Every finding on record at Liberty Commons Nursing and Rehabilitation Center

Based on record review and interviews with the Pharmacy Consultant, physician and staff, the facility failed to transcribe the correct medication administration route and failed to administer scheduled medications in the correct form when nursing staff crushed an extended-release medication for 1 of 4 residents reviewed for gastric feeding tube (Resident #50).The findings included: Resident #50 was admitted to the facility on [DATE] with diagnoses that included history of stroke with dysphagia (difficulty swallowing) and presence of a feeding tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 had severely impaired cognitive skills for daily decision making. He received all nutrition and fluids via a feeding tube. Review of Resident #50's active care plan, last reviewed 6/29/26, revealed a focus area for requiring tube feeding to assist in maintaining or improving nutritional status. The interventions included nothing by mouth status as ordered by the physician. A review of Resident #50's active physician orders included the following:An order dated 10/25/23 for nothing by mouth.An order dated 1/7/24 for all medications to be crushed and administered via feeding tube.An order dated 7/28/26 to 8/4/26 for Mucinex (an over-the-counter medication that helps clear chest congestion) 12-hour 600 milligrams (mg). Give one tablet by mouth daily for expectorant for 14 days. Take with a full glass of water. Do not crush. This order was changed on 8/4/26 to guaifenesin (a medication that helps clear mucous) 30 milliliters (ml) by feeding tube twice a day until 8/12/25.All other medications were written to be provided through the gastric feeding tube. A review of the July 2026 and August 2026 Medication Administration Records (MARs) revealed an order for Mucinex extended-release 12-hour 600 mg. Give one tablet by mouth daily for expectorant for 14 days. Take with a full glass of water. Do not crush. The Mucinex order was documented as provided to Resident #50 as scheduled at 9:00 AM on 7/29/26, 7/30/26, 7/31/26, 8/1/26, 8/2/26 and 8/3/26. On 8/5/26 at 12:16 PM, a phone interview occurred with Nurse #4 who had entered the order for Mucinex extended-release medication into Resident #50's physician's orders on 7/28/26 and had provided Mucinex extended-release to Resident #50 on 7/31/26, 8/1/26 and 8/2/26. Nurse #4 stated that he recalled receiving a verbal order from the physician on 7/28/26 for Mucinex to be provided daily. Nurse #4 added that he wasn't sure if the Electronic Medical System automatically defaulted to the oral route or if he entered the wrong route for the Mucinex order. A review of Resident #50's July 2026 and August 2026 MARs was completed and Nurse #4 stated that he provided Mucinex extended-release tablet as ordered by crushing and letting it dissolve in water prior to administering via Resident #50's feeding tube. Nurse #4 stated he was unaware the medication should not have been crushed and must have overlooked that the order read by mouth and not to crush. Nurse #4 confirmed he was aware Resident #50 received all his medications via the feeding tube and nothing by mouth. Multiple attempts were made to reach Nurse #5 who had provided Mucinex 600 mg extended-release tablets to Resident #50 on 7/29/26, 7/30/26 and 8/3/26 but were not successful. An interview occurred with Unit Manager #1 on 8/5/26 at 11:26 AM. She verified that Resident #50 received all nutrition, fluids and medications via the feeding tube and nothing by mouth. She reviewed Resident #50's medical record and confirmed there was an order dated 7/28/26 for Mucinex 12-hour tablet by mouth and that the order read not to crush the medication. Unit Manager #1 also verified Resident #50's July 2026 and August 2026 MARs indicated he received Mucinex extended-release tablets on 7/29/26, 7/30/26, 7/31/26, 8/1/26, 8/2/26 and 8/3/26. Unit Manager #1 stated on 8/4/26, she completed a MAR review for Resident #50 and noticed that Mucinex extended-release had been entered as an oral route instead of by feeding tube and had been entered as extended-release. Unit Manager #1 received a clarification order to provide medication that could be administered via the feeding tube. She acknowledged that extended-release tablets should not be crushed, and the order should have been clarified prior to administering to Resident #50. A telephone interview was conducted with the Pharmacy Consultant on 8/5/26 at 2:52 PM, who explained that by crushing the Mucinex extended-release tablet the therapeutic range shrunk and the medication wouldn't last as long as intended. She added that by crushing the medication there would not have been any significant side effects to Resident #50. The Physician was interviewed via the telephone on 8/6/26 at 9:40 AM and stated that by crushing the Mucinex extended-release tablet, the medication effects would have resulted in a more concentrated dosage at once instead of spreading throughout the extended-release period, however by crushing the medication, there would not have been any significant effects to Resident #50. The Physician added that he would have expected the nursing staff to have clarified the order regarding the correct medication route and whether Mucinex extended-release tablets should have been administered to Resident #50, prior to administering, since he received all his medications via a feeding tube. An interview occurred with the Director of Nursing (DON) on 8/6/26 at 10:25 AM. She explained that the Electronic Medical System automatically defaulted to the oral route when entering medications and that Nurse #4 should have changed the route to via the feeding tube for Resident #50 when Mucinex was entered. The DON added she would have expected the nursing staff to have clarified the order for Mucinex prior to administering to Resident #50 as the order read not to crush the tablet and Resident #50 received all his medications via the feeding tube.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of skin condition and Level II Preadmission Screening and Resident Review (PASRR) conditions for 3 of 26 residents reviewed for accuracy of assessments (Resident #7, Resident # 2 and Resident #77). The findings included:1.Resident #7 was admitted to the facility on [DATE] with diagnoses that included atherosclerosis (buildup of plaque in and on the artery walls) of extremities, diabetes mellitus, and severe protein calorie malnutrition.Resident #7's active physician orders included an order dated 3/20/26 for an alternating pressure mattress with pump and an order dated 6/9/26 for calcium alginate with silver (a wound dressing that soaks up heavy drainage while preventing infection) and a superabsorbent gelling fiber dressing, covered with a silicone border dressing, once daily and as needed for 30 days to the left heel pressure ulcer.Resident #7's care plan revised 6/4/26, revealed he had a pressure ulcer on his left heel. Interventions included the use of an alternating pressure mattress and providing wound treatment as ordered.A review of the Wound Evaluation and Management Summary completed by the Wound Physician on 6/9/26 revealed that Resident #7 had a Stage 4 pressure ulcer on the left heel.The June 2026 Treatment Administration Record (TAR) revealed Resident #7's alternating pressure mattress was checked for proper inflation and pump function every shift and he received daily dressing changes to the left heel wound as ordered from 6/6/26 to 6/12/26.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #7 was not coded for a pressure reducing device to the bed and was not coded as receiving pressure ulcer treatment.During an interview on 8/5/26 at 2:55 p.m., the MDS Nurse stated that she did not code Resident #7's assessment dated [DATE] and explained the nurse who had was no longer employed by the facility. The MDS Nurse confirmed the assessment was not coded correctly for the use of an alternating pressure mattress and pressure ulcer care.During an interview on 8/6/26 at 11:29 a.m., the Director of Nursing stated that it was her expectation that the MDS assessments be completed accurately. 2. Resident #2 was readmitted to the facility on [DATE] with a diagnosis of dementia. The Wound Evaluation and Management Summary completed by the Wound Physician on 6/30/26 revealed that Resident #2's wound exam included:An unstageable pressure wound to the left medial shin (inner side- wound bed covered with nonviable tissue). The wound was present on readmission. An unstageable pressure wound to the right distal lateral (outer side of the foot that is far away from the ankle) foot. The wound was present on readmission.A stage 2 pressure ulcer to the right lateral (outer side) foot. The wound was present on readmission.A stage 4 pressure ulcer to the right 5th toe. The wound was present on readmission.A stage 4 pressure ulcer to the right 4th toe. The wound was present on readmission.An unstageable pressure wound to the left proximal posterior thigh (back upper part). The wound was present on readmission.A review of the July 2026 Treatment Administration Record (TAR) revealed that Resident #2 received daily wound care to the left medial shin, right distal lateral foot, right lateral foot, right 5th toe, and right 4th toe as ordered from 7/5/26 to 7/11/26.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was coded as having no Stage 2 pressure ulcers, three unhealed Stage 4 pressure ulcers that were not present on admission and three unstageable pressure ulcers, with only one coded as present on admission.During an interview on 8/6/26 at 8:50 a.m., the Wound Nurse stated that all of Resident #2's pressure ulcers were present upon readmission to the facility. The Wound Nurse explained that Resident #2 was readmitted on [DATE] with three unstageable wounds (left medial shin, left proximal posterior thigh, and right distal lateral foot), two Stage 4 pressure ulcers (right 4th toe and right 5th toe), and one Stage 2 pressure ulcer (right lateral foot).During an interview on 8/5/26 at 2:55 p.m., the MDS Nurse stated that she had failed to select the appropriate coding item for Resident #2's wounds. She stated that she was new to the facility and was still learning the residents and the coding error was a mistake. During an interview on 8/6/26 at 11:29 a.m., the Director of Nursing stated that it was her expectation that the Minimum Data Set (MDS) assessments be completed accurately.3. A review of admission records revealed that Resident #77 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and anxiety. The PASRR Level II Determination Notification for Resident #77, dated 7/19/26, revealed that the resident was approved for a limited nursing facility stay not to exceed 30 days, with an expiration date of 8/18/26.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #77 was coded as not having a serious mental illness as determined through the state Level II Preadmission Screening and Resident Review (PASRR) process.During an interview on 8/5/26 at 2:55 p.m., the MDS Nurse stated that she had failed to select the appropriate coding item on the assessment. She confirmed that Resident #77 had a diagnosis of schizophrenia and should have been coded as having a serious mental illness based on the Level II PASRR determination.During an interview on 8/6/26 at 11:29 a.m., the Director of Nursing stated that it was her expectation that the Minimum Data Set (MDS) assessments be completed accurately.

Based on record review and interviews with the Pharmacy Consultant, physician and staff, the Pharmacy Consultant failed to identify a resident (Resident #50) that received all medications via a feeding tube was ordered an extended-release medication for 1 of 4 residents reviewed for a gastric feeding tube.The findings included: Resident #50 was admitted to the facility on [DATE] with diagnoses that included history of a stroke with dysphagia (difficulty swallowing) and presence of a gastric feeding tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 had severely impaired cognitive skills for daily decision making based on staff assessment of cognition. He received all nutrition and fluids via a feeding tube. A review of Resident #50's active physician orders included the following:An order dated 10/25/23 for nothing by mouth.An order dated 1/7/24 for all medications to be crushed and administered via feeding tube.An order dated 7/28/26 to 8/4/26 for Mucinex (an over-the-counter medication that helps clear chest congestion) 12-hour 600 milligrams (mg). Give one tablet by mouth daily for expectorant for 14 days. Take with a full glass of water. Do not crush. All other medications were written to be provided through the gastric feeding tube. A review of the July 2026 Medication Administration Record (MAR) indicated Resident #50 received the Mucinex extended-release 12-hour 600 mg tablet at 9:00 AM, as ordered by the physician on 7/29/26. The Pharmacy Consultant completed a Medication Regimen Review on 7/29/26 which did not address any concerns related to Resident #50's order for Mucinex 12-hour 600 mg, one tablet by mouth daily for 14 days, take with a full glass of water and do not crush. The Pharmacy Consultant was interviewed via phone on 8/5/26 at 2:52 PM. She was able to review Resident #50's medical record and indicated she had made a note regarding which medications Resident #50 was prescribed when she completed the Medication Regimen Review on 7/29/26. The Pharmacy Consultant acknowledged that there was an order for Mucinex 12-hour 600 mg, one tablet by mouth daily for 14 days, take with a full glass of water and do not crush listed on Resident #50's active medications and had overlooked it during her review. The Pharmacy Consultant stated that she should have alerted the Director or Nursing (DON) of this discrepancy since Resident #50 received all medications via a feeding tube and the medication should not have been crushed. A phone interview was held with the physician on 8/6/26 at 9:40 AM and verified Resident #50 received all medications via a feeding tube and the order for Mucinex 12-hour 600 mg tablets should not have been crushed. He indicated the Pharmacy Consultant should have notified the DON of this order discrepancy at the time of her Medication Regimen Review on 7/29/26. An interview occurred with the DON on 8/6/26 at 10:25 AM who stated the Pharmacy Consultant should have alerted her to Resident #50's order for Mucinex 12-hour 600 mg tablet that was ordered via mouth, when he was only ordered medications via a feeding tube and the Mucinex extended-release tablet should not have been crushed.

Based on record review and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 27 out of 31 days (7/3/26, 7/4/26, 7/6/26, 7/7/26, 7/10/26, 7/11/26, 7/12/26, 7/13/26, 7/14/26, 7/15/26, 7/16/26, 7/17/26, 7/18/26, 7/19/26, 7/20/26, 7/21/26, 7/22/26, 7/23/26, 7/24/26, 7/25/26, 7/26/26, 7/27/26, 7/28/26, 7/27/27, 7/28/26, 7/29/26, 7/30/26, 7/31/26, and 8/2/26).The findings included: A review of the facility's daily posting for nurse staff for 7/3/26 to 8/2/26 as compared to the daily staffing schedule revealed an inaccurate total of nursing staff responsible for resident care worked, which included the following: a. The nursing schedule for 7/3/26 indicated that one Registered Nurse (RN) worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/3/26 documented that no RN's worked from 7:00 PM to 7:00 AM. b. The nursing schedule for 7/4/26 indicated that one RN worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/4/26 documented that no RN's worked from 7:00 PM to 7:00 AM. c. The nursing schedule for 7/6/26 indicated that two RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/6/26 documented that no RN's worked from 7:00 PM to 7:00 AM. d. The nursing schedule for 7/7/26 indicated that one RN worked from 7:00 AM to 7:00 PM and 2 RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/7/26 documented that no RN's worked from 7:00 AM to 7:00 PM or from 7:00 PM to 7:00 AM. e. The nursing schedule for 7/10/26 indicated that two RNs worked from 7:00 PM to 7:00 AM and 6 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 7/10/26 documented that no RNs worked from 7:00 PM to 7:00 AM and that 7 NAs worked the 7:00 AM to 3:00 PM shift. f. The nursing schedule for 7/11/26 indicated that one Medication Aide (MA) and one RN worked the 7:00 PM to 7:00 AM shift. The daily posted nurse staffing sheet for 7/11/26 documented that no MA or RN worked the 7:00 PM to 7:00 AM shift. g. The nursing schedule for 7/12/26 indicated that two RNs worked the 7:00 AM to 7:00 PM shift, one RN worked 7:00 PM to 7:00 AM and 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 7/12/26 documented that one RN worked 7:00 AM to 7:00 PM, no RN worked 7:00 PM to 7:00 AM and 7 NAs worked 3:00 PM to 11:00 PM. h. The nursing schedule for 7/13/26 indicated that one RN worked 7:00 PM to 7:00 AM and 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 7/13/26 documented that no RN worked 7:00 PM to 7:00 AM and 7 NAs worked 3:00 PM to 11:00 PM. i. The nursing schedule for 7/14/26 indicated that one RN worked 7:00 AM to 7:00 PM, one RN worked 7:00 PM to 7:00 AM and 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 7/14/26 documented that no RNs worked 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM and 7 NAs worked 3:00 PM to 11:00 PM. j. The nursing schedule for 7/15/26 indicated that one RN worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/15/26 documented that no RN worked the 7:00 PM to 7:00 AM shift. k. The nursing schedule for 7/16/26 indicated that 6 NAs worked 7:00 AM to 3:00 PM, 6 NAs worked 3:00 PM to 11:00 PM and two RNs worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/16/26 documented that 7 NAs worked 7:00 AM to 3:00 PM, 7 NAs worked 3:00 PM to 11:00 PM, and no RNs worked the 7:00 PM to 7:00 AM shift. l. The nursing schedule for 7/17/26 indicated that one RN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/17/26 documented that no RN worked the 7:00 PM to 7:00 AM shift. m. The nursing schedule for 7/18/26 indicated that 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 7/18/26 documented that 7 NAs worked 3:00 PM to 11:00 PM. n. The nursing schedule for 7/19/26 indicated that one RN worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/19/26 documented that no RN worked the 7:00 PM to 7:00 AM shift. o. The nursing schedule for 7/20/26 indicated that one RN worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/20/26 documented that no RN worked the 7:00 PM to 7:00 AM shift. p. The nursing schedule for 7/21/26 indicated that one RN worked the 7:00 AM to 7:00 PM shift and two RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/21/26 documented that no RNs worked 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM shift. q. The nursing schedule for 7/22/26 indicated that one RN worked 7:00 AM to 7:00 PM and one RN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/22/26 documented that no RN worked 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM. r. The nursing schedule for 7/23/26 indicated that one RN worked from 7:00 AM to 7:00 PM. The daily posted nurse staffing sheet for 7/23/26 documented that no RN worked 7:00 AM to 7:00 PM. s. The nursing schedule for 7/24/26 indicated that two RNs worked 7:00 AM to 7:00 PM, two RNs worked 7:00 PM to 7:00 AM, 6 NAs worked 3:00 PM to 11:00 PM and 4 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/24/26 documented that no RNs worked 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM, 7 NAs worked 3:00 PM to 11:00 PM and 5 NAs worked 11:00 PM to 7:00 AM. t. The nursing schedule for 7/25/26 indicated that one RN worked 7:00 PM to 7:00 AM, 5 NAs worked 7:00 AM to 3:00 PM and 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 7/25/26 documented that no RN worked 7:00 PM to 7:00 AM, 7 NAs worked 7:00 AM to 3:00 PM and 7 NAs worked 3:00 PM to 11:00 PM. u. The nursing schedule for 7/26/26 indicated that 3 RNs worked from 7:00 AM to 7:00 PM, one RN worked 7:00 PM to 7:00 AM and 6 NAs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 7/26/26 documented that one RN worked 7:00 AM to 7:00 PM, no RN worked 7:00 PM to 7:00 AM and 7 NAs worked 7:00 AM to 3:00 PM. v. The nursing schedule for 7/27/26 indicated that one RN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/27/26 documented that no RN worked from 7:00 PM to 7:00 AM. w. The nursing schedule for 7/28/26 indicated that one RN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/28/26 documented that no RN worked 7:00 PM to 7:00 AM. x. The nursing schedule for 7/29/26 indicated that one RN worked from 7:00 AM to 7:00 PM and two RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/29/26 documented that no RNs worked 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM. y. The nursing schedule for 7/30/26 indicated that one RN worked from 7:00 AM to 7:00 PM and one RN worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/30/26 documented that no RNs worked from 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM. z. The nursing schedule for 7/31/26 indicated that one RN worked from 7:00 AM to 7:00 PM and two RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 7/31/26 documented that no RNs worked from 7:00 AM to 7:00 PM or 7:00 PM to 7:00 AM. aa. The nursing schedule for 8/2/26 indicated that two RNs worked from 7:00 AM to 7:00 PM and two RNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 8/2/26 documented that one RN worked from 7:00 AM to 7:00 PM and no RNs worked from 7:00 PM to 7:00 AM. On 8/5/26 at 1:00 PM, an interview occurred with the Staff Scheduler. She reviewed the staffing schedules and daily postings and verified the number of staff who worked from 7/3/26 to 8/2/26 did not match. She explained that she would either capture the RN supervisor in the top portion of the daily posting under Administrative nursing staff during the week and in the bottom portion of the daily posting under staff directly responsible for resident care for the weekends. She added that she had been counting all other RNs with the Licensed Practical Nurses (LPNs) and didn't know she should have separated them. In addition, the Staff Scheduler stated that she had failed to ensure the daily posted nurse staffing sheet had been updated when an NA didn't come to work and was an oversight. The Administrator was interviewed on 8/6/26 at 10:40 AM 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 review, staff interviews, Pharmacy Consultants, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to discontinue a medication per physician's order resulting in the resident receiving the previous ordered dose of acetaminophen (used to relieve mild to moderate pain) and the newly ordered dose of acetaminophen. This was for 1 of 5 residents (Resident #27) reviewed for unnecessary medications. The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, osteoarthritis, and type 2 diabetes mellitus with diabetic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27's cognition was intact. She received routine pain medications, no PRN (as needed) pain medications, and reported pain frequently at a rating of 8 out of 10. Resident #27's active care plan, last reviewed 2/14/25, included the focus area of pain. The interventions included, in part, administer medication as ordered, and observe for adverse reactions with every interaction with the resident. Report to physician if noted. A physician's order for Resident #27 dated 3/02/23 indicated acetaminophen (APAP) extended release (ER) oral tablet 650 milligrams (mg) by mouth three times a day for chronic pain Do not crush do not exceed 3 grams (3000 mg) APAP from all sources within 24 hours. The total daily dose of acetaminophen ordered to be administered was 1,950 mg. A physician's order for Resident #27 dated 4/15/25 indicated acetaminophen oral tablet 500 MG tablet, give 2 tablets (1000 mg) by mouth two times a day for pain. The total daily dose of acetaminophen ordered to be administered from the new order was 2,000 mg. The previous order for acetaminophen ER 650 that was initiated on 3/02/23 for Resident #27 was not discontinued and remained an active order. Due to the previous order for acetaminophen ER 650 not being discontinued when there was a new acetaminophen order, the combined total daily dose of acetaminophen ordered to be administered was 3,950 mg. A review of the medication administration record (MAR) for Resident #27 from 4/15/25 through 4/30/25 showed acetaminophen 650 mg was administered three times a day (at 6:00 AM, 12:00 PM, and 9:00 PM), and acetaminophen 1000 mg was administered two times a day (at 9:00 AM and 5:00 PM). An interview was conducted on 4/30/25 at 2:04 PM with the Unit Manager that entered the acetaminophen 1000 mg order. The order for Resident #27, dated 4/15/25, was reviewed with the Unit Manager, she verified the order read to change acetaminophen to 1000 mg twice a day. She stated she did remember receiving and entering the acetaminophen order when Resident #27 returned from an appointment with the orthopedic physician. She stated she did not change the acetaminophen order as it read, she only entered the new order. She stated it was an oversight that she did not discontinue the previous scheduled acetaminophen order. An interview was conducted on 5/01/25 at 10:41 AM with the Nurse Practitioner (NP). She stated she was made aware of the extra order of acetaminophen for Resident #27 on 04/30/25 and she ordered a liver enzymes lab, which she also stated came back with no abnormalities. She stated no liver damage had appeared to have occurred. She explained the extra acetaminophen order was discontinued on 4/30/25. She further explained she also ordered an acetaminophen level for Resident #27 however those results had not been returned yet and she anticipated the results to be okay as well. A phone interview was conducted on 5/02/25 at 6:15 PM with Pharmacy Consultant #1. She stated when looking at acetaminophen orders and the maximum dose that they recommended 3 grams (g)/3000 mg/day total, but technically it would take 4g/4000mg/day over a long period of time to cause liver damage. A phone interview was conducted on 5/02/25 at 6:35 PM with Pharmacy Consultant #2. She stated herself and Pharmacy Consultant #3 performed monthly reviews at the facility which included medication dosage amounts residents were receiving per day. She also stated Pharmacy Consultant #3 completed the monthly review on the evening of 4/30/25. Pharmacy Consultant #2 did not see any notes referring to the acetaminophen order for Resident #27 at that time. She explained when they looked at acetaminophen orders the maximum dose that they recommend was 3 grams (g)/3000 mg/day total, but technically it would take 4g/4000mg/day over a long period of time (She did not know how long would be considered a long time) to cause liver damage (liver damage was the concern for excessive amounts of acetaminophen). The recommendation of 3000 mg/day was put in place as a precautionary due to the possibility of the residents having an undiagnosed condition or health condition that may interfere with larger doses of acetaminophen. She indicated that they see a lot of acetaminophen orders that exceed the 3000 mg/day recommended dose, up to 4000mg/day orders. She did not feel the amount of 3950 mg of Tylenol for Resident #27 would cause any liver damage. She also stated the pharmacist would have sent the facility a physician recommendation for Resident #27's acetaminophen orders requesting a lower dosage and liver panel during the pharmacist review but would not be surprised if the physician denied the recommendation to lower the total acetaminophen daily dosage as it happens all the time. A phone interview was conducted on 5/03/25 at 9:48 AM with Pharmacy Consultant #3. She verified the pharmacy performed the monthly medication reviews for the facility. She explained during the medication review process she would review active orders on the resident's medication administration record (MAR). Pharmacy Consultant #3 indicated she looked for several things during the review including duplicate orders, high risk medications, and dosage amounts. She explained that it was standard for acetaminophen orders to include the verbiage do not exceed 3 grams (3000 mg) APAP from all sources within 24 hours. She also explained if the order did not include this verbiage during the review she would send the facility a recommendation to add to the acetaminophen order. She indicated that some physicians add this verbiage themselves to the order, and some don't due to the facility and/or the pharmacy adding it as the standard practice. She stated the maximum dose of acetaminophen in adults was 4g/4000mg/day and for the elderly it was lowered to 3g/3000mg/day as a precautionary measure. This in part was because some elderly residents may not have the ability to describe signs/symptoms of an underlying medical conditions that may go undiagnosed and may affect the maximum dose of 4g/4000mg/day acetaminophen. She added some facility systems automatically add the verbiage. Pharmacist Consultant #3 explained when she reviewed an acetaminophen order that exceeds the 3000mg/day amount, she reviewed the chart to see when the last liver function lab was completed, notified the facility making them aware, and requested a physician review and liver function labs if there was not a current one in the chart. She stated she completed the monthly review for the facility on 4/30/25 at 6:30 PM. She indicated if the acetaminophen order had been discontinued 4/30/25 prior to her review it would not have been included on Resident #27's active order lists. She was also very familiar with Resident #27 and stated they did monitor her pain levels and pain medications. She then stated Resident #27 had a high pain threshold. A phone interview was conducted on 5/02/25 at 7:40 PM with the Director of Nursing (DON) regarding their processes for receiving and checking orders. The DON stated the process they had in place was that when a resident returns from a doctor's appointment the returning paperwork was given to the resident's nurse. That nurse would enter the orders into the electronic system, notify the responsible party, and then the unit manager would do a second check to ensure the orders were entered correctly. After the unit manager checked the orders, the paperwork would be left for the physician to review. If a completely new medication was ordered by the outside physician, the primary care provider would be called, if it was a change in a medication the resident was already receiving, the paperwork would be put in the physician's binder for review when he came in. With Resident #27's orders, the Unit Manager entered the original orders, so the second check was not done at that time. During the morning meeting the DON checks to see if the responsible party and physician had been notified. With the acetaminophen orders for Resident #27, the Unit Manager entered the original order and so the 2nd nurse check wasn't completed. The interview further revealed monthly order reconciliation was completed by the pharmacist and the pharmacist review for Resident #27 was completed on the afternoon of 4/30/25. An interview was conducted on 4/30/25 at 2:45 PM with the Director of Nursing. She stated she was unaware the acetaminophen order for Resident #27 was not changed per order and she expected all physician orders to be transcribed and followed through with. The DON indicated that one of the scheduled acetaminophen orders should have been discontinued per order. A phone interview was conducted on 4/30/25 at 2:12 PM with the Medical Director which explained he was not aware of the acetaminophen orders for Resident #27 because he was new to the facility and had only been there for 2 weeks. He stated he would look at her medications to modify for an alternate pain medication regimen. He indicated he did not think there was any negative outcome to her liver because she had only taken the extra acetaminophen since 4/17/25.

Based on record reviews, and former Medical Director and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered Ativan ( a medication used to treat anxiety) to Resident #60 that had been prescribed for Resident #57. This deficient practice affected 1 of 5 residents reviewed for unnecessary medications (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses of diabetes type 2, hypertension and atrial fibrillation. Resident #60 did not have a diagnosis of anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #60 was cognitively intact and did not receive antianxiety medication. A review of Resident #60's March 2025 physician orders included an order for Oxycodone 5 mg one tablet by mouth four times a day for pain. There were no orders for Ativan. A review of Resident #57's physician orders included an order dated 1/28/25 for Ativan 0.5 milligrams (mg) every 24 hours as needed for fourteen days. This order was completed on 2/11/25. An incident report dated 3/5/25, written by Nurse #1, revealed upon giving report to the oncoming shift nurse, a miscount with narcotics was found. Resident #60 received Ativan 0.5 mg ordered for Resident #57, instead of Oxycodone (a medication used to treat pain) 5mg as ordered. The incident was reported to the Director of Nurses (DON), former Medical Director as well as Resident #60, who was his own Responsible Party. New orders were received to hold the scheduled Oxycodone for 6:00 PM and monitor vital signs throughout the rest of the day and night. A review of Resident #60's March 2025 Medication Administration Record (MAR) indicated the 6:00 PM dose of Oxycodone 5mg was not given. On 4/30/25 at 3:10 PM, an interview occurred with Nurse #1. She explained that typically Resident #60's Oxycodone was the last medication card in the narcotic lock box. She grabbed the last medication card thinking it was Oxycodone for Resident #60, signed out the Oxycodone on the narcotic count sheet and provided the medication to Resident #60 at 6:00 PM as ordered. During the narcotic count with the oncoming nurse at 7:00 PM, it was discovered that Ativan for a different resident, had been pulled instead of the Oxycodone for Resident #60. Nurse #1 stated she immediately reported the incident to the DON, went and assessed Resident #60, and reported the error to Resident #60 and the former Medical Director. Nurse #1 stated that Resident #60 was showing no side effects of receiving the medication. Nurse #1 stated that she should have verified that the correct medication had been pulled by reading the medication label. Nurse #1 stated that the former Medical Director advised her to hold the 6:00 PM scheduled dose of Oxycodone and monitor for any adverse side effects. A phone interview was conducted with the former Medical Director on 5/1/25 at 9:05 AM and stated that she had been notified of the medication error, but didn't feel that it would have caused Resident #60 any harm. She had ordered for the dose of Oxycodone to be held and for staff to monitor Resident #60 throughout the rest of the day and night for any negative side effects. The former Medical Director did not feel this was a significant error, however felt Resident #60 should have received Oxycodone as ordered. The DON was interviewed on 5/1/25 at 10:48 AM and stated that Nurse #1 had provided Resident #60 with another resident's Ativan instead of his ordered Oxycodone on 3/5/25. She acknowledged that the error was immediately reported to her. The DON explained that Resident #60 was assessed for any negative side effects which continued throughout the rest of the evening and night, Resident #60 as well as the former Medical Director were notified of the error and an order was received to hold the 6:00 PM dose of Resident #60's Oxycodone and to continue monitoring his vital signs. The DON stated that immediate education was started with Nurse #1 as well as all other nursing staff regarding medication errors and verifying the medication is the correct one ordered for the residents. The DON confirmed that Resident #60 did not have any negative outcomes or adverse reactions from receiving Ativan instead of Oxycodone. The DON stated that she completed a spot check every morning of the narcotic count sheets and verified the count with the nurse. The facility alleged past noncompliance (PNC) on 3/11/25, however this could not be determined due to a new citation for a significant medication error.

Based on observations, staff, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to follow dental consult Physician order dated 2/28/24 for 1 (Resident #49) of 1 resident reviewed for dental services. The findings included: Resident #49 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident, hemiplegia, and acute gingivitis. Review of Resident #49's hospital discharge summary dated 12/21/23 read he had poor dentition and bleeding gums. There was no recommended intervention except the use of an antiseptic mouthwash four times daily. Review of Resident #49's admission Physician orders dated 12/21/23 included an order for First-Mouthwash BLM Mouth/Throat Suspension (mouth rinse made of different medications used to relieve pain from mouth and throat sores) four times a day for gingivitis. Review of Resident #49's admission Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment, exhibited no behaviors, was dependent on staff for all of his activities of daily living (ADLs). Review of a nursing note dated 2/28/24 at 12:37 PM documented by Nurse #1 read a small amount of blood was noted in Resident #49's mouth. His mouth was cleaned with a swab dipped in water and the bleeding was noted to be coming from his right lower gum. The Physician was notified. Review of Resident #49's February 2024 Physician orders included an order dated 2/28/24 for a dental consult due to a large cavity and red gums. Review of a Nursing Concern/Visit Request for the Physician form dated 2/28/24 completed by Nurse #1 read Resident #49 was bleeding from his lower right gum and a large cavity to his right lower back tooth. The note recommended a dental consult. The note was signed by NP #1 on 2/29/24 with agreement regarding the dental consult and another mouthwash was ordered. The form was last signed by the Unit Manager on 3/1/24. Review of a NP #1 progress note dated 2/29/24 read Resident #49's chief complaint was bleeding gums and a cavity. The note read Resident #49 had poor dental hygiene inflamed gums, red, bleeding gums and a number of civilities that needed to be seen by a dentist for treatment. Resident #49 acknowledged improvement in oral pain since admission to the facility. The progress note read the plan was to begin magic mouthwash (prescription mouthwash used to treat oral pain) three times daily and the facility was to make a dental appointment for Resident #49's cavities and severe gingivitis. Review of Resident #49's March 2024 Physician orders included an order dated 3/5/24 for Peridex (antiseptic mouthwash used to treat gingivitis in adults) mouthwash every morning and at bedtime for gingivitis for 30 days swish for 30 seconds after toothbrushing then expectorate. Review of Resident #49's electronic medical record did not include any documentation of a dental consult since his admission on 12/21/23. An interview was completed on 4/2/24 at 9:36 AM with the Director of Nursing (DON). She stated the reason there was no dental consults in Resident #49's electronic medical record was because the appointment was never made until today and was scheduled for 4/11/24 at 8:00 AM. At this time, the DON was unable to offer any explanation as to why Resident #49's dental appointment was never obtained. An observation and attempted interview was completed on 4/2/24 at 11:45 AM with Resident #49. He was lying in bed and it appeared that he recently received oral care. When asked to open his mouth for observation he obliged. Observed were multiple missing teeth to upper and lower, irritation at his gum lines and at least one hole to one of his right lower back teeth. When questioned about pain in his mouth, he shook his head no. An interview was completed on 4/3/24 at 8:45 AM with the Social Worker. She explained that it was the responsibility of the previous receptionist schedule consult appointments and transportation. An interview was completed on 4/3/24 at 10:05 AM with Nursing Assistant (NA) #1. He stated Resident #49's oral status has been the way it is now since he was admitted in late December 2023 and he thought the dentist was supposed to see him but apparently never did. NA #1 stated was Resident #49 on a purred diet and required assistance with his meals. He stated his appetite was good and he had not noticed that Resident #49's dental status impaired his hunger or eating ability. Review of Resident #49's electronic medical record revealed no significant weight loss since his admission and no oral medications for pain were prescribed since admission. An interview was completed on 4/3/24 at 10:00 AM with Nurse #1. She recalled an aide getting her to look at Resident #49's mouth because he observed blood in his mouth after oral care. She stated she went to assess Resident #49's mouth and noted that his gums were very red, appeared inflamed and he had a large cavity on one of his right back bottom teeth. She stated he denied pain but she wrote a Nursing Concern/Visit Request for the Physician form for NP #1 to assess his mouth the next morning. Nurse #1 stated she also made the Unit Manager aware and think she obtained an order for a dental consult on 2/28/24. Nurse #1 stated at no point since identifying the condition of his teeth and gums has he complained of pain as long as he uses his prescribed mouthwashes as ordered and he was complaint with that. Nurse #1 stated it was not until 4/2/24 that anyone mentioned anything about Resident #49's dental consult. An interview was completed on 4/4/24 at 8:50 AM with the Unit Manager. She stated the previous receptionist was responsible to setting on consult appointments and she put the original order in electric computer for Resident #49's dental consult on 2/28/24 and gave a copy of the NP #1 signed Nursing Concern/Visit Request for the Physician form with the dental consult order for the previous receptionist to set up later that day. She was unable to explain why she signed the form on 3/1/24 but NP #1 signed the form on 2/29/24. The Unit Manager stated she would leave the signed referral forms on top of the previous receptionist's laptop keyboard or on top of her laptop if it was closed. She stated she would then follow up with the previous receptionist about a week later to make sure consult appointment had been made. The Unit Manager stated for Resident #49, she did follow up with the previous receptionist a week later and recalled her telling her that she was still working on it and mentioned something about his insurance. The Unit Manager stated the previous receptionist did not show up for work last week so she was not aware of the status of the dental appointment at present but she contacted NP #1 about the missed appointment on 4/2/24 and he now has a dental appointment for 4/11/24. A telephone interview was completed on 4/3/24 at 2:10 PM with the previous receptionist. She stated she worked at the facility up until last week and was responsible for setting up consult appointments and transportation for the residents. She explained the Unit Manager or the nurse would fill out a referral form, get it signed by NP #1 or the Physician. She stated it was then given to her to set up consult appointment and transportation if needed. The previous receptionist recalled attempting to schedule a dental appointment for Resident #49 but there was a problem with his insurance. She stated she did not mention the insurance problem to anyone at the facility but the Unit Manager. An interview was completed on 4/3/24 at 9:00 AM with NP #1. She stated she was aware that Resident #49's dental issues on his admission in December 2023. She recalled the pharmacy consultant recommending the discontinuation his mouthwash prescribed in the hospital. She stated she agreed with the recommendation and discontinued the mouthwash but it was not long before Resident #49 started complaining of oral pain so she restarted the mouthwash and ordered a dental consult. NP #1 stated sometime around the first of March 2024, she inquired about his dental appointment and the Unit Manager told her the previous receptionist was still working on it. NP #1 stated that was when she ordered the Perdex mouthwash for 30 days. She stated she was made aware on 4/2/24 that Resident #49's dental consult order dated 2/28/24 or 2/29/24 had never been acted on. NP #1 stated she wrote another order on 4/2/24 and the facility obtained a dental appointment that day for 4/11/24. She stated she assessed Resident #49 on 4/2/24 to ensure his mouthwashes were adequate pain control. He indicated he was not experiencing any oral pain. NP #1 stated she expected her orders to be acted on and if there a problem with reimbursement, the facility was to assist in finding the resources for him to see a dentist. An interview was completed on 4/4/24 at 9:05 AM with the Administrator who confirmed that the previous receptionist made the consult appointments for the residents. He stated the previous receptionist did not show up for work last week and would not return calls from the facility. He stated until the new receptionist was trained, the Social Worker would assist with making the consult appointments. The Administrator stated a problem with Resident #49's insurance was not an acceptable reason not to schedule the dental appointment and had the previous receptionist made the Social Worker, the DON or himself aware, it could have been handled then because lack of insurance was not an excuse for not receiving dental care.

Based on observations, resident, staff interviews and record review, the facility failed to promote dignity by not assisting a resident who required staff assistance with activities of daily living (ADLs) with the removal of facial hair. This was for 1 (Resident #38) 3 residents reviewed for ADLs. The findings included: Resident #38 was admitted to the facility on [DATE] with a diagnosis of osteomyelitis. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #38 was cognitively intact, exhibited no behaviors and she was dependent on staff for her personal hygiene. Review of Resident #38's revised care plan dated 2/14/24 read Resident #38 was resistant to Physician recommendations related to eating from the vending machine and not eating sugar free snacks, refusals of showers in the mornings and getting up out of the bed. Resident #38 was also care planned last revised on 3/15/24 for staff assistance with her personal hygiene. Review of Resident #38's electronic medical record and behaviors monitoring from 2/1/24 to present did not include any behaviors associated with refusal of personal hygiene. An observation and interview was completed with Resident #38 on 4/1/24 at 9:45 AM. She was sitting slightly upright in bed wearing a silk sleeping cap and a gown. Observed to her face was large amount of facial hair extending from in front of both ears downward to underneath her chin. When asked if the facial hair was her preference, she stated it was not. She stated staff last helped her remove the facial hair about two weeks ago. Another observation was completed on 4/2/24 at 9:20 AM. Resident #38's facial hair was unchanged. She stated staff came in earlier this morning and assisted her with her ADLs because she was going out for an eye appointment later this morning. An interview was completed on 4/3/24 at 10:05 AM with Nursing Assistant (NA) #1. He stated Resident #38 was always cooperative with him and was not known to refuse ADL assistance. He stated she preferred to sleep in each morning and would ask staff to return to complete ADLs later at times and on occasion, she would refuse to get out of the bed. NA #1 stated Resident #38 was not known to refuse assistance with her personal hygiene. An interview was completed on 4/3/24 at 10:50 AM with NA #2. She stated Resident #38 was always cooperative with her and she never refused any assistance with any of her ADLs with her. A wound care observation was completed on 4/3/24 at 11:55 AM with the Staff Development Coordinator (SDC) in Resident #38's Room positioning her for wound care. Resident #38 was observed with no changed in her facial hair. She motioned to her facial hair and stated, I need to get on this and say something about it. This surveyor confirmed to the SDC who was present that Resident #38 was referring to her facial hair while the SDC shook her head in agreement. Another observation was completed on 4/3/2444 at 4:00 PM. Resident #38 was up in a wheelchair sitting in the hallway. She was clean shaven and stated after her wound care was completed earlier this morning, the staff came in and used something like Veet or Nair (hair removal cream) to remove her facial hair. An interview was completed on 4/4/24 at 10:05 AM with the Director of Nursing. She stated Resident #38's should be assisted with the removal of any unwanted facial hair to promote personal dignity.

Based on observations, staff and responsible party (RP) interviews and record review, the facility failed to honor a resident dependent of staff assistance with his shower preference. This was for 1 of 1 residents (Resident #33) reviewed for choices. The finding included: Resident #33 was admitted on [DATE] with diagnoses of a subdural hemorrhage and aphasia (unable to speak). Review of Resident #33's admission Activity Review dated 5/10/23 completed with his RP read it was very important to Resident #33 to choose between a bed bath, sponge bath or a shower. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #33 had severe cognitive impairment, exhibited no behaviors and he was dependent of staff for bathing. Review of Resident #33's comprehensive care plan included a care area for assistance with his activities of daily living (ADLs) last revised 2/6/24. Interventions included his preference of showers on the shower bed initiated 8/10/23. Review of Resident #33's undated electronic Aide Care Guide/Kardex include the direction under the bathing area that he preferred showers on the shower bed. An observation was completed on 4/1/24 at 10:10 AM of Resident #33 lying in bed wearing a hospital gown. His lips appeared dry with yellowish colored debris on his right lower lip that looked like dried skin. He had the body odor of sweat, but there was no evidence of him sweating. There were no odors of incontinence. A telephone interview was completed on 4/1/24 at 2:20 PM with Resident #3's RP. She stated he was not getting any showers and it was his preference before his injury. She stated she had made management aware on several occasions but it never did any good. She stated the facility always told her that he refused to take showers. An observation was completed on 4/3/24 at 9:00 AM of Resident #33. He appeared to have been recently bathed and dressed in a clean gown. An interview was completed on 4/3/24 at 10:00 AM with Nurse #1. She stated Resident #33 was known for his tensing up behaviors. She stated giving his medications thorough in his feeding tube could take an a while time due to his tensing up causing the medications not to drain into his stomach properly until he finally relaxed enough. An interview was completed on 4/3/24 at 10:05 AM with Nursing Assistant (NA) #1. He stated he completed a bed bath on Resident #33 earlier this morning. NA #1 stated Resident #33 can be combative at times and was known to tense his extremities whenever staff tried to bath, dress or change him. NA #1 stated he had never taken Resident #33 to the shower room because he would be hesitant to put him on the shower bed due to his behaviors. Review of shower schedule last updated 1/30/24 indicated Resident #33's was to receive his showers on Wednesdays and Saturdays on the evening shift. Review of Resident #33's electronic aide documentation for bathing from 1/1/24 to 4/2/24 did not include any documentation of a shower. The facility provided copies of Resident Shower Sheets that all read that bed baths were given instead of showers. The date of these sheets were 1/6, 1/10, 1/13, 1/17, 1/20, 1/24, 1/31, 2/7, 2/14, 2/21, 3/2, 3/16, 3/13, 3/26/243/30/24 and 4/3/24. An interview was completed on 4/3/24 at 4:00 PM with NA #3. She stated she had no problems with Resident #33 in the shower room. She stated she was unable to recall the last time she gave Resident #33 a shower and she was uncertain what days and shift Resident #33 was scheduled to receive his showers. An interview was completed on 4/3/24 at 410pm with NA #4. She stated she had taken Resident #33 to the shower room in the past using the shower stretcher but he was known for tensing up and becoming combative. NA #4 stated she was uncertain the days and shift Resident #33 was scheduled for his showers. An interview was completed on 4/4/24 at 10:05 AM with the Director of Nursing (DON). She stated Resident #33 was known to refuse his ADLs and to become combative. The DON stated because he was known for those behaviors, it should be care planned and monitored. She stated she expected the staff to attempt to perform his showers and document his refusals then notify his RP of any refusals.

Based on record review and interviews with staff, the facility failed to refer a resident (Residents #25) for a level II Preadmission Screening and Resident Review (PASRR) for a newly diagnosed serious mental illness for 1 of 2 residents reviewed for PASRR. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnosis that included Bipolar Disease, Dementia, Parkinson's Disease, and seizure disorder. She was admitted with a level 1 PASRR as of 04/15/19 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Record review revealed Resident #25 was diagnosed on [DATE] with bipolar disorder. There was no evidence a referral for a level II PASRR screening was completed following the identification of this new serious mental health diagnosis. Resident #25's annual Minimum Data Set, dated dated dated [DATE] indicated she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was conducted on 04/02/24 at 3:34 PM with the Administrator. He stated the Social Worker (SW) was responsible for ensuring residents with a newly evident diagnosis of a serious mental illness was referred for a level II PASRR evaluation. He also stated a PASRR level II screening request should have been sent at the time Resident #25 was newly diagnosed with bipolar disorder. He verified Resident #25 had not been referred for level II evaluation at any point after the new diagnosis through present day. He indicated there was not a system in place to monitor for PASRR completion. He further stated they had not had a SW for a while but recently hired one who was being trained for the position.

Based on observations, staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of dental status and range of motion for 2 of 21 residents reviewed for MDS accuracy (Resident #49 and Resident #53). The findings included: 1. Resident #49 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident, hemiplegia, and acute gingivitis. Review of Resident #49 hospital discharge summary dated 12/21/23 read he had poor dentition and bleeding gums. There was no recommended intervention except the use of an antiseptic mouthwash four times daily. Review of Resident #49's admission Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment, exhibited no behaviors, was dependent on staff for all of his activities of daily living (ADLs). He was not coded for missing broken natural teeth, cavities, bleeding or inflamed gums. An observation completed on 4/1/124 at 12:47 PM revealed multiple missing teeth in Resident #49's mouth both upper and lower gums. There was no evidence of bleeding gums at the times of the observations and he denied oral pain. A telephone interview was complete on 4/4/24 at 9:42 AM with the Corporate MDS Nurse #1. She stated she completed all the MDS coding remotely and relied on some of the observation information emailed to her regarding Resident #49's current dental status. She stated clearly, the information she was provided was incorrect. An interview was completed on 4/4/24 at 10:05 AM with the Director of Nursing (DON). She stated the facility did not have any in-house MDS Nurses and that Corporate Nurses had been completing the MDS assessments remotely with the assistance of emailed observations. The DON stated it must have been an oversight. 40197 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included a stroke resulting in hemiplegia (weakness to one side of the body) and hemiparesis (paralysis to one side of the body) of the right dominant side. Resident #53's baseline care plan included a focus area initiated on 2/27/24 for Activities of Daily Living (ADL) self-care performance deficit related to intracranial hemorrhage with right hemiparesis. A review of the Occupational Therapy Evaluation dated 2/27/24 indicated Resident #53's right upper extremity had impaired range of motion. A review of Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had moderately impaired cognition and required assistance from staff for ADLs. She was not coded with any range of motion deficits to the upper body. On 4/1/24 at 10:45 AM, an interview and observation were conducted with Resident #53. She was unable to lift or use her right arm or hand and used her left hand to gesture and write on the erasable white board. Resident #53 was observed on 4/2/24 at 11:48 AM propelling herself in the hallway. A sling was present to the right arm, and she was using her left hand to pull herself on the handrails in the hallway. An interview occurred with the Occupational Therapist on 4/3/24 at 2:57 PM. She verified that Resident #53 was unable to use the right arm or hand due to paralysis. A telephone interview was completed with the Corporate MDS Nurse #1 on 4/4/24 at 9:42 AM. She explained that she completed all MDS coding remotely and received the information from record reviews and emailing different staff members. She reviewed Resident #53's 3/4/24 MDS and verified that range of motion was not coded as impaired for one of the upper extremities but should have been. The Corporate MDS Nurse #1 stated she felt it was an oversight. On 4/4/24 at 10:13 AM, the Administrator and Director of Nursing were interviewed and stated it was their expectation for the MDS to be coded accurately.

Based on observations and interviews with residents and staff, the facility failed to maintain bedside tables free from dried spills and debris for two rooms (room [ROOM NUMBER] and 212), failed to repair a broken dresser drawer (room [ROOM NUMBER]) and failed to ensure a resident ' s bedpan was labeled and stored in a sanitary manner. This deficient practice affected 1 of 3 resident halls (200 Hall). The findings included: 1. An observation of room [ROOM NUMBER] on 04/01/24 at 12:32 PM revealed bed A bedside table had a dried yellowish hardened substance on base of table measuring approximately 1 x 2 inches. Also bed A and B bedside tables with built up black substance on 2 separate 2.5 x 2 inch triangle areas on the base of each table. room [ROOM NUMBER] was occupied with 2 residents at the time of the survey. Housekeeper #1 observed in room wiping the top of A bed bedside table. An observation of room [ROOM NUMBER] on 04/02/24 at 09:55 PM revealed a bedpan with a white powder like substance on the rim and the inside of the bedpan sitting in the seat of a wheelchair in the bathroom. The bedpan was not labeled nor was it in a plastic bag. An interview and observation were conducted on 04/02/24 at 11:55 AM with Nursing Assistant (NA) #3. She stated the bedpans should be kept in a plastic bag with the residents' name on it. She confirmed a bedpan with a white powder like substance was in a wheelchair in the bathroom of room [ROOM NUMBER]. The bedpan was not in a bag. She stated she did not leave the bedpan like that, and she did not notice it this morning. She further stated she was assuming it was resident in bed-B ' s bedpan, but she was not positive. She further stated the resident in bed-A was incontinent of bowel and bladder and bed-B would request the bedpan at times. An observation of room [ROOM NUMBER] on 04/02/24 at 12:00 PM revealed the bedside tables remained in the same condition with yellowish hardened and black substances on the base of the tables. The bedpan remained in the wheelchair in the bathroom with a white powder like substance on the rim and the inside of the bedpan. An observation of room [ROOM NUMBER] on 04/03/24 at 8:55 AM revealed the bedside tables remained in the same condition with yellowish hardened and black substances on the base of the tables. The bedpan remained in the wheelchair in the bathroom with a white powder like substance on the rim and the inside of the bedpan. An interview was conducted on 04/03/24 at 11:28 AM with the housekeeping supervisor. She stated housekeeping staff are to clean the entire bedside tables daily. The task is included on the daily checkoff sheet for the housekeepers to follow. Review of housekeeping checkoff list revealed the area that read wipe bedside table, as being completed for 04/1/24 through 04/04/24. An interview was conducted on 04/03/24 at 1:19 PM with Housekeeper #1. She stated she was responsible for cleaning the 200 hall the week of 4/1/24. She stated she did use the check list while performing her duties. She further stated the task on the check list read wipe bedside table, and she was under the impression that just meant the top of the bedside table, not the legs and base. She did not recall that task being elaborated or explained in detail during orientation. Review of housekeeping checkoff list for room [ROOM NUMBER] and 212 revealed the area that read wipe bedside table, as being completed for 04/3/24. An observation of room [ROOM NUMBER] on 04/03/24 at 3:35 PM revealed the bedpan remained in the wheelchair in the bathroom with a white powder like substance on the rim and the inside of the bedpan. An interview was conducted on 04/03/24 at 4:16 PM with Nursing Assistant (NA) #4. She stated all personal items such as bedpans, shampoo, body wash, and bath basins should have the residents ' room #, bed and stored in a plastic bag. She verified she was assigned room [ROOM NUMBER] on 04/02/24 and 04/03/24 but she was unaware that it was not stored in a plastic bag. An interview was conducted on 04/04/24 at 10:25 AM with the Director of Nursing (DON). She stated nursing staff should clean bedpans if they are dirty and keep them stored in a plastic bag with their room number. An interview was conducted on 04/04/24 at 10:28 AM with the Administrator. He stated the bedside tables were to be cleaned daily by housekeeping. 2. An observation of room [ROOM NUMBER] on 04/01/24 at 12:36 PM revealed room [ROOM NUMBER] A and B bedside tables revealed 209-A bedside table had dried tan/brownish hardened substance on the base of table and 209-B bedside table had dried black splatters which appeared dirt like on the base of table. An observation of room [ROOM NUMBER] on 04/02/24 at 12:10 PM revealed the bedside tables remained in the same condition with dried tan/brownish hardened substance and black splatters which appeared dirt like on the base of the tables. An observation of room [ROOM NUMBER] on 04/03/24 at 9:02 AM revealed the bedside tables remained in the same condition with dried tan/brownish hardened substance and black splatters which appeared dirt like on the base of the tables. An interview was conducted on 04/03/24 at 11:28 AM with the housekeeping supervisor. She stated housekeeping staff are to clean the entire bedside tables daily. The task was included on the daily checkoff sheet for the housekeepers to follow. This task had been signed as being completed by Housekeeper #1. She indicated this task was thoroughly explained in orientation. She verified the 2 bedside tables in room [ROOM NUMBER] needed to be cleaned. An interview was conducted on 04/03/24 at 1:19 PM with Housekeeper #1. She stated she was responsible for cleaning the 200 hall the week of 4/1/24. She stated she did use the check list while performing her duties. She further stated the task on the check list read wipe bedside table, and she was under the impression that just meant the top of the bedside table, not the legs and base. She did not recall that task being elaborated or explained in detail during orientation. An interview was conducted on 04/04/24 at 10:28 AM with the Administrator. He stated the bedside tables are to be kept clean by housekeeping. 3. An observation of room [ROOM NUMBER] on 04/01/24 at 12:42 PM revealed the dresser drawer remained in the same condition with the front panel attached on one side and the right side hanging down overlapping the bottom drawer. An observation of room [ROOM NUMBER] on 04/02/24 at 12:14 PM revealed the dresser drawer remained in the same condition with the front panel attached on one side and the right side hanging down overlapping the bottom drawer. There was exposed rough wood on the edge of the drawer where it broke away from the side panel. An observation of room [ROOM NUMBER] on 04/03/24 at 9:05 AM revealed the dresser drawer remained in the same condition with the front panel attached on one side and the right side hanging down overlapping the bottom drawer. There was exposed rough wood on the edge of the drawer where it broke away from the side panel. An interview was conducted on 04/03/24 at 11:00 AM with the Maintenance Assistant. He stated he was not aware of the dresser drawer being broken in room [ROOM NUMBER] and he did not have a work order for it. He verified the drawer was broken and removed the drawer to repair. An interview was conducted on 04/03/24 at 11:05 AM with the Maintenance Manager. He stated he was not aware of the dresser drawer being broken and he did not have a work order for it. He verified the drawer was broken and would have expected staff to complete a work order so it could be repaired. An interview was conducted on 04/03/24 at 11:08 AM with a cognitively intact resident in room [ROOM NUMBER]. He stated the drawer had been broken since he had been in room [ROOM NUMBER]. He was moved to room [ROOM NUMBER] on 7/14/2023. He thought they were aware it was broken. An interview was conducted on 04/03/24 at 12:02 PM with Nurse #3. She stated if something needed repair in the facility, she would let the unit supervisor know or she would fill out a work order request for maintenance making them aware of the situation. She stated that she had not noticed the broken drawer. An interview was conducted on 04/04/24 at 10:28 AM with the Administrator. He stated all furniture and equipment was to be in good repair and if it was broken staff were to report it to maintenance for repairs by completing a work order and putting it in the maintenance box.

Based on observations, staff interviews and record review, the facility failed to provide nail care to a resident dependent of staff assistance with his activities of daily living (ALDs). This was for 1 (Resident #49) of 4 residents reviewed for ADLs. The findings included: Resident #49 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident, right hemiplegia and prediabetes. The quarterly Minimum Data Set, dated dated dated [DATE] indicated severe cognitive impairment, he exhibited no behaviors and he was dependent on staff for all of his ADLs. Resident #49 was care planned on 12/22/23 and last revised 1/23/24 for an ADL self-care performance deficit related to an intercranial hemorrhage. Interventions included to check his nail length, trim and clean as necessary. Report any changes to the nurse. Review of Resident #49's March 2024 Physician orders included an order dated 12/22/23 for blood glucose checks twice daily for nutrition monitoring. This order was discontinued on 3/22/24 due to the discontinuation of his tube feedings. Review of Resident #49's April 2024 Physician orders included an order dated 1/30/24 for a right hand/wrist splint for 4-6 hours on day shift. Monitor resident's tolerance and skin integrity while the splint is in place/at removal one time a day to prevent contracture. Review of Resident #49's March 2024 and April 2024 medication administration records (MARs) included documented evidence that the floor nurses were initialing off ensuring the right hand splint was on correctly and there was no skin integrity concerns. An observation was completed on 4/1/24 at 12:47 PM of Resident #49. He was lying in bed wearing his right hand splint. The fingernails to his left hand were grown out over his fingertips approximately 1/2 inch, appeared jagged with a dark black substance underneath the nails. Observation of the fingernails to his splinted right hand revealed his nails extended approximately 3/4 of an inch past his fingertips. The nails were jagged and appeared to have a less black colored substance underneath the nails. An observation was completed on 4/2/24 at 11:45 AM of Resident #49. He was again wearing his right hand splint and his fingernails were unchanged. Another observation was completed on 4/2/24 at 4:00 PM of Resident #49. He was sitting in a reclining chair in the lounge watching television. His right hand splint had been removed and his fingernails were unchanged. When asked to allow observation of his right palm, Resident #49 presented his right hand. Observed were four fingers curled over into his palm that he was unable lift so the fingernails to the right hand were not visible. An observation was completed on 4/3/24 at 9:53 AM of Resident #49. He was lying in bed. He left hand fingernails were unchanged. Resident #49's right hand splint had not been applied yet so his fingernails to his right hand were not visible due to his right hand contracture. An interview was completed on 4/3/24 at 10:00 AM with Nurse #1. She stated Resident #49's splint application order populated on the MAR for 9:00 AM. She stated she just had not had time to go and apply the splint yet this morning. Nurse #1 stated it was the nurses who were responsible for applying and removing Resident #49's right hand splint. When asked if she noticed the condition of Resident #49's fingernails when she applied his hand splint yesterday, she stated she thought it was already on him when she came in at 7:00 AM yesterday. Nurse #1 was unable to say who may have applied the splint. Review of the MAR with Nurse #1 for 4/2/24 revealed it was initiated by an orientee Nurse #1 worked with yesterday. Nurse #1 confirmed she did remove Resident #49's right hand splint yesterday but she did not notice the condition of his fingernails. She stated she would cut and clean his fingernails today after the aide completed his bath. When questioned if the aides were allowed to provide his nail care, Nurse #1 stated she was unsure since at one time they were performing blood glucose checks on him but that stopped when his tube feeding stopped last month. An interview was completed on 4/3/24 at 10:05 AM with Nursing Assistant (NA) #1. He stated nobody in particular was responsible for cutting Resident #49's fingernails and whoever noticed the need was responsible for cutting his fingernails. NA #1 stated he had not noticed the condition of Resident #49's fingernails. A telephone interview was completed on 4/4/24 at 9:30 AM with Nurse #4. She confirmed she worked first shift Monday 4/1/24 with Resident #49 and that she initialed off that she applied his right hand splint and noted the skin integrity to his hand. When questioned about if she noticed the condition of Resident #49's fingernails on 4/1/24, she stated she thought his splint may have already been on his hand when she first saw him around 9:00 AM. Nurse #4 stated the aides were also trained on the application and removal of his right hand splint and it was added to the MAR for the nurses to just ensure that it was being done. Nurse #4 stated she did not recall removing Resident #49's right hand splint either. She stated NA #1 was instructed to complete nail care and shave all the male residents on 4/1/24 but apparently, he did not do it as instructed. Nurse #4 stated anyone could do Resident #49's nail care because he was not diabetic. An interview was completed on 4/4/24 at 10:05 AM with the DON. She stated Resident #49 was not ever considered a diabetic and that anyone who noticed that his fingernails were dirty, long and jagged should immediately clean and trim them when identified.

Based on record reviews and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of dental (Resident #30), urology (Residents #160 and #36) and podiatry (Resident #36). This was for 3 of 21 resident records reviewed. The findings included: 1. Resident #30 was admitted to the facility on [DATE]. A review of Resident #30's physician orders included an order dated 1/4/24 for a dental consult on 1/5/24 at 10:00 AM. A review of Resident #30's electronic medical record (EMR) did not include any dental consult progress notes. On 4/2/24 at 9:35 AM, an interview occurred with the Director of Nursing (DON) who stated the dental consult from 1/5/24 was not located in the facility and she would reach out to the provider to get a copy faxed over. The DON further stated it was the receptionist's responsibility to upload consultations to the EMR, but she had recently departed the facility. The Administrator was interviewed on 4/2/24 at 3:46 PM and provided the dental consult note from 1/5/24 that was faxed to the facility on the day of the interview. He stated the reason Resident #30's consults were not in the EMR was because the receptionist was responsible to upload the consults after the nurses had reviewed them but she apparently wasn't doing her part and was no longer employed at the facility. He further indicated the medical records person from the sister facility was working a couple of days a week at his facility to assist in getting things caught up. A phone interview was conducted 4/3/24 at 2:10 PM with Receptionist #1, who had departed from the facility the week of 3/25/24. She verified the receptionist was responsible for scanning consultations into the EMR system but was unable to state why Resident #30's dental progress note was not present in her medical record. The DON was interviewed again on 4/3/24 at 3:22 PM and explained when a resident returned from a medical consultation appointment, the nurses reviewed the form and took off any necessary orders. The consultation progress note was then placed in the medical records box where the receptionist was responsible for scanning and uploading the document into the resident's medical record. On 4/4/24 at 10:13 AM, the Administrator indicated it was his expectation for consultation progress notes to be scanned and uploaded to the resident medical record in a timely manner. A telephone interview was conducted on 4/4/24 at 1:17 PM with the medical records person from the sister facility. She explained she was working at the facility one day a week and focused on coding, certifications, auditing of regulatory visits and attended the Medicare meeting for compliance. She stated it was the responsibility of the receptionist to scan consults into the EMR and she (the medical records person) was not scanning consults. 2. Resident #160 was admitted to the facility on [DATE] with diagnoses that included chronic hematuria (blood in urine) and presence of a urinary catheter. Review of a nursing progress note dated 3/26/24 indicated Resident #160 was seen at the urology clinic with orders to start Avodart (a medication used to treat an enlarged prostate) 0.5 milligrams (mg) one capsule by mouth every day. A review of Resident #160's physician orders included Avodart 0.5 mg one capsule by mouth every day that was started on 3/26/24. A review of Resident #160's electronic medical record (EMR) did not include urology progress notes. On 4/2/24 at 9:35 AM, an interview occurred with the Director of Nursing (DON) who stated the urology consult from 3/26/24 was not located in the facility and she would reach out to the provider to get a copy faxed over. The DON further stated it was the receptionist's responsibility to upload consultations to the EMR, but she had recently departed the facility. The Administrator was interviewed on 4/2/24 at 3:46 PM and provided the dental consult note from 1/5/24 that was faxed to the facility on the day of the interview. He stated the reason Resident #30's consults were not in the EMR was because the receptionist was responsible to upload the consults after the nurses had reviewed them but she apparently wasn't doing her part and was no longer employed at the facility. He further indicated the medical records person from the sister facility was working a couple of days a week at his facility to assist in getting things caught up. A phone interview was conducted 4/3/24 at 2:10 PM with Receptionist #1, who had departed from the facility the week of 3/25/24. She verified the receptionist was responsible for scanning consultations into the EMR system but was unable to state why Resident #160s urology progress note was not present in his medical record. The DON was interviewed again on 4/3/24 at 3:22 PM and explained when a resident returned from a medical consultation appointment, the nurses reviewed the form and took off any necessary orders. The consultation progress note was then placed in the medical records box where the receptionist was responsible for scanning and uploading the document into the resident's medical record. On 4/4/24 at 10:13 AM, the Administrator indicated it was his expectation for consultation progress notes to be scanned and uploaded to the resident medical record in a timely manner. A telephone interview was conducted on 4/4/24 at 1:17 PM with the medical records person from the sister facility. She explained she was working at the facility one day a week and focused on coding, certifications, auditing of regulatory visits and attended the Medicare meeting for compliance. She stated it was the responsibility of the receptionist to scan consults into the EMR and she (the medical records person) was not scanning consults. 31227 3. Resident #36 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident (CVA), hemiplegia, obstructive and reflux uropathology. The quarterly Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact, exhibited no behaviors, coded for a urinary catheter and not coded for any open areas to his feet. Review of Resident #36's comprehensive care plan included a care area dated 10/23/23 and last revised on 2/7/24 for an indwelling catheter related to obstructive uropathy. Another care area was for actual impairment to his skin integrity to his left 1st and 2nd toes on 2/5/24 last revised 2/28/24. An interview was completed on 4/1/24 at 1:23 PM with Resident #36. He stated his injuries to his toes were a result of the podiatrist visit and the facility had been doing wound care with the wound doctor since sometime in January 2024 when it first happened. Resident #36 stated he had a urology appointment back in late January 2024 and another follow up urology appointment later in the week to discuss the possibility of getting a suprapubic catheter. Review of Resident #36's electronic medical record did not include any documentation regarding any urology consults or podiatry consults that he stated resulted in the injuries to his left foot. The following documentation was requested 4/2/24 at 9:00 AM from the Administrator: copies al all podiatry consult notes and urology consults from 1/1/24 to present. On 4/2/24 at 9:36 AM, the Director of Nursing (DON) stated she reached out to their podiatry provider to get copies of Resident #36's notes because they were not in the electronic medical record. She stated the previous medical records person was the receptionist and she walked out last week and things have not been uploaded. The DON was able to provide a recent podiatry note dated 3/22/24 but this note was not related to his original injuries to his left foot back in January 2024. She stated they faxed over the 3/22/24 podiatry note today at her request. On 4/2/24 at 1:56 PM, the Administrator provided a copy of a podiatry note dated 1/4/24 and an incident report dated 1/9/24 related to Resident #36's toes injuries as a result of the 1/4/24 podiatry visit. The Administrator stated the 1/4/24 podiatry note was faxed to the facility today. At same time Administrator provided a urology consult note dated 1/31/24 with orders to follow up again in 1-2 months. He stated the urology note was also faxed to the facility today. An interview was completed on 4/2/24 at 3:46 PM with the Administrator. He stated the reason Resident #36's consults were not in his electronic medical record was because the receptionist was responsible to upload the consults after the nurses have reviewed then but she apparently was not doing her part. He stated she was let go last week and the medical records person from the sister facility was coming a couple of days a week to assist in getting things caught up. A telephone interview was completed on 4/4/24 at 1:17 PM with the medical record's person at the sister facility. She stated she came to the facility on e day a week and focused on coding, certifications, auditing of regulatory visits and attended Medicare meetings for compliance. She stated it was the responsibility of the previous receptionist to scan consults into the electronic medical record.

Based on record reviews, observations, responsible party (RP), resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following annual recertification and complaint survey on 2/17/22. This was for seven deficiencies that were cited in the areas of Resident Rights/Exercise of Rights, Self Determination, Notice Requirements Before Transfer/Discharge, Accuracy of Assessments, Care Plan Timing and Revision, Activities of Daily Living Care Provided for Dependent Residents and Resident Records-Identifiable Information. In addition, six deficiencies were cited during the annual recertification and complaint survey on 2/9/23 in the areas of Self Determination, Notice Requirements Before Transfer/Discharge, Accuracy of Assessments, Care Plan Timing and Revision, Activities of Daily Living Care Provided for Dependent Residents and Resident Records-Identifiable Information. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: The citations are cross referenced to: 1) F550- Based on observations, resident, staff interviews and record review, the facility failed to promote dignity by not assisting a resident who required staff assistance with activities of daily living (ADLs) with the removal of facial hair. This was for 1 (Resident #38) 3 residents reviewed for ADLs. During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to treat residents in a dignified manner by not responding to call lights resulting in feeling of anger and frustration. This was for 5 of 5 residents reviewed for dignity. The Administrator and Director of Nursing (DON) were interviewed on 4/4/24 at 10:30 AM and felt the repeat citation was due to the use of agency staff in the facility. They stated that they have started tracking agency staff to keep consistency for the care of the residents. 2) F561- Based on observations, staff, and responsible party (RP) interviews and record review, the facility failed to honor a resident dependent of staff assistance with his shower preference. This was for 1 of 1 resident (Resident #33) reviewed for choices. During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to honor residents' choices related to showers and shampoos. This was for 3 of 4 residents reviewed for choices. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to honor a resident's choice related to showers for 1 of 1 resident reviewed for choices. The Administrator and DON were interviewed on 4/4/24 at 10:30 AM and felt the repeat citation was due to the use of agency staff in the facility. They stated they have started tracking agency staff to keep consistency for the care of the residents. 3) F623- Based on record review and staff interviews, the facility failed to notify the resident and/or the responsible party (RP) in writing of the reason for hospital transfer/discharge for 4 of 4 residents reviewed for hospitalization s (Residents #40, #17, #15 and #2). During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to notify the responsible party in writing of the reason for the discharge to the hospital for 4 of 5 sampled residents reviewed for hospitalization s. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to notify the resident and or responsible party (RP) in writing of the reason for the transfer/discharge to the hospital and failed to send a copy of the discharge notice to the Ombudsman for 3 of 3 sampled residents reviewed for hospitalization . The DON was interviewed on 4/4/24 at 10:30 AM and stated it was her responsibility to get the reason for hospital transfer form completed and was unaware of the regulation that it needed to be provided in writing. 4) F641- Based on observations, staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of dental status and range of motion for 2 of 21 residents reviewed for MDS accuracy (Resident #49 and Resident #53). During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of nutrition, restraints, dental status, accidents, pressure ulcers, and pain management. This was for 7 of 22 residents reviewed. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of bladder incontinence, pressure ulcer, & nutrition for 3 of 20 sampled residents whose MDS were reviewed. The Administrator and DON were interviewed on 4/4/24 at 10:30 AM and felt the reason for the repeat citation was not having an MDS coordinator in the facility in the past year. Currently the MDS assessments were being completed offsite by corporate MDS nurses. 5) F657- Based on record review and staff interviews, the facility failed to revise the comprehensive care plan for the discontinuation of an antipsychotic medication for 1 (Resident #33) of 5 residents reviewed for unnecessary medications. During the facility's annual recertification and complaint survey dated 2/17/22 , the facility failed to review and revise the care plan in the areas of medication and pressure ulcer. This was for 2 of 22 residents reviewed. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to review and revise the care plan in the areas of code status and pressure ulcer for 2 of 20 sampled residents whose care plans were reviewed. The Administrator and DON were interviewed on 4/4/24 at 10:30 AM and felt the reason for the repeat citation was not having an MDS coordinator in the facility in the past year. Currently the MDS assessments were being completed offsite by corporate MDS nurses. 6) F677- Based on observations, staff interviews and record review, the facility failed to provide nail care to a resident dependent of staff assistance with his activities of daily living (ALDs). This was for 1 (Resident #49) of 4 residents reviewed for ADLs. During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to provide nail care to residents' dependent on staff assistance with activities of daily living (ADLs). This was for 5 of 8 reviewed for ADLs. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to trim and clean dependent residents' nails and failed to provide incontinent care for 3 of 8 residents reviewed for Activities of Daily Living (ADL's). The Administrator and DON were interviewed on 4/4/24 at 10:30 AM and felt the repeat citation was due to the use of agency staff in the facility. They stated they have started tracking agency staff to keep consistency for the care of the residents. 7) F842- Based on record reviews and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of dental (Resident #30), urology (Residents #160 and #36) and podiatry (Resident #36). This was for 3 of 21 resident records reviewed. During the facility's annual recertification and complaint survey dated 2/17/22, the facility failed to have complete and accurate medical records in the areas of wound care, protective skin coverings, medications and topical treatments. This was for 3 of 22 residents reviewed. During the facility's annual recertification and complaint survey dated 2/9/23, the facility failed to maintain accurate medical records for 1 of 1 resident reviewed for diabetic wound care. The Administrator and DON were interviewed on 4/4/24 at 10:30 AM and felt the repeat citation was due to the turnover in receptionists in the past year.

Based on record review and staff interviews, the facility failed to notify the resident and/or the responsible party (RP) in writing of the reason for hospital transfer/discharge for 4 of 4 residents reviewed for hospitalization s (Residents #40, #17, #15 and #2). The findings included: 1. Resident #40 was admitted to the facility on [DATE]. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 ' s cognition was severely impaired. A review of Resident #40's nurses notes revealed he was transferred to the hospital on 12/27/23 for lethargy. There was no documentation in the resident ' s medical record that written notice of transfer was provided to the resident and/or Responsible Party (RP) regarding the transfer. Resident #40 returned to the facility on [DATE]. Attempted to interview the RP without success. An interview was conducted on 04/02/24 at 3:34 PM with the Administrator. He verified that the Social Worker (SW) failed to complete the form for Resident #40 and therefore, the responsible party (RP) was not notified in writing when the resident was discharged to the hospital on 12/27/23. An interview was conducted on 04/02/24 at 3:59 PM with the Director of Nursing (DON). She stated normally nursing notified the responsible party (RP) by phone and sends the notice of discharge/transfer with the resident to the hospital. The facility had not been mailing the notice of transfer to the responsible party (RP). Multiple attempts were made to contact the Social Worker (SW) from 2020, without success. 2. Resident #17 was admitted to the facility on [DATE]. A review of Resident #17's nurses notes, and transfer form revealed he was transferred to the hospital on 03/04/24 for lethargy. There was no documentation in the resident ' s medical record that written notice of transfer was provided to the resident and/or Responsible Party (RP) regarding the transfer. Resident #17 returned to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact. An interview was conducted on 04/02/24 at 3:34 PM with the Administrator. He verified that the Social Worker (SW) failed to complete the transfer form for Resident #17 and therefore, the responsible party (RP) was not notified in writing when the resident was discharged to the hospital on 03/04/24. An interview was conducted on 04/02/24 at 3:59 PM with the Director of Nursing (DON). She stated normally nursing notified the responsible party (RP) by phone and sends the notice of discharge/transfer with the resident to the hospital. The facility had not been mailing the notice of transfer to the responsible party (RP). Multiple attempts were made to contact the Social Worker (SW), without success. 31227 3. Resident #15 was admitted on [DATE] with diagnoses of adult failure to thrive, dysphagia and cerebral vascular accident (CVA). The most recent re-admission Minimum Data Set, dated dated dated [DATE] indicated she had moderate cognitive impairment. Review of Resident #15's medical record included a nursing note dated 10/19/23 at 3:30 AM, she was transferred to the hospital for large amount of emesis. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. Review of Resident #15's medical record included a nursing note dated 11/2/23 at 4:20 PM, she briefly lost consciousness during therapy and she was transferred to the hospital. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. Review of Resident #15's medical record included a nursing note dated 11/22/23 at 8:52 AM, she was transferred to the hospital for small bowel series and possible gastric tube placement. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. Review of Resident #15's medical record included a nursing note dated 1/11/24 at 2:35 PM, she was experiencing nausea and vomiting and was transferred to the hospital again for an evaluation. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. Review of Resident #15's medical record included a nursing note dated 1/23/24 7:25 PM, she was transferred to the hospital for not being able to follow commands, She was alert but unresponsive and sent to the hospital for an evaluation. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. Review of Resident #15's medical record did not include a nursing note explaining why she was sent back out to the hospital on 3/27/24. There was no documentation that a written notice of transfer was provided to the resident and/RP for the reason of the transfer. On 4/2/24 at 4:01 PM an interview occurred with the Director of Nursing (DON) who stated that a copy of the transfer notice was sent with the resident to the hospital. The DON explained that the RP was notified by phone when a resident was sent to the hospital but she was unaware a written notice of transfer with the reason was required. The DON stated the facility had not been mailing or providing residents or RP's anything in writing regarding the reasons for hospital transfers. An interview was conducted with Nurse #2 on 4/3/24 at 1:50 PM and stated a copy of the face sheet, any Do Not Resuscitate (DNR) information, medication list, transfer form, and any other pertinent documents were sent with the resident when they were transferred to the hospital. The RP was notified by phone for the reason of the transfer. The Administrator was interviewed on 4/4/24 at 10:13 AM and stated he would expect the resident and/or RP be provided with the written reason for hospital transfer per the regulation. 40197 4. Resident #2 was originally admitted to the facility on [DATE] with diagnoses that included end stage renal disease, congestive heart failure and chronic obstructive pulmonary disease (COPD). A medical record review revealed Resident #2 was transferred to the hospital and readmitted to the facility for respiratory issues on 11/9/23 to 11/14/23, 11/23/23 to 11/28/23 and 1/4/24 to 1/11/24. There was no documentation that written notices of transfers were provided to the resident and/or responsible party (RP) for the reasons of the transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact. On 4/2/24 at 4:01 PM an interview occurred with the Director of Nursing (DON) who stated that a copy of the transfer notice was sent with the resident to the hospital. The DON explained that the RP was notified by phone when a resident was sent to the hospital and was unaware a written notice of transfer with the reason was required. An interview was conducted with Nurse #2 on 4/3/24 at 1:50 PM and stated a copy of the face sheet, any Do Not Resuscitate (DNR) information, medication list, transfer form, and any other pertinent documents were sent with the resident when they were transferred to the hospital. She added that when a resident was discharged to the hospital a phone call was made to the RP for the reason of the transfer. The Administrator was interviewed on 4/4/24 at 10:13 AM and stated he would expect the resident and/or RP to be provided with the written reason for hospital transfer per the regulation.

Based on staff and resident interviews, and record review, the facility failed to transfer a resident with a mechanical lift according to the care planned intervention for Resident #2. This deficient practice was for 1 (Resident #2) of 3 residents reviewed for supervision to prevent accidents. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnosis that included limited movement of Bilateral Lower Extremities (BLE) due to severe osteoarthritis of bilateral knees. Resident #2's care plan last revised 02/02/23 indicated the problem area of activities of daily living (ADL) self-care performance deficit related to activity Intolerance and debility. Interventions included resident to be transferred via mechanical lift with 2 staff member assistance. The significant change in status Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #2's cognition was moderately impaired. Resident #2 was also coded as requiring extensive assistance with 2 people with bed mobility, total assistance with 2 people for transfers, and range of motion (ROM) impairment to both sides of lower extremities. Review of nursing note in the medical record dated 04/20/23 revealed Resident #2 reported to Nurse #2 that she had pain to her right hand that started after getting out of bed this afternoon. Nurse #2 documented her assessment of Resident #2 ' s right hand, at her knuckle at third digit was starting to bruise, appeared swollen, and resident reported increased pain with use. Resident #2 ' s Kardex (a guide for resident care needs used by Nursing Assistant (NA) was observed on the NAs electronic documentation system. The Kardex revealed Resident #2 was to be transferred by 2 staff members via a mechanical lift. An interview with the Rehab Director was conducted on 07/05/23 at 10:04 AM. He indicated he was familiar with mechanical lifts. He also indicated nurses, or the Director of Nursing (DON) would reach out to the therapy department if they have concerns regarding a resident needing a mechanical lift. He indicated a therapist would evaluate for the need of a mechanical lift and the evaluation and determination were based on the safety of staff and residents during a transfer. Interview with Resident #2 was conducted on 07/05/23 at 1:23 PM. She stated she does not remember what happened to her hand at the end of April. She indicated staff used to just slide her over from the bed to the chair and not use any mechanical machine. She also stated she does not like for staff to use the mechanical lift, but now she knows they must use it for safety reasons. Observation of Resident #2 ' s right hand revealed no bruising or swelling. A phone interview was conducted with Nurse #2 on 07/05/23 at 2:25 PM. She stated when she went in on 04/20/23 to give Resident #2 her medications she complained of pain to her right hand. She also stated she administered her a pain pill and assessed her hand for injuries. Her skin at the knuckle and third digit was purplish in color and appeared swollen, and Resident #2 reported increased pain with use of her hand. She indicated when she asked the resident what had happened the resident reported she was transferred from her bed to her to her recliner earlier today by the Nursing Assistant (NA) and felt pain immediately after the transfer. She further stated she had not reported that she had pain after the transfer. A phone interview was conducted with NA #1 on 07/05/23 at 2:33 PM. She indicated that when she transferred Resident #2 from the bed to the recliner that the resident requested that she not use the mechanical lift on 04/20/23. She stated she slid the chair over to the bed, adjusted the bed so it was leveled with the chair and Resident #2 then pushed herself from the bed into the chair. She further stated Resident #2 had not complained of pain to her right hand until the time of the transfer and she did not observe any discoloration to her right hand. An interview with the Director of Nursing (DON) was conducted on 07/06/23 at 3:33 PM. She indicated the nursing staff were to access the Kardex (a guide for resident care needs used by Nursing Assistants) to obtain information prior to providing care. She further indicated that Nursing Assistant #1 should have used a mechanical lift with 2 people to assist with the transfer of Resident #2 to ensure safety.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification surveys dated 2/17/22 and 2/9/23 for one deficiency in the area of supervision to prevent accidents (F689). The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F689 Based on staff and resident interviews, and record review, the facility failed to transfer a resident with a mechanical lift according to the care planned intervention for Resident #2. This deficient practice was for 1 (Resident #2) of 3 residents reviewed for supervision to prevent accidents. During the recertification survey dated 2/17/22 the facility failed to prevent repeated falls by not providing effective interventions for each fall for 1 of 4 residents reviewed for accidents. The resident sustained fracture of the fingers on 9/10/21 and left and right hip fractures on 9/24/21 after the fall. During the recertification survey dated 2/9/23 the facility failed to prevent a fall for a resident with cognitive impairment and poor decision-making skills who required extensive staff assistance with bed mobility and positioning for 1 of 8 residents reviewed for accidents. The resident rolled for her side onto the floor resulting in a left femur fracture. The bed was in the high position while the Nursing Assistant left the room to throw dirty linens in the laundry bin outside the resident's room. An interview was completed on 7/6/23 at 1:00 PM with the Interim Administrator. He stated his first day was 7/3/23 and felt the repeat citation for supervision to prevent accidents was due to staff and management turnover since the pandemic.

Based on record review and Administrator #1 and Director of Nursing (DON) #1 interviews the facility administration failed to have effective systems in place to prevent, identify, assess, treat, and manage residents with and at risk for pressure sores. This failure resulted in Resident #16 developing an avoidable abrasion under her left leg immobilizer identified on 09/06/22 at an orthopedic consult visit. The abrasion went untreated and area deteriorated into an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on 9/13/22. The Wound Physician resolved Resident #16's avoidable pressure ulcer on 1/10/23 with an order for 7 days of dressing changes to protect of the healed area. The lack of reassessment after 1/10/23 resulted in the Wound Physician being consulted on 1/24/23 where she observed the area had reopened into a stage 4 pressure ulcer (deep wound reaching the muscle, ligaments of bone) on 1/24/23. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). The facility also failed to provide care to a diabetic ulcer as ordered by the Wound Physician for 1 of 3 residents reviewed for care to maintain well-being (Resident #10). Immediate jeopardy began on 9/6/22 when the facility administration failed have effective systems in place to identify and prevent further deterioration of an abrasion on Resident #16's left lateral calf underneath her leg immobilizer. Immediate jeopardy was removed on 2/7/23 when the facility provided and implement an acceptable creditable allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Examples #2, #3 and #4 were cited at scope and severity of E. The findings included: Cross Reference to: F 684: Based on record review, observations, staff and Wound Physician interviews, the facility failed to provide wound care as ordered by the Wound Physician to a diabetic ulcer on the lower extremity (Resident #10) for 1 of 3 residents reviewed for well-being. F 686: Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. An unstageable pressure ulcer means a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue) or eschar (dead tissue). Treatments were not performed. The facility failed to assess the wound after 1/17/23 and it re-opened as a stage 4(deep wound reaching the muscle, ligaments of bone) pressure ulcer on 1/24/23. The facility also failed to provide treatments as ordered for Resident #45 and ensure the alternating air mattress was functioning and set according to manufacturer's instructions for Resident #12 and Resident #46. This deficient practice affected 4 of 4 sampled residents reviewed for pressure ulcers (#16, #12, #45 and #46). An interview was completed on 2/3/23 at 10:00 AM with Administrator #1. He stated the facility's administration identified a problem with pressure ulcers in the facility the first part of January 2023 but had not had an opportunity to address the concerns. An interview was completed on 2/7/23 at 10:00 AM with Director of Nursing (DON) #1. She stated she started as the DON on 1/13/23 was not aware of the problem with skin surveillance and avoidable pressure ulcers until it was brought to her attention on 1/23/23 by Resident #16's orthopedic Physician follow up visit. Administrator #1 was notified of the immediate jeopardy on 2/3/23 at 10:00 AM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to provide leadership and oversight to implement effective systems to identify changes in skin integrity, complete thorough skin assessments, provide treatments as ordered, and manage pressures ulcers. In September of 2022, the facility identified a care concern involving Resident # 16. The resident had an orthopedic appointment 9/6/2023 and the physician had ordered care to be provided to an abrasion that was noted under the immobilizer. There was a delay in care, which allowed the wound to worsen due to a lack of monitoring. The facility conducted a root cause analysis with input from the Medical Director as to the cause of the wound and implemented a plan of correction including wound education, looking under the immobilizer, and documentation of skin checks. The Director of Nursing was responsible for monitoring the plan of correction and reporting progress to the Quality Assurance Team. On 1/10/2023, the wound physician assessed Resident # 16. The wound was resolved, and orders given to apply a protective dressing. On 1/23/2023, noted resident to have a dressing dated 01/16/23 to the left lateral leg with dried blood and new blood. The wound physician reassessed the area on 1/24/2023 and provided a diagnosis of a stage IV [NAME] ulcer. It was determined that the adverse event response initiated in September 2022 with regards to the wound on the backside of Residents #16 left leg, was completed by the administrative team on 9/28/2022. However, monitoring of this event had not continued or been integrated into the quality assurance processes. Monitoring of pressure ulcers, prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessments, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician all orders for wound care were followed had not consistently been audited or reported on during daily clinical meetings. All residents have the potential to be affected by the deficient practice. 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 completed As a part of the root cause analysis, the Corporate Chief Clinical Officer, Director of Clinical Services, Nurse Consultant, Regional Director of Operations, and Administrator conducted a review on 2/3/2023 of the policies for daily clinical and wound prevention and treatment. Based on this review, it was determined that reeducation on the daily clinical process was needed for the Administrator and Interim Director of Nursing. A review was conducted of the tools and work process for alerts with the Administrator and the Interim Director of Nursing. The Regional Clinical Consultant provided this education on 2/3/2023. This included the need for the Administrator and Interim Director of Nursing to use the tools provided by the corporate team for this process. A review of the work process for alerts in the clinical dashboard was also included. No changes were required to the policies. The facility failed to implement and follow through with the policies. The Regional Operations Director and the Quality Assurance Nurse Consultant will monitor ongoing compliance by attending this daily clinical meeting weekly for a minimum of six months. Regional Director of Operations and Quality Assurance Nurse Consultant determined on 2/2/2023 that the administrative team completed the adverse event response initiated in September 2022 on 9/28/2022. However, monitoring of this event had not continued nor integrated into the quality assurance processes. Monitoring of pressure ulcer prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessment, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician orders for wound care had not consistently been audited or reported on during daily clinical meetings. On 2/3/2023, the Interim Director of Nursing and Administrator were educated on the need to adhere to the clinical review meeting objectives which including staying focused on adverse events that require ongoing monitoring have been addressed. The Quality Assurance (QA) Nurse Consultant completed this education on 2/3/2023. The clinical review meeting is a meeting held at least three times a week. This meeting is attended by the Administrator, Interim Director of Nursing, Wound Nurse, MDS Nurse, Dietary Manager, Social Services Director and Activities Director. During this meeting, the team reviews monitoring of pressure ulcer prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessment, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician order for wound care. This information will be annotated on a form created specifically for this meeting and will be given to the Medical Director to review and initial. Then this form will be taken to the monthly Quality Assurance meeting to ensure continual compliance with policy. Additionally, on 2/3/2023 the QA Nurse Consultant reeducated the Interim Director of Nursing and Administrator on the need to review during the daily clinical meeting all orders since the previous daily clinical meeting. The Interim Director of Nursing will print the order listing report from the electronic health record by entering a date range and attach it to the daily clinical meeting form. If a dressing has a stop date identified, then the Interim Director of Nursing, Wound Nurse, or MDS Nurse should enter an additional order for the next day to remove the dressing and initial next to the specific order listing identifying it as corrected. Inter-Disciplinary Team (IDT,) consisting of Interim Director of Nursing, MDS Nurse, Director of Rehabilitation, Dietary Manager, RN Unit Manager, Wound Nurse, and Administrator, in daily clinical meeting should review the alerts dashboard for alerts related to existing pressure ulcers. If an alert for an existing pressure ulcer is identified, then the Interim Director of Nursing, Wound Nurse, or MDS Nurse should review the resident's assessment and chart to ensure that this wound has been previously assessed, is being seen by the Wound Physician, and has a wound care order. The IDT was educated on 2/6/2023 by the QA Nurse Consultant on the new process. This trigger will create an alert on the electronic medical record clinical main alert/overview screen that the IDT reviews as part of the daily clinical meeting whenever a nurse documents a new or existing wound on the skin check user defined assessment. The Interim DON will start the audits on 2/6/23 that focus on direct observation of the nurses accurately performing skin and wound assessments and wound treatments to assure compliance on all shifts to include weekends. On 2/3/2023, the Regional Director of Operations and the QA Nurse Consultant were onsite to provide supervision of the Interim Director of Nursing and Administrator to ensure implementation of this credible allegation and the credible allegation related to F686. This supervision will continue with weekly monitoring to ensure completion of the plans of correction, that the daily clinical process is occurring, timely identification of adverse events, and completed review by the IDT. The Regional Director of Operations and the QA Nurse Consultant will attend the monthly Quality Assurance Committee meetings either in person or remotely to ensure that compliance is being monitored and that adverse events are consistently reviewed during monthly QA. Alleged date of immediate jeopardy removal 02/07/23. On 02/07/23, the facility's credible allegation for Immediate Jeopardy removal effective 02/07/23 was validated by the following: The facility's creditable allegation for immediate jeopardy removal was validated by Administrator #1 and Director of Nursing (DON) #1 interviews and record review. Administrator #1 and DON #1 received re-education and in-serviced on 2/3/23 by the Quality Assurance Nurse Consultant. Policies were reviewed but there were no changes in facility's policies made. The in-servicing sign in sheets were reviewed for administration signatures. Validation of the education of the new process was completed by interviews with the Administrator #1, DON #1 Minimum Data Set (MDS) Nurse and Nurse Practitioner (NP) #1. Immediate jeopardy was removed on 2/7/23.

Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. An unstageable pressure ulcer means a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by eschar (dry, dark scab of dead skin), slough (yellow tissue that is stingy and thick) and granulation tissue (part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries form around the edges of a wound). Treatments were not performed. The facility failed to assess the wound after 1/17/23 and it re-opened as a stage 4 (deep wound reaching the muscle, ligaments of bone) pressure ulcer on 1/24/23. The facility also failed to provide treatments as ordered for Resident #45 and ensure the alternating air mattress was functioning and set according to manufacturer's instructions for Resident #12 and Resident #46. This deficient practice affected 4 of 4 sampled residents reviewed for pressure ulcers (#16, #12, #45 and #46). Immediate jeopardy began on 9/6/22 when a pressure ulcer on Resident #16's left lateral calf developed underneath a leg immobilizer and the facility failed to implement interventions to prevent worsening of the ulcer. Immediate jeopardy was removed on 2/6/23 when the facility provided and implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Examples #2, #3 and #4 were cited at scope and severity of E. The findings included: 1. Resident #16 was admitted on [DATE] with cumulative diagnoses of dementia, congestive heart failure, chronic kidney disease, coronary artery disease and osteoporosis. Resident #16 was care planned on 9/17/19 for a risk of pressure ulcers. This care plan was the active care plan during the survey. Interventions were to assist with frequent position changes and turn for pressure reduction and comfort, float her heels in bed, pressure reducing mattress on the bed, provide incontinence care as needed and report to the nurse immediately of any redness, open areas or irritation to her skin. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and personal hygiene. She was assessed as having no weight loss or weight gain and no pressure ulcers. A nursing note dated 8/17/22 at 5:20 PM read Resident #16 returned from the emergency roiagnom on [DATE] wearing a left leg immobilizer due to a left distal femur fracture with orders to wear the immobilizer until she was evaluated on 9/6/22 by the orthopedic physician and to check her skin daily to her left lower extremity due to the presence of the leg immobilizer. The electronic medical record (EMR) from 8/17/22 to 8/22/22 did not include any evidence that Resident #16's left lower leg had any skin concerns. An orthopedic PA note dated 8/22/22 read Resident #16 was to have daily checks for skin breakdown due to the leg immobilizer. Resident #16's August 2022 Physician orders included an order dated 8/23/22 that read for staff to check her skin for breakdown daily due to immobilizer use on every shift. Resident #16's August 2022 and September 2022 treatment administration records (TAR) revealed staff initials indicating Resident #16's left lower leg under her immobilizer was intact from 9/6/22 through 9/12/22. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she thought she recalled a blister that popped on 9/6/22 and she just covered it with a sheet of calcium alginate and a dry dressing and assumed the orthopedic Physician would write wound care orders. An orthopedic PA note dated 9/6/22 read there was an observed abrasion to her left lower lateral leg. The orthopedic consult note included orders to pad the area under her immobilizer and consult wound management for wound care orders. A telephone interview was completed on 2/6/23 at 9:00 AM with the Orthopedic PA. He stated on 9/6/22, he observed an area to Resident #16's left lower leg and wrote on his consult note orders to pad the area for protection and to consult the wound provider for wound care orders. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she did not follow up after Resident #16's 9/6/22 appointment for wound care orders. A form titled Review to Ensure Quality Pressure Injury related to Leg Immobilizer dated 9/16/22 read wound care orders given at the orthopedic office visit on 9/6/22 were not implemented. The form was initiated by DON #2. The form read Nurse #14 received Resident #16 back from her orthopedic appointment on 9/6/22 and she placed the consult note with wound care orders in the medical records box to be scanned into the electronic medical record (EMR). She stated she read the note but did not recognize that the note included orders to be entered into the EMR and implemented. The facility was unable to provide any contact information for Nurse #14 who was no longer an agency nurse for the facility. A telephone interview was completed on 2/1/23 at 4:50 PM with DON #2. She stated nobody knew about the area discovered at the 9/6/22 orthopedic appointment until on 9/13/22 when a staff member told the Wound Nurse that there was drainage coming from Resident #16's leg immobilizer who consulted with the Wound Physician in the facility at the time. She stated after her investigation it was determined that Nurse #14 did not implement the wound care orders from the 9/6/22 orthopedic consult. The September TAR revealed staff initials indicating Resident #16's left lower leg under her immobilizer was intact from 9/7/22 through 9/12/22. There were no nursing notes in the electronic medical record from 9/8/22 through 9/12/22 and a nursing note dated 9/13/22 at 12:21 PM read Resident #16's skin was being monitored for irritation to her leg. The daily skin checks under her immobilizer from 9/6/22 through 9/12/22 indicated no concerns. A telephone interview was completed on 2/2/23 at 1:27 PM with Nurse #13. She stated she initialed off on 9/7/22 and 9/12/22 that she completed the skin check under Resident #16's left leg immobilizer when she did not do it. A telephone interview was completed on 2/2/23 at 1:40 PM with Nurse #8. She stated she initialed off that she assessed the skin under Resident #16's leg immobilizer on 9/8/22, 9/10/22 and 9/11/22 but she did not see any open areas. If she had seen any open areas, she would have notified the Charge Nurse or MD #2. A weekly skin assessment completed by Nurse #3 dated 9/9/22 indicated there were no skin abnormalities. A telephone interview was completed on 2/2/23 at 2:37 PM with Nurse #3. She was unable to recall completing Resident #16's weekly skin assessment on 9/9/22 but stated she must not have seen an open area to Resident #16's left lower leg. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She did not assess the area until 9/13/22 when it was reported that there was drainage noted on her leg immobilizer. A Wound Physician note dated 9/13/22 indicated she was asked to assess Resident #16 for an unstageable pressure to her left lateral calf on 9/13/22. The assessment revealed Resident #16 had an unstageable pressure ulcer to her left lateral calf with moderate serosanguinous (consisting of both blood and serous fluid) drainage at least 7 days in duration. The note described the wound as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. There was no pain associated with the pressure ulcer. The note read the Wound Physician performed an in-house mechanical debridement (removal of dead, damaged, or infected tissue) of the area with orders to cleanse the left lateral calf with wound cleaner, apply Gentamicin (antibiotic) ointment with Santyl (debriding agent) and to cover it with a calcium alginate (a dressing made from salts of alginic acid obtained from seaweed) dressing and wrap with gauze every day. Resident #16's cumulative Physician orders indicated the Wound Physician's new wound care orders were written on 9/13/22. A telephone interview was completed on 2/3/23 at 8:15 AM with the Wound Physician. She recalled there was redness or the beginning of cellulitis so that's why she started the Gentamycin ointment. She stated the area identified on 9/13/22 to Resident #16's left lateral calf was avoidable and an untreated pressure ulcer could lead to infections and possible osteomyelitis (bone infection). A telephone interview was completed on 2/2/23 at 4:41 PM with MD #2. He stated he thought he recalled getting a phone care from the Wound Physician on 9/13/22 to discuss Resident #16's pressure ulcer. He stated Resident #16's pressure ulcer that developed underneath an immobilizer was avoidable and any pressure ulcer that was not treated would deteriorate and could lead to infection, sepsis (blood infection) and possible osteomyelitis. A grievance dated 9/23/22 indicated Resident #16's family member found a dressing to her left lower calf dated 9/20/22. The grievance read the Wound Nurse and floor staff were interviewed and verified the treatment was ordered for daily. The facility began auditing of residents with pressure ulcers for documentation of treatments along with re-education to the nurses to follow the treatment orders frequency as ordered. A form titled Review to Ensure Quality completed by DON #2 dated 9/23/22 read Nurse #13 and Nurse #14 documented Resident #16's wound care treatments completed on 9/21/22 and 9/22/22 but the wound care treatment was not provided. The facility was unable to provide any contact information for Nurse #14 why documented she completed Resident #16's stating she was an agency nurse. Resident #16's TARs for September 2022 through October 2022 indicated documented evidence of daily skin checks under her left leg immobilizer until the immobilizer was discontinued on 10/27/22. A Wound Physician note dated 12/6/22 read Resident #16's left lateral calf pressure ulcer had improved measuring 5.3 cm by 1.3 cm x 0.1 cm with moderate serous drainage with 50% granulation and 50% skin. A Wound Physician note dated 12/13/22 read Resident #16's left lateral calf pressure ulcer had deteriorated from her last visit on 12/6/22. The area measured 5.5 cm by 2.0 cm by 0.1 cm with moderate serosanguinous drainage with 70% granulation tissue and 30% skin. Resident #16's new treatment orders dated 12/14/22 were to cleanse her left lateral calf with wound cleaner, apply a Collagen sheet (sheet, pad or gel derived from bovine or porcine collagen), cover with an ABD (a highly absorbent, multilayer, soft, non-woven moisture barrier) pad and secure with gauze wrap every day. Resident #16's December 2022 treatment administration records (TAR) indicated no documented evidence that her wound care to her left lateral calf was completed on 12/28/22, 12/29/22 and 12/31/22. An interview on 1/24/23 at 3:00 PM was completed with the Wound Nurse about the lack of wound care documentation on 12/28/22. She confirmed she was assigned Resident #16 on 12/28/22 but stated she did not do the treatment on 12/28/22. She stated she was on a medication cart and the MDS Nurse took over around noon that day and she assumed the MDS Nurse would do the dressing change. An interview was completed on 1/26/23 at 10:40 AM with the MDS Nurse. She recalled only completing the noon medication pass on 12/28/22 and she did not complete Resident #16's dressing change. She stated she was relieved by a Medication Aide (MA), and she could not provide treatments to pressure ulcers. An interview was completed on 1/26/23 at 10:10 AM with Nurse #4. She confirmed she worked with Resident #16 on 12/29/22 and 12/31/22. She reported she did not complete her wound treatments. She stated Nurse #3 relieved her on those days and she did not ask Nurse #3 to complete Resident #16's wound care. A telephone interview was completed on 1/26/23 at 10:25 AM with Nurse #3. She stated she worked the evening of 12/29/22 and 12/31/22. She stated she was not instructed in report that Resident #16's pressure ulcer care needed to be completed to her left lower calf on 12/29/22 and 12/31/22. A Wound Physician note dated 1/10/23 read as follows. Resident #16 had a stage 4 pressure ulcer 114 days in duration. The note read the area to her left lateral calf was resolved with the area scabbed. There were new orders to apply a Vaseline or equivalent and cover with a dry dressing daily for one week. Review of Resident #16's January 2023 orders included this order and read to start the new treatment on 1/11/23 for 7 days. Review of Resident #16's January 2023 treatment orders read a new order dated 1/10/23 for 7 days the staff were to apply a Vaseline dressing and cover with a dry dressing daily through 1/17/23. There were no additional orders for the area after 1/17/23. Resident #16's January 2023 TAR indicated documented evidence that her wound care was completed 1/11/23 through 1/16/23 but there was no documented evidence that Resident #16's wound care was completed on 1/17/23. A telephone interview was completed with Nurse #5 on 2/2/23 11:54 AM. She remembered completing Resident #16's wound care on 1/14/23 and 1/15/23 and recalled the wound as in healing stage. She stated there was no observed drainage, but she did not recall seeing a scab. A telephone interview was completed on 1/26/23 at 11:40 AM with the Nurse #8. She stated she completed Resident #16's wound care on 1/16/23 but she did not recall exactly how the area looked but stated it must have looked healed since she did not document anything unusual that day. A telephone call was attempted on 2/2/23 at 12:00 PM to Nurse #12 to inquire why she did not do Resident #16's wound care on 1/17/23 but the voice message mailbox was full. An observation and family interview were conducted on 1/23/23 at 11:18 AM. Resident #16 was sitting up in her wheelchair and her family member stated she just returned from an appointment with her orthopedic physician. Observed to Resident #16's left lateral calf was a dressing dated 1/16/23. It appeared to have not been changed since 1/16/23 for a total of 7 days. There was old bloody drainage and new bloody drainage observed on and around the old dressing. The family member stated this was not the first time she had found Resident #16's pressure ulcer dressing days old and she had brought it to the attention of the facility in the past. Resident #16's skin assessment completed by Nurse #3 on 1/21/23 noted an existing skin concern. A telephone interview was completed on 1/26/23 at 10:05 AM with Nurse #3. She confirmed she completed Resident #16's skin assessment dated [DATE]. She recalled seeing a dressing to her left lower calf, but she did not notice the date written on the dressing nor did she remove it. When Nurse #3 was informed that at the time of her assessment on 1/21/23, the dressing to Resident #16's left lower calf was 5 days old. She stated the Wound Nurse or Wound Physician would be the ones to assess an open wound. An interview on 1/23/23 at 3:00 PM was completed with the Wound Nurse. She stated she completed wound rounds with the Wound Physician on Tuesdays. She stated after the order for the Vaseline dressing was completed after 7 days, there were no additional orders since the area was resolved by the Wound Physician on 1/10/23. Arrangements were made for a surveyor observation of the healed area to her left lateral calf on 1/24/23. The Wound Nurse agreed to get surveyor prior to the Wound Physician's assessment was completed on 1/24/23. An observation was conducted on 1/24/23 at 8:35 AM of Resident #16's left lateral calf. The old dressing previously described dated 1/16/23 was still in place. An interview was completed on 1/24/23 at 2:50 PM with DON #1. She stated she received a call from the orthopedic office on 1/23/23 who reported the dressing on Resident #16's left lower leg dated 1/16/23 appeared to be bleeding and that she told the Wound Nurse to assess it at that time. She stated she would ensure the Wound Nurse followed up with the surveyor regarding the scheduled wound assessment on 1/24/23. She stated it was her expectation that resident wound treatments were administered as ordered and observation be done of a newly healed pressure ulcer due to the increased likelihood it could reopened. An interview on 1/24/23 at 3:00 PM was completed with the Wound Nurse. She stated after the order for the Vaseline dressing was completed after 7 days, there were no additional orders since the area was resolved by the Wound Physician on 1/10/23. She stated she did not assess Resident #16's left lateral leg after her Vaseline treatment orders were completed. She stated she assumed that the floor nurses would notify her if the area had not resolved or declined when they completed their skin assessments. The Wound Nurse stated she forgot to assess the area reported by the orthopedic office on 1/23/23 but asked the Wound Physician to assess it earlier today. She stated the previously healed pressure ulcer had reopened and was now a stage 4 pressure ulcer again. The Wound Nurse stated she forgot to get the surveyor earlier to observe Resident #16's left lateral calf and that her next wound treatment was not until Thursday 1/26/23. The Wound Physician note dated 1/24/23 read as follows: Resident #16 was assessed and evaluated for a stage 4 pressure ulcer to her left lateral calf that was at least 1 day in duration. It measured 6.0-centimeter (cm) by 1.5 cm x 0.1 cm with area of necrotic (dead) tissue and granulated (healing) tissue. The wound was debrided, new treatment orders were given, and the Wound Physician estimated the wound would heal with continued physician evaluation and interventions in 63 days. A telephone interview was completed on 1/25/23 at 2:15 PM with the Wound Physician. She stated the original onset of the left lateral calf pressure ulcer was from her left leg immobilizer she wore after the left femur fracture in August 2022. The Wound Physician stated there was only a scabbed area near the bottom of her left lateral leg on 1/10/23 and she assumed the facility would have contacted her if on 1/17/23 the area did not appear intact. She stated she was asked by the facility to assess Resident #16's left lateral calf on 1/24/23 and noted the healed pressure ulcer had re-opened and presented with 10% of necrotic tissue and 90% granulation. The Wound Physician stated it was her opinion that resident skin surveillance was a problem at the facility. She stated Resident #16's re-opened area should have been discovered and treated immediately when the facility noted a concern as of 1/23/23. She further stated she expected all of Resident #16's pressure ulcer treatments be administrated as ordered. A telephone interview was completed on 1/25/23 at 1:43 PM with NP #1 who stated she recently started at the facility the end of December 2022. She stated she was told that Resident #16's pressure ulcer to her left lower calf was resolved but could not recall who told her. She stated the Wound Nurse, and the Wound Physician assessed all pressure ulcers every Tuesday and the Wound Physician wrote her own treatment orders. NP #1 stated she did not routinely observe a pressure ulcer unless specifically requested by a nurse. She stated it was her expectation that Resident #16 receive her treatments as ordered and would have expected the area to her left lateral leg be assessed after 1/17/23 when the Vaseline dressing for 7 day was completed to ensure the wound had not reopened or declined since it apparently still was scabbed as of 1/10/23. A wound care observation of Resident #16's left lateral calf was completed on 1/26/23 at 9:43 AM with the Wound Nurse. There was noted necrotic tissue to the center of the lower, smaller section of the pressure ulcer with pink/red tissue extending higher up on her calf. The Wound Physician stated it was a stage 4 pressure ulcer. Another wound care observation was completed on 2/2/23 at 10:35 AM with Nurse #1. The old dressing had a small amount of serosanguinous drainage. There was no evidence of redness or infection. The area was improved since previous observation completed on 1/26/23. Administrator #1 was notified of the immediate jeopardy on 2/3/23 at 10:00 AM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 09/06/23 Resident #16 returned from an orthopedic appointment and the transporter gave the nurse the post visit order sheet. The orthopedic MD noted: that a new abrasion was noted to the left lateral aspect of the left lower leg. New orders were received for treatment to the area underneath the immobilizer. The orders included that the dressing and padding must be changed daily, and a wound management consult was advised. The nurse placed the after-visit note/order sheet in the medical records box as she had been instructed to do in the past. On 09/13/23 the Certified Nurse Aide was lifting the resident's immobilized leg and felt a wet area on the immobilizer with her hand. On 9/13/23 the resident went to an orthopedic appointment and new orders were received. On 9/13/2023 the wound nurse reviewed the orders and upon assessment of the resident #16 noted a dressing placed by the orthopedic doctor. On 09/13/22 the wound doctor evaluated the left lower leg and noted areas to the left lateral calf and left anterior knee. Treatments were initiated to both left lateral calf stage 4 pressure ulcer and to the unstageable deep tissue injury to the left anterior knee based on the wound physician's assessment and orders. On 09/15/22 the Director of Nursing completed the Root Cause Analysis. This is an internal process of review to help determine how the wound occurred and what could be done to correct the occurrence or action. On 1/10/23 the wound doctor assessed the wound and documented that the area was epithelized and had resolved, and that the area presented with a scab. The recommendation was for a Vaseline or equivalent and dry protective dressing for 7 days. The new wound care orders initiated were for a collagen sheet apply once daily x 7days. The dressing dated 1/16/23 was the last day of ordered wound care. The dressing remained in place until noted on 01/23/23. The dressing was removed on 01/23/23 by the wound nurse and a new dressing was applied. On 1/24/23 the wound physician assessed the area and noted that a previous stage 4 injury that closed on 1/10/23 had reopened to the left lateral calf and orders were initiated to the wound. Resident #16 received a total body skin assessment on 02/02/2023 by the Interim Director of Nursing (DON). The total body skin assessment revealed that Resident #16 had a current wound on the left lateral calf and a treatment was in place that was being managed by the treatment nurse or the staff nurse according to the physician's order. On 02/03/2023, the Interim Director of Nurses reviewed Resident #16's orders and care plan to ensure preventative measures were currently in place to prevent new skin issues and worsening of current wounds. On 02/02/2023, the Interim Director of Nurses began identification of residents that were potentially impacted by this practice by completing total body skin assessments on all current residents on 02/03/23. This audit was completed by reviewing 100% of current residents to identify any residents with new pressure wounds or skin integrity alterations. On 02/02/2023- 02/03/23, the Interim Director of Nurses assessed and audited 100% of all current pressure wounds to assure current wound measurements were completed. On 2/3/2023, the nurse consultant audited 100% of all residents with identified pressure wounds to assure a current treatment order was correct and in place on the electronic treatment record. On 2/3/2023 the Interim DON completed a 100% audit of all resident Braden scores for risk for pressure ulcers. On 2/03/2023, 100% of residents with pressure wounds or at risk for pressure ulcers were audited by the Minimum Data Set nurse to ensure preventative measures were currently in place to prevent new skin breakdown and address the current pressure wound. Root Cause Analysis was completed on 2/03/2023 with the following staff in attendance: Administrator, Interim Director of Nurses, Regional Operations Manager, the Quality Assurance Nurse Consultant and the Medical Director. Root cause analysis was done related to staff members lack of daily skin surveillance and thorough skin assessments to identify changes in skin integrity and initiate interventions/treatments for a resident at risk for skin breakdown. Upon interview of the nursing staff/agency it was determined that the root cause was the facility administration failure to provide effective oversight and leadership to ensure effective systems were in place to: Prevention of avoidable pressure sores. Identification of residents at risk. Provide wound care and dressing changes per physician's orders. Conduct thorough skin assessments. Review and provide needed treatment from physician referrals regarding identified wounds. Ensure physician's orders for wound care were followed. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 02/02/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultant/Senior Regional Staff Education Specialist began in-service of 100% of all licensed nurses, full time, part time, as needed nurses, including agency to include: The Skin Assessment/Pressure Ulcer Assessment Process to include how to identify when a skin or wound assessment is due to be completed in the electronic health record. Identification of New Orders and Provision of Ordered Treatments. Wound/Skin/Treatment/Order Documentation Process. The Post Follow Up of Appointment Orders Process and the Order Clarification Process. Documentation and notification of the Administrator/Director of Nurses if a treatment cannot be completed for any reason. On 02/02/23 education was initiated by the Quality Assurance Nurse Consultants for 100% of all licensed nurses, including agency nurses, on the Nurse Practice Act and North Carolina Board of Nursing Position statement on Wound Care. In addition, on 02/02/23, the Quality Assurance Nurse Consultants/ Senior Regional Staff Education Specialist began direct observation, with return demonstration, of how to complete a skin assessment/wound assessment utilizing a competency check list of the steps of the skin/wound/order/treatment process and the nurses were instructed to identify on the skin assessment, for residents with immobilizers/braces, the condition of the skin under or surrounding the immobilizer or brace. Including notification of the physician and wound nurse for further assessment and treatment orders for any new or worsening changes to the skin. On 2/2/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultant/Senior Regional Staff Education Specialist began education of all Certified Nursing Assistants, Medication Aides and agency Certified Nursing Assistants on observing the resident's skin when providing care and timely notification of the nurse regarding noted areas of alterations in skin integrity. The Certified Nursing Assistant education included: what skin integrity concerns are to be reported to the nurse. This includes changes such as odor from a wound/swelling/increased redness/pain/drainage from wound site/new areas of redness or new skin breakdown. As of 2/02/23 the Quality Assurance Nurse Consultants began education of all licensed nurses, including agency on the following expectations: the wound nurse or nurse assigned is to complete the weekly pressure ulcers assessment after rounding with the wound doctor. The nurse is responsible to look at the User Defined Assessment in the electronic medical record in order to complete the weekly skin assessment timely. All orders are to be transcribed by the nurse who receives the order. If the nurse needs clarification of the order, the nurse is to contact the physician for clarity of the order. During morning clinical meeting all orders are to be reviewed to ensure clarity. All Staff would be expected to do daily monitoring of the high-risk skin area. Certified Nursing Assistants are to report noted skin integrity alterations to the nurse. As of 2/5/2023, no Licensed Nurses or Certified Nursing Assistants will work without the education/training and competency check off list completed. This is to include agency and new staff. The Interim Director of Nurses and Administrator are responsible to ensure all staff are educated as well as to maintain monitoring and tracking of sustained compliance for staff that still require education to include newly hired licensed nurses, Certified Nursing Assistants and agency. After 2/05/23 the Interim Director of Nursing will be responsible to ensure Licensed Nurses and Certified Nursing Assistances are educated on the applicable policies and procedures related to skin/wound care and the serious complications that might occur for failing to identify and treat a wound in a timely manner. Alleged date of immediate jeopardy removal 02/06/23. On 2/7/23, the facility's credible allegation for immediate jeopardy removal was validated by multiple staff interviews including administrative staff were conducted and revealed the facility and agency nurses had in-services on preventive risk assessments, treatment guidelines, inaccurate or false documentation, treatment errors and reviewing consults for new orders. In-servicing was completed with the aides-current and agency on skin concerns and reporting any areas of concern. Care plan of the residents with pressure ulcers or at risk for pressures ulcers were initiated and reviewed. The in-servicing sign in sheets were reviewed for staff signatures. Immediate jeopardy was removed on 2/6/23. 40197 2) Resident #12 was admitted to the facility on [DATE]. His diagnoses included severe protein-calorie malnutrition, diabetes type 2 and a stroke with paralysis to the left side. A review of Resident #12's active care plan, last reviewed 11/22/22, included the following focus areas: - Risk for pressure ulcer development due to decreased sensation related to left sided hemiparesis (paralysis). The interventions included a pressure reducing mattress to the bed. - Currently with a pressure ulcer to the right heel and at risk for development of additional pressure ulcers due to decreased ability to re-position and incontinence- resident refusing repositioning. The interventions included air matt [TRUNCATED]

Based on record review and staff, Wound Nurse, Director of Nursing (DON) #2, Medical Director (MD) #2, and Nurse Practitioner (NP) #2 interviews, the facility failed to notify the MD #2 or NP #2 that Resident #16's developed an abrasion to her left lateral calf under her immobilizer on 9/6/22 resulting in no assessment or treatment until 9/13/22 when the area was discovered as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The Wound Physician noted on 9/13/22 the pressure ulcer as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). Immediate jeopardy began on 09/06/22 when an abrasion to Resident #16's left lateral calf was identified underneath the leg immobilizer and did not notify or consult MD #2 for wound treatment orders. Immediate jeopardy was removed on 2/8/23 when the facility provided and implemented an acceptable credible table allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease and osteoporosis. Review of a nursing note dated 8/17/22 at 5:20 PM read she returned from the emergency roiagnom on [DATE] wearing a left leg immobilizer due to a left distal femur fracture with orders to wear the mobilizer until she was evaluated on 9/6/22 by the orthopedic physician and to check her skin daily to her left lower extremity due to the presence of the leg immobilizer. Review of an orthopedic Physician Assistant (PA) note dated 9/6/22 read there was an observed abrasion to her left lower lateral leg. The note included orders to pad the area under her immobilizer and consult wound management for wound care orders. A telephone interview was completed on 2/6/23 at 9:00 AM with the Orthopedic Physician Assistant (PA). He stated on 9/6/22, he observed an abrasion to Resident #16's left lower leg and wrote on his consult note orders to pad the area for protection and to consult the wound provider for wound care orders. Review of the electronic medical record (EMR) did not include any documented evidence that MD #2 was notified of the abrasion discovered at the orthopedic visit on 9/6/22. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she thought she recalled a blister on Resident #16's left lower leg under her immobilizer that popped on 9/6/22 and she just covered it with a dry dressing and assumed the orthopedic PA would write wound care orders. She stated she did not notify MD #2 on 9/6/22 when the abrasion was first identified by the orthopedic PA. The Wound Nurse stated she did not read the orthopedic consult note on 9/6/22 because the receiving nurse (Nurse #14) should have reviewed it and implemented any new orders. Review of a Wound Physician note dated indicated she was asked to assess Resident #16 for an unstageable pressure to her left lateral calf on 9/13/22. A telephone interview was completed on 2/2/23 at 4:41 PM with MD #2. He stated he was not notified about Resident #16's pressure ulcer to her left lateral calf until 9/13/22 when the Wound Physician called him because she was concerned about the appearance of the wound and suspected an infection. He stated nobody from the facility notified him of a pressure ulcer until then. He stated he would have expected to be notified due to the risk associated with a pressure ulcer getting infected and he would have given wound care orders on 9/6/22 if the orthopedic PA had not. He stated Resident #16's pressure ulcer that developed underneath an immobilizer was avoidable and any pressure ulcer that was not treated would deteriorate and could lead to infection, sepsis (blood infection) and possible osteomyelitis. A telephone interview was completed on 2/1/23 at 4:28 PM with DON #2. She stated apparently nobody knew about the area identified by the orthopedic office on 9/6/22 until a staff member told the Wound Nurse that there was drainage coming from Resident #16's immobilizer on 9/13/22. She stated she did not read the orthopedic consult note until 9/13/22 when it was discovered Resident #16 had an unstageable pressure ulcer. DON #2 stated after her investigation it was determined that Nurse #14 did not implement the wound care orders from the 9/6/22 orthopedic consult. She stated an untreated open area underneath an immobilizer was avoidable and could lead to complications such as a wound infection sepsis (blood infection) and possible osteomyelitis. Administrator #1 was notified of the immediate jeopardy on 2/6/23 at 5:33 PM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 09/06/22 Resident #16 returned from an orthopedic appointment and the transporter gave the nurse the post visit order sheet. The orthopedic MD noted: that a new abrasion was noted to the left lateral aspect of the left lower leg. New orders were received for treatment to the area underneath the immobilizer. The orders included that the dressing and padding must be changed daily, and a wound management consult was advised. The nurse placed the after-visit note/order sheet in the medical records box as she had been instructed to do in the past. It was scanned into PCC on 09/12/22, but no orders were noted or transcribed from that post visit note as no one was aware that there were new orders. On 09/13/22 the Certified Nurse Aide was lifting the resident's immobilized leg and felt a wet area on the immobilizer. On 9/13/22 the resident went to an orthopedic appointment and new orders were received. On 9/13/2022 the wound nurse reviewed the orders and upon assessment of resident #16, noted a dressing placed by the orthopedic doctor to the left lateral calf. On 09/13/22 the wound doctor was notified and evaluated the left lower leg and noted areas to the left lateral calf and left anterior knee. Treatments were initiated to the left lateral unstageable calf wound to cleanse the wound, apply Santyl for 30 days and Gentamycin for 14 days with calcium alginate once daily for 30 days. Per physician's post visit note the treatment to the deep tissue injury to the left anterior knee was to cleanse the wound, apply skin prep to area and cover with protective dressing once daily for 30 days. On 2/7/2023 the Interim Director of Nurses audited notification for residents that were potentially impacted by this practice by reviewing 100% of post appointment documents and any resulting orders received from the appointment, for the last 30 days. The audit was done for completion of notification of the attending physician and the responsible party. Root Cause Analysis was completed on 2/07/2023 with the following staff in attendance: Administrator, Interim Director of Nurses, Regional Operations Manager, the Quality Assurance Nurse Consultant and the Medical Director. Root cause analysis was conducted related to staff failure to notify the attending physician, upon return from an appointment, of newly received orders. Upon interview of the nursing staff/agency it was determined that the root cause was that the nurse failed to put the order in the electronic health record so that the treatment was initiated, and the referral could have been followed up on in the daily clinical meeting. This resulted in the physician not being notified of the new abrasion and ordered treatment. The facility administration's failed to provide effective oversight and leadership to ensure effective systems were in place related to follow up of orders and notification to the physician of new orders or recommendations received from an appointment. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 02/7/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultants began in-service of 100% of all licensed nurses, full time, part time and as needed nurses, including agency. The education included: The Change in Condition/Notification/Documentation Process of the attending physician/responsible party/resident, to include notification of changes in skin/wounds, newly received orders, following return from an appointment and the importance of following the post appointment process. When a resident returns from an appointment, the nurse is to obtain the post visit note and review it for new orders or recommendations. The nurse is to notify the physician and responsible party/resident. The nurse is to transcribe any new orders. The post visit note is sent to medical records and will be uploaded into the electronic health record within 72 hours post visit. The interdisciplinary team will review the post visit note and any applicable orders as part of the Daily Clinical Process. The interdisciplinary team will review the hard copy information from the post visit note to confirm that needed orders are contained in the electronic medical record. If the resident returns without a post visit note or orders, it is the responsibility of the nurse to follow up and call the physician's office to obtain any new orders and then transcribe those orders. The nurse will as well notify the responsible party/resident and document the notification. On 2/7/2023 the Interim Director of Nurses/Administrator and interdisciplinary team were educated on the expectation that the post appointment process, to include newly received orders/progress notes or other physician/NP/PA information received from an appointment involving a change in condition such as a wound, will be followed as part of the Daily Clinical Review Process. The process is to include review of notification of the attending physician and responsible party and that the notification is documented in the electronic health record. This education was completed by the Quality Assurance Nurse Consultant. As of 2/8/2023, no Licensed Nurses will work without the education completed. This is to include agency and new staff. The Interim Director of Nurses and Administrator are responsible to ensure all staff are educated as well as to maintain monitoring and tracking of sustained compliance for staff that still require education to include newly hired licensed nurses and agency nurses as well as any newly hired interdisciplinary team members. After 2/08/23 the Interim Director of Nursing will be responsible to ensure Licensed Nurses are educated on the applicable policies and procedures related to nursing follow up post appointment to assure the notification process is completed and that new orders are initiated to prevent serious complications that might occur for failing to follow these processes Alleged date of immediate jeopardy removal 02/08/23. On 02/09/23, the facility's credible allegation for Immediate Jeopardy removal effective 02/08/23 was validated by staff interviews and record review. Staff were interviewed to validate in- service completion. Review of the appointment and order follow up process education was completed. Review of the appointment/order follow up sheet was completed, and the Quality Assurance (QA) Committee met to discuss the appointment/order follow up findings. Immediate jeopardy was removed on 2/8/23.

Based on observations, staff interviews and record review, the facility failed to prevent a fall on 8/16/22 for a resident with cognitive impairment and poor decision-making skills who required extensive staff assistance with bed mobility and positioning for 1 (Resident #16) of 8 residents reviewed for accidents. Resident #16's rolled from her side onto the floor resulting in a left femur fracture. The bed was in the high position while Nursing Assistant (NA) #11 left the room to throw dirty linens in the laundry bin outside the resident's room. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease, and osteoporosis. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and personal hygiene. Resident#16 was care planned on 9/11/19 and last revised on 8/16/22 for an actual fall with a risk for further falls. The new intervention of adding grab bars to her bed was implemented on 8/16/22. A nursing note dated 8/16/22 at 2:45 PM read Resident #16 was lying in bed upon entry to the room. The was noted a large red area noted to her right upper lateral thigh and a red are also noted to the inside of her left knee. Resident #16 stated areas were itchy when they were touched. The nurse attempted to roll Resident #16 onto her back for asses her further when Resident #16 yelled and grimaced in pain then immediately reached for right thigh. Resident #16 stated she was not in pain until she was moved. Medical Director (MD) #2 was notified of findings and orders for x-rays were given. Orders were given for Tramadol (narcotic pain reliever) 50 milligrams (mg) every 8 hours as needed for pain. Review of Resident #16's August 2022 medication administration record (MAR) indicated received pain medication on 8/16/22 but not on 8/17/22. Review of Resident #16's August 2022 orders included an order dated 8/18/22 for Percocet (narcotic pain reliver) every 6 hours while the Tramadol and Naproxen were discontinued. Another nursing note dated 8/17/22 at 10:11 AM read Resident #16 was assessed and the area noted to right lateral thigh and left medial knee were red blanchable in color. Resident #16 denied any pain, numbness or tingling at this time and she was able to move her extremities at her baseline. The note read the facility was waiting for an x-ray technician to arrive. Another nursing note dated 8/17/22 at 11:06 AM read due to the delay in obtaining x-rays MD #2 was notified and orders were given to send Resident #16 to the hospital for evaluation. Review of the ER note dated 8/17/22 read x-rays of the left knee demonstrated a nondisplaced femur fracture, and knee immobilizer was applied to her left leg, Naproxen (nonsteroidal anti-inflammatory drug) 500 mg twice daily for pain as needed pain and to follow up with an orthopedic Physician. Another nursing note dated 8/17/22 at 5:20 PM read Resident #16 returned from the emergency room (ER) with an immobilizer to her left leg. The report from the ER nurse stated Resident #16 had a fracture to her left distal femur and there were orders to follow up with an orthopedic Physician, leg immobilizer and Naproxen for pain. Resident #16 stated she only experienced pain when her knees were moved. (There was no documentation stating as to why her pain meds were changed to Percocet, but I imagine they weren't working as well as Percocet The corrective action for the past non-compliance dated 8/16/22 was as follows: The root cause analysis was determined that NA #11 used poor safety judgement. The investigation of the incident was reviewed. It read NA #11 began Resident #16's care at 12:30 PM and was in the room for approximately 20 minutes. NA #11 raised the bed to perform care to hip height and then stripped the bed linen with Resident #16 still in the bed. NA #11 stated Resident #16 was lying on her back when she collected the linen to put them in the laundry bin outside the of the room. She stated as she was exiting the room when Nurse #13 entered the room. Nurse #13 stated Resident #16 was lying on her back when she raised left leg to cross over her right leg and rolled out of the bed onto the floor. Nurse #13 immediately did a head-to-toe assessment but there was no complaints of pain and no physical evidence of an injury. NA #11 with the assistance of another agency aide (full name unknown) assisted her with the mechanical lift to place Resident #16 in the bed while Nurse #13 called MD #2. At 2:45 PM, MD #2 gave orders for inhouse x-rays to right shoulder, both hips and both knees and the x-ray provider was notified. On 8/17/22 at 7:00 AM, staff education was initiated on bed mobility and at 9:30 AM, it was reported to the DON that the x-ray technician did not come on 8/16/22 so MD #2 was notified, and he gave orders to send Resident #16 to the ER for an evaluation. Resident #16 returned from the ER with a diagnosis of a distal femur periprosthetic fracture with a leg immobilizer to her left leg and orders to follow up with an orthopedic Physician as soon as possible. A telephone interview was completed on 2/7/23 at 10:45 AM with NA #11. She stated she was completing Resident #16's routine care and recalled removing Resident #16's sheets and rolled her back over onto her back and stepped out to the doorway where the dirty hamper was located. She stated as she was doing that, Nurse #13 walked into the room to put some cream on a rash to her back. NA #11 stated she did not see Resident #16 fall, but she was suspended and received re-education. A telephone interview was completed on 2/7/23 at 1:39 PM with Nurse #13. She stated she got Resident #16's rash cream and went to apply it to her back since NA #11 had her in the bed. She stated when she walked into the room, she observed Resident #16 lying in bed while NA #11stood at the foot of the bed when Resident #16 crossed her legs at the ankles, and she rolled out of the bed. She stated she did a head-to-toe assessment at that time and then NA #11 with another agency aide placed her in the bed using a mechanical lift. She stated Resident #16 did not appear to have any evidence of injuries and did not complain of pain at that time. She recalled re-education at the time of the incident. Corrective Action That Will Be Accomplished: There was no apparent injury at the time of the incident at 12:30 PM until DON #2 assessed Resident #16's area of redness to her right thigh and left inner knee. MD #2 ordered Resident #16 be transferred to theER on the morning on 8/17/22 to rule out any fractures where she was diagnosed with a left distal femur fracture. The care plan was updated on 8/16/22 and orders were given for grab bars to assist in turning and positioning Resident #16 while in bed. Identification of Other Residents: On 8/17/22, Director of Nursing (DON) #2 100% audits of all falls that occurred in the previous 14 days was completed to assure that no other residents' incidents were related to bed positioning, mobility or staff error had occurred. There were no other incidents identified. On 8/18/22, DON #2 and the MDS Nurse audited all care plans for the presence of bed mobility with the appropriate interventions. The result of the audit included 51 of 53 resident were in compliance with the care planned intervention and as of 8/18/22 100% of all care plans were in compliance for the needed level of assistance with bed mobility. Systemic Changes: DON #2 and DON #1 who was the RN Supervisor at that time began education for all licensed nurse and aides to include agency staff began 8/17/22 at 7:00 AM on bed positioning, mobility, and safe provision of care. Education needed to be completed no later than 8/21/22 or the staff person would not be allowed to work until the training was completed. Quality Assurance: DON #1 was responsible for the ongoing monitoring of bed positioning, mobility and safe provision of care were completed weekly for 2 weeks and monthly for 3 months for the compliance with safe provision of care. The monitoring included observations of 4 aides to include agency aides on various shift to include weekends. Reports were present the quality assurance (QA) committee to ensure compliance and corrective action. A weekly QA meeting would continue to monitor and audit for compliance. The date of compliance was 8/18/22. As part of the validation process, the plan of correction was reviewed and verified through review of the audit sheet, the in-service records, and staff interviews. Observations were conducted on 2/1/23, 2/2/23, 2/3/23 and 2/7/23 of staff completing care on resident while lying in the bed. There were no observed incidents where staff left a resident unattended of left the bed in the high position prior to leaving the resident's room. Interviews with the staff involved incident dated 8/16/22 were completed and with current staff. Interviews revealed they had received in-serving and education on the provision of safe care with bed mobility and positioning. The validation process verified the facility's date of compliance of 8/18/22.

Based on record review and Hospital Case Manager, Ombudsman, Business Office Manager, Regional Director, Former Administrator, and current Administrator interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for 1 of 1 resident reviewed for hospital transfer. Resident #106 was medically stable to return on [DATE] when the facility refused to readmit the resident. The resident remained in the hospital until [DATE] where she expired. Based on the reasonable person concept a resident transferred to the hospital for an acute condition expects to return to their home at the facility following stabilization at the hospital. Refusal to permit the resident's return and the resident's subsequent 23 day stay at the hospital following stabilization would cause a reasonable person to experience a negative psychosocial outcome that would include feelings of anxiety, fear, frustration, and/or a depressed mood. The findings included: Resident #106 was admitted to the facility on [DATE]. Financial ledger documentation for Resident #106 revealed the following: - On [DATE] the Business Office Manager (BOM) switched Resident #106's payor source as private pay. - On [DATE] the BOM spoke with Resident #106 about her outstanding bill as she owed over $30,000. The check which Resident #106 provided for the previous two months was returned with non-sufficient funds. - On [DATE] the BOM received another check with non-sufficient funds. She spoke with Resident #106 in which the resident provided her with a credit card. However, the credit card was expired. The BOM told Resident #106 I did explain to her, that we were probably going to have to issue a 30 Day discharge notice. She said she understood, but has no one to care for her, and she cannot care for herself. The care plan updated on [DATE] identified the focus area as Resident #106 preference for discharge was to remain at the facility for long term. The goal included Resident #106 would a have positive adjustment to life at the facility for 90 days, and the facility would continue to meet her needs daily for 90 days. Interventions included the activities department to provide activities that were meaningful to her; family would bring items from home that would help her adjustment; and had care plan meetings with the team quarterly. Financial ledger documentation for Resident #106 indicated on [DATE] the BOM went to see Resident #106 about payment. Resident #106 indicated she ordered another debit card from her bank, but had not received it. The BOM indicated she would give her until Monday morning [[DATE]], and then I am going to proceed with a 30 Day discharge notice. I have attempted to help her with this on several occasions, and to no avail. Review of the Nursing Home Notice of Transfer/Discharge form dated [DATE] documented the scheduled discharge date of [DATE], for failure, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility. The Former Administrator (Administrator #2) signed the form on [DATE] that documented the discharge was to be Resident #106's home. Review of the Hearing Request form dated [DATE] documented the scheduled discharged of [DATE], was unsigned by Resident #106. There was no evidence in the medical record of discharge planning for Resident #106. Review of the Skilled Nursing Facility/Nursing Home to Hospital Transfer Form dated [DATE] at 11:15 AM indicated Resident #106 was transferred to the hospital due to abnormal lab values. The quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #106's cognition was intact, and she required total assist of 2 or more staff members for transfers and toilet use as well as extensive assistance of 2 or more staff members staff for bed mobility and dressing. She was not coded as having behaviors or delusions. The discharge MDS dated [DATE] indicated Resident #106's return to the facility was anticipated. A review of the Hospital Case Manager note dated [DATE], the Hospital Case Manager submitted the FL-2 (a form that described a resident's medical condition and the amount of care they need when they entered a facility) to the facility and left messages with the facility to confirm Resident #106 was able to return. The Hospital Case Manager was notified by phone by the BOM and Administrator #2 that Resident #106 owes us over $45,000 and our corporate office told us we can't take her back . 30 day discharge notice was given to patient on [DATE] and she did not appeal . her notice was due on [DATE]. The Hospital Case Manager asked if Resident #106 had been notified of being unable to return and facility staff stated no, you have to tell her. She's at your hospital. The note revealed the facility indicated they had not started a Medicaid application because we know she doesn't meet the criteria because she has a house. A review of the hospital discharge summary dated [DATE] indicated Resident #106 was admitted on [DATE] from the facility due to a drop in hemoglobin levels. In the Emergency Department, her blood pressure and potassium levels were low. The low potassium was treated, and she received 3 units of blood. She was stable for discharge on [DATE], but unfortunately she would not be accepted back at Liberty Commons due to reported debts. Her hospitalization was subsequently prolonged awaiting court hearing on ,d+[DATE] where the [NAME] County DSS [Department of Social Services] assumed guardianship since she had no available family. During her hospitalization , she developed severe metabolic acidosis and went into cardiac arrest which required cardiopulmonary resuscitation (CPR) for 20 minutes. The court appointed guardian was called and Resident #106 was made into a Do Not Resuscitate (DNR). Resident #106 went into cardiac arrest again and expired on [DATE]. An interview with the Hospital Case Manager on [DATE] at 9:46 AM revealed the facility was notified Resident #106 was ready for discharge on [DATE]. The facility told her they would not readmit Resident #106 because she owes of thousands of dollars. Resident #106 ended up being at the hospital for almost a month until her death. Resident #106 did not have next of kin to act on her behalf; therefore, an application for an emergency court appointed guardian was submitted. Resident #106 was unable to be admitted to another facility because she expired the same day a court appointed guardian was assigned on [DATE]. The Business Office Manager (BOM) was interviewed on [DATE] at 11:34 AM. She indicated Resident #106 was admitted to the facility for skilled Medicare days and then moved to long-term care as private pay. Resident #106 had a long-term care insurance policy, but her claims were denied. She indicated Resident #106 had stopped paying her bill in [DATE]. She stated she had spoken to Resident #106 about non-payment and Resident #106 had indicated she ran out of checks. Resident #106 provided a debit card, but it was expired. She stated she encouraged Resident #106 to call her bank to have them resend a new debit card and more checks. She helped Resident #106 with transferring her mail from her home address to the facility's address so the debit card and checks could be sent to the facility. She stated she did not believe Resident #106 ever spoke to her bank regarding a new debit card or checks, and she did not assist Resident #106 with contacting the bank. She stated she felt like Resident #106 was able to pay, but Resident #106 not having checks available was a barrier. She was instructed by the facility's corporate office to issue a 30-day discharge for non-payment. She explained the 30-day discharge to Resident #106, and she voiced understanding. She stated Resident #106 was willing to return to her personal residence but did not discuss safe discharge planning. The issue date of the 30-day discharge was [DATE] with the scheduled discharge date to be [DATE]. She indicated Resident #106 was transferred to the hospital on [DATE]. She stated Administrator #2 told the Hospital Discharge Planner Resident #106 could not return to the facility because a 30-day discharge notice was issued, and they could not take her back. Administrator #2 was interviewed on [DATE] at 2:01 PM by telephone. She indicated the BOM spoke with Resident #106 several times regarding non-payment but the resident had several excuses as to why she could not pay. Resident #106 had a change of condition on [DATE] and was sent to the hospital for evaluation. She indicated she was instructed by the corporate office that she was not allowed to accept Resident #106 back because of non-payment and they had already issued a 30-day discharge notice. She did not know if safe discharge planning was initiated and stated Resident #106 was going to return to her home. A telephone interview with the Regional Director on [DATE] at 2:30 PM was conducted. He indicated while Resident #106 was at the hospital, the 30-day discharge notice had expired. He stated they do not pause the discharge notice while residents were in the hospital. He further stated the facility made the decision to issue a 30-day notice, but he became aware and was involved in the decision. It is the facility's responsibility to ensure safe discharge planning, and he is not involved with this process. The Ombudsman was interviewed by telephone on [DATE] at 3:01 PM. She indicated she was not aware of the circumstances of Resident #106's discharge, but knew she was notified of her discharge. She indicated while it is not a requirement, some facilities involve her when a 30-day discharge notice was given to residents. She further stated the facility should have readmitted Resident #106, and another 30-day discharge notice should have been given to Resident #106. The current Administrator (Administrator #1) was interviewed on [DATE] at 9:55 AM. He indicated he had only been at the facility for 2 weeks. He stated his understanding was Resident #106 was issued a 30-day discharge notice on [DATE] and went to the hospital on [DATE]. He indicated he felt the facility gave sufficient notice to Resident #106 regarding the pending discharge for non-payment. He stated the facility gave Resident #106 a 30, 60, and 90 days' notice prior to issuing the 30-day discharge notice. He indicated he felt the discharge was safe due to Resident #106 being admitted to the hospital He stated discharge planning was not needed since Resident #106 was sent to the hospital.

Based on staff family, emergency room (ER) Physician, Medical Director #2, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to protect the resident from injury of unknown origin (right proximal tibia/fibula fracture) resulting in physical harm. This was for 1 (Resident #16) of 8 residents reviewed for accidents. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease, and osteoporosis. Review of Resident #16's care plan included a care plan for osteoporosis with a risk for fractures dated last revised on 7/9/21. Interventions included observation, document and report any signs or symptoms of an acute fracture, compression fractures, loss of height and complaints of back pain. Resident #16 was also care planned on 9/11/19 for an actual fall and the interventions included two staff assist with transfers dated 10/23/19. The quarterly Minimum Data Set (MDS) dated [DATE] indicated she had moderate cognitive impairment, exhibited no behaviors, required extensive to total assist with her activities of daily living. Review of a nursing note dated 1/18/23 at 10:50 AM read Resident #16 was transferred to the hospital due to right lower extremity (RLE) pain. Review of a nursing note dated 1/18/23 at 10:50 AM read Resident #16 was transferred to the hospital due to right lower extremity (RLE) pain. Review of the emergency room (ER) Physician's report dated 1/18/23 read as follows: Resident #16 complained of leg pain for several days and today the facility noted some swelling and discoloration of her RLE. The report read the facility was concerned about a deep vein thrombosis (DVT) and transferred her to the ER for an evaluation. Resident #16 has dementia and bed bound. Resident #16 stated her RLE had been hurting for several day after she fell . She stated she did not remember exactly how or when she fell and denied that anyone hurt her. The report read despite the facility's concern for a DVT, her RLE appearance was concerning for a traumatic injury with bruising and swelling. X-rays revealed a proximal tibia fracture and osteopenia noted. The report read with osteopenia, Resident #16's bed bound status, it was suspected the fracture may have occurred during a position change or during a transfer and doubtful it occurred from a fall. The report read she contacted NP #1 at the facility and NP #1 reported Resident #16 had complained of leg pain for several days but denied any known falls or injuries. NP #1 as advised for the need for orthopedic follow up and she was placed in an immobilizer then discharged back to the facility with orders for Tylenol or Motrin for pain. A telephone interview was completed on 1/25/23 at 11:20 AM with ER Physician. She stated she treated Resident #16 on 1/18/23 and noted her fracture to her right tibia/fibula fracture was acute with noted swelling, pain and bruising. She recalled calling NP #1 and informed her of her findings with the need for Resident #16 to see an orthopedic Physician as soon as possible and she recommended Tylenol as needed for pain. Review of a nursing note dated 1/18/23 at 3:30 PM read the emergency room (ER) was contacted for report on Resident #16. The note read the ER nurse reported the following: The good thing is that it looks to be an old fracture based on calcification and callus formation and the ER Physician stated it was indicative of an old fracture. NP #1 was notified, and she stated she would contact the ER Physician and let the facility know what orders or next step were needed. NP #1 called back and informed the writer that she spoke with the ER Physician and confirmed the ER findings suggested an old RLE fracture. This note was written by Director of Nursing (DON) #1. An interview was completed on 2/7/23 at 11:30 AM with DON #1. She stated she assessed Resident #16's right leg on 1/18/23 due to Nursing Assistant (NA) #8 reporting her right knee appeared bruised and swollen but she did not complain of any pain, and nobody had reported acute pain to her in the days prior. She stated Resident #16 did often complain of pain all over due to her osteoporosis. She notified MD #2 and he ordered to be sent to the ER for an evaluation. She stated she called the hospital on 1/18/23 to get an update of Resident #16's condition and spoke to an ER Nurse but did not recall her name. She stated informed Administrator #1 on 1/18/23 what was reported to her by the ER Nurse. DON #1 stated at no time did the facility suspect staff error there did not perceive it as neglectful. An interview was completed on 1/25/23 at 2:53 PM with NA #8. She recalled seeing Resident #16's right leg the morning of 1/18/23 and noted bruising and swelling. She stated Resident #16 did not complain of pain to her right leg, but she got DON #1 to assess it. She stated she was assigned Resident 16 on first shift on 1/17/23 and there was no evidence of injury or any voiced pain. An interview was completed on 1/25/23 at 3:00 PM with NA #10. She confirmed working with Resident #16 on night shift on 1/17/23 and she did not observe any evidence of an injury to Resident #16's right leg and she did not complain of pain. An interview was completed on 2/3/23 at 3:40 PM with NA #9. She confirmed working with Resident #16 on second shift on 1/17/23 and she did not observe any evidence of an injury to Resident #16's right leg and she did not complain of pain. Review of a NP #1 note untimed dated 1/20/23 read Resident #16 reported RLE pain on 1/18/23 and staff noted her RLE was significantly more swollen. She was sent to the ER and NP #1 spoke with the ER Physician who stated she was diagnosed with a proximal right tibia/fibula fracture that was not likely an acute finding due to severe osteopenia, non-ambulatory and no reports of a fall or injury according to the documentation and staff. A telephone interview was completed on 1/25/23 at 1:43 PM with NP #1. She recalled speaking with the ER Physician on 1/18/23 but interpreted their conversation indicated Resident #16's fracture was old, calcified and osteopenia. She stated documented Resident #16's complaints of pain for several days because that was what DON #1 and facility staff reported to her. She stated DON #1 and Administrator #1 were notified around the same time when DON #1 called the ER and spoke with an ER Nurse who reported the same interpreted information as she did. NP #1 stated she did not read the ER documentation and was not aware Resident #16 had an acute fracture until she returned from her orthopedic appointment on 1/23/23. NP #1 stated she did not think there was any evidence of staff neglecting to provide all safety precautions related to Resident #16. An observation and family interview were conducted on 1/23/23 at 11:18 AM. Resident #16 was sitting up in her wheelchair with a right lower leg immobilizer to her leg. Resident #16 denied pain at this time. The family member stated last week she was notified on 1/18/23 of a possible fracture to Resident #16's right lower leg. She stated Administrator #1 spoke to her and said the fracture diagnosed in theER on [DATE] was an old fracture and that she had not experienced any falls, staff had not reported any injury until 1/18/23 and it was suspected the injury could have happened during routine care from rolling her or transferring her using the mechanical lift. She stated the orthopedic Physician she saw today told her it was not an old fracture but new. An interview was completed on 1/23/23 at 1:57 PM with Administrator #1 who stated he was informed by NP #1 or DON #1 that Resident #16's injury was not an acute injury and was due to osteopenia. An interview was completed on 1/26/23 at 12:16 PM with Administrator #1. He stated the facility should considered the injury to Resident #16's right leg suspicious but at the time it was identified on 1/18/23 and due to inconsistencies in what the facility understood and what was documented in the ER report, he did not. A telephone interview was completed on 2/8/23 at 1:30 PM with MD #2. He stated although he could not say for sure, but he felt that the transfer the shower was the anticipated etiology for the fracture. He further stated that it is possible that Resident #16 may not have required pain medication immediately and that the leg may have swollen days after the break.

Based on record review, observation and staff interview, the facility failed to prevent repeated falls by not providing effective interventions after each fall (Resident #16) for 1 of 4 sampled residents reviewed for accidents. Resident #16 sustained fracture of the fingers on 9/10/21 and left and right hip fractures on 9/24/21 after the fall. Findings included: Resident #16 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #16 had severe cognitive impairment and needed supervision with 1-person physical assist with transfers and ambulation in room. The assessment further indicated that the resident had 2 or more falls since admission, reentry, or prior assessment. Resident #16's care plan that was initiated on 6/28/21 was reviewed. The care plan problem was I have had actual fall with risk for further. The goal was my risk for future falls will be minimized through current interventions. The approaches included encourage me to call for assistance prior to transfers (10/1/21), encourage me to lock my breaks before standing up (10/1/21), encourage me to use my walker when ambulating ( 6/28/21), encourage me to wear non-slip socks when not wearing shoes (6/28/21), ensure that call light is within reach (6/28/21), Physical therapy (PT) to evaluate as needed (6/28/21), hipster to be worn at all times (10/15/21), make sure that I have non-slip shoes that fit appropriately ( 6/28/21), observe me for possible side effects from medications that may affect my gait and balance and report to nurse if I have change in my gait or balance (10/7/21) and reinforce safety reminders frequently (10/1/21). Resident #16's incident reports were reviewed. The reports revealed that the resident had 5 falls since admission to the facility and 2 of the 5 falls, the resident sustained fractures. The report dated 9/9/21 at 12:20 AM revealed that Resident #16 was observed on the floor outside of her bathroom after hearing the roommate yelling she fell . The resident was assessed for injury and no deformity noted to the lower extremities. The root cause of the fall was determined to be self- toileting at night. The intervention was to check frequently for needs. There was no new intervention added to the care plan until 10/1/21. The report further indicated that after the resident was placed in bed, she complained of pain to her right thumb and right hip/leg, the physician was informed, and x-ray was ordered. The x-ray report dated 9/10/21 revealed acute, non-displaced fracture at base of first distal phalanx and mild subluxation at first metacarpophalangeal joint. The nurse's note dated 9/11/21 at 4:32 AM, the physician was notified of the x-ray report, and he ordered to maintain the broken fingers taped together. The report dated 9/15/21 at 6:59 AM revealed that Resident #16 was observed sitting on the floor at the doorway of room. Resident was assessed for injury. Range of motion to all extremities with no change in limitations noted. The root cause of the fall was determined to be self- toileting at night. The intervention was to check frequently for needs and frequent reminders to get assistance. There was no new intervention added to the care plan until 10/1/21. The nurse's note dated 9/15/21 at 9:41 AM revealed that Resident #16 noted to be in pain when trying to stand up. When asked, she stated that her hips hurt. The resident was medicated with [MEDICATION(S)] (a narcotic used to treat pain) and the physician was notified, and he ordered x-ray of bilateral hips and pelvis. The x-ray report dated 9/15/21 revealed no fractures. The nurse's note dated 9/23/21 revealed that Resident #16 continued not to bear weight on her right lower extremity, the physician was notified and computerized tomography CT) scan of the pelvis was ordered. The CT scan report dated 9/24/21 revealed displaced comminuted right superior pubic ramus fracture and nondisplaced left inferior pubis ramus fracture. The nurse's note dated 9/25/21 at 5:12 PM indicated that the physician called, and Resident #16 had fractures to her right and left pelvis. The physician had ordered for weight bearing as tolerated. The report dated 10/11/21 at 8:00 PM revealed that Resident #16 was observed on the floor in front of her bed. Complete body assessment was completed with no redness, scratches or open areas noted. The root cause of the fall was determined to be confusion, poor safety awareness and self-transfers. The intervention was hipster for protection. There was new intervention added to the care plan to prevent further falls except for the hipster on 10/15/21. The report dated 1/4/22 at 8:30 AM revealed that Resident #16 was observed on the floor by the bathroom door. The resident complained of lower back pain. The resident was educated the importance of using the wheelchair and calling for assistance by using the call bell. The report stated that the resident continued to ambulate independently to the bathroom without calling for help or use of wheelchair. [MEDICATION(S)] was administered for pain. The physician was notified, and x-ray was ordered. The x-ray report did not show any acute fracture. The root cause of the fall was dementia with resident complaining of forgetfulness and not calling for assistance. The report did not include intervention to prevent further fall and there was no new intervention added to the care plan after the fall to prevent further fall. The report dated 2/4/22 at 4:14 PM revealed that Resident #16 was observed on the floor beside her bed. Head to toe assessment was completed with no injury noted. The root cause of the fall was determined to be resident was leaning against the side of the bed and was found on the floor wearing improper footwear. Intervention was to ensure when out of bed, resident was wearing non-skid socks. There was new intervention added to the care plan after the fall to prevent further falls. Resident #16 was observed up in wheelchair in her room on 2/15/22 at 12:45 PM and on 2/16/22 at 9:27 AM, and 1:40 PM. There was a walker (folded) noted between the wall and the nightstand and was not within reach of the resident. The Registered Nurse (RN) Supervisor was interviewed on 2/16/22 at 1:39 PM. She reported that they (Director of Nursing (DON), Support Nurse, MDS Nurse, Rehabilitation Director and Dietary Manager) used to have a clinical meeting daily Monday through Friday and discussed falls, what and how it happened and what intervention to put in place. The RN Supervisor reported that the MDS Nurse was supposed to add the interventions discussed during the meeting to the care plan. She stated that due to staff turn -over, the clinical meeting did not happen consistently. Nurse Aide (NA) #1, assigned to Resident #16 was interviewed on 2/16/22 at 1:41 PM. NA #1 stated that she started working at the facility a month ago. She stated that the resident was confused, frequently continent of bowel and bladder and she went to the bathroom when needed. She stated that the resident was not on a toileting program. She explained that the resident was ambulatory but unsteady and she was better off using a walker. NA #1 observed the walker folded against the wall and she indicated that she didn't know that the resident had been falling. NA #5, assigned to Resident #16, was interviewed on 2/17/22 at 9:13 AM. NA #5 stated that Resident #16 was confused, high risk for falls and would not remember to follow instructions like to use the call light or call for assistance. She could ambulate but unsteady and she was mostly continent of bowel and bladder. She reported that the resident would go to the bathroom unassisted and had been falling. She added that the resident was not on a toileting schedule. NA #5 indicated the resident needed close supervision to prevent her from falling. A follow interview was conducted with the RN Supervisor and the Support Nurse on 2/17/22 at 9:14 AM. They both stated that Resident #16 was high risk for falls, she was unsteady but would get up and walk. She would not remember to follow directions. She was not supposed to go to the bathroom unassisted, but she did it anyway. They both indicated that the resident needed close supervision, and frequent checks and they would suggest moving her close to the nurse's station and to involve her in activities. The RN Supervisor revealed that they had not tried putting the resident on a toileting schedule. The MDS Nurse was interviewed on 2/17/22 at 2:15 PM. She stated that she started as MDS Nurse 4-5 months ago. She revealed that Resident #16 was high risk for falls, she was confused and would not remember to follow instructions. She could walk but unsteady. She was aware that some of her falls were from trying to use the bathroom. She added that taking her to the bathroom before and after meals and at bedtime might help in preventing her from falling but these had not been tried. She reported that using a walker would also help her from falling but there was no space in her room for the walker, it was folded and stored away from her. The MDS Nurse reviewed the resident's care plan for falls and verified that there was no new intervention added to the care plan after each fall. Nurse #4, assigned to Resident #16, was interviewed on 2/17/22 at 4:56 PM. The nurse stated that Resident #16 was confused and was high risk for falls. She was able to ambulate but unsteady. She had several falls trying to get up and walk unassisted. She had falls trying to go to the bathroom and she knew when she has to go. She reported that Resident #16 was not on a toileting program, but she thought that might help in preventing her from falling, however she didn't think the staff has the time to take her to the bathroom as scheduled. She reported that she saw her walking unassisted, and the staff could not watch her every minute. Resident #16's attending physician was unable to be reached for an interview. The Director of Nursing (DON) was interviewed on 2/17/2 at 3:34 PM. She reported that she just started as DON of the facility in January 2022. She stated that Resident #16 was high risk for falls. She reported that one day she saw her walking on the hallway unassisted. The DON indicated that big turn-over of direct care staff and administrative staff and change of roles had contributed to these concerns with falls. She indicated that the Support Nurse and the MDS Nurse were new to their roles.

Based on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide 2 person assistance with bed mobility as specified in a resident's plan of care and electronic Kardex for 1 (Resident #1) of 4 residents reviewed for accidents. The failure to have 2 staff members present to assist Resident #1 with bed mobility resulted in the resident falling from her bed and she sustained a subdural hematoma (a collection of blood outside the brain) and a frontal scalp laceration which required treatment at a hospital. The findings included: Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #1's quarterly Minimum (MDS) data set [DATE] indicated severe cognitive impairment and she exhibited no behaviors. She was coded as requiring 2 person assistance with bed mobility and coded for no falls. Resident #'s 1 current care plan that was last revised on 7/12/19 read she required assistance with the activities of daily living (ADLs) due to dementia. Interventions included 2 person assistance with repositioning and turning in bed. Resident #1's undated electronic Kardex read she required 2 person assistance with repositioning and turning in bed. Review of an incident note dated 7/18/19 at 4:00 PM completed by Nurse #1 read Nursing Assistant (NA) #2 came out of Resident #1's room at approximately 3:30 PM and requested assistance. Nurse #1 went to assist Resident #1 because NA #2 reported she had fallen out of the bed. Nurse #1 noted Resident #1 lying on her back on the floor next to the bed. She ensured Resident #1 was alert and had no signs of acute distress. Nurse #1 sent NA #2 to get the Director of Nursing (DON) who was onsite and responded immediately. Resident #1 was assessed for injuries and Emergency Medical Services (EMS) was at approximately 3:35 PM for her to be evaluated as a precautionary measure. Resident #1 was noted with a small laceration to her left forehead with bleeding controlled, and a bandage applied along with an ice pack. Nurse #1 remained with Resident #1 until EMS arrived. The Responsible Party (RP) was notified of the fall at approximately 3:45 PM. The Nurse Practitioner was in the facility and also made aware. NA #1's written statement dated 7/18/19 read as follows: She and NA #2 had just laid Resident #1 down in bed using a mechanical lift. NA #2 was taking the mechanical lift out of the room and get a brief. NA #1 documented she attempted to remove the lift pad out from under Resident #1 in bed. NA #1 tucked the pad under Resident #1 then turned her towards her and attempted to remove the lift pad. NA #1 documented the lift pad wasn't moving so she turned Resident #1 onto her back to tuck it further under Resident #1 then turned her towards her again in an effort to remove the lift pad. She documented when she did this and pulled the lift pad, Resident #1 rolled over too far. NA #1 documented she braced her knees against the bed frame in an effort to break her fall and yelled for help. She documented her legs gave way and Resident #1 fell to the floor. In an interview on 7/31/19 at 1:05 PM, NA #1 stated she and NA #2 had laid Resident #1 in bed using the mechanical lift and was preparing to provide her incontinence care. NA #1 stated Resident #1 had just been moved into a new room and all of her personal items had not yet been moved from her old room. NA #1 stated she realized there were no briefs in the new room. NA #1 stated she did not wait for NA #2 to return before attempting to get the lift pad out from under Resident #1 by rolling her on her side and tucking the lift pad under her. She stated she rolled her over further to get more of the pad under her when Resident #1's legs slid off the bed and she continued to roll. NA #1 stated she tried to catch her using her legs up against the bed frame, but she was unable to hold her weight. NA #1 stated Resident #1 fell on to the floor at the bedside and she called out for help. NA #2 went to get Nurse #1. NA #2's written statement dated 7/18/19 read as follows: She and NA #1 laid Resident #1 in bed using the mechanical lift. She was removing mechanical lift from the room and get a brief. NA #2 documented apparently NA #1 began removing the lift pad out from under Resident #1. As she was opening the door, she heard Resident #1 fall and NA #1 call out for help. She documented she observed Resident #1 on the floor beside the bed and she apparently hit her head. She then went to get Nurse #1. In an interview on 7/31/19 at 11:47 AM, NA #2 stated Resident #1 had been moved to a different room at the end of first shift at the request of the RP. NA #2 confirmed there was no change in Resident #1's bed. She stated her personal items were still being transferred to her new room. NA #2 stated she and NA #1 had laid Resident #1 down in the bed using the mechanical lift then realized there were no briefs in the new room. She stated she was removing the mechanical lift out of Resident #1's room and was going to get a brief when she heard NA #1 call for help and heard Resident #1 fall. She stated she was uncertain if the bed was in the low or raised position but thought it was in the normal position because Resident #1 was not in a low bed. NA #2 stated she did not see the actual fall because the privacy curtain was pulled. She stated when she looked behind the curtain, she saw Resident #1 lying on the floor beside her bed with NA #1 on the floor next to her. NA #2 stated she saw blood on the floor and went to get Nurse #1. NA #2 stated NA #1 should not have been attempting to take the lift pad out from under Resident #1 and she should have waited for her to return with a brief. Nurse #1's written statement dated 7/18/18 read as follows: She was called to the room and noted Resident #1 on the floor with NA #1 beside her. Nurse #1 documented Resident #1 appeared alert and there was no indication of acute distress other than a small laceration to left of her forehead. Nurse # notified the DON, EMS and RP. In an interview on 7/31/19 at 1:00 PM, Nurse #1 stated she was also the RN Supervisor, but she had worked on a medication cart on first shift on 7/18/19. Nurse #1 recalled Resident #1 was moved from the 200 hall to the 300 hall around the time second shift was coming on at 3:00 PM. She stated NA #2 called her to Resident #1's room where she saw her on the floor beside her bed with NA #1 on the floor next to her. Nurse #1 stated she observed a small laceration to the left side of Resident #1's forehead. She stated she sent NA #2 to get the DON and an ice pack. Nurse #1 stated she completed a neurological assessment and noted no changes in Resident #1's mental status or neurological status. She noted no acute injuries and only observed the laceration. After the complete body assessment , the NP and the RP were notified. Resident #1 was sent out to the hospital for an evaluation. Review of the local hospital emergency room visit dated 7/18/19 read as follows: Resident #1 sustained a fall with anterior head trauma and a frontal scalp laceration. There were no acute traumatic injuries and per her RP, Resident #1's mental status was at baseline. The laceration measured at approximately 1-2 centimeters. A computerized axial tomography scan (CT Scan) revealed a small subtle trace right subdural frontal hematoma. A CT Scan is a series of x-rays taken at different angles processed by a computer that reveal potential bones, blood vessel and soft tissue injuries. There was no evidence of hemorrhage or no shifting and noted frontal soft tissue swelling to Resident #1's head. She was transferred to a larger hospital for further evaluation. Review of the receiving hospital's Neurology History and Physical dated 7/19/19 read Resident #1's attending Physician requested a neurological evaluation due to a [MEDICAL CONDITION]. Family reported Resident was at baseline with dementia and that Resident #1 had a previous history of a [MEDICAL CONDITION] approximately 3 to 4 months ago. Family report the CT scan done at that time of her first [MEDICAL CONDITION] revealed no acute abnormality. She was not started on any antiepileptic (medication to treat [MEDICAL CONDITION]) drugs at that time. Neurosurgical intervention was differed given her examination and the size of the hematoma. The plan was since Resident #1 was not taking any anticoagulation or antiplatelet agents, she would be monitored for increased intracranial pressure or worsening and now prescribed [MEDICATION NAME] (antiepileptic drug). In an interview on 7/31/19 at 1:25 PM, the NP stated the Physician was out of the country at present, but she was in the facility when the fall happened on 7/18/19. She stated it was an unfortunate accident and the NA #1 made a mistake. She stated the fall could have been avoided if 2 staff were present during bed mobility. In an interview on 7/31/19 at 2:20 PM, the Nurse Consultant and DON stated NA #1 should have followed the care plan and electronic Kardex and not attempted to remove the lift pad out from under Resident #1 herself. The Administrator, DON and Nurse Consultant each stated it was their expectation that all aides should review with electronic Kardex prior to providing any care to a resident and if the electronic Kardex indicated any resident as 2 person assistance for bed mobility, 2 staff should remain at the bedside while bed mobility was performed. The Nurse Consultant stated the facility implemented a corrective action plan on 07/18/19 to prevent a reoccurrence. She stated their investigation findings revealed Resident #1 sustained a subdural hematoma from the fall on 7/18/19. She was receiving care in bed and rolled off edge resulting in laceration and a bump to her forehead. Resident #1 was sent to the hospital on [DATE]. On 7/18/19, the involved staff re-enacted the incident with the Administrator and the DON. The involved staff were interviewed, and it was determined that the staff failed to check the electronic Kardex prior to her care. All nurses and aides were re-educated on the importance of checking electronic Kardex prior to initiating care. Review of the facility's immediate correction action plan dated 7/18/19 read as follows: Corrective action for the involved resident dated 7/18/19 read as follows: Resident #1 was assessed for potential injuries. Next, the Physician and RP were notified and Resident #1 was sent to the hospital for an evaluation. Corrective action for other potentially affected residents dated 7/18/19 read as follows: Audit of all electronic Kardex's to ensure residents requiring 2 person assistance with bed mobility and positioning was correct. This was completed by the DON with 100% compliance. She stated the electronic Kardex updated automatically based on the care plan which was completed by the MDS Nurse and revised as needed. Beginning 7/18/19, the DON and Unit Managers interviewed and observed aides for the ability to access the electronic Kardex and interviewed to determine if aides were aware of how to access the electronic Kardex prior to initiating resident care each time they worked. Results of the interviews and observations on 7/18/19 was 100% of the aides were aware of how to access the electronic Kardex and aware that it should be accessed prior to care each time assisted a resident with care. Systemic Changes and Education initiated on 7/18/19 read as follows: On 7/18/19 the DON began education of all full time, part-time and as needed (prn) licensed nurses and aides of the following: -Utilization of electronic Kardex and following the plan of care -Bed positioning safety -The DON would ensure that any of the above identified staff who did not complete in-service training by 7/23/19 would not be allowed to work until training completed. -In-service was incorporated into the new employee facility orientation training for all staff Quality Assurance Plan initiated on 7/18/19 read as follows: The DON and Unit Managers would monitor staff using the Bed Positioning Quality Assurance (QA) tool for compliance. This would be done weekly x 2 weeks then monthly x 3 months or until resolved. Reports would be presented to weekly QA committee by Administrator or DON to ensure corrective action was appropriate. Compliance would be monitored, and ongoing auditing program would be reviewed weekly at QA meeting. The weekly QA meeting was attended by the Administrator, DON, MDS Nurse, Therapy Manager, Environmental Manger and the Dietary Manager. The plan alleged compliance on 7/23/19. Review of the facility plan of correction revealed evidence of 100% auditing of residents requiring 2 person assistance for bed mobility, evidence of 100% all staff interviewing and observation of accessing the electronic completed on 7/21/19. The facility provided evidence of 100% staff education on bed mobility and positioning completed on 7/23/19. The facility also provided evidence of a QA audits of observations of bed mobility and positioning completed on 7/22/19 and 7/26/19 on all three shifts and read as ongoing. Resident's deemed alert and oriented revealed no current concerns related to staff providing them with assistance of bed mobility and them feeling unsafe. Observations revealed two staff were assisting residents with bed mobility as specified on the care plans.The facility's date of compliance was validated as 7/23/19.

Based on observation, record review, resident interview, and staff interview, the facility failed to treat a resident with dignity and respect during the provision of incontinent care for 1 of 2 residents (Resident #4) reviewed for dignity. This failure caused Resident #4 to cry and to feel as if he was a bother. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4' s cognition was fully intact. He had no behaviors and no rejection of care. Resident #4 required the extensive assistance of 1 for personal hygiene, toileting, and dressing. He had functional impairment with range of motion on 1 side of his upper and 1 side of lower extremities. Resident #1 was occasionally incontinent of bowel and bladder. The active care plan for Resident #4 included the focus area of occasional incontinence (initiated on 7/9/18). The interventions included assistance with incontinent care (initiated on 7/9/18). An interview was conducted with Resident #4 on 2/25/19 at 11:40 AM. Resident #4 was alert and oriented with no impaired cognition noted. He indicated he had impaired range of motion on one side of his upper and lower extremities and he needed assistance with Activities of Daily Living (ADLs). He reported that this included assistance with incontinent care. Resident #4 stated that a couple of weeks ago he had an episode of incontinence and he needed staff to change his brief. He reported that Nursing Assistant (NA) #6 was working with him that day and provided his incontinent care. He stated that NA #6 was snatching me around during incontinent care. Resident #4 explained that he felt NA #6 was rough with him. He shared that NA #6 said something to him about being childish and he thought she was talking about him being incontinent. He revealed this incident made him very depressed because there were times that he had no control over his incontinence. Resident #4 further revealed he cried about this incident after NA #6 left his room. He indicated he had not informed the Administrator about the incident as he felt like every time he complained about something that things got worse. Resident #4 stated NA #6 had worked with him after this incident and she had not apologized. An interview was conducted with the Social Worker (SW) on 2/27/19 at 10:00 AM. She stated she was familiar with Resident #4. She indicated his cognition was intact, and he had no behavioral issues. The SW was asked if Resident #4 had reported any issues with his care. She revealed that on 2/26/19 Resident #4 reported to her that an incident had occurred with NA #6 during incontinence care. She indicated that Resident #4 spoke about NA #6 being rough with him and making him feel like he was a bother to her. The SW stated she had not written a grievance about this yet, but she was planning on writing it today. She reported she had not spoken to NA #6 yet as she was not working yesterday, and she had not had a chance to call her by phone. An interview was conducted with the Administrator on 2/27/19 at 10:30 AM. She stated the SW had just reported to her the statement Resident #4 made regarding care by NA #6. She reported that the SW was in the process of writing a grievance form at this moment. The Administrator stated NA #6 had the tendency to speak very loudly to all people, including the residents. She explained that it was possible that this loud tone of voice used by NA #6 could be misinterpreted as her yelling, being impatient, or something along those lines. She indicated she was aware that NA #6 was not as [MEDICATION NAME] as some of the other NAs, but she had never had any concerns reported to her about NA #6 being rough with any resident. A grievance report form dated 2/26/19 completed by the SW on 2/27/19 indicated Resident #4 reported that while receiving incontinent care that NA #6 was rough while tuning and repositioning him. This form indicated that Resident #4 stated that some NAs gave 110% and others walked in and asked what he needed in a tone of voice that makes me feel like a bother. A phone interview was conducted with NA #6 on 2/28/19 at 8:35 AM. She stated she was familiar with Resident #4. She indicated his cognition was intact, he had no behavioral issues, and he needed assistance with ADLs including incontinent care. NA #6 revealed she had spoken with the Administrator by phone about Resident #4 ' s report. She stated she was unable to remember ever being rough with Resident #4 or saying something to him about being childish. She additionally stated she had not known Resident #4 was upset by her. NA #6 stated she was going to apologize to Resident #4 for upsetting him the next time she saw him. A follow up interview was conducted with Resident #4 on 2/28/19 at 9:00 AM. Resident #4 was lying in bed in his room. He was alert and oriented. He stated he reported the information about NA #6 to the SW and the Administrator. He reiterated his report and provided the same information as in the interview conducted on 2/25/19 at 11:40 AM. An interview was conducted with the Administrator on 2/28/19 at 10:39 AM. She indicated it was her expectation for all residents to be treated with dignity and respect.

Based on observation, record review, and interviews with resident, Psychiatric Nurse Practitioner (PNP), psychotherapist, and staff, the facility failed to promptly obtain psychotherapy services as ordered by the PNP for a resident (Resident #4) with a [DIAGNOSES REDACTED]. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of nursing notes dated 7/13/18 indicated Resident #4 had frequent episodes of crying and made statement he didn ' t want to live any more. The physician was notified, and an order was obtained for a psychiatric consultation and for [MEDICATION NAME] (antidepressant medication). Resident #4 was placed on suicide precautions with hourly checks conducted by nursing staff. Resident #4 ' s family member was also notified. A physician's order [REDACTED]. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 ' s cognition was intact. He self-reported feeling down/depressed hopeless on 7 to 11 days, trouble falling asleep/staying asleep/or sleeping or much on 7 to 11 days and feeling tired/having little energy on 12 to 14 days. Resident #4 had other behavioral symptoms on 1 to 3 days and he received antidepressant medication and antianxiety medication on 7 of 7 days. The behavioral symptoms Care Area Assessment (CAA) for Resident #4 ' s 7/13/18 significant change MDS assessment indicated he was alert and able to verbalize his needs. He was previously living at home when he fell and sustained a right tibia and fibula fracture and was hospitalized . Following hospitalization , Resident #4 was discharged to a different nursing facility prior to his transfer to this nursing facility. Resident #4 preferred to stay in his room and showed little interest in activities. He had a significant decline in mood, episodes of crying, and had verbalized the desire to no longer be living. Resident #4 ' s physician and family were aware, a psychiatric consultation was pending, and his treatment was revised. The care plan focus area of Resident #4 ' s risk for suicide and or injuries related to suicidal attempt related to depression with [MEDICAL CONDITION] was initiated on 7/13/18. The following interventions were initiated on 7/13/18: - One-hour checks for 72 hours. - Always take any of the following statements seriously and report to nurse, such as: I ' d be better off dead, I ' m going to end this, (my) family/friends/everyone would be better off without me. - Report to nurse immediately if Resident #4 verbalized any type of suicidal thoughts. - Encourage Resident #4 to discuss any feelings of loss, frustration, decreased self-worth. - Encourage Resident #4 to get out of room throughout the day to socialize with other residents. - Inspect Resident #4 ' s room every shift and remove any objects that could possibly be used to harm himself. - Provide one on one care as needed. - Remind Resident #4 of his areas of strength and self-worth daily. - Invite Resident #4 and assist him to activities of interest each day. The care plan focus area of Resident #4 ' s episodes of displaying the following behaviors: crying, making verbalizations of depression, and restlessness was initiated on 7/13/18. The following interventions were initiated on 7/13/18: - Administer medications as ordered, monitor/document side effects and effectiveness. - Anticipate and meet needs when possible. - Approach in a calm manner. - Assess for underlying causes of frustration/behaviors such as: hunger, thirst, discomfort, toileting needs, pain, and intervene when possible. - Assist Resident #4 to develop more appropriate methods of coping and interacting with others and encourage the expression of feelings. - Document inappropriate behaviors and the response to interventions. - Give Resident #4 positive feedback when displaying appropriate behaviors. - Intervene as necessary to protect the rights and safety of others. - When possible, discuss Resident #4 ' s behavior with him, and explain why behavior was inappropriate and/or unacceptable. A Social Worker (SW) late entry note for 7/13/18 (entered on 7/16/18) indicated she was informed that Resident #4 had expressed he no longer wished to live. The SW reported she spoke with Resident #4 on 7/13/18. He was in his room, laying in bed, and appeared calm and relaxed. He stated, I am tired of facing everyday .everyday is the same thing .I just get in these moods .I would not hurt myself or do something stupid like that I have no desire to live. Resident #4 declined a psychiatric consultation reporting that he didn ' t want to talk to anyone. The SW indicated she provided emotional support and reassurance. The Nurse Practitioner (NP) was made aware of SW ' s discussion with Resident #4. A nursing note dated 7/24/18 indicated Resident #4 stated he wanted to go home, there was nothing here for him, and nothing to live for here. Resident #4 agreed to a psychiatric consultation scheduled for 7/25/18. A consent for psychiatric services was signed by Resident #4 on 7/24/18. A physician's order [REDACTED].#4 related to depression. An NP note dated 7/25/18 indicated Resident #4 had been isolating himself, only remained awake for meals, had no interest in doing anything, and was feeling down and unmotivated all of the time. Resident #4 stated he was depressed because he wanted to go back home. He also expressed feeling down because of a lack of family support. Resident #4 denied hurting himself and/or others but admitted that he didn ' t feel like living anymore. The NP indicated she spoke with the Psychiatric Nurse Practitioner (PNP) on this date (7/25/19) about Resident #4. A PNP note dated 7/25/18 indicated she saw Resident #4 for an initial psychiatric visit. Resident #4 ' s cognition was intact and he self-reported depression and a passive death wish (PDW). He denied [MEDICAL CONDITION]. Staff reported Resident #4 was irritable and exhibited excessive eating and sleeping. She noted that Resident #4 ' s physician recently ordered [MEDICATION NAME] and she had no plans to add any other medications at this time. The PNP indicated a referral was to be made for a psychotherapy evaluation and treatment. A PNP note dated 8/22/18 indicated Resident #4 continued with depressed mood, but no statements of PDW or [MEDICAL CONDITION], and no outward symptoms of anxiety. The PNP again indicated a referral was to be made for a psychotherapy evaluation and treatment. A psychotherapy note indicated Resident #4 was seen for a mental health assessment/diagnostic interview. The psychotherapist indicated she spoke to facility staff about Resident #4 and was informed he primarily stayed in his room, had not associated or talked with anyone, and appeared to be very depressed. Staff reported concerns over Resident #4 experiencing [MEDICAL CONDITION]. The psychotherapist met with Resident #4 and completed an initial assessment. This assessment identified the [DIAGNOSES REDACTED]. A safety evaluation revealed Resident #4 currently had wishes to die but had no suicidal intent/plan. He stated he wished he would just close his eyes and not wake up. During the session, Resident #4 was noted to be triggered by a question and began crying uncontrollably. The psychotherapist provided crisis therapy services to assist Resident #4 with his overwhelming emotions. Resident #4 was noted to respond well to the psychotherapists interventions and techniques. An interview was conducted with the Director of Nursing (DON) on 2/27/19 at 8:15 AM. The initial psychiatric note for Resident #4 dated 7/25/18 and the initial psychotherapy note dated 8/27/18 were reviewed with the DON. She stated she was unsure what the process was for the obtainment of psychotherapy services after the PNP made a referral. She explained that the PNP and the psychotherapist worked for the same company. She further explained that once the PNP was involved she made a referral internally through her company to obtain psychotherapy for the resident. A phone interview was conducted with the PNP on 2/27/19 at 12:40 PM. The initial psychiatric note for Resident #4 dated 7/25/18 and the initial psychotherapy note dated 8/27/18 were reviewed with the PNP. She was asked what the normal process was for a referral to psychotherapy. She stated she worked closely with the psychotherapist and that any resident she provided services to was also seen for psychotherapy unless the resident refused and/or of it the resident ' s cognition prevented productive psychotherapy. The PNP indicated that after her initial visit, the psychotherapist normally saw the resident on her next visit to the facility. She stated she thought the psychotherapist visited the facility once per week. She reported that these psychotherapy sessions allowed her to get more information and insight into the background of the resident which assisted her with decision making. The PNP indicated that Resident #4 had expressed [MEDICAL CONDITION] and a PDW. She revealed that Resident #4 had severe depression and that while she had not thought he had any active suicidal thoughts, that because his depression was so severe that it was vital to take any expressed [MEDICAL CONDITION] seriously. She indicated that her expectation was for psychotherapy to commence for Resident #4 within 2 weeks of her initial visit. She was unable to explain why Resident #4 ' s initial psychotherapy session was over a month after her initial visit. A phone interview was conducted with the psychotherapist on 2/27/19 at 9:10 AM. She was asked what the process was for a referral to psychotherapy. She stated she worked closely with the PNP and that any resident the PNP provided services to was also seen by her for psychotherapy unless the resident refused and/or of it the resident ' s cognition prevented productive psychotherapy. She indicated that after the PNP ' s initial visit, she normally saw the resident for psychotherapy on her next visit to the facility. The psychotherapist stated she visited the facility once per week. The initial psychiatric note for Resident #4 dated 7/25/18 and the initial psychotherapy note dated 8/27/18 were reviewed with the psychotherapist. She was unable to explain why she had not seen Resident #4 for an initial psychotherapy session until over a month after the PNPs initial visit. The psychotherapist revealed that this was out of the normal timeframe as the next date she was at the facility after the PNP ' s 7/25/18 visit was 7/30/18. She stated she reviewed her records and she saw no refusals of psychotherapy for Resident #4 prior to 8/27/18. She reported that Resident #4 was receptive to her on 8/27/18 at their initial visit. She stated he self-reported a history of child abuse, expressed PDW, and was very emotional with periods of crying. The psychotherapist indicated she provided 9 psychotherapy sessions to Resident #4 from 8/27/18 through 11/12/18. She reported Resident #4 had been participating in sessions and had a noted improvement with his mood for several weeks, but then became very depressed again and on 11/12/18 he asked her to leave and requested to be discharged from psychotherapy services. An interview was conducted with Resident #4 on 2/28/19 at 9:00 AM. Resident #4 was lying in bed in his room. He was alert and oriented. He confirmed he had received psychotherapy services at the facility for a couple of months. He stated he liked the sessions at first. Resident #4 explained that as the sessions progressed that he had to talk about stuff I didn ' t want to talk about it .I just ended up feeling worse afterwards. He stated he asked the psychotherapist not to come back. During an interview with the DON on 2/27/19 at 8:15 AM she indicated it was her expectation for psychotherapy services to be initiated within 1 to 2 weeks after a referral was made by the PNP. An interview was conducted with the Administrator on 2/28/19 at 10:39 AM. She indicated it was her expectation for psychotherapy services to be initiated within 1 to 2 weeks after a referral was made by the PNP.

Based on record review and staff, Nurse Practitioner (NP) and Physician interview, the facility administered [MEDICATION NAME], a nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) to a resident and failed to recognize that the resident was allergic to the drug. In the presence of initial gastrointestinal (GI) symptoms, the facility failed to recognize the use of the [MEDICATION NAME] as potentially causing or contributing to the GI symptoms, resulting in the continued administration of the [MEDICATION NAME]. The resident required hospitalization due to hemoglobin (protein molecules in red blood cells that carries oxygen to the body's tissues) of 4.2 (normal value 11XXX,[DATE].5) and received 6 units of blood. This was evident for 1 of 3 sampled residents reviewed (Resident #1). Immediate jeopardy began on [DATE] when Resident #1 started to receive the [MEDICATION NAME] and was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: Resident #1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident 1's cognition was intact and she was always incontinent of bowel and bladder. The assessment further indicated that Resident #1 needed extensive assistance with toileting. Resident #1's care plan dated [DATE] was reviewed. There was no care plan to address the use of the NSAID. The electronic and hard copy medical records were reviewed. The monthly Medication Administration Records (MARs) and the nurse's and NP's progress notes from (MONTH) through (MONTH) (YEAR) were reviewed and listed the resident's allergy to [MEDICATION NAME]. The MARs and the notes did not indicate what allergic reaction the resident had to the [MEDICATION NAME]. The doctor's progress notes dated [DATE] also indicated that the resident was allergic to [MEDICATION NAME] and the reaction was hives. The physician's orders [REDACTED]. Resident #1 had a doctor's order dated [DATE] for [MEDICATION NAME] 200 milligrams (mgs) 3 tablets by mouth with meals for arthritis and was discontinued on [DATE] due to black stools. Resident #1's laboratory report dated [DATE] revealed that her hemoglobin level was 11.8 The nurse's and NP notes for Resident #1 were reviewed. The notes dated [DATE] at 6:22 PM indicated that the resident complained of sore stomach and she was noted to have a small amount of brown liquid emesis(vomitus). The notes dated [DATE] at 7:54 AM, the resident was given [MEDICATION NAME] due to indigestion and at 11:59 AM, the notes revealed that the resident had loose stools and was eating small amount. On [DATE] at 11:41 PM, the resident was yelling out loudly and wanted to know where she was and who put her here. On [DATE] 5:47 PM, the resident had emesis and diarrhea. The NP was informed and assessed the resident with no new order and at 7:36 PM, the notes revealed that the resident was vomiting. The NP notes dated [DATE] (entered on [DATE] at 2:28 PM) revealed that she was called to check on Resident #1. The resident had vomited some burgundy looking fluid and she had black tarry stools. Her stool was positive for blood. She stopped the [MEDICATION NAME] and she ordered complete blood count (CBC) on [DATE] and to monitor the resident. On [DATE] at 11:11 AM, the notes indicated that the Physician had assessed the resident and he ordered [MEDICATION NAME] (an antibiotic) for urinary tract infection [MEDICAL CONDITION] and intravenous fluid (IVF) for dehydration. On [DATE] at 11:28 AM, the notes indicated that the resident was alert with confusion. On [DATE] at 4:11 AM, the notes indicated that the resident was alert with confusion. The notes further indicated that the nurse received a call from the laboratory at 1:30 AM that the resident had a critical hemoglobin of 4.2. The Physician was informed and requested to call the family if they wanted the resident to be sent out to the hospital. The family requested to send the resident to the hospital. Resident #1 was sent to the hospital at 2:10 AM on [DATE]. The physician and NP progress notes for Resident #1 were reviewed. The notes revealed that Resident #1 was seen by the Physician on [DATE] and by the NP on [DATE] but the notes did not address the resident's GI symptoms of sore stomach, brown emesis, indigestion and loose stools. The physician's notes dated [DATE] indicated that the resident had 2 episodes of emesis and diarrhea. The stool was positive for blood but the hem occult card (a card used to check for the presence of blood in the stool) was expired. The resident was more lethargic and confused than usual but arousable. There was mild generalized tenderness to the abdomen on palpation. The NP notes dated [DATE] revealed that [MEDICATION NAME] was started for UTI and IVF for nausea and vomiting. The resident stated that she still didn't feel good and she appeared weak and tired. She appeared very pale. The notes further indicated that the resident had black tarry stool and was positive for blood. The plan was CBC was ordered to check for the extent of bleeding since patient did have black tarry stool on the same day that she started to have symptoms of nausea and vomiting. Stopped her daily [MEDICATION NAME] that day as well. She has been on [MEDICATION NAME] 20 mgs daily while on [MEDICATION NAME]. Result still pending. The hospital discharge summary dated [DATE] was reviewed. The discharge summary listed the resident's allergy to [MEDICATION NAME]. The admitting [DIAGNOSES REDACTED]. The discharge [DIAGNOSES REDACTED]. Resident #1 had received 6 units of blood transfusion. On [DATE] at 3:10 PM, a family member of Resident #1 was interviewed. The family member stated that she had discussed her concerns with Nurse #2 regarding Resident #1 having black stools and had been throwing up several days before the hospitalization . Nurse #2 informed the family member that the black stool was from the iron medication. On [DATE] at 11:38 AM, Nursing Assistant (NA) #1 was interviewed. She stated that she was assigned to Resident #1. She stated that the resident was having black and loose stools days before she was discharged to the hospital. NA #1 stated that the nurses especially Nurse #2 were aware that the resident was having black stool. On [DATE] at 4:34 PM, NA #2 was interviewed. She stated that she was assigned to Resident #1. NA #2 stated that Resident #1 was always incontinent of bowel and bladder and she needed assistance with toileting. She had described the resident's stool as cranberry color. She stated the resident was passing cranberry colored stool couple of days before she was discharged to the hospital. NA #2 indicated that the nurses were aware of the cranberry colored stool and they stated that it was from the iron pill the resident was taking. The NA also revealed that Resident #1 was alert and oriented but became more confused during the time she was passing cranberry colored stool. On [DATE] at 9:10 AM, NA #3 was interviewed. The NA stated that he was assigned to Resident #1. NA #3 indicated that the resident was having dark, black and loose stools several days before she was sent to the hospital. He revealed that the resident's stool was not normal and she was more confused. NA #3 stated that the nurses were aware of the black stools especially Nurse #2. On [DATE] at 10:50 AM, Nurse #1 (author of nurse's notes dated [DATE]) was interviewed. She stated that she remembered Resident #1 had complained of sore stomach and had brown emesis. Nurse #1 stated that she didn't call the physician nor the NP to inform them of the resident's complaint of sore stomach and the brown emesis but she had left a note in the communication book for the physician and NP. Nurse #1 didn't know that the resident was allergic to [MEDICATION NAME]. On [DATE] at 11:05 AM, Nurse #2 (author of nurse's notes dated [DATE]) was interviewed. She stated that she had informed the NP on [DATE] of resident's having black stools. The NP ordered to discontinue the [MEDICATION NAME] and to check the CBC on [DATE]. Nurse #2 further indicated that the resident was having loose stools and was vomiting. The Nurse didn't know that Resident #1 was allergic to [MEDICATION NAME]. Nurse #2 stated that she didn't know that the resident was having black stools until [DATE] but the resident was receiving iron pill. On [DATE] at 12:50 PM, the NP was interviewed. She stated that she was aware that Resident #1 was placed on [MEDICATION NAME] but she had missed that she was allergic to it. She stated that she was not informed that Resident #1 had complained of sore stomach and was noted to have brown emesis on [DATE]. She indicated that she had assessed the resident on [DATE] when she was informed that the resident was passing black stools. She had discontinued the [MEDICATION NAME] and ordered CBC that Monday ([DATE]). The NP further indicated that the CBC was not drawn on Monday because the laboratory was scheduled to come every Monday, Wednesday and Friday. She had seen the resident on [DATE] but the CBC was still pending. On [DATE] at 9:35 AM, the Physician was interviewed. He stated that he ordered the [MEDICATION NAME] not knowing that Resident #1 was allergic to it. He stated that the pharmacy should have caught the allergy and alerted the facility. He also indicated that he came to assess the resident on [DATE] and nobody had informed him that the resident was having black stools. He treated the resident with antibiotic for UTI and IVF for dehydration. The Physician also stated that if he had known the resident was having black stools, he should have done differently, send the resident to the hospital or check the CBC stat. The physician further indicated that he was made aware that the resident was having black stools after reading the hospital records. On [DATE] at 4:34 PM, the Director of Nursing (DON) was interviewed. She stated that she could not find a note in the communication book dated [DATE] and some notes were already shredded. The DON further stated that she expected the nurse to call the physician or the NP for symptoms like brown colored emesis and stomach pain. On [DATE] at 8:30 AM, the DON was again interviewed. She stated that the facility had a schedule for routine blood draw every Monday, Wednesday and Friday. If the laboratory work was ordered stat, she had to draw the blood and sent it to the hospital and usually the result was available in ,[DATE] hours. The DON stated that when Resident #1 was noted to have black stools, the CBC should have been ordered stat. The Nurse Consultant and the DON were informed of the Immediate jeopardy on [DATE] at 9:30 AM. On [DATE] at 3:41 PM, the facility provided the following Credible Allegation of Compliance: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Resident #1 had an allergy to [MEDICATION NAME] noted. Physician ordered [MEDICATION NAME] for the resident for Arthritis on ,[DATE] /18. Staff and the physician failed to identify the resident's allergy to [MEDICATION NAME]. On [DATE] Resident #1 complained of stomach discomfort and brown colored emesis. Interviews by the Director of Nurses with assigned nursing assistants revealed that they had notified the facility nurses about a change in patient condition for several days prior to the nurses notifying the physician. The patient was noted by the nursing assistants to have black stools. Interview by the Director of Nurses with facility nurses revealed that they contributed the black stool to the resident's receiving iron supplementation. On [DATE] the nurse notified the physician of the change in condition and the Nurse Practitioner ordered a CBC to be drawn on [DATE]. Results of the CBC received on [DATE] revealed a HGB of 4.2. The physician was notified and the resident was transferred to the hospital for further evaluation. The resident was admitted and received six liters of blood. The resident returned to the facility on [DATE] and remains a resident of the facility. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Audits: On [DATE] the resident D.M. was assessed by the floor nurse for any change in condition and allergies related to current orders. Results: No identified change in condition identified or medication vs. allergies were identified. On [DATE] the Director of Nurses, Support Nurse and staff nurses assessed all residents for change in condition by utilizing the 24 hr. report, change in condition report and observation and assessment of each resident. Results: 5 residents were identified with a change in condition using the Situation, Background, Assessment, and Recommendation (SBAR) Change in Condition Form Corrective Action: The physician has been notified of the identified changes in condition by the staff nurse. On [DATE] all resident allergies were audited by the Support Nurse and Director of Nurses to ensure that they are not receiving medications that they are allergic to or have documented side effects of medications. Results: None were identified. Education: Nursing Education: Employees to receive education: All Full time, Part time and as needed (PRN) Nurses, Nursing Assistants and Medication Aides, Physician and Nurse Practitioner. Topics discussed: Verification of Allergies with new orders prior to administration of meds/treatments/tests. Location of identified allergies for each resident under their name in the electronic health record. Notification of Physician for any identified allergies or side effects related to ordered medications. Change in Condition identification which includes identification of medication side effects. Change in Condition Reporting. Follow Through by Nurses on Reported Change in Condition by Nursing Assistants. Reporting to Director of Nurses and or Administrator by Nursing Assistants if nurses do not respond to their reports of a change in condition. Change in Condition Follow Through. When was it started: [DATE] all staff have received the required education. The Director of Nurses will ensure that any employee who has not received this education by [DATE] will not be allowed to work until the education is provided. The Director of Nursing will ensure that all staff should receive this education. This training will be incorporated into the new hire orientation process for all licensed nursing, medication aides and nursing assistant The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: The Director of Nurses/Support Nurse will monitor change in condition daily Monday- Friday x 4 weeks and monthly for 2 months. All changes in condition will be reviewed for reporting, notification and timely implementation and follow through. Reports will be presented to the weekly QA committee by the Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nurses, Minimum Data Set Coordinator, Therapy, Health Information Manager, and the Dietary Manager. Any issues identified will be reported to the Administrator for appropriate action. The title of the person responsible for implementing the Quality Improvement Plan. The Administrator. Compliance Date: [DATE] The credible allegation was verified on [DATE] at 3:50 PM as evidenced by staff interview and review of the in-service records. Nurses were interviewed and they verified that they had received training on verification and notification of MD of allergies and identification and notification of MD of resident's change in condition. Nursing Assistants were interviewed and they verified that they had received training on notification of nurses, DON and Administrator of resident's change in condition. The sign in sheets for the in-service were reviewed.