Every finding on record at Mercer Healthcare Center

Based on resident interview, record review, and staff interview, the facility failed to provide a program of activities to meet the needs and interest of each resident. This deficient practice had the potential to affect three (3) of six (6) residents reviewed for the care area of activities. Resident Identifiers: #35, #9, and #101. Facility Census: 116. Findings included: a) Resident #35 During an interview on 06/15/26 at 11:35 AM, Resident #35 stated he wished someone could come into his room to talk with him. When asked if anyone from the Activities Department visited him, Resident #35 stated, That hasn't happened in a long time. Review of Resident #35's comprehensive care plan showed a focus related to activities. A goal initiated on 02/27/26 and revised on 03/09/26 was as follows: Resident will participate in 1:1 [one on one] activities of choice in and out of room as tolerated by resident. Enjoys companionship for conversation during 1:1 time. The Activities Department was asked to provide a list of residents for whom they provided one-on-one activities. Resident #35 was not on the list. Resident #35's activity participation record was reviewed. For the month of May 2026, the activity participation record showed the resident received one-on-one activities on one occasion, on 05/09/26. So far for the month of June 2026, Resident #35 received one-on-one activities on one occasion, on 06/11/26. On 06/17/2026 at 2:14 PM, Activities Leader #154 stated she spent time speaking with Resident #35 while passing his meal trays and at other times throughout the day. Activities Leader #154 acknowledged Resident #35's activity participation record only documented one-on-one activities once in May 2026 and once thus far in June 2026. No further information was provided through the completion of the survey process. b) Resident #9 The care plan dated 05/29/26 included an intervention for behaviors to offer and encourage attendance and involvement in facility activities. The care plan also included a focus that reads: [Resident #9] is self directed for activities. The Minimum Data Set (MDS) dated [DATE] shows Resident #9 has a Brief Interview for Mental Status (BIMS) of one (1) indicating she is severely impaired in the ability to make daily decisions. Section F of that same MDS indicates it is somewhat important for Resident #9 to do things with groups of people and go outside when the weather is good. The activity participation log shows Resident #9 has participated in two (2) group activities within the last three (3) months. All other listed activities are documented as independent. There are no listed refusals of group activities. During an interview with Activities Leader #154 at 2:00 PM on 06/17/26, she stated Resident #9 is difficult to deal with outside and wanders in and out of activities but does not spend enough time in the activity to document participation. c) Resident #101 In an interview with Resident #101 on 06/16/26 at 8:50 AM, he stated he is not attending church services and group activities because he is not being told about them. A review of the MDS section F dated 06/03/26 shows it is very important for Resident #101 to do things with groups of people and to participate in religious services or practices. A review of the Activity Preferences Interview dated 06/04/26 shows Resident #101 has current interests in games, Bible study, and group social activities. A review of the Activity Participation log shows Resident #101 has participated in two (2) group activities. On 06/11/26, the log shows he participated in a social time group and on 06/12/26 it shows he participated in a snack cart group. The activities calendar for June 2026 had a religious activity on 06/04/26 and there was an impromptu religious group activity on 06/15/26. Resident #101 did not attend either activity and the log does not show that he refused these activities. In an interview with Activities Leader #154 at 2:00 PM on 06/17/26, she stated that she goes in each morning and informs Resident #101 of the day's activities and he shows interest in them. However, she states that when she returns to get him for those activities he states he is tired and will participate the next day. Activities Leader #154 confirmed the Activity Participation log did not show any refusals.

Based on observation, record review and staff interviews the facility failed to develop and/or implement plans of care related to Post-Traumatic Stress Syndrome (PTSD), Oxygen, Dementia interventions, and Epilepsy. This failure was found to be true for four (4) of 30 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #82, , #79, #5, and #9. Facility Census: 116. a) Resident #5 On 06/15/26 at approximately 3:54 PM, observation of Resident #5 revealed oxygen being administered via nasal cannula at 3.5 liters per minute. Review of the physician's order indicated the resident was prescribed oxygen at 2 liters per minute. The discrepancy was immediately brought to the attention of facility staff. At approximately 3:52 PM, RN #5 confirmed that the physician's order was for oxygen administration at 2 liters per minute. The oxygen flow rate observed was not consistent with the current physician order and resident care plan. b) Resident #82 Resident #82 was originally admitted to the facility on [DATE], and was re-admitted on [DATE]. During the course of the resident's stay in the facility, the resident was diagnosed with EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS on 03/27/2026. A review of the resident's current care plan found the care plan had not been updated with this new diagnosis as an area of focus, nor were goals or interventions/tasks put into place for this diagnosis. Surveyor asked the facility Director of Nursing (DON) who was the responsible party for completing the resident's care plan, and DON responded the MDS RN. On 06/17/2026 at 11:46 AM, surveyor approached the MDS RN #70 about epilepsy not being found on the resident's care plan. MDS RN stated yes, we should have included it, we missed this. I will correct it immediately. c) Resident #79 A record review on 06/15/2026, revealed that Resident #79 was admitted with a diagnosis of PTSD. Review of Resident #79's care plan revealed no mention of the PTSD diagnosis.During an interview on 06/17/26 at 1:15PM, The Director of Social Services (DSS) stated, She has never had any triggers that I am aware of. That is why I did not care plan it. The State Agency (SA) asked, Did you talk with the famiy about it to see if they knew the triggers? DDS responded, Yes, and they was not sure.A record review on 06/17/26 at 1:45 PM, showed that Psychiatric Evaluations had been done with Resident #79 monthly since her admission. All of the evaluations read that patient has reported no triggers for past trauma, up unitll 01/14/26 which reads patient is angry due to past trauma. The Psychiatric Evaluation from 05/12/24 reads patient reports she was in a car wreck when she was 6 and was molested by her father when she was 12.During a phone interview on 06/1726 at 2:06 PM, The SA asked the Health Care Surrogate (HCS), Do you know what or when if anything happened to indicate the diagnosis of PTSD? The HCS responded, Oh Yes, She had an car accident when she was little that caused a head injury and her stepfather molested her for a very long time.During an interview on 06/17/26 at 2:32 PM, The DSS with the Administrator present confirmed that the Psychiatric Evaluations from January 2026, and May 2026 revealed the trauma for Resident #79. d) Resident #9 The care plan for Resident #9 regarding dementia had an intervention for cup holder to wheelchair. Resident #9 was observed multiple times on 06/16/26 and 06/17/26 with no cup holder on her wheelchair. In an interview with Director of Rehab #153 on 06/17/26 at 10:01 AM, she stated the cup holder should be on Resident #9's wheelchair and it was not.

Based on record review and staff interview, the facility failed to provide adequate notice of last covered Medicare A days to Resident #127's Medical Power of Attorney (MPOA). This was true for one (1) of three (3) residents sampled for beneficiary notification during the Long-Term Care Survey process. Census: 116 Resident identifier: #127Findings included: a) Resident #127 A policy titled Policies and Standard Procedures states, this notice [NOMNC] will be provided at least [two] 2 days in advance of the last covered day to allow for adequate time to appeal, if the beneficiary so chooses. The Notice of Medicare Non-Coverage (NOMNC) reads as follows: Medicare coverage of your current skilled services will end on date: 03/04/26. The telephone notification per the NOMNC was made on 03/06/26 at 10:00AM to the Medical Power of Attorney (MPOA). In an interview with Social Services Designee #55 on 06/17/26 at 9:15AM, she confirmed Resident #127's MPOA was not notified of Medicare coverage of skilled services ending at least two (2) days in advance.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) included a diagnosis of Epilepsy. This was found to be true for one (1) of 30 residents reviewed during the long term care survey process. Resident identifer: #82. Facility census: 116. Findings included: a) Resident #82 Resident #82 was most recently admitted to the facility on [DATE]. On 03/27/26, the resident was diagnosed with-EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUSMedical Management 03/27/2026 DX #8 During Stay The last quarterly Minimum Data Set (MDS) was completed on 04/30/26. Epilepsy is one of the choices on the MDS Section I Current Diagnoses. For Resident #82, Epilepsy was not check marked, showing the resident as having this diagnosis. The resident's MDS was reviewed with the MDS RN #70 on 06/17/2026 at 11:33 AM. When asked about epilepsy not being on the MDS, she stated let me look into this and I will get back with you. On 06/17/2026 at 11:46 AM, MDS RN stated yes, we should have marked Epilepsy, we missed this.

Based on record review and staff interview, the facility failed to ensure Resident #83's [NAME] Virginia Physician's Orders for Scope of Treatment (POST) form was signed by his medical power of attorney (MPOA) while Resident was lacking capacity. This was true for one (1) of nine (9) residents sampled for advance directives during the Long-Term Care Survey process. Census: 116 Resident identifier: #83Findings included: a) Resident #83 The POST form dated [DATE] was signed by Resident #83. The last capacity evaluation dated [DATE] showed Resident #83 did not have [NAME] to make decisions based on disorientation and an inability to process information due to dementia. An interview with Director of Nursing (DON) on [DATE] at approximately 11:00AM confirms Resident #83 did not have capacity on [DATE] but signed his POST form changing his end of life wishes. The previous POST form dated [DATE] was signed by Resident #83's MPOA and designated he should receive full treatments and Cardiopulmonary resuscitation (CPR).

Based on record review and staff interview, the facility failed to provide required information for continuity and coordination of care when a resident was transfered, including a list of resident's medication and when it was last given. This was found to be true for two (2) of three (3) residents reviewed during the long term care survey process. Resident identifiers: #10, #120. Facility census: 116. Findings included: a) Resident #120 Resident #120 had an unplanned, acute transfer to an emergency room (ER) at the local facility on 04/27/26, after experiencing abnormal vital signs. The facility utilized an Interact Hospital Transfer Form to convey information to the acute care facility. The facility failed to include the following information which would be necessary for the continuity of care: -A copy of the Resident's Advanced Directives-A list of medications the Resident was taking and when last administered, or the Medication Administration Record (MAR). The facility utilizes an Acute Care Transfer Document Checklist which lists Documents Recommended to Accompany Resident/Patient and instructs the person completing the form to check all that apply. The form had no checkmarks indicating what information accompanied the resident to the receiving provider. A review of the resident's progress notes for the date of transfer also did not convey what information was sent to the receiving provider. Surveyor asked the Director of Nursing (DON) to provide copies of what was sent to the receiving provider for the resident's transfer on 04/27/26. The DON provided a copy of the Hospital Transfer Form, the Acute Care Transfer Document Checklist, and a list of the resident's current diagnoses. The surveyor pointed out the checklist was not marked. The DON stated, Our staff know to send all the forms listed on the checklist.This discussion occurred on 06/16/26 at 3:05 PM. The Corporate RN for Clinical Operations was also present. b) Resident #10 This resident lacks capacity to make medical decisions and has impaired communication skills. Resident #10 had two transfers out of the facility: 02/06/26 to 02/11/26 and 01/03/26 to 01/07/26. Both transfers were to an acute care facility for acute respiratory symptoms.The facility utilized an Interact Hospital Transfer Form to convey information to the acute care facility on both occasions. The facility failed to include the following information which would be necessary for the continuity of care:-A copy of the Resident's Advanced Directives-A list of medications the Resident was taking and when last administered, or the Medication Administration Record (MAR).The facility utilizes an Acute Care Transfer Document Checklist which lists Documents Recommended to Accompany Resident/Patient and instructs the person completing the form to check all that apply. The form had no checkmarks indicating what information accompanied the resident to the receiving provider.A review of the resident's progress notes for the dates of the transfers also did not convey what information was sent to the receiving provider.Surveyor asked the Director of Nursing (DON) to provide copies of what was sent to the receiving provider for the resident's transfers on 01/03/26 and 02/06/26. The DON provided copies of the Hospital Transfer Form, the Acute Care Transfer Document Checklist, and a list of the resident's current diagnoses.The surveyor pointed out the checklist was not marked. DON stated, our staff know to send all the forms listed on the checklist. Surveyor then stated that yes, staff may know, but due to turnover, new staff may not be told timely, or someone may not be aware and it is good practice to either mark the checklist or document in the medical record progress notes what was sent to the receiving provider. This discussion occurred on 06/16/26 at 3:05 PM. The Corporate RN for Clinical Operations was also present.

Based on record review and staff interview, the facility failed to include a diagnosis of major depressive disorder on the most recent Preadmission Screening and Resident Review (PASARR). Failure to coordinate the PASARR and the Minimum Data Set (MDS) can lead to duplicative effort and treatment. This was found to be true for two (2) of seven (7) residents reviewed during the long term care survey process. Resident identifiers: #52, #82. Facility census: 116. Findings included: a) Resident #52 Resident #52 was admitted to the facility on [DATE]. Among the list of diagnoses, the resident had the following: -VASCULAR DEMENTIA, MILD, WITH MOOD DISTURBANCE 07/23/25 DURING STAY -MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD 07/23/25 -ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT 10/23/2024 admission The most recent PASARR for the resident was completed on 10/16/24 at an acute care facility. In Section III, Question 30 asks the person completing the PASARR to check all current diagnoses that apply. The person completing the PASARR checked number (n) Other related conditions and specified them as Behavioral Disturbance and Adjustment Disorder. However, major depressive disorder was not checked. Question 47 of the PASARR asks for the primary diagnosis and Dementia was checked. Even though the list of diagnoses included major depressive disorder, single episode, the resident is and has been receiving an anti-depressant since 08/29/25. Resident's orders:-Escitalopram Oxalate Tablet 20 MGGive 1 tablet by mouth one time a day for DepressionPharmacy Active 8/29/2025 A review of the most recent Minimum Data Set (MDS) completed on 05/07/26 had the following diagnoses checked:-Non-Alzheimer's Dementia-Depression An additional diagnosis of Adjustment Disorder with Mixed Disturbances of Emotions and Conduct was typed in. A review of the resident's care plan documents depression and dementia as focus areas. Surveyor asked the Nursing Home Administrator (NHA) who in the facility was responsible for ensuring the PASARRs were kept up to date, the NHA stated the Director of Admissions. The PASARR was then reviewed with the Director of Admissions on 06/17/2026 at 12:50 PM. b) Resident #82 Resident #82 was originally admitted to the facility on [DATE], and had a re-admission on [DATE]. A review of the resident's medical record documented the resident to have the following pertinent diagnoses: -MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD 11/25/2025 Principle(#67)Admission-UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY 09/12/2025 Admission-EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS 03/27/2026 During Stay-GENERALIZED ANXIETY DISORDER 05/19/2026 During Stay The most recent Preadmission Screening and Resident Record (PASARR) was completed on 09/10/25 by the facility. Question 30 asks the person completing the PASARR to check all diagnoses that apply. Only #n Other related conditions was marked. Below the entry, it specified dementia. Major Depression was not marked on the PASARR under Question 30. Question 47 asks for the primary diagnosis and Dementia was marked. A review of the most recent Minimum Data Set (MDS), completed on 04/30/26, had the following diagnoses marked: -Non-Alzheimer's Dementia-Depression-Major Depressive Disorder, recurrent, mild was added under other active diagnoses. The MDS and the PASARR diagnoses do not match, as Major Depression was not on the PASARR. Surveyor asked the Nursing Home Administrator (NHA) who in the facility was responsible for ensuring the PASARRs were kept up to date, the NHA stated the Director of Admissions. The PASARR was then reviewed with the Director of Admissions on 06/17/2026 at 12:50 PM.

Based on record review and staff interview, the facility failed to notify the physician when Resident #130's blood sugars were outside of the ordered parameters. This was found during a complaint investigation. Census: 116 Resident identifier: #130Findings included:a) Resident #130A review of the orders reveals an order with a start date of 06/04/25 that reads: notify [Medical Doctor] MD if blood sugar is less than 60 and/or greater than 400.During a review of the Medication Administration Record for June 2025, the following dates had blood sugars outside of the parameters and the physician was not notified according to the progress notes:06/07/25-42406/11/25 -4806/20/25-47606/21/25-431During an interview with the Director of Nursing on 06/18/26 at 1:30PM, she confirmed according to the progress notes, the physician was not notified of blood sugars outside of the ordered parameters.

The facility failed to ensure oxygen therapy was administered in accordance with physician orders and the resident's care plan for 1 of 1 resident reviewed for oxygen administration Resident #5. Facility census: 116. Findings include:a) Resident #5During observation on 06/15/26 at approximately 3:52 PM, Resident #5 was observed receiving supplemental oxygen via nasal cannula. The oxygen concentrator was checked and found to be set at 3.5 liters per minute. Review of the physician's order revealed Resident #5 was prescribed oxygen at 2 liters per minute via nasal cannula.The oxygen flow rate observed was 1.5 liters per minute greater than the physician-ordered setting. The discrepancy was immediately brought to the attention of facility nursing staff RN #5. The oxygen concentrator setting was subsequently verified and adjusted to the physician-ordered rate of 2 liters per minute.

Based on record review and staff interview, the facility failed to ensure Resident #83's medical record was accurately completed. This was true for one (1) of nine (9) residents reviewed for advance directives and two (2) of five (5) residents. Resident identifiers: #83 and #9. Census: 116. Resident identifier: #83.a) Resident #83 A Physician's Determination of Capacity form dated 11/18/25 showed Resident #83 lacked capacity due to a diagnosis of dementia and disorientation and inability to process information. Resident #83 has a surrogacy selection form designating a Medical Power of Attorney (MPOA) as his healthcare surrogate that was dated 11/17/25. Resident #83 was admitted to hospice care on 12/3/25 and the hospice Long Term Care Status Form was signed by Emergency Contact #2, the resident's sister. In an interview with Director of Nursing at 2:40PM on 06/16/26, she confirmed the hospice admission paperwor was not signed by Resident #83's MPOA. b) Resident #9 Resident #9 was observed throughout the facility on 06/16/26 and 06/17/26 by surveyor wandering in her wheelchair down A Hall and into several other residents' rooms.An interview with Licensed Practical Nurse (LPN)#2 at 2:20PM on 06/17/26 confirmed Resident #9 wandered the halls and into other residents' rooms frequently. The care plan with a revision date of 05/26/26 has a focus that reads, Resident wanders in her wheelchair throughout facility. Resident will go into others rooms and needs to be redirected. The June 2026 the Behavior Monitoring log for Resident #9 showed she had no behaviors of wandering and rummaging in other resident's rooms. In an interview with Director of Nursing (DON) on 06/17/26 at 2:25PM, she confirmed the documentation was not correct.

Based on observation, record review and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible for Residents #47, #56, and #71. These were random opportunities for discovery. Resident identifiers: #47, #56, and #71. Facility census: 120. Findings include: a) Resident #47 Observations made At approximately 1:18 PM on 01/20/25, 2:00 PM on 01/21/2025, and 3:30 PM on 01/22/2025, Resident #47's over the bed table was observed sitting on the fall mat to the left side of his bed. The over the bed table was placed diagonally, from the top of the fall mat, in a way that exposed the metal bottom, and wheels, of the table, leaving the resident open to landing on them if he were to fall out of bed. Licensed Practical Nurse (LPN) #97 acknowledged the table on the fall mat at approximately 3:35 PM on 01/22/2025 and stated the table is usually always on the mat because the resident reaches over and gets his water off of the table. At approximately 4:00 PM, on 01/22/2025, an interview was conducted with the Director of Nursing (DON) and Administrator. During the interview, it was determined the facility had not tried any alternative fall interventions for the resident to make the water more accessible without placing the table on the fall mat. 49465 b) Resident #56 An observation on 01/22/25 at 11:00 PM, revealed a bottle of Povidone Iodine Prep Solution setting on the dresser in Resident #56's room. During an interview on 01/22/25 at 11:00 PM, Resident #56 stated, They leave all kinds of stuff in here. An observation on 01/22/25 at 11:10 PM, with the Director of Nursing (DON) revealed that Resident #56's room door was shut. The state agency (SA) knocked on the door. A Nursing Assistant (NA) came to the door and stated, We are doing wound care. Give us just a few minutes. During an observation, and interview on 01/22/25 at 11:25 PM, the DON in Resident #56's room showed that the Povidone Iodine Prep Solution was no longer on the dresser. The DON opened the dresser drawers and found the solution in the drawer with 6 bottles of skin prep solution and several unwrapped gauze pads. The DON confirmed that the items should not be in Resident #56's room. c) Material Safety Data Sheet (MSDS) A review of the MSDS for the Povidone Iodine Prep Solution on 01/22/25 at 12:10 PM, under Section 2 {Hazards Identification} reads as follows: Causes eye irritation. May be harmful if swallowed. May be harmful if contact with skin. Call a posion control center/doctor if you feel unwell. 49751 d) Resident #71 Record review on 11/22/25 review of Resident #71's care plan revealed the following Focus ~Gerald has experienced an actual fall in facility, risk for falls related to weakness, cognition, medications and incontinence, previous falls. Goal Resident will not sustain major injury related to falls through review date. Interventions -apply abdominal binder as needed to prevent resident from pulling on tube. -FALL RISK : Defined perimeter mattress to bed to help patient identify edges of bed. -FALL RISK: Fall mats to (both sides) of bed while in bed to help prevent injury. -FALL RISK: Keep bed in lowest position except when providing care. - Gerichair -Hipsters to be worn at all times -Hourly checks while in bed -Physician to review for unusual behavior. -Q1h(Every Hour) incontinence checks. -Weighted blanket while in bed to provide comfort. Observations On 11/21/24 at 1:20 PM surveyor observed Resident #71 in bed with the bed in lowest position, no weighted blanket was on Resident #71 and there was no fall mat on the Left side of the bed ( The fall mat was slid between the wall and closet). Further observations on 11/22/24 at approximately 2:00 PM resident #71 remained in bed this time legs were off the right side of the bed and the fall mat was not in the left side of the bed, the weighted blanket was not on Resident #71, and no hipsters were on Resident #71. During an interview with the Director of Nursing (DON) on 11/22/24 at approximately 3:00 PM in the room with Resident #71, the DON confirmed the left side floor mat was not beside the bed, the resident did not have hipsters on, however at this time DON confirmed the weighted blanket was on the resident. The surveyor also noted the weighted blanket was on Resident #71 that previously was not on him. Which showed staff came into room and did not place the fall mat back to the left side of the resident's bed and did not ensure the hipsters was on Resident #71. Resident #71, was care planted to have these items in place as fall interventions to prevent injury incase of a fall.

Based on record review, resident interview and staff interview the facility failed to monitor the effectiveness of pain medications in accordance with professional standards of practice. This failed practice was found true for (1) one of (7) seven residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier: #31. Facility census: 120. Findings Include: a) Resident #31 During an interview on 01/28/24 at 9:15 AM, Resident #31 stated, I hurt all the time. They are waiting on something from the pharmacy. A record review on 01/28/24 of Resident #31's current orders revealed an order for Oxycodone-Acetaminophen oral tablet 5-325 to give (1) one tablet by mouth every (8) eight hours as needed for pain. The order had a start date of 11/04/24. Further record review of Resident #31's Medication Administration Reports (MAR's) for the months of 11/2024, 12/2024, and 01/2025 revealed that Resident #31 was given the Oxycodone-Acetaminophen (5) five times without checking the effectiveness of the medication. During an interview on 01/28/24 at 2:00 PM the DON confirmed that the effectiveness of the pain medicine was not monitored according to the MAR.

Based on observation, record review, and staff interview, the facility failed to store and label medications in accordance with professional standards of care. Multiuse vials of insulin had not been dated when opened. Additionally, multiuse vials of insulin had not been discarded 28 days after opening. These were random opportunities for discovery. Resident identifiers: #83, #85, #80, #62, #51, #61, and #57. Facility census: 120. Findings included: a) Policy review The facility's policy titled Vials and Ampules of Injectable Medications stated as follows: Expiration Dates: Unopened vials expire on the manufacturer's expiration date. When a vial is opened, the nurse records the opened date on the vial. Since opening a vial triggers a shortened expiration date that is unique for that vial, the nurse may record the expiration date on the vial. Triggered expiration dates may be found on the manufacture's [sic] package insert, on the package, or on a reference chart by pharmacy, or by contacting the pharmacist. b) A2 Hallway Cart On 01/22/25 at 9:10 AM, inspection of the A2 hallway medication cart was made with Licensed Practical Nurse (LPN) #20 in attendance. In the cart was a multi-use vial of aspart insulin for Resident #83. The vial had not been dated when first accessed. The vial was delivered by the pharmacy on 01/20/25. LPN #20 confirmed the vial had not been dated when opened. Review of Resident #83's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #61. The vial had a handwritten opening date of 11/21/24 and a handwritten expiration date of 12/22/24. This was confirmed by LPN #20. No packaging insert was in the insulin box. The Lantus insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials can be used for 28 days after opening. Review of Resident #61's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #61. The vial had a handwritten opening date of 11/24/24 and a handwritten expiration date of 12/[illegible]/24. This was confirmed by LPN #20. No packaging insert was in the insulin box. The Novolog insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials of Novolog may be kept for up to 28 days after use. Review of Resident #61's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #51. The vial had a handwritten opening date of 12/14/24 and a handwritten expiration date of 01/13/25. This was confirmed by LPN #20. No packaging insert was in the insulin box. Review of Resident #51's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #57. The vial had a handwritten opening date of 12/16/24 and a handwritten expiration date of 01/13/25. This was confirmed by LPN #20. No packaging insert was in the insulin box. Review of Resident #57's physician's orders showed the resident was still receiving this medication. c) B1 Hallway Cart On 01/22/25 at 9:10 AM, inspection of the B1 hallway medication cart was made with Licensed Practical Nurse (LPN) #21 in attendance. In the cart was a multi-use vial of aspart insulin for Resident #85. The vial had not been dated when first accessed. The vial was delivered by the pharmacy on 12/30/24. LPN #21 confirmed the vial had not been dated when opened. Review of Resident #85's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #85. The vial had a handwritten opening date of 12/19/24 and a handwritten expiration date of 01/18/25. This was confirmed by LPN #21. No packaging insert was in the insulin box. The Lantus insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials of Lantus can be used for 28 days after opening. Review of Resident #85's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #62. The vial had a handwritten opening date of 12/05/24 and a handwritten expiration date of 01/04/25. This was confirmed by LPN #21. No packaging insert was in the insulin box. Review of Resident #62's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #80. The vial had a handwritten opening date of 11/24/24 and a handwritten expiration date of 12/24/24. This was confirmed by LPN #21. No packaging insert was in the insulin box. Review of Resident #80's physician's orders showed the resident was still receiving this medication. No further information was provided through the completion of the survey process.

Based on observation and record review the facility failed to ensure food is prepared in a form designed to meet the individual needs of each resident. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #37, #47, #76, #51, #29, #79, #98, and #88. Facility Census: 113. Findings Include: a) On 01/27/25 at 12:37 PM during the noontime meal service it was noted the facility was serving kielbasa sausage. At 12:37 PM on 01/27/25 Employee #162 the district food manager (DFM) was overheard asking [NAME] #146 if she had ground kielbasa. She replied, no. She indicated she thought the kielbasa meet the requirement for the mechanical and advanced diets. Employee #162 advised [NAME] #146 that it needed to be ground. By this point in service the entire A unit of the facility had been served. Employee #162 DFM then indicated to the Dietary Manager (DM) they had run out of ground kielbasa. It was at this time [NAME] #146 was asked by the surveyor if she had ran out of ground kielbasa or had not prepared any. She stated, I did not prepare any. I did not know it needed to ground. A review of the Consistency Census Report provided by the DM found the following residents on A unit should have been served ground kielbasa, Resident #47, #76, #51, #29, #79, #98, #88, and #113. A review of the Kielbasa recipe provided by the facility and used by the facility to prepare the food found the following, .1. For Ground: Measure the desired # (number) of servings into food processor. Grind to appropriate consistency. If needed add gravy or broth to moisten the meat. An interview with the Nursing Home Administrator (NHA) at approximately 1:15 PM on 01/27/25 she confirmed there was a mix up in the kitchen. She stated, I thought we caught them all and replaced them before they reached the residents. When advised that only A unit tray which was replaced while the surveyor was conducting her observation was Resident #47. She stated, I checked on them. The only two who I am not sure of was (First name of Resident #98) and (First Name of Resident #76). Nurse Aide (NA) #19 was then asked by the NHA in the presence of the surveyor what king of meat Resident #76 had on his tray. NA #19 stated the meat was big pieces. She stated we have taken it to the kitchen like that before and they told us it was okay as long as it had gravy on it. 49465 b) Resident #37 An observation on 01/20/25 at 1:15 PM revealed that Resident #37 was served a pork chop in its whole form. Further Observation of Resident # 37 eating her lunch meal, showed that she had a right-hand contracture, and she was struggling to eat her pork chop in its whole form. A record review on 01/20/25 at 1:45 PM, of Resident #37's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/24, Section S, question S3100A revealed that Resident #37 had a right-hand contracture. Section S, question S3200A indicates that Resident #37's dominant side is the right side. An observation on 01/20/25 at 2:00 PM revealed that Resident #37 did not eat her meat. During an interview on 01/20/25 at 2:00 PM, the State Agency (SA) asked Resident # 37, How come you did not eat your meat. Resident #37 was Aphasic and pointed toward her meat and made a cutting motion and shook her head no. An observation on 01/22/25at 1:10 PM, of Resident #37 eating her lunch, revealed that she was served a turkey slice in its whole form. Further observation showed that Resident #37 did not eat her turkey. During an interview ON 01/22/25 AT 2:00 PM, the administrator confirmed that Resident #37 had a right-hand contracture and could use help cutting up her meat.

Based on observation and staff interview, the facility failed to ensure the ice machines in the A and B hall pantries were clean and sanitary. In addition, the microwave in the B-hall nutrition pantry was rusted. This failed practice had the potential effect more than an isolated number of residents. Facility Census: 120. Findings Include: a) A and B hall pantries During an observation of the A hall pantry at 11:10 am on 01/20/25, found the ice machine was not clean. The grate were the cups or containers would sit was covered in white scaly substance. The certified dietary manager (CDM) removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. During an observation of the B hall pantry at 11:15 am on 01/20/25, found the ice machine was not clean. The grate where the cups or containers would sit to be filled with ice was covered in a white scaly substance. The CDM removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. Also, in the B hall pantry there was a microwave which was rusting. The CDM agreed the microwave needed replacement.

Based on record review and staff interview, the facility failed to make good faith attempts to correct quality deficiencies related to complete and thorough investigations, despite being cited multiple times in the past and identifying issues related to the investigations. This has the potential to affect more than a limited number of residents. Facility census: 120. Findings include: a) Current survey At approximately 1:00 PM on 01/28/2025, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was that took the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving the statement, however, it was signed by Resident #8. In the initial report, dated 09/24/2024 at 12:45 PM, Social Worker (SW) #62 documented Resident interviewed and investigation began. However, no statement from Resident #319 was found. At approximately 2:30 PM on 01/28/2025, an interview was conducted with SW #62, with the Administrator in attendance, regarding the incomplete statements from the various residents and the missing statement from Resident #319. SW #62 and the administrator acknowledged the statements not being dated, and the statement identifying Resident #46 as the resident giving the statement but being signed by Resident #8. When SW #62 was asked where the statement from Resident #319 was, that was mentioned in the initial report, he stated I briefly spoke with him, I remember I asked him if he was ok, and he nodded. I wouldn't have taken a statement at that time because I hadn't started the investigation yet. However, upon further review, it was determined Resident #319 was not in the facility at the time SW #62 stated he interviewed the resident, as he was sent out to the hospital a day prior, on 09/28/24. SW #62 stated the initial report should have stated he spoke with the resident's representative. b) Past surveys Upon review of deficiencies from past surveys, dating back to the facility's prior annual survey on 08/22/23, it was determined the facility had been surveyed four (4) times prior to this survey. Of those four (4) times, the facility was cited for failing to thoroughly investigate allegations three (3) times. The dates the facility was cited for failing to complete thorough investigations are: -08/22/2023 -01/31/2024 -05/07/2024 c) Administrator Interview At approximately 3:00 PM on 01/28/2025, an interview was conducted with the Administrator regarding the facility's Quality Assurance and Performance Improvement (QAPI) process. During the interview, the Administrator stated the facility was aware of issues with investigations being completed thoroughly. The Administrator stated she realized she needed to be more involved in investigations taking place in the facility due to issues being identified. However, the same issues remained during the current survey.

Based on record review and staff interview the facility failed to ensure Resident #108's Discharge Minimum Data set was coded to accurately reflect the location where the resident was discharged to. This was true for one (1) of 36 sampled residents reviewed during the long-term care survey process. Resident Identifier: #108. Facility Census: 113. Findings include: a) Resident #108 A review of Resident #108's medical record at 10:52 am on 01/27/25 found a Discharge Summary dated 01/08/25 which indicated the resident was transferred to another long-term care facility. A review of the discharge Minimum data set (MDS) with an assessment reference date of 01/08/25 found section A2105 was coded with the number 04 which indicated the resident was discharged to Short Term General Hospital. However, this section should have been coded 02 Nursing home. An interview with the Nursing Home Administrator (NHA) at 2:05 PM on 01/27/25 confirmed this MDS was inaccurate.

Based upon record review and staff interviews, the facility failed to refer one (1) of eight (8) residents who had a newly evident serious mental health disorder diagnsis for a level II review. This was true for one (1) of eight (8) records reviewed. Resident identifier: #85. Facility census: 120. Findings included: a) Resident #85 Major depressive order was added as a diagnosis in the electronic medical record on 11/04/24, for resident #85. The last PASARR was completed on 06/03/24. During an interview with the Director of Nursing (DON) on 01/23/25 at 12:32 PM the PASARR was reviewed PASARR with her and she acknowledged the error.

Based on record review and staff interview, the facility failed to thoroughly investigate an allegation of abuse of Resident #319. This was true for one (1) of nine (9) residents reviewed for abuse during the survey process. Resident identifiers: #319, #320, #46, #50, #54, #40, and #8. Facility census: 120. Findings include: a) Resident #319 At approximately 1:00 PM on 01/28/25, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All of the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was taking the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving the statement, however, it was signed by Resident #8. In the initial report, dated 09/24/2024 at 12:45 PM, Social Worker (SW) #62 documented Resident interviewed and investigation began. However, no statement from Resident #319 was found. At approximately 2:30 PM on 01/28/2025, an interview was conducted with SW #62, with the Administrator in attendance, regarding the incomplete statements from the various residents and the missing statement from Resident #319. SW #62 and the administrator acknowledged the statements not being dated, and the statement identifying Resident #46 as the resident giving the statement but being signed by Resident #8. When SW #62 was asked where the statement from Resident #319 was, that was mentioned in the initial report, he stated, I briefly spoke with him, I remember I asked him if he was ok, and he nodded. I wouldn't ' t have taken a statement at that time because I hadn't started the investigation yet. However, upon further review, it was determined Resident #319 was not in the facility at the time SW #62 stated he interviewed the resident, as he was sent out to the hospital a day prior, on 09/28/2024. SW #62 stated the initial report should have stated he spoke with the resident's representative.

Based on observation and staff interview, the facility failed to ensure they honored the residents right to receive meal trays in a dignified manner. This was a random opportunity for discovery during the Long-Term Care Survey process. Facility Census:113. Resident identifier: #71. Findings include: a) Resident #71 01/22/25 03:06 PM Resident #71's roommate was served approximately six (6) minutes before Resident #71 was served. During an interview, on 01/22/25 at 3:10 pm with the Administrator, she confirmed Resident #71 should have been served and assisted with eating after the roommates' tray was delivered.

Based on record review and staff Interviews the facility failed to ensure residents were being served a meal free from allergens. Resident #10 had a fish oil allergy and was served a fish sandwich. This past non-compliance had the potential to affect more than a limited number of residents. The state agency (SA) determined this failed practice put Resident #10 in immediate jeopardy by being served a fish sandwich. Fish oil allergies have the potential to cause stomach pain or diarrhea, swelling in the throat, difficulty breathing, dizziness or fainting, very low blood pressure, and shock. All those symptoms had the potential to severely impair residents' health and lead up to causing death. This also has the potential to cause resident #10 to have emotional and psychological impact. This action not only put Resident #10 at risk for harm but placed the remaining residents in an Immediate Jeopardy (IJ) situation because food allergies were not identified properly. The facility was first notified of the past non-compliance IJ at 6:15 PM on 06/10/24. The state agency (SA) reviewed the Plan of Correction (POC) put in place on 05/24/24 at 6:30 PM on 06/10/24. The SA accepted the POC on 06/10/24 at 7:22 PM. Facility census: 104. Resident identifiers: #10, #91, #64, #67, #63, #59, #49, #78, #55, #4, #11, #79, #52, #7, #37, #50, #75, #92 Findings included: a) Resident #10 At approximately 3:30 PM on 06/10/24 a review of the facility reportable's, revealed on 05/24/24 Resident #10, was served a fish sandwich. Further review revealed the facility Administrator was first notified by staff that Resident #10 was served a fish sandwich and had taken a bite of the sandwich before realizing it was not a hamburger on 05/24/24 at 2:15 PM. his was immediately reported, and a plan of correction started. At this time Dietary staff and Direct care staff involved in plating, serving, and delivering the tray to Resident #10 were disciplined and educated. At 3:50 PM Record review of progress notes on Resident #10 revealed a note that stated, 5/24/2024 14:15 (2:15 PM) Resident served fish on lunch tray. Resident took one bite and noticed and spit food out. Did not swallow any. No reaction noted. Vitals stable. (first Name) emergency contact notified. and another note reads 5/24/2024 15:24 (3:24 PM) Note Text: (first Name) Nurse Practitioner (NP) to see residents. Gave a new order for Benadryl 50 (milligram)mg by mouth (PO) Q6 hours (every six (6) hours) PRN (as needed), 1st dose now for prevention. Resident awareness. Review of the facility records revealed the agency immediately implemented a Performance Improvement Plan (PIP) to address the fact that Resident#10 had been served an allergen during the lunch meal. The PIP identified the problem by summarizing the following: Resident with seafood allergy was served fish sandwich The facility's goal, as stated in the PIP, was, Residents who have known food allergies will not be served food that include food or ingredients that contain those allergens. A root cause analysis investigation determined the kitchen staff did not adhere to the serving line process to ensure tray accuracy. It also noted the staff serving the tray may not have followed the meal passing process accurately. Further review of the plan of correction revealed the following The Meal Tray Passing Process education / training was given to all staff members who were tasked with delivering resident meals and included the following details: Perform hand hygiene Remove the tray from the Cambro (meal delivery) cart. Identify the resident to receive tray Confirm that the resident may eat without assistance. If the resident does require assistance, immediately give the tray to a CNA, Nurse, or trained feeding assistant. Knock on resident's door, wait for a response, enter room Sit the tray on the over bed table If the room lights are off or low, ask if you may turn a light on so they are able to see better. Ensure the over the bed tray table is positioned so that the individual is able to comfortably reach their meal and drink Read the tray ticket Remove the dome from the plate and confirm that the meal on the plate matches what is printed on the ticket. DO NOT LEAVE THE MEAL IN THE RESIDENT ROOM IF THE TICKET DOESN'T MATCH THE MEAL. Explain to the resident what's on the tray and ask them if everything looks ok With the resident's permission, unroll the silverware, remove lids from dessert cups and open milk or any other packages served with the meal If the resident is satisfied and can comfortably eat their meal, you may exit the room Perform hand hygiene. The Serving Line Process education / training was given to ALL kitchen staff and included the following details: Cook - Take and record all temperatures at the beginning of the line process Cook - Ensure serving utensils are the correct serving size Aide - Prepare trays with silverware, straw, napkin, and condiments Aide - Begin the serving line by reading aloud the following: ~Resident diet ~Entrée including texture ~Starch including texture ~Vegetables including texture ~Bread including texture ~Dessert including texture Resident allergies. If no allergies, say, No allergies aloud. Cook - Plate meal Aide - Ensure meal matches tray ticket Aide - Cover the meal, place it on the Cambro (meal delivery) cart The Meal ticket Inservice education / training was given to ALL kitchen staff and included the following details: Meal tickets are printed once per day for all meals. Meal tickets must: ~ Be torn or cut ~Be placed in order, Activities will provide the kitchen with a chart to determine who has chosen to have a meal in the dining room. *Residents eating in A side dining room are served first. Residents dining at the same table must be served at the same time *B side diners are served immediately after A side diners. ~ While placing the meal tickets in order the designee MUST note alternative orders on the meal ticket and strike through anything the resident does not wish to receive ~ While reviewing the meal ticket allergies MUST be highlighted. The diets must also be highlighted. ~ Any changes to the meal ticket must be noted by striking through any item the resident will not be receiving and hand writing anything the resident will receive as a substitution (approved by the RD[registered Dietitian]) ~ If new residents are admitted to our center, the nurse will bring a diet order to the kitchen. You MUST create a meal ticket for that resident for any meal they'll receive prior to the next printing. For example, if a resident admits on Friday night, you'll need to create a meal ticket for three (3) Meals on Saturday, three (3) meals on Sunday and breakfast on Monday morning. Please review all attached examples ( Attached were meal tickets that had marks on them and substitutions hand written to provide a visual example of the inservice provided for meal ticket inservice.) Staff Interviews Licensed Practical Nurse (LPN) Unit Charge Nurse Licensed Practical Nurse (UCN LPN) Certified Nursing Assistant (CNA) Minimum Data Set Registered Nurse (MDS RN) Assistant Director of Nursing (ADON) Culinary Aide (CA) Medical Records Associate (MRA) Cook (CK) At 4:40 PM on 06/10/24, LPN #112, UCN LPN # 60, CNA # 134, MDS RN #46 all stated that they had been educated on the meal pass process with making sure of staff and residents hand hygiene and making sure the ticket and meal tray match and that no food allergies were overlooked prior to serving the tray to the resident. Also stated that any adaptive equipment required is provided. Do not serve the meal tray if it is wrong. At 4:52 PM on 06/10/24, ADON #82, UNC RN #21, MRA #85 stated they were educated on the meal pass process and they are to ensure staff and residents hand hygiene is good, look at the meal ticket and the meal tray to make sure the tray is being served as ticket states. Identify any allergies and do not serve the meal tray if it is wrong. At 4:54 PM on 06/10/24, CA #86 stated he was educated on the meal tray process that the ticket must match the meal tray and any allergies are to be known and not served to the resident. At 04:46 PM on 06/10/24, CK # 94 stated the reader reads off the tray ticket and identifies any allergies and if there are allergies they are to serve the alternative meal. At 04:58 PM on 06/10/24 CNA #87 stated she was educated to be sure the tickets are compared to what is on the tray and that they are to not serve anyone food that is noted on the ticket to be allergic. At 05:00 PM 0n 06/10/24 Employee #41 stated that the meal tray pass process education was to ensure that the meal tray and the meal tray ticket match and they are not serving residents any foods that are marked as allergies on the meal tray ticket. If an issue is identified the tray is not to be served. Following observations of resident trays and meal tickets were reviewed for correctness/allergies: Resident #91--06/10/24 6:00 PM - no issues were identified. Resident #64-06/10/24 6:00 PM - no issues were identified. Resident #67-06/10/24 6:03 PM - no issues were identified. Resident #63-06/10/24 6:05 PM - no issues were identified. Resident #59-06/10/24 6:08 PM - no issues were identified. Resident #49-06/10/24 6:10 PM - no issues were identified. Resident #78-06/10/24 6:10 PM - no issues were identified. Resident #55 ' s meal ticket revealed an allergy to onions. The resident stated they had not been served any onions while at the facility-06/10/24 6:12 PM. Resident #4 06/10/24 6:14 PM - no issues were identified. Resident #11-06/10/24 6:16 PM - no issues were identified. Resident #79-06/10/24 6:18 PM - no issues were identified. Resident #52-06/10/24 6:20 PM - no issues were identified. 06/10/24 at approximately 6:00 PM All staff observed , reviewed the meal ticket to the meal tray and made sure the tray was correct. No issues identified at this time. This observation was made in Unit B Hall. The observation included the delivery of trays to Resident #7, Resident #37, Resident #50, Resident #75, Resident #92 by Registered Nurse (RN) #81, and a certified nurse aide.

Based on document review, staff interview, and resident interview, the facility failed to identify each resident's allergies and provide an appropriate alternative. This resulted in an immediate jeopardy (IJ) for Resident #73, who was allergic to shrimp. This deficient practice was true for one (1) of three (3) residents reviewed for food allergies. Resident Identifier: #73. Facility census: 107. Resident #73 was served pureed Shrimp and Sausage Jambalaya for lunch on 01/19/24 at approximately 1:00 PM, had an allergic reaction, and required physician-prescribed medication to alleviate facial swelling. The facility immediately began to implement corrective measures and the deficient practice was corrected on 01/19/24 by 11:00 PM, prior to the start of the survey, therefore making it Past Noncompliance. The Administrator was notified of the Past Noncompliance IJ on 05/06/24 at 4:18 PM. Findings included: Record review, completed on 05/06/24 at 12:00 PM, revealed the following details: The Immediate Jeopardy (IJ) began on 01/19/24 at approximately 1:00 PM when Resident #73 ate a teaspoon of pureed food (which was ultimately Shrimp and Sausage Jambalaya) before determining she did not like it. Resident did not eat any more. Resident and/or the Certified Nursing Assistant (CNA) delivering the lunch tray had no way of knowing the pureed food was Shrimp and Sausage Jambalaya because the tray ticket listed the correct meal for Resident #73. At that time, no one had identified an error. Unit Manager / RN #101 documented in a nurse's note, on 01/19/2024 at 1:30 PM, Resident has allergy to shrimp. Resident was served shrimp on her lunch tray. Resident assessed after knowledge of shrimp being ingested. Resident does have mild facial swelling to right side. Resident reports no shortness of breath or any other symptoms. No adverse reactions observed. Resident reports to SW (Social Worker) that she only ate a teaspoon size bite and did not like it, so she did not eat it. A nurses note written by Unit Manager/RN #101, dated 01/19/2024 at 1:36 PM, documented, Dr. [Doctor's Last Name] notified of resident face swelling. Gave new order for Solumedrol 60 mg IM (intramuscular) now and Benadryl 50 mg now and Q6 (every six) hours PRN (as needed). Resident aware of new orders. Unit Manager / RN #101 followed-up with Resident #73 at 01/19/2024 at 2:49 PM and noted, Resident reports no adverse reactions to incident with shrimp. The Administrator contacted [NAME] #150 on 01/19/24 at 2:00 PM to ask how the shrimp incident occurred despite the meal ticket stating Resident #73 had a shellfish allergy. The following details were documented by the Administrator: [Cook's First Name] said that things had been 'hectic' and that interruptions affected her focus. Explained to [Cook's First Name] that as the cook she has an absolute responsibility to ensure the meal tickets are followed. I compared the meal tickets to a prescription when explaining the severity and explained that a misstep like the one today could have ended catastrophically. [Cook's First Name] voiced understanding and had no questions or comments. It was also noted that [NAME] #150 was a no show no call off for her shift the next day and ended her employment at the facility. Review of the facility records revealed the agency immediately implemented a Performance Improvement Plan (PIP) to address the fact that Resident #73 had been served an allergen during the lunch meal. The PIP identified the problem by summarizing the following: On Friday, 01/19/24, a resident was served shrimp at mealtime. Resident has known and documented shellfish allergy. The resident's meal ticket was correct, but the meal served did not match the lunch ticket printed. The facility's goal, as stated in the PIP, was to ensure residents be served the meal that's printed on the tray ticket with 100% accuracy. A root cause analysis investigation determined the kitchen staff did not adhere to the serving line process to ensure tray accuracy. It also noted the staff serving the tray may not have followed the meal passing process accurately. Interventions in the PIP were listed as: On 01/19/24, an education Serving Line Process was given to all kitchen staff members for re-education. On 01/19/24, an education Meal Passing Process was initiated with all staff. All staff members were given the education at the beginning of their next shift. To avoid distraction during the tray line process, a runner will be assigned each day during the tray line. This culinary employee will be responsible for retrieving any additional items during tray line. The cook and kitchen aide responsible for ticket accuracy will not be interrupted. During orientation, all new staff members will be given the meal passing process in-service. Additionally, [First Name] [Last Name], CNA and scheduler will be responsible for a training that uses real props to simulate the proper way to set a meal up. Orientees will also be assigned a staff member to observe tray set up prior to passing trays independently. [First Name], Culinary Director or designee will observe the serving line 5x a week for two (2) weeks during a mealtime to ensure the serving line process is followed. The results will be documented and critiqued daily. Critiques will be reviewed with the Administrator and or [First and Last Name of the Dietary Regional Manager]. Following the two-week observation period, the timeframe will be reassessed. Administrator, Culinary Director, or designee will observe five meal set ups daily five days per week for two weeks. Results will be documented, critiqued, and reviewed daily five days per week. Following a two-week observation period, the timeframe will be reassessed. The Serving Line Process education / training was given to ALL kitchen staff and included the following details: Cook - Take and record all temperatures at the beginning of the line process Cook - Ensure serving utensils are the correct serving size Aide - Prepare trays with silverware, straw, napkin, and condiments Aide - Begin the serving line by reading aloud the following: Resident diet Entrée including texture Starch including texture Vegetables including texture Bread including texture Dessert including texture Resident allergies. If no allergies, say, No allergies aloud. Cook - Plate meal Aide - Ensure meal matches tray ticket Aide - Cover the meal, place it on the Cambro (meal delivery) cart. The Meal Tray Passing Process education / training was given to all staff members who were tasked with delivering resident meals and included the following details: Perform hand hygiene Remove the tray from the Cambro (meal delivery) cart. Identify the resident to receive tray Confirm that the resident may eat without assistance. If the resident does require assistance, immediately give the tray to a CNA, Nurse, or trained feeding assistant. Knock on resident's door, wait for a response, enter room Sit the tray on the over bed table If the room lights are off or low, ask if you may turn a light on so they are able to see better. Ensure the over the bed tray table is positioned so that the individual is able to comfortably reach their meal and drink Read the tray ticket Remove the dome from the plate and confirm that the meal on the plate matches what is printed on the ticket. DO NOT LEAVE THE MEAL IN THE RESIDENT ROOM IF THE TICKET DOESN'T MATCH THE MEAL. Explain to the resident what's on the tray and ask them if everything looks ok With the resident's permission, unroll the silverware, remove lids from dessert cups and open milk or any other packages served with the meal If the resident is satisfied and can comfortably eat their meal, you may exit the room Perform hand hygiene. Review of the training materials and signature sheets confirmed all of the above-mentioned training were completed. Review of the kitchen's serving line audits and resident meal delivery audits revealed the facility had meaningfully critiqued the updated training and determined they had been effective. During an interview, on 05/06/24 at 12:32 PM, CNA #71 confirmed she had received training/education on the meal tray process. She reported the expectations related to food allergies were to identify the resident to receive the tray, read the tray ticket and then confirm the meal on the plate matches what is printed on the ticket. Staff are not to leave a tray in the room if the ticket does not match. Staff are to tell the resident what is on their tray and confirm the resident thinks everything looks ok. CNA #10 was interviewed on 05/06/24 at 12:40 PM. CNA #10 confirmed she had received the training/education on the meal tray process. She reported it was necessary to identify the resident receiving the tray, read the tray ticket, and be certain the meal on the plate matches what is printed on the ticket. She went on to say they were instructed to never leave a tray in the resident's room if there is any question about the food matching the ticket. Residents are to be told what is on their tray and should also confirm they think everything looks ok. Review of Resident #73's medical record, completed on 05/07/24 at 8:40 AM, revealed: -An annual Nutritional Assessment completed by the Dietician, dated 12/13/23, which reflected that the resident had an allergy to shrimp. -The nutritional section of resident's care plan addressed the food allergy. -Resident had capacity to make decisions -Resident's quarterly Minimum Data Set, with an assessment reference date (ARD) of 03/05/24, demonstrated resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating resident was cognitively intact. During an interview on 05/07/24 at 10:45 AM, Resident #73 reported she had experienced a mild allergic reaction when she had been served the pureed Shrimp and Sausage Jambalaya in January. She stated CNA #71 had acted promptly in reporting the concern to RN #76. Resident #73 stated she received prompt attention, was assessed by the nurse, and received medication within a very short timeframe. Resident stated she only had some swelling in her face and never felt she was in any distress. Resident stated she was pleased with the care she received. Resident #73 stated she and/or the CNA had no way of knowing the pureed food was Jambalaya because pureed food is so smooth and almost pudding-like. Resident did state that she had only eaten a small teaspoon of the food before deciding she did not like the taste and stopped eating it. Resident #73 reported it only took the shot and a dose of the Benadryl medication before she felt perfectly fine again. Resident stated she did not feel a face-to-face visit from her physician was necessary. CNA #45 and CNA #71 were interviewed on 05/07/24 at 2:05 PM. They reported they had identified Resident #73's face was red, a little blotchy, puffed and a little swollen on one side when they were picking up resident trays. CNA #71 immediately reported the concern to RN #76. RN #76 was interviewed on 05/07/24 at 2:20 PM and reported she had assessed Resident #73 immediately after being told the CNAs had a concern. RN #76 reported the resident's face was splotchy (marked with red spots) and had minimal swelling. Resident was not in respiratory distress and was not itching. Resident had reported to her that she had only had a tiny bite of the pureed meal because she did not like the taste of it. RN #76 stated 15-minute checks were completed on resident throughout the next few hours to ensure her respiratory status did not change. The RN reported resident responded well to the medication and there were no identified concerns. During an interview on 05/07/24 at 11:30 AM, the Administrator reviewed all in-service training records with the surveyor to verify all staff members had received the appropriate training/education to prevent an error in food delivery to any resident in the future. The Administrator stated the cook would have been the employee who pureed the Shrimp and Sausage Jambalaya and the one who would have scooped the pureed food on Resident #73's tray by mistake. The Administrator emphasized that every kitchen employee not present in the building was educated by phone ON THE SAME DAY of the incident to ensure such a mistake never happened again. Observation of the tray line service for the B-Hall, on 05/07/24 at 12:40 PM, revealed the kitchen staff followed the serving line process to ensure Culinary Aide #86 read the tray ticket aloud and [NAME] #93 plated the meal correctly for Resident #73 as well as Resident #104 and Resident #56, who all had a shellfish allergy. Both staff members confirmed they had received training on the tray line process. Observation of the meal tray passing process on 05/07/24 at 1:00 PM, for rooms B1-B40, revealed staff followed the process of identifying the resident to receive the tray, reading the tray ticket, confirming the meal on the plate matched what was printed on the tray ticket, and ensuring the resident was pleased with how everything looked before leaving the room.

Based on record review, staff interview and resident observation the facility failed to ensure nursing staff administered medications and enteral feedings as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Not receiving her enteral feedings and flushes as ordered by the physician placed Resident #75 in an immediate jeopardy (IJ) situation where likely serious harm or death existed. The facility was notified of the IJ at 6:25 PM on 08/17/21. The facility submitted their first abatement plan of correction (POC) at 6:59 PM on 08/17/21. The state agency requested changes and the second abatement POC was submitted at 7:05 PM on 08/17/21. The abatement POC was accepted by the state agency at 7:05 PM on 08/17/21. After observation of the implementation of the abatement POC, the IJ was abated at 12:00 PM on 08/19/21. The IJ started on 08/17/21 and ended on 08/19/21. The facility's approved abatement POC consisted of the following: 1. The Clinical Care Supervisor (CCS) on A side spoke with the NP that was in the facility. At 4:15 pm, the NP gave verbal consent to provide Resident #75 the enteral feeding late. Unit Charge Nurse was immediately suspended for an allegation of abuse and / or neglect. The reportable packet was submitted to APS, OHFLAC, and Ombudsman. 2. All other residents who have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Coordinators checked all other residents' orders for enteral feedings at 4:10 pm and no other residents were identified as being affected by the alleged deficient practice. All nurses will be in serviced on the importance of following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #75 will be placed on the list to be seen via the NP on 8/18/2021. 3. The nurses will administer scheduled enteral feedings timely if there are any discrepancies they will report them to the physician immediately. The UCN will sign the prescribed tube feeding out, prior to each administration of the enteral feeding, via a log sheet. The enteral feedings will be stored in the nurse storage room and signed out per ordered enteral feeding. The CCS or designee will monitor enteral feeding sign out log and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Daily monitoring of the resident's enteral feeding orders will be conducted by a CCS and / or designee 5 times a week to ensure compliance with medication regimen. The CCS and / or designee will discuss any findings with the Director of Nursing Services (DNS). The DNS will report any findings in QAA monthly for 3 months. Once the IJ was abated a deficient practice remained and the scope and severity was decreased from a J to an E. A deficient practice remained for Residents #88, #32, #8, #48, #40, #78, #46, #10, #89, #81, #49, #33, #80, #87, #5, #24, #45, #41, #64, and #17. For these residents the facility neglected to serve the residents their snacks/supplements and meals, and/or falsified the medical record to indicate the residents had consumed percentages of the snacks/supplements and meals which were not served to them. Resident Identifiers: #75, #88, #32, #8, #48, #40, #78, #46, #10, #89, #81, #49, #33, #80, #87, #5, #24, #45, #41, #64, and #17. Facility Census: 89. Findings Included: a) Resident #75 A review of resident #75's medical record found a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The POST form indicated the resident was to be provided feeding through a new or existing surgically placed tube. Further review of the medical record found Resident #75 began receiving an enteral feeding through a surgically placed feeding tube on 07/08/21. Review of Resident #75's enteral feed orders found the following active orders on 08/17/21: -- Four times a day flush with 90 ml (milliliters) of water before and after each feeding. This was scheduled to be completed at 10:00 am, 2:00 PM, 6:00 PM, and 10:00 PM. This order was started on 07/28/21. -- Four times a day [MEDICATION(S)] 1.5 - 300 ml 4 times a day at 150 ml per hour. This was scheduled at 10:00 am, 2:00 PM, 6:00 PM, and 10:00 PM. This order was started on 07/28/21. Resident #75's weight record was reviewed and found she weighed 120 pounds (lbs) on 01/10/21 and weighed 87.3 Lbs on 07/08/21 which represents a 27.25% weight loss. This is considered a severe weight loss in six (6) months. Resident #75's height was recorded in the medial record at being 64 inches. Resident #75's drug regimen also included the following medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] -- [MEDICATION(S)] Tablet 2.5 MG by mouth two times a day scheduled at 10:00 am and 10:00 PM. -- [MEDICATION(S)] 5/325 MG one tablet by mouth every six (6) hours scheduled at 12:00 am, 6:00 am, 12:00 PM and 6:00 PM. The following observations were made on 08/17/21 regarding Resident #75: -- 9:30 am Resident #75 resting in her bed Enteral Feeding was not running. -- 10:00 am Resident #75 resting in her bed Enteral Feeding was not running. -- 10:30 am Resident #75 resting in her bed Enteral Feeding was not running. -- 10:45 am Resident #75 resting in her bed Enteral Feeding was not running. -- 11:00 am Resident #75 still resting in her bed Enteral Feeding was not running. The Speech Therapist (ST) was in the room and the residents mouth and lips were dried and cracked. The ST stated, I thought I got that cleaned up. The ST then finished cleaning the resident's mouth. -- 11:43 am Resident #75's enteral feeding was still not running. Licensed Practical Nursing (LPN) #95 (The nurse assigned to care for Resident #75), was observed at the other end of the hall passing medication to other residents. -- 11:57 am LPN #95 was observed leaving the unit with her Cigarettes in her hand. She stated, I got to go outside to warm up. Her Medication Cart was observed parked at the nurse's station and was unlocked. No other staff members were in the area. LPN #95 returned to the unit at 12:05 PM. When asked if her medication cart was locked, she reached out and said, Oh sorry. She then sat down at the nurse's station. Resident #75's feeding was still not running. -- From 11:57 am until 3:05 PM, Resident #75's room and/or LPN #95 was under continuous observation by the surveyors. LPN #95 was never observed entering the room of Resident #75. The following times were noted and documented during this period of continued observation: -- 1:32 PM a Nurse Aide was feeding Resident #75 her lunch tray, the Resident stated she did not want it. -- 1:41 PM LPN #95 returned to the unit. It was not clear where she had been. -- 1:52 PM LPN #95 was not at the nurses station and was not observed to be on the unit She still had not entered Resident #75's room. -- 1:54 PM LPN #95 was observed returning to the unit. -- 2:06 PM LPN #95 was observed taking medication into room A12. -- From 2:07 PM to 2:36 PM LPN #95 was in room A15 helping with a treatment which another surveyor was observing. -- 2:39 PM LPN #95 was standing at the treatment cart by the nurse's station. She still had not entered Resident #75's room. -- 2:43 PM LPN #95 was back at the nurse's station. -- 2:46 PM LPN #95 was still at the nurse's station. -- 2:50 PM LPN #95 was still at the nurse's station. LPN #95 still had not entered Resident #75's room. -- 2:53 PM LPN #95 was not seen at the nurse's station or on the hall way. -- 2:58 PM LPN #95 was observed exiting the front of the building with another nurse. -- 3:05 PM LPN #95 returned to the unit, she still had not entered Resident #75's room. Resident #75 was observed resting in her bed and her enteral feeding was still not running. An interview with LPN #95 at 3:07 PM on 08/17/21 found Resident #75 had one [MEDICATION(S)] left in her medication card. A review of the Narcotic control log found the last dose of [MEDICATION(S)] was signed out at 6:00 am. LPN #95 stated this one will be gone today. When asked when it was due to be administered, she stated 12:00 PM. She agreed it was going to be administered late. When asked about Resident #75's eternal feeding and flushes, LPN #95 stated it was due at 10:00 am and 2:00 PM and she had administered those to Resident #75 at the scheduled times. LPN #95 did not have to look at Resident #75's medical record to give the times the enteral feeding was ordered nor the time the pain medication was due. This indicates she knew it was time for Resident #75's feedings, flushes, and pain medication, but neglected to provide Resident #75 with the care she required. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nor was Resident #75's [MEDICATION(S)] which was scheduled to be administered at 10:00 am nor was Resident #75's [MEDICATION(S)] which was scheduled to be administered at 12:00 PM. An interview with the Nursing Home Administrator, Clinical Coordinator #125 and Clinical Coordinator #126 and at 3:15 PM confirmed the eternal feedings, flushes, [MEDICATION(S)], and [MEDICATION(S)] were not initialed on the MAR. The observations made by the surveyor were shared with the staff. An observation of Resident #75 beginning at 3:39 PM on 08/17/21 found the resident resting in bed. LPN #95 was preparing to enter her room. LPN #95 took a 1000 milliliter bag of [MEDICATION(S)] 1.5 and transferred it into another empty bag which she labeled as [MEDICATION(S)] and dated and timed it. She hung the bag on the IV pole and threaded the tubing through the pump. She had two (2) cups of water with her. One (1) had medication mixed in it and had condensation on the outside of the cup indicating it was cold water. The other cup did not have condensation on the outside of the cup indicating it was not cold water. The nurse connected the syringe to the tube. The nurse then poured water into the syringe and held it up. The syringe was less than half full and took several minutes (about 10) to run into the feeding tube. The feeding tube was observed to be the color of the feeding [MEDICATION(S)] when the nurse began pouring the water into the syringe. She kept squeezing the tube to get the water to flush through the tube. LPN #95 at one point asked the resident if her belly was full, indicating this as a reason for the water not going into the tube. However, it was obvious the tube contained dried [MEDICATION(S)] from previous feedings which caused the delay in the water going through the tube. Once the water went through the tube, the tube was clear and no longer the color of the feeding. LPN #95 continued and connected Resident #75 to the feeding pump. The feeding pump was set to run at 150 ml per hour until 300 ml had been administered. LPN #95 then told Nurse Aide #65, Resident #75 needed mouth care. At 3:39 p.m. on 08/17/21, LPN #95 stated this was Resident #75's 2:00 p.m. feeding. She was asked again if Resident #75 received her 10:00 am feeding, she stated she did. However, the 20 observations starting at 9:00 am and ending at 3:05 PM indicated there was no possible way the enteral feedings and flushes scheduled at 10:00 am and 2:00 PM were administered prior to surveyor intervention at 3:07 PM on 08/17/21. Once the POC was accepted the State Agency began observing for implementation. An interview with Clinical Care Supervisor (CCS) #24 on 08/17/21 at 7:30 PM confirmed she had not started Resident #75's tube feeding for the 6:00 PM administration. She stated, I'm getting ready to go start it in a few minutes. Observation of Resident #75 at 8:00 PM on 08/17/21 with Clinical Coordinators #125 and #126 confirmed the feeding pump was still running from the administration which was begun by LPN #95 at 3:50 PM. It had ran from 3:50 PM until 8:00 PM for a total of four (4) hours and 10 minutes. The order was for the feeding to run for two hours only. The pump indicated it still had 124 Ml to deliver to the resident. Clinical Coordinators agreed the pump needed to be stopped and they would call the physician for further direction. Therefore the IJ could not be abated at this time. Upon the return of the surveyors to the facility on [DATE] at approximately 9:00 am, the Nursing Home Administrator (NHA) stated they had an ad hoc Quality Assurance Meeting last night and made a revision to the POC. She presented the following document used to train staff: Since the bag of enteral feeding can be hung for 24 hours, there are times that the feeding will be stopped and resumed on the next ordered start time. To ensure that we are monitoring that the enteral feeding in being administered, two nurses will sign each time a bag is either hung and/or a feeding time is begun (if the bag/container can be hung for 24 hours and provide multiple feedings. On 08/18/21 at 11:05 am Resident #75's feeding was running. It was stopped at 11:15 am which was correct. At 11:22 am on Registered Nurse (RN) #35 entered Resident #75's room to perform her enteral tube feeding flush and to disconnect her from her feeding pump. RN #35 washed her hands and donned a pair of gloves. She proceeded to turn on the water faucet to obtain water to flush the tube with. She then closed the window blind and closed the door to the room. She never changed her gloves after touching the faucet, the blinds, or the door. She then continued to disconnect the feeding pump from Resident #75's feeding tube and flushed the tube with water. Due to these breeches in infection control the IJ was not abated. On 08/18/21 at 1:47 PM the NHA and this surveyor observed Resident #75's feeding pump connected and running into Resident #75's feeding tube. A review of the A side enteral visualization sheet was reviewed. This is the sheet in which two (2) nurses were to sign off on each time a Residents feeding was resumed. The last entry on the sheet was by RN #35 at 9:00 am which was for the 10:00 am feeding not the 2:00 PM feeding which was already running at the time of the review. The NHA agreed if the feeding was running, the sheet should have been signed by two (2) nurses. The NHA agreed the POC was not followed by RN #35. Therefore the IJ could not be abated at this time. On 08/19/21 at 9:15 am LPN #34 entered Resident #75's room and began her enteral feeding. She followed proper procedures. She checked for placement, checked residual, flushed the tube in accordance with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She and CCS #24 both signed the visualization sheet as directed by the POC. LPN #34 allowed the feeding to run for two (2) hours as directed by the physicians order and then disconnected the feeding by following procedures. The IJ was abated at 12:00 PM on 08/19/21 when LPN #34 completed the 10:00 am feeding of Resident #75. This failure constituted an immediate jeopardy due to neglectful manner Resident #75's enternal feedings were not administered, the including the nurses inability to recognize the feeding tube was clogged and it wasn't that the resident was just full. This failure continued through the IJ abatement period. a) Snack pass 1. Evening HS (bedtime) snack pass on 08/16/21 Observation of the HS snack pass from 8:15 PM to 9:15 PM on 8/16/21, found the following: On B - Hallway, Licensed Practical Nurse (LPN) #77, was observed pushing a three (3) tier rolling snack cart. Snacks on the cart included: Beverages: coffee and orange Kool-aid, Potato chips, cheetos, mini crackers with cheese in individual serving bags, vanilla pudding, individually wrapped soft sugar cookies, nutrigrain bars, and fig newtons. LPN #77 said the kitchen provided the items on the cart before they left for the evening, around 8:00 PM. (None of these snacks were labeled for individual residents.) LPN #77 was asked, where are the snacks and supplements labeled for individual residents? LPN #77 said she did not know, maybe someone had passed them already. LPN #77 said she would look in the resident rooms to see if anyone had a snack. After observation, LPN #77 said she couldn't find any snacks in resident rooms other than the ones she had passed. LPN #77 said normally the kitchen puts the snacks labeled for individual residents on a tray and leaves them at the nurses station. LPN #77 concluded the kitchen staff did not send out any snacks or supplements labeled for individual residents. LPN #77 said she did not know what residents received individual snacks. She said the snacks she had on her cart could be given to any resident requesting them. Observation of A-Hallway Nurse Aide (NA) #65 was passing a snack cart with the same assortment of snacks present on the B-Hall cart. NA #65 said she did not believe any individual snacks were sent from the kitchen. NA #65 said she did not know which residents had individual snacks. She said the snacks on her cart could be given to any resident requesting them. LPN's # 6 and #95 confirmed A-Hallway residents did not receive any snacks labeled for individual residents. At 8:40 PM on 08/16/21, the administrator confirmed she was unable to locate any individual snacks or supplements for residents. The administrator said she could not run a computer generated snack list at this time but would provide one the following day. The Administrator provided a list of the HS snacks ordered by the physician at 8:24 AM on 8/17/21. Review of the HS snack list found the following residents should have received a supplement ordered by the physician: --Resident #88 was ordered 1/2 cup of High cal high pro pudding. --Resident #32 was ordered Boost plus, 4 ounces. --Residents #8, #48 and #40 were ordered Boost, Glucose Control, 120 milliliters. At 8:34 AM on 8/17/21, the Dietary Supervisor (DS) said her staff should have sent out the individual snacks before they went home at 8:00 PM on 08/16/21. She stated she would ask the afternoon shift why individual snacks were not sent to the floor. A tour of the A and B Hall nourishment pantries at 4:50 PM on 08/17/21, with the Director of Nursing (DON) confirmed staff passing the snack carts on 08/16/21, would not have had access to high cal pudding and Boost because these items were not available in the pantries. At 5:05 PM on 08/17/21, the DS with the DON present, verified her staff did not send snacks out on the evening of 08/16/21 because, They couldn't find the labels. The DS said she found yesterdays labels today beside the meat slicer in the kitchen. On 08/17/21, the surveyor reviewed the Documentation Survey Report V2. This report is completed by NA's and includes a category for documentation of the percentage of the HS snacks consumed by the Residents. At 1:00 PM on 08/17/21, the Documentation report was discussed with the administrator and DON who confirmed the following documentation from NA's for the HS supplements on 08/16/21: --Resident #88 consumed 50% of the high cal high pro pudding. --Resident #32 consumed 100% of the Boost Plus --Resident #8 consumed 100% of Boost, Glucose Control (120 ml) --Resident #40 consumed 100% of Boost Glucose Control (120 ml) --Resident #48 consumed 100% of Boost Glucose Control (180 ml) No answer was provided by the DON or the administrator when asked how the above 5 residents consumed their HS supplement when three (3) LPN's and the DS confirmed the HS Supplements were never provided on 08/16/21. 2. Morning snack pass on 08/17/21 The 10:00 AM snack cart arrived on the B-Hall at 10:30 AM on 08/17/21. Twelve (12) employees walked by the snack cart, without passing any snacks. At 11:15 AM observation found snacks/supplements were being passed. Staff served Resident #81 a high calorie, high protein pudding, without leaving a spoon for the resident to use to consume the pudding. At 11:57 AM the following supplements were still on the snack cart: --Boost and Pudding for Resident #40 --Boost for Resident #78 --Mighty shake for Resident #46 --Pudding for Resident #10 At 12:00 noon the DON passed by the snack cart. When asked, what is this cart, the DON stated the snack cart. When asked what time does it come out, she stated 9:30-10:00 AM. When asked what time is it now, the DON stated, Noon, I think the orientee was passing them and she must have gotten side tracked. The DON lifted the mighty shake and the milk and said it's still cold, but the milk no. She said I will take this back to the kitchen. The DON acknowledged all the snacks not delivered by staff. The snacks for A-Hall were being passed at 11:23 AM on 08/17/21. At 11:55 AM, the Activity Assistant (AA) #15 and the Clinical Care Supervisor (CCS) #24, were standing by the cart,. When asked what was on the cart, CCS #24 grabbed 2 cartons of boost, and said general snacks if they want them. When asked what time does the cart come out, the CCS #24 stated, any time in the AM. When the surveyor asked to see the boost in their hands, AA #15 took off with the boost in her hand and the CCS said, we are taking them now. On 8/17/21 at 04:20 PM, NA #99 was observed carrying a tray. When asked who's tray, he stated Resident #89's lunch tray. I asked him to lift the dome lid and the food was not disturbed. The following consumption of supplements were documented by staff: --Resident #78 on 08/17/21 at 9:43 AM 50% - at 12:00 Noon the DON returned this supplement to the kitchen. --Resident #46 on 08/17/21 at 9:34 AM 25% - at 12:00 Noon the DON returned this supplement to the kitchen. --Resident #10 on 08/17/21 at 13:14 PM 100%- at 12:00 Noon the DON returned this supplement to the kitchen. --Resident #40 on 08/17/21 at 21:40 PM 50% - at 12:00 Noon the DON returned this supplement to the kitchen. --Resident #81 on 08/17/21 at 10:00 AM 25% - this resident never received a spoon to consume her pudding, this observation was made at 11:15. --Resident #89 on 08/17/21 at 13:00 PM 100% - Resident #89's lunch tray was observed at 4:20 PM and the resident did not consume any food. On 8/17/21 at 04:20 PM the CNA #99 was carrying a tray, I asked who's tray he stated Resident #89's lunch tray I asked him to lift the [NAME] lid and the food was not disturbed. 3. Evening snack pass on 08/17/21 The 03:00 PM snack cart arrived on A-Hall at 3:48 PM and B-Hall at 3:50 PM. At 4:20 PM the A-Hall snacks and at 4:21 PM the B-Hall snacks were not passed. On 08/17/21 at 4:41 PM, Resident #81's pudding was not on the snack cart. When asked who passed the snacks NA #78 stated she did. NA #78 verified Resident #81 did not have a snack. Observation with NA #78 confirmed the residents pudding, dated 08/17/21 AM (the 10:00 AM snack.) NA #78 lifted the lid and said, it's completely full. At 05:15 PM the A-Hall snack cart, contained unopened Boost for Resident #5 and #87. At 05:25 PM the B-Hall snack cart was observed outside the kitchen door. The cart contained Boost for Resident #32 with a R written on the label and Boost for Resident #10. Resident #10's Boost was still unopened on the A-Hall cart. An interview with the DS at 5:27 PM on 08/17/21, revealed Resident #81 was to get a PM snack of high calorie high protein at the 3:00 PM snack pass. When asked who prepared the PM snacks the DS stated, the dietary assistant. The DS did not know if the dietary assistant sent Resident #81's pudding. The DS confirmed snacks/supplements times were 3:00 PM, 10:00 AM, and 8:00 PM. The surveyor showed the Administrator the unopened carton of Boost at approximately 6:00 PM on 08/17/21. The Boost was left in the surveyor work room. The same Boost was observed in the surveyor work room on the morning of 08/18/21. The following consumption was documented by staff: --Resident #32 on 08/17/21 at 2:00 PM 100% - at 5:25 PM on 8/17/21, the residents Boost was observed unopened. --Resident #10 on 08/17/21 at 9:36 PM - 50%. (The resident does not get Boost at the 8:00 PM snack pass) 4. Monring snack pass on 8/18/21 Observed the B-Hall snack cart at 11:00 AM and 11:35 AM. The cart contained Boost for Resident #88 and #49. Resident #49 resides on A-Hall. Observation of the B-Hall snack cart found the cart was setting by the kitchen door at 11:45 AM. The cart contained Boost for Resident # 33. The carton was marked with an R - for refusal. At 12:17 PM on 08/18/21, NA #80, said Resident #49 received for a snack consisting of, juice and thickened water, she asked for the water. NA #80 said the resident had nothing else on the snack cart. The following consumption's were documented by staff: --Resident #88 on 08/18/21 at 10:00 AM 25% - the snack (Boost) was still setting on the cart at 11:35 AM. --Resident #33 on 08/18/21 at 10:00 AM resident not available - The residents carton was marked as refused. The Administrator acknowledged on 08/18/21 at 03:02 PM, the discrepancies when recording the percentage of the snacks consumed and acknowledged the observations did not match the documentation. 5. Evening snack pass on 08/18/2021 The A-Hall cart arrived at 03:05 PM. At 04:30 PM the snack cart was still sitting untouched. The DON and three (3) home office consultants walked by the cart without passing the snacks. At 04:44 PM, the Administrator observed the untouched snack cart which included: --Fruit for Resident #80 --Boost and Magic cup for Resident #49 --Boost for Resident #87 --Boost for Resident #5 --Boost for Resident #24 --Boost for Resident #45 --Mighty shake for Resident # 41 --pudding for Resident #45 --cookie and 2% milk for Resident #64 --cookie and pudding for Resident #17.

Based on staff interview, observation, and record review, the facility failed to ensure three (3) of six (6) residents reviewed for pressure ulcers received care to promote the healing of existing pressure ulcers. For Resident #4 who was identified by the facility as being high risk for the development of pressure ulcers and was not provided treatment or services to prevent the development of two Suspected Deep Tissue Issues (SDTI) in house aquired pressure ulcers. This represents acutal harm for Reisdent #4. Resident identifiers: #4, #54 and #81. Facility census: 89. a) Resident #4 A Record review found the resident was admitted to the facility on [DATE]. Review of the discharge summary provided to the facility noted the resident was a functional quadriplegic with a decubitus ulcer, stage 4 to the back and an infected sacral decubitus ulcer. A nursing assessment, version 3 - V2, completed on 04/06/21 found a section, entitled: Skin Evaluation. The nurse completing the assessment noted the resident had a Stage 4 pressure ulcer on the lower back and a Stage 3 pressure ulcer on the sacrum. No other skin conditions were recorded. On 04/08/21 a wound assessment - initial pressure ulcer assessment - V2 was completed for the pressure area to the Mid back. The area was staged as a Stage IV. Length was 9.4 centimeters (cm), width was 9.0 cm and depth was 0.5. On 04/08/21 a wound assessment - initial pressure ulcer assessment - V2 was completed to the pressure area on the sacrum. The area was noted to be unstageable. The length was 8 cm., width was 8 cm, the depth was 0.5 cm. Two new wounds were noted to the residents gluteal fold on 04/08/21: --The left gluteal fold #1 was staged as a suspected Deep Tissue Injury. The length was 0.8 cm, the width was 0.5 cm, and the depth was unable to be determined. --The left gluteal fold #2 was staged as a Suspected Deep Tissue Injury. The length was 0.9 cm, width was 0.5 cm, and the depth was undetermined. Review of the treatment administration record (TAR) for April 2021 found the facility did not write any orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders for treatment on 04/11/21 are as follows: --Cleanse pressure area to mid back with wound cleanser, dry and apply proximal AG (abbreviation unknown), every day shift every 3 days. --Cleanse pressure area to sacrum with wound cleanser, dry, and and apply proximal. Every day shift every 3 days. --Cleanse pressure area to left gluteal fold, dry, and apply proximal dressing. Every day shift for every 3 days. The 4 pressure areas were not measured again until 04/13/21. (The facility completes weekly measurements of wounds.) The area to the mid back measured 10 cm in length, 8.6 cm in width, 0.8 cm in depth. An increase from the measurements on 04/08/21 when the length was 9.4 centimeters (cm), width was 9.0 cm and depth was 0.5. The area to the sacrum measured 16 cm in length, 10.5 cm in width and the depth was undetermined. An increase from the measurements on 04/08/21, when the length was 8 cm., width was 8 cm ., and the depth was 0.5. The area to the left gluteal fold #1 measured 0.6 cm in length, 0.4 cm in width, 0.1 in depth and was now staged as a stage II pressure area. The area to the left gluteal fold #2 measured 0.9 cm in length, 0.5 cm in width, 0.1 cm in depth and was now staged as a stage II. The facility referenced the pressure ulcers upon admission. The wound to the sacrum and the wound to the mid back. The next reference to the pressure areas was on 04/08/21 when the resident had 2 new wounds to the gluteal fold. An interview with the resident on 08/16/21 at 9:00 PM found he was unable to voice any concerns with his care. At 11:10 AM on 08/17/21, the above issues were discussed with the Director of Nursing (DON). The DON said the treatment nurse really did treatments on 04/08/21 but the orders were not put into the computer correctly. The DON provided copies of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Failure to implement the comprehensive care plan for a resident who has a pressure ulcer a wound increased in size and failed to progress towards healing as anticipated resulted in actual harm to Resident #3. The facility failed to write any orders to treat the wounds until 6 days after admission. . b)Resident# 54 On 8/17/21 at 2:00 PM,during wound care observation on Resident # 54, the Clinical Care Supervisor (CCS) # 22 cleaned towards the wound's center while performing wound care. According to American College of Surgeons Division of Education .when cleaning the wound you start at the center of the wound, work in a circular pattern and clean toward the edges. Do not return to the wound center after cleansing to avoid recontamination of the wound. c) Resident # 81 During medical record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However on the following days from 08/01/21 to 08/10/21, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/18/21 at 2:14 PM, the Director of Nursing (DON) acknowledged the amount of Pro-stat consumer was not recorded as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, resident representative interview, policy and procedure review, and staff interview, the facility failed to ensure Resident #178 and #179 was not neglected. Each resident did not receive timely and necessary medical treatment. Resident #179 had bruising to the face, shoulder and hip which the facility failed to adequately assess and treat in a timely manner. Once Resident #179 was transferred to the hospital per the request of her representative, the resident was found to have a bilateral brain bleed, a fractured shoulder, fractured collarbone and a fractured hip. This failure resulted in actual harm for Resident #179 due to increased pain and delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #178 was admitted to the facility 12/14/20. The nursing assessment completed on admission indicated Resident #178 had sores to the right buttock and left buttocks. This assessment was completed by a Licensed Practical Nurse (LPN). The Pre- Admission Screening (PAS) for Resident #178 indicated the resident had a Stage 2 pressure ulcer to the left buttock. The facility neglected to assess and treat the identified wounds to the right and left buttock until 12/22/20. At which time the wounds had worsened. This neglect resulted in actual harm for Resident #178. This was true for two (2) of three (3) residents reviewed for the care area of abuse and neglect. Resident identifiers: #179 and #178. Facility census 81. Findings included: a) Resident # 179 On 03/15/21 at 2:34 PM, a phone interview was conducted with the Medical Power of Attorney (MPOA) for Resident #179. The MPOA stated, he received a phone call on 11/14/20. The call was from Licensed Practical Nurse (LPN) #60, telling him his mother (Resident #179) had bruises on her face, shoulder, and hip. He asked if she was ok, and the LPN #60 assured him she was. LPN #60 told him they believe the resident received the injury's the day before while outside the facility at the [CONDITION(S)] center. At that time, he called his brother who lived nearby to go to the facility and check on his mother. The facility would not allow his brother to see her until the next day on Sunday (11/15/20). His brother initiated a video chat with him while in his mother's room. He stated his mother would not talk to them she would just moan. He said, he called the nurses station many times asking about his mother and her injuries. At one point he said LPN #60 told him his mother was singing earlier in the day. He continued to say this went on for several days. He said he was very concerned about his mother because every time he would video chat with her all she would do is moan. Then on 11/17/20, he called the facility and asked for the nurse to go to his mother's room and video chat with him. He asked the nurse to put the iPad close to his mother and he asked, Mother what is wrong? What happened to you? His mother began to cry and said, They Dropped Me and broke my elbow. He then stated, he called the nurses station again and demanded his mother be sent to the hospital. The MPOA stated, he was later contacted by a doctor from the emergency room (ER) at a local hospital and was told his mother needed to be sent to a different hospital for a higher level of care due to her injuries. Which included a bilateral brain bleed, broken collarbone, broken shoulder and broken hip. He said, it upset him so much because his mother had such severe injuries, and no one cared enough to get her medical attention. The facility completed an abuse and neglect investigation into this matter. Upon review of the investigation the following statements were reviewed and read as follows, The Social Worker #54 on a statement dated, 11/14/2020 wrote, Arrived at facility after receiving information of possible reportable. I observed resident and gathered witness statements from the staff. I called Administrator for instruction. She instructed I speak to a Unit Charge Nurse and ask for (name of Resident #179's attending physician) to be contacted about sending out resident or doing additional testing. I spoke to (Name of LPN #60) who called (name of attending physician) relayed message and asked if he would like additional testing or to be sent out. He declined stating if she (resident #179) wasn't showing signs of pain, discomfort, or neuro symptoms she did not require this. LPN #60 stated that was what he said the first time he was contacted about her (Resident #179). Nurse Aide (NA) #120 on a statement dated 11/14/20 wrote, I did provide care for (Name of Resident #179) yesterday Friday 13th, 2020. I did not see any bruising, and she did not act like she was in pain from what I noticed. She didn't have a fall that I know of. NA #96 in a statement dated 11/14/20, wrote, (Name of NA #36) came and asked me for help providing care for (name of Resident #179) Upon providing care we found multiple bruises along the right side of her body. The bruises were not present on 11/13/2020 at 6:15 PM, while assisting nurse with treatments. They were present when providing care during our shift, therefore we informed the nurse. NA #77 in a statement dated 11/14/20, wrote, I was assisting with care on (name of Resident #179) when taking clothing off we noticed bruising. Bruising on side of face, shoulder and hip. Resident said, some girl was rough and her shoulder hurts. NA #36 in a statement dated 11/14/2020, wrote, I was doing my rounds checking my residents. I went to check (name of Resident #179) I asked (name of NA #77) and (name of NA #96) to help me clean her up. As we were cleaning her up taking her clothes off thats when noticed the bruises on her right side of her face, the shoulder, hip and arm. I then asked (name of NA #96) to go get the nurse. (Name of NA #36 and NA #77) stayed in the room to finish cleaning her up. That's when (name of Resident #179) said that the girl was rough with her and that her shoulder hurts. I asked her what girl was rough with her, but she didn't answer me. LPN #60 in a statement dated 11/14/20, wrote, While passing medication on the afternoon of 11/14/2020, I was approached by (name of NA#96) who stated that he needed me in residents room, upon entering the room, (name of NA #96 and NA #36), also pointed out that resident had marked purple bruising to her right shoulder, right hip, right temple, right outer canthes of her eye and right ear/earlobe. [CONDITION(S)] observed around the outer canthus of the right eye with some abnormal red discoloration also observed outside the edemateus region. Resident denies pain, denies pain upon palpation to the area. States, she rolled me too hard. Resident is transported out of the facility 3x/week for [CONDITION(S)], and had treatment yesterday (11/13/20), Wound care was completed by this nurse last night around 8 PM and no bruising/[CONDITION(S)] was not observed at that time, nor was it observed by myself this morning, as resident was on her side when entered her room. Register Nurse #119 in a statement dated 11/14/20, wrote, Prior to the start of my shift on 11/13/2020, I assisted LPN #60 to turn (name of Resident #179) and apply her wound vac. At that time, no bruising or swelling was noted. Throughout my shift, resident did not experience any falls and did not have any verbal or nonverbal complaints of pain or discomfort. No bruising or swelling was noted. throughout my shift. When I reported off to oncoming nurse, resident was resting quietly and was not in any acute distress. Activities Assistant #92 in a statement dated 11/17/2020, wrote, I facetimed (name of Resident #179)'s son (Name of MPOA) 4 PM, while he was talking with her she started crying and said something about those girls dropped her on the floor and broke her elbow. He asked her if she was in pain and she said she was hurting really bad. He told her don't worry he would get them to have her checked out and make sure she was ok, we hung up so he could call the nurse. Once the son found out he started asking her questions about who dropped her or where she was. I didn't hear everything she said. Nurse Aide #115 on a statement dated, 11/17/20 wrote, I provided care for (Name of Resident #179) Thursday night into Friday morning, the 12th into the 13th. I didn't notice anything bruising wise. She slept all night that night, but she never acted like she was in pain. She didn't have a fall that I'm aware of. LPN #117 in a statement dated 11/17/2020 wrote, I was the night shift nurse on shift the morning of 11/13/2020. It was brought to my attention that Resident #179 has sustained multiple bruises to her right side of her body. I had contact with the resident at approx. 0400 AM that morning to D/C her wound vac and apply a dressing to her wound and give her AM medication prior to [CONDITION(S)]. The resident was fine upon me leaving her that morning, I had two CNA's on the hall that morning (Name of NA #116) an (Name of NA #121), (Name of NA #116) was assigned to get (Name of Resident #179) dressed cleaned and transferred to our stretcher for [CONDITION(S)]. (Name of NA #121) told (Name of NA #116) she would help her get (name of Resident #179) ready and, on the stretcher, after she finished with the resident she was with. (Name of NA #116) had (Name of Resident #179) on the stretcher before (Name of NA #121) went to help her. Which tells me she put (Name of Resident #179) on the stretcher alone. I was not there to witness what occurred in the room as I was on a med Pass on A2 hall. I have never helped transfer (Name of Resident #179) to a stretcher for [CONDITION(S)] or any other reason. Physical Therapist Assistant (PTA) #104 on a statement dated 11/17/20, wrote, While treating patient on 11/12/2020 and 11/13/2020, I did not notice any bruising or discoloration on patient's skin, however, on one of those days, during her therapy time with me, she (name of Resident #179) stated, they dropped me I said, they dropped you, who dropped you? Patient did not respond. I did not report this because I did not notice or see any physical evidence and patient has a history of being confused at times. Administrator in a statement dated 11/17/20, wrote, This administrator in the presence of Director of Nursing spoke with (name of Resident #179) at bedside. I introduced myself and proceeded to ask her about any type of fall she has had recently. She stated, they dropped me she said it was women not men, when asked if it were the staff here at the nursing home she said no at [CONDITION(S)]. She did not identify any specific person or description of anyone. Nurse Aide #115 in a statement dated 11/18/20 wrote, I have to transfer (name of Resident #179) before when I first started here but it's too hard on one person to do it so I won't do that anymore. The last morning, she went to [CONDITION(S)] I had (Name of NA #118) help me transfer her over from the bed to the stretcher. As far as someone saying I've dropped (name of Resident #179) because someone wouldn't help me that's the first time I've heard that. Night shift is good about helping one another but day shift not so much. The only person I work good with here is (name of NA #118). If she needs help, I help her and if I need help, she helps me. We do team work very well together and it's a shame it's not like that with everyone. NA #118 in a statement dated 11/19/20 wrote, On Friday Nov. 13, 2020 I went to A side to speak to (Name of NA #116) about being mandated to stay over that morning. I asked (Name of LPN #117) where she was, he told me she was with (name of Resident #179). I went into (name of Resident #179) cleaned up and ready to transfer to [CONDITION(S)]. She (NA #116) asked me to help slide her onto the facility stretcher, I did, and she was transferred safely, we buckled her down so she wouldn't fall off. (Name of Resident #179) didn't seem to show any signs of pain or anything after that I went back to B side. Further review of the investigation conducted by the facility found, they attempted to obtain statements from the [CONDITION(S)] center, but was informed their lawyer advised them to not provide statements. The following interviews were conducted by this surveyor: On 03/18/21 at 10:20 AM, the facility Attending Physician (AP) was interviewed via phone. The AP was asked if he recalled getting a second phone call concerning Resident # 179. He stated, he was informed the following day or so that the bruising was extending, and the resident was sent out to the hospital. He stated that he requested for the facility to get an x-ray inhouse. He was unaware the x ray not obtained. He was also unaware that no neuro checks were initiated at this point. After Attending Physician was told of the extensive injuries Resident #179 had after going to the local hospital he said, sounds like we could have done better, in the way of following up. He said, he was concerned about sending her out unless it was a serious injury do to COVID and there were no beds available at the local hospital. He said, he was relying upon the nurse's assessment which was conveyed to him over the phone. An interview on 03/18/21 at 10:42 AM, with Nurse Aide #96 revealed he recalled taking care of Resident #179 on the evening of her return from [CONDITION(S)] on 11/13/20. NA #96 said, he did not see any bruising on the resident at that time. In addition, he stated, he took care of her on the following day with NA #36 and noticed the bruising on Resident #179. When asked if Resident #179 appeared to be in pain he stated, some days she talks a lot and some days she does not, but she did moan while we were providing care. He further stated, when we saw the bruises, I let LPN #60 know about the bruising. During a phone interview with Nurse Aide #36 on 03/18/21 at 11:03 AM, NA #36 was asked if she took care of Resident #179. She said, she did. She was asked if she noticed any bruising on Resident #179 on Friday the 13th, 2020. She said, no, but she was the one that discovered the bruises on the next day, Saturday, 11/14/20. She stated, I had two other nurse aides help me with Resident #179. I asked NA #96 to go get LPN #60 to come and look at the bruises. She was asked if Resident #179 appeared to be uncomfortable. NA #36 stated, she moaned when we moved her, but she has contractures to her legs and arms, so it was painful for her anyway. She was asked about the process for transporting residents from the facility to the [CONDITION(S)] center. She said she is not at the facility when Resident # 179 goes to the [CONDITION(S)] center. For other transfers out of the facility, facility staff transfer residents to the facility's stretcher. Facility staff then use the stretcher to transport residents to the entry way of the facility. Facility staff transfer the residents to the ambulance stretcher. Due to COVID, ambulance personal do not go to resident's rooms. NA #36 stated when the resident returns to the facility from [CONDITION(S)], some staff use a draw sheet, and some staff transfer with two people, but she always uses three people. One person to hold the feet and two on each side to move the body. On 03/18/21 at 11:22 AM, an interview via phone with LPN #60, confirmed LPN #60 recalled 11/14/20 was a weekend. They discovered Resident # 179 had some bruising on the right side of her face, eye, ear, and shoulder. She was asked if she called the Attending Physician, she said, she did, and she did not get any new orders. She went on to say Resident # 179 was already getting a scheduled pain medication. When asked if neuro checks were initiated, LPN #60 stated, no because she had bruising to her face and not her head. She was asked if she remembered getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why she made Late Entries in the electronic medical record three (3) days after Resident # 179 had been discharged , which were the same as the first notes that were originally entered, only with more details, she answered, I do not know why. She was asked if during this time frame in November of 2020, did the ambulance personal go to the resident's room to transport the residents? She said yes, they go to the resident's room and they load them on the stretcher and on return would unload them to their bed. During an interview on 03/17/21 at 12:36 PM, the Director of Nursing (DON) was asked about all the late entry notes on the electronic medical record of Resident #179. The DON reviewed all the late entries made by LPN #60 3 to 4 days after the incident. The DON stated, These notes make all of this look so convoluted. On 03/18/21 at 12:15 PM, the Administrator was asked how she would expect the staff to transfer residents. She said with a draw sheet unless Physical Therapy said they were to be moved using a lift. She was asked during the month of November did the ambulance crew go to the resident's room to transport residents to [CONDITION(S)]. She stated, that due to COVID the staff would transfer the resident to the facility stretcher, take the resident to the lobby, and transfer the resident to the ambulance stretcher. The same process is followed when residents return to the facility. The administrator stated this was to prevent unnecessary people going through the facility. When asked if the resident was assessed to have a mechanical lift for transfers, would the staff use a mechanical lift in the room and in the lobby of the facility for transfers, the administrator replied, Yes. She was then asked if she would be surprised to know facility staff confirmed both verbally and in writing a mechanical lift was not used to transfer Resident #179. She said yes, she would because the staff have been in serviced. The administrator reviewed the statements from staff contained in the investigation and was made aware of the telephone interviews completed by the surveyor. At this time the administrator reviewed the Kardex (a Kardex informs staff on what care the resident requires.) Under the heading Transferring/ Positioning: *Transfer self-performance: 2-person physical assist with Mechanical lift. * Bed Mobility self-performance: Patient requires 2-person physical assist. Review of the Documentation Survey Report: (documentation by the NA's to indicate how the staff transferred the resident, including the number of staff and equipment used) Although Resident #179 was transferred out of the facility three times a week for [CONDITION(S)], the staff rarely documented the transfers on the documentation tool. The week Resident #179 sustained the injury the following was documented: On 11/12/20 Night shift (22:00-6:00) time: 11:50 PM, Transfer: self-performance- How resident moves between surfaces -T (total dependence) Transfer: support provided- 1-person physical assist Devices used: NA (this is not an option on the list of devices. On 11/13/20 Evening shift (2:00PM-10:00PM) time: 9:59 PM, E- Extensive assistance- Resident involved in activity. (Resident #179 was unable to assist with her transfer. 1- person physical assist. Devices used: OT (Other) not a mechanical lift as ordered. This information was shown to Administrator and Director of Nursing (DON) on 03/18/2021 at 5:10 PM. After reviewing the documentation, the DON stated she is not so sure Resident #179 received the injuries while out of the facility. Resident #179 was found to have been injured on 11/14/20, however; she did not receive medical treatment until 11/17/20 at 5:45 PM after her MPOA insisted she be transferred to a local hospital for evaluation or treatment. Resident #179's attending physician verbally confirmed in an interview he wanted Resident #179 to have in house x rays and neurological assessments, and if both were okay she would not need to be transferred out, due to the hospital bed shortage related to COVID. The facility staff neglected to obtain the neurological assessments or x rays. Once the MPOA insisted on Resident #179 being transferred to a local hospital the following injuries were identified at the hospital: *Bilateral intracranial hemorrhages (Bleeding on both sides of the brain) *Subluxation of the glenohumeral (dislocated shoulder) *fracture of the distal clavicle from traumatic fracture (fractured Collarbone) *small osseous fragments seen along the scapular spine which could reflect traumatic fracture (bone fragments along the shoulder blade) * right hip fracture. Even though the location where Resident #179 sustained the injuries can not be determined the facility neglected to assess and treat the injuries timely once they were identified by the facility staff. b) Resident #178 Medical record review started on 03/17/21 at 10:06 AM, found Resident #178 was admitted from an acute care facility on 12/14/20. Further review of the record found a Pre-admission Screening (PAS) completed by the transferring acute care facility, dated 12/14/20. This form under question #24 - Decubitus yes; location left buttock, stage 2, size 3 centimeters (cm) in length and 5 cm in width. Review of the nursing assessment completed by Employee #22, LPN dated 12/14/20., found the following: Section G, Skin Condition, (page 5) #2 Skin Evaluation: .Resident has a sore noted to both right and left buttocks. The left buttocks are larger in size and appears pink around edge and black center and the right buttocks is smaller in size and pink outer and lighter shade of pink in center. Initial Pressure Ulcer Assessment completed by Employee #50, Clinical Care Supervisor (CCS) dated on 12/22/20 (seven (7) days after the wound was identified by LPN #22); found two (2) pressure ulcers: One (1) on the right buttocks which measures 2.0 cm in length and 1.5 cm in width and depth of 0.1 cm; stage 2 with no drainage; area cleansed with wound cleanser and dry and Proximal dressing applied. One (1) area on left buttock and measured 7 cm in length and 6.5 cm in width and depth unable to determine and classified as an unstageable pressure ulcer with no drainage and presence of eschar (dehydrated, necrotic tissue that is thick, leathery and black; area cleansed with wound cleanser and dry and Proximal dressing applied. No physician orders written. Review of Skilled Service Notes found the following: --12/16/20- 3:53 pm- Patient has no wounds requiring treatment currently by Employee #88, Licensed Practical Nurse (LPN). --12/17/20- 3:44 pm- Patient has no wounds requiring treatment currently by Employee #88, LPN. --12/18/20- 11:28 am- Patient has no wounds requiring treatment currently by Employee #9, LPN. --12/19/20-10:17 am- Patient has no wounds requiring treatment currently by Employee #9, LPN. --12/20/20-11:42- Patient has no wounds requiring treatment currently by Employee #80, Registered Nurse (RN). --12/21/20-12:25 pm- Patient has wound(s); wound treatment was provided during this shift. Additional wounds: pressure area noted to left buttock with darkened, dry, leather-appearing wound bed; border of reddened tissue present; apparent pressure area present to medial aspect of left buttock with moist, light pink wound bed with border of yellow tissue. Pressure area x2 noted to right buttock with wound beds light pink and moist with border of light-yellow tissue. Right heel noted with reddened, intact skin. Clinical Care Coordinator (CCS) advised of observations for further evaluation. By Employee #88 LPN. --12/22/20- 10:29 am- Patient has wound(s); wound treatment was provided during this shift. Additional wounds: pressure area noted to left buttock with darkened, dry, leather-appearing wound bed; border of reddened tissue present; apparent pressure area present to medial aspect of left buttock with moist, light pink wound bed with border of yellow tissue. Pressure area x2 noted to right buttock with wound beds light pink and moist with border of light-yellow tissue. Right heel noted with reddened, intact skin. Clinical Care Coordinator (CCS) advised of observations for further evaluation. By Employee #88 LPN. --12/24/20-5:20 pm - Patient has wound(s) but no treatment was provided during this shift. Site and description: right buttocks- stage 2 to right buttocks; unable to visualize wound bed due to dressing. Left buttock- unstageable to left buttock; unable to visualize wound bed due to dressing by Employee #40, LPN. Review of Baseline Care Plan dated and signed on 12/23/20, found: Problem: Potential skin breakdown. Goal: Skin integrity will be maintained or improved during the transition period. Interventions: [MEDICATION(S)] ointment to bilateral lower legs. Assist patient with repositioning every two hours and as needed for comfort while in bed or up in chair. Review of Physician Orders on admission 12/14/20 through 12/31/21, found no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Treatment Administration Record (TAR) for period 12/14/20 through 12/31/20 found no record of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure Ulcer reassessment completed by Employee #41, (RN) on 01/05/21- left buttocks unstageable 8 cm in length and 5.5 cm in width depth unable to determine (UTD). Undermining present around the entire wound edge. Unable to determine presence due to slough tissue and necrotic tissue present. Edges are not attached, and a moderate amount of bloody, purulent brown colored drainage noted and odor which remained after area was cleansed. Temporary wet to dry dressing applied in order to consult Name of Physician for further treatment orders. Area covered with an ABD pad and tape. Right buttocks- Stage II. measured 2 cm in length and 1 cm in width and depth unable to be determined (UTD) with no drainage or odor noted. Area was cleansed with wound cleanser and assessed. Non-blanchable area noted with partial loss of dermis. Surrounding area is macerated and reddened but blanchable. Area was covered with ABD pad due to proximity of pressure ulcer to left buttocks, awaiting further orders from Name of Physician. Medical records remain silent concerning contact of Physician/Nurse Practitioner (NP) and treatment orders for wounds. Review of an Acute Care Transfer dated 01/07/21, found under skin condition coccyx- stage 2 pressure ulcer. NP note on 01/13/21-History of present illness: Nurse asked me to evaluate wound to buttock; resident noted to left and right buttocks. States came here with a wound to her buttock. Resident complains of discomfort to area. Foul odor noted to wound with purulent green discharge. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . and Pressure ulcer of right buttock, stage 2. Wound culture obtained. Continue [MEDICATION(S)] which was ordered for pneumonia. Refer to wound clinic as soon as possible (ASAP). Wet to dry dressing to right buttock twice daily. Optiform to left buttock 2 x a week and as needed, monitor and notify if any change. Review of Physician orders found treatment orders written by the NP on 01/13/21 for left and right buttocks. Physician visit on 01/14/21- The document states this resident has a Stage 3 to left buttocks. and the NP seen the resident on 01/13/21 and ordered a C&S of the left buttocks with wet to dry dressings twice daily and Opti form to right buttock 2 x weekly and prn- stage 2. Nursing called early this am due to patient was tearful with wound care. [MEDICATION(S)] ordered. Refer to wound clinic. Documented the nurse gave the medication at 2:56 am after notifying the physician. Review of MDS with ARD of 12/21/20 under Section M-Skin conditions: reports one (1) stage 2 pressure ulcer. Under Section S- Skin Condition indicates the resident has two (2) new or reoccurring pressure ulcers that occurred prior to admission and the resident has two (2) pressure ulcers on left buttocks; no mention of right buttocks area noted on admission. 01/25/21- C&S results noted on this date Scant [CONDITION(S)] (MRSA) and new order for [MEDICATION(S)] D/S twice daily for 14 days on 01/26/21- [MEDICATION(S)] discontinued and [MEDICATION(S)] 750 mg IV daily for 10 days and [MEDICATION(S)] 1.5 grams IV every 6 hours for 10 days. Wound Assessment completed by Employee #80, RN on 01/26/21 reads: left buttocks Stage 4 and measures 11 cm in length and 7 cm in width depth 2 cm. Undermining present around the entire wound edge and tunneling of 5 cm at 10 o'clock. Eschar tissue present. Edges are not attached, and a moderate amount of bloody, purulent brown colored drainage noted and odor which remained after area was cleansed. Called and made appointment with the wound care clinic (scheduled for 01/27/21) Right buttocks- Stage II. measured 7 cm in length and 3.5 cm in width and 1 cm in depth with scant amount of blood tinge drainage and odor present after cleansing of wound noted. On 01/27/21 Resident out to wound clinic and was transported to emergency room from office due to Sacrum pressure ulcer gangrenous black tissue. The resident was admitted for surgical debridement and care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Policy for Wound management (issued on 05/01/2016 and revised 05/10/18): 1. This policy serves as a guide for the interdisciplinary team (IDT) to promote wound healing and prevent infection . 2. At the time of admission/readmission, the discharge records from the prior facility will be reviewed for information relating to wounds, pressure ulcers, and/or alteration in skin integrity. Staging from another facility is not adopted for use in the facility. 3. To identify the resident at risk for development of pressure ulcer 4. Wounds are evaluated at the time of admission/readmission by a licensed nurse. Within 24 hours, an RN will complete an assessment of the wound/pressure ulcer. Documentation will be made in the patient's medical record. 5. At least daily documentation by a licensed nurse is recommended on any wound receiving treatment. 6. Weekly wound assessments are recommended on any wound receiving treatment. 7. Closed pressure ulcers should be followed and documented on for two (2) weeks using the at least daily documentation and weekly assessment. 8. Wound care guidelines are provided; however, the guidelines do not take the place of timely physician notification and following a physician order.

Based on medical record review, observation, policy review and staff interview, the facility failed to ensure Resident #178, who was admitted with pressure ulcers received necessary treatment and services, consistent with professional standards of practice. Specifically, the facility failed to provide treatment to existing pressure ulcers which resulted in the worsening of the pressure ulcers that required hospitalization for debridement and infected pressure ulcers resulting in actual harm for Resident #178. For Resident #38, the facility failed to follow their protocol related to the identification of a newly developed pressure ulcer until the after surveyor's intervention. This was true for two (2) of four (4) residents investigated for the care area of pressure ulcers. Resident identifiers: #178 and #38. Facility census: 81. Findings Included: a) Resident #178 Medical record review started on 03/17/21 at 10:06 AM, found Resident #178 was admitted from an acute care facility on 12/14/20. Further review of the record found a Pre-admission Screening (PAS) completed by the transferring acute care facility, dated 12/14/20. This form under question #24 - Decubitus yes; location left buttock, stage 2, size 3 centimeters (cm) in length and 5 cm in width. Review of the nursing assessment completed by Employee #22, LPN dated 12/14/20., found the following: Section G, Skin Condition, (page 5) #2 Skin Evaluation: .Resident has a sore noted to both right and left buttocks. The left buttocks are larger in size and appears pink around edge and black center and the right buttocks is smaller in size and pink outer and lighter shade of pink in center. Initial Pressure Ulcer Assessment completed by Employee #50, Clinical Care Supervisor (CCS) dated on 12/22/20 (seven (7) days after the wound was identified by LPN #22); found two (2) pressure ulcers: One (1) on the right buttocks which measures 2.0 cm in length and 1.5 cm in width and depth of 0.1 cm; stage 2 with no drainage; area cleansed with wound cleanser and dry and Proximal dressing applied. One (1) area on left buttock and measured 7 cm in length and 6.5 cm in width and depth unable to determine and classified as an unstageable pressure ulcer with no drainage and presence of eschar (dehydrated, necrotic tissue that is thick, leathery and black; area cleansed with wound cleanser and dry and Proximal dressing applied. No physician orders written. Review of Skilled Service Notes found the following: --12/16/20- 3:53 pm- Patient has no wounds requiring treatment currently by Employee #88, Licensed Practical Nurse (LPN). --12/17/20- 3:44 pm- Patient has no wounds requiring treatment currently by Employee #88, LPN. --12/18/20- 11:28 am- Patient has no wounds requiring treatment currently by Employee #9, LPN. --12/19/20-10:17 am- Patient has no wounds requiring treatment currently by Employee #9, LPN. --12/20/20-11:42- Patient has no wounds requiring treatment currently by Employee #80, Registered Nurse (RN). --12/21/20-12:25 pm- Patient has wound(s); wound treatment was provided during this shift. Additional wounds: pressure area noted to left buttock with darkened, dry, leather-appearing wound bed; border of reddened tissue present; apparent pressure area present to medial aspect of left buttock with moist, light pink wound bed with border of yellow tissue. Pressure area x2 noted to right buttock with wound beds light pink and moist with border of light-yellow tissue. Right heel noted with reddened, intact skin. Clinical Care Coordinator (CCS) advised of observations for further evaluation. By Employee #88 LPN. --12/22/20- 10:29 am- Patient has wound(s); wound treatment was provided during this shift. Additional wounds: pressure area noted to left buttock with darkened, dry, leather-appearing wound bed; border of reddened tissue present; apparent pressure area present to medial aspect of left buttock with moist, light pink wound bed with border of yellow tissue. Pressure area x2 noted to right buttock with wound beds light pink and moist with border of light-yellow tissue. Right heel noted with reddened, intact skin. Clinical Care Coordinator (CCS) advised of observations for further evaluation. By Employee #88 LPN. --12/24/20-5:20 pm - Patient has wound(s) but no treatment was provided during this shift. Site and description: right buttocks- stage 2 to right buttocks; unable to visualize wound bed due to dressing. Left buttock- unstageable to left buttock; unable to visualize wound bed due to dressing by Employee #40, LPN. Review of Baseline Care Plan dated and signed on 12/23/20, found: Problem: Potential skin breakdown. Goal: Skin integrity will be maintained or improved during the transition period. Interventions: [MEDICATION(S)] ointment to bilateral lower legs. Assist patient with repositioning every two hours and as needed for comfort while in bed or up in chair. Review of Physician Orders on admission 12/14/20 through 12/31/21, found no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Treatment Administration Record (TAR) for period 12/14/20 through 12/31/20 found no record of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure Ulcer reassessment completed by Employee #41, (RN) on 01/05/21- left buttocks unstageable 8 cm in length and 5.5 cm in width depth unable to determine (UTD). Undermining present around the entire wound edge. Unable to determine presence due to slough tissue and necrotic tissue present. Edges are not attached, and a moderate amount of bloody, purulent brown colored drainage noted and odor which remained after area was cleansed. Temporary wet to dry dressing applied in order to consult Name of Physician for further treatment orders. Area covered with an ABD pad and tape. Right buttocks- Stage II. measured 2 cm in length and 1 cm in width and depth unable to be determined (UTD) with no drainage or odor noted. Area was cleansed with wound cleanser and assessed. Non-blanchable area noted with partial loss of dermis. Surrounding area is macerated and reddened but blanchable. Area was covered with ABD pad due to proximity of pressure ulcer to left buttocks, awaiting further orders from Name of Physician. Medical records remain silent concerning contact of Physician/Nurse Practitioner (NP) and treatment orders for wounds. Review of an Acute Care Transfer dated 01/07/21, found under skin condition coccyx- stage 2 pressure ulcer. NP note on 01/13/21-History of present illness: Nurse asked me to evaluate wound to buttock; resident noted to left and right buttocks. States came here with a wound to her buttock. Resident complains of discomfort to area. Foul odor noted to wound with purulent green discharge. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . and Pressure ulcer of right buttock, stage 2. Wound culture obtained. Continue [MEDICATION(S)] which was ordered for pneumonia. Refer to wound clinic as soon as possible (ASAP). Wet to dry dressing to right buttock twice daily. Optiform to left buttock 2 x a week and as needed, monitor and notify if any change. Review of Physician orders found treatment orders written by the NP on 01/13/21 for left and right buttocks. Physician visit on 01/14/21- The document states this resident has a Stage 3 to left buttocks. and the NP seen the resident on 01/13/21 and ordered a C&S of the left buttocks with wet to dry dressings twice daily and Opti form to right buttock 2 x weekly and prn- stage 2. Nursing called early this am due to patient was tearful with wound care. [MEDICATION(S)] ordered. Refer to wound clinic. Documented the nurse gave the medication at 2:56 am after notifying the physician. Review of MDS with ARD of 12/21/20 under Section M-Skin conditions: reports one (1) stage 2 pressure ulcer. Under Section S- Skin Condition indicates the resident has two (2) new or reoccurring pressure ulcers that occurred prior to admission and the resident has two (2) pressure ulcers on left buttocks; no mention of right buttocks area noted on admission. 01/25/21- C&S results noted on this date Scant [CONDITION(S)] (MRSA) and new order for [MEDICATION(S)] D/S twice daily for 14 days on 01/26/21- [MEDICATION(S)] discontinued and [MEDICATION(S)] 750 mg IV daily for 10 days and [MEDICATION(S)] 1.5 grams IV every 6 hours for 10 days. Wound Assessment completed by Employee #80, RN on 01/26/21 reads: left buttocks Stage 4 and measures 11 cm in length and 7 cm in width depth 2 cm. Undermining present around the entire wound edge and tunneling of 5 cm at 10 o'clock. Eschar tissue present. Edges are not attached, and a moderate amount of bloody, purulent brown colored drainage noted and odor which remained after area was cleansed. Called and made appointment with the wound care clinic (scheduled for 01/27/21) Right buttocks- Stage II. measured 7 cm in length and 3.5 cm in width and 1 cm in depth with scant amount of blood tinge drainage and odor present after cleansing of wound noted. On 01/27/21 Resident out to wound clinic and was transported to emergency room from office due to Sacrum pressure ulcer gangrenous black tissue. The resident was admitted for surgical debridement and care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Policy for Wound management (issued on 05/01/2016 and revised 05/10/18): 1. This policy serves as a guide for the interdisciplinary team (IDT) to promote wound healing and prevent infection . 2. At the time of admission/readmission, the discharge records from the prior facility will be reviewed for information relating to wounds, pressure ulcers, and/or alteration in skin integrity. Staging from another facility is not adopted for use in the facility. 3. To identify the resident at risk for development of pressure ulcer 4. Wounds are evaluated at the time of admission/readmission by a licensed nurse. Within 24 hours, an RN will complete an assessment of the wound/pressure ulcer. Documentation will be made in the patient's medical record. 5. At least daily documentation by a licensed nurse is recommended on any wound receiving treatment. 6. Weekly wound assessments are recommended on any wound receiving treatment. 7. Closed pressure ulcers should be followed and documented on for two (2) weeks using the at least daily documentation and weekly assessment. 8. Wound care guidelines are provided; however, the guidelines do not take the place of timely physician notification and following a physician order. b) Resident #38 During an observation of wound care on 03/17/21 at 10:34 AM, with the Clinical Care Supervisor (CCS) #50 and the Licensed Practical Nurse (LPN) #58 it was noted and pointed out to CCS #50, three new areas of concern on Resident #38's feet. CCS #50 stated she did not have a treatment order for those areas. There was no prior assessment of those areas. During a brief interview with Director of Nursing on 03/17/21 at 11:38 AM, the DON was made aware of the wound care observation, and the new areas of concern. The DON stated, she would go and reevaluate Resident #38's feet. On 03/18/21 at 10:13 AM, the DON provided documentation on the three areas of concern on Resident #38 feet identified by surveyor on the previous day. Right foot was a new vascular ulcer. A blanchable redness area on right outer foot. The left outer foot had a Suspected Deep Tissue Injury (SDTI), with measurements of length 1cm by 1cm. These new areas were not documented prior to surveyor intervention.

Based on resident representative interview, staff interview, observation and record review the facility failed to ensure residents received care in accordance with professional standards of care. Resident #179 had bruising to the face, shoulder and hip which the facility failed to adequately assess and treat in a timely manner. Once Resident #179 was transferred to the hospital per the request of her representative, the resident was found to have a bilateral brain bleed, a fractured shoulder, fractured collarbone and a fractured hip. This failure resulted in actual harm for Resident #179. Resident #21 was hospitalized for COVID - 19 upon readmission to the facility the staff failed to ensure he received the medications recommended by the infectious disease doctor upon his discharge from the hospital. Resident #49 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was true for three (3) of 26 sampled residents during the Long-Term Care Survey. Identified Residents #179, #21, and #49. Facility census 81. Findings included: a) Resident # 179 On 03/15/21 at 2:34 PM, a phone interview was conducted with the Medical Power of Attorney (MPOA) for Resident #179. The MPOA stated, he received a phone call on 11/14/20. The call was from Licensed Practical Nurse (LPN) #60, telling him his mother (Resident #179) had bruises on her face, shoulder, and hip. He asked if she was ok, and the LPN #60 assured him she was. LPN #60 told him they believe the resident received the injury's the day before while outside the facility at the [CONDITION(S)] center. At that time, he called his brother who lived nearby to go to the facility and check on his mother. The facility would not allow his brother to see her until the next day on Sunday (11/15/20). His brother initiated a video chat with him while in his mother's room. He stated his mother would not talk to them she would just moan. He said, he called the nurses station many times asking about his mother and her injuries. At one point he said LPN #60 told him his mother was singing earlier in the day. He continued to say this went on for several days. He said he was very concerned about his mother because every time he would video chat with her all she would do is moan. Then on 11/17/20, he called the facility and asked for the nurse to go to his mother's room and video chat with him. He asked the nurse to put the iPad close to his mother and he asked, Mother what is wrong? What happened to you? His mother began to cry and said, They Dropped Me and broke my elbow. He then stated, he called the nurses station again and demanded his mother be sent to the hospital. The MPOA stated, he was later contacted by a doctor from the emergency room (ER) at a local hospital and was told his mother needed to be sent to a different hospital for a higher level of care due to her injuries. Which included a bilateral brain bleed, broken collarbone, broken shoulder and broken hip. He said, it upset him so much because his mother had such severe injuries, and no one cared enough to get her medical attention. The facility completed an abuse and neglect investigation into this matter. Upon review of the investigation the following statements were reviewed and read as follows, The Social Worker #54 on a statement dated, 11/14/2020 wrote, Arrived at facility after receiving information of possible reportable. I observed resident and gathered witness statements from the staff. I called Administrator for instruction. She instructed I speak to a Unit Charge Nurse and ask for (name of Resident #179's attending physician) to be contacted about sending out resident or doing additional testing. I spoke to (Name of LPN #60) who called (name of attending physician) relayed message and asked if he would like additional testing or to be sent out. He declined stating if she (resident #179) wasn't showing signs of pain, discomfort, or neuro symptoms she did not require this. LPN #60 stated that was what he said the first time he was contacted about her (Resident #179). Nurse Aide (NA) #120 on a statement dated 11/14/20 wrote, I did provide care for (Name of Resident #179) yesterday Friday 13th, 2020. I did not see any bruising, and she did not act like she was in pain from what I noticed. She didn't have a fall that I know of. NA #96 in a statement dated 11/14/20, wrote, (Name of NA #36) came and asked me for help providing care for (name of Resident #179) Upon providing care we found multiple bruises along the right side of her body. The bruises were not present on 11/13/2020 at 6:15 PM, while assisting nurse with treatments. They were present when providing care during our shift, therefore we informed the nurse. NA #77 in a statement dated 11/14/20, wrote, I was assisting with care on (name of Resident #179) when taking clothing off we noticed bruising. Bruising on side of face, shoulder and hip. Resident said, some girl was rough and her shoulder hurts. NA #36 in a statement dated 11/14/2020, wrote, I was doing my rounds checking my residents. I went to check (name of Resident #179) I asked (name of NA #77) and (name of NA #96) to help me clean her up. As we were cleaning her up taking her clothes off thats when noticed the bruises on her right side of her face, the shoulder, hip and arm. I then asked (name of NA #96) to go get the nurse. (Name of NA #36 and NA #77) stayed in the room to finish cleaning her up. That's when (name of Resident #179) said that the girl was rough with her and that her shoulder hurts. I asked her what girl was rough with her, but she didn't answer me. LPN #60 in a statement dated 11/14/20, wrote, While passing medication on the afternoon of 11/14/2020, I was approached by (name of NA#96) who stated that he needed me in residents room, upon entering the room, (name of NA #96 and NA #36), also pointed out that resident had marked purple bruising to her right shoulder, right hip, right temple, right outer canthes of her eye and right ear/earlobe. [CONDITION(S)] observed around the outer canthus of the right eye with some abnormal red discoloration also observed outside the edemateus region. Resident denies pain, denies pain upon palpation to the area. States, she rolled me too hard. Resident is transported out of the facility 3x/week for [CONDITION(S)], and had treatment yesterday (11/13/20), Wound care was completed by this nurse last night around 8 PM and no bruising/[CONDITION(S)] was not observed at that time, nor was it observed by myself this morning, as resident was on her side when entered her room. Register Nurse #119 in a statement dated 11/14/20, wrote, Prior to the start of my shift on 11/13/2020, I assisted LPN #60 to turn (name of Resident #179) and apply her wound vac. At that time, no bruising or swelling was noted. Throughout my shift, resident did not experience any falls and did not have any verbal or nonverbal complaints of pain or discomfort. No bruising or swelling was noted. throughout my shift. When I reported off to oncoming nurse, resident was resting quietly and was not in any acute distress. Activities Assistant #92 in a statement dated 11/17/2020, wrote, I facetimed (name of Resident #179)'s son (Name of MPOA) 4 PM, while he was talking with her she started crying and said something about those girls dropped her on the floor and broke her elbow. He asked her if she was in pain and she said she was hurting really bad. He told her don't worry he would get them to have her checked out and make sure she was ok, we hung up so he could call the nurse. Once the son found out he started asking her questions about who dropped her or where she was. I didn't hear everything she said. Nurse Aide #115 on a statement dated, 11/17/20 wrote, I provided care for (Name of Resident #179) Thursday night into Friday morning, the 12th into the 13th. I didn't notice anything bruising wise. She slept all night that night, but she never acted like she was in pain. She didn't have a fall that I'm aware of. LPN #117 in a statement dated 11/17/2020 wrote, I was the night shift nurse on shift the morning of 11/13/2020. It was brought to my attention that Resident #179 has sustained multiple bruises to her right side of her body. I had contact with the resident at approx. 0400 AM that morning to D/C her wound vac and apply a dressing to her wound and give her AM medication prior to [CONDITION(S)]. The resident was fine upon me leaving her that morning, I had two CNA's on the hall that morning (Name of NA #116) an (Name of NA #121), (Name of NA #116) was assigned to get (Name of Resident #179) dressed cleaned and transferred to our stretcher for [CONDITION(S)]. (Name of NA #121) told (Name of NA #116) she would help her get (name of Resident #179) ready and, on the stretcher, after she finished with the resident she was with. (Name of NA #116) had (Name of Resident #179) on the stretcher before (Name of NA #121) went to help her. Which tells me she put (Name of Resident #179) on the stretcher alone. I was not there to witness what occurred in the room as I was on a med Pass on A2 hall. I have never helped transfer (Name of Resident #179) to a stretcher for [CONDITION(S)] or any other reason. Physical Therapist Assistant (PTA) #104 on a statement dated 11/17/20, wrote, While treating patient on 11/12/,11/13/2020, I did not notice any bruising or discoloration on patient's skin, however, on one of those days, during her therapy time with me, she (name of Resident #179) stated, they dropped me I said, they dropped you, who dropped you? Patient did not respond. I did not report this because I did not notice or see any physical evidence and patient has a history of being confused at times. The Administrator in a statement dated 11/17/20, wrote, This administrator in the presence of Director of Nursing spoke with (name of Resident #179) at bedside. I introduced myself and proceeded to ask her about any type of fall she has had recently. She stated, they dropped me she said it was women not men, when asked if it were the staff here at the nursing home she said no at [CONDITION(S)]. She did not identify any specific person or description of anyone. Nurse Aide #115 in a statement dated 11/18/20 wrote, I have to transfer (name of Resident #179) before when I first started here but it's too hard on one person to do it so I won't do that anymore. The last morning, she went to [CONDITION(S)] I had (Name of NA #118) help me transfer her over from the bed to the stretcher. As far as someone saying I've dropped (name of Resident #179) because someone wouldn't help me that's the first time I've heard that. Night shift is good about helping one another but day shift not so much. The only person I work good with here is (name of NA #118). If she needs help, I help her and if I need help, she helps me. We do team work very well together and it's a shame it's not like that with everyone. NA #118 in a statement dated 11/19/20 wrote, On Friday Nov. 13, 2020 I went to A side to speak to (Name of NA #116) about being mandated to stay over that morning. I asked (Name of LPN #117) where she was, he told me she was with (name of Resident #179). I went into (name of Resident #179) cleaned up and ready to transfer to [CONDITION(S)]. She (NA #116) asked me to help slide her onto the facility stretcher, I did, and she was transferred safely, we buckled her down so she wouldn't fall off. (Name of Resident #179) didn't seem to show any signs of pain or anything after that I went back to B side. Further review of the investigation conducted by the facility found, they attempted to obtain statements from the [CONDITION(S)] center, but was informed their lawyer advised them to not provide statements. The following interviews were conducted by this surveyor: On 03/18/21 at 10:20 AM, the facility Attending Physician (AP) was interviewed via phone. The AP was asked if he recalled getting a second phone call concerning Resident # 179. He stated, he was informed the following day or so that the bruising was extending, and the resident was sent out to the hospital. He stated that he requested for the facility to get an x-ray inhouse. He was unaware the x ray not obtained. He was also unaware that no neuro checks were initiated at this point. After Attending Physician was told of the extensive injuries Resident #179 had after going to the local hospital he said, sounds like we could have done better, in the way of following up. He said, he was concerned about sending her out unless it was a serious injury do to COVID and there were no beds available at the local hospital. He said, he was relying upon the nurse's assessment which was conveyed to him over the phone. An interview on 03/18/21 at 10:42 AM, with Nurse Aide #96 revealed he recalled taking care of Resident #179 on the evening of her return from [CONDITION(S)] on 11/13/20. NA #96 said, he did not see any bruising on the resident at that time. In addition, he stated, he took care of her on the following day with NA #36 and noticed the bruising on Resident #179. When asked if Resident #179 appeared to be in pain he stated, some days she talks a lot and some days she does not, but she did moan while we were providing care. He further stated, when we saw the bruises, I let LPN #60 know about the bruising. During a phone interview with Nurse Aide #36 on 03/18/21 at 11:03 AM, NA #36 was asked if she took care of Resident #179. She said, she did. She was asked if she noticed any bruising on Resident #179 on Friday the 13th, 2020. She said, no, but she the one that discovered the bruises on the next day, Saturday, 11/14/20. She stated, I had two other nurse aides help me with Resident #179. I asked NA #96 to go get LPN #60 to come and look at the bruises. She was asked if Resident #179 appeared to be uncomfortable. NA #36 stated, she moaned when we moved her, but she has contractures to her legs and arms, so it was painful for her anyway. She was asked about the process for transporting residents from the facility to the [CONDITION(S)] center. She said she is not at the facility when Resident # 179 goes to the [CONDITION(S)] center. For other transfers out of the facility, facility staff transfer residents to the facility's stretcher. Facility staff then use the stretcher to transport residents to the entry way of the facility. Facility staff transfer the residents to the ambulance stretcher. Due to COVID, ambulance personal do not go to resident's rooms. NA #36 stated when the resident returns to the facility from [CONDITION(S)], some staff use a draw sheet, and some staff transfer with two people, but she always uses three people. One person to hold the feet and two on each side to move the body. On 03/18/21 at 11:22 AM, an interview via phone with LPN #60, confirmed LPN #60 recalled 11/14/20 was a weekend. They discovered Resident # 179 had some bruising on the right side of her face, eye, ear, and shoulder. She was asked if she called the Attending Physician, she said, she did, and she did not get any new orders. She went on to say Resident # 179 was already getting a scheduled pain medication. When asked if neuro checks were initiated, LPN #60 stated, no because she had bruising to her face and not her head. She was asked if she remembered getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why she made Late Entries in the electronic medical record three (3) days after Resident # 179 had been discharged , which were the same as the first notes that were originally entered, only with more details, she answered, I do not know why. She was asked if during this time frame in November of 2020, did the ambulance personal go to the resident's room to transport the residents? She said yes, they go to the resident's room and they load them on the stretcher and on return would unload them to their bed. During an interview on 03/17/21 at 12:36 PM, the Director of Nursing (DON) was asked about all the late entry notes on the electronic medical record of Resident #179. The DON reviewed all the late entries made by LPN #60 3 to 4 days after the incident. The DON stated, These notes make all of this look so convoluted. On 03/18/21 at 12:15 PM, the Administrator was asked how she would expect the staff to transfer residents. She said with a draw sheet unless Physical Therapy said they were to be moved using a lift. She was asked during the month of November did the ambulance crew go to the resident's room to transport residents to [CONDITION(S)]. She stated, that due to COVID the staff would transfer the resident to the facility stretcher, take the resident to the lobby, and transfer the resident to the ambulance stretcher. The same process is followed when residents return to the facility. The administrator stated this was to prevent unnecessary people going through the facility. When asked if the resident was assessed to have a mechanical lift for transfers, would the staff use a mechanical lift in the room and in the lobby of the facility for transfers, the administrator replied, Yes. She was then asked if she would be surprised to know facility staff confirmed both verbally and in writing a mechanical lift was not used to transfer Resident #179. She said yes, she would because the staff have been in serviced. The administrator reviewed the statements from staff contained in the investigation and was made aware of the telephone interviews completed by the surveyor. At this time the administrator reviewed the Kardex (a Kardex informs staff on what care the resident requires.) Under the heading Transferring/ Positioning: *Transfer self-performance: 2-person physical assist with Mechanical lift. * Bed Mobility self-performance: Patient requires 2-person physical assist. Review of the Documentation Survey Report: (documentation by the NA's to indicate how the staff transferred the resident, including the number of staff and equipment used) Although Resident #179 was transferred out of the facility three times a week for [CONDITION(S)], the staff rarely documented the transfers on the documentation tool. The week Resident #179 sustained the injury the following was documented: On 11/12/20 Night shift (22:00-6:00) time: 11:50 PM, Transfer: self-performance- How resident moves between surfaces -T (total dependence) Transfer: support provided- 1-person physical assist Devices used: NA (this is not an option on the list of devices. On 11/13/20 Evening shift (2:00PM-10:00PM) time: 9:59 PM, E- Extensive assistance- Resident involved in activity. (Resident #179 was unable to assist with her transfer. 1- person physical assist. Devices used: OT (Other) not a mechanical lift as ordered. This information was shown to Administrator and Director of Nursing (DON) on 03/18/2021 at 5:10 PM. After reviewing the documentation, the DON stated she is not so sure Resident #179 received the injuries while out of the facility. Resident #179 was found to have been injured on 11/14/20, however; she did not receive medical treatment until 11/17/20 at 5:45 PM after her MPOA insisted she be transferred to a local hospital for evaluation or treatment. Resident #179's attending physician verbally confirmed in an interview he wanted Resident #179 to have in house x rays and neurological assessments, and if both were okay she would not need to be transferred out, due to the hospital bed shortage related to COVID. The facility staff failed to obtain the neurological assessments or x rays as ordered by the physician. Once the MPOA insisted on Resident #179 being transferred to a local hospital the following injuries were identified at the hospital: *Bilateral intracranial hemorrhages (Bleeding on both sides of the brain) *Subluxation of the glenohumeral (dislocated shoulder) *fracture of the distal clavicle from traumatic fracture (fractured Collarbone) *small osseous fragments seen along the scapular spine which could reflect traumatic fracture (bone fragments along the shoulder blade) * right hip fracture. Even though the location where Resident #179 sustained the injuries can not be determined the facility failed to assess and treat the injuries timely once they were identified by the facility staff. b) Resident #21 A review of Resident #21's medical record on 03/16/21 at 2:08 p.m. found a hospital discharge summary dated 01/06/21. This summary indicated Resident #21 was hospitalized due to COVID-19. The discharge summary included a progress note from the infectious disease physician who treated Resident #21 while in the hospital. The progress note included the following, . 5. If the patient is discharged , I will treat the patient with [MEDICATION(S)] 300 mg p.o. b.i.d. and [MEDICATION(S)] 500 mg p.o. daily for 10 more days. This page of the discharge summary was signed by the facility's nurse practitioner on 01/13/21. Further review of the record indicated the resident was readmitted to the facility on [DATE]. Review of Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of this MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Director of Nursing (DON) at 11:26 a.m. on 03/17/21 confirmed Resident #21 only received three (3) days of [MEDICATION(S)] and did not receive the [MEDICATION(S)]. She indicated she had reviewed the medical record and found no reason why Resident #21 did not receive the [MEDICATION(S)] and [MEDICATION(S)] as requested by the infectious disease physician. C) Resident #49 (R49) A medical record review on 03/16/21 revealed an order (as written) Foley catheter #18FR with 10CC balloon. Change drainage bag when catheter is changed and as needed. Start date 12/17/20. During an observation on 03/15/21 at 4:05 PM, it was discovered R49 had no catheter drainage bag hanging from their bed. The Director of Nursing (DON) on 03/16/21 at 11:15 AM verified R49 did not have a catheter and the order for the catheter had not been discontinued.

Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sensitivity was received and appropriate antibiotic was ordered by facility's physician/staff. The facility's abatement plan of correction consisted of the following: 1. Resident # 57 was identified as being affected by the alleged deficient practice of failing to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].#57 physician was notified immediately by the Director of Nurses (DON) on 1/29/2020. Resident #57 physician current course of treatment implemented was to obtain a UA with C & S this was completed on 1/29/2020 by the Unit Charge Nurse (UCN). The Unit Charge Nurse obtained an order for [REDACTED]. Quality Standards Nursing Coordinator educated the Director of Nurses (DON), Clinical Care Supervisor (CCS), and Registered Nursing Assessment Coordinator (RNAC) on antibiotic stewardship data base, documentation expectations, and follow through immediately on 1/30/2020. All Unit Charge Nurses on duty will be educated immediately by a Quality Standards Nursing Coordinator on 1/30/2020 on reading/interrupting a UA with C & S lab results, documentation expectations, communication with physician on lab results, and follow through. Nurse Practitioner examined Resident #57 and reviewed findings with physician in person on 1/30/2020. The CCS or designee will obtain C & S results from the lab by 2/3/2020. The CCS or designee will immediately upon receipt of lab results will report to physician or nurse practitioner for further orders as necessary. 2. DON or designee will educate all nurses at the being of each shift prior to going to the floor until all nurses have been educated starting 1/30/2020 - 2/3/2020. Any nurse on leave of absence will be educated immediately upon return to work prior to going to the floor to provide care. Quality Standards Nursing Coordinator completed an audit of current antibiotic use on 1/29/2020 and no other residents were identified as being affected by the alleged deficient practice. The nurse receiving lab results will review results with the physician or nurse practitioner by the end of the shift. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The UCN must contact the physician or nurse practitioner and obtain new orders within accordance with antibiotic stewardship. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The CCS or designee will monitor antibiotic stewardship to ensure diagnostic results have been obtained and the physician or nurse practitioner was made aware and required documentation is completed daily. Antibiotic Stewardship data base will be reviewed daily by the CCS or RNAC or designee daily. 3. The DON will review all findings and report in QAA monthly for follow up to assure POC is effective. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. No further information was provided at the close of the survey at 12:30 PM on [DATE].