Every finding on record at Maple Grove Health and Rehabilitation Center

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid (CMS) Form 10123-Notice of Medicare Non-Coverage (NOMNC) 48 hours prior to the last covered Medicare day. This was for 1 of 3 residents (Resident #68) reviewed for Beneficiary Notices.Findings included:Resident #68 was admitted to the facility on [DATE].A review of Resident #68's Comprehensive Minimum Data Set (MDS) dated [DATE] revealed he was moderately cognitively impaired. Review of Resident #68's NOMNC form revealed the effective date coverage of his current skilled nursing and therapy services service would end on 7/23/26. It further revealed Medicare would probably not pay for his skilled nursing and therapy services after that effective date, and Resident #68 might have to pay for any services he received. The form included Resident #68's rights to appeal the decision. The form indicated that a verbal notice was given to Resident #68's Responsible Party on 7/22/26 and was signed by Social Worker #2 on 7/23/26.Record review revealed Resident #68 remained in the facility until he discharged back to the community on 7/28/26.On 8/6/26 at 8:06 AM an interview was conducted with Social Worker #2. Social Worker #2 indicated she was aware of the 48-hour advance notice requirement, however, on 7/21/26 she was having trouble with her printer and could not print Resident #68's NOMNC form. Social Worker #2 indicated she went to see Resident #68 on 7/21/26 to offer a verbal notice but he requested that she provide the information to his Responsible Party. Social Worker #2 further explained she called the Responsible Party on 7/22/26 to provide the Responsible Party with verbal notice. Social Worker #2 indicated that she thought she had called the Responsible Party on 7/21/26 but was unable to provide documentation that this had occurred. On 8/6/26 at 9:45 AM an interview was conducted with the Administrator, and she indicated that Social Worker #2 should have ensured Resident #68's Responsible Party was provided with the NOMNC information within the required timeframe.

Based on observations, record review, and staff interviews, the facility failed to maintain an accurate treatment administration record for 1 of 5 residents reviewed for complete and accurate medical records (Resident #98).The findings included:Resident #98 was admitted into the facility on 2/6/26.Resident #98 had a physician's order dated 7/23/26 for Bacitracin-Polymyxin B (antibiotic ointment) apply to left shin topically every day shift (7:00 AM to 7:00 PM) for blister.Resident #98's July 2026 Treatment Administration Record (TAR) indicated the antibiotic ointment was administered on 7/31/26 by the Treatment Nurse.Resident #98's August 2026 TAR indicated the antibiotic ointment was administered on 8/1/26 and 8/2/26 by Nurse #3.An observation on 8/4/26 revealed Resident #98 had a dressing to her left shin that was dated 7/31/26.On 8/5/26 at 9:04 AM a telephone interview with Nurse #3 revealed she did not apply the antibiotic ointment to Resident #98's left shin as ordered on 8/1/26 or 8/2/26. Nurse #3 stated that Resident #98 refused to have the treatment to her shin completed on both dates. Nurse #3 further explained she must have signed the TAR in error for 8/1/26 and 8/2/26.An interview with the DON on 8/5/26 at 10:00 AM revealed that she expected all nurses would ensure treatments were documented accurately.During an interview on 8/5/26 at 11:40 AM, the Administrator stated she expected the nursing staff to document all treatment administration accurately.

Based on record review, observations, and interviews with the resident's Responsible Party, staff, Nurse Practitioner (NP), Medical Director, law enforcement, and the hospital physician, the facility failed to protect Resident #1's right to be free from injury of an unknown origin. Resident # 1 sustained facial swelling, hematoma and contusion extending from the right eye to the corner of his right lip. The source of the injury to Resident #1 was not observed by anyone, the source of injury could not be explained by the resident, and the injury was suspicious. On 10/09/25, Resident #1's was observed by Nurse Aide (NA) #2 to have swelling to the residents' right side of face. The resident was transferred to the hospital via Emergency Medical Services (EMS) who noted the resident had been assaulted by a facility staff member. Observations of Resident #1 during the investigation showed swelling to the residents' right side of the face and soreness was reported by the resident. This deficient practice affected 1 of 3 residents reviewed for resident abuse/injury of unknown origin (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included seizures, bipolar disease, major depressive disorder, anxiety disorder, osteoarthritis, schizophrenia, cognitive communication deficit, alcoholic hepatitis without ascites, chronic pancreatitis, convulsions, and psychosis not due to a substance or unknown physiological condition. Review of physician order dated 10/31/23 revealed Resident #1 was ordered Eliquis (a blood thinner used to prevent and treat blood clots) 5 milligrams (mg) two times a day. Review of physician order dated 06/12/24 revealed Resident #1 was ordered Keppra 5 milligrams (mg) two times a day for seizures. Review of lab dated 06/18/25 revealed Resident #1 had received labs to monitor the residents Keppra level. The labs further revealed Resident #1's level was at 44.6 mg/ml (micrograms per milliliter). The normal range is from 10.0 mg/ml to 40.0 mg/ml.Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. The MDS further revealed Resident #1 had impaired range of motion of the upper extremity on his left side. The MDS further revealed Resident #1 was not coded for any behaviors. Review of Resident #1's care plan revised on 09/16/25 revealed Resident #1 had inappropriate behaviors such as being resistive to treatment and care, refusing appointments which resulted in missed treatments, refused showers, disrobing, pulled and tore his brief, banging on the wall at night due to the residents diagnoses of bipolar, schizophrenia, psychosis, and anxiety. The goal was for Resident #1 to comply with routine care and have a decrease in behavior. Interventions included document care being resisted per facility protocol and notify physician of patterns in behavior, discuss with Resident #1 implications of not complying with therapeutic regimen, and if he refuses care, leave him and return in 5-10 minutes.A phone interview conducted with Nurse Aide (NA) #1 on 10/13/25 at 12:20 PM revealed she had worked from 3:00 PM to 11:00 PM on 10/08/25. NA #1 further revealed while providing incontinence care to Resident #1 on 10/08/25 around 7:45 PM the resident scratched NA #1 on the left side of her face with his right hand. NA #1 stated she had started on the right side of Resident #1's bed and had cleaned the resident and then rolled Resident #1 onto his back. NA #1 indicated she went to the left side and gradually raised Resident #1's hip to fasten his brief and Resident #1 took his right hand and reached across and scratched NA #1 in on the left cheek. NA #1 indicated she had told Medication Aide (MA) #1 that Resident #1 had scratched her but did not report this to the assigned Nurse. NA #1 indicated she told MA #1 that it was okay and thought she would report the resident's behaviors and her scratch. NA #1 stated Resident #1 was often aggressive and cussed staff. NA #1 revealed she had worked with Resident #1 multiple times and it was no surprise the resident had aggressive behavior towards her. NA #1 denied hitting Resident #1. A follow-up phone interview with NA #1 on 10/14/25 at 4:15 PM revealed NA #1 had worked in the facility for about a year and had been assigned to Resident #1 multiple times. NA #1 indicated Resident #1 was often could be resistive to care and at times aggressive towards staff. On 10/08/25 NA #1 worked 2nd shift from 3:00 PM until 11:00 PM and was assigned Resident #1. NA #1 revealed around 7:30 PM she provided incontinence care to Resident #1 and she had started on the left side of the resident and rolled Resident #1 to clean him and place his brief under him. NA #1 stated she went to the right side to fasten his brief she gently raised the resident's right hip to fasten the brief and Resident #1 struck out with his right hand and scratched her on the left cheek. NA #1 indicated she stated to Resident #1 ouch.you shouldn't do that. NA #1 revealed she fastened Resident #1's brief and pulled the bed cover over up on the resident. NA #1 she returned to Resident #1's room around 10:00 PM and indicated Resident #1 had no behaviors and she was able to check the resident's brief. NA #1 indicated Resident #1 brief was dry and she ended her shift at 11:00 PM. NA #1 denied she had hit Resident #1. NA #1 stated she did not report the resident scratching her on the cheek because she did not feel upper management would have done anything.Review of a photo that NA #1 sent through text message on 10/14/24 at 4:25 PM showed a picture of NA #1 with the left side of her face showing in the picture. Review of the photo revealed two one-inch scratches near the corner of her eyebrow. There were two scratches near her eye that were about 1 1/2 inches long and one near her mouth about 2 inches long. NA #1 indicated the picture had been taken during the day on 10/09/25.A phone interview with Medication Aide (MA) #1 on 10/13/24 at 12:15 PM revealed she had worked from 7:00 PM to 11:00 PM on 10/08/25 to administer medications and around 9:15 PM she had observed NA #1 with a scratch on her left cheek. NA #1 confirmed Resident #1 had scratched her during incontinence care. MA #1 indicated she told NA #1 she needed to report what had happened. MA #1 stated NA #1 told her it was okay and none of her business. MA #1 revealed she entered Resident #1's room shortly after to give the resident his medicine. MA #1 indicated the lights were on in the room and she did not see any signs that Resident #1 had been hurt and did not show any signs of pain or being upset. MA #1 revealed she had visited Resident #1 later in her shift around 10:45 PM to assist with brushing his teeth and revealed Resident #1 did not complain of any pain or discomfort and did not show any signs that he had been hit. MA #1 revealed during her shift Resident #1 showed no signs that any incident had occurred and observed no injuries on Resident #1. MA #1 indicated she did not report NA #1's injury due to NA #1 telling MA #1 that she did not need to worry about it.A phone interview with NA #2 on 10/13/25 at 2:05 PM revealed she worked 3rd shift from 11:00 PM until 7:00 AM starting on 10/08/25. NA #2 indicated she had entered Resident #1's room at 2:00 AM to give her first rounds of incontinence care. NA #2 indicated Resident #1's light was off, but the hallway light was on, and she was able to check Resident #1's brief. NA #2 stated Resident #1's brief was dry and the resident was lying on his right side. NA #2 indicated she went back into Resident 1's room around 5:30 AM and stated that the right side of the resident's face was swollen, the right eye was black, and he had a busted lip with dried blood. NA #2 indicated she went and got Nurse #1 who assessed the resident. NA #2 stated Resident #1 stated NA #1 by name and that NA #1 had hit him. NA #2 revealed the resident was often combative and could be aggressive but slept all of her shift until she observed the injury the morning of 10/09/25.A follow up interview with NA #2 and Medication Aide (MA) #1 on 10/16/25 at 11:20 AM revealed on 10/08/25 Medication Aide (MA) #1 worked during second shift from 7:00 PM to 11:00 PM to administer medications to residents. MA #1 indicated around 9:15 PM she observed NA #1 with a scratch on the left side of her face that appeared to be very red and have some bloody raised spots. MA #1 indicated NA #1 reported Resident #1 had scratched her during care and she told NA #1 to report the resident's behaviors but NA #1 told MA #1 did not need to worry about it. MA #1 revealed shortly after observing NA #1 she entered Resident #1's room around 10:30 PM and gave Resident #1 multiple medicines orally. MA #1 indicated Resident #1 was up in his bed awake with the lights on and Resident showed no signs of pain, discomfort, or any behavior that an incident had occurred. MA #1 indicated she left her shift at 11:00 PM. NA #2 revealed she worked 10/08/25 from 11:00 PM until 7:00 AM on 10/09/25 and she had arrived at the facility about 10:45 PM on 10/08/25 and NA #1 was finishing up rounds. NA #2 indicated NA #1 had not given any kind of report before leaving. NA #2 stated she had checked on Resident #1 at 1:00 AM and 3:00 AM and both times the resident was asleep, and his brief was dry. NA #2 indicated Resident #1's light was turned off in his room, but she was able to see to check his brief due to the light in the hall. NA #2 revealed when she checked on Resident #1 at 1:00 AM and 3:00 AM the resident was lying on his right side and showed no sign of pain or discomfort. NA #2 revealed around 5:30 AM on 10/09/25 she had entered Resident #1's room to get him up and ready for the day and observed Resident #1's right side of his face to be swollen. NA #2 indicated she immediately went and got Nurse #1 to assess Resident #1. NA #2 stated Resident #1 said NA #1's name and that she had hit him.Review of progress note dated 10/09/25 revealed Nurse #1 was made aware by Nurse Aide #2 and Medication Aide #1 that Resident #1 had swelling to the right of his face. The note further revealed upon assessment that the resident had swelling to the right eye, cheek, and lip. Dried blood was observed under the resident's fingernails on his right hand, outside of mouth, and inside his mouth and on his chest. The note indicated vital signs were taken, pain assessment was completed, and a skin assessment was completed. The Director of Nursing (DON), Emergency Medical Service (EMS), Medical Director (MD), and the family were notified.A phone interview with Nurse #1 on 10/13/25 at 11:20 AM revealed on 10/09/25 at around 5:15 AM she was notified by NA #2 and Medication Aide #1 that the right side of Resident #1's face was swollen. Nurse #1 stated she had assessed Resident #1 and observed the resident's right cheek to be swollen, right eye swollen, a cut in his mouth in the cheek area, dried up blood around the resident's corner mouth, and dried blood under the resident's fingernails on his right hand. Resident #1 stated NA #1's name and that she had hit him in the face. Nurse #1 revealed she notified the Director of Nursing, Administrator, Medical Director, Law Enforcement, and the Responsible Party (RP). Resident #1 was sent out to the hospital to be further assessed. Nurse #1 revealed she was not aware of any concerns with Resident #1 until she was notified by NA #2 and Medication Aide #1. Nurse #1 indicated she had been surprised Resident #1 had voiced a specific name due to him not usually calling staff by their name. The nurse indicated Resident #1 often yelled at staff like you or nurse come here.A phone interview with Resident #1's Responsible Party (RP) on 10/13/25 at 9:20 AM revealed she was notified by Nurse #1 the right side of Resident #1's face was swollen, and Resident #1 had reported to staff that [NA #1's name] had hit him repeatedly and the NA would be suspended during the investigation. The RP indicated she was concerned that staff told her they believed the incident occurred during the evening of 10/08/25 but staff had not observed resident #1's injuries until the morning of 10/09/25. Review of hospital emergency department progress notes dated 10/09/25 revealed Resident #1 was brought in by EMS and reported the resident was assaulted by a staff member who punched him in the face and the resident had right facial pain. It was documented that the resident had traumatic injuries to his face which appeared to be superficial. The records indicated Resident #1 face showed soft tissue swelling of the pre-[NAME] (transitional teeth located between the canine and molar teeth) and peri mandibular (lower jaw) areas but no fractures or acute abnormal findings. The physician Resident #1 had poor dentition, and needed to follow-up with dentistry, but had no acute infection suspected. Resident #1 was discharged back to the facility on [DATE] with orders for Tylenol 1000 mg every 6 hours and Robaxin (muscle relaxant) as needed for pain.Review of Resident #1's hospital after care summary dated 10/09/25 revealed Resident #1 was diagnosed with assault, injury of head, contusion of the face (bruise just beneath the skin), and facial hematoma (pooling of blood in the surrounding tissues after an injury to the blood vessels).A phone interview with the hospital Physician on 10/27/25 at 11:05 AM revealed it was reported by Emergency Medical Services (EMS) that Resident #1 had been assaulted by a staff member. The Physician stated Resident #1 was alert but unable to give information without being coached. The Physician indicated Resident #1's contusion, hematoma, and swelling to the right side of his face would be appropriate for an individual that was assaulted. It was further revealed it was possible that Resident #1 had self-injured himself, but he would have to hit himself very hard and possibly more than once.An interview and observation with Resident #1 on 10/13/25 at 1:45 PM revealed the resident was an African American gentleman and had swelling to his right cheek bone with brown color discoloration. Resident #1 stated he was still sore and held his mouth when he spoke. Resident #1 stated NA #1's name and that she had hit him several times but was unable to provide any further information. Observation of Resident #1 fingernails observed them to be trimmed and rounded with no jagged edges. Resident #1 revealed he felt safe since NA #1 was suspended and had no issues eating. An interview and observation with Resident #2 on 10/13/25 at 2:15 PM indicated he was Resident #1's roommate. It was further revealed Resident #2 was blind and wore headphones during the investigation. Resident #2 was unable to identify if he had heard of any incident that occurred on 10/08/25 through 10/09/25. Resident #2 was not interview able.An interview with the Police Officer assigned to Resident #1's case on 10/14/25 at 11:50 AM revealed law enforcement had been contacted by the facility on 10/09/25 and informed a resident had accused a staff member of assaulting them. The Police Officer indicated he was not the initial officer that responded but was now assigned to the case. The Police Officer stated he had spoken to the initial officer and Resident #1 had repeated NA #1's name and stated NA #1 had hit him several times and had stated the incident occurred at night. The interview further revealed the Police Officer had spoken to Resident #1 on this date (10/14/25) and Resident #1 indicated a staff member named [NAME] or [NAME] had hit him and the incident had occurred during the day. The Police Officer noted both times Resident #1 was interviewed details of the incident had changed. The Police Officer revealed he was still investigating and would need to interview staff. Review of a police report dated 10/27/25 revealed on 10/09/25 at 6:05 AM it was reported to a reference of assault. The reported further revealed law enforcement was dispatched at 6:30 AM to the facility. The report indicated Resident #1 reported he was struck by a staff member. Law enforcement did an investigation and was unable to determine the cause of injury. The case was presented to the District Attorney and was closed. An interview with the Director of Nursing (DON) on 10/13/25 at 11:15 AM revealed around 5:45 AM on 10/09/25 she was notified by Nurse #1 that Resident #1 had swelling to the right side of the face and Resident #1 had stated NA #1's name and that she had hit him. It was further revealed that the DON advised Nurse #1 to notify the family, Medical Director, and the Administrator. The DON also advised Nurse #1 to get statements from staff, complete a thorough oral mouth exam due to possible abscesses, and a skin assessment on Resident #1. The DON indicated Resident #1's RP requested for the resident to be sent out to the hospital to be further assessed. The DON revealed NA #1 worked on 10/08/25 from 3:00 PM until 11:00 PM. The DON stated she interviewed NA #1 on 10/10/25 and observed NA #1 to have a scratch on the left side of her face that looked angry. NA #1 told the DON that she was providing incontinence care to Resident #1 around 7:45 PM on 10/08/25 and the resident scratched her during care. The DON indicated NA#1 did not report what had happened or Resident #1's behaviors to Nurse #1 during her shift on 10/08/25. The DON revealed Resident #1 had ongoing behavior of being resistive to care and being aggressive towards staff, but staff were educated to walk away when any resident became aggressive or combative. The DON indicated Resident #1 had never recalled staff names prior to the incident and was surprised he continued to report NA #1 had assaulted him. The DON stated NA #1 denied causing any harm to Resident #1. The DON revealed she had interviewed NA #2 who worked third shift on 10/08/25 from 11:00 PM to 7:00 AM on 10/09/25. The DON explained NA #2 indicated she had checked Resident #1 throughout the night, and he was asleep, and she did not want to wake him. NA #2 reported to the DON that she did not observe Resident #1's facial swelling until around 5:30 AM when she had turned on the resident's bedroom light and observed it. NA #2 indicated during her checks during third shift she left the resident's light off and checked his brief and it was dry throughout shift. The DON indicated during the initial investigation she was unable to determine how Resident #1's injury had occurred.An interview with the Rehabilitation Director on 10/14/25 at 11:35 AM revealed Resident #1 had bed rails since admission to assist with bed mobility. The Rehabilitation Director indicated they had assessed Resident #1 on 10/14/25 and found no concerns with the resident using a bed rail. The Rehabilitation Director indicated in the past Resident #1 had slid out of bed frequently. The interview further revealed Resident #1 could slide out of bed but was unable to ambulate to put himself back into bed.An interview with the Assistant Administrator and the Administrator on 10/14/25 at 12:20 PM revealed on 10/13/25 they had spoken to Resident #1 and observed the resident to become aggravated and take his bedside remote and jerk it up and down aggressively. The Administrator indicated Resident #1's bedside remote cord was tightened, but felt Resident #1 could have possibly injured himself with his bedside remote or had a seizure and hit his bedrail.A phone interview with Resident #1's Psychiatrist on 10/14/25 at 1:05 PM revealed he was not aware that there had been an incident with Resident #1 on 10/09/25. The Psychiatrist stated facility staff had never communicated to him that the resident had outburst or was being aggressive towards staff. The Psychiatrist indicated he did not believe Resident #1 would be able to injure himself and cause a contusion and hematoma to his face but was not aware of any ongoing behaviors.A phone interview with the Nurse Practitioner (NP) on 10/14/25 at 1:10 PM revealed she was familiar with Resident #1 and stated Resident #1 could be combative at times and was sometimes resistant to care. The NP indicated she assessed Resident #1 on 10/13/25 and Resident #1 showed no signs of pain, and his swelling was healing quickly. The NP explained she was unable to determine if NA #1 had assaulted Resident #1 and it was also possible that he somehow injured himself. The NP stated Resident #1s left arm was impaired and contracted but he had excellent strength in his right hand and arm.A phone interview with the Medical Director on 10/16/25 at 4:10 PM revealed on 10/15/25 she had assessed Resident #1. The Medical Director further revealed Resident #1 had previously thrown himself on the floor and had ongoing outburst behaviors towards staff. The Medical Director indicated she was unable to determine if the resident's injuries were an outcome of NA #1 hitting him after reviewing the medical records and speaking to staff. The Medical Director stated she felt that it was very possible that Resident #1 had injured himself due to his outbursts and behaviors. The Medical Director indicated Resident #1 had been followed for seizures and had not had any issues in a long time and labs were completed frequently to follow Resident #1's Keppra levels. The MD indicated Resident #1's labs and had not shown any levels of Keppra that were concerning. The Medical Director stated Resident #1 did not complain of pain or discomfort and was almost healed on 10/15/25.

Based on record review, and Responsible Party, dental provider Chief Operating Officer, Medical Director, staff and hospital physician interviews, the facility failed to provide the necessary assistance to obtain dental services for 1 of 3 residents reviewed for routine and emergency dental services (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included seizures, osteoarthritis, and cognitive communication deficit.Review of physician order dated 10/31/23 revealed Resident #1 was ordered Eliquis (anticoagulant medication) 5mg (milligrams) twice a day.Review of the in-house dental list provided by the facility revealed 07/09/25 was the last time the dentist was in the facility. Resident #1 was not seen by the dentist on 07/09/25. Review of a notice sent by the in-house dentist office on 08/22/25 revealed the notice had been emailed to Social Worker (SW) #1 and SW #2 and indicated Resident #1 required a medical consultation for medication adjustment before he could be added back to the routine dental visits.Review of a notice sent by the in-house dentist office on 09/29/25 revealed the notice had been emailed to Social Worker (SW) #1 and SW #2 and indicated Resident #1 required a medical consultation for medication adjustment before he could be added back to the routine dental visits. The notice included the dentist had requested this since 02/05/25 and Resident # 1 would not be able to be added to the routine dental visit list on 10/22/25 because a medical consultation had not been completed. It was noted Resident #1 had teeth that needed fillings and multiple teeth that needed to be extracted. An interview with the in-house contracted dental providers Chief Operating Officer (COO) on 10/15/25 at 2:55 PM revealed Resident #1 had not been assessed by the dentist since 02/05/25 and the resident was aggravated during this routine dental visit. The COO indicated Resident #1 required a medical consultation for medication adjustment to assist with Resident #1's comfort before the resident could be seen in the future for routine visits. The COO stated they had reached out to the facility by email on 08/22/25 and 09/29/25 to Social Worker #1 and Social Worker #2 to follow up about the resident being seen but had not received any responses. The COO stated Resident #1 was overdue to be assessed by the dentist and possibly needed to have tooth extractions and tooth fillings completed. An interview with Social Worker #1 on 10/16/25 at 11:30 AM revealed the in-house dentist kept a running list of residents that needed to be seen, and the SW was able to add residents if they had experienced dental pain or requested to be seen. SW #1 indicated she was provided with a copy of who was going to be seen at each routine dental visit. SW #1 stated she was not aware of any notices being sent on 08/22/25 or 09/29/25 from the in-house dental provider for Resident #1 to receive a medical consultation for future appointments. An interview conducted with Social Worker #2 on 10/16/25 at 11:45 AM revealed she had been employed for 6 months and had received notices and the routine list from the in-house dental provider. It was further revealed she did not recall any notices or concerns from the in-house dental office regarding Resident #1. The SW did not recall receiving any emails on 08/22/25 and 09/20/25 about Resident #1. Review of Resident #1 quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required extensive support with one person assistance with personal hygiene care. The MDS further revealed Resident #1 did not have mouth or facial pain, discomfort, or difficulty with chewing. The MDS indicated Resident #1 had not behaviors during the look back period.Review of Resident #1's care plan revised on 09/16/25 revealed the resident had deficit pertaining to teeth or oral cavity characterized by altered oral mucous membrane, problems with teeth and gums, and other oral dental problems related to the history of carious teeth (teeth that have cavities or tooth decay). The goal was for the Resident #1 to be able to chew food sufficiently, provide appropriate oral hygiene, and to be able to eat and drink free of pain. Interventions included coordinating arrangements for dental care, dietary referral as needed for chewing or swallowing, ensure resident is tolerating current diet consistency, and observe for and notify physician of signs and symptoms of oral or dental problems needing attention or possible evaluation such as pain, abscess, debris in mouth, cracked or bleeding lips, missing, loose, broken, eroded, decayed teeth; black or white coated tongue, ulcers of mouth, and lesions.Review of hospital records dated 10/9/25 revealed Resident #1 was brought in by Emergency Medical Services (EMS) from the facility, and it was reported he was assaulted by a staff member who punched him in the face, and he had right facial pain. It was documented Resident #1 had traumatic injuries to his face which appeared to be superficial. The records indicated the resident's face showed soft tissue swelling of the pre-[NAME] (transitional teeth located between the canine and molar teeth) and peri mandibular (lower jaw) areas but no fractures or acute abnormal findings. The record revealed Resident #1 had poor dentition, and needed to closely follow-up with dentistry, but had no acute infection suspected.Review of a notice emailed to the in-house dentist office by SW #2 on 10/09/25 revealed SW #2 sent a request for Resident #1 be seen during the routine visit at the facility on 10/22/25. The notice included the in-house dental providers response that Resident #1 could not be added to the list to be seen because Resident #1's medical consultation had not been completed after 4 attempts since 02/05/25. An interview with Resident #1's Responsible Party (RP) on 10/13/25 at 9:20 AM revealed she was notified by Nurse #1 on 10/09/25 that Resident #1 had been observed with the right side of his swollen with concerns he had been hit by a Nurse Aide (NA). It was further revealed when Resident #1 was discharged back to the facility Resident #1 face was swollen and was sore when eating. An interview and observation with Resident #1 on 10/13/25 at 1:45 PM revealed the resident had swelling to his right cheek bone with some color discoloration. Observations further revealed Resident had multiple teeth missing in the front with some discoloration to several teeth. Resident #1 stated he was still sore and held his mouth when he spoke. Resident #1 revealed he had no issues eating. Review of progress note dated 10/13/25 revealed the Nurse Practitioner (NP) assessed Resident #1 on this date for an acute visit following a reported assault and emergency department visit for evaluation. The note further revealed Resident #1 during the exam denied any pain around the face or nasal area. Remainder of emergency department exam showed only soft tissue swelling consistent with the hematoma, contusion, and periodontal disease, for which he followed by the in-house dentist. Resident #1 denied any vision changes, headache, pain, or focal tenderness. An interview with the Assistant Director of Nursing (ADON) on 10/16/25 at 3:40 PM revealed when Resident #1 was discharged back to the facility on [DATE] the Resident's Responsible Party (RP) was visiting and spoke to a staff member and requested that Resident #1 be seen by dental. The ADON further revealed Resident #1 had no complaints of pain and had no issues eating. The ADON indicated she was not aware until 10/16/25, a medical consultation was required for Resident #1 to be seen during routine dental visits. The ADON indicated the NP and the Medical Director had assessed Resident #1 and did not have any concerns with the resident's dental status and indicated dental services could wait until the routine dentist visit on 10/22/25. The ADON stated the facility was in the process of getting Resident #1's medical consultation completed, and he would be added to the 10/22/25 routine list to be examined. An interview with the facility Medical Director on 10/16/25 at 4:10 PM revealed Resident #1 had not complained of any mouth pain or discomfort. The Medical Director indicated she was not aware of pending consultations for Resident #1 but did not think there had been any outcome or harm due to staff not following up with the in-house dental provider and Resident #1 having a medical consultation completed. The Medical Director indicated facility staff were good at communicating issues and the resident would have been assessed by the dentist immediately if Resident #1 had shown signs of pain or discomfort.An interview was conducted with the Administrator, Assistant Administrator, and Director of Nursing (DON) on 10/16/25 at 6:00 PM. The Administrator revealed they had found where the facility had been notified on 08/22/25 and 09/29/25 that Resident #1 required a medical consultation for adjusting his medicine before he could be scheduled for a routine dental visit. The Administrator stated they were not aware how it was missed, but the facility should have followed up with the dentist to get the medical consultation completed so that Resident #1 could have been seen. The DON and Administrator indicated if Resident #1 had shown any signs of pain and discomfort, they would have sent him out immediately. The Assistant Administrator and Administrator explained the facility was in the process of getting Resident #1's medical consultation so he could be seen for a routine visit on 10/22/25 but did not think it was urgent due to the NP and Medical Director assessing the resident and not having any dental concerns.An interview with hospital Physician on 10/27/25 at 11:05 AM revealed Resident #1 was assessed on 10/09/25 at the hospital for possible assault with facial swelling. The Physician stated during the assessment the resident had no evidence of infection or abscesses. The Physician indicated Resident #1's swelling was not caused due to any dental issues but recommended follow-up with his dentist.

Based on observation, record review and interviews with the resident and staff, the facility failed to provide a cognitively dependent resident with access to a hearing amplifier to accommodate a hearing deficit. This deficient practice occurred for 1 of 1 resident reviewed for accommodation of needs (Resident #96). The reasonable person concept was applied for Resident #96 due to his inability to hear what was happening around him. A reasonable person would feel social isolation, loneliness, and frustration. Findings included: Resident #96 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's disease. A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #96 had moderately impaired cognition and moderately impaired hearing with the use of a hearing device. Resident #96's care plan revised on 12/14/23 revealed a focus area for inability to express emotion, listen and share information; auditory alteration/deficit characterized by decreased lack of hearing related to hearing deficit, uses hearing amplifier. The interventions included use of pocket talker to hear. On 2/26/24 at 9:49 AM an observation and interview were conducted with Resident #96. He was observed sitting on the side of the bed in a quiet room. Resident #96 indicated that he had a hard time hearing and could not recall when he last had access to a hearing amplifier but thought he had one at one time. A review of the Pace of the Triad Primary Comprehensive Assessment progress note dated 11/9/23 revealed a chronic medical condition of severe hard of hearing. The Pace Nurse Practitioner (Pace NP #1) indicated in this note that Resident #96's was severely hard of hearing, and the hearing loss was chronic and ongoing. Pace NP #1 revealed that Resident #96 was examined using a pocket talker which was effective and without the pocket talker, hearing loss did appear to significantly affect Resident #96's ability to communicate and/or perform Activities of Daily Living (ADL's). Pace NP #1 further revealed that in previous notes hearing aides were not tolerated however hearing loss was adequately addressed using the pocket talker which Resident #96 tolerated well and was at his bedside for as needed use. A review of psychiatric note dated 1/26/24 indicated that during Resident #96's treatment visit he was observed to be hard of hearing and repeatedly said I don't know, and I can't hear you. On 2/28/24 at 9:07 AM an interview was conducted with the Activity Director. She indicated that Resident #96 was hard of hearing and that she must raise her voice for him to hear her. She further revealed that she was not aware of any available hearing devices and had not used or offered any hearing devices such as a hearing amplifier during activities. On 2/28/24 at 9:19 AM an interview was conducted with Nursing Assistant (NA) #1, and she indicated that she was familiar with Resident #96 and that he had a hard time hearing but was able to hear if she raised her voice. She further indicated that she was not aware if he had hearing aids or a hearing amplifier available. On 2/28/24 at 9:27 AM an interview was conducted with Resident 96's assigned medication aide (Medication Aide #1) and she indicated that Resident #96 was hard of hearing and that she had to raise her voice for him to hear but he was able to hear. She further revealed that she could not recall if Resident #96 had hearing aids or hearing amplifier available. On 2/28/24 at 9:39 AM an interview was conducted with Social Worker #1, and she revealed that Resident #96 was hard of hearing, and she had to raise her voice for him to hear her and she did not use any hearing devices when speaking with him. A follow up interview was conducted on 2/28/24 at 10:06 am and she indicated that she went to Resident #96's room and located a hearing amplifier in his room inside the drawer of his bedside table. On 2/28/24 at 3:27 PM a follow up visit was made to Resident #96 with Unit Manager #1 present. Unit Manger #1 was able to locate the hearing amplifier in the bedside table drawer and asked Resident #96 while using a raised voice if he would allow the use of the hearing amplifier so she could talk with him. Resident #96 responded by nodding head yes and reached hand out to hold the base of the amplifier. Unit Manager #1 then offered the headset to Resident #96, and he leaned his head toward Unit manager #1 to accept the hearing device but Unit Manager #1 realized that the left earpiece of the amplifier was dangling loose. Unit Manager #1 attempted to reattach it, but attempts were not successful. Unit Manager #1 explained to Resident #96 that the amplifier was broken, and she would have to get him a new one and he agreed by nodding his head yes. A follow up interview was conducted with Resident #96 on 2/29/24 at 1:56 PM and he indicated that he would like for staff to use the hearing amplifier so that I can hear better. On 2/29/24 an interview was attempted with the Pace of the Triad Medical Director as DNP #1 was not available. Attempts to interview the Pace of the Triad Medical Director were not successful. An interview was conducted with the Administrator on 2/29/24 at 1:19 PM. She indicated that the hearing amplifier was listed as an intervention on Resident #96's care plan and care guide but that it was up to the staff to determine if they felt they needed the device to effectively communicate with Resident #96. She further revealed that she was not made aware by Unit Manager #1 that the hearing amplifier was broken at that time.

Based on medical record review and staff interviews the facility failed to complete a significant change in status assessment for 1 of 1 resident reviewed for significant change (Resident #70). Findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses of dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #70 required supervision with eating, upper body dressing, lower body dressing partial /moderate staff assistance for oral hygiene, toileting hygiene, putting on/taking off footwear, and personal hygiene. Resident #70 was independent in the mobility areas of roll left and right, sit to lying, lying to sit, sit to stand, chair and bed transfer. Resident #70 had no weight loss. Review of the quarterly MDS dated [DATE] revealed Resident #70 was dependent on staff in the following areas of mobility: eating, oral hygiene, toileting, shower/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, and personally hygiene. In the area of Mobility, Resident #70 required substantial/maximal assistance to roll left and right and was dependent on staff for sit to lying, lying to sit, sit to stand, chair/bed to chair transfer, and tub shower transfer. Resident #70 was assessed to have had weight loss and was not on a physician-prescribed weight loss regimen. A review of Resident #70's MDS assessments revealed a Significant Change in Status Assessment had not been completed after the noted decline in activity of daily living in eating, dressing, personal hygiene, chair and bed transfers and weight loss. An interview on 5/17/23 at 1:30 PM the MDS Nurse #1 stated that a Significant Change in Status Assessment should be done whenever there is a change in two or more areas of improvement or decline. MDS Nurse #1 further revealed that a Significant Change in Assessment should have been completed on 1/18/23 assessment and must have been overlooked. An interview on 2/29/24 at 1:18 PM with the Administrator revealed that a Significant Change in Assessment should be completed per MDS guidelines.

Based on observations, record review, and interviews with resident and staff, the facility failed to provide nail care to a resident who needed extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice affected 1 of 7 residents (Resident # 90) reviewed for ADLs. Findings included: Resident #90 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body). Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #90 was cognitively intact and required extensive assistance with personal hygiene. Review of Resident #90's care plan revised 01/25/24 revealed a need for Activities of Daily Living (ADL)/Personal Care with the following intervention including the resident required assistance for personal hygiene, and grooming. During observation and interview on 02/26/24 at 12:03 pm, Resident #90 was observed lying in bed with fingernails on both hands that were about 1/2 inch long. Resident #90 stated he wanted his nails clipped and would ask the staff. An observation was conducted on 02/27/24 at 12:41 pm of Resident #90 lying in bed and his nails remained long. Resident #90 stated he did not ask to have his nails clipped and would ask his nurse today. On 02/28/24 at 10:25 am an observation was made of Resident #90 and his nails remained long on both hands. Resident #90 stated he had asked the Nurse to clip his nails on 02/27/24, however he did not remember what nurse he had asked. An interview was conducted on 02/28/24 at 10:59 am with the MDS Nurse and she indicated residents' nails were usually clipped when the Nursing Assistant (NA) provided ADL care, unless they had diabetes. The MDS Nurse was in the room and verified with Resident #90 he asked to have his fingernails clipped on 02/27/24 by the nurse, and the nurse he asked said okay, but never clipped them. A review of Resident #90's Activities of Daily Living documentation from December 2023 to present revealed no documentation that showers had been provided and no refusals noted. Attempt to contact NAs who were assigned to work with Resident #90 on 02/26/24 and 02/27/24 was unsuccessful. An interview was conducted 02/29/24 at 11:16 am with the Nurse (Nurse #2) who was assigned to Resident #90 on 02/26/24 and 02/27/24 and she indicated the Resident did not request to have his nails clipped. She indicated staff had not informed her Resident needed his nails clipped. Nurse #2 stated she did not notice Resident #90 needed his nails clipped or she would have clipped them. An interview was conducted with the Administrator and Director of Nursing (DON) on 02/29/24 at 3:08 pm. The DON indicated Resident #90's fingernails were clipped on 02/28/24 and his nails should be clipped if he requested them to be clipped.

Based on observations, resident and staff interviews and record review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint surveys dated 1/18/22 and current survey 3/06/24 in the area of accurately coding Minimum Date Set (MDS). The facility also failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 1/18/22, 1/27/23 and the current survey 03/06/24, in the area of Activity of Daily Living (ADL) care provided for dependent residents. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This citation is cross referenced to: 1 F 641 Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area hearing, speech, and vision for 1 of 1 resident reviewed for communication. (Resident #96). During the previous recertification and complaint survey date 1/18/22 the facility failed to accurately code the nutrition section of the minimum data set (MDS) for 2 of 5 residents reviewed for Nutrition 2 F 677 Based on observations, record review, and interviews with resident and staff, the facility failed to provide nail care to a resident who needed extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice affected 1 of 7 residents (Resident # 90) reviewed for ADLs. During the previous recertification and survey on 1/27/23 the facility failed to provide showers, nail care, and mouth care to residents who needed extensive and/or were dependent on staff for Activities of Daily Living (ADL). During the previous recertification and complaint survey on 1/18/22, the facility failed to provide a haircut (Resident #71) for 1 of 3 activity of daily living dependent residents reviewed. During an interview on 2/29/24 at 3:23 PM, the Administrator stated the Quality Assurance (QAPI)) committee, regarding the repeated deficiencies the Administrator stated the old plan of correction would be revisited and analyzed to see where the failures and breakdowns happened. This would help analyze the cause of repeat deficiency. The Administrator indicated once the plan was put in place, audits and the monitoring phase would be completed. She further indicated that sporadically monitoring and auditing throughout the year should be continued to ensure the repeated deficiencies do not recur. Repeated concerns were also discussed in QAPI meeting and the QAPI committee would see how the approach can be changed if needed. This could be education and training of staff or revision of the approach or new approach if needed.

Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area hearing, speech and vision for 1 of 1 resident reviewed for communication. (Resident #96). The findings included: Resident #96 was admitted to the facility on [DATE] with diagnosis of hearing deficit. A review of Resident #96's electronic medical record (EMR) included Pace of the Triad Primary Comprehensive Assessment progress note dated 11/9/23. This assessment revealed a chronic medical condition of severe hard hearing. The Pace Nurse Practitioner (Pace NP #1) indicated in this note that Resident #96's was severely hard of hearing, and the hearing loss was chronic and ongoing. Resident #96's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and coded the resident as not having a hearing deficit. Resident #96's care plan revised on 12/14/23 by MDS Nurse #1 revealed a focus area for inability to express emotion, listen and share information; auditory alteration/deficit characterized by decreased lack of hearing related to hearing deficit, uses hearing amplifier. The interventions included use of pocket talker to hear. An interview was conducted with MDS nurse #1 on 02/28/24 11:08 AM. She revealed that she completed this assessment, and she thought Resident #96 could hear adequately. She further indicated that she did not realize he had been previously assessed to have hearing impairment at the time of the assessment nor was she aware of having access to hearing amplifier/pocket talker. MDS Nurse #1 then confirmed that she was the MDS Nurse that revised the hearing care plan on 12/14/23 which indicated that Resident #96 had a hearing deficit and the intervention of the use of a hearing amplifier. The MDS Nurse #1 then indicated that she might have coded this section incorrectly. An interview on 2/29/24 at 1:19 PM with the Administrator revealed that Resident #96's hearing should be assessed per MDS guidelines.

Based on record review and staff and resident interviews, the facility failed to implement their policy for immediately notifying the Administrator of an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #4). Findings included: The facility abuse policy, last revised 10/15/22, read in part, Any employee who witnesses or suspects that abuse, neglect, exploitation, or misappropriate of property has occurred will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. The Administrator will ensure for all allegation that involves abuse or results in serious bodily injury, the Division of Health Service Regulation, Health Care Personnel Section, and Adult Protective Services are notified immediately but no later than 2 hours after the allegation is received, and determination of alleged abuse is made. Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, mild with other behavioral disturbances. The Minimum Data Set, dated dated dated [DATE] showed Resident #4 was moderately cognitively impaired. An interview was conducted with the hospice social worker on 8/31/23 at 2:30pm. She revealed that while she was visiting Resident #4 on 6/6/23, Resident #4 reported an allegation of physical abuse but that it was not something that had occurred recently and that she had made Unit Manger #1 aware of the allegation that day. An interview was conducted with Unit Manager #1 on 8/31/23 at 3:37 PM. She revealed that she was notified on 6/6/23 by the hospice social worker that Resident #4 had made an allegation of physical abuse. Resident # 4 was immediately assessed and found no signs of abuse and that she did not tell the previous Administrator as she had thought the hospice social worker had already made her aware. Review of facility's 24-hour Initial Allegation Report to the state agency revealed that the Administrator was made aware of the incident on 6/9/23. An interview was conducted with the previous Administrator on 8/31/23 at 1:59 PM. She stated that she was made aware of the allegation on 6/9/23 and immediately initiated the investigation and the allegation was not substantiated. During an interview with the current Administrator on 8/31/23 12:05pm, she indicated that all staff members need to follow the facility abuse protocols and that the Administrator should be notified immediately when there is an allegation of abuse. The facility provided the following corrective action plan with a completion date of 6/13/23. On 5/30/23, an Inservice was started with all staff by the DON (Director of Nursing) on abuse, resident rights, and customer service emphasizing abuse reporting to the Administrator. On 6/9/23, it was decided by the Administrator to expand the education to hospice services due to a hospice employee's late reporting of an allegation that occurred on 6/6/23. On 6/13/23, quizzes were initiated by the SDC with all employees to ensure a successful understanding of the education on abuse, resident rights, and burnout. Any staff member who did not pass the quiz after 3 attempts was not allowed to work until they were reeducated and successfully passed. The quizzes were completed on 6/13/23. After 6/13/23, all staff that had not worked, taken and passed the quiz, completed it upon their next scheduled shift. The Administrator ensured all areas of concern were addressed. The decision to QAPI late reporting was made by the Administrator on 6/9/23. Starting 6/12/23, The IDT (Interdisciplinary Team) began reading progress notes 5x per week x 4 weeks during the Cardinal Meetings (the clinical meeting), including notes from the weekend, to identify any allegations of abuse. The purpose is to ensure appropriate interventions are in place and allegations are reported in a timely manner. The Administrator and DON are in attendance of the cardinal IDT meetings and will ensure the abuse process is followed and staff reeducated as necessary for all identified areas of concern. The QAPI committee met during the July QAPI and reviewed reportable allegations to determine trends and/or issues that may need further interventions and the need for additional monitoring. Completion Date: 6/13/23 The Corrective Action Plan was validated on 8/31/23 and concluded the facility had implemented an acceptable corrective action plan on 6/13/23. Interviews with current nursing staff including hospice staff revealed the facility had provided education and training on abuse, notification of supervisor immediately, ensure resident is safe and the Administrator is the Abuse Coordinator. The audits conducted starting on 5/31/23 revealed residents were asked about abuse and if they had been abused. Skin checks were completed for all non-alert and oriented residents on 5/29/23. The audits continued through the validation date. Staff quizzes related to abuse were also reviewed and completed. QAPI committee minutes reviewed, and the reportable allegations were reviewed at that time. On 8/31/23 there was sufficient evidence to support the facility's Corrective Action Plan was implemented and carried out by 6/13/23.

Based on record reviews and interviews with the consultant pharmacist, Nurse Practitioner, Medical Director, and a representative of the facility's contracted pharmacy, the facility failed to ensure there was an appropriate indication for prescribing an oral antibiotic shown to be ineffective against systemic infections for a resident with a surgical wound infection. This occurred for 1 of 4 residents (Resident #2) reviewed for the provision of care according to professional standards. The findings included: Resident #2 was admitted to the facility on [DATE] from another skilled nursing facility. His cumulative diagnoses included a history of a myocardial infarction (heart attack) and status post coronary artery bypass graft (a surgical procedure used to treat coronary artery disease). The resident's electronic medical record (EMR) included a Nursing Progress Note dated 4/28/23 which reported Resident #2 was being seen by a wound clinic for treatment of a surgical wound to his sternum (breastbone). A culture of the surgical wound was obtained by the facility on 5/3/23 with the laboratory results reported on 5/5/23. The lab culture was positive for methicillin resistant staphylococcus aureus (MRSA). Resident #2 was sent out to the hospital Emergency Department (ED) on 5/9/23 for placement of a peripherally inserted central catheter (PICC) line for antibiotic therapy. A review of the resident's ED Provider Note dated 5/9/23 reported intravenous (IV) vancomycin (an antibiotic) was indicated to treat his MRSA wound infection. Resident #2's physician orders and May 2023 Medication Administration Record (MAR) documented the resident received IV vancomycin as ordered from 5/10/23 to 5/13/23. A Nursing Progress Note dated 5/26/23 at 9:49 PM reported his PICC line was removed on 5/26/23. A review of the resident's weekly Skin/Wound/Treatment Note dated 7/12/23 at 1:30 PM reported the area to Resident #2's chest wound was healed. Resident #2's EMR included a Nurse Practitioner (NP) Progress Note dated 7/26/23. The note indicated Resident #2 was seen for an acute visit due to the reopening of his sternal incision. It read, in part: .He [Resident #2] reports he was taking a shower when he noticed scab removed from upper sternal incision in area of previous wound and noticed area had drainage. Review of chart revealed wound culture on [5/3/23] with MRSA growth from sternal incisional wound, which had 3 days IV tx [treatment] of vancomycin at that time and now same area has reopened; therefore will extend treatment of abx [antibiotic] therapy to be sure infection resolved . The Assessment and Plan included #2 (of 3) which noted, .Recurrent MRSA infection, sternal incision, reopening of skin, ordered vancomycin therapy; will repeat culture if no improvement to r/o [rule out] multiple organisms . A physician's order was received on 7/26/23 for 500 milligrams (mg) vancomycin to be given by mouth twice daily for MRSA wound infection for 10 days and new orders were initiated for daily wound treatments to the surgical incision. Resident #2's July 2023 and August 2023 MARs documented the resident received the oral formulation of vancomycin as ordered from 7/26/23 to 8/5/23. According to [NAME]-Comp, a comprehensive medication database used by medical professionals, the indications for IV vancomycin therapy include the treatment of skin / soft tissue MRSA infections and surgical site MRSA infections. However, the oral administration of vancomycin was reported as, Ineffective for treating systemic infections. Vancomycin was documented as being poorly absorbed into the body when it is taken orally. The full prescribing information for oral vancomycin from the National Library of Medicine of the National Institutes of Health (NIH) indicated vancomycin is administered orally only for the treatment of enterocolitis (inflammation that occurs throughout the intestine) caused by Staphylococcus aureus (including methicillin-resistant strains) and for the treatment of antibiotic-associated pseudomembranous colitis (a severe inflammation of the inner lining of the large intestine) caused by C. difficile (a specific type of bacteria). Orally administered vancomycin is not effective for other types of infection. A telephone interview was conducted on 8/31/23 at 9:50 AM with the Nurse Practitioner who prescribed the oral vancomycin for Resident #2 on 7/26/23. Although the NP no longer worked at the facility, she recalled Resident #2 and explained that she ordered oral vancomycin for this resident because she thought it would be a first-line choice based on his history. The NP stated she thought she had used the oral formulation of vancomycin prophylactically (as a preventative treatment) in the past and only a couple of times before for a localized infection. When asked if she was aware that oral vancomycin was not effective against systemic infections due to its poor absorption, the NP indicated she was not. A review of Resident #2's EMR included weekly Skin/Wound/Treatment Notes dated 8/2/23 and 8/9/23. These notes each revealed the resident's wound was improving. The resident's most recent Minimum Data Set (MDS) assessment was a quarterly assessment dated [DATE]. The assessment reported Resident #2 had intact cognition. He was independent with walking, locomotion, and eating. The resident required supervision only for the remainder of his Activities of Daily Living. The MDS reported Resident #2 had a surgical wound. A weekly Skin/Wound/Treatment Notes dated 8/16/23 reported Resident #2's wound continued to be described as improving. On 8/17/23, the facility's consultant pharmacist authored a Note to Attending Physician/Prescriber. The note read, in part: Resident had order on 7/26/23 for oral vancomycin bid [twice daily] x [times] 10 days for the treatment of MRSA Wound infection. Please note that oral Vancomycin is not effective in the treatment of any infection other than c-difficile. An MRSA wound infection would require IV Vancomycin (or oral Zyvox [an antibiotic] as another option). Please evaluate current wound infection to see if re-treatment is necessary. Resident #2 was sent out to the hospital on 8/22/23. A review of his hospital History and Physical notes dated 8/22/23 reported the resident's chronic sternal wound did not appear to be acutely infected at that time. A telephone interview was conducted on 8/31/23 at 11:10 AM with the consultant pharmacist who assumed responsibility for reviewing Resident #2's medications each month. The pharmacist discussed her 8/17/23 Note to Attending Physician/Prescriber. During the interview, the pharmacist reiterated the information documented in her communication to the provider, stating oral vancomycin would not be an effective treatment against any infections other than C. difficile. An interview was conducted with the facility's Medical Director (who was also a Medical Doctor or MD) on 8/30/23 at 5:00 PM. During the interview, the MD was asked if she had a concern related to the use of oral vancomycin for the treatment of a skin/wound infection when it was known to be ineffective against systemic infections. The MD adamantly stated she did not. The MD reported she much preferred using an oral antibiotic before escalating the treatment to an intravenous antibiotic. During a follow-up interview conducted on 8/30/23 at 5:15 PM, the MD again stated she did not think that an intravenous antibiotic was warranted when the oral vancomycin was prescribed. She reiterated her desire was to always use an oral antibiotic before opting to use an IV antibiotic formulation. A telephone interview was conducted on 8/31/23 at 12:11 PM with a [NAME] President (VP) of the facility's contracted pharmacy. During the conversation, the VP reported he had been made aware of the concern regarding oral vancomycin having been prescribed as treatment for a wound infection. The VP reported the pharmacy would need to conduct education with the healthcare professionals to increase their awareness of the differing indications for oral vancomycin versus intravenous vancomycin.

Based on observations and staff interviews, the facility failed to ensure dishware was stored and stacked clean and dry; The facility also failed to ensure the food items not provided by the facility were dated and labeled with the residents' names, dates and room numbers when stored in the snack/nourishment refrigerators; and food items served to but refused by residents were not stored in 1 of 3 residents' nourishment rooms. These practices had the potential to affect food served to residents. Findings included: 1. On 1/25/23 at 11:40 a.m., during an observation of the meal service tray line preparation, 44-food stained and/or greasy plates were stacked in the plate warmer located ready for use next to steamtable. There were also 3-sectioned/divided plates with dried food stains, one of which was also chipped stacked on the meal service trayline. There were 4-large muffin tins with dried food debris and greasy stains and 1-large (6deep) steamtable pan with dried food stains stacked on the storage rack next to clean and dry pots and pans. The Dietary Consultant removed the identified soiled dishware and rewashed the plates and put the soiled pans in the 3-compartment sink. 2. On 1/25/23 at 12:15 p.m., accompanied by the Assistant Dietary Manager, the 100/200 hall nourishment room was observed. The refrigerator contained one (20 oz.) resealed bottle of soda and one unopened 8 ounce container of organic whole milk that were not labeled with a resident's name and date of storage. Also, stored in the top cabinet above the sink in the nourishment were 5(.75oz) sealed single serve dry cereals. On 1/25/23 at 12:20 p.m., the Assistant Dietary Manager revealed the container of organic milk in the refrigerator was not purchased by the facility's dietary services. He also stated that the dietary department did not store cereals in the nourishment rooms, cereals were only served on residents' meal trays during breakfast. He discarded the container of organic milk and the 5-containers of cereals into the trash bin.

Based on an observation and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from standing water and refuse. These unsanitary practices had the potential to affect the environment of the residents. Findings included: During an observation, accompanied by the Dietary Manager (DM) on 1/23/23 at 10:05 a.m., there was a mattress with puddles of water floating on top, lying on the ground next to the trash compactor. Also, there was a large pool of standing water and leaves beneath and surrounding the trash compactor. On 1/23/23 at 10:06 a.m., the DM stated the leaves should have been raked from beneath the trash compactor so the rainwater could drain. The DM indicated she had no knowledge why a mattress was placed on the ground next to the compactor. During an interview on 1/27/23 at 11:10 a.m., the Administrator stated that his expectation was for the facility's environmental and dietary staff to check and ensure the trash compactor and the surrounding area were free from debris when they disposed of trash from the facility.

Based on record review, resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and respond to concerns voiced by residents during Resident Council meetings for 8 of 12 months (April, May, July, August, September, October, November and December 2022). Findings included: The Resident Council minutes were reviewed for April, May, July, August, September, October, November and December 2022 and revealed no concerns or grievances were documented from residents. The minutes indicated Resident #18, Resident #32, Resident #47, Resident # 48, Resident#52, Resident #67, Resident #73, Resident #87 and Resident # 392 attended these meetings. The identified Residents were interviewable with a BIMS (brief interview mental status) greater than 11. On 01/24/23 at 10:30 am a Resident Council meeting was held and attended by Resident #67, Resident #48, Resident # 86, Resident #392, Resident #18, Resident #47, Resident #52, Resident #50, Resident #65 and Resident #73. During the meeting the residents were notified that based on review of the Resident Council minutes for April, May, July, August, September, October, November and December no concerns were voiced by the residents. The residents in attendance reported this was not true and that concerns had been reported each meeting for the last year. Resident #48 stated that concerns with smoking, staffing, food, bathing and missing items were ongoing concerns that had been reported for months. The residents stated the Activity Director told them at the beginning of each meeting grievances and concerns were not reported in the minutes. The residents also stated that their concerns had not been addressed and they were unaware of efforts to resolve their concerns as they remained ongoing. During the meeting, Resident # 32 explained the Council Members voiced grievances and concerns during the meetings, however the concerns and grievances were never resolved by the facility. Resident #32 added the facility has had five Administrators within the year, and nothing was being done for our concerns. During an interview with the Activity Director on 01/24/23 at 4:00 pm, the Activity Director stated she oversaw the Resident Council meetings and documented the minutes but not concerns or grievances. She stated she was told by the Administrator not to document concerns and grievances in the minutes but on a separate concerns form. The Activity Director provided the January 2023 concern form from the Resident Council meeting and no concerns were recorded. The Administrator was interviewed on 01/26/23 at 1:13 pm. The Administrator indicated that the Resident Council members could voice grievances and concerns in the meeting but if there were private issues, they were having they could come to him or the SW individually. He stated he did attend the Resident Council meeting in January 2023. He indicated that he expected the residents to feel free to voice their concerns and grievances, during their Resident Council meetings and any concerns or grievances to be documented in the Council minutes as well as a grievance form filed.

Based on observation, record reviews, psychiatric nurse practitioner and staff interviews, the facility failed to administer duloxetine hydrochloride (an antidepressant medication) for eleven days as ordered by the psychiatric nurse practitioner for 1 of 5 sampled residents (Resident# 27) reviewed for unnecessary drugs. Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included: major depressive disorder, disorganized schizophrenia, and bipolar disorder. The quarterly assessment dated [DATE] indicated Resident #27 was severely, cognitively impaired; had no behaviors; and, received antipsychotic and antidepressant medications. The care plan dated 12/17/22 revealed Resident #27's use of psychotropic drugs (antipsychotic, antidepressant) with the potential for side effects of cardiac, neuromuscular, gastrointestinal systems related to his psychological diagnoses. Interventions included: evaluate effectiveness and side effects of medications for possible reduction of psychotropic drugs; and monitor his mood/behaviors (anxiety, agitation, hallucinations, depression) with documentation per facility policy. The Psychiatry Follow Up Note dated 1/11/23 recommended Resident #27 receive a GDR (gradual dose reduction) of duloxetine hydrochloride from 60mg (milligrams) per day to 30mg per day; and staff to monitor the resident's sleep, appetite, weight, mood and behavior. Review of the clinical records revealed an order was written on 1/14/23 by the psychiatric nurse practitioner for Resident #27 to receive 30mg duloxetine hydrochloride capsule delayed release particles, everyday. The review of the January 2023's medication administration record (MAR) indicated duloxetine hydrochloride 60mg was discontinued and last administered to Resident #27 on 1/14/23. The MAR also revealed Resident #27 was to begin receiving duloxetine hydrochloride 30mg per day on 1/15/23 pending confirmation and to discontinue the medication on 1/16/23. The January 2023 MAR indicated Resident #27 did not receive any dosage of duloxetine hydrochloride from 1/15/23 through 1/25/23 (eleven days). On 1/23/23 at 4:01 p.m., Resident #27 was observed sitting quietly in his room feeding himself a sandwich and drinking water while watching a television show. The resident was alert and verbally pleasant. Resident #27 showed no disruptive behaviors and voice or showed any signs of pain. During a telephone interview on 1/27/23 at 9:56 a.m., the Psychiatric Nurse Practitioner stated that she had been working closely with Resident #27's family with tapering his medications. She revealed she wrote an order for Resident #27's 60mg duloxetine hydrochloride to be changed to 30mg duloxetine hydrochloride on 1/14/23. She indicated that during an onsite visit on 1/25/23 she discovered the medication had been discontinued. The Psychiatric Nurse Practitioner stated she reported the discrepancy to the Director of Nursing. She stated that she rewrote the order for the 30 mg duloxetine hydrochloride on 1/25/23 after assessing the Resident #27. She concluded the 11 days without the medication in his system did not appear to affect Resident #27 in a negative way. On 1/27/23 at 10:35 a.m., the Director of Nursing (DON) confirmed the Psychiatric Nurse Practitioner had informed her someone had discontinued Resident #27's duloxetine hydrochloride order for 30mg per day on 1/15/23. An interview with Unit Manager #1 on 1/27/23 at 1:00 p.m. revealed she created the Psychiatric Nurse Practitioner's telephone order to discontinue Resident #27's 30mg duloxetine hydrochloride on 1/14/23 and she confirmed the order by reviewing the pending orders in the electronic MAR.

Based on record review, resident representative interviews and staff interviews, the facility failed to explain to resident representatives that the binding arbitration agreement was not a condition of admission for 3 of 3 residents who entered into an Arbitration Agreement with the facility. (Resident #89, Resident #492, and Resident #493). The findings included: The Resident and Facility Arbitration Agreement, last revised on 08/01/22, included a statement that executing this agreement is not a precondition of admission. a. Resident #89 was readmitted to the facility on [DATE]. A review of Resident #89's admission assessment dated [DATE] indicated that Resident #89 had severe cognitive impairment. During an interview with the resident representative on 1/27/23 at 1:20pm she indicated that the admission coordinator explained the process of arbitration and that this needed to be signed to admit Resident #89. b. Resident #492 was admitted to the facility on [DATE] with a diagnosis of dementia. During an interview with the resident representative on 1/27/23 at 10:29am she indicated that she could not recall who met with her to sign the admission paperwork, but it was explained as a requirement of admission. c. Resident #493 was admitted to the facility on [DATE] with a diagnosis of dementia. During an interview with the resident representative on 1/27/23 at 10:27am she revealed that she met with Medical Records Staff member filling in for admission. The arbitration process was explained and that it was required for admission. A telephone interview was conducted with the Admissions Coordinator on 1/27/23 at 9:58am. She indicated that she is responsible for completing the admission paperwork which included the arbitration agreements, with residents or resident representatives but that other departments fill in when she is not available. She further revealed that she understood the arbitration agreement to be required for admission and was not aware that the agreement stated it was not a precondition of admission. An interview was conducted with the facility administrator on 1/27/23 at 11:05am. He indicated that he is an interim administrator but that it is his expectation for the arbitration agreement to explained to the person and ensure their understanding before signing the agreement and it is not a requirement for admission.

Based on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 2/4/20 and 1/18/22 and for complaint survey on 8/18/21 in order to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 1/27/23. The deficiencies were in the area of notice requirements before transfer/ discharge, Activity of Daily Living (ADL) care provided for dependent residents and residents free of significant medication errors. The continued failure during four federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: 1. F623 -Based on record review and staff interviews, the facility failed to provide the resident and/or Responsible Party (RP) written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization (Residents #342, #442 and #80). During the previous recertification and complaint survey on 2/4/20, the facility failed to provide written notification to the resident, resident's representative, and the ombudsman when a resident was transferred or discharged from the facility. This was evident for 3 of 4 residents reviewed for hospitalization and discharge. 2. F677 - Based on observations, record review, and resident and staff interview ' s the facility failed to provide showers, nail care, and mouth care to residents who needed extensive and/or were dependent on staff for Activities of Daily Living (ADL). This was for 2 of 2 residents (Resident #79 and #80) reviewed for ADL' s. During the previous recertification and complaint survey on 1/18/22, the facility failed to provide a haircut for 1 of 3 activity of daily living dependent residents reviewed. 3. F760 - Based on observation, record reviews, psychiatric nurse practitioner and staff interviews, the facility failed to administer duloxetine hydrochloride (an antidepressant medication) for eleven days as ordered by the psychiatric nurse practitioner for 1 of 5 sampled residents (Resident# 27) reviewed for unnecessary drugs. During the previous complaint survey on 8/18/21, the facility failed to send medication with a resident who left the facility for the weekend including medications for hypertension and pain management. This occurred for 1 of 3 residents reviewed for medication error. The administrator was unavailable for the Quality Assurance interview. An interview with the Mobile Administrator assisting in the survey was conducted on 1/27/23 at 1:49 PM. The Mobile Administrator stated the Quality Assurance (QA) committee does 1) identifies areas of concern, 2) does a root cause analysis, 3) develops a plan, audits, and monitors that plan and 4) discusses the outcome. System change and addition task would put in place as needed to resolve the issue. The Mobile Administrator further stated that if there were repeated deficiencies that were identified then the area of concern would become a focus area. The old plan would be revisited and analyzed to see where the failures, and where the breakdown happened. The root cause would be revisited and new interventions, monitoring tools would be put in place. Audit / education would be completed as needed. The team would continuously monitor until the deficient area concerns have been resolved.

Based on staff interviews and record review, the facility failed to offer a pneumococcal (pneumonia) vaccine for 1 of 5 residents (Resident #69) reviewed for immunizations. Findings included: Resident #69 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was severely cognitively impaired. Further review revealed the MDS coded the pneumonia vaccine as not up to date and that the pneumonia vaccine was not offered. Review of the policy titled Infection Control Guidelines, which had a revision date of 03/10/20, read in part; There are two pneumococcal (Pneumonia) vaccines recommended for adults. These vaccines are the pneumococcal conjugate 13 vaccine (PCV 13) and the pneumococcal polysaccharide 23 vaccine (PPSV23). These vaccine recommendations are established by the Centers for Disease and Control (CDC) and the Advisory Committee on Immunization Practices (ACIP). Pneumonia vaccines are given on admission unless contraindicated was noted on the consent/release form. A review of Resident #69's medical record revealed there was no documentation to indicate whether the resident received the pneumococcal vaccine. Consent signed by family on 6/21/22 was noted in Resident #69 ' s electronic medical record. No refusal form or nursing note revealing refusal was on file. An interview was conducted on 01/26/23 at 10:02 AM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She stated if a resident refused a vaccine she would add refused under immunizations in Point Click Care (PCC). She stated if a resident refused a vaccine, it should be documented in the nursing notes and a refusal form signed. An interview was conducted on 01/27/23 at 11:35 AM with the Director of Nursing (DON). She stated if a resident originally consented/refused to receive a vaccine but later refused/consulted, she expected nursing to document the consent/refusal in the nursing notes. She also stated a new consent/refusal form should be filled out and filled in chart. She further stated the administration of a vaccine should be documented on the Medication Administration Record (MAR).

Based on record review, observation resident and staff interviews the facility failed to treat Resident #392, 1 of 1 resident reviewed for catheter care, with dignity. The facility failed to have Resident #239's catheter bag covered for privacy and dignity. The findings included: Review of Resident #392's medical record revealed she was originally admitted to the facility on [DATE] with most recent readmission on 01/13/23. Her diagnoses included chronic kidney disease, sepsis, urinary tract infection. Review of Resident #392's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required supervision to extensive assistance with all activities of daily living, such as, turning in bed, transferring, eating, toileting, bathing, and personal hygiene. Resident #392 also required an indwelling urinary catheter. On 01/23/23 at 12:04 PM Resident #392 was observed sitting in her wheelchair in the doorway of her room. Her catheter bag was hanging from the side of her wheelchair with the bag uncovered. From the hallway the catheter bag was observed to contain dark amber urine. No privacy bag observed on the wheelchair or in the Resident's room. On 01/23/23 at 12:50 PM Resident #392 was observed ambulating in her wheelchair in the hallway with the uncovered urine catheter bag hanging from her wheelchair. Dark amber urine was again visible due to no privacy cover on the urine catheter bag. During an interview and observation on 01/23/23 at 3:24 PM Resident #392 was observed in her wheelchair in the vending area. Her catheter bag was enclosed in a privacy bag. She revealed the catheter bag was covered after staff observed surveyors looking at her catheter bag in the hallway. She further revealed the catheter bag had not been covered since her admission. She stated she would have liked for her catheter bag to have been covered since her admission so that her urine was not visible to other residents and visitors. An interview with NA #7 on 01/26/23 at 3:26 PM revealed she was typically assigned to Resident #392's hall and was familiar with the Resident. She said she did not remember a time when the Resident's urine catheter bag was covered with a privacy bag. NA #7 stated she would normally make sure the bag was below the bladder, free of kinks and covered in a privacy bag. She further stated she observed a resident with an uncovered catheter bag, she could obtain a bag from central supply or ask a nurse for one. During an interview with the Senior Administrator on 01/26/23 at 3:26 PM revealed there should be no reason for a resident not to have a privacy cover on their catheter bag. She stated her expectation was urine catheter bags would be covered at all times with a privacy bag to ensure the resident's privacy was protected. In an interview with the facility Administrator on 01/27/23 at 10:10 AM he stated that the facility did not want the Resident's urine to be in plain sight. He further stated it was his expectation for catheter bags to be covered with a privacy cover to maintain the Resident's dignity and privacy.

Based on observations, record review, and resident and staff interview ' s the facility failed to provide showers, nail care, and mouth care to residents who needed extensive and/or were dependent on staff for Activities of Daily Living (ADL). This was for 2 of 2 residents (Resident #79 and #80) reviewed for ADL ' s. The findings include: 1. Resident #80 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis) and hemiparesis (partial weakness) to one side of the body following a cerebral infarction (stroke), contractor (a fixed tightening of muscle, tendons, ligaments, or skin) of left hand, and Parkinson ' s Disease. Review of Significant Change Minimum Data Set (MDS) assessment, dated 01/13/23, revealed Resident #80 ' s cognition was severely impaired. The resident required extensive assist of one person for bed mobility and toilet use, and she was totally dependent of one person for personal hygiene and bathing. Resident #80 had functional limitations in range of motion (ROM) on one side of upper and lower extremities. Her dental status was coded indicating she had no obvious or likely cavities or broken natural teeth. Review of Resident #80 ' s care plan dated 11/08/22 with a revision date of 12/10/22 revealed a focus for Activities of Daily Living with the following interventions: Personal Hygiene/Grooming-Provide total care for wash and dry face, skin, nails, hands, and perineum, and Bathing-total dependence with one person assist. During observation on 01/23/23 at 11:13 AM, Resident #80 was observed lying in bed with mouth open. Tongue, teeth, gums and between teeth and side of mouth with dry brown/yellowish/white substance noted. Substance appears hard on tongue and teeth. Lips appear dry and cracked. An observation and interview with Nurse #5 were conducted on 01/23/23 at 03:48 PM. Observation of Resident #80 revealed she was lying in bed with mouth open. Tongue, teeth, gums and between teeth and side of mouth with dry brown/yellowish/white substance noted. Substance appears hard on tongue and teeth. Lips appeared soft and shiny. Interview with Nurse #5 was conducted. She stated that resident is a mouth breather and keeps her mouth open all the time. She stated she gets mouth care every shift (7am-3pm, 3pm-11pm, and 11pm-7am). Nurse #5 assessed residents ' mouth and stated it normally looks like that because her mouth gets dry from having mouth open. During observation on 01/24/23 at 09:45 AM, Resident #80 was observed in bed. Head of bed elevated, Resident #80 was observed lying in bed with mouth open. Tongue, teeth, gums and between teeth and side of mouth with dry brown/yellowish substance noted. Continues to appear hard on tongue. Lips appear dry and cracked. During observation and interview with Nursing Assistant (NA)/Medication Aide #9 were conducted on 01/25/23 at 04:15 PM. Resident #80 was observed in bed. Head of bed elevated, mouth open, mucous membranes moist with small amount of yellowish/brown material on it. Teeth with yellowish substance on them. Lips appeared soft and shiny. During interview with NA/Medication Aide #9 she indicated she checks the shower chart prior to going to her assigned area to see who is scheduled a shower during her shift. She stated she includes mouth care in morning care. During observation on 01/26/23 at 11:20 Resident #80 was observed in bed. Head of bed elevated, mouth open, mucous membranes moist with small amount of yellowish/brown material on it. Teeth slightly improved. On 01/27/23 at 11:13 AM an interview was conducted with the Administrator. He stated his expectation was for mouth care to be performed every shift and more frequently with a resident that received nothing by mouth and was a mouth breather. On 01/27/23 at 11:25 AM an interview was conducted with Nurse #2. She stated she performs mouth care on Resident #80 at least three times during her shift. She also stated she appeared to have a small amount of dried blood between her bottom teeth and bottom lip that she attempted to get off but did not want to hurt her mouth. She further stated the resident needed frequent mouth care due to her mouth breathing. She always keeps her mouth open which dries her mouth out. Observation of Resident #80 and interview was conducted on 01/27/23 at 11:35 AM with the Director of Nursing (DON). She confirmed Resident #80 ' s tongue and mouth were open, mucous membranes moist with yellowish/brown material on it and her teeth had a yellowish substance on them. She stated mouth care did need to be performed. She also stated it was her expectation that nurses, and Nursing Assistants (NA ' s) perform mouth care on residents every shift. She further stated when a resident received nothing by mouth and was considered a mouth breather, that resident would require more frequent mouth care. Her expectation would be for mouth care to be more preformed more frequent and a mouth lubricant to be administered. 46725 2. Resident #79 was admitted to the facility on [DATE] with diagnosis of hemiparesis. Review of the admission minimum data set (MDS), dated [DATE], revealed Resident #79 to be cognitively intact and require total assistance with bathing, dressing, and transfers. Review of Resident #79's care plan dated 11/26/22 with a revision date of 1/24/23 revealed a focus for Activities of Daily Living/Personal are with the following interventions: the resident required total care for personal hygiene including nail care and bathing. During observation and interview on 1/24/23 at 9:13am, Resident #79 was observed lying in bed with fingernails on both hands that were very long, jagged and hair that was matted to his head. Resident #79 stated he had asked the nursing staff (unable to recall names) for assistance with trimming his fingernails and showers. An interview with Unit Manager #1 was conducted on 1/24/23 at 10:28 AM. She stated the daily shower list was located at the nurses' station in a binder. She also stated that the NAs were to view the list in the AM to see who has showers due for the day. She stated there has been times that some residents did not get their scheduled showers due to the facility being short staffed. She stated they will try to get staff to stay over to complete the task or staff would complete the shower the next day, but it did not always occur. If the resident refuses a shower the NA would tell the nurse, the nurse will ask the resident and if the resident continued to refuse the NA and nurse would document refusal. A review of the facility shower schedule was completed on 1/25/23 at 9:11am. Resident #79 was not listed anywhere on this schedule and handwritten note at the bottom stating that Resident #79's room number was missing. During an observation on 1/25/23 at 11:49am Resident # 79's long fingernails and matted hair remained unchanged. An interview was conducted with NA #13 on 01/25/23 at 11:49 AM. He indicated that he was the NA assigned to resident #79 and had completed am care this morning. NA #13 was not aware Resident #79's fingernails were long or that he needed a shower. He indicated that he has only worked at this facility for 2 days but that he checks the shower book to know which of his residents are on the schedule for a shower and nails are trimmed as needed. He reviewed the shower book and stated that he did not see Resident #79 assigned to a shower day. A review of Resident #79's Activities of Daily Living documentation from November 2022 to present revealed no documentation that showers had been provided and no refusals noted. A review of the grievance logs from November 2022 to present revealed a grievance submitted by Resident #79 on 12/27/22 with a complaint that he had not gotten a shower. The resolution was that staff were to be educated that about making sure residents are given showers on schedule. An interview was conducted with the Administrator on 01/27/23 at 10:10 AM. He revealed since he has been the administrator at this facility, he has not experienced any staffing problems that would interfere with staff's ability to perform their duties to provide resident care. He stated he has not seen any indication of decreased staffing and administrative nurses have not been pulled to work in a NA role. He further stated staff say that they are short to relieve themselves of the responsibility to provide showers. The administrator said his expectation was for the facility to honor the resident's preference for shower or bath by providing person-centered care.

Based on record review, staff, family, and the Psychiatric Mental Health Nurse Practitioner (PMHNP) interviews, the facility failed to provide care and treatment to a resident who had a mental health diagnosis and had an increase in a behavior of refusing food, activities of daily living care (ADL), and pressure ulcer treatments for greater than two weeks. The facility did not actively pursue options to address the mental health issue when the resident had an increase in the refusal of food, ADL care, and treatment of the pressure ulcer. The increase in the refusals continued until the Resident was discovered to be unresponsive on 12/3/2022 and was sent to an acute care hospital. During the transfer of the Resident to the hospital the Resident was discovered to have maggots in her bed and in her skin folds that included the sacral pressure ulcer. The Resident was diagnosed with sepsis at the hospital and required intubation (the insertion of an artificial airway), antibiotics, and had an unplanned weight loss. The facility did not obtain a psychiatric review of the Resident's decision-making status or intent of self harm for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. The immediate jeopardy started on 11/16/2022 when Resident #1 refused all pressure ulcer dressing changes to a stage 4 sacral pressure ulcer. Immediate Jeopardy was removed on 12/10/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, bipolar disorder, juvenile rheumatoid arthritis with systemic involvement, chronic obstructive pulmonary disease, and type II diabetes mellitus. The Resident was [AGE] years old. A review of the Psychiatry notes revealed Resident #1 was seen for an initial visit on 8/26/2022 for psychiatric medication management. The PMHNP documented the staff reported no behavioral concerns at that time. The Resident reported no depression, no auditory visual hallucinations, and denied suicidal ideation and homicidal ideation. The Resident reported her sleep and appetite were appropriate. The Resident reported a history of emotional and verbal abuse by her ex-husband. The medication reviewed was Cymbalta, a medication used to treat depression and generalized anxiety. This was the only Psychiatry consult visit in the electronic medical record. A review of the physician orders included Cymbalta HCL capsule delayed release 30 milligram (mg) give one capsule by mouth two times a day for depression related to bipolar disorder. A review of Resident #1's Medication Administration Record (MAR) for November 2022 documented the Cymbalta 30 mg dose was administered as ordered. The electronic medical record documented Resident #1 weighed 225.0 pounds on 9/14/2022. She did not have another documented weight since 7/7/2020, 223.2 pounds. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact for decision making, was always incontinent of bowel and bladder, required extensive assistance of one staff member for bed mobility and dressing, and was totally dependent on staff for toilet use and bathing. The Resident had documented behaviors of rejection of care, 1 to 3 days, during the lookback period. The assessment further indicated Resident #1 had two stage 2 pressure ulcers and one stage 4 pressure ulcer. Resident #1's care plan, dated 10/20/2022, had focused areas with interventions as follows: 1) Resident #1 had a problematic manner in which the Resident acts characterized by inappropriate behavior: Resistive to treatment/care related to activities of daily living (ADL), refusing incontinence care, refuses medication, refuses to be weighed, refuses medical procedures, refuses showers, refuses grooming of hair. The interventions included to document care being resisted per facility protocol and notify physician of patterns in behavior. 2) Actual development of pressure ulcers related to episodes of resisting care from staff with examples of ADL care, repositioning, and wound care. Risk of further decline of wounds due to treatment refusal. Interventions included to notify appropriate personnel of changes in eating or drinking patterns. 3) Resident has a PASRR (preadmission screening and resident review) that does not expire due to a diagnosis of Bipolar. The goal read, the facility will monitor as needed to identify any changes in condition through the next review and the interventions were to monitor. 4) Resident has psychotropic drugs with the potential for or characterized by side effects of cardiac, neuromuscular, gastrointestinal systems, or due to a diagnosis of bipolar disorder. The goal read; the Resident would show minimal/no side effects of medications taken through the next review. The interventions included to observe the Resident's mental status functioning on an ongoing basis. An interview was conducted with Administrator #2 on 12/08/2022 at 3:20 p.m. and she reported she was an Administrator at another location but in October 2022 she was covering for Administrator #1 while he was out of work. She explained she became aware Resident #1 had been refusing all care and had refused Activities of Daily living (ADL) care with urine dripping onto the floor. At that time, she met with the Resident to discuss that refusing care was within her rights but allowing the room to become so unsanitary that it can become a health risk to other residents was not acceptable. She stated she listened to the Resident and negotiated an acceptable time the Resident would be ready to have her ADL care and wound care conducted. She further revealed, when the staff came to provide the care, the Resident's oxygen saturation dropped very low, and emergency medical services had to be called. The Resident was transferred to the hospital. She stated she was not working at the facility when the Resident returned. Resident #1 was discharged to the hospital on 10/20/2022 and readmitted to the facility on [DATE]. A review of the hospital discharge record dated 10/25/2022, documented Resident #1 was sent to the emergency department on 10/20/2022 for an evaluation of her sacral wound and hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The reported history from the facility was the Resident had been refusing wound care checks for the last two weeks. On the day of the admission, when the facility staff rolled the Resident to address her sacral wound, her oxygen saturation dropped to 50% on 5 liters of oxygen. At the hospital, the emergency room staff reported foul-smelling purulent drainage from the stage 4 sacral wound. Resident #1 was discharged to the hospital on 11/06/2022 and was readmitted to the facility on [DATE]. A review of the hospital discharge record dated 11/12/2022 documented, according to the report from the skilled nursing facility, Resident #1 had a recent history of refusing all sacral pressure ulcer care at the facility. A review of Resident #1's physician orders for treatments included 1) clean sacrum, apply calcium alginate with silver, cover with a proximal dressing every Monday, Wednesday, and Friday until healed. The order was started on 11/14/2022 with an indefinite stop date, 2) Cleanse bilateral lower extremities with normal saline, apply xeroform to open areas, cover with ABD, wrap with Kerlix and Coban three times a week, on Monday, Wednesday, and Friday. A review of the Treatment Administration Record (TAR) for Resident #1 had documented Resident #1 refused all treatments for the stage 4 sacral pressure ulcer from 11/16/2022 through discharge on 12/3/2022. The wound care to the bilateral lower extremities was documented as administered. An interview was conducted with Resident #4, on 12/8/2022 at 2:52 p.m. Resident #4 had moderate cognitive impairment. She was the roommate of Resident #1. She revealed she had observed flies in the facility since she had moved to her current room and had seen a lot of fruit flies at night. She added that Resident #1 does not eat very much, and staff sometimes leave her meal tray in the room overnight. The flies like to fly around her food and stuff. She added Resident #1 would not let the staff give her any care, that included turning her, changing her sheets, and wound care. She stated she informed staff that she did not like the smell in the room. An interview was conducted, on 12/08/2022 at 4:12 p.m., with Nurse #1 and she revealed she had provided wound treatments for Resident #1 for several months. She stated during the last part of October 2022 the Resident had begun to refuse the wound care constantly. She revealed when the Resident was readmitted on [DATE] she allowed the unit manager to assess the wound on 11/15/2022. After that assessment, the Resident refused all dressing changes to her sacral stage 4 pressure ulcer. The Nurse added she felt like she had to beg the Resident to do any care for her and sometimes came back six times a day to request permission to complete dressing changes. She indicated success with the lower extremity leg wraps/dressing changes but no success with the sacral dressing changes. The Resident had been refusing almost all ADL care and this was an increase in the frequency of the Resident's previous refusal pattern. She added the physician and family had been made aware in the past of the refusal. When asked if the Physician or Psychiatry provider had been updated since the last admission, she stated the refusals would be documented on the chart. She added the family had been successful in the past when the Resident refused but she had not personally called the family since the 11/12/2022 admission. She reported the family had brought the Resident food, trying to get her to eat because the Resident would refuse to eat her meal trays. An interview was conducted with the Director of Rehabilitation (DOR) on 12/08/2022 at 3:43 p.m. and she reported the Occupational therapy and physical therapy department had been working with Resident #1. She added they had worked with the Resident in the past and had picked her back up for therapy after her last readmission, on 11/12/2022. She revealed, prior to 11/12/2022, the staff would update the Resident in the morning that she would have therapy that day. The therapist would then check with the nursing assistant and nurse to see if they would assist the Resident to be ready for her therapy appointment. The Resident would refuse therapy in the past, but the therapist had usually been able to work with her on bed mobility, rolling side to side, and other bed bound areas. She reported that since the last hospital stay and readmission, the refusals had gotten worse and the resident was refusing to be changed, dressed, groomed or anything. She added the facility had recently changed her mattress, but it took several staff members to convince the Resident she needed a fresh mattress because of the urine saturation. An interview was conducted with the primary care provider (PCP), on 12/08/2022 at 5:21 p.m. and he revealed Resident #1 had refused care for her wounds in the past and that she would make perfectly good sense when talking with her but when he began to discuss wound care, she would immediately begin to refuse care. He stated education regarding the consequences of refusal of care were provided to the Resident on multiple occasions that included the risk of infection or death. When asked if he had been informed the Resident had an increase in refusals of care during November 2022, he stated he had been informed in the past and he could not say if he had or had not been informed in November. An interview was conducted with Resident #1's daughter, on 12/09/2022 at 11:19 a.m. She revealed the staff do not update the family on her mother's condition. She reported the last time she received a phone call from the facility was when her mother was going to be transferred to the hospital on 12/3/2022. At that time, she had not received a phone call regarding her mother's refusal of care or to update the family on her status, since the previous hospital admission and discharge. She stated she had not been informed that her mother had an increase in the number of refusals for care and had not been called during November regarding the refusals. She indicated that the staff would call her, in the past, and request she speak with her mother to convince her to allow care, and this had not occurred in a while. She stated the talks with a family member had previously been successful. An interview was conducted with the PMHNP on 12/09/2022 at 1:07 p.m. and she revealed she had seen Resident #1 on 8/26/2022 and this had been her last appointment with the Resident. She added the staff had not contacted her in October 2022 or November 2022 to provide an update that the Resident had an increase in a behavior of refusing care. She revealed if she had been made aware the Resident was refusing wound care treatments for a stage 4 pressure ulcer, greater than 2 weeks, she would have reviewed the medications and considered recommending an inpatient treatment to have her mental status be evaluated. She stated she had serious concerns when she was not updated regarding psychiatric behavior changes, even if the behavior was a known previous behavior but had increased in frequency because this can lead to a decline in overall health. Sometimes adding interventions or treatments for anxiety can help. She stated a resident refusing wound care for even one week, with a stage 4 pressure ulcer could lead to severe infections and a decline in health, and for an oriented resident this would be considered self-harm and required an inpatient evaluation. An interview was conducted with the facility Social Worker on 12/09/2022 at 2:08 p.m. and revealed she had not informed the psychiatry provider of a need to visit Resident #1 because staff had not informed her the refusals occurring for the Resident were an increase from her prior refusals. She added that the Psychiatric provider services were discontinued on 11/19/2022 and a new provider was implemented. She stated she had requested the clinical nursing staff to provide her a list of what residents should be seen by the new provider and Resident #1 was not included on the list. A review of the electronic medical record for Resident #1 documented she was discovered unresponsive by staff on 12/3/2022 and 911 was called. The Resident was sent to an acute care hospital. A review of the Emergency Medical Services (EMS) documentation was conducted for Resident #1 for the date of service on 12/3/2022. The Resident was moved onto the stretcher bed and during the transfer, the EMS staff observed a strong stench like necrotic tissue (the death of body cells or tissue through disease or injury). The sheet under the Resident was soiled with red and yellow stains. During the transfer maggots fell on to the mattress from the Resident's sheets. An interview was conducted with EMS staff #1 on 12/12/2022 at 1:27 p.m. and revealed on 12/3/2022 the team arrived at the facility to pick up a resident that was not responding. He stated upon arrival the room had a strong odor. He added when the team transferred Resident #1 to the stretcher, maggots fell off of the sheet back onto the bed. A review of the hospital discharge records revealed Resident #1 was admitted on [DATE] with a diagnosis of Sepsis, altered mental status, and staff documented observing maggots on the Resident's abdominal pannus, buttocks, perineum, and every fold of the groin. She required intubation for her respiratory status and was admitted to the critical care unit. The Resident's weight for the hospital admission was 91.7 kilograms (201.74 pounds). An interview was conducted with Hospital Nurse #1 on 12/12/2022 at 3:22 p.m. and revealed he had been the nurse assigned to Resident #1 on 12/3/2022. He indicated he was in the room while two emergency room technicians rolled the resident to remove the sheets from the nursing facility. He was able to visualize a stage 4 sacral pressure ulcer with no dressing in place, open to air, and maggots were present on her skin folds, buttocks, and in the wound. He added the respiratory status of the Resident was the priority because she was being treated as a code sepsis (sepsis is defined as the body's overwhelming and life-threatening response to an infection that can lead to tissue damage, organ failure, and death. Code sepsis was designed to facilitate early recognition of severe sepsis and rapidly deliver a bundle of care) and therefore the wound care to remove the maggots from her skin and wound was conducted in the critical care area. An interview was conducted with Administrator #1 on 12/09/2022 at 3:00 p.m. and he revealed he had not been aware the refusals of behavior had increased from the Resident's history, and it was his expectation that psychiatry services be consulted for all residents with a known history of mental illness with a change in behavior. The Administrator was notified of immediate jeopardy on 12/09/2022 at 5:00 p.m. Credible Allegation of IJ removal: Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance. Resident #1 who has a Diagnosis of Bipolar Disorder, had an increase in behaviors of refusing care including incontinence care from 1-3 days per week. Resident had a daily refusal of wound care for 17 days, from November 16, 2022, through December 3, 2022. The resident developed maggots in the wound that she consistently refused care for, and she was noted to have decrease in meal intake, resulting in weight loss. Psychiatry services and the family were not notified of the consistent refusals and self-injurious behaviors. The facility did not coordinate with the psychiatry provider, related to the resident's unresolved self-injurious behaviors of refusals of ADL care, incontinence care and wound care, to establish new interventions and the facility's failure to implement fly reduction measures including ensuring doors are not propped open resulted in development of maggots on the groin pannus skin folds, buttocks, wound, and perineal area on 12/3/2022. On 12/3/22, at approximately 9:30 am, Resident #1 had a change in condition, with a decreased level of consciousness, shallow respirations, and a temperature of 99.9. The nurse made the physician aware with an order to send the resident to the emergency room for evaluation. EMS arrived at the facility to transport the resident to the emergency department. The emergency medicine technician notified Nurse #1 that there were maggots on resident #1 sheets. The nurse notified the Administrator. The Administrator instructed housekeeping to deep clean resident #1's room and replace the mattress. On 12/3/22, the Administrator initiated an investigation to determine the root cause of the maggots. The emergency room notes indicate that maggots were identified in the resident's groin pannus skin folds, buttocks, wound, and perineal area. All residents with mental disorders and/or who have a history or trauma and/or post-traumatic stress disorder that are at risk related to non-compliance with wound care, ADL care, and nutritional intake have the potential to be affected. On 12/7/2022, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and Treatment Nurse reviewed wounds for all residents, including residents with mental disorders and/or who have a history of trauma and/or post-traumatic stress disorder that are at risk related to non-compliance with wound care to the point of extreme detriment up to including potential self-harm and self-injurious behavior. The purpose of the audit is to ensure all identified residents are receiving the necessary treatment. There were no identified areas of concern. The audit was completed on 12/7/22. On 12/7/2022, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and Treatment Nurse assessed all residents including residents with mental disorders and/or who have a history of trauma and/or post-traumatic stress disorder that are at risk related to non-compliance with ADL care. The purpose of the audit is to ensure all identified residents are receiving the necessary treatment. There were no identified areas of concern. The audit was completed on 12/7/22. On 12/9/2022, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and Treatment Nurse reviewed meal intake for 72 hours to identify residents' mental disorders and/or who have a history of trauma and/or post-traumatic stress disorder that are at risk related to non-compliance with nutritional intake. The purpose of the audit is to ensure all identified residents are receiving the necessary treatment. The Director of Nursing will ensure all residents identified with concerns will be referred to psych services, nutritional services, and physician notification. * Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 12/9/2022, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and Treatment Nurse reviewed progress notes x 30 days and current diagnosis to identify residents with mental disorders and/or who have a history of trauma and/or post-traumatic stress disorder that are at risk related to non-compliance with wound care, ADL care, and nutritional intake, to the point of extreme detriment up to including potential self-harm and self-injurious behavior. The purpose of the audit is to ensure all identified residents are receiving the necessary physical and mental health treatment. The Director of Nursing or Assistant Director of Nursing will meet with the psych NP before resident visit to discuss newly referred residents and residents already on case load, with potential for self-harm and self-injurious behavior, to ensure psych services understands the urgency and the behaviors are addressed. Behaviors including refusals will be monitored through the morning clinical meetings by review of the progress notes and behavior documentation 5 x per week by the Director of Nursing and Assistant Director of Nursing and referrals will be made by social services to psych services related to consistent refusals and self-injurious behaviors. The Social Worker is in attendance of the morning clinical meeting where the discussion will take place on the urgency of the referral. On 12/9/2022, 100% in-service was initiated by the Staff Development Coordinator with the Nurses, Treatment Nurse and Nursing Assistants regarding refusals of care, alternatives to treatment, notifications, recognizing mental disorders, referrals to psych services, and documentation. The focus of the in-services is to train staff to address early refusals of care, worsening mental health issues, providing alternatives to treatment, and proper notification through documentation of refusals prior to a resident displaying self-harm and self-injurious behavior. In-service will be completed by 12/9/2022. On 12/9/22, the in-services were sent by the Administrator to the remaining staff who had not worked via care feed (an electronic communication system for staff). All contracted staff including agency that has not worked, will receive the in-service upon the next scheduled shift. All staff will be required to sign an in-service sheet on arrival to their next scheduled shift. The Educator will review the education and validate staff knowledge and understanding of the education. All contracted staff including agency that has not worked, will receive the in-service upon the next scheduled shift. Staff Development Coordinator will monitor the schedule for new assigned agency staff to ensure they are educated prior to their scheduled shift. * Date of corrective action completion 12/10/2022 On 12/13/2022 the facility's credible allegation for Immediate Jeopardy removal was validated. The validation was evidenced by record review of in-services given to staff, and audits completed by staff management. Validation was also evidenced by interview of staff members from different departments. The facility's in-service records were available and reviewed. There was documentation that in-services had been completed per the facility's alleged credible allegation of compliance. The facility's audits were also reviewed. There was documentation that audits had been completed. Different staff members from different departments were interviewed and reported that they had attended in-service training on residents who are non-compliant or refuse treatment. Their signatures were verified on the in-service training records. Staff members were able to report specific details of the training they had received. The immediate jeopardy was removed on 12/10/2022.

Based on observations, record review and staff, Hospital Nurse, Emergency Medical Services Staff and Pest Control Representative interviews the facility failed to implement fly reduction measures to protect vulnerable residents with wounds from the development of maggots and failed to ensure doors to the outside were not left open allowing the entry of flies into the facility. This resulted in 1 of 3 residents (Resident #1) reviewed for wound care developing maggots on her abdominal pannus (the area of excess skin and fat that hangs over the pubic region), buttocks, perineum (the thin layer of skin between the vaginal opening and anus), every fold of the groin, and sacral wound. Immediate Jeopardy began on 12/3/2022, when Resident #1 was discovered to have maggots on her mattress, sheets, abdominal pannus, buttocks, perineum, every fold of the groin, and stage IV sacral wound. The Immediate Jeopardy was removed on 12/10/2022 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the monitoring systems put into place are effective and education was completed. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, bipolar disorder, juvenile rheumatoid arthritis with systemic involvement, chronic obstructive pulmonary disease, obesity, and type II diabetes mellitus. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact, was always incontinent of bowel and bladder, required extensive assistance of one staff member for bed mobility and dressing, and was totally dependent on staff for toilet use and bathing. The assessment further indicated Resident #1 had two stage 2 pressure ulcers and one stage 4 pressure ulcer. A review of Resident #1's electronic medical record revealed, on December 3, 2022, the Resident was transferred to an acute care hospital due to a change in the level of consciousness. A review of the Emergency Medical Services (EMS) documentation was conducted for Resident #1 for the date of service on 12/3/2022. The Resident was moved onto the stretcher bed and during the transfer, the EMS staff observed a strong stench like necrotic tissue (the death of body cells or tissue through disease or injury). The sheet under the Resident was soiled with red and yellow stains. During the transfer maggots fell on to the mattress from the Resident's sheets. An interview was conducted with EMS Staff #1 on 12/12/2022 at 1:27 p.m. and revealed on 12/3/2022 the team arrived at the facility to pick up a resident that was not responding. He stated upon arrival the room had a strong odor. He added when the team transferred Resident #1 to the stretcher, maggots fell off of the sheet back onto the bed. A review of the Hospital records for Resident #1 revealed she arrived at the emergency roiagnom on [DATE] and staff observed maggots on the Resident's abdominal pannus, buttocks, perineum, and every fold of the groin. An interview was conducted with Hospital Nurse #1 on 12/12/2022 at 3:22 p.m. and revealed he had been the nurse assigned to Resident #1 on 12/3/2022. He indicated he was in the room while two emergency room technicians rolled the resident to remove the sheets from the nursing facility. He was able to visualize a stage 4 sacral pressure ulcer with no dressing in place, open to air, and maggots were present on her skin folds, buttocks, and in the wound. He added the respiratory status of the Resident was the priority because she was being treated as a code sepsis (sepsis is defined as the body's overwhelming and life-threatening response to an infection that can lead to tissue damage, organ failure, and death. Code sepsis was designed to facilitate early recognition of severe sepsis and rapidly deliver a bundle of care) and therefore the wound care to remove the maggots from her skin and wound was conducted in the critical care area. An observation was conducted of the facility on 12/8/2022 at 2:10 p.m. and a recreational room was located between the 100 hall and the 200 hall. A door to the courtyard was open with a 1/2 inch gap open to the outside. The doors to enter the recreational room from the hall, were open. No flies were observed in the recreational room. An interview was conducted with Resident #3 on 12/8/2022 at 2:31 p.m. The Resident was cognitively intact. When asked if he had seen any flies at the facility, he stated he had seen flies multiple times in the last month but had not seen any during the current week due to the cooler and wet weather. When the Resident was asked if he had seen where the flies came from, he stated to look at the meal tray situation. He lifted a meal tray and stated it was from the previous night. The tray was observed to be in a Styrofoam food container with the lid closed. The Resident opened the tray and it contained a sandwich and broccoli and cheddar soup. Another tray with two sandwiches was present and he revealed it was from two days ago. The Resident resided on the same hall as Resident #1 on the opposite side of the nursing station and was not in close proximity to Resident #1's room. An observation was conducted of the 200 hall on 12/8/2022 at 2:50 p.m. and a Geri chair was stored in the hall, maroon in color. In the back storage area of the chair a crushed piece of food that looked like bread, the size of the palm of a hand was in the compartment with a soiled washcloth that had yellow dried stains and a dried out wet wipe. An interview was conducted with Resident #4, on 12/8/2022 at 2:52 p.m. Resident #4 had moderate cognitive impairment. She was the roommate of Resident #1. She revealed she had observed flies in the facility since she had moved to her current room and had seen a lot of fruit flies at night. She added that Resident #1 did not eat very much, and staff sometimes left her meal tray in the room overnight. The flies like to fly around her food and stuff. She added that a staff member came around on 12/8/2022 spraying the hall area but did not enter their room. An observation of Resident #1's room was conducted on 12/8/2022 at 2:52 p.m. and there were no flies present. Resident #1 was not present in the facility at the time of the investigation. An interview was conducted on 12/8/2022 at 4:12 p.m. with Nurse #1 and she indicated the family of Resident #1 would bring the Resident food, trying to get her to eat, and then the meal trays would be left in the room. She added the Resident would yell loudly if staff removed the food trays. She added that she had seen flies in the room on several occasions for the last three months and Resident #1 owned her own fly swatter that her family provided. An observation was conducted on 12/8/2022 at 4:30 p.m. of the 300 hall that connected to the 100 hall. A door to the courtyard was observed to be propped open. Nurse #1 was present during the observation, and she revealed some of the independent smokers of the facility would enter the courtyard from the day room side, closer to the nursing station on the 200 hall. She added this was a longer walk so when the residents leave the courtyard, they exit through the door on the 300 hall. This door was observed propped open at that time. She assisted in counting the square foot tiles to Resident #1's room and it was 40 feet from the Resident's room. She added that the smokers had been educated in the past to not prop open the doors, but it had continued to occur. A review of the pest reports for September - November 2022 revealed: September 27, 2022: five pest summary locations had miscellaneous flies found and totaled 155. The exterior of the facility assessment had a recommendation to reroute the downspouts to prevent standing water and attraction by pest. The status was listed as pending with an initial date of 8/23/2022. October 24, 2022: five pest summary locations had miscellaneous flies found and totaled 100. The general comments area identified two missing fly traps. The exterior of the facility had a recommendation to reroute the downspouts to prevent standing water and attraction by pest. The status was listed as pending with an initial date of 8/23/2022. November 22, 2022: five pest summary locations had miscellaneous flies found and totaled 120. The exterior recommendation continued to state, downspouts not directed away from the foundation. Please reroute downspouts to prevent standing water and attraction by pest. The status was listed as pending with an initial date of 8/23/2022. An interview was conducted with the pest control representative on 12/8/2022 at 5:13 p.m. He revealed he visited the facility monthly and does an exterior inspection, recommended treatment as needed and then would do an interior inspection with a pest control treatment. He stated he had electronic fly traps present in the facility and since the facility had begun construction, three fly traps had been missing. He demonstrated, by walking to the locations, the three missing fly traps. One was beside the door in the recreational room, and one was on the opposite side of the courtyard, by the door to the 300 hall. He pointed to the two screws that were present on the wall where the fly trap device hung previously. An electrical outlet was beneath the area of the missing fly trap. The third device that was missing, was in an area that residents are not currently residing. He added that he had not identified a pest issue with flies in the facility. An interview was conducted with the Administrator on 12/8/2022 at 4:58 p.m. and he revealed he had been employed at the facility a few months. He stated he had been made aware of maggots at the facility for Resident #1 on 12/6/2022 when the Admission Coordinator logged into the hospital system to review when the Resident might be returning. He stated at that point, the team became aware of the maggots and deep cleaned Resident #1's room. He stated no flies were present at that time. He revealed education to the staff and residents would be conducted immediately to not prop doors open. The Administrator provided copies of the pest control visit reports for the previous three months and stated a Maintenance Director would normally be the person working with the Pest control representative and reviewing the reports, but the facility did not have a Maintenance Director and he was covering that role. A follow up interview was conducted with the Administrator on 12/8/2022 at 5:42 p.m. and he revealed he ordered eight fly traps to replace the missing ones on 12/7/2022 by telephone to the pest control representative. An interview was conducted with the Administrator and Corporate consultant on 12/9/2022 at 3:00 p.m. and the corporate consultant stated the missing fly traps cannot be installed until an electrician reviews the devices. The Administrator was notified of immediate jeopardy on 12/09/2022 at 5:00 p.m. Alleged date of IJ removal: 12/10/2022 Credible Allegation of IJ removal: * Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance. On 12/3/22, at approximately 9:30 am, Resident #1 had a change in condition, with a decreased level of consciousness, shallow respirations, and a temperature of 99.9. The nurse made the physician aware with an order to send the resident to the emergency room for evaluation. EMS arrived at the facility to transport the resident to the emergency department. The emergency medicine technician notified Nurse #1 that there were larvae on resident #1 sheets. The nurse notified the Administrator. The Administrator instructed housekeeping to deep clean resident #1's room and replace the mattress. On 12/3/22, the Administrator initiated an investigation to determine the root cause of the larvae. The facility's failure to implement fly reduction measures including ensuring doors are not propped open resulted in development of larvae on the groin pannus skin folds, buttocks, wound, and perineal area on 12/3/2022. All residents with wounds have the potential to be affected related to non-compliance with maintaining an effective pest control system. On 12/7/2022, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and Treatment Nurse initiated an audit to visualize all current residents with wounds. This audit was to ensure there were no signs and symptoms of worsening of the wound and no larvae in the wound bed. There were no other areas of concern identified during the audit. The audit was completed on 12/7/22. * Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 12/3/2022, a 100% audit of all resident rooms, common areas, and all entrances to the facility was completed by the Maintenance Director to identify any concerns related to pest control. There were no other areas of concern identified during the audit. On 12/3/22, the maintenance director did not observe any doors propped open. On 12/7/2022, the Administrator contacted the Pest Control Company for additional treatment. On 12/7/2022, the Administrator contacted Support Services to order air curtains for the main entrance and both courtyards used for smoking, to aid in the prevention of flies entering the center. Support Services indicated that the air curtains would arrive by approximately 12/13/2022 due to being a special order, with subsequent installation by Support Services after receipt of items. The Administrator will oversee the process to ensure the timely completion of the receipt and installation of the air curtains. On 12/8/2022, the contracted pest control company arrived, inspected the facility for pests, and treated the perimeter of the building with a chemical solution to kill and deter flies. Wall-mounted fly lights were ordered on 12/8/2022 by the pest control company to be placed near the four courtyard doors, the exit door nearest resident #1 room, near the lobby entrance, and the 500/700 hallway. The pest control company indicated the wall-mounted fly lights would arrive approximately 12/12/2022, and the Support Services will install the wall-mounted fly lights once received. The Administrator will oversee the process to ensure the timely completion of the receipt and installation of the wall-mounted fly lights On 12/8/22, the Administrator conducted a resident council meeting with 16 residents in attendance with the discussion of pest prevention, including not propping doors open. On 12/9/22, the education was reviewed with all other alert and oriented residents that did not attend the resident council meeting by the Administrator. On 12/8/22, the Administrator checked all exit doors to ensure no doors were propped open for a point of entry for pests. There were no other identified areas of concern. On 12/9/22, the Maintenance Director placed an alarm on the courtyard #1 door (the door that's 40 feet from the affected resident's room) to alert staff when residents access the courtyard so they can ensure doors are closed to prevent the point of entry for pests. On 12/9/22, the Maintenance Director adjusted the courtyard #2 door closure to ensure the door closes properly and sealed to prevent the point of entry for pests. On 12/7/2022, 100% in-service was initiated by the Staff Development Coordinator with the Administrator, Medical Records, Accounts Receivable, Nurses, Nursing Assistants, Housekeeping staff, Social Worker, Accounts Payable, Therapy Staff, Maintenance Staff, receptionist, Medical Records or Supply Clerk in regards to Pest Control to include (1) Prevention of pest control concerns and (2) reporting pest control concerns into the Maintenance Work Order tracking System and notification of Administrator, Director of Nursing and the Maintenance Director. In-service will be completed by 12/8/2022. After 12/8/2022, the Administrator will ensure the in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the Staff Development Coordinator or Director of Nursing prior to next scheduled work shift. All contracted staff including agency that has not worked, will receive the in-service upon the next scheduled shift. Staff Development Coordinator will monitor the schedule for new assigned agency staff to ensure they are educated prior to their scheduled shift. On 12/9/2022, 100% in-service was initiated by the Staff Development Coordinator with the Administrator, Medical Records, Accounts Receivable, Nurses, Nursing Assistants, Housekeeping staff, Social Worker, Accounts Payable, Therapy Staff, Maintenance Staff, receptionist, Medical Records and Supply Clerk regarding to ensure the point of entry for pests including doors are not left open by staff or residents. In-service will be completed by 12/9/2022. After 12/9/2022, the Administrator will ensure the in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the Staff Development Coordinator or Director of Nursing prior to next scheduled work shift. All staff will be required to sign an in-service sheet on arrival to their next scheduled shift. The Educator will review the education and validate staff knowledge and understanding of the education. All contracted staff including agency that has not worked, will receive the in-service upon the next scheduled shift. Staff Development Coordinator will monitor the schedule for new assigned agency staff to ensure they are educated prior to their scheduled shift. On 12/9/22, the Administrator began daily courtyard door monitoring for the identified doors to ensure the doors are not propped opened. *Date of corrective action completion 12/10/2022 On 12/13/2022 the facility's credible allegation for Immediate Jeopardy removal was validated. The validation was evidenced by record review of in-services given to staff, and audits completed by staff management. Pest control invoices were available showing extra services conducted. Installation of air curtains and fly lights were seen already installed or being installed. Validation was also evidenced by interview of staff members from different departments. Observations made on 12/13/2022 from 1:00 pm until 3:00 pm revealed that no pests were found in the facility. Three new air curtains were either installed or being installed on tour, bringing that number to five. New fly lights were installed bringing the number of such lights to 13. A door that residents could prop open had an alarm installed on it to prevent this from being done. The facility's in-service records were available and reviewed. There was documentation that in-services had been completed per the facility's alleged credible allegation of compliance. The facility's audits were also reviewed. There was documentation that audits had been completed. Different staff members from different departments were interviewed and reported that they had attended in-service training on Pest Control. Their signatures were verified on the in-service training records. Staff members were able to report specific details of the training they had received. The immediate jeopardy was removed on 12/10/2022.

Based on record review and staff interview, the facility failed to protect a resident who was severely cognitively impaired (Resident #1) from sexual abuse from another resident who was moderately cognitively impaired (Resident #2). Resident #2 willfully entered Resident #1's room, removed his pants, unfastened Resident #1's brief and climbed on top of her with the intention of having sexual intercourse with her. Resident #1 was sent to the hospital emergency department and had a sexual assault nurse exam (SANE). There was no obvious trauma on exam. This deficient practice affected one of three residents reviewed for abuse. Findings included: Resident #1 was admitted to the facility on [DATE], Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] for Resident #1 assessed her cognition as severely impaired. She was non-verbal and required extensive to total dependence on staff with all activities of daily living. Resident #2 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS dated [DATE] for Resident #2 identified his cognition as moderately impaired. No behaviors were identified during the look-back period. He was independent with one-person stand by assistance for transfers. A care plan with an initiation date of 9/19/19 and currently active for Resident #2 identified he demonstrated sexual behavior by touching self (masturbating) and thought some female staff members were his girlfriends and wanted sexual favors from them. A phone interview on 6/22/22 at 12:11 pm with Nurse Aide (NA) #1 revealed he had been the NA for Resident #1 on 6/19/22 on second shift. He stated about 7:30 pm to 7:45 pm he entered Resident #1's room to check on the residents. He stated Resident #1's roommate was still eating her dinner, so he went to check on Resident #1 and found that Resident #2 was on top of her in bed. NA #1 stated the privacy curtain was partially pulled and that was why he didn't see Resident #2 in the room when he first entered. He explained Resident #2 had his pants pulled down and Resident #1's brief had been unfastened and opened. NA #1 stated he yelled at Resident #2 to get off of her and then he called out for staff to come and help him. He indicated Resident #2 started to get off the bed and he assisted him back into his wheelchair. Several other NAs showed up. They took Resident #2 out into the hallway. He checked on Resident #1 and put her brief back on her. NA #1 stated he did not see if Resident #2 had an erection or if he had penetrated Resident #1. He added the Nurse #1 got to the room and assessed Resident #1 and she was sent to the hospital. NA #1 stated Resident #1 was non-verbal and couldn't call out for help or explain what had happened to her. He added he had not worked with Resident #2 and did not know if this behavior had occurred previously. An interview with NA #2 on 6/22/22 at 12:20 pm revealed she was employed at the facility for [AGE] years on second shift. She stated on 6/19/22 she was assigned to another unit and heard a staff member calling for help. She explained when she arrived at Resident #1's room, she saw Resident #2 leaning on Resident #1's bed and he was naked from the waist down. NA #2 added she assisted NA #1 to get Resident #2 into his wheelchair and then she went out of the room to get some additional help. She stated the Nurse #1 arrived at the room and she went back to her assignment. NA #2 indicated she had taken care of Resident #2 and she had never seen him having sexual contact with any other residents, but he did frequently masturbate in his room. A nursing progress note dated 6/20/22 about the incident on 6/19/22 for Resident #1 revealed the writer, (Nurse #1) was notified by Nurse Aide #4 (NA #4) that Resident #2 had been in Resident #1's room. When this nurse entered the hallway Resident #2 was in the hallway in his wheelchair with 2 NAs present. Upon visual assessment of Resident #1, bruising, bleeding or scratches were not noted. Administrator, Director of Nursing (DON) and Hospice were notified, and a new order was received from Resident #1's physician to send her to the emergency room . The Responsible Party was notified. An interview on 6/22/22 at 11:14 am with Nurse #1 revealed she was the nurse for both Resident #1 and Resident #2 on 6/19/22 from 7:00 pm to 7:00am. She stated NA #4 came and got her and stated they found Resident #2 in Resident #1's room. She stated when she arrived at the room Resident #2 was sitting out in the hallway with 2 NAs and Resident #1 was lying in her bed with a brief on. Nurse #1 stated she assessed Resident #1 and did not observe any bruising, redness or bleeding and she appeared to be in her normal state of health. She explained she contacted Resident #1's physician who gave an order to send her out to the emergency room for evaluation. Nurse #1 stated she had worked with both residents previously and she had never observed Resident #2 have any sexual behaviors toward other residents. She added Resident #2 was placed on 1:1 monitoring until he was discharged to the hospital the next day. A documented interview of Resident #2 by the facility Senior Administrator on 6/20/22 revealed, in part, Resident #2 was asked if he knew why a staff member was following him around today and he responded, because I was on top of that girl. When asked why he was on top of that girl, Resident #2 responded, I tried to have sex with her, but I couldn't. Resident #2 was asked if he placed his penis in Resident #1 and he replied, No. He added he laid on top of her for about 10 minutes. Resident #2 was asked why he did this, and he replied, Something in my head told me to do this. When asked if he understood what he did last night was wrong he responded, Yes, I know it was wrong. A documented interview of Resident #1's roommate, Resident #10, by the facility Senior Administrator on 6/20/22 revealed she saw a man enter her room, take his pants off and climb on the woman in the bed next to hers. She stated her roommate did not make any noise when the man was on top of her. Hospital records dated 6/19/22 indicated a SANE evaluation was performed and the Resident #1 was medically cleared. The facility provided the following corrective action plan with a correction date of 6/21/22. 1.) Corrective action for Resident #1 was accomplished on 6/19/22 by ensuring Resident #1's safety. Resident #2 was immediately assisted into his wheelchair, taken out of the room, and placed on 1:1 monitoring by Certified Nursing Assistant #1, Certified Nursing Assistant #2, and Certified Nursing Assistant #3. Nurse #1 completing a visual assessment of Resident #1. Nurse #1 observed no visual scratches or markings. Nurse #1 notified Resident #1's physician. The physician gave an order to send Resident #1 to the hospital for evaluation. Nurse #1 notified Resident #1's representative that the resident was being transported to the hospital. 2.) Corrective action for all residents having the potential to be affected, on 6/19/22, 100% skin checks were initiated on all residents who could not report signs/symptoms of abuse by the nursing supervisors. The skin checks were completed on 6/20/22 with no identified areas of concern. On 6/19/22, the Nursing Supervisors completed a 100 % assessment of all non-alert residents that are unable to report signs and symptoms of abuse, to include sexual abuse. The Nursing Supervisors utilized a resident census to complete the audit. No other resident had signs or symptoms of abuse, to include sexual abuse. On 6/20/22, the Social Worker completed 100 % Resident Questionnaires with all alert and oriented residents with a BIMS of 13 or higher. The Questionnaire asked: 1.) Do you know what it means to be abused to include sexual abuse? 2.) Are there any instances that you felt you were abused in any way to include touched inappropriately or sexual abuse? 3.) Are there any residents, staff, or visitors, coming into your room unwelcomed? On 6/20/22, the Western Regional Clinical Director audited 100% of resident progress notes for the last 30 days. The audit ensured that no other resident had any documentation of sexually inappropriate behaviors or entering other residents' rooms uninvited. There was no other resident identified during the audit. 3.) Education was conducted for all residents on what to do if they suspect or observe resident abuse by the Social Worker on 6/21/22. Also, the Regional Vice President educated the Resident Council on sexual abuse identification and reporting on 6/21/2022. There were no concerns voiced after the education. On 6/19/22 and 6/20/22 an in-service was initiated by the Social Worker and Nursing Supervisors with 100% of all staff to include nurses, certified nursing assistants, medication aides, dietary staff, laundry and housekeeping staff, therapy staff, administrator, admissions coordinator, accounts receivable, account payable, activities director, activities assistant, medical records, central supply clerk, maintenance director, maintenance assistant, ward clerk, including agency and contract staff, and all part-time staff regarding resident to resident abuse and residents that wander into other residents room unwanted or uninvited. On 6/21/22, the Social Worker and Nursing Supervisors completed in-servicing with all staff, including agency and contract staff who had worked on 6/19/22, 6/20/22 and/or 6/21/22. After 6/21/22, the receptionist mailed the in-services via certified mail to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the Director of Nursing or Assistant Director of Nursing prior to next scheduled work shift. 4.) Continued compliance will be maintained, beginning on 6/21/22 Behavioral Monitoring in Cardinal Interdisciplinary Team Meeting (Administrator, Director of Nursing, Social Worker, Unit Managers, Dietary Manager, and Therapy Managers) by monitoring progress notes to identify residents wandering into rooms unwelcomed or uninvited. 5 days a week x 4 weeks. Beginning 6/21/22, Skin assessments utilizing the Skin Checks User Defined Assessment in Point Click Care Computer by the Director of Nursing, Assistant Director of Nursing, Treatment Nurse, Unit Managers and/or House Supervisor for residents with BIMS less than 13, for 5 residents per week x 4 weeks. Beginning 6/21/22 100% Safe Surveys for all resident with a BIMS of 13 or higher per week x 4 weeks completed by the Social Worker, RN supervisor and/or the Admissions Director. These audits are to ensure interventions are in place to prevent potential abuse. All findings will be given to the Quality Assurance Performance Improvement Committee for review and recommendations. The Quality Assurance Performance Improvement Committee will meet monthly x 2 months to review the Behavioral Monitoring Audit Tool, the Skin Checks Assessment, and the Safe Survey's to determine trends and/or issues that may need further interventions put in place and to determine the need for further and/or frequency of monitoring. 5.) Date of alleged Immediate Jeopardy removal on 6/21/22. The facility's corrective action plan was validated on 6/23/22. Neither resident was in the facility. Skin checks were completed on 6/20/22. Residents were educated on what to do if they suspected abuse. Resident questionnaires had been completed. Education was provided to members of the Resident Council. Staff in-service was completed on 6/21/22. This information was validated through signed in-service documentation and staff interview. The deficient practice was corrected on 6/22/2022.

Based on record review, observation, resident, staff and physician interviews, the facility failed to ensure 1 of 3 residents (Resident #1), who was on an anticoagulant (blood thinner) and required extensive assistance with Activities of Daily Living (ADL) care, was provided care safely to prevent injury. During a bed bath provided by nursing assistant (NA) #1 on 10-26-21, Resident #1 was positioned on her left side on an air mattress when NA #1 turned away and Resident #1 rolled off the bed onto the floor resulting in 4 fractures to her left leg, acute blood loss, and a 10-centimeter laceration to her left lower leg. Resident #1 was hospitalized for 3 days. Immediate Jeopardy began on 10-26-21 when Resident #1 was being provided a bed bath and rolled out of bed onto the floor causing serious injury that included 4 fractures to her left leg, acute blood loss and laceration to her left lower leg. This resulted in Resident #1 spending 3 days in the hospital and ongoing intolerable pain. Immediate Jeopardy was removed on 11-11-21 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure monitoring systems put in place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included chronic [CONDITION(S)], [CONDITION(S)], below knee amputation right side, history of pathological fracture, [CONDITION(S)], pulmonary embolism and [CONDITION(S)]. Resident #1's active care plan dated 7-16-21 revealed a goal that Resident #1 would have fewer falls. The interventions for the goal were in part; assist during transfer and mobility, bed in lowest position after staff administered care and rehab/therapy referral. The resident's active care plan also included an area focused on Activities of Daily Living (ADL) care. The interventions included: bathing 1-2 persons total assist, personal hygiene extensive assistance and bed mobility extensive assistance with one person. Physician order dated 8-31-21 revealed Resident #1 was ordered [MEDICATION(S)] (pain medication) 5/325mg (milligrams) four times a day. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance with one person for bed mobility toileting and personal hygiene and total assistance with one person for bathing. The MDS also documented Resident #1 was coded for impairments with upper/lower extremity range of motion, history of falls, resident height as 5 feet 2 inches and weighed 313 pounds, and she received anticoagulant medication and pain medication on 7 of 7 days. Physician order dated 10-17-20 revealed Resident #1 was ordered [MEDICATION(S)] (blood thinner) 2.5mg (milligrams) twice a day. NA #1 was interviewed on 11-4-21 at 10:55am. The NA acknowledged she was the NA bathing Resident #1 on 10-26-21. NA #1 described rolling Resident #1 onto her left side to wash her back. NA #1 said she had looked away and removed her hands from the resident, who was still laying on her left side, to reach for a towel on the nightstand that was approximately arm's length away and the resident had fallen on the floor. She also stated she did not see the resident fall and could not remember the position the resident was laying on the floor. NA #1 was interviewed by telephone on 11-6-21 at 9:38am. Discussed with NA #1 that Resident #1 had indicated she had rolled the resident too hard and had rolled her off the bed. NA #1 reported she had not rolled Resident #1 too hard but explained the resident often had her left foot hanging off the edge of the bed as she did on 10-26-21. She stated she had not thought Resident #1 was close enough to the edge of the bed to fall out of bed. Also discussed leaving Resident #1 to obtain a basin of water out of the bathroom. NA #1 stated she had not left Resident #1's side and that she had retrieved all of her supplies needed prior to starting ADL care. Resident #1 was interviewed on 11-4-21 at 10:11am. The resident described the circumstances in which she fell out of bed as follows; NA #1 pulled Resident #1 close to her using the draw sheet then rolled Resident #1 onto her left side and the resident slid out of the bed. Resident #1 stated she spent 3 days in the hospital and now had 4 fractures in her left leg and a cut on her left lower leg. She discussed having pain issues prior to falling out of bed but described her pain now as intolerable. During the interview Resident #1 was noted to be grimacing. Resident #1 stated she planned on having a discussion with her physician to have her pain medication moved from every 6 hours to every 4 hours as needed. A second interview occurred with Resident #1 on 11-4-21 at 12:50pm. Resident discussed the nursing assistant (NA #1) was providing her with a bed bath on 10-26-21. The resident explained when NA #1 rolled her to her left side, the NA rolled her too hard rolling her off the bed and she fell on the floor. Resident #1 stated she did not have any side rails at the time, and she was on an air mattress. She explained there was usually only one NA present to provide care unless she asked for 2 NA's to be present due to her larger than average size and difficulty with mobility due to her below the knee amputation of her right leg. The resident stated she had not been able to roll herself over but if she had a side rail, she could hold herself over on her side. She stated she was sent to the hospital and needed a blood transfusion because she was anemic from losing blood. Resident #1 was observed grimacing during the interview and she stated she had always had pain but now it was almost intolerable. The resident discussed her pain medication being effective but would prefer to have the medication moved to every 4 hours. The Wound Care (WC) nurse was interviewed on 11-4-21 at 4:35pm. The WC nurse acknowledged she and the Director of Nursing were the first to respond after Resident #1 had fallen out of the bed on 10-26-21. She stated Resident #1 had informed her while she was applying the bandage that her left leg started coming off the bed pulling her down onto the floor. The WC nurse stated she had questioned NA #1 after she had completed dressing Resident #1's left lower leg and the NA informed her that she had rolled Resident #1 onto her left side and then left the resident to go to the bathroom to obtain the basin of water and when she returned the resident was on the floor. During an interview with the Director of Nursing (DON) on 11-4-21 at 4:46pm, the DON stated she entered Resident #1's room on 10-26-21 after she had heard NA #1 state the resident was on the floor. She said when she entered Resident #1's room, the resident explained that her leg was coming off the bed and she fell on the floor. The DON explained after the resident had been sent to the hospital, she interviewed NA #1 who stated she had turned to get a washcloth out of the basin and when the NA turned back around the resident had fallen on the floor. She further commented NA #1 should have received assistance from another NA which would have avoided the residents fall. The DON discussed two new interventions were added for Resident #1 that included the assistance of 2 people when providing care and quarter rails to Resident #1's bed. Review of the nursing note completed by Nurse #1 dated 10-26-21 revealed at 11:10am Resident #1 was receiving care from NA #1. The resident's bed was at the height of the NA. Documented text revealed while Resident #1 was lying on her left side, the residents lower body started to slide off the bed and the upper body proceeded to come off the bed. Resident #1 complained of left hip and leg pain. The resident left the facility by ambulance at 11:45am. Review of the incident report completed by Nurse #1 dated 10-26-21 revealed Resident #1 was lying on the floor on her left side with her upper body towards the foot of the bed and her lower body towards the head of the bed. The report documented a large amount of blood to the left lower extremity, the resident's bed was at the height of the nursing assistant (NA #1) (approximately three and a half feet) with the air mattress inflated. The incident report revealed the resident complained of left hip and leg pain. Resident #1's statement in the documentation read resident was lying on her left side while receiving care and her lower body started to slide off the bed and then her upper body. Documentation showed the resident representative and physician were notified and the resident was transported to the hospital. Nurse #1 was interviewed on 11-4-21 at 3:31pm. The nurse stated when she arrived at Resident #1's room on 10-26-21, the wound care nurse and Director of Nursing were already in the room. She stated she saw a pool of blood and the resident laying on the floor with her head at the foot of the bed and her feet at the head of the bed. The nurse discussed her interview with NA #1 when she entered the resident room stating NA #1 told her the resident was on her left side and just rolled out of bed. The nurse also stated she spoke with Resident #1 while obtaining vital signs and she told her the bottom half of her body started coming off the bed and then the top half of the body came off the bed and she fell on the floor. The nurse commented Resident #1 was unable to roll to either side on her own. Nurse #1 stated Resident #1 was sent to the emergency room . Resident #1's hospital record dated 10-26-21 was reviewed. The hospital record documented Resident #1 arrived in the emergency roiagnom on [DATE] at 12:07pm presenting with a fall and laceration to her lower left extremity. Documentation from the emergency room revealed blood loss [CONDITION(S)] and x-rays were completed showing multiple fractures including left proximal tibia, left distal tibia and fibula including open fracture, proximal left tibia, and distal left femur. The results of the emergency room exam showed Resident #1 would be admitted to the hospital for administration of antibiotics, immobilization and serial blood transfusion as necessary. Hospital records revealed Resident #1 was discharged back to the facility on [DATE] with an order for [MEDICATION(S)] (pain medication) 10-325mg (milligrams) every 4 hours as needed, and wound care to left lower leg laceration daily using xeroform and a dry dressing. Discharge documentation also revealed Resident #1 had received 3 blood [CONDITION(S)] during her hospital stay related to blood loss from the resident's multiple fractures and laceration to her left lower extremity. Resident #1's Physician was interviewed by telephone on 11-5-21 at 5:14pm. The Physician acknowledged Resident #1 had a significant fall. He stated the resident's weight and her diagnosis of [CONDITION(S)] had impacted the seriousness of her fall. The facility's Administrator was interviewed by telephone on 11-6-21 at 2:15pm. Discussed the facility's Performance Improvement Plan (PIP) dated 10-26-21 regarding Resident #1's fall on 10-26-21. The Administrator had acknowledged the Root Cause Analyses (RCA) had not addressed Resident #1's position on the bed or that the resident had an air mattress. The Administrator stated the facility's focus was the fact Resident #1 had an amputation which caused the resident's center of gravity to be altered resulting in the fall from the bed. Observation of ADL care occurred on 11-4-21 at 10:25am. NA #1 was performing the ADL care with a second NA. The observation revealed, during bed mobility, Resident #1 was turned onto her right side by NA #1 with the resident's body on the edge of the mattress and the second NA holding Resident #1 on the bed while the resident held onto the side rail. The Administrator was notified of Immediate Jeopardy on 11-6-21 at 1:29pm. The facility provided a credible allegation of Immediate Jeopardy removal dated 11-11-21. Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance On 10/26/21 during a bed bath Resident #1 was identified to have fallen off the bed onto the floor. The resident fell on to the floor with her upper body positioned at the foot of the bed and her lower body at the head of the bed. The nursing assistant (NA #1) involved was reaching for a towel at the foot of the bed when the resident moved her left leg (per resident statement to interim Director of Nursing (DON)) off the bed causing Resident #1 to fall from the bed to the floor. NA #1 was unable to validate exact cause of the fall as she had looked away from the resident to get the towel and was therefore not looking at the resident at the time of the fall. The resident stated immediately after the incident to the interim DON that she (Resident #1) moved her left leg over her right amputated leg to off the side of the bed causing her to fall off the bed. Resident # 1 was noted with acute bleeding and complaints of pain. Facility staff notified facility medical providers and obtained orders to send to hospital for acute evaluation. Evaluation at the hospital revealed 4 fractures: right leg (right ankle [NAME] fracture, right tibial plateau fracture with history of right transtibial amputation), left leg (left tibial plateau fracture, left medial femoral condyle fracture), acute blood loss requiring transfusion of 3 units packed red blood cells and a laceration to her left lower leg. Resident #1 was hospitalized for 3 days. All residents who require ADL assistance in bed have the potential to be affected by this deficient practice. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 10-26-21 the facility initiated an investigation and initiated a Performance Improvement Plan (PIP) which was completed 10/29/21. The facility investigation determined the root cause of the fall: NA performing ADL care (bed bath) rolled resident to side without additional assist or side rails to assist resident with bed perimeters. The interventions indicated to apply side rails to resident bed and increase ADL care assistance during bed baths, transfers, and positioning. Bed rails have been added to Resident #1's bed as of 10/29/21 upon return to the facility from the hospital, to assist with turning and positioning and to assist her with bed perimeters. As of 10/29/21 upon return to the facility from the hospital, additional staff has been added for Resident #1's activities of daily living care (positioning, bathing, changing, transfers) for added safety. Resident #1 has had no additional falls from bed to floor since this incident. On 10/26/21 the interim DON, Unit Supervisor, interim facility administrator, and regional support staff initiated in servicing on positioning, safety devices (bed rails), and required assistance for amputees to all direct care staff. The education provided was as follows: Whenever you are giving ADL care make sure resident is in safe position while turning. Educate resident to use side rail properly and if you feel you need help notify charge nurse to get help. As a result of review during this survey we have broadened our review of residents who could be affected by falls from bed to floor. As of 11/6/21 we are now addressing; 1) bed position during care, 2) bed position if staff member is not directly working with resident during care to assure, they are left in a safe position and 3) additional and similar bed position precautions to be taken for residents specifically on an air mattress. In expanding our broader scope of potential risk factors, it was determined that all residents who receive care in bed could be affected by this non-compliance. On 11/6/21 in servicing was expanded to include all residents for positioning, safety devices and required assistance in bed during care to include the following: resident is positioned in center of bed during care with safety devices (bed rails, wedges, call lights) as indicated in place before moving away from resident and considering all mattress surfaces (pressure relief mattress, air mattress or specialty mattress). This education also includes information on an air mattress: air alternates with weight distribution causing an uneven (higher area) surface in areas where there is no weight on an air mattress. This education began 11/6/21 by the interim DON, Unit Supervisor, interim facility administrator, and regional support staff and will be completed 11/10/21. No direct care staff will be eligible to work until he/she has completed this education. The interim Administrator and interim Director of Nursing will be responsible for tracking and assuring that all nursing staff receive the required education. The interim DON, Unit Supervisor, interim facility administrator, and regional support staff will observe resident ADL care and resident positioning during care to ensure staff understand safe positioning of resident during care. These observations will begin 11/6/21 and be completed by 11/10/21. No direct care staff will be allowed to provide ADL care that involves positioning in bed until observation of care has been completed. The interim Administrator and the Interim Director of Nursing will be responsible for tracking audits related to staff observations. Alleged date of IJ removal: 11/11/21. The credible allegation was verified on 11/15/21. Education was provided to all staff 10/26 regarding positioning, safety devices, and required assistance. Education was provided on 11/6/21 regarding bed positioning, use of bed rails, air mattress safety, pressure relieving mattress, activity of daily living care provision, ensuring resident in center of bed. Staff completed quizzes after each in-service training. Facility staff conducted audits of persons with assistive and safety devices per plan of correction. Observation while in the facility revealed resident's resting in the center of bed. Interview with agency nursing staff at 4:50 PM on 11/15/21 revealed that she had recent training on repositioning and ensuring residents are placed in the center of the mattress. Interview with facility nursing assistant at 4:54 PM revealed that she received training on falls, turning and repositioning, and ensuring good bed placement prior to care provision. Review of 4 residents with falls since the date of compliance revealed no falls related to the provision of care or bed placement. The facility's date of compliance,11/11/21 was validated on 11/15/21.

Based on observation, record review, resident, staff, physician and contractor interviews for the facility's call system, the facility failed to have a functioning call system and 12 of 14 alert and oriented residents (Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26 and Resident #27) did not have an alternate means to call for staff assistance. The call system was in disrepair throughout the entire facility causing the residents to express feelings of being scared, concerned and not cared for by the facility. Immediate Jeopardy began on 8-6-21 when it was observed resident's call lights were not working and they did not have an alternate means to call for assistance. The facility did not conduct on going monitoring which caused no means for some residents to call for staff assistance. This was likely to cause serious injury, serious harm or death. Immediate Jeopardy was removed 8-12-21 when the facility implemented an acceptable creditable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of F that is not Immediate Jeopardy to ensure monitoring systems put in place are effective. Findings included: Resident #23 was admitted to the facility on [DATE] The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. During an interview with Resident #23 on 8-6-21 at 9:25am, the resident commented that his call light had not been working for approximately 3 days. Resident #23 voiced concern regarding what he would do if he needed assistance from staff. He further explained he had informed the Director of Nursing the day the call light system was not working (8-3-21) and stated the Director of Nursing informed him the facility was trying to get the call light system fixed. Resident #23 said he was not provided an alternate means to call for staff assistants. An observation was made of resident rooms on 8-6-21 at 9:30am. The observation revealed rooms 104, 106, 108, 110, 112, 115, 208, 215, 224, 228, 230 and 231 did not have a working call light system and the residents in those rooms did not have an alternative means of call for assistance. Resident #18 was admitted to the facility on [DATE] The residents quarterly Minimum Data Set revealed Resident #18 was cognitively intact. Resident #18 was interviewed on 8-6-21 at 2:30pm. The resident discussed not having a call light, bell or lanyard since April 2021. He stated, it's been a little scary because I can't call for help unless I yell and even then, they cannot hear me because they are in another resident room. The resident said he had not had any accidents such as falls but did have to wait an hour or longer to be provided incontinence care and stated, I just had to wait until someone came to check on me. Resident #18 clarified that staff would check on him every 30 minutes to an hour. Resident #27 was admitted to the facility on [DATE]. Resident #27's annual Minimum Data Set revealed he was cognitively intact. Resident #27 was interviewed on 8-6-21 at 2:40pm. The resident discussed the call light system had been malfunctioning since April but said, sometimes it worked and sometimes it did not and for the past few days it has not worked at all. The resident discussed receiving a bell yesterday (8-5-21) but stated, I don't feel it is adequate because staff cannot hear the ding. It's scary, you have people falling and getting sick and there is no way to get them help but to yell. Resident #21 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #21 was cognitively intact and required supervision with one person for toileting. During an interview with Resident #21 on 8-6-21 at 2:45pm, the resident discussed having a bell on his table but stated when he was in the bathroom there was no way to call for assistance if he needed it. Resident #21 stated he had received the bell yesterday (8-5-21) because the call light system was not working but said, What am I supposed to do in the bathroom? I am scared if I fall in there no one will know. Observation of Resident #21's bathroom revealed the call light system was pulled out of the wall exposing the wires and there was no other means available for the resident to call for assistance. Resident #17 was admitted to the facility on [DATE]. The residents quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #17 was cognitively intact and required supervision with one person for toileting. Resident #17 was interviewed on 8-6-21 at 2:50pm. The resident discussed if he needed help, he would use his call light system. Resident #17 said, I did not know it was not working. What about the bathroom? The resident stated when he came back to his room this afternoon (8-6-21), he saw a bell on his table but did not know what it was for. He further said, Oh they will know if I need help. I can yell loud, but it does bother me I would have to yell. The Interim Director of Nursing (DON) was interviewed on 8-6-21 at 9:40am. The DON discussed being aware the call light system had not been working in the entire facility for the past 3 days but explained each resident had been provided a bell to be able to call for staff assistance. She observed rooms 104, 106, 108, 110, 112, 115, 208, 215, 224, 228, 230 and 231 and found no bell or alternate means for the residents to call for assistance. The DON stated she did not know why the rooms did not have a bell and explained the nursing staff was responsible for monitoring each resident to assure they had means to call for assistance. During an interview with the Administrator on 8-6-21 at 10:05am, the Administrator discussed having a plan of correction (POC) in place for the call light system. He explained in April 2021, management had become aware the facility's call light system was malfunctioning and had placed a bell or a wireless lanyard in each resident room. The Administrator stated an audit had been completed to assure each resident had a bell or lanyard present to call for staff assistance and did not know why the rooms that were observed to did not have a bell or lanyard present. He further said the nursing staff was responsible for monitoring the resident rooms to assure each resident had a bell or lanyard present. A review of the facility's POC dated 4-28-21, listed the problem identified was call lights in rooms not functioning properly. The action taken on the POC was all call lights have been tested for proper function. The plan section for the POC read call light service has been contacted. Staff have been communicated on select call lights not functioning. Alternate manual bells have been provided to residents. Staff will conduct 15-minute checks on all rooms with nonfunctioning call light. The POC's monitoring was call light rounds check will be reviewed daily in cardinal meeting. All call lights will be tested weekly. Daily concern rounds to monitor the call light. The resolution date in the POC was Until the call light system for the rooms is fixed. A nursing assistant (NA) #3 was interviewed on 8-6-21 at 1:15pm. The NA stated she had been checking on the residents every 30-45 minutes. She discussed being aware the call light system had not been functioning but was not aware she was to check on the residents every 15 minutes. The NA further stated she was not aware if the residents assigned to her had a bell/lanyard to call for assistance and said she would ask the residents during her rounds if they needed anything. NA #4 was interviewed on 8-6-21 at 1:20pm. The NA explained she was aware the call light system was not functioning and said she had been checking on her residents every 30 minutes to see if they needed assistance. NA #4 discussed not being aware she was to check on the residents every 15 minutes and stated it was not possible to check on the residents every 15 minutes due to the volume of residents she was assigned. She further said she was not aware if each of her residents had a bell/lanyard to call for assistance. During an interview with NA #5 on 8-6-21 at 1:25pm, the NA stated she was aware the call light system was not functioning and did not know if her residents had a bell/lanyard in their room to call for assistance. The NA further stated she could not check on her residents every 15 minutes because she was usually in a resident room for 30 minutes at a time and she was not aware that she was to be checking on her residents every 15 minutes. She said when she checked on her residents, she would ask them if they needed anything. The Assistant Maintenance Director was interviewed on 8-6-21 at 1:30pm. The Assistant Maintenance Director stated he had not been testing the call light system weekly and was not aware he was supposed to test the call light system weekly. He further stated when a resident or staff member informed him a call light was not working, he would attempt to repair that call light. The Assistant Maintenance Director acknowledged the call light system had not been working consistently since April and had stopped working 3 days ago. He explained the facility had a contract with a company to come replace the call light system since June 2021 but did not know when the system was to be replaced. The contract between the facility and a system monitoring company was reviewed. The contract was for the call light system in the facility to be replaced. The date on the approved contract was 6-14-21. The Administrator and DON were interviewed on 8-6-21 at 3:23pm. The Administrator discussed not being aware the residents were not wearing their lanyards and the monitoring system in the facility's April 2021 POC was not being followed. The DON discussed reviewing the staffing but stated the facility used agency staff and often there were call outs. The Administrator discussed the facility having a contract to have the call light system replaced but stated it was not his responsibility to follow up with the contract company for an installation date. He stated the facility's corporate maintenance staff would be responsible to follow up with the contract company. The corporate maintenance staff member was interviewed by telephone on 8-6-21 at 3:50pm. The maintenance staff member explained the facility had an old call light system that needed to be replaced. He discussed speaking with the contract company that would be replacing the facility's call light system every week but had not received a date when the system would be installed from the contract company. The maintenance staff member said he had also been in contact with his manager in the corporate office weekly updating her on the progress for the new call light system. The Manager in the corporate office was interviewed on 8-6-21 at 3:53pm. The Manger stated she had not been made aware the contract company had not begun installing the new call light system but acknowledged the approval for the contract company was dated 6-14-21. The contract company was interviewed by telephone on 8-6-21 at 5:25pm. The contractor stated he had spoken with the facility's corporate office and explained why he was not able to provide a start date to install the new call light system. The contractor said the facility did not have an electronic copy of the facility's layout so, he was having to draw the blueprints by hand and then the blueprints had to be accepted by the engineers. He said the company was actively working on getting the project approved but still could not provide a start date. The facility's Medical Director was interviewed on 8-6-21 at 4:19pm. The Medical director discussed being aware the call light system was not working but was unaware there were several residents without means to call for assistance. He said there was a safety concern if the residents were not able to call for assistants and if the facility had a call light system for the residents it needed to be functional. A telephone interview occurred with the interim DON on 8-9-21 at 9:10am. The interim DON discussed all residents having a bell or lanyard on Friday (8-6-21) but she had not completed an audit today (8-9-21) or over the weekend to assure all residents had an alternate communication devise accessible to them. She further stated she had instructed the staff to check on the residents every 2 hours. The Administrator was notified of Immediate Jeopardy on 8-9-21 at 4:45pm. The facility provided a credible allegation of Immediate Jeopardy removal dated 8-12-21. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance. On April 28, 2021, Maple Grove Health and Rehabilitation Center administrator was made aware of facility call light system (combination of resident rooms on North, South and West Halls, not the entire halls) not functioning properly during a facility tour. On April 28, 2021, a call light audit was conducted by facility maintenance director to ensure all call lights in the facility were functioning. This audit revealed 22 rooms/55 beds/ 19 residents had call lights that were not functioning properly. On April 28, 2021, a combination of a wireless call light system lanyard (to keep on resident person) or a tap bell (at bedside) as appropriate were placed in resident rooms to ensure resident safety for the identified resident rooms where call lights were noted not functioning properly. On April 28, 2021, a facility Plan of Improvement was put in place to ensure resident safety. All call lights have been tested for proper functioning. Call light system repair company has been notified. Staff have been informed on select call lights not functioning properly. Alternate manual bells have been provided to residents. Staff will conduct 15-minute checks on all rooms with non-functioning call lights. Call light rounds will be reviewed in the daily Cardinal Meeting. All call lights will be tested weekly. Resolution to call lights malfunctioning Plan of Improvement resolved due to wireless lanyard call light systems in place. No other audits were performed for call lights functioning properly. On April 28, 2021, Maple Grove Health and Rehabilitation Center administrator held an impromptu meeting with facility department heads to inform them of facility call light system not functioning properly. On April 28, 2021, facility maintenance director contacted corporate maintenance consultant of facility call bell system not functioning properly. Corporate maintenance consultant came to facility and installed two wireless lanyard call light systems. The wireless lanyard call light system has a receiver box that is plugged into a wall outlet and a battery-operated lanyard is given to the resident to use as the resident would use a call light. The receiver box has a screen that reflects the room that the lanyard was activated in as well as a speaker with an alarm to notify staff. On May 5, 2021, after several visits to repair Maple Grove Health and Rehabilitation Center call light system, the repair/installation company notified corporate maintenance consultant that Maple Grove Health and Rehabilitation Center call light system could not be repaired. The call light system repair/installation company did not convey to Maple Grove Health and Rehabilitation Center, nor to corporate maintenance department, to anticipate additional call lights malfunctioning. Therefore, Maple Grove Health and Rehabilitation Center staff did not resume facility call light audits to ensure proper functioning. Corporate maintenance department requested a quote from the call light system, the repair/installation company. On June 10, 2021, corporate maintenance department received a quote from the call light system, the repair/installation company for replacement of Maple Grove Health and Rehabilitation Center facility call light system. On June 16, 2021, corporate approved the call light system, the repair/installation company quote to replace Maple Grove Health and Rehabilitation Center call light system. On June 29, 2021, corporate maintenance department approved Maple Grove Health and Rehabilitation Center request to replace the facility call light system. Multiple attempts were made from corporate maintenance department to the call light repair/instillation company via phone for an estimated instillation date from June 29, 2021, through August 6, 2021. On August 6, 2021, a state surveyor identified twelve resident rooms (104, 106, 108, 110, 112, 115, 208, 215, 224, 228, 230, and 231) call systems were not properly functioning, and the resident was noted by the surveyor not to have a tap bell or lanyard at this time. These rooms were not identified on the initial call light audit on April 28, 2021, as not functioning properly nor had anyone reported any call light malfunctions in these rooms. On August 6, 2021, Maple Grove Health and Rehabilitation Center administrator held an impromptu Quality Assurance Performance Improvement meeting with facility department heads to inform them of facility call light system not functioning properly. Facility department heads agreed to initiating a substitution call light system using a wireless lanyard call system (to be kept on resident person who demonstrated the ability to understand the use of the lanyard system) or tap bells (placed at bedside for residents that understood and had the ability to use a tap bell and in bathrooms of residents that used bathroom) to maintain resident safety. Any resident that does not have the cognitive and/or physical ability to use the lanyard system or tap bell has been identified. Staff were notified by the administrator, interim DON and nurse managers of residents that will require at least every 30-minute rounds. The administrator, interim DON and nurse managers will monitor the rounds daily to ensure, wireless lanyards are in place and functioning, tap bells are in place at bedside and in bathrooms and at least every 30-minute rounds are being completed by the assigned CNA/nurse daily. On August 6, 2021, residents who have the cognitive and/or physical ability to use the lanyard system or tap bell have been identified and staff will round on at least every 30 minutes were educated on the use of his/her alternate call light system by the administrator, interim DON and nurse managers. On August 6, 2021, staff were educated on the alternate call light system. Staff were educated to ensure each resident had the assigned call light in place and were able to use his/her assigned call light during rounds and each additional visit to resident room to ensure resident safety. The staff was also educated on cognitively impaired or having physical inability to use the alternate call light system will be checked at least every 30 minutes to ensure safety and resident needs are met. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On August 6, 2021, all residents residing in the facility were assessed by nurse management (interim Director of Nursing and 4-unit managers) for the use of wireless call bell lanyards, tap bells or 30-minute safety/needs rounds (census 119): Lanyards were assigned to residents: 35 Tap bells were assigned to residents at bedside and in bathroom as appropriate: 84 Residents requiring 30-minute safety/needs rounds: 26 Any resident residing in the facility refusing to use any of the appropriately assigned alternate call light system will be re-assessed for an alternate appropriate call light system to meet each individual resident safety/needs. A list of residents residing in the facility has been placed at each nursing station for nurse and CNA staff to reference for identified resident alternative call light system. This list will be updated daily as needed by the unit managers, the interim DON and/or the administrator. On August 6, 2021, at approximately 8:00p.m., Regional Maintenance consultant installed an additional wireless lanyard call system to ensure every resident room was covered by the wireless lanyard system. On August 6, 2021, the facility administrator educated all department heads. The interim DON and Staff Development Coordinator educated nurses, certified nursing assistants (CNAs), housekeeping staff, therapy staff, maintenance staff, dietary staff, and agency staff working. The education regarding the resident call system covered: Staff educated on the wireless call bell lanyards and tap bell at bedside & in bathroom and 30-minute safety/needs rounds now and at the beginning of each shift until call bell system is replaced. The nursing assistants, nurses, agency staff, unit managers, interim director of nursing (DON) role is, during routine care rounds, nursing staff will ensure residents have lanyards in place and functioning/battery is not dead, (if battery is dead the nurse or unit manager will replace the battery. Extra batteries will be kept in medication rooms on each unit) and tap bells are within reach and 30-minute safety/needs are being met. During routine care rounds the nursing assistants, nurses, agency staff, unit managers, interim director of nursing will also check the wireless lanyards central monitor for low power symbol indicating that battery is low. The nursing assistants, nurses, agency staff, unit managers, interim director will replace batteries of the identified lanyard to ensure optimal power is maintained. All cognitive residents were educated on August 6, 2021, on when and how to use the tap bells and wireless lanyard call system by the unit managers, the interim DON and/or the administrator. All cognitive residents continue to be re-educated as needed on the use of tap bells and/or the lanyard wireless call system as needed by the assigned nurse, assigned CNA or unit managers, the interim DON and/or the administrator. All cognitive residents will continue to be educated on the use of tap bells and lanyard wireless call system as needed by the assigned nurse, assigned CNA or unit managers, the interim DON and/or the administrator. Any concerns of tap bells or wireless lanyard not working/appropriate for any resident will be reported to the administrator immediately for any changes needed. Any safety or resident needs not being met due to the call light system will be reported to the administrator immediately and corrected to ensure each individual resident safety and needs are met. The in-service was started on August 6, 2021, by the administrator with all department heads. The interim DON and Staff Development Coordinator educated nurses, CNAs, and agency staff working. The education is added to all new staff and agency staff orientation. The education completion date is August 10, 2021. By August 6, 2021, the administrator, maintenance worker, interim Director of Nursing or unit nurse manager began performing call light rounds daily. The rounds include ensuring resident can use call light (tap bell or lanyard wireless call system) and staff are responding to call lights (tap bell or lanyard wireless call system) appropriately as well as staff are performing at least 30-minute safety/need rounds to ensure all resident needs are met and resident safety is maintained. These rounds will be conducted daily by unit managers, any negative findings (resident refuses to use assigned alternate call light, alternate call light not in place, alternate call light not functioning properly, resident no longer able to effectively use alternate call light due to change in cognitive/physical ability) these rounds will be reported immediately to the interim DON and/or the administrator for corrective action that will ensure all residents safety/needs are met. On August 10, 2021, corporate maintenance department contracted with a different call light instillation company for Maple Grove Health and Rehabilitation Center new call instillation. This different company was contracted due to previous company stating multiple times to corporate maintenance department via phone the instillation company has been unable to obtain the needed parts nor does the company have the staff. On August 10, 2021, corporate maintenance department contacted Maple Grove Health and Rehabilitation Center administrator with a start date for replacing the facility call light system by the call light system repair/installation company. The start date is August 12, 2021. The estimated completion date of the call light instillation is September 3, 2021. The Administrator is responsible for ensuring this plan is followed. Maple Grove Health and Rehabilitation Center IJ removal August 12, 2021. Validation of the facility's credible allegation occurred on 8-13-21 and was evidenced by staff interviews, record reviews, observation, facility training that included staff ensuring the residents had a tap bell or a wireless lanyard within reach and a tap bell located in the bathroom, staff is to check that the lanyards are on the residents person or the tap bell is within reach of the resident during staff rounds and staff is to check the wireless monitoring system during rounds for any low battery detection and replace the lanyard battery if needed. Observation of hall 100 revealed residents had a tap bell or a lanyard present and within reach with all lanyards functioning properly. Observation of hall 200 revealed a new call light system had been installed in each resident room and bathroom. The new call light system was observed to be functioning properly.

Based on record review, hospital record review, family interview, staff interviews, consultant pharmacist, nurse practitioner, and physician interviews, the facility administered multiple unnecessary doses of a steroid medication to Resident #1 over the course of six days which had an outcome of elevated blood sugars requiring insulin administration to correct. The facility also failed to monitor blood sugars after the physician ordered monitoring. Resident #1 was admitted to the hospital and diagnosed with urinary tract infection with [CONDITION(S)]. This problem affected 1 of 3 Residents (Resident #1) reviewed for medication errors. The findings included: Resident #1's hospital discharge summary dated 1/19/2021 revealed that the resident was discharged with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 received [MEDICATION(S)] (steroid) for COVID-19 treatment while in the hospital and the medication was completed on 1/16/2021. Resident #1 was not discharged on [MEDICATION(S)] or insulin. The resident was discharged on [MEDICATION(S)] (oral antidiabetic medication). The summary indicated hospice would be revoked while the resident was at the Skilled Nursing Facility (SNF) and hospice should resume after discharged from the SNF. Resident #1 was admitted to the facility's COVID unit on 1/21/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's medical record revealed no baseline care plan for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A standing order titled All Residents Admit Orders for the COVID unit included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission medication orders titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication orders were transcribed by Nurse #1 and did not have a physician's signature on the order page. The orders further revealed that they were not signed off or reviewed by a second nurse. Resident #1's progress note dated 1/21/2021 revealed [MEDICATION(S)] was not listed. The note was signed by the Nurse Practitioner (NP) and revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A pharmacy notification dated 1/21/2021 at 2:58 pm questioned whether the [MEDICATION(S)] was really four times daily (qid). A clarification was requested before the pharmacy sent the medication. An additional notification was sent by the pharmacy on 1/21/2021 at 7:58 pm that stated clarify [MEDICATION(S)] qid. The notifications were faxed to the facility. The notifications were not signed by the physician. Resident #1's medication administration record (MAR) for the month of January 2021 revealed the resident received [MEDICATION(S)] 6mg by mouth qid beginning on 1/22/2021 and it was discontinued on 1/28/2021. The resident was administered 25 doses of [MEDICATION(S)] 6mg. An interview with Resident #1's family member on 6/1/2021 at 11:32 am revealed they were contacted by the facility when a medication error occurred for a steroid. They stated that the man that called them informed them there were no orders for blood sugar checks or insulin. They further revealed that they had contacted the facility before the medication error occurred to inquire about Resident #1's blood sugar levels. The family member indicated they informed the facility that Resident #1 had diabetes. The family member stated blood sugar checks began after they spoke with the Director of Nursing (DON). The family member contacted the area ombudsmen who notified the family member to contact emergency services (911) if the facility was not meeting the resident's needs. Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for January 2021 revealed Resident #1's blood sugar level was not recorded in the morning on 1/27/2021 or 1/28/2021. Medication Regimen Review dated 1/28/2021 by the consultant pharmacist (Pharmacist #2) revealed Resident #1 was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacist #2 indicated that the typical protocol had been for QD (daily) and requested verification of the [MEDICATION(S)] (steroid) order. Pharmacist #2 noted the Director of Nursing (DON) was emailed 1/28/2021 at 12:00 (am or pm not provided) the information regarding the high frequency of ordered [MEDICATION(S)]. A nurse progress note dated 1/28/2021 revealed Resident #1's blood sugar level was 445 mg/dl (milligrams per deciliter). According to the Mayo Clinic, 140 mg/dl or less was considered a normal blood sugar level. Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order continued with Resident #1's blood sugar should be checked every 4 hours for 24 hours. The IDT Review of Incident report 1/28/2021 indicated that a medication error occurred on 1/28/2021 and described the incident as an incorrect [MEDICATION(S)] order. The actions taken during investigation revealed the medical doctor and family were notified of the medication error. New orders were updated on the MAR and in Resident #1's chart. The area identifying follow up, systemic changes, in-servicing and monitoring were left blank. No outcome was identified. Post facility hospital records indicated Resident #1 was admitted to the hospital 2/1/2021. She remained in the hospital until 2/11/2021 when she was discharged home with hospice. Resident #1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 5/28/2021 at 9:33 am with Nurse #1 revealed he was working at the facility as a contract (agency) nurse at the time the medication transcription error occurred. Nurse #1 stated that a standing order was taped at the nurse's station on the COVID unit that included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The standing order was used to transcribe Resident #1's medication orders. Nurse #1 revealed that the transcription error was identified after Resident #1's family member called and asked Nurse #1 about the resident's medications. The family member informed Nurse #1 that the resident should not be on [MEDICATION(S)]. Nurse #1 then reviewed the resident's orders and determined that Resident #1 was receiving an incorrect dose of [MEDICATION(S)]. He did not recall the frequency for the use of [MEDICATION(S)]. An interview with the consultant pharmacist (Pharmacist #1) on 5/28/2021 at 2:15pm revealed she had not seen an order like [MEDICATION(S)] 6mg qid before this order. Pharmacist #1 revealed that the indicated dose and frequency of 6mg qid were high for [MEDICATION(S)]. The pharmacy and dispensing team made 2 attempts to clarify the [MEDICATION(S)] medication order by faxing the facility's nursing station on 1/21/2021. Pharmacist #1 revealed that the pharmacy did not dispense the medication until 1/23/2021 or 1/24/2021. The medication was dispensed after the pharmacy received a refill request. Pharmacist #1 further indicated that a result of taking [MEDICATION(S)] (steroid) 6mg qid was increased blood sugar levels. An interview with the Nurse Practitioner (NP) on 5/28/2021 at 3:45 pm revealed that there were standing orders at the nurse's station for COVID patients. She further revealed that Resident #1 should not have received [MEDICATION(S)] at admission due to the order stating the resident should receive it 7 days after admission. The NP was not aware that Resident #1 was receiving [MEDICATION(S)] until she was notified of the medication transcription error. The NP stated that Resident #1's blood glucose level was elevated at the time that the medication error was identified on 1/28/21. She did not recall the exact blood sugar level. The NP revealed that she was typically notified of medication issues when nurses received faxes at the facility. In an interview on 6/1/2021 at 4:22 pm, the NP indicated that she signed all orders to include every order sheet. The NP revealed that all orders must have a doctor or nurse practitioner's signature. A follow up interview was conducted with the NP on 6/2/2021 at 2:03 pm. The NP was shown the standing order document that was provided to the survey team by the Director of Nursing (DON). The NP did not recognize the standing orders and relayed that it was not her handwriting. She did not know who wrote the order for [MEDICATION(S)] on the standing order sheet. She further relayed that she clearly wouldn't have ordered [[MEDICATION(S)]] QID. An interview with the DON on 5/28/2021 at 4:21 pm revealed that it was the responsibility of the nurse on the unit to review received faxes and to call the doctor as indicated. The DON also stated that a physician's signature at the top of the standing order page was good for all the orders on the page. The DON further revealed that the process for transcribing orders should include a second nurse review. He did not know why the transcribed order for [MEDICATION(S)] was not reviewed by a second nurse. The DON was unaware of how Resident #1 received doses of [MEDICATION(S)] prior to the medication being dispensed by the pharmacy. The DON relayed that nurses should follow doctor's orders and that he didn't know why Resident #1's blood sugar levels were not checked prior to 1/28/2021. An interview with the Administrator on 5/29/2021 at 12:25 pm revealed that the facility was unaware that Resident #1 had diabetes until the resident's family member began contacting the facility regarding the resident's blood sugar levels. An interview was conducted with the physician on 6/1/2021 at 5:56 pm. The physician revealed that he provided the facility with standing orders and a [MEDICATION(S)] protocol that included [MEDICATION(S)] 6mg to be given daily for 10 days for residents on the COVID unit. The physician stated that he provided a typed and signed standing order to the facility for the nurses to use. The physician was shown the standing order that was provided to surveyors by the Director of Nursing and used to transcribe the [MEDICATION(S)]. He revealed that he did not know who wrote the order for [MEDICATION(S)] on the handwritten standing order sheet. He stated that it was not his handwriting and that the order was not signed by him. He further revealed that he would never prescribe [MEDICATION(S)] 6mg four times a day and that an effect of receiving [MEDICATION(S)] was a high blood sugar level. The physician stated that nurses would call or fax the physician or nurse practitioner regarding medications that needed to be reviewed. The physician was unaware of any pharmacy notifications dated 1/21/2021. An interview was conducted with the Director of Nursing (DON) and the Administrator on 6/2/2021 at 9:40 am. The DON revealed that on 1/28/2021 he received the pharmacy recommendation via email to clarify the [MEDICATION(S)] medication order. The DON relayed that the recommendation was forwarded to the COVID unit manager (Nurse #2) who was to contact the doctor for medication clarification. The DON was unaware of the communications sent by pharmacy on 1/21/2021 asking for [MEDICATION(S)] medication clarification. In reviewing the standing orders sheet, the DON revealed that he was unaware that the [MEDICATION(S)] order was not signed by a physician. He further revealed that unsigned physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON indicated that blood sugar levels may not be monitored for residents with diabetes unless there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with Nurse #2 on 6/2/2021 at 10:06 am revealed she was the unit manager for the COVID unit at the time that Resident #1 was residing at the facility. Nurse #2 was familiar with the medication transcription error that occurred for Resident #1. Nurse #2 stated that she did not recall receiving pharmacy notifications on 1/21/2021 regarding a [MEDICATION(S)] order clarification. She revealed that [MEDICATION(S)] should never have been given without a second nurse completing a review of the orders. She further revealed that the error could have been prevented with a second nurse verification of the orders. Nurse # 2 indicated the Nurse Practitioner or Physician should sign all orders. A follow up interview was conducted 6/2/2021 at 1:29 pm. Nurse #2 recalled the COVID unit's standing orders were taped at the nurse's station and that it had the physician's signature on it. When shown the standing orders that were provided by the facility, Nurse #2 stated that she did not recognize them. Nurse #2 did not know who wrote the order for [MEDICATION(S)]. She was unable to locate the original standing orders because she no longer had access to COVID unit documents. Nurse #2 revealed that Resident #1's blood sugar checks were ordered after the family member inquired about them and informed the facility that Resident #1 had diabetes. She was unaware that Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Administrator on 6/2/2021 at 3:21 pm. The Administrator revealed orders should come from the doctor and that sometimes the doctor only signed the order on the front. The Administrator stated that the physician was notified when orders needed signatures. The Administrator revealed that the Physician and the Nurse Practitioner were the only providers that could write orders at the facility. He indicated that there was not a physician's signature on the standing order sheet for [MEDICATION(S)]. The Administrator stated pharmacy recommendations should be followed as written. He further revealed that it was the responsibility of the DON to ensure that recommendations are carried out by nurses. He did not recall discussing the pharmacy recommendations that were dated 1/21/2021 during the facility's team meetings. The Administrator became aware of the medication transcription error on 1/28/2021 during a facility team meeting. The Administrator stated that he was part of the investigation for the medication transcription error and that it was inconclusive as to who wrote the [MEDICATION(S)] order. The Administrator revealed that he recently spoke with the physician regarding the standing order and that the physician denied writing the order for [MEDICATION(S)]. The Administrator further indicated that he was not sure how a diabetes diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review, staff interviews and physician interview the facility failed to prevent an accident by leaving an agitated and dependent resident unsupervised on a bed that was in an elevated position and the resident fell off the bed onto the floor. This was evident for 1 of 5 sampled residents reviewed for accidents (Resident #46). As a result of the unsupervised fall Resident #46 hit his head on the floor and was observed by staff bleeding from a small wound to his forehead. The resident was transported to the hospital by Emergency Medical Services (EMS) for evaluation and treatment. At the hospital Resident #46 was diagnosed with [REDACTED]. Findings Included: Resident #46 was admitted to facility on 9/27/16 with a history of dementia with behavioral disturbances. A fall risk evaluation dated 12/1/19 for Resident #46 identified the resident was at risk for falls. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment and required extensive with 1-person assistance with bed mobility, transfers, and required staff assistance to stabilize with transfers from bed to chair. He had impaired range of motion of bilateral lower extremities and a history of falls. Resident #46's care guide, that was in place when he fell on [DATE], specified Resident #46 had a Hi-low bed and the bed was to be returned to lowest position after giving care . Resident #46's care plan, that was in place when he fell on [DATE], revealed he was at risk for falls. Care plan interventions included: assist during transfer and mobility, place shoes in wheelchair seat when in bed to reduce anxious behavior and provide frequent staff observation of resident. The care plan goal was Resident #46 would not sustain serious injury through next review. Resident #46's care plan, that was in place when the resident fell on [DATE], also revealed he exhibited inappropriate behaviors including; being resistive to treatment and medications and refusing to go to bed. Care plan interventions included: allow for flexibility in activities of daily living routine to accommodate resident's mood, if resident refuses care, leave resident and return in 5-10 minutes. The care plan goal specified Resident #46 would accept care through next review. An Incident report, completed by the Director of Nursing (DON), for an incident that occurred on 2/5/20 at 2:50 AM, specified Nursing Assistant (NA) #2 reported Resident #46 slid from bed, noted to be sitting with his back against the bed; resident unable to give description; Immediate action: resident was placed back in bed; no injury observed at time of incident. An Incident report, completed by Nurse #1, for an incident that occurred on 2/5/20 at 3:45 AM, specified Nurse #1 was called to Resident #46's room by NA #2. The resident was noted to be bleeding from small wound to right forehead and his ear. Emergency Medical Services (EMS) was contacted. Immediate action taken was pressure applied to bleeding. Resident was prepared for transfer. Resident sent to hospital for evaluation via EMS. Administrator, Director of Nursing (DON), responsible representative notified. On 2/11/20 at 2:45 PM an interview was conducted with NA #2. NA #2 stated on 02/05/20 at about 2:50 AM he went into Resident #46's room and the resident had slid to the floor and was in a sitting position with his back to the bed, which was in low position. The NA stated he left the room to get the nurse and the nurse told him to get the resident up, and she would be down after she finished documenting. NA #2 stated he went back to the residents' room and Resident #46 was still in the same position on the floor and he did not see any injuries. The NA stated he picked Resident #46 up and put him back in the bed. He stated Resident #46 was yelling at him, being combative, and attempting to get out of bed. NA #2 stated he proceeded to gather materials to give the resident a bath. He stated he elevated the resident's bed and proceeded to wash Resident #46. NA #2 said he turned the resident over towards his left side to wash his back side and then left Resident #46 unsupervised on the elevated bed when he went to the bathroom to freshen the water, he was using to wash the resident. NA #2 explained while he was in the bathroom, he heard a noise, went out of the bathroom and saw Resident #46 face down on the floor. He stated the resident still had his eyeglasses on, which had broken and saw blood coming from a cut on the resident's forehead. NA#2 stated he used a towel to apply pressure to the resident's forehead cut and picked the resident up and put him in the bed. The NA stated he pulled the room's call light out of the wall and yelled for the nurse to come into the room. NA #2 stated Nurse #1 came into the room and told him to leave because the resident was agitated with him and she applied pressure to the resident's forehead cut and the resident was combative with the nurse as well. NA #2 stated he was aware he should have informed the nurse when resident was combative and usually would, but on this occasion he did not inform the nurse about the resident becoming combative when he was attempting to provide care. On 2/11/20 at 5:33 PM an interview was conducted with Nurse #1. Nurse #1 stated on 02/05/20 NA #2 called her to Resident #46's room and she observed the resident in bed bleeding from his forehead. She stated she called 911 and applied pressure to residents' forehead. Nurse #1 stated NA #2 informed her that the resident was combative and fell on the floor. She stated she was unaware that earlier in the shift NA #2 found Resident #46 on the floor before this fall occurred and she did not instruct NA #2 to pick Resident #46 up from the floor. Nurse #1 stated EMS arrived and took over the care of Resident #46 and the resident was combative with them as well. Resident #46's hospital records dated 2/5/20 revealed [DIAGNOSES REDACTED]. On 2/11/20 at 3:10 PM, NA #2 demonstrated the height of Resident #46's bed, which NA #2 had raised to provide care, on 2/05/20 when the resident fell from the bed. The height of the bed was measured as 2 feet and 4 inches. NA #2 stated it could have possibly been a little higher than measured. .On 2/13/20 at10:37 AM, NA #3 was interviewed. NA #3 stated Resident #46 attempted to be independent and he was at risk for falls. She stated the interventions in place to try to minimize Resident #46's falls included to keep his bed in a low position. An interview was conducted on 2/12/20 at 2:59 PM with Physician #2. MD #2 stated she evaluated Resident #46 after he returned from the hospital following his fall on 02/05/20. She specified, she did a skin assessment, which revealed no other injuries except for the laceration to right forehead. The MD stated the resident had no recollection of what happened when she evaluated him. An interview was conducted on 2/13/20 at 3:08 PM with the DON. She stated an investigation was completed of Resident #46's fall on 02/05/20. The DON stated, it was determined the resident's fall was caused by the resident being agitated and not because the staff member left the resident's bed elevated. The DON believed NA #2 was in a hurry trying to get the resident ready because the resident was agitated and was trying to get out of bed. On 2/13/20 at 3:43 PM an interview occurred with the Administrator. She stated the facility did not believe the height of the resident's bed was a contributing factor for the laceration.

Based on record review, physician and staff interviews the facility failed to transfer a resident from the bed to the chair using 2 staff members and a mechanical lift according to her plan of care which resulted in a fall and a fracture of her right femur. This was evident for 1 of 3 residents reviewed for accidents (Resident #38). Findings Included: Resident #38 was admitted to the facility 6/6/13 and [DIAGNOSES REDACTED]. A fall risk evaluation dated 1/22/19 for Resident #38 identified a score of 1 which indicated resident was not at risk for falls. The evaluation had sections that were not completed. A resident care guide dated 2/21/19 stated the resident required the aid of 2 persons and mechanical lift for transfers. Review of the physical therapy plan of care dated 2/22/19 for Resident #38 revealed she was referred to therapy to assess use of her new motorized wheelchair. Physical therapy was needed to improve her balance and fall recovery skills to decrease her risk for falls. Assessment of current transfer status was not completed. A quarterly minimum data set ((MDS) dated [DATE] for Resident #38 revealed she required extensive two-person assistance with transfers, balance was not steady and required staff assistance to stabilize with transfers from bed to chair. She had impaired range of motion of upper / lower extremity on one side, had not experienced any falls, had modified independent cognition and no refusal of care behaviors during the look-back period. An incident note dated 4/2/19 at 12:08 pm indicated Resident #38 was transferred from the bed to the chair. The resident slid on her feet. While the resident was sliding, NA #1 lowered her down to the floor safely. Prior to the transfer, the resident refused to put her shoes on. The resident was observed to be lying flat on the floor. She was assessed and noted swelling of her right outer ankle and right knee. The resident complained of pain with range of motion. The resident was placed back to bed with assistance from other staff members. No other bruises or active bleeding noted. The resident ' s physician was notified, and an order received to x-ray her right knee and ankle. Notified the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and message was left for resident ' s responsible party. An interview on 5/9/19 at 9:30 am with NA #1 revealed she was the NA for Resident #38 on 4/2/19. She stated mid-to-late morning she was getting the resident from the bed to the chair after she had gotten her dressed. She stated the resident would not allow her to put her shoes on and the resident had on regular socks. NA #1 explained the resident was sitting on the side of her bed which was in the regular position and when she transferred her, the resident ' s right leg slipped backwards, and she aided the resident to the floor. She added the resident was on her back with her right leg bent backwards underneath her. NA #1 stated she called for the nurse to assess the resident. She explained at the time of the fall the resident was a 1 person transfer from bed to chair and the resident could pivot on one of her legs. She stated she was alone when she did the transfer. NA #1 stated she knew what type of assistance a resident needed by looking at their care guide. She added the therapy department determined how a resident should be transferred. An interview on 5/8/19 at 3:52 pm with Nurse #2 revealed she was the nurse for Resident #38 on 4/2/19 and assessed her after her fall. She stated NA #1 called her into the resident ' s room and when she arrived the resident was lying on the floor next to her bed on her back. She stated NA #1 told her the resident started to slip while she was transferring her from the bed to the chair and NA #1 aided the resident to the floor. Nurse #2 added NA #1 told her that the resident wouldn ' t put her shoes on before the transfer, was wearing regular socks and that was why she slipped on the floor. Nurse #2 explained the resident was a 2 person assist for transfers and would often refuse to let the staff use the lift with transfers. Nurse #2 stated she was not sure if NA #1 had transferred the resident by herself or if she had another staff member with her. She explained the resident had some swelling of her right leg and when she notified the resident ' s physician he ordered x-rays. Nurse #2 stated the x-rays showed a fracture of her right leg and the resident was sent out to the hospital for treatment. Review of the radiology report dated 4/2/19 for Resident #38 revealed a 2-view x-ray of her right tibia / fibula showed an acute comminuted fracture at the distal shaft of the visualized right femur. A 2-view x-ray of the right ankle revealed no acute fracture or dislocation. The visualized bony structure appeared osteopenic. Review of a nursing note dated 4/2/19 at 2:50 pm for Resident #38 revealed she was alert and non-verbal, able to follow directions. The x-ray of her right knee and ankle revealed an acute comminuted [MEDICAL CONDITION] shaft of the visualized right femur. Her physician was notified and received an order to send the resident to the emergency room . Review of the emergency department record for Resident #38 dated 4/2/19 revealed the patient fell when she was transferred from the bed and slid on the floor at about 11:00 am. She had pain in her right knee and right hip. The right knee was mildly swollen. Noted on x-ray she had a closed [MEDICAL CONDITION] distal femur. Orthopedic surgery was consulted, and plan was to continue with non-operative treatment as patient was high risk for surgery and wheelchair bound at baseline. Review of the medical record revealed Resident #38 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of Resident #38 on 5/6/19 at 4:35 pm revealed she was lying in bed and the bed was in a low position. She was observed to have a soft cast on her right leg from her upper mid-thigh to mid-calf. Her right foot appeared swollen. The resident used hand gestures and verbalized noises but was unable to speak or carry on a conversation. An observation of Resident #38 on 5/7/19 at 10:15 am revealed she was lying in bed and the bed was in a low position. The resident would not allow observation of her right leg. An observation of Resident #38 on 5/8/19 at 4:02 pm revealed she was lying in bed. She was alert and awake. A soft cast was present on her right leg. An interview on 5/9/19 at 9:43 am with the Rehab Director (RD) revealed the therapy and nursing departments worked together to determine a resident ' s transfer status. She stated Resident #38 had been seen by physical therapy 2/22/19 through 4/2/19. The RD explained the resident had a new motorized wheelchair and therapy had picked her up to assess her for safety with the new chair. She reviewed the physical therapy assessment dated [DATE] and stated the goal on the assessment for transfers was for the resident to be able to transfer from bed to chair with stand by assistance. She added the assessment didn ' t indicate what her transfer status was on 2/22/19. The RD stated the resident ' s condition fluctuated from day-to-day related to her health condition and her cooperation with care. She added the resident did have behaviors of refusal of care including using the lift for transfers. The RD explained after the resident fell she inserviced the therapy staff on improved communication between therapy and nursing and the therapy department also gained additional access to the resident ' s electronic care guides. An interview on 5/9/19 at 9:50 am with the Physical Therapist (PT) who completed the assessment of Resident #38 on 2/22/19 revealed he had assessed the resident for safety with her new electric wheelchair. He stated when working with the resident during that time he could transfer her from bed to chair by himself and she was able to stand and pivot on one leg. The PT explained the resident ' s right side was her weak side from a previous stroke and the one person stand to pivot transfer should be done with her left leg. He added it was his understanding that NA #1 had attempted to transfer the resident with her weak right leg and the combination of that and the resident not having the correct footwear on were a concern. An interview on 5/9/19 at 10:48 am with the DON revealed she was familiar with the fall Resident #38 had on 4/2/19 and she expected the NAs to follow the care guides when determining how to transfer a resident. The DON provided a copy of the care guide dated 4/2/19 and it stated Resident #38 was a 2 person transfer with a lift. The DON added she believed NA #1 had seen therapy transfer the resident with a one person assist and that may be why NA #1 attempted the transfer by herself. She stated after the incident the nursing staff were inserviced on use of the care guides. A follow-up interview with the PT on 5/9/19 at 11:05 am revealed he had not changed or notified nursing that Resident #38 ' s transfer status was now a one person assist during her treatment period of 2/22/19 through 4/2/19. An interview on 5/9/19 at 11:47 am with the Administrator revealed after Resident #38 ' s fall she had interviewed NA #1 and suspended her for not following the care guide when transferring the resident. She stated the nursing staff were inserviced on 4/2/19 on following the resident ' s care guides. The Administrator added the facility audited all the resident ' s care guides to ensure their transfer status was correct. She stated she had not initiated any monitoring tools to verify that staff were completing transfers according to their care guides. An interview on 5/9/19 at 12:24 pm with the Physician for Resident #38 revealed he was aware of the resident ' s recent fall and fracture of her right femur. He stated the resident did have predisposing factors such as her right sided weakness, her weight and osteopenia, but he did believe the fall had contributed to her fracture. An interview on 5/9/19 at 12:45 pm with the DON revealed the facility had determined the reason Resident #38 fell was because NA #1 had not followed the care guide. She stated the facility did in-service the nursing staff on using the care guides and assure that the iPad where the care guides were located could be accessed by the nursing staff. The DON added the facility was to initiate some return demonstrations by the NAs on access to the care guides. She was unable to provide any documentation that these return demonstrations were completed. An interview on 5/9/19 at 1:07 pm with the Administrator revealed she did not have a full quality assurance plan that included documented evidence the facility had monitored that the nursing staff were transferring residents according to their care guides and plan of care.

Based on record review and staff interviews, the facility failed to notify the attending physician when the prescribed pain relief medication was not effective and Resident #4 continued with complaints of pain. This was evident in 1 of 3 sampled residents where notification of physician was reviewed. Findings included: The facility has a policy titled " Notification of Changes " dated 1/2009 that read in part: The facility will inform the resident ' s physician when there is a need to alter treatment or to commence a new treatment. Resident #4 was originally admitted to the facility on [DATE] via Hospice for respite care and discharged to home on 9/16/14. On 11/7/14 Resident #4 was readmitted to the facility after a hospitalization with cumulative [DIAGNOSES REDACTED]. At this time the resident was not participating in Hospice. Review of the hospital discharge summary (undated) revealed Resident #4 was taken off of [MEDICATION NAME], hydrated with improvement of her mental status. The hospital summary indicated prior to this hospitalization , [MEDICATION NAME] dosages had been increased by the community Hospice staff and increasing lethargy and poor intake occurred. The family requested [MEDICATION NAME] be discontinued because they believed this caused severe confusion to Resident # 4. Review of the admission physician ' s note dated 11/1/14 revealed resident with [MEDICAL CONDITION], lumbar spondylosis with known history of hip and low back pain. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #4 was able to make her needs known with the ability to understand others. Resident # 4 had some impaired cognition and required extensive assistance from staff for the completion of activities of daily living (ADL). Review of the 11/7/14 admission physician orders revealed the attending physician approved the hospital discharge orders which included [MEDICATION NAME] 37.5-mg/[MEDICATION NAME] 325-mg combination tablets (also refer as [MEDICATION NAME]) by mouth (po) one (1) every 6 hours as needed for pain. Review of the " Pain management assessment form for residents unable to self-report " dated 11/7/14 at 11:25 PM and authored by Nurse #1 revealed Resident #4 with moderate pain. Grimacing was noted as the behavior exhibited by the Resident #4 that may be indicative of pain. Continued record review revealed the origin of the resident ' s pain was sometimes the legs and most times unable to ascertain the location. Review of the nurses ' progress notes revealed: On 11/13/14 at 12:25 PM Resident #4 complained of (c/o) pain and [MEDICATION NAME] was provided. There was no documentation of the effectiveness of the medication. On 11/17/14 at 10:54 PM Nurse #1 authored Resident #4 appeared to be in a lot of pain this shift. Resident #4 was medicated with [MEDICATION NAME] at 3:45 PM and 5 PM when awakened to check the oxygen level. " She (referring to Resident #4) instantly began to cry. I asked her if she was in pain and she nodded her head. " There was no indication that additional measures to relieve pain was implemented. On 11/18/14 at 8:17 PM Nurse #1 authored Resident #4 intermittently yelled out in apparent pain. She also cried when moved for ADL. [MEDICATION NAME] given for pain. Results not positive. " MD (Medical Doctor) notified of situation. " There was no indication a physician follow-up occurred. On 11/19/14 at 1:46 AM Nurse #2 authored Resident #4 will burst into tears and when asked why she was crying she was unable to give the reason. There was no facial grimacing " will continue to monitor. " Review of the Medication Administration Record [REDACTED]. Review of the attending physician ' s progress notes dated 11/20/14 emailed on 02/09/2015 at 5:07 PM revealed the " patient appears to be alert and crying without reason. Does not complaint of pain. Drooling. Did not recognize me but does not answer questions. " The plan revealed orders written for [MEDICATION NAME] (an antibiotic), push fluids, discontinue " [MEDICATION NAME] and place patient on [MEDICATION NAME] APAP 5/325 mg every 6 hours. " However, further review of the resident ' s medical record confirmed that [MEDICATION NAME] was not ordered until 11/24/14. On 11/20/14 at 11:11 PM Nurse #1 authored Resident#4 yelled out in apparent pain. New orders were obtained to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 5 mg and [MEDICATION NAME] 325 mg tablets po ([MEDICATION NAME]) every 6 hours prn. [MEDICATION NAME] is an opioid used to relieve moderate to severe pain. This note further stated Resident #4 was spitting out her fluids and spit out her pain medication. Interview with Nurse #1 on 2/06/15 at 3:10 PM revealed " I know I notified him (referring to the physician). " Nurse #1 indicated she was unaware of dates and the physician was called or whether the physician called back. Interview on 2/6/15 at 5:10 PM with Nurse #1 revealed " I tried to give her the PRN (as needed) [MEDICATION NAME], but she couldn ' t swallow. I gave her Tylenol Suppository for her fever, but it did not affect her pain; she was still moaning. Nurse #1 indicated she had not notified the attending physician. . She had pain on movement, and we had to move her every two hours or more frequent. I knew when she was in pain because of her facial grimacing and her moaning. I did not request the assistance of my supervisor. " On 11/21/14 at 6:56 AM Nurse #2 indicated Resident #4 burst into tears and was groaning. The resident spit out her medications when administered. The responsible party was notified but no indication that the attending physician was notified. Interview on 2/6/15 at 10:12 AM via the phone with Nurse #2 revealed he remembered the resident well. Did not remember calling the attending physician about her pain management On 11/22/14 at 12:02 AM Nurse #2 indicated the resident usually moans when turned and repositioned. On 11/22/14 at 6:50 PM Resident #4 was moaning in pain when moved or during incontinent care. Tylenol suppository was administered for an elevated temperature of 101 degrees Fahrenheit. Resident #4 did not eat or drink. No indication that he attending physician was notified. On 11/23/14 4:38 AM authored by Nurse #3 revealed Resident #4 was lethargic and moaned in pain upon any movement. [MEDICATION NAME] was administered but resident could not swallow. The RP was notified and requested liquid pain medication due to resident ' s refusal. MD notified by writing in the doctor ' s book (MD) located at the facility. Interview on 2/6/15 at 5:10 PM with Nurse #3 revealed the off going nurse (could not remember the nurse) called the physician and he did not respond. Because he did not call back, I decided to put it in the communication book. Continued interview with Nurse #3 revealed she tried to administer [MEDICATION NAME], but Resident #4 couldn ' t swallow. Nurse #3 indicated she gave a Tylenol Suppository for a fever, but it did not affect her pain. Resident #4 was still moaning with pain when moved by staff every two hours or more frequent. Further interview revealed she knew when Resident #4 was in pain because of her facial grimacing and her moaning. " I did not request the assistance of my supervisor " Record review revealed no indication that the attending physician was aware of the information written in the MD book or if the facility attempted to call the physician regarding the lack of effectiveness of the pain medication and spitting out her medications. There was no indication that the medical director was notified. On 11/23/14 at 8:28 PM Situation Background Assessment Planning (SBAR) and progress note authored by Nurse #4 revealed Resident #4 was not eating or drinking, spitting out medications and not communicating as normal. The note continued to indicate under the column labeled family concerns revealed a reconsidered for Hospice Care and other measures for comfort. A call was made to the physician ' s answering machine. No indication that the physician returned the call or that the medical director was contacted. On 11/24/14 12:30 AM Nurse #3 indicated Resident #4 moans in pain upon movement. [MEDICATION NAME] given at 11:30 PM with little effect. By 11/24 at 12:15 PM the MD communicated with the facility and prescribed [MEDICATION NAME] 30 mg every 6 hours for 24 hours. [MEDICATION NAME] is in a group of drugs called nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs). It works by reducing hormones that cause inflammation and pain in the body. [MEDICATION NAME] is used short-term (5 days or less) to treat moderate to severe pain. On 11/24/14 at 2:16 PM Resident #4 was transferred to the hospital and admitted to the Hospice program. Interview on 2/6/15 at 4 PM with the administrator and director of nurses (DON) was held. The DON indicated her expectations were staff to follow the policy for notification, not to use the MD notebook but to contact the physician directly.

Based on record reviews, staff and physician interviews the facility failed to conduct ongoing assessments for the severity of pain and failed to provide effective pain management for 1 of 2 sampled residents reviewed for pain management (Resident #4). Findings included: Review of the assessment form titled " Pain management log for the resident unable to self-report (PMLRUSR) and Pain management log for the resident able to self-report (PMLRASR) revised 1/28/2008 " revealed: ? Facial gestures that indicated the degree of pain on a scale from 0 (with no pain) to 10 (unbearable pain). ? Rate of the resident ' s sedation. ? Date/Time ? Possible pain behaviors ? Medicine or Non -drug pain control method ? Results ? Possible behaviors indicating pain relief, side effects. ? Respiratory rate. There were no instructions provided with this form by the Director of Nurses (DON). Resident #4 was originally admitted to the facility on [DATE] via Hospice for respite care and discharged to home on 9/16/14. On 11/7/14 Resident #4 was readmitted to the facility after a hospitalization with cumulative [DIAGNOSES REDACTED]. At this time the resident was not participating in Hospice. Review of the hospital discharge summary (undated) revealed Resident #4 was taken off of [MEDICATION NAME], hydrated with improvement of her mental status. The hospital summary indicated prior to this hospitalization , [MEDICATION NAME] dosages had been increased by the community Hospice staff and increasing lethargy and poor intake occurred. The family requested [MEDICATION NAME] be discontinued because they believed this caused severe confusion to Resident # 4. Review of the admission physician ' s note dated 11/1/14 revealed resident with [MEDICAL CONDITION], lumbar spondylosis with known history of hip and low back pain. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #4 was able to make her needs known with the ability to understand others. Resident # 4 had some impaired cognition and required extensive assistance from staff for the completion of activities of daily living (ADL). Record review revealed no care plan had been developed. Review of the 11/7/14 admission physician orders [REDACTED]. Review of the " Pain management assessment form for residents unable to self-report " dated 11/7/14 at 11:25 PM and authored by Nurse #1 revealed Resident #4 with moderate pain. Grimacing was noted as the behavior exhibited by the Resident #4 that may be indicative of pain. Continued record review revealed the origin of the resident ' s pain was sometimes the legs and most times unable to ascertain the location. Review of the nurses ' progress notes revealed: On 11/13/14 at 12:25 PM Resident #4 complained of (c/o) pain and [MEDICATION NAME] was provided. There was no documentation of the effectiveness of the medication. On 11/17/14 at 10:54 PM Nurse #1 authored Resident #4 appeared to be in a lot of pain this shift. Resident #4 was medicated with [MEDICATION NAME] at 3:45 PM and 5 PM when awakened to check the oxygen level. " She (referring to Resident #4) instantly began to cry. I asked her if she was in pain and she nodded her head. " There was no indication that additional measures to relieve pain was implemented. On 11/18/14 at 8:17 PM Nurse #1 authored Resident #4 intermittently yelled out in apparent pain. She also cried when moved for ADL. [MEDICATION NAME] given for pain. Results not positive. " MD (Medical Doctor) notified of situation. " There was no indication a physician follow-up occurred. On 11/19/14 at 1:46 AM Nurse #2 authored Resident #4 will burst into tears and when asked why she was crying she was unable to give the reason. There was no facial grimacing " will continue to monitor. " Review of the Medication Administration Record [REDACTED]. On 11/20/14 at 11:11 PM Nurse #1 authored Resident #4 yelled out in apparent pain. New orders were obtained to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 5 mg and [MEDICATION NAME] 325 mg tablets po ([MEDICATION NAME]) every 6 hours prn. [MEDICATION NAME] is an opioid used to relieve moderate to severe pain. This note further stated Resident #4 was spitting out her fluids and spit out her pain medication. On 11/21/14 at 6:56 AM Nurse #2 indicated Resident #4 burst into tears and was groaning. The resident spit out her medications when administered. On 11/22/14 at 12:02 AM Nurse #2 indicated the resident usually moans when turned and repositioned. On 11/22/14 at 6:50 PM Resident #4 was moaning in pain when moved or during incontinent care. Tylenol suppository was administered for an elevated temperature of 101 degrees Fahrenheit. Resident #4 did not eat or drink. On 11/23/14 4:38 AM authored by Nurse #3 revealed Resident #4 was lethargic and moaned in pain upon any movement. [MEDICATION NAME] was administered but resident could not swallow. The RP was notified and requested liquid pain medication due to resident ' s refusal. MD notified in DR book. Will continue to monitor. There was no indication of monitoring until 11/23/14 at 9 AM when [MEDICATION NAME] was administered. There was no indication that an order was received for liquid pain medication. On 11/23/14 at 8:28 PM Situation Background Assessment Planning (SBAR) and progress note was written by Nurse #4 revealed Resident#4 was not eating or drinking, spitting out medications and not communicating as normal. The note continued to indicate under the column labeled family concerns revealed a reconsidered for Hospice Care and other measures for comfort. On 11/24/14 at 12:30 AM Nurse #3 indicated Resident #4 moans in pain upon movement. [MEDICATION NAME] given at 11:30 PM with little effect. On 11/24/14 at 12:15 PM the MD returned a call and a new order was received for [MEDICATION NAME] 30 mg every 6 hours for 24 hours. [MEDICATION NAME] is in a group of drugs called nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs). It works by reducing hormones that cause inflammation and pain in the body. [MEDICATION NAME] is used short-term (5 days or less) to treat moderate to severe pain. Record review revealed the PMLRUSR and the PMLRASR form was not used for Resident #4. The resident was transferred at 2:16 PM on 11/24/14 to the hospital and admitted to a Hospice program. Interview on 2/6/15 at 10:12 AM via the phone with Nurse #2 revealed he remembered the resident well. Resident # 4 had difficulty expressing her needs. " She would have expressions on her face as if in pain especially when she was moved. " When asked about the pain protocol of the facility and how he accurately assessed the resident ' s pain he replied " could tell by her facial grimacing that she was in pain. " Nurse #2 indicated he did not have to administer pain medication during his shift. Interview on 2/6/15 at 10:22 AM with Nurse #1 via the phone revealed Resident #4 on initial admission to the facility could verbalize freely when she was in pain. Continued interview indicated when medication for pain was given it was not effective. Nurse #1 indicated on the occasion when the pain medication helped it would not last (no determined time). Further interview with Nurse #1 revealed the pain medications became less effective and did not control her pain at all. " When the resident became unable to verbalize her thoughts I would look at her facial gestures. " Interview on 2/6/15 at 2:13PM with the attending physician revealed he was familiar with the resident for years and did not believe the resident was pain but a behavior response due to a declining mental status. An inquiry was made about why pain medication was prescribed the attending physician indicated he ordered these medications in response to the family. Interview on 2/6/15 at 5:10 PM with Nurse #3 revealed " I tried to give her the PRN (as needed) [MEDICATION NAME], but she couldn ' t swallow. I gave her Tylenol Suppository for her fever, but it did not affect her pain; she was still moaning. She had pain on movement, and we had to move her every two hours or more frequent. I knew when she was in pain because of her facial grimacing and her moaning. I did not request the assistance of my supervisor. " Interview on 2/6/15 at 4 PM with the administrator and DON was held. The DON indicated her expectation was staff to complete the PMLRUSR or the PMLRASR form and to have residents pain free and comfortable. At the end of the exit conference held on 2/6/15 at 6:55 PM (attended by the administrator, DON and corporate representative), the DON indicated she had developed an action plan to address pain management but was unable to locate the plan. On 2/6/15 at 7:15 PM, the DON confirmed she was not able to locate her action plan.

Based on record review, interview with the nurse practitioner, and staff interviews, the facility failed to use a mechanical lift to transfer Resident #1, who subsequently sustained a left femur fracture. This was evident for one of three residents reviewed for accidents, who required a mechanical lift for transfer. The facility failed to provide one on one staff supervision as developed in the plan of care for 2 of 3 (resident #2 and resident #4) residents identified at risk for falls. Findings included: Record review indicated Resident #1 was initially admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. hemiparesis. Review of the annual Minimum Data Set (MDS) with an assessment reference date of 08/15/13 indicated the resident had moderately impaired cognition and was totally dependent on staff for transfers which required two plus person physical assistance. Review of the care plan dated 08/26/13, indicated Resident #1 required assistance for transfers from one position to another related to lack of strength and status [REDACTED]. The care plan goals indicated Resident #1 would receive necessary physical assistance to transfer through the next review. Interventions included: Transfers with two persons provided for physical assist with a mechanical lifting device. Resident #1 was to be monitored for safety awareness. Review of the current undated resident care guide for Resident #1 indicated, " Handling/ /Movement: Non-ambulatory, mechanical (lifting device) medium sling, Aid of 2 persons. " Interview with MDS Nurse #2 conducted on 10/14/13 at 11:58 AM indicated, " The resident ' s care plan from admission has always reflected use of a lift for transfers. I changed the care plan for transfers on 04/9/13 to indicate ' Provide two persons for physical assist with mechanical aid (named brand Lift). ' The aides were already using a lift and it was already on (Resident #1 ' s) care guide to use the lift as part of their training. " Review of the nursing notes dated 09/09/13 at 1:05 PM read: The resident is alert and oriented to self and able to communicate needs to staff. The resident complains of pain to the left hip. The resident reports he heard something pop when he was being put to bed. The physician was made aware and ordered an x-ray to the left hip. As needed pain medication was given for pain. Review of the physician's order [REDACTED]. Vicodin 5/500 milligram tablet, give 1 by mouth every 8 hours times 3 days, then give Vicodin 5/500 milligram tablet, 1 by mouth every 8 hours as needed for pain. Review of the radiology report dated 09/09/13 read, " Exam: Hip Unilateral Complete, Minimal 2V (2 views), Left. Results: Hip series. Findings: There is no acute fracture or dislocation. Narrowing of the hip joint space is noted which suggests arthritis. Conclusion: No acute fracture or dislocation. Degenerative changes of the hip. " The nursing notes of 09/09/13 at 3:47 PM read: The x-ray report was received and it showed no fracture or any dislocation noted. The nursing notes dated 09/10/13 at 3:37 AM read: The resident continues to have swelling to the left knee and lower leg. (The resident) complained of pain and received pain medication. The pain medication was effective. The nursing notes dated 09/10/13 at 9:55 AM read: Resident continues to complain of pain to left knee. The on call (referring to the physician) was notified and ordered an x-ray to the left knee. The resident was given pain medication. The physician's order [REDACTED]. (immediately) related to edema and pain. (Apply) an ice pack to the left thigh every 4 hours for edema. Change Vicodin (pain medication) to every 4 hours scheduled. Morphine (pain medication) 2 milligrams, was ordered to be given intramuscularly prior to the resident ' s transfer via Emergency Medical Services. The patient was to be moved to the local hospital. Review of the radiology report dated 09/10/13 read: " Exam: Knee Exam 3V (views), Left. Results: The distal femoral shaft has an acute fracture with lateral displacement. Conclusion: Acute distal femur fracture. " The nursing notes of 09/10/13 at 1:48 PM read: The resident ' s x-ray showed a Distal Femur Fracture. The Nurse Practitioner ordered for resident to be sent to the local hospital. The resident was in pain when leaving. Two milligrams of Morphine (pain medication) was given per the Nurse Practitioner ' s order. Review of the facility Nurse Practitioner ' s note dated 09/10/13 read: " Chief Complaint: AV Femur Fracture. The nurse (referring to Nurse #6) reported the patient started complaining of left hip and thigh pain yesterday morning (09/09/13) and notes edema to the left thigh. (Nurse#6) denies recent fall; states patient is usually transferred from bed to chair with the lift, but was assisted back to bed via 2 person assist approximately 2 days ago (09/08/13). A hip x-ray was obtained yesterday (09/09/13) and was negative for acute fracture and dislocation. This morning, the patient reportedly continued to complain of pain and the on-call provider ordered a left knee x-ray. The conclusion of the three views revealed an Acute Distal Femur Fracture. The Patient reports feeling a " pop " when assisted back to bed 2 days ago (09/08/13). (The resident) states the left hip and thigh " hurts " and (the resident) can ' t move (the resident ' s) left leg due to the pain. " Interview with the Nurse Practitioner conducted on 10/14/13 at 11:15 AM indicated, " I had come in on Tuesday(09/10/2013), (Resident #1) was in lot of pain, and the doctor had ordered a left hip x-ray on Monday (09/09/13), which was negative for a hip fracture. On Tuesday (09/10/13), the hall Nurse (Nurse #6) showed me the x-ray report which showed a Left Distal Femur Fracture. (Resident #1) was still complaining of pain on Tuesday (09/10/13), and I sent (Resident #1) to the hospital, because of my assessment of an obvious fracture. (Resident #1) told me (Resident #1) felt something pop when the Nursing Assistants were putting him (Resident #1) back in the bed. (Resident #1) said it happened on Sunday (09/08/13). The Nurse (Nurse #6) told me the aides did not use the lift to transfer (Resident #1) on Sunday (09/08/13); that is what (Referring to Nurse #6) told me on Tuesday 09/10/13, while I was there. I wasn ' t there when it happened on Sunday and (Nurse #6) wasn ' t there. (Nurse #6) was told they didn ' t use the lift that day Sunday (09/08/13), to transfer (Resident #1) back to bed. " Interview with Nurse #6 was conducted on 10/14/13 at 10:10 AM. Nurse #6 indicated (Resident #1) sustained a fracture to the left leg. Nurse #6 indicated there was no documentation to indicate the resident had a fall. Nurse #6 indicated the resident was sent to the hospital on Monday (09/09/13), and on that day, Nurse #6 saw the resident ' s leg was swollen, and stated the doctor was there that day and assessed the resident. Nurse #6 indicated further that Resident #1 was complaining of left hip pain, and the doctor ordered an x-ray. The x-ray revealed no fracture of the left hip. Nurse #6 revealed on Tuesday (09/10/13), the resident was still complaining of pain at 7:00 AM when Nurse #6 arrived. Nurse #6 revealed she and the third shift (Nurse #7) decided to call the on call doctor and the doctor ordered a stat (immediate) x-ray to the left leg. The results of the x-ray showed a Distal Femur Fracture. The resident was sent immediately to the hospital on Tuesday (09/10/2013). An interview was conducted on 10/14/13 at 11:00 AM with the attending physician regarding whether the physician knew how Resident #1 was transferred on Sunday (09/08/13). The attending physician was unaware of how the resident had been transferred. A direct care staff interview was conducted on10/14/13 at 12: 32 PM with Nursing Assistant (NA #3) who worked weekends only. NA #3 was asked how Resident #1 was transferred back to bed on the afternoon of Sunday (09/08/13). NA #3 revealed, " When you read the care guide it said to use two aides for transfers. I got NA #4 to help me use the lift to transfer (Resident #1) from the chair to bed. After changing (Resident #1), the resident was left to rest until dinner. After dinner I asked NA #5 to help me use the lift to transfer (Resident #1) from bed to chair. (Resident #1) did not express any pain during the transfers. " An attempt to interview NA #5 was made on 10/15/13 at 12:00 Noon was unsuccessful. A direct care staff interview was conducted 10/14/13 at 12:50 PM with NA #4 regarding the transfer conducted on Sunday (09/08/13). NA #4 revealed, " I only helped (referring to NA #3) to transfer (Resident #1) after lunch from the chair to the bed. (NA #3) already had the pad on the lift to transfer (Resident #1). I was using the remote, and I was moving the lift. (NA #3) had to be behind (Resident #1) to hold (Resident #1 ' s) legs and move (Resident #1) to the bed, while I was holding the lift. We just had to lower the lift and place (Resident #1) in the middle of the bed. " A second interview with Nurse #6 was conducted 10/14/13 at 1:20 PM regarding how the Nursing Assistants transferred Resident #1on Sunday (09/08/13). Nurse #6 ' s knowledge of the events changed from the information noted in the Nurse Practitioner ' s notes. Nurse #6 indicated, " According to my notes, all I wrote was (referring to Resident #1) heard something pop when (Resident #1) was being transferred. I was not there at the time, and I do not know how (Resident #1) was transferred. They (referring to the NA ' S) are supposed to transfer (Resident #1) with 2 person assist using a lift, according to (Resident #1 ' s) care guide. " An interview conducted on 10/15/13 at 10:40 AM with the Director of Nurses (DON) and Nurse #6 revealed, " The resident told us that two people put (referring to Resident #1) back to bed without a lift. " The DON indicated, " That is when we started the investigation on 09/10/13. " Resident #1 was in the hospital at the time of the survey, and was unavailable for an interview. An interview with the Administrator conducted on 10/15/13 at 11:45 AM, revealed, " I could not figure out how the fracture happened. We could not identify how the fracture occurred. I didn ' t have the Nurse Practitioner ' s note dated 09/10/13 when we did the investigation. " An Administrative staff interview with the Director of Nurses (DON) was conducted on 10/15/13 at 1:00 PM. When asked about the DON ' S expectations related to transfers for Resident #1, the DON indicated, " My expectation is that we would follow (the resident ' s) care guide and we would use the lift for transfers. " An Interview with the Administrator was conducted on 10/15/13 at 1:25 PM regarding expectations of the staff for transfers of Resident #1. The Administrator indicated, " I would expect the staff to use the lift for transfers, and use the correct lift pad. " 2. A. Resident #4 was admitted to the facility on [DATE] and had cumulative [DIAGNOSES REDACTED]. The most recently revised care plan dated 09/24/13 identified the resident as a risk for recurrent falls with interventions that included the following: four wheeled walker for ambulation, assist during transfer and mobility, one to one monitoring, low bed, non skid strips at bedside and assist to bathroom as needed. Observation of the care card on 10/14/13 at 12:05pm indicated resident required one person assist for activities of daily living (ADL), cane/walker for ambulation, feeds self, wheelchair as needed, falls risk, diabetes, wanders, resident swings, hits, and kicks others and attempts to leave facility unsupervised. Record review on 10/14/13 for resident #4 revealed the resident ' s current medications included Buspar, Ativan, Zoloft, Seroquel and Novolog. Record review of the progress notes on 10/14/13 at 11:00am revealed the following: On 09/20/13 at 10:33pm resident had to be reminded to use walker. On 09/21/13 resident continued to ambulate without the use of her walker. On 09/22/13 at 1:03pm resident was noted to ambulate without the use of her walker. On 09/24/13 at 5:09 the resident was reviewed by the Quality review committee and a family meeting was held. The meeting revealed the resident had a history of [REDACTED]. Resident used a hemi walker at home versus a rolling walker. The resident ' s responsible party (RP) brought in a new pair of non-skid soles/socks. Therapy will try to evaluate resident with a meri-walker if applicable. Resident on 1:1 supervision. On 09/28/13 resident was attempting to get out of bed and sustained a fall. Resident stated she was trying to get out of bed and slid on the floor. No injuries noted. RP was notified and a note was left for the MD. Bed in lowest position. Resident complained of pain and was given Tylenol, with no further complaints of pain. Record review on 10/14/13 at 11:00am did not show that one to one supervision was being done at the time of the fall on 09/24/13 as indicated in the care plan nor was the care plan updated to reflect the fall/changes to resident ' s care. 2. B: Resident #2 was admitted to the facility on [DATE] and had cumulative [DIAGNOSES REDACTED]. Review of the most recent MDS (minimum data set) with an ARD (assessment reference date) of 10/07/13 revealed resident #2 was extensive assist requiring 1 person assist with the following: bed mobility, transfers, walking on unit, toileting and hygiene. No behaviors were documented during this assessment period. The most recently revised care plan dated 08/21/13 identified the resident as a wanderer with interventions that included the following: administer medications as ordered, allow resident to wander and check resident daily to ensure resident has an alarm bracelet on and is functioning properly. The most recently revised care plan dated 10/14/13 identified the resident as at risk for recurrent falls with interventions that included the following: keep bed in lowest position, monitor effectiveness of medications and provide one to one monitoring. Observation of the care card on 10/14/13 at 12:00pm identified resident as needing 1 person assistance, assist with feeding, at risk for falls, needs bed in low position, uses wheelchair and has no behaviors. Record review for resident #2 revealed the resident ' s current medications included Lasix, Namenda, Aricept, Trazadone and Ativan. Record review of the progress notes on 10/14/13 at 10:30am revealed the following: Upon admission to the facility on [DATE] resident #2 was admitted to the East unit and was immediately transferred to the Sparks unit due to fairly aggressive wandering. Record review of progress note dated 09/24/13 indicated resident sustained [REDACTED]. Resident was noted with swinging behaviors and wandering. Record review of progress note dated 10/08/13 at 9:32am revealed resident was noted walking and pacing the floor. Resident was reworked to her chair several times. Resident was placed on 1:1 supervision. Resident then began to walk in and out of resident rooms removing things. Resident yelled and gritted teeth at the nurse and told her to leave her alone. Nurse attempted to redirect resident to the hall and resident yelled stop. Resident was given Ativan. On 10/12/13 at 11:38am nurse noted resident had made several attempts to get up and ambulate. Resident was able to ambulate for short distances with hands on assistance from staff. Review of the Master Schedule for the Sparks unit revealed the following: September 17, 2013 through September 30, 2013 there were 5 aides scheduled for one to one supervision on first shift, 3.5 aides scheduled for one to one supervision on second shift and 1 aide scheduled for one to one supervision on third shift. This left a total of 29.5 shifts unaccounted for 1:1 supervision for resident #4 during this time period. October 1, 2013 through October 15, 2013 there were 12 aides scheduled for one to one supervision on first shift, 13 aides scheduled for one to one on second shift and no aides scheduled for third shift for one to one supervision. Resident #4 was scheduled for 1:1 supervision for 45 consecutive shifts during this time period while resident #2 was scheduled for 24 consecutive shifts during this time period. During this time period the Master Schedule does not indicate two staff assigned to 1:1 supervision at any time during this time frame to cover 1:1 supervision for resident #2 and resident#4 simultaneously. Review of the aide daily assignment sheets revealed the following: September 17, 2013 through September 30, 2013 there were 4 aides assigned for one to one supervision on first shift, 4 aides assigned for one to one supervision on second shift and 2 aides assigned for one to one supervision on third shift for resident #4. Resident #2 was identified as having 1:1 supervision on 3 shifts during this time period. Review of the 24 hour report sheets revealed the following: September 18, 2013 - resident #4 was documented as having a fall with injury to her left facial area, one to one noted. There is no documentation noted for one to one supervision on second or third shift. October 1, 2013 through October 15, 2013 there were 3 aides assigned for one to one supervision on first shift, 8.5 aides assigned for one to one supervision on second shift and no aides assigned for one to one supervision on third shift. Resident #4 was designated 1:1 supervision for 9 of the 11.5 shifts identified. Resident #2 was designated 1:1 supervision for 2 of the 11.5 shifts identified. Interview on 10/14/13 at 10:20am with nurse #1 indicated there are two residents who currently require one to one supervision. Nurse #1 identified those residents as resident #2 and resident #4. Nurse #1 revealed both residents were on one to one supervision on all three shifts. Observation of resident #2 and resident #4 on 10/14/13 at 10:20am revealed both residents in an activity in the activity room. Both residents had a staff member sitting with them at the time of the observation. Observation on 10/14/13 at 12:00pm revealed resident #2 and resident #4 in bingo activity in the dining room. Both residents had a staff member sitting with them at the time of the observation. Observation on 10/15/13 at 9:10am revealed resident #4 lying in bed asleep with a sitter at the bedside. Observation on 10/15/13 at 9:15am revealed resident #2 sitting in the dining room eating breakfast and her assigned aide passing out trays to other residents in the dining room. Aide #2 was passing out trays to other residents in the dining room and when asked if she was assigned to resident #2 she replied " yes " . Interview on 10/15/13 at 9:45am with the DON revealed the master schedule identifies which staff are working on a particular day and is posted daily. The DON revealed the scheduler is responsible for completing the master schedule. The DON further indicated the charge nurse makes the assignment for the aides on a daily basis. When asked where on the master schedule would the assignment for one to one supervision be identified she stated " it should have been written under the extra assignment/duty section. " The DON stated that both resident #2 and resident #4 were on one to one supervision for first and second shifts only. When asked what her expectation of one to one supervision means, she stated " usually we try lots of interventions before we go to one to one. Usually I speak with the administrator and therapy as well. The nurse documents in the nurses ' notes that we are going to put a resident on one to one and monitor that. " When asked if the nurse will document the exact shifts the resident is to have one to one supervision in her notes she stated " the nurse will not document exact shifts in her note, she will document that on the 24 hour report sheet. " The DON indicated there is no MD order written when a resident is placed on one to one supervision. When asked about the staffing for the residents who require one to one supervision the DON stated " sometimes the scheduler does not get someone to work the one to one assignment so when I get here I will pull someone and if it is on nights the night shift coordinator will pull someone. Sometimes the nurse does the one to one and when she has to give her meds one of the aides will take them until she (nurse) can take them back. " October 8, 2013 - resident #2 was documented as having prn (as needed) ativan and one to one supervision noted. Second shift resident was documented as having a skin tear and no documentation noted for third shift. Interview on 10/15/13 at 10:15am with nurse #2 indicated the management staff has a daily morning meeting to discuss residents that are on one to one supervision and falls. Nurse #2 revealed the QI nurse monitors falls and will update the care plans as needed. Nurse #2 was asked what one to one supervision means to her and she stated " one CNA to one patient, usually for safety and it is around the clock on all three shifts. It is usually for safety or for a multitude of reasons such as a resident that has pulled out a [DEVICE] and falls. There are many reasons why residents are on one to one. When asked how she would document on the care plan if a resident was on one to one supervision for only one shift she stated " I haven ' t seen it for just one shift. I would think I would put that on the care plan. " Interview on 10/15/13 at 10:20am with the scheduler indicated she completed the master schedule for all three shifts. When asked how she is informed if a resident requires one to one supervision she stated " the nurse supervisor (DON) will let me know if there is a one to one. " The scheduler indicated she uses GCA ' s on first shift and will give aides the opportunity to sign up for a one to one assignment. She further revealed that in the event the aides do not sign up then she will use GCA ' s. The scheduler stated " the nurse usually does the one to one on the weekends in the unit when I cannot find coverage. " When asked what one to one supervision means to her she stated " it means someone is with them at all times. The one to one shadows, walks with them. I try to put an extra person when I can. It varies how often I can do that. I always give them (staff) an opportunity to sign up. I put sign up sheets in the dining room for the aides to sign up for one to one ' s. " Interview on 10/15/13 at 10:35am with aide #2 revealed her title is geriatric care aide (GCA). When asked what one to one supervision means to her she stated " I ' m gonna be with her (resident) all day, every step and to the bathroom. I assist her to walk and keep an eye on her at all times, making sure nothing happens to her. " When asked if she assists other resident ' s while assigned to one to one supervision she stated " I only assist others if needed. I will try to keep my eyes on her at all times. Aide #2 indicated she does not take resident to the bathroom but she has had to take her in the past due to the resident ' s assigned aide assisting another resident at the time and the resident really needed to use the bathroom. When asked if she was aware why the resident was on one to one supervision and if she required one to one supervision on all three shifts she stated " she is on one to one because she fell and damaged her face pretty good. She has one to one on all three shifts. " Interview on 10/15/13 at 10:40am with aide #1 revealed her title is GCA and that her normal assignment is to assist with facility transports but she had been pulled to provide one to one supervision for resident #2. When asked what one to one supervision means to her she stated " I stay with her at all times unless therapy has her. I go with her to the bathroom; she can pull her pants down herself. I go to activities with her. At lunch I will set resident up first but then I will help others. If I see that she tries to get up I stop and go help her. " When asked if she knew why resident #2 required one to one supervision she stated " she isn ' t able to stand long. They have tried different wheelchairs for her, one was too tall, one was too wide and then when they found one to fit she wouldn ' t stay in the wheelchair. She has to be monitored to sit in the wheelchair because she will try to get up. " Aide #1 indicated she did not know if resident required one to one supervision on all three shifts. Aide #1 stated " I report off to the aide that gets here first. I don ' t know who has her but I tell the aide that she is a one to one. " Interview on 10/15/13 at 10:45am with nurse #1 revealed resident #2 and resident #4 are on one to one supervision for all three shifts. Nurse #1 indicated she looks at the daily nursing schedule to identify the aides assigned to work in the unit and makes out the assignment stating which aide is assigned to each resident as needed if the master schedule has not already identified the assignment of each aide. Nurse #1 stated " I am not sure how they do the assignments on 3rd shift. They might pull an aide from west hall or the scheduler will find someone. " Nurse #1 indicated that each aide assigned to a one to one supervision assignment has to wait until his/her relief arrives to take over the one to one supervision before they can leave for their assigned shift. When asked what one to one supervision means to her, nurse #1 stated " one resident to one staff member ratio. The assigned staff stays with that resident at all times and other staff assist them as needed. If a GCA (geriatric care aide) is sitting with the resident, the CNA assigned to the resident gives the care and the GCA stays with them while the CNA gives the care. " Nurse #1 indicated the GCA does not provide ADL (activities of daily living) care to any residents that all ADL care is provided by an aide. Nurse #1 indicated on first shift the one to one supervision is provided by sitters and on second and third shifts the one to one supervision is provided by aides. Nurse #1 indicated the unit is staffed with three aides on first and second shift and one medication aide and two aides on third shift. A phone interview was attempted with nurse #5 on 10/15/13 at 12:00pm. Message left for nurse to return the call. A phone interview was conducted on 10/15/13 at 12:10pm with medication aide #1 that indicated she worked on the Sparks unit and assisted living hall on third shift. When asked if there were any resident ' s that required one to one supervision currently she indicated resident #2 and resident #4 were on one to one on third shift. Med aide #1 indicated she makes out the assignment for one to one ' s for her shift. She revealed all three staff assigned to the unit does the one to one assignments. She stated " If there are only two aides working, then when they do rounds herself or the other aide will watch the resident that requires one to one supervision. When asked med aide #1 about the staffing assignment on 09/28/13 and who was assigned to the one to one where the schedule indicated that herself and one aide were assigned to the unit she indicated she could not remember. Interview on 10/15/13 at 12:20pm with the Administrator revealed her expectation of a resident on one to one supervision means the resident should be in an environment that they are receiving attention by someone that does not have a regular assignment. The administrator stated " this person can be the nurse or med aide. " When asked how a nurse can give medications and provide one to one supervision the administrator stated " they can take the person (resident) with them while they give their meds or they can be pushed up to the nurses ' desk with them. " The administrator revealed when the assigned staff providing the one to one needs a break, the nurse or med aide will cover the one to one supervision. When asked who covers one to one supervision on 3rd shift (11:00pm - 7:00am) the administrator revealed a staff member would be pulled to cover the one to one and would not be given an additional assignment. Interview on 10/15/13 at 1:15pm with nurse #3 revealed that is a resident was placed on one to one staff supervision as needed, the care plan would read " as needed " and if the supervision was at all times the care plan would read " at all times " . Nurse #3 was asked to clarify the interpretation of resident #2 and resident #4 care plan that read as follows: provide one to one monitoring and nurse #3 stated " I would interpret this as at all times. " Interview on 10/15/13 at 1:20pm with nurse #4 revealed the DON or the QI (Quality Improvement) nurse will notify MDS (minimum data set) when to update the care plan for a resident with one to one staff supervision. Nurse #4 revealed that if the one to one supervision was identified in a fall care plan the QI nurse would update the care plan as needed. Nurse #4 further revealed when a resident is placed on one to one supervision the interventions will be revised to fit the intent for the resident in question. When asked what one to one supervision means to her, nurse #4 stated " The resident needs one to one constant supervision at all times. " Interview on 10/15/13 at 2:15pm with the administrator stated " We do not have a policy and procedure for one to one ' s. " On 10/15/13 at 2:30pm the Administrator presented a list of staff that had provided one to one supervision for resident # 2 and resident #4 from October 1, 2013 through October 14, 2013 for first and second shifts only.

Based on observations, staff interviews, resident interviews and record review the facility failed to secure the drainage tubing of an indwelling catheter for 1 of 1 sampled residents with indwelling catheters. (Resident #1) The findings include: Resident #1 was readmitted to the on 4/25/11 with [DIAGNOSES REDACTED]. The "Nursing Admission & Re Entry" form, dated 4/25/11 noted the resident had "old skin folds" to the right and left gluteal fold. There was no mention of any open area to the penis or history of wounds to the penis area. The "Flowsheet of Non-Ulcer Skin Conditions" dated 4/26/11, noted the resident had an indwelling urinary catheter and "Chronic [DIAGNOSES REDACTED] ( an abnormal physical condition in males in which the urethra (the canal through which urine is expelled) opens on the under surface of the penis) without other abnormalities." The most recent minimum data set (MDS), dated [DATE] revealed the resident had moderately impaired cognition. He was totally dependent on facility staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident required extensive assistance for eating. He had no noted pressure ulcers, no surgical wounds, and no other open wounds. He had an indwelling urinary catheter. The "Flowsheet of Non-Ulcer Skin Conditions" dated 5/3/11, noted the resident had an indwelling urinary catheter and "Chronic [DIAGNOSES REDACTED] without other abnormalities." According to the physician progress notes [REDACTED]. Under the review of systems and physical examination sections there was no mention of any open areas or history of open area to his penis. The "Flowsheet of Non-Ulcer Skin Conditions" dated 5/10/11, noted the resident had an indwelling urinary catheter and "Chronic [DIAGNOSES REDACTED] without other abnormalities." The "Report of Consultation" form resident #1 had a "hospital follow up" appointment on 5/16/11. The report noted in the findings section the resident complained of spasms and "pain @ catheter site." It was noted the resident was to see the urologist on 5/18/11. The "Flowsheet of Non-Ulcer Skin Conditions" dated 5/17/11, noted the resident had an indwelling urinary catheter and "Chronic [DIAGNOSES REDACTED] without other meatal abnormalities." On 5/18/11 resident #1 saw the urologist. The physical exam noted "There is traumatic [DIAGNOSES REDACTED] to the penis. There is mild [DIAGNOSES REDACTED] (redness) and induration at the meatus (the opening of the urethra on the body surface through which urine is discharged ). Catheter is adequately placed." The assessment section also revealed the resident had "meatitis" (inflammation of the urinary meatus) The plan included the recommendation that the meatus be cleansed two times a day with hydrogen peroxide and covered with antibiotic ointment. The "Flowsheet of Non-Ulcer Skin Conditions" dated 5/25/11, noted the resident had an indwelling urinary catheter and "Chronic [DIAGNOSES REDACTED] without other abnormalities." An observation of resident #1's care on 6/1/11 at 11:26AM revealed nursing assistant (NA) #1 and nurse #2 were providing peri care. The resident complained of discomfort to his penis. The penis was noted as having a fileted (split open) appearance from the tip to about halfway down the shaft of the penis. There was an additional small open area with a scant amount of bloody drainage and redness on the left side of the penis (resident's). It was noted the indwelling catheter tubing was not secured anywhere to prevent undue tension on the catheter. Resident #1 had been turned and moved around in the bed and the catheter tubing was observed being pulled on due to this movement. The resident stated he had a "slit" there (on his penis). Nurse #2 indicated the "slit" area was something new and she was not sure when exactly it happened, but she thought and NA #1 confirmed that the "slit" happended when he went out to the urologist for a catheter change on 5/18/11. NA #1 stated the resident should have had a securement strap to anchor the catheter. The NA was not sure when the securement system could have come off. Nurse #2 indicated the resident should have a securement strap to anchor the tubing and prevent tension. She was not sure what had happened to the leg strap. Nurse #2 left the room and returned with a securement strap. She applied it to the resident's upper left thigh. The resident stated he used to have a strap but he was not sure when it was removed or by whom. NA #1 and nurse #2 indicated the NA and the nurse were responsible for monitoring the catheter site for changes. They also stated the treatment nurse (TN) was responsible for monitoring the penis site. During an interview on 6/1/11 at 12:33PM, nurse #1 indicated an indwelling cather's tubing should be secured to the resident to prevent tugging and pulling on the tubing. She was not sure why the resident's catheter was not secured. Nurse #1 indicated the resident had a "chronic" condition (the [DIAGNOSES REDACTED]) to the penis area and it had not changed that she was aware of. Nurse #1 stated the nurses were cleansing the penis with hydrogen peroxide two times a day, then they applied an antibiotic ointment to the site. She indicated the urologist ordered the treatment on 5/18/11. The TN was interviewed on 6/1/11 at 4:20PM. The TN indicated she assessed the resident's skin on a weekly basis. Her last assessment of the resident's skin was on 5/25/11. She noted the [DIAGNOSES REDACTED] was a chronic condition the resident had. She had not noted the new "split" area on her weekly skin assessments. The TN indicated all resident's with indwelling catheters should have a securement system in place. She indicated the securement system was monitored daily. She thought she saw one on the resident yesterday morning. After reviewing some of the resident's medical record she noted the nurses were doing the antibiotic treatment to the area. On 6/1/11 the " Flowsheet of Non-Ulcer Skin Conditions " dated 5/25/11 was amended (by the TN) to contain the following additional observation, " sm (small) tear at tip. " The physician and responsible party were listed as being notified of the small tear on 5/18/11. The director of nursing (DON) was interviewed on 6/1/11 at 5:18PM. She stated she expected the urinary catheter tubing to be secured to the resident. The DON expected the NAs and nurses to assess the indwelling urinary catheter site every shift during catheter care.