Every finding on record at Lincolnton Rehabilitation Center

Based on observation and staff interviews, the facility failed to remove expired food stored for use in the walk-in cooler and dry goods storage room, failed to ensure leftover food was dated, maintain a clean ice machine and ensure lights were free of dust. These practices had the potential to affect food served to residents. The findings included:a. An initial observation of the kitchen was completed with the Assistant Dietary Manager on 8/24/2026 at 10:45AM. The following was observed in the walk-in cooler: -One 4 lb container of pimento cheese labeled with an open date of 8/13/2026 and a use by date of 8/20/2026.-One 1 gallon container of Italian dressing opened without a labeled open date or use by date. There was no expiration date visible. - A cardboard container of celery had clear fluid leaking onto an open cardboard box of strawberries stored below.In an interview on 8/24/2026 at 10:50 AM, the Assistant Dietary Manager verified the leaking celery container and the wet cardboard underneath. She stated she had been unaware of the leak and acknowledged the wet cardboard should have been removed. She also stated she was unaware of the mislabeled containers in the walk in cooler. She explained she was new to the position but confirmed the items would be discarded. She did not recall the last time the cooler had been checked for labeling, storage, or expiration dates.b. An observation of the dry storage area was completed on 7/24/2026 at 11:10AM which revealed the following: -One 16 oz container of Kiwi Lime dessert syrup expired on 7/23/2026.-One 15 oz container of Mango dessert syrup expired on 7/9/2026.In an interview on 8/24/2026 at 11:12 AM, the Assistant Dietary Manager stated she was unaware of the expired items. She verified the sauces were expired and stated they would be discarded. She did not recall the last time the dry storage area had been checked for expiration dates. c. An observation of the ice machine was completed on 8/24/2026 at 11:20AM which revealed the following:-The ice machine had a dark brownish black substance across the upper metal rim where the hard plastic door opening meets the metal seal and ice cap. The ice machine was full. The ice was not touching the area where the dark browning black substance was located. The last posted monthly service date was 8/10/2026. In an interview on 8/24/2026 at 11:20 AM, the Assistant Dietary Manager stated that the Maintenance Director maintained the ice machine. She was unaware of the dark substance on the rim. This was the only ice machine in the kitchen. This ice machine was used to serve the residents' beverages. During an interview with the Maintenance Director on 8/24/2026 at 11:29 AM, he stated he was responsible for monthly cleaning, which he reported completing on 8/10/2026. He was not aware of the dark growth on the ice machine and stated dietary staff had not reported it.d. An observation of the lunch preparation area was completed on 8/26/2026 at 11:30AM which revealed the following: -Dust hanging from seven elongated light covers aligned over the food service preparation area.During an interview with the Assistant Dietary Manager on 8/27/2026 at 9:48AM, the Assistant Dietary Manager confirmed there was dust on the light covers and stated she did not know when they were last cleaned. The Assistant Dietary Manager stated keeping the light covers clean was important to protect meals from contamination.In a follow up interview with the Maintenance Director on 8/27/2026 at 10:00 AM, he stated he performed monthly light cleaning but could not recall when it was last done. He reported he was responsible for maintaining the ceiling vent in the kitchen but did not remember the last time the filter had been changed.In an interview with the Administrator on 8/27/2026 at 2:00 PM, she stated the Registered Dietitian conducted walkthroughs to identify kitchen issues. She stated the Maintenance Director was responsible for addressing repairs and was effective in doing so. The Administrator stated the current leadership team, including the Assistant Dietary Manager and Registered Dietitian, had been providing guidance, training, and education for staff since changes in kitchen leadership.

Based on record review, and resident, resident representative, staff, Consulting Pharmacist and Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to the initiation or increase of the medications for 3 of 5 residents reviewed for unnecessary medications (Resident #73, Resident #36 and Resident #13).The findings included:a. Resident #73 was initially admitted on [DATE] diagnoses of dementia with other behavioral disturbance, generalized anxiety disorder, post-traumatic stress disorder, schizoaffective disorder bipolar type, depression. Record review revealed Resident #73 had been on sertraline (antidepressant medication) 50 milligrams (mg) since 5/13/2025.Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had intact cognition and received antidepressant medication during the 7-day look back period.Resident #73's physician's orders revealed an order dated 7/15/2025 to increase sertraline 100 mg by mouth daily for depression/anxietyA Psychiatric Nurse Practitioner (NP) note dated 7/15/2025 indicated Resident #73 reported feeling more depressed and thought her medications needed to be adjusted, the Psychiatric NP discussed an increase in sertraline with Resident #73. The note revealed no documentation for a discussion of the side effects, risks or benefits of increasing sertraline. Treatment plan to increase sertraline to 100mg.A nurses note dated 7/15/2025 written by Nurse #2 revealed a new order for sertraline 100mg was received and residents' family was notified. Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had intact cognition and received antidepressant medication during the 7-day look back period.Resident #73's Medication Administration Record (MAR) from 7/15/2025 to 8/25/2026 indicated Resident #73 was administered sertraline as ordered by the physician.A review of Resident #73's medical record revealed no information indicating if Resident #73 was informed in advance of the risks and benefits of increasing sertraline.An interview with Resident #73 was conducted on 8/26/2026 at 3:35 PM. Resident #73 stated she did not recall any facility staff or providers discussing the risks, benefits or side effects of an increased dose of sertraline.b. Resident #36 was admitted on [DATE] with diagnoses of depression, anxiety disorder.Resident #36's admission MDS dated [DATE] revealed Resident #36 was moderately cognitively impaired.Record review revealed Resident #36 had a state appointed Division of Social Services Guardian who was responsible for all health decisions. Resident #36's physician orders revealed an active order dated 6/23/2026 for clonazepam (medication used to treat panic disorder and off label for anxiety treatment) 0.25mg by mouth twice daily for anxiety.Resident #36's physician orders revealed a discontinued order dated 6/23/2026 for sertraline 25mg daily by mouth for depression/anxiety.A Psychiatric NP progress note dated 6/23/2026 revealed a plan to switch Resident #36 clonazepam 0.25mg twice daily for anxiety and start sertraline 25mg daily for depression/anxiety.Resident #36's physician orders revealed an active order dated 7/14/2026 for sertraline 50mg daily by mouth for depression/anxiety.A Psychiatric NP Progress note dated 7/14/2026 indicated Resident #36 reported she still experienced anxiety, and the plan was to increase sertraline to 50mg daily.A nurse's note dated 7/14/2026 written by Nurse #1 indicated Resident #36's Guardian was notified new sertraline orders. Resident #36's MAR from 6/23/2026 to 8/26/2026 indicated Resident #36 was administered clonazepam and sertraline as ordered by the physician.A review of Resident #13's medical record revealed no information indicating if Resident #36's Resident Representative was informed in advance of the risks and benefits of initiating clonazepam and sertraline.During a telephone interview on 8/27/2026 at 10:13 AM Resident #36's Resident Representative indicated she had received email correspondence at the time of Resident #36's admission for psychotropic medication consent. Resident #36's Resident Representative verified on 6/23/2026 and 7/14/2026 she had not received email correspondence from the facility regarding the risk, benefits or side effects related to the initiation of clonazepam or the increase in sertraline.c. Resident #13 was admitted on [DATE] with diagnoses of anxiety, bipolar disorder and post-traumatic stress disorder. Resident #13 was her own Responsible Party for health care decisions.Resident #13's admission MDS dated [DATE] revealed Resident #13 was cognitively intact. The MDS indicated Resident #13 received antianxiety medication during the 7-day look back period.Resident #13's physicians' orders revealed an active order dated 8/4/2026 for clonazepam 0.25 mg by mouth twice daily for anxiety.An interview with Resident #13 was conducted on 8/26/2026 at 3:15 PM. Resident #13 revealed she did not recall any facility staff or providers discussing the risks, benefits or side effects of clonazepam with her when she started clonazepam.A Psychiatric NP progress note dated 8/4/2026 indicated Resident #13 reported having breakthrough anxiety and feeling nervous a lot of the time, with a plan to discontinue the current as needed medication and start clonazepam scheduled twice daily.Resident #13's MAR from 8/4/2026 to 8/25/2026 indicated Resident #13 was administered clonazepam as ordered by the physician.A review of Resident #13's medical record revealed no information indicating if Resident #13 was informed in advance of the risks and benefits of initiating clonazepam.During an interview on 8/26/2026 at 3:15 PM, Resident #13 stated she did not recall any facility staff or providers discussing the risks, benefits or side effects of starting clonazepam.An interview on 8/26/2026 at 2:50 PM was conducted with Nurse #1, who indicated if a resident was admitted on psychotropic medication a psychotropic medication consent was to be completed. Nurse #1 thought if a new psychotropic medication was started or increased after admission the unit managers would obtain the psychotropic medication consent. Nurse #1 stated if she had obtained a psychotropic medication consent it would be documented in her progress note. Nurse #1 verified when she notified a resident or resident representative of a new order or medication increase that did not always include the side effects, risk and benefits.A telephone interview on 8/27/2026 at 11:22 AM was conducted with Nurse #2 who indicated if a residents dose of a psychotropic medication was increased she did not obtain a new consent but would notify the resident or resident representative of the new dose. Nurse #2 stated if she had obtained verbal consent, she would have documented that the consent was obtained in her note.An interview on 8/26/2026 at 2:53 PM was conducted with Unit Manager #1 who indicated she was unsure if psychotropic medication consents were obtained when psychotropic medication was increased. Unit Manager #1 stated psychotropic medication consents were obtained when residents were admitted on psychotropic medications and when new psychotropic medications were started after admission. An interview on 8/27/2026 at 10:31 PM with the Psychiatric NP revealed the facility was responsible for obtaining psychotropic medication consents, and her understanding was the consent was supposed to be completed when psychotropic medications were initiated and increased. The Psychiatric NP stated she did discuss medication side effects with some residents, related to if they notice something different to notify the nurse so they could contact the Psychiatric NP. The Psychiatric NP stated if she had fully reviewed side effects, risks and benefits it would be documented in her progress note. A telephone interview on 8/27/2026 at 4:21 PM with the Consulting Pharmacist and Director of Nursing (DON) revealed the Consulting Pharmacist did not review psychotropic consents for the facility during her monthly medication reviews and expected the facility to follow their policy. The Consulting Pharmacist verified antidepressants, and antianxiety medications were psychotropic medications and required consent when they were initiated. The Consulting Pharmacist added a new consent may not be required if the increase in a psychotropic medication was discussed and planned when it was ordered but agreed that discussion should be documented in the medical record.An interview with the DON on 8/27/2026 at 11:00 AM revealed the floor nurses and unit managers were responsible for obtaining psychotropic medication consent when a resident was admitted on a psychotropic medication, and when a psychotropic medication was initiated after admission or increased. The DON indicated the Psychiatric NP would also inform the resident or resident representative of side effects, risk and benefits of a psychotropic medication and that nurses would also go over that when they notified the family.An interview with the Administrator on 8/27/2026 at 2:34 PM revealed the Administrator indicated she believed there was confusion from the nurses that documenting notification of a new medication was intended to mean a consent was obtained. The Administrator expected documentation of notification to be enough that consent was obtained.

Based on record review, review of the facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 6 residents reviewed for activities (Resident #65, #64, #71, #10, #25, #105). The residents expressed not being able to leave the facility since admission made them feel sad, mad or depressed and they missed going shopping and participating in activities they enjoyed. The findings included: A review of the facility activity calendars from July 2024 to July 2025 revealed scheduled activities inside of the facility during the week and on the weekends. There were no activities scheduled outside of the facility. Observation on 7/1/2025 at 4:20 PM revealed the facility was located in a rural area that was within a 5-to-10- minute driving distance to numerous local and commercial shops, grocery stores, fast food and sit-down restaurants. During a resident council meeting on 7/01/25 at 1:30 PM the residents indicated they did not get to go on trips outside of the facility for activities because the facility did not have a van. a. Resident #65 was admitted to the facility on [DATE]. Review of Resident #65's annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #65 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #65 was cognitively intact. An interview was conducted with Resident #65 on 6/30/2025 at 9:40 AM. Resident #65 stated the facility did not have a van for trips outside the facility, but it would be nice to get out of the facility. During a follow-up interview on 7/2/2025 at 9:45 AM, Resident #65 stated she would love to be able to go shopping, and stated it bothered her she could not do that anymore, and that she missed going out to shop. Resident #65 stated she had not gone out of the facility for an activity since she was admitted because the facility did not have a van. b. Resident #64 was admitted to the facility on [DATE]. Review of Resident #64's annual MDS assessment dated [DATE] indicated it was not very important to participate in group activity or go outside the facility. The quarterly MDS assessment dated [DATE] indicated Resident #64 was moderately cognitively impaired. An interview was conducted with Resident #64 on 7/2/2025 at 9:48 AM. Resident #64 stated she would like to be able to go on activities outside of the facility. Resident #64 stated it got old sitting in the same building all the time and it was enough to make anyone depressed. Resident #64 stated she had not been on an activity outside the facility since she was admitted since the facility did not have a van for activities outside the facility. c. Resident #71 was admitted to the facility on [DATE]. Review of Resident #71's annual MDS assessment dated [DATE] indicated it was not very important to participate in group activities and to go outside the facility and indicated Resident #71 was cognitively intact. An interview was conducted with Resident #71 on 7/2/2025 at 9:50 AM. Resident #71 stated had not participated in activities at the facility, but she would have participated if the activity involved going outside of the facility on a trip. Resident #71 stated she missed going shopping and would love to be able to do her own shopping. Resident #71 stated it was sad that residents could not go out and do some of the things they enjoyed. Resident #71 stated she was not aware of any activities offered that involved leaving the outside of the facility since she was admitted . d. Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's annual MDS assessment dated [DATE] revealed it was very important to Resident #10 to participate in activities with a group and to go outside the facility, it also indicated Resident #10 was cognitively intact. An interview was conducted with Resident #10 (Resident Council President) on 7/2/2025 at 12:48 PM. Resident #10 stated the residents can't go out to eat because the facility did not have a van. Resident #10 stated she would like to go out to eat and that it made her sad and sometimes mad that residents can't go to a restaurant or out somewhere. e. Resident #105 was admitted to the facility on [DATE]. Review of Resident #105's admission MDS assessment revealed it was somewhat important to Resident #105 to participate in group activities and go outside the facility, it also indicated Resident #105 was cognitively intact. An interview was conducted with Resident #105 on 7/2/2025 at 12:53 PM. Resident #105 stated she would love to go out shopping, or out to dinner as a group. Resident #105 stated it made her feel sad that she was always in the building, but the facility did not have a van, so residents were not able to go outside of the facility for activities. f. Resident # 25 was admitted to the facility on [DATE]. Review of Resident #25's admission MDS assessment indicated it was not very important to participate in activities with groups and somewhat important to go outside the facility. The admission MDS indicated Resident #25 was cognitively intact. An interview was conducted with Resident #25 on 06/29/25 at 11:31 AM. Resident #25 stated she would love to go to the bookstore and go to a fast food restaurant, or at least go through the drive-through, on the way back, but the facility did not have a van, so they could only go out for medical appointments. During a follow up interview on 7/2/2025 at 12:57 PM, Resident #25 stated she did not participate in the in-house activities because she was not interested in any of them. Resident #25 stated if residents were able to get out of this building that would be great. Resident #25 stated staying inside the same walls all the time was depressing, and she thought residents should have the right to get out of the building. During an interview on 7/2/2025 at 8:49 AM the Activity Director stated the facility did not have any scheduled activities that were off the facility campus because the facility did not have a van. The Activity Director stated after 2020 (Covid) the facility had a new transport company that would charge $60 per person. The Activity Director stated if residents needed anything she went shopping for them once a week, and the facility could arrange transport at the residents' expense. The Activity Director stated she thought the facility only had one company that was used for transport. The Activity Director stated the facility had not had an off campus activity since 2020 (before Covid) and prior to that they had two outings a month such as shopping or going out to eat. The Activity Director stated she thought the company that used to provide transport had gone out of business. The Activity Director agreed it would be good for the residents to be able to have activities outside of the facility and have the ability to interact with the community. The Activity Director could not provide a specific date for the last activity that was outside the facility campus. During a joint interview with the Director of Nursing (DON) and Administrator, the Administrator and DON both agreed it was important for residents to have interaction with the community and be able to participate in activities outside of the facility. The DON stated she was not aware any residents had voiced they wanted to go on activities outside the facility. The DON stated the facility did not have a van to use for outside activities. The DON stated the facility went shopping for the residents to get requested items. The Administrator and DON verified that residents had not been out for a personal shopping trip unless a family member had transported them, since prior to 2020. During an interview on 7/2/2025 at 1:40 PM the Director of Clinical Services stated the facility did not have a way to get residents to activities outside of the facility. The Director of Clinical Services stated they bring activities to the facility and the residents go outside of the building, and no residents had asked to go on trips. The Director of Clinical Services stated they did not have knowledge that residents wanted to go out on trips outside the facility, and they did not have a van available. The Director of Clinical Services stated if they had knowledge they would have tried to make accommodations and stated that activities outside of the facility campus were provided at the company's other facilities.

Based on observations, record reviews, and interviews with residents and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 2 of 2 residents reviewed for accommodation of needs (Resident #32 and Resident #39). The findings included: a. Resident #32 was admitted to the facility on [DATE]. Review of Resident #32's medical records revealed she had stayed in her current room since 05/23/2023. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. The MDS indicated walking between locations inside the room for more than 10 feet did not occur for Resident #32 during the assessment period. During an observation conducted on 06/29/2025 at 10:19 AM, the switch for the light fixture behind Resident #32's bed was attached with a cord 24 inches in length. The cord was 4 feet from the floor and 5 feet from Resident #32's bed. Resident #32 was unable to reach the cord from the bed if needed. An interview was conducted with Resident #32 on 06/30/2025 at 9:06 AM. She stated she was bedbound and had been in her room for a very long time. Resident #32 stated she had never been able to reach the light cord to turn her overhead light on. She revealed she did not have any control of the light fixture behind her bed as she could not stand up to reach the broken switch cord on the wall. Resident #32 explained she had to rely on nursing staff to control the light fixture, and it was very inconvenient to her because she enjoyed using her computer and needed the overhead light to see the computer screen. She wanted the maintenance staff to fix the switch cord to accommodate her needs as soon as possible. Subsequent observations conducted on 06/30/2025 at 2:00 PM, 07/01/2025 at 8:31 AM, and 07/01/2025 at 3:59 PM revealed the switch cord for the light fixture behind Resident #32's bed remained inaccessible. An observation and interview were conducted with Nurse Aide (NA)#1 on 07/02/2025 at 9:12 AM. The switch cord for the light fixture behind Resident #32's bed remained inaccessible from her bed. NA#1 acknowledged that the switch cord was too short for Resident #39 to reach, and it needed to be fixed. NA #1 stated she had never thought about the light cord being too short for Resident #39 to reach but stated that she did turn the overhead light on for Resident #32 when she made her morning rounds so Resident #32 could use her computer. NA #1 also stated that she had not reported the light cord to anyone at the facility. An interview was conducted with Unit Manager (UM) #1 on 07/02/2025 at 9:32 AM. She acknowledged that the switch cord for the light fixture behind Resident #32 bed was broken. UM #1 stated the light cord needed to be fixed immediately to ensure Resident #32 had full accessibility to the light fixture. b. Resident #39 was admitted to the facility on [DATE]. Review of Resident #39's medical records revealed she had stayed in her current room since 02/01/2024. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. The MDS indicated walking between locations inside the room for more than 10 feet did not occur for Resident #39 during the assessment period. During an observation conducted on 06/29/2025 at 11:11 AM, the switch for the light fixture behind Resident #39's bed had a broken cord. The broken cord was 2 inches in length and was 6 feet from the floor and 5 feet from Resident #39's bed. Resident #39 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #39 on 06/30/2025 at 9:06 AM. She stated she had never been able to reach her light cord to turn the overhead light on and she had been in her current room for a very long time. Resident #39 stated she would like to be able to turn the light on and off when she needed it because she enjoyed reading and doing word puzzles while lying in bed. Resident #39 stated she did not have any control of her overhead light, and she had to rely on the nursing staff to turn the light on and off because she had a stroke and could not stand up and reach the light switch cord. Resident #39 also stated that it was inconvenient to her, and she would like the light switch cord repaired as soon as possible. Subsequent observations conducted on 06/30/2025 at 2:15 PM, 07/01/2025 at 9:01 AM, and 07/01/2025 at 3:49 PM revealed the switch cord for the light fixture behind Resident #39's bed remained inaccessible. An observation and interview were conducted with NA#1 on 07/02/2025 at 9:12 AM. The switch cord for the light fixture behind Resident #39's bed remained inaccessible from her bed. NA#1 acknowledged that the switch cord was broken, and it needed to be fixed. NA #1 stated she had not noticed the switch cord behind Resident #39's bed was broken and that she had not reported the broken switch cord to anyone at the facility. An interview was conducted with Unit Manager #1 on 07/02/2025 at 9:32 AM. She acknowledged that the switch cord for the light fixture behind Resident #39's bed was broken. UM #1 stated the light cord need to be fixed immediately to ensure Resident #39 had full accessibility to the light fixture. During an interview conducted on 07/02/2025 at 10:06 AM with the Maintenance Supervisor, he stated the nursing staff would let him know if anything in the facility needed repair including the overhead lights and light switch cords. The Maintenance Manager stated he depended on the staff to report repair needs by completing work orders and leaving them at the nursing station or by verbal notification. He explained that he checked the nursing station several times a day for any work orders to ensure all repair needs were addressed in a timely manner. He stated he did not know the switch cords for Resident #32 and Resident #39 needed repairing. An interview was conducted with the Director of Nursing (DON) on 07/02/2025 at 10:30 AM. The DON stated she was not aware Resident #32 and Resident #39 could not access their light switch cords, but she did expect staff to notify maintenance if anything in the facility needed repair. The DON also stated that she expected staff to be more attentive to residents' living environment, and to report repair needs in a timely manner to accommodate the residents' needs. An interview was conducted with the Administrator on 07/02/24 at 10:35 AM. The Administrator stated he expected the nursing staff to pay attention to residents' rooms and report all repair needs to the maintenance department in a timely manner. It was his expectation for all dependent residents to have full accessibility and control of the light fixture behind the bed all the time.

Based on record review, and resident and staff interviews the facility failed to provide a resident with the opportunity to participate in the review and revision of his care plan for 1 of 3 residents reviewed for care plans (Resident #80). The findings included: Resident #80 was admitted to the facility on [DATE]. Resident #80's significant change Minimum Data Set (MDS) dated [DATE] noted he was cognitively intact and required maximum assistance or was dependent on staff for most activities of daily living. Review of Resident #80's electronic health record noted no care plan meeting had been conducted since 1/8/25. An interview on 6/29/25 at 12:25 PM with Resident #80's revealed he had not been invited to a care plan meeting. He had attended in the past and felt like he should have had an opportunity to attend. An interview on 7/01/25 at 10:53 AM with the Social Worker revealed her assistant scheduled the care plan meetings and Resident #80's care plan meeting was not on her paper copy of June or July 2025 calendar of meetings. She stated the MDS nurse scheduled the care plan meetings. An interview on 7/01/25 at 10:58 AM with the Social Services Assistant revealed she scheduled resident care plan meetings via a scheduling software based on a schedule provided by the Minimum Data Set (MDS) nurse. She did not remember if Resident #80 had been invited to a care plan meeting or not. An interview on 7/01/25 at 11:04 AM with the MDS Nurse revealed Resident #80 had not had a care plan meeting since 1/08/25. She was unable to say why he had not had a care plan meeting in April but did state he should have had a care plan meeting in April. She looked in the care plan software system and stated he did not have an invitation in the system. She looked at her paper copies of the June and July care plan meetings and was unable to locate his name on the schedule. An interview on 7/02/25 at 8:40 AM with the Administrator revealed he was new to the facility and unaware of the resident care plan schedules. He stated that residents should be invited to the care plan meetings as required by the regulation.

Based on record review, staff and Nurse Practitioner interviews, the facility failed to provide resident care in a safe manner for 1 of 3 residents (Resident #1) reviewed for accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including hemiplegia to the left side and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and required substantial to maximal assistance with toileting hygiene and bed mobility. The care plan dated 3/28/2024 revealed Resident #1 required two-person assistance for incontinent care and bed mobility. An incident report dated 6/17/2024 at 6:26 AM completed by Nurse #1 indicated Nurse Aide (NA) #1 was providing care to Resident #1 in bed. NA #1 rolled Resident #1 to her left side and Resident #1 slid off the side of the bed feet first and NA #1 lowered her to the floor. Resident #1 was assessed, had no complaints of pain and no injuries were noted. The Nurse Practitioner (NP) and Resident Representative (RR) were notified as was the on-coming nurse (Nurse #2). A skin assessment completed by Nurse #2 on 6/17/2024 at 9:32 AM revealed Resident #1 was noted to have discoloration to the right lateral (outer) upper arm, right axillary arm (armpit), right and left middle abdomen, left outer thigh, right inner heel, and a red area to the left knee. Abrasions were noted to the right second, fourth and fifth toe, tip of right second great toe, and right distal (top) foot. Also noted was a reddened area with slight abrasion to the middle back. A Nurse Practitioner (NP) note dated 6/17/2024 at 10:05 AM indicated NA #1 was providing care for Resident #1 and she slid off the side of the bed and was lowered to the floor. Resident #1 started complaining of lower extremity pain and was noted to have a bruise on her right heel. Resident #1, at baseline, had atrophy (muscle wasting) to her lower extremities which made assessing for injury difficult and due to her complaints of pain she was transferred to the Emergency Department (ED) for further evaluation. The ED records dated 6/17/2024 revealed Resident #1 reported she was receiving care when she started sliding off the bed with her feet hitting the floor and then was lowered down to the floor. Resident #1 had bruising to her right foot and was complaining of leg pain, but no head trauma or other injury was noted. Left and right leg x-rays were obtained and negative for fracture or acute injury. Resident #1's condition was stable, and she was discharged back to facility with no new orders. An interview conducted with Resident #1 on 4/30/2025 at 2:00 PM revealed she did not recall the date or the NA's name, but a NA was assisting her with incontinent care in bed, and she was turning from one side to the other and rolled off the side of the bed to the floor. Resident #1 stated usually two NAs assisted her with care but when the incident occurred only one NA was present. Resident #1 stated after the incident she started having lower leg pain and was transferred to the ED for further evaluation. Resident #1 revealed x-rays obtained were negative for fracture or injury and she was discharged back to the facility. Resident #1 indicated she had no further pain or discomfort related to the fall. Several attempts made to contact NA #1 were unsuccessful. A phone interview with Nurse #1 on 4/30/2025 at 2:43 PM indicated on 6/16/2024 to 6/17/2024 he was the third shift (11pm-7am) nurse assigned to Resident #1. Nurse #1 stated on 6/17/2024 at the end of his shift he responded to Resident #1's room when NA #1 activated the call bell. Nurse #1 revealed he observed Resident #1 lying on the floor beside her bed. He indicated NA #1 reported that Resident #1 was rolling to her left side, slid off the side of the bed and was lowered down to the floor. Nurse #1 indicated Resident #1 was not complaining of any pain or discomfort and he completed an assessment with no injuries noted. He revealed he reported the incident to the oncoming nurse and notified the NP and RR. Nurse #1 stated Resident #1 required two-person assistance with bed mobility, but he did not recall if NA #1 had a second person assisting her when the incident occurred. An interview was conducted with Nurse #2 on 4/30/2025 at 3:30 PM. Nurse #2 stated she was the first shift (7a-3p) nurse assigned to Resident #1 on 6/17/24. She stated Nurse #1 reported at shift change that NA #1 was turning Resident #1 during care and she slid off the side of the bed and was lowered to the floor. Nurse #2 indicated that Resident #1 required two-person assistance with incontinence care and bed mobility and NA #1 did not have a second person assisting her when the incident occurred. She revealed that Nurse #1 completed an assessment and Resident #1 had no visible injuries and no complaints of pain. Nurse #2 revealed she completed a skin assessment a few hours after the incident and Resident #1 had a bruise on her right heel. Nurse #2 indicated Resident #1 started complaining of increased pain to both legs and she notified the NP. She stated the NP gave an order to transfer Resident #1 to the ED for further evaluation. Nurse #2 stated that Resident #1 was transferred to the ED around 10:00 AM and returned to the facility around lunch time. She indicated the ED report noted x-rays obtained of Resident #1's right and left leg were negative for fractures or injury and there were no new orders. An interview was conducted with the NP on 4/30/2025 at 1:20 PM. She stated on 6/17/2024 she was notified that Resident #1 rolled out of bed to the floor during care. The NP revealed due to Resident #1 having atrophy to her lower extremities at baseline, it was difficult to assess her for injuries and combined with her complaints of increased pain she was transferred to the ED for further evaluation. She indicated x-rays obtained in the ED were negative for fractures and Resident #1 was discharged back to the facility with no new orders. The NP revealed that one person should not assist a resident with incontinent care and bed mobility when two-person assistance was required to ensure the resident's safety. During an interview with the Director of Nursing (DON) on 4/30/2025 at 5:45 PM she stated she was aware of the incident that occurred on 6/17/2024. The DON indicated Resident #1 required two-person assistance with incontinent care and bed mobility and NA #1 assisting her without a second person was unsafe. An interview conducted with the Administrator on 4/30/2025 at 6:00 PM revealed he was aware of the incident that occurred on 6/17/2024. He stated to ensure care was provided in a safe manner a resident requiring two-person assistance should not be assisted by one person. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 06/17/2024 at approximately 6:26 AM, Nursing Assistant #1 was providing ADL care to Resident #1. As Nursing Assistant #1 turned Resident #1 towards her (left) side, the resident's feet begin to slide off the bed with her heels landing on the floor. Nurse Assistant #1 held Resident #1 up and lowered her to the floor into a supine position. Nursing Assistant #1 then went to Floor Nurse #1 to notify him that the resident had slid off the bed and was laying on the floor. Floor Nurse #1 stated that Resident #1 didn't have any visual injuries or complaints of pain. The resident was assisted back to bed by Floor Nurse #1 and Nursing Assistant #1 using a mechanical lift. Approximately 7:00 AM, Floor Nurse #1 reported to the oncoming nurse that resident had slid out of bed and didn't have any change in range of motion or visual injuries. At 9:32 AM a skin evaluation was completed by the oncoming nurse with noted discoloration to the right lateral upper arm, right axillary arm, right and left mid abdomen, right inner heel and abrasions to the right second toe, tip of right second great toe, distal foot, toes 4 and 5, a red area to (left) knee and discoloration to the left lateral thigh. Also noted was a reddened area with slight abrasion to the middle of her back. At approximately 10:05 AM, the provider gave an order to transfer Resident #1 to the hospital due to pain. The Responsible Party (RP) was notified of order to transfer to hospital at the same time. At 1:25 PM, Resident #1 returned to the facility by stretcher via emergency medical services (EMS) with no further orders. The Medical Director and RP were notified of Resident #1's return. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Nursing Assistant #1's education file was audited by the Director of Nursing on 6/21/2024 to ensure that the employee received training validation of Kardex prior to providing resident ADL care. Nursing Assistant #1 was noted to have received the necessary training during general orientation on 3/19/2024. On 6/17/2024 at 3:14 PM, verbal education was provided over the phone by the Unit Manager and the Assistant Director of Nursing, to Nursing Assistant #1 regarding accessing the Kardex and reading it to know the care residents required for bed mobility. Education was also provided to Nursing Assistant #1 on ensuring a resident's correct body position in the bed before rolling or asking resident to roll to their side while in bed. On 6/21/2024, the Director of Nursing completed an audit of current residents to ensure that no falls/incidents had occurred in the last 30 days related to not providing the appropriate assistance with bed mobility. No occurrences were noted. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/17/2024, education was initiated by the Staff Development Coordinator (SDC) to the direct care staff regarding checking the Kardex located in the Point of Care to know what assistance was required when providing ADL care. Staff education was completed 6/21/2024. Staff that did not receive the education by 6/21/2024 will receive prior to working next shift. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. An ADHOC quality assurance (QA) meeting was held on 6/17/2024 by the interdisciplinary team and it was determined that Nursing Assistant #1 failed to follow the resident's Kardex that 2-person assist was required for bed mobility which resulted in a fall. On 6/24/2024 audits were initiated to observe 2 staff members providing 2 sampled residents' ADL care to ensure care is being provided according to the Kardex, weekly for 8 weeks by the Director of Nursing and or Unit Managers. Effective 6/17/2024, the Administrator and the Director of Nursing are ultimately responsible for ensuring the plan is implemented and monitored for effectiveness. The Quality Assurance Improvement Committee will review the results of the weekly audits during the monthly meetings for 3 months. The committee will determine if further actions are needed. The facility's alleged date of compliance is 6/22/2024. Validation of the facility's corrective action plan was conducted 4/30/2025 which included record review and staff interviews. A phone interview conducted with the former Staff Development Coordinator revealed on 6/17/2024 she initiated providing education to all nursing staff related to accessing the electronic medical record (EMR), reviewing resident care needs and ensuring care was provided according to the EMR. Interviews conducted with nursing staff revealed they received education on accessing and reviewing the EMR prior to providing resident care and ensuring care was provided according to the EMR. The nursing staff interviewed also confirmed the observations of resident care audits were completed. The facility's corrective action plan completion date of 6/22/2024 was validated.

Based on observations, record review, and resident and staff interview the facility failed to provide incontinence care when requested for 2 of 3 residents reviewed for activities of daily living care (Resident #53 and Resident #80). Resident #53 was noted to have a new open area to the right buttocks when incontinence care was provided, and Resident #53 reported the area was sore. Findings included: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses of hip fracture and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #53 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. Resident #53 was interviewed in her room on 04/08/24 at 9:49 AM. During the interview she stated she had been sitting in a soiled brief since after breakfast at 8:45 AM. She stated Nurse Aide (NA) #1 had answered her call light around 8:45 AM and stated she was picking up breakfast trays on the hall and could not provide incontinence care but would return after trays were off the hall. Resident #53 stated NA #1 had not returned to the room and she was sitting in feces. She stated she knew NA #1 had a lot to do and she was not upset over having to wait. On 04/08/24 at 9:58 AM the surveyor told NA #1 that Resident #53 needed incontinence care. NA #1 stated she was passing out soap on the hall and that she knew the resident had been waiting for incontinence care but had not been back in the room. An observation was conducted on 04/08/24 at 10:18 AM of incontinence care for Resident #53 with NA #1 and Unit Manager #1. Resident #53 was noted to have bowel movement in her brief at the time of the observation. She was noted with redness on her bottom and stated the area was, sore. The stool was not observed to be dried to the resident's skin. On 04/08/24 at 11:11 AM an interview was conducted with NA #1. During the interview she stated Resident #53 had turned her call light on around 8:30-8:45 AM and stated she needed to be changed. NA #1 stated she went into the room and turned the call light off because she could not provide incontinence care while meal trays were on the halls. She stated she was going to go back to Resident #53's room and provide care but she had forgotten. On 04/11/24 at 12:21 PM an interview was conducted with Unit Manager #1. During the interview she stated no staff member had ever told Nurse Aides that they could not provide incontinence care while meal trays were on the halls. She stated unless the Nurse Aides were actively assisting someone with a meal, they should stop what they're doing and provide incontinence care. She stated Resident #53 had redness to her bottom when she was assisting NA #1 with incontinence care, and she notified the wound nurse. On 04/08/24 at 5:15 PM a nursing progress note written by the Assistant Director of Nursing (ADON) revealed Resident #53 was noted with a new open area to the right buttocks which was caused by excoriation. A new order for zinc oxide (a cream used to treat minor skin irritations) was applied and the ADON left a message for the wound Physician to see Resident #53. A physician order dated 04/08/24 revealed Resident #53 received an order for zinc oxide to be applied to the residents buttocks every shift three times a day for a duration of 30 days. On 04/11/24 at 3:24 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated she was the acting wound nurse in the facility. She stated she went in and assessed Resident #53 on 04/08/24. She stated she noted excoriation (scraped or abraded skin) on the resident's buttocks. The ADON stated she initiated Zinc Oxide for treatment of the area. She stated she felt the area was caused by the way the resident sat in the bed and not from sitting in a soiled brief because she had this issue prior while being in the facility. A wound note written by the wound physician dated 04/09/24 revealed Resident #53 had a new wound care assessment completed. Resident #53 was noted to have a non-pressure wound of the right upper buttock measuring 1.4-centimeter (cm) length by 0.6 cm width by 0.1 cm depth. The duration of the wound was noted to be at least 2 days. On 04/09/24 at 8:55 AM an interview was conducted with the Director of Nursing (DON). She stated NA #1 should have provided care when the resident asked. The interview revealed staff were able to provide care regardless of if meal trays were on the hall. The interview revealed she did not feel like having residents wait for incontinence care was an acceptable practice. 2. Resident #80 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #80 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. An observation conducted on 04/08/24 at 10:30 AM revealed Resident #80 yelled into the hall and notified NA #1 she had a soiled brief. NA #1 was observed entering the room. Resident #80 was interviewed in her room on 04/08/24 at 10:45 AM. During the interview she stated she had been sitting in a soiled brief since 9:30 AM and knew this because she had been looking at the clock on the wall. She stated she had told NA #1 that she was sitting in a soiled brief with bowel movement and NA #1 acknowledged her and left the room. She stated she was still sitting in bowel movement and needed to be changed. On 04/08/24 at 10:50 AM the surveyor told Unit Manager #1 that Resident #80 was sitting in a soiled brief. An observation was conducted on 04/08/24 at 10:57 AM of Unit Manager #1 and Assistant Director of Nursing (ADON) providing incontinence care to Resident #80. Resident #80's top sheet, bed pad and fitted sheet were observed to be soiled with feces. Resident #80 was observed to have feces extending down onto the thighs and covering her urinary catheter. A complete bed change was observed after the nurses provided incontinence care to Resident #80. On 04/08/24 at 9:49 AM an interview was conducted with NA #1. During the interview she stated Resident #80 had told her she needed to be changed however she had already started running water down the hall for another resident's bed bath. The interview revealed she had planned on completing the bed bath prior to changing Resident #80. NA #1 stated she did not know Resident #80 had been sitting in a soiled brief since 9:30 AM. On 04/11/24 at 12:21 PM an interview was conducted with Unit Manager #1. Unit Manager #1 stated once you see a call light on you should provide the care or let another staff member know so the care was provided. Unit Manager #1 stated she had to complete an entire bed change for Resident #80 due to incontinence and that was not common in the facility. She stated typically the Nurse Aides were good about providing care. On 04/11/23 at 3:24 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she did assist Resident #80 with incontinence care and had to complete a bed change due to the incontinence. The ADON stated Nurse Aides should be providing care upon resident request. On 04/09/24 at 8:55 AM an interview was conducted with the Director of Nursing (DON). She stated NA #1 should have provided care when the residents asked. The interview revealed she did not feel like having residents wait for incontinence care was an acceptable practice.

Based on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested for 1 of 3 residents reviewed for dignity (Resident #80). Resident #80 stated it made her upset to sit in a soiled brief and made her feel like a third-class citizen and she paid her bill like everyone else. The Findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #80 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. An observation conducted on 04/08/24 at 10:30 AM revealed Resident #80 yelled into the hall and notified NA #1 she had a soiled brief. NA #1 was observed entering the room. Resident #80 was interviewed in her room on 04/08/24 at 10:45 AM. During the interview she stated she had been sitting in a soiled brief since 9:30 AM and knew this because she had been looking at the clock on the wall. She stated she had told NA #1 that she was sitting in a soiled brief and NA #1 acknowledged her and left the room. She stated she was still sitting in bowel movement and needed to be changed. During the interview Resident #80 stated, It makes me feel like a third-class citizen, I pay my bill like everyone else. She went on to say it made her upset having to sit in a soiled brief filled with bowel movement. On 04/08/24 at 10:50 AM the surveyor told Unit Manager #1 that Resident #80 was sitting in a soiled brief. An observation was conducted at 10:57 AM of Unit Manager #1 and Assistant Director of Nursing (ADON) providing incontinence care to Resident #80. Resident #80's top sheet, bed pad and fitted sheet were observed to be soiled with feces. Resident #80 was observed to have feces extending down onto the thighs and covering her urinary catheter. A complete bed change was observed after the nurses provided incontinence care to Resident #80. On 04/08/24 at 9:49 AM an interview was conducted with Nurse Aide (NA)#1. During the interview she stated Resident #80 had told her she needed to be changed however she had already started running water down the hall for another resident's bed bath. The interview revealed she had planned on completing the bed bath prior to changing Resident #80. NA #1 stated she did not know Resident #80 had been sitting in a soiled brief since 9:30 AM. On 04/11/24 at 12:21 PM an interview was conducted with Unit Manager #1. Unit Manager #1 stated once you see a call light on you should provide the care or let another staff member know so the care was provided. Unit Manager #1 stated she had to complete an entire bed change for Resident #80 due to incontinence and that was not common in the facility. She stated typically the Nurse Aides were good about providing care. She stated no resident should feel upset, like a third-class citizen or have to sit in bowel movement. On 04/11/23 at 3:24 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she did assist Resident #80 with incontinence care and had to complete a bed change due to the incontinence. The ADON stated Nurse Aides should be providing care upon resident request. The interview revealed no resident should feel upset or have to ask twice to be changed while sitting in a brief with bowel movement. On 04/09/24 at 8:55 AM an interview was conducted with the Director of Nursing (DON). She stated NA #1 should have provided care when the resident asked. The DON stated Resident #80 should never feel like a third-class citizen or upset because staff would not change her brief.

Based on record review and resident, Resident Representative,staff, Infusion Center staff, Nurse Practitioner, and Medical Director interviews the facility failed to provide a safe and orderly discharge for 1 of 3 residents (Resident #1). On 8/28/23 Resident #1 had a scheduled medical appointment and prior to the appointment the resident's belongings were packed by staff and were sent with him to the appointment. Resident #1 was not provided with discharge paperwork or discharge instructions and did not understand what was happening. The discharge location was not verified, home health services were not ordered at the time of discharge, and the resident was not followed up with to ensure his needs were met. This resulted in Resident #1 feeling like he was being thrown out, abandoned, and was mad. Findings included: Review of the hospital discharge summary dated 08/26/23 revealed Resident #1 was admitted to the hospital on 08/07/23 due to Resident #1 having generalized body weakness and the family had also taken him to the hospital for placement. Resident #1 was admitted with throat cancer and a tracheostomy and was diagnosed with adult failure to thrive and increased general weakness. Resident #1 was discharged from the hospital on 08/26/23 and referred to the facility for skilled services. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cancer, malnutrition, respiratory failure, and muscle weakness. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was alert and oriented. The MDS further revealed Resident #1 had a tracheostomy. A phone interview conducted with the Respiratory Therapist (RT) revealed on 04/11/24 at 11:05 AM revealed Resident #1 was assessed on 08/27/23 and revealed Resident #1 had a cuffed tracheostomy and recommended it be changed to an uncuffed tracheostomy because uncuffed tubes allow airway clearance but provide no protection from aspiration and cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration. The RT revealed nursing staff was not familiar with caring for a resident with a cuff tracheostomy. The RT further revealed he was unable to change the tracheostomy due to the facility not having the supplies needed. The RT indicated he did not write physician orders and that the Nurse Practitioner (NP) or Medical Director (MD) would have to be notified to obtain the order to change the tracheostomy type. The RT indicated Resident #1 was not in distress and could have waited to have his trach changed when supplies were obtained but the Director of Nursing (DON) made the RT aware the decision was made to send Resident #1 to the ED after the infusion appointment on 08/28/23. Review of a progress note completed by Nurse #1 dated 8/28/23 revealed Resident #1 was at the emergency room (ED). A phone interview conducted with Resident #1 on 04/11/24 at 6:10 PM revealed on 08/28/23 he was advised and aware he was going to an infusion appointment. Resident #1 further revealed while he was waiting on the transporter at the front of the facility and a staff member (unable to recall specific staff member) dropped a bag in his lap with all his belongings and reported he was going to the Emergency Department (ED) after his appointment with no other information. Resident #1 indicated once he arrived at the infusion appointment with his bag the infusion staff nurse revealed to Resident #1 they had received a message from the facility to send the resident to the ED after his appointment. The infusion staff nurse explained to him that they could not send him to the ED because Resident #1 did not have an order. Resident #1 stated at this time he felt he was being discharged without knowledge and he felt like he was being thrown out, abandoned and was mad. Resident #1 revealed the Infusion Nurse contacted the facility Admissions Director and was told Resident #1 could not return to the facility. Resident #1 further revealed he contacted a family member to pick him up and take him home from his infusion appointment because he had nowhere else to go. Resident #1 indicated the facility had his personal phone number and did not attempt to contact his Resident Representative (RR) until 08/30/23 after Resident #1's primary care office reached out to the facility. Resident #1 stated the facility did not provide any discharge information, discharge services, medicines, or supplies once he left the facility. Resident #1 indicated he was able to perform self trach care and had medications and tube feeding formula when he returned home. A phone interview conducted with Infusion Center Nurse #1 on 04/10/24 at 1:20 PM revealed on 08/28/23 the infusion center received a message that Resident #1 needed to be sent to the ED after his infusion appointment. It was further revealed Infusion Center Nurse #1 contacted the Admissions Director because Resident #1 did not have any orders and the infusion center did not feel comfortable sending the resident to the ED. It was reported by the facility Admission Director that the facility was unable to care for Resident #1 and the resident needed to go to the ED to help find placement. It was observed by Infusion Center Nurse #1 that Resident #1 had a bag packed with his belongings and Resident #1 was observed to be frustrated and was confused on being discharged without notice. Infusion Center Nurse #1 stated Resident #1 contacted his RR to pick him up and Infusion Center Nurse #2 retrieved a small bag of supplies to send home with him. A phone interview with Infusion Center Nurse #2 on 04/10/24 at 9:45 AM revealed Resident #1 arrived at the infusion center upset, with his belongings with him, and reported he believed was being discharged without notice. It was further revealed Infusion Center Nurse #1 contacted the facility and it was reported Resident #1 could not return to the facility and had to be sent to the ED after his appointment. Infusion Center Nurse #2 indicated the infusion center staff did not feel comfortable sending the resident to the ED without orders and the resident did not observe to be in medical distress. Infusion Center Nurse #2 stated Resident #1 called his RR to come get him from the infusion center. Infusion Center Nurse #2 stated she felt like the facility had dumped Resident #1 and she was very upset for Resident #1. A phone interview with the prior Admissions Director on 04/09/24 at 6:00 PM revealed she recalled having a conversation with the infusion care center staff and it was an ugly conversation but could not recall anything that was discussed. It was further revealed the Admissions Director could not recall any part of what had occurred with Resident #1 from 08/28/23 through 08/31/23. A phone interview conducted with Resident #1's Resident Representative (RR) on 04/11/24 at 10:15 AM revealed Resident #1 was admitted to the facility after his hospital stay due to needing more care than the family could assist with. It was further revealed on 08/28/23 the RR was not notified prior that Resident #1 was being sent out for an infusion appointment but was contacted by the facility Admissions Director that Resident #1 was on his way to an infusion appointment and would have to be sent to the ED because the facility could not care for the resident's tracheostomy. The RR stated the facility Admissions Director revealed Resident #1 could not return to the facility. The RR revealed she arrived at Resident #1's infusion appointment and the Infusion Center Nurse #1 had contacted the facility as well and had reiterated the same information that the resident could not return to the facility. It was further revealed Resident #1 had a bag with his belongings and was very mad about being discharged without notice. The RR further revealed she took Resident #1 home because she felt like the facility had dumped him and she had no other choice. An interview conducted with the Assistant Director of Nursing (ADON) on 04/10/24 at 3:05 PM revealed she assisted in getting Resident #1 ready for his appointment on 8/28/23 and had given him a folder that had information for his appointment. The ADON indicated she did not recall the resident having a bag packed or having any concerns. The ADON stated Resident #1 was admitted with a cuffed trach that the facility did not have supplies for, and staff did not have the training to care for. The ADON stated she believed Resident #1 was admitted by accident because the facility normally would not accept a resident with a cuffed trach. The ADON indicated she had thought Resident #1 had been sent to the ED to have Resident #1's trach changed and was not aware until Resident #1's primary care office reached out on 08/30/23 that the resident was at home. The ADON revealed then she reached out to Resident #1's RR and it was revealed Resident #1 did not have the preferred liquid form of metformin and insulin. The ADON indicated she contacted the on-call provider on 08/30/24 and obtained orders for Resident #1's medications. The ADON was not aware that no staff from the facility had reached out to Resident #1 and was not sure why he did not return to the facility. An interview conducted with the facility Social Worker (SW) on 04/11/24 at 9:25 AM revealed he did not become involved with Resident #1 until 08/30/23 when Resident #1's primary care office contacted the facility to let them know Resident #1 was at home. The SW further revealed at that time he completed an Adult Protective Services (APS) report to make sure Resident #1 was safe and completed referrals for in home health but did not follow up to see if Resident #1 had been accepted for services. An interview conducted with the Director of Nursing (DON) on 04/10/24 at 3:35 PM revealed the Respiratory Therapist (RT) assessed Resident #1 on 08/27/24 and recommended Resident #1 have his tracheostomy changed from a cuffed to an uncuffed trach. The DON further revealed Resident #1 had an appointment at the infusion center on 08/28/23 and she decided for the Resident #1 to have his tracheostomy changed at the Emergency Department (ED) afterwards since the facility did not have the supplies to do so at the facility. The DON stated she could not recall why she did not notify the Nurse Practitioner (NP) or the Medical Director (MD) to obtain orders to do so. The DON stated she had planned for Resident #1 to come back to the facility in the evening of 08/28/23 and was not aware the resident had taken his belongings with him. The DON revealed nursing staff failed to follow up with the whereabouts of Resident #1 during second and third shift on 08/28/23 with the thought Resident #1 was still at the hospital, and no one realized he wasn't there on 8/29/23 either. The DON indicated on 08/30/23 it was found out that Resident #1 went home from his appointment on 08/28/23 when the facility received a phone call from Resident #1's primary care office. The DON indicated an APS report was completed, referrals from in home health were completed, and orders were obtained for Resident #1 to receive medicine. The DON stated she was not aware the prior Admissions Director told Resident #1 that he could not return to the facility. An interview with the Nurse Practitioner (NP) on 04/11/24 at 10:35 AM revealed she had not assessed Resident #1 during his stay in the facility and did not recall any conversation with the facility that Resident #1 was being sent out to have their trach changed. The NP indicated she could not recall who and on what date, but she was notified Resident #1 had left against medical advice (AMA). A phone Interview with the Medical Director (MD) on 04/10/24 at 4:55 PM revealed he had not assessed Resident #1 during his stay in the facility. The MD further revealed he could not recall who had reported that Resident #1 had left against medical advice (AMA) on 08/30/23. Interview with the Administrator on 04/11/23 at 4:00 PM revealed he was made aware by the DON on 8/28/23 that Resident #1 was being sent out to the infusion center on 8/28/23 and then heading to ED for trach change. The Administrator further revealed it was RT's recommendations and was not aware the RT could not write orders. The Administrator revealed he was unsure if Resident #1 had left with his belongings and was not aware of who was responsible for following up with Resident #1's whereabouts after he did not return from his appointment.

Based on record review and resident, Resident Representative,staff, Infusion Center staff, Nurse Practitioner, and Medical Director interviews the facility failed to permit a resident to return to the facility from therapeutic leave for 1 of 3 residents (Resident #1). On 8/28/23 Resident #1 had a scheduled medical appointment and prior to the appointment the resident's belongings were packed by staff and were sent with him to the appointment. Resident #1 was not allowed to return to the facility following the appointment. This resulted in Resident #1 feeling like he was being thrown out, abandoned, and was mad. Findings included: Review of the hospital discharge summary dated 08/26/23 revealed Resident #1 was admitted to the hospital on 08/07/23 due to Resident #1 having generalized body weakness and the family had also taken him to the hospital for placement. Resident #1 was admitted with throat cancer and a tracheostomy and was diagnosed with adult failure to thrive and increased general weakness. Resident #1 was discharged from the hospital on 08/26/23 and referred to the facility for skilled services. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cancer, malnutrition, respiratory failure, and muscle weakness. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was alert and oriented. The MDS further revealed Resident #1 had a tracheostomy. A phone interview conducted with the Respiratory Therapist (RT) revealed on 04/11/24 at 11:05 AM that Resident #1 was assessed on 08/27/23 and revealed Resident #1 had a cuffed tracheostomy and recommended it be changed to an uncuffed tracheostomy because uncuffed tubes allow airway clearance but provide no protection from aspiration and cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration. The RT revealed nursing staff was not familiar with caring for a resident with a cuff tracheostomy. The RT further revealed he was unable to change the tracheostomy due to the facility not having the supplies needed. The RT indicated he did not write physician orders and that the Nurse Practitioner (NP) or Medical Director (MD) would have to be notified to obtain the order to change the tracheostomy type. The RT indicated Resident #1 was not in distress and could have waited to have his trach changed when supplies were obtained but the Director of Nursing (DON) made the RT aware the decision was made to send Resident #1 to the ED after the infusion appointment on 08/28/23. A phone interview conducted with Resident #1 on 04/11/24 at 6:10 PM revealed on 08/28/23 he was advised and aware he was going to an infusion appointment. Resident #1 further revealed while he was waiting on the transporter at the front of the facility a facility staff member (unable to recall specific staff member) dropped a bag in his lap with all his belongings and reported he was going to the Emergency Department (ED) after his appointment with no other information. Resident #1 indicated once he arrived at the infusion appointment with his bag the infusion staff nurse revealed to Resident #1 they had received a message from the facility to send the resident to the ED after his appointment. The infusion staff nurse explained to him that they could not send him to the ED because Resident #1 did not have an order. Resident #1 stated at this time he felt he was being discharged without knowledge and he felt like he was being thrown out, abandoned and was mad. Resident #1 revealed the Infusion Nurse contacted the facility Admissions Director and was told Resident #1 could not return to the facility. Resident #1 further revealed he contacted a family member to pick him up and take him home from his infusion appointment because he had no other place to go. Resident #1 indicated he was able to care for himself and contact 911 in case of an emergency. A phone interview conducted with Infusion Center Nurse #1 on 04/10/24 at 1:20 PM revealed on 08/28/23 the infusion center received a message that Resident #1 needed to be sent to the ED after his infusion appointment but did not explain what Resident #1 was being sent to the ED for. It was further revealed Infusion Center Nurse #1 contacted the Admissions Director directly and it was explained by the Admissions Director Resident #1 needed a trach change. The Infusion Center Nurse #1explained to the Admissions Director Resident #1 did not have any orders and the infusion center did not feel comfortable sending the resident to the ED. It was reported by the facility Admission Director that the facility was unable to care for Resident #1 and the resident needed to go to the ED to help find placement and the resident could not return to the facility. It was observed by Infusion Center Nurse #1 that Resident #1 had a bag packed with his belongings and Resident #1 was observed to be frustrated and confused on not being able to return to the facility. A phone interview with Infusion Center Nurse #2 on 04/10/24 at 9:45 AM revealed Resident #1 arrived at the infusion center upset, with his belongings with him, and reported he believed was being discharged without notice. It was further revealed Infusion Center Nurse #1 contacted the facility and it was reported Resident #1 could not return to the facility and had to be sent to the ED after his appointment. Infusion Center Nurse #2 indicated the infusion center staff did not feel comfortable sending the resident to the ED without orders and the resident did not observe to be in medical distress. A phone interview with the prior Admissions Director on 04/09/24 at 6:00 PM revealed she recalled having a conversation with the infusion care center staff and it was an ugly conversation but could not recall anything that was discussed. It was further revealed the Admissions Director could not recall any part of what had occurred with Resident #1 from 08/28/23 through 08/31/23. A phone interview conducted with Resident #1's Resident Representative (RR) on 04/11/24 at 10:15 AM revealed Resident #1 was admitted to the facility after his hospital stay due to needing more care than the family could assist with. It was further revealed on 08/28/23 the RR was contacted by the facility Admissions Director that Resident #1 was on his way to an infusion appointment and would have to be sent to the ED because the facility could not care for the resident's tracheostomy. The RR stated the facility Admissions Director revealed Resident #1 could not return to the facility. The RR revealed she arrived at Resident #1's infusion appointment and the Infusion Center Nurse #1 had contacted the facility as well and had reiterated the same information that the resident could not return to the facility. It was further revealed Resident #1 had a bag with his belongings and was very mad about being discharged without notice. The RR further revealed she took Resident #1 home because she felt like the facility had dumped him and she had no other choice. An interview conducted with the Assistant Director of Nursing (ADON) on 04/10/24 at 3:05 PM revealed she assisted in getting Resident #1 ready for his appointment on 8/28/23 and had given him a folder that had information for his appointment. The ADON indicated she did not recall the resident having a bag packed or having any concerns. The ADON stated Resident #1 was admitted with a cuffed trach that the facility did not have supplies for, and staff did not have the training to care for. The ADON stated she believed Resident #1 was admitted by accident because the facility normally would not accept a resident with a cuffed trach. The ADON indicated she had thought Resident #1 had been sent to the ED to have Resident #1's trach changed and was not aware until Resident #1's primary care office reached out on 08/30/23 that the resident was home. The ADON was not aware that no staff from the facility had reached out to Resident #1 and was not sure why he did not return to the facility. An interview conducted with the Director of Nursing (DON) on 04/10/24 at 3:35 PM revealed the Respiratory Therapist (RT) assessed Resident #1 on 08/27/24 and recommended Resident #1 have his tracheostomy changed from a cuffed to an uncuffed trach. The DON further revealed Resident #1 had an appointment at the infusion center on 08/28/23 and she decided for the Resident #1 to have his tracheostomy changed at the Emergency Department (ED) afterwards since the facility did not have the supplies to do so at the facility. The DON stated she could not recall why she did not notify the Nurse Practitioner (NP) or the Medical Director (MD) to obtain orders to do so. The DON stated she had planned for Resident #1 to come back to the facility in the evening of 08/28/23 and was not aware the resident had taken his belongings with him. The DON revealed nursing staff failed to follow up with the whereabouts of Resident #1 during second and third shift on 08/28/23 with the thought Resident #1 was still at the hospital, and no one realized he wasn't there on 8/29/23 either. The DON indicated on 08/30/23 it was found out that Resident #1 went home from his appointment on 08/28/23 when the facility received a phone call from Resident #1's primary care office. DON stated she was not aware the prior Admissions Director told Resident #1 that he could not return to the facility. An interview with the Nurse Practitioner (NP) on 04/11/24 at 10:35 AM revealed she had not assessed Resident #1 during his stay in the facility and was not notified Resident #1 had been assessed by the RT and required an order to be obtained to have the resident's trach changed. A phone Interview with the Medical Director (MD) on 04/10/24 at 4:55 PM revealed he had not assessed Resident #1 during his stay in the facility and was not notified Resident #1 had been assessed by the RT and required an order to be obtained to have the resident's trach changed. Interview with the Administrator on 04/11/23 at 4:00 PM revealed he was made aware by the DON on 8/28/23 that Resident #1 was being sent out to the infusion center on 8/28/23 and then heading to ED for trach change. The Administrator further revealed it was RT's recommendations and was not aware the RT could not write orders and the physicians had not been notified about Resident #1.

Based on record review, resident, Infusion Center Nurse, Nurse Practitioner, Medical Director, and staff interviews the facility failed to notify the physician of a facility-initiated discharge for 1 of 3 residents (Resident #1) reviewed for notification. On 8/28/23 Resident #1 had a scheduled medical appointment and prior to the appointment the resident's belongings were packed by staff and were sent with him to the appointment. Findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses which included cancer, malnutrition, respiratory failure, and muscle weakness. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was alert and oriented. The MDS further revealed Resident #1 had a tracheostomy. Interview conducted with the Respiratory Therapist (RT) revealed on 04/11/24 at 11:05 AM revealed Resident #1 was assessed on 08/27/23. She indicated he had a cuffed tracheostomy and recommended it be changed to an uncuffed tracheostomy due to nursing staff not being familiar with caring for a resident with a cuffed tracheostomy with a different cannula. The RT further revealed he was unable to change the tracheostomy due to the facility not having the supplies needed. The RT indicated Resident #1 was not in distress and could have waited to have his trach change when supplies were obtained. Review of progress note completed by Nurse #1 dated 8/28/23 revealed Resident #1 was sent to the emergency room (ED). A phone interview conducted with Resident #1 on 04/11/24 at 6:10 PM revealed on 08/28/23 he was advised and aware he was going to an infusion appointment. Resident #1 further revealed while he was waiting on the transporter at the front of the facility a staff member (unable to recall specific staff member) dropped a bag in his lap with all his belongings and reported he was going to the Emergency Department (ED) after his appointment with no other information. Resident #1 further revealed he contacted a family member to pick him up and take him home from his infusion appointment because he had nowhere else to go. A phone interview conducted with Infusion Center Nurse #1 on 04/10/24 at 1:20 PM revealed on 08/28/23 the Infusion Center received a message that Resident #1 needed to be sent to the ED after his infusion appointment. She indicated she was contacted the Admissions Director because Resident #1 did not have any orders and the Infusion Center did not feel comfortable sending the resident to the ED. It was reported to the Infusion Center Nurse #1 from the facility Admissions Director the facility was unable to care for Resident #1 and the resident needed to go to the ED to help find placement. It was indicated Infusion Center Nurse #1 indicated Resident #1 had a bag packed with his belongings. A phone interview with the prior Admissions Director on 04/09/24 at 6:00 PM revealed she recalled having a conversation with the infusion care center staff and it was an ugly conversation but could not recall anything that was discussed. It was further revealed the Admissions Director could not recall any part of Resident #1 being discharged on [DATE]. Interview conducted with the Director of Nursing (DON) on 04/10/24 at 3:35 PM revealed the Respiratory Therapist (RT) assessed Resident #1 on 08/27/24 and recommended Resident #1 have his tracheostomy changed from a cuffed to an uncuffed tracheostomy. The DON further revealed Resident #1 had an appointment to the infusion center on 08/28/24 and she decided for the Resident #1 to have his tracheostomy changed at the Emergency Department (ED) afterwards since the facility did not have the supplies to do so at the facility. The DON stated she could not recall why she did not notify the Nurse Practitioner (NP) or the Medical Director (MD) to obtain orders for ED transfer and tracheostomy change. The DON stated she had planned for Resident #1 to come back to the facility in the evening of 08/28/23 and was not aware the resident had taken his belongings with him. The DON stated she was not aware the facility Admissions Director had reported to the infusion center that Resident #1could not return to the facility. Interview with the Nurse Practitioner (NP) on 04/11/24 at 10:35 AM revealed she had not assessed Resident #1 during his stay in the facility and did not recall any conversation with the facility that Resident #1 was being sent out to have their trach changed. The NP indicated she could not recall who notified her that Resident #1 had left against medical advice (AMA) but someone from the facility had reported it to her. Interview with the Medical Director (MD) on 04/10/24 at 4:55 PM revealed he had not assessed Resident #1 during his stay in the facility. The MD further revealed he was not notified that the resident had been sent out to the emergency room to have his tracheostomy changed. The MD further revealed he was unable to recall who notified the MD Resident #1 had left AMA and was not returning to the facility on [DATE].

Based on observations, record reviews and resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place in the areas of dignity and respect (F550) and notification of change (F580). Additionally, the facility's QAA Committee failed to identify deficient practice for a discharge that occurred on 8/28/23 and implement corrective action to ensure compliance was sustained in the area of safe and orderly discharge (F624). These 3 deficiencies were cited on the complaint investigation survey of 2/15/24 and subsequently recited on the current recertification and complaint investigation survey of 4/13/24. The facility's continued failure during two surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F 550: Based on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested for 1 of 3 residents reviewed for dignity (Resident #80). Resident #80 stated it made her upset to sit in a soiled brief and made her feel like a third-class citizen and she paid her bill like everyone else. During the complaint investigation survey of 02/15/24 the facility failed to treat a resident in a dignified manner when a Nurse Aide (NA) was rough and pushing on her during a transfer. This made the resident feel unsafe during the transfer and she stated this was a dignity issue. Additionally, the facility failed to assist a resident at eye level during a meal reviewed for dignity. An interview conducted with the Administrator who also headed QAA committee and Director of Nursing (DON) on 04/13/24 at 11:00 AM revealed the facility had discussed frequently at quarterly QAA meetings customer services and respect towards residents. The DON further revealed she did not know why these incidents had occurred. F 580: Based on record review, resident, Infusion Center Nurse, Nurse Practitioner, Medical Director, and staff interviews the facility failed to notify the physician of a facility-initiated discharge for 1 of 3 residents (Resident #1) reviewed for notification. On 8/28/23 Resident #1 had a scheduled medical appointment and prior to the appointment the resident's belongings were packed by staff and were sent with him to the appointment. During the complaint investigation survey of 02/15/24 the facility failed to notify the Physician of a resident's wound upon admission and failed to notify the Physician when the resident's wound had started to deteriorate. An interview conducted with the Administrator who also headed QAA committee and Director of Nursing (DON) on 04/13/24 at 11:00 AM revealed the facility had discussed frequently at quarterly QAA meetings notification. The DON further revealed nursing staff had failed to make appropriate notification and would continue to educate and put rules in place for proper notification. F 624: Based on record review and resident, Resident Representative,staff, Infusion Center staff, Nurse Practitioner, and Medical Director interviews the facility failed to provide a safe and orderly discharge for 1 of 3 residents (Resident #1). On 8/28/23 Resident #1 had a scheduled medical appointment and prior to the appointment the resident's belongings were packed by staff and were sent with him to the appointment. Resident #1 was not provided with discharge paperwork or discharge instructions and did not understand what was happening. The discharge location was not verified, home health services were not ordered at the time of discharge, and the resident was not followed up with to ensure his needs were met. This resulted in Resident #1 feeling like he was being thrown out, abandoned, and was mad. During the complaint investigation survey of 02/15/24 the facility failed to meet the resident's care needs upon discharge by not communicating the physician ordered wound care treatments and ensuring the needed medical equipment was delivered for a resident reviewed for a safe and orderly discharge. An interview conducted with the Administrator who also headed QAA committee and Director of Nursing (DON) on 04/13/24 at 11:00 AM revealed the facility had discussed frequently at quarterly QAA meetings about safe and orderly discharges. The DON further revealed she could not recall why discharges had been an issue, but steps would be put into place to guarantee residents would not be discharged unsafe in the future.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for resident with mental health diagnosis upon admission and residents with new mental health diagnoses for 2 of 3 residents (Resident #67 and #90) reviewed for PASRR. The findings include: 1. Review of Resident #67's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident had been diagnosed with anxiety disorder on 6/22/23, major depressive disorder on 6/22/23, post-traumatic stress disorder (PTSD) on 12/28/23, and mood (affective) disorder on 1/31/24. No PASRR level II had been completed per Resident # medical records. During an interview on 4/11/24 at 8:57 AM with the Social Worker (SW) revealed he had been employed as the facility SW over the past several years and since that time had been responsible for completing PASRR upon a resident admission if needed, when a change in condition or behavior had occurred, or when there had been a new diagnosis. He revealed he would review a resident's diagnosis and PASRR level once they were admitted and should be notified by nursing if a new diagnosis had been added for a resident or there had been a change in condition to determine if paperwork for a level II PASRR would need to be completed. The SW stated he had not been made aware of Resident #67 new mental health diagnosis of anxiety disorder, major depressive disorder, PTSD, and mood (affective) disorder and felt it could have been an oversight, however based on new diagnosis and the preadmission level I PASRR, paperwork for a PASRR level II should have been completed. During an interview on 4/11/24 at 5:35 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated based on Resident #67 newly added diagnosis of anxiety disorder, major depressive disorder, PTSD, and mood (affective) disorder a PASRR level II should have been completed. 2. Review of Resident #90 medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident was diagnosed with major depressive disorder on 3/08/24 and unspecified mood disorder on 3/08/24 upon admission. No PASRR level II had been completed per Resident #90 medical records. During an interview on 4/11/24 at 8:57 AM with the Social Worker (SW) revealed he had been employed as the facility SW and since that time had been responsible for completing PASRR upon a resident admission if needed, when a change in condition or behavior had occurred, or when there had been a new diagnosis. He revealed he would review a resident's diagnosis and PASRR level once they were admitted and should be notified by nursing if a new diagnosis had been added for a resident or there had been a change in condition to determine if paperwork for a level II PASRR would need to be completed. The SW stated Resident #90 admission diagnosis and level of PASRR had simply been overlooked, however based on Resident #90 admission diagnosis of major depressive disorder and unspecified mood disorder and the preadmission PASRR level I, paperwork for a PASRR level II should have been completed. During an interview on 4/11/24 at 5:35 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated based on Resident #90 admission diagnosis of major depressive disorder and unspecified mood disorder a PASRR level II should have been completed.

Based on observation, record review, staff and resident interview the facility failed to treat a resident (Resident #6) in a dignified manner when Nurse Aide (NA) #2 was rough and pushing on her during a transfer. This made Resident #6 feel unsafe during the transfer and she stated this was a dignity issue. Additionally, the facility failed to assist a resident at eye level during a meal (Resident #3) for 2 of 4 residents reviewed for dignity. The findings included: 1. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses which included muscle wasting and atrophy, muscle weakness, and difficulty in walking. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was cognitively intact. She required substantial/maximal assistance with transfers from chair to bed. Resident #6 had no behavior or refusal of care indicated. Resident #6 had a plan of care in place regarding impaired communication related to the use of glasses initiated on 5/30/2023. Interventions were inclusive of providing extensive assistance of 1staff person transfer with gait belt. An interview was completed with Resident #6 on 1/30/23 at 3:08 PM. Resident #6 stated approximately one month ago a Nurse Aide (NA) on 3rd shift was pushing her, pulling on her, and rushing her when transferring her from the wheelchair back to her bed. Resident #6 verbalized that made her feel unsafe during that transfer. Resident #6 was able to identify NA #2 as the aide who was rough with her during care. A follow up interview was performed on 1/31/24 at 11:00 AM with Resident #6. She verbalized she did not allow NA #2 to assist with transferring her after the prior incident due to feeling unsafe and afraid of being hurt. She stated she allowed NA #2 to assist her with providing incontinent care in the bed at night because she can assist with rolling while in bed. An additional interview and observation was conducted on 1/31/24 at 3:01 PM with Resident #6. Resident #6 explained the incident with NA #2 was a dignity issue for her. She voiced NA #2 made her feel this tall holding up her thumb and index fingers spaced approximately one inch apart. A telephone interview was conducted with NA #2 on 1/31/24 at 10:30 AM. She stated she never had a problem with Resident #6 not allowing her to assist with care. NA #2 verbalized Resident #6 allowed her to provide incontinent care and did not complain of her being rough with care. NA #2 stated Resident #6 sometimes did not stand well, and she must try to pick her up and put her into bed. She described picking her up as using a gait belt to assist her up and lifting her into the bed. She verbalized Resident #6 had not complained of pain or discomfort or asked her to stop during transfers. NA #2 stated she had last worked with Resident #6 last weekend on Sunday (1/28/24) and assisted her with incontinent care. NA #2 was not aware of any other concerns related to Resident #6. A telephone interview on 1/31/24 at 9:08 AM was conducted with Nurse #1. She worked night shift every weekend and was routinely assigned to Resident #6. Nurse #1 verbalized Resident #6 did not like NA #2 to assist her to bed at night on the weekends. Nurse #1 stated Resident #6 requested for her to put her to bed on the weekends instead of NA #2. She verbalized she did not ask Resident #6 why she did not want NA #2 to put her to bed. Nurse #1 stated NA #2 still worked with Resident #6. The nurse verbalized Resident #6 allowed NA #2 to perform incontinent care during the night but asked Nurse #1 to assist her to bed and to help pull her up in the bed during the night. An interview was conducted on 1/31/24 at 4:38 PM with the Medical Director (MD). He stated staff had not reported any behavior issues, concerns, refusal of care, or any manipulative behaviors for Resident #6. The MD verbalized staff have not reached out to him to report any concerns of dignity. An interview with the Director of Nursing (DON) was conducted on 2/1/24 at 10:24 AM. The DON was interviewed regarding the grievance dated 12/12/23 for Resident #6. She was not aware of the grievance prior to 1/30/24 and she revealed the facility was currently following their reporting process and investigating the grievance further. She explained staff should explain to residents what they were going to do. She verbalized some residents have pain and staff should try to be as gentle as possible when providing activity of daily living (ADL) care and transfers. The DON stated staff should look at the resident's care guide for how a resident transferred. She voiced that all residents should be treated with dignity and respect. She stated residents have the right to refuse care and the residents wishes and rights should be honored and respected. The DON verbalized residents should always be handled in a safe, dignified, respectful manner. She stated if a resident did not want to be cared for by a particular staff member, the staff member should not continue to go into the resident's room and care for them and their wishes should be honored. She voiced that residents should feel comfortable and safe. An interview was conducted on 1/30/24 at 4:45 PM with the Regional Director of Clinical Services. She stated the facility had spoken to Resident #6 about the grievance she reported on 12/12/23 today. She verbalized the facility was reporting the incident to the police, was interviewing staff, and had suspended the NA associated with the grievance, and was investigating Resident #6 report of staff being rough during care. The Regional Clinical Director was not aware of the grievance prior to 1/30/24. An interview was performed with the [NAME] President of Operations and the Regional Director of Clinical services together on 2/1/24 at 12:26 PM. They stated residents should be treated with respect and dignity. They voiced the facility should have ensured the resident was cared for the way she wanted to be cared for. The Regional Clinical Director discussed speaking with Resident #6 and stated Resident #6 told her She was not happy. They stated staff received training in dignity and respect during general orientation, annually, and as needed when issues arise. 50045 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease with late onset, dementia, dysphagia, generalized muscle weakness. Resident #3's care plan dated 12/13/23 revealed Resident #3 should maintain her current level of function by having one staff member assist Resident #3 while eating. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required substantial/maximum assistance with feeding. A continuous observation conducted on 1/30/24 from 1:01 pm to 1:13 pm revealed Resident #3's bed was observed in a low position with NA #8 towering over her while feeding. NA#8 was not engaged in any conversation with Resident #3. There was no chair observed in Resident #3's room. An interview with NA #8 was conducted on 1/30/24 at 1:25 pm. NA #8 verbalized she received education about feeding during orientation. She learned how to deliver a tray and how to feed the resident, which included sitting while feeding the resident. An interview with NA #9 was conducted on 1/30/24 at 1:29 pm. NA #9 verbalized that she witnessed NA #8 standing while assisting residents with the lunch meal. NA #9 explained that they were provided frequent education on assisting residents with meals. An interview with the Assistant Director of Nursing (ADON) was conducted on 2/1/24 at 9:23 am. The ADON stated that NAs and Nurses received education about feeding during day two of orientation by the Staff Development Coordinator (SDC). She verbalized the correct way to feed a resident, which included sitting at eye level with the resident. The ADON reported if she witnessed a staff member standing while feeding a resident, she would redirect the staff member and get them a chair. An interview with the SDC was conducted on 2/1/24 at 9:39 am. She stated that NAs and Nurses received education about feeding during clinical orientation. She reported staff are instructed to sit eye to eye level with the resident and to only feed one resident at a time, even in the dining room. The SCD stated staff received yearly education and completed feeding competencies in March of 2023. She reported that if she witnessed a staff member standing while feeding, she would get them a chair and have them sit down. An interview with the Director of Nursing (DON) was conducted on 2/1/24 at 9:56 am. The DON stated NAs and Nurses were educated about feeding during general orientation, yearly, and on an as needed basis. She verbalized the correct steps for feeding a resident, which included having staff sit while feeding. The DON verbalized if she witnessed a staff member feeding a resident while standing, she would ask the resident if they were comfortable with the staff member standing and if not, she would get the staff member a chair. She stated if the staff member was standing while feeding, the bed would need to be raised to eye level. The DON reported that standing while feeding could be intimidating to some residents. An interview with the Regional Clinical Director was conducted on 2/1/24 at 10:24 am. She stated NAs and Nurses received education on feeding during competency skill checks, yearly education, clinical orientation, and on an as needed basis. The Regional Clinical Director verbalized the correct steps for feeding a resident, including that staff should be seated while feeding residents. She stated if she witnessed a staff member feeding a resident while standing, she would knock on the door, quietly remind the staff member, and ask them to take a seat. The Regional Clinical Director stated it would be intimidating if residents were fed with a staff member standing over them.

Based on record review staff, and Physician interviews the facility failed to notify the Physician of a resident's wound upon admission and failed to notify the Physician when the resident's wound had started to deteriorate for 1 of 1 resident reviewed for notification (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included malignant neoplasm of the vulvar, vulvar lesions. Review of the facility's admission documentation by Nurse #4 dated 11-24-23 revealed an initial skin assessment that documented Resident #1's external vaginal area was red and irritated, her outer labia skin was hard/crusty, and there was a darkened area on Resident #1's left labia area. The skin assessment also showed Resident #1's bottom was red. Review of the Physician orders dated 11-24-23 revealed an order for Resident #1 to have weekly skin assessments but there were no orders for wound care to Resident #1's vulvar lesions. The Wound Care (WC) Nurse was interviewed on 1-31-24 9:08am. The WC Nurse revealed Resident #1's vulvar lesions were deteriorating throughout the resident's admission but stated she had not informed the Physician of the deterioration. She explained she had informed Resident #1 of the deterioration and had educated her on the importance of returning to Oncology to have her lesions treated. An interview with the Physician occurred on 1-30-24 at 2:00pm, with a follow up telephone interview on 2-13-24 at 11:04am. The Physician discussed first learning about Resident #1's vulvar lesions on 11-28-23 when he performed his admission assessment. He stated at that time Resident #1's vulvar lesion was extensive in the shape of a V pattern extending downwards towards her anus. The Physician described the lesion as having necrotic tissue, green colored drainage, and an odor. While reviewing the initial skin assessment written on 11-24-23, the Physician said he had found Resident #1's vulvar lesion much worse than how it was described in the initial skin assessment. He stated he would have expected the admitting nurse to inform him of Resident #1's vulvar lesions at the time of Resident #1's admission so he could have provided orders. The Physician also discussed not being informed of Resident #1's vulvar lesions deteriorating but explained Resident #1 was in a weakened state and due to her extensive comorbidities and cancer, the deterioration was unavoidable. An interview was conducted with the Regional Nursing Consultant on 2-1-14 at 12:25 pm. The Regional Nursing Consultant stated the admitting nurse should review the hospital discharge orders and if there were not wound care orders present then she should inform the Physician of the resident's wound. She discussed wound care orders not being obtained upon Resident #1's admission and stated the admitting nurse should have contacted the Physician for wound care orders. A telephone interview occurred with Nurse #4 on 2-14-24 at 1:08pm. Nurse #4 confirmed she admitted Resident #1 and had completed the skin assessment on 11-24-23. Nurse #4 discussed remembering Resident #1's vulvar wound on admission. She said she could not remember if there were wound care orders from the hospital and stated she had not contacted the facility Physician for wound care orders. Nurse #4 explained when Resident #1 had been admitted to the facility she was not familiar with the procedure to obtain orders, how to document the wound and the need to measure the wound.

Based on record review, resident and staff interviews the facility failed to communicate, investigate and resolve a grievance for 1 of 1 resident (Resident #6) reviewed for grievances. The findings included: Resident #6 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was cognitively intact. An interview with Resident #6 conducted on 1/30/23 at 3:08 PM revealed she had completed a grievance form approximately one month ago reporting a NA being rough when providing care for her. She verbalized NA #1 on 2nd shift filled out the grievance form for her. The facility's grievance log was reviewed from November 2023 through January 2024 and did not reveal Resident #6 name on the grievance log. An interview was performed on 1/30/23 at 4:35 PM with Resident #6. She verbalized she thought the grievance form was given to the Social Worker (SW) after the NA had filled out the grievance form with her. She stated she did not hear from the SW, and nothing ever happened after she filled out the grievance form. A telephone interview was conducted on 1/31/24 at 9:07 AM with NA #1 and revealed she remembered filling out the grievance form for Resident #6. She stated Resident #6 was upset and told her no one would help her when she wanted to go to bed. She said Resident #6 told her it was after 1:00 AM when someone came to help her to bed and the NA was rough and pulled on her. NA #1 stated Resident #6 did not have any bruises or marks. She explained she notified the nurse, who told her to complete a grievance for Resident #6 and to put the grievance in the SW's box. NA #1 stated Resident #6 did not have any behaviors, did not refuse care, or have any manipulative behaviors if she didn't get her way. She verbalized she had not witnessed Resident #6 have any behaviors with other staff. An interview and observation was conducted on 1/30/24 at 4:57 PM with the SW. The SW stated he was not aware of a grievance form for Resident #6 from approximately a month ago. He stated when staff filled out a grievance form during non-business hours, they slide the paper grievance form under his door, he then added the grievance to the grievance log, and distributed the grievance to the department manager associated with the grievance for follow up. The SW stated the interdisciplinary team would talk about grievances in the morning meeting. He specified the department managers returned the grievance form to him once the follow up was completed and he filed the grievance form in the grievance book. An observation of the facility's grievance book with the SW revealed a grievance form dated 12/12/23 filed by Resident #6 for an NA being rough with her during care. The SW stated he was unable to recall if the grievance for Resident #6 was discussed in the morning meeting. Review of Resident #6's Grievance form dated 12/12/23 was completed on 1/30/24 at 5:15 PM and revealed the back section of the grievance form titled Conclusion of Grievance was filled out by the Assistant Director of Nursing (ADON) and signed by the Nursing Home Administrator (NHA) but was incomplete in the following areas: - summary statement of the grievance, - summary of the pertinent findings/ conclusions regarding residents' concerns - corrective actions taken or to be taken by the facility because of the grievance. - steps taken to investigate the grievance. - date the written decision was issued. - identification of the method used to provide notification to the resident. - delivery method of conclusion - was grievance conclusion accepted or declined? - resident/ responsible party offered conclusion; date notification offered. An interview was completed on 1/31/24 at 3:10 PM with the Assistant Director of Nursing (ADON) and revealed the ADON had spoken with NA #1 on 12/13/23 and asked her can you tell me what happened last night. She stated she did not ask NA #1 specifically about the grievance or the information included in the grievance. The ADON verbalized she did not speak to any other residents, nurses, NAs, or other staff to further investigate Resident #6 grievance complaint. The ADON verbalized she did not ask Resident #6 if she remembered completing a grievance, what she had put in the grievance, or specifics about the grievance she had filed. She stated she did not use the words rough or push when she asked Resident #6 questions. The ADON verbalized the grievance process had been discussed in orientation, but no other specific training had been provided. She explained the Administrator was the grievance official, and the SW assisted with grievances. She verbalized grievances that were brought to the morning meeting by the SW and were given to the respective department for follow up. A follow up interview was conducted on 2/1/24 at 8:45 AM with the Regional Clinical Director and revealed she did not know NA #2 was the NA who Resident #6 had reported as being rough during care through the grievance she filed on 12/12/23. She stated the facility was investigating the grievance allegation regarding Resident #6. She stated the facility suspended NA #1 originally because her name was on grievance and the facility thought it was against her. She verbalized she did not realize the grievance was about NA #2. She stated the facility suspended NA #2 at the end of the day yesterday pending investigation. A follow up interview was conducted with the SW on 2/1/24 at 9:26 AM and he explained the Grievance process. The SW stated grievance boxes were located outside the SW's office and outside the dayroom door. He verbalized anyone could fill out a grievance form. The SW stated when he received a grievance, he looked at the grievance and then logged it on the grievance log. The SW explained he would give the grievance to the associated department to be addressed and for follow up. He stated he reviewed open grievances and the ones that have been resolved with department managers in the morning meeting but did not review specifics. He verbalized he only reviewed the resolution of the closed grievances if a manager asked what the resolution was. He explained once a grievance was resolved the department returned the grievance form to him to file in the grievance book. The SW stated he followed up with the resident or RP (Resident Representative) once the grievance was resolved and provided a copy if requested. The SW was asked to explain the Conclusion of Grievance section located on the back of the grievance form. The SW reviewed Resident #6 grievance form and stated the back portion of the form titled Conclusion of Grievance should have been completed. The SW stated the person who completed the grievance investigation and follow up should complete the back section of the form titled Conclusion of Grievance. The SW was unable to specify why the Conclusion of Grievance section for Resident #6 grievance was not completed. An interview was conducted on 2/1/24 with the Director of Nursing (DON). The DON was interviewed regarding the grievance dated 12/12/23 for Resident #6. She was not aware of the grievance prior to 1/30/24 and she revealed the facility was currently following their reporting process and investigating the grievance further. She explained staff should explain to residents what they were going to do. She stated all staff were educated on the grievance process and any staff member could write up a grievance. She stated the grievance official in the building was the Administrator and the SW maintained the grievance log and resolved grievances. the DON verbalized if the SW received the grievance during building hours, he would give the grievance to the DON if the issue was nursing related. She explained if grievances were received during non-business hours the SW would bring them to the morning meeting. She verbalized grievances were distributed to the associated department to complete and then they were returned to the SW to be filed in the grievance book. The DON reviewed the back page of Resident #6 grievance form titled Conclusion of Grievance. The DON stated she completed all boxes when she completed a Conclusion of Grievance section. She verbalized she expected other staff to complete all boxes on the grievance form as well, for any grievance in any department. She verbalized she could not say if any follow up had been completed with Resident #6 grievance because the Conclusion of Grievance section had not been entirely completed. An interview was conducted on 2/1/24 at 12:26 PM with the [NAME] President of Operations and the Regional Clinical Director. They were asked to explain the grievance process and stated anytime a person had a concern they should fill out the grievance form. They verbalized if the issue in the grievance required reporting it should be brought to the DON and Administrator. They stated the SW should receive the grievance, decipher the issue, understand the problem, and then follow through with completing the grievance. They stated after the grievance had resolved the facility should provide the resolution of the grievance to the person or family. They stated the SW should have read the grievance for Resident #6 and reported the grievance to the DON or Administrator. The [NAME] President of Operations stated failure with Resident #6 grievance was because the facility did not follow the grievance process. He stated the NA should have given the grievance to the nurse and the nurse should have taken the grievance to the DON or Administrator. He stated the facility's grievance process was broken.

Based on record review and staff, Physician, and family interviews the facility neglected to obtain wound care orders on admission, complete and document thorough weekly skin and wound assessments that included measurements and descriptions, the occurrence of a new sacral wound and notify the Physician of the resident's refusal to attend oncology appointments and deterioration of the wounds. Additionally, the facility neglected to involve the family with discharge planning to determine if they were able to provide wound care when the resident was discharged home. This occurred for 1 of 1 resident (Resident #1) reviewed for neglect. The findings included: The hospital discharge summary dated 11-24-23 revealed Resident #1 would be discharged to the facility but had no documentation regarding Resident #1's vulvar cancer lesions or wound care orders. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included vulvar lesions, malignant neoplasm of the vulvar, severe protein-calorie malnutrition. Nurse #4's admission note dated 11-24-23 did not have any documentation that she had contacted the Physician or hospital for wound care orders to Resident #1's vulvar lesions. There was also no documentation that the facility Physician was made aware of Resident #1's vulvar lesions. Review of the facility's admission documentation by Nurse #4 dated 11-24-23 revealed an initial skin assessment that documented Resident #1's external vaginal area was red and irritated, her outer labia skin was hard/crusty, and there was a darkened area on Resident #'1's left labia area. The skin assessment also showed Resident #1's bottom was red. There were no wound measurements documented. A review of the Physician orders dated 11-24-23 revealed an order for weekly skin assessments but there were no orders documented for wound care to Resident #1's vulvar lesions. A telephone interview occurred with Nurse #4 on 2-14-24 at 1:08 pm. Nurse #4 confirmed she had admitted Resident #1 and had completed the skin assessment on 11-24-23. She explained she had never seen a vulva wound like Resident #1's before and did not know how to describe the wound on the skin assessment. She also said she was unaware she was supposed to measure the wound. Nurse #4 discussed remembering Resident #1's vulvar wound did not have any drainage at the time of admission. She said she could not remember if there were wound care orders from the hospital and stated she had not contacted the facility Physician for wound care orders. Nurse #4 explained when Resident #1 had been admitted to the facility she was not familiar with the procedure to obtain orders, how to document the wound and the need to measure the wound. She also explained the wound care nurse was responsible for reviewing new admissions for any wound care needs. Resident #1's care plan dated 11-25-23 revealed the resident was at risk for skin impairment due to limited mobility, weakness, and stage 4 vulvar cancer. Resident #1's goals were to minimize the risk of complications for skin impairments. The interventions included encouraging good nutrition and hydration, keeping skin clean and dry, monitoring for signs and symptoms of infection, turn, and repositioning with care rounds. Resident #1's discharge plan was to return home. The goal for Resident #1 was to verbalize/communicate required assistance post-discharge and the services required to meet her needs before discharge. The interventions included establishing a pre-discharge plan with the resident's family/caregiver and evaluate progress. Revise the plan as needed. The Physicians admission documentation dated 11-28-23 revealed Resident #1 had multiple comorbidities that included vulvar lesions with some necrotic (dead tissue) and green drainage. The Physician documented his plan to start betadine wet to dry dressings to Resident #1's vulvar lesions. A Physician order dated 11-28-23 read for Resident #1 to have a betadine wet to dry dressing applied to the right vulvar lesion daily. Review of Resident #1's Treatment Administration Record (TAR) from November 2023 through December 2023 revealed Resident #1 had received all wound care treatments as ordered for the vulvar lesions. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, did not have any refusal of care, and was documented as having open cancer lesions. The MDS also documented Resident #1 as needing extensive assistance with all activities of daily living care. The MDS further revealed Resident #1 was planning to discharge back into the community and was involved in the discharge process. The subsequent skin assessments dated 11-30-23, 12-5-23, and 12-12-23 did not contain any description of Resident #1's vulvar cancer lesions and only 12-5-23 contained measurements. There were no skin assessments completed the week of 12-19-23. Resident #1's vulvar lesion measurement on 12-5-23 was 15.4 centimeters long and 4.9 centimeters wide. This was the only documented measurement in Resident #1's medical record. A review of the facility's Physician orders revealed an order written on 12-21-23 for wound care to the sacral area that read, clean with normal saline, apply calcium alginate (absorbs wound fluid) to wound bed then cover with a foam dressing daily. Resident #1's medical record did not contain documentation as to when the sacral wound was first observed or a description of the wound or size of the wound. Review of Resident #1's Treatment Administration Record (TAR) from November 2023 through December 2023 revealed Resident #1 had received all wound care treatments as ordered for the sacral wound. The skin assessment completed by Nurse #5 on 12-26-23 described the external vaginal area as red/irritated, outer labia skin was hard/crusty, and a darkened area on the left labia. The skin assessment documented Resident #1's sacrum was red and there was a treatment in place but there were no measurements documented for the vulva lesions or the sacrum wound. A review of the interdisciplinary discharge summary completed by social work, therapy, and nursing dated 12-28-23 revealed Resident #1 was planning to be discharged home on 12-30-23. The discharge summary documented that a referral was made to home health to include physical/occupational therapy and nursing services for medication review but did not include a list of Resident #1's medication or instructions for her wound care. The home health referral dated 12-28-23 revealed an order for Resident #1 to discharge home on 12-30-23 with a home health evaluation for physical/occupational therapy and nursing services. The home health referral did not include an order for evaluation/treatment for Resident #1's wounds to her vulvar and sacral areas. Resident #1's medical record revealed a discharge note dated 12-30-23 written by Nurse #2. The discharge note described Nurse #2 performing wound care to Resident #1's vulvar area as well as her sacrum prior to discharge but did not include any documentation as to the description of the wounds or measurements. The discharge note continued to document that discharge instructions were provided to Resident #1 that included her medications and prescriptions but not instructions on the wound care. Nurse #2 documented that Resident #1 had told her there was a family member who was a nurse and was able to manage her medications and perform the needed wound care. The Wound Care (WC) Nurse was interviewed on 1-31-24 9:08 am. The WC Nurse explained Resident #1's Oncologist was monitoring the resident's vulvar lesions but stated she was aware Resident #1 was refusing to attend the appointments, so the facility was monitoring and treating the vulvar lesions. She confirmed she was completing both the wound dressing and wound treatments for Resident #1. The WC Nurse discussed completing weekly wound care assessments on residents with skin impairments and stated she would measure the wounds at that time. The WC nurse confirmed she completed the weekly wound assessments on Resident #1 but had not completed measurements as required. She explained she had not completed a skin assessment on Resident #1 the week of 12-19-23 but had been informed of the sacral wound by a nurse aide (could not remember who) I think on 12-22-23. She confirmed she had not documented a description of the sacral wound and had not measured it because I forgot. The WC Nurse said she had not measured or provided specific details about Resident #1's vulvar wound or sacral wound because she was expecting the resident to return to the Oncologist. The WC Nurse revealed Resident #1's vulvar lesions were deteriorating throughout the resident's admission but stated she had not informed the Physician of the deterioration or that Resident #1 was refusing to attend her oncology appointments. She explained she had informed Resident #1of the deterioration and had educated her on the importance of returning to Oncology to have her lesions treated. An interview with the Physician occurred on 1-30-24 at 2:00 pm, with a follow up telephone interview on 2-13-24 at 11:04am. The Physician discussed first learning about Resident #1's vulvar lesions on 11-28-23 when he performed his admission assessment. He stated at that time Resident #1's vulvar lesion was extensive in the shape of a V pattern extending downwards towards her anus. The Physician described the lesion as having necrotic tissue, green colored drainage, and an odor. While reviewing the initial skin assessment written on 11-24-23, the Physician said he had found Resident #1's vulvar lesion much worse than how it was described in the initial skin assessment. He stated he thought Resident #1's vulvar lesions were being managed by Oncology and was unaware the resident had been refusing to attend her appointments. The Physician discussed not seeing any documentation of Resident #1's sacral wounds but remembered being informed of the sacral wound and providing orders to treat the wound. He also discussed not being informed of Resident #1's vulvar lesions deteriorating but explained Resident #1 was in a weakened state and due to her extensive comorbidities and cancer, the deterioration was unavoidable. The Physician stated he would have wanted to see more details documented on the skin assessments of how the wounds appeared, if there was any drainage/what type/color of drainage, and measurements. An interview was conducted with the Social Worker on 1-30-24 at 3:00 pm. He stated Resident #1 initiated her discharge from the facility and planned to go and stay with a family member. The Social Worker stated he made a referral to a home health agency which included an order for physical/occupational therapy and nursing services to review her medications. He indicated he was not aware of her wound care needs and wound care was not included in the order sent to the home health agency. He stated he received confirmation from the home health agency that they received the order and start of care was scheduled for 1-6-24. The Social Worker stated he also placed an order for the needed medical equipment which included a wheelchair and hospital bed. He stated he was not aware that the needed equipment was not available. He stated he was informed by Resident #1 that she was communicating her discharge needs to the family, so he did not schedule a meeting with them prior to discharge. The Social Worker indicated the family was not present on the day of discharge and Resident #1 was transported to the family home by a wheelchair transport company. A telephone interview occurred with Nurse #2 on 1-31-24 at 11:16 am. Nurse #2 confirmed she had discharged Resident #1 on 12-30-23 to home. She stated she could not remember if Resident #1's family was present for the discharge or who she provided the discharge instructions to. Nurse #2 said she had reviewed the wound care treatment with Resident #1 and stated Resident #1 had told her the family knew how to perform her wound care. She explained she had provided some wound care supplies to Resident #1 but stated she could not remember if she had provided written wound care instructions. Nurse #2 confirmed she had provided wound care to Resident #1 prior to discharge. She stated she had not documented a description of Resident #1's vulvar lesions or sacral wound and she had not obtained any measurements. Nurse #2 discussed remembering that Resident #1's sacral wound was open and draining. She also remembered Resident #1's vulvar wound had a green drainage with necrotic tissue. A telephone interview was conducted with Resident #1's family on 1/31/24 at 10:00 am. They stated the facility did not contact them to review Resident #1's discharge instructions or wound care needs prior to her being discharged . They indicated when Resident #1 arrived home on 12/30/23 they were concerned they would not be able to meet her needs. They stated Resident #1 required extensive assistance with mobility and transfers, but the medical equipment company did not have a hospital bed available. The family reported since the hospital bed was not available, they allowed Resident #1 to remain in a recliner chair until her transfer back to the hospital. The family stated they observed Resident #1's vulvar wound to have an odor and green drainage and took her to the hospital for evaluation on 1/2/24. A follow-up telephone interview was conducted with Resident #1's family on 2-13-24 at 9:55 am. The family stated Resident #1 was totally immobile and was not able to do anything. They provided incontinent care to Resident #1 in the recliner chair. The family explained they were not doing any type of wound care and had no intention of touching the wounds. The family stated they did not receive any wound care instructions from the facility or Resident #1 upon her arrival home. The family communicated that Resident #1 had a folder with a face sheet, list of medications, list of diagnoses, and an interdisciplinary discharge summary. An interview was conducted with the Director of Nursing (DON) on 2-1-24 at 10:25 am. She revealed she was aware Resident #1 was planning to discharge home with family. She stated the Social Worker was responsible for coordinating resident discharges and involving the family in the discharge planning process. The DON indicated Resident #1 was not able to manage her wound care independently and her discharge instructions should have been reviewed with the family. An interview was conducted with the Regional Nursing Consultant on 2-1-14 at 12:25 pm. She stated resident discharges were an interdisciplinary care team process lead by the Social Worker. She stated the discharge planning was ongoing throughout a resident's stay at the facility. She indicated Resident #1 was cognitively intact however the Social Worker should have asked her permission to involve her family in the discharge planning process. The Regional Nurse Consultant further indicated that Resident #1's care needs including her wound care instructions should have been discussed with the family prior to her discharge from the facility. The Regional Nursing Consultant also stated she had become aware of the issue regarding skin assessments and measuring of resident wounds not being completed on 1-2-24. She explained during Resident #1's stay in the facility, the facility had staffing issues which caused a lack in management oversite. The Regional Nursing Consultant said there should have been more thorough skin assessments completed, weekly skin assessments to include measurements and the Physician should have been made aware of Resident #1's wound condition.

Based on record review, family member, home health agency, physician and staff interviews, the facility failed to meet the resident's care needs upon discharge by not communicating the physician ordered wound care treatments and ensuring the needed medical equipment was delivered for 1 of 1 resident (Resident #1) reviewed for a safe and orderly discharge. The findings included: Resident #1 was admitted to the facility on [DATE] and discharged to the family home via wheelchair transport on 12/30/23. Her admitting diagnosis included malignant neoplasm of the vulva. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. She required extensive assistance from staff with toileting, hygiene, bathing, dressing and transfers. The MDS further revealed Resident #1 was planning to discharge back to the community and was involved in the discharge process. Review of Resident #1's care plan dated 12/13/23 indicated Resident #1's goal was to discharge home with family. Review of the interdisciplinary discharge summary dated 12/28/23 revealed Resident #1 was planning to discharge home with family on 12/30/23 and a referral was made to a home health agency for physical/occupational therapy and nursing to provide a medication review. The discharge summary did not include Resident #1's list of medications or wound care instructions for her vulva and sacral wounds. The physician order dated 11/30/23 regarding wound treatment to Resident #1's vulva area stated clean the open vulva lesion area daily with normal saline, apply betadine and allow to air dry. The physician order dated 12/22/23 regarding wound treatment to Resident #1's sacrum area stated clean the area with normal saline daily, apply calcium alginate (water absorbing wound dressing) to the wound bed and cover with foam gauze. Review of the home health agency referral dated 12/28/23 revealed an order for Resident #1 to discharge home on 12/30/23 with a home health evaluation for physical/occupational therapy and nursing services. The home health referral did not include an order for nursing to evaluate and treat Resident # 1's vulva and sacral wounds. A telephone interview was conducted with the home health agency on 2/13/24 at 9:18 am. They confirmed they received the referral for Resident #1 on 12/28/23 for physical/occupational therapy and nursing services. The home health agency verbalized that start of care would have been initiated on 1/6/24 and Resident #1 would have been assessed by the admission nurse who would have completed a full body assessment and addressed the wound care needs at that time. The nurse's note (Nurse #2) dated 12/30/23 indicated Resident #1 was being discharged home with family and a referral was made to a home health agency. The discharge packet of information was reviewed with Resident #1 including her list of medications and wound care instructions. An interview was conducted with the Physician on 1/30/24 at 2:00pm. The Physician stated Resident #1 was in a weak and vulnerable state and the lesion to her vulva was significant which caused further breakdown to her sacrum area. He stated due to her poor health and nutrition further skin breakdown was unavoidable. The Medical Director indicated it was possible for Resident #1's vulva wound to have worsened during the 3 days she was home after discharge from the facility. A telephone interview was conducted with Nurse #2 on 1/31/24 at 11:16 am. She stated she did not recall if Resident #1's family was present on the day of discharge or if discharge instructions or wound care needs were reviewed with the family. Nurse #2 stated she reviewed the list of medications and wound care instructions for the vulva and sacral wounds with Resident #1. She also gave Resident #1 the needed wound care supplies. Nurse #2 did not recall giving Resident #1 a printed list of medications or wound care instructions. An interview was conducted with the Social Worker on 1/30/24 at 3:00 pm. He stated Resident #1 initiated her discharge from the facility and planned to go and stay with a family member. The Social Worker stated he made a referral to a home health agency which included an order for physical/occupational therapy and nursing services to review her medications. He indicated he was not aware of her wound care needs and wound care was not included in the order sent to the home health agency. He stated he received confirmation from the home health agency that they received the order and start of care was scheduled for 1/6/24. The Social Worker stated he also placed an order for the needed medical equipment which included a wheelchair and hospital bed. He stated he was not aware that the needed equipment was not available. He stated he was informed by Resident #1 that she was communicating her discharge needs to the family, so he did not schedule a meeting with them prior to discharge. The Social Worker indicated the family was not present on the day of discharge and Resident #1 was transported to the family home by a wheelchair transport company. A telephone interview was conducted with Resident #1's family on 1/31/24 at 10:00 am. They stated the facility did not contact them to review Resident #1's discharge instructions or wound care needs prior to her being discharged . They indicated when Resident #1 arrived home on 12/30/23 they were concerned they would not be able to meet her needs. They stated Resident #1 required extensive assistance with mobility and transfers, but the medical equipment company did not have a hospital bed available. The family reported since the hospital bed was not available, they allowed Resident #1 to remain in a recliner chair until her transfer back to the hospital. The family stated they observed Resident #1's vulva wound to have an odor and green drainage and took her to the hospital for evaluation on 1/2/24. An interview was conducted with the Director of Nursing (DON) on 2/1/24 at 10:25 am. She revealed she was aware that Resident #1 was planning to discharge home with family. She stated the Social Worker was responsible for coordinating resident discharges and involving the family in the discharge planning process. The DON indicated Resident #1 was not able to manage her wound care independently and her discharge instructions should have been reviewed with the family. An interview was conducted with the Regional Nursing Consultant on 2/1/24 at 12:25 pm. She stated resident discharges were an interdisciplinary care team process lead by the Social Worker. She stated the discharge planning was ongoing throughout a resident's stay at the facility. She indicated Resident #1 was cognitively intact however the Social Worker should have asked her permission to involve her family in the discharge planning process. The Regional Nurse Consultant further indicated that Resident #1's care needs including her wound care instructions should have been discussed with the family prior to her discharge from the facility. Review of Resident #1's hospital discharge summary dated 1/10/24 revealed she was admitted on [DATE] for multiple illnesses including chronic progression of her vulva cancer and sacral wound. The vulva area contained leathery eschar (dead tissue) over the wound. Resident #1's hospital record further revealed she was evaluated by general surgery and given the extent of the eschar tissue; simple debridement was not appropriate. There were no specific hospital interventions for Resident #1's wounds documented. The recommendation was for a referral to a specialized care hospital where she could receive multidisciplinary surgery. The specialized care hospital was not accepting new patients, determined the procedure was non-emergent and Resident #1 was discharged home with family. A follow-up telephone interview was conducted with Resident #1's family on 2/13/24 at 9:55 am. The family stated Resident #1 arrived home via wheelchair transport company. A male family member along with the wheelchair transport driver lifted Resident #1 in the wheelchair up the stairs (3 stairs) into the home. The family did not consider this a struggle for them or the wheelchair transport driver. Resident #1 remained in the wheelchair throughout the whole process and the family did not recall Resident #1 having any signs or symptoms of distress. The family did recall Resident #1 was excited to be home. The family stated Resident #1 was totally immobile and was not able to do anything. They provided incontinent care to Resident #1 in the recliner chair. The family explained they were not doing any type of wound care and had no intention of touching the wounds. The family stated they did not receive any wound care instructions from the facility or Resident #1 upon her arrival home. The family communicated that Resident #1 had a folder with a face sheet, list of medications, list of diagnoses, and an interdisciplinary discharge summary. The family did not reach out to the home health agency due to Resident #1 being discharged on a Saturday as well as it being a holiday weekend. The family stated they took the holiday weekend into account and knew that home health would start the following week. The family transported Resident #1 to the hospital for evaluation of her vulva wound on 1/2/24. A male family member placed Resident #1 in a private vehicle and when they arrived at the hospital a security guard took Resident #1 into the emergency department. A follow-up telephone interview was conducted with the Physician on 2/14/24 at 9:52am. The Physician stated he was informed Resident #1 had a family member that was aware of the wound care needs and was comfortable performing the ordered treatments when Resident #1 was discharged home. He indicated the ordered wound care treatments were not going to improve Resident #1's vulva and sacral wounds and due to her having multiple comorbidities deterioration of the wounds were unavoidable.

Based on record review, staff, and Physician interviews, the facility failed to assess skin impairments for 1 of 2 residents (Resident #1) reviewed for pressure ulcers. The findings included: The hospital discharge summary dated 11-24-2023 revealed Resident #1 would be discharged to the facility but had no documentation regarding Resident #1's vulva cancer lesions or wound care orders. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included malignant neoplasm of vulva, cancer lesions vulva area, severe protein-calorie malnutrition. Review of the facility's admission documentation by Nurse #4 dated 11-24-2023 revealed an initial skin assessment that documented Resident #1's external vaginal area was red and irritated, her outer labia skin was hard/crusty, and there was a darkened area on Resident #'1's left labia area. The skin assessment also showed Resident #1's bottom was red. There were no wound measurements documented. Resident #1's care plan dated 11-25-2023 revealed the resident was at risk for skin impairment due to limited mobility, weakness, and stage 4 vulvar cancer. Resident #1's goals were to minimize the risk of complications for skin impairments. The interventions included encouraging good nutrition and hydration, keeping skin clean and dry, monitoring for signs and symptoms of infection, turn, and repositioning with care rounds. The Physicians admission documentation dated 11-28-2023 revealed Resident #1 had multiple comorbidities that included vulva lesions with some necrotic (dead tissue) and green drainage. The Physician documented his plan to start betadine wet to dry dressings to Resident #1's vulva lesions. A Physician order dated 11-28-2023 read for Resident #1 to have a betadine wet to dry dressing applied to the right vulvar lesion daily. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, did not have any refusal of care, and was documented as having open cancer lesions. The subsequent skin assessments dated 11-30-2023, 12-5-2023, and 12-12-2023 did not contain any description of Resident #1's vulva cancer lesions and only 12-5-2023 contained measurements. There were no further skin assessments completed until 12-26-2023 which described the external vaginal area as red/irritated, outer labia skin was hard/crusty, and a darkened area on the left labia. There were no measurements documented for 12-26-2023. Resident #1's vulva lesion measurement on 12-5-2023 was 15.4 centimeters long and 4.9 centimeters wide. This was the only documented measurement in Resident #1's medical record. A nurse's note dated 12-30-23 written by Nurse #2 revealed Resident #1 was discharged home. The nurse documented she had performed wound care prior to Resident #1 leaving the facility, however there was no documentation of what Resident #1's vulva lesions looked like or measurements. The Wound Care (WC) Nurse was interviewed on 1-31-2024 9:08am. The WC nurse explained Resident #1's Oncologist was monitoring the resident's vulva lesions but stated Resident #1 was refusing to attend the appointments, so the facility was monitoring and treating the vulva lesions. The WC nurse discussed completing weekly wound care assessments on residents with skin impairments and stated she would measure the wounds at that time. She said she had not measured or provided specific details about Resident #1's vulva wound or sacral wound because she was expecting the resident to return to the Oncologist. The WC nurse revealed Resident #1's vulva lesions were deteriorating throughout the resident's admission but stated she had not informed the Physician. She explained she had informed Resident #1of the deterioration and had educated her on the importance of returning to Oncology to have her lesions treated. During a telephone interview with Nurse #2 on 1-31-2024 at 11:16am, Nurse #2 confirmed she had cared for and discharged Resident #1 on 12-30-2023. She stated she performed wound care to Resident #1's vulva area and sacral region. Nurse #2 said she was unaware she had to document what the wounds looked like upon discharge or their measurements. She stated the vulva lesion on 12-30-23 had a green discharge and was necrotic. The Regional Clinical Director was interviewed on 2-1-2024 at 10:24am. The Regional Clinical Director discussed receiving a phone call on 1-2-2024 from Resident #1's family voicing concerns related to the resident's wound care during her admission in the facility. She stated when she began to investigate the concern, she realized assessments had not been completed as ordered/with specific information about the wounds including measurements. The Regional Clinical Director explained she started a Performance Improvement Plan (PIP) on 1-4-2024 related to skin management that included proper assessment/documentation of wounds and performing weekly measurements. The PIP also included education on skin management and audits. She also explained during the time Resident #1 was a resident, there had been some staffing issues and oversite of staff duties was lax. The Regional Clinical Director stated there should have been more thorough skin assessments and measurements completed on Resident #1. During a telephone interview with the Physician on 2-13-2024 at 11:04am, the Physician stated the first time he was made aware of Resident #1's vulva lesions was when he completed the admission examination on 11-28-2024. Upon being made aware of Nurse #4's initial skin assessment, the Physician stated when he saw Resident #1 on 11-28-2023 her vulva lesions were much more severe. He explained the vulva lesion was in a V shape extending downwards containing necrotic tissue and a green drainage and odor. The Physician discussed wanting to see on a skin assessment specific information on how the area looked, if there was drainage, odor, any signs or symptoms of infection, and measurements. He stated he was not aware Resident #1 was not receiving weekly skin assessments or that the assessments were not specific. The Physician also said he was not aware that measurements were not being performed weekly. He discussed the difficulty of measuring a cancerous growth but stated he still would have wanted to see measurements. The Physician revealed that he thought Resident #1 was going to the Oncologist for her wound care and was not aware she had been refusing to go to her appointments. He also said he was not made aware of Resident #1's lesions deteriorating but stated due to the resident's multiple comorbidities and cancer, deterioration of the lesions was unavoidable. The facility provided the following corrective action plan with a completion date of 01/05/24. 1. Resident #1 discharged home with home health on 12/30/2023. The center performed a discharge follow up call on 1/2/24 conducted by Social Services Assistant to Resident #1. During the call, the Social Services Assistant was notified by the resident's family member that Resident #1 was in the hospital. In a conversation with the family member, concern was noted with cancerous lesion. The family member alleged that a dressing was left in place during the resident's stay. Based upon record review, resident's current treatment was lidocaine external cream 4%, topically, apply every shift to vulvar lesion. In conjunction to apply betadine external solution 10% to the labia/pubis topically every day shift. Additional review of the resident's record revealed missing skin check and measurement of the wound. Based upon findings, the center failed to follow skin management protocol. ADHOC QAPI was held on 1/2/2024, to include the Medical Director. 2. The center conducted a skin audit of all current residents. Audit was conducted by center nurse leadership on 1/3/2024-1/4/2024 with new additional skin integrity findings. 3. Licensed nurses were in-serviced to check residents' skin on the days they are due and document. They are to notify the physician and responsible party of any skin issues and document response from the physicians and responsible party. They are to follow the skin preventative protocol. Education completed by Staff Development Coordinator/designee by 1/3/2024. Certified Nursing Assistants were in-serviced regarding the skin care program. They are to notify the nurse of any skin changes. Education completed by Staff Development Coordinator/designee by 1-3-2024. Wound Nurse/Unit Manager will maintain a log of any identified skin issues specifying the origin (pressure, stasis, surgical, etc.) and making sure there are treatments, care plans, preventive measures, MD, and resident representative (RP) notification. Education completed by Staff Development Coordinator/designee by 1-3-2024. Residents with pressure ulcers/injuries will be reviewed in a weekly focus meeting. Focus meeting is collaborative meeting with the interdisciplinary team that focuses on specific clinical systems. The interdisciplinary team includes nursing, dietary, therapy, and administrative staff. In respect to wounds, the following areas are reviewed: nutrition, preventative measures, treatments, support surfaces and progress. Effective 1-5-2024, newly hired staff will be educated during department orientation by the Staff Development Coordinator. Effective 1-5-2024, Director of Nursing/Unit Managers will audit weekly for skin checks to validate completion. 4. Effective 1-5-2023, data obtained during the audit process will be analyzed for patterns and trends and reported to The Quality Assessment and Assurance (QA & A) Committee by the Administrator monthly x 3 months. At that time, the QA & A committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Validation of the facility's POC was conducted on 2-1-2024 through record review, staff interviews, and observation of wound care. The licensed nurses interviewed were able to recall the education on skin management and discussed how to document wounds, completing weekly wound assessments which would include measuring resident wounds. The resident records reviewed showed recent weekly skin audits that included a description of the resident wounds and measurements. The skin management education was reviewed and contained staff signature sign in sheets. The completion date of 01/05/24 was validated.

Based on record review, observations, and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 3-11-21 and 11-10-22. This was for a deficiency in Infection Control (F880). The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag was cross referenced to: F880: Based on record review, observation, and staff interviews the facility failed to implement their infection control policy when the wound care nurse did not perform hand hygiene or don a new pair of gloves after cleaning a wound that was draining and before applying a clean dressing. This occurred for 1 of 3 resident (Resident #9) for pressure ulcer treatment. During the recertification and complaint investigation conducted on 3-11-21, the facility was cited for facility staff not wearing personal protective equipment (masks, gowns, and gloves) when caring for residents on enhanced droplet precautions. During a recertification and complaint investigation conducted on 11-10-22, the facility was cited for staff not performing hand hygiene after removing a dirty dressing and before cleansing the wound. The Regional [NAME] President of Operations was interviewed on 2-1-24 at 12:57 pm. The Regional [NAME] President of Operations explained he was aware of the past infection control citations but stated he did not know why the processes put in place through Quality Assurance had not been followed. He discussed the wound care nurse had not followed the process for hand hygiene and said he thought it maybe due to a comprehension issue with the wound care nurse.

Based on observations, staff interviews, physician interviews and record reviews facility staff failed to notify the physician of continued combative behaviors, resident refusal of [MEDICATION NAME] at bedtime, continued refusals of finger stick blood sugars and failed to document blood pressures daily for three days for one (1) of fourteen (14) sampled residents. (Resident #1). Immediate Jeopardy began on 1/19/12 when Resident #1 continued to exhibit combative behaviors and refused [MEDICATION NAME] 25 units subcutaneously at bedtime. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place. The findings are: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated no impairment in short and long term memory and no impairment in cognition for daily decision making. The MDS also indicated Resident #1 had no behavioral symptoms directed toward others, required extensive assistance by staff for transfers, dressing and hygiene, required set up assistance only with eating, was incontinent of bowel and bladder and had upper and lower extremity impairment on one side. A review of physician orders [REDACTED]. A review of physician orders [REDACTED]. A review of physician orders [REDACTED]. A review of laboratory results dated [DATE] indicated a hemoglobin A1C (a test to give an overall view of how the blood sugar levels are controlled or out of control in individuals with diabetes) was 11.9 percent (normal range was less than 7 percent). A review of physician orders [REDACTED]. A review of a physician's progress note dated 1/17/12 revealed Resident #1 had increased confusion. "Patient has had tremendous decrease in level of consciousness in the last ten days. Was alert and communicating with decent memory and focus. Now unfocused, unable to answer questions directly. Vital signs/blood sugar not recorded last three (3) days. Confusion on patient with multiple medical problems. No obvious cause. Possible small stroke. Plan to check labs and monitor vitals." A review of physician orders [REDACTED]. Chest x-ray posteroanterior (PA) and lateral views due to increased confusion. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the MAR indicated [REDACTED]. A review of a physician's progress note dated 1/19/12 revealed "patient combative, spitting and refusing meds." Blood sugar "high" according to nursing staff. "Dementia with possible mini [MEDICAL CONDITION]." A review of nurse's notes dated 1/19/12 at 3:30 PM stated Resident #1 refused all medications, was spitting them out and was combative during care. A review of the MAR indicated [REDACTED]. There was no documentation in the nurse's notes the physician was called. A review of nurse's note dated 1/20/12 stated Resident #1 refused meal and a nursing assistant attempted to feed resident. The notes further stated the resident was spitting out food, refused fluids and refused finger stick blood sugar and all medications. A review of the MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. A review of nurse's notes dated 1/21/12 at 3:30 PM and signed by LN # 5 stated a venipuncture was performed this afternoon on Resident #1 and vital signs were documented as follows: temperature 101.0, pulse 154, BP 138/87, respiration's 20. Oxygen saturation percentage was 95% on room air, bilateral lung congestion was noted, resident was very difficult to arouse and warm to the touch. The notes further stated the resident had not eaten or taken any fluids this shift and the nurse was unable to get resident to take oral medications due to decreased level of consciousness. A review of laboratory reports dated 1/21/12 at 2:41 PM revealed abnormal laboratory values as follows: Glucose 822 (critical value) normal range 70 -110 BUN 71 (critical value) normal range 7 - 18 Creatinine 3.60 (critical value) normal range 0.50 - 1.20 White Blood Cell 23.7 (high) normal range 4.8 - 10.8 Total Protein 8.6 (high) normal range 6.4 - 8.2 SGOT 53 (high) normal range 15 - 37 Calcium 10.6 (high) normal range 8.5 - 10.1 Carbon [MEDICATION NAME] 17 (low) normal range 21 - 32 Blood Cultures were positive with streptococcus and staphylococcus bacteria. A review of a transfer form dated 1/21/12 with no time revealed Resident #1 was transferred by emergency medical services to the hospital. A review of a hospital history and physical dated 1/21/12 revealed Resident #1 was admitted with altered mental status with possibilities including infection and diabetic ketoacidosis (a serious complication of diabetes that occurs when the body produces very high levels of blood acids);[MEDICAL CONDITION] and underlying infection with elevated white blood cell counts and urinary tract infection; rapid heart rate with fever and dehydration; acute [MEDICAL CONDITION] and a large new acute left sided stroke. During an interview on 1/30/12 at 1:15 PM LN #1 stated she was told during report from a night shift nurse on 1/21/12 Resident #1 did not drink or take her medications for the last couple of days. She stated she did not go to Resident #1's room immediately after report but went to her room later in the morning and the resident did not respond, moved her right (R) arm slightly and wouldn't talk to her. She explained she did not call the physician because she wanted to get the blood drawn first. She further stated she drew blood on the resident around noon and sent it to the laboratory and the laboratory called back with critical values. She explained she called the physician's answering service and sent Resident #1 to the hospital on [DATE] at approximately 3:00 PM. During an interview on 1/30/12 at 3:10 PM with LN #3 she stated she was concerned on Friday evening 1/20/12 that Resident #1 was still abusive and refused her medications. She explained she did not call the physician after Resident #1 refused her [MEDICATION NAME] at bedtime and stated she reported off to the night shift nurse to keep an eye on the resident because something did not seem right. During an interview on 1/31/12 at 8:35 AM the physician stated Resident #1 had very volatile hypertension, diabetes and recent [MEDICAL CONDITION]. He stated he was not aware of the missed [MEDICATION NAME] doses on 1/19/12 and 1/20/12 and he was unaware of the resident's continued combative behaviors and confusion. He further stated staff should have told him about missed [MEDICATION NAME] doses, continued refusals of finger stick blood sugars and continued confusion and combativeness. He stated if he had known about the missed insulin doses and the continued refusals of finger stick blood sugars he would have ordered for them to do a finger stick blood sugar or he would have sent the resident to the hospital. During an interview on 1/31/12 at 8:49 AM with LN #4 she stated she was Resident #1's nurse during the night shift on 1/20/12 and the resident was very noncompliant, combative and was physically and verbally abusive. She stated she tried to draw blood work but she couldn't get it and she tried to do a finger stick blood sugar but the resident wouldn't let her. She verified she did not call the physician during her shift but reported to the day shift on Saturday morning 1/21/12 she was unable to draw the blood and the resident had refused her medications and finger sticks. During an interview on 1/31/12 at 3:36 PM with LN #5 she verified she was the nursing supervisor during the day on 1/21/12. She stated she did not receive a report from the night shift nurses that morning and she saw Resident #1 at approximately 11:00 AM on 1/21/12 to assist a nurse with drawing blood. She stated the resident "was not alert at all" when she went into her room. She stated she did not check the resident's vital signs or call the physician because she was focused on getting the blood drawn. She further stated Resident #1 was very sick when they drew her blood. She explained she took the blood to the laboratory and they called critical values to the facility within the hour and the resident was sent to the hospital. During an interview on 1/31/12 at 9:00 AM the Director of Nurses (DON) stated she expected nursing staff to notify the physician when a resident refused insulin and they should notify the physician when a resident had continued combative behaviors and confusion and they should document information in the nurse's notes. During a follow up interview on 1/31/12 at 10:25 AM the physician stated an elevated blood sugar would have been very serious for Resident #1 and affected her dehydration. He stated he verified his answering service had not received any calls from the facility after he saw the resident while he was in the facility on 1/19/12. The Administrator was informed of Immediate Jeopardy on 1/31/12 at 4:10 PM for Resident #1. The facility provided a credible allegation of compliance which included: I. Resident # 1 was admitted to facility on June 28, 2011. Resident #1 was transferred from facility to the hospital on January 21, 2012, related to changes in behavior, resulting in refusal of Finger Stick Blood Sugar (FSBS), refusal of routine insulin doses, and lack of notification to Physician of continued change in condition and status decline, as evidenced by critical laboratory values. On January 31, 2012, three (3) nurses were identified as primary providers in the assessment, interventions and notification regarding clinical changes for Resident # 1. These nurses were individually in-serviced/educated by the Staff Development Coordinator (SDC) on the following processes. ? Notification: Nurses will notify physician and responsible party regarding, refusal of medications, diagnostic procedures, and/or changes in condition. ? Use of the 24-Hour Report Resident Change in Condition Book: Identifies acute changes in resident's conditions by utilizing check marks to identify type of change, narrative if indicated, and follow up validation by check mark of action taken with acute change in condition. ? Resident Refusal of/or Failure to Follow MD orders: Notification of physician, responsible party, nursing, and other interdisciplinary team members when residents refuse plan of care. Education to resident/family and documentation needed while also protecting resident right to refuse. ? Condition Change of a Resident and expectations on communication at change of shift: Nurses will utilize the 24 hour report as a communication tool to other shifts and nursing administration for changes in resident condition. ? Notification to physician and responsible party will be documented in the nurse's notes and identified as completed on the 24 hour Report. ? Protocols for Physician Notification: Provision of resource guidelines for nurse's recognition, identification, assessment, intervention, and documentation of pertinent and relevant information related to Resident Change in Condition. The Medical Director, Executive Director, Director of Nursing Services and the Staff Development Coordinator conducted a Performance Improvement (PI) meeting on January 31, 2012 to address Resident #1's change in condition and hospitalization . The Committee determined through root cause analysis the change in condition for Resident #1 was related to the delay in implementation of MD orders, and Physician notification of resident refusal of medications, diagnostic testing, and clinical decline that was not readily identified. Based on this root cause, the ED and DNS developed a "Performance Improvement" plan on 1/31/2012 to provide the following interventions to prevent re-occurrence. ? Notification: Nurses will notify physician and responsible party regarding, refusal of medications, diagnostic procedures, and/or changes in condition. ? Use of the 24-Hour Report Resident Change in Condition Book: Identifies acute changes in resident's conditions by utilizing check marks to identify type of change, narrative if indicated, and follow up validation by check mark of action taken with acute change in condition. ? Resident Refusal of/or Failure to Follow MD orders: Notification of physician, responsible party, nursing, and other interdisciplinary team members when residents refuse plan of care. Education to resident/family and documentation needed while also protecting resident right to refuse. ? Lab Protocol: Facility process of receiving orders, scheduling lab draw, validating return reports, review, reporting and documentation with follow up if indicated. Documentation of refusals, or inability to obtain diagnostic test with subsequent notification to physician and responsible party as indicated. ? Condition Change of a Resident and expectations on communication at change of shift: Nurses will utilize the 24 hour report as a communication tool to other shifts and nursing administration for changes in resident condition. ? Notification to physician and responsible party will be documented in the nurse ' s notes and identified as completed on the 24 hour Report. II. On 1/31/2012 Facility RN's and LPN's were in-serviced and educated by the ADNS and SDC on the processes as described in Section "I" In-service bullets. Weekend nurses, and PRN nurses and remaining nurses who have not been in-serviced will be ineligible to work until this mandatory in-service training completed. There have been no newly hired licensed nurses since January 31, 2012. Newly hired licensed nurses (RN's and LPN's) will be provided this training during new employee orientation that will be conducted by the SDC effective January 31, 2012 and thereafter. III. On 01/31/2012 the new 24-hour report was initiated and will be utilized by the nurses, nursing administration and interdisciplinary team to communicate identified changes in resident condition, assessment, intervention, and notification to MD and RP of event, progress, critical lab values, and resolution of identified changes. The DNS/ADNS/Unit Manager/Weekend Supervisor will do a review of medical records on residents identified on the 24 hour change in condition sheet for notification of MD and Responsible Party, documentation, and assessment of the resident, which will be done daily. The resident's medical record will be reviewed during morning meeting (Mon - Fri) and the Interdisciplinary team will address any areas of concern related to documentation, notification of MD and Responsible Party. The DNS/ADNS/Unit Manager/Weekend Supervisor will be responsible for identification and resolution for any concerns on change of condition. IV. The Unit Manager, Shift and Weekend Supervisors will audit new admissions, re-admissions, and the 24 hour report for change resident conditions on a daily basis. DNS/ADNS will be responsible for identification and resolution of concerns with change in Resident condition/s. Results of these audits will be analyzed and reviewed at the facility ' s monthly Performance Improvement (PI) meeting monthly for six (6) months and then quarterly thereafter. Immediate Jeopardy was removed on 2/2/12 at 4:00 P.M. with interviews of licensed nursing staff who confirmed they received inservice training on 2/2/12 prior to reporting on duty. Interviews with nursing staff revealed awareness of expectations to notify the physician and responsible party when a resident had a change in condition, use of the 24 Hour Report Resident Change in Condition Book, actions required with resident refusal of/or failure to follow physician's orders [REDACTED]. Observations of the 24 Hour Reports and laboratory protocol on 2/2/12 revealed the documents were at the nurse's station and staff was completing documentation as in-serviced.

Based on observations, staff interviews, physician interviews and record reviews facility staff failed to notify the physician of continued combative behaviors, resident refusals of [MEDICATION NAME] at bedtime, continued refusals of finger stick blood sugars and failed to document blood pressures daily for three days for one (1) of fourteen (14) sampled residents. (Resident #1). Immediate Jeopardy began on 1/19/12 when Resident #1 continued to exhibit combative behaviors and refused [MEDICATION NAME] 25 units subcutaneously at bedtime. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician orders dated 6/28/11 revealed [MEDICATION NAME] 14 units subcutaneously daily at bedtime for diabetes; [MEDICATION NAME] 2 milligrams orally before breakfast for diabetes mellitus; [MEDICATION NAME] 2.5 milligrams orally daily for blood pressure; [MEDICATION NAME] 0.2 milligrams orally twice a day for blood pressure; [MEDICATION NAME] 150 milligrams orally twice daily for blood pressure. There were no physician orders to check finger stick blood sugars. A review of an admission nurse's note dated 6/28/11 at 3:30 PM revealed Resident #1's blood pressure was 164/90. There was no documentation in the nurse's notes the physician was called. A review of nurse's note dated 7/1/11 at 2:00 PM revealed Resident #1's blood pressure this AM was 194/91. Blood pressure was rechecked one (1) hour after blood pressure medication was given and blood pressure was 138/78. A review of a vital sign flow sheet dated 7/3/11 revealed Resident #1's weekly blood pressure was 160/92. There was no documentation in the nurse's notes the blood pressure was rechecked or the physician was called. A review of a physician's progress note dated 7/12/11 revealed the physician was asked by Minimum Data Set (MDS) staff to see resident due to reports of anxiety and dementia. "Patient not available for exam at this time will evaluate at follow up visit next week." A review of a nurse's note dated 7/13/11 revealed resident was having periods of confusion and physician was notified. A review of a physician's order dated 7/13/11 revealed to check finger stick blood sugars before breakfast meal. A review of a vital sign flow sheet dated 7/31/11 revealed Resident #1's weekly blood pressure was 146/84. A review of a physician's progress note dated 8/2/11 revealed Resident #1 was seen on routine rounds and had increased systolic blood pressures (the systolic pressure is usually the first number recorded in the blood pressure) and her blood sugars were fluctuating in the 100 range in the mornings. A review of a physician's order dated 8/2/11 revealed to increase [MEDICATION NAME] to 5 milligrams orally each day for elevated systolic blood pressures. A review of a physician's progress note dated 9/6/11 revealed patient was seen and examined and medical record was reviewed. Finger stick blood sugars were in the 240 range in the mornings and blood pressures were averaging 130's/80's. Will plan to increase [MEDICATION NAME] from 14 units to 17 units daily at bedtime. A review of a physician's order dated 9/06/11 revealed to increase [MEDICATION NAME] to 17 units subcutaneously daily at bedtime. A review of a nurse's note dated 9/08/11 revealed Resident #1 was extremely agitated with nursing assistants, would not let them change her and refused all care. A review of a nurse's note dated 11/3/11 revealed Resident #1 was found during lunch with her tray on floor. The notes stated the resident was clammy and difficult to arouse, her blood sugar was 358. Vital signs were documented as follows: 136/76, pulse 72 and the physician was notified and no new orders were received. A review of a physician's progress note dated 11/8/11 revealed the patient was seen in follow up, staff concerned about elevated blood sugars as high as 350. Continues to have blood sugars in a range from 290-150 in the mornings. Blood pressures are stable. Will plan to increase [MEDICATION NAME] and blood sugar checks. A review of a physician's order dated 11/8/11 revealed to increase [MEDICATION NAME] from 17 units to 20 units subcutaneously daily at bedtime and increase finger stick blood sugars checks before breakfast each morning and before supper each evening. A review of a vital sign flow sheet dated 12/18/11 revealed Resident #1's weekly blood pressure was 134/76. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated no impairment in short and long term memory and no impairment in cognition for daily decision making. The MDS also indicated Resident #1 had no behavioral symptoms directed toward others, required extensive assistance by staff for transfers, dressing and hygiene, required set up assistance only with eating, was incontinent of bowel and bladder and had upper and lower extremity impairment on one side. A review of a nurse's note dated 12/12/11 at 6:45 PM revealed Resident #1 had slurred speech, drooping of the left (L) side of her face and her tongue was protruding from her mouth. The resident's blood pressure was documented as 104/68. A review of a nurse's note dated 12/12/11 at 7:10 PM Resident' #1's blood sugar was 416 then rechecked and was 382 and the resident was transported to the hospital. A review of a nurse's note dated 12/14/11 at 7:00 PM revealed Resident #1 returned to the facility from the hospital. A review of a nurse's note dated 12/16/11 at 2:00 PM revealed Resident #1's blood pressure was 180/89. There was no documentation in the nurse's note the physician was called. A review of a physician's order dated 12/20/11 revealed to increase [MEDICATION NAME] to 10 milligrams orally each day due to increased blood pressure. A review of laboratory results dated [DATE] indicated a hemoglobin A1C (a test to give an overall view of how the blood sugar levels are controlled or out of control in individuals with diabetes) was 11.9 percent (normal range was less than 7 percent). A review of a physician's progress note dated 12/27/11 revealed blood pressures over the last week range in 148-150's/80-90's. The notes further stated the resident's high blood pressure was severe, still uncontrolled and her diabetes was out of control. A review of a physician's order dated 12/27/11 revealed to increase [MEDICATION NAME] from 20 units to 25 units daily at bedtime; increase [MEDICATION NAME] to 0.3 milligrams orally twice daily for blood pressure. . A review of a physician's order dated 1/12/12 revealed to obtain a urinalysis and culture and sensitivity due to increased confusion. A review of a nurse's note dated 1/13/12 revealed at 1:00 PM an in and out catheterization was performed on Resident #1 and cloudy yellow urine was obtained. A review of laboratory results dated [DATE] revealed the urinalysis had abnormal results of urine glucose 300 (normal range 0-0.8) and a trace of [MEDICATION NAME] (normal range was no [MEDICATION NAME] present). The physician's initials were documented on the laboratory results but they were not dated or timed. A review of urine culture results dated 1/13/12 revealed "mixed bacterial flora, probable contamination." The physician's initials were documented on the laboratory results but they were not dated or timed. A review of a nurse's note dated 1/17/12 revealed "late entry for 1/16/12." Resident #1 refused care of any kind until 10:00 PM on this shift, was verbally and physically abusive toward staff, was yelling at roommate and refused to allow brief to be changed until 10:00 PM. A review of a nurse's note dated 1/17/12 revealed "late entry for 5:30 PM" Resident #1 took all contents of her dinner tray and poured them into bed. She rolled the sheets up and yelled for a nursing assistant to change sheets. The sheets were changed and the resident stated she poured the food out because she didn't want it. A review of a physician's progress note dated 1/17/12 revealed increased confusion. "Patient has had tremendous decrease in level of consciousness in the last ten days. Was alert and communicating with decent memory and focus. Now unfocused, unable to answer questions directly. Vital signs/blood sugar not recorded last three (3) days. Confusion on patient with multiple medical problems. No obvious cause. Possible small stroke. Plan to check labs and monitor vitals." A review of physician's orders dated 1/17/12 at 6:30 PM revealed blood pressure daily; finger stick blood sugars daily - fasting each morning; CBC; CMP; Blood Cultures x 2. Chest x-ray posteroanterior (PA) and lateral views due to increased confusion. A review of a nurse's note dated 1/17/12 at 7:00 PM revealed Resident #1 was verbally and physically abusive toward staff and the physician was notified. A review of a physician's order dated 1/17/12 at 7:40 PM revealed [MEDICATION NAME] 0.5 milligrams orally every four (4) hours as needed for agitation. A review of a nurse's note dated 1/17/12 at 7:40 PM revealed Resident #1 received [MEDICATION NAME] 0.5 milligrams orally. A review of a nurse's note dated 1/19/12 revealed "late entry for 1/18/12" a Nursing Assistant (NA) reported Resident refused care at 12:30 AM and 2:30 AM and demanded three (3) times to leave her alone. At 5:00 AM the NA was able to provide peri-care and at 6:30 AM the resident refused [MEDICATION NAME] and finger stick blood sugar. There was no documentation in the nurse's notes the physician was called. A review of a nurse's note dated 1/18/12 at 4:00 PM revealed Resident #1 was aggressive times two (2) on this shift, refused to be changed and the responsible party was notified. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of a physician's progress note dated 1/19/12 revealed "patient combative, spitting and refusing meds." Blood sugar "high" according to nursing staff. "Dementia with possible mini [MEDICAL CONDITION]." Change to [MEDICATION NAME] Patch." A review of a physician's order dated 1/19/12 revealed "correction" [MEDICATION NAME] 5 milligrams orally or intramuscularly every four (4) hours as needed for agitation; discontinue [MEDICATION NAME] 0.3 milligrams orally and begin [MEDICATION NAME] 0.3 milligrams and change weekly. A review of a nurse's note dated 1/19/12 at 3:30 PM revealed Resident #1 refused all medications, was spitting them out and was combative during care. There was no documentation in the nurses notes the physician was called. A review of the MAR indicated [REDACTED]. A review of a nurse's note dated 1/19/12 at 5:30 PM revealed Resident #1 was screaming, refusing care and was physically combative. The resident's blood pressure was documented as 98/65 and there was no documentation in the nurse's notes the physician was called. A review of the MAR indicated [REDACTED]. There was no documentation in the nurses notes the physician was called. A review of a nurse's note dated 1/20/12 revealed Resident #1 refused meal and a nursing assistant attempted to feed resident. The notes further stated the resident was spitting out food, refused fluids and refused finger stick blood sugar and all medications. There was no documentation in the nurses notes the physician was called. A review of the monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order to check blood pressures daily. In addition, the MAR indicated refused blood sugar and medications; on 1/19/12 "refused finger stick for blood sugar check"; on 1/20/12 "refused finger stick for blood sugar check" and on 1/21/12 "refused finger stick for blood sugar check and fluids." A review of laboratory reports drawn in the facility and dated 1/21/12 at 2:41 PM revealed abnormal laboratory values as follows: Glucose 822 (critical value) normal range 70 -110 BUN 71 (critical value) normal range 7 - 18 Creatinine 3.60 (critical value) normal range 0.50 - 1.20 White Blood Cell 23.7 (high) normal range 4.8 - 10.8 Total Protein 8.6 (high) normal range 6.4 - 8.2 SGOT 53 (high) normal range 15 - 37 Calcium 10.6 (high) normal range 8.5 - 10.1 Carbon [MEDICATION NAME] 17 (low) normal range 21 - 32 Blood Cultures were positive with streptococcus and staphylococcus bacteria. A review of a nurse's note dated 1/21/12 at 3:30 PM and signed by LN # 5 stated a venipuncture was performed this afternoon on Resident #1 and blood cultures, CBC, CMP were obtained. Resident #1's vital signs were documented as follows: temperature 101.0, pulse 154, BP 138/87, respiration's 20. Oxygen saturation percentage was 95% on room air, bilateral lung congestion was noted, resident was very difficult to arouse and warm to the touch. A responsible party was notified and the Director of Nurses (DON) was notified. The notes further stated the resident had not eaten or taken any fluids this shift and the nurse was unable to get the resident to take oral medications due to decreased level of consciousness. A review of a transfer form dated 1/21/12 with no time indicated resident was transferred by emergency medical services to the hospital. A review of a hospital history and physical dated 1/21/12 revealed Resident #1 was admitted to the hospital with [REDACTED]. During an interview on 1/30/12 at 1:15 PM LN #1 stated she usually worked the 7:00 AM to 7:00 PM shift on Saturday, Sunday and Monday. She further stated Resident #1 had high blood pressure and elevated blood sugars. She explained she checked the resident's blood sugar with a blood glucose meter and when it was greater than 500 the meter would read "HI." She verified she sent Resident #1 to the hospital on [DATE] at approximately 3:00 PM. She stated she was told during report from a night shift nurse Resident #1 did not drink or take her medications for a couple of days. She explained she went to the resident's room later in the morning and the resident did not respond but moved her right (R) arm slightly and wouldn't talk to her. She further stated she had been told nursing staff and laboratory staff had tried to draw blood from the resident for several days but were unsuccessful. She explained she drew the blood around noon and sent it to the laboratory and the laboratory called back with critical values. She stated she checked Resident #1's vital signs and her heart rate was "really high" but she did not remember documenting them in the resident's medical record. She further stated she called the doctor, the responsible party and her supervisor called the Director of Nurses (DON). During an interview on 1/30/12 at 2:20 PM with LN #2 she stated she asked the physician to look at Resident #1 on Tuesday 1/17/12 while he was in the facility. She stated the resident was kicking and hitting when they went to the room. The physician examined the resident, LN #2 checked her blood sugar and it was in the 200 range but did not remember checking her blood pressure. She explained she saw Resident #1 the next day and she was still combative and refusing medications, finger stick blood sugars and personal care. During an interview on 1/30/12 at 3:10 PM with LN #3 she stated she was concerned on Friday evening 1/20/12 that Resident #1 was still abusive and refused her medications. She stated Resident #1 had high blood pressure and high blood sugars. She explained she had called the doctor earlier in the week and got an order for [REDACTED]. She stated she reported off to the night shift nurse to keep an eye on the resident because something did not seem right. She further stated before the resident became confused and combative she always wanted to take her blood pressure medicine because she had a headache when she didn't take it. During an interview on 1/31/12 at 6:42 AM with Nursing Assistant (NA) #1 she stated she provided care to Resident #1 on 1/19/12 during the night shift. She explained she reported to the nurse the resident refused care at 12:30 AM and at 2:30 AM. She stated the resident allowed her to provide peri-care. During an interview on 1/31/12 at 8:35 AM the physician stated Resident #1 had very volatile hypertension, diabetes and recent [MEDICAL CONDITION]. He stated he examined her during the last week she was in the facility and she was distant, less alert and less pleasant. He stated he was very worried about her blood pressure and one missed dose of blood pressure medication was critical for her. He stated he was not aware of the missed [MEDICATION NAME] doses on 1/19/12 and 1/20/12, he was unaware staff were unable to draw blood after he ordered the tests on 1/17/12 and he was unaware of the continued refusals of finger stick blood sugars after he saw the resident on 1/19/12. He further stated staff should have told him about missed [MEDICATION NAME] doses, the inability to draw her blood and continued confusion and combativeness. He explained he was very worried about the resident's blood pressure and wanted her to stay as calm as possible because he thought she might have another stroke. He stated if he had known about the missed insulin doses and the continued refusals of finger stick blood sugars he would have ordered for them to do a finger stick blood sugar or he would have sent the resident to the hospital. During an interview on 1/31/12 at 8:49 AM with LN #4 she stated she was Resident #1's nurse during the night shift on 1/20/12 and the resident was very noncompliant, combative and was physically and verbally abusive. She stated she tried to draw the blood work but she couldn't get it and she tried to do a finger stick blood sugar but the resident wouldn't let her. She verified she did not call the physician during her shift but reported to the day shift on Saturday morning 1/21/12 she was unable to draw the blood and the resident had refused her medications and finger sticks. During an interview on 1/31/12 at 9:00 AM the Director of Nurses (DON) stated she expected nursing staff to notify the physician when a resident refused blood sugars or insulin, they should assess and monitor the resident when there was a significant change in their condition and they should document information in the nurses notes. During a follow up interview on 1/31/12 at 10:25 AM the physician stated an elevated blood sugar would have been very serious for Resident #1 and affected her dehydration. He stated he verified his answering service had not received any calls from the facility after he saw the resident while he was in the facility on 1/19/12. During an interview on 1/31/12 at 12:55 PM with NA #2 she stated she saw Resident #1 on 1/21/12 at lunch time and she was sitting up in her bed with her mouth open and she "looked like she was in a daze." She explained the resident looked pale, was not talking and did not act the way she normally did. She stated the resident did not get out of bed all day and when the nurse drew blood from both arms the resident did not try to pull away or fight her. During an interview on 1/31/12 at 3:36 PM with LN #5 she verified she was the nursing supervisor during the day on 1/21/12. LN #5 stated she saw Resident #1 at approximately 11:00 AM on 1/21/12 to assist a nurse to draw blood on the resident. She stated the resident "was not alert at all" when she went into her room and she was very sick at that point. She explained she took the blood to the laboratory and they called critical values to the facility within the hour. She stated she did not ask anyone to check vital signs or do an assessment because she was helping the nurse draw the blood and then she transported the blood to a laboratory out of the facility. During an interview on 2/1/12 at 11:22 AM with NA# 3 she stated she was assigned to care for Resident #1 on 1/21/12. She stated the resident was "really out of it" that day and would not talk to her and she did not look good at all. She stated she did not talk to the nurse and did not check the resident's vital signs. She explained she changed the resident's brief once before she went to the hospital because it was wet and she thought one of the other NA's changed her earlier that morning. The Administrator was informed of Immediate Jeopardy on 1/31/12 at 4:10 PM for Resident #1. The facility provided a credible allegation of compliance which included: I. Resident # 1 was admitted to facility on June 28, 2011. Resident #1 was transferred from facility to the hospital on January 21, 2012, related to changes in behavior, resulting in refusal of Finger Stick Blood Sugar (FSBS), refusal of routine insulin doses, and lack of notification to Physician of continued change in condition and status decline, as evidenced by critical laboratory values. On January 31, 2012, three (3) nurses were identified as primary providers in the assessment, interventions and notification regarding clinical changes for Resident # 1. These nurses were individually in-serviced/educated by the Staff Development Coordinator (SDC) on the following processes. ? Notification: Nurses will notify physician and responsible party regarding, refusal of medications, diagnostic procedures, and/or changes in condition. ? Use of the 24-Hour Report Resident Change in Condition Book: Identifies acute changes in resident's conditions by utilizing check marks to identify type of change, narrative if indicated, and follow up validation by check mark of action taken with acute change in condition. ? Resident Refusal of/or Failure to Follow MD orders: Notification of physician, responsible party, nursing, and other interdisciplinary team members when residents refuse plan of care. Education to resident/family and documentation needed while also protecting resident right to refuse. ? Condition Change of a Resident and expectations on communication at change of shift: Nurses will utilize the 24 hour report as a communication tool to other shifts and nursing administration for changes in resident condition. ? Notification to physician and responsible party will be documented in the nurses notes and identified as completed on the 24 hour Report. ? Protocols for Physician Notification: Provision of resource guidelines for nurse's recognition, identification, assessment, intervention, and documentation of pertinent and relevant information related to Resident Change in Condition. The Medical Director, Executive Director, Director of Nursing Services and the Staff Development Coordinator conducted a Performance Improvement (PI) meeting on January 31, 2012 to address Resident #1's change in condition and hospitalization . The Committee determined through root cause analysis the change in condition for Resident #1 was related to the delay in implementation of MD orders, and Physician notification of resident refusal of medications, diagnostic testing, and clinical decline that was not readily identified. Based on this root cause, the ED and DNS developed a "Performance Improvement" plan on 1/31/2012 to provide the following interventions to prevent re-occurrence. ? Notification: Nurses will notify physician and responsible party regarding, refusal of medications, diagnostic procedures, and/or changes in condition. ? Use of the 24-Hour Report Resident Change in Condition Book: Identifies acute changes in resident ' s conditions by utilizing check marks to identify type of change, narrative if indicated, and follow up validation by check mark of action taken with acute change in condition. ? Resident Refusal of/or Failure to Follow MD orders: Notification of physician, responsible party, nursing, and other interdisciplinary team members when residents refuse plan of care. Education to resident/family and documentation needed while also protecting resident right to refuse. ? Lab Protocol: Facility process of receiving orders, scheduling lab draw, validating return reports, review, reporting and documentation with follow up if indicated. Documentation of refusals, or inability to obtain diagnostic test with subsequent notification to physician and responsible party as indicated. ? Condition Change of a Resident and expectations on communication at change of shift: Nurses will utilize the 24 hour report as a communication tool to other shifts and nursing administration for changes in resident condition. ? Notification to physician and responsible party will be documented in the nurses notes and identified as completed on the 24 hour Report. II. On 1/31/2012 Facility RN's and LPN's were in-serviced and educated by the ADNS and SDC on the processes as described in Section "I" In-service bullets. Weekend nurses, and PRN nurses and remaining nurses who have not been in-serviced will be ineligible to work until this mandatory in-service training completed. There have been no newly hired licensed nurses since January 31, 2012. Newly hired licensed nurses (RN's and LPN's) will be provided this training during new employee orientation that will be conducted by the SDC effective January 31, 2012 and thereafter. III. On 01/31/2012 the new 24-hour report was initiated and will be utilized by the nurses, nursing administration and interdisciplinary team to communicate identified changes in resident condition, assessment, intervention, and notification to MD and RP of event, progress, critical lab values, and resolution of identified changes. The DNS/ADNS/Unit Manager/Weekend Supervisor will do a review of medical records on residents identified on the 24 hour change in condition sheet for notification of MD and Responsible Party, documentation, and assessment of the resident, which will be done daily. The resident's medical record will be reviewed during morning meeting (Mon - Fri) and the Interdisciplinary team will address any areas of concern related to documentation, notification of MD and Responsible Party. The DNS/ADNS/Unit Manager/Weekend Supervisor will be responsible for identification and resolution for any concerns on change of condition. IV. The Unit Manager, Shift and Weekend Supervisors will audit new admissions, re-admissions, and the 24 hour report for change resident conditions on a daily basis. DNS/ADNS will be responsible for identification and resolution of concerns with change in Resident condition/s. Results of these audits will be analyzed and reviewed at the facility ' s monthly Performance Improvement (PI) meeting monthly for six (6) months and then quarterly thereafter. Immediate Jeopardy was removed on 2/2/12 at 4:00 P.M. with interviews of licensed nursing staff who confirmed they received inservice training on 2/2/12 prior to reporting on duty. Interviews with nursing staff revealed awareness of expectations to notify the physician and responsible party when a resident had a change in condition, use of the 24 Hour Report Resident Change in Condition Book, actions required with resident refusal of/or failure to follow physician's orders, the laboratory protocol, communication at the change of shift regarding resident change in condition and documentation of notification to the physician and responsible party in the nurses notes. Observations of the 24 Hour Reports and laboratory protocol on 2/2/12 revealed the documents were at the nurse's station and staff was completing documentation as in-serviced.