Every finding on record at Kannapolis Health and Rehabilitation

Based on record review, observations, and interviews with family, staff, Nurse Practitioner, and Physician, the facility failed to provide the necessary supervision for a resident who was severely cognitively impaired, had difficulty swallowing, and was on a mechanical soft diet (foods that are naturally soft or altered [chopped, ground, mashed, or pureed] to require minimal chewing, making them safer and easier to swallow) with nectar thickened liquids (thickened consistency to slow the flow of the liquid to prevent choking and aspiration by allowing more time for the airway to close). Resident #103's family member, Family Member #1, was repeatedly observed by staff bringing the resident food items that were not consistent with his ordered diet and the facility failed to implement effective interventions to protect the resident from an avoidable accident. On 5/6/2025 Nurse #1 observed Family Member #1 bring the resident a burger, chicken nuggets, french fries, and sweet tea. Nurse #1 explained to Family Member #1 that Resident #103 was on a modified diet and should not eat the food brought in due to the risk of choking. Family Member #1 did not comply and they set the food up for the resident to eat in his room and left the facility at approximately 9:53 pm. Nurse #1 was aware Family Member #1 exited the facility, and she (Nurse #1) knowingly left the resident unsupervised with the food in front of him. Nurse #1 indicated she checked on the resident at 9:59 pm and then instructed Nurse Aide #3 to check on the resident. At approximately 10:14 pm when Nurse Aide #3 went to the resident's room to check on him, she observed Resident #103 with food in his mouth, a hamburger in his hand that was partially eaten and he was pale, unresponsive, and had a very faint pulse. Cardiopulmonary Resuscitation (CPR) was initiated and Emergency Medical Services (EMS) were called. Upon EMS arrival they continued CPR but resuscitation efforts were unsuccessful. Resident #103 was pronounced deceased at 11:20 pm. Additionally, the facility failed to provide incontinence care in a safe manner when a resident was rolled out of bed hitting the floor. The resident was on an air mattress that was raised to the highest position. The resident sustained a two-centimeter (cm) laceration to his left forehead and was transferred to the Emergency Department for treatment and returned to the facility the same shift. This was for 2 of 7 residents reviewed for supervision to prevent accidents (Resident #103 and Resident #53). Findings included:1. Resident #103 was admitted to the facility on [DATE] diagnoses of difficulty swallowing, dementia, and stroke.Resident #103's face sheet indicated Family Member #1 was his emergency contact and Resident #103 was his own responsible party. Speech Therapy Notes for January 2025 revealed Resident #103 was treated by Speech Therapy for dysphagia (difficulty swallowing) and he was discharged from services on 1/28/2025 with a mechanical soft diet with thin liquids.Speech Therapy notes for March 2025 revealed services were initiated for Resident #103 on 3/27/2025 when he returned from the hospital on a regular diet with thin liquids. The Speech Therapist note for 3/27/2025 stated Resident #103's dietary order was changed to pureed with regular liquids due to pocketing (held food in his mouth) and choking during his initial evaluation. A Physician's Order dated 3/27/2025 indicated Resident #103 was a full code (desired resuscitative measure to be used if his breathing or heart stopped). Resident #103's quarterly Minimum Data Set assessment dated [DATE] indicated he was severely cognitively impaired, had no behaviors, required moderate assistance with eating, and he was on a mechanically altered and therapeutic diet. The assessment did not document any chewing or swallowing issues. On 4/4/2025 a Speech Therapy Discharge Summary written by the Speech Therapist stated Resident #103 was upgraded to a mechanical soft diet with regular liquids and specified regular consistency bread products and pureed fruit. A Physician's Order dated 4/4/2025 indicated Resident #103 should receive a mechanical soft diet with nectar thick liquids. The Physician's Order also indicated Resident #103 should have pureed fruit and no straws, and may have the following regular consistency foods: pancakes, muffins, biscuits, sliced bread, rolls, cake, cookies, crackers, coffee cake, pimento cheese, and peanut butter and jelly sandwiches. A progress note written by Director of Nursing (DON) #2 on 4/9/2025 at 10:53 pm indicated Resident #103's family brought water that was not nectar thick and regular consistency foods to Resident #103 and the family wanted staff to feed Resident #103 a regular diet. The note further stated it was explained to the family member (Family Member #1) that Resident #103 was seen by the Speech Therapist and it was not safe for him to eat a regular diet at this time because he was at risk of choking. A Physician's Order for a Speech Therapy evaluation and treatment dated 4/10/2025 stated Resident #103 should receive treatment for dysphagia to include diet modifications, safety and tolerance, laryngeal exercises (utilized to improve swallowing), and patient and caregiver education. The Speech Therapist's consultation notes indicated Resident #103 had a Bedside Swallow Exam on 4/10/2025 and required a mechanical soft diet with nectar thickened liquids. The swallowing exam on 4/10/2025 indicated Resident #103 had pocketing of food and coughing and choking with an increased diet texture. During a telephone interview with the Speech Therapist on 3/5/2026 at 12:00 pm she stated she evaluated Resident #103 on 4/10/2025 because nursing reported he was pocketing food and Family Member #1 had complained because she wanted him to receive a regular diet. She explained that when she attempted to upgrade the resident's diet he coughed and choked and she did not upgrade it. The Speech Therapist stated Resident #103 was on a mechanical soft diet with regular liquids and no straw in January 2025 and then his diet changed to a mechanical soft diet with nectar thick liquids, and at some point prior to May 2025 Resident #103's diet changed to mechanical soft with nectar thick liquids and no straws. The Speech Therapist stated Resident #103 could feed himself if he was given the consistency that was ordered for him. The Speech Therapist also stated Family Member #1 was noncompliant and would give Resident #103 a regular diet after she spoke with her regarding the risk of choking if Resident #103 did not follow his ordered diet. The Speech Therapist stated she was not aware of a waiver being signed for Resident #103 to eat a regular diet or any other interventions regarding Resident #103 receiving food from the family that was inconsistent with his dietary order. The Speech Therapist stated she notified Family Member #1 each time the diet order was changed. The Speech Therapist stated Resident #103 would not have understood the dangers of eating foods that were not prescribed for him. Resident #103's Physician Order for 4/24/2025 indicated Resident #103 should receive a mechanical soft diet with nectar thickened liquids consistency with no raw vegetables and pureed fruit and continue with no straw. On 4/29/2025 at 7:45 pm a Nurses' Progress Note written by Nurse #7 stated Resident #103 was discharged to the hospital due to altered mental status. A Hospital Discharge summary dated [DATE] at 1:15 pm stated Resident #103's diagnoses during his hospitalization were anemia due to gastrointestinal bleeding and there was no documentation of a diet order on the discharge summary from the hospital. On 5/6/2025 a Physician's Order stated Resident #103's diet was a mechanical soft diet with nectar thickened liquids. Resident #103's active care plan on readmission 5/6/2025 included a care plan for nutritional risk related to dementia and malnutrition that was initiated on 11/22/2024. This care plan indicated Resident #103's family brought in foods that were not conducive with his diet order despite education regarding choking hazards. The interventions, also initiated on 11/22/2024, included that the resident required supervision and assistance with meals; and for difficulty swallowing, choking, coughing, drooling, and holding food in his mouth to be reported. The interventions did not specify who the signs of difficulty swallowing should be reported to. Resident #103's active care plan did not include any aggressive or combative behaviors. The only behavioral issue noted in the care plan was wandering. Unit Manager #2 was interviewed by phone on 3/5/2026 at 2:36 pm and stated she remembered having conversations with Family Member #1 on two occasions (she did not recall the dates) regarding the risk of Resident #103 choking if he ate food that was not on his prescribed diet. Unit Manager #2 explained that she had not observed Family Member #1 giving Resident #103 foods that he should not have; but Family Member #1 would come to her and complain that Resident #103 had not received a regular diet and that she had brought him regular food. Unit Manager #2 stated Family Member #1 was still insistent that Resident #103 could eat a regular diet. Unit Manager #2 stated Family Member #1 usually visited Resident #103 every other week. Unit Manager #2 stated she did not realize she had not written progress notes regarding her conversations with Resident #103's Family Member pertaining to the risk of choking if he ate foods that were not on his ordered diet. Unit Manager #2 stated Resident #103 would have been fine to eat the diet he was ordered (mechanical soft with nectar thick liquids) but he would have needed to be supervised if he was eating a regular diet since he would be at risk of choking. The Assistant Director of Nursing (ADON) was interviewed on 3/5/2026 at 11:27 am and stated the facility had several meetings with Resident #103's family member, Family Member #1, regarding the importance of following Resident #103's diet orders to prevent choking. The ADON stated she did not know why there were no progress notes regarding the meetings the facility had with Family Member #1. The ADON stated she was not aware of the facility obtaining a waiver to allow Resident #103 to eat foods that were not on his diet. The ADON stated Family Member #1 brought Resident #103 food that was not consistent with the resident's diet frequently. She further stated she had observed Family Member #1 bringing hard candy, beef stew, and cheese puffs on different occasions. The ADON stated when Family Member #1 brought in foods for Resident #103 that were not consistent with the resident's ordered diet she (the ADON) re-educated Family Member #1 on the risk of choking for Resident #103. Resident #103's medical record from 1/17/2025 through 5/6/2025 revealed no evidence of care plan meetings or other meetings (as referenced by the ADON in interview) held with Resident #103's Family Member related to education /interventions pertaining to the risk of choking if the resident ate foods that were not on his ordered diet. The only reference related to conversations with Family Member #1 during this time period (1/17/2025 through 5/6/2025) was in the 4/9/2025 note written by DON #2. A Nurse's Progress Note written by Nurse #1 on 5/7/2025 at 9:43 am stated Resident #103 refused his evening meal on 5/6/2025 and his family member (Family Member #1) brought him a burger, chicken nuggets, french fries, and a tea. Nurse #1 had tried to explain to Family Member #1 that Resident #103 was on a mechanical soft diet with nectar thick liquids and should not eat the meal Family Member #1 brought because of the risk of choking, but Family Member #1 insisted the resident could eat a regular diet. Family Member #1 gave the resident the foods she brought (hamburger, chicken nuggets, french fries, and a tea) and left Resident #103 sitting up in bed at 9:53 pm on 5/6/2025. Nurse #1 indicated she checked on Resident #103 after Family Member #1 left and asked Nurse Aide #3 to check on Resident #103; and at 10:14 pm Nurse Aide #3 found Resident #103 was pale, unresponsive, and had a very faint pulse. Nurse #1 immediately began CPR and she instructed Nurse Aide #3 to call for EMS. EMS arrived within a few minutes and continued CPR and Resident #103 was pronounced expired at 11:20 pm. Nurse Aide #3 was interviewed by phone on 3/4/2026 at 6:36 pm and she stated she was familiar with Resident #103 but she was not usually assigned to him. She indicated she was aware Family Member #1 would bring food in for the resident that was not consistent with Resident #103's diet. Nurse Aide #3 stated if she had observed Family Member #1 giving Resident #103 food that was not consistent with his diet she would notify the nurse assigned to him. Nurse Aide #3 stated she was not assigned to Resident #103 on the evening shift (3:00 pm to 11:00 pm) of 5/6/2025 but she was told by Nurse #1, at approximately 10:00 pm on 5/6/2025, to check on the resident because Family Member #1 gave him food that was not consistent with his mechanical soft diet with nectar thick liquids. Nurse Aide #3 stated Nurse #1 instructed her to check on Resident #103 because Nurse #1 was taking a break. Nurse Aide #3 revealed she checked on Resident #103 shortly after 10:00 pm and found him pale and unresponsive. Nurse Aide #3 further revealed that Resident #103 had food in his mouth and a hamburger in his hand that was partially eaten, and he was sitting up in bed. Nurse Aide #3 stated she did not see any vomit, just food in Resident #103's mouth when she checked on him. Nurse Aide #3 stated she immediately called for Nurse #1, and the nurse came and assessed him and began CPR. Nurse Aide #3 stated Resident #103 was not breathing when she called for Nurse #1. During a telephone interview on 3/5/2026 at 11:42 am with Nurse #1 she stated on 5/6/2025 Resident #103 was readmitted to the facility from the hospital before her shift began at 3:00 pm and she was assigned to Resident #103 on the 3:00 pm to 11:00 pm shift on 5/6/2025. Nurse #1 stated she cared for Resident #103 frequently before he discharged to the hospital and returned on 5/6/2025. Nurse #1 stated Resident #3 would refuse his meal trays at time, and she would assist him with eating after the refusal and he would eat when assisted. Nurse #1 stated Family Member #1 had brought in food that was not consistent with the resident's mechanical soft diet with nectar thick liquids before the incident on 5/6/2025. Nurse #1 stated she would try to remove the food or drink and would tell Family Member #1 that Resident #103 was at risk of choking if she fed him a regular diet or fluids that were not thickened. She indicated when Resident #103 received his dinner tray on 5/6/2025, which included his mechanically soft diet with nectar thick liquids, he had refused his tray. Nurse #1 stated Family Member #1 arrived at 9:43 pm and she (Nurse #1) told Family Member #1 that Resident #103 had refused his dinner tray. Family Member #1 stated that Resident #103 did not need a mechanically soft diet and nectar thick liquids and she brought him a burger, chicken nuggets, french fries, and a tea with a straw. Nurse #1 stated she explained to Family Member #1 that Resident #103 was at risk of choking if Resident #103 ate a regular consistency meal and did not follow his ordered mechanically soft diet with nectar thick liquids; but Family Member #1 set the resident up with the food she brought. Nurse #1 stated Family Member #1 left the facility at 9:53 pm and she (Nurse #1) went to the resident's room at 9:59 pm and attempted to remove the food Family Member #1 brought. She explained that Resident #103 was adamant he wanted the food and she thought he would become combative if she took the food away. Nurse #1 stated she did not add thickener to the tea or remove the meal. Nurse #1 reported she left the room after she attempted to remove the food. Nurse #1 stated at 10:00 pm while she was on her way to break she asked Nurse Aide #3 to check on Resident #103 while she (Nurse #1) took a break. Nurse #1 stated Nurse Aide #3 went to check on Resident #103 at 10:14 pm and found him pale, unresponsive, and he had a very faint pulse. Nurse #1 indicated she called a code and moved Resident #103 to a mattress and back board on the floor (because he was on an air mattress), began CPR immediately, and sent Nurse Aide #3 to call for EMS. She stated EMS arrived and took over CPR for Resident #103, and he was pronounced dead at 11:20 pm on 5/6/2025. A follow up interview was conducted by phone with Nurse #1 on 3/17/2025 at 1:46 pm and she stated that DON #2 had instructed her to re-educate Resident #103's family on the danger of the resident choking if the family brought in food that was not consistent with Resident #103's ordered diet and to refer Family Member #1 to the Speech Therapist when she insisted he should have a regular diet. She was unable to specify when this instruction from DON #2 was received. Nurse #1 reported Family Member #1 would insist each time she came in (Nurse #1 did not remember any dates) that Resident #103 should be on a regular diet. She revealed she was not given any other interventions to implement for when Family Member #1 brought in foods that were not consistent with Resident #103's diet. Nurse #1 stated she did try to take the hamburger, chicken nuggets, french fries and tea (which had a straw) from Resident #103 on the evening of 5/6/2025 but he refused and she was afraid he would become combative if she attempted to take the food because he was holding onto the food and would not allow her to take it. An EMS Report dated 5/6/2025 indicated a call was received at 10:19 pm in response to a cardiac arrest and they arrived on scene at Resident #103 at 10:26 pm. Resident #103 was on a mattress on the floor with a back board under him, receiving CPR by Fire Department personnel. It was reported that the resident was last seen between 10-15 minutes prior to the call to 911. It was also reported that Resident #103 was eating when he was last seen. Fire Department personnel found food near the resident. The report indicated that EMS believed the resident went into cardiac arrest after possibly choking on food. The resident was pale, not breathing, pulseless, and still warm to touch. Fire Department personnel were suctioning the resident's airway of vomit. EMS began treating the resident with CPR and the resident continued to vomit. EMS opted to secure the airway with Endotracheal Tube (placing a flexible tubing into the windpipe to ensure a clear, protected, and controlled passage for oxygen to reach the lungs) though it was difficult and took multiple attempts for success and constant suctioning was needed to remove large amounts of vomit from the resident's airway. After 45 minutes or more into the arrest, EMS consulted the physician and resuscitation efforts were discontinued. The resident's time of death was 11:20 pm. Multiple attempts were made to contact EMS for interview, but they were unable to be reached. A review of Resident #103's death certificate dated 5/6/2026 revealed his immediate cause of death was heart attack and his secondary causes of death were chronic anemia and dementia.During a phone interview with Family Member #1 on 3/18/2026 at 10:28 am she stated that on 5/6/2025 in the evening she went to see Resident #103 after he was readmitted from the hospital. She indicated she brought takeout food for the resident (a burger, french fries, and tea). She stated when she left the facility that evening the resident had 2 more bites of his cheeseburger left and she told Nurse #1 he was finishing his meal. Family Member #1 indicated Nurse #1 stated she would check on Resident #103. She stated that on that evening, she was not informed by staff that Resident #103 could not have a regular diet. She reported she spoke with EMS after Resident #103 passed away and they indicated the resident had vomited and they suctioned a small amount of hamburger from his esophagus (tube through which food passes from the throat to the stomach) and that he had vomited before they (EMS) arrived. Family Member #1 stated she had 2 care plan meetings during Resident #103's stay at the facility, the first one was on admission and the second was just before Easter 2025 (4/20/2025) and they discussed her (Family Member #1's) issues with the resident's care but no one had talked to her about his diet or the risk of choking with her related to foods she brought in for the resident. She indicated that Resident #103 had been on a regular diet in the hospital during his admission from 4/29/2025 through 5/6/2025, so she had assumed he was still on a regular diet and no one told her he was on a mechanical soft diet with thickened liquids. She stated she had a conversation with the DON #2 the day after Resident #103 died [DATE]) and the DON told her the resident should not have had a regular diet because the Speech Therapist had evaluated him and put him on a mechanical soft diet with thickened liquids.A phone interview was conducted with Family Member #2 on 3/18/2026 at 10:06 AM. She stated that the family just did not understand why Resident #103 could eat a regular diet in the hospital and then when he returned to the facility he would be placed back on a mechanical soft diet with thickened liquids. Family Member #2 stated the facility did not have any meetings with her where they discussed the dangers of feeding Resident #103 a regular diet. She revealed that she had brought Resident #103 food several times which included cheeseburgers, french fries, chicken sandwiches, and tea. Nurse Practitioner #1 was interviewed on 3/5/2026 at 10:45 am and she stated she did not recall having a conversation with Resident #103's family regarding his diet or that he should eat a mechanical soft diet with nectar thickened liquids. Nurse Practitioner #1 stated Resident #103 should not have been left alone, and staff should have supervised him when he was given food that was not consistent with his ordered diet as it put the resident at risk of choking. The Physician was interviewed on 3/5/2026 at 12:20 pm and stated he was not made aware Resident #103 received foods that were inconsistent with his dietary orders and had not spoken with Family Member #1 regarding Resident #103's diet. The Physician stated he should have been made aware of Family Member #1 bringing in foods that could have caused Resident #103 to choke. The Physician stated the facility should have provided supervision for Resident #103 when he was given a regular diet by Family Member #1 because he was at high risk for choking. The Physician stated Resident #103 would not have understood that the hamburger, french fries, chicken nuggets, and tea he was given by Family Member #1 would have put him at risk of choking. On 3/4/2026 at 11:35 am DON #2, who no longer worked at the facility, was interviewed by telephone and stated she remembered Resident #103 was on an altered diet and Family Member #1 constantly brought in foods that were not consistent with his diet. DON #2 stated she spoke with Family Member #1 multiple times and educated her on the risk of choking if the resident ate foods that were not on his diet, but the family member continued to bring in foods Resident #103 should not have. She stated Family Member #1 was not receptive to the diet and insisted he could eat a regular diet. DON #2 stated the Physician was not involved with speaking with Family Member #1 regarding the risks of choking if he ate a regular diet, but Nurse Practitioner #2 was involved with speaking with the family. DON #2 stated Family Member #1 visited Resident #103 about once every two weeks and she brought him food each time. DON #2 stated she had not witnessed Resident #103 choking or coughing when he was eating and he was not resistant to his ordered diet consistency. DON #2 indicated Resident #103 usually ate in the dining room for all meals, but would eat in his room when Family Member #1 brought him food which usually was during the evening meal. DON #2 stated Resident #103 was able to eat his ordered diet without assistance but should not have been left unsupervised when staff were aware Family Member #1 gave food that was not consistent with his diet as he was at risk of choking.During a follow-up interview by phone with DON #2 on 3/13/2026 at 3:10 pm she stated when Family Member #1 first brought foods that were not consistent with Resident #103's diet she educated the nursing staff to educate the family. DON #2 was unable to recall the date of the staff education, but indicated Family Member #1 had been bringing in food for the resident since the resident's admission [DATE]). She was not able to provide any evidence of this education. DON #2 stated they had care plan meetings with Family Member #1 regarding the risk of choking when she gave Resident #103 foods that were not on his diet. She did not recall the dates of these meetings and could not provide documentation of the care plan meetings. DON #2 stated they did not remove the food Family Member #1 brought if Resident #103 stated he wanted it because she felt that would be misappropriation and Resident #103 would become aggressive if it was removed. DON #2 stated Resident #103 had a history of aggressive and combative behaviors at times. DON #2 stated she did not know what the facility had failed to do since they had educated Family Member #1 when she brought in the food Resident #103 should not have had. She stated the facility did not obtain a waiver for Resident #103 to eat the foods Family Member #1 brought to him and when asked if the facility notified Adult Protective Services (APS) of Family Member #1 bringing in foods that were not consistent with Resident #103's ordered diet she indicated she did not call them because she thought they would not have returned her call.Nurse Practitioner #2 was interviewed by phone on 3/13/2026 at 3:03 pm and stated she did not remember Resident #103 and did not remember having a conversation with Family Member #1 regarding the resident being brought food that was not consistent with his ordered diet. She stated if she had a conversation with Family Member #1 she would have written a progress note. (Nurse Practitioner #2 was identified by DON #2 as the Nurse Practitioner who had a meeting with Family Member #1 regarding the risk of choking if she fed Resident #103 a regular diet.) Nurse Practitioner #2 stated if Resident #103 was severely cognitively impaired the facility should have met with Family Member #1 and the provider to develop interventions and to make sure the resident was aware of the risk of choking. Nurse Practitioner #2 stated if Resident #103 did not understand the risk of choking that Family Member #1 should have obtained a Health Care Power of Attorney to make decisions for Resident #103. On 3/3/2026 at 4:43 pm a phone interview was conducted with Administrator #2, the Administrator on 5/6/2025, and he stated he did not remember the incident regarding Resident #103 choking. He stated DON #2 would have done a plan of correction and would remember the incident. Administrator #1, the facility's current administrator, was interviewed by phone on 3/17/2025 at 1:39 pm and stated during this current survey she had requested the Health Care Power of Attorney (HC POA) records for Resident #103 from the previous owners of the facility and there was no HC POA on file for Resident #103. Administrator #1 stated she had also requested the care plan meeting notes for Resident #103 and there were no care plan notes that indicated the facility's Interdisciplinary Team met with Family Member #1 to discuss interventions regarding her bringing him food that was not consistent with his diet. The Administrator was notified of immediate jeopardy on 3/5/2026 at 4:15 pm.The facility provided the following corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 5/6/25, the facility failed to remove food and/or provide supervision when a severely cognitively impaired resident (Resident #103) readmitted to the facility with a history of dementia, stroke, and difficulty swallowing, was on a mechanical soft diet with nectar thickened liquids was provided a hamburger, chicken nuggets, French fries, and a sweet tea by his daughter. Resident #103's nurse made the resident's daughter aware during her visit, Resident #103 refused his dinner and spit out his medications. The daughter asked the nurse, is it that mashed food, he won't eat that referring to dinner. At 9:53pm prior to leaving, the family member communicated to the nurse she brought food for the resident and set the food up on his bedside table. The nurse informed the daughter Resident #103 couldn't have that food. When the nurse attempted to remove the food, Resident #103 refused for it to be taken away. After the nurses' failed attempt to remove the food, the nurse exited the room failing to provide supervision while Resident #103 consumed the food.At 9:59pm, the nurse checked on the resident and he did not appear to be choking or having difficulty swallowing the food. The nurse asked the NA to provide frequent checks on Resident #103. At 10:14pm, the NA made the nurse aware Resident #103 was exhibiting a change in his condition. Upon assessment, Resident #103 was found to be pale, unresponsive with a faint pulse. The Nurse assessed and there was no food present in Resident #103's mouth. Resident #103 was a full code and CPR was initiated. Emergency Medical Services (EMS) was called at 10:20pm, arriving at 10:23pm and took over the chest compressions and artificial ventilation efforts (CPR). Resuscitation efforts were unsuccessful, and Resident #103 was pronounced deceased at 11:20pm. The resident's daughter returned to the facility and was present during the code and pronouncement. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents with modified diets to include mechanical soft, puree, and thickened liquids have the potential to be affected by the deficient practice. On 5/7/25 The Director of Nursing and the Assistant Director of Nursing conducted an audit of all current residents with modified diets to include mechanical soft, puree, and thickened liquids. Ten residents were identified to be on a pureed diet, twenty-two residents were identified to be on a mechanical soft diet, and five residents were on thickened liquids. The Director of Nursing and the Assistant Director of Nursing continued their audit of mechanically altered diets and thickened liquids to ensure tray tickets matched diet orders. No discrepancies were noted.On 5/7/25, the Director of Nursing and Assistant Director of Nursing interviewed staff to identify residents on mechanically altered diets and/or thickened liquids to ascertain residents consuming foods and/or liquids inconsistent with physician diet orders. No concerns were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 5/7/25 The Director of Nursing and/or Assistant Director of Nursing began educating all nursing staff on the immediate removal of food/drink inconsistent with physician diet orders and notification to licensed nurses. Licensed nurses will educate residents and/or family on risks versus benefits at that time. On 5/7/25, the Director of Nursing educated the Director of Rehab (DOR) who communicates with their team after clinical meetings. During daily clinical meetings, new admits and/or physician orders of therapeutic diets are communicated and Social Worker, along with the IDT, is responsible for scheduling care plan meetings to review informed care decisions. During daily clinical meetings and review of progress notes, change of conditions and Situation Background Assessment Recommendation (SBAR), care plan meetings will be scheduled through the Social Worker with residents and/or family as needed to obtain informed care decision consents, as well as a referral to speech therapy. An interfacility communication form will be completed and provided to the Director or Rehab (DOR) for speech referrals and the Certified Dietary Manager for physician diet [TRUNCATED]

Based on observations, record review, and staff interviews, the facility failed to discard expired multi-use medications on 1 of 2 medication carts reviewed (Medication Cart [DATE]) and failed to date multi-use medications upon opening, as required by manufacturer recommendations, on both medication carts reviewed (Medication Cart [DATE] and Medication Cart [DATE]). These failures have the potential to result in the administration of expired or improperly labeled medications.Findings included: 1) An inspection was conducted on [DATE] at 11:10 AM of Medication cart [DATE] in the presence of Med Aide #1. The observation revealed no opened date on the following multi-dose medications:-Two multi-dose bottles of neo-polymyxin B eye drop with no opened date (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-One multi-dose bottle of tobramycin 0.03 % eye drops with no opened date (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-One multi-dose bottle of latanoprost ophthalmic solution 0.005 % eye drops with no opened date (according to the manufacturer's directions, this medication must be discarded 42 days after opening).- Three insulin glargine dial-a-dose pens (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-Two insulin lispro insulin dial-a-dose pens (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-One insulin aspart dial-a-dose pen (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-One insulin degludec dial-a-dose pen (according to the manufacturer's directions, this medication must be discarded 56 days after opening). An interview was conducted on [DATE] at 11:20 AM with Medication Aide (MA) #1. She confirmed all multi-use medications should be dated upon opening, and she discarded the undated items discovered during the inspection. MA #1 explained she did not handle the insulin as that would be the nurse's responsibility. She stated if any insulin had to be administered today Nurse #2 would be administering them. She explained she normally checked the dates on the eye drops but she had not checked them on the day of the interview. She went on to say she did not realize the bottles of eye drops were not labeled with an open date. An interview was conducted on [DATE] at 11:23 AM with the Assistant Director of Nursing (ADON). She explained medication aides and nurses were to always write the open date and the expiration date on multi dose insulin vials/pens and the opened date on eye drops. She stated she was unaware the staff were not marking the open dates and expiration dates on the medications. The ADON discarded the insulin that was not dated on Medication cart [DATE]. 2a) An inspection was conducted on [DATE] at 11:42 AM of Medication cart [DATE] in the presence of Med Aide #2. The observation revealed a multi-dose bottle of timolol eye drops with no open date (according to the manufacturer's directions, this medication must be discarded 28 days after opening). Med Aide #2 confirmed the medication should be dated upon opening and she discarded the bottle of eye drops. 2b) An inspection was conducted on [DATE] at 11:42 AM of Medication cart [DATE] in the presence of Med Aide #2. The observation revealed the following expired multi-dose medications: -One insulin glargine dial-a-dose pen opened [DATE] (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-Two insulin lispro dial-a-dose pen, one with an open date of [DATE] and one with an open date of [DATE] (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-Two bottles of neo-polymyxin eye drops opened on [DATE] and on [DATE] (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-Tobram eye drops opened on [DATE] (according to the manufacturer's directions, this medication must be discarded 28 days after opening).-Four bottles of latanoprost eye drops opened [DATE], [DATE], [DATE], and the fourth bottle opened on [DATE] (according to the manufacturer's directions, this medication must be discarded 42 days after opening).On [DATE] at 11:40 AM an interview was conducted with Medication Aide (MA) #2. She stated she didn't realize the eye drops were expired and/or did not have an open date on them. She went on to explain it was hard to take the time to figure out if the medication was expired because she felt she was always running out of time and that it was an oversight. A follow-up interview was conducted on [DATE] at 11:51 AM with the Assistant Director of Nursing (ADON). The ADON explained medication aides and nurses were to always write the open date and the expiration date on multi dose insulin vials/pens and the opened date on eye drops. She stated she was unaware the staff were not doing labeling medications with the open date. The ADON discarded the insulins that were expired on Medication cart [DATE].A follow-up interview was conducted on [DATE] at 12:10 PM with Medication Aide (MA) #2. One of the Latanoprost eye drops had an open date for [DATE] written on the bottom of the bottle and [DATE] on the lid of the medication bottle. When asked why there were two dates on the bottle MA #2 stated she did not see the date written on the bottom of the bottle and she had written [DATE] on the lid. She further explained she did not recall who came to her this morning ([DATE]) but they told her, Everything in the medication cart should have a date on it. The MA explained she went through and wrote [DATE] on the medications which did not have a date on them.

Based on observation, record review, and interviews with residents and staff, the facility did not maintain a resident bed in safe working condition for 1 of 1 resident room reviewed for a safe and homelike environment on 1 of 4 halls (Resident #58).An initial observation of Resident #58's room on 03/01/2026 at 1:58PM, revealed Resident #58 was in a semi-private room and positioned in the bed near the door. Observation revealed the head of the bed was elevated in an upright position and the bed was positioned above its lowest setting. At the time of observation, the bed was unplugged. Electrical wiring was observed hanging beneath the bed. Multiple internal wires (white, blue, red, and yellow) were visible along with a gold-colored exposed wire. The exposed wiring appeared damaged and was not properly secured to the bed frame. A review of the facility maintenance work order logbook dated 09/15/2025 through 03/01/2026 revealed no documentation of a work order submitted regarding Resident #58's bed.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact and dependent on staff assistance for transferring in and out of bed.On 03/01/2026 at 2:38 PM, Resident #58 who resided in room [ROOM NUMBER], was interviewed and stated her bed had not been functioning properly and reported the bed had not been working for several months. Resident #58 stated she reported her bed concerns to the Maintenance Director because she was unable to independently adjust or move the bed because the bed remote was not working. Resident #58 reported maintenance staff had come to look at the bed several times; however, she was unable to recall the specific dates. Resident #58 stated maintenance staff did not return after those visits, and the bed had not been repaired. Resident #58 further stated the bed remained partially elevated in a sitting position and caused back soreness and discomfort. Resident #58 reported the position was uncomfortable and made it difficult for her to remain asleep.On 03/02/2026 at 9:53 AM, an interview was conducted with Nurse Aide (NA) #1. NA #1 stated she typically provided care for Resident #58. NA #1 observed the resident's bed was in a high position and stated when care was not being provided the bed should be lowered to the near-lowest height. NA #1 stated Resident #58's bed appeared to be in the highest position. NA #1 also observed a frayed electrical cord and noted the bed was not plugged in. NA #1 reported the bed remote was missing the down button, preventing the bed from being lowered. NA #1 stated maintenance concerns were typically documented by staff in the maintenance logbook and reported she would notify the Maintenance Director. NA #1 stated she had not previously noticed the bed would not lower and reported Resident #58 had not voiced any concerns regarding the bed. NA #1 further stated Resident #58 preferred to remain in bed.On 03/02/2026 at 12:33 PM, an interview was conducted with a Housekeeper. The Housekeeper reported she typically cleaned Resident #58's room and she had not previously noticed concerns with Resident #58's bed. During the interview, the Housekeeper observed the bed remote appeared broken and the bed could not be lowered.On 03/02/2026 at 12:38 PM, an interview and observation were conducted with the Maintenance Director. The Maintenance Director stated he was not aware of any concerns regarding Resident #58's bed prior to 03/02/2026. The Maintenance Director inspected Resident #58's bed and observed exposed wiring beneath the bed. He stated the wiring appeared to have been pulled from the control box connected to the motor. The Maintenance Director further observed the bed was plugged in. The Maintenance Director examined the bed remote and observed one of the buttons was damaged and the internal wiring was exposed. He stated if someone attempted to press the button there was a potential risk of electrical shock. The Maintenance Director confirmed the bed could not be lowered and stated he would replace the bed himself. The Maintenance Director stated the facility had a system in place for reporting maintenance concerns. He reported staff were to document maintenance issues using the paper log located at the nurses' station. The Maintenance Director stated staff were expected to record repair concerns in the log for maintenance to review and address.On 03/04/2026 at 10:00 AM, an interview with the Administrator was conducted. The Administrator stated her expectation would be for staff to identify and report maintenance concerns promptly and ensure resident equipment was maintained in safe working conditions.

Based on record review, observations, and Nurse Practitioner (NP), resident, and staff interviews, the facility failed to obtain a physician's order for the use of continuous oxygen for 1 of 6 residents reviewed for respiratory care (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. A physician's progress note dated 10/24/25 read that Resident #16 had chronic respiratory failure on 3 liters of oxygen via nasal cannula. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #16 was cognitively intact and was coded with the use of oxygen. Resident #16's active care plan, last reviewed 12/31/25 included a focus area for COPD, at risk for respiratory distress. The interventions included oxygen via nasal cannula as ordered. An NP progress note dated 1/17/26 read that Resident #16 utilized 3 liters of oxygen continuously. A review of Resident #16's nursing progress notes from 9/11/25 to 2/28/26 revealed he was using oxygen continuously. A review of Resident #16's December 2025, January 2026, February 2026 and March 2026 Physician orders did not include an order for oxygen. In an observation, conducted in conjunction with an interview, on 3/1/26 at 11:30 AM, Resident #16 was lying in bed watching television. The meter on the oxygen concentrator showed oxygen was flowing at 2 liters via nasal cannula to the resident. Resident #16 stated he used oxygen continuously. Resident #16 did not present with any shortness of breath or distress during the interview and observation and was able to carry on a conversation. Resident #16 was observed lying in bed watching television on 3/2/26 at 12:32 PM. The meter on the oxygen concentrator showed oxygen was flowing at 2 liters via nasal cannula to the resident. Resident #16 was not short of breath during the observation. On 3/3/26 at 9:16 AM, Resident #16 was observed with the meter on the oxygen concentrator showing the oxygen was flowing at 2 liters via nasal cannula to the resident. Resident #16 was not short of breath during the observation. On 3/3/26 at 12:00 PM, an interview occurred with Medication Aide (MA) #1 who had been assigned to care for Resident #16 frequently. She confirmed Resident #16 utilized oxygen continuously and stated that she recalled he had used 2 liters of oxygen in the past and thought that's what he still used. The MA verified there was no order in the resident's medical record for the continuous use of oxygen but could not explain why one wasn't present. In an interview on 3/3/26 at 2:48 PM, the Assistant Director of Nursing (ADON) stated Resident #16 required continuous oxygen for his COPD. The ADON verified there was no order for the continuous use of oxygen in the resident's medical record and stated there should have been an order written for it. She felt it had been dropped off the order list at some time but was unable to definitively say when. The ADON stated she would contact the provider and ensure Resident #16 had an order for the prescribed amount of oxygen. A phone interview occurred with NP #2 on 3/3/26 at 4:50 PM. The NP explained that when she last assessed Resident #16 on 1/17/26, she had made no changes to his plan of care, which included the use of oxygen at 3 liters continuously. She stated she would expect the facility to have an order for Resident #16's use of oxygen at 3 liters via nasal cannula continuously.

Based on record review and physician, resident and staff interviews, the facility failed to administer insulin in accordance with the physician's orders for 13 out of 30 days in June 2025 for 1 of 3 residents reviewed for significant medication error (Resident #33). The findings included: Resident #33 was originally admitted to the facility on [DATE] with diagnoses that included diabetes type 2. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact and received seven days of insulin injections during the seven-day look back period. Resident #33's care plan, last reviewed on 6/10/25 included a focus area for diabetes. The interventions included providing diabetic medication as ordered by the physician. A review of Resident #33's physician orders included the following: An order dated 5/27/25 for Humalog insulin. Inject 12 units subcutaneously (SQ) three times a day. An order dated 6/3/25 for Humalog Kwikpen. Inject per sliding scale before meals and at bedtime. The sliding scale was as follows: If fasting blood sugar is 0-250= 0 units. Notify physician if less than 70. 251-300= 6 units301-350= 8 units351-400= 10 units401-450= 12 unitsGreater than 450 give 15 units and recheck in 2 hours. Notify physician for continued result greater than 450. An order dated 6/17/25 for Lantus Solostar insulin. Inject 38 units SQ daily. A review of the June 2025 Medication Administration Record (MAR) revealed the following insulin was not signed off as given or refused by Resident #33: Humalog insulin. Inject 12 units SQ three times a day. Missing documentation for 6/2/25 at 5:00 PM, 6/6/25 at 11:00 AM, 6/8/25 at 5:00 PM, 6/13/25 at 5:00 PM, 6/16/25 at 5:00 PM, 6/17/25 at 5:00 PM, 6/19/25 at 11:00 AM, 6/20/25 at 5:00 PM, 6/25/25 at 11:00 AM, 6/26/25 at 5:00 PM, 6/28/25 at 6:00 AM and 11:00 AM, and 6/29/25 at 11:00 AM and 5:00 PM. Lantus Solostar insulin. Inject 38 units SQ daily at 9:00 AM. Missing documentation for 6/19/25, 6/25/25, 6/28/25 and 6/29/25. Humalog Kwikpen. Inject per sliding scale before meals and at bedtime. Missing documentation for 6/6/25 at 11:00 AM, 6/8/25 at 4:00 PM, 6/13/25 at 4:00 PM, 6/14/25 at 9:00 PM, 6/16/25 at 4:00 PM, 6/19/25 at 11:00 AM, 6/20/25 at 4:00 PM and 9:00 PM, 6/25/25 at 11:00 AM, 6/26/25 at 4:00 PM, 6/28/25 at 6:00 AM and 11:00 AM and 6/29/25 at 11:00 AM. A quarterly MDS assessment dated [DATE] indicated Resident #33 was cognitively intact and received six days of insulin injections during the seven-day look back period. Resident #33's active care plan, last reviewed 1/21/26, included a focus area for diabetes. The interventions included providing diabetic medications as ordered by the physician. An interview with Resident #33 was conducted on 3/1/26 at 11:57 AM. She recalled asking nursing staff about receiving her insulin injections in June 2025 but could not remember the specific dates or frequency. She stated that having to ask about her insulin occurred frequently and that she was always told that someone would give her the insulin injection. On 3/3/36 at 10:13 AM, an interview occurred with Medication Aide (MA) #1 who was assigned to care for Resident #33 on 6/6/25 for the 7:00 AM to 3:00 PM shift, 6/13/25 for the 3:00 PM to 11:00 PM shift, 6/19/25 for the 7:00 AM to 3:00 PM shift, 6/20/25 for the 3:00 PM to 11:00 PM shift, 6/25/25 for the 7:00 AM to 3:00 PM shift, 6/28/25 for the 7:00 AM to 3:00 PM shift and 6/29/25 for the 7:00 AM to 3:00 PM shift. She explained that an MA was not allowed to administer insulin and that one of the nurses would have done this for any resident requiring insulin, to include Resident #33. She indicated that she would have to ask a nurse to provide the insulin when it was due to be given. MA #1 indicated that the nurse would be either the floor nurse, the Assistant Director of Nursing (ADON) or the MDS nurse and that there was not a nurse assigned to administer insulin. MA #1 reviewed the June 2025 MAR and verified that the referenced dates were blank and did not indicate if the insulin was provided or refused by Resident #33. She was unable to recall which nurse would have administered the insulin as ordered to Resident #33. A phone interview occurred with MA #12 on 3/5/26 at 2:50 PM. He was assigned to care for Resident #33 on 6/8/25 for the 3:00 PM to 11:00 PM shift. MA #12 stated that as an MA he could not administer insulin injections and would have to ask a nurse to provide the insulin when it was due to be given. He was unable to recall which nurse would have administered Resident #33's insulin on the evening of 6/8/25. A phone interview was conducted with MA #9 on 3/4/26 at 11:54 AM, who explained that as an MA she could not administer insulin injections and would have to ask a nurse to provide the insulin when it was due to be given. She indicated that a nurse would administer Resident #33's insulin. The MAR was reviewed with MA #9 for missing insulin documentation on 6/14/25 at 9:00 PM. She was unable to recall which nurse would have administered Resident #33 with her insulin. On 3/4/26 at 11:58 AM, a phone interview occurred with MA #10, who explained that as an MA she was unable to administer insulin injections and would have to locate a nurse to provide the insulin when it was due to be administered. She indicated that either the floor nurse, unit manager or ADON would have provided insulin injections to Resident #33. MA #10 was assigned to Resident #33 on 6/2/25, 6/16/25, 6/17/25 and 6/29/25 for the 3:00 PM to 11:00 PM shift. She was unable to recall which nurse administered insulin injections to Resident #33 during the referenced dates. The ADON was interviewed on 3/3/26 at 4:18 PM and explained that when an MA was working on the medication cart, a nurse would come and administer insulin as needed for the residents. She indicated it would be whoever was available and there was no designated nurse responsible for insulin injections on any given shift. The ADON reviewed Resident #33's June 2025 MAR and verified the referenced dates were blank and did not indicate if the insulin was provided or refused by Resident #33. She was unable to state who would have administered the insulin injections. An interview was conducted with MDS Nurse #2 on 3/4/26 at 9:58 AM. She stated that she had been the Unit Manager for the area that Resident #33 resided in June 2025. She explained that an MA would not have been able to administer insulin injections and that it would have been either the floor nurse, ADON, unit manager or MDS nurse, but there was not a designated staff member to provide insulin injections. MDS Nurse #2 reviewed Resident #33's June 2025 MAR and verified there were multiple blank areas for Resident #33's insulin injections that did not indicate if the insulin was provided or refused by Resident #33. MDS #2 stated she couldn't recall if she had administered insulin to Resident #33 on the referenced dates in June 2025. A phone interview was completed with Nurse #5 on 3/4/26 at 11:47 AM. She stated that MAs were not allowed to administer insulin and that either she would assist with insulin injections when she worked at the facility, as well as the ADON, unit manager, or any nurse that was available. She was assigned as the floor nurse in the area that Resident #33 resided on 6/19/25, 6/25/25, 6/28/25 and 6/29/25 for the 7:00 AM to 3:00 PM shift. The dates were reviewed with Nurse #5, but she could not recall if she administered insulin to Resident #33 or another nurse. The Physician was interviewed on 3/4/26 at 12:42 PM and stated that he would expect nursing staff to document when insulin was provided as ordered. He reviewed Resident #33's medical record and indicated there was no ill effects if she had not received insulin on the referenced dates and that her accuchecks remained at her baseline. The Director of Nursing was interviewed on 3/4/26 at 1:28 PM. She indicated she had begun employment at the facility early part of February 2026. She stated that MAs were expected to request a nurse to provide the insulin when it was due. She indicated that it would be expected for nursing staff to document when insulin was provided or refused by any resident.

Based on record review, observation, and interviews with resident and staff, the facility failed to ensure a resident who was dependent on staff assistance for incontinence care (Resident #18) and for changing soiled clothing (Resident #87) received assistance when needed for 2 of 11 residents reviewed for activities of daily living (Residents #18 and #87). The findings included:1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia. The resident's active care plan, last updated on 10/03/25, identified incontinence as a focus area. Interventions included cleansing the perineal area with each incontinence episode, monitoring and documenting intake and output per facility policy, and monitoring/documenting for signs and symptoms of urinary tract infection. Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was severely impaired and he did not refuse any care. Resident #18 was independent with bed mobility, he required supervision or touching assistance to walk 50 feet with two turns, and he required partial/moderate assistance with transfers. Resident #18 required substantial/maximal assistance to shower/bathe self, and personal hygiene, and he was dependent on staff for toileting hygiene. He was always incontinent with bowel and bladder. On 03/02/26, a continuous observation was conducted from 1:03 PM to 1:25 PM. During this period, Resident #18 was observed lying in bed on his left side with his eyes closed. He was wearing black, thin pants, and his brief was visibly exposed above the waistline. The bed sheet beneath him displayed a straw colored wet area extending approximately 10 inches around his lower body, with an additional yellowish brown dried border extending about 3 inches beyond the wet area. No nursing assistants were present or available on the hall at any point during the observation period. An interview was conducted on 03/02/26 at 2:01 PM with Nursing Assistant (NA) #6. She confirmed she was the direct care NA for Resident #18 and that she was accompanied by an orientee. NA #6 reported that she provided incontinence care to Resident #18 between 8:15 AM and 8:30 AM. She stated that she returned to check on him at 11:30 AM and noted that his brief was wet and required changing, at which time the resident refused care. She reported notifying Nurse #2 of the refusal. NA #6 stated that she did not return to Resident #18's room after the 11:30 AM check. She further stated she went to lunch at 1:30 PM and did not change the resident prior to leaving for lunch. When asked why, she replied, because I had to get food, I was starving. NA #6 also reported that she completes incontinence rounds every two hours and as needed. At the time of the interview she had not been back to Resident #18's room. An observation and interview were conducted on 03/02/26 at 2:14 PM with Nursing Assistant (NA) #7. He confirmed that he had been orienting with NA #6 throughout the day. NA #7 stated they provided incontinence care to Resident #18 at approximately 8:30 AM. He reported they entered the resident's room again prior to lunch, though he was unable to recall the exact time. According to NA #7, Resident #18 stated he was tired and requested that they return later to complete the change. NA #7 further stated that neither he nor NA #6 returned to Resident #18's room after that visit prior to lunch. He also reported that he was not aware of NA #6 notifying Nurse #2 that Resident #18 had refused incontinence care at any point during the day.During an observation and interview conducted on 03/02/26 at 1:30 PM, the Director of Nursing (DON) confirmed that Resident #18's clothing, brief, and bed linens were wet and that the resident required changing. She stated that her expectation was for staff to provide incontinent care before a resident's clothing or bedding becomes wet or soiled. The DON further indicated she was unaware that Resident #18 had not received the necessary incontinence care. An observation and interview were conducted on 03/02/26 at 1:40 PM with Nursing Assistant (NA) #5. NA #5 removed and confirmed that Resident #18's clothing, brief, and linens were wet with urine. Resident #87's skin was intact with no redness noted. She stated that although she was not assigned as Resident #18's direct care NA for the day, the Director of Nursing requested her assistance in changing the resident. An interview was conducted on 03/02/26 at approximately 4:05 PM with Nurse #2. She confirmed she was the direct care nurse for Resident #18 on this date. Nurse #2 stated that Nursing Assistant #6 did not notify her at any time on 03/02/26 that Resident #18 had refused incontinent care.2. Resident #87 was admitted to the facility on [DATE] with diagnoses that included intermittent explosive disorder (a mental health condition characterized by recurrent, impulsive, and intense outbursts of aggression or violence that are grossly disproportionate to the situation) and vascular dementia. Resident #87's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was severely impaired and he exhibited no behaviors. He usually understood others and he had highly impaired hearing. Resident #87 required set-up/clean-up with eating and required supervision or touching with oral hygiene. He required partial/moderate assistance with personal hygiene and substantial/maximum assistance with dressing. Resident #87's active care plan, last revised on 02/28/26, included the focus area of an activity of daily living (ADL) self-care deficit. The interventions included for staff to assist with dressing and undressing and to assist him to choose simple comfortable clothing that enhances his ability to dress self. An observation was conducted on 03/01/26 at 11:43 AM of Resident #87 lying in bed wearing a plain blue long-sleeved shirt. The shirt contained dried food particles and dried white and tan-colored spill marks. Resident #87 was eating his lunch at the time of the observation and stated, I'm okay. An observation was conducted on 03/01/26 at 2:52 PM of Resident #87 lying on his bed wearing a long sleeved shirt. The shirt had dried food particles and dried spill marks present.An observation was conducted on 03/02/26 at 10:00 AM of Resident #87 lying on his bed wearing the same soiled long sleeved shirt observed the previous day. The shirt continued to have dried food particles and dried spill marks. When asked if he knew how long he had been wearing the shirt, Resident #87 stated, It's been 3 days; it needs to be changed. He was unsure whether he had asked anyone to change the soiled shirt. An observation and interview were conducted on 03/02/26 at 10:25 AM with Medication Aide (MA) #1. She accompanied this surveyor to Resident #87's room and confirmed that the resident's shirt was soiled with crumbs, dried and hardened food spots, and dried white colored beverage spills. She further verified that this was the same soiled shirt Resident #87 had been wearing on 03/01/26. MA #1 stated she would notify the Nursing Assistant (NA) assigned to Resident #87 that his clothing needed to be changed. She also confirmed she was the direct care MA for Resident #87 on both 03/01/26 and 03/02/26. MA #1 reported that she assumed the assigned NA would have changed the resident's shirt during morning care or after lunch on 03/01/26.An interview was conducted on 03/02/26 at 1:50 PM with Nursing Assistant (NA) #5. NA #5 confirmed that she was the direct care NA for Resident #87 on this date. She stated she had not provided morning care to Resident #87 at the time Medication Aide (MA) #1 notified her, around 10:30 AM, that the resident's shirt was soiled and had been worn since the previous day. NA #5 reported that she then entered the room at that time and provided morning care to Resident #87. Unsuccessful attempts were made to interview the direct care Nursing Assistant assigned to Resident #87 on 03/01/26 for the 7:00 AM to 7:00 PM and the 7:00 PM to 7:00 AM shifts. An interview was conducted on 03/04/26 at 2:03 PM with the Director of Nursing (DON). The Director of Nursing stated that residents were expected to remain neat, clean, and dressed in clean garments, with their activities of daily living (ADL) needs met. She explained that staff were expected to change residents' clothing after meals if soiling occurs. She also reported she was not aware that Resident #87's ADL had not been met.

Based on observations, record review and staff and Medical Director interviews, the facility did not administer intravenous (IV) fluids (give fluids through a vein) according to physician orders for 1 of 2 residents reviewed for intravenous therapy (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE] with a diagnosis of chronic pain.The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact.Resident #6 had a verbal order from the Medical Director that was received and transcribed by Unit Manager #2 on 2/27/26 at 8:52 AM and stated 0.9% sodium chloride intravenous solution was to be administered at 80 milliliters/hour (mL/hr.) for a total of 2 liters for dehydration. Review of Resident #6's medication administration record (MAR) for February 2026 included an order dated 2/27/26 for the administration of sodium chloride intravenous fluids to be infused at 80 mL/hr. for a total of 2 liters. The MAR included a confirmation space for each 8 hour shift (day, evening and night shift). A checkmark indicated administered, 2 indicated refused, and 9 indicated other/see nurses' notes. Review of the MAR for 2/27/26 revealed the evening and night shifts and were coded as administered. Review of the MAR for 2/28/26 revealed the day and evening shifts and were coded as administered. The 2/28/26 night shift was coded as other/see nurses notes. The MAR note created on 2/28/26 at 11:21 PM by Nurse #3 stated Resident #6 refused IV fluids for the night shift.Review of Resident #6's MAR for March 2026 included an order dated 2/27/26 for the administration of sodium chloride intravenous fluids to be infused at 80 mL/hr. for a total of 2 liters. The 3/1/26 MAR had Nurse #2's initials and a checkmark symbol for day and evening shifts indicating the IV fluids were administered. The 3/1/26 MAR had an entry by Nurse #3 at 7:44 AM that IV fluid D5NS infusing due to no sodium chloride 0.9% available. The 3/1/26 MAR entry for night shift was coded by Nurse #3 on 3/1/26 at 8:07 AM with a 9 and it stated IV D5 0.9 NS infusing at 80mL/hr.On 03/01/2026 at 3:42 PM, an observational interview of Resident #6 seated in her manual wheelchair revealed she had a saline lock (a small, flexible tube placed in the hand or arm vein that acted like a port for medicine and fluids) in her forearm. A one-liter bag of 5% dextrose (sugar) and 0.9% sodium chloride was infusing. The bag of IV solution of 5% dextrose and 0.9% sodium chloride (D5NS) was connected by thin transparent tubing to the saline lock in Resident #6's forearm. The bag was labeled 3/1 and had no initials. Resident #6 had received approximately one half of the one-liter bag of IV fluids. Resident #6 reported that she was getting IV fluids because she was dehydrated and needed some more fluids. Resident #6 stated she didn't like to drink so the fluids were helping her. Resident #6 was unable to identify the type of fluids infusing and reported that she had been receiving IV fluids all day.During an interview on 3/2/26 at 10:44 AM, Nurse #2 stated she received report during the 3/1/26 morning shift at approximately 7:00 AM that Resident #6's IV fluids had completed infusing during the night and that a new bag had been hung just before shift change. Nurse #2 stated she did not complete the visual inspection of the IV fluid bag or tubing during her initial medication pass on 3/1/26 or at any time during the 3/1/26 day shift and therefore could not confirm which fluids had been given. She acknowledged she was required to visually confirm the fluid type, amount of fluid infused, and that the IV fluid's flow rate matched the provider's order but did not do it because she became distracted when passing medications for the units not go to check it afterward. She stated that the 0.9% sodium chloride fluid was usually available through the automated medication dispensing system. Nurse #2 stated she was aware that as a medication nurse, she was required to follow provider orders as written. She said she would begin the notification process with the provider regarding the IV fluid error. Attempts to conduct a telephone interview with Nurse #3 on 3/2/26 and on 3/3/26 to interview her regarding her two MAR entries on 3/1/26 that stated D5NS was infusing were unsuccessful. During an interview on 03/02/2026 at 2:15 PM, the Medical Director reported he was not yet informed that D5NS had been hanging for Resident #6 instead of the ordered sodium chloride IV solution. Medical Director stated he had no concerns about adverse outcomes from Resident #6 being administered the D5NS fluid. The Medical Director reported he was aware there had been a prior shortage of the IV fluid 0.9% sodium chloride and could not speculate as to why they did not administer the 0.9% sodium chloride fluids. The Medical Director stated he expected staff to notify the provider of any issues with medication administration. Medical Director stated he expected staff to notify the on call provider when he or another facility provider was not on site. He added that IV fluids were given for dehydration and, because Resident #6 was not diabetic, he believed the liter of D5NS was not harmful. In an interview on 3/2/26 at 2:55 PM, the Director of Nursing (DON) stated she was not aware that Nurse #2 and Nurse #3 had administered the wrong IV fluids to Resident #6. She reported that staff were expected to administer IV fluids according to the provider's orders. The DON stated that Nurse #2 acknowledged she did not check the fluids and later realized she had infused the wrong solution. The DON said that Nurse #2 should have notified the provider that the 0.9% sodium chloride solution was not available for Resident #6 and monitored the resident for any adverse. The DON explained that staff used an automated medication distribution system that dispenses the ordered fluids for each resident and that staff were required to use pharmacy supplied fluids. The DON stated the pharmacy sent IV fluids with labels for the individual resident that included resident identifiers, name of what was in the bag of fluids, flow rate, and expirations date. She added that some stock fluids were also available in the automated medication dispensing system if needed. During a follow up interview on 3/4/26 at 12:30 PM, the DON indicated she was not aware the nursing staff documented D5NS was used because the 0.9% sodium chloride solution was not available for Resident #6. She stated staff should have notified the pharmacy, which would have provided clarification on why the sodium chloride was unavailable.

Based on observations, record review and resident and staff interviews, the facility failed to store a plastic syringe used for enteral water flushes (water flushes are essential to maintain gastrostomy/feeding tube patency, prevent clogging and support hydration), dry and with the plunger separated from the syringe and free from moisture for 1 of 2 residents reviewed for enteral feeding management (Resident #27). This practice had the potential for bacterial growth and contamination.Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses of muscle weakness, malnutrition, adult failure to thrive, gastrostomy status (indicates the presence of a gastrostomy tube/feeding tube, which is surgically placed to provide direct access to the stomach for nutrition and hydration when oral intake is insufficient or unsafe), and dysphagia.Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact and was coded for tube feeding. The MDS confirmed Resident #12's average fluid intake per day by IV fluids or tube feeding was 501 cc/day or more per day.Review of Resident #27's order dated 01/07/26 revealed the resident was ordered to receive water flush of 60 milliliters (ml) four times a day.During observation and interview with Resident #27 on 03/02/26 at 10:10 AM the syringe used for enteral water flushes was observed with the plunger in the syringe which was wet with clear condensation. The syringe was stored in a plastic bag on the bedside table dated 02/26/26. Resident #27 stated that around 9:00 AM that day Nurse #4 gave his ordered water flush and put the syringe back together and laid it on his bedside table. Resident #27 indicated nursing staff rarely left syringe apart to allow it to air dry.Review of Resident #12's Medication Administration Record (MAR) dated 03/02/26 revealed Nurse #4 had signed off Resident #12's morning flush at 9:00 AM.An interview with Nurse #4 on 03/02/26 at 10:15 AM revealed she was not aware the syringe required to be dried before placing the syringe back in the storage bag. Nurse #4 indicated she was aware the plastic syringe and plunger should be washed if residue was left in the syringe but was not aware the plunger should be separated to air dry to prevent any bacterial growth in the syringe. Nurse #4 confirmed she had given Resident #27's his water flush through his feeding tube earlier this shift on 03/02/26.An interview and observation on 03/03/26 at 9:40 AM revealed the Director of Nursing (DON) in Resident #27's room. The DON observed Resident #27's syringe at bedside which was wet with the plunger inside the syringe. The DON revealed the plastic syringe, and plunger should be washed and the plunger should be left out of the syringe to allow it to air dry to prevent any bacterial growth. The DON discarded the syringe and further revealed nurses had been educated on this protocol and all new hires had been educated during orientation. The DON revealed the facility's policy was that plastic syringes were to be discarded every 24 hours and for the plunger to be taken out of the plastic syringe after use to air dry.An interview with the Administrator on 03/04/26 at 9:30 AM stated Nurse #4 should have washed the plastic syringe and allowed them to dry completely to prevent any bacterial growth.

Based on record review, observations, and staff interviews, the facility failed to post the daily nurse staffing sheet daily for 1 out of 5 days observed (3/1/26). The facility also failed to post accurate daily staffing information as compared to the daily staffing schedules for licensed and unlicensed nursing staff for 22 out of 28 days reviewed (2/1/26, 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/7/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/18/26, 2/19/26, 2/20/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, and 2/28/26). The findings included: 1) The posted daily nursing staffing sheet was observed outside the Director of Nursing's (DON) office door on 3/1/26 at 10:40 AM and was dated 2/17/26. The DON was interviewed on 3/2/26 at 1:10 PM and stated that she had been at the facility since 2/5/26 and was managing the schedule and daily posted nursing staffing sheets. The DON reported that she had failed to update the daily posted nurse staffing sheets, which was why the sheet dated 2/17/26 remained posted. 2) A review of the facility's daily posting for nursing staff for the past 28 days (2/1/26 to 2/28/26) as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 2/1/26 indicated that 5 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM and 9 NAs worked from 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 2/1/26 documented that 6 NAs worked from 7:00 AM to 3:00 PM and 7 NAs worked from 3:00 PM to 11:00 PM. b. The nursing schedule for 2/2/26 indicated that 11 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/2/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. c. The nursing schedule for 2/3/26 indicated that 12 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/3/26 documented that 10 NAs worked from 7:00 AM to 3:00 PM. d. The nursing schedule for 2/4/26 indicated that 10 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/4/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. e. The nursing schedule for 2/5/26 indicated that 12 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/5/26 documented that 10 NAs worked 7:00 AM to 3:00 PM. f. The nursing schedule for 2/6/26 indicated that 9 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/6/26 documented that 8 NAs worked 7:00 AM to 3:00 PM. g. The nursing schedule for 2/7/26 indicated that 8 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/7/26 documented that 6 NAs worked 7:00 AM to 3:00 PM. h. The nursing schedule for 2/9/26 indicated that 10 NAs worked from 7:00 AM to 3:00 PM and 3 Licensed Practical Nurses (LPNs) worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 2/9/26 documented that 9 NAs worked 7:00 AM to 3:00 PM and 4 LPNs worked 3:00 PM to 11:00 PM. i. The nursing schedule for 2/10/26 indicated that 11 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/10/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. j. The nursing schedule for 2/11/26 indicated that 9 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/11/26 documented that 8 NAs worked 7:00 AM to 3:00 PM. k. The nursing schedule for 2/12/26 indicated that 9 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/12/26 documented that 7 NAs worked 7:00 AM to 3:00 PM. l. The nursing schedule for 2/13/26 indicated that 11 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/13/26 documented that 7 NAs worked 7:00 AM to 3:00 PM. m. The nursing schedule for 2/14/26 indicated that 9 NAs worked from 7:00 AM to 3:00 PM and 8 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 2/14/26 documented that 8 NAs worked 7:00 AM to 3:00 PM and 6 NAs worked from 3:00 PM to 11:00 PM. n. The nursing schedule for 2/15/26 indicated that 8 NAs worked from 7:00 AM to 3:00 PM and 9 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 2/15/26 documented that 7 NAs worked 7:00 AM to 3:00 PM and 8 NAs worked from 3:00 PM to 11:00 PM. o. The nursing schedule for 2/18/26 indicated that 11 NAs worked from 7:00 AM to 3:00 PM and 2 Registered Nurses (RNs) worked from 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 2/18/26 documented that 9 NAs worked from 7:00 AM to 3:00 PM and 1 RN worked from 3:00 PM to 11:00 PM. p. The nursing schedule for 2/19/26 indicated that 10 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/19/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. q. The nursing schedule for 2/20/26 indicated that 4 LPNs and 9 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/20/26 documented that 3 LPNs and 8 NAs worked 7:00 AM to 3:00 PM. r. The nursing schedule for 2/24/26 indicated that 11 NAs worked from 7:00 AM to 3:00 PM, 2 LPNs worked 3:00 PM to 11:00 PM and 7 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/24/26 documented that 9 NAs worked 7:00 AM to 3:00 PM, 1 LPN worked 3:00 PM to 11:00 PM and 6 NAs worked 11:00 PM to 7:00 AM. s. The nursing schedule for 2/25/26 indicated that 11 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/25/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. t. The nursing schedule for 2/26/26 indicated that 10 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/26/26 documented that 9 NAs worked 7:00 AM to 3:00 PM. u. The nursing schedule for 2/27/26 indicated that 14 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/27/26 documented that 12 NAs worked 7:00 AM to 3:00 PM. v. The nursing schedule for 2/28/26 indicated that 3 LPNs and 10 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/28/26 documented that 2 LPNs and 9 NAs worked 7:00 AM to 3:00 PM. On 3/4/26 at 9:35 AM, an interview occurred with the Director of Nursing who stated that she was managing the staffing schedule and daily postings. She was able to review the staffing schedules and daily postings and verified the number of staff working from 2/1/26 to 2/28/26 did not match. She stated that she had failed to count the Medication Aides (MAs) and Restorative Nurse Aides in the total number of NAs working, as well as had not updated the daily posted nurse staffing sheet when a staff member came in to cover a need. The Administrator was interviewed on 3/4/26 at 1:28 PM and stated that the daily staff schedule posting and the staffing schedule should match the number of staff worked on any given shift.

Based on record reviews and Resident Representative (RR), resident and staff interviews, the facility failed to indicate if grievances had been resolved, how the results were communicated to the complainant, when the results of the grievances had been provided to the complainant and also failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #52, #69 and #39). The findings included: A review of the facility grievance policy, dated 11/14/25, included, in part, In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: The date the grievance was received. The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the residents' concern(s). A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued. 1) Resident #52 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. A review of the facility's grievance logs from April 2025 to February 28, 2026, revealed a grievance report had been initiated on 1/21/26 by Resident #52, regarding a desire to have the change left over from a shopping trip deposited back into his resident funds. Review of the grievance form revealed it did not indicate if the grievance had been resolved, how the results of the investigation were communicated to the complainant, when the results were communicated to the complainant and no indication that a written summary was provided. An interview occurred with Resident #52 on 3/4/26 at 9:50 AM who had filed the grievance form on 1/21/26. He stated he couldn't recall if anyone discussed the resolution with him and stated that he had never received nor been offered a written resolution of the grievance from the facility The Business Office Manager was interviewed on 3/4/26 at 10:10 AM and stated that Resident #52's funds were deposited back into his account. She stated that she had spoken with Resident #52 to let him know the money had been deposited but didn't provide anything for him in writing. A phone interview was conducted with Social Worker #2 on 3/4/26 at 11:04 AM. She reported that she had been employed at the facility for approximately seven months and that her last day was 2/5/26. She stated she maintained the grievance logs and provided resolutions by phone or in person when they had not already been addressed by other management staff. She added that she had not been issuing written grievance resolutions because she was unaware this was required. Social Worker #2 could not recall if she had spoken with Resident #52 or if someone else did. The Administrator was interviewed on 3/3/26 at 3:10 PM and stated that she felt the grievance for Resident #52 had been resolved. She added that she was not aware a written resolution to grievances was required and that the facility had only been discussing the resolution with the RR or resident via phone or in person. She acknowledged that the facility needed to complete the portion of the grievance form to indicate when the grievance was resolved, if the complainant was satisfied, and how the investigation results were communicated. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries. 2) Resident #69 was admitted to the facility on [DATE]. A review of the facility's grievance logs from April 2025 to February 28, 2026, revealed the following grievance reports were initiated by Resident #69's RR: A grievance report initiated on 7/10/25 regarding missing clothes. This grievance form had a check mark that the grievance was resolved. There was no indication of how the results of the investigation were communicated to the RR, when the results of the investigation were communicated to the RR and no indication a written summary was provided. A grievance report initiated on 9/10/25 regarding concerns of notification. This grievance form did not indicate if the grievance was resolved, how the results of the investigation were communicated to the RR, when the results of the investigation were communicated to the RR and no indication a written summary was provided. A grievance report initiated on 10/23/25 regarding showers, room cleanliness and receiving statements. There was an attachment of a nursing progress note from the former Director of Nursing dated 10/24/25 where she met with Resident #69's RR regarding her concerns. The grievance form did not indicate if the grievance had been resolved, how the results of the investigation were communicated to the RR and no indication that a written summary was provided. A quarterly MDS assessment dated [DATE], indicated Resident #69 had moderately impaired cognition. A phone interview occurred with Resident #69's RR on 3/3/26 at 5:01 PM. She explained that when she had a concern, the facility would normally talk to her on the phone or when she visited her husband. She stated she had never received anything in writing regarding the resolution of her grievance concerns and was not always satisfied with the resolutions. A phone interview was conducted with Social Worker #2 on 3/4/26 at 11:04 AM. She reported that she had been employed at the facility for approximately seven months and that her last day was 2/5/26. Social Worker #2 stated that each time Resident #69's RR had a concern it was addressed by the nursing department either via phone or face to face. She stated she maintained the grievance logs and provided resolutions by phone or in person when they had not already been addressed by other management staff. She added that she had not been issuing written grievance resolutions because she was unaware this was required. The Administrator was interviewed on 3/3/26 at 3:10 PM and stated that she was not aware a written resolution to grievances was required and that the facility had only been discussing the resolution with the RR or resident via phone or in person. She acknowledged that the facility needed to complete the portion of the grievance form to indicate when the grievance was resolved, if the complainant was satisfied, and how the investigation results were communicated. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries. 3. Resident #39 was admitted to the facility on [DATE]. A review of the facility grievance policy, dated 11/14/25, included, in part, In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was intact. A review of the facility's grievance logs from April 2025 to February 28, 2026, revealed a grievance report had been initiated on 1/19/26 by Resident #39, regarding her not receiving incontinence care on 01/18/26. The grievance form did not indicate if the grievance was resolved, how the results of the investigation were communicated to the complainant or when the results were communicated to Resident #39. An interview occurred with Resident #39 on 03/02/26 at 11:57 AM. The resident explained when she had a concern, the facility would normally talk to her about the results. She stated she had never received anything in writing regarding the resolution of her grievance concerns. A phone interview was conducted with Social Worker #2 on 03/04/26 at 11:04 AM. She reported she had been employed at the facility for approximately seven months and that her last day of employment with the facility was 02/05/26. Social Worker #2 stated when Resident #39 or her emergency contact had a concern it was addressed by the nursing department either via phone or face to face. She stated she maintained the grievance logs and provided resolutions by phone or in person when they had not already been addressed by other management staff. She added that she had not been issuing written grievance resolutions because she was unaware this was required. An interview was conducted on 03/03/26 at 3:10 PM with the Administrator. She stated she was not aware a written resolution to grievances was required and that the facility had only been discussing the resolution with the resident or Resident Representative (RR), via phone or in person. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries.

Based on record reviews and interviews with Responsible Party (RP), residents, and staff, the facility failed to provide the resident and RP with a written notice of transfer including the reason for the hospital transfer for 4 of 4 residents reviewed for hospitalization (Residents #33, #53, #69 and #31). The findings included: 1) Resident #33 was admitted to the facility on [DATE]. Review of the medical record revealed a family member was listed as Resident #33's RP. Resident #33 was transferred to the hospital on 5/20/25 for shortness of breath, 9/9/25 for shortness of breath, 11/16/25 for nausea and vomiting, 11/27/25 for abdominal pain and 12/26/25 for abdominal pain. Resident #33 was readmitted to the facility after each hospitalization. There was no documentation that a written notice of transfer was provided to the RP and resident, for each of the dates the resident was transferred to the hospital, including the reason for the transfers. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #33 was cognitively intact. A phone interview was completed with Resident #33's RP on 3/2/26 at 5:05 PM. She stated she was always informed by phone when Resident #33 was transferred to the hospital but had not received anything in writing from the facility. On 3/3/26 at 2:34 PM, an interview was conducted with Unit Manager #1, who stated when a resident was transferred to the hospital, a copy of the face sheet, medication list, any Do Not Resuscitate information, other pertinent information and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Unit Manager did not know who was responsible for the written notice of transfer when a resident was transferred to the hospital. Social Worker #1 was interviewed on 3/3/26 at 2:40 PM and explained that she had worked at the facility for approximately three weeks but was not working at the facility from May 2025 to December 2025. Social Worker #1 was unable to explain why a written notice of transfer including the reason for the hospital transfer was not sent to the RP when Resident #33 was transferred to the hospital. Social Worker #1 stated she was unaware of a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital. An interview occurred via phone on 3/4/26 at 11:04 AM, with the former Social Worker #2 who stated that she worked at the facility for about seven months and her last day there was 2/5/26. She stated she was not working at the facility in May 2025. Social Worker #2 stated that she was unaware a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital and had not been informed to provide this document for Resident #33's transfers to the hospital on 9/9/25, 11/16/25, 11/27/25 or 12/26/25. The Administrator was interviewed on 3/3/26 at 2:53 PM and stated she had been employed at the facility since 11/21/25. She stated she was not aware a written notification was required to the resident and/or RP when a resident was transferred to the hospital. 2) Resident #53 was admitted to the facility on [DATE]. Review of the medical record revealed a family member was listed as Resident #53's RP. Resident #53 was transferred to the hospital on 7/30/25 following a fall, 1/4/26 for altered mental status and 2/18/26 for altered mental status. Resident #53 was readmitted to the facility after each hospitalization. There was no documentation that a written notice of transfer was provided to the resident and RP, for each of the dates the resident was transferred to the hospital, including the reason for the transfers. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #53 had moderately impaired cognitive skills for daily decision making. Attempts to interview Resident #53's RP were unsuccessful. On 3/3/26 at 2:34 PM, an interview was conducted with Unit Manager #1, who stated when a resident was transferred to the hospital, a copy of the face sheet, medication list, any Do Not Resuscitate information, other pertinent information and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Unit Manager did not know who was responsible for the written notice of transfer when a resident was transferred to the hospital. Social Worker #1 was interviewed on 3/3/26 at 2:40 PM and explained that she had worked at the facility for approximately three weeks but was not working at the facility from July 2025 to January 2026. Social Worker #1 was unable to explain why a written notice of transfer including the reason for the hospital transfer was not sent to the RP when Resident #53 was transferred to the hospital, prior to her employment. Social Worker #1 stated she was unaware of a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital, therefore one was not provided to Resident #53's RP on 2/18/26. An interview occurred via phone on 3/4/26 at 11:04 AM, with the former Social Worker #2 who stated that she worked at the facility for about seven months and her last day there was 2/5/26. Social Worker #2 stated that she was unaware of a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital and had not been informed to provide this document for Resident #53's transfers to the hospital on 7/30/25, or 1/4/26. The Administrator was interviewed on 3/3/26 at 2:53 PM and stated she had been employed at the facility since 11/21/25. She stated she was not aware a written notification was required to the resident and/or RP when a resident was transferred to the hospital. 3) Resident #69 was admitted to the facility on [DATE]. Review of the medical record revealed a family member was listed as Resident #69's RP. Resident #69 was transferred to the hospital on [DATE] for shortness of breath. Resident #69 was readmitted to the facility after the hospitalization. There was no documentation that a written notice of transfer was provided to the RP and resident, including the reason for the transfer. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #69 had moderately impaired cognition. A phone interview was completed with Resident #69's RP on 3/1/26 at 5:52 PM. She stated she had been informed by phone when Resident #69 was transferred to the hospital but had not received anything in writing from the facility. On 3/3/26 at 2:34 PM, an interview was conducted with Unit Manager #1, who stated when a resident was transferred to the hospital, a copy of the face sheet, medication list, any Do Not Resuscitate information, other pertinent information and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Unit Manager did not know who was responsible for the written notice of transfer when a resident was transferred to the hospital. Social Worker #1 was interviewed on 3/3/26 at 2:40 PM and explained that she had worked at the facility for approximately three weeks but was not working at the facility in December 2025. Social Worker #1 was unable to explain why a written notice of transfer including the reason for the hospital transfer was not sent to the RP when Resident #69 was transferred to the hospital. Social Worker #1 stated she was unaware of a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital. An interview occurred via phone on 3/4/26 at 11:04 AM, with the former Social Worker #2 who stated that she worked at the facility for about seven months and her last day there was 2/5/26. Social Worker #2 stated that she was unaware of a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital and had not been informed to provide this document for Resident #69's transfer to the hospital on [DATE]. The Administrator was interviewed on 3/3/26 at 2:53 PM and stated she had been employed at the facility since 11/21/25. She stated she was not aware a written notification was required to the resident and/or RP when a resident was transferred to the hospital. 4. Resident #31 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #31 was listed as her own Responsible Party (RP). Resident #31 was transferred to the hospital on [DATE] with complaints of shortness of breath and low oxygen saturation. Following the hospitalization, Resident #31 was readmitted to the facility. Review of the medical record revealed no documentation that a written notice of transfer, including the reason for the transfer, was provided to Resident #31 and/or her emergency contact. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31's cognition was intact. Resident #31 was hospitalized and was not available for an interview during the survey time. Attempts to interview Resident #31's emergency contact were unsuccessful. On 03/03/26 at 2:34 PM, an interview was conducted with Unit Manager #1 who explained when a resident was transferred to the hospital, a copy of the face sheet, medication list, any Do Not Resuscitate information, the Bed Hold policy and other pertinent information and was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. Unit Manager #1 did not know who was responsible for the written notice of transfer when a resident was transferred to the hospital. An interview occurred via phone on 03/04/26 at 11:04 AM, with former Social Worker #2 who stated that she worked at the facility for about seven months and her last day there was 02/05/26. Social Worker #2 stated that she was unaware a written notice of transfer including the reason for the hospital transfer was required when a resident was transferred to the hospital and had not been informed to provide this document for Resident #31's transfer to the hospital on [DATE]. The Administrator was interviewed on 03/03/26 at 2:53 PM and stated she had been employed at the facility since 11/21/25. She stated she was not aware that a written notification was required to be given to the resident and/or RP when a resident was transferred to the hospital.

Based on record reviews, and Nurse Practitioner (NP), Physician, Pharmacist, Endocrinologist, and staff interviews, the facility failed to prevent a significant medication error related to hydrocortisone prescribed for Resident #137 (hydrocortisone tablets are a steroid medication that works by decreasing inflammation, slowing down an overactive immune system or replacing the cortisol hormone that helps the body respond to stress) when Resident #137 missed a dose of hydrocortisone on ([DATE]), received the wrong dose of hydrocortisone for two days ([DATE] and [DATE]) and then the medication was abruptly stopped. Abrupt cessation of hydrocortisone for adrenal insufficiency can cause an adrenal crisis, where the body experiences a sudden drop in cortisol levels and can lead to life-threatening complications such as low blood pressure. Resident #137 went 18 days without receiving hydrocortisone. Resident #137 was scheduled to be seen by the Endocrinologist on [DATE] for the missed doses of hydrocortisone but she was transferred to the hospital on [DATE] at the request of family and admitted for weakness and low blood pressure ,d+[DATE] (normal blood pressure is ,d+[DATE]). This was for 1 of 9 residents reviewed for significant medication errors (Resident #137). The findings included: Review of the hospital discharge orders for Resident #137 dated [DATE] revealed an order hydrocortisone 10 milligrams (mg) tablet for adrenal insufficiency, (administer) 15 mg (1.5 tablets) in AM and 10 mg (1 tablet) in afternoon by mouth with food. Double or triple dose for illness for 3 days as directed (during illness, the body requires additional cortisol to regulate inflammation, blood pressure, and maintain blood volume.) Resident #137 was admitted to the facility on [DATE] with diagnoses including adrenocortical (adrenal) insufficiency. Adrenal insufficiency is a disorder in which the adrenal glands produce insufficient amounts of cortisol. A deficiency of cortisol can result in a life-threatening crisis characterized by low blood pressure. Additional diagnoses for Resident #137 included diabetes, malnutrition, high blood sodium levels, breast cancer, syncope and collapse (fainting), and abnormal gait. A physician's order transcribed from the hospital discharge summary by Unit Manager #1 dated [DATE] specified hydrocortisone 10mg give 1.5 tablets by mouth in the afternoon for inflammation for 3 days. The stop date for the order was [DATE]. A physician order dated [DATE] for midodrine (a medication that elevates blood pressure) 10 mg every 8 hours for low blood pressure, do not give fore blood pressure over ,d+[DATE]. An NP admission note written by NP #4 dated [DATE] was reviewed. NP #4 documented Resident #137 was to take hydrocortisone 10 mg 1.5 tablets every evening with a stop date of [DATE]. Review of Resident #137's medication administration record (MAR) documented by Nurse #1 that on [DATE] Resident #137 did not receive the hydrocortisone due to the medication not being available. Further review of the MAR documented hydrocortisone 10mg 1.5 tablets was administered on [DATE] and [DATE]. Review of the medication administration record for [DATE] documented Resident #137 did not receive hydrocortisone from [DATE] to [DATE]. Review of the blood pressures for Resident #137 revealed the following: (normal blood pressure ,d+[DATE]) - [DATE] ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM - [DATE] ,d+[DATE] at 2:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM - [DATE] ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM; ,d+[DATE] at 2:00 PM; ,d+[DATE] at 10:00 PM - [DATE] ,d+[DATE] at 6:00 AM Unit Manager #1 was interviewed on [DATE] at 8:47 AM. Unit Manager #1 reported she transcribed the discharge hospital orders for Resident #137 upon her admission to the facility on [DATE]. Unit Manager #1 explained she read the hydrocortisone order to be for 3 days only and transcribed the order as she understood it. Unit Manager #1 reported she had not clarified the order with the hospital, and she had not called the Endocrinologist to ask for clarification. Unit Manager #1 reported she was not certain if the NP or the physician had reviewed the orders for Resident #137. Unit Manager #1 reported after she transcribed the hospital discharge orders, she asked Unit Manager #2 to check the orders and Unit Manager #2 did not report any transcription mistakes to her. When asked how she understood the orders for hydrocortisone, Unit Manager #1 explained she thought that the medication was to be given for only 3 days, and it didn't occur to her to call the Endocrinologist for clarification or ask the physician or NP to review the order. Unit Manager #1 reported she was not aware Resident #137 did not receive the medication on [DATE]. Unit Manager #1 reported she was not aware she had not correctly transcribed the order for hydrocortisone. Unit Manager #2 was interviewed on [DATE] at 10:07 AM. Unit Manager #2 reported she reviewed Resident #137's hospital discharge orders and the orders in the electronic documentation system and she did not notice the hydrocortisone was ordered for only 3 days. Unit Manager #2 reported when she reviewed the hospital discharge orders, she thought the medication was supposed to be ordered for 3 days only and she did not notice the dose was not ordered correctly. Unit Manager #2 reported she did not call the physician, NP, or the Endocrinologist for clarification of the hydrocortisone order. NP #4 was interviewed by phone on [DATE] at 12:50 PM. NP #4 reported she saw Resident #137 for her admission assessment on [DATE]. NP #4 explained she reviewed the hospital discharge orders and the orders in the electronic documentation system, but she did not notice the hydrocortisone was transcribed incorrectly. NP #4 reported hydrocortisone should not have been stopped abruptly because it would cause the body to lose an essential hormone and could cause an adrenal crisis. A pharmacist note written by Pharmacist #1 and dated [DATE] documented based upon the information available at the time of the review, and assuming the accuracy and completeness of such information it is my professional judgement that at such time, the resident's medication regimen contained no new irregularities . A follow-up phone interview was conducted on [DATE] at 1:00 PM with Pharmacist #2 and Pharmacist #3. Pharmacist #3 explained that hydrocortisone was used in adrenocortical insufficiency to replace the hormone cortisol the body made to maintain blood pressure and other functions. Pharmacist #3 reported she was unable to say if Resident #137 was affected adversely by the cessation of the hydrocortisone, as the Endocrinologist would have been responsible for managing the dosage of hydrocortisone. A physician history and physical note written by the Physician dated [DATE] documented hydrocortisone was to continue for adrenal insufficiency. The history and physical note did not document the hydrocortisone dose. A phone interview was conducted with the Physician on [DATE] at 1:03 PM. The Physician reported he had reviewed the hospital discharge orders but had not reviewed the orders transcribed into the electronic documentation system. The Physician reported the hydrocortisone was a significant medication error and the medication should not have been stopped abruptly. The admission Minimum Data Set assessment dated [DATE] assessed Resident #137 to be cognitively intact. A NP progress note dated [DATE] was reviewed. NP #2 documented that on [DATE] Resident #137's family member asked about the hydrocortisone and NP #2 documented that the hydrocortisone appeared to not be ordered. NP #2 documented she discussed Resident #137's symptoms and labs with the Endocrinologist and it appears that (Resident #137) is supposed to be on hydrocortisone 15 mg in the morning and 10 mg in the evening, which is not currently ordered. (Resident #137) received 3 days of hydrocortisone since admission to the facility (per medication administration record). The note documented the Endocrinologist ordered hydrocortisone 20 mg to be given now and 10 mg in the evening for 3 days and then 15 mg in the morning and 10 mg in the evening. The note documented the endocrinologist wanted Resident #137 to come to the office to be seen on [DATE]. A physician order dated [DATE] to administer hydrocortisone 20 mg, give 1 tablet by mouth once per day for 2 days. Administer 10 mg tablet in the evening. Beginning [DATE] administer hydrocortisone 15 mg in the morning and 10 mg in the evening. NP #2 was interviewed on [DATE] at 9:40 AM. The NP reported she was not working on [DATE] when Resident #137 was admitted to the facility and NP #4 did the admission assessment. NP #2 reported she had reviewed Resident #137's medications (she was uncertain of the exact date) and made a call to the Endocrinologist to clarify the hydrocortisone order. NP #2 reported on [DATE] Resident #137's family member inquired about the hydrocortisone and NP #2 was able to talk to the Endocrinologist and received clarification of the order. NP #2 explained Resident #137 should have continued hydrocortisone and it should not have been stopped abruptly because it could cause an adrenal crisis if stopped. A follow-up phone interview was conducted with NP #2 on [DATE] at 10:50 AM. NP #2 clarified that the Endocrinologist had ordered hydrocortisone to be given immediately, plus gave orders for the medication for the following days. A follow-up interview was conducted by phone with the Physician on [DATE] at 2:48 PM and he reported the hydrocortisone dose would have been determined by the Endocrinologist, and NP #2 did the right thing by contacting the Endocrinologist for orders on [DATE]. The Physician explained stopping hydrocortisone abruptly could cause an adrenal crisis. The Physician reported he would have expected the Unit Manager to call him, the NP, the hospital or the Endocrinologist for clarification of orders. A nursing note dated [DATE] at 12:15 PM documented Resident #137 was taken to her endocrinology appointment by her family member but returned to the facility without being seen by the Endocrinologist. The family member reported he was running late and was unable to get Resident #137 to the appointment on time, and he requested Resident #137 be sent to the emergency room . Hospital emergency room records dated [DATE] for Resident #137 documented she was admitted to the hospital for weakness and low blood pressure. Blood pressure on admission to the emergency room was ,d+[DATE]. Resident #137 was a [AGE] year-old female with a past medical history significant for adrenal insufficiency. A computed tomography (CT) scan was completed on [DATE] and a large volume pneumoperitoneum (a condition where air or gas was in the abdominal cavity) was revealed, leading to concerns for a large bowel perforation. The decision was made with Resident #137 and her family member to undergo a laparotomy. Resident #137 was taken urgently to the operating room at 9:00 PM on [DATE] for lysis of adhesions, resection of the colon with a colostomy. After the surgery, Resident #137 was transferred to ICU, and she developed worsening low blood pressure. Lab results showed severe acute blood loss anemia. Resident #137 lost pulses and her abdomen was reopened in the ICU where approximately 750 cubic centimeters of blood were discovered. Resident #137 received several rounds of cardiopulmonary resuscitation efforts, and she died at 5:10 AM on [DATE]. The Endocrinologist was interviewed by phone on [DATE] at 4:49 PM. The Endocrinologist reported she recalled talking to NP #2 and ordered Resident 137 to receive hydrocortisone 20 mg immediately. The Endocrinologist explained that stopping hydrocortisone abruptly would have caused an adrenal crisis and this crisis would have caused Resident #137 difficulties with controlling her blood pressure and caused fatigue, as well as other symptoms. The Endocrinologist explained that the adrenal crisis would not have contributed to the bleeding post-operatively. The Administrator was notified of immediate jeopardy on [DATE] at 10:45 AM. The facility submitted the following corrective action plan with a compliance date of [DATE]. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice On [DATE] Resident #137 was admitted to the facility. The hospital discharge summary orders for Resident #137 read: hydrocortisone 10mg tablet, (administer) 15mg (1.5 tablets) in AM and 10 mg (1 tablet) in afternoon by mouth with food, double or triple doses for illness for 3 days as directed. Resident #137 had a diagnosis of adrenal insufficiency and was prescribed hydrocortisone. The Unit Manager transcribed the order on [DATE]: hydrocortisone 10 milligrams (mg) give 1.5 tablet by mouth in the afternoon for inflammatory for 3 days until [DATE]. Resident #137's Medication Administration Record (MAR) was reviewed and there was no documentation of any doses of hydrocortisone administered from [DATE] - [DATE]. One 20mg Hydrocortisone was administered the morning of [DATE]. On [DATE], Resident #137 was transferred to the hospital, and she underwent a laparotomy for lysis of adhesions, resections of the sigmoid colon with end colostomy. Post surgery she was transferred to the Intensive Care Unit (ICU) and developed hypotension and was found to have experienced severe acute blood loss anemia and died on [DATE]. Address how the facility will identify other residents having the potential to be affected by the same deficient practice The facility recognizes that all newly admitted and readmitted residents have the potential to be affected from the prior noncompliance with significant medication errors All newly admitted and readmitted residents between [DATE] - [DATE] medication orders were audited by the Director of Nursing and or Unit Managers to ensure orders were transcribed correctly on [DATE]. 30 residents were audited with no discrepancies noted. A quality review was completed on [DATE] by the Director of Nursing and or Unit Manager of current residents with a diagnosis of adrenal insufficiency and with hydrocortisone orders to ensure medication is ordered, transcribed correctly, and being given as ordered, no discrepancies noted. On [DATE], a quality review of current residents admitted and readmitted within the past 30 days prior to [DATE] was conducted by the Director of Nursing and Unit Manager to ensure all other newly admitted or readmitted patients' medications are administered per physician orders and transcribed correctly on the Medication Admission Record (MAR). Address what measures will be put into place or systemic changes made to ensure the deficient practice will not recur. On [DATE], a Root Cause Analysis was completed by the Director of Clinical Services, and the Executive Director regarding omission of medication administration for resident #137. It was determined through root cause and analysis that the significant medication error was due to the oversight of transcribing the orders incorrectly and there was no verification conducted by a second nurse. The Director of Nursing and/or the nurse managers provided education on [DATE] to current nurses on the importance of transcribing all new orders from discharge summaries, verified by 2 nurses to ensure medications are transcribed and administered per physician orders to the residents. Newly hired nurses will be educated on hire during the orientation process. The Executive Director provides oversight for the education of nurses to ensure that 100% of all licensed staff were reeducated on the importance of administrating all ordered medications. Education was completed on [DATE]. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing and or Nurse Managers will conduct Quality Improvement Monitoring 5 times per week for 4 weeks, 1 time per week for 3 months and 1 time monthly for 3 months in clinical morning meeting to review the medication administration records of all new residents when admitted or readmitted to ensure all medications are transcribed correctly and medications are administered as ordered per physician starting [DATE]. Upon receiving hospital discharge summaries medication orders are verified with the provider, 2 nurse verification system; 1 Nurse transcribes all orders, then 1 Nurse verifies/confirms that orders were transcribed correctly. They also review the previous days admissions during the morning meeting and verify during the meeting. On [DATE], when the deficient practice of transcribing orders that resulted in a significant medication error was identified the center Executive Director conducted an ADHOC Quality Assurance Performance Improvement (QAPI) meeting to determine the root cause analysis of the deficient practice. The QAPI committee put a plan of action in place to include quality improvement monitoring and the frequency of monitoring beginning on [DATE] to ensure medication administration orders were transcribed correctly and medications were administered as ordered. The QAPI committee included the Executive Director, Medical Director, Director of Nursing, the Manager of Social Services, a Unit Manager, Wound Care Nurse, and two floor Nurses. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly to ensure ongoing compliance for 4 months. Quality Improvement schedule will be modified based on findings of the monitoring. The Center Executive Director alleges compliance on [DATE]. The corrective action plan was validated on [DATE]. Education for all nurses was reviewed, and interviews were conducted with the Unit Managers and the staff nurses to confirm receipt of the education. Initial audits of new admissions from [DATE] to [DATE] were reviewed and no significant medication errors were identified. Quality reviews of current residents and new admissions were reviewed, and no issues were identified. Morning meeting and QAPI meeting notes were reviewed with the DON and Administrator. The immediate jeopardy removal date of [DATE] and the compliance date of [DATE] was validated.

Based on record review, and Nurse Practitioner (NP) and staff interviews the facility failed to provide 1 of 1 resident (Resident #190) with a Continuous Positive Airway Pressure (CPAP) machine (a CPAP machine provides constant and steady air pressure to help a resident breath while asleep) reviewed for respiratory services. Findings included: A Discharge Summary dated 6/6/2024 from the hospital was reviewed and stated Resident #190 required a CPAP machine when he was sleeping and napping. The Discharge Summary further stated Resident #190 had been noncompliant in the past with his CPAP but had been compliant during his hospitalization . Resident #190 was admitted to the facility on [DATE] with of respiratory disease and obstructive sleep apnea. A review of Resident #190's Physician's Orders revealed no orders for a CPAP were found. Nurse #2, who admitted Resident #190 on 6/6/2024, was interviewed by phone on 1/8/2025 at 1:07 pm and she stated she did not remember Resident #190 and was not able to say whether his hospital Discharge Summary stated he needed a CPAP machine. Resident #190's initial Care Plan dated 6/6/2024 specified he should have 4 liters of oxygen per minute and required a CPAP machine. A 5-day Minimum Data Set assessment dated [DATE] indicated Resident #190 was severely cognitively impaired. Resident #190's Medication Administration Record (MAR) for 6/2024 did not indicate he was provided a CPAP machine. The Respiratory Therapist was interviewed by phone on 1/8/2025 at 2:15 pm and she stated she did not have access to the records at the facility and did not remember Resident #190. The Respiratory Therapist stated when she evaluated and treated residents at the facility, she did a written note that was scanned and placed in the resident's electronic record. She stated if she saw Resident #190 after he was admitted there would be a note in his electronic record. A hospital Emergency Department Note dated 6/9/2024 at 1:17 pm indicated Resident #190 was seen in the Emergency Department but was not in respiratory distress. The note further indicated a chest x-ray showed pleural effusions and pulmonary edema and re-admission back to the hospital was recommended due to the pulmonary edema and his CPAP not being available. An interview was conducted with the Nurse Practitioner on 1/9/2025 at 1:15 pm and she stated Resident #190 was in very bad shape when he was admitted , and she felt that he should not have been discharged from the hospital. She further stated she saw him the day after he was admitted and did not remember if he had a CPAP or not. The Nurse Practitioner stated she did not know if the CPAP would have made a difference is his outcome since he was already so sick. On 1/9/2025 at 7:52 am the Director of Nursing (DON) was interviewed and stated Resident #190 was admitted to the facility on [DATE] and discharged on [DATE] when his Responsible Party called emergency services to have him sent to the hospital. The DON also stated Resident #190 did not have his CPAP during his stay. She stated he came from the hospital without CPAP supplies or a CPAP machine and usually when a resident is on a CPAP they are sent to the facility with the machine. The DON stated she did not know why the hospital had discharged him without the CPAP. The DON stated she called the Respiratory Therapist on the evening of 6/6/2024 when Resident #190 was admitted and again on the morning of 6/7/2024 but she did not try to reach her again. The DON stated she did not know why the Respiratory Therapist did not come to assess Resident #190 and set up his CPAP. The DON stated the Responsible Party came into the facility on [DATE] and called emergency services because he did not have his CPAP since he was admitted but Resident #190 was not in respiratory distress. The Director of Nursing also stated she was not able to find a progress note written by the Respiratory Therapist in the resident's record. The Administrator was interviewed on 1/9/2025 at 2:08 pm and stated the nursing staff should have ensured Resident #190's CPAP was in place when he was admitted and if they could not get the CPAP on admission, they should have sent him back to the hospital.

Based on record review, and Consultant Pharmacist, and Director of Nursing interviews the Consultant Pharmacist failed to recognize a medication error when the facility failed to follow admission orders for hydrocortisone used for adrenal insufficiency. This was for 1 of 9 residents reviewed for medication errors (Resident #137). The findings included: Review of the hospital discharge orders for Resident #137 dated 8/28/24 revealed an order hydrocortisone 10 milligrams (mg) tablet for adrenal insufficiency, (administer) 15 mg (1.5 tablets) in AM and 10 mg (1 tablet) in afternoon by mouth with food. Double or triple dose for illness for 3 days as directed (during illness, the body requires additional cortisol to regulate inflammation, blood pressure, and maintain blood volume.) Resident #137 was admitted to the facility on [DATE] with diagnoses including adrenocortical (adrenal) insufficiency. Adrenal insufficiency is a disorder in which the adrenal glands produce insufficient amounts of cortisol. A deficiency of cortisol can result in a life-threatening crisis characterized by low blood pressure. A physician's order transcribed from the hospital discharge summary by Unit Manager #1 dated 8/29/24 specified hydrocortisone 10mg give 1.5 tablets by mouth in the afternoon for inflammation for 3 days. The order concluded on 9/1/24. Review of Resident #137's medication administration record (MAR) documented that on 8/29/24 Resident #137 did not receive the hydrocortisone due to the medication not being available. Further review of the MAR documented hydrocortisone 10mg 1.5 tablets was administered on 8/30/24 and 8/31/24. Review of the medication administration record for September 2024 documented Resident #137 did not receive hydrocortisone 9/1/24 to 9/18/24. A pharmacist note written by Pharmacist #1 and dated 8/30/24 documented based upon the information available at the time of the review, and assuming the accuracy and completeness of such information it is my professional judgement that at such time, the resident's medication regimen contained no new irregularities . A phone interview was conducted on 1/8/25 at 3:03 PM with Pharmacist #1 and Pharmacist #3, her clinical manager. Pharmacist #1 reported she conducted a remote review of the admission orders for Resident #137 on 8/30/24. Pharmacist #1 reported during the admission review of information for new residents, she reviewed the information that was available in the electronic documentation system, and if the hospital discharge orders were not uploaded into the system, she would have looked at only the orders in the electronic documentation system. Pharmacist #3 explained that the facilities are encouraged to upload all information into the electronic documentation system, so all information is available to the pharmacist, but she did not recall if the hospital discharge orders were available during her review. A follow-up phone interview was conducted on 1/15/25 at 1:00 PM with Pharmacist #2 and Pharmacist #3. Pharmacist #2 performed a medication review for Resident #137 on 9/19/24 and reported she had not reviewed the hospital discharge orders, only the medication orders available in the electronic documentation system. Pharmacist #3 explained that after the interview on 1/8/25, she had investigated when the hospital discharge orders were available in the electronic documentation system and discovered that the facility had not scanned the orders in for 2 weeks. The Director of Nursing (DON) and Administrator were interviewed by phone on 1/16/25 at 11:09 AM. The DON reported the admission orders for Resident #137 were not uploaded into the electronic documentation system until 9/12/24 and the admission orders were not available for Pharmacist #1 to review on 8/30/24. The Administrator explained that typically the hospital discharge orders were put into the system by the corporate admissions team, but the orders for Resident #137 were emailed to the DON and that caused the delay loading the orders into the electronic documentation system.

Based on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of swallowing for 1 of 4 residents (Resident #75) reviewed for MDS accuracy. The findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and oropharyngeal dysphagia. Review of Resident #75's care plan, last revised on 12/06/24, included a focus area that read Resident #75 had a nutritional problem or potential problem due to mechanically altered diet related to obesity, cerebral infarction and dysphagia. The interventions included for staff to monitor/record/report to physician, as needed, signs and symptoms of malnutrition, emaciation, muscle wasting, significant weight loss. Registered Dietician to evaluate and make diet change recommendations as needed. Resident #75's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was moderately impaired. She had no range of motion limitations and required set-up/ clean-up assistance with eating. The area of swallowing for Resident #75 was coded for no swallowing disorders. A phone interview was conducted on 01/08/25 at 11:50 AM with the Registered Dietician. She verified she does complete the nutrition section of the MDS assessment. She explained that Resident #75 did have swallowing problems which resulted in choking and coughing when eating and drinking fluids. She stated it was an oversight that she did not accurately code the quarterly MDS assessment in the area of nutrition. An Interview was conducted on 01/09/25 at 1:15 PM with the Administrator. He stated he expected the MDS assessments to be accurately coded to reflect the residents' conditions, abilities, concerns, and diagnoses.

Based on record review, and physician and staff interviews, the facility failed to notify the Physician when a prescribed dose of hydrocortisone was not administered for 1 of 1 resident reviewed for notification (Resident #137). The findings included: Resident #137 was admitted to the facility on [DATE] with diagnoses including adrenocortical (adrenal) insufficiency. Adrenal insufficiency is a disorder in which the adrenal glands produce insufficient amounts of cortisol. A deficiency of cortisol can result in a life-threatening crisis characterized by low blood pressure. A physician's order transcribed from the hospital discharge summary by Unit Manager #1 dated 8/29/24 specified hydrocortisone 10mg give 1.5 tablets by mouth in the afternoon for inflammation for 3 days. Review of Resident #137's medication administration record (MAR) documented by Nurse #1 that on 8/29/24 Resident #137 did not receive the hydrocortisone due to the medication not being available. There were no nursing notes indicating the physician had been notified Resident #137 had not received the dose of hydrocortisone on 8/29/24. Nurse #1 was interviewed by phone on 1/16/25 at 7:48 AM. Nurse #1 reported she did not specifically recall why the medication was not available for Resident #137 on 8/29/24. Nurse #1 reported if she did not document she had called the physician, she probably had not called him. Nurse #1 reported she should have notified the physician the medication was not administered. Unit Manager #1 was interviewed by phone on 1/16/25 at 10:39 AM. Unit Manager #1 reported she did not recall Nurse #1 reporting the hydrocortisone was not in the facility to administer to Resident #137. Unit Manager #1 reported she did not know if the physician was notified the medication was not administered to Resident #137. An interview was conducted by phone with the Physician on 1/15/25 at 2:48 PM. The Physician reported he had not been notified the hydrocortisone was not administered to Resident #137 on 8/29/24 and he would have expected to be notified of any medication not administered.

Based on record review, and Nurse Practitioner and staff interviews, the facility failed to prevent Resident #27 from receiving an extra dose of Lyrica (a medication used to treat nerve and muscle pain). This was for 1 of 9 residents whose medications were reviewed. The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis. A review of Resident #27's physician orders included an order dated 4/12/24 for Pregabalin (Lyrica) 75 milligrams (mg), give two capsules by mouth every 12 hours for pain. Review of a facility incident report dated 7/25/24 indicated that Resident #27 had received 300 mg of Lyrica instead of 150 mg. The nurse practitioner (NP) and responsible party were notified. A review of the Controlled Medication Utilization Record indicated the Lyrica was packaged in 150 mg capsules. On 7/25/24 at 9:00 AM Nurse #3 administered two capsules of Lyrica 150 mg instead of one as ordered. On 1/9/25 at 9:20 AM, a phone interview occurred with Nurse #3. He stated it was an oversight to have provided Resident #27 with 300 mg of Lyrica instead of 150 mg and most likely didn't review the narcotic card label that read 150 mg tablets were present. On 1/8/25 at 1:32 PM, an interview occurred with the Unit Manager #2, who completed the incident report dated 7/25/24. She explained that the pharmacy had packaged the Lyrica in 150 mg capsules and the order read to give two 75 mg capsules. During the investigation, Nurse #3 stated he inadvertently provided two capsules without looking at the medication label for the strength. The NP was notified and provided an order to monitor Resident #27. She recalled Resident #27 showed no ill effects from receiving 300 mg of Lyrica instead of 150 mg. An interview was conducted with the Director of Nursing (DON) on 1/9/25 at 9:07 AM, who reviewed the Controlled Medication Utilization Record and physician orders. It was discovered during the investigation, that Nurse #3 didn't review the medication label and inadvertently gave 300 mg instead of 150 mg of Lyrica. She added that she would expect the right dosage of medication to be given as ordered. A phone interview was completed with NP #2 on 1/9/25 at 9:17 AM and was able to recall Resident #27 receiving 300 mg of Lyrica instead of 150 mg in July 2024. She stated the extra dose of medication would not have caused any serious side effects as Resident #27 had been taking the medication for an extended period and most likely would have only caused drowsiness. She didn't feel this was a significant medication error and recalled ordering the staff to monitor Resident #27. NP #2 stated she would expect the nursing staff to provide the correct dosage of medication.

Based on record review, and staff and Responsible Party interviews, the facility failed to send 2 of 9 residents (Resident # 188 and Resident # 189) with a list of their ordered medications and Discharge Summary when they were discharged from the facility on 7/26/2024. Resident #188 was discharged on [DATE] with Resident #189's Discharge Summary and Medication List. Resident #188 did not receive the correct Discharge Summary and Medication List until 7/29/2024. Resident #189 was discharged without a Discharge Summary and Medication List on 7/26/2024 and the Family Member returned to the facility on [DATE] to obtain the Discharge Summary and Medication List. Findings included: 1. Resident #188 was admitted to the facility on [DATE] with diagnoses of arthritis and fractures. An admission Minimum Data set assessment dated [DATE] indicated Resident #188 was cognitively intact and she planned to discharge home. Resident #188's Care Plan dated 7/11/2024 indicated she planned to discharge back to the community. Resident #188 discharged on [DATE]. A complaint/grievance report dated 7/31/2024 indicated Resident #188 was given another resident's (Resident #189's) discharge summary and medication list when she was discharged home from the facility. During an interview with Nurse #2 on 1/8/2025 at 11:09 am she stated she did remember Resident #188 receiving the wrong discharge summary and medication list, but she did not remember being made aware she made the mistake. The Director of Nursing was interviewed on 1/9/2025 at 1:37 pm and stated she spoke with Nurse #2 who discharged Resident #188 on 7/26/2024 and Nurse #2 stated she accidentally picked up the wrong packet and sent it home with Resident #188. The Director of Nursing stated Nurse #2 was responsible for placing the Discharge Summary and Medication List in Resident #188's packet and ensuring it was sent with her at discharge. 2. Resident #189 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hematoma and history of fall. An admission Minimum Data Set assessment dated ,d+[DATE] indicated Resident #189 was mildly cognitively impaired and planned to discharge back to the community. Resident #189's Care Plan dated 6/28/2024 indicated she planned to return home with family assistance. During an interview with the Responsible Party on 1/8/2025 at 1:02 pm she stated Resident #189's discharge paperwork that included her medication list was not sent home with her and the family returned to the facility to obtain the medication on the day Resident #189 discharged . Nurse #1 was interviewed on 1/8/2025 at 12:25 pm and stated the Social Worker had mixed up the discharge folder when Resident #189 was discharged home, and she was sent home with Resident #188's Discharge Summary and Medication List. Nurse #1 stated she was Resident #188's nurse on 7/26/2024 but she did not discharge her from the facility and did not remember who had discharged her. The Director of Nursing was interviewed on 1/9/2025 at 1:37 pm and she stated Nurse #1 was responsible for ensuring the discharged resident received the correct packet with a discharge summary and medication list at discharged . She stated Nurse #1 should have ensured Resident #189 had the packet when she was discharged home. On 1/9/2025 at 2:11 pm the Administrator was interviewed and stated Nurse #1 and Nurse #2 should have ensured the correct discharge paperwork was sent home with Resident #188 and Resident #189.

Based on record review, and Responsible Party and staff interviews the facility failed to protect the private health information of 1 of 1 resident (Resident #189) when her discharge summary and medication list was sent home with another resident. A reasonable person would not want their private medical information shared with another resident. Findings included: Resident #189 was admitted to the facility on [DATE]. Resident #189's admission Minimum Data Set assessment dated [DATE] indicated she was moderately cognitively impaired. Resident #189 discharged from the facility to home on 7/26/2024. A Complaint/Grievance Report form dated 7/31/2024 by Resident #188 indicated she received Resident #189's discharge summary and medication list when she discharged from the facility. During an interview with Nurse #1 on 1/8/2025 at 12:26 pm she stated there were two residents (Resident #189 and Resident #188) that were scheduled to discharge from the facility on 7/26/2024. She stated Resident #189's records were sent home with Resident #188 by mistake. Resident #188 returned to the facility with the incorrect records, reported the incident and received her own discharge summary and medication list. Resident #189's Responsible Party was interviewed by phone on 1/8/2025 at 1:02 pm and stated when Resident #189 was discharged from the facility she did not have her Discharge Summary or Medication List in the paperwork that was sent home with her and the Responsible Party returned to the facility on [DATE] to get the discharge summary and the medication list. During an interview with the Director of Nursing on 1/9/2025 at 1:37 pm she did not recall if Resident #189 was notified of the breach of privacy when her Discharge Summary and Medication List was sent home with Resident #188. The DON stated Nurse #1 should have ensured the correct packet was sent with Resident #189 and Resident #188. On 1/9/2025 at 2:10 pm the Administrator was interviewed and stated the staff should have notified Resident #189 or her Responsible of Party of the privacy breach when Resident #189's medical records were sent home with Resident #188. The Administrator stated Resident #189, or her Responsible Party should have been made aware of the potential risk to her personal health information.

Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to transcribe orders for inserting a peripheral intravenous (IV) line, 0.9% normal saline (NS) (water and salt) solution, and flushes (solution that's injected into an IV line to clean it and prevent blockages) for a midline (a type of peripheral IV that is longer than a peripheral IV). This was for 1 of 1 resident (Resident #75) reviewed for IV fluids. The findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, diabetes mellitus, and diverticulitis of intestines. Resident #75's quarterly Minimum Data Set (MDS) dated [DATE] indicated her cognition was moderately impaired. A review of the January 2025 physician orders revealed an order dated 01/01/25 to have a midline IV placed. The orders did not reveal orders for 0.9% NS at 500 milliliters (ml)/hour, a peripheral IV, or midline flushes to maintain patency. A review of the nursing progress notes revealed a note dated 01/02/25 that read Resident #75 had a midline IV placed in the right upper arm. The midline catheter was patent with 0.9% NS flowing per orders. An interview was conducted on 01/07/25 at 12:27 PM with Unit Manager #1. She stated Nurse #3 entered the order for Resident #75 to have a midline IV put in if staff were unable to get a peripheral line inserted. The midline IV was inserted by a healthcare company that specialized in vascular access on 01/02/25. She was aware Nurse #3 did not enter the order for the peripheral IV line, 0.9% NS fluids, or the midline IV flushes. A phone interview was conducted on 01/08/25 at 1:00 PM with Nurse #3. He stated he did not originally obtain the orders for Resident #75 to receive NS fluids and peripheral IV. He was told verbally by Supervisor #1 to try and get a peripheral IV line started on Resident #75 and that if he was unable to get the peripheral IV line inserted, they had an order for a midline IV to be placed. He then stated he did not enter the orders because he thought the Supervisor #1 had entered them. An interview was conducted on 01/08/25 at 3:18 PM with Unit Manager #1. She stated she was working on 01/02/25 when the healthcare company that specialized in vascular access inserted the midline IV for Resident #75. She also stated the policy did not include maintenance orders for the midline which included to flush lumen with NS followed by heparin every shift. She explained she forgot to transcribe the flush orders after the midline was inserted. A phone interview was conducted on 01/08/25 at 6:15 PM with Supervisor #1. She stated she did receive orders to attempt to insert a peripheral IV line and to start 0.9% NS at 500ml/hr because Resident #75's eating and drinking had slowed down. Supervisor #1 indicated Resident #75 was alert and verbally responsive and was displaying no signs or symptoms of distress. She explained she communicated with Physician Assistant (PA) #1 through the tele triage in the electronic documentation system. She also stated PA#1 gave orders that if they were unable to insert the peripheral IV line, they could order for a midline IV to be inserted. Supervisor #1 indicated she passed this on to Nurse #3 and asked him if he would transcribe the orders to the electronic medical record. She then explained the orders did not get transcribed due to a miscommunication between her and Nurse #3. A follow-up phone interview was conducted on 01/09/25 at 9:22 AM with Nurse #3 related to the orders not being entered into the electronic medical record. He stated that when he got an order for peripheral IV line insertion and fluids on a resident that he had attempted to insert the peripheral IV line prior to entering the order. If he was unable to successfully place the peripheral IV line, he would have called to get healthcare company specialized in vascular access to place a midline. He indicated he did not see an order for starting the 0.9% fluids on the electronic medical record although he was aware that was the reason for starting the peripheral IV line to begin with. He explained that he misunderstood Supervisor #1 related to transcribing the orders, he thought she had transcribed them. He also stated Resident #75 was alert and verbally responsive with no signs or symptoms of acute distress. An interview was conducted on 01/09/25 at 10:58 AM with Nurse Practitioner #3. She stated all orders should be entered into the electronic medical record when they are received. Orders for any IVs, 0.9% NS fluids, and IV flushes should be entered. Flushes should have been performed per facility policy. An interview was conducted on 01/08/25 at 2:50 PM with the Director of Nursing (DON). She indicated she was unaware the IV, IV flushes, or 0.9% NS orders for Resident #75 were not entered into the electronic medical record. The DON stated she expected the nurse who received the order to transcribe it when they received it. An interview was conducted on 01/09/25 at 1:15 PM with the Administrator. He stated he expected all orders to be entered into the electronic medical record as soon as they are received.

Based on resident observation, record review, and interviews with the nursing staff, Nurse Practitioner (NP), and Medical Director, the facility failed to administer pain medication prior to completing 50 wound dressing changes during the previous 34 days for a resident with a Stage 4 pressure ulcer and severe cognitive impairment. This occurred for 1 of 2 residents (Resident #16) reviewed for pressure ulcers. Resident #16's Stage 4 pressure ulcer on her left heel required scheduled wound dressing changes; the frequency of these dressing changes increased from once daily to twice a day on 6/22/23. At that time, Resident #16 had an order for an opioid pain medication to be administered twice daily. However, the frequency of this pain medication (med) was reduced with instructions to administer only one dose of the opioid pain medication every 24 hours as needed for heel/leg pain (Start Date 6/23/23). The order also included a notation to give the pain medication 60 minutes prior to dressing changes. Staff interviews revealed Resident #16 would frequently holler out and kick during wound dressing changes and she would sometimes yell so loudly during wound care that she could be heard out in the hallway (even with the door closed). Nursing staff described the resident's level of pain during dressing changes as, off the scale and severe. Immediate Jeopardy began on 6/23/23 when Resident #16's medication orders were reduced to once daily dosing and no longer coincided with the frequency of the resident's wound dressing changes provided twice a day. Immediate Jeopardy was removed as of 8/9/2023 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Resident #16 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes, peripheral vascular disease, hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following unspecified cerebrovascular disease, a history of gout, chronic pain syndrome, Alzheimer's disease, and dementia. The resident's physician's orders included the following, in part: --325 mg acetaminophen to be given as two tablets by mouth every 6 hours as needed for pain (Start Date 5/25/23). --Left heel: Clean with 1/4 strength Dakins (a solution used to prevent and treat skin and tissue infections), pack with gauze soaked with Dakins, covered by a dry dressing every day and evening shift (Start Date 6/22/23). --50 milligrams (mg) tramadol (an opioid pain medication) to be given as one tablet by mouth every 24 hours as needed for heel/leg pain. Give 60 minutes prior to dressing changes (Start Date 6/23/23). Tramadol is a controlled substance medication. A review of Resident #16's electronic medical record (EMR) included a progress note dated 6/28/23 and authored by the Nurse Practitioner (NP) who helped to care for the resident. The History of Present Illness noted, .She has a left heel unstageable pressure ulcer under treatment. The wound MD is closely following it for treatment interventions and the wound nurse is following it for daily drsg [dressing] changes . Resident #16's most recent Minimum Data Set (MDS) was a significant change assessment dated [DATE]. The MDS reported the resident had severely impaired cognition. Resident #16 required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. She was totally dependent on staff for eating. The resident was reported to be incontinent of bladder and bowel. The MDS indicated Resident #16 had one unhealed Stage 4 pressure ulcer. The assessment reported the resident received as needed (PRN) medication for pain, which included an opioid pain medication on 1 out of 7 days during the look back period. A Wound Evaluation and Management Summary dated 7/6/23 revealed Resident #16 was seen for follow-up by the facility's Wound Care Physician #1 for an assessment and evaluation. The resident was reported to have a Stage 4 pressure wound (full thickness) of the left heel of greater than 88 days duration. The size of the wound was measured as 6.4 centimeters (cm) length by 5.8 cm width by 1.8 cm depth. The wound was reported to have deteriorated due to the generalized decline of the patient. Resident #16 was also followed by Wound Care Physician #1 on 7/13/23 and 7/20/23. The Wound Evaluation and Management Summary from the 7/20/23 visit indicated the size of resident's Stage 4 pressure wound (full thickness) of the left heel was measured as 7.4 cm in length by 5.7 cm width by 1.7 cm depth. The wound progress was reported as Exacerbated due to generalized decline of patient. The Additional Wound Detail note read: progressive necrosis of plantar foot wound noted. Do not think that this wound will heal, and if it does, it will mean over 2 years of dressing changes and pain from wound. Will check with family to see if they would consider a below knee amputation to give healed wound, less pain over time and decrease need for daily dressing changes for the foreseeable future. The resident's most recent care plan (last date of review completed on 7/20/23) included the following areas of focus: --Resident has Activities of Daily Living (ADL) self-care performance deficits related (in part) to weakness, debility, and residual left hemiparesis for old cerebrovascular accident (CVA or stroke), Alzheimer's disease, and dementia. A notation within this area of focus (dated 7/4/23) reported the resident had a significant change in condition with deterioration of a pressure wound to her left heel. --Resident has actual skin breakdown/cellulitis with potential for further impaired skin integrity related to incontinence, a history of diabetes, and impaired mobility. An undated notation within this area of focus documented, medication for pain prior [to] dressing changes as ordered and deterioration. The planned interventions included providing treatment(s) to the resident's left heel as ordered and continuing treatment via the wound physician. The resident's physician's orders included the following, in part: --Left heel: Clean with 1/4 strength Dakins, pack with gauze soaked with Dakins, covered by an ABD pad (a highly absorbent, non-woven material that [NAME] moisture away from the wound) with dry dressing every day and evening shift (Start Date 7/25/23). --250 mg cephalexin (an antibiotic) to be given as 1 tablet by mouth every 12 hours for left heel cellulitis times 14 days (Start Date 7/26/23). Resident #16 continued to be followed by Wound Care Physician #1 on 7/27/23. The Wound Evaluation and Management Summary from the 7/27/23 visit indicated the size of resident's Stage 4 pressure wound (full thickness) of the left heel was measured as 7.6 cm in length by 5.6 cm width by 1.9 cm depth. The wound progress was reported as not improved. On 8/2/23, Resident #16 was seen by Wound Care Physician #2 (a provider covering for Wound Care Physician #1). The Wound Evaluation and Management Summary from the 8/2/23 visit indicated the size of resident's Stage 4 pressure wound (full thickness) of the left heel was measured as 9.2 cm in length by 6.7 cm width by 1.9 cm depth. The wound progress was again reported as not improved. Wound Care Physician #1 was not available for an interview. An observation of Resident #16's wound care was scheduled with the facility's Wound Care Nurse for the morning of 8/3/23. On 8/3/23 at 7:45 AM, the Wound Care Nurse cautioned that although Resident #16 would frequently holler out and kick during the wound dressing changes, she would have to continue to complete her wound care. The nurse stated she typically needed to have another staff member in the room to help hold the resident during the wound dressing change. The Wound Care Nurse confirmed Resident #16 had been premedicated for pain. On 8/3/23 at 7:57 AM, Nurse Aide (NA) #1 and the Wound Care Nurse were accompanied to Resident #16's room for her wound dressing change. Both the nurse and NA were observed as they washed their hands and donned clean gloves. The Wound Care Nurse explained to Resident #16 what they were planning to do. The resident gave permission for the wound dressing change and observation of the wound care at that time. Resident #16 was repositioned onto her right side; the NA supported her with one hand while gently holding her other hand. As the Wound Care Nurse removed the wound's outer dressing and gauze packing the wound, the resident moaned and called out in pain. She also appeared to try and move her leg away as the wound was re-packed and dressed; the Wound Care Nurse requested the NA attempt to hold her foot and leg still. As the resident exhibited these obvious signs of pain, NA #1 was observed as he rubbed the resident's back and leg to help soothe her. At the conclusion of the wound care, both NA #1 and the Wound Care Nurse agreed the resident did relatively well during this dressing change. NA #1 explained that sometimes he could hear the resident yell so loudly during wound care that she could be heard out in the hallway (even with her door closed). A review of the resident's EMR included her July 2023 and August 2023 Treatment Administration Records (TARs). The TARs from 7/1/23 to 8/3/23 indicated the resident's wound dressing was scheduled to be changed every day and every evening shift (twice daily). A review of Resident #16's Controlled Medication Utilization Record (a declining inventory sheet) revealed from 7/1/23 to the morning of 8/3/23, only 17 doses of tramadol had been withdrawn from the inventory dispensed for this resident. One dose of tramadol was withdrawn from Resident #16's inventory on each of the following dates: --7/2/23 at 12:19 PM --7/3/23 at 10:00 AM --7/5/23 at 10:00 PM --7/9/23 at 9:00 PM --7/12/23 at 9:00 PM --7/13/23 at 10:00 AM --7/14/23 at 10:00 AM --7/17/23 at 11:00 AM --7/22/23 at 10:00 AM --7/23/23 at 11:00 AM --7/24/23 at 10:00 AM --7/25/23 at 11:05 AM --7/26/23 at 12:06 PM --7/27/23 at 9:00 AM --7/28/23 at 10:00 AM --7/31/23 at 10:30 AM --8/3/23 at 6:07 AM A review of the resident's Medication Administration Record (MAR) from July 2023 and August 2023 revealed from 7/1/23 to the morning of 8/3/23, only 4 doses (two tablets) of 325 mg PRN acetaminophen was administered to Resident #16 on the following dates: --7/3/23 at 10:08 PM --7/6/23 at 10:42 AM --7/19/23 at 5:52 AM --7/20/23 at 5:49 AM An interview was conducted with the Wound Care Nurse on 8/3/23 at 2:00 PM. Upon inquiry, the Wound Care Nurse reported she completed the facility's wound dressing changes on Monday through Friday's day shift while the hall nurses completed the wound care during the evening shifts and on weekends. When asked about the pre-medication for Resident #16, the nurse stated she always checked with the hall nurse to be sure the resident had received her pain medication prior to doing her dressing change. When the results of Resident #16's Controlled Medication Utilization Record were shared, the Wound Care Nurse stated from now on she would need to verify the resident had been pre-medicated before proceeding with a dressing change instead of just asking the nurse about it. At that time, the nurse confirmed the resident's orders for tramadol included only one dose every 24 hours. The Wound Care Nurse reported Resident #16's pain meds had been reduced by the NP some time ago because twice daily dosing sedated her too much. The nurse reported Resident #16 did very well with the dressing change today and NA #1 had even commented to her about it. She reported the resident usually exhibited three (3) times the behaviors related to pain during dressing changes that were observed earlier that morning (on 8/3/23). When repeating what NA #1 said about the resident sometimes yelling out so loud in pain that she could be heard out in the hallway, the nurse acknowledged this statement was true. A telephone interview was conducted on 8/7/23 at 2:22 PM with Nurse #8. Nurse #8 was identified by her initials on Resident #16's July 2023 TAR as having completed the resident's evening wound dressing changes on 7/2/23, 7/5/23, and 7/12/23. Nurse #8 was also identified as having withdrawn one dose of tramadol for Resident #16 on 7/5/22 at 10:00 PM and on 7/12/22 at 9:00 PM. When asked if she could recall whether the tramadol was given to the resident as pre-medication prior to the dressing changes on those evenings, the nurse thought they likely were because she typically completed dressing changes after her medication pass was done. When asked about the resident's level of pain during the evening dressing changes, the nurse stated, for sure, she had discomfort with the dressing changes. The nurse stated she had not worked with the resident in the last 3 weeks or so but when she did, Resident #16 would occasionally cry out in pain when she completed the dressing changes. A telephone interview was conducted on 8/7/23 at 2:37 PM with Nurse #4. Nurse #4 was identified by her initials on Resident #16's July 2023 TAR as having completed evening wound dressing changes for the resident on 7/9/23, 7/17/23, and 7/23/23. The nurse recalled that the resident initially received her pain medication (tramadol) twice daily to help cover her pain with the twice daily dressing changes. However, the pain medication was later reduced to once daily. The nurse reported it was difficult to know what to do because the order for pain medication indicated it was to be given one hour before a dressing change, but the dressing changes were done twice daily. The nurse stated she would give the resident her pain medication in the morning and acetaminophen later as well. When asked about the resident's level of pain experienced during the evening dressing changes, Nurse #4 stated, It was off the scale. The nurse described her pain as severe and reported Resident #16 would holler out and try to move her feet away. Nurse #4 reported she would always give the resident chewing gum after her dressing change as a reward because she knew the resident enjoyed it. A telephone interview was conducted on 8/7/23 at 3:59 PM with Nurse #9. Nurse #9 was identified by her initials on Resident #16's July 2023 TAR as having completed evening wound dressing changes for the resident on 7/3/23, 7/8/23, 7/10/23, 7/13/23, 7/14/23, 7/22/23 7/27/23, and 7/31/23. Upon inquiry, Nurse #9 was asked how Resident #16 tolerated her dressing changes. The nurse stated, Most of the time, she doesn't like it. She flinches. Nurse #9 added that the resident might call out Ow at times and would also try to move her leg some. When asked if she could estimate the resident's level of pain exhibited, the nurse stated it varied but was probably a 5 (on a scale of 0 to 10, with 0 indicative of no pain). She stated, I try to do it [the dressing change] as easy as I can. Upon further inquiry, the nurse reported removing and replacing the packing from Resident #16's wound tended to be the most painful part of the dressing change for her. Nurse #9 stated she has given the resident PRN acetaminophen quite a few times in the past to help with the pain. When asked why she did not give the acetaminophen to the resident every time she had to do a dressing change, the nurse stated it would have been because someone else had probably given it to her. An interview was conducted on 8/3/23 at 3:55 PM with the facility's Director of Nursing (DON). During the interview, the DON was shown Resident #16's TARs (which documented dressing changes were scheduled to be completed twice daily), along with her order for 50 mg tramadol to be given as one tablet by mouth every 24 hours as needed for heel/leg pain to be given 60 minutes prior to dressing changes. When asked about the discrepancy in the frequency of the wound care and pre-medication orders, the DON recalled that at some point in time Resident #16's pain medication had been reduced due to sedation. The DON reported the order for the pain medication should have been written differently and added to the resident's TAR to ensure the resident was always pre-medicated prior to her dressing changes. A telephone interview was conducted on 8/4/23 at 9:27 AM with the facility's Administrator, DON, and Wound Care Nurse. During the interview, the Wound Care Nurse reported she had received a verbal order from Wound Care Physician #1 some time ago for the frequency of the dressing changes for Resident #16 to be completed twice daily (instead of once a day). Upon review of the resident's medical record, the Wound Care Nurse reported the verbal order for twice daily dressing changes was received on 6/22/23 due to the large amount of drainage the resident had from her wound. The DON reported Resident #16's pain management was addressed last evening (8/3/23) with new orders written by the facility's Medical Director. A telephone interview was conducted on 8/4/23 at 8:00 AM with the resident's NP and her Clinical Services Manager. During the interview, the NP was informed that Resident #16's wound dressing change for the Stage 4 pressure ulcer on her left heel was observed on the morning of 8/3/23. Although the Wound Care Nurse and NA both reported the resident was less vocal and less resistant to the wound care than usual, the resident was observed to exhibit obvious signs of pain even after being pre-medicated. When the NP was asked if she was aware of the resident having pain with the dressing changes, the NP stated Resident #16 was at a point where she needed to have a portion of her limb amputated. She stated until then, the resident would have pain there. She added, no amount of pain med will take care of that pain. When asked if the NP intended for Resident #16 to be pre-medicated with a dose of tramadol prior to each dressing change, the NP replied, Correct that's for the first wound [first dressing change]. The NP reported at one point, she tried to schedule an opioid pain medication twice daily but that was too much for this resident. The NP stated, She was truly lethargic with twice a day dosing. Upon further inquiry, the NP reported she did not know until yesterday (8/3/23) that the resident was getting a dressing change twice a day. She stated, My intentions were daily if they were doing it [dressing changes] daily and [that she be] pre-medicated before [the wound care]. When asked if the NP was aware the resident was not always being pre-medicated for dressing changes, she responded by saying, No, I wanted her to be pre-medicated before the dressing changes daily. The NP stated Resident #16 did have medication orders for PRN acetaminophen and the NP would encourage administration of it in addition to the tramadol to help with the pain. An interview was conducted on 8/2/23 at 2:14 PM with the facility's Medical Director (who is also a Medical Doctor or MD). During the interview, the MD reported Resident #16's wound would not heal at this point due to the lack of circulation to her limb. He stated a surgical consult was requested and amputation of her lower leg was recommended. He reported Resident #16's family needed to decide as to whether the amputation would be done. A follow-up telephone interview was conducted on 8/4/23 at 9:40 AM with the facility's Medical Director. During the interview, the MD reported although the resident was under another provider's service, he was the physician for all residents in the building. The observation of Resident #16's wound dressing change on 8/3/23 and staff interviews were discussed, along with the resident's medication records which revealed she was not routinely pre-medicated for the dressing changes scheduled each day. When asked, the MD reported twice daily dressing changes would not deter a wound from healing and would only help. The MD recalled Resident #16's NP had shared that the resident's pain medication was previously cut back due to oversedation. However, the MD reported that yesterday (8/3/23), he went ahead and changed her medication regimen. The MD stated he trusted the changes would help the resident's level of comfort going forward and he would follow-up with her as needed. The Administrator was notified of immediate jeopardy on 8/8/2023. The facility provided the following immediate jeopardy removal plan: Credible Allegation of Immediate Jeopardy Removal F-697 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Based on observations, record reviews, and State Surveyor and staff interviews, the facility failed to provide pain management for a resident with severe cognitive impairment, who had a Stage 4 pressure ulcer of her heel (Resident #16). Resident #16 has been assessed by the Wound Care nurse on 08/03/23 and pain medication was administered. Regional Director of Clinical Services, along with Executive Director notified medical director regarding pain management and new orders received for additional pain medication and hospice consult, and transcribed to the Medication Administration Record, Resident #16's responsible party was notified of new orders to include medication changes. Resident #16's Plan of Care has been updated on 08/03/2023 by the Minimum Data Set Nurse to reflect resident's problem, goal, and interventions. Current Facility Residents with wounds have the potential to be affected. a. Current Residents with wounds (12) had Pain Assessments completed by a Licensed Nurse on 8/08/23 using a Pain Assessment to determine those that are at risk for pain. a.i. Current residents with wounds (12) were reviewed to ensure current orders included pain management. These Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated on 08/08/23. b. Current Residents with wounds (12) had orders for pain management received for wound care prior to treatment. Pain Evaluations were performed by a Licensed Nurse on 08/08/23 to ensure that pain management has been addressed for residents with wounds and appropriate interventions are in place. b.i. These affected Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated, accordingly on 8/08/23. The residents and/or Responsible Party was notified of changes made with current orders to include pain medications and plan of care. The Facility has a contract with a Certified Wound Company with Physicians who makes rounds weekly for consultation, assessment, and treatment orders. The Certified Wound Physician is available by phone and via telehealth for consultation, assessment and treatment orders. Current Certified Wound Physician and Wound Care Nurse will be re-educated by Regional Director of Clinical Services on 08/08/2023 related to assessing pain before, during and after wound care is provided. Physician will be included in updating resident's plan of care to include pharmacological and non-pharmacological pain interventions are being offered prior to wound care management. Resident's that have dementia or other cognitive impairment will be medicated per nonverbal pain cues and assessment. Regional Director of Clinical Services also educated Wound Care Nurse on 08/08/2023, to provide a copy of the Certified Wound Physician notes and orders to the primary care provider (Nurse Practitioner or Medical Director) weekly. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 08/08/2023, the Director of Nursing conducted education with the Nurse Manager/Wound Care Nurse to ensure the following Licensed Nursing Staff will assess pain before, during and after wound care is provided, to verify that pharmacological pain interventions are offered prior to wound care management, will communicate with wound care provider of any pain management changes, pain medications are to be administered as per physician orders for residents with documentation in the medical record, according to the plan of care. Wound care education will be provided by the Nurse Manager during orientation for newly hired nurses and ongoing. On 08/08/2023, the Director of Nursing conducted education with the Nurse Manager/Wound Care Nurse to ensure the Nurse Aides were provided education related to reporting pain to the nurse based on the request or observation of the patient according to the plan of care. Current Certified Wound Physician and Wound Care Nurse will be re-educated by Regional Director of Clinical Services on 08/08/2023 related to assessing pain before, during and after wound care is provided. Physician will be included in updating resident's plan of care to include pharmacological and non-pharmacological pain interventions are being offered prior to wound care management. Regional Director of Clinical Services also educated Wound Care Nurse to provide a copy of the Certified Wound Physician notes and orders to the primary care provider (Nurse Practitioner or Medical Director). On 08/08/2023, the Director of Nursing and/or Nurse Manager conducted re-education with Licensed Nursing Staff to ensure the following: a. Licensed Nursing Staff - assess pain before, during and after wound care is provided. b. Licensed Nursing Staff- education provided on how to anticipate needs and assess pain for residents that are cognitively impaired. c. Licensed Nursing staff - education provided to verify that pharmacological pain interventions are offered prior to wound care management. d. Licensed Nursing staff - will communicate with resident's primary care provider to notify of any signs and symptoms of pain and to request any pain medication. e. Licensed Nursing staff - will communicate with wound care provider of any pain management changes. Wound care education will be provided by the Nurse Manager during orientation for newly hired nurses and ongoing f. Licensed Nursing Staff- pain medications are to be administered as per physician orders for residents with documentation in the medical record, according to the plan of care. g. Starting on 08/08/2023 Nurse Aides were provided education related to reporting pain to the nurse based on the request or observation of the patient according to the plan of care. h. Staff not educated prior to 08/08/2023 will be educated prior to working their next shift. The Executive Director will validate the staff education was completed prior to the staff member working their next shift i. Certified Wound Physician received education by the Regional Director of Clinical Services on 08/08/2023 related to assessing pain before, during and after wound care is provided according to the plan of care. j. Newly hired nursing staff will be educated by the Nurse Manager during the orientation period going forward. The Executive Director is responsible for the implementation of this credible allegation F-697 Abatement Plan for removal of Immediate Jeopardy Transitional Health Services of Kannapolis (8/09/2023) Dated alleged Immediate Jeopardy removal: 08/09/23. The validation of the credible allegation conducted on 08/10/23 included licensed and certified nurse staff completed in-service education related to pain assessment of verbal and nonverbal residents prior to wound care, during wound care and post wound care. Random nurse staff were interviewed and explained the policy related identification of signs and symptoms of pain and proper reporting to the physician and Responsible Party of pain medication effectiveness. The nurse management staff began audits to monitor pain assessments for residents residing in the facility on 08/08/23. Resident care plans were reviewed and updated on 08/08/23 to reflect current pain management goals and interventions related to pain management during wound care. Resident #16 was observed asleep in bed. The wound care nurse revealed that she had performed wound care as ordered the morning of 08/10/23 and Resident #16 had received her scheduled pain medication as ordered 30 minutes prior to her wound care and Resident #16 tolerated her wound care with no verbal or nonverbal signs or symptoms of pain. Interviews were conducted with alert and oriented residents that received wound care and pain management provided during wound care with no concerns identified. Immediate Jeopardy removal date effective 08/09/23.

Based on observations, resident and staff interviews, and record reviews, the facility failed to allow residents who were assessed to be safe smokers the ability to smoke independently per their individual preference for 2 of 4 residents (Resident #46 and #31) reviewed for smoking. Resident #46 verbalized this practice resulted in his feelings of being treated like a child and a prisoner. The findings included: 1. Resident #46 was admitted to the facility on [DATE]. A review of Resident #46's electronic medical record included a Smoking Evaluation dated 2/22/23. The smoking evaluation indicated Resident #46 smoked. The last section on the Smoking Evaluation indicated the resident was determined to be a Safe Smoker. Upon request, a copy of Resident #46's Smoking Evaluation was provided by the facility. The printed Smoking Evaluation had an Effective Date of 5/26/23 (Signed on 8/1/23). The Summary of Evaluation concluded the resident was determined to be a Safe Smoker. The supervision needed while smoking was None. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #46 had intact cognition and was independent with eating and locomotion on/off the unit. Resident #46's care plan (dated as last reviewed on 7/25/23) included an area of focus which indicated he was a smoker. The goal for this area of focus read: The resident will not suffer injury from unsafe smoking practices through the review date. The planned interventions included: instruct resident about smoking risks and hazards and about smoking cessation aids that are available; the resident is able to light own cigarette; the resident's smoking supplies are stored at the nursing station. An interview was conducted with Resident #46 on 8/1/23 at 9:15 AM. During the interview, the resident stated the facility's smoking policy changed when the new Administrator started a few months ago. Since that time, he has only been allowed to smoke while supervised at designated smoking times. The resident stated, I'm [age] years old and I don't need to be treated like a child. The resident was asked if the designated smoking times were okay with him. He emphatically stated, No and added that he felt like he was a prisoner. When asked how much time he was given to smoke during the designated smoking times, the resident reported he could only smoke for 1/2 hour. Resident #46 stated he was allowed to stay outside after the smoking times but could no longer smoke. The resident did not express any problem with the facility storing his cigarettes and lighter for him in between the smoking breaks. On 8/1/23 at 9:30 AM, a sign was observed hung on the door leading to the designated smoking area. The sign read: Smoking Times 9:30-10:00 11:30 - 12:00 1:30 - 2:00 3:30 - 4:00 7:00 - 7:30 9:30 - 10:00 An observation was conducted on 8/1/23 at 9:37 AM as the facility's Director of Nursing (DON) was accompanied by two residents in wheelchairs to the outdoor area designated for smoking. On 8/1/23 at 9:38 AM, two more residents, including Resident #46, were observed to go out to the smoking area. The residents were provided with their cigarette (or pipe) and lighters. On 8/1/23 at 9:40 AM, the Business Office Manager went outside to the smoking area and the DON went indoors. The Business Office Manager was observed as he stood outside and watched the residents as they smoked. On 8/1/23 at 9:50 AM, an interview was conducted with the Business Office Manager as he was outside in the smoking area. Upon inquiry, the manager reported all four of the smokers were grandfathered in for smoking. The manager stated that all four residents were pretty much independent, but he added that we supervise them. An interview was conducted on 8/2/23 at 12:22 PM with the Administrator and Regional Director of Nursing regarding the facility's smoking policy. During the interview, the Administrator reported that the facility was now a Smoke-free facility. However, the Administrator also reported, We have a few smokers here that were grand-fathered in. She reported the designated smoking times with supervision did include the safe smokers. The Administrator also stated all smoking materials for the smokers were kept in a locked box and brought out for the smokers at the designated smoking times. When asked why a safe smoker needed to adhere to designated smoking times for supervision, the Regional Director of Nursing only responded by saying the facility could remedy this practice for the residents who have been assessed to be safe smokers. 38129 2. Resident #31 was admitted to the facility on [DATE] with the diagnosis of nicotine dependence. The quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition and was independent for all his activities of daily living except personal hygiene required limited assistance and bathing was limited to transfer only. Resident #31's care plan updated 7/25/23 documented the resident smoked. The goal was for no injury and interventions were for the resident to light his own cigarette, supplies stored at the nurses' station, instruct the resident on smoking risks and cessation, and aides available to supervise. On 08/01/23 at 10:22 an interview was conducted with Resident #31. The resident stated he wanted to smoke at night and was independent. The resident stated he participated in the scheduled smoking during the day, but wanted to smoke after the schedule was over for the day. The facility required the resident smoke supervised on a schedule. The resident stated that it was not necessary for him to be supervised and did not like the restriction. He was able to manage on his own. Resident #31 was assessed for smoking safety and documented by Social Work as independent on 2/22/23 and 8/1/23. Resident #31 was observed on 8/1/23 at 11:30 am smoking with the scheduled resident group. Nursing Assistant (NA) #4 was present. The NA placed a smoking apron and was handed his cigarettes and lighter and expected to independently smoke. The resident lit his cigarette, smoked the cigarette, and extinguished/discarded the cigarette in the appropriate receptacle when done smoking. The resident re-entered the building independently. NA #4 was interviewed on 8/1/23 at 11:30 am. She stated that Resident #31 was independent with smoking, I just hand him his supplies. On 08/01/23 at 9:50 am an interview was conducted with the Business Office Manager who was outside in the smoking area supervising. He reported all the smokers (4) were grandfathered in for smoking. The Business Office Manager further reported all of them were pretty much independent, but he added that we supervise them.

Based on record review, resident and staff interviews, the facility failed to treat a resident in a dignified manner, when a Nursing Assistant made disrespectful comments to a resident when providing incontinent care for 1 of 3 residents reviewed for dignity (Resident#2). Resident #2 said the NAs comments made her feel awful, like a dog, or not really like a human being, like she was less than a person or a person without feelings. The findings included: Resident #2 was readmitted to the facility on [DATE] and the resident ' s cumulative [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent Minimum Data Set (MDS) revealed a quarterly assessment with an Assessment Reference Date (ARD) of 1/3/20. The resident was coded as having been cognitively intact. The resident was coded as having had no hallucinations or delusions and the resident was coded as requiring extensive assistance of one to two people for all activities of daily living (ADLs) including: Bed mobility, transfer (such as transfer from the bed to the wheelchair, dressing, toileting, and personal hygiene, except for eating, where the resident was coded as independent with setup help. The resident was coded as having been always incontinent of both bowel and bladder. The care plan for Resident #2, which was most recently revised on 12/19/19, specified the resident had Focus areas which included: a self-care performance deficit and altered bowl elimination related to impaired mobility and incontinence. Further review revealed another focus area related to incontinence care which was the resident had altered bowl elimination related to impaired mobility and incontinence. One of the interventions for the potential for skin breakdown and bowel and bladder incontinence included: Check for soiling frequently, provide incontinent care post incontinent episode. During an interview with Resident #2 on 2/4/20 at 7:47 AM the resident stated one evening in (MONTH) 2020 she was incontinent of stool and two nursing assistants (NAs) provided incontinent care for her. While the NAs were providing the care one of the NAs made comments regarding how she had a Bowel movement (BM) that upset her. The resident specified the NA ' s comments about her included; she did not even know how to have a BM, and the resident did not know how to s**t on herself and was nasty. Resident #2 stated the NA just went on and on about it. The resident stated it had occurred about a month ago. The resident identified the NA who had made the comments as NA #1. The resident said NA #1 had not made comments to her like that before, but the NA felt like she could talk to residents any way she would like. The resident stated NA #2 who was also providing the incontinent care was training with NA #1 and did not say anything when NA #1 made the comments. The resident stated the comments which were made by NA #1 made her feel awful, felt like a dog, or . not really like a human being. The resident stated she told Nurse #1, who worked during the night shift (11:00 PM to 7:00 AM), about what had happened. A phone interview was conducted with NA #1 on 2/4/20 at 8:20 AM. NA #1 said she and NA #2 were providing incontinent care for Resident #2 on 1/9/20 and had not disrespected Resident #2. The NA stated she and the resident were tight, they were close, and she talked to her like she would talk to her. The NA stated the facility had told her she had hurt the resident ' s feelings very bad; she did not remember saying anything which would have offended the resident, and the facility had not investigated the allegation. The NA stated she had not said anything about the resident having been stupid or she had s**t on herself. Review of a statement completed by NA #2, dated 1/10/20, revealed during second shift (3:00 PM to 11:00 PM), she and NA #1 were providing care for Resident #2 and when NA #1 opened Resident #2 ' s brief and there was stool everywhere. The NA documented NA #1 stated, This s**t is ridiculous and that a grown woman should not sit in her own stool. When NA #1 left the room to obtain additional supplies, NA #2 noted the resident started telling her nobody should be treated that way, she was a human being, and not an animal. NA #2 was interviewed via phone on 2/4/20 at 1:15 PM and stated she was present on 1/9/20 when NA #1 had made comments to Resident #2 regarding her bowel movement and incontinence care. The NA said it was her first day working at the facility and she was training and was assigned to work with NA #1. The NA remembered her, and NA #1 went to Resident #2 ' s room, she was incontinent of BM and NA #1 was not happy. NA #1 told the resident her a** should not look like that, and if she would roll over, she wouldn ' t have BM on her. The NA clarified NA #1 had not said BM but had said s**t and had said it in a manner which was not in a joking tone but an aggravated tone. NA #2 continued when NA #1 left the room for supplies the resident told her NA #1 should not talk to residents like that, like a dog, and the resident was crying. The NA continued when she went in the following day the Director of Nursing and Administrator had interviewed her and she explained to them she did not know what to do because it was her first day working on the floor. During a second interview conducted with Resident #2 on 2/4/20 at 2:07 PM the resident stated the comments made by NA #1 made her feel worthless, made her cry, tear up, feel very sad, and she felt like it was verbal abuse. The resident said she had told Nurse #1 because she had felt comfortable talking with her and she had told the nurse she felt like she had been verbally abused. A phone interview was conducted with Nurse #1 on 2/5/20 at 9:28 AM. The nurse stated Resident #2 told her that NA #1 said something to her, and it had hurt her feelings. The resident told her that NA #1 said something and laughed at her and she felt awful about what was said. During an interview conducted on 2/5/20 at 10:40 AM with Social Worker (SW) #2 he said on 1/10/20 he and the Administrator met with Resident #2 about the concern. The SW remembered Resident #2 shared a problem she had about NA #1, who she had felt uncomfortable with, but she did not want the NA to lose her job. The resident said she had diarrhea during the evening of 1/9/20 and NA #1 became angry with her. An interview was conducted with the Unit Manager (UM) on 2/5/20 at 11:01 AM. The UM stated she spoke with Resident #2 shortly after lunch on 1/10/20 and the resident told her about an incident that occur on 1/9/20, when she had diarrhea, which was chronic for her, and she had needed to be changed. The UM said the resident informed her that NA #1 and NA #2 came into change her and NA #1 was verbally inappropriate with her and made comments such as; No grown woman should be s**tting herself like this, and a grown woman should not have s**t all over herself. The resident had told her when NA #1 went to obtain additional supplies she had told NA #2, that ' s not how you talk to somebody. The UM stated she felt the statement made to Resident #2 by NA #1 was terrible, the language used was demeaning, it negatively impacted the resident ' s dignity, it had been said in front of new employee who she was responsible for training, and the behavior was unacceptable. The UM said she could tell it made the resident feel really bad and it bothered her. The UM said the resident told her it made her feel like she was less than a person or a person without feelings. On 2/4/20 at 3:39 PM the administrator was interviewed, and she said it was reported to her on 1/10/20 that Resident #2 alleged someone had been mean to her and spoken ill to her. She explained she and SW #2 interviewed Resident #2, and the resident alleged NA #1 said nasty things to her, but she did not want to get anyone into trouble. The administrator stated she asked the resident how the comments from NA #1 made her feel and the resident responded she was hurt by the comments.

Based on record review, staff interviews and physician interviews, the facility failed to notify the physician of the resident ' s change in condition when a resident experienced daily diarrhea, resulting in a delay of treatment of [REDACTED].#1.) Findings included: Resident #1 was admitted on [DATE] for rehabilitation after a [MEDICAL CONDITION] surgery. The resident had the [DIAGNOSES REDACTED]. The admission minimum (MDS) data set [DATE] revealed the resident was cognitively intact and required extensive assistance of one staff member with activities of daily living. A review of the bowel movement log revealed Resident #1 started having diarrhea on 2/24/17 and had one or more loose bowel movements per day until 3/9/17, with the exception of 3/3/17 she received [MEDICATION NAME] and there was a formed stool. The bowel movements were loose and no other description was provided. 02/24/2017 8:28 PM BM large Loose 02/25/2017 11:22 AM BM medium Formed 02/25/2017 9:24 PM BM small Loose 02/25/2017 11:37 PM BM large Loose 02/26/2017 1:27 PM BM extra large Loose 02/27/2017 1:25 PM BM large Loose 02/27/2017 6:32 PM BM small Loose 02/28/2017 8:45 AM BM large Loose 02/28/2017 11:43 AM BM extra large Loose 03/01/2017 12:52 PM BM large Loose 03/01/2017 8:41 PM BM small Loose 03/02/2017 12:04 AM BM small Loose 03/02/2017 9:07 AM BM extra large Loose 03/02/2017 8:17 PM BM small Loose 03/02/2017 11:41 PM BM large Loose 03/03/2017 1:14 PM BM medium Formed 03/03/2017 9:36 PM BM small Loose 03/03/2017 11:23 PM BM large Loose 03/04/2017 9:01 PM BM small Loose 03/05/2017 9:35 PM BM large Loose 03/06/2017 12:39 PM BM extra large Loose 03/06/2017 6:03 PM BM large Loose 03/07/2017 11:16 AM BM medium Loose 03/07/2017 4:46 PM BM small Loose 03/08/2017 1:46 PM BM extra large Loose 03/08/2017 6:24 PM BM small Loose 03/08/2017 11:42 PM BM large Loose 03/09/2017 11:58 PM BM extra large Loose A progress note dated 2/27/17 revealed the Nurse Practitioner (NP) saw the resident for loose stools that had progressively become more frequent. The note indicated the staff was concerned for [MEDICAL CONDITION] infection. The NP noted Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] for constipation and ordered [MEDICAL CONDITION] stool culture and [MEDICATION NAME] 4 milligrams (mg) every 6 hours as needed for loose stools. A review of the nurse practitioner ' s order dated 2/27/17 revealed a stool culture for [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg every 6 hours as needed for diarrhea. A review of the nurses ' notes from 2/27/17 to 3/10/17 revealed the resident had no changes in condition documented, and there was no notation of increase in bowel movements or diarrhea. Nurses ' notes indicated the blood pressure and pulse were stable and within normal limits. A review of the Medication Administration Record [REDACTED]. A progress note dated 3/8/17 revealed the NP saw the resident for diarrhea. The NP re-ordered [MEDICAL CONDITION] stool culture and the resident was treated with [MEDICATION NAME] 4 mg every 6 hours as needed for loose stools. The resident had a blood pressure of 122/80, a pulse of 86, temperature of 98 F and was in no distress. The labs were reviewed and the creatinine was at baseline. The resident complained of dizziness and the NP planned orthostatic blood pressures. A review of the nurse practitioner ' s order dated 3/8/17 revealed a stool culture for [MEDICAL CONDITION], to assess orthostatic blood pressure for three days, and to discontinue the [MEDICATION NAME] 500 milligrams each day and the [MEDICATION NAME] 6 grams each day. A review of the physician's order [REDACTED]. A progress note dated 3/9/17 indicated the NP saw the resident for an abnormal lab result of creatinine 5.85 (normal range 0.6 - 1.3). The resident ' s blood pressure was 140/70 and pulse 80. The same progress note further revealed the assessment was acute kidney injury on [MEDICAL CONDITION] from dehydration. The resident was started on intravenous fluids at 125 cubic centimeters (cc) per hour. The nephrologist ordered a stat (urgent) renal ultrasound for today and repeat the basic metabolic panel (BMP) tomorrow. A review of the physician's order [REDACTED]. A review of Resident #1 ' s laboratory results for a stool culture of [MEDICAL CONDITION] collected on 3/9/17 revealed the stool was positive for [MEDICAL CONDITION] on 3/13/17. A review of the physician's order [REDACTED].#1 to the emergency room for an evaluation of the dehydration. The NP indicated in a progress note dated 3/10/17 she saw the resident for elevated white blood cell count (WBC). The resident ' s blood pressure was 106/60 and pulse 62. The assessment was worsening kidney function and elevated WBC. The resident had acute kidney injury due to diarrhea. The NP sent the resident to the emergency room for evaluation. Resident #1 was admitted to the hospital on [DATE] and the hospital history and physical was reviewed. The hospital course documented Resident #1 had [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] in the setting of a generalized debilitated state and moderate malnutrition. The resident was seen by her nephrologist and was treated with [MEDICATION NAME] (antibiotic) and IV fluids. The resident had a two-week history of diarrhea with weakness. The discharge summary revealed [DIAGNOSES REDACTED]. The resident received aggressive IV fluid resuscitation for acute dehydration. At the time of the hospital discharge on 3/22/17, the resident ' s creatinine returned to baseline. On 4/3/17 at 4:50 pm an interview was conducted with the NP. The NP stated that on 2/27/17 she was informed by staff Resident #1 was having loose stools, but not every day. The NP stated that she asked the resident about her diarrhea and was informed the diarrhea was every day. The NP ordered the [MEDICAL CONDITION] stool culture on 2/27/17 for the resident ' s diarrhea. When the NP asked the staff for the results of the [MEDICAL CONDITION] test on 3/6/17, the NP was informed the results were pending. The NP stated she did not write any new orders to complete a stool for [MEDICAL CONDITION], but was waiting for the [MEDICAL CONDITION] results from 2/27/17. The NP stated she was not aware until 3/8/17 that the stool culture had not been done. The NP stated that her expectation was for staff to follow orders as written and to notify her of any changes. The resident was sent to the emergency roiagnom on [DATE] and was referred to her nephrologist while she was hospitalized . On 4/4/17 at 8:40 am an interview was conducted with the Director of Nursing (DON). The DON stated that she expected staff to follow physician's order [REDACTED]. On 4/4/17 at 9:00 am an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated that the resident had 4 to 6 loose bowel movements on day shift for over a week leading up to the hospitalization . NA #1 stated she reported to the nurse that Resident #1 had multiple bowel movements. An additional interview was conducted on 4/6/17 at 2:02 pm via telephone with NA #1. NA #1 stated that the diarrhea was more than once a day and frequency was not documented because she did not have time to document and provide resident care. NA #1 stated that the diarrhea was liquid with mucous and foul smelling. She informed the nurse on duty at least once a shift over 10 days the resident had diarrhea. NA #1 stated that the resident was tired and commented that everything she eats goes right through her. The resident also had a decrease in appetite. NA #1 stated that she discussed the resident ' s diarrhea with the NP on 3/8/17. An interview was conducted on 4/6/17 at 3:40 pm via telephone with the resident ' s physician. The physician stated he remembered Resident #1 and had reviewed the records when the stool culture was missed as part of quality review. The physician explained he was informed by the facility that the order for [MEDICAL CONDITION] stool sample on 2/27/27 was missed. The physician stated he was informed by his NP that the resident had one loose stool a day. The resident did not present with a [MEDICAL CONDITION] infection because the facility staff informed the NP that Resident #1 had one bowel movement a day. On 4/7/17 at 11:40 am an interview was conducted via telephone with Nurse #4. Nurse #4 stated that she remembered Resident #1 and was on duty 3/3/17 for day shift. Resident #1 had two loose stools on day shift and that she administered [MEDICATION NAME] once at 10:00 AM per the resident ' s request. Nurse #4 stated she did not have a concern for dehydration because the resident was drinking fluids and there was no further diarrhea after the resident received the [MEDICATION NAME]. Nurse #4 stated she would inform the physician if a resident had repeated need for an as needed medication or concerns regarding diarrhea.

Based on record review, staff interviews and physician interviews, the facility failed to complete a lab order for a stool culture for a bacterial infection ([MEDICAL CONDITION]) resulting in a delay of [DIAGNOSES REDACTED].#1.) Findings included: Resident #1 was admitted on [DATE] for rehabilitation after a [MEDICAL CONDITION] surgery. The resident had the [DIAGNOSES REDACTED]. The admission minimum data set for Resident #1 dated 1/30/17 revealed the resident was cognitively intact and required extensive assistance of one staff member with activities of daily living. The resident was continent of bowel and occasionally incontinent of urine. A review of the bowel movement log revealed Resident #1 started having diarrhea on 2/24/17 and had one or more loose bowel movements per day until 3/9/17, with the exception of 3/3/17 when she received [MEDICATION NAME] and there was a formed stool. The bowel movements were loose and no other description was provided. A progress note dated 2/27/17 revealed the Nurse Practitioner (NP) saw the resident for loose stools that had progressively become more frequent. The note indicated the staff was concerned for [MEDICAL CONDITION] infection. The NP noted Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] for constipation and ordered [MEDICAL CONDITION] stool culture and [MEDICATION NAME] 4 milligrams (mg) every 6 hours as needed for loose stools. A review of the nurse practitioner ' s order dated 2/27/17 revealed a stool culture for [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg every 6 hours as needed for diarrhea. A review of the Medication Administration Record [REDACTED]. A review of Resident #1 ' s laboratory results from 2/27/17 through 3/8/17 revealed there was no laboratory result present for a stool culture for [MEDICAL CONDITION], which was ordered on [DATE]. A review of the laboratory results of the resident ' s creatinine dated 3/7/17 revealed the creatinine (kidney function) result was 5.85 (normal range 0.6 - 1.3) and the blood urea nitrogen (BUN) (shows hydration) result was 33 (normal range 3-25). The resident ' s baseline creatinine was 1.6. A progress note dated 3/8/17 revealed the NP saw the resident for diarrhea. The NP re-ordered [MEDICAL CONDITION] stool culture and the resident was treated with [MEDICATION NAME] 4 mg every 6 hours as needed for loose stools. The resident had a blood pressure of 122/80, a pulse of 86, temperature of 98 F and was in no distress. The labs were reviewed and the creatinine was at baseline. The resident complained of dizziness and the NP planned orthostatic blood pressures. A review of the nurse practitioner ' s order dated 3/8/17 revealed a stool culture for [MEDICAL CONDITION], to assess orthostatic blood pressure for three days, and to discontinue the [MEDICATION NAME] 500 milligrams each day and the [MEDICATION NAME] 6 grams each day. A progress note dated 3/9/17 indicated the NP saw the resident for an abnormal lab result of creatinine 5.85 (normal range 0.6 - 1.3). The resident ' s blood pressure was 140/70 and pulse 80. The same progress note further revealed the assessment showed an acute kidney injury on [MEDICAL CONDITION] from dehydration. The resident was started on intravenous fluids at 125 cubic centimeters (cc) per hour. The nephrologist ordered a stat (urgent) renal ultrasound for today and repeat the basic metabolic panel (BMP) tomorrow. A review of the physician's order [REDACTED]. A review of Resident #1 ' s laboratory results for a stool culture of [MEDICAL CONDITION] collected on 3/9/17 revealed the stool was positive for [MEDICAL CONDITION] on 3/13/17. Laboratory results of the resident ' s creatinine (kidney function) dated 3/10/17 was 9.61 (normal range 0.6 - 1.3). The blood urea nitrogen (BUN) (shows hydration) result was 55 on 3/10/17 (normal range 3-25). The resident ' s baseline creatinine was 1.6. A review of the physician's order [REDACTED].#1 to the emergency room for an evaluation of the elevated creatinine and BUN. The NP indicated in a progress note dated 3/10/17 she saw the resident for elevated white blood cell count (WBC). The resident ' s blood pressure was 106/60 and pulse 62. The assessment was worsening kidney function and elevated WBC. The lab result showed a creatinine of 9.61 and a BUN 55. The resident had acute kidney injury due to diarrhea (kidney became injured due to a lack of blood flow). The NP sent the resident to the emergency room for evaluation. Resident #1 was admitted to the hospital on [DATE] and the hospital history and physical was reviewed. The hospital course documented Resident #1 had [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] in the setting of a generalized debilitated state and moderate malnutrition. The resident was seen by her nephrologist and was treated with [MEDICATION NAME] (antibiotics) and IV fluids. The resident had a two-week history of diarrhea with weakness. The resident ' s creatinine increased to 9.7. The discharge summary revealed [DIAGNOSES REDACTED]. The resident received aggressive IV fluid resuscitation for acute dehydration and sodium [MEDICATION NAME] for acidosis. At the time of the hospital discharge on 3/22/17, the resident ' s creatinine returned to baseline at 1.6. Resident #1 was not interviewed because she had been discharged at the time of the site visit. On 4/3/17 at 4:50 pm an interview was conducted with the NP. The NP stated that on 2/27/17 she was informed by staff Resident #1 was having loose stools, but not every day. The NP stated that she asked the resident about her diarrhea and was informed the diarrhea was every day. The NP ordered the [MEDICAL CONDITION] stool culture on 2/27/17 for the resident ' s diarrhea. When the NP asked the staff for the results of the ordered [MEDICAL CONDITION] test on 3/6/17, the NP was informed the results were pending. The NP stated she did not write any new orders to complete a stool for [MEDICAL CONDITION], but was waiting for the [MEDICAL CONDITION] results from 2/27/17. The NP stated she was not aware until 3/8/17 that the stool culture had not been done. The NP stated that she contacted the resident ' s nephrologist on 3/9/17 regarding the resident ' s elevated creatinine, and the nephrologist ordered a stat (immediate) ultra sound of the kidneys. The NP stated that the physician ordered on [DATE] for the resident to go to the ER. The NP thought that the resident was to go for an evaluation of the elevated creatinine of 5.85, but instead the resident went to the ER to have an IV placed. The NP stated that her expectation was for staff to follow orders as written. The NP stated that the physicians and NPs now have direct access to the lab results on-line to improve follow up. The NP further stated the increased creatinine lab result was related to acute injury to the kidney from dehydration secondary to diarrhea. The NP stated that another creatinine lab level was completed on 3/10/17 and it had increased to 9.6, and it had not improved after Resident #1 received intravenous fluids. The resident was sent to the emergency roiagnom on [DATE] and was referred to her nephrologist while she was hospitalized . On 4/4/17 at 8:40 am an interview was conducted with the Director of Nursing (DON). The DON stated that she expected staff to follow physician's order [REDACTED]. On 4/4/17 at 10:30 am an additional interview was conducted with the DON. The DON stated a root cause analysis was conducted for the missed [MEDICAL CONDITION] lab order dated 2/27/17. The DON stated that the error was investigated, education was provided for all staff that was responsible for lab process, a quality improvement/quality assurance summary was documented, there was a QAPI (quality assurance performance improvement) meeting, which included the medical director, and a prospective review of lab orders and the process was performed. The four-point plan of correction was completed. An audit revealed no other missed labs at the time of the incident and no other missed labs since the incident to date. The four-point plan of correction was reviewed and all components were present on 3/31/17. An additional interview was conducted on 4/6/17 at 2:02 pm via telephone with NA #1. NA #1 stated that she discussed the resident ' s diarrhea with the NP and a culture was ordered, and NA #1 collected that specimen. An interview was conducted on 4/6/17 at 3:40 pm via telephone with the resident ' s physician. The physician stated he had reviewed the records when the stool culture was missed as part of quality review. The physician explained he was informed by the facility that the order for [MEDICAL CONDITION] stool sample on 2/27/27 was missed. The facility provided its plan of action on 4/4/17 at 11:00 am. A review of the plan of action dated 3/9/17 for the incident revealed Resident #1 had a missed physician order [REDACTED]. On 3/10/17 a Quality Assurance/Performance Improvement committee meeting was held and a root cause analysis was performed. The error was determined that the [MEDICAL CONDITION] stool culture was not placed into the laboratory vendor ' s electronic system. On 3/8/17 the management team put in place an audit of all laboratory orders and the process for three times a week for 30 days and each week thereafter. The Consultant Nurse reviewed the laboratory error report, plan of action documentation, education in-service attendance record, and prospective/ongoing audits. No other laboratory errors were identified. Further review of the plan of action showed in-servicing of all nursing staff of the laboratory process and follow up was completed on 3/9/17. The documentation showed audits were performed on 3/9/17, 3/10/17, 3/13/17, 3/15/17, 3/17/17, 3/20/17, 3/22/17, 3/24/17, 3/27/17, 3/29/17, and 3/31/17, and there were no further laboratory processing errors. Sign-in sheets for in-services were reviewed and interviews with the staff revealed they were aware of the process for timely completion of laboratory orders. An interview was conducted on 4/6/17 at 2:10 pm via telephone with Nurse #2. Nurse #2 stated the expected laboratory process was that the laboratory vendor would draw or retrieve a specimen the day after it was ordered and placed in their system, unless the request was for urgent (stat). Nurse #2 stated the process as follows: order received; order placed in E-lab (electronic access to laboratory vendor); lab to be drawn is placed in the nurses ' station lab log book; laboratory staff come to the facility to draw the blood or receive the specimen; the lab result is placed in E-lab; and a reminder to check for lab result is placed in the medication administration record. Nurse #2 stated that all orders have a three piece carbon and the gold piece is reconciled each day to ascertain that the order was followed. Nurse #2 also stated that the vendor provided lab services and results on the weekend, and the staff retrieved the results from the vendor ' s website.

Based on record review, staff interviews and physician interviews, the facility failed to recognize and to assess for a change in condition when a resident experienced daily diarrhea, resulting in a delay of a [DIAGNOSES REDACTED].#1.) Findings include: Resident #1 was admitted on [DATE] for rehabilitation after a [MEDICAL CONDITION] surgery. The resident had the [DIAGNOSES REDACTED]. The resident had a care plan dated 1/25/17 for potential imbalance of nutrition and hydration. The admission minimum (MDS) data set [DATE] revealed the resident was cognitively intact and required extensive assistance of one staff member with activities of daily living. A review of the bowel movement log revealed Resident #1 started having diarrhea on 2/24/17 and had one or more loose bowel movements per day until 3/9/17, with the exception of 3/3/17 she received [MEDICATION NAME] and there was a formed stool. The bowel movements were loose and no other description was provided. 02/24/2017 8:28 PM BM large Loose 02/25/2017 11:22 AM BM medium Formed 02/25/2017 9:24 PM BM small Loose 02/25/2017 11:37 PM BM large Loose 02/26/2017 1:27 PM BM extra large Loose 02/27/2017 1:25 PM BM large Loose 02/27/2017 6:32 PM BM small Loose 02/28/2017 8:45 AM BM large Loose 02/28/2017 11:43 AM BM extra large Loose 03/01/2017 12:52 PM BM large Loose 03/01/2017 8:41 PM BM small Loose 03/02/2017 12:04 AM BM small Loose 03/02/2017 9:07 AM BM extra large Loose 03/02/2017 8:17 PM BM small Loose 03/02/2017 11:41 PM BM large Loose 03/03/2017 1:14 PM BM medium Formed 03/03/2017 9:36 PM BM small Loose 03/03/2017 11:23 PM BM large Loose 03/04/2017 9:01 PM BM small Loose 03/05/2017 9:35 PM BM large Loose 03/06/2017 12:39 PM BM extra large Loose 03/06/2017 6:03 PM BM large Loose 03/07/2017 11:16 AM BM medium Loose 03/07/2017 4:46 PM BM small Loose 03/08/2017 1:46 PM BM extra large Loose 03/08/2017 6:24 PM BM small Loose 03/08/2017 11:42 PM BM large Loose 03/09/2017 11:58 PM BM extra large Loose A progress note dated 2/27/17 revealed the Nurse Practitioner (NP) saw the resident for loose stools that had progressively become more frequent. The note indicated the staff was concerned for [MEDICAL CONDITION] infection. The NP noted Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] for constipation and ordered [MEDICAL CONDITION] stool culture and [MEDICATION NAME] 4 milligrams (mg) every 6 hours as needed for loose stools. A review of the nurse practitioner ' s order dated 2/27/17 revealed a stool culture for [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg every 6 hours as needed for diarrhea. A review of the nurses ' notes from 2/27/17 to 3/10/17 revealed the resident had no changes in condition documented, and there was no notation of increase in bowel movements or diarrhea. Nurses ' notes indicated the blood pressure and pulse were stable and within normal limits. A review of the Medication Administration Record [REDACTED]. Resident #1 received [MEDICATION NAME] on 2/27/17, 2/28/17 at 6:00 am, 3/3/17 at 10:00 am, and 3/5/17. No documentation of the results/response was present on the MAR. A review of the basic metabolic panel (BMP) laboratory result revealed Resident #1 ' s average baseline creatinine (kidney function) dated 3/1/17 was 1.6 (normal range 0.6 - 1.3). The resident had a weekly BMP to evaluate the kidney function, hydration, and electrolyte level. A review of the laboratory results of the resident ' s creatinine dated 3/7/17 revealed the creatinine result was 5.85 and the blood urea nitrogen (BUN) (shows hydration) result was 33 (normal range 3-25). A progress note dated 3/8/17 revealed the NP saw the resident for diarrhea. The NP re-ordered [MEDICAL CONDITION] stool culture and the resident was treated with [MEDICATION NAME] 4 mg every 6 hours as needed for loose stools. The resident had a blood pressure of 122/80, a pulse of 86, temperature of 98 F and was in no distress. The labs were reviewed and the creatinine was at baseline. The resident complained of dizziness and the NP planned orthostatic blood pressures. A review of the nurse practitioner ' s order dated 3/8/17 revealed a stool culture for [MEDICAL CONDITION], to assess orthostatic blood pressure for three days, and to discontinue the [MEDICATION NAME] 500 milligrams each day and the [MEDICATION NAME] 6 grams each day. A review of the physician's order [REDACTED]. A review of the physician's order [REDACTED]. A progress note dated 3/9/17 indicated the NP saw the resident for an abnormal lab result of creatinine 5.85 (normal range 0.6 - 1.3). The resident ' s blood pressure was 140/70 and pulse 80. The same progress note further revealed the assessment was acute kidney injury on [MEDICAL CONDITION] from dehydration. The resident was started on intravenous fluids at 125 cubic centimeters (cc) per hour. The nephrologist ordered a stat (urgent) renal ultrasound for today and repeat the basic metabolic panel (BMP) tomorrow. A review of the physician's order [REDACTED]. A review of Resident #1 ' s laboratory results for a stool culture of [MEDICAL CONDITION] collected on 3/9/17 revealed the stool was positive for [MEDICAL CONDITION] on 3/13/17. Laboratory results of the resident ' s creatinine (kidney function) dated 3/10/17 was 9.61 (normal range 0.6 - 1.3). The blood urea nitrogen (BUN) (shows hydration) result was 55 on 3/10/17 (normal range 3-25). A review of the physician's order [REDACTED].#1 to the emergency room for an evaluation of the elevated creatinine and BUN. The NP indicated in a progress note dated 3/10/17 she saw the resident for elevated white blood cell count (WBC). The resident ' s blood pressure was 106/60 and pulse 62. The assessment was worsening kidney function and elevated WBC. The lab result showed a creatinine of 9.61 and a BUN 55. The resident was had acute kidney injury due to diarrhea. The NP sent the resident to the emergency room for evaluation. Resident #1 was admitted to the hospital on [DATE] and the hospital history and physical was reviewed. The hospital course documented Resident #1 had [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] in the setting of a generalized debilitated state and moderate malnutrition. The resident was seen by her nephrologist and was treated with [MEDICATION NAME] (antibiotics) and IV fluids. The resident had a two-week history of diarrhea with weakness. The resident ' s creatinine increased to 9.7. The discharge summary revealed [DIAGNOSES REDACTED]. The resident received aggressive IV fluid resuscitation for acute dehydration. At the time of the hospital discharge on 3/22/17, the resident ' s creatinine returned to baseline at 1.6. On 4/3/17 at 4:50 pm an interview was conducted with the NP. The NP stated that on 2/27/17 she was informed by staff Resident #1 was having loose stools, but not every day. The NP stated that she asked the resident about her diarrhea and was informed the diarrhea was every day. The NP ordered the [MEDICAL CONDITION] stool culture on 2/27/17 for the resident ' s diarrhea. When the NP asked the staff for the results of the [MEDICAL CONDITION] test on 3/6/17, the NP was informed the results were pending. The NP stated she did not write any new orders to complete a stool for [MEDICAL CONDITION], but was waiting for the [MEDICAL CONDITION] results from 2/27/17. The NP stated she was not aware until 3/8/17 that the stool culture had not been done. The NP stated that she contacted the resident ' s nephrologist on 3/9/17 regarding the resident ' s elevated creatinine, and the nephrologist ordered a stat (immediate) ultra sound of the kidneys. The NP stated that the physician ordered on [DATE] for the resident to go to the ER. The NP thought that the resident was to go for an evaluation of the elevated creatinine of 5.85, but instead the resident went to the ER to have an IV placed. The NP stated that her expectation was for staff to follow orders as written. The NP further stated the increased creatinine lab result was related to acute injury to the kidney from dehydration secondary to diarrhea. The NP stated that another creatinine lab level was completed on 3/10/17 and it had increased to 9.6, and it had not improved after Resident #1 received intravenous fluids. The resident was sent to the emergency roiagnom on [DATE] and was referred to her nephrologist while she was hospitalized . On 4/4/17 at 8:40 am an interview was conducted with the Director of Nursing (DON). The DON stated that she expected staff to follow physician's order [REDACTED]. On 4/4/17 at 9:00 am an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated that the resident had 4 to 6 loose bowel movements on day shift for over a week leading up to the hospitalization . NA #1 explained she was not aware of a stool culture order for 2/27/17, but obtained the stool sample on 3/8/17 for the nurse. NA #1 stated she reported to the nurse that Resident #1 had multiple bowel movements. On 4/4/17 at 9:10 am an interview was conducted with Nurse #1. Nurse #1 stated she was out on leave when the first order for stool culture on 2/27/17 was written. Nurse #1 processed the second order for [MEDICAL CONDITION] stool culture on 3/8/17. Nurse #1 stated she was aware of the diarrhea from the 24-hour nursing shift report, but there was no diarrhea on her shift. On 4/4/17 at 10:30 am an additional interview was conducted with the DON. The DON stated a root cause analysis was conducted for the missed [MEDICAL CONDITION] lab order dated 2/27/17. She explained the nurse that missed the [MEDICAL CONDITION] lab had resigned and 2/27/17 was three days before the nurse ' s last day. The DON felt that the nurse was distracted and the incident was isolated. An additional interview was conducted on 4/6/17 at 2:02 pm via telephone with NA #1. NA #1 stated that the diarrhea was more than once a day and frequency was not documented because she did not have time to document and provide resident care. NA #1 stated that the diarrhea was liquid with mucous and foul smelling. She informed the nurse on duty at least once a shift over 10 days the resident had diarrhea. NA #1 stated that the resident was tired and commented that everything she eats goes right through her. The resident also had a decrease in appetite. NA #1 stated that she discussed the resident ' s diarrhea with the NP and a culture was ordered, and NA #1 collected that specimen. She cannot remember the date. An additional interview was conducted on 4/6/17 at 2:10 pm via telephone with Nurse #1. Nurse #1 stated that she only had Resident #1 for one shift and the resident did not have lose stools and she never gave [MEDICATION NAME]. She was aware that a stool culture was ordered 2/27/17, but was not aware that it had not been collected. An interview was conducted on 4/6/17 at 2:10 pm via telephone with Nurse #2. Nurse #2 stated that she had limited contact with Resident #1, but she was aware that the resident had an order to receive intravenous fluids for an elevated creatinine. Nurse #2 stated that the laboratory vendor would draw or retrieve a specimen the day after it was ordered and placed in their system, unless the request was for urgent (stat). Nurse #2 stated that the process for completing lab orders was that the vendor provided lab services and results on the weekend, and the staff retrieved the results from the vendor ' s website. An interview was conducted on 4/6/17 at 3:40 pm via telephone with Nurse #3. Nurse #3 stated that the resident did not have diarrhea on her night shift on 3/8/17, and she did not administer [MEDICATION NAME]. Nurse #3 stated she informed the NP by telephone of the resident ' s creatinine increase to 5.85. She explained the NP did not inquire about the results of the [MEDICAL CONDITION]. Nurse #3 stated giving [MEDICATION NAME] with [MEDICAL CONDITION] was contraindicated. She also stated that the nursing staff was moved around the facility, and she could not remember if Resident #1 had a decline because of the diarrhea. An interview was conducted on 4/6/17 at 3:40 pm via telephone with the resident ' s physician. The physician stated he remembered Resident #1 and had reviewed the records when the stool culture was missed as part of quality review. The physician explained he was informed by the facility that the order for [MEDICAL CONDITION] stool sample on 2/27/27 was missed. The physician stated he was informed by his NP that the resident had one loose stool a day. The resident did not present with a [MEDICAL CONDITION] infection because the facility staff informed the NP that Resident #1 had one bowel movement a day. The physician stated he will review the record to evaluate when the intravenous fluids (IV) were started in response to the creatinine increase of 5.85 on 3/8/19. The physician stated his understanding was that the resident needed IV access and received IV access on 3/8/17 and the fluids were started on that evening (3/8), not 3/9/17. On 4/7/17 at 8:30 am an interview was conducted again with the resident ' s physician. The physician stated that on 3/7/19 the weekly basic metabolic panel lab (BMP) was ordered. The BMP result was reported to him on 3/8/17 at 6:41 pm. The physician stated he asked staff for the resident ' s status: vital signs, mentation, and overall condition. The physician stated the resident remained at baseline according to staff. Intravenous fluids were ordered and the resident ' s nephrologist was notified. The physician stated he was paged at 7:53 pm on 3/8/17 because staff were unable to place an intravenous catheter. At 7:55 pm the physician responded to send the resident to the emergency room . The resident had an intravenous catheter placed at the emergency room at 9:06 pm. The resident returned to the facility and intravenous fluids were started at 10:29 pm at 125 milliliters per hour. The resident received a liter of fluid overnight. The physician stated the NP saw the resident on 3/9/17 in the morning and ordered a second liter of fluid. The physician stated he discussed the delay of [MEDICAL CONDITION] results with the facility DON. The physician was informed that the DON called the lab vendor and the [MEDICAL CONDITION] could take 3 to 5 days to complete. The physician stated that [MEDICATION NAME] could be given by nursing when there was no confirmation of [MEDICAL CONDITION], which was standard practice. The NP was informed that the resident had diarrhea once a day. On 4/7/17 at 11:40 am an interview was conducted via telephone with Nurse #4. Nurse #4 stated that she remembered Resident #1 and was on duty 3/3/17 for day shift. Resident #1 had two loose stools on day shift. The nursing assistant assisted the resident for one episode and Nurse #4 assisted for the second episode. Nurse #4 stated that the stool was brown, of loose consistency, with no odor or mucous, and of moderate amount. Nurse #4 administered [MEDICATION NAME] at 10:00 am, which was requested by the resident. The resident had no further stools on her shift. Nurse #4 stated that when she provided an as needed medication, she reviewed how often previous doses were given. Nurse #4 cannot remember the previous doses without reviewing the chart. Nurse #4 remembered the resident was drinking well and requested a snack on her shift. Nurse #4 received a 24-hour nursing report at start of shift and there were no reports of diarrhea. Nurse #4 stated she did not have a concern for dehydration because the resident was drinking fluids and there was no further diarrhea. Nurse #4 stated she would inform the physician if a resident had repeated need for an as needed medication or concerns regarding diarrhea.

Based on record review, staff interviews and physician interviews, the facility failed to assess 12 days of loose stool and failed to maintain hydration status which resulted in the resident ' s dehydration and acute on [MEDICAL CONDITION] requiring hospitalization for 1 of 3 residents (Resident #1). Findings included: Resident #1 was admitted on [DATE] for rehabilitation after a [MEDICAL CONDITION] surgery. The resident had the [DIAGNOSES REDACTED]. The resident had a care plan dated 1/25/17 for potential imbalance of nutrition and hydration. The admission minimum (MDS) data set [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of one staff member with activities of daily living. The resident was continent of bowel and occasionally incontinent of urine. A review of the bowel movement log revealed Resident #1 started having diarrhea on 2/24/17 and had one or more loose bowel movements per day until 3/9/17, with the exception of 3/3/17 she received [MEDICATION NAME] and there was a formed stool. The bowel movements were loose and no other description was provided. A progress note dated 2/27/17 revealed the Nurse Practitioner (NP) saw Resident #1 for loose stools that had progressively become more frequent. The note indicated the staff was concerned for [MEDICAL CONDITION] infection (infection of the gastrointestinal tract). The NP noted the resident was on [MEDICATION NAME] and [MEDICATION NAME] for constipation and ordered [MEDICAL CONDITION] stool culture and [MEDICATION NAME] 4 milligrams every 6 hours as needed for loose stools. A review of the nurse practitioner ' s order dated 2/27/17 revealed a stool culture for [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg every 6 hours as needed for diarrhea. A review of the Medication Administration Record [REDACTED]. A review of the laboratory results of the resident ' s creatinine dated 3/7/17 revealed the creatinine (kidney function) result was 5.85 (normal range 0.6 - 1.3) and the blood urea nitrogen (BUN) (shows hydration) result was 33 (normal range 3-25). The resident ' s baseline creatinine was 1.6 on March 1, 2017. A progress note dated 3/8/17 revealed the NP saw the resident for diarrhea. The NP re-ordered [MEDICAL CONDITION] stool culture and the resident was treated with [MEDICATION NAME] 4 mg every 6 hours as needed for loose stools. The resident complained of dizziness and the NP planned orthostatic blood pressures. A review of the nurse practitioner ' s order dated 3/8/17 revealed a stool culture for [MEDICAL CONDITION], to assess orthostatic blood pressure for three days, and to discontinue the [MEDICATION NAME] 500 milligrams each day and the [MEDICATION NAME] 6 grams each day. A progress note dated 3/9/17 indicated the NP saw the resident for an abnormal lab result of creatinine 5.85 (normal range 0.6 - 1.3). The resident ' s blood pressure was 140/70 and pulse 80. The same progress note further revealed the assessment showed an acute kidney injury on [MEDICAL CONDITION] from dehydration. The resident was started on intravenous fluids at 125 cubic centimeters (cc) per hour. The nephrologist ordered a stat (urgent) renal ultrasound for today and repeat the basic metabolic panel (BMP) tomorrow. A review of the physician's order [REDACTED]. A review of Resident #1 ' s laboratory results for stool culture of [MEDICAL CONDITION] dated 3/9/17 revealed the stool was positive for [MEDICAL CONDITION] on 3/13/17. Laboratory results of the resident ' s creatinine (kidney function) dated 3/10/17 was 9.61 (normal range 0.6 - 1.3). The blood urea nitrogen (BUN) (shows hydration) result was 55 on 3/10/17 (normal range 3-25). The resident ' s baseline creatinine was 1.6. A review of the physician's order [REDACTED].#1 to the emergency room for an evaluation of dehydration (as a result of elevated creatinine and blood urea nitrogen lab tests). Resident #1 was admitted to the hospital on [DATE] and the hospital history and physical was reviewed. The hospital course documented Resident #1 had [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] in the setting of a generalized debilitated state and moderate malnutrition. The resident was seen by her nephrologist and was treated with [MEDICATION NAME] (antibiotic) and IV fluids. The resident had a two-week history of diarrhea with weakness. The discharge summary revealed [DIAGNOSES REDACTED]. The resident received aggressive IV fluid resuscitation for acute dehydration. At the time of the hospital discharge on 3/22/17, the resident ' s creatinine returned to baseline. Resident #1 was not interviewed because she had been discharged at the time of the site visit. On 4/3/17 at 4:50 pm an interview was conducted with the NP. The NP stated that on 2/27/17 she was informed by staff Resident #1 was having loose stools, but not every day. The NP stated that she asked the resident about her diarrhea and was informed the diarrhea was every day. The NP ordered the [MEDICAL CONDITION] stool culture on 2/27/17 for the resident ' s diarrhea. When the NP asked the staff for the results of the [MEDICAL CONDITION] test on 3/6/17, the NP was informed the results were pending. The NP stated she did not write any orders, but was waiting for the [MEDICAL CONDITION] results from 2/27/17. The NP stated she was not aware until 3/8/17 that the stool culture had not been done. The NP stated that her expectation was for staff to follow orders as written. The NP further stated the increased creatinine lab result was related to acute injury to the kidney from dehydration secondary to diarrhea. NP stated the delay in treatment of [REDACTED]. The NP stated that another creatinine lab level was completed on 3/10/17 and it had increased to 9.6, and it had not improved after Resident #1 received intravenous fluids. The resident was sent to the emergency roiagnom on [DATE] and was referred to her nephrologist while she was hospitalized . On 4/4/17 at 9:00 am an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated that the resident had 4 to 6 loose bowel movements on day shift for over a week leading up to the hospitalization . NA #1 stated she reported to the nurse that Resident #1 had multiple bowel movements. The resident was assisted to the bathroom to urinate. NA #1 stated she could not remember if the amount of urine had decreased. NA #1 stated that all residents have fluids of their choice at the bedside. On 4/4/17 at 9:10 am an interview was conducted with Nurse #1. Nurse #1 stated she was out on leave when the first order for stool culture on 2/27/17 was written. Nurse #1 stated she was aware of the diarrhea from the 24-hour nursing shift report. Resident #1 had fluids at the bedside. An additional interview was conducted on 4/6/17 at 2:02 pm via telephone with NA #1. NA #1 stated that the diarrhea was more than once a day and frequency was not documented because she did not have time to document and provide resident care. NA #1 stated that the diarrhea was liquid with mucous and foul smelling. She informed the nurse on duty at least once a shift over 10 days the resident had diarrhea. NA #1 stated that the resident was tired and commented that everything she eats goes right through her. The resident also had a decrease in appetite. NA #1 stated that she discussed the resident ' s diarrhea with the NP and a culture was ordered, and NA #1 collected that specimen. She could not remember the date. An additional interview was conducted on 4/6/17 at 2:10 pm via telephone with Nurse #1. Nurse #1 stated that she only had Resident #1 for one shift and never gave [MEDICATION NAME] for diarrhea on her shift. She was aware that a stool culture was ordered 2/27/17, but was not aware that it had not been collected. An interview was conducted on 4/6/17 at 3:40 pm via telephone with the resident ' s physician. The physician stated he remembered Resident #1 and had reviewed the records when the stool culture was missed as part of quality review. The physician explained he was informed by the facility that the order for [MEDICAL CONDITION] stool sample on 2/27/27 was missed. The physician stated he was informed by his NP that the resident had one loose stool a day. The physician stated he would review the record to evaluate when the intravenous fluids (IV) were started in response to diarrhea caused dehydration creatinine increase of 5.85 on 3/8/19. The physician stated his understanding was that the resident needed IV access and received IV access on 3/8/17 and the fluids were started on that evening (3/8), not 3/9/17. On 4/7/17 at 8:30 am an interview was conducted again with the resident ' s physician. The physician stated that on 3/7/19 the weekly basic metabolic panel lab (BMP) was ordered. The BMP result was reported to him on 3/8/17 at 6:41 pm. The physician stated he asked staff for the resident ' s status: vital signs, mentation, and overall condition. The physician stated the resident remained at baseline according to staff. Intravenous fluids were ordered and the resident ' s nephrologist was notified. The physician stated he was paged at 7:53 pm on 3/8/17 because staff were unable to place an intravenous catheter. At 7:55 pm the physician responded to send the resident to the emergency room . The resident had an intravenous catheter placed at the emergency room at 9:06 pm. The resident returned to the facility and intravenous fluids were started at 10:29 pm at 125 milliliters per hour. The resident received a liter of fluid overnight. The physician stated the NP saw the resident on 3/9/17 in the morning and ordered a second liter of fluid. The physician stated he discussed the delay of [MEDICAL CONDITION] results with the facility DON and the cause of dehydration was from the diarrhea. On 4/7/17 at 11:40 am an interview was conducted via telephone with Nurse #4. Nurse #4 stated that she remembered Resident #1 and was on duty 3/3/17 for day shift. Resident #1 had two loose stools on day shift. The nursing assistant assisted the resident for one episode and Nurse #4 assisted for the second episode. Nurse #4 stated that the stool was brown, of loose consistency, with no odor or mucous, and of moderate amount. Nurse #4 administered [MEDICATION NAME] at 10:00 am, which was requested by the resident. The resident had no further stools on her shift. Nurse #4 stated that when she provided an as needed medication, she reviewed how often previous doses were given. Nurse #4 cannot remember the previous doses without reviewing the chart. Nurse #4 stated she would inform the physician if a resident had repeated need for an as needed medication or concerns regarding diarrhea.

Based on record review, resident interview, family interview, nurse practitioner interview and staff interviews the facility failed to implement interventions for a resident with cognitive impairment (Resident #1), to prevent an elopement on 2/26/17 out a facility bedroom window for one of one sampled residents with exit seeking behavior Resident #1 exited the window, walked 111 feet, going up a steep incline and fell down the incline. Resident #1 sustained a fracture of the left forearm. Immediate jeopardy began on 2/26/17 at 10:21 AM when facility staff failed to monitor Resident #1's whereabouts after exit seeking behavior had been demonstrated. Immediate jeopardy was lifted on 3/3/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedures for identifying residents with elopement behaviors and providing immediate interventions. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission Data Collection Mood and Behaviors dated 9/14/16 indicated Resident #1 was withdrawn and sometimes refused medications. Admission Nurse's Notes indicated the resident was alert and oriented. A cerebrovascular accident resulted in expressive aphasia. The resident ambulated with a cane and independently repositioned herself in bed without difficulty. An Elopement Risk Assessment was not available for review in the medical record after admission. Review of the initial care plan for a problem of mood/behavior (no initial date, but an update of 12/15/16) included impaired or inappropriate behaviors, ineffective coping skills, violence to others, wandering and exit seeking behavior. The approaches for exit seeking behavior included to anticipate and address resident needs, psychiatry consult as needed, and safety checks as indicated. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had short and long term memory problems, no behaviors were exhibited or assessed and she required limited assistance of one staff for activities of daily living. Review of a nurse's note dated 11/5/16 on the 3-11 pm shift revealed the resident was walking with a cane, was concerned about seeing her sister. She was outside and the aides were assisting her back in the facility. A wanderguard in place. Review of a telephone order dated 11/5/16 at 4:30 PM indicated a wanderguard was to be placed on the resident. A communication form (SBAR) dated 11/5/16 at 6:15 PM, used to notify the physician, indicated the resident was observed outside without staff. The intervention documented as used was wanderguard. An Elopement Risk Assessment was not available for review in the medical record after this incident. Review of a nurse's note dated 11/27/16 indicated Resident #1 was agitated around 3:00 PM and tried to go out the front door. The note documented wants to find her sister. The resident was redirected and had increased agitation. Staff redirected Resident #1 to her room. Around 3:00PM the C N A (aide) hollers for nurse. And res (resident) was found to be climbing out of window. Staff redirect and res states she wants to go for a walk outside. Staff take res outside and walk with her 1 on 1 staff with res this shift. Review of the communication form dated 11/27/16 to the physician indicated the resident attempted to go out bedroom window. Interventions initiated included 1 on 1 for one shift, then every 30 minute checks. The unit manager and maintenance supervisor were notified. An Elopement Risk Assessment was not available for review in the medical record after this incident. Review of the updated care plan of 12/15/16 included impaired or inappropriate behaviors, ineffective coping skills, violence to others, wandering and exit seeking behavior. The approaches for exit seeking behavior included to anticipate and address resident needs, psychiatry consult as needed, and safety checks as indicated. Review of the Nurse Practitioner's initial visit dated 1/16/17 indicated her group of physicians was assuming care of the resident from another physician's group. The Assessment and Plan included in part 1. Vascular Dementia-pt (patient) is at increased risk for eloping. Continue monitoring and ensure wanderguard is in place. Defer to MH (mental health) . A nurse's note dated 1/17/17 at 4:20 PM indicated Resident#1 was reviewed by the care plan team. The resident continued to have exit seeking behaviors and was easily redirected by staff. A nurse's note dated 1/19/17 at 2:00 PM documented Alarm sounding upon entering hallway. Staff inform(ed) this nurse that resident had walked out the door. Staff members outside trying to redirect resident without success. Staff was able to redirect resident and escort her back into facility. Resident was upset, wanted to talk to her friend. Allowed resident to talk to friend at another facility via telephone. After conversing with friend, resident calm down with no further exit seeking noted. NP (nurse practitioner) in facility and informed. A nurse's note dated 1/19/17 at 6:00 PM RP (Responsible Party) in facility, informed RP of resident elopement attempt. RP inquired again about placement to unit that's secured. Informed RP that SW was working on placing resident to a memory care facility. The care plan had updates of 1/19/17 regarding the resident attempts to exit the building. Approaches included wanderguard alarm and to check placement every shift and function. There were no new interventions. The care plan had a problem of Exit seeking behavior with the one approach to Anticipate and address resident needs. The pre-printed approaches for this problem were not identified as an approach, which included Elopement risk assessment, increase 1:1 monitoring as needed, personal wander prevention device check for placement each shift and function daily, remove the resident from the area and Establish behavior management program Specify___(blank). Review of the Quarterly Minimum (MDS) data set [DATE] indicated Resident #1 had long and short term memory impairment, with a Brief Interview for Mental Status (BIMS) of 3. She was required supervision of one person for activities of daily living. The MDS assessed Resident #1 with verbal behaviors towards others and no wandering behavior or rejection of care. Review of the care plan dated 2/9/17 revealed no changes in the problems or approaches for falls or elopement risk. Review of the telephone orders revealed mental health orders were made on 1/7/17, 1/16/17 and again on 2/8/17. Resident #1 was seen by mental health on 2/21/17 and on 2/27/17. Review of their progress notes revealed Resident #1 was seen by a psychologist for mental health assessment/diagnostic interview. Visits were requested by staff due to depression, agitation, wandering and use of psychiatric medications. The safety evaluation included The patient is at risk for elopement. There were no changes made to medications, and no plan provided to the facility on behavior management for Resident #1. Review of a nurse's note dated 2/26/17 at 11:30 AM revealed Resident #1 was found outside on 2/26/17. The documentation included Prior to being found, was at church services and left services headed to front redirected to 400 hall. Aide observed resident agitated offered to walk with resident, she refused. Wanted to find pocket (sic) was going on about missing money/and pocketbook. Never seen resident with pocketbook. Administered Ativan at 10:15 (AM) of .5mg x1 po (half a milligram one time orally). Resident's family reported resident outside. She immediately ran outside. Resident on ground in behind oxygen tank outside. Asked what happen Speech unclear pointing to top of hill 'walked up and I fell down.' Unable to measure pain but screaming and cursing when moving left arm and left leg. Notified all transferred via ambulance. Observed window open and screen on ground of resident room. Review of an emergency room report dated 2/26/17 indicated she had fall with a forearm fracture of the radius. A cast was applied to the arm and she was discharged back to the facility. An Elopement Risk Evaluation was completed on 2/28/17 with a determination Resident #1 was at risk for elopement. Review of the Social Worker's notes dated 2/27/17 indicated she had called several facilities looking for a memory care bed. The Social Worker note dated 2/28/17 indicated placement was found and the resident was transferred to another facility at 1:30 PM on 2/28/17. The family had previously requested placement in a secure facility. Interview with aide #1, on 3/1/17 at 4:15 PM revealed Resident #1 was usually calm, and she remembered the resident had a wander guard bracelet. Aide #1 explained the resident usually was in her room, but could go about the facility. Aide #1 added the resident would get agitated, and staff would try to calm her down. Aide #1 knew the resident had a wander guard by the aide care plan. When asked how she would monitor those residents with exit seeking behavior, aide #1 explained she would check on them frequently and their whereabouts. Interview with Administrator 3/1/17 at 5:00 PM revealed the book with pictures of residents that were at risk for elopement was not correct. Interview with the Director of Nursing (DON) on 3/1/17 at 5:05 PM revealed an action plan had been started on 2/26/17 due to Resident #1 getting out the window. Their plan had not been completed at this time. The inservices were being presented with the last one on 3/2/17 during staff meeting. A drill for missing resident had been conducted by maintenance. Interview with Nurse #3 on 3/2/17 at 10:35 AM revealed the Elopement Risk Assessment would be completed on a quarterly basis by the nurses on the floor. She did the assessment after the incident on 2/26/17 for Resident #1. Interview with aide #2 on 3/2/17 at 11:29 AM revealed she worked on the 7-3 shift on 2/26/17 and was assigned to Resident #1. She explained the resident could dress herself, she walked with a cane and went to the dining room for meals. On 2/26/17, she was assisted to the church activity by aide #2 at 10:00 AM. The resident did not stay in the activity and was coming down the hall. She was stopped by nurse #2. Aide #2 assisted the resident to her room and informed nurse #3 that Resident #1 was going to the front of the building. The aide further explained she stayed with Resident #1 for a while and calmed the resident down. Resident #1 was looking for her pocket book and aide #2 assisted in looking for the item. After a few minutes, aide #2 left Resident #1 and went down the hall to document on the hall computer. She explained it may have been 10 minutes later, a family member was telling a nurse a resident was walking outside the building and was unsteady. Aide #2 went outside and heard yelling. Nurses #2 and #3 went outside with her. They found Resident #1 outside on the ground and was yelling. Resident #1 was found behind the oxygen storage tank that was fenced in, lying on her left side face down. Resident #1 was asked by aide #2 what was she doing and she replied Looking for my pocketbook. Aide #2 further explained the resident then said she went up the hill to see up there. The resident was assessed for injuries by the nurses. Resident #1 attempted to stand up, and would grab her left arm. EMS arrived and assessed the resident. They (EMS) said she could not move her fingers and her wrist was swelling. Interview with nurse #3 on 3/2/17 at 12:00 PM revealed a family member told them a resident was outside. She and aide #2 went out to the back of the facility and found Resident #1 lying on the ground around 10:23 AM. Nurse #4 came outside and called 911 from her phone. The resident was not moved and complained of arm pain when she sat up independently. The EMT (Emergency Medical Technician) arrived and checked the resident. Nurse #3 gave the time frames of when she saw the resident as: Resident #1 was at church at 10:00 AM, she was at her room and received an Ativan at 10:15 AM. Continued interview on 3/2/17 at 12:05 PM revealed Nurse #3 explained she saw the window screen pushed out and the window was open. A pad was across the window track ledge. Resident #1 informed her she had gone out the window. Interview with Resident #7 on 3/2/17 at 1:45 PM revealed he was looking out his window and saw a woman walking back and forth on the driveway pavement. He then saw her walk cross ways up the hill above the tank (oxygen). The woman then fell and rolled down the hill. His family member left to let the nurses know someone may be hurt outside. He did not know what time this occurred, he stated It was before lunch. Interview with Resident #7's family member on 3/2/17 at 1:47 PM revealed she saw the woman outside and walking unsteady. She saw the woman try to climb the hill and fall down. She was only able to see her feet at that point because she was behind the fenced in tank. She did not know the time she was outside, it might have been 10:30 going on 11:00 AM. Interview with the DON on 3/2/17 at 2:00 PM revealed she would expect the nurses to do an elopement risk assessment if a resident was outside the facility and they had not had eyes on them. When asked if a risk assessment would have been done for the event on 11/5/16 and 11/27/16 she stated Yes. No explanation was provided as to why the assessment was not available in the medical record. The DON explained interventions should be implemented after each incident. Interview with the maintenance assistant staff on 3/2/17 at 3:00 PM revealed he had not received notification Resident #1 had attempted to exit her bedroom window on 11/27/16. Interview on 3/3/17 at 10:55 AM with the nurse practitioner (NP) revealed the physician group she works with began care for Resident #1 in January 2017. She was familiar with Resident #1, and had been notified regarding the fall on 2/26/17. She had not been notified of any other behavior issues, or exit seeking behavior prior to 2/26/17. The physician on-call was notified at the time of the incident and she saw the resident on 2/27/17. At the time of that visit, she ordered more x-rays. A visit was made by her on 1/16/17 with a note indicating the resident had vascular dementia and was at increased risk for eloping. Staff were to continue monitoring and ensure wander guard was in place. Her plan was to Defer to MH. The resident was referred to mental health. The NP explained the resident stayed/associated with the staff more so than with other residents. The staff usually were able to monitor her due to their close association with the resident. The area behind the facility from the resident's window, across the parking lot, up the hill behind the oxygen storage tank was measured on 3/3/16 at 3:00 PM by a therapy staff member using their rolling distance calculator and measured 111 feet. The dimensions of the opened window was measured using a tape measure on 3/3/17 at 3:10 PM. The window measured 41 inches in width and 44 inches in height. The window ledge was at waist height or about 36 inches from the ground. On 3/2/17 the Administrator was notified of Immediate Jeopardy at 5:50 PM. The Administrator provided the following credible allegation of compliance on 3/3/17 at 6:00 PM: To remove immediacy, THC of Kannapolis has initiated and/or completed the following: On 2/26/17 at 10:05am, Resident #1 was observed leaving church service and walking towards the front door and was then redirected by the certified nursing assistant to her room for distraction. On 2/26/17 at 10:10am, the licensed nurse observed the certified nursing assistant with Resident #1 in her room offering to take resident outside for a walk in an attempt to reduce her agitation however, resident refused. And at 10:15am, the licensed nurse administered Ativan 0.5mg orally x 1 dose for agitation with intentions of reassessing effectiveness. On 2/26/17 at 10:21 am, Resident #1 was observed walking outside the rear parking lot by another resident's family member who then called out to alert the licensed nurse. The licensed nurses immediately ran outside where they found her on the grassy surface just beyond the parking area. The licensed nurse physically assessed Resident #1 and due to resident's complaint of ankle pain, she did not move resident and another licensed nurse received an order and called EMS at approximately 10:45am for transfer to hospital for further evaluation. Licensed nurses remained with Resident #1 until EMS arrived and transported her to the hospital at approximately 11:00am. Upon Resident #1's return to the facility on [DATE] at 5:10pm, Resident #1's window was properly secured by the Maintenance Director to allow only a 4 inch opening and continuous 1:1 supervision was immediately provided by certified nursing assistants until her discharge on 3/1/17 at approximately 1:15pm as mutually agreed by the facility and residents family. On 2/27/17, the Interdisciplinary Team (IDT), consisting of the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, MDS licensed nurses, Social Services, Activities Director, Admissions Director, Human Resources, Dietary Manager and Environmental Services Director, met to review and revise Resident #1's plan of care and additional interventions were initiated to maintain safety, to include 1.) updated Elopement Risk Assessment completed , 2.) residents room moved closer to nurses station with bed away from secured window, 3.) non-skid footwear applied and 3.) Social Services initiated transfer to a facility with a secured unit. On 2/26/17, the Maintenance Director visually and manually inspected facility exit doors and 17 wander guards utilizing the wander guard monitoring system to ensure proper placement and functioning. On 2/26/17- 2/27/17, the Maintenance Director manually secured all facility windows that open to only allow a 4 inch opening to ensure resident safety. On 2/28/17, licensed nurses completed an Elopement Risk Assessment of a census of 85 residents to identify residents currently at risk for eloping and validated appropriate interventions are in place. On 2/28/17, the IDT completed a quality monitoring of residents footwear by visual inspection to validate safe footwear was in place i.e.; wanderguards, redirection, psychological services, 1:1 supervision and rooms near nurse's station for closer visualization and monitoring. On 3/2/17, the IDT conducted a Quality Assurance Performance Improvement (QAPI) Meeting to review, investigate and initiate a Root Cause Analysis (RCA). Root Cause Analysis determined 1.) windows were not properly secured to prevent elopement and 2.) residents exhibiting exit-seeking behaviors were not properly reassessed and reviewed for additional safety interventions as indicated to prevent elopement and maintain resident safety. On 3/2/17, MDS and social services reviewed and/or revised safety care plans for 11 identified residents at risk for elopement to ensure the plan reflected appropriate interventions to maintain resident safety. Identified changes were documented in the medical record and updated on the Treatment Administration Record (TAR), Care Plan and Kardex. On 3/2/17, the DCS reviewed residents currently receiving psychological services and on 3/3/17 psychological evaluation orders were received by the physician to ensure residents at risk for elopement are being evaluated for the need of additional services to maintain the well-being and safety of residents. On 3/2/17, the Licensed Nurse/Activities Coordinator/Human Resources Coordinator and Medical Records completed an audit of 87 residents' physician orders [REDACTED].) physician orders [REDACTED].) physicians' orders for wanderguards were in place and transcribed onto the Treatment Administration Record (TAR) with Q (every) shift monitoring by licensed nurses for proper placement and functioning. On 3/2/17, Elopement Books were verified by the DCS to validate that current assessments, face sheets, demographics and photographs were available for quick reference. On 3/2/17, the RN supervisor completed an Elopement drill with all department staff in the facility including licensed nurses, certified nursing assistants, dietary staff, maintenance staff, activities staff, laundry staff, MDS and department heads on 2nd and 3rd shift and again on 1st first shift on 3/3/17 to ensure facility staff were educated on the elopement procedure in the event of a resident elopement. On 2/27/17, the DCS reeducated the IDT including certified nursing assistants on the Elopement Guideline, Missing Resident Search, identifying and responding to residents with exit-seeking behaviors and interventions for residents at risk for elopement which may include but, is not limited to 1:1 supervision, providing activities, back rub or exercise, music, snacks, repositioning, medication review and relaxation techniques to include utilizing the Interact Stop and Watch tool to communicate changes in residents behaviors to the nurse supervisor for further assessment. Residents at risk for elopement will be supervised by licensed nurses and certified nursing assistants Q 15 minutes and documented on the Resident Safety Check form to monitor and supervise residents for exit seeking behaviors and to identify and implement appropriate interventions to maintain safety. All other present department staff including certified nursing assistants were educated by 3/3/17. Employees will not be permitted to work until education requirement is met. Newly hired staff will be educated upon hire. On 2/27/17, the DCS and RN Supervisor began reeducation to licensed nurses on completing Elopement Risk Assessments, implementation and validation of appropriate interventions to prevent elopement i.e; wanderguards, redirection, psychological services, 1:1 supervision and rooms near nurses station for closer visualization and monitoring., obtaining and transcribing timely psychological evaluations orders, wanderguard placement with Q shift monitoring orders and updating the residents plan of care to maintain safety. Newly hired licensed nurses will not be permitted to work until education requirement is met. In addition to shift-to-shift visual inspections of wanderguard for proper placement and functioning by licensed nurses, the Maintenance Director or trained designee will also inspect that doors remain properly secured and windows remain properly secured allowing only a 4 inch for residents' safety. The validation of the credible allegation was completed on 3/3/17 at 7:30 PM by the following: A review of the audits of all residents for the need of a wander guard, review of the list of residents with wanderguards was reviewed for completion of the elopement risk assessment, orders for wander guards and the shift checks by nursing on the MARs, and care plan updates. Review of the inservice information and staff signature sheets and interviews were conducted with staff from all three shifts on the information. The elopement notebook was reviewed for current residents on the wanderguard list. Random windows were checked on each hall for the placement of the screw to allow a 4 inch gap. After these reviews and interviews were conducted, the facility had implemented their credible allegation of compliance.

Based on record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place. This was for one recited deficiency that was cited on 6/12/15, 5/19/16 on recertification surveys and subsequently recited in February 2017 on a complaint survey. The deficiency was in the area of supervision to prevent accidents (F323). The continued failure of the facility during three federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. Resident #1 sustained a fracture of her left forearm (radial). Immediate jeopardy began on 2/26/17 at 10:21 AM when facility staff failed to monitor Resident #1's whereabouts after exit seeking behavior had been demonstrated. Immediate jeopardy was lifted on 3/3/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedures for identifying residents with elopement behaviors and providing immediate interventions. The findings included: This tag is crossed referenced to F:323: Based on record review, resident interview, family interview, nurse practitioner interview and staff interviews the facility failed to implement interventions for resident #1, to prevent an elopement on 2/26/17 out a facility bedroom window for one of one sampled residents with exit seeking behavior. Resident #1 had attempted an elopement on 11/25/16 out the same window. Resident #1 exited the window, walked 111 feet, going up a steep incline and fell down the incline. Resident #1 sustained a [MEDICAL CONDITION] forearm. During the recertification of 5/19/16: Based on observations, record review and staff interviews the facility failed to supervise 1 of 3 residents assessed as an unsafe smoker. During the recertification of 6/12/15: Based on record review, resident interview and staff interview the facility failed to manage inappropriate behaviors and implement effective interventions for 1 of 1 sampled residents (Resident #203) who exposed himself to a resident (Resident #59) and inappropriately touched residents Interview with the Administrator on 3/2/17 at 2:05 pm revealed the facility had a QA and A program that met on a regular basis. The accident/incidents were reviewed Monday through Friday in their morning meeting. The facility had monitored accidents and incidents but did not have a QA plan in place for resident elopements. On 3/2/17 the Administrator was notified of Immediate Jeopardy at 5:50 PM. The Administrator provided the following credible allegation of compliance on 3/3/17 at 6:00 PM: On 2/26/17 at 10:21 am, Resident #1 was observed walking outside the rear parking lot by another resident's family member who then called out to alert the licensed nurse. The licensed nurses immediately ran outside where they found her on the grassy surface just beyond the parking area. The licensed nurse physically assessed Resident #1 and due to resident's complaint of ankle pain, she did not move resident and another licensed nurse received an order and called EMS at approximately 10:45am for transfer to hospital for further evaluation. Licensed nurses remained with Resident #1 until EMS arrived and transported her to the hospital at approximately 11:00am. Upon Resident #1's return to facility on 2/26/17 at 5:10pm, Resident #1's window was properly secured by the Maintenance Director to allow only a 4 inch opening and continuous 1:1 supervision was immediately provided by certified nursing assistants until her discharge on 3/1/17 at approximately 1:15pm as mutually agreed by the facility and residents family. On 2/27/17, the Interdisciplinary Team (IDT), consisting of the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, MDS licensed nurses, Social Services, Activities Director, Admissions Director, Human Resources, Dietary Manager and Environmental Services Director, met to review and revise Resident #1's plan of care and additional interventions were initiated to maintain safety, to include 1.) updated Elopement Risk Assessment completed , 2.) residents room moved closer to nurses station with bed away from secured window, 3.) non-skid footwear applied and 3.) Social Services initiated transfer to a facility with a secured unit. The Regional Director of Clinical Services reeducated the IDT on 3/3/17 on Federal Regulation F 520 and Consulates QAPI Committee Policy regarding the expectations regarding maintaining an ongoing Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee consists of the Executive Director, Director of Clinical Services, Medical Director and at least 3 other members and meets at least monthly (Medical Director at least quarterly). Education also included the processes and procedures of implementing, reviewing and revising ongoing action plans for areas of deficiency that have been identified to attain and maintain substantial regulatory compliance and provide the highest level of care to residents. Newly hired IDT employees will be educated upon hire. The Regional Director of Clinical Services or the Regional Vice President of Operations will attend QAPI meetings at a minimum of quarterly to assure compliance with Federal Regulation F 520 to sustain and maintain compliance with Federal Regulation F 323-Resident Safety to include ongoing monitoring and revisions to the plan as necessary. The validation of the credible allegation was completed on 3/3/17 at 7:30 PM by the following: Review of the inservice information and staff signature sheets and interviews were conducted with Administrative staff on the information. Review of the audits for elopement assessments, and the QA minutes of 3/2/17 were completed.

Based on staff interview and medical record review, the facility failed to assess and recognize pain for 1 of 4 sampled residents reviewed for pain. (Resident # 4). The findings are: Resident #4 was admitted to the facility on [DATE] at 4:00 PM with [DIAGNOSES REDACTED]. The Admission Data Collection Form dated 07/29/16 assessed the resident as being alert and oriented to person, place and time and revealed the resident was cognitively intact. Record review revealed resident #4 was discharged from the facility on 07/30/16 at approximately 7:00 AM. Admission/Readmission Data Collection Nurse's Notes (not dated but attached to the Admission Documents dated 07/29/16), revealed Resident #4 had been prescribed scheduled and as needed (PRN) medications. The medications were: [MEDICATION NAME] 20 mg oral tablet, extended release - 3 tablets oral every 12 hours and [MEDICATION NAME] 20 mg oral tablet - 1 tablet oral every 4 hours PRN Pain, Moderate (4-7). The medications were ordered on [DATE] and were to be started on 07/29/16. Nurse's Notes written on 07/29/16 at time of resident's admission to the facility indicated the medications had been ordered from the pharmacy. However, no pain assessment had been completed by the facility upon admission of the resident. The Pain Assessment document had been included with the resident's admission packet, but had not been completed (was blank). A pain medication monitoring flow sheet had been completed on 07/30/16. The flow sheet indicated the resident had been experiencing aching pain all over and had reported the pain as being a level #7 on a pain scale of 1 to 10, with #10 being the worst pain. Resident #4 had received PRN [MEDICATION NAME] HCL 20 mg just prior to his discharge and departure from the facility on 07/30/16 at 6:10 AM. An interview conducted with nurse #5 on 03/03/17 revealed she was not sure (and could not recall) why a pain assessment had not been completed for the resident when he was admitted . Nurse #5 stated at the time of the resident's admission, there was a lot going on. She stated resident #4's medications had to be verified, written up, and had to be faxed to the pharmacy.

Based on observation, record review, staff interview and physician interview the facility failed to monitor and identify one of one resident (Resident #146) who had significant weight loss of 14% in a quarter. The findings included: Resident #146 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent minimum data set (MDS) assessment dated [DATE] indicated Resident #146 required supervision to include encouragement/cueing and set up only for dining. The MDS further indicated Resident #146 required extensive assistance to complete activities of daily living. Section K of the MDS assessment revealed Resident #146 weight was 133lbs. Resident #146 was cognitively impaired as evidenced by a brief interview for mental status (BIMs) score of 10. Review of Resident #146 care plan revealed a goal that stated Resident #146 would receive appropriate staff support with bed mobility, transfers, and eating. The approaches included; allow resident time to eat, no straws, clear cup with 2 handles at meals, encourage resident to eat, keep needed items in easy reach at right side, monitor and report decline in abilities, open and set up items and resident required supervision of 1 staff person for eating at times. Review of Resident #146 physician progress notes [REDACTED].#146 had recent history of [MEDICAL CONDITIONS] with dysphagia and s/p percutaneous endoscopic gastrostomy (PEG tube is passed into a the stomach or abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) placement. Patient is eating well and PEG had been unused. The assessment indicated a [DIAGNOSES REDACTED]. Review of Resident #146 ' s physician progress notes [REDACTED].#146 Labs showed low [MEDICATION NAME] of 2.7. The assessment stated malnutrition with a plan to add prostat 30cc 3 times a daily (tid). Review of physician order [REDACTED].#146 to receive puree foods and thin liquids with no straws. Review of Resident #146 Kardex (nursing assistant care guide) updated 2/23/16 revealed Resident #146 had a regular diet with a frozen treat with meals. The care guide also indicated the resident was dependent on staff for feeding. Review of weight taken 3/16 (no day of the week provided) indicated Resident #146 weight was 133lbs. Review of Resident #146 consultation report from the [MEDICATION NAME] dated 3/7/16 revealed a [DIAGNOSES REDACTED]. The findings included PEG tube removed in office. physician progress notes [REDACTED].#146 had a history of [REDACTED]. The note continued with Resident #146 was sent to GI and her PEG was removed without problems. The assessment stated dysphagia resolved with a plan to monitor intake. Review of Resident #146 ' s meals and fluids detailed entry report for the month of March 2016 revealed documented consumption for 20 of 93 meals with consumption at or below 50% documented for 3 meals and consumption between 50-75% for five meals. This report only contained documentation that a supplement was offered and accepted one of the eight meals where intake was at or below 75%. Review of Resident #146 Occupational Therapy (OT) treatment encounter note dated 4/11/16 revealed interventions that included establishing and maintaining safe posture during feeding and task modification to improve performance and safety in feeding. The note stated, Patient seen at breakfast, in bed with head of bed partially elevated, food dropped on chest . The OT treatment encounter note was signed by OT#1. Review of Resident #146 OT treatment encounter note dated 4/12/16 revealed skilled interventions that included; positioning techniques to facilitate safe swallowing skills, facilitate upright posture and proper body alignment to increase socialization and to enhance participation in ADL tasks. The note continued with Resident #146 was educated on proper positioning for posture, self feeding and pain management with little to no carryover. Resident #146 required repositioning frequently throughout the day. The OT treatment encounter note was signed by OT#1. Review of physician progress notes [REDACTED].#146 was seen for a monthly visit. Past 30 days no acute events noted. The assessment indicated resident #146 [MEDICAL CONDITIONS] was stable with a plan to monitor her weight. Nutritional Review dated 4/28/16 indicated Resident #146 weight was 133lbs. The note revealed Resident #146 weight trend for the past 30, 90, and 180 days was stable. Resident#146 ability to chew/swallow was documented as poor. The resident supplemental intake was left blank. The note indicated Resident #146 had the ability to feed herself. Review of Resident #146 ' s meal and fluids detailed entry report for the month of April 2016 revealed documented consumption for 10 out of 90 meals with consumption at or below 50% documented for 4 meals and consumption between 50-75% for 1 meals. This report contained documentation that a supplement was not offered for the month of April. Resident #146 was observed on 5/15/16 at 12:42pm to be eating lunch in her bed by herself in her room. Resident #146 had a standard drinking glass. Resident #146 was noted to have a large amount of food on her face and on her personal clothing protector. The resident was observed to have her frozen nutritional treat on her tray. Review of weight taken 5/16 (no date provide) indicated Resident #146 weight was 117.5 lbs. Dietary note dated 5/16/16 revealed Resident #146 refused April and May weight measurement. The director of nursing services (DON) then requested a weight for May. 117 pounds was reported to the Registered Dietician (RD) by director of nursing services (DON). The dietary note revealed Resident #146 ' s usually body weight was between 130lbs and 135lbs. Resident #146 received a puree diet with a frozen treat with her lunch meal, a Multivitamin and Prostat 30cc 3 x a day (tid) with fortified cream 1 time daily (QAM). The dietary note continued with Resident #146 ' s [MEDICATION NAME] was low at 2.67 on 4/11/16. The recommendations revealed continue with Prostat due low [MEDICATION NAME], start 60cc med pass 2.0 and add to weekly weight monitoring until sable. Review of Resident #146 ' s meal and fluid detailed entry report for the month of May revealed documented consumption of 21 out of 42 meals with consumption at or below 50% documented for 12 meals and consumption between 50 - 75% for 1 meal. This report contained documentation that a supplement was offered and accepted 2 of the 13 meals where intake was at or below 75%. Resident #146 was observed on 5/16/16 at 8:10am eating breakfast alone in her room. The resident ' s meal tray was observed to have a carton of milk, cranberry juice in the original container (small cup with aluminum lid). Resident was observed to have food on her chest and food coming out of the left side of the resident ' s mouth. Resident #146 was observed on 5/16/16 at 12:56pm eating lunch in her room alone in a Broda chair. The resident was observed to have food on her chest and food that came out of her mouth on the left side. No frozen treat (supplement) was observed on Resident #146 meal tray. Resident #146 meal card identified frozen nutritional treat. Resident #146 was observed on 5/17/16 at 12:17pm eating lunch in her room in a Broda chair. Resident ' s meal consisted of pureed spaghetti, regular salad and pudding in a cup. The resident had no frozen nutritional treat. The meal card on the resident ' s meal tray identified frozen nutritional treat. Resident #146 was observed to have food coming out of the left side of her mouth and food on her chest. Observation on 5/18/16 at 12:35pm revealed Resident #146 to be eating lunch in her room. Food was observed to be coming out of the left corner of her mouth. Resident #146 had yellow pudding running down the side of the Broda chair with pudding up turned upside down on the arm of the Broda chair. Resident was observed to have yellow pudding sitting on her chest. The resident was observed to attempt to eat her frozen nutritional treat. Resident #146 exhibited difficulty eating her frozen treat as evidenced by not being able to hold the frozen nutritional treat (left side [MEDICAL CONDITION]) and eating with her right hand. The frozen nutritional treat was observe to move with the spoon and slide across the bedside table as Resident #146 attempted to scoop the frozen nutritional treat onto her spoon. Staff (unknown) came into the room and stated, They usually place a towel over her . The staff member was observed to wipe the food from resident chest and wipe the food spilling from the left side of the resident ' s mouth. The NA was observed to cover the resident with a clean towel to protect her clothing and left the room. Review of physician progress notes [REDACTED].#146 had a history of [REDACTED]. The physician noted Resident #146 had no shortness of breath or no pain. The assessment stated weight loss with a plan of med pass 60cc qid. Interview with the DON on 5/19/16 at 2:38pm revealed the facility conducted daily meetings in which changes of condition were reviewed and physician orders. The orders for the resident nutritional dining needs should be transcribed on the chart and on the Medication Administration Record [REDACTED]. Her expectation was that staff look at the resident meal tickets to identify the resident is getting what is ordered. The information regarding dining needs should be carried over to the care plan. The DON further revealed the nursing assistants (NA) used the Kardex that should be updated to match the plan of care. The DON indicated that the NA ' s should be documenting the resident ' s consumption daily in the care tracker. The DON stated that the resident meals and fluids detailed entry report was not reviewed in the morning meetings. Interview with Dietary Manager on 5/17/16 at 2:40pm revealed he became aware of resident nutritional dining needs after the physician order [REDACTED]. The information regarding a residents nutritional needs would come on the meal card. The dietary department would put the adaptive dining equipment and or nutritional supplement on the resident ' s meal tray according to the dining slip. Interview with the District Registered Dietician (RD) on 5/18/16 at 1:27 pm revealed she was brought Resident #146 medical chart by the DON on Monday (5/16/16) and was told there was no weight for April 2016 and May 2016. The RD stated she was told the resident refused to be weighted for the Month of April and May. The RD continued with the DON then requested a weight for May. She believed it was May 10, 2016. She further indicated she reacted immediately to the weight of 117lbs in March 2016 when it became available to her. She calculated the residents weight loss over a period of 6 months (November through May) as Resident #146 having a 14.2% weight loss (calculated from November weight of 137 and May weight of 117.5). The RD stated today (5/18/16) she would try discontinue the recommended med pass (nutritional supplement) due to Resident #146 refusal and she would implement house shakes (nutritional supplement) with meals. The RD further indicated she was not responsible for care planning. Interview with Dietary Manager on 5/18/16 at 3:45 pm revealed he was responsible for the MDS section K. He indicated he received residents weights by nursing or restorative nursing. He stated it varied who took weights. The Dietary Manager revealed he looked at the weights and passed them to the RD for review. If the weight looks crazy he requests a re-weight. The Dietary Manager indicated when he completed section K of the MDS assessment dated [DATE] he used the weight for March of 133lbs because it was the most recent weight available. He was unaware if Resident #146 refused the weight for April or if it was missed. He further indicated it was the responsibility of the RD to implement interventions in regards to weight loss. He stated he notified the RD of the May 2016 weight of 117lbs on Monday (5/16/16) as soon as he be became aware of Resident #146 weight. He was unsure of the day in May Resident #146 weight was taken. Interview with the DON on 5/18/16 at 4:13pm revealed Resident #146 weights were running in the 130 ' s and stable until the end of March. The DON stated she assumed they were having problems with the facility scales. On 3/31/16 the facility requested the scales be calibrated by a medical equipment services. It was between 4/4/16 and 4/6/16 the facility scales were fixed. We reweighed Resident #146 in April and got a weight of 119lbs with the newly calibrated scale. OT picked up Resident #146 on 4/11/16 as a response to the weight loss. On Monday (5/13/16) Resident #146 weight was 117lbs. She further revealed she weighed the Resident #146 on a wheelchair scale at 119lbs and the Hoyer lift scale at 117lbs. She indicated she was unaware of why the 119lb weight was not on the April 2016 facility weight sheet. The restorative aide would put the facility weight list in the dietary room for the Dietary Manager. The DON indicated the facility weight sheet was not utilized in morning meetings for monitoring of residents intake. Residents should be reweight with any 5% increase or 5% decrease in weight. Interview with OT #1 on 5/19/16 at 10:48am revealed she assessed Resident #146 for positioning during dining and not weight loss. She revealed that when Resident #146 was in her Broda chair she ate better. The OT stated Resident #146 had a positioning angel issue when she was eating in the bed. Resident #146 had a tendency to wiggle and slide down. Resident #146 had a severe stoke and the OT indicted she believed she had no feeling on the left side. OT #1 revealed she had included in her assessment of Resident #148 dated 4/11/16 that food had dropped on Resident #146 chest. She indicated that it wasn ' t an alarming amount of food on her chest and believed the resident was getting more food in her mouth than on her chest. The OT revealed she used a regular plate when assessing Resident #146 ability to feed herself and had not used any type of bowl. Due to not using a bowl for the assessment she was unaware if resident #146 had difficulty while attempting to scoop. OT#1 stated, Sometime the pudding is the only thing the resident eats . Interview with NA # 1 on 5/19/16 at 10:59am revealed she was familiar with Resident #146. She indicated Resident #146 would normally eat all of her sweets and she was not big on eating her pureed items. She indicated Resident #146 ate a good amount of her breakfast and wasn ' t a big eater at lunch. She stated that she did offer to assist with Resident #146 but Resident #146 would only eat a couple of bites. NA#1 stated she recalled Resident #146 being in restorative dining at one time (NA unaware of date). Resident #146 was taken off restorative dining and put in 2nd dining. Resident #146 showed inappropriate behaviors in the dining room to include putting her leg up on the table as she ate and moving about in her chair. Resident#146 no longer ate in the dining room, she ate meals in her room independently. NA#1 indicated she was not told Resident #146 required assistance and was not one of the resident on the hall that was identified for feeding assistance. NA#1 revealed Resident leaned a lot in her chair and would get food on her. NA#1 further stated, If you can get her to sit up she does better. Resident #146 wouldn ' t stay seated upright for long. She scoots in her seat. NA #1 indicated Resident #146 had left side weakness. NA#1 stated when she documented Resident #146 consumption she didn ' t include the food remaining on the plate or the food that lands on the resident ' s chest. NA# 1 revealed believed Resident #146 had difficult eating with the use of only her right hand. She further indicated Resident #146 could benefit from an adaptive plate that would assist with keeping food on her plate. Interview with NA# 10 on 5/19/16 at 11:10am revealed Resident #146 did not require assistance to eat. NA# 10 indicated she had noticed that Resident #146 would get food on her chest while eating. NA#10 stated that if the Resident #146 didn ' t like certain food items she wouldn ' t hold the food in her mouth. She stated that occasionally Resident #146 ' s food would come out the side of her mouth. She stated Resident #146 liked sweets such as her frozen nutritional treat and deserts. Resident #146 did well eating if staff added jelly in her grits. NA# 10 described Resident #146 as having problems manipulating a bowl or had problems with cups like Ice cream. The NA indicated in the instance the ice cream wasn ' t soft enough she couldn ' t get it out or the spoon sticks in it. NA #10 stated Resident #146 didn ' t have her other hand to hold a cup steady as she scooped. She indicated in the instance she completed the residents consumption sheet and she identified everything on the plate gone and food on the residents chest she would document the resident ate 95%. Interview with the facility physician on 5/19/16 at 11:27am revealed it was her expectation to be informed in the instance a resident loses more than 5lbs a month. She indicated she needed to be informed so she could trouble shoot why the weight loss was occurring and implement preventative measures in an attempt to prevent further weight loss. She stated she was unaware of the Resident #146 weight loss. She further revealed had she been aware of the significant weight loss in April 2016 she would have put interventions into place immediately. The physician indicated she would check the residents Pre-[MEDICATION NAME] levels to determine how poorly resident #146 was malnourished. She further revealed she might have to prescribe Resident #146 a protein supplement and an appetite stimulant. Interview with Restorative Aide #1 on 5/19/16 at 11:44am revealed she was responsible for taking and recording Resident weights. She revealed that in the instance a residents weight was low or appeared off she would reweight the resident. She indicated that she gave the weights to the Dietary Manager. In the instance the Dietary Manger thought there was a discrepancy in a weight he would request a reweight. She indicated the last weight she recalled seeing was about 117lb or 119lbs. The Restorative Aide recalled the mechanical lift was recalibrated sometime in April 2016. She indicated when Resident #146 was on restorative dining she assisted the resident by setting up her meal tray, starting Resident #146 off and watching her eat independently. She did well eating in restorative dining. She revealed after ending restorative dining resident #146 still received assistance in secondary dining. Resident #146 no longer was in secondary dining and ate in her room due to inappropriate behaviors. Resident #146 would occasionally have difficulty holding a cup and scooping and require assistance. Therapy assessed Resident #146 and gave her a cup with handles to see if that would help with drinking. She indicated Resident #146 would have food that would come out of the left side of her mouth when she fed herself. She indicated she did not believe it was an excessive amount. The Restorative Aide stated Resident #146 would keep more food in her mouth when she fed the resident.