursement. The Administrator stated she was not aware the resident was owed money. On 12/17/24 at 1:08 pm a second interview was conducted with the Business Office Manager. The Business Office Manager stated after review of the documentation of Resident #24's billing discrepancy, it was identified the resident had 2 days in skilled nursing February 2024 and DSS allowed charges for an entire month, not prorated. DSS provided documentation for the facility to charge for the entire month of February which was not discovered until 5/24/24. DSS was asked to correct their documentation for the facility to bill correctly for February on 12/17/24. The resident was owed approximately $700. The Business Office Manager stated she had not remembered the last date she had spoken to DSS to correct the billing so the facility could release the funds they were holding before today (12/17/24). On 12/17/24 at 3:20 pm a phone interview was conducted with DSS Staff. DSS staff stated she was called today (12/17/24) by the facility Business Office Manager regarding Resident #24's PML for 2 days in February 2024 that he was charged for an entire month. The DSS staff member did not remember communicating on 7/31/24 with the facility Business Officer Manager regarding the PML that was coded for the full month when the timeframe was for 2 days. The DSS staff stated she reviewed her records and found that the State Office decided the PML to be billed for the full month amount. The DSS staff stated normally the amount would be prorated to the actual number of days. The DSS staff had not known why the PML came back as a full month and commented that her supervisor reviewed her work and approved of this amount before it was submitted to the facility. She further stated she could not pro-rate the days on her end, the supervisor would need to address this. On 12/17/24 at 3:30 pm an interview was conducted with the DSS Supervisor. She stated today (12/17/24) was the first time she was made aware by her staff that Resident #24 was charged PML for a full month instead of 2 days for February 2024. She further stated she was not aware and had not remembered the 7/31/24 email to her staff regarding the question from the facility Business Office Manager about the PML charges and that DSS staff was made aware of the mistake. The DSS Supervisor stated she would submit to zero out the PML for 2 days and if the system would not allow the change due to the age of several months, a correction by the State Office would be requested. She stated the paperwork was initiated today (12/17/24) and would be provided to the facility to reimburse the resident.

Based on record review and resident, staff, and Nurse Practitioner and Physician interviews the facility failed to provide services for two of three sampled residents (Resident #3 and Resident #5) with a urinary catheter or symptoms of urinary tract infection. For Resident #3 the facility failed to 1) assure an accurate monitoring of his output after a newly placed catheter per the plan of care 2) assure that nursing staff communicated about problems the resident was having with the catheter and 3) clarify with the physician and urologist what measures should be taken if the catheter became occluded or leaking when they became aware Resident #3 had the catheter and was experiencing these problems. For Resident #5 the facility failed to 1) obtain a urine specimen until two days after it was ordered and 2) communicate urinalysis results to the Physician or Nurse Practitioner so an evaluation for possible treatment could be done. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Resident #3's diagnoses included in part Parkinsons disease, benign prostrate hypertrophy with a history of urinary retention and a history of TURP (transurethral resection of the prostate- a surgery where part of an enlarged prostate is removed.) Resident #3's annual Minimum Data Set (MDS) assessment, dated 5/31/23, coded Resident #3 as cognitively intact. The resident was also coded as needing supervision for hygiene and occasionally incontinent of bladder. Resident #3's care plan, last reviewed on 8/2/23, included the information that Resident #3 was at risk for UTI due to having a history of recurrent indwelling urinary catheter use and a history of ESBL (Extended Spectrum Beta-Lactamase-which are enzymes produced by some bacteria that make them resistant to antibiotics). This had been added to Resident #3's care plan on 1/8/20 and remained part of his active care plan. One of the interventions was to monitor Resident #3's output per the facility's policy. According to hospital records and urology notes, Resident #3 was hospitalized from 6/11/23 to 6/13/23 after experiencing suprapubic pain and dysuria (painful urination). A bladder scan upon admission showed he had greater than 500 ml (milliliters) in his bladder and a urinary catheter was inserted for retention. He was evaluated by a hospital infectious disease physician and treated with intravenous fluids and antibiotics. Prior to his discharge on 6/13/23, he was able to successfully void without the urinary catheter, and he was discharged back to the facility with instructions for a urology follow up. According to the Urologist's 7/6/23, After Visit Summary, Resident # 3 was noted to have BPH (an enlarged prostate) with obstruction/lower urinary tract symptoms; urinary retention due to BPH, and recurrent UTI. The summary also noted he was to take an antibiotic for seven days and follow up with the urologist in about 4 weeks around 8/3/23. There were no directions on the Urology summary regarding measures to take if the urinary catheter began to leak or became occluded. On 7/6/23 at 1:32 PM the Unit Nurse Manager made the following notation in the nursing notes. Resident #3 had gone to his urology appointment and returned with a 16 French/ 10 cc indwelling urinary catheter draining clear amber colored urine into a leg bag. The resident also had orders for Flomax 0.4 mg (milligrams) to be administered at bedtime. From 7/6/23 through 7/18/23 there were no recorded urine output measurements for Resident #3 per the plan of care. The Director of Nursing (DON) was interviewed on 8/24/23 at 10:25 AM and reported that per policy residents with new catheters were to have output measured for the first 30 days after insertion. On 7/18/23 at 10:25 PM Nurse #2 documented in Resident #3's Medication Administration Record that she had administered Oxycodone 5 mg (milligrams) per a PRN (as needed order) for pain. On 7/19/23 at 1:47 AM Nurse #2 entered the following information into Resident #3's nursing notes. Resident #3 was complaining of abdominal pain and the pain medication had only been effective for a short while. He was insisting on going to the hospital, had approximately 250 ml of dark urine in his urinary catheter bag, and had positive bowel sounds in all four abdominal quadrants. Nurse #2 further noted his abdomen was soft with some tenderness around his umbilicus. The physician was contacted, and orders received to send the resident to the hospital. Nurse #2 was interviewed on 8/22/23 at 11:08 AM and reported the following. She had started caring for Resident # 3 on 7/18/23 at 7:00 PM. That night he complained of discomfort in his belly. He also reported he could not pee. The Nurse Aide had reported that he had urine output during the day. She had thought the problem could possibly be related to his bowels but was more focused on his bladder being the issue. She did change the urinary drainage bag at 7:00 PM on 7/18/23 so she could determine if any urine was coming out. He did have 250 cc of dark yellow urine before she sent him to the hospital. She had encouraged him to drink fluids, and she thought he drank approximately 32 oz of fluid prior to going out to the hospital. She palpated his bladder, and it was not distended before she sent him out. He seemed to have some relief at intervals prior to being sent out and was not hurting the entire time. Resident #3 was interviewed on 8/22/23 at 2:30 PM and reported the following about the dates of 7/18/23 and 7/19/23. Around 3:00 PM on 7/18/23 they had changed his urinary drainage bag. That evening around 6:00 PM he noticed he was having pain over his bladder. He talked to Nurse #2 who felt of his abdomen and thought it might be related to his bowels. She also encouraged him to drink fluids, and she gave him something for pain. He drank two 500 ml water bottles that evening, but then stopped because the pain was getting much worse and nothing was going into the urinary bag any longer after 7:00 PM that night. He felt the catheter had failed. Finally, he could not take the pain anymore and they sent him to the hospital around midnight. Once they changed the catheter at the hospital, he got relief. According to Resident #3's hospital ED (Emergency Department) notes, dated 7/19/23, Resident #3 arrived at the hospital at 2:44 AM on 7/19/23 and the urinary catheter was able to be replaced by a nurse. The ED physician specifically noted the following in the ED notes. At 4:15 AM he evaluated Resident #3, and the resident was complaining of suprapubic pain and bladder fullness since his catheter bag had been changed around 3:00 PM the previous day. There was 100 ml of urine in his urinary bag. At 4:16 AM the physician talked to the nurse who reported Resident #3's bladder scan showed he had greater than 1275 ml of urine in his bladder. At 4:26 AM the physician noted Resident #3 had a firm mass consistent with a distended bladder palpated to his umbilicus. His plan was to have the urinary catheter replaced and labs completed. At 4:41 AM the physician noted the hospital nurse had successfully replaced the urinary catheter and there was approximately 1400 ml of urine in the urinary drainage bag after replacement of the catheter. The physician further noted the suprapubic pain had resolved. Resident #3 was discharged on [DATE] from the hospital ED at 11:38 AM with instructions to follow up with his physician. He was placed on an antibiotic and also instructed to follow up with urology in two weeks. On 7/19/23 Resident #3 returned to the facility and orders were entered for the first time into the electronic record for the Resident to have a 16 French 10 cc balloon indwelling urinary catheter. The bag was to be replaced every two weeks. There was no indication in the record that it was confirmed if the catheter could be replaced or measures to take if it became obstructed again or was found to be leaking. Beginning on 7/19/23 urine output started to be recorded every shift in Resident #3's record. For the date of 8/1/23, there was no urine output recorded. Resident #3 was interviewed on 8/22/23 at 2:30 PM and reported the following. On 8/1/23 he had an appointment for a diagnostic test (a magnetic resonance imaging-MRI) not related to his catheter that morning. He was accompanied by a friend. The appointment was out of town. On the way, he noted there was nothing draining in his urinary bag and mentioned it to the friend who indicated that they would be back at the facility around 1:00 PM to have it checked. When he arrived for his MRI and laid down, suddenly a lot of urine came around his catheter tubing and the staff had to clean the floor and MRI table because of the amount of urine. His RP was made aware of the problem and called before he went back to the facility, to alert the facility staff that there had been problems with his catheter again. He thought that once he arrived back at the facility, someone would check it and make sure things were taken care of. He arrived back at 3:00 PM on 8/1/23, and no one came to check his catheter. The friend, who had accompanied him, also spoke to someone at the nursing desk about him needing to be checked. He laid down because he was in pain again. No one came to check about his catheter until around 6:00 PM that night. He thought the Unit Manager would come and check on his catheter, but she did not do so, and he had been upset about that. Resident #3's RP was interviewed on 8/23/23 at 10:11 AM and reported the following. She felt the staff were not caring for the urinary catheter correctly, and he had experienced problems with it. The date of 8/1/23 was in particular a problem, as he started to have problems early in the morning with the catheter not draining correctly. The friend, who had accompanied Resident #3 on 8/1/23 to the MRI visit, was interviewed on 8/23/23 at 10:10 AM and reported the following. He recalled that when he was driving Resident #3 to his out- of- town appointment on the morning of 8/1/23, that Resident # 3 commented there was nothing in his urinary drainage bag. When they arrived, the MRI staff checked it for kinks but could do nothing further. Following the MRI test, the MRI staff had let the friend know that his bladder had released from around the catheter tubing while he was on the MRI table and urine had gone everywhere. When they returned to the facility, he signed Resident #3 back in at the nursing desk and let the person at the desk know that he was having trouble with the urinary catheter tubing. Resident #3's RP had already called them before they arrived back to alert them to a problem. He stayed for about 30 minutes before having to leave. No one came to check on Resident #3 during that timeframe. On 8/23/23 the Unit Manger provided a written statement regarding the events of 8/1/23. The statement in part read, I spoke to [Resident #3's] RP via telephone regarding MRI appointment on 8/1/23. Per RP, {Resident #3} was placed into MRI machine for procedure when staff noticed large amount of urine leaking from Foley catheter insertion site. RP states staff (from the MRI) informed him that catheter was checked and was noted to be sealed and intact, no urine output was observed in bag possibly due to it being clogged. MRI machine cleaned and test completed. The Unit Manger was interviewed on 8/22/23 at 4:00 PM and reported she did go to speak to Resident #3 after he returned and before she left on 8/1/23. The Unit Manager reported Resident #3 was upset with her and did not want to talk to her at the time. She did not check his urinary catheter. NA #1 was interviewed on 8/24/23 at 9:15 AM and reported the following. NA #1 had cared for Resident #3 between the hours of 3:00 PM to 7:00 PM on 8/1/23. She had been working on another unit that day up until 3 PM. She arrived on Resident #3's unit around 3:15 PM on 8/1/23 and he was already back from his appointment. She looked in and waved to him. He was on the phone at that time, and she did not disturb him. That was her first time caring for Resident #3. Around 5:00 PM, Nurse #3 told her that Resident #3 had soiled himself with stool and needed to be cleaned. She went immediately. He was having some diarrhea and she cleaned him. He told her his catheter was hurting really bad. He was in tears. He wanted to talk to the Unit Manager. She could not find the Unit Manager. Resident #3 then asked to speak to a nurse that was on another hall (Nurse #4). She went to speak to Nurse #4 who told her that Nurse #3 was Resident #3's nurse. She went back to Nurse # 3 and told her about Resident # 3's complaints. She knew Nurse #3 went in to see Resident # 3, but she did not know what all she did. Around dinner time Resident #3 seemed better. She checked him at 6:45 PM before she left, and he was asleep. NA #2, who had cared for Resident # 3 from 7 PM to his transfer to the hospital on 8/1/23, was interviewed on 8/24/23 at 4:55 PM and reported the following. She was aware Resident #3's catheter was not right that night and that it was leaking. She did not recall if he was in pain. She knew that Nurse #3 knew about the issue and the resident talked to the nurse. Nurse #3 was interviewed on 8/23/23 at 11:36 PM and reported the following. She got to work a little after 3:00 PM that day. No one reported anything to her in report about Resident #3 having problems with his catheter earlier that morning while he was at the MRI. She also did not know he had gone to the hospital on 7/19/23 with an occlusion of his catheter. If she had known this information, she would have told the NA to note exactly the fluids he was taking in and she would have made more frequent checks to see his output compared to his intake. She recalled that around 5:00 PM, Resident #3 wanted something for constipation, and she administered his medication. At that time, he did not mention problems with the catheter. Later in the evening, she had to administer medications at different times to him so as to spread his medications apart. At some point, he mentioned to her that he thought his catheter was kinked. She looked at the catheter and there was 150 cc in the urinary drainage bag. His abdomen was not distended. She readjusted the strap. He did mention that if he did not make urine, he wanted to be sent out. Sometime around 9:00 PM, she went to give his medications and he was talking on the phone with his RP. The RP wanted to talk to her. She spoke to the RP who informed her that she wanted Resident #3 sent out for not having urine output. The nurse then let her know she would get the paperwork ready. She called the physician and had the resident sent out. On 8/1/23 at 11:30 PM Nurse #3 entered the following notation into Resident #3's nursing notes. Writer went into resident's room to give medication. Resident was on the phone speaking with [RP}, who requested to speak with writer. Writer explained to RP resident has requested to go to ER if he does not produce urine within a certain amount of time. [RP (Responsible Party)} stated she wanted him to go to the ER (emergency room ) as well if he does not urinate. Resident did not produce urine and was encouraged to drink fluids. Writer did call EMS they arrived at 11:14 PM. RP was called and made aware. Review of hospital ED notes revealed Resident #3 had been sent to the ED on 8/1/23 and was there for 12 hours. The ED physician noted Resident # 3 had reported his catheter had not been draining all day, and he was having abdominal pressure. The catheter was exchanged for a new one and drained 1150 ml of urine. He was discharged on [DATE] at 12:31 PM with instructions to follow up with his physician. According to the facility record, Resident # 3 returned to the facility on [DATE]. Review of Resident # 3's Medication Administration Record revealed output monitoring resumed on 8/2/23. Review of a renal ultrasound study, dated 8/4/23, revealed a renal ultrasound was completed on 8/4/23. Review of a urology office visit note, dated 8/9/23, revealed the Urologist saw the resident that day and discussed possible suprapubic catheter placement in future. The Urologist noted she advised Resident #3 he would have to have a negative urine culture prior to a suprapubic catheter being placed. The resident was to continue an antibiotic for 30 days and follow up with the Urologist on 8/31/23 or sooner if problems. Resident #3 was interviewed on 8/22/23 at 2:30 PM and reported the following. During the 8/9/23 urology visit, the Urologist talked to him about having a suprapubic catheter inserted, but the Urologist wanted him to clear a urinary tract infection prior to the procedure being done. Therefore, as of 8/22/23 he continued with the urinary catheter that had been inserted on 8/1/23 and antibiotics. On 8/23/23 at 11:30 PM Nurse #5 documented the following in a nursing note. Resident #5 was complaining of lower abdominal pain, discomfort, pressure, and retaining urine. The nurse noted the following outputs. 3:30 PM -500 ml, 6:00 PM 300 ml, 11:30 PM 100 ml. The nurse further noted she called the on- call provider at 11:45 PM and one of the orders she received was to replace the urinary catheter. The nurse further noted she changed the urinary catheter without difficulty and the volume of residual urine was 500 ml. The Medical Director, who serves as the Resident #3's physician, was interviewed on 8/24/23 at 3:30 PM about the lack of orders in the record for measures to take when the catheter was occluded or leaking given that it had been replaced by a hospital nurse on 7/19/23. The physician reported the following. Typically, with new catheters she wanted the Urologist to be consulted when it needed to be replaced or the resident sent to the emergency department. Given that he had been to the hospital twice with an occlusion/leaking and the facility staff had successfully replaced it after an on- call provider's order on 8/23/23, then she felt the Urologist needed to be consulted and a plan made regarding what to do when it occluded. The Physician reported that at times a catheter can be irrigated rather than replaced and it could be confirmed if that would be an option for Resident # 3. The Physician stated she would clarify that with the urologist. The Physician also reported that every time a catheter is reinserted then there is the potential to introduce bacteria into the bladder. The Physician also reported that if there was build up of urine in the bladder it could potentially cause problems with a resident's ureters, but she was not aware of any harm he had experienced when it had occluded thus far. The facility Nurse Consultant, DON, and Administrator were interviewed on 8/24/23 at 5 PM. The Nurse Consultant reported that on 8/24/23 they had consulted with Resident #3's Urologist that day and received directions that if Resident #3 experienced occlusion problems when the Urology office was open, they were to send the resident there. If the office was closed, then facility staff could try to reinsert the urinary catheter and if unsuccessful then they could send the resident to the hospital. According to the Nurse Consultant, the staff had not been recording Resident #3's specific output from the dates of 7/6/23 through 7/18/23, but they had been monitoring it. The DON had spoken to staff on 8/24/23 to try to recall the output Resident # 3 had between 7/6/23 and 7/18/23 and although not specific, the staff felt the resident was having sufficient output up until 7/18/23 when the urinary catheter occluded. 2. Resident #5 was admitted to the facility on [DATE]. Resident # 5's diagnoses in part included Alzheimer's disease. Resident #5's annual MDS (Minimum Data Set) assessment, dated 8/7/23, coded Resident # 5 as cognitively intact. The resident was also assessed to always be incontinent of urine. On 8/14/23 at 3:59 PM the Unit Manger entered a nursing note noting the following. Resident #5 had been seen by the medical provider due to complaints of burning and discomfort. Orders were given to obtain a urinalysis. On 8/14/23 an order was entered into the electronic record for a urinalysis. Review of documented temperature readings for Resident # 5 between the dates of 8/14/23 and 8/22/23 revealed Resident # 5 was afebrile. The Unit Manger was interviewed on 8/23/23 at 3:05 PM and reported the following. She was unsure what had happened to delay the collection of the urine and the reporting of the results. She had reviewed the MAR (Medication Administration Record) on 8/23/23 and noted Nurse #6 had checked on the MAR that the urine specimen had been collected on 8/14/23 (the day it had been ordered). Nurse #6 was interviewed on 8/24/23 at 9:30 AM and reported the following. She recalled there was something in report about a urine specimen for Resident # 5 one day, but she did not recall it coming up in report that she needed to obtain one, and she had not done so on 8/14/23. She did not recall that she had signed that she had collected a urine specimen on 8/14/23. Two days later, on 8/16/23 at 2:51 PM, Nurse # 2 made a nursing note that she had obtained the urine specimen by performing a straight catheterization. The specimen had a large amount of sediment with a foul odor. The specimen was placed in the refrigerator for lab pick up. Nurse # 2 was interviewed on 8/23/23 at 12:40 PM and reported the following. She had worked with Resident # 5 on 8/14/23 and did not know the resident needed a urine specimen or she would have gotten one. The resident was not difficult to catheterize. She learned about the need for the urine specimen on 8/16/23 and obtained it. A review of labs revealed the 8/17/23 urinalysis was negative for nitrates. It had 4+ bacteria and to numerous to count white blood cells. The culture showed greater than 100,00 colonies of mixed gram- negative rods. There was no predominant microorganism present. The lab report noted, Recollection is suggested if clinically indicated. Between the dates of 8/17/23 and 8/22/23 there was not a notation about follow up regarding the lab or symptoms Resident # 5 was experiencing or that the NP or physician were notified. Resident #5 was interviewed on 8/22/23 at 10:05 AM and reported the following. She had been experiencing urinary burning since the previous Monday (8/14/23) and told the staff about the problem. The staff had collected a urine specimen on 8/16/23. She had never heard anything further after they collected the urine. She was continuing to have urinary burning, and she felt she had a urinary tract infection. On 8/22/23 at 10:12 AM Nurse # 4 was interviewed about Resident # 5's complaints and lack of follow up. Nurse # 4, who was assigned to Resident # 5, was observed to go and find the urine specimen results and stated he would see that there was follow up. On 8/22/23 at 11:57 AM the Unit Manager documented the following in the nursing notes. Results of the urinalysis and culture were called into the Nurse Practitioner. The NP was informed Resident #5 was still complaining of dysuria. The NP gave orders to start Resident #5 on Bactrim DS 800-160 mg (milligrams) daily for five days. The DON (Director of Nursing) was interviewed on 8/23/23 at 5:20 PM and reported the following. She had not been aware there was a delay in getting a urine specimen for Resident #5 or following up about the results. She did not know why it had occurred. It was the facility's procedure to collect the urine specimen on the day it was ordered. The specimen then was placed in the refrigerator where their lab, which came daily, then picked the specimen up. If the urine specimen needed to be picked up sooner than when the lab arrived for the daily pick up, then the lab could be called, and they would come pick up the specimen earlier. Once the results were returned, there was to be follow up with the provider. The Nurse Practitioner (NP) was interviewed on 8/23/23 at 3:00 PM and reported the following. The first time the urine result was brought to her attention was on 8/22/23, and she was in the facility two to three times per week. She had not been aware the urine specimen was not done until two days after she ordered it to be done.

Based on record review, family Interview, and staff interview, the facility failed to assure a resident they discharged to another facility 1) was transitioned to the receiving facility with orders and 2) the receiving facility knew the specific date the resident was coming in order that a room be prepared for the resident. This was for one (Resident # 7) of one resident reviewed for discharge planning. The findings included: Resident # 7 was admitted to the facility on [DATE]. The resident's diagnoses in part included Alzheimer's disease. Resident # 7's quarterly MDS (Minimum Data Set) assessment, dated 7/26/23 coded Resident # 7 as severely cognitively impaired. She also required assistance with her activities of daily living. On 8/22/23 at 10:35 AM Resident # 7's family member was observed to be at the resident's bedside and voiced she had requested Resident # 7 be transferred to another facility (Facility # 2). According to the family member, everything about the transfer had been approved and Resident # 7 was planning to discharge that day (8/22/23) from Facility # 1. She and Resident # 7 were just waiting at that time for the actual transfer to take place. On 8/22/23 at 11:36 AM a progress note was entered into Resident # 7's record noting the resident was transferred to another facility that shift and had departed Facility # 1 by way of Facility # 1's transport system. During a follow up interview with Resident # 7's family member via phone on 8/24/23 at 10:53 AM the family member reported the transition to Facility # 2 had not gone smoothly as she had thought it would. The family member reported the following events. On 8/21/23 she had received a phone call from Facility # 1's Unit Manager asking if she still wanted Resident # 7 moved. She had let the Unit Manager know she did, but it was her understanding that all had not been finalized. She reported she was confused. She explained when she arrived at Facility # 1 on 8/22/23 the Unit Manger asked the family member what time she wanted Resident # 7 to transfer. The family member had informed them that she was waiting on Facility # 1's staff to let her know that. Facility # 1's Social Worker informed her the facility's transporter could take Resident # 7 in their van. Therefore, she thought everything had been worked out with Facility # 2 and asked if 11:00 AM would work. When Facility # 1's staff came to transport Resident # 7, she thought all the paperwork had been sent to Facility # 2 and that Facility # 2 knew Resident # 7 was coming. Before leaving, the Unit Manager gave her Resident # 7's medications, and she followed the van to Facility # 2 where she found Facility # 2 did not know the resident was coming and they had no paperwork for her. They placed Resident # 7 in an activity room for a short period until they could get paperwork and a room cleaned for her. Facility # 2's Admission Coordinator was interviewed via phone on 8/23/23 at 10:30 AM and reported the following. Facility # 1 and Facility # 2 were sister facilities (owned by the same corporation), and Facility # 2 had been talking to Facility # 1 about accepting Resident # 7 as an admission when a bed became available. On 8/21/23 she had talked to Facility # 1's Social Worker and informed him that a bed had become available. Facility # 1's SW told her that he would get the paperwork to her. No date of transfer was ever confirmed. On 8/22/23 Resident # 7 arrived at Facility # 2 without her knowing about it. There were no orders accompanying Resident # 7, and the room that had become available had not yet been cleaned. It took Facility # 2 about 30 to 45 minutes to deep clean the room, and then they placed Resident # 7 in her new room. They also contacted Facility # 1 and obtained Resident # 7's orders. She indicated that did not take very long. On 8/23/23 at 3:05 PM Facility # 1's Unit Manager was interviewed and reported the following. The week prior to Resident # 7's discharge, there had been a discussion about Resident # 7 being discharged to another facility. On 8/21/23 Resident # 7's family member informed her that Resident # 7 was going to Facility # 2, and she would like for the transfer to take place on 8/22/23. She confirmed with Resident # 7's Responsible Party (RP) that he also wanted this. She (the Unit Manager) explained medications to the family member and the family member signed for the medications. The Social Worker usually went through discharge paperwork with residents before they leave, and therefore she thought he (the Social Worker) had done so and everything had been done correctly. Facility # 1's Social Worker was interviewed on 8/23/23 at 1:05 PM and reported the following information. Resident # 7's RP (Responsible Party) on record was Resident # 7's husband, but the RP always deferred to the family member for decision making about Resident # 7's care. While Resident # 7 had resided at Facility # 1, Resident # 7 was also followed by hospice services, which were provided by their corporation's hospice provider. The hospice Social Worker had alerted him on 8/18/23 that Resident # 7's family member wanted her transferred to Facility # 2. He had talked to Facility # 1's Business Office Manager, who had alerted him that there were no open beds at Facility # 2. Then on 8/21/23 he received a call from the hospice Social Worker asking if they could move forward with Resident # 7's discharge to Facility # 2. The hospice Social Worker let him know at that time Facility # 2 had a bed open. He informed the hospice Social Worker they could move forward. Later that day (8/21/23) he received a phone call from the Admissions Coordinator at Facility # 2 letting him also know they had a bed which just came available. No definite plans were made at that time for a specific transfer time. On 8/21/23 he talked to the Unit Manger at Facility # 1, who let him know the family member would like Resident # 7 transferred on 8/22/23. The next morning before he arrived at work, he received a text message from the hospice Social Worker asking what time Resident # 7 was going to transfer. He interpreted that was a go. During the morning clinical meeting on 8/22/23 he was informed by the Administrator to ask Facility # 1's transport staff member when they could transport Resident # 7. The physician was scheduled to be at the facility that morning (8/22/23) but did not come till later that day. The plan had been for the physician to sign all the paperwork when she arrived the morning of 8/22/23, but that had not happened. He had not realized that Resident # 7's paperwork had not been signed by the physician and sent to Facility # 2 until after Resident # 7 was sent. At around 11:46 AM on 8/22/23, he received a phone call from Facility # 2's Admission's Coordinator letting him know they had no paperwork and they had not realized she was coming. He immediately went to medical records and Resident # 7's order summary and other paperwork was sent at that time. They used the orders they had on file for Resident # 7. When the physician arrived shortly thereafter on 8/22/23, she signed the paperwork and did not change any of Resident # 7's orders. Therefore, there had been no problems with the orders which had been sent to Facility # 2 being inaccurate since the physician did not change anything. On 8/23/23 at 5:25 PM Facility # 1's Administrator was interviewed and reported the following. Prior to Resident # 7 leaving on 8/22/23, she thought everything had been in place for Resident # 7 to discharge with appropriate paperwork and notification to Facility # 2.

Based on observation, record review, resident and staff interview the facility failed to ensure double portions were provided as ordered by the physician for 1 of 1 resident reviewed for nutrition (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnosis including diabetes and renal failure. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact and was able to communicate needs. The resident was on a regular diet. A review of the diet order dated 11/03/2022 revealed a regular order with double portions. A review of the dietary menu for the week of 06/11/2023 revealed Resident #1 was to receive a regular diet with double portions. The 06/14/2023, planned lunch menu listed 2 cups of cheese ravioli with marinara sauce, 2 cups of Caesar salad, 1 cup mandarin oranges, 1 dinner roll, sweet tea, and water. During an observation of the lunch meal on 06/14/2023 at 12:14 PM, revealed Resident #1 received 1 cup of cheese ravioli with marinara sauce, 2 cups of Caesar salad, 1 cup mandarin oranges, 1 dinner roll, sweet tea, and water. An interview with Resident #1 was conducted on 06/14/2023 at 12:15 PM. The resident stated he was not surprised that they gave him the wrong portions and had not noticed the portions were not doubled. An interview with the Dietary Manager (DM) was conducted on 06/14/2023 at 12:22 PM. The DM entered the resident's room and stated Resident #1 was supposed to receive double portions of his entrees and there was only one portion on the resident's plate. The double portion was missed due to an oversite in the kitchen, during the tray line and she will get him another portion right away. A telephone interview with the Registered Dietician (RD) was conducted on 06/14/2023 at 2:37 PM. The RD stated Resident #1 did have an order for double portions for entrees and expected the facility staff ensured he received the correct order. The RD also stated the resident did not have any weight loss since returning to the facility in April 2023 and was ordered double portions of entrees due to his request. An interview with the Director of Nursing was conducted on 06/14/2023 at 2:44 PM. The DON stated Resident #1 was supposed to receive double portions for his entrees and it was missed in the kitchen. The DON also stated the resident is very hands on with his care and the staff usually double checks his meal trays, but it was an oversite.

Based on observation and staff interview the facility 1) failed to implement their policy for transmission-based precautions when Resident #8 presented with fever and cough and 2) perform hand hygiene during meal delivery and set up which required a Nurse Aide to position residents or their personal belongings on 1 of 2 units. The findings included: Review of the facility's policy, entitled 2022 COVID-19 Response Program revealed the policy originated on 10/2022 and was last reviewed in 4/2023. The policy noted it referenced the CDC's (Centers for Disease Control) recommendations in their policy. The policy directed that health care personnel should initiate transmission- based precautions when there is suspected or confirmed COVID 19 (Coronavirus Disease). 1. Resident # 8 was admitted to the facility on [DATE]. Resident # 8's diagnoses included in part cancer and epilepsy. Resident # 8's quarterly MDS (Minimum Data Set) assessment, dated 12/22/22, coded the resident as cognitively impaired and as not moving around or off the unit on which he resided during the assessment period. On 3/1/23 at 4:09 PM Nurse # 1 made an entry noting the following. Nurse called to resident's room per family request to get his temperature which was 99.7. Resident also noted to have congested non-productive cough. VS (vital signs) 129/87, p (pulse)84- R (Respirations) 18, O2-93% on RA (room air). There was no documentation that Resident # 8 was placed on transmission- based precautions when he started showing signs of a cough and fever. Nursing notes on 3/2/23 at 3:15 PM revealed Resident # 8 was transferred to the hospital on 3/2/23 when he had a change in responsiveness. Hospital records revealed Resident # 8 was evaluated in the hospital on 3/2/23 and found to be COVID positive. Nurse # 1 was interviewed on 4/25/23 at 2:44 PM and again on 4/26/23 at 3:20 PM and reported the following. Resident # 8's family was concerned about Resident # 8 on 3/1/23 because of a cough and low- grade fever. While in the room assessing Resident # 8, she also heard the resident cough, and the resident had a low- grade fever. She had not suspected that Resident # 8 had COVID and did not initiate transmission- based precautions. The facility's DON (Director of Nursing) was interviewed on 4/25/23 at 2:10 PM and 4 PM and again on 4/26/23 at 1:20 PM. The DON reported the following. Testing for other residents and staff had begun on 3/3/23 and transmission- based precautions were put in place on that date for those residents who tested positive. The facility had been able to contain the virus from spreading to their other wing. 2. Meal observations were made on the long -term care wing beginning on 4/26/23 at 12:10 PM and ending at 12:22 PM. Nurse Aide (NA) #1 was observed as he delivered meal trays to residents who were in their rooms. Between the time of 12:10 PM and 12:22 PM, the following was observed. NA # 1 was observed to obtain the meal tray for Resident # 16 and set up the meal tray for Resident # 16 in her room. In doing so, he handled personal items in her room. He then went to the meal cart, obtained Resident # 15's tray and set her meal tray up. NA # 1 then went back to the meal cart, obtained Resident # 17's meal tray. He set up Resident # 17's meal tray. He then helped Resident # 17 to begin eating by placing the spoon in her hand. He then guided her hand and spoon to her mouth several times to encourage her to begin eating. He then went back to the meal cart and obtained Resident # 19's meal tray, assisted her to sit up on the side of the bed and set her meal tray up. He then went back to the meal cart and obtained Resident # 18's meal tray and set her meal tray up for her. He then went to the meal cart and obtained Resident # 21's meal tray, took it to his room, assisted him to sit up and position in bed to eat, and then set his meal tray up. He then went back to the meal cart, obtained Resident # 20's meal tray, and set it up for Resident # 20. Between assisting these residents and going back and forth to the meal cart, NA # 1 did not perform any hand hygiene. It was observed that there were multiple hand sanitizing dispensers on the hallway between the rooms where the residents were served. NA # 1 was interviewed on 4/26/23 at 12:38 PM about the lack of hand hygiene as he was assisting with meal set up between multiple residents, which required him to help position some of them or touch their personal items. NA # 1 acknowledged he had not performed hand hygiene and apologized. NA # 1 reported he needed to get used to doing that. The DON was interviewed on 4/26/23 at 1:20 PM and validated Nurse Aides should be performing hand hygiene between resident contacts. The DON stated the reason the hand sanitizer was on the hallway walls was so the staff would use it.

Based on staff, family, and physician interviews, and record review the facility failed to implement their policy for COVID-19 testing when 1 of 1 sampled resident (Residents # 8) presented with symptoms consistent with possible COVID-19 on 3/1/23 and did not initiate testing of other residents and staff who had been exposed to Resident #8 on 3/1/23 until 3/3/23. On 3/3/23 when testing occurred, twelve residents and three staff members tested COVID positive. The outbreak was contained to one of two facility skilled nursing wings. Findings included: Review of the facility's policy, entitled 2022 COVID-19 Response Program revealed the policy originated on 10/2022 and was last reviewed in 4/2023. The policy noted it referenced the CDC's (Centers for Disease Control) recommendations in their policy. The policy directed that anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. The policy also noted the facility should perform testing for all residents and health care personnel identified as close contacts or on the affected unit if using a broad-based approach regardless of vaccination status. The testing was recommended to start immediately (but not earlier than 24 hours after the exposure). Resident # 8 was admitted to the facility on [DATE]. Resident # 8's diagnoses included in part cancer and epilepsy. Resident # 8's quarterly Minimum Data Set (MDS) assessment, dated 12/22/22, coded the resident as cognitively impaired and as not moving around or off the unit on which he resided during the assessment period. A review of activity notes revealed Resident# 8 was one of thirteen residents who attended Bingo at 2:00 PM on 3/1/23. On 3/1/23 at 4:09 PM Nurse # 1 made an entry noting the following. Nurse called to resident's room per family request to get his temperature which was 99.7. Resident also noted to have congested non-productive cough. (Physician) notified of resident's condition. Chest x-ray suggested by nurse, but MD gave order for Mucinex 600 mg (milligrams) BID (twice per day) x 2 weeks instead because of no history of PNA (pneumonia) or COPD (chronic obstructive pulmonary disease). Resident given 1 dose of Tylenol 1000 mg (milligrams) for fever and standing order of 15 ml (milliliters) Robitussin for cough and tolerated well. Will continue to provide care. VS (vital signs) 129/87, p (pulse)84- R (Respirations) 18, O2-93% on RA (room air). Nurse # 1 was interviewed on 4/25/23 at 2:44 PM and again on 4/26/23 at 3:20 PM and reported the following. Resident # 8's family was concerned about Resident # 8 on 3/1/23 because of a cough and low-grade fever. While in the room assessing Resident # 8, she heard the resident cough one time, and it was like a cold cough; but not severe. When Resident # 8 had coughed, he sounded congested. She had called the on- call physician and let the physician know the family was concerned, she also heard the resident cough, and the resident had a low-grade fever. Nurse # 1 had also asked the physician if they could get an x-ray, but at that time the physician did not want to do one. When Resident # 1 started with the cough, there had been no COVID cases in the facility for a very long time. There were supplies to test for COVID in the facility, but she had not thought to perform one or ask the physician about one. In retrospect she felt she should have done so. On 3/2/23 at 3:15 PM Nurse # 2 made an entry noting the following information. She had been summoned to Resident # 8's room due to the resident being nonresponsive. The resident's eyes were closed, his skin warm and dry and his respirations even and unlabored. The resident's oxygen saturation was 78-80% on room air. The resident was provided with oxygen. The resident's physician was in the facility and made aware of the resident's condition. Orders were received to transfer the resident to the hospital. A call was placed to 911 and the resident was transferred to the hospital. Nurse # 2 was not available for interview during the survey. Resident # 8's responsible party was interviewed on 4/26/23 at 11:36 PM and reported the following. On 3/1/23 another family member had been visiting Resident # 8 and had brought to the nursing staff's attention that they felt the resident was running a fever and had a deep cough. Review of Resident # 8's initial hospital physical exam on 3/2/23 revealed his pulmonary effort was normal and he had adequate air entry. He was oriented to person and place. Hospital records included documentation he was tested on [DATE] for COVID and found to be positive. The hospital physician noted that one of Resident # 8's cancer medications could worsen COVID symptoms. The resident was hospitalized for care. Resident # 8's hospital discharge summary, dated 3/12/23, revealed Resident # 8's initial chest x-ray upon admission had shown no acute process. At time of hospital discharge, he had been diagnosed with pneumonia due to infectious organism, but the discharge summary did not note the pneumonia had been related to COVID or any other specific organism. On 3/14/23 Resident # 8 was transferred back to the facility for care. Review of facility COVID tracking logs revealed the facility identified they were first in a COVID outbreak on 3/3/23. The facility's first date of initial testing was on 3/3/23. On the initial testing date of 3/3/23, twelve residents tested positive for COVID. The last date noting a resident or staff member tested positive during the outbreak was on 3/22/23; by which date 37 residents had tested positive in the skilled nursing facility. No further resident or staff member tested positive following 3/22/23. A review of records provided by the facility revealed that 83% of residents were currently COVID vaccinated. All staff were vaccinated for COVID or had a documented, approved exemption. Resident # 8's record indicated his Responsible Party reported he was vaccinated prior to admission for COVID. There was no documentation of the vaccine date on the resident's record. The facility's Director of Nursing) (DON) was interviewed on 4/25/23 at 2:10 PM and 4 PM and again on 4/26/23 at 1:20 PM. The DON reported the following. At the time Resident #8 began being symptomatic with a fever and cough on 3/1/23, they had not had COVID in the facility for a long time. At the time, she had been the Infection Preventionist, and it had not occurred to her to test Resident #8 before he was transferred out of the facility on 3/2/23 since they had not had any residents in a long time with COVID. He had resided in a room by himself. The hospital did not let the facility know until 3/3/23 that Resident # 8 was positive for COVID. Therefore, testing for other residents or staff, who had been exposed to Resident # 8 on 3/1/23 when he was coughing and running a fever, did not begin until 3/3/23. On 3/3/23, they tested all their residents and staff in the skilled part of the facility and twelve residents, and three staff members tested COVID positive. Of the twelve residents who tested positive on 3/3/23, only one had mild symptoms of COVID (a runny nose and cough). The residents, who tested positive, were placed on transmission- based precautions. The facility had two wings for their skilled nursing facility. The spread of the infection never traveled to the other skilled nursing wing of the facility, and they were able to contain it once they did start testing and isolating residents. There were no residents hospitalized due to a COVID infection. Physician # 1 was the on-call physician for the date of 3/1/23. Physician # 1 was interviewed on 4/26/23 at 3:00 PM revealing the following. When Nurse # 1 called her on 3/1/23, it was her understanding that only the family and not the nurse had heard the cough and Resident # 8 was not currently febrile at the time of the call. Remotely, she had looked in Resident # 8's record and found that Resident # 8 had just been seen by his primary physician the previous day. Nurse # 1 had let her know that Resident # 8's family members were very supportive and wanted a lot of interventions and services done for any of his problems. At the time, given his history, the fact that he had just been seen by his primary physician, and it appeared that only the family was hearing the cough, she felt Mucinex was the best treatment. She had not ordered a COVID test to be done. During the interview with the facility's Medical Director (Resident #8's Physician) on 4/26/23 at 5:15 PM, the Medical Director reported the following. She did not feel as if the spread of the COVID outbreak could definitively be attributed to Resident #8 or that the lack of immediate testing had contributed to further problems.

Based on record review and staff interview, the facility failed to assure pressure sore dressing changes were documented for three (Residents # 3, # 6, and #7) of three sampled residents with pressures sores. The findings included. 1. Resident # 6 was admitted to the facility on [DATE] with a Stage IV pressure sore. On 2/2/23 treatment orders were changed for the care of Resident # 6's pressure sore. The new order was to cleanse the pressure sore and apply Dakin's .5 % moistening guaze packing; followed by a foam dressing. Review of Resident # 6's 2023 February and March Treatment Administration Records (TARS) revealed there was no documentation Resident # 6's Stage IV pressure sore dressing change occurred on the following dates on the TARS: 2/3/23 through 2/8/23; 2/10/23 through 2/13/23; 2/15/23; 2/24/23 through 2/28/23; and 3/3/23. Nurse # 2, who was the manager of the unit where Resident # 6 resided, was interviewed on 3/8/23 at 11:10 AM and the blanks on the TARS were reviewed. Nurse # 2 reported the following. Near the first of February 2023, the facility's previous Wound Nurse left employment. There was no Wound Care nurse between 2/3/23 to 2/8/23, but she knew the dressing changes were done by nurses because she oversaw that they were done. They were just not documented as completed. There was a new facility wound nurse (Nurse # 3) who currently alternated with a Nurse Aide (NA # 1) to do dressing changes. NA # 1 was certified as a NA II and was approved to do dressing changes. Also, Nurse # 2 reported the facility was transitioning from paper medical records to electronic records for treatments between February and March 2023. Nurse # 3, who was the facility's new Wound Care Nurse, was interviewed with Nurse 2 on 3/8/23 at 11:10 AM. Nurse # 3 reported she started to work on 2/9/23 and rotated working with a NA # 1 to do dressing changes since 2/9/23. According to Nurse # 3, she and NA # 1 had done Resident # 6's dressing changes but not documented them on the days following 2/9/23 which had incomplete documentation on the TARS. The facility's Nurse Aide II (NA # 1) was interviewed on 3/8/23 at 12:30 PM and corroborated that she alternated working with Nurse # 3 to do dressing changes, and there had been days she had completed Resident # 6's dressing changes but not documented them as complete. 2. Resident # 7 was readmitted to the facility on [DATE]. Orders were obtained on 2/14/23 to apply the following dressing to Resident # 7's Sacral pressure sore. The pressure sore was to be cleansed with normal saline. Silver alginate was then to be applied followed by a foam dressing. The following dates on Resident # 7's February and March treatment administration records revealed no documentation the Sacral pressure sore dressing change was completed: 2/15/23; 2/17/23; 2/25/23 through 2/28/23; and 3/3/23 through 3/4/23. On 3/8/23 at 11:10 AM, the facility's February and March treatment administration records were reviewed with Nurse # 2 (who managed Resident # 7's unit) and Nurse # 3 (who was the facility's current Wound Care Nurse.) Nurse # 3 reported she started to work on 2/9/23 and rotated working with a Nurse Aide II employee (NA # 1) to do dressing changes since 2/9/23. According to Nurse # 3, she and the Nurse Aide II had done Resident # 7's dressing changes but not documented them on the days in February which had incomplete documentation on the TARS. According to Nurse # 2, on the dates of 3/3/23 and 3/4/23, Nurse # 4 would have been responsible for Resident #7's dressing change. The facility's Nurse Aide II was interviewed on 3/8/23 at 12:30 PM and corroborated that she alternated working with Nurse # 3 to do dressing changes, and there had been days she had completed Resident #7's dressing changes but not documented them as complete. Nurse # 4 was interviewed on 3/8/23 at 12:40 PM and reported she had completed dressing changes for Resident #7 in March, 2023 but she thought she missed signing off on some of them. She reported the facility had switched from paper charting to digital charting. She had done paper charting for [AGE] years, and she had to remember to switch between the Medication Administration and the TAR in the new digital system in order to complete documentation and may have not done so. 3. Resident # 3 resided at the facility from 6/20/22 to 10/28/22. Resident # 3 had an order, dated 9/15/22, to apply a dressing change to a Sacral pressure sore. The order directed the pressure sore was to be cleansed and calcium alginate followed by a foam dressing was to be applied. Resident # 3's September 2022 Treatment Administration Record, revealed no documentation the dressing was completed from 9/28/22 through 9/30/22. According to an interview with Nurse # 2 on 3/8/23 at 11:10 AM, the previous Wound Care Nurse, who had been responsible for Resident # 3's dressing changes during the resident's facility residency, was no longer an employee.

Based on record review and staff interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of admission to hospice services. This was for one (Resident # 6) of eight sampled residents whose MDS assessments were reviewed. The findings included: Resident # 6 was admitted to the facility on [DATE]. According to orders, on 2/8/23, Resident # 6 was admitted to hospice services. Review of the record on 3/8/23 revealed Resident # 6 had been scheduled to have a significant change MDS assessment completed with an (ARD) assessment reference date set to be 2/21/23, and the assessment had never been completed. The MDS Coordinator was interviewed on 3/8/23 at 2:40 PM and reported the following. She had been the only MDS Coordinator since May 2022. Prior to that date, there had been another nurse to assist her. She was trying her best to keep up but was not able to meet all the MDS deadlines. She confirmed that it had been identified that Resident # 6 was due a significant change assessment, and the ARD had been set up. The MDS Coordinator also confirmed that the assessment should have been completed but had not been. The Administrator was interviewed on 3/8/23 at 5:00 PM and reported the following. At the current time, the facility did not have any plan in place to catch up late MDS assessments. He felt they needed another employee to help the one MDS nurse they had, but that nurses trained in the MDS process were hard to find.

Based on record review and staff interview the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date. This was for one (Resident # 8) of eight sampled residents whose MDS assessments were reviewed. The findings included: Resident # 8 was admitted to the facility on [DATE]. Resident #8 had a quarterly MDS assessment done on 11/16/22. Review of the record on 3/8/23 revealed Resident # 8 had a quarterly MDS assessment with a ARD (Assessment Reference Date) of 2/8/23 scheduled to be completed, but it had not been completed. The MDS Coordinator was interviewed on 3/8/23 at 2:40 PM and reported the following. She had been the only MDS Coordinator since May 2022. Prior to that date, there had been another nurse to assist her. She as trying her best to keep up, but was not able to meet all the MDS deadlines. She confirmed that Resident # 8 should have had a quarterly MDS assessment completed seven days following the ARD date of 2/8/23, but it had not been completed. The Administrator was interviewed on 3/8/23 at 5:00 PM and reported the following. At the current time, the facility did not have any plan in place to catch up late MDS assessments. He felt they needed another employee to help the one MDS nurse they had, but that nurses trained in the MDS process were hard to find.

Based on staff interviews, record reviews and Physician interview the facility failed to protect a resident's right to be free from physical and emotional injuries for 1 of 2 sampled residents (Resident #222). Resident # 222 sustained a bruising on bilateral upper extremities with open skin tears on anterior right arm, posterior wrist to left arm, bruising on the left upper lip and the resident's emotional response & behaviors were crying, fretful, and agitated. The findings included: Resident #222 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] specified the resident had clear speech and was usually able to make herself understood and usually able to understand others. The MDS also specified the resident had severely impaired cognition. The MDS did not indicate Resident # 222 as resistive to care. A care plan updated [DATE]indicated Resident #222 had an Activities of Daily Living (ADL)self-care performance deficit related to immobility, incontinence, and dementia. The resident's care plan also indicated the resident was combative with care at times. Interventions included: - she requires extensive to total assist with bed mobility - she refuses for her nails to be cut and nail care to be done - skin checks to be done on Nurse Aide (NA) rounds and as needed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not on any anticoagulant (blood thinner) medication. A 24-Hour Initial Report for an Allegation of abuse was faxed to the Health Care Personnel Registry on [DATE] from the facility. A review of 5- Working Day Report submitted by the facility for all allegation of abuse was faxed to the Health Care Personnel Registry on [DATE]. The report documented the facility's Director of Nursing (DON) and Administrator became aware of the allegation of abuse on [DATE]. Resident #222 was documented as having been severely impaired. The alleged incident occurred on [DATE] at approximately 12:00 PM. The allegation description was an allegation of physical abuse 7am-3pm shift, resident reporting she got bruises on her arms and lip from the morning nurse. Resident stating the nurse from the morning (referring to Nurse Aide (NA)#3) beat me up. NA#3 was placed on suspension pending investigation of allegation. The resident's emotional response & behaviors were crying, fretful, and agitated. The document also indicated the following timeline for allegation of abuse: [DATE] around 2:30PM, NA#2 reported to staff nurse that resident had bruising on left upper lip, and left forearm/ elbow. The nurse stated she and house supervisor went to room and assessed the resident and saw bruising on resident. Resident was asked what happened and resident told nurse she was beat up. Director of Nursing (DON) was notified on [DATE] at 12:20PM and her and unit manager with wound nurse went in room to asses resident. Bruising was noted to lip outside and inside. Red bruising was also noted on left arm. DON notified the police at 6:30 PM of allegation. Police came out at 7:36 PM and interviewed resident. 2 aides gave written statements to DON Aide that was the person in question was an agency aide. DON and Administrator notified nursing agency of allegation and requested personal information and told the agency the nurse aide would no longer be used while investigating allegation DON sent 24-hour report [DATE] at 2:00PM to Department of Social services (DSS). [DATE] allegation was substantiated. Agency was told of findings. Review of the facility's Investigation Guide indicated the following details: On [DATE], Interim DON was notified of an abuse allegation that was alleged to have occurred on [DATE]. On [DATE] NA #1 reported to Nurse #1 that Resident #222 had bruising on left upper left and on left forearm/ elbow. Resident # 222 was assessed by Nurse#1 and Nurse #1 noted the bruising. Nurse #1 asked Resident # 222 what happened, and the resident stated that she was beat up by the morning nurse. Resident # 222 was fully assessed again with bruising and skin tears noted on the assessment. Review of the skin assessments from [DATE] - [DATE] revealed no injury or bruises on Resident # 222's left or right arms. The skin assessments revealed Resident # 222 had no history of bruises. Review of the form dated [DATE] titled, Skin Monitoring: Comprehensive NA Shower Revealed. the resident had scattered bruises on bilateral upper extremities. Open skin tears on right arm and left wrist. Review of Nurse #1's nurse's note written on [DATE], documented Noted bruising on bilateral upper extremities with open skin tears on anterior right arm, posterior wrist to left arm. Resident stated that she got the bruises from the morning nurse. Resident stated, The nurse from the morning beat me up. She snatched my arms and squeezed them. Therefore, all my arms are bruised. The resident indicated she had to grab the nurse breast to stop her from hurting her and that was all she could do. A telephone interview was conducted with Nurse #1 on [DATE] at 9:00AM, Nurse #1 stated on [DATE], NA #2 reported to her that she observed bruises on Resident # 222 bilateral upper extremities with open skin tears and observed the resident bleeding on her lips. Nurse #1 stated she completed the skin assessment and observed the bruises on the resident upper extremities and the resident's lips was injured. Nurse #1 stated she asked the resident what had happened to her and the resident reported that the morning nurse had beat her up. Nurse #1 reported the allegation of the alleged abuse of Resident # 222 to Nurse #2 who was the weekend supervisor. Review of NA#2 statement note dated [DATE] documented she was told by NA#1 that Resident #222 stated NA #3 beat her up. She (NA#2) went to Resident # 222 to check on her and she noticed her lips appeared to be busted. She noticed a medium size skin tear which was flapped over exposing arm tissue. It was bruised on her left wrist. When she asked the resident, what happened she stated the Nurse was mean to her and rough with her when she told her to stop, she started grabbing her by her arms. NA#2 pulled Nurse #1 to the side to let her know her findings and asked if she could go in room with her to assess the resident. Nurse #1 asked the resident what had happened. The resident told Nurse#1 about the same information that she had told her before. A telephone interview was conducted with NA#2 on [DATE] at 9:25 AM, NA#2 stated she was not assigned to Resident # 222 on [DATE]. NA# 2 indicated she was asked to go see Resident # 222 by NA#1 who indicated she had observed bruises on Resident # 222 and the resident reported to her that she had been beaten up by NA#3. NA#2 reported she observed the resident with bruises on her left upper extremities and noticed her lips was bleeding. She asked the resident what happened, and the resident indicated her morning NA had beaten her up. NA#2 stated she reported her observation and the abuse allegation to Nurse #1. Review of NA#1 statement note dated [DATE] documented she overheard Resident#222 yelling and screaming while she was in the process of changing another resident. She didn't think anything of it because Resident #222 always yells when she wants some attention. Later after lunch trays came out her tray was already in her room. She went to check on the resident because she always doesn't like to eat breakfast or lunch and she always needs encouragement. When she went to the resident's room to check if she was eating lunch, she noticed her lip was busted and she looked at the resident's arms and they were bleeding and bruised. The resident was saying that NA #3 beat her up and threw her around. She told NA#2 and told Nurse#1. A telephone interview was conducted with NA#1on [DATE] at 9:30AM, NA#1 stated she was in the process of changing another resident when she had Resident # 222 yelling and screaming. She did not think of anything but after she finished changing the other resident, she went to check on Resident #222. She noticed NA #3 coming from Resident # 222's room. Upon entering Resident # 222's room, she observed the resident with bruises on her left arm upper extremities and her lips was bleeding. She asked NA#2 to go in the resident's room with her to confirm what she observed. NA #1 also indicated she had spoken and observed Resident # 222 in the morning during breakfast and she did not have any bruises on her upper left or right arms. The resident told both NA#1 and NA#2 that NA#3 beat her up. They reported their findings to Nurse # 1. Review of the skin/ wound progress notes written by treatment Nurse #3 dated [DATE] documented Resident provided with full head to toe skin assessment. Generalized skin observed clean dry fragile and warm to touch. Resident is awake and verbally responsive. Reports discomfort to upper extremities and feet. Observed with dark purple bruising to left upper lip. Bottom lip is slightly excoriated. Right forearm observed with a large purplish/ red discolored area that measures 6 inches x 4 inches. Noted with scattered purplish/red discolored areas around large, bruised area. Has a 1 inch linear 100% dermal scab to right lower distal anterior forearm. Left arm observed with multiple purplish/red discoloration extending from the upper arm to hand. Has multiple scattered purplish/ red areas to left upper arm. Noted with 4 distinct purplish/ red oval discoloration consecutive to each other on the lateral left elbow, each measuring 2 cm in size. Has scattered purplish/ red discoloration to left forearm. Noted with a 1 inch linear 100 % dermal scabbed area. Left hand dorsal observed with 1 linear 100% dermal scabbed area with purplish/ red discoloration locally. An interview was conducted with the Nurse #3 on [DATE] at 11:20 AM, Nurse #3 stated she completed Resident #222 skin assessment on [DATE]. She reported she observed bruises on the resident as purple color discolorations on the left arms. Nurse #3 indicated it was consistent with fingerprints on the resident's left upper extremities. She stated she observed Resident #222 bottom lip was excoriated. She further stated the resident reported to her that NA#3 beat her up and that was the reason she had bruises on her left arm and her lips. An interview was conducted with the weekend supervisor Nurse#2 on [DATE] at 3:10PM, Nurse #2 stated Nurse #1 reported to her that Resident # 222 had bruises on her left arm upper extremities and the resident was reporting that NA#3 had beaten her up. Nurse #2 reported she went to Resident #222 to complete the skin assessment. She reported she observed bruises on the resident's left arm. NA#3 was no longer employed at the facility. Review of the abuse investigation revealed no statement written by NA#3. The Director of Nursing who completed the investigation was no longer employed at the facility. The Administrator who completed the abuse investigation was no longer employed at the facility. Resident # 222 was no longer at the facility. She expired on [DATE]. On [DATE] at 10:10 AM the Medical Director (MD) was interviewed and stated she was made aware of the abuse allegation. She stated the resident had history of being combative and resistive of care. MD reported she did not recall Resident # 222 as having history of bruises before [DATE]. MD indicated the abuse allegation happened on the weekend and she did not examine the resident. An interview was conducted with the current Administrator on [DATE] at 11:30 AM. The Administrator stated she was an interim Administrator at the time of Resident # 222 abuse allegation. The Administrator reported she was not part of the staff that investigated the abuse allegation of Resident # 222 in [DATE]. The Administrator stated the staff at the facility should treat the residents with dignity and respect. She reported the staff should not abuse the residents at the facility. She also indicated the staff at the facility will continue to be in serviced on prevention of abuse and especially with residents who had behavioral symptoms and dementia. A telephone interview was conducted with the current DON on [DATE] at 11:41 AM. DON stated she was not employed at the facility when Resident # 222 had an allegation of abuse. She stated the staff at the facility will continue to be educated on how to prevent abuse and neglect. She stated no residents should be abused at any time at the facility. The facility provided the following corrective action plan with a completion date of [DATE] # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The alleged staff was identified as an agency Certified Nurse Aide (CNA) # 3. The Administrator notified the Staffing Agency of the allegation on [DATE]. The Director of Nursing reported the allegation to the Nurse Aide Registry on [DATE]. The NA #3 no longer could work at the facility. On [DATE] the Administrator requested validation of Abuse and Neglect Training for CNA # 3. The Staffing Agency provided the facility with the Abuse and Neglect Training Post Test that CNA #3 had taken on [DATE]. The test showed a passing score of 100. The Staffing Agency also provided Nurse Aide Skills Competency and Assessment which includes: Patient Rights, Abuse Detection/reporting, Residents refusing care, Dementia Care. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The Director of Nursing and Social Worker interviewed alert and oriented residents on [DATE] to ensure no other allegations of abuse had occurred. There were no other allegations of abuse identified or reported. The Licensed Nursing Staff began a physical assessment of all non-alert/oriented residents to ensure there were no other injuries or evidence of abuse. No other allegations or injuries were identified. The assessments were completed by [DATE]. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; [DATE] - The Administrator, Director of Nursing conducted an in-depth analysis of the mechanisms, policies, training of staff relative to Abuse prevention and determined the following would continue and or be implemented: Education and training on Abuse will continue to be provided to all newly hired staff during Facility Orientation. The facility will continue to require any Staffing Agency provide validation that Abuse Screening, Training, and professional licenses if applicable and/or qualifications required by law has been obtained on all their employees prior to them working at the facility. Posting of abuse policy and procedures throughout the facility visible to employees, families and residents. [DATE] - The Staff Development Coordinator began in-servicing all staff (including agency staff) on Abuse Prevention that included how to appropriately care for demented, combative, agitated residents. In-services to be completed by [DATE]. Nursing staff who did not receive the education will not be allowed to work until education is provided. There were at least nine agency staff included in the Abuse Prevention in-services provided by the facility from [DATE] to [DATE]. Continued monitoring of care is completed daily through routine clinical rounds conducted by the Unit Managers and Director of Nursing as well as rounds completed by Clinical Consultants. The monitoring includes observation of providing activities of daily living, and day-to day interaction with residents including those resident's with behavioral issues. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. On [DATE] the facility decided that a) Monitoring for signs/symptoms of abuse will be conducted through weekly skin assessments completed by the Licensed Nursing Staff and review of Incident Accident Reports in routine clinical meetings. B) Continued monitoring of care is completed daily through routine clinical rounds conducted by the Unit Managers and Director of Nursing as well as rounds completed by Clinical Consultants. The monitoring includes observation of providing activities of daily living, and day-to day interaction with residents including those resident's with behavioral issues. Results will be reviewed and discussed in the monthly Quality Assurance Performance Improvement Committee meetings. The Quality Assurance Committee will assess and modify the action plan as needed to ensure continued compliance. The Committee was notified of this responsibility on [DATE]. Completion date: [DATE] Onsite validation was completed on [DATE] through staff interviews and record review. Staff were interviewed to validate in- service completion and prevention of abuse. Observations were made of residents throughout the facility and no bruises or skin tears were observed. Review of the weekly skin assessment was completed, and the Quality Assurance (QA) Committee met to discuss the weekly skin assessments findings. The facility's correction action plan was validated to be [DATE].

Based on record reviews and staff interviews, the facility failed to follow their abuse policies and procedures in the areas of immediately reporting to administration, and protection of residents by allowing the alleged perpetrator to continue to work and be assigned to take care of residents, and notification of law enforcement for two days for 1 of 2 sampled residents (Resident # 222). The findings included: The policy and procedure for Resident Abuse undated stated the following procedure: If abuse or suspicion of abuse is identified, the employee must immediately report the findings to the supervisor. If the supervisor (like stated above) is not the administrator, director of nursing, or the social work, that supervisor must immediately contact either the administrator, director of nursing, or social work of the allegation. Once allegation is known, any employees accused of the allegation, they must be sent home immediately and will be suspended, pending investigation. If any visitors are accused of the allegation, they must be asked to leave the facility to allow for an investigation. Facility is to thoroughly investigate the allegation, contact appropriate departments (i.e., police department, department of social services) and determine whether the allegation will be substantiated or unsubstantiated. Reasonable suspicion of crime against any resident shall be reported to the law enforcement entities - no later than 2 hours following the allegation. A 24-Hour Initial Report for an Allegation of abuse was faxed to the Health Care Personnel Registry on [DATE] from the facility. A review of 5- Working Day Report submitted by the facility for all allegation of abuse was faxed to the Health Care Personnel Registry on [DATE]. The report documented the facility's Director of Nursing (DON) and Administrator became aware of the allegation of abuse on [DATE]. Resident #222 was documented as having been severely impaired. The alleged incident occurred on [DATE] at approximately 12:00 PM. The allegation description was an allegation of physical abuse 7am-3pm shift, resident reporting she got bruises on her arms and lip from the morning nurse. Resident stating the nurse from the morning (referring to Nurse Aide (NA)#3) beat me up. NA#3 was placed on suspension pending investigation of allegation. The resident's emotional response & behaviors were crying, fretful, and agitated. The document also indicated the following timeline for allegation of abuse: [DATE] around 2:30PM, NA#2 reported to staff nurse that resident had bruising on left upper lip, and left forearm/ elbow. The nurse stated she and house supervisor went to room and assessed the resident and saw bruising on resident. Resident was asked what happened and resident told nurse she was beat up. Director of Nursing (DON) was notified on [DATE] at 12:20PM and her and unit manager with wound nurse went in room to assess resident. Bruising was noted to lip outside and inside. Red bruising was also noted on left arm. DON notified the police at 6:30 PM of allegation. Police came out at 7:36 PM and interviewed resident. 2 aides gave written statements to DON Aide that was the person in question was an agency aide. DON and Administrator notified nursing agency of allegation and requested personal information and told the agency the nurse aide would no longer be used while investigating allegation DON sent 24-hour report [DATE] at 2:00PM to Department of Social services (DSS). [DATE] allegation was substantiated. Agency was told of findings. Review of the facility's Investigation Guide indicated the following details: On [DATE], Interim DON was notified of an abuse allegation that was alleged to have occurred on [DATE]. On [DATE] NA #1 reported to Nurse #1 that Resident #222 had bruising on left upper left and on left forearm/ elbow. Resident # 222 was assessed by Nurse#1 and Nurse #1 noted the bruising. Nurse #1 asked Resident # 222 what happened, and the resident stated that she was beat up by the morning nurse. Resident # 222 was fully assessed again with bruising and skin tears noted on the assessment. Review of the form dated [DATE] titled, Skin Monitoring: Comprehensive NA Shower Revealed. the resident had scattered bruises on bilateral upper extremities. Open skin tears on right arm and left wrist. Review of Nurse #1's nurse's note written on [DATE], documented Noted bruising on bilateral upper extremities with open skin tears on anterior right arm, posterior wrist to left arm. Resident stated that she got the bruises from the morning nurse. Resident stated, The nurse from the morning beat me up. She snatched my arms and squeezed them. Therefore, all my arms are bruised. The resident indicated she had to grab the nurse breast to stop her from hurting her and that was all she could do. A telephone interview was conducted with Nurse #1 on [DATE] at 9:00AM, Nurse #1 stated on [DATE], NA #2 reported to her that she observed bruises on Resident # 222 bilateral upper extremities with open skin tears and observed the resident bleeding on her lips. Nurse #1 stated she completed the skin assessment and observed the bruises on the resident upper extremities and the resident's lips was injured. Nurse #1 stated she asked the resident what had happened to her and the resident reported that the morning nurse had beat her up. Nurse #1 reported the allegation of the alleged abuse of Resident # 222 to Nurse #2 who was the weekend supervisor. A telephone interview was conducted with NA#2 on [DATE] at 9:25 AM, NA#2 stated she was not assigned to Resident # 222 on [DATE]. NA# 2 indicated she was asked to go see Resident # 222 by NA#1 who indicated she had observed bruises on Resident # 222 and the resident reported to her that she had been beaten up by NA#3. NA#2 reported she observed the resident with bruises on her left upper extremities and noticed her lips was bleeding. She asked the resident what happened, and the resident indicated her morning NA had beaten her up. NA#2 stated she reported her observation and the abuse allegation to Nurse #1. A telephone interview was conducted with NA#1on [DATE] at 9:30AM, NA#1 stated she was in the process of changing another resident when she had Resident # 222 yelling and screaming. She did not think of anything but after she finished changing the other resident, she went to check on Resident #222. She noticed NA #3 coming from Resident # 222's room. Upon entering Resident # 222's room, she observed the resident with bruises on her left arm upper extremities and her lips was bleeding. She asked NA#2 to go in the resident's room with her to confirm what she observed. NA #1 also indicated she had spoken and observed Resident # 222 in the morning during breakfast and she did not have any bruises on her upper left or right arms. The resident told both NA#1 and NA#2 that NA#3 beat her up. They reported their findings to Nurse # 1. An interview was conducted with the Nurse #3 on [DATE] at 11:20 AM, Nurse #3 stated she completed Resident #222 skin assessment on [DATE]. She reported she observed bruises on the resident as purple color discolorations on the left arms. Nurse #3 indicated it was consistent with fingerprints on the resident's left upper extremities. She stated she observed Resident #222 bottom lip was excoriated. She further stated the resident reported to her that NA#3 beat her up and that was the reason she had bruises on her left arm and her lips. An interview was conducted with the weekend supervisor Nurse#2 on [DATE] at 3:10PM, Nurse #2 stated Nurse #1 reported to her that Resident # 222 had bruises on her left arm upper extremities and the resident was reporting that NA#3 had beaten her up. Nurse #2 reported she went to Resident #222 to complete the skin assessment. She reported she observed bruises on the resident's left arm. NA#3 was no longer employed at the facility. The Director of Nursing who completed the investigation was no longer employed at the facility. The Administrator who completed the abuse investigation was no longer employed at the facility. Resident # 222 was no longer at the facility. She expired on [DATE]. An interview was conducted with the current Administrator on [DATE] at 11:30 AM. The Administrator stated she was an interim Administrator at the time of Resident # 222 abuse allegation. The Administrator reported she was not part of the staff that investigated the abuse allegation of Resident # 222 in [DATE]. The Administrator stated the weekend supervisor Nurse #3 on [DATE] was required to report immediately to the DON and Administrator per facility abuse policy. The Administrator reported CNA#3 should have been suspended immediately and the police should have been notified immediately. She also indicated the staff at the facility will continue to be in serviced on reporting the allegation immediately to their supervisor. A telephone interview was conducted with the current DON on [DATE] at 11:41 AM. DON stated she was not employed at the facility when Resident # 222 had an allegation of abuse. She stated the staff at the facility will continue to be educated reporting an allegation of abuse immediately to their supervisors. She stated no residents should be abused at any time at the facility. The facility provided the following corrective action plan with a completion date of [DATE]. # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The Director of Nursing submitted the allegation of abuse report to the Division of Health Service Regulation (DHSR) agency on [DATE]. Investigation was initiated. Administrator contacted the local police department [DATE] at 5:10 pm. Police interviewed the resident [DATE] at 7:30 p.m. The alleged staff was identified as an agency CNA#3. The Administrator notified the Staffing Agency of the allegation on [DATE]. The Director of Nursing reported the allegation to the Nurse Aide Registry on [DATE]. The CNA#3 no longer could work at the facility. The Director of Nursing and Nurse Consultant counseled the Nurse Supervisor on [DATE] for failing to report the allegation to Administration immediately. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The Licensed Nursing Staff began a physical assessment of all non-alert/oriented residents to ensure there were no other injuries or evidence of abuse. No other allegations or injuries were identified. The assessments were completed by [DATE]. The Director of Nursing interviewed all alert/oriented residents on [DATE] to determine if other allegations of abuse had occurred. There were no other allegations reported or abuse identified. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; After completing a root cause analysis of why the allegation was not reported to Administration immediately, it was determined the Licensed Practical Nurse notified the Nurse Supervisor and thought the supervisor was contacting Administration. The Nurse Supervisor failed to report the allegation timely to Administration. [DATE] Staff Development Coordinator and or Director of Nursing will in-service all staff to ensure each person knows the policy and procedure revision for abuse reporting. The in-service material included identification and reporting of suspected abuse, protecting the resident involved as outlined in the facility policy: 7. B (2) - All alleged violations are to be reported immediately to the Administrator, Director of Nursing, Nursing Supervisor, On-Call Nurse and/or other Administrative Designee. 6. A - Protecting the Resident During the Investigation of the Alleged Abuse: The Administrator in consultation with the appropriate supervisor will decide on an employee working status. The employee may be terminated or suspended from their duties pending the results of the investigation. It will be the direct responsibility of the Nursing Supervisor to ensure that the resident involved continues to receive appropriate care. In-services will be completed by [DATE]. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. [DATE] - The Director of Nursing will monitor all allegations of abuse for one month to determine if facility policy was followed for reporting the allegation to Administration immediately, steps to protect the resident were taken (alleged staff suspended, removed from work duties). Audit results will be documented on the audit tool titled Allegations of Abuse Reporting. Results will be reviewed and discussed in the monthly Quality Assurance Performance Improvement Committee meetings. The Quality Assurance Committee will assess and modify the action plan as needed to ensure continued compliance. The Committee was notified of this responsibility on [DATE]. As part of the validation process on [DATE], the plan of correction was reviewed. The licensed staff, nursing assistants, supervisors who interact with residents and alert and oriented residents that were interviewed were aware of to whom and how to report allegations, incidents, and or complaints. Five direct care staff representing all three shifts were interviewed to determine whether each staff member was trained in and knowledgeable about, how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions and knowledgeable regarding what, when, and to who to report according to the facility policies. The facility alleges full compliance with this plan of correction effective [DATE].

Based on observation, record review, resident and staff interviews, the facility failed to treat resident in a dignified manner by asking him to have a bowel movement in his incontinence brief when he asked to be transferred to the bedside commode for 1 of 1 sampled resident reviewed for respect and dignity (Resident #1). The resident voiced he felt humiliated and disrespected. The findings included: Resident #1 was admitted to the facility on [DATE]. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was moderately intact and required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. He was occasionally incontinent of urine and continent of bowel. When entering Resident #1's room on 1/4/22 at 1:40 pm, he was calling out help. He stated he needed to get up to use the toilet. After he pressed his call light, Nursing Assistant #1 (NA#1) walked into the room, she had a brief conversation with Resident #1 then walked out of the room and shut the door leaving Resident #1 in bed. After approximately 5 minutes, NA#1 went back into Resident #1's room to provide incontinence care. An interview was conducted on 1/4/22 at 2:15 pm with NA #1. She verbalized she had told Resident #1 to go ahead and have a bowel movement in his brief then she would provide incontinence care since he had an incontinence brief on. NA#1 stated she had been assigned to care for Resident #1 in the afternoon after another nursing assistant left early and she did not think Resident #1 was capable of standing up to get to the bedside commode. When entering Resident #1's room on 1/4/22 at 2:22 pm, he was observed lying in bed with covers over his head and face. Resident #1 stated he wanted to use the bedside commode, but NA#1 told him to go in the brief and he would clean him. He reported this had happened other times when nursing assistants did not assist him to the bedside commode and asked him to go in the incontinence brief. Resident #1 verbalized he felt humiliated and disrespected when he did not get assistance to the bedside commode and was told to go in his brief. During observation on 1/4/22 at 2:25 pm, a bedside commode was observed in Resident #1's bathroom. A pair of black sneakers soiled with dry brown stool were also observed at Resident #1's bedside. An interview was conducted on 1/4/22 at 2:30 pm with the nurse who was caring for Resident #1. Nurse #1 indicated Resident #1 should have been assisted to use the bedside commode. Nurse #1 stated Resident #1's shoes should have been sent to laundry for washing if they were soiled. She put the shoes in a plastic bag and put them in the laundry hamper in the hallway. During an interview on 1/4/22 at 3:30 pm with the Director of Nursing (DON), she indicated Resident #1 should have been transferred to the bedside commode when he asked for assistance. The DON stated she expected nursing staff to put soiled clothes and shoes in the dirty laundry bins so they could be washed. She communicated she would address the issue. An interview was conducted with the Administrator on 1/4/22 at 3:35 pm. She indicated nursing staff should treat residents with dignity and provide assistance with toileting as requested by the Resident. The Administrator stated the soiled shoes should not have been left at Resident #1's bedside.

Based on record review and staff and resident interviews, the facility failed to perform correct procedure for indwelling urinary catheter insertion which resulted in emergency hospitalization for 1 of 2 sampled residents. (Resident # 70). The findings included: Review of facility policy, Catheter Insertion, it was written, item P. When urine stops flowing, attach the saline filled syringe to the lear lock. Push the plunger and inflate the balloon. Item U. Document the date, time, and observations made pertinent to resident care such as urine color, consistency, odor, sediment, and resident tolerance of the procedure. Resident #70 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED].#70 had an indwelling catheter for bladder appliance. The care plan revision dated 6/06/15 stated as an intervention, Catheter: change per MD orders only. On review of physician orders [REDACTED]. A review of nursing notes written by Nurse #2 dated 2/13/16 at 4:00 AM indicated the nurse did not document urine return during or post procedure to change the resident's indwelling catheter. Nursing notes written by Nurse #3 dated 2/13/16 at 11:00 AM no urine output noted in collection bag. Small amount dried blood noted to penis. RN (Registered Nurse) in building made aware and to come check. Nursing notes written by Nurse #4 dated 2/13/16 at 12:00 PM read Attempted to flush foley cath (indwelling urinary catheter), met impedance. Replaced foley cath with sterile tech. No urine flow seen. Multiple clots of blood removed. Flushed another time but still no return of flush or urine. Dr. notified. Order given to send to ER (emergency room ). Telephone order given to send resident to emergency roiagnom on [DATE]. Review of Resident #70's Admission History and Physical from the emergency room dated 2/13/16 assessment and plan revealed; #1 hematuria and [MEDICAL CONDITION] secondary to blood clot from trauma. Regarding the procedure on 2/13/16 of the nurse and his hospitalization . He had discussed his concerns with administration and the Director of Nursing. He explained his concerns had been resolved. An interview with Nurse #5 on 3/8/16 at 10:00 AM was conducted. Nurse #5 (Quality Assurance Nurse/Helping with Staff Development) stated the night shift normally did catheter changes. She stated Nurse #2 was no longer employed at the facility. She was terminated after an investigation of the incident from 2/13/16. She explained on 2/13/16, Nurse #2 did not wait for urine return before inflating the balloon and the Director of Nursing conducted an investigation. She also stated the Director of Nursing recently completed an in-service on Foley catheter placement and on Intake and output for catheter care. Nurse #5 expressed expectation that the licensed staff would report to the nurse in charge if there are problems with indwelling catheters. An interview with Director of Nursing (DON) on 3/9/16 at 3:00 PM was conducted. She stated indwelling catheter insertion training was not included in their orientation. She stated there was an in-service on Foley Catheter Placement done on 3/7/16 with 11 staff attending. On 3/8/16 she conducted an in-service on Intake & Output for Catheters with 16 staff members. She explained staff training and in-service is done with staff development, through quality improvement processes, and during orientation training. She included that training is on-going. She indicated her expectation was the catheter care would include visualization of urine return prior to the inflation of balloon. During interview with Director of Nursing (DON) on 3/10/16 at 11:05 AM, stated an investigation was done and Nurse #2 was interviewed and asked to demonstrate what occurred on 2/13/16. It was determined Nurse #2 had inflated the balloon prior to getting urine return for Resident #70.

Based on observation, record review and staff interviews the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor these interventions that the committee put into place in June of 2015. The deficiency was in the area of failure to provide incontinence care. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referenced to: F315 on the current survey of 3/10/16 - Based on record reviews and staff and resident interviews, the facility failed to perform correct procedure for indwelling urinary catheter insertion which resulted in emergency hospitalization for 1 of 2 residents. (Resident #70). On 3/10/16 at 5:30 PM, an interview was conducted with the Quality Assessment Nurse, Director of Nursing and the Administrator. The facility has a functioning Quality Assessment Committee with committee members representing all departments. The Quality Assessment Nurse revealed that the committee had worked on the areas of wounds developing and implementing a Process Improvement Project (PIP). The committee had discussed behaviors and catheters.