Every finding on record at Huntersville Health & Rehabilitation Center

Based on observations, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications kept at bedside for 1 of 3 resident reviewed for self-administration (Resident #46). The findings included: Resident #46 was admitted to the facility on [DATE] with diagnosis of arthritis. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #46 cognitively intact. Review of Resident #46's medical records revealed no documentation Resident #46 was assessed to safely self-administer medications. A physician order dated 03/17/26 revealed an order for Tylenol 325 milligram (mg) give 2 tablets by mouth every 6 hours as needed for pain. Resident #46 did not have a physician's order for decongestant nasal spray. On 06/08/26 at 2:25 PM Resident #46 was observed to have a bottle of over the counter (OTC) Tylenol 325 milligrams (mg) and a bottle of decongestant nasal spray sitting on her bedside table. Resident #46 stated she had the Tylenol medication for when she worked with therapy services, she would take one prior to receiving therapy to alleviate pain and one tablet would help her pain level for a duration of 3 days. Resident #46 stated she would use the decongestant nasal spray one spray to each nostril daily for congestion. She explained she had received the medication from a family member who brought it into the facility for her. Resident #46 stated the medication had been sitting on her bedside table for a couple of weeks and no staff member had mentioned anything to her about it. An observation of Resident #46's room conducted on 06/09/26 at 12:15 PM revealed a bottle of over the counter (OTC) Tylenol 325 milligrams (mg) and a bottle of decongestant nasal spray sitting on her bedside table. An observation of Resident #46's room conducted on 06/10/26 at 9:00 AM revealed a bottle of over the counter (OTC) Tylenol 325 milligrams (mg) and a bottle of decongestant nasal spray sitting on her bedside table. An interview and observation were conducted on 06/10/26 at 9:10 AM with Nurse #1. The interview revealed she was not aware of any medication on Resident #46's bedside table. She explained that there were no residents in the facility allowed to keep medications at the bedside nor were there any residents on the unit assessed to self-administer medications. She stated she was unaware Resident #46 was taking Tylenol 325 mg or using the decongestant nasal spray. Nurse #1 was observed to go into Resident #46's room and pick up the bottle of Tylenol along with the bottle of nasal spray and place it at the nurses' station. She explained she would contact Resident #46's family member and let them know to pick up the medication. On 06/11/26 at 11:38 AM an interview was conducted with the Director of Nursing (DON). During the interview she stated no resident in the facility was allowed to keep medication from home in their room. She explained Family Members were notified of the facility policy regarding medication storage upon admission but would often bring in item's to residents without staff knowledge. The DON stated Resident #46 should have been assessed to self-administer medication if she wanted to keep and administer the medications in her room. On 06/11/26 at 11:41 AM an interview was conducted with the Administrator. He stated he expected the nurses to be observant of medication at bedside and if they saw any medication at the bedside to immediately remove it.

Based on record review and staff interviews, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation request to North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) for a resident diagnosed with a serious mental illness. This deficient practice affected 1 of 3 residents reviewed for coordination of PASRR assessments (Resident #10).The findings included:A review of Resident #10's medical record revealed that Resident #10 was deemed by the State to be Level I PASSR. The Level I PASSR was dated 8/21/2009 with no expiration date. Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia, depression and anxiety.A review of Resident #10's medical record revealed a hospital stay from 10/18/2025 to 10/22/2025. A review of an updated North Carolina Medicaid Long Term Care FL-2 form (FL-2) dated 10/22/2025 and completed by the hospital physician indicated Resident #10 had a diagnosis of bipolar disorder.Resident #10 had a physician order dated 10/22/2025 for venlafaxine hydrochloride (an antidepressant) 75 milligrams (mg) taken orally every morning for depression; venlafaxine hydrochloride 150 mg taken orally once daily for depression; and buspirone hydrochloride (an antianxiety medication) 10 mg, taken orally, three times a day for anxiety.Bipolar disorder was added to Resident #10's facility diagnoses list on 10/22/2025.There was no documentation that a Level II PSARR evaluation was completed when Resident #10 had the addition of a new serious mental illness.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact. The MDS coded Resident #10 with bipolar disorder and use of antidepressant medication. The MDS indicated Resident #10 had not been evaluated by Level II PASRR and determined to have a serious mental illness.Further review of Resident #10's medical record indicated a physician's order dated 5/19/2026 for lorazepam (used to treat anxiety) one (1) mg, taken orally 3 times a day for anxiety; and mirtazapine (an antidepressant) 15 mg taken orally at bedtime for depression. An interview with the Discharge Planning Director was conducted on 6/10/2026 at 10:25 AM. The Discharge Planning Director indicated that assuring the Level II PASSR evaluations were current and accurate was her responsibility. The Discharge Planning Director reported that she became aware that Resident #10 required a Level II PASRR evaluation when Resident #10 returned to the facility after a hospital stay from 4/26/2026 to 5/8/2026. While the hospitalization was not related to psychiatric issues, the Discharge Planning Director stated the hospital discharge summary noted the bipolar disorder diagnosis. The Discharge Planning Director indicated she had missed the addition of the bipolar disorder diagnosis for Resident #10 in 10/2025 by mistake. The Discharge Planning Director indicated that she had started to work on the Level II PASRR evaluation request by obtaining an updated FL-2 form from the Medical Director which was completed and signed on 5/19/2026. The Discharge Planning Director reported she had not requested the Level II PSARR evaluation or submitted the FL-2 form to NC MUST until 6/9/2026 (yesterday). The Discharge Planning Director stated she uploaded the clinical documents for the Level II PSARR evaluation review to NC MUST on 6/10/2026 which would trigger an onsite Level II evaluation with Resident #10. An interview with the Administrator was conducted 6/11/2026 at 8:15 AM. The Administrator indicated the Discharge Planning Director was responsible for submitting requests for the Level II PASSR evaluations. The Administrator explained the Discharge Planning Director missed Resident #10's Level II PSARR evaluation by mistake and the evaluation should have been done immediately when the Discharge Planning Director realized the diagnosis warranted a screening. The Administrator stated his expectation was that the Level II PASRR evaluations would be accurate and up to date.

Based on record review and interviews with staff, the facility failed to protect a resident's right to be free from staff to resident physical abuse when Nurse Aide #2 hit a severely cognitive impaired resident with an open hand three times during care. Resident #1 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as fear, anxiety, helplessness, and dehumanization from being abused by their caregiver. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed she was coded with severe cognitive impairment and needed moderate assistance with personal hygiene, toileting hygiene, dressing and transfers. She was always incontinent of bowel and bladder and did not have any behaviors during the 7-day look back. Resident #1 was care planned on 3/2/26 for combative behaviors with care. The interventions included to assure the resident she is safe, listen to the resident, and try to calm the resident. The initial allegation report completed by the Administrator on 4/14/26 and submitted at 2:42 PM for an allegation of resident abuse for Resident #1 that the facility was made aware of at 1:45 PM. The summary of the incident indicated during a two-person care interaction, Nurse Aide (NA) #1 alleged NA #2 slapped Resident #1 three times while the resident was combative, trying to punch and bite staff. NA #1 immediately notified the Unit Manager and NA #2 was promptly suspended pending investigation. Skin assessment of the resident revealed no concerns. A review of Resident #1's body audit completed on 4/14/26 by the Wound Nurse found no new marks, redness or wounds. NA #2's written statement on 4/14/26 revealed: A NA said that I hit a resident today and I did not do so.NA #2 was unavailable for interview. NA #1 stated during an interview on 4/21/26 at 12:10 PM that on 4/14/26 around 1:30 PM, NA #2 asked her for assistance with providing care to Resident #1. Resident #1 had a history of being resistive to care, and NA #1 assumed NA #2 had attempted to provide care to the resident and needed more help. When NA #1 walked into Resident #1's room, she noticed the resident was agitated. She explained the resident was swinging her arms and had a frown on her face, which was the resident's typical behavior when agitated. Resident #1 was leaning up from her bed with one leg hanging off her bed, and NA #1 then informed the resident they were going to change, dress and get her out of bed. NA #1 said she was going to provide incontinence care and dress the resident's lower half and NA #2 was going to dress the resident's top half of her body. Resident #1 was laid down on her bed and rolled over on her side. The resident grabbed and held on the bed rail making it difficult to move the resident. NA #2 removed the resident's hands from the bed rail. NA #1 stated Resident #1 then tried to bite NA #2. NA #2 then popped the resident on the lips, like someone would discipline a child with an open hand and said, you're not going to fight us or bite us. The strike to the resident's mouth made an audible pop sound. NA #1 said she was in the middle of providing incontinence care to the resident and was shocked by what NA #2 had done. After NA #2 had popped the resident, she continued to provide care to the resident's upper body. The resident became more agitated right after the pop and started kicking her legs, making it difficult to finish care. NA #1 stated her thought was she needed to quickly finish providing care to Resident #1, get her dressed and remove her from NA #2. After she completed incontinence care, NA #1 told NA #2 she (NA #1) would finish getting Resident #1 dressed, and NA #2 did not need to help with care anymore. NA #1 indicated she then took charge of providing care. NA #1 said NA #2 remained in the room and was standing back away from the resident. She stated that she did not know why NA #2 stayed in the room. NA #1 reported she positioned Resident #1 sitting upright on the edge of the bed to change the resident's shirt. NA #2 was standing near the end of the bed facing NA #1 and behind the resident. While putting on a new shirt, the resident's arm was stuck in the shirt, and NA #1 told Resident #1 she needed to put her arm through the shirt. NA #1 said while helping the resident with her arm, Resident #1 swung at her. NA #2 then struck Resident #1 on the left side of her face/cheek area with an open hand with the same level of force as the first strike (strong enough to be felt, but not hard) and heard an audible pop sound from the strike. NA #2 repeated to the resident you're not going to fight us or bite us. After the strike, Resident #1's facial expressions appeared more agitated and intense, and she did not make any noise. NA #1 then told NA #2 to please stop, I have this, I just need to transfer her to her chair. NA #1 reiterated that she did not know why NA #2 remained in the room because NA #2 was not helping provide care at that time. NA #1 then began to transfer the resident to her wheelchair and Resident #1 began to swing her arms at NA #1. Resident #1 was mid-transfer when NA #2 popped the resident on the back of her head with an open hand and repeated, you're not going to hit us. NA #1 did not hear an audible sound from the strike to the head. NA #1 stated she told NA #2 to stop, I've got this and quickly transferred the resident to her wheelchair and removed the resident from the room so she was away from NA #2. NA #1 said she wheeled the resident to the dining area on the hall and immediately went to the Unit Manager to report the incident. NA #1 stated in a follow-up interview on 4/21/26 at 2:30 PM that Resident #1 did not make any noise after each strike from NA #2. The resident appeared to look more agitated with her facial expressions. NA #1 explained that she was in shock and in process of changing the resident after the first strike, and did not want to leave the resident naked. NA #1 said the second and third strike on Resident #1 happened within 45 seconds and her thought was to get the resident away from NA #2 as quickly as possible. NA #1 stated in retrospect, she should have stopped care with the resident after the first strike on Resident #1, removed NA #2 from the room, and reported the incident to the Unit Manager. The DON stated during interview on 4/22/26 at 2:00 PM that NA #1 and NA #2 should have stopped providing care to the resident when she became agitated. She added that NA #1 should have asked NA #2 to leave the resident's room after the first strike on the resident and reported the incident to a nurse. On 4/22/26 at 2:00 PM the Administrator was interviewed. The Administrator stated on 4/14/26 the Unit Manager and NA #1 reported to him and the Director of Nursing (DON) that NA #2 had struck Resident #1 three times during the provision of care. The DON told the Unit Manager to remove NA #2 from the hall and bring her to their office. The Unit Manager then immediately completed a skin assessment on Resident #1. The Administrator stated the skin assessment of Resident #1 found no new signs of bruising or redness on the resident. When NA #2 arrived in their office, the DON asked NA #2 to write a statement about the incident. NA #2 said that nothing had happened. At that time, the DON told NA #2 that an allegation of abuse had been made and NA #2 was not able to work until the investigation was completed. The DON then escorted NA #2 out of the building. The Administrator stated NA #1 told him and the DON that NA #1 and NA #2 were performing care to Resident #1. NA #1 said Resident #1 tried to bite NA #2 and she (NA #2) told the resident, You're not going to hit or bite us, and then NA #2 placed her hand over the mouth of Resident #1. The Administrator indicated that NA #1 said she was in shock but did not stop providing incontinence care. NA #1 then reported she sat the resident up at the edge of the bed to put her shirt on and Resident #1 swung her arms at NA #1. The Administrator stated NA #2 then made contact with her open hand on the left side of the resident's face. Care continued and Resident #1 continued to have behaviors when NA #1 was transferring the resident from bed to chair. That was when NA #2 made contact with her open hand on the back of the resident's head. NA #1 then removed Resident #1 from the room away from NA #2 and reported it to the Unit Manager. The Administrator reported that after the incident, the resident was placed at nursing station to be visible, and the resident was in a good mood and no signs of distress. The Resident's family, physician, police, and Adult Protective Services (APS) were all notified and the state initial report was submitted. The Administrator added the abuse allegation was unsubstantiated because the resident did not remember what happened, there were no visible marks or bruises on the resident, and NA #1 was the only witness to say the resident was hit by NA #2. He added that he was unaware of any prior disagreements between the two NAs. The Administrator stated NA #2 was terminated from the facility on 4/20/26 because of other work-related issues not related to the abuse allegation.

Based on record review and interviews with staff, the facility failed to protect the resident's right to be free from physical restraints when Nurse Aide #2 was witnessed by another staff member (Nurse Aide #1) to hold Resident #1's hands down against her chest to restrict her arm movements during care when the resident became combative. Resident #1 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as panic, distress, anger, and fear from being physically restrained by their caregiver. This deficient practice affected 1 of 1 resident reviewed for physical restraints (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease.Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed she was coded with severe cognitive impairment and did not have any behaviors during the 7-day look back period. Resident #1 was care planned on 3/2/26 for combative behaviors with care. The interventions included to assure the resident she is safe, listen to the resident, and try to calm the resident.The investigation report completed by the Administrator on 4/20/26 related to an allegation of staff to resident abuse for Resident #1 indicated Nurse Aide (NA) #1 reported while she was attempting to remove the resident's brief on 4/14/26 NA #2 was holding Resident #1's hands to prevent injury. NA #1 stated during an interview on 4/21/26 at 12:10 PM that on 4/14/26 around 1:30 PM, NA #2 asked her for assistance with providing care to Resident #1. Resident #1 had a history of being resistive to care, and NA #1 assumed NA #2 had attempted to provide care to the resident and needed more help. When NA #1 walked into Resident #1's room, she noticed the resident was agitated. She explained the resident was swinging her arms and had a frown on her face, which was the resident's typical behavior when agitated. Resident #1 was leaning up from her bed with one leg hanging off her bed, and NA #1 informed the resident they were going to change, dress and get her out of bed. NA #1 said she was going to provide incontinence care and dress the resident's lower half and NA #2 was going to dress the resident's top half of her body. Resident #1 was laid down on her bed and rolled over on her side. The resident grabbed and held on the bed rail making it difficult to move the resident. NA #2 removed the resident's hands from the bed rail, placed them on the resident's upper chest and held her hands there to prevent the resident from swinging her arms. NA #2 held Resident #1's hands until NA #1 completed incontinence care for the resident. NA #1 stated Resident #1 then tried to bite NA #2 while she was holding the resident's hands down. NA #2 then popped the resident on the lips, like someone would discipline a child with an open hand and said, you're not going to fight us or bite us, as she continued to restrain the resident's hands. The resident became more agitated after being popped on the lips while her hands were held down and started kicking her legs, making it difficult to finish care. NA #1 stated in a follow-up interview on 4/21/26 at 2:30 PM that she had received training on how to deal with residents who have behaviors, and on abuse. NA #1 did not realize at the time of the incident that NA #2 holding the resident's hands down on her chest was a restraint. NA #1 added, she and NA #2 should have stopped care when Resident #1 was being combative and tried again later. NA #2 was unavailable for interview.The Director of Nursing (DON) stated during interview on 4/22/26 at 2:00 PM, NA #1 had reported to her and the Administrator that NA #2 was holding Resident #1's hands against the resident's chest to prevent the resident from getting injured while care was being provided. She added that holding Resident #1's hands prevented the resident from injuring herself if she swung her arms and hit the bed rail. The DON indicated that NA #1 reported that Resident #1's hands were restrained when NA #2 struck the resident. She reported that she and the Administrator had not considered holding the resident hands as a restraint since it was to prevent the resident from injuring herself. She indicated that NA #1 and NA #2 should have stopped providing care when the resident became combative, told a nurse and attempted care later. The DON stated that staff had received previous training on all types of abuse that included physical restraints. During an interview on 4/22/26 at 2:00 PM the Administrator voiced her agreement with the DON that the NAs should have stopped providing care to Resident #1 when she became combative, reported to a nurse and attempted care later.

Based on record review and interviews with staff, the facility failed to implement their policy and procedure in the areas of protection, prevention and reporting abuse for 1 of 3 residents reviewed for abuse (Resident #1). NA # 2 witnessed NA # 1 strike a cognitively impaired resident (Resident #1) and did not effectively intervene or immediately report to nursing or administration; this resulted in NA # 2 striking the resident two more times. A reasonable person would expect a witness to remove a cognitively impaired, vulnerable resident from an abusive situation and protect them from further abuse. A reasonable person would feel very dehumanized and helpless from repeated physical abuse. Findings included:The facility's abuse policy dated 10/17/23 was reviewed. The policy read all employees are responsible for immediately reporting to the Administrator, or in their absence the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incident of patient abuse. The policy included the prevention of abuse and neglect.by advocating and enforcing resident patient rights and reporting incidents. Resident #1 was admitted on [DATE] with diagnoses that included Alzheimer's disease.Nursing Assistant (NA) #1 was interviewed on 4/21/26 at 12:10 PM and stated that on 4/14/26 around 10:30 AM, NA #2 asked her for assistance providing care to Resident #1. Resident #1 had a history of being resistive to care, and NA #1 assumed NA #2 had attempted to provide care to the resident and needed more help. When NA #1 walked into Resident #1's room, she noticed the resident was agitated. Resident #1 was leaning up from her bed with one leg hanging off her bed, and NA #1 then informed the resident they were going to change, dress and get her out of bed. NA #1 said she was going to provide incontinence care and dress the resident's lower half and NA #2 was going to dress the resident's top half of her body. Resident #1 was laid down on her bed and rolled over on her side. The resident grabbed and held on to the bed rail making it difficult to move the resident. NA #2 removed the resident's hands from the bed rail, placed them on the resident's upper chest and held them to prevent swinging from the resident. NA #1 stated Resident #1 then tried to bite NA #2 while she was holding the resident's hands. NA #2 then popped the resident on the lips, like someone would discipline a child with an open hand and said you're not going to fight up or bite us. NA #1 said she was in the middle of providing incontinence care to the resident and was shocked by what NA #2 had done. The resident became more agitated and started kicking her legs, making it difficult to finish care. NA #1 stated her thought was she needed to quickly finish providing care to Resident #1, get her dressed and remove her from NA #2. After she completed incontinence care, NA #1 told NA #2 she would finish getting Resident #1 dressed, and NA #2 did not need to help with care anymore and NA #1 took charge of providing care. NA #1 positioned Resident #1 sitting upright on the edge of the bed to change the resident's shirt. NA #2 was standing near the end of the bed facing NA #1 and behind the resident. While putting on a new shirt, the resident's arm was stuck in the shirt, NA #1 told Resident #1 she needed to put her arm through the shirt. NA #1 said while helping the resident with her arm, Resident #1 swung at her. NA #2 then struck Resident #1 on the left side of her face/cheek area with an open hand with the same level of force as the first strike. NA #2 repeated to the resident you're not going to fight us or bite us. NA #1 then told NA #2 to please stop, I have this, I just need to transfer her to her chair. NA #1 then began to transfer the resident to her wheelchair and Resident #1 began to swing her arms at NA #1. Resident #1 was mid-transfer when NA #2 popped the resident on the back of her head with an open hand and repeated, you're not going to hit us. NA #1 stated she told NA #2 to stop, I've got this and quickly transferred the resident to her wheelchair and removed the resident from the room away from NA #2. NA #1 said she wheeled the resident to the dining area on the hall and immediately went to the Unit Manager to report the incident. NA #1 stated in a follow-up interview on 4/21/26 at 2:30 PM that Resident #1 did not make any noise after each strike from NA #2. The resident appeared to look more agitated with her facial expressions. NA #1 said she was in shock and in process of changing her, did not want to leave the resident naked after the first strike. NA #1 said the second and third strike on Resident #1 happened within 45 seconds of each and her thought was to get the resident away from NA #1 as quickly as possible. NA #1 stated in retrospect, she should have stopped care with the resident after the first strike on Resident #1, removed NA #2 from the room, and reported the incident to the Unit Manager. NA #2 was unavailable for interview.The Director of Nursing (DON) stated on 4/22/26 at 2:00 PM NA #1 and NA #2 should have stopped providing care to the resident when she became agitated. She added NA #1 should have asked NA #2 to leave the residents room after the first strike on the resident and reported the incident to her nurse. On 4/22/26 at 2:00 PM the Administrator was interviewed. The Administrator stated on 4/14/26 the Unit Manager and NA #1 reported to him that NA #2 had struck Resident #1 three times during the provision of care. The DON told the Unit Manager to remove NA #2 from the hall and bring her to their office. The Unit Manager then immediately completed a skin assessment on Resident #1. The Administrator stated the skin assessment of Resident #1 found no new signs of bruising or redness on the resident. When NA #2 arrived in their office, the DON asked NA #2 to write a statement about the incident. NA #2 said that nothing had happened then the DON told NA #2 that an allegation of abuse had been made and NA #2 was not able to work until the investigation was completed. The DON then escorted NA #2 out of the building. The Administrator then stated NA #1 told him and the DON, that NA #1 And NA #2 were performing care to Resident #1. NA #1 said Resident #1 tried to bite NA #2 and she told the resident, You're not going to hit or bite us, and then NA #2 placed her hand over the mouth of Resident #1. The Administrator said NA #1 said she was in shock but did not stop providing incontinence care. NA #1 then reported she sat the resident up at the edge of the bed, to put her shirt on and Resident #1 swung her arms at NA #1. The Administrator stated NA #2 then made contact with her open hand on the left side of the resident's face. Care continued, and Resident #1 continued to have behaviors when NA #1 was transferring the resident from bed to chair, and NA #2 made contact with her open hand on the back of the resident's head. NA #1 then removed Resident #1 from the room away from NA #2 and reported it to the Unit Manager. The Administrator said once the skin assessment was completed, the resident was placed at nursing station to be visible, and the resident was in a good mood and no signs of distress. The Residents family, physician, police, and Adult Protective Services (APS) were all notified and the state initial report was sent to the state. The Administrator added the abuse allegation was unsubstantiated because the resident did not remember what happened, there were no visible marks or bruises on the resident, and NA #1 was the only witness to say the resident was hit by NA #2, and he was unaware if there had been any prior disagreement between the two NA's . Furthermore, NA #1 and NA #2 should have stopped providing care when the resident became combative, told a nurse and attempted to provide care later. NA #1 should have removed NA #2 from the resident's room after the first strike to protect the resident and reported it to the Unit Manager. The Administrator said NA #2 was terminated from the facility on 4/20/26 because of other work-related issues not related to the abuse allegation.

Based on record review, Responsible Party, Medical Director, and staff interviews, the facility failed to ensure a safe and orderly discharge when the facility failed to remove a midline catheter (a long peripheral intravenous catheter, typically 6-15 centimeters in length, that is inserted into a large vein in the upper arm or forearm) before discharging a resident home for 1 of 3 residents reviewed for discharge (Resident #229). The findings included: Resident #229 was admitted to the facility 11/11/24 with diagnoses that included dysphagia and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #229 had moderate cognitive impairment. A review of Resident #229's physician orders revealed an order dated 12/10/24 that read in part; midline [catheter] to be placed one time a day for hydration. Resident #229 had a physician's order dated 12/11/24 for an intravenous solution of one liter of normal saline at 75 milliliters (ml) per hour given one time on 12/11/24 for hyponatremia. A review of Resident #229's discharge summary dated 12/20/24 and signed by Nurse #1 revealed no devices including a midline catheter were indicated. The discharge summary revealed that there were no orders that required a midline IV access upon discharge. A telephone interview with Resident #229's Responsible Party (RP) occurred on 5/7/25 at 9:37 AM. He stated on the day of Resident #229's discharge, he received medications from the nursing staff and took Resident #229 home. The RP could not remember what education he received before discharge from the nursing staff. He stated when Resident #229 arrived home, she (Resident #229) pointed to her right arm to the midline IV still in place. The RP stated he called the facility and made them aware of the IV that remained in Resident #229's arm. An interview conducted with Unit Manager #1 on 5/7/25 at 12:02 PM revealed Resident #229 had a midline IV in place while she was at the facility. He stated he could not recall the specifics of Resident #229's discharge but stated generally when residents were discharged , an assessment would be completed beforehand and if there was no need for an IV after discharge, the midline catheter would be taken out. Unit Manager #1 also indicated all education was typically completed with residents and families before discharge. An interview with Nurse #1 on 5/7/25 at 2:21 PM indicated the discharge for Resident #229 was rushed due to her wanting to go home and could not recall what education had been given to Resident #229 and her RP. He did not recall if Resident #229 had an IV when he discharged her on 12/20/24. Nurse #1 stated he later found out that the Director of Nursing (DON) went to Resident #229's home after her discharge to remove the midline catheter that was left in place. An interview with the Therapy Director on 5/7/25 at 11:45 AM revealed he worked with Resident #229 after her admission to the facility and she experienced an acute decline which ended her rehabilitation stay and she wanted to return home. He stated he worked with the Discharge Planner on the needed durable medical equipment she needed to be successful at home. The Therapy Director explained all resident discharges were discussed at the interdisciplinary team (IDT) meetings each week. An interview with the Discharge Planner occurred on 5/7/25 at 3:00 PM. She started discussing discharge planning at the care plan meeting with each resident. The Discharge Planner stated when therapy is coming to an end, she discusses what type of equipment is needed for discharge or any other resources required after the resident's facility stay. She stated IDT meetings were held twice a week and upcoming discharge needs from therapy, nursing, and discharge planning were discussed then. An interview conducted with the Director of Nursing (DON) on 5/7/25 at 3:12 PM revealed Resident #229 had a midline catheter while at the facility. The DON stated nursing staff alerted her that Resident #229 was discharged home with the midline catheter in her arm. She could not recall which staff member informed her. The DON stated she went to Resident #229's home and removed the midline catheter later that day on 12/20/24. She stated the midline catheter should have been removed during an education session with Resident #229 and her RP before she discharged home because she no longer required the IV fluids for hyponatremia. An interview with the Medical Director on 5/7/25 10:35 AM revealed she did not recall Resident #229's discharge but stated if the midline catheter was in place, it should have been removed before she left the facility and was an oversight by nursing staff in this instance. An interview with the Administrator was conducted on 5/7/25 at 3:36 PM. He stated the midline catheter in Resident #229's arm should have been removed by nursing staff prior to discharge.

Based on record review and staff interviews the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II for a resident with a level II PASRR that expired prior to admission to the facility. This deficient practice occurred for 1 of 2 residents reviewed for PASRR (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Review of the PASRR level II dated [DATE] revealed it expired on [DATE] prior to Resident #43's admission to the facility [DATE] and a level II PASRR had not been obtained since admission. An interview conducted with the Assistant Discharge Planner [DATE] at 11:24 AM revealed she had been working at the facility for approximately four months. She indicated when a resident was admitted to the facility the PASRR was completed by the hospital prior to admission. The Assistant Discharge Planner stated she used the Medicaid Uniform Screening Tool (MUST) to access the completed PASSR and then entered it into the resident's electronic medical record (EMR). The Assistant Discharge Planner revealed she was unaware Resident #43 had a level II PASRR that expired, she thought it was a PASRR level I, and did not obtain a new PASRR level II for Resident #43. An interview with the Discharge Planner on [DATE] at 10:45 AM revealed she and the Assistant Discharge Planner were responsible for monitoring and completing all level II PASRRs. She stated the Assistant Discharge Planner reviewed Resident #43's PASRR when she was admitted but was unaware the PASRR was a level II that had expired. The Discharge Planner indicated a level II PASRR should have been obtained for Resident #43 but was overlooked. During an interview with the Administrator on [DATE] at 5:35 PM he revealed the Discharge Planner and Assistant Discharge Planner were responsible for monitoring and ensuring all level II PASRRs were obtained. He stated if a resident was admitted with a PASRR level II that was expired then a new level II PASRR should be obtained.

Based on record review, resident and staff interviews, the facility failed to provide a bagged meal or snack for 1 of 1 resident reviewed for dialysis (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included stage 5 chronic kidney disease. Resident #83's admission assessment dated [DATE] indicated she was cognitively intact and oriented to person, place, time and situation. The admission Minimum Data Set (MDS) was in progress and no information was available. A physician's order dated 5/01/25 revealed Resident #83's dialysis treatments were Mondays, Wednesdays, and Fridays at 12:25 PM. An interview conducted with Resident #83 on 5/06/25 at 12:30 PM revealed she was admitted to the facility from the hospital on 5/01/25 for short term rehabilitation. She stated during her hospital stay she started dialysis treatments and was continuing treatments at an outpatient dialysis center on Mondays, Wednesdays and Fridays. Resident #83 revealed the facility transported her to the dialysis center on 5/02/25 and 5/05/25, and she left the facility at 11:15 AM and returned around 5:00 PM. She indicated she had breakfast at 8:00 AM before she left for dialysis but was starving when she returned to the facility. Resident #83 revealed a bagged lunch was not provided and she was unsure if that was something the facility offered but it would be nice to have on the days she went to dialysis. During an interview with the Dietary Manager on 5/06/25 at 4:56 PM she indicated bagged lunches were prepared and kept in the kitchen for residents that went to dialysis. She stated nursing staff were responsible for getting a bagged lunch from the kitchen to send with the resident to dialysis. The Dietary Manager revealed she was unaware a bagged lunch was not sent with Resident #83 to dialysis and was unsure as to why because a bagged lunch was prepared and available in the kitchen on 5/02/25 and 5/05/25. An interview conducted with Nurse Aide #1 (NA) on 5/07/25 at 9:00 AM revealed she was assigned to Resident #83 on 5/02/25 and 5/05/25. NA #1 stated when one of her assigned residents was going to dialysis, she was responsible for getting a bagged lunch from the kitchen to send with the resident. NA #1 indicated on 5/02/25 and 5/05/25 Resident #83 went to dialysis without lunch because she forgot to get her bagged lunch from the kitchen. An interview conducted with the Medical Director on 5/07/25 at 9:50 AM indicated Resident #83 not having lunch when she went for dialysis was not ideal, however she would not have any adverse outcomes. The Medical Director stated a bagged lunch should be provided and sent with Resident #83 on the days she went for dialysis treatment. An interview conducted with the Administrator on 5/06/25 at 5:45 PM indicated bagged lunches were prepared and available for residents on the days they went to dialysis and should be sent with the resident.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #53. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (Treatment Nurse). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: - When coming on duty. - Before and after assisting a patient with personal care (e.g., oral care, bathing). - Before and after changing a dressing. - After any contact with potentially contaminated materials (used wound/treatment dressings). A wound observation was made on 05/07/25 at 9:54 AM on Resident #53 with the Treatment Nurse. The Treatment Nurse was observed cleaning the bedside table with disinfectant wipe and placed her wound supplies on the table after it dried. The Treatment Nurse washed her hands in Resident #53's bathroom using soap and water, then donned a clean gown and clean gloves. She then removed the old dressing from the residents left posterior thigh and placed the soiled dressing into the trash can. The Treatment Nurse went into Resident #53's bathroom and washed her hands. She then, donned a clean pair of gloves and proceeded to clean the area around the wound with a wound care solution. She applied skin prep to the outer portion of the wound, then doffed her gloves without sanitizing her hands, donned clean gloves and packed the wound with a wet to dry dressing packing the gauze into the residents wound with her finger and a Q-tip. She then doffed her gloves and without sanitizing her hands, donned clean gloves and moved to Resident #53's second wound located on the left thigh. She cleaned the wound with skin prep and applied Calcium Alginate to the area with a dry dressing. The Treatment Nurse then doffed her gloves and without sanitizing her hands, donned clean gloves to assist Resident #53 adjust her pants back up in the correct position and placed a wedge under the residents left side. She then doffed her gown, washed her hands with soap and water, collected her supplies and trash and wiped down the table and left the resident's room. An interview conducted on 05/07/25 at 10:20 AM with the Treatment Nurse revealed she was not aware that she had not sanitized her hands each time she had doffed her gloves. She stated she had to change gloves so much during the wound care that she must have forgotten to always sanitize her hands when she removed her gloves. The Treatment Nurse further stated she knew she was supposed to always sanitize her hands when she removed her gloves each time and before putting on clean gloves and typically had hand sanitizer with her in the room however she was just nervous. An interview conducted on 05/07/25 at 10:38 AM with the Infection Preventionist (IP) revealed she was not aware of the errors made by the Treatment Nurse during wound care. She stated her expectation was that she would sanitize her hands every time that she removed her gloves and before putting on clean gloves during wound care. The IP further stated staff received education on infection control annually and multiple times during the year. An interview on 05/07/25 at 1:03 PM with the Director of Nursing (DON) revealed she was aware of the Treatment Nurse's errors during wound care and said she had been provided with additional education regarding doffing and donning and sanitizing in between glove changes. The DON stated it was her expectation that the Treatment Nurse follow infection control best practices to avoid introducing microorganisms into the wounds. She further stated there was a lot of donning and doffing and she felt the Treatment Nurse had just become nervous during the observation. An interview on 05/07/25 at 3:35 PM with the Administrator revealed he would expect the Treatment Nurse to follow the Hand Hygiene policy for wound care.

Based on observations, record reviews, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when the Wound Nurse failed to don a gown before entering residents' room to provide care for Resident #1 who was under transmission-based precautions. The deficient practice occurred for 1 of 2 staff members observed for infection control practices. The findings included: Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 03/26/2024 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. On 10/02/24 at 11:28 AM an observation was made of Wound Nurse #1 entering Resident #1's room to provide wound care. Resident #1 was under EBP for a wound located on her sacrum. The EBP signage located on Resident #1's door instructed staff to wear a gown and gloves during high contact resident care activities such as changing briefs or assisting with toileting and wound care for chronic wounds. Gowns were available across the hall from the resident's room in a three-compartment container. She was observed entering the resident's room, performing hand hygiene and applying gloves. Wound Nurse #1 provided incontinence care for Resident #1 and completed Resident #1's wound care. Wound Nurse #1 was observed with gloves on and changed them according to their handwashing policy and procedure but did not wear a gown while providing wound care or changing Resident #1's brief. An interview was conducted on 10/02/24 at 11:50 AM with Wound Nurse #1. Wound Nurse #1 was asked if Resident #1 was under any kind of precautions and replied yes, Enhanced Barrier Precaution's which meant she needed to wear a gown and gloves before entering the resident's room. Wound Nurse #1 stated she would typically wear a gown while providing wound care however had just forgotten to put it on. She stated she would normally put on a gown while providing any wound care in the building. On 10/02/24 at 12:35 PM during an interview with the Director of Nursing (DON) she stated all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned PPE. The interview revealed Wound Nurse #1 should have worn a gown while providing incontinence care and wound care for Resident #1.

Based on record reviews and staff interviews, the facility failed to remove expired food items, date open and perishable foods stored in 1 of 1 reach-in cooler and 1 of 1 walk-in freezer and ensure steamer pans were not stacked wet for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents. The findings included: The facility's kitchen was toured on [DATE] at 10:20 AM. An observation was conducted of the reach-in cooler and the following was observed: a. A container of vanilla pudding was noted with a creation date of ,d+[DATE] (no year). The expiration date was noted to be ,d+[DATE] (no year). b. A container of cantaloupe was noted with an expiration date of [DATE]. c. A container of tuna salad was noted with an expiration date of [DATE]. d. A container of pineapple pieces was noted without a creation date or expiration date. e. A second container of tuna salad was noted without a creation date or expiration date. f. A container of lettuce salad was noted without a creation date or expiration date. g. A container of shredded cheddar cheese was noted without an open date or expiration date. h. A container of chicken noodle soup was noted without a creation date or expiration date. i. Two trays of various sandwiches were noted to be individually wrapped and no sandwiches had a creation date or expiration date. An observation of the walk-in freezer was conducted [DATE] at 10:30 AM. A bag of chicken meat was noted to be stored open and no open date was on the bag. The dishwashing area was observed on [DATE] at 10:35 AM, and a shelving unit was noted in the drying area. Three steamer pans were noted to be wet with dripping water and were stacked on top of each other and nestled. During the observations, the Dietary Manager (DM) reported that all expired food should have been discarded on [DATE], the food labeled with the creation and the expiration date, the bag of chicken should have been closed and labeled, and the clean steamer pans should have been allowed to air dry completely before they were stacked and nestled together. The DM reported no staff had checked on the reach-in cooler or freezer that date. An interview was conducted with Cook #1 on [DATE] at 12:31 PM. Cook #1 explained he had worked on [DATE] and he had made the trays of sandwiches for the facility on that date. Cook #1 reported he was aware he should have labeled the sandwiches with the creation date and the expiration date, but he had forgotten because he had been busy. Cook #1 explained he did not check the reach-in cooler for expired food on [DATE]. The dietary aide who worked [DATE] was not available for interview. The DM was interviewed again on [DATE] at 1:29 PM. When asked about the date on the vanilla pudding, the DM reported he thought it was an error in labeling and that the vanilla pudding had not been in the reach-in cooler since March of 2023. The DM explained the dietary aides were responsible for checking the cooler, fridge, and freezer for expired items and he was not certain why the expired food in the reach-in cooler was not discarded, and why the food was not labeled in the reach-in cooler or freezer. The DM reported he thought that staff were rushing to complete their work and did not allow the steamer pans to dry completely before stacking. The Administrator was interviewed on [DATE] at 3:01 PM. The Administrator reported the dietary staff should discard expired items, label perishable foods, and allow all dishes to dry before stacking for storage.

Based on observations, staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation dated [DATE] for one deficiency in the area of dietary services F 812. Also, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following the complaint survey date [DATE] for one deficiency in the area of accurate medical records F 842. These deficiencies were cited during a recertification and complaint survey dated [DATE]. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F 812 Based on record reviews and staff interviews, the facility failed to remove expired food items, date open and perishable foods stored in 1 of 1 reach-in cooler and 1 of 1 walk-in freezer and ensure steamer pans were not stacked wet for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents During the recertification and complaint investigation date [DATE] the facility failed to date, remove, and/or discard food items stored for use with signs of spoilage, stored past the use by date and/or stored open to air in 1 of 1 walk in cooler, 1 of 1 walk in freezer, and 1 of 1 dry storage area. These practices had the potential to affect residents served this food. F 842 Based on a resident interview, staff interviews and record review, the facility failed to accurately document an allergy (Resident #281) and the amount of nutritional supplement provided during medication administration (Resident #2). This failure occurred for 2 of 2 sampled residents reviewed for accuracy of the medical record. During the complaint investigation date [DATE] the facility failed to document in the medical record the effectiveness of pain medication administered. This occurred for 1 of 1 sampled resident reviewed for pharmaceutical services. Interview was conducted with the Administrator on [DATE] at 2:45 pm about his repeat tag for the kitchen. He indicated that he expected all citations to be monitored through the center's QAPI program. Any repeat citation would require continuous monitoring through the monthly QAPI meetings until the deficient practice has been resolved. After resolved, the center would continue to monitor the resolved issue through its quarterly QAPI meetings. Education would be completed to ensure staff are aware of expectations and these expectations would be tracked by way of auditing.

Based on observations, a resident interview, staff interviews and record review, the facility failed to honor food preferences for 1 of 3 sampled residents reviewed for food preferences (Resident #281). The findings included: Resident #281 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus, iron deficiency anemia, gastroesophageal reflux disease and lipoprotein deficiency, among others. An admission Minimum Data Set assessment dated [DATE] (in progress) indicated her cognition was intact, she had clear speech, able to understand and be understood, required set up/clean up assistance with meals and no weight loss/gain. A care plan revised 1/22/24 identified Resident #281 was at risk for nutritional decline related to a recent hospitalization , adjustment to a new environment, and diagnoses. Interventions included encouraging good food intake, recording the percentage of food eaten, and reviewing food preferences with the resident as needed. Food intake records from 1/17/24 - 1/24/24 documented that Resident #281 ate an average of 51 - 75% of her meals provided by the facility. Resident #281 was interviewed and observed in her room on 1/22/24 at 11:15 AM, during the interview, she expressed that her food requests were not honored. Resident #281 stated that when she completed the menu to request her meal preferences for the next day's meals, she rarely received food according to the menu she completed. She stated that when staff came to pick up her meal tray after the meal, they did not offer an alternate when she expressed that she did not receive her preferences, staff just removed her meal tray. Resident #281 was observed with her lunch meal and interviewed on 1/24/24 at 12:00 PM. Resident #281 received spaghetti with meat sauce, garlic bread, orange sherbet, and lemonade. The lunch meal tray card on her meal tray revealed buttered egg noodles were also circled as a request. Resident #281 stated that when she completed her menu for the lunch meal for 1/24/24, she circled buttered egg noodles and wrote corn on her menu to give herself some additional items she could eat in case she did not like the spaghetti. Resident #281 stated she did not receive the buttered egg noodles or the corn. Resident #281 stated she wanted the egg noodles and the corn, but when she asked staff about those items, she was told it was not available. Resident #281 stated I don't receive my preferences 90% of the time and when I ask, staff say, we are out of that. Resident #281 stated that last week she completed her menu and asked for salad dressing, but she received a salad with no dressing, so she used a pack of dressing she brought from the hospital. The Dietary Manager (DM) was interviewed on 1/24/24 at 1:56 PM. He stated that the residents were given a menu to complete each day to select the food items they want to eat and that the tray card for each meal was based on the resident's food preferences that were obtained on admission. He stated that if a resident wrote in a request on the menu they received, and it was available, the dietary staff would prepare it for the resident. He stated that dietary staff provided the menus daily between 3 PM - 4 PM and picked up the completed menus from nursing staff around 6 AM the next morning. He stated that the menu tickets were discarded daily so he did not have them available for review. The DM stated he could not explain why Resident #281 did not receive the items per her preference (buttered egg noodles, corn, salad dressing) because those items were available. An interview with dietary aide (DA) #1 occurred on 1/25/24 at 12:40 PM. DA #1 stated she plated the lunch meal on the unit where Resident #281 resided. DA #1 stated she did not provide buttered egg noodles or corn to Resident #281 for lunch on 1/24/24 because she did not have them available to serve. DA #1 stated that she had the pasta that was served with the spaghetti so that's what she served Resident #281. She stated mixed vegetables were also available, but that she did not offer Resident #281 a substitute for the corn. A follow up interview with the DM occurred on 1/25/24 at 1:43 PM. He stated that the DA should have called the kitchen to notify him if there were food items that residents requested but she did not have available once she got on the unit to serve. The DM stated the foods Resident #281 requested were available and had he been notified; he would have made sure those items were provided. A phone interview with the Registered Dietitian (RD) occurred on 1/25/24 at 3:40 PM. The RD stated that the DA should go to the kitchen to get any food requested by a resident if those foods were available. The RD stated that she expected the DM to follow up on any food concerns that were brought to his attention regarding honoring resident food preferences. The Administrator stated in an interview on 1/25/24 at 2:18 PM that the facility should honor resident food preferences or let the resident know if the request was something that the facility did not have and then try to accommodate the request with something comparable.

Based on a resident interview, staff interviews and record review, the facility failed to accurately document an allergy (Resident #281) and the amount of nutritional supplement provided during medication administration (Resident #2). This failure occurred for 2 of 2 sampled residents reviewed for accuracy of the medical record. The findings included: 1. Resident #281 was admitted to the facility from the hospital on 1/16/24. Diagnoses included type 2 diabetes mellitus, and diabetic neuropathy, among others. A hospital discharge summary dated 1/16/24 for Resident #281 recorded she had an allergy to the medication Metformin (used to treat type 2 diabetes mellitus). The January 2024 Medication Administration Record (MAR) for Resident #281 recorded she had an allergy to the medication Metformin. January 2024 Physician (MD) Order Summary recorded a MD order dated 1/17/24 for Metformin HCL (hydrochloride) tablet 500 mg, give 1 tablet by mouth two times a day related to type 2 diabetes mellitus with diabetic neuropathy. A nurse practitioner (NP) progress note dated 1/18/24 recorded Resident #281 had an allergy to the medication Metformin. A care plan revised 1/19/24 recorded Resident #281 had an allergy to Metformin. A MD progress note dated 1/19/24 recorded Resident #281 had an active allergy to Metformin. An admission Minimum Data Set assessment dated [DATE] (in progress) indicated her cognition was intact, she had clear speech, and she was able to understand and be understood. A NP progress note dated 1/22/24 recorded Resident #281 had an allergy to the medication Metformin. The NP progress note documented the plan for her diagnosis of type 2 diabetes mellitus was to monitor blood glucose levels every twice daily and continue prescription medication management with Metformin HCL 500 mg twice daily. Resident #281 stated in an interview on 1/25/24 at 12:43 PM that she was not allergic to the medication Metformin and that she took the medication at home with no problems. She stated that the NP asked her about continuing the medication while she was at the facility, and she told the NP she was not allergic, so the NP ordered it. Resident #281 stated that she did not know where that the documentation came from indicating that she was allergic to Metformin. The Director of Nursing (DON) stated in an interview on 1/23/24 at 1:02 PM that documentation of allergies was obtained from the hospital discharge summary and from pre-admission records. The DON stated Resident #281 was admitted from the hospital and reviewed her hospital discharge summary during the interview. The DON stated that the allergy to Metformin was recorded in the hospital discharge summary which was given to the MD/NP for review. The DON stated that the NP reviewed the hospital discharge summary for Resident #281, recorded in her progress note to continue the Metformin and wrote an order for it. The NP stated in an interview on 1/23/24 at 1:21 PM that she spoke to Resident #281 about the allergy to Metformin that was recorded in her hospital discharge summary because the hospital discharge summary indicated Metformin was a medication she took at home prior to the hospitalization . The NP said that Resident #281 said she was not allergic to Metformin and that she wanted to continue taking the medication while she received therapy at the facility, so the NP wrote the order. The NP stated she should have advised nursing staff to remove the allergy from her medical record and stated, Metformin needs to be removed from her medical record as an allergy for this patient. 2. Resident #2 was admitted to the facility on [DATE]. Diagnoses included dysphagia, elevated body mass index, vascular dementia with psychosis, mood disturbance and anxiety, among others. A progress note dated 1/22/24 by the Registered Dietitian (RD) recorded a recommendation to add a high calorie no sugar added nutritional supplement of 90 milliliters (ml) twice daily for additional calories and to prevent further weight loss. The January 2024 Medication Administration Record (MAR) for Resident #2 recorded to provide 90 ml of a high calorie no sugar added nutritional supplement twice daily. Nurse #1 recorded on the January 2024 MAR for Resident #2 that she provided 237 ml of the supplement at 9 AM and 5 PM on 1/24/24. An interview with Nurse #1 occurred on 1/25/24 at 12:30 PM. Nurse #1 stated that the MD orders for nutritional supplements kept changing. Nurse #1 stated that she provided Resident #2 with 90 ml of the supplement per the order, but that she documented 237 ml because she used a larger cup to provide the supplement. Nurse #1 stated that the documentation of 237 ml was an error. The RD stated in a phone interview on 1/25/24 at 3:37 PM that providing additional calories from a high calorie nutritional supplement to Resident #2 would not be a problem for this Resident due to her history of weight loss, but incorrect documentation of the amount of the nutritional supplement administered could cause a miscalculation of calories received during a nutritional assessment. The Director of Nursing stated on 1/25/24 at 1:30 PM in an interview that the medical record should be documented accurately; the nurse should record the amount of supplement given and should give the amount of nutritional supplement per the MD order.

Based on observations, record review, resident, staff, and family interviews the facility failed to ensure a resident was seated in a safe position on the bed after a transfer which resulted in a fall with femur fracture for 1 of 3 residents reviewed for accidents (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included stroke with hemiplegia and hemiparesis affecting the left side, vertigo, presence of left artificial knee joint and muscle weakness. A quarterly Minimum Data Set, dated dated dated [DATE] for Resident #19 revealed she was cognitively intact with no refusals or rejection of care. Resident #19 required extensive 2 person assist with transfers and bed mobility. Review of a fall note for Resident #19 authored by Nurse # 3 and dated 3/17/23 read in part: During a transfer using the sit to stand lift, the CNA positioned the patient on her bed and while removing the sit to stand the patient slipped off the side of the bed. Review of a nurse note for Resident #19 authored by Nurse # 3 and dated 3/18/23 read in part: the patient has a complaint of left knee pain. Nurse received a new order for x-ray of left knee related to pain from fall. Review of a left knee x-ray report for Resident #19 dated 3/19/23 revealed an acute, transverse, non-displaced fracture of the distal femur metaphysis (a portion of the femur close to the knee). Review of the hospital Discharge Summary dated 3/24/23 for Resident #19 read in part: the resident presented to the Emergency Department on 3/20/2023 for the evaluation of left knee pain following falling out of bed on 3/17/23. Xray of the left femur revealed possible impacted fracture comminuted displaced fracture involving the distal femoral metaphysis just above the femoral component of the total knee arthroplasty. Subsequent imaging confirmed moderately comminuted and mildly displaced periprosthetic fracture of the distal femur. Diagnoses: Displaced comminuted fracture of shaft of left femur. She underwent left femur open reduction internal fixation (a surgery to repair a broken bone) on 3/22/23 and the procedure was uneventful. Continue non-weight bearing on the left lower extremity (which is her baseline). The resident was discharged back to the facility on [DATE]. During an interview on 4/5/23 at 1:15 PM Resident #19 revealed a couple of weeks ago at night a Nurse Aide (NA) was helping her get ready for bed. She had been up in her wheelchair. The NA got her up from the wheelchair with the sit to stand lift and positioned her on the edge of the bed. Resident #19 stated as the NA was removing the sit to stand from her room, she felt like she was falling. She tried to hold the side rail but fell to the floor on her side. She explained she called to the NA and said, come back in here and help me. The NA came and saw her on the floor and went to get more staff to help get her up. Resident #19 revealed three staff members got her up from the floor with the mechanical lift. She stated her leg was hurting, but the nurse gave her something for the pain. She did not request to be sent to the hospital. An interview was conducted on 4/5/23 at 4:51 PM. Nurse #3 revealed she was assigned to care for Resident #19 on the night of her fall. She explained she had left the room after giving Resident #19 her medications, shortly after NA #1 came out in the hall and said Resident #19 had fallen. Nurse #3 did not witness the fall but was told by NA #1 she was getting the resident ready for bed and transferred her with the sit to stand lift from the wheelchair to the bed. She sat the resident on the side of the bed and as she was removing the sit to stand from the room, Resident #19 slid off the bed and fell to the floor. Nurse #3 further explained NA #1 said she thought Resident #19 was seated on the bed better than she was. Nurse #3 revealed when she went to the resident's room she was on the floor, lying on her right side. She completed a full head to toe assessment and took vital signs. Nurse #3 stated there was no bruising, redness, or open areas on the resident. Resident #19 was moved to her bed with the mechanical lift. She complained of pain in her left knee, and it had a small amount of swelling. Nurse #3 explained this resident had a history of left knee pain and the left knee normally had a little swelling related to a past surgery. She had given scheduled pain medication to the resident during medication pass, so at this time she offered an ice pack. She further explained the resident did not show any physical signs of pain, she did not grimace, moan or cry out in pain. Nurse #3 returned the following morning on 3/18/23 and asked Resident #19 how is your knee, and the resident said it still hurts. Nurse #3 revealed at that time she called the provider and obtained an order for an x ray because the resident was still experiencing pain. Nurse #3 explained the x-ray provider came and completed the x-ray on the evening of Sunday 3/19/23. On Monday morning 3/20/23 the facility received the results of the x-ray, and it revealed Resident #19 had a femur fracture. The family and Physician were notified, and the resident was sent to the hospital. During an interview on 4/6/23 at 9:07 AM NA #1 revealed on the evening of 3/17/23 she was putting Resident #19 back to bed from her wheelchair with the sit to stand lift. She sat the resident on the side of the bed, then began to back the sit to stand lift out of the resident's room. While backing the lift out of the room she saw Resident #19 slip off the bed. She saw the resident falling but could not get to her to prevent the fall because she was moving the sit to stand lift. NA #1 further revealed she went to get the nurse and while the nurse was with the resident, she went to get more staff to help get the resident off the floor. The mechanical lift was used to move the resident from the floor to the bed. NA #1 stated Resident #19 said her leg hurt but she did not notice any obvious injuries. An interview was conducted with the Director of Nursing (DON) on 4/6/23 at 12:29 PM. The DON revealed Resident #19 had a fall on Friday night 3/17/23, and she was made aware of the fall on Monday 3/20/23 when she returned to work. It was reported to her that NA #1 was transferring Resident #19 from the wheelchair to the bed with the sit to stand lift, and the resident was not seated well on the bed and fell to the floor. The DON stated she personally educated NA #1 on ensuring residents are seated properly and secure on the side of the bed prior to leaving their side. Education was also provided to the rest of the staff. The facility initiated a 4-point plan to prevent this from reoccurring. During an interview on 4/6/23 at 2:30 PM the Administrator revealed after he was made aware of Resident #19's fall, he spoke to the resident and staff members to identify a root cause. Based on his interview with Resident #19 and NA #1 the facility concluded that the root cause for Resident #19's fall was that she was not placed securely on the side of the bed, and this resulted in a fall. The Administrator stated after the facility identified the root cause for Resident #19's fall they put in place a 4-point plan to prevent reoccurrence. NA #1 had received 1:1 education, in addition all other nursing staff had been educated. The facility also implemented monitoring. The facility provided the following correctivce action plan with a completion date of 3/24/23. Corrective action plan: Resident #19 is a 77 y/o female who admitted to Huntersville Health and Rehab Center on 08/13/2016 status post stroke and is currently residing on the long-term care unit. Her medical history includes cerebral infarction, dysarthria, hemiplegia, hemiparesis, anemia, anxiety, vertigo, dysphagia, hypomagnesemia, muscle weakness, unsteadiness on feet, HTN, GERD, DM2, major depressive disorder, osteoarthritis, and hyperlipidemia. Overall, Resident #19 is alert and oriented to person, place, time, and situation, has a BIMs of 14, struggles with depression and anxiety, and has some age-related confusion. In terms of her functional status, she requires moderate to extensive assist for ADL's and mobility. On 3/17/2023, Resident #19 endured a witnessed fall from the edge of the bed, and on 3/18/2023 she reported having knee pain. The resident was assessed by the center's nurse and NP as a result x-rays were ordered. On 3/20/2023 X-ray results were reviewed and showed left acute, transverse, non-displaced fracture at distal femoral metaphysis. The family was updated on the x-ray results and the resident was sent to hospital for evaluation. The hospital confirmed the fracture and scheduled resident for an ORIF to left leg. On 3/20/2023, the Administrator met with Resident #19 and discussed the details of her fall from 3/17/2023. Resident #19 reported that the C.N.A had just finished sitting her on the edge of the bed with the sit to stand machine, however that she did not feel that she was on the bed good. The patient has a BIMs of 14 and was therefore able to recall the details of the event. When asked if she told the C.N.A. that she did not feel secure, she reported no. The resident went on to state the C.N.A. proceeded to leave the room with the machine but left her on the edge of the bed. She reported that she started to slide from the bed, hitting her knee on the floor. She then stated that she is normally able to sit on the edge of the bed, but this time she did not feel that she was on the bed good enough. The Administrator and DON interviewed the involved C.N.A and she reported that she had just finished transferring Resident #19 to the bed as normal, and that Resident #19 normally is able to sit on the edge of the bed without any issues. The root cause of this fall is that the patient was not on the bed securely. The root cause is not related to the actual transfer, or the use of the sit to stand equipment. The patient acknowledges through her recall of the event. How the facility is addressing the non-compliance for the resident affected: The CNA, upon witnessing the fall, immediately when to get the nurse. Resident #19 was assessed by nurse on duty and assisted to bed by mechanical lift and staff. The patient continued to be monitored, and offered her an ice pack, which was declined, patient had no complaints throughout the night. The patient continued to receive her normal doses of scheduled pain meds, unrelated to the fall. The patient, upon complaint of new pain the following morning, received intervention via x-ray and ultimately discharge to the hospital on 3/20/2023 around 9:40am for follow-up care. The CNA received education the following day, on 3/18/23 to ensure that patients are balanced before leaving the patients side after transfer. How the facility is addressing other current residents at risk All residents are at risk of this deficient practice. On 3/21, staff and residents were interviewed to determine who uses the sit to stand lift, it was determined that Resident #19 was the only current resident who was using the sit to stand. On 3/21, residents were asked to share any concerns related to how they are transferred, no concerns were voiced. Residents were asked 1) Have you had any concerns regarding how staff assist with your transfers? 2) Do you feel secure when staff are transferring you? Resident interviews included residents on the C.N.A track, residents who do not require use of mechanical lift, and residents who require use of mechanical lift. How the facility will ensure that noncompliance does not reoccur: Education was provided 03/21-03/24/2023. Current nursing staff were educated on ensuring patients are secure and balanced prior to leaving the patient's side, education provided by center leadership, by the SDC, DON, or designee. New employees will be educated by SDC or designee during the orientation process of this process as well. How the facility will monitor to ensure the noncompliance does not reoccur: DON or designee will monitor 5 patient transfers for security and balance before walking away weekly x 4; then 3x weekly; then monthly x 4. Any staff member observed to be non-compliant with the education will receive education and/or counseling, up to and including suspension and/or termination. The results will be reported to the monthly QAPI Committee for review and discussion to ensure substantial compliance. Once the QA Committee determines the problem no longer exists, then the review will be completed on a random basis. Date of completion 03/24/2023 The person responsible for implementing this plan is the Administrator. The facility provided a plan of corrective action for the incident that happened on 3/17/23. Validation was completed through observations, staff interviews, and record review. Observations were made of residents seated or positioned safely in their beds and in wheelchairs. Multiple observations were made of Resident #19 positioned safely in her bed. Interviews with nurses and nurse aides stated they had recently received education on ensuring the residents are seated in safe and secure positions before leaving the resident's side. A review of monitoring tools revealed the facility was conducting ongoing audits to ensure the residents were being seated in safe positions. The facility's action plan was validated to be completed as of 3/24/23.

Based on staff interview and record review, the facility failed to document in the medical record the effectiveness of pain medication administered to Resident #18. This occurred for 1 of 1 sampled resident reviewed for pharmaceutical services. The findings included: Resident #18 admitted to the facility 2/13/23. Diagnoses included fracture of left pubis, and osteoarthritis of left hip, among others. A physician order dated 2/13/23 recorded Hydrocodone-Acetaminophen tablet 5-325 milligrams (MG), give one tablet by mouth (po) every (q) 6 hours as needed (prn) for pain for 30 days. The order discontinued on 2/17/23. A physician order dated 2/13/23 recorded Acetaminophen Extra Strength tablet 500 MG, give two tablets po q eight hours prn for pain. A physician order dated 2/17/23 recorded pain assessment using 0-10 scale, q day and night shift. A physician order dated 2/17/23 recorded Hydrocodone-Acetaminophen tablet 5-325 MG, give one tablet po q six hours for pain. An admission Minimum Data Set, dated dated dated [DATE] assessed Resident #18 with clear speech, intact cognition, experienced frequent pain in the last five days, rated seven out of ten at assessment, and received pain medication scheduled and prn. Review of the Medication Administration Record (MAR) for February 2023 recorded Resident #18 received the following: - 2/14/23, 8:25 AM Hydrocodone-Acetaminophen tablet 5-325 MG; pain rated eight out of ten. - 2/14/23, 3:55 PM Hydrocodone-Acetaminophen tablet 5-325 MG; pain rated nine out of ten. - 2/21/23, 12 AM Hydrocodone-Acetaminophen tablet 5-325 MG; pain rated six out of ten. - 2/21/23, 8 AM Hydrocodone-Acetaminophen tablet 5-325 MG; pain rated eight out of ten. Review of the February 2023 MAR and nurse progress notes revealed there was no documentation that the pain medication was effective after administration. During a phone interview with Nurse #1 on 4/5/23 at 5:00 PM Nurse #1 stated that she was the Nurse for Resident #18 on 2/14/23 for the 7 AM - 7 PM shift. Nurse #1 stated when she came on shift, Resident #18 complained of pain, and rated her pain an eight out of ten, so she medicated her. Nurse #1 stated she followed up with Resident #18 and the Resident said the medication was effective. Nurse #1 stated it was quite possible that she did not put a note in her record about that. Nurse #1 stated that later in the shift, she assessed Resident #18's pain and it was a nine out of ten, which could have been after therapy, so she medicated her again. When Nurse #1 followed up, Resident #18 rated her pain six out of ten, and said her pain had improved. Nurse #1 stated she knew to assess and document the effectiveness of pain management but could not explain why there was no documentation for the effectiveness of the pain medication she administered to Resident #18 on 2/14/23. Nurse #2 stated on 4/10/23 at 12:19 PM during a phone interview that she was the Nurse for Resident #18 on the 7 PM - 7 AM shift on 2/21/23. Nurse #2 stated it was her practice to assess for pain during her rounds and medication pass. After administration of pain medication, Nurse #2 stated it was her practice to return and assess the effectiveness. Nurse #2 stated could not really say why she did not document the effectiveness of pain medication after administration to Resident #18 because she could not remember what happened that night. Nurse #2 stated she knew to assess pain level at the time of administration of pain medication and to reevaluate the effectiveness. The Director of Nursing stated on 4/6/23 at 12:30 PM that she expected nurses to assess the effectiveness of pain medication during the same shift of administration and document the effectiveness in the resident's medical record.

Based on record review, Medical Director and staff interviews, the facility failed to ensure the resident had an order for use of a Continuous Positive Airway Pressure (CPAP) machine with oxygen for 1 of 2 residents reviewed for providing respiratory care. Findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). A review of Resident #5's hospital discharge orders dated 9/28/22 revealed he needed CPAP with oxygen at 2 liters continuously while sleeping. The hospital discharge summary stated to not discontinue the oxygen concentrator. A review of Resident #5's admission orders dated 9/28/22 did not indicate an order for CPAP with oxygen at 2 liters per minute continuously while sleeping. A review of Resident #5's interim care plan dated 9/28/22 revealed Resident #5 was not care planned for CPAP with continuous oxygen during sleeping. A review of the discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #5 was cognitively intact. The MDS documented he had shortness of breath while lying flat. An interview with Nurse #1 on 12/29/22 at 2:54 PM revealed she was the admitting nurse for Resident #5. Nurse #1 stated she did not recall Resident #5 very well but believed he was alert and oriented and had a CPAP in his room upon admission but needed an oxygen concentrator to hook up to it. Nurse #1 was unaware if Resident # 5 had an order for CPAP when he was admitted to the facility. Nurse #1 said the Admissions person reviewed the discharge information for each resident and then sent the discharge summary to the admitting nurse to enter orders and have them verified by the MD. Nurse # 1 stated the order for the CPAP indicated on the discharge summary should have been added to Resident # 5's admitting orders. A review of the Medical Director (MD) progress note dated on 9/30/22 indicated Resident #5 was alert and oriented to both year and place and denied any shortness of breath or cough. The resident indicated he needed a concentrator for his CPAP. The DON was aware of his need for a concentrator and was obtaining one at that time. Attempts to interview previous DON were unsuccessful. The MD was interviewed on 12/30/22 at 9:33 AM and stated she believed Resident #5 had a CPAP in his room but not an oxygen concentrator in his room when she saw him on 9/30/22. The MD stated Resident #5 indicated to her on 9/30/22 that he needed a concentrator for his CPAP and that the Director of Nursing was aware and was getting a concentrator for him. The MD stated typically resident families will provide a CPAP for residents who need one and if the family does not have one, the facility will rent a CPAP to the resident. Normally, the admitting nurse would add the CPAP orders to the Medication Administration Record (MAR) based upon the hospital discharge summary. The MD recalled Resident #5 was alert and oriented and was able to set up the CPAP himself. Resident #5's oxygen saturation levels were within normal range for a diagnosis of COPD with his lowest registered at 88. The MD stated his blood pressure was good and he had no difficulty with his breathing. Resident #5 would have benefited from using the CPAP without the oxygen concentrator hooked to it. The current Director of Nursing (DON) and Administrator were interviewed on 12/30/22 at 1:07 PM. They stated the admissions person received the orders from the hospital and then gave them to the unit manager to place into the MAR and verify them with the facility provider. The order for the CPAP should have been placed on the MAR.

Based on staff interviews and record review, the facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours for 1 of 2 sampled residents reviewed for abuse investigations (Resident #11). The findings included: The facility policy, Abuse, Neglect, Misappropriation, Crime, effective 1/23/20, recorded in part, Any and all suspected or witnessed incidents of patient abuse, neglect, theft and/or exploitation or any reasonable suspicion of a crime against a patient brought to the attention of the Center's Administration will result in internal investigation, appropriate and timely reporting to the State Survey Agency and other legally designated agencies as well as staff corrective action. Resident #11 was admitted to the facility 7/7/22 and discharged home on 8/4/22. Review of Resident #11's Resident Property List, dated 7/7/22, recorded that Resident #11 had $2205 at the time of his admission to the facility, preferred to keep the money and have a family member come pick it up. A 24-hour Initial Abuse Report, dated 8/4/22 (Thursday), recorded that Resident #11 alleged on the morning of 8/4/22, he had $2000 taken from him and that he was upset that he was not able to locate the money. The Report recorded the allegation was reported to law enforcement on 8/4/22 at 12:30 PM. The Report was signed by the prior Director of Nursing (DON) on 8/8/22 (Monday). Review of the fax confirmation revealed the 24-hour Initial Abuse Report was faxed to the state agency on 8/9/22 (Tuesday) at 12:17 PM. Review of a written statement by Nurse #2 dated 12/30/22 recorded that Resident #11 reported to staff on 8/4/22 that he had approximately $2000 the night before, but that on the morning of 8/4/22 his money was no longer in his bag of belongings. A telephone interview with prior DON on 12/30/22 at 1:30 PM revealed when Resident #11 discharged home from the facility on 8/4/22, Resident #11 alleged that $2000 was taken from him. Resident #11 stated that he had his money the night before, but that now the money was no longer in his bag. The DON stated that she began the investigation and spoke to his family who confirmed that Resident #11 often sold his personal belongings and kept large sums of cash. The DON further stated that she thought that was also the day she left the facility immediately after obtaining a positive COVID 19 test result. She stated she failed to delegate the task of faxing the 24-hour Initial Report to the state agency and did not fax it until 8/9/22. A telephone interview with the prior Administrator on 12/30/22 at 1:15 PM revealed he was notified of the allegation of misappropriation of resident property on 8/4/22, but that he did not fax the 24-hour Initial Report to the state agency as he expected the DON to complete that task. The current Administrator stated in interview on 12/30/22 at 1:05 PM that he spoke to the prior DON regarding the allegation of misappropriation of resident property for Resident #11 and she informed him that the incident occurred over the weekend, that she was notified on Monday 8/8/22 so she submitted the 24-hour Initial investigation to the state agency the next day. The Administrator stated when an allegation of missing property was reported to the facility, he expected staff to notify the unit manager, the DON and Administrator immediately. He expected the DON and/or Administrator would complete the investigation and submit a 24-hour Initial Report to the state agency per the facility policy.

Based on record review, staff, Medical Doctor, and Nurse Practitioner interviews the facility failed to follow their abuse policy in the areas of reporting, notification, assessment, and investigation procedures for (Resident # 5 and Resident #284) for 1 of 1 facility abuse investigations reviewed. The Findings Included: Review of the facility policy titled Abuse, Neglect, Misappropriation/ Crime with a effective date of 11/01/19, revealed the following: Policy: A licensed nurse will immediately respond to all allegations and/or reasonable suspicions of staff to patient, patient to patient, and/or visitor to patient, abuse, neglect, mistreatment, exploitation or any misappropriation of patient property or crime against a patient. 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of a patient property are to be reported immediately but (a) no later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or result in serious bodily injury or (b) no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 5. A licensed will closely monitor and document thoroughly the behavior and condition of the patient involved to evaluate any injury. 6. For all patients involved in the incident, a licensed nurse must notify the following: a.) Attending Physician b.) Responsible Party 10. The Administrator or his/her designee must immediately initiate an investigation. This investigation includes interviewing all staff involved (directly and indirectly), and family involved, all patients involved, and any visitors involved. An interview was conducted on 6/8/22 at 10:43AM with Resident # 5 which revealed a man came into her room and scared her to death. She further stated he got over beside the table and reached for my arm. She stated she started screaming. She stated she did not want to get anyone in trouble. Review of Resident # 5's most recent MDS dated [DATE] revealed she was cognitively impaired. An interview conducted on 6/9/22 at 10:23AM with Resident #284 revealed he does get turned around in the building. He further revealed he remembered going into another room but does not remember anything else. Review of Resident #284 most recent Admission MDS (in progress) dated 6/2/22 revealed he was a wanderer and cognitively impaired. An interview conducted on 6/8/22 at 2:47PM with Resident #72's responsible party (RP) revealed Resident #72 had called her and stated a man was wandering around the facility and he raped someone. An interview with Receptionist (Service Ambassador) # 1 on 6/7/22 at 10:04AM revealed she received a call from Resident #72 responsible party last week (the week of 5/30/22). She further revealed the RP expressed concerns her mother (Resident #72) had told her someone had been assaulted or raped. She stated she told Resident #72 responsible party (RP) she would let the facility know, and someone would take care of it. She revealed she reported it to the MDS Nurse #1. An interview with MDS Nurse #1 on 6/7/22 at 10:01AM revealed last week Resident #72 daughter called and asked to speak with a service ambassador. She further stated during the phone call the RP was concerned because her mother (Resident #72) had called and told her an assault or rape had occurred at the facility. The MDS Nurse #1 stated she reported it immediately to Unit Manager #2 to investigate. On 6/7/22 at 9:55AM an interview was conducted with Unit Manager # 2 She revealed she did not speak with the nurse assigned to these residents. The Unit Manager #2 revealed she reported it to the DON and was only responsible for asking the questions to the alert and oriented residents. An interview was conducted on 6/6/22 at approximately 2:15PM with the Director of Nursing (DON). The Director of Nursing revealed there was an incident reported regarding Resident #284 wandering and she had some of the information regarding the incident. She further revealed Unit Manager #2 was not scheduled to work today and she would provide the additional information tomorrow. By the end of the day the DON provided Unit Manager #2 statement and a handwritten note. The DON revealed the facility had interviewed the alert and oriented residents and obtained the Unit Manager #2 statement. She stated Regional Nurse Consultant #1 concluded no body checks or 24 hour/5 day report was needed. On 6/7/22 at 3:30PM an interview with Regional Nurse Consultant #1 and DON was conducted. The Regional Nurse Consultant #1 revealed the DON called her after the in-house investigation had been completed. She further stated after the discussion she decided there was nothing to report. She revealed she was not aware of any conversations Resident #5 had concerning someone hurting her. The DON stated the wound care nurse practitioner did a head-to-toe assessment on Resident #5 on 6/1/22. An interview conducted on 06/08/22 02:36 PM with Wound Nurse Practitioner revealed she did not perform a head-to-toe assessment on Resident #5 on 6/1/22. She further revealed she provided assessment only to the wound she was treating. An interview was conducted with Unit Manger #2 on 6/7/22 at 3:50PM which revealed she did not interview or assess Resident # 5 after she reported it to the DON. A joint interview conducted with Unit Manager #2 and DON on 6/8/22 at 4:21PM revealed the facility did not contact Resident #5's RP or Resident #284's RP. DON revealed no assessment was done on Resident #5 or Resident #284. The DON and Unit Manager #2 further revealed no-one had spoken to the nurse or certified nursing assistants that worked on 5/30/22. They further revealed the time of the incident was still uncertain, but it was between the evening to night. The DON revealed that her instinct was to do a 24 hour and 5-day report but after discussion with the Regional Nurse Consultant #1 it was decided it was not reportable. The DON stated we have the Unit Manager #2 statement and the alert and oriented residents on that hall interviews regarding any screams heard or if they felt safe. The DON further stated we did not feel like this was something to investigate related to the Resident #72 periods of confusion. An interview conducted on 6/8/22 with Nurse #5 who was assigned on 5/30/22 stated no-one from the facility had called her to ask about the incident. An interview with Nurse Practitioner conducted on 6/8/22 at 10:52AM revealed she was not notified of incident regarding Resident #5 and Resident #284. An interview conducted on 6/8/22 at 11:06AM with Medical Doctor revealed he was Resident #5 and Resident # 284 physician and was not aware of any incidents regarding Resident #5 and Resident #284. Review of Resident #5's progress notes revealed no documentation related to the incident on 5/30/22. An interview conducted on 6/9/22 1:39 PM with the Administrator revealed he was informed from the DON and the Nurse Consultant #1 that it was not a reportable and they had investigated it. He further revealed the DON had talked to other staff members and other cognitive patients about this incident. He stated he was told that Resident #77 was cognitively impaired. He further stated it was the DON and the Nurse Consultant #1 decision to not report. He further revealed the way the information was presented it was just a discussion and not an allegation.

Based on observations, record review, and staff interviews the facility failed to repair a broken grab bar for a Resident (Resident #24) for 1 out of 7 residents reviewed for a safe, clean, comfortable, and homelike environment. Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #42 was cognitively intact and required extensive with two people assist for bed mobility. An observation and interview conducted on 6/6/22 at 11:15 AM revealed Resident #42's left side grab rail was broken. Resident #42 was further observed moving the grab rail and moved it side to side and picked the rail up to show that it was broken. The grab rail was observed to not be attached to the bed. Resident #42 stated he was frustrated that it had been broken since admission, and he had reported to the nursing staff multiple times. Resident #42 indicated he used the grab rail to assist with bed mobility. An interview conducted with Nurse Aide (NA) #1 on 6/7/22 at 2:05 PM revealed Resident #42 had complained bout the broken bed rail multiple times since admission. NA #1 further revealed she had told the Director of Maintenance when Resident #42 was admitted the bed rail was broken and it had not been fixed. NA #1 indicated Resident #42 liked to use the bed rail for re-positioning and assist with incontinence care. An interview conducted with the Director of Maintenance (DOM) on 6/7/22 at 2:45 PM revealed he was not aware Resident #24's left side grab rail was broken and stated nursing staff were supposed to put in a work order on the computer when something needed to be repaired. He stated he did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DOM stated the grab rail was broken and should have been fixed before resident had moved into the room. An interview conducted with the Administrator on 6/8/22 at 2:45 PM revealed he was not aware Resident #42's grab rail was broken. The Administrator further revealed nursing staff should have completed a work order to have the grab rail repaired.

Based on observation, record review and staff interviews the facility neglected to provide incontinence care to a resident who was soiled with dried fecal matter and urine for 1 of 3 (Resident #2) residents reviewed for activities of daily living. The resident stated that her bottom was burning and stinging so badly and all she could think about was sitting in hot water and soaking her rear end. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan updated on [DATE] read in part, potential for skin impairment related to bowel incontinence. The goal read; resident will have no evidence of skin impairment through the next review. The interventions included: keep skin clean and dry, lotion to dry skin, moisture barrier cream as needed for protection of skin, peri care with incontinent episodes, pressure reduction mattress, and weekly skin assessments Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #2's cognition was not assessed, and she required total assistance with toileting. The MDS further revealed that Resident #2's pain was not assessed, and she was always incontinent of bowel and bladder. No pressure ulcers or moisture associated skin damage were noted during the assessment reference period. No behaviors or rejection of care were noted on the MDS. A continuous observation of Resident #2 was made on [DATE] from 10:42 AM to 11:20 AM. Resident #2 was resting in bed with a sheet and comforter covering her. The sheet and comforter were folded down and there was brown fecal matter noted on the bed sheet and pad that was under Resident #2. There was a dried brown/pink ring noted on the pad under Resident #2 that extended from her lower back area to behind her knees in addition there was dried brown fecal matter noted to Resident #2's outer left thigh. Resident #2 stated, it is stinging and burning how about giving me a bath. Resident #2 was observed to have egg pieces under her neck and when near Resident #2 a very strong odor of [MEDICATION(S)] and feces was noted. At 10:46 AM assistance was requested from the staff for Resident #2. Resident #2 continued to state her bottom was burning and stinging so bad. At 10:49 AM NA #1 entered Resident #2's room and Resident #2 stated I need my bottom cleaned, I am sitting on food. NA #1 replied she needed to gather some supplies and exited the room. Resident #2 hollered out Jxxxx Cxxxxx it's burning can't you do something quickly. Coming back means never. NA #1 returned to the room at 11:00 AM and Resident #2 stated Gxx it is killing me Bring me some hot water and help. NA #1 was observed to get a pan of water with wash cloths and began washing Resident #2's face, Resident #2 stated I need you to wash my rear end. NA #1 continued to wash Resident #2 and removed her soiled gown which was noted to have a large ring approximately 10 inches wide and brown in color that was dried. When NA #1 pulled the covers off of Resident #2 the odor of [MEDICATION(S)] and feces was very prevalent. The soiled brief that Resident #2 had on was heavily soiled to where the liquid and stool had come through the plastic material on the outside of the brief. The contents had leaked through Resident #2's gown, pad, sheet and onto her air mattress which NA #1 had to clean before turning Resident #2 onto her back again. Resident #2 entire buttocks area was noted to be beefy red with scratch marks visible. There was some skin peeling along the buttock crack. With each wipe of the washcloth on her bottom by NA #1 Resident #2 would holler out ouch that hurts or ouch that is burning and stinging. Once clean NA #1 applied a barrier cream to Resident #2's entire buttock and peri area. NA #1 explained that when she arrived at work, she was scheduled to work on a different unit in the facility and was pulled to Resident #2's unit around 10:00 AM. NA #1 stated that she had not provided any care to Resident #2 since arriving on the unit but added that night shift would have changed her before they left for the day. Once Resident #2 was clean and dry with clean bed sheets and linen NA #1 gathered her supplies and exited the room. Resident #2 was asked if she felt better, and she replied yes. NA #2 was interviewed on [DATE] at 12:05 PM. NA #2 confirmed that she was the other NA working the unit where Resident #2 resided. She stated that when she reported to work at 6:45 AM and received report from NA #3. She was told everyone has been changed and was good to go and then NA #3 left the unit because her shift was over. NA #2 stated she believed there would be 3 NAs on the unit, so she had started her normal round. She stated that she realized after getting started that she was the only NA on the unit when the breakfast trays arrived. NA #2 stated that she began passing out and setting up the trays on the unit. She confirmed that she delivered and set up Resident #2's breakfast tray. NA #2 stated that she did not check Resident #2 for incontinence issue prior to or when she delivered her breakfast tray, and she was not aware that she needed care. She set the tray up and exited Resident #2's room. NA #2 went on to say that NA #1 arrived on the unit around 10:00 AM after breakfast was over and the trays had been collected and returned to dietary. She stated once NA #1 arrived on the unit they split the unit up and they each began to care for their assigned residents. NA #2 stated that Resident #2 was the responsibility of NA #1 and she had not provided any care to Resident #2. NA #3 was interviewed on [DATE] at 3:40 PM. NA #3 confirmed that she had worked on Resident #2's unit the previous night from 11:00 PM to 7:00 AM and provided care to her. NA #3 explained that they did a round at 11:00 PM and made sure everyone was dry and did not need incontinent care and then they let the resident sleep through night unless they used their call light for assistance. NA #3 explained at 4:00 AM they began to complete the last round of the night and got to Resident #2 around 4:45 AM. She stated that Resident #2 was wet, and they provided incontinent care, applied barrier cream to her bottom, got her fresh ice water and tidied her room and let her return to sleep. NA #3 reported off to NA #1 that Resident #2 had been dried and was good to go at change of shift at 6:45 AM. Nurse #1 was interviewed on [DATE] at 1:00 PM. Nurse #1 confirmed that he was caring for Resident #2. He stated that Resident #2 remained on air mattress due to a history of pressure ulcers. Currently Nurse #1 stated that Resident #2 had some moisture associated skin damage on her buttock and described it as the entire buttock was red and Resident #2 was known to frequently scratch that area. Nurse #1 stated that Resident #2 routinely received [MEDICATION(S)] (barrier cream) to her buttocks every day and routinely complained of her bottom hurting but with her impaired cognition could not fully assess her pain. Nurse #1 stated that when Resident #2 would complain of her bottom hurting, he would give her [MEDICATION(S)] (antihistamine) and that would calm her itching and relieve her discomfort. The Unit Manager (UM) was interviewed on [DATE] at 1:30 PM. The UM stated that the NAs were expected to do a walking round each morning when giving report. She stated that she could not say when Resident #2 had been cared for last but stated she should have been checked at the very minimum before her breakfast tray was delivered and set up to her. She stated she expected all the residents including Resident #2 to be checked and care provided to ensure they were not soiled in this case during the breakfast meal. The UM confirmed that there were some issues with staffing that morning but had not realized that NA #1 had not arrived at the unit until after breakfast was over. The Director of Nursing (DON) was interviewed on [DATE] at 1:50 PM. The DON stated that she would not be concerned if Resident #2 was yelling out or that would not automatically make the staff go into her room because she often did that. She went on to explain that she did not have facility acquired pressure ulcers in the facility and that indicated to her that the staff were providing good incontinence care and turning the residents frequently. Given that information she believed she had one time event that she needed to ensure did not become a common occurrence. The DON stated that the NAs did not do walking rounds and those would be more easily implemented with the Nurses than with the NAs but stated they had to do a better job of checking on resident to make sure they did not have an immediate care need. The DON confirmed that they had some staffing issues that morning and she had pulled NA #1 from a different unit to help NA #2 on the unit where Resident #2 resided. The Administrator was interviewed on [DATE] at 11:39 AM. The Administrator stated that they had management conduct daily rounds on each resident. She stated that the manager that rounded on Resident #2 on [DATE] had been in her room around 9:30 AM but did not notice any smell or issue that would have raised question that Resident #2 required an immediate care need but did not negate the fact that Resident #2 needed care.

Based on observations, record review and staff interview the facility failed to provide sufficient nursing staff to provide incontinence care to a resident who was soiled with dried fecal matter and urine and failed to clean a dependent resident's fingernails before allowing her to eat finger foods for 1 of 3 (Resident #2) resident reviewed for staffing. The findings included: This tag is cross referred to: F600: Based on observation, record review, and staff interviews the facility neglected to provide incontinence care to a resident who was soiled with dried fecal matter and urine for 1 of 3 (Resident #2) residents reviewed for activities of daily living. The resident stated that her bottom was burning and stinging so badly and all she could think about was sitting in hot water and soaking her rear end. F677: Based on observation, record review and staff interview the facility failed to clean a dependent resident's fingernails before allowing her to eat finger foods for 1 of 3 residents reviewed for activities of daily living (Resident #2). Nurse Aide (NA) #1 was interviewed on 08/03/21 at 11:15 AM about staffing and she indicated she did not wish to discuss the staffing situation at the facility. NA #2 was interviewed on 08/03/21 at 12:05 PM. NA#2 stated that they often worked short because the staff would call in or not show up. She indicated that generally they ran 3 NAs on the unit where she worked but on 08/03/21 she was the only NA on the unit until 10:00 AM when NA#1 came to assist but at that point they were so far behind that it was almost impossible to catch up. She indicated that she delivered breakfast trays and set up everyone to eat and then checked on those residents that could not feed themselves and then collected the breakfast tray by herself before NA #1 arrived to help. The Unit Manager (UM) was interviewed on 08/03/21 at 1:30 PM. The UM stated that she was unaware of the staffing situation that had occurred earlier on the shift, she stated that she thought they had 2 to 3 NAs on the unit where Resident #2 resided along with an orientee. She was unaware that NA #1 did arrive to the unit until after breakfast and that NA #2 was working by herself. The Director of Nursing (DON) was interviewed on 08/03/21 at 1:50 PM. The DON stated that the facility was contracted with 3 staffing agencies and they utilized what they could from those agencies but like every other place staff was [NAME]. She stated she had hired NAs that she did not feel like were a good fit just to have a staff member. The DON added that the facility had recently implemented shift differentials for the various shift to encourage staff member to work over or pick up extra shifts. She added that when she realized that there was a staff member that was not at work, she pulled NA #2 and orientee to go help on the unit where Resident #2 resided because those residents required a lot more hands on care than the short-term rehab residents. The DON added that staff members were tired and the last year had been rough on everyone, but they needed everyone to step up to the plate and pitch in to care for the residents. The DON stated if a team member was unable to complete their assignment, they needed to ask for assistance from her or a management team member so that everything that needed to be done got done.

Based on record review, staff, Physician, and Nurse Practitioner (NP) interviews, the facility failed to monitor a resident's condition to prevent a hypoglycemic reaction after the resident, who did not have a [DIAGNOSES REDACTED].#221) reviewed for change in condition. This resulted in an abnormal drop in blood sugar with a blood sugar reading of 40 milligram per deciliter (mg/dl) and unresponsiveness that required Emergency Department (ED) evaluation and treatment for [REDACTED]. Immediate jeopardy began on 11/19/2018 when staff failed to monitor Resident #221's condition after she was administered insulin in error which resulted in an abnormal drop in blood sugar with a blood sugar reading of 40 mg/dl, unresponsiveness and the resident being transferred to the hospital for treatment of [REDACTED]. The facility remains out of compliance at a lower scope and severity Level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Findings included: The facility's Hypoglycemic Protocol (no date) read in part: · For a FSBS (finger stick blood sugar) below 70 and is conscious: give 3 glucose tablets or snack and re-check FSBS in 15 minutes. · For a FSBS below 70 and unconscious/ unable to chew tablets: give [MEDICATION NAME] 1 [MEDICATION NAME] Intramuscular or Subcutaneous times one (1) and recheck FSBS in 15 minutes. Resident #221 was readmitted to the facility on [DATE]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed that Resident #221 was cognitively intact and did not have a [DIAGNOSES REDACTED]. The resident's care plan dated 10/4/2018 revealed no care plan for diabetes. Resident #221's physician orders [REDACTED]. The Medication Error Report dated 11/19/2018 revealed Resident #221 received 20 units of [MEDICATION NAME] Insulin, in error, during the 9:00 PM medication administration by Nurse #4. A nursing note written by Nurse #4 on 11/19/2018 at 9:00 PM, specified Resident #221's the blood sugar reading was 93 mg/dl. A second entry written by Nurse #4 was made on 11/19/2018 at 9:20 PM which specified the blood sugar reading was 193 mg/dl. According to the nursing home's lab service, normal blood sugar ranges are between 70 to 130 mg/dl (for a person who does not have a [DIAGNOSES REDACTED]. An interview was completed on 4/30/2019 at 5:49 PM with Nurse #4. Nurse #4 revealed she had worked a double shift on 11/19/2018 (7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM) and administered insulin to Resident #221 in error during the 9:00 PM medication pass. She realized the error occurred once she left Resident #221's room and read the names located outside the room doors and looked at the picture on the electronic Medication Administration Record [REDACTED]. Nurse #4 notified the on-call/after-hours provider service at 12:11 AM on 11/20/2018 and received orders from the NP to monitor Resident #221 and recheck her blood sugar at 6:00 AM on 11/20/2018. Nurse #4 verbalized that she reported the incident and reviewed the orders with the oncoming shift. Additional attempts were made to contact Nurse #4 during the survey for clarification and further interview with no success. According to manufacturer's instructions, [MEDICATION NAME]has an onset of insulin effect in 1 1/2-2 hours and reaches its peak concentration in blood six to eight hours after it is taken but can remain close to peak levels for up to 24 hours. A telephone interview with Nurse #5 was completed on 5/10/2019 at 11:15 AM. Nurse #5 stated that Nurse #4 was panicking when she arrived on the unit on 11/19/2018 and informed her that she administered the wrong medication to Resident #221. Nurse #5 verbalized she and Nurse #4 went to immediately check Resident #221 and assess her condition. Nurse #5 directed Nurse #4 to obtain a blood sugar reading and notify the on-call/ after-hours provider service. The blood sugar reading obtained by Nurse #4 was 71 mg/dl. She was not present when Nurse #4 made notification and received orders back from the NP. An interview was completed with Nurse #5 on 4/30/2019 at 5:31 PM. Nurse #5 stated she and Nurse #4 assessed Resident #221 on 11/19/18 at the start of 3rd shift (11:00 PM to 7:00 AM). She recalled obtaining a blood sugar reading around midnight but did not recall notifying the on-call/ after-hours provider service of the blood sugar reading. She stated Resident #221 was responsive (alert, verbal) and doing well at that time. The call log dated 11/20/2018 for the on-call/after-hours provider service revealed Nurse #4 placed one initial call at 12:11 AM on 11/20/2018. The call log noted the on-call/ after-hours provider service returned that call at 12:13 AM on 11/20/2018. During the same call at 12:13 AM on 11/20/2018, the Registered Nurse (RN) with the on-call/after-hours provider service advised Nurse #4 to feed the resident a meal of carbohydrates, proteins, and fats after she had spoken to the on-call provider. The RN on-call also gave direction to check the resident's blood sugar more closely (every two hours), and again at 6:00 AM per the original order given by the on-call provider. Additional advisement by the RN on-call was to send the resident to the ED if she became unstable and call the on-call/ after-hours provider service back to let us know she was sent out. No further calls were recorded on the call log between the facility and the on-call/ after-hour provider. A telephone interview with Nurse #5 was completed on 5/10/2019 at 11:15 AM. She recalled Nurse #4 saying, the orders given by the NP were to monitor Resident #221 throughout the night and recheck her blood sugar at 6:00 AM on 11/20/2018. Nurse #5 stated that a blood sugar reading of 71 mg/dl was not bad. She stated she gave Resident #221 some orange juice and peanut butter crackers for a snack after the blood sugar reading of 71 mg/dl was obtained. The Medication Error Report dated 11/19/2018 reiterated Nurse #4 contacted the on-call/ after-hours provider service to provide notification of the medication error and receive further orders/ direction. Orders were given by the NP to monitor Resident #221 and recheck blood sugar at 6:00 AM on 11/20/2018. The NP order dated 11/20/2018 at 12:11 AM read: Check blood sugar at 6:00 AM. A telephone interview was completed on 5/1/2019 at 9:23 AM with the NP. The NP was notified by the on-call/ after-hour provider service at 12:11 AM on 11/20/2018 of an incident that occurred at the facility. The NP returned the call to the facility at 12:13 AM on 11/20/2018. She spoke with Nurse #4 and was informed that the wrong medication was given to Resident #221 who had no [DIAGNOSES REDACTED]. She gave instruction to monitor Resident #221. The NP explained the medication administered was [MEDICATION NAME] (a long acting insulin medication used to lower blood sugar in people with diabetes) and its primary effect would be [DIAGNOSES REDACTED] (symptoms that could be exhibited were altered mental status, low blood sugars and sweating). She could not recall if she was contacted regarding the continued monitoring of Resident #221 throughout the night or when Resident #221 was sent to the local ED. The NP stated she did not indicate to Nurse #4 what was to be monitored or provide a specified monitoring schedule for Resident #221. The NP explained [MEDICATION NAME] had a peak time of 12 hours, and she felt that 6:00 AM would be a good time frame to recheck the blood sugar. The nursing note written by Nurse #5 dated 11/20/2018 at 1:06 AM read: Resident #221 lying supine in bed, eyes closed and responsive. Respiration even and unlabored. An interview with Nurse #5 on 4/30/2019 at 5:31 PM. Nurse #5 verbalized that she checked on Resident #221 on 11/20/18 around 1:00 AM and Resident #221 was lying in bed, eyes closed and responsive (verbal). During an interview with Nurse #5 on 5/10/2019 at 11:15 AM, she stated she checked on Resident #221 on 11/20/2018 at 2:00 AM. The resident was sleeping. Nurse #5 verbalized that she did not document this observation. Nurse #5 stated the next time she observed Resident #221 was at 5:30 AM. Continued review of Resident #221's nursing notes revealed no further blood sugar readings or monitoring of Resident #221 on 11/20/2018 from 2:00 AM until Nurse #5 observed the resident at 5:30 AM. Nurse #5 recorded a blood sugar reading of 40 mg/dl. The Situation, Background, Assessment, Recommendation note dated 11/20/2018 read: Around 5:30 AM Nurse #5 went in to check Resident #221's blood sugar and noted Resident #221 unresponsive (unable to arouse, non-verbal) with shallow breathing, blood drooling from the left side of her mouth and eyes closed. Blood sugar reading was 40 mg/dl. Oxygen was applied via nasal cannula at 5 liters per minute. Vital Signs were: pulse (87), respirations (16), oxygen saturation (91%), and blood pressure reading did not register. Resident #221's mouth locked up, tongue was sticking out. Resident #221's skin was cold to touch. Standing orders were implemented with the administration of [MEDICATION NAME] (a hormone used to treat severe low blood sugar) 1 [MEDICATION NAME] (amp) Intramuscular (IM) times one (1) dose. Per the standing orders, the blood sugar was rechecked, and the blood sugar reading increased to 95 mg/dl. Resident #221 began to respond. 911 was notified. DON (Director of Nursing) was notified. Family was contacted. Resident was transferred to the ED. Resident #221 verbally was responsive. An interview was completed with Nurse #5 on 4/30/2019 at 5:31 PM. Nurse #5 explained she went in to check on Resident #221 on 11/20/2018 at 5:30 AM to obtain the ordered 6:00 AM blood sugar reading. She expressed Resident #221 was unresponsive (non-verbal, hard to wake) with shallow breathing, and blood drooling from the left side of her mouth. Resident #221's eyes were closed, and she was cold and sweaty. Nurse #5 stated Resident #221's blood sugar reading was 40 mg/dl. Nurse #5 explained she implemented the facility's standing orders and administered [MEDICATION NAME] 1amp IM times one (1) dose, applied 5 L (liters) of oxygen via nasal cannula, contacted 911, notified the Director of Nursing (DON) and left a note in the physician communication book of the incident. A follow up telephone interview was completed on 5/2/2019 at 4:21 PM with Nurse #5. She stated she did not recall communicating with the on-call/after-hours provider service regarding Resident #221's 71 mg/ dl blood sugar reading. Nurse #5 recalled Resident #221 being symptomatic when she went to obtain the ordered blood sugar at 5:30 AM. Nurse #5 could not explain why she did not notify the on-call/ after-hour provider knowing Resident #221 had been administered the wrong medication. A telephone interview with Nurse #5 was completed on 5/10/2019 at 11:15 AM. Nurse #5 stated at around 5:30 AM on 11/20/2018, she went to obtain the ordered blood sugar check and Resident #221 was unresponsive. She called for help from facility staff. Nurse #5 gave direction to staff to notify EMS (Emergency Management Services) and she implemented the facility's standing orders for [DIAGNOSES REDACTED]. She administered [MEDICATION NAME] 1 amp IM times one (1) dose, applied oxygen via nasal cannula at 5 L, notified the Director of Nursing (DON), and placed a note in the physician communication book. Nurse #5 stated Resident #221 was responding prior to EMS arriving to the facility. She rechecked her blood sugar. The blood sugar reading was 95 mg/dl. EMS arrived and transported Resident #221 to the ED. Nurse #5 took responsibility for monitoring Resident #221 throughout the evening due to her receiving a medication not prescribed to her in error. Nurse #5 could not explain why Nurse #4 waited to provide notification to the on-call/after-hours provider service. The resident's blood sugar reading of 71 mg/dl on 11/20/2018 at 12:16 AM that was obtained by Nurse #4 was at the lowest of the normal blood sugar range and the [MEDICATION NAME]had not reached its peak concentration in the blood. According to manufacturer's instructions, the peak concentration would occur 6-8 hours after the administration at 9:00 PM. Therefore, the peak concentration was expected between 3:00 AM - 5:00 AM. According to Nurse #5's interview, she last checked on Resident #221 at 2:00 AM. Nurse #5 did not monitor the resident during the medication's peak concentration in the blood. An attempt was made to interview the Nurse Aides assigned to Resident #221 during the night of 11/19/2018 and 11/20/2018. They did not respond to the voicemail messages. A telephone interview was completed on 5/1/2019 at 1:58 PM with the resident's Physician, in which he recalled Resident #221 and her receiving the wrong medication. He stated he would have given an order for [REDACTED].#221 experienced were typical of [DIAGNOSES REDACTED]. He said the staff responded appropriately by rechecking the blood sugar, taking emergency action (administering [MEDICATION NAME]), and sending her to the emergency department for further evaluation. The Physician stated there was a direct correlation between Resident #221 having received the wrong medication and being sent out to the hospital. The Physician reviewed the hospital records and stated Resident #221's emergency department treatment was for [DIAGNOSES REDACTED] and mild feeling of general weakness. A follow up interview with the resident's Physician was completed at the facility on 5/1/2019 at 3:57 PM in which he revealed he could not make a definitive correlation that the wrong medication being administered would be the cause of Resident #221 being transferred to the emergency department. The Physician stated he re-reviewed the medical record and Resident #221 responded to the [MEDICATION NAME] appropriately. Resident #221 was verbal, responding prior to transfer and her blood sugar was at 95 mg/dl prior to leaving the facility with EMS (Emergency Management Services). An additional interview with the resident's Physician was completed at the facility on 5/1/2019 at 6:10 PM. The Physician explained he reviewed the hospital documentation and there were two separate issues that he wanted to identify-[MEDICAL CONDITION] and wrong medication being administered. He stated that Resident #221 responded to the treatment that was administered prior to being sent to the emergency department and her [DIAGNOSES REDACTED] was resolved prior to leaving the facility. The Physician further explained once in the emergency department, Resident #221 received some IV (intravenous) support for her blood sugars ([MEDICATION NAME] IV). Once Resident #221 was admitted to the hospital, her hospital admission was related to [MEDICAL CONDITION] and not her blood sugar. The EMS Run report dated 11/20/2018 read in part: the resident had a Glascow Coma Scale (GCS; assessment used to determine level of consciousness) of 3 when they arrived and her blood sugar was 52 mg/dL at 5:58 AM. Started [MEDICATION NAME] infusion and GCS improved to 15 (scale is 3-15). At 6:18 AM her blood sugar was 113 mg/dL. Hospital records dated 11/20/2018 read in part: the resident presented to ED today due to [DIAGNOSES REDACTED]. She was brought to the ED today after the facility noted persistent [DIAGNOSES REDACTED], despite patient denying any discomfort. Upon arrival she was noted to have [DIAGNOSES REDACTED], though relatively alert and responsive. She was provided with [MEDICATION NAME] infusions. An interview was completed with the DON on 5/3/2019 at 5:54 PM. She explained Resident #221 should have received continued monitoring via accuchecks (pricking the finger to get a blood sugar reading), the nurses should have offered snacks due to the medication that was administered in error and notified the on-call/after-hours provider service if the blood sugar continued to drop. The Administrator was notified of immediate jeopardy on 5/14/19 at 1:15 PM via telephone call. On 5/15/2019 the facility provided the following credible allegation for immediate jeopardy removal: · Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: For Resident #221 the nurse administered insulin to her when the medication was intended for another resident. The nurse failed to document in the patient chart assessing or monitoring of patient during the shift. · On, (MONTH) 19, (YEAR), Resident #221 received 20 units of [MEDICATION NAME] at approximately 9:00 p.m., intended, for another resident. Resident #221's blood sugar at 9:20 p.m. was 193. · The on-call Nurse Practitioner (NP) was notified by the On-call RN of the error at 12:18 a.m. when the resident # 221's blood sugar was 71 mg/dl. Based on nurse #5 statement the patient was given a snack of orange juice and peanut butter crackers. The Nurse Practitioner gave the order to check blood sugar at 6:00 AM to the on-call Registered Nurse. The Registered Nurse on call, gave order to the Nurse #4 that the resident should be fed a meal of carbohydrates, proteins and fats. The on-call Registered Nurse also ordered to check blood sugar more closely every two hours and again at 6:00 AM during conversation with Nurse #4 at 12:11 a.m. She was also asked to send to the Emergency Department if patient became unstable and call after hours back to let them know she was sending resident #221 to the Emergency Department. Based on documentation there is no indication that this was done. · Nurse #5 reassessed the resident at 1:06 a.m. and found the patient was lying in the bed with eyes closed and responsive. Respirations were even and unlabored. · At approximately 5:30 a.m. nurse entered the resident #221's room to check the blood sugar and noted resident #221 was unresponsive with shallow breathing, mouth locked-up, her blood sugar indicated (40). Oxygen 5 liters administered via nasal cannula. Vitals signs were a pulse of (87), respirations (16), and oxygen saturation of 91%. The nurse was unable to obtain a blood pressure. · Based on the blood sugar reading of 40 at around 5:30 a.m., standing orders were implemented, and [MEDICATION NAME] 1mg administered. Between the hours of 5:30 a.m. and 6:10 a.m. resident #221's blood sugar increased to 95. · On (MONTH) 20, (YEAR) at approximately 6:10 a.m. resident #221 was transferred to the Emergency Department via Emergency Services and treated for [REDACTED]. The resident #221 was admitted subsequently [MEDICAL CONDITION]. · Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On (MONTH) 14, 2019 a 72-hour shift summary (a list of all documentation in the progress notes) was obtained and reviewed by the Director of Nursing to identify changes in resident conditions and evaluated if the physician was notified. · (MONTH) 14, 2019 current nurses on staff were re-educated on How to respond to a change in condition, with a focus on medication errors and notifying the physician immediately and then the responsible party. The following information was relayed to the nursing staff, 1) Notification of the physician of changes in resident conditions immediately or as soon as practicable. 2) Following physician orders. 3) Orders are to be carried out and placed into the system (all monitoring should be documented in the progress notes. Example given, blood sugars should be documented each and every time they are obtained). 4) Notification of the family or responsible party after the physician is notified. Let the family member know of the orders that have been received from the physician. (If you do not get the family member, document in the progress notes each of your attempts and results of each.) 5) In the case of a medication error for a blood sugars the appropriate blood pressure, pulse and blood sugar should monitored and physician notified for further orders if indicated. · Additional education provided was information from the National Institute of Health as follows. [DIAGNOSES REDACTED] can have severe, life-threatening consequences. When the blood glucose (BG) level falls to 60 mg/dL (normal >70 mg/dL), most patients begin to exhibit signs and symptoms of [DIAGNOSES REDACTED], both sympathetic ([MEDICAL CONDITION] palpitations, diaphoresis, tremulousness) and parasympathetic (nausea and hunger). The most severe and feared complications of [DIAGNOSES REDACTED] include [MEDICAL CONDITION], coma, and death, which can occur at BG levels <40 mg/dL. · Protocol for Hypoglycemic episode approved by Medical Director: If a resident has a low or near low blood sugar, the following protocol to be performed by licensed nursing staff: PO Able Patient: Hypoglycemic Monitoring - Blood Sugars less than 70: 1) Immediately give fruit juice, sugar beverage and high carbohydrate snack (ex: crackers and peanut butter) 2) At 15 minutes, recheck blood sugar. If BS is less than 70: a) Administer 1 tube glucose gel orally 3) At 30 minutes, recheck blood sugar. If BS is less than 70: a) Administer [MEDICATION NAME] 1 mg subcutaneously b) Notify provider for further instructions c) Notify RP Non-PO Able Patient: Hypoglycemic Monitoring - Blood Sugars less than 70: 1) If unable to take PO, unable to use G Tube, OR unconscious/unresponsive, administer [MEDICATION NAME] 1 mg subcutaneously 2) Notify provider for further instructions 3) Notify RP If at any time a patient has a blood sugar less than 50 OR unresponsive/unconscious due to low blood sugar: 1) Administer [MEDICATION NAME] 1 mg. subcutaneously 2) Initiate EMS 3) Notify provider for further instructions 4) Notify RP · Any nurse not able to be contacted to be educated a message was left on voicemail of education if available but will not be allowed to work until they have either received the education face to face or verbally. Education started on (MONTH) 14, 2019 and completed on (MONTH) 14, 2019. · All new nurses hired will receive education How to respond to a change in condition, with a focus on medication errors and notifying the physician immediately and then the responsible party. Emphasizing the following information. 1) Notification of the physician of changes in resident conditions immediately or as soon as practicable. 2) Following physician orders. 3) Orders are to be carried out and placed into the system (all monitoring should be documented in the progress notes. Example given, blood sugars should be documented each and every time they are obtained). 4) Notification of the family or responsible party after the physician is notified. Let the family member know of the orders that have been received from the physician. (If you do not get the family member, document in the progress notes each of your attempts and results of each, example, left voicemail.) 5) In the case of a medication error for a blood sugars the appropriate blood pressure, pulse and blood sugar should monitored and physician notified immediately for further orders if indicated and any changes afterwards. The Unit Coordinators will run a 24-hour shift summary (a list of all documentation in the progress notes) Tuesday through Friday and a 72-hour shift summary (a list of all documentation in the progress notes) and review for resident changes in condition. Any changes identified will be followed up on to ensure that the physician was notified, if new orders were received, were the orders followed and documentation in progress notes? Was the family notified and documentation in the progress notes? · Additional Education for New Hires: From the National Institute of Health as follows- [DIAGNOSES REDACTED] can have severe, life-threatening consequences. When the blood glucose (BG) level falls to 60 mg/dL (normal >70 mg/dL), most patients begin to exhibit signs and symptoms of [DIAGNOSES REDACTED], both sympathetic ([MEDICAL CONDITION] palpitations, diaphoresis, tremulousness) and parasympathetic (nausea and hunger). The most severe and feared complications of [DIAGNOSES REDACTED] include [MEDICAL CONDITION], coma, and death, which can occur at BG levels <40 mg/dL. · Protocol for Hypoglycemic episode approved by Medical Director: If a resident has a low or near low blood sugar, the following protocol to be performed by licensed nursing staff: PO Able Patient: Hypoglycemic Monitoring - Blood Sugars less than 70: 1) Immediately give fruit juice, sugar beverage and high carbohydrate snack (ex: crackers and peanut butter) 2) At 15 minutes, recheck blood sugar. If BS is less than 70: a) Administer 1 tube glucose gel orally 3) At 30 minutes, recheck blood sugar. If BS is less than 70: a) Administer [MEDICATION NAME] 1 mg subcutaneously b) Notify provider for further instructions c) Notify RP Non-PO Able Patient: Hypoglycemic Monitoring - Blood Sugars less than 70: 1) If unable to take PO, unable to use G Tube, OR unconscious/unresponsive, administer [MEDICATION NAME] 1 mg subcutaneously 2) Notify provider for further instructions 3) Notify RP If at any time a patient has a blood sugar less than 50 OR unresponsive/unconscious due to low blood sugar: 1) Administer [MEDICATION NAME] 1 mg. subcutaneously 2) Initiate EMS 3) Notify provider for further instructions 4) Notify RP · Completion date 5/17/2019 Immediate Jeopardy was removed on 5/17/2019 following observations and staff interviews, which included identifying signs and symptoms of [DIAGNOSES REDACTED], monitoring of residents and physician notification. Nursing interviews revealed receipt of education regarding the facility's hypoglycemic protocol, monitoring of residents and physician notification. Documentation was reviewed regarding education provided on the signs and symptoms of [DIAGNOSES REDACTED], the causes of [DIAGNOSES REDACTED] and the facility's hypoglycemic protocol.

Based on record review, staff, Physician, Nurse Practitioner (NP), and Pharmacy Consultant interviews, the facility failed to prevent a significant medication error by administering a long acting insulin to a resident that had no [DIAGNOSES REDACTED].#221). This resulted in Resident #221 experiencing a blood sugar reading of 40 milligrams per deciliter (mg/dl) that required Emergency Department (ED) evaluation and treatment for [REDACTED]. Findings included: Resident #221 was readmitted to the facility on [DATE]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that Resident #221 was cognitively intact. Resident #221 had adequate hearing and vision, could make self-understood and understand. Review of Section I (Active Diagnoses) did not indicate Resident #221 had a [DIAGNOSES REDACTED].#221 did not receive any insulin injections, nor did Resident #221 have any orders for insulin. Review of the care plan revealed no care plan for diabetes. Review of Resident #221's physician orders indicated no orders for the resident to receive insulin. Review of the Medication Error Report dated 11/19/2018 revealed Resident #221 received 20 units of [MEDICATION NAME] Insulin (insulin used to control high blood sugar. [MEDICATION NAME] reaches a peak concentration in your blood six to eight hours after you take it but can remain close to peak levels for up to 24 hours), in error, during the 9:00 PM medication administration by Nurse #4. Nurse #4 contacted the on-call/after-hours provider service to provide notification of the medication error and receive further orders/ direction. Orders were given by the NP to monitor Resident #221 and recheck blood sugar at 6:00 AM on 11/20/2018. Review of the call log dated 11/19/2018 for the on-call/ after-hours provider service revealed Nurse #4 placed one initial call at 12:11 AM. The on-call/after-hours provider service returned that call at 12:13 AM. No further calls were recorded. Review of Resident #221's nursing notes revealed the following blood sugar readings and information: · 11/19/2018 9:00 PM blood sugar reading- 93 mg/dl (blood sugar reading prior to the administration of insulin). Normal blood sugar ranges are between 70 to 130 mg/dl. · 11/19/2018 9:20 PM blood sugar reading- 193 mg/dl (blood sugar reading after the administration of insulin) · 11/20/2018 12:16 AM blood sugar reading- 71 mg/dl · Review of nursing note dated 11/20/2018 at 1:06 AM read in part: Resident #221 lying supine in bed, eyes closed and responsive. Respiration even and unlabored. · On 11/20/2018 at 5:30 AM, the blood sugar reading was 40mg/dl. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 11/20/2018 read in part: Around 5:30 AM Nurse #5 went in to check Resident #221's blood sugar and noted Resident #221 unresponsive with shallow breathing, blood drooling from the left side of her mouth and her eyes closed. Blood sugar reading was 40 mg/dl. Oxygen was applied via nasal cannula at 5 liters per minute. Vital Signs were: pulse (87), respirations (16), oxygen saturation (91%), and blood pressure reading did not register. Resident #221's mouth locked up, tongue was sticking out. Resident #221's skin was cold to touch. Standing orders were implemented with the administration of [MEDICATION NAME] (a hormone used to treat severe low blood sugar) 1 amp IM/SQ times one (1) dose. Per the standing orders, the blood sugar was rechecked, and the blood sugar increased to 95 mg/dl. Resident #221 began to respond. 911 notified. DON (Director of Nursing) was notified. Family was contacted. Resident was transferred to the ED. Resident #221 verbally was responsive. An interview was completed on 4/30/2019 at 5:49 PM with Nurse #4. Nurse #4 revealed she had worked a double shift (7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM) and administered insulin to Resident #221 in error during the 9:00 PM medication pass. The nurse further explained she confused Resident #221 with the resident located in the adjacent room. She realized the error occurred once she left Resident #221's room and read the names located outside the room doors and looked at the picture on the electronic Medication Administration Record [REDACTED]. Nurse #4 notified on-call/after-hours provider service and received orders from the NP to monitor Resident #221 and recheck her blood sugar at 6:00 AM. Nurse #4 verbalized that she reported the incident and reviewed the orders with the oncoming shift. An interview was completed with Nurse #5 on 4/30/2019 at 5:31 PM. Nurse #5 stated she and Nurse #4 assessed Resident #221 at the start of 3rd shift (11:00 PM to 7:00 AM). She recalled obtaining a blood sugar reading around midnight but did not recall notifying the on-call/after-hours provider service of the blood sugar reading. She stated Resident #221 was responsive and doing well at that time. Nurse #5 verbalized that she checked on Resident #221 around 1 AM and Resident #221 was lying in bed, eyes closed and responsive. Nurse #5 explained she went in to check on Resident #221 around 5:30 AM and to obtain the ordered blood sugar. She expressed Resident #221 was unresponsive with shallow breathing, and blood drooling from the left side of her mouth. Resident #221's eyes were closed, and she was cold and sweaty. Nurse #5 stated Resident #221's blood sugar reading was 40 mg/dl. Nurse #5 explained she implemented the facility's standing orders and administered 1 amp ([MEDICATION NAME]) IM (intramuscular)/SQ (subcutaneous) times one (1) dose, placed 5 L (liters) of oxygen via nasal cannula, contacted 911, notified the Director of Nursing (DON) and left a note in the physician communication book of the incident. A telephone interview was completed on 5/1/2019 at 9:23 AM with the NP. The NP stated she received a call from Nurse #4 that she administered the wrong medication to a resident that has no [DIAGNOSES REDACTED]. She further stated the only thing to do would be to monitor Resident #221. The NP explained the medication administered was [MEDICATION NAME] (a long acting insulin medication used to lower blood sugar in people with diabetes) which primary effect would be [DIAGNOSES REDACTED] (symptoms that could be exhibited were altered mental status, low blood sugars and diaphoresis-sweating). She could not recall if she were contacted regarding the continued monitoring of Resident #221 throughout the night nor when Resident #221 was sent to the local ED. The NP did not indicate a specified monitoring schedule for Resident #221. The NP explained [MEDICATION NAME] had a peak time of 12 hours, and she felt that 6:00 AM would be a good time frame to recheck the blood sugar. A telephone interview was completed on 5/1/2019 at 9:36 AM with the facility Pharmacy Consultant. The Pharmacy Consultant stated the facility responded appropriately when Resident #221 was observed experiencing hypoglycemic symptoms. She explained Resident #221 received a long acting insulin- [MEDICATION NAME]. This means that medication would typically be given once a day and blood sugars would be sustained over a 24-hour period. The Pharmacy Consultant expressed Resident #221's symptoms made sense and Resident #221 would experience a slow decline over a 24-hour period since the medication given was long acting insulin. A telephone interview was completed on 5/1/2019 at 1:58 PM with the Physician, in which he recalled Resident #221 and her receiving the wrong medication. He stated he would have given an order for [REDACTED].#221 experienced. He said the staff responded appropriately by rechecking the blood sugar, taking emergency action (administering [MEDICATION NAME]), and sending her to the emergency department for further evaluation. The Physician stated there was a direct correlation between Resident #221 having received the wrong medication and being sent out to the hospital. The Physician reviewed the hospital records and stated Resident #221's emergency department treatment was for [DIAGNOSES REDACTED] and mild feeling of general weakness. A follow up interview with the Physician was completed at the facility on 5/1/2019 at 3:57 PM in which he revealed he could not make a definitive correlation that the wrong medication being administered would be the cause of Resident #221 being transferred to the emergency department. The Physician stated he re-reviewed the medical record and Resident #221 responded to the [MEDICATION NAME] appropriately. Resident #221 was verbal, responding prior to transfer and her blood sugar was at 95 mg/dl prior to leaving the facility with EMS (Emergency Management Services). An additional interview with the Physician was completed at the facility on 5/1/2019 at 6:10 PM. The Physician explained he reviewed the hospital documentation and there were two separate issues that he wanted to identify-[MEDICAL CONDITION] and wrong medication being administered. He stated that Resident #221 responded to the treatment that was administered prior to being sent to the emergency department and her [DIAGNOSES REDACTED] was resolved prior to leaving the facility. The Physician further explained once in the emergency department, Resident #221 received some IV (intravenous) support for her blood sugars ([MEDICATION NAME] IV). Once Resident #221 was admitted to the hospital, her hospital admission was related to [MEDICAL CONDITION] and not her blood sugar. Review of the hospital records dated 11/20/2018 read in part: the resident presented to ED today due to [DIAGNOSES REDACTED]. She was brought to the ED today after facility noted persistent [DIAGNOSES REDACTED], despite patient denying any discomfort. Upon arrival she was noted to have [DIAGNOSES REDACTED], though relatively alert and responsive. She was provided with [MEDICATION NAME] infusions. Review of the hospital records dated 11/20/2018 revealed the following blood sugar readings: 11/20/2018 at 7:49 AM- 60 mg/dl 11/20/2018 at 7:59 AM- 141 mg/dl 11/20/2018 at 8:37 AM- 158 mg/dl 11/20/2018 at 10:07 AM- 29 mg/dl 11/20/2018 at 10:21 AM- 224 mg/dl 11/20/2018 at 11:25 AM- 96 mg/dl 11/20/2018 at 11:45 AM- 63 mg/dl Review of the Hospital Critical Care note dated 11/21/2018 read in part: She had [DIAGNOSES REDACTED] which may have been from an erroneous [MEDICATION NAME] injection at rehab. [DIAGNOSES REDACTED]- currently on [MEDICATION NAME] infusion at 75 cc's per hour. Further review of the hospital records identified [DIAGNOSES REDACTED] as a [DIAGNOSES REDACTED]. An interview was completed on 5/1/2019 at 6:30 PM with the Director of Nursing (DON). She explained she reviewed the proper steps for medication administration with Nurse #4 on 11/20/2019, which included, 1- prepare medication 2- identify the resident 3- ensure the correct route per order 4- right dose and 5- right time. The DON expressed proper identification of a resident would involve verifying the photo in the EHR (electronic health record) versus relying solely on the resident (residents give consent on admission for photographs for identification purposes), names were located on the outside of the doors for a semi private room and the outside of the main door for a private room, residents also have hospital bracelets in place or a facility name bracelet in place. Based on the resident's cognition, the staff may ask the resident their name for verification purposes. She stated she would need to verify with her Staff Development Coordinator (SDC) to determine if medication administration were discussed during orientation. No facility training was completed with the nursing staff after this incident. She explained the Pharmacy Consultant completed medication administration observations in (MONTH) (YEAR) with the cart nurses. The DON indicated medication administration had not been completed with Nurse #4 after the medication administration error. The DON verbalized she expected staff to double check themselves and to follow the rights of medication administration to ensure the residents received their ordered medications. An interview was completed with the Staff Development Coordinator (SDC) on 5/1/2019 at 2:48 PM. The SDC explained nurses were trained on the Rights of Medication Administration- right person, route, time, medicine, and dose regarding medication administration. The SDC stated she had not completed any recent training with nurses regarding the 5 rights of medication administration nor has she completed any medication administration observations.