Every finding on record at Meridian Center

Based on observation and staff interviews, the facility failed to label and date food items stored for use in the reach-in refrigerator for 1 of 1 reach-in refrigerator and failed to use gloves when handling an unpeeled cucumber for 1 of 5 kitchen staff observed. These practices had the potential to affect food served to residents.Findings included:A.On 6/7/26 at 9:15 am the initial kitchen observation was completed with kitchen staff #1. The reach-in refrigerator had the following food items that were not in the original manufacturer's packaging and were not dated: Six applesauce cups no longer in the original package, One yellow pudding consistency food item in a large metal bowl with plastic wrap which was lying in the food and no longer covering. The food item appeared to be runny with water pooling on the edges, and Fourteen poured cups of thickened liquid were in plastic cups. On 6/7/26 at 10:45 am an interview was completed with the Dietary Manager (DM). The DM stated that all food items required an expired by date when placed in alternate packaging. B.On 6/9/26 at 12:32 pm an observation and interview were completed with kitchen staff #2. Kitchen staff #2 was observed holding 2 cucumbers with bare hands. Kitchen staff #2 was preparing to start cutting the cucumber over a bowl of already sliced cucumbers when asked about gloves and she stopped before slicing. Kitchen staff #2 stated she took her gloves off for something else and had not replaced her gloves to directly handle and prepare residents' food. Kitchen staff #2 further stated she was required to wear gloves when directly handling resident food items for preparation. On 6/9/26 at 12:38 pm an interview was completed with the Dietary Manager (DM). The DM was informed that kitchen staff #2 had not worn gloves when directly handling and preparing resident food. The DM stated staff were required to wear gloves when handling food. On 6/11/26 at 11:45 am the Administrator was interviewed. The Administrator was informed of the kitchen observation of the undated food items and a kitchen staff member not wearing gloves while handling/preparing food. The Administrator had no comment.

Based on record review, staff and resident interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #8) accepted a meal purchased by Resident #144 through an online food delivery service and failed to reimburse Resident #144 for the cost of the meal. The deficient practice was for 1 of 2 residents reviewed for misappropriate of resident property (Resident #144).Findings Included:Resident #144 was admitted to the facility on [DATE].Review of Resident #144's quarterly Minimum Data Set (MDS) Assessment indicated Resident #144 was cognitively intact.An initial allegation report dated 5/2/26 completed by the Administrator showed that Resident #144 made the Registered Nurse (RN) Weekend Supervisor aware on 5/2/26 that on 5/1/26, Nurse Aide #8 took his online food delivery service order and did not deliver it to him.A review of the 5-day investigation report dated 5/8/26 completed by the Administrator revealed that on 5/5/26 the Director of Nursing interviewed Resident #144 and he indicated that on 5/1/26 he felt pressured by Nurse Aide #8 to order the staff member food via an online food delivery service, but he did willingly order the food. Resident #144 was also reported to have stated Nurse Aide #8 agreed to pay him back in the amount of $26.19 however she did not pay him back on 5/1/26 and that he wanted his money returned. The report indicated that both local law enforcement and the county departement of social services were notified, however neither agency made an onsite visit nor filed charges.An interview was conducted with Resident #144 on 6/7/26 at 10:36 AM. Resident #144 indicated that the allegation was that he and Nurse Aide #8 were discussing lunch and that he agreed to buy Nurse Aide #8 lunch from an online food delivery service. He explained that although he felt pressured, he agreed and that Nurse Aide #8 was supposed to reimburse him that day but never did so he reported the incident the next day. Resident #144 further revealed that the Administrator refunded the full amount of money and felt that the complaint had been resolved.An attempt was made to interview Nurse Aide #8 by telephone however the phone number was no longer in service.An attempt was made to interview RN Weekend Supervisor, but attempts were unsuccessful.An interview was conducted with the Administrator 6/11/26 11:11 AM. The Administrator indicated he was contacted by the RN Weekend Supervisor on 5/2/26 and she reported that Resident #144 stated on 5/1/26 he had ordered from an online food delivery service and Nurse Aide #8 never gave it to him. The Administrator indicated that Nurse Aide #8 was identified and was immediately suspended pending an investigation. The Administrator indicated that both law enforcement and the department of social services were contacted but neither agency made an onsite visit and no charges were filed. The Administrator further revealed the RN Weekend Supervisor misunderstood Resident #144's initial allegation and when the Director of Nursing interviewed Resident #144 on 5/5/26 he stated he had felt pressured by Nurse Aide #8 to order her food via an online food delivery service but that he did consent to order the food. Resident #144 indicated that the staff member had agreed to pay him back $26.19, however she did not pay him back the money. The Administrator revealed that Nurse Aide #8 was interviewed, and she indicated that she and Resident #144 were discussing lunch and Resident #144 asked her what she wanted for lunch and that he placed the order via an online food delivery service on his phone and she would pay him back. The Administrator indicated that Nurse Aide #8 did not pay Resident #144 for the meal on 5/1/26 and was suspended on 5/2/26. The Administrator further revealed that upon completion of the investigation the facility did not substantiate the allegation of misappropriation of resident property because Resident #144 willingly ordered the staff member lunch. However, Nurse Aide #8 was terminated based on violating the facility policy which stated employees may not solicit, extend or accept gifts or gratuities from patients/residents, their families, visitors or referral sources. The Administrator indicated out of good faith the facility refunded Resident #144 $26.19 on 5/6/26. The Administrator indicated that facility staff should never solicit, extend or accept gifts or gratuities from residents.An interview was conducted with the Director of Nursing on 6/11/26 at 11:51 AM and she indicated she interviewed Resident #144 on 5/5/26 and he indicated that he stated he had felt pressured by Nurse Aide #8 to order her food via an online food delivery service but that he did consent to willingly order the food. Resident #144 indicated that the staff member had agreed to pay him back $26.19, however she did not pay him back the money. The DON further revealed that Nurse Aide #8 should not have asked Resident #144 to order her food and that this was against facility policy.

Based on observations, record review, and resident and staff interviews, the facility failed to provide nail care for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #68). The findings included:Resident #68 was admitted to the facility on [DATE] with diagnoses including essential hypertension, communication deficit, unspecified visual loss, and chronic pain syndrome.A care plan dated 6/5/2026 indicated Resident #68 had an ADL self-care performance deficit with a goal that read Resident #68 would maintain his current level of function. The care plan revealed the resident was dependent on the assistance of one staff with personal hygiene.The significant change Minimum Data Set (MDS) assessment completed 5/22/2026 documented Resident #68 as cognitively intact, without refusal of care behavior, and dependent on others for personal hygiene.Resident #68 was observed on 6/7/2026 at 10:39 AM. The free edge of Resident #68's fingernails on both hands were either jagged or broken, extended past his fingertips by what appeared to be more than 1/2 inch, or about the width of a pencil eraser. An interview conducted with Resident #68 on 6/7/2026 at 10:39 AM indicated his preference was to keep his fingernails short. He stated he has never had long nails, and he always kept his nails short. The resident stated long fingernails made him feel uncomfortable especially with his vision loss.A second observation on 6/8/2026 at 1:21 PM of Resident #68 revealed the free edge of Resident #68's fingernails on both hands were either jagged or broken, extended past his fingertips by what appeared to be more than 1/2 inch, or about the width of a pencil eraser. A second interview on 6/8/2026 at 1:21 PM with Resident #68 stated he had asked a Nurse Assistant (NA) at least three times to cut his nails. He was unable to recall who the NA was and the time. Resident #68 stated it made him feel frustrated because he was unable to do it himself anymore and he felt like the staff do not care and like he was forgotten. During this interview Resident #68 used his call light to request his fingernails to be cut. The Speech Language Pathologist (SLP) was the staff member who responded to the light and told the resident she would let his nurse know.A review of the shower log revealed Resident #68 was documented as a receiving shower on 6/8/2026. A follow-up interview with Resident #68 on 6/9/2026 at 10:02 AM revealed he had received a shower on 6/8/2026 but did not have nails cut.A third observation of Resident #68's fingernails on 6/9/2026 at 7:23 AM revealed them to be unchanged, and in the same condition as the observations from 6/7/2026 at 10:39 AM and 6/8/2026 at 1:21 PM. A third interview with Resident #68 was conducted on 6/9/2026 at 7:23 AM. Resident #68 shared that he asked the NA that came in his room the evening on 6/8/2026 and she stated, she did not have time to cut his fingernails. Resident #68 indicated the NA never gave her name. Resident #68 stated he was there because he needed help not because he wanted to be there and he was upset because he was unable to get the care he asked for. Resident #68 stated he didn't like having long nails. NA #1 was interviewed 6/9/2026 at 10:00 AM and accompanied to Resident #68's room to observe his fingernails. During the interview NA #1 confirmed she was assigned to Resident #68 on 6/9/2026. NA #1 stated that she performed nail care on shower days. She stated nail care included cleaning under the nails and cutting/trimming if needed. NA #1 stated if she observed a resident's nails long, she would cut them even if it was not their shower day. NA #1 observed Resident #68's nails and stated they were long. NA #1 stated it was not Resident #68's shower day but she assured Resident #68 she would give him a shower and provide the requested nail care that day. NA #1 was unaware of why nail care had not been provided to Resident #68. Unit Manager (UM) #1 was interviewed on 6/9/2026 at 10:08 AM and accompanied to Resident #68's room to observe his fingernails. She stated that nail care was performed when residents received showers or as needed. UM #1 observed Resident #68's nails and stated she was going to make sure Resident #68's nails were cut as soon as possible. She agreed Resident #68's nails were long. The Unit Manager was unable to explain why Residents #68 had not received nail care. A follow up interview with Resident #68 was conducted 6/9/2026 at 4:28 PM. Resident #68 had received a shower that day, and nail care was provided by NA #1. Resident #68 stated his nails were cut to the length he liked and felt comfortable with.An interview with Director of Nursing (DON) was conducted 6/9/2026 at 10:22 AM and she indicated that nail care was provided to residents on shower days or as needed. The DON stated she expected staff to provide nail care to residents on shower days and at any time it was requested. The DON was unable to explain why nail care had not been provided on shower days or when requested by Resident #68.The Administrator was interviewed on 6/11/2026 at 12:40 PM and stated he was unaware Resident #68 had not received nail care. He was unable to explain why the nail care had not been provided. The Administrator stated he expected staff to provide nail care with their routine care and if it was requested.

Based on observations, record review, and resident, resident representative, staff, Neurosurgery Staff Nurse, Wound Care Physician, and Medical Director interviews, the facility failed to follow up with the neurosurgeon's office regarding a follow up appointment to address resident's staples. The deficient practice affected 1 of 1 resident reviewed for quality of care (Resident #1).The findings included:A review of Resident #1's hospital Discharge summary dated [DATE], it was noted that the resident underwent a C4-T2 (4th cervical vertebra through 2nd thoracic vertebra) posterior fusion on 4/30/26. It was also noted that there were no follow-up visits scheduled for Neurosurgery or guidance provided regarding the 15 staples present in her surgical incision.Resident #1 was admitted to the facility on [DATE]. Her diagnoses included a non-displaced cervical fracture C6 and C7 (cervical spine in neck) acute 3-column fracture of C6 (a severe and unstable cervical spine injury in which all three structural columns of the vertebra are involved, and carries a high risk of spinal cord compromise), unspecified protein calorie malnutrition (a condition where the body lacks sufficient protein and calories to meet metabolic needs, leading to impaired body function and tissue loss), and history of feeding tube placement for nutritional support.An admission note dated 5/12/26 at 9:04PM written by Nurse #8 revealed Resident #1 had a surgical wound described as skin issue to the posterior neck, containing 18 staples. Under the skin section the note stated skin warm & dry, skin color within normal limits (WNL) and turgor (skin elasticity) was normal.An advanced skin check written by Nurse #8 on 5/12/26 at 9:24PM noted Resident #1's skin was warm and dry. It also stated skin color and turgor were WNL. The note also contained skin issue described as surgical wound that was present on admission located on the resident's posterior neck which contained 18 staples.Resident #1's telehealth admission note written by the telehealth physician dated 5/12/26 at 9:10PM contained no information regarding her surgical history or her surgical wound containing staples. That note did not contain a skin assessment. Review of Resident #1's post-emergency room and hospitalization note dated 5/13/26 at 7:23PM, written by the facility Nurse Practitioner stated that the resident's past surgical history included C4 to T2 posterior spinal fusion on 4/30/26 for acute 3-column fracture of C6, performed by Neurosurgery following mechanical fall with non-displaced cervical fractures at C6 and C7. The note also stated the visit was an acute visit as she was new to the skilled nursing facility service following recent hospitalization and spinal surgery. The nurse practitioner noted the resident was hospitalized from [DATE] until 5/12/26 after presenting to the emergency department with neck pain following a mechanical fall. Neurosurgery was consulted and she underwent C4 to T2 posterior fusion on 4/30/26. The nurse practitioner further noted that the resident was found to be clinically stable on the day of discharge from the hospital with no acute symptoms compared to prior and had follow-up appointments scheduled with ophthalmology, cardiology, and orthopedics. She noted under the integumentary(skin) portion of the note, that the resident's skin was warm and dry with no warmth or erythema.An advanced skilled nurse evaluation note dated 5/13/26 03:52AM written by Nurse #8 noted she had a skin issue described as posterior neck surgical wound which was present on admission, with 18 staples. The note did not contain any other information regarding the incision.A review of advanced skilled nurse evaluation, written by Nurse #9 which was dated 5/13/26 at 11:55AM revealed she noted the surgical wound described as skin issue to the posterior neck, containing 18 staples that were present on admission. No other information regarding her skin or the wound was noted.A review of Resident #1's telehealth provider visit dated 5/13/26 at 8:49PM, written by the telehealth physician contained no information regarding her surgical history or her surgical wounds containing staples. That note did not contain a skin assessment. An advanced skilled nurse evaluation note dated 5/14/2026 at11:32AM written by Nurse #10 noted she had the skin issue described as posterior neck surgical wound, which was present on admission, with 18 staples. That note did not contain any other information regarding the incision or a skin assessment.A review of an advanced skilled nurse evaluation written by Nurse #8 on 5/14/26 at 11:32AM noted Resident #1 had a surgical wound described as skin issue to the posterior neck, containing 18 staples that were present on admission. That note did not contain a skin assessment or any other details regarding the resident's wound.Review of an encounter note written by the facility Nurse Practitioner, dated 5/15/25, revealed Resident #1 had a past surgical history of C4 to T2 posterior spinal fusion on 4/30/2026 for acute 3-column fracture of C6, performed by Neurosurgery following mechanical fall with non-displaced cervical fractures at C6 and C7. In the history of present illness, it noted the resident was a [AGE] year-old Caucasian female with a complex medical history including non-displaced fracture of 6th cervical vertebrae. Under Integumentary it was noted her skin was warm and dry, no warmth, no erythema (redness).An advanced skilled nurse assessment dated [DATE] at 11:03AM written by Nurse #9 noted Resident #1 had skin issue described as posterior neck surgical wound, which was present on admission, with 18 staples. No other skin assessment or description of the wound available with that note.A review of an advanced skilled nurse assessment dated [DATE] at 5:44PM written by Nurse #11stated Resident #1 had a skin issue described as posterior neck surgical wound which was present on admission, with 18 staples. That note did not contain any other information regarding the incision. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact with no behaviors present. Resident #1 was dependent for toileting hygiene and showering, otherwise required supervision or set up assistance for all other ADLs and bed mobility. Resident #1 used a walker. She was noted to have a surgical incision. The resident was also coded for having a feeding tube from which she received 51% or more of her caloric intake through. Review of the care plan dated 5/31/26 Resident #1 had a focus listed for surgical wound management. The goals included the wound will be free of signs or symptoms of infection and would show signs of improvement. The intervention listed was to paint with betadine to posterior neck every day. She was also noted to be at risk for falls due to impaired mobility, recent hospitalization, and fracture of her cervical vertebra. The goal was to have no falls. Interventions included to provide education for safe techniques, educate the resident regarding the use of the call light, and provide verbal cues for safety and sequencing when needed.During an interview with Resident #1's son and daughter-in-law on 6/8/26 at 2:30PM, they stated that they were concerned that the resident had no follow up appointment scheduled to see the Neurosurgeon and no plan to remove the staples from the resident's surgical incision. Her daughter-in-law stated that the Neurosurgeon was very involved and she was sure he would want to see the resident. She further stated that she would think the staples would be very uncomfortable. The resident stated they had been in there so long she hardly noticed them anymore. The daughter-in-law pointed out that the resident was 'not a complainer'.An interview was obtained with the Wound Care Physician and Wound Care Nurse on 6/9/26 at 2:00PM. The Wound Care Physician stated he was not worried about Resident #1's surgical incision because he had seen it and everything looked great. He further explained the wound edges were approximated there were no signs or symptoms of infection. The Wound Care Physician stated the staples were fine, and could stay there for 6 months. Surveyor clarified with Wound Care Physician that he would recommend Resident #1's staples stay in for 6 months? He stated, not necessarily, that would not be the normal practice. He stated Resident #1's staples could be in a couple weeks up to a couple months. He stated it would just depend on when the Neurosurgeon wanted them out, but they weren't hurting anything. The Wound Care Physician stated he could take them out on a follow up visit, but that the Neurosurgeon may want to be the want that wanted to remove them. The Wound Care Nurse stated it would have been the responsibility of the admitting nurse to find out when the staples needed to be removed and if there was no guidance from the discharge paperwork from the hospital, it would have been their responsibility to follow up with the Neurosurgeon. The Wound Care Physician stated the Neurosurgeon needed to be contacted to find out if he wanted to see the resident or when he wanted them removed, but from an infection standpoint the wound looked good. He further stated that from a comfort standpoint, the staples may be uncomfortable.During an interview with the Director of Nursing (DON) on 6/9/26 at 2:20PM, she revealed that she was not sure when the staples in Resident #1's neck were supposed to be removed as there was not a scheduled follow up made for the resident to see the Neurosurgeon. She stated if there was no follow up appointment listed on the resident's discharge summary from the hospital, then she expected the facility staff including the admitting nurse, other staff nurses, providers, and herself to have caught that and called the Neurosurgeon's office to get an appointment made. She further explained from her nursing opinion, staples would not normally be left in longer than 14 days. She stated she would make sure she got ahold of the Neurosurgeon's office immediately. An interview with the DON on 6/9/26 at 4:15PM revealed the scheduler was able to call the Neurosurgeon's office and was told to leave Resident 1's staples in place and they wanted to see her in their office. The DON stated the appointment was scheduled for the next day (9/10/26 at 8:40AM).A telephone interview was conducted on 6/10/26 at 2:40PM with Nurse #10 revealed she was not aware that Resident #1 did not have a follow-up appointment with Neurosurgery scheduled. She stated she would have made scheduling aware if she realized, but that task was usually taken care of upon admission to the facility. She stated she was not aware that the resident's staples had been in since 5/4/26. An interview with the Neurosurgery Office Nurse was conducted on 6/10/26 at12:27PM revealed that they generally remove staples 2 weeks post-op (after operation). She stated she would have expected that information to be stated on the residents' hospital discharge paperwork, but if it wasn't she would have expected the facility to reach out to their office to ask. She stated there was no record of the facility contacting them regarding Resident #1 until 6/9/26.During an interview on 6/10/26 at 2:00PM with the Medical Director, she stated that removal of surgical wound staples could vary depending on the surgeon. She further explained that surgeons often prefer to remove their own patient's staples. She stated generally, they are removed after 14 days. She stated her expectation would have been that facility staff would have reached out to the surgeon's office to get guidance on the staple removal within 14 days of her admission to the facility. An interview was obtained with Nurse #9 on 6/10/26 at 2:40PM that revealed she was not aware that Resident #1 had no follow up appointment scheduled with her Neurosurgeon. She stated that was usually taken care of right away when the residents are admitted to the facility. She stated she did not admit the resident so she was not aware of what the discharge paperwork from the hospital would have included. She stated was not aware the staples had been present in her neck since 5/4/26.An observation and interview were completed on 6/10/26 at 3:00PM with Resident #1. The surgical incision no longer had staples present and there was no drainage, swelling, or redness noted. The resident stated the first 2 staples hurt when being removed but she could hardly feel the rest being removed.An attempt for an interview with Nurse #8 (who admitted Resident #1 to the facility who was no longer employed at the facility) was made on 6/10/26 at 3:15PM. No return phone call was received. On 6/10/26 at 3:53PM a request for information was sent to the Neurosurgeon via fax. There has been no reply as of 6/19/26.An interview was conducted on 6/11/26 at 8:19AM with the Medical Records and Transportation staff member. She stated when a resident was admitted to the facility, her process was to look at all paperwork, but she primarily focused on the after-visit notes, appointment paperwork, and discharge summary. She further explained anytime there was an appointment noted on the paperwork she would have immediately made the arrangements for that appointment. She stated sometimes the paperwork may not contain a specific appointment date but may have included follow up with surgeon and she would then call them and make the appointment herself. She stated Resident #1's paperwork did not say that she had staples and she had not seen the resident personally, so she did not know that she needed an appointment to address staples. She stated she was not medical so she relies on the nurses to tell her if there was a particular appointment she would need to make in that situation. She stated as soon as she was told by the DON (on 6/9/26) to make an appointment for Resident #1, she immediately called the Neurosurgery office and was able to get her in for an appointment right away the next day. She revealed she asked the Neurosurgery office staff why Resident #1 did not have any follow-up appointments scheduled and was told because nobody at the facility made one.

Based on observation, record review, resident and staff interviews, the facility failed to provide personal care in a safe manner when Resident # 44 was left unattended in shower room with the side rails on shower stretcher left in down position. Resident #44 rolled off the right side of shower stretcher and required transfer to the hospital for medical evaluation. This was for 1 of 4 residents reviewed for accidents (Resident #44).Findings included: Resident #44 was admitted to the facility on [DATE]. The residents' diagnoses included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body) following Cerebral infarction (ischemic stroke) affecting left non-dominant side, and contractures of left wrist and hand. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #44 was cognitively intact and had range of motion impairment on one side of his upper and lower extremities. The MDS also indicated Resident #44 was dependent rolling left and right.Resident #44's care plan dated on 12/10/25 revealed a focus area of risk for falls: Impaired mobility, cognitive loss, history of Stroke with left Hemiplegia. Interventions included provide verbal cues for safety and sequencing. An additional focus that was included was Resident #44 requires assistance with Activities of Daily Living (ADL), bathing, personal hygiene due to impaired balance due to history of Stroke with left Hemiplegia. Intervention included Resident #44 prefers showers on scheduled bathing days with the use of shower bed/stretcher for shower and provide dependent assist of one for personal hygiene and bath.An interview with Resident #44 on 6/9/2026 at 2:15 PM was completed. Resident #44 stated that he had a fall in the shower room and ended up on the floor lying on his back. Resident #44 was unable to recall the date of his accident and stated it was a couple of months ago. Resident #44 stated the Nurse Aide (NA) that was giving him his shower left the shower room to go get a towel. He stated he was left unattended in the shower room. Resident #44 stated he felt like he was slipping and when he tried sliding to the left towards the wall, he fell off the right side of shower stretcher on to the floor. Resident #44 was unsure how long he was on the floor but stated he thought it was less than two minutes. Resident #44 stated he remembered being in pain and uncomfortable. Resident #44 could not recall what pain level he reported at the time of the accident. Resident #44 stated he had pain in his head, hip and neck. He could not recall if he hit his head on anything. Resident #44 stated that it was usually just one staff member that gave him a shower. Resident #44 revealed that the rails were down on the shower stretcher when the NA left and normally when he receives a shower the rails are up. Resident #44 was unsure why the shower stretcher rails were down and was unable to recall the name of the NA providing the care. Nurse #1 was interviewed 6/9/2026 at 4:13 PM and stated she was working the day the accident occurred. She stated she had gone to lunch and when she returned, she was informed by Nurse #6 that Resident #44 was on the floor of the shower room. Nurse #1 stated she and Nurse #6 completed skin check, pain assessment, change in condition and fall risk evaluation. Nurse #1 stated she completed the transfer form and sent it to hospital with Resident #44. Nurse #1 stated they used a mechanical lift to assist with getting Resident #44 off the shower floor and back stretcher and to transfer from shower stretcher back to bed. Nurse #1 stated she notified the Physician and orders were completed for Resident #44 to be transferred to the emergency room (ER) for further evaluation. Nurse #1 stated there were no findings and Resident #44 was transported back to the facility. She stated that Resident #44 was compliant with care and does not have a history of attempting to get up and walk without assistance. Observation on 6/9/2026 at 4:20 PM of the shower room and shower stretcher was completed with interview with Nurse #1. The shower stretcher was up against the wall to the left of the door. The Shower stretcher was approximately 3 feet in height. Nurse #1 stated Resident #44 was lying to the right of the shower stretcher on the floor approximately 2 feet from the shower stretcher. Nurse #1 stated Resident #44 was found lying on his back.Attempted phone contact was made on 6/9/2026 at 6:20 PM with NA #9. NA #9 was providing care to Resident #44 at the time of accident. NA#9 refused interview and is no longer an employee at the facility. Nurse #6 was interviewed on 6/10/2026 at 11:30 AM. Nurse #6 has been working at the facility for 14 years. She stated she recalled working with Resident #44 on the day of the accident. Nurse #6 stated she was the weekend supervisor that weekend. She stated that NA#9 that gave Resident #44 a shower notified her that Resident #44 was on the floor. She stated that when she went to the shower room Resident #44 was lying on his back and stated that he was trying to roll over and fell off the shower stretcher. Nurse #6 stated the rails on the shower stretcher should have been up but had been left down. Nurse #6 stated she and Nurse #1 completed assessments on Resident #44 and notified the Physician. After talking with physician, they got Resident #44 ready for transportation to the ER. Nurse #6 stated immediate training was provided to staff for safe resident handling, how to use a shower stretcher, with demonstrations provided and neglect. Nurse #6 stated that administrative staff had all come into facility that day. She stated that the Administrator and DON were the ones providing the training. Nurse #6 stated she assisted with the skin checks on the residents who were not alert and oriented. She stated there were no findings with the skin assessments completed on cognitively impaired residents. A review of the incident report dated 1/17/2026 at 11:04 AM was completed. The incident report was completed by Nurse #1 and revealed that Resident #44 received assistance with bathing by Nursing Assistant( NA) #9. NA #9 stated she left the shower room, leaving Resident #44 unattended, to get a towel. NA #9 stated as she re-entered the shower room, she observed resident #44 on the floor. Resident #44 was complaining of pain in his head, hip and neck. Nurse #1 contacted on-call provider and orders were received for Resident #44 to be sent to the local hospital for further evaluation. Resident #44 was transported to local hospital. A review of an emergency department report dated 1/17/2026 revealed Resident #44 was transported for evaluation following an unwitnessed fall at the facility. Resident #44 was alert and oriented and complained about head, hip and neck pain. Extensive imaging studies were performed to evaluate Resident #44 for any fractures. Two Computed Tomography (CT) scans revealed no cervical concerns and no concerns with swelling with the prevertebral soft tissue. All these imaging studies were negative. Resident #44 was transported back to the facility on 1/17/2026 with no new orders. The Social Worker was interviewed on 6/10/2026 at 11:40 AM and stated she was not at the facility at the time of the accident but did come to facility to assist with the interviews with the alert and oriented residents. Interviews were completed with residents that had a Brief Interview for Mental Status (BIMS) for 12 or higher. The Social Worker stated there were no findings with the interviews conducted. She stated she could not recall the details of the accident. An interview with the Physician was conducted 6/10/2026 at 1:47 PM. She stated she remembered being notified of the fall and giving orders to have Resident #44 transported to the ER for further evaluation. The Physician stated she recalled Resident #44 was evaluated and there were no injuries and Resident #44 was transported back to the facility. She stated the staff were trained, the equipment was working properly, and she felt this was an isolated accident that unfortunately occurred. There were no new orders from this accident. An interview with the Maintenance Director was conducted 6/11/2026 at 10:22 AM. The Maintenance Director confirmed that there was nothing wrong with the shower stretcher. He stated all shower stretchers and chairs were evaluated on the day of the accident and all were in working order. He stated the shower stretcher and chairs are checked monthly. The Maintenance Director stated the accident was not due to the equipment, the shower stretcher being used at the time of the accident was in working order and the side rails were working.An interview with the DON was completed on 6/11/2026 12:02 PM and she stated she was called and notified of the accident. She stated she came to the facility immediately to begin working in the report and training with the staff. She stated the training that was provided was safe resident handling, how to use a shower stretcher with completed demonstrations and resident neglect. The DON stated she did not think NA #9 left Resident #44 unattended thinking Resident #44 would fall. The DON was unsure why NA #9 did not raise the rails on the shower stretcher. The DON confirmed that staff were trained to not leave residents in shower rooms unattended.Observation of a shower stretcher like the one used at time of accident was completed 6/11/2026 at 1:59 PM. The shower stretcher had workable side rails that would rise and lower, the wheels would lock in place and also included safety pins to secure the position of the side rails when raised. The facility implemented the following Corrective Action Plan with a compliance date of 1/17/2026. 1. How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 01/17/2026, resident #1 received assistance with bathing by Certified Nursing Assistant #1 (AS). Resident #1 was care planned dependence of 1 staff member for bathing. Certified Nursing Assistant #1 stated she entered the shower room with resident #1 to give him a shower via a shower bed. Certified Nursing Assistant #1 assisted resident #1 with shaving and bathing. Certified Nursing Assistant #1 stated she left the shower room, leaving resident #1 unattended, to get linen. Certified Nursing Assistant #1 stated as she re-entered the shower room, she observed resident #1 on the floor. Certified Nursing Assistant #1 immediately notified the nurse. Nurse #1 assessed resident #1 and noted bleeding on his right third and fourth toe. Resident #1 noted his pain as a 5 to his hip, head and neck. Vital signs were obtained by Nurse #1 and noted as within resident #1 baseline. Nurse #1 contacted on-call provider on 01/17/2026 at 11:00AM and ordered resident #1 to be sent to the local hospital for further evaluation. Nurse #1 contacted resident #1 responsible party on 01/17/2026 at 11:15AM. Resident #1 was transported to the local hospital. The Administrator notified the facility Medical Director of resident #1 fall. An interview with Resident # 1 was conducted by the Registered Nurse Weekend Supervisor. Residents # 1 stated he was laying on the shower stretcher. Resident #1 stated he was attempting to turn on his left side and fell onto the floor from the shower stretcher. An x-ray of resident #1 pelvis was obtained at the local hospital on [DATE]. The x-ray results indicated no acute fracture or dislocation. Computed Tomography (CT) of resident #1 head and spine was obtained at the local hospital on [DATE]. The CT results did not indicate a fracture or intracranial abnormality. Resident #1 returned to the facility on [DATE] with no new orders. On 01/17/2026, the Administrator submitted an initial allegation report to the North Carolina Division of Health Service Regulation, local police department, and local adult protective services. On 01/17/2026, root cause analysis identified Certified Nursing Assistant #1 did not ensure resident safety by providing supervision during resident #1 shower leading to the fall. On 01/18/2026, the Administrator submitted a five-day allegation report and investigation summary to the North Carolina Division of Health Service Regulation. Certified Nursing Assistant #1 was placed on administrative leave on 01/17/2026 pending investigation. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice?The Director of Nursing and / or designee completed care plan reviews to identify residents in the facility that require assistance with bathing by 01/18/2026. Resident #1 care plan and Kardex was updated to reflect assistance required by 01/18/2026.By 01/17/2026, The Director of Nursing / designee conducted an audit of all falls in the last 60 days to ensure no falls with injury occurred during resident bathing. No concerns noted during the audit. On 01/17/2026, the Administrator and Assistant Administrator conducted a 90 day look back utilizing an audit tool of resident grievances / incidents and accident logs to ensure no concerns were identified related to resident transfers while utilizing a mechanical lift as well as no resident concerns related to staff not providing supervision while bathing while using a shower bed / in a shower room. No concerns were identified. The Maintenance Director conducted an audit of all facility shower chairs and shower stretchers to ensure all shower chairs and shower stretchers are equipped with safety mechanisms per manufacturers instructions on 01/17/2026. No issues identified. On 01/17/2026, the Social Worker conducted interviews with alert and oriented residents that scored a 13 or higher on the Brief Interview of Mental Status (BIMS) evaluation to ensure residents that require a mechanical lift for transfers with 2 staff assistance and residents that require assistance with bathing have staff present in the shower room. No issues identified. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? On 01/17/2026, the Director of Nursing and / or designee-initiated re-education to licensed nurses and certified nursing assistants on the facility's safe resident handling program to include level of staff assistance required during resident bathing, where to locate individual resident assistance required on care plan and to remain in the shower room during the resident's shower. Licensed Nurses and Certified Nursing Assistants provided return demonstration for utilization of shower chairs and stretchers and completed Safe Resident Handling: Learner Assessment post test. Any nurse and / or certified nursing assistant that did not receive education on 1/17/26 was identified and will receive education and conduct a return demonstration for utilization of shower chairs and stretchers and complete Safe Resident Handling: Learner Assessment post test prior to their next scheduled shift by the Director of Nursing and or Unit Manager Beginning on 1/18/26, The Director of Nursing / Nursing Supervisor will conduct random quality monitoring of 5 nursing staff member observations during resident showers to ensure staff members are providing the required assistance indicated on the resident care plan and that the staff member(s) remain in the shower room during the residents shower, that shower equipment is fully operational on 1st and 2nd shifts, 3x per week for 4 weeks, then 2x per week for 4 weeks, then 1x per week for 4 weeks.Beginning on 1/18/26, The Administrator / Designee will conduct random quality monitoring of all shower chairs and shower stretchers to ensure safety equipment (safety belts and foot rests for shower chairs and safety pins for shower stretchers) are properly installed and in working condition 3x per week for 4 weeks, then 2x per week for 4 weeks, then 1x per week for 4 weeks. An in-prompt QAPI meeting was on 01/17/2026 by the Administrator and Assistant Administrator to discuss the plan of correction and corrective measures for the deficient practice.All newly hired Licensed Nurses and Certified Nursing Assistants to include newly hired Agency Licensed Nurses and Agency Certified Nursing Assistants will be educated during new hire orientation on the facility's safe resident handling program to include level of staff assistance required during resident bathing, where to locate individual resident assistance required on care plan and to remain in the shower room during the resident's shower and the facility's abuse prohibition policy with an emphasis on neglect and who to report to and timeframes of reporting by the Director of Nursing and / or Nursing Supervisor. 4. How will the facility monitor its corrective actions to ensure the deficient practice will not recur?The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety x 3 months. The improvement-monitoring schedule will be modified based on the findings of monitoring. The results of the quality monitoring will be reviewed at the monthly QAPI meeting for 3 months to sustain substantial compliance. Allegation of Compliance Date: 01/19/2026 The Corrective Action plan was validated by reviewing the completed audit of all shower/bathing equipment. Observations of shower stretchers and chairs were completed. A review of staff training and staff interviews were completed confirming the education provided for the safe handling program. A review of the monthly quality monitoring documentation was completed. The correction date of 1/19/2026 was validated.

Based on observations and staff interviews, the facility failed to secure a bottle of prescription eye drops that was left unattended on top of the second-floor medication cart for 1 of 5 medication carts reviewed for medication storage (second floor medication cart).The findings included:A continuous observation was conducted on 6/9/26 from 9:15 AM to 9:18 AM. During that time, the second-floor medication cart parked outside of room [ROOM NUMBER], contained a bottle of prescription eye drops (timolol, used to reduce high pressure in the eye) that were sitting on top of the cart. The cart was unattended and an observation of the hallway revealed the nurse for this cart (Nurse #7) was not present in the hallway. Also, at 9:15 AM Unit Manager #1 walked past the medication cart but did not acknowledge or remove the prescription eye drops. There were 2 residents observed sitting in the hallway in the vicinity of the medication cart during the observation. On 6/9/26 at 9:19 AM Nurse #7 returned to the medication cart and stated she would not normally leave medications on top of the cart. She stated another resident was going to be leaving for an appointment, so she went to his room to give him his medications before he left. Nurse #7 stated she should have put the medication (eye drops) back inside the medication cart.During an interview on 6/9/26 at 9:20 AM with Unit Manager #1, she revealed she did not notice the prescription eye drops sitting on the medication cart when she walked by or she would have removed it. Unit Manager #1 stated the expectation would be that the nurse put the medication back in the medication cart before leaving the medication cart. An interview was conducted on 6/9/26 at 9:36 AM with the Director of Nursing (DON). She stated she would expect the nurse to complete the medication pass first, but if she had to leave her medication cart, she would expect the nurse to put the medication in the cart before leaving the cart.

Based on observation and resident and staff interviews, the facility failed to provide food that was palatable in taste and temperature. The deficient practice affected 3 of 3 residents reviewed for food (Resident #14, #83, and #139). Findings included:1a. On 6/7/26 at 9:10 am during the initial kitchen observation, there were two carts of breakfast trays returned to the kitchen for washing. Several of the plates had what appeared to be French toast that was dark brown with shriveled edges that was not eaten or had bites taken. The toast felt hard when touched.On 6/7/26 at 9:12 am kitchen staff #1 was interviewed. She stated the carts were breakfast trays returned from this morning. She had no comment regarding the French toast that was not eaten and returned on the tray nor its consistency. On 6/7/26 at 9:15 am the cook was interviewed. The cook stated she prepared the breakfast which included French toast and had no comment about the toast. Resident #14 was admitted to the facility on [DATE]. Resident #14's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact.The diet order for Resident #14 was regular, liberalized.On 6/7/26 at 9:30 am an interview and observation were completed with Resident #14. The resident stated her breakfast tray was delivered at approximately 8:45 am and her French toast was burnt, and she could not eat it. The toast was observed to be dark brown and dry in appearance. The resident stated the food frequently does not taste good. The food can be cold, dry and overcooked. On 6/8/26 at 10:00 am an interview was conducted with Resident #14. The resident stated she had sausage this morning that was overcooked and hard. The resident could not cut the outer edge of the sausage with the knife and could not eat it. The resident further commented that the sausage was frequently burned, and she had informed the nursing assistant when the trays were picked up after breakfast.b. Resident #83 was admitted to the facility on [DATE].Resident #83's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact.The diet order dated 4/29/26 for Resident #83 was regular, liberalized.On 6/7/26 at 9:40 am an interview was completed with Resident #83. The resident stated the food was frequently overdone, dry, sometimes cold, and doesn't taste good. The resident commented she does not want the alternate, she wants her food cooked appropriately. The resident further commented that just this morning the French toast was badly burned and not edible and the breakfast sausage was consistently burned, dry, and hard.c. Resident #139 was admitted to the facility on [DATE].The quarterly Minimum Data Set, dated [DATE] for Resident #139 documented that he was cognitively intact.The diet order dated 3/18/26 for Resident #139 was regular, liberalized.On 6/7/26 at 10:06 am Resident #139 was interviewed. He stated the food was horrible and often not edible. Resident #139 had around 300 pictures of food in his phone that had been served at the facility. The most current picture was the breakfast served on this day 6/7/2026, which was French toast and cereal. The toast in the picture was observed to be dark in color and very flat and shriveled in the center. The resident stated he was unable to cut the toast and did not eat it.On 6/7/2026 at 1:36 pm Resident #139 was interviewed. He did not eat the facility lunch provided; he obtained a sandwich from outside the facility. The facility does have ham sandwich as an alternate, but the resident does not like their ham.On 6/8/2026 at 8:59 am Resident #139 was observed to be eating cereal at this time. The resident had two sausage patties on his plate for breakfast. He picked up one of two circular sausage patties and started shaking it. The sausage patty appeared firm like rubber and had shriveled edges. The resident attempted to cut a sausage patty with a fork and was unable to. The sausage patty had dark brown edges that appeared about 1 inch and then lighter brown towards the center. On 6/9/2026 at 10:30 am Resident #139 was observed to be sleeping in his room. The breakfast tray was observed sitting on the bed table. The eggs and cereal appeared to have been mostly eaten. The sausage patties remained, had the same overcooked appearance and were left uneaten. On 6/7/26 at 10:45 am an interview was completed with the Dietary Manager (DM). The DM was informed of the residents' food concerns including cold and overcooked food. The DM stated he had not observed the French toast and the cook was new. He was unaware that the residents had reported food palatability concerns regarding flavor, temperature, and overcooked food.On 6/09/26 at 1:16 pm a lunch test tray with the DM was completed. The test lunch tray was the last one to be delivered. The lunch included potato wedges, sloppy joe sandwich on a bun, salad with cheese shreds, and a dessert. The sloppy joe was of good texture and taste and warm enough to enjoy. The salad appeared wilted. The potato and dessert appeared tasteful. The DM was interviewed and commented that hot food affected the cold food's temperature after being plated and placed into the closed transport tray cart. The rise in temperature during transport in the closed cart was seen with ice cream also which started to melt by the time it reached the resident. On 6/11/26 at 11:45 am the Administrator was interviewed. The Administrator was informed of the residents' food concerns and the observations of food provided. The Administrator had no comment.

Based on observation, record reviews, and interviews with staff, resident, and the Medical Director, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. On 2/21/25, Resident #8 was being transferred to dialysis in the facility's transportation van. When Transportation Driver #1 made a left turn, Resident #8 and the wheelchair she was seated in tipped over onto the floor of the van. The Transportation Driver called 911. Resident #8 complained of pain to the right side of her neck and face and was transported to the hospital via Emergency Medical Services (EMS). Resident #8 was receiving a blood thinner which increased her risk of bleeding. While at the hospital, Resident #8 was found to not have sustained any injuries but was admitted for one day to receive her missed dialysis treatment before returning to the facility. This practice had a high likelihood of causing a serious adverse outcome, including death or serious injury. This deficient practice was for 1 of 7 residents reviewed for accidents (Resident #8).Findings included: Review of the manufacturer's operating instructions dated 2014 for the facility's securement system used in the transportation van showed the following instructions for the use of the 4-Point Wheelchair Securement System: 1. Center wheelchair facing forward in Securement Zone and lock wheelchair brakes (or power off electric chair). 2. Attach four retractors into Floor Anchorage points and lock them in place, with an approximate distance of 48 to 54 between the front and rear retractors. 3. Completely pull out each webbing and attach J-hooks to compliant WC19 (a WC19 is a term used to describe a standard wheelchair designed to be used in vehicles) Chair Securement Points near seat level (or solid frame members) at an approximate 45-degree side angle. 4. Move wheelchair forward and back to remove webbing slack or manually tension webbing with retractor knobs. Resident #8 was admitted to the facility on [DATE] with diagnoses which included End-Stage Renal Disease (ESRD), congestive heart failure and atrial fibrillation. The physician's order dated 12/8/23 and the current medication administration records revealed Resident #8 received 2.5mg (milligrams) apixaban two times per day. Apixaban is an anticoagulant medication (blood thinner). The quarterly minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact, received anticoagulant medication, had no falls, and received dialysis therapy. The review of the Incident Report prepared by Unit Manager #1 and the Interdisciplinary Team Review completed by Nurse #6, both dated 2/21/25 documented that as Resident #8 was transported to the dialysis center in the facility's transportation van, the resident's wheelchair turned over, onto its side. The Resident was assessed and transported to the Emergency Department for further evaluation. The Resident was unable to give a description of what had happened. There were no witnesses. There were no injuries observed at the time of the incident. Review of the Emergency Medical Services (EMS) Report dated 2/21/25 documented that upon EMS arrival on the scene, Resident #8 was observed on the floor of the transport van with a wheelchair turned on its' side and underneath the resident. The Resident was alert, speaking full sentences. Transportation Driver #1 informed EMS that he was transporting the Resident in her wheelchair in the van to the dialysis center and when the van turned a corner the Resident and her wheelchair overturned. The Resident complained of pain to the right side of her face and the right side of her neck. EMS freed the wheelchair from the safety straps and removed the wheelchair from under the resident. A cervical collar was placed on the Resident, and she was transferred to a stretcher and in the EMS unit where assessment and interview were completed. The Resident denied loss of consciousness, chest pain, shortness of breath, nausea and vomiting. The Resident revealed she was enroute to the dialysis center and her last dialysis treatment was on Wednesday, 2/19/25. The Resident denied any other injuries and was able to move lower extremities with no pain to pelvis/hips and had equal hand grip. The duration of head and neck pain was ten minutes. The Resident was transferred to the Emergency Department of the hospital, answering questions appropriately. Transportation Driver #1 was not available for interview during the survey. Review of the hospital Emergency Department assessment and plan dated 2/21/25 revealed Resident #8 was evaluated for right-sided head/neck pain due to resident stating her head and neck were injured by striking something inside the transport van on her way to the dialysis center. The result of the computed tomography (CT) scan of the resident's head and neck showed no acute intracranial pathology or cervical spine pathology. The Emergency Department physician contacted the resident's outpatient nephrologist and it was decided that it was too late in the day for the Resident to go to the dialysis center this day. Also, there was no indication that the Resident would be able to be transported from the nursing home to the dialysis center on 2/22/25 (Saturday). Because the Resident's next scheduled dialysis appointment would not be until 2/24/25 (Monday), the recommendation was for Resident #8 to be evaluated for admission to the hospital and receive her dialysis treatment on this night of 2/21/25. The hospital Discharge summary dated [DATE] revealed Resident #8 also reported right hip pain and the right hip x-ray showed no acute fracture or abnormality. The pain was mild and managed conservatively. The resident received her normal treatment of dialysis on Friday night (2/21/25) and would continue on her Mondays, Wednesdays, and Fridays schedule. There were no new physician orders made during this hospitalization. The summary indicated the Resident's condition was good at discharge and that she returned to the facility. During an interview on 8/12/2025 at 10:21 a.m., Resident #8 revealed that in February 2025 she had a fall in the facility's transportation van enroute to the dialysis center. She recalled that as the transportation van driver was making a left turn, her wheelchair fell sideways to the right in the van causing her to hit her neck and face. The resident did not recall what she hit her neck and face on. She stated she was hospitalized overnight. The Resident indicated the accident did not result in any fractures, but she had constant back pain since the accident. A second interview was conducted with Resident #8 while awaiting transport to the dialysis center on 8/13/25 at 10:23 a.m. The Resident was observed sitting upright in a wheelchair The Resident recalled that the February accident occurred at approximately 12:30 p.m. when Transportation Driver #1 made a left turn onto another street. She revealed she was the only passenger in the van. She stated that Transportation Driver #1 did not attempt to move or reposition her after the fall. The Resident stated EMS arrived and applied a neck brace and transported her to the hospital. She stated she believed Transportation Driver #1 must have turned the van too fast causing her wheelchair to turn over on its side. A telephone interview was conducted with the facility's Medical Director on 8/13/25 at 3:10 p.m. The Medical Director recalled being notified by the Administrator and the Director of Nursing of Resident #8's accident in the van the same day. She stated she reviewed the incident records, the hospital reports, including the x-rays which showed the Resident had no injuries as a result of the accident. The Medical Director indicated Resident #8 receiving blood thinner medication did not place her at risk of serious injury or death as a result of the minor accident. The Medical Director concluded the resident was sent to the hospital as a precaution following the accident. An interview was conducted with the Administrator on 8/12/25 at 3:45 p.m. He stated Transportation Driver #1 notified him of the accident and his call for EMS on 2/21/25 via telephone. The Administrator stated when he arrived on the scene of the accident, EMS was on-site. He revealed he observed Resident #8 in the facility's van, in her wheelchair, alert and verbal. He stated he interviewed Transportation Driver #1 at the scene of the accident and on return to the facility and Transportation Driver #1's account of the accident remained the same. The Transportation Driver #1 informed him (Administrator) that he was transporting Resident #8 to the dialysis center in the van and when he made a left turn onto another street, the Resident's wheelchair tilted over. Transportation Driver #1 reported he stopped the van and telephoned EMS then the facility. The Administrator stated Transportation Driver #1 insisted he had double checked the immobility of the Resident's wheelchair in the van to ensure no movement. The Administrator revealed Transportation Driver #1 was originally hired in June 2024 as the Maintenance Assistant but in January 2025 became one of two facility transportation drivers. The Administrator added Transportation Driver #1 was trained by the former Maintenance Director. The Administrator provided documentation of Transportation Driver #1's facility transportation training dated 1/13/25 and signed by Transportation Driver #1. This signed training documentation included: Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs; Authorized Driver Checklist; Vehicle Safety Competency; The Wheelchair tie down and Occupant Restraint System; Mobile Device Use Agreement for Drivers of Company Vehicles; and Procedures to Follow after a Vehicle Accident. The former Maintenance Director was interviewed on 8/15/25 at 11:03 a.m. and explained he was the Maintenance Director at the facility during the time of the accident involving the wheelchair turning over in the facility's van during transport. He revealed the van was purchased by the facility in January 2025 and after a complete inspection, he replaced the ratchets and straps before the van was used by the facility because they were old and loose. He stated that he inspected the facility's two transportation vans including the wheelchair securement systems, yearly. He stated that within twenty-four hours of the accident in February 2025, he inspected the van including having Transportation Driver #1 re-enact the securing method of the Resident's wheelchair in the van, as he did on the day of the accident. He stated that the demonstration concluded Transportation Driver #1 securely strapped Resident #8's wheelchair to the floor of the van; and inspection of the van identified no defective equipment. On 8/13//25 at 5:13 p.m., the Administrator was notified of immediate jeopardy. The facility implemented the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to havebeen affected by the deficient practice;Root cause analysis has revealed that on 02/21/2025 at approximately 11:57am, resident #8 sustained a fall while being transported to dialysis in the facility van. The facility Van driver stated as he was turning onto Meadow Pl at 6 miles per hour the wheelchair tipped over due to the ratchet system used to secure residents in place not properly adjusted to ensure that Resident #8 wheelchair was secured inside the facility van. Resident #8 (BIMS - 15) did not provide details regarding the incident as she only stated that she was having current back and neck pain. At the time of the incident, the van driver called Emergency Services. EMS and Fire Department arrived at the scene of the incident at 12:11pm. The incident occurred at the intersection of Ferndale Boulevard and Meadow Place. The resident was safely transported to the hospital by Emergency Medical Services at 12:25pm. Administrator, Resource Operator and Registered Nurse arrived at the scene of the incident at 12:11pm. It was observed by the facility's Administrator and Registered Nurse that resident #8 was strapped in her wheelchair via a facility van lapbelt. Resident #8's wheelchair was latched via the floor track ratcheting system x1 strap from the rear of the wheelchair to the left sided frame and x1 strap from the rear of the wheelchair to the right sided frame. Additionally, the wheelchair was latched by utilizing the floor ratcheting system x1 strap to the front frame of the right side of the wheelchair and x1 strap to the front frame of the left side of the wheelchair. Resident #8 was transported to hospital for evaluation on 02/21/2025 by Emergency Medical Services. The resident was assessed at the hospital. According to the hospital records, a CT of Resident #8's head and C-Spine. CT scan from hospital dated 02/21/2025 at 2:30 pm revealed no fractures to head or spine. Resident #8 was discharged from the hospital on [DATE] back to the facility. Upon her return, the Licensed Nurse assessed resident #8. A new order from the hospital for zofran 4MG was prescribed every 6 hours for nausea and vomiting. The facility van driver was interviewed by the facility Administrator at the facility. The van driver's statement revealed, Resident #8 was loaded into the van at 11:55am by the van driver. The facility van driver secured the wheelchair via 4 straps on the floor track ratcheting system and placed and secured the van's lapbelt on the resident. The van driver checked to ensure the wheelchair was secure prior to departing from the facility. The van driver departed from the facility heading to Kidney Center. Facility Van driver stated as he was turning onto Meadow Pl at 6 miles per hour the wheelchair tipped over. The facility Van driver stated he immediately called Emergency Services. The van driver stated that he was unaware of what caused the incident as he believed that he secured the resident's chair per the manufacturer's recommendation for the ratcheting system. The van driver stated that as he was making a left turn he heard the wheelchair tilt and immediately stopped the facility van. The facility van driver was placed on administrative leave pending investigation on 02/21/2025. A formal investigation was initiated by the Administrator on 02/21/2025. As a result of the investigation, it was determined that the ratchet system used to secure residents in the facility van was not properly used by the van driver per manufacturers recommendations on 2/21/25. On 02/21/2025, the Administrator reviewed the restraint manufacturer's instructions for how to secure a wheelchair and person to the facility van. The Administrator re-educated the Maintenance Director to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to the beginning of his next scheduled shift. From 02/22/2025 - 02/24/2025, an outsource transportation company was utilized to transport residents to medical appointments. The Maintenance Director re-educated to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to beginning their next scheduled shifts. The Medical Director and the Resident #8 responsible party were notified of the incident by the Administrator. The wheelchair for Resident #8 was inspected by the Maintenance and Therapy department to ensure proper functioning. No issues identified during either inspection. Following Resident #8 readmission from the hospital, Resident #8 was transported via facility van to medical appointments in a standard wheelchair. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 2/21/25, the Administrator reviewed a list of residents who have been transported by facility staff and all outsourced transportation companies in the last 30 days to ensure no other residents sustained an injury during transportation. No additional incidents were identified as a result of the audit. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 02/21/2025, an audit was conducted by the Administrator to ensure all facility van drivers were current on van safety education and skills competencies were up to date. No negative findings as a result of the audit. Education consisted of the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs. On 02/21/2025, the Administrator and Maintenance Director inspected the ratcheting system and all seat belts in the facility van. All ratchet straps and seatbelts were in proper working order. The Administrator re-educated the Maintenance Director to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to the beginning of his next scheduled shift. Beginning 02/25/2025, the Administrator and Maintenance Director re-educated 2 facility van drivers on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs. The safety tips are comparable to the restraint manufacturer's instructions. Return demonstration was conducted by 2 van drivers to ensure proper methods are used while securing residents / wheelchairs in the van via the ratcheting system. Any van driver that was not educated will receive education prior to their next scheduled shift. Newly hired drivers will be trained upon hire in orientation by the Maintenance Director. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Effective 02/21/2025, the Administrator will audit resident transportations on 10 residents 2 times per week for 4 weeks, then 1 time per week for 8 weeks utilizing a monitoring tool to ensure residents are transported without incident regardless of the transportation organization and that all facility van drivers remain educated on facility van safety policies to include restraint manufacturer's instructions. On 02/21/2025, an ADHOC Quality Assurance Performance Improvement meeting was conducted by the Administrator with the interdisciplinary team members to review the root cause of the incident, discuss immediate measures to ensure all other residents are safe, education required for facility licensed van drives and how the center will ensure quality monitoring going forward to ensure no other residents are not safely transported regardless of the transportation organization. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to ensure compliance is maintained ongoing. The QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. Alleged date of Immediate Jeopardy Removal: 02/26/25The deficiency correction date is alleged to be 02/26/25. The facility's corrective action plan was validated by the following on 8/15/25: The facility provided audits of residents in wheelchairs who were interviewed if they felt safe with the wheelchair securing methods used in the transportation vans and if they felt safe with the driving of the transportation van drivers. Only 1 of the 2 facility van drivers were currently working at the facility. Transportation Driver #1 was currently on leave. The Maintenance Director also worked as a transportation van driver, documentation specified Transportation Driver #1, Transportation Driver #2, and the Maintenance Director received the training on the restraint system's manufacturer's instructions. The facility provided documentation of the restraint system's manufacturer's video of correct application of the use of the 4-Point Wheelchair Securement System in transport vans. This training included checklists, observations and audits that included return demonstration on securing a resident in their wheelchair inside the transportation van, and of and on loading of residents into the vans. Interviews with Transportation Driver #2 and the Maintenance Director verified they received the training with return demonstration of wheelchair securement system in the transportation van according to the restraint system's manufacturer instructions. The monitoring of all residents using the transport van was conducted and presented in the facility's QA meeting. An observation was conducted on 8/15/25 at 10:02 a.m. of Transportation Driver #2 as she secured three residents according to the restraint system's instructions. After securing the wheels of wheelchair to the floor of the transportation van and strapping Transportation Driver #2 tested the immobility of the wheels and the handles of each resident's wheelchair after with positive results of wheelchair immobility. Transportation Driver #2 stated she always tested both areas (top and bottom) of each wheelchair to ensure safety. The facility's IJ removal date and compliance date for the corrective action plan of 2/26/25 was validated.

Based on observations, record reviews, and staff and Medical Director interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 1 of 2 residents whose blood glucose levels were checked (Residents #135). This occurred while there was at least one resident with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer potentially exposes residents to the spread of blood borne infections. Care must also be taken by personnel handling glucometers to protect the glucometers against cross-contamination via contact with other surfaces. Immediate Jeopardy began on 8/14/25 when Nurse #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's instructions. Immediate Jeopardy was removed on 8/20/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included:The facility's document entitled, Procedure: Fingerstick Glucose Measurement (Reviewed and Revised on 7/15/25) outlined the following process, in part:Step #22 (of 27): Clean and disinfect the blood glucose meter [glucometer] after use with EPA approved disinfectant, following manufacturer's instructions.Upon request, additional documents were provided by the facility in lieu of a Policy / Procedure for glucometer disinfection:---A Glucometer Cleaning & Disinfection Observation described the purpose of the observation as: Bloodborne pathogens such as Hep B [hepatitis B], Hep C [hepatitis C], and HIV [human immunodeficiency virus] can be transmitted to other patients if glucometers are not cleaned & disinfected. Such transmission has occurred in the past in LTC [long term care] facilities that do not use a cleaning & disinfecting procedure. The requirements of the observation included, in part: - .The glucometer is cleaned and disinfected after each use. If the nurse is unsure whether the glucometer is clean, it should be cleaned and disinfected before use. -The glucometer is wiped down with the product specified for use by the manufacturer. Products approved for the [brand name] meter include: [4 brands of disinfectant wipes, including the facility's disinfectant] -Staff clean & disinfect surfaces that come into contact with the glucometer (e.g., overbed tables, med [medication] carts, etc.).-The glucometer remains wet for the time specified in the directions on the cleaning and disinfecting product.---Clinical Competency Validation Fingerstick Glucose Measurement included step #19 (of 23): Cleans and disinfects the blood glucose meter after use with EPA approved disinfectant, following manufacturer's instructions.A Healthcare Professional Operator's Manual & In-Service Guide (Dated 2023) from the manufacturer of the facility's glucometer included a section on Cleaning and Disinfecting your [brand name of the glucometer]. It noted the following information, in part: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The products listed as having been validated for disinfecting the facility's glucometer included the brand of disinfectant wipes available for use at the facility. The manufacturer instructions for the glucometer used at the facility indicated the cleaning and disinfection procedure required the following step:#4 (of 6). To disinfect the meter, clean the meter with one of the validated disinfecting wipes.Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use.The manufacturer's labeling of the brand of disinfectant wipes used at the facility was reviewed and read, in part: Kills HIV-1 [human immunodeficiency virus], HBV [hepatitis B virus], and HCV [hepatitis C virus] on precleaned environmental surfaces/objects previously soiled with blood/body fluids in health care settings or other settings in which there is an expected likelihood of soiling of inanimate surfaces/objects with blood/body fluids and in which the surfaces/objects likely to be soiled with blood/body fluids can be associated with the potential for transmission of HIV-1 (associated with AIDS), HBV, and HCV. The directions for use of the disinfectant wipes addressed the required contact time for disinfection. The manufacturer instructed that surface(s) should remain visibly wet for 30 seconds to kill the bacteria and viruses (as individually listed on the label), except a 1 minute contact time is required to kill Candida albicans (a fungus) and Trichophyton interdigitale (a fungus); a 2 minute contact time is required to kill Candida auris (a fungus); and a 3 minute contact time is required to kill Clostridium difficile spores (a resistant, dormant structure produced by C. diff bacterium).An observation of blood glucose monitoring was initiated on 8/14/25 at 11:25 AM with Nurse #1. The observation began as Nurse #1 prepared to conduct a blood glucose check for Resident #7. The nurse removed a (brand name) glucometer stored inside a plastic bag from the top right drawer of the medication cart and placed the glucometer on top of the medication cart. It could not be determined by observation whether the surface of the medication cart had been previously disinfected. Nurse #1 then collected additional supplies for monitoring, including alcohol wipes, a glucose strip, and a single-use lancet. At 11:26 AM, the Nurse was observed to insert the glucose strip into the meter. Immediately afterwards, she placed the meter back on top of the medication cart, donned gloves, picked up the glucometer and supplies, then entered Resident #7's room. Nurse #1 used the lancet to obtain a blood sample from the Resident, then placed the meter (with the glucose strip inserted) on top of Resident #7's bedside tray table while she wiped the remaining blood from the resident's finger. The resident's blood glucose result was 137. At 11:28 AM, Nurse #1 was observed as she removed her gloves while still in the resident's room, picked up the used glucometer, and returned to the medication cart. The Nurse obtained a (brand name) disinfectant wipe from the bottom drawer of the medication cart and wiped the glucometer with the disinfectant wipe for a count of 5 seconds. She then placed the glucometer on a paper towel on top of her medication cart. Upon inspection of the meter placed on the paper towel, the meter appeared to be completely dry and had no signs of being visibly wet. The nurse returned to Resident #7's room, washed her hands, then came back to the medication cart to prepare an as needed medication requested by the resident. A continuous observation of the medication cart and glucometer was conducted. On 8/14/25 at 11:35 AM, Nurse #1 moved the medication cart directly in front of another room to conduct a blood glucose check for Resident #135. The medication cart was positioned so that the nurse was at the doorway of the resident's room. At that time, Nurse #1 reported that she had to wait three (3) minutes before she could use the glucometer for another resident after having disinfected the meter. When asked to clarify, the nurse stated the shared glucometer needed to dry for 3 minutes before being used for another resident. Meanwhile, she collected the additional supplies needed for the blood glucose check, including alcohol wipes, a glucose strip, and a single-use lancet. Then, Nurse #1 picked up the shared glucometer and began to insert a glucose strip into the meter. The nurse was already directly in front of the doorway of Resident #135's room, therefore she was asked to stop at that time and review the labeling on the canister containing the disinfectant wipes used on the shared glucometer. When the canister was again pulled out of the medication cart, the directions for disinfection were read. While reviewing the manufacturer's directions on disinfectant wipes, Unit Manager #1 walked by the medication cart. At that time, the disinfection of the shared glucometer was discussed with the Unit Manager. When asked, the Unit Manager reported she herself typically wrapped a wet disinfectant wipe around the glucometer to meet the requirement of a 3-minute contact time. When asked to clarify, she confirmed the 3-minute contact time was the amount of time the shared glucometer remained in contact with a wet disinfectant wipe (not the drying time). An interview was conducted on 8/14/25 at 1:02 PM with the facility's Infection Preventionist (IP). The IP provided a copy of the facility's Procedure: Fingerstick Glucose Measurement (Reviewed and Revised on 7/15/25). During the interview, the IP detailed the steps outlined in the document and reported the education provided to the licensed nurses was based on that information. The IP stated she would expect the nurse to make sure a surface barrier was in place for the glucometer so the meter was not placed directly on a medication cart that may not be clean. She also reported that the glucometer should not be placed on resident property such as a bedside tray table inside a resident's room (because it's dirty) and that a used glucometer should be wrapped in paper towels prior to leaving the room. Additionally, the IP noted a glucometer should be cleaned according to the directions on the disinfectant wipes being used. The IP stated the contact time meant the time the glucometer was wet. She added that the nurse should wait until the glucometer was completely dry before using that glucometer again. When asked, the IP stated a glucometer should be disinfected between residents and after being used for the last resident having his or her blood glucose checked before replacing it into the storage bag kept on the medication cart. A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility's Administrator and DON. During the interview, concerns encountered during the survey were addressed. When the observation of blood glucose monitoring and disinfection of a shared glucometer was discussed, the DON reported she would expect the nurses to wipe and disinfect the glucometer according to the instructions provided by the manufacturer of the disinfectant wipes. Upon further inquiry, the DON stated the contact time noted on the disinfectant wipes' canister referred to the actual contact time with a wet disinfectant wipe, not the drying time of the glucometer. Upon request, the facility provided a Diagnosis Report for its current residents on 8/18/25. The Diagnosis Report indicated 8 residents were identified as having at least one bloodborne pathogen, which included hepatitis C and HIV. A telephone interview was conducted on 8/19/25 at 10:55 AM with the facility's Medical Director. During the telephone interview, the Medical Director was asked what her thoughts were related to the observation of the failure to disinfect a shared glucometer in accordance with the manufacturer's instructions. The Medical Director stated she did not agree that this was an immediate jeopardy situation and declined to make any additional comments.The facility's Resource Operator of the Southeast Market was informed of the immediate jeopardy (IJ) by telephone on 8/18/25 at 1:45 PM (in the absence of the Administrator who was on leave). The facility provided the following plan for IJ removal:How will the corrective action be accomplished for those residents found to have been affected by the deficient practice?Resident #135 was not affected related to the shared blood glucose meter not being cleaned and disinfected according to manufacturer's instructions in between residents. The facility licensed nurse did not clean and disinfect the blood glucose meter per manufacturer recommendations prior to entering Resident # 135's room. The licensed nurse cleaned the glucometer for a time frame less than the manufacturer's instructions. The shared blood glucose meter for Resident #135 was not used to obtain a blood sugar check. The surveyor observing at the time the blood sugar was being obtained, the surveyor intervened and stopped the licensed nurse from using the blood glucose meter. Prior to the deficient practice, the facility licensed nurse was last educated on 2/10/25 on manufacturer instructions related to cleaning and disinfecting blood glucose meters. On 8/14/25, the Infection Preventionist re-educated the licensed nurse on shared blood glucose meters that can be contaminated with blood and must be cleaned and disinfected after each use with an approved EPA product and procedure in accordance with the manufacturer's instructions to prevent potentially exposing residents to the spread of blood borne infections with return demonstration. The EPA registered disinfectant manufacturer's instructions included the following: 3 minute contact time for Sporicidal, 2 minute contact time for Fungicidal, 1 minute contact time for Fungicidal and 30 second contact time for Virucidal and Bactericidal.A root cause analysis was conducted and based on the findings, the facility licensed nurse failed to follow the manufacturer instructions to clean and disinfect shared blood glucose meters prior to inserting a blood test strip. The facility licensed nurse was being observed by the surveyor to ensure infection control practices were being followed and the facility licensed nurse became anxious and nervous during the observation to perform blood sugar check. The Medical Director was immediately notified on 08/14/25 by the Director of Nursing via telephone of the facility Licensed Nurse failing to follow the contact time for cleaning and disinfecting blood glucose meters and inserting a blood test strip in the meter prior to full contact time. On 08/19/25, the Director of Nursing notified the local department via telephone of the facility Licensed Nurse failing to follow the manufacturer instructions to disinfect a shared blood glucose meter potentially exposing residents to the spread of blood borne pathogens. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.All residents requiring blood glucose monitoring have the potential to be affected by the deficient practice. A list of residents that have orders for blood glucose monitoring was obtained from Electronic Medical Record by the Director of Nursing on 8/18/25 to identify residents who require blood glucose monitoring to observe infection control practices related to cleaning and disinfecting the blood glucose meter according the manufacturer instructions for the EPA- registered disinfectant. 55 residents were identified with orders to obtain blood glucose monitoring. The Director of Nursing or the Infection Preventionist educated licensed nurses and medication aides to include agency licensed nurses and medication aides on cleaning and disinfecting of blood glucose meters after use per manufacturer instructions to prevent contamination and potential to spread blood borne pathogens and outcomes if the facility licensed nurse failed to do so on 08/18/25 - 08/19/25 in person with validation of understanding. Newly hired licensed nurses and medication aides to include newly hired agency licensed nurses and medication aides will be educated on cleaning and disinfecting of blood glucose meters upon hire by the Director of Nursing or Infection Preventionist. The Director of Nursing or the Infection Preventionist completed skilled competency check off through observation for licensed nurses and medication aides on the use of blood glucose meters to include cleaning and disinfecting according to manufacturer instructions on 08/18/25 - 08/19/25. The Director of Nursing or Infection Preventionist will conduct a skilled competency check off for newly hired staff to include newly hired agency staff on the use of blood glucose meters to include cleaning and disinfecting according to manufacturer instructions. On 8/18/25, individual glucometers were ordered by the Director of Nursing for each resident requiring blood glucose testing. An ADHOC Quality Assurance Performance Improvement Committee was held on 08/18/25 to formulate and approve a credible allegation of immediate jeopardy for removal of the deficient practice. Date of Removal of Immediate Jeopardy 8/20/25The facility's credible allegation of immediate jeopardy removal was validated on 8/20/25. A review was conducted of the education for glucometer disinfection procedures provided by the Director of Nursing and Infection Preventionist dated 8/18/25-8/19/25 for licensed nursing staff. Observations were conducted on 8/20/25 as three licensed nurses performed glucose blood checks for four residents. No infection control concerns were identified. Staff interviewed were able to verbalize the education and training provided in reference to the glucometer disinfection and the required disinfectant wet contact times for the glucometer. The immediate jeopardy removal date of 8/20/25 was validated.

Based on record review and interviews with staff, residents, and the dialysis center Nurse Manager, the facility failed to provide transportation back to the facility after hemodialysis was completed which caused the residents to wait up to 2 hours to return. The residents requested they be transported back to the facility and not wait, which made one resident late for dinner. This deficient practice affected 2 of 3 residents reviewed for dialysis (Residents #22 and #8). The findings included:1a.Resident #22 was admitted to the facility on [DATE] with the diagnosis of end stage renal disease (ESRD) dependent on hemodialysis. Resident #22's quarterly Minimum Data Set, dated [DATE] documented the resident had intact cognition. The care plan for Resident #22 dated 7/14/25 documented he had impaired renal function and was at risk for complications of hemodialysis. The interventions were hemodialysis on Monday, Wednesday and Friday and to watch for complications. On 08/12/25 at 9:41 am Resident #22 was interviewed. The resident stated he attends dialysis Monday, Wednesday, and Friday and was usually done at 3:30 pm. Resident #22 indicated at present there was only one van driver to pick up and when she was busy, he could wait up to 2 hours to be picked up to return to the facility and the dialysis center was across the street. Resident #22 stated there used to be two drivers, one for each of the two vans and When there were two drivers, I never had to wait 2 hours. The resident stated he has complained to the van driver that he does not want to wait to return to the facility and this problem had been going on for months. The resident commented he was late for dinner, and his tray was sitting on his table and was cold every time he returned late at 6:00 pm. 1b.Resident #8 was admitted to the facility on [DATE] with the diagnoses of ESRD and diabetes.The annual Minimum Data Set, dated [DATE] documented Resident #8 had an intact cognition. Resident #8's care plan dated 6/18/25 documented she had impaired renal function and was at risk for complication of hemodialysis. The interventions were hemodialysis Monday, Wednesday, and Friday and to watch for complications. On 8/15/25 at 10:25 am Resident #8 was interviewed. Resident #8 stated that her dialysis treatment was completed at about 3:00 pm and she was picked up at 5:00 pm or later and it was a 10-minute return ride back to the facility. The resident stated she had not missed dinner, but it was sitting in her room upon return. The resident commented she has had to wait up to 2 hours for pick up and wants to return after dialysis was completed. Resident #8 indicated the facility provided lunch in an insulated bag.On 8/12/25 at 2:40 pm the Administrator stated that one of the transportation staff that drove the van was absent on extended leave, since about March 2025 and there are two vans but one driver at present. On 08/14/25 at 2:32 pm an interview was conducted with the resident appointment Scheduler. The scheduler stated there was one transportation van driver, and the second driver was absent. The facility was using an outside vendor when there were multiple outside appointments to address. The Scheduler indicated if the facility driver was running late to pick up a resident, the maintenance staff were back up or an outside transport service would be called which would take about 30 to 40 minutes to reach the residents. The Scheduler stated there had not been a report that a resident was waiting for 2 hours to be picked up. On 08/15/25 at 10:17 am an interview was conducted with the dialysis center Nurse Manager. She stated there were three residents from the facility that attended hemodialysis on Monday, Wednesday, and Friday in the afternoon and sometimes the return transportation arrived as late as 6:00 pm. The residents were done with dialysis at approximately 3:30 to 4:00 pm. The Nurse Manager indicated the residents remained in the center with nursing supervision until the van arrived. She stated 6:00 pm was past the dialysis center closure time and the nursing staff had to remain with the residents until they were picked up by the facility transport and the center closed at 4:30 pm when residents were not waiting to be picked up. The Nurse Manager explained the facility was called when the residents were done and ready for pick up. The receptionist and transport person were notified by telephone that the residents were ready for pick up after each dialysis session. The interview further revealed the residents missed dinner, had a diagnosis of diabetes, and this was a concern. The problem of late pickups has gotten more frequent over the past couple of weeks. On 08/15/25 at 10:29 am an interview was conducted with the facility Receptionist. She stated the dialysis center sometimes called the main phone (receptionist) number for the van driver to pick up the residents from the dialysis center and the calls came in close to 4:00 pm. The Receptionist indicated sometimes there was a second request on the same day for pick up when the van driver had not arrived yet. She was not sure how long it was after she received the second call. The Receptionist noted the van driver had a mobile phone and sometimes the dialysis center would call the van driver directly. She was unaware how long the residents were waiting for pick up when there was a delay. On 8/15/25 at 11:17 am the facility transportation Van Driver was interviewed. She stated one of the van drivers had been absent for months and she was the only driver at this time. The Van Driver indicated she had to pick up residents in Greensboro and local (High Point) from dialysis on Monday, Wednesday and Friday. She stated that some days she was late picking up the local dialysis center residents. The Van Driver explained she picked up the Greensboro dialysis center residents from dialysis first. When she was late, the facility Scheduler was notified. The Van Driver stated sometimes an outside vendor was asked to pick up the residents from the local dialysis but there was not always availability and some days the vendor had no availability. She further stated there had been days that she was 2 hours late picking up the local dialysis residents including Residents #22 and Resident #8 when they had completed their dialysis. The Van Driver revealed Resident #8 stated he had not wanted to wait, and the concern was reported to the Scheduler. She further commented that maintenance staff was rarely available to drive the van for resident transportation, and it took 10 minutes to pick up and return the residents from the local dialysis center. On 8/15/25 at 1:05 pm the Maintenance Director was interviewed. He stated one of the van drivers had been out and there was one van driver at present. The Maintenance Director indicated there was limited use of the maintenance staff for driving. Previously, the van driver would review the schedule for resident appointments the day before and request the vendor assist with pick up from dialysis. When the request was made the day before this would ensure the vendor could provide services. The Maintenance Director noted the vendor would mostly likely not be able to provide services within an hour because this was too short notice; they would be booked. On 08/15/25 at 1:53 an interview was conducted with the Administrator. The Administrator stated the van delay to pick up residents from dialysis had been better and was now late again up to two hours occasionally. The Administrator stated he was not aware two residents transported for dialysis had concerns and would prefer to be picked up after treatment was finished and not wait two hours. The Administrator indicated there were two resident transportation vans but only one driver at present.

Based on staff interviews and record review, the facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), that is the State Mental Health or Intellectual Disability Authority, when a significant change in condition was identified for a resident with a mental disorder or intellectual disability (Resident #39) and failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for PASRR Level II residents identified to have a significant change in his or her physical or mental status (Resident #11 and Resident # 179). This deficient practice affected 3 of 3 residents reviewed who had a significant change in condition. The findings included: 1.Resident #39 was admitted to the facility on [DATE]. His cumulative diagnoses included a diagnosis of schizoaffective disorder. The resident's electronic medical record (EMR) included information from the North Carolina Medicaid Uniform Screening Tool (NC MUST). This record revealed Resident #39 was evaluated and found to have a PASRR Level I determination with a start date of 6/23/24. The PASRR Level I evaluation assessed the resident for the appropriateness of nursing facility placement and no further PASRR screening was required unless a significant change occurred with the individual’s status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. The Level II designation specified there was no end date and no limitation unless the resident had a change in condition. Resident #39's electronic medical record revealed a change of condition progress note dated 1/26/25 which indicated Resident #39 had a change in behavioral symptoms related to agitation and psychosis. The progress note also indicated that the resident was ordered .5 milligrams of Risperdal, an antipsychotic medication, two times a day for agitation. Physician order dated 1/26/25 revealed a new order for Risperdal .5 milligrams to be administered two times a day for agitation. A psychiatric follow up evaluation note dated 1/27/25 indicated that the psychiatric provider was informed by nursing staff that Resident #39 exhibited manic-like behavior with agitation, paranoia, packing and change in sleep pattern. The provider further indicated that a new order of Xanax .5 milligrams every day was ordered for agitation. Physician order dated 1/27/25 revealed a new order for .5 milligrams of Xanax every day for agitation. An interview was conducted on 8/13/25 at 1:40 PM with the Social Services Director and Social Worker. They indicated that they did not realize Resident #39 had a significant change in condition related to his behaviors and therefore did not initiate a Level II screening. The Social Workers also indicated that a Level II PASRR screening should have been initiated for Resident #39 due to the change in behavior and treatment. A telephone interview was conducted with the Administrator on 8/15/2025 at 3:49 PM. He indicated that due to Resident #39 having a diagnosis of a serious mental illness with a change in behaviors and treatment he should have been screened for a level II PASRR. 2. Resident #11 was admitted to the facility on [DATE]. The resident’s cumulative diagnoses included schizophrenia and bipolar disorder. A PASRR Level II Determination Notification letter issued for Resident #11 (dated 2/23/17) was reviewed. The letter noted Resident #11 had a PASRR number ending with the letter “B,” which was indicative of a PASRR Level II determination with “No end date, No limitation unless change in condition. No specialized services required.” The resident’s quarterly Minimum Data Set (MDS) assessment dated [DATE] reported the resident had moderately impaired cognition with a mood severity score of 9 (indicative of mild depression). No signs / symptoms of a possible swallowing disorder were reported. Resident #11 was not assessed as having experienced a significant weight loss. Resident #11 was discharged to the hospital on 6/3/25 with re-entry to the facility on 6/7/25. The hospital Discharge summary dated [DATE] reported his discharge diagnoses included acute respiratory failure with hypoxia, aspiration pneumonia and dysphagia. The resident’s most recent MDS was a significant change in status assessment dated [DATE]. The MDS reported that Resident #11 was a PASRR Level II resident due to serious mental illness. He had moderately impaired cognition and a mood severity score of 15 (indicative of moderately severe depression). The MDS assessment indicated Resident #11 was experiencing signs / symptoms of possible swallowing disorder (coughing or choking during meals or when swallowing medications). The resident was also identified as having a significant weight loss without being on a physician-prescribed weight-loss regimen. A review of Resident #11’s Care Area Assessment (CAA) Worksheet for Functional Abilities (dated 6/25/25) indicated this problem/need was triggered due to the resident’s self-care and mobility deficits. Underlying problems were reported to include a diagnosis of pneumonia, mood decline, and nutritional problems. There was no update PASRR Level II referral after the resident’s significant change assessment. An interview was conducted on 8/13/25 at 10:58 AM with the facility’s MDS Coordinator. During the interview, the MDS Coordinator was asked if a referral was made to the State mental health authority for evaluation of a resident after he or she was identified as having a significant change in condition. At that time, the MDS Coordinator reported the facility’s Social Worker assumed responsibility to request a re-evaluation for a PASRR Level II resident having a significant change. The MDS Coordinator confirmed a re-evaluation would need to be done when a significant change in status MDS was completed due to a change in the resident’s mental or physical status. An interview was conducted on 8/13/25 at 12:00 PM with the facility’s Social Worker (SW) and Social Services Director. The SW and Director reported that up to this point, PASRR Level II residents were not referred to the State mental health authority for re-evaluation when an MDS assessment was initiated for a significant change unless there was a change in a psychiatric diagnosis or behavior. Therefore, a PASRR re-evaluation was not requested for Resident #11 after being identified as having a significant change in status. A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility’s Administrator and Director of Nursing (DON). The Administrator reported that he became aware during the survey that a referral for re-evaluation for PASRR Level II residents was not always being made. The Administrator stated he would expect this to be done in accordance with the regulations. 3. Resident #179 was admitted to the facility on [DATE] with re-entry to the facility on 1/15/24 from a hospital. His cumulative diagnoses included schizophrenia, bipolar disorder, and adult failure to thrive. A PASRR Level II Determination Notification letter issued for Resident #179 (dated 2/8/24) was reviewed. The letter noted Resident #179 had a PASRR number ending with the letter “B,” which was indicative of a PASRR Level II determination with “No end date, No limitation unless change in condition. No specialized services required.” The resident’s most recent Minimum Data Set (MDS) was a significant change in status assessment dated [DATE]. The MDS reported that Resident #179 was a PASRR Level II resident due to serious mental illness. The resident was identified as having a significant weight loss without being on a physician-prescribed weight-loss regimen. A review of Resident #179’s Care Area Assessment (CAA) Worksheet for Functional Abilities (dated 4/17/25) indicated the resident was reported to have a declining change in condition related to “adult failure to thrive, multiple other health conditions.” There was no update PASRR Level II referral after the resident’s significant change assessment. An interview was conducted on 8/13/25 at 10:58 AM with the facility’s MDS Coordinator. During the interview, the MDS Coordinator was asked if a referral was made to the State mental health authority for evaluation of a resident after he or she was identified as having a significant change in condition. At that time, the MDS Coordinator reported the facility’s Social Worker assumed responsibility to request a re-evaluation for a PASRR Level II resident having a significant change. The MDS Coordinator confirmed a re-evaluation would need to be done when a significant change in status MDS was completed due to a change in the resident’s mental or physical status. An interview was conducted on 8/13/25 at 12:00 PM with the facility’s Social Worker (SW) and Social Services Director. The SW and Director reported that up to this point, PASRR Level II residents were not referred to the State mental health authority for re-evaluation when an MDS assessment was initiated for a significant change unless there was a change in a psychiatric diagnosis or behavior. Therefore, a PASRR re-evaluation was not requested for Resident #179 after being identified as having a significant change in status. A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility’s Administrator and Director of Nursing (DON). The Administrator reported that he became aware during the survey that a referral for re-evaluation for PASRR Level II residents was not always being made. The Administrator stated he would expect this to be done in accordance with the regulations.

Based on observations and staff interviews, the facility failed to ensure 1 of 2 kitchen icemakers was free from black and gray debris and wet mixing bowls were not stacked together before they were fully dry. This had the potential to affect all residents who received ice and/or food that came into contact with the mixing bowls. An observation completed on 08/11/25 at 9:38 AM revealed 1 of the facility's 2 icemakers in the kitchen had black and gray debris running down the ice divider inside of the ice maker and then along the top ridge of the icemaker where the door opened and closed. The black and gray debris was wet in nature and appeared to be running down the divider and potentially dripping onto the ice. Additional observations at this time revealed 3 large metal mixing bowls that had recently been washed, nested together on a storage shelf. When pulled apart visible liquid drained from each of the bowls and onto the floor.An interview with the Dietary Manager on 08/11/25 at 9:46 AM revealed the ice maker was scheduled to be cleaned monthly by the maintenance department. The Dietary Manager stated he believed it was scheduled to be cleaned later that week. He also reported he did not know the ice machine was dirty and indicated he did not know what the black and gray substance was on the ice machine's divider and that he would not want that substance dripping into ice he was going to use. The Dietary Manager also reported that he tries to keep metalware separated until fully dry but insisted that there was not a lot of space to store the wet dishes. The Dietary Manager reported that the ice machine should be free from dirt and debris and that metalware should not be nested while still wet and should be fully dry before being stacked.An interview with the Maintenance Director on 08/12/25 at 1:02 PM revealed he was the staff member responsible for the routine maintenance and cleaning of the ice machines located in the kitchen. He reported he completed a deep cleaning of the ice machine once every 6 months and if requested through the maintenance service request system the facility utilized. He reported he believed it was the responsibility of the Dietary Manager and his staff to ensure that the ice machine was clean on a daily basis. The Maintenance Director reported he had most recently deep cleaned the ice machine approximately 3 weeks ago but stated be must have missed pulling out the divider panel and stated it had not been cleaned.An interview with the Administrator on 08/12/25 at 1:20 PM revealed he expected the ice machine to be cleaned as needed and to be free from dirt and debris. He also reported that metalware should be fully dry before being stacked or nested together.

Based on record review and staff interview, the facility failed to complete an admission Minimum Data Set (MDS) assessment in the 14-day timeframe for 1 of 33 residents (Resident #190) reviewed for MDS assessments.Findings included:Resident #190 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 2 diabetes, and hypertension.During the record review for Resident #190 it was noted the MDS admission assessment had an assessment reference date of 08/06/25, however it was not complete.An interview was conducted on 08/15/25 at 10:13 am with the MDS Coordinator and she verified Resident #190's MDS admission assessment was not completed and should have been completed by 08/12/25. She indicated she was running behind and would get it done.On 08/15/25 at 12:22 pm an interview was conducted with the Administrator, and he indicated that his expectation was for all MDS assessments to be completed on time.

Based on staff interviews and record review, the facility failed to develop a comprehensive care plan to address a resident's needs as identified in the admission assessment for 1 of 36 residents (Resident #4) whose care plans were reviewed.The findings included: Resident #4 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included diabetes and unspecified convulsions (seizure disorder).The resident's most recent Minimum Data Set (MDS) assessment was a comprehensive admission assessment dated [DATE]. A review of the MDS revealed the resident had intact cognition. She had impairment of range of motion of her upper and lower extremities on both sides of her body and utilized a walker for mobility. The resident required set-up or clean-up assistance for eating and personal hygiene; partial/moderate assistance for bed mobility and sit to stand; substantial/maximum assistance for bathing and dressing her upper body; and was dependent on staff for toileting and transfers. Resident #4 was assessed as always incontinent of bladder and bowel. She did not receive either a therapeutic diet or mechanically altered diet but was reported to be edentulous (had no natural teeth). Resident #4 was reported to be at risk for developing pressure ulcers/injuries but did not have an unhealed pressure ulcer/injury at the time of the MDS assessment.Resident #4's Care Area Assessments (CAAs) were reviewed and noted the following care areas were triggered:--Communication (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Communication - Functional Status be addressed in the care plan? Yes.--Functional Abilities (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Functional Abilities (Self-Care and Mobility) - Functional Status be addressed in the care plan? Yes.--Urinary Incontinence and Indwelling Catheter (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Urinary Incontinence and Indwelling Catheter - Functional Status be addressed in the care plan? Yes.--Nutritional Status (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Nutritional Status - Functional Status be addressed in the care plan? Yes.--Dehydration/Fluid Maintenance (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Dehydration/Fluid Maintenance - Functional Status be addressed in the care plan? Yes.--Dental Care (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Care - Functional Status be addressed in the care plan? Yes.--Pressure Ulcer/Injury (CAA Worksheet dated 6/17/25). A question and answer posed on the CAA Worksheet read, Will Pressure Ulcer/Injury - Functional Status be addressed in the care plan? Yes.A review of Resident #4's current care plan revealed the areas of focus identified in her comprehensive assessment and in accordance with the information provided by the CAAs were not included. The areas of focus which were not addressed or completed in the resident's current care plan included: Communication, Functional Abilities (Self-Care and Mobility), Urinary Incontinence, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, and Pressure Ulcer/Injury.An interview was conducted on 8/13/25 at 11:06 AM with the facility's MDS Coordinator related to Resident #4's care plan. Upon request, the MDS Coordinator reviewed Resident #4's. When asked, the MDS Coordinator reported the nursing staff typically completed an initial assessment and plan related to the resident's care upon his or her admission, and the MDS nurse would add to the care plan. Upon review of Resident #4's care plan, the MDS Coordinator confirmed the CAAs triggered for this resident indicated there were several areas of focus which still needed to be addressed in the care plan. She further explained by stating that when the CAA indicated a particular area of focus would be included in a care plan, then the comprehensive care plan needed to include it. The MDS Coordinator reported Resident #4's comprehensive care plan should have been completed by 6/24/25. When asked if Resident #4's comprehensive care plan was completed, the MDS Coordinator stated, No.A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility's Administrator and Director of Nursing (DON). Upon inquiry, the Administrator reported he would expect a comprehensive care plan to be developed in a timely manner.

Based on staff interviews and record review, the facility failed to submit a quarterly Minimum Data Set (MDS) assessment within the required time limit for 1 of 4 residents (Resident #75) reviewed for the Resident Assessment facility task.The findings included:Resident #75 was admitted to the facility on [DATE]. The resident's electronic medical record (EMR) revealed her history of Minimum Data Set (MDS) assessments included the following, in part:--A quarterly MDS dated [DATE] was reported as electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) database and accepted;--However, a quarterly MDS dated [DATE] was reported only as completed in Resident #75's EMR.An interview was conducted on 8/13/25 at 11:02 AM with the facility's MDS Coordinator. During the interview, the nurse reviewed Resident #75's history of MDS submissions. Upon this review, the MDS Coordinator noted the 6/11/25 quarterly MDS completed for Resident #75 should have been sent to CMS but was not. She stated, That's an error. The MDS Coordinator reported that although the MDS was completed timely, it was not submitted timely. A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility's Administrator and Director of Nursing (DON). During the interview the Administrator reported he would expect MDS assessments to be transmitted timely.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect whether anticonvulsant and anticoagulant medications were administered for 1 of 36 residents (Resident #4) whose MDS assessment was reviewed.The findings included:Resident #4 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included diabetes and unspecified convulsions (seizure disorder).The resident's electronic medical record (EMR) included her Physician's Orders. These orders included, in part:--25 milligrams (mg) lamotrigine (an anticonvulsant medication) given as one tablet by mouth in the evening (Initiated 6/4/25). --75 mg pregabalin (an anticonvulsant medication) to be given as one capsule by mouth two times a day (Initiated 6/4/25). Further review of Resident #4's Physician's Orders and Medication Administration Record (MAR) did not reveal the resident received an anticoagulant at any time during the month of June 2025.The resident's admission Minimum Data Set (MDS) was dated 6/10/25. The medication section of this MDS assessment did not indicate Resident #4 received an anticonvulsant medication. Additionally, the assessment reported that she received an anticoagulant medication during the 7-day look back period. An interview was conducted on 8/13/25 at 11:06 AM with the facility's MDS Coordinator related to Resident #4's admission MDS. At that time, the MDS Coordinator reviewed the resident's admission MDS assessment and electronic medical record (EMR). When asked, the MDS Coordinator confirmed the resident did receive anticonvulsant medications but no anticoagulant medication during the 7-day look back period. The MDS Coordinator stated the MDS was inaccurately coded.A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility's Administrator and Director of Nursing (DON). During the interview the Administrator reported he would expect the MDS assessments to be coded accurately.

Based on observations, record review, and staff, resident, and Nurse Practitioner (NP) interviews the facility failed to transfer a resident safely from a shower to the resident's room. On 06/12/24 Resident #1 was being pushed in a shower chair down the hall by Nursing Assistant (NA) #1 and the resident fell forward out of the chair hitting the floor. The fall resulted in the resident being sent out to the hospital for complaints of severe pain. Resident #1 indicated from a 1-10 (10 being the most pain) her pain level was an 11 in her lower extremities and wanted to be sent out to the hospital immediately. Resident #1 was admitted to the hospital on 6/12/24 and was diagnosed with a left tibial plateau fracture (top part of the shin bone), right foot great toe fracture, and an acute displaced (bones are out of alignment) spiral (broken by twisting force) fracture of the right femur (thigh bone) requiring surgical repair. This was for 1 of 3 residents reviewed for providing supervision to prevent accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included pain, debility, and abnormalities of gait and motion. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired and was totally dependent with bathing and transfers. The MDS further revealed Resident #1 was coded for frequent pain and no impairment to range of motion. It was also indicated Resident #1 was coded for anticoagulants daily. Resident #1's MDS revealed the resident weighed 274 pounds (lb.) and was 62 inches in height. Review of Resident #1's care plan revised 06/05/24 revealed Resident #1 was at risk for falls related to impaired mobility, impaired balance, weakness, pain, oxygen tubing (trip hazard), anxiety and use of psychotropics drugs and pain medication. Review of progress note completed by Nurse #1 on 06/12/24 revealed Resident #1 was alert and oriented and was able to make needs known by staff. The note further revealed Resident #1 was being transported back to her room from a shower and the shower chair tilted over and the resident fell to the floor. The note indicated Resident #1 was assessed and Resident #1 appeared to be sluggish and the right hip was malformed. Nurse #1 and other staff attempted to assist Resident #1 off the floor using a mechanical life and Resident #1 screamed and cried of severe pain. The note revealed the Nurse Practitioner (NP), and Responsible Party (RP) were notified, and Resident #1 was sent to the hospital for evaluation and treatment. Review of incident report dated 06/12/24 revealed Resident #1 had fallen with severe pain to the bi-lower extremities. NA #1 reported that as she returned from the shower Resident #1 started to slide from the shower chair and NA #1 immediately reported she stopped to attempt to assist however the resident fell from chair. The incident report further revealed the location of the fall was the hall and predisposing factors were the rugs/carpeting and equipment. Review of Emergency Department note dated 06/12/24 revealed Resident #1 revealed she was in a shower chair that was being rolled across the floor when the wheels got stuck causing her to fall out of the chair. The note further revealed Resident #1 complained of severe right hip pain and bi-lateral knee pain. It was noted Resident #1's right leg was shortened and externally rotated. Resident #1 was given intravenous Fentanyl (narcotic analgesic) and Zofran (antiemetic). X-rays completed on 6/12/24 revealed Resident #1 sustained a left tibial plateau fracture, right foot great toe fracture, and an acute displaced spiral fracture of the right femur. An orthopedic surgeon was consulted and it was determined the femur fracture required surgical repair which would be completed the next day. Resident #1 returned to the facility on [DATE]. Interview conducted with Resident #1 on 09/03/24 at 12:10 PM revealed she had often showered in a shower chair and not had any issues before. Resident #1 further revealed she was only 5'2 and her feet were unable to touch the ground when she was sitting in the shower chair. Resident #1 stated on 06/12/24 she was leaving the shower room and, on the way back to her room NA #1 was pushing her fast pass the nurses' station. She felt the shower chair jerk when shower chair crossed over the threshold onto the carpeted hallway from the wood plank floor. Resident #1 indicated she felt like she went flying and hit her knees first and then went to her back. Resident #1 indicated from a 1-10 (10 being the most pain) her pain level was an 11 in her lower extremities and wanted to be sent out to the hospital immediately. Resident #1 stated she felt like the incident on 06/12/24 was a setback in being able to return home because of her physical mobility due to the injuries received. Resident #1 revealed she had a history of drug and alcohol abuse and was upset that she had to be on more pain medicine and was in more pain than before. A phone interview conducted with NA #1 on 09/04/24 at 3:15 PM revealed on 06/12/24 she was transferring Resident #1 back to her room in a shower chair and the shower chair felt like it got caught and jerked when she passed the threshold onto the carpet past the nurses station. NA #1 further revealed the shower chair tilted forward, and Resident #1 went to her knees and then onto her back. NA #1 indicated Resident #1 immediately started to yell in pain and Nurse #1 had the resident sent out to the hospital. NA #1 indicated she often showered Resident #1, and the resident had always been able to balance and had no issues in the shower chair during transfers. NA #1 indicated the shower chairs were often hard to push on the carpet and the wheels would sometimes get stuck. Interview conducted with Nurse #1 on 09/03/24 at 10:45 AM revealed on 06/12/24 she heard Resident #1 yelling ouch, ouch, it hurts, and observed Resident #1 laying on the hallway floor on her back past the nurse's station in front of the shower chair. Nurse #1 further revealed NA #1 reported she was pushing Resident #1 back to her room in the shower chair and the wheelchair tugged like the resident's leg got caught and caused the wheelchair to tip forward. Nurse #1 stated she assessed Resident #1 and decided to have the resident sent out to the hospital due to the resident being in severe pain. Nurse #1 revealed Resident #1 was alert and oriented and was able to voice her own needs and concerns. Nurse #1 also revealed Resident #1 was able to sit up without assistance and her feet did not touch the floor in the shower chair due to the resident's height. Interview conducted with the Director of Nursing (DON) on 09/03/24 at 11:10 AM revealed on 06/12/24 she was notified by a staff member that Resident #1 had fallen and found Resident #1 on the floor on her back with Nurse #1 and NA #1. The DON further revealed Nurse #1 had already assessed her and it was determined to send the resident out to the hospital due to the resident having pain in her legs. The DON further revealed NA #1 had reported to her that she had transferred the resident back to her room from the shower room and Resident #1 started to slide down in the chair onto the floor. The DON revealed she did not believe any fault in the incident but completed in-service training regarding transfers with staff and interventions included Resident #1 was changed to a shower bed for showers and footrests and safety belts added to shower chairs. A phone interview conducted with the prior Nurse Practitioner (NP) on 09/03/24 at 11:55 AM revealed she was not present in the facility on 06/12/24 but was notified Resident #1 had a fall. The NP further revealed Resident #1 had history of osteopenia and comorbidities but was able to sit up without assistance that she could recall. The NP further revealed she did not recall details of the incident that occurred on 06/12/24. An interview conducted with the Director of Rehab on 09/03/24 at 1:30 PM revealed Resident #1 was last seen for physical therapy in March 2024. It was further revealed Resident #1 was able to sit on the side of her bed with limited to no assistance with sitting up. The Director Rehab indicated the shower chair was appropriate for Resident #1. The Administrator was notified of immediate jeopardy on 09/04/24 at 6:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. The corrective action plan was as followed: Date of Immediate Jeopardy Removal: 06/14/24 How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On June 12, 2024 at 12:21pm, Nursing Assistant (NA) #1 was assisting resident #1 from the shower room back to her room as the resident was seated in the shower chair. Resident #1 fell out of the shower chair as she was being transported from the shower room to her room at an area on the carpeted hallway between the nurses' station and the resident's room. Nurse #1 immediately assessed resident #1 to include vital signs, neuro checks, and pain assessment. Nurse #1 noted Resident #1 to have increased pain to her lower extremities during assessment. Resident #1 was yelling and stating she was in pain. Resident #1 was unable to state specifically where her pain was located. The pain assessment conducted by Nurse #1 noted increased pain with movement to bilateral lower extremities by resident #1. A progress note dated June 12, 2024 at 12:21pm identified resident #1 right hip was malformed. Nurse #1 notified Nurse Practitioner (NP) and obtained an order to send resident #1 to the local hospital for further evaluation. Resident #1 was sent to the local hospital due to severe pain in bilateral lower extremities and her right hip being malformed. The center recognizes that all residents that utilize shower chairs, shower stretchers and wheelchairs have the potential to be affected from the noncompliance with shower chairs, shower stretchers and wheelchairs. A review of resident#1 hospital admission records dated June 12, 2024 at 2:26pm releveled resident #1 had a left tibial plateau fracture, right foot great toe fracture, tibia/fibula fracture of the right leg, and an acute displaced spiral fracture of the right femur. Resident #1 was admitted to the local hospital on June 12, 2024. Resident #1 underwent an open reduction internal fixation of the right distal femur intramedullary (IM) nail retrograde on June 13, 2024. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 6/12/24, the Director of Nursing audited incidents that occurred between 5/12/24 and 6/12/24 to ensure no significant events with any other residents were identified. No additional residents were identified to have significant injuries. The audit revealed no similar events, no injuries to any other residents. On 6/12/24, the Director of Nursing and Unit Manager conducted a quality review to identify residents' mobility status as it relates to requiring the use of wheelchairs, shower stretchers and shower chairs. Identified residents' charts were reviewed to ensure no other significant events occurred during the transport by staff. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? The Maintenance Director completed a quality review on 6/12/24 on shower chairs and shower stretchers to ensure safety mechanisms were properly installed to ensure resident safety while being transported to and from the shower rooms. The safety mechanism is a safety belt designed for PVC shower chairs equipped with a quick release buckle. The safety belts were installed on all shower chairs. On June 12, 2024, the Director of Nursing and/or Nursing Supervisor provided education to Licensed Nurses and Certified Nursing Assistants to include Agency Licensed Nurses and Agency Certified Nursing Assistants on Guidelines for Safe Bathing with the use of Shower Chair to prevent incidents and accidents as it relates to properly and safely transporting residents in shower chairs. The education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. All newly hired Licensed Nurses and Certified Nursing Assistants to include newly hired Agency Licensed Nurses and Agency Certified Nursing Assistants will be educated during new hire orientation on Guidelines for Safe Bathing with the use of Shower Chair to prevent incidents and accidents as it relates to properly and safely transporting residents in shower chairs. The education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? Effective June 13, 2024, The Unit Manager and/or Director of Nursing will begin to observe a random sample of 8 residents per week for 4 weeks, then 5 residents per week for 4 weeks, then 3 residents per week for 4 weeks to ensure resident safety is maintained during transport in shower chairs by properly securing safety mechanisms on shower chairs. On June 12, 2024, when the deficient practice was identified, The Nursing Home Administrator arranged an ADHOC Quality Assurance Performance Improvement meeting to be conducted on June 13, 2024, in collaboration with the Medical Director to discuss the root cause analysis of the deficient practice, implement a plan of correction to include monitoring beginning on June 13, 2024, to ensure resident safety during transportation in shower chairs. The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety x 3 months. The improvement-monitoring schedule will be modified based on the findings of monitoring. On 09/04/24, the facility's corrective action plan for immediate jeopardy removal effective 06/14/24 was validated by the following: Staff interviews revealed they had received education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. A quality review was conducted to identify residents' mobility status. The Maintenance Director completed a quality review on all shower chairs and shower stretchers to ensure safety mechanisms were properly installed to ensure resident safety while being transported to and from the shower rooms and safety belt were installed on all shower chairs. Audits of transfers had been conducted and will continue to be conducted to be reviewed that residents had been transferred safely in shower chairs and beds. The immediate jeopardy removal plan was verified as corrected by 6/14/24.

Based on record review, resident interview, staff interview and Nurse Practitioner interview, the facility failed to provide assistive devices to prevent accidents for 1 of 4 residents (Resident #110) reviewed for falls. Resident #110 fell out of bed, hit her head on the floor, yelled, and screamed of pain, sustaining a 36 centimeters [cm] full thickness curvilinear (crescent) wound to the lateral aspect of the right lower leg and the right first toenail was almost completely avulsed (torn off) with only attachments on the lateral proximal (from the side to the center) nail. Findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease (COPD) and hypertension (HTN). Resident #110's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and with no behaviors. The quarterly assessment further indicated Resident #110 required extensive assistance of two persons physical assist with bed mobility, transfers, and total assistance of two persons physical assist with bathing. The care plan revised on 08/28/23, indicated Resident #110 required assistance with activities of daily living (ADL's) and mobility. The goal for this care plan was Resident #110 would improve the level of function in ADL's and mobility. The interventions included transfer/assist rail as an enabler for turning and repositioning in bed. This intervention was initiated on 03/01/23. The admission/readmission nursing documentation version-11 assessment that was completed on 11/23/23 by Nurse #3 at 02:42 pm was reviewed. The documentation indicated that the integumentary system was reviewed and revealed that Resident #110 had no new skin injury /wounds identified. The documentation further indicated that Resident #110 did have a previously noted skin injury/wound of a stage 1 to buttocks that was healing. No other skin injuries/wounds were identified in the assessment. An interview was conducted with Nurse #3 on 05/17/24 at 10:47 am. After a short hospital stay on 11/23/23, Nurse #3 indicated that she physically assessed Resident #110 upon readmission. Nurse #3 indicated her assessment revealed that Resident #110 only had a stage 1 to buttocks that was healing and no other skin injuries/wound. Nurse #3 indicated that stage 1 to buttocks was a preexisting wound. Nurse #3 indicated that Resident #110 did not have any pain on readmission. Review of incident report provided by facility, dated 11/24/23 at 09:04 pm indicated that Resident #110 had an incident in her room. The report indicated that NA #8 called Nurse #4 to Resident #110's room. Report indicated Resident #110 was on the floor closer to the window. Report indicated that Resident #110 denied hitting her head. Report indicated an extremely large amount of blood was noted and it was difficult to determine where the blood was coming from. Report indicated Resident #110 was face down and there was difficulty seeing where blood was coming from. Report indicated Resident #110 was repositioned on her back and a large flap of skin 7inches x 8 inches was noted. Report indicated Resident #110 toenail was almost off. Report indicated that Resident #110 stated she kept rolling when her position changed while rolling from back to left side. Report indicated Emergency Medical Services (EMS) called and Resident #110 transported to emergency room (ER) for evaluation. Report indicated that Resident #110 description of the incident was rolled out of bed while being changed. Review of eInteract (Situation, Background, Assessment and Recommendation) SBAR change in condition evaluation dated 11/24/23 and completed by Nurse #4 at 10:20 pm indicated Resident #110 had a fall and sustained a laceration. The evaluation further indicated that Resident #110 had a new onset of pain with a pain intensity of 10 (rated on a scale of 1-10, with 10 being the worst). The evaluation also indicated that pressure was applied to Resident #110's leg until emergency medical services (EMS) arrived. Review of progress note dated 11/24/23 at 10:36 pm, written by Nurse #4, indicated that NA #8 called Nurse #4 to Resident #110's room. Nurse #4 note indicated that Resident #110 was on the floor closer to the window. Note further indicated that Resident #110 was facedown, and an extremely large amount of blood noted. The eInteract change in condition evaluation guide assessment completed by Nurse #4 on 11/24/23 at 10:57 pm was reviewed. Evaluation indicated that Resident #110 had a fall at night that required sutures to the leg. Evaluation indicated physician orders obtained to transfer Resident #110 to the ER. Evaluation also indicated that Resident #110 had a very large laceration front/lateral right lower leg approximately 8inches x 7 inches and right toenail was hanging off. Evaluation also indicated that Resident #110 pain level was 10 (rate pain on a scale of 0 to 10. 0=no pain, 4-5=moderate pain, 10=excruciating pain). The evaluation indicated the exact location of Resident 110's pain was the right lower leg (front) that had a large flap of skin hanging off leg. Multiple attempts were made to reach Nurse #4 for an interview were unsuccessful. Interview was conducted with Resident #110 on 05/13/24 at 02:24 pm. Resident #110 indicated that she could not remember what happened on 11/24/23. Written statement from NA #8 dated 11/27/2023, used by the facility during their initial investigation, revealed NA #1 was providing ADL care to Resident #110 on 11/24/23 when Resident #110 fell out of bed. NA #8 indicated that she was assisting Resident #110 with turning to the left side of her bed. NA #8 further indicated that Resident #110 usually grabbed the side rail, but on this occurrence, Resident #110 did not grab rail and rolled off bed. An Interview was conducted with NA #8 on 05/16/24 at 12:52 pm. NA #8 Indicated recalled the fall that occurred while she was providing care to Resident #110 on 11/24/23. NA #8 indicated that Resident #110 bed did not have the 1/4 bed rails raised in an up position even though it was supposed to. NA #8 indicated after she was done with washing the front side of Resident #110, she proceeded to turn and reposition Resident #110 towards Resident #110 left side. NA #8 stated she informed Resident #110 that she was going to assist her to turn towards Resident 110's left side. NA #8 indicated that she placed her right hand on Resident #110 right hip while her left hand was flipping Resident #110 over. NA #8 indicated that Resident #110 was noted to be reaching out to grab the 1/4 bed rail but was not able to because it was not raised to an up position. NA #8 indicated that Resident #110's right leg kept going over while upper body was still in bed. NA #8 indicated she was not able to stop Resident #110 from flipping over. NA #8 indicated that Resident #110 fell out of bed and hit the floor. NA #8 indicated Resident #110 hollered and screamed in pain. NA #8 indicated that Nurse #4 came into Resident 110's room after hearing the hollering and screaming. NA #8 indicated that she did not review the plan of care for Resident #110 prior to providing care. NA #8 indicated that she had worked with Resident #110 multiple times and did not need to review plan of care. NA #8 indicated that she did not raise the 1/4 bed rails into an up position, because they are usually up when she comes into Resident 110's room. Review of emergency department provider note completed on 11/25/23 at 12:35 am indicated that Resident #110 arrived at Hospital via EMS. Note indicated that Resident #110 presented with a large (36cm) full-thickness curvilinear wound to the lateral aspect of the right lower leg and the right first toenail was almost completely avulsed with only attachments on the lateral proximal nail. Note further indicated that these injuries occurred when staff were rolling Resident #110 and she fell out of the bed. Note also indicated that Resident #110 hit her head and was complaining of pain at the right first toenail where the nail was partially torn off. Nurse Practitioner (NP) progress note dated 11/27/23 was reviewed. NP note indicated that Resident #110 was being evaluated following an emergency department visit due to rolling out of bed causing laceration. Note further indicated that Resident #110 was readmitted with staples in her right lower leg and sutures in her right great toe. Indicated that Resident #110 reported increased pain due to injuries. Interview with NP was conducted on 5/16/24 at 05:01 pm. NP indicated that she evaluated Resident #110 on 11/27/23, after readmission back to facility. Indicated that Resident #110 indicated that she had rolled out of bed. Indicated that Resident #110 required a lot of help with moving in bed. Indicated that Resident #110 returned to facility with staples in her right lower leg and sutures in her right great toe. Indicated that Resident #110 reported increased pain due to injuries and ordered scheduled pain medication three times a day for three days for pain and resumed every 8 hours as needed. Attempts were made to reach the Medical Director. The administrator indicated that the Medical Director was out of the country and did not have a replacement. Administrator indicated that Nurse practitioner was available. An interview was conducted with the Director of Nursing (DON) on 05/17/24 at 12:35 pm. DON indicated that residents should be free from accidents. An interview was conducted with the Administrator on 05/17/24 at 12:51 pm. The Administrator indicated that all residents should be free from incidents and accidents.

Based on observations, resident and staff interviews and record review, the facility failed to honor a resident's choice to receive showers as scheduled or requested. This was for 1 (Resident #88) of 3 residents reviewed for choices. The findings included: Resident #88 was admitted on [DATE] with cumulative diagnoses of atrial fibrillation, cerebral vascular accident with left sided paralysis and chronic obstructive pulmonary disease (COPD). Review of the facility's Recreation Comprehensive assessment dated [DATE] read choosing between and bath or shower was very important to him. Resident #88 quarterly Minimum Data Set, dated dated dated [DATE] indicated he had moderate cognitive impairment, exhibited no behaviors, coded for impairment on one side for his upper and lower extremities and set up only for bathing. He was also coded with occasional bladder incontinence and always continent of bowels. Review of Resident #88's care plan last revised on 5/9/24 read he required extensive staff assistance for bathing. There was no care plan for the refusal of showers. An interview was completed with Resident #88 on 5/13/24 at 11:07 AM. His hair appeared to be oily and unwashed. He stated the staff do not give him his showers like they were supposed to. He stated his shower days and time was on Wednesdays and Saturdays on second shift. Resident #88 stated staff never showered him on third shift because he was sleeping at that time. An interview was completed with the Director of Nursing (DON) on 5/14/24 at 9:40 AM. She stated showers were given on first and second shifts only. She stated the only time a shower would be given on third shift would be for a resident with an extreme accident or going to the hospital for a procedure. She provided documentation that Resident #88's shower days were Wednesday and Saturdays on second shift. +Review of December 2023 bathing/shower records indicated Resident #88 received a shower on the following days: 12/6/23, 12/16/24 and 12/20/24. *12/8/23-documneted for 4:35 AM by Nursing Assistant (NA) #3. A telephone interview was attempted with NA #3 on 5/14/24 at 6:20 PM but the mailbox was full and she was no longer employed by the facility. There were a total of 3 showers for December 2023 with no documentation of any refusals. +Review of January 2024 bathing/shower records indicated Resident #88 received a shower on the following days: 1/2/24, 1/3/24, 1/13/24, 1/28/24 There were a total of 4 showers for January 2024 with no documentation of any refusals. +Review of February 2024 bathing/shower records indicated Resident #88 received a shower on the following days: 2/3/24, 2/10/24 *2/4/24-documented for 12:28 AM, 2/5/24 at 3:59 AM, 2/9/24 at 6:50 AM, 2/11/24 at 5:02 AM and 2/12/24 at 6:59 AM by NA # 5. A telephone interview was attempted with NA #5. Message left but no return calls at the time of exit. She was no longer employed by the facility. There were a total of 2 showers for February 2024 with no documentation of any refusals. +Review of March 2024 bathing/shower records indicated Resident #88 received a shower on the following days: 3/16/24, 3/27/24, 3/30/24 *3/8/24-documented for 4:42 AM by NA # 9. A telephone interview was attempted and a message was left for NA #9 on 5/15/24 at 6:44 PM with no return call at the time of exit. She was no longer employed by the facility. *3/16/24 at 11:59 AM-documented by NA # 7. A telephone interview was attempted to NA #7 but her mailbox was full. At the time of exit, she had not returned calls to the facility. There were a total of 3 showers for March 2024 with no documentation of any refusals. +Review of April 2024 bathing/shower records indicated Resident #88 received a shower on the following days:4/7/24, 4/10/24. 4/27/24 *4/15/24-documented at 3:55 AM and again at 3:57 AM by NA #6. A telephone interview was completed on 5/15/24 at 6:24 PM with NA #6. She stated she documented both showers on 4/15/24 on third shift in error because there were no showers given on third shift unless a resident was extremely soiled and Resident #88 was continent. *4/28/24-documented at 6:59 AM by NA #6. A telephone interview was completed on 5/15/24 at 6:24 24. She stated it was a documentation error and she did not complete a shower. There were a total of 3 showers for April 2024 with no documentation of any refusals. +Review of May 2024 from 5/1/24 to 5/15/24 bathing/shower records indicated Resident #88 received a shower on the following days: 5/1/24, 5/5/24, 5/8/24 *5/3/24-documented at 1:57 AM by NA #6. A telephone interview was completed on 5/15/24 at 6:24 24. She stated it was a documentation error and she did not complete a shower. *5/5/24 -documented at 12:45 AM by NA #6. A telephone interview was completed on 5/15/24 at 6:24 24. She stated it was a documentation error and she did not complete a shower. There were a total of 3 showers from 5/1/24 to 5/15/24 with no documentation of any refusals. An interview was completed on 5/14/24 at 12:19 with Nurse #1. She stated Resident #88 had left side paralysis and required staff assistance with some of his activities of daily living (ADLs). She stated he required extensive staff assistance with his showers and was not aware of any shower refusals. An interview was completed on 5/14/24 at 12:31 PM with NA #4. She stated Resident #88 required assistance with his showers, but he refused them at times. She stated his refusals were documented in the task section of the electronic medical record NA #4 also stated the aides were to let the nurse know of any shower refusals. Review of Resident #88's nursing notes from 12/4/23 to 5/15/24 did not include any notes regarding his refusals of his showers. An interview was completed on 5/15/24 at 2:35 PM with NA #1. She stated Resident #88 required extensive staff assistance with showering and rarely refused. An interview completed on 5/15/24 at 3:30 PM with NA #10. She stated Resident #88 did not refuse his showers and looked forward to them. An interview was completed with the Administrator on 5/16/24 at 10:30 AM. He stated Resident #88's shower preference were to honored.

Based on observations, record and staff interviews the facility failed to protect a resident's right to be free from abuse when Resident #420 struck Resident #133 with a cane. This affected 1 of 9 residents reviewed for abuse. The findings included: Resident #420 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, insomnia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #420 was cognitively intact with no behaviors. Resident #420's Care Plan dated 4/1/20 included the focus area of risk for distressed/fluctuating mood symptoms related to: neurocognitive disorder, encephalopathy, new environment, anxiety, PTSD, new roommate. Interventions included observe for signs of delirium, including delusions/hallucinations; notify physician/advance practitioner as needed; encourage Resident #420 to seek staff support for distressed mood. Resident #133 was admitted to the facility on [DATE] with diagnoses that included unspecified severe dementia with other behavioral disturbance and long term use of aspirin. Review of the quarterly MDS dated [DATE] revealed Resident #133 was severely cognitively impaired with no behaviors. Resident #133's Care Plan updated 6/11/23 included the focus area of risk for elopement due to history of wandering in residents' rooms. Interventions included divert resident/patient by giving alternative objects or activities and redirect resident/patient if near exits or doorways. Review of a Facility Reported Incident (FRI) 24-hour report dated 10/13/23 revealed that there was a resident to resident altercation. Resident #133 wandered into Resident #420's room and Resident #420 struck Resident #133 with her cane. Residents were immediately separated. Resident #133 was sent to the emergency room for further evaluation. This allegation type was classified as resident abuse. A review was completed of the 5-working day investigation report dated 10/18/23. The review revealed staff reported a resident-to-resident altercation. Resident #133 allegedly wandered into Resident #420's room, which startled Resident #420. Resident #420 struck Resident #133 with her cane multiple times. Residents were immediately separated. Police were called, skin assessments were completed, Resident #133 was noted with bruising and was sent to the emergency room . Resident #133's family was made aware of altercation. Alleged aggressor (Resident #420) was placed on 1:1 immediately and telehealth psych evaluation was conducted with new orders to send to the emergency room for further evaluation. Upon return of Resident #133 safety checks were initiated. Upon return of Resident #420, room change was completed and 1:1 was initiated. Clinical nurse practitioner, psych nurse practitioner and social work support continued. Resident #420 sustained medication adjustments. Family meeting was held with Assistant Administrator, Social Services Director, Nurse Practitioner, and Director of Nursing on 10/18/23. Allegation was substantiated. Resident #133 was noted as alert and confused, severely impaired, and had a history of dementia with behavioral disturbances, anxiety and care planned for wandering. Resident #420 was noted as alert with history of anxiety disorder, PTSD, psychosis, and major depressive disorder. A review of the hospital after visit summary on 10/13/23 for Resident #133 revealed there were no bony injuries, computed tomography scan (CT) revealed head and neck without any acute findings. Also, CT of pelvis without any acute findings. Resident #133 had soft tissue trauma to both knees and to the head. A review of the skin assessment on 10/13/23 for Resident #133 revealed that there was one hematoma above the right eye, one hematoma on the right knee, one hematoma on the left upper thigh, and three hematomas on the left knee. An observation and interview were conducted with Resident #133 on 5/14/24 at 2:40 PM. Resident #133 was sitting in a chair, spoke very low and unable to answer questions. Resident #420 no longer resided in the facility. A phone interview was conducted with Nurse #5 on 5/15/24 at 5:28 PM and revealed she didn't witness the incident, but heard some commotion on the hall, when she arrived on the hall the two residents were in the hall and Resident #420 had a cane in her hand and Resident #133 indicated Resident #420 beat her. Resident #133 was not crying; she had a knot on her head. The interview further revealed Nurse #5 was familiar with both residents and indicated Resident # 133 would wander around the facility and Resident #420 could be territorial of her space. Nurse #5 indicated that both residents were very pleasant, and the incident caught everyone off guard as there had been no altercations before. A phone interview was conducted with Nurse #6 on 5/15/24 at 5:48 PM and revealed she didn't see the incident, when she saw Resident #420 and Resident #130, they were in the hall and the incident had just occurred. Nurse #6 indicated that Resident #420 indicated she hit Resident #130 because she was startled that she came in her room. Resident #133 wasn't crying, but indicated that her head hurt, Nurse #6 gave Resident #133 acetaminophen. Residents were immediately separated. Resident #133 went to the hospital for evaluation. An interview was conducted with Nurse Aide #2 on 5/16/24 at 8:10 AM. Nurse Aide #2 revealed she worked the day of the incident, but she was doing patient care with another resident when the incident occurred. She was familiar with Resident #133 and worked with her regularly. Nurse Aide #2 indicated that sometimes Resident #133 would wander and if she saw her try to go in other resident's rooms, she would redirect her. Nurse Aide #2 further revealed that to her knowledge, this was the first time either resident had been in an altercation. An interview was conducted with Nurse #1 on 5/16/24 at 8:18 AM and revealed she was not working on the day of the incident but was familiar and had worked with both residents. The interview further revealed Resident #133 had dementia and sometimes would wander in and out of resident's rooms and in the hall and sometimes, due to her dementia, redirection was a little harder than other times. Resident #420 mostly kept to herself and there was never a problem, until that incident. Nurse #1revealed nothing like this had ever happened and they didn't see it coming, Resident #420 was protective over her room and things. An interview was conducted with the Social Worker on 5/16/23 at 8:23 AM and revealed she had worked with both residents and knew them well. Resident #133 had dementia and would wander up and down the halls and was easy to redirect. There had been no incidents like this before and they were shocked. Resident #420 kept to herself, saw a psychiatrist, and had a state appointed guardian; Resident #420 had experienced trauma in her life. Resident #420 was very neat, and her room was clutter free and she didn't want anyone messing in her room, unless they notified her first and then she would usually be okay with it. The Social Worker indicated on the day of the incident, she heard a commotion, because her office was close in proximity Resident #420's room and when she walked in the hall Resident #420 was telling Resident #133 to get away. The residents were immediately separated; responsible parties were notified, and police were notified. Police came and interviewed Resident #420 and were unable to interview Resident #133 due to her dementia. No charges were filed against Resident #420 due to her being a ward of the state. Both residents were sent to the hospital for evaluation. Psychiatry was notified and Resident #420 was seen on 10/13/23. Resident #420 had no injuries and Resident #133 had a knot on her head, but she didn't seem to be in any pain. An interview was conducted with Director of Nursing (DON) and Social Services Director on 5/16/24 at 8:43 AM and revealed they were familiar with both residents. DON revealed Resident #133 had dementia and would wander up and down the halls, Resident #420 was private, but she did like to attend activities. Resident #420 was never known to be aggressive. Interview with DON further revealed that after altercation, residents were immediately separated, and skin checks were performed. Social Services Director indicated Resident #420 had no injuries and Resident #133 had some bruising but had no pain. Both residents were sent to the hospital. Interview further revealed that the DON felt like this could not have been prevented and they had no way of knowing this was going to happen, but after it happened the facility took all measures to ensure safety. An interview was conducted with the former Administrator on 5/16/24 at 12:15 PM and revealed Resident #133 was pleasantly confused and would harmlessly wander the halls and she supposedly wandered into Resident #420's room. Resident #420 was startled, and it appeared that she hit Resident #133 with her cane. Residents were separated and both residents went to the hospital. Resident #133 didn't seem to be in any pain, there was a knot on her head and bruising on her leg. Interview further revealed that Resident #420 had never done anything like this before and they couldn't predict this, the incident was out of the blue. Resident #420 did indicate that Resident #133 startled her. The facility implemented the following Corrective Action Plan with a completion date of 10-18-23. On 10/13/23, Resident #133 with a history of dementia wandered in Resident #420's room resulting in a resident-to-resident physical encounter on 2 south. 10/13/24, the residents were immediately separated upon identification by staff, with an RN physical assessment completed both residents. 10/13/24, the aggressor female resident (Resident #420) was immediately placed on 1:1 and High Point Police Department called. Center arranged immediate FaceTime eval on 10/13/24 from the center psych provider and subsequently sent to hospital for further evaluation. 10/13/24, the victim's family was notified of the physical encounter and was offered room change to a homestead/secured unit which was declined. 10/13/24, the victim (Resident #133) was transferred out of the center post event for further evaluation. 10/13/23, Upon return resident (Resident #133) will be placed on safety checks related to wandering behaviors. On 10/13/23, Resident #133 with a history of dementia wandered in Resident #420's room resulting in a resident-to-resident physical encounter on 2 south. Both residents were immediately separated upon identification by staff, with an RN physical assessment completed. Immediate investigation of concerns began by center leadership the aggressor female resident (Resident #420) was immediately placed on 1:1 and High Point Police Department was called. The facility arranged immediate FaceTime eval on 10/13/24 from the center psych provider and subsequently sent to hospital for further evaluation. The victim's family was notified of the physical encounter and was offered room change to a homestead/secured unit which was declined. The victim (Resident #133) was transferred out of the center post event for further evaluation. Upon return resident (Resident #133) will be placed on safety checks related to wandering behaviors. On 10/13/23, Resident interviews were conducted on 2 south to identify any other residents with wandering behaviors noted by staff and/or residents, with no other resident identified. Review of residents on antipsychotics was completed to ensure behavior-monitoring tools were in place along with corresponding care task management behavioral monitoring. 10/14/24, Education provided to staff on Behaviors: Management of Symptoms, regarding ensuring resident safety by reporting, identifying, preventing and managing behavioral symptoms and importance of reporting and redirecting wandering residents. Administrator and/or Director of Nursing will interview five staff members per week for twelve weeks to validate staff knowledge of abuse and neglect reporting and notifying the supervisor if conflicts with a resident occur. Director of Nursing/Social Work or designee to complete 5 random audits weekly with residents and/or staff members to inquire and evaluate interaction/response to wandering and inquire as to any resident behaviors that need to be addressed x 6 weeks. Immediate action to be taken for any positive findings. Results of these audits/interviews will be brought before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. The Administrator will interview five residents with a brief interview of mental status of eight or greater per week for twelve weeks to inquire if they have felt abused or have witnessed or suspected abuse / neglect. In the monthly Quality Assurance and Performance Improvement Meeting, the Interdisciplinary Team will review all resident to resident / abuse allegations to ensure appropriate interventions are in place and care plan updated x8 weeks. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to assure compliance is maintained ongoing. QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. The facility's alleged compliance date was 10/18/23. The Corrective Action Plan was validated onsite on 5/17/24 and concluded the facility had implemented an acceptable corrective action plan on 10/18/23. Interviews with current nursing staff revealed they received education on and training on abuse, neglect, reporting and resident to resident physical altercations. The audits conducted on 10/13/23 revealed residents were asked about residents with wandering behaviors with no other resident identified. On 5/17/24 there was sufficient evidence to support the facility's Corrective Action Plan that was implemented and carried out by 10/18/23.

Based on record review, staff interviews and physician interviews, the facility neglected to (1) administer intravenous (IV) antibiotics to treat a stage IV sacral pressure sore for 12 days. This occurred for 1 of 3 residents (Resident #1) reviewed for intravenous therapy. This caused Resident #1 to be readmitted to the hospital with [CONDITION(S)] and bacteremia resulting in a second surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 passed away while in the hospital. Findings included: Review of the hospital discharge summary dated [DATE] revealed Resident #1's pressure ulcer measured 11 centimeters long, 13 centimeters wide, 3.5 centimeters deep with 3 centimeters of undermining. The wound bed tissue had 90% granulation with a moderate amount of serosanguinous drainage. Resident #1 was to receive [MEDICATION(S)] (antibiotic) 1 gram intravenously daily with a stop date of [DATE] to treat a stage IV sacral pressure sore. Resident #1 was readmitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was to receive [MEDICATION(S)] (antibiotic) 1 gram intravenously via Peripherally Inserted Central Catheter (PICC) line daily with a stop date of [DATE]. Resident #1's care plan in place on [DATE] (originally dated [DATE]) revealed a goal that the resident would not have any complications related to her Intravenous (IV) therapy. The interventions for the goal were in part; flush IV per policy, inspect site for signs and symptoms of inflammation each shift, monitor catheter with each dressing change to check for migration, monitor for allergic reaction to the medication. Resident #1's care plan also had a goal that her wound would have evidence of healing as evidenced by decrease in size, absence of [CONDITION(S)] and drainage. The interventions for the goal were in part; assist resident in turning and repositioning, observe skin condition daily and provide wound treatment as ordered. Resident #1's Treatment Administration Record (TAR) for the month of [DATE] revealed the resident received wound care treatments that started [DATE] and continued through [DATE]. There was no documentation of the size or condition of the wound. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitting nurse (Nurse #1) was interviewed on [DATE] at 1:05pm. Nurse #1 discussed reviewing the discharge medications from the hospital for Resident #1. She stated she had not reviewed the hospital discharge summary where Resident #1's intravenous antibiotic stop date was located and said when she verified the medication with the on-call physician she requested a stop date for the intravenous antibiotic and was given a date of [DATE]. The nurse commented that the on-call physician requested the nurse practitioner or the facility physician review the intravenous antibiotic but she stated that was not completed because she did not know how to leave messages for the nurse practitioner or facility physician. Nurse #1 clarified she had not attempted to find out how to leave a message for the nurse practitioner or physician. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired and was coded for a stage 4 pressure ulcer and intravenous (IV) medication. The wound care physician's documentation revealed the physician saw Resident #1 on [DATE]. He documented Resident #1's stage IV pressure ulcer of the sacrum was approximately 56 days in duration and that there was moderate serous exudate present with 100% granulation tissue. He noted in his documentation that Resident #1 had not appeared to have any pain associated with the wound. He had documented the size of the wound as 9 centimeters long by 5.5 centimeters wide and 1.9 centimeters deep with no undermining and a surface area of 49.5 centimeters. The facility's wound physician was interviewed by telephone on [DATE] at 10:07am. The wound physician stated he was not informed of the resident's return to the facility until [DATE] and was unaware the resident had received and should have been still receiving intravenous antibiotics on [DATE]. He also stated he could not comment if Resident #1 missed 12 days of antibiotic could have deteriorated the wound. An interview with the facility's nurse practitioner (NP) occurred by telephone on [DATE] at 9:39am. The NP acknowledged she had signed off on the order for the intravenous antibiotic stop date of [DATE]. She said she had read Resident #1's hospital discharge summary but not in detail and assumed the stop date on [DATE] was correct. The NP discussed learning of the error after the resident had been discharged and the facility had begun their investigation. She stated it was at that time she read through Resident #1's discharge summary and realized the intravenous antibiotic should have been stopped on [DATE]. The Director of Nursing (DON) was interviewed on [DATE] at 12:29pm. The DON stated the facility investigated the reason Resident #1 had not received her intravenous antibiotic as ordered from the hospital and discovered there were errors in communication with the nurse practitioner and facility physician as well as the admitting nurse not reading through Resident #1's discharge summary for the accurate stop date. She also stated she had completed education on [DATE] with nursing staff on transcribing orders and reading resident hospital discharge summaries. During a telephone interview with the Infectious Disease nurse practitioner (NP) on [DATE] at 11:26am, the NP discussed her follow up with Resident #1 on [DATE] was initiated by her due to the last date of the intravenous antibiotic was [DATE]. She discussed Resident #1 had developed an infection in the bone of her sacrum and was septic. She stated the sacral wound appeared significantly worse then when the resident was discharged from the hospital on [DATE]. She described the wound to have slough that was gray and no viable tissue covering the wound bed. The NP explained the resident had [CONDITION(S)] and bacteremia prior to the discharge on [DATE] but upon discharge the bacteremia had been cleared but the resident still required the intravenous antibiotic until [DATE] due to the [CONDITION(S)] and to prevent the bacteremia from returning. She attributed the deterioration of the wound and the resident being septic to not having the antibiotics for 12 days. The NP discussed sending the resident back to the hospital from her office on [DATE] where Resident #1 underwent surgery to debride the wound and perform a bone biopsy. She stated Resident #1 died on [DATE] with contributing factors of [CONDITION(S)] and untreated bacteremia. Resident #1's admission hospital records dated [DATE] revealed an assessment of her sacral wound. The assessment documented Resident #1's wound as a stage IV sacrum pressure injury measuring 10 centimeters long, 9.5 centimeters wide, 4 centimeters deep with 4 centimeters undermining. The documentation described the wound bed tissue as 90% necrotic with yellow slough and 10% non-granulating tissue with exposed bone. The type and amount of drainage documented was moderate purulent drainage with a strong foul odor. The admission documentation revealed Resident #1 was started on intravenous antibiotics for [CONDITION(S)]. Review of Resident #1's death certificate signed [DATE] revealed Primary cause of death was [CONDITION(S)] secondary to sacral decubitus ulcer. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: F600. 1.On [DATE] at 2:30pm the facility had received a phone call from the hospitals emergency room manager questioning the facility about Resident #1 not receiving her IV antibiotic treatment. Immediately following the hospital emergency room managers call, the facility received a call from Resident #1's family member about neglectful care. On [DATE] the facility completed an initial investigation report concerning the allegations of neglect and missed antibiotic IV therapy. On [DATE] the facility had completed their investigation and concluded the resident had received the IV antibiotics as ordered and the allegation of neglect was unsubstantiated. The corrective action the facility provided included the resident was re-hospitalized and had surgery. 2. The facility conducted an ADHOC QAPI meeting on [DATE] and developed an action plan that consisted of the following 4 points. a. It was discovered upon admission to hospital for worsening wound that resident had missed antibiotic order from admission. b. All residents with orders for antibiotics on admission have potential to be effected. Nursing leadership audited 100% of new admissions for the last 30 days to ensure that orders for antibiotics were transcribed and delivered accordingly. c. Education provided to the licensed nurses on how to review discharge summaries from hospital and ensure orders transcribed correctly. All staff reeducated on neglect, to include not providing ordered medication is considered neglectful. d. All new admission charts to be brought to the clinical morning meeting for nursing leadership to review discharge summary compared to orders in point click care to ensure orders carried out accordingly. Results of these audits will be [NAME] before the Quality Assurance and Performance Improvement Committee responsible for ongoing compliance. The facility began education on [DATE] which covered neglect; the failure of the center and its employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish and emotional distress. Missing medications or treatment is neglect. On [DATE] the facility completed audits of new admissions for the past 30 days. The Immediate Jeopardy plan of correction was validated on [DATE] and the corrections were implemented by [DATE] as the facility alleged. Validation was evidenced by staff interviews, record reviews, observation, facility training that included the facility's abuse and neglect policy and procedure, reading discharge summaries and discharge orders and, communication process with the facility physician and nurse practitioner. Observation of the units revealed communication books for the physician and nurse practitioner at each nursing station. Record review of three residents, who were on intravenous therapy, revealed all orders were in place and none of the residents had missed a dose of their medication.

Based on record review, staff interviews, physician and surgical Physician Assistant (PA) interviews the facility neglected to provide wound treatment to a resident's right above knee amputation, abdominal abscess, right buttock wound and left above knee amputation for 1 of 3 residents (Resident #4) reviewed for wound care. Resident #4 was re-hospitalized on [REDACTED]. Findings included: Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's hospital discharge records dated 3-6-20 revealed the following wound care orders; 1. buttocks wound, apply [MEDICATION NAME] AG with allevyn foam and change every other day. 2. Abdominal wound, Dakin's wet to dry dressing daily. 3. Left above knee amputation, saline wet to dry dressing daily. Review of the nursing admission documentation dated 3-6-20 completed by Nurse #2, revealed in part that Resident #4 was alert and oriented to person, place and time with independent decision-making skills for daily routine. The documentation also revealed a skin assessment that included; wound to right buttocks, open left above knee amputation and an abdominal abscess. The nurse documented that she applied Z-guard (barrier cream) to the resident's buttocks, acknowledged staples in the resident's right above knee amputation, gauze wrapping to the residents left above knee amputation and gauze packing to the abdominal abscess. The admission nurse documented that she reviewed the medication orders with the provider and there were no issues identified. During an interview with Nurse #2 on 6-25-20 at 11:09am by telephone, the nurse stated she had admitted Resident #4. She discussed, when a resident is admitted , the admitting nurse will call the physician or hand the orders to the physician for review and once the orders are received, they are transcribed onto the Medication Administration Report (MAR) or the Treatment Administration Report (TAR). She stated she did not remember speaking with the facility physician or know why there were no orders for Resident #4's wounds and could not recall if she saw wound care orders on the resident's discharge paperwork from the hospital. Nurse #2 said once treatment for [REDACTED]. Nursing documentation on 3-7-20 completed by Nurse #6 revealed acknowledgment of the resident's wounds and that her staples were intact but no mention of wound care being completed. An attempt was made on 6-25-20 at 11:10am to contact Nurse #6 and received no response. Nursing documentation on 3-8-20 completed by Nurse #3 revealed the nurse applied z-guard to the resident's buttock wound, changed dressing to her abdominal abscess with no further documentation. During an interview with Nurse #3 on 6-25-20 at 11:39am by telephone, the nurse stated she had not seen any wound care orders for Resident #4 but stated I was told what to do by the admission nurse (Nurse #2). She also said she could not remember what wound care she provided and did not know why there was not documentation to what type of wound care she provided. Review of the nursing note dated 3-9-20 completed by Nurse #7 revealed documentation that Resident #4 had removed her sutures from the left above knee amputation and the facility physician was notified. Resident #4's care plan dated 3-9-20 revealed no goals or interventions for treating the resident's wounds. Review of nursing notes for 3-10-20 completed by Nurse #4 revealed no documentation of wound care being completed. During an interview with nurse #4 on 6-25-20 at 9:32am by telephone, the nurse stated she had worked with Resident #4 on 3-10-20 and remembered the resident had amputation wounds but said she did not remember providing any wound care to Resident #4 and stated we didn't have any wound care orders for her. A review of the Physician orders dated March 2020 for Resident #4 revealed there were no orders for wound care from 3-6-20 to 3-10-20. The facility's nurse practitioner (NP) evaluated Resident #4 on 3-10-20. She documented the right above knee amputation had staples intact and staff had reported the resident would remove her dressing from the left above knee amputation site and touch the wound. The NP also documented that she was about to send the patient back to the hospital for further evaluation but had reviewed Resident #4's discharge summary from the hospital and documented it was noted that there is to be a wet to dry dressing applied but staff reported the resident would remove the dressing. The NP documented Resident #4 was medically stable and referred the resident to the facility's wound care physician. Resident #4's March 2020 TAR and MAR indicated [REDACTED]. Resident #4 was seen by the wound care physician on 3-10-20 with the following wound care measurements; (1) Abdomen abscess measured 16cm (centimeters) long, 5.5cm wide and 3cm deep with moderate drainage. (2) Above knee left amputation measured 16.0cm long, 5.5cm wide and 3.3cm deep with moderate drainage. There was no further measurements or documentation regarding Resident #4's right above knee amputation or her right buttocks wound. The following wound care orders were documented in the physician orders 3-11-20; 1. Abdominal wound, clean with normal saline, apply silver alginate and cover with an ABD pad every other day. 2. Right above knee amputation, clean staples with normal saline and cover with a dry dressing daily. 3. Right buttock, clean with soap and water, apply [MEDICATION NAME] and cover with a dry dressing daily. There were no orders documented in the physician orders for wound care to the left above knee amputation. The facility's wound care physician was interviewed on 7-14-20 at 10:12am. The physician said he had not mentioned or written orders for Resident #4's left above knee amputation because the resident had pre-existing orders from when the resident was discharged from the hospital, and he had not planned on changing them. He also stated he would consult on new surgical wounds, but the resident should have had a follow up visit with the surgeon and if there were issues with Resident #4's wounds, the facility should have contacted the surgeon. Nursing note dated 3-11-20 completed by Nurse #5 revealed wound care being completed to the left above knee amputation with Dakin's moistened gauze, cover with ABD pad, wrap with gauze and ace bandage. Nurse #5 was interviewed on 6-25-20 at 3:22pm by telephone. The nurse stated she remembered seeing orders from Resident #4's hospital discharge summary for wound care to her amputation sites and performed wound care as ordered but denied remembering that Resident #4 had an abdominal abscess or wound to her right buttocks. The nurse stated she did not perform wound care to those areas. Resident #4 was seen by the wound care nurse on 3-12-20. The documentation dated 3-12-20 from the wound care nurse was as follows; 1. Left above knee amputation had partial thickness skin loss with a moderate amount of drainage. The wound measured 16.0 centimeters (CM) long, 5.5cm wide and 3.3cm deep. 2. Abdomen abscess had partial thickness skin loss with moderate amount of drainage. The wound measured 31cm long, 0.3cm wide and 3.0cm deep. 3. Stage 3 pressure ulcer to right buttocks with a moderate amount of drainage. The wound measured 2.0cm long, 1.6cm wide and 0.1cm deep. There was no documentation regarding Resident #4's right above knee amputation. The March 2020 TAR for Resident #4 revealed consistent wound care was being completed as ordered for the residents abdominal wound, right buttocks wound and right above knee amputation from 3-12-20 until resident was discharged to the hospital on 3-15-20. The TAR/nursing documentation did not reflect wound care being completed to the left above knee amputation from 3-6-20 to 3-10-20 and then from 3-12-20 to 3-15-20 The facility's physician was interviewed by phone on 6-25-20 at 3:10pm. The physician stated if a resident came from the hospital with wound care orders, then those orders were carried over until the resident could be seen by the wound care physician. He also said he did not know if the facility nurses were providing wound care but felt the facility nurses were attempting to do wound care and stated, per the NP note the resident kept removing the dressings. The physician said he was not notified of the resident removing her dressings and stated the resident was discharged before he was able to complete his assessment. The Director of Nursing (DON) was interviewed on 6-25-20 by telephone at 3:57pm. The DON stated she did not know about Resident #4's MAR indicated [REDACTED]. Resident #4 was hospitalized on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #4's hospital discharge summary dated 4-16-20, the physician documented that upon residents admission on 3-15-20 to the hospital that it appeared the resident had not received wound care to her bilateral amputations or abdominal wound and was taken directly to the operating room where Resident #4 received wound washouts and debridement's to her left and right above knee amputations and abdominal wound. The discharge summary also documented Resident #4 had multiple surgical interventions for wound washouts and wound vac placements during her hospitalization . The resident was subsequently discharged on [DATE] to a rehabilitation facility. The resident's hospital surgical physician assistant (PA) was interviewed on 7-9-20 at 10:29am by telephone. The PA stated she had cared for Resident #4 during her hospitalization from [DATE] to 3-6-20 and cared for the resident during her last hospitalization from [DATE] to 4-16-20. She discussed not having any contact with the facility from 3-6-20 to 3-15-20 and was not aware of the facility contacting the office regarding Resident #4's wounds. The PA stated there were wound care orders provided for the facility upon the residents discharge from the hospital but that upon Resident #4's readmission on 3-15-20 it had not appeared that wound care had been provided. She stated, the wounds to her amputations and abdomen were terrible with skin breakdown and infection. She also said the resident had to have multiple surgeries to remove the infection and dead skin tissue. The PA discussed the amount of skin damage and infection present could not have happened in 1-2 days. She also stated the resident had advanced [MEDICAL CONDITION] and stated, which made consistent daily wound care even more important.

Based on staff interviews, police officer interview, dispatch service interviews, record review, and 911 emergency audio recordings, the facility failed to respond to phone calls to the facility and on-site visit by a police officer on [DATE] which resulted in a delay in emergency services, including resuscitation, to one of three residents (Resident #1) reviewed for quality of care. Resident #1 was found to be unresponsive, in her room, with the call light on, on [DATE] at approximately 10:07 PM and Cardio [MEDICAL CONDITION] Resuscitation efforts were unsuccessful and discontinued. The resident was pronounced dead 10:46 PM. Immediate jeopardy began on [DATE] when Resident #1 was found to be unresponsive, in her room, with the call light on. The immediate jeopardy continued after the resident was found unresponsive due to the failure of the facility to ensure appropriate and timely response to call lights, answering telephone calls, and responding to visitors at the front door when the magnetic lock was engaged. The immediate jeopardy was removed on [DATE] at 8:40 PM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. Findings included: Resident #1 was admitted to the facility on [DATE] and died on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) revealed the most recent assessment was a comprehensive significant change assessment with an Assessment Reference Date (ARD) of [DATE]. Review of the assessment revealed the resident was coded as having been cognitively intact. The resident was coded as having been able to make herself understood and was able to understand others. The resident was not coded as having had displayed behavioral symptoms during the observation period. The resident was coded as having required extensive or total assistance of two or more people for all activities of daily living (ADLs) except for eating, which the resident was coded as independent with supervision. The resident was not coded as having experienced shortness of breath during the assessment period. The resident was coded as having received suctioning and [MEDICAL CONDITION] care during the assessment period. A review was completed of a Progress Note for Resident #1, documented by the resident's Nurse Practitioner (NP), which was dated [DATE]. The NP documented the resident was a [AGE] year-old female who was seen for a routine visit for chronic disease management. The NP documented the resident had been seen for an exacerbation of [MEDICAL CONDITION] recently and the resident had reported tender areas on her legs. The resident was documented as having been noncompliant with the prescribed treatment for [REDACTED]. The resident denied any shortness of breath or wheezing. The resident was documented as having had an intermittent cough at baseline secondary to having had a [MEDICAL CONDITION] and the resident had complaints her secretions (bodily fluid related to the [MEDICAL CONDITION]) had been thicker and she wanted something to help loosen the secretions. The NP ordered guaifenisen 600 milligrams (mg) every 12 hours for secretions. A review of Resident #1's (MONTH) (YEAR), Medication Administration Record [REDACTED]. The medication was to be administered to the resident on an as needed basis for shortness of breath, according to the MAR. The medication was documented as having been administered for 20 minutes, the resident's pulse was documented as having been 87, the resident's oxygen saturation was documented as having been 96%, and the medication was administered by Nurse #1. Auditory review of an audio recording from the City of Hight Point 911 dispatch service revealed a call made by Resident #1 dated [DATE] and timed 8:50 PM. Resident #1 could be heard stating she could not breathe. Despite multiple attempts by the call taker, the resident was unable to provide detail regarding her location. Review of the documentation associated with the call, City of High Pint Event Report dated [DATE] and timed 8:50 PM, revealed the call was made from a cellular phone. Further review of the associated documentation revealed the ping of the resident's phone was 0.97 miles from a cellular phone tower which would have put the caller near or at the facility. At 8:52 PM documentation attempts were made to call the facility but there was no answer and there was no emergency number on file. A phone interview was conducted with the City of High Point 911 dispatch supervisor on [DATE] at 7:09 PM. The supervisor stated he was at the 911 dispatch center the evening the call came in from Resident #1 and had assisted on the call. The supervisor stated he had tried to call the facility at least twice, at approximately 8:52 PM, after the 911 call had come in from Resident #1. The supervisor stated there was no answer at the facility during any of his attempts to call the facility. The supervisor stated the call taker who had initially taken the call, felt like the caller may had been at the facility, but the ping location from the cellular phone was not exact and they did not know if the caller may have been at the facility, at the emergency room (ER) across the street, out on the street, or any other location in the area. The supervisor stated he had tried other options, including municipality utility record review, to obtain alternate phone numbers for the facility, but he was unable to obtain any other phone numbers to reach the facility. The supervisor stated due to not knowing the exact location of the caller it was determined to dispatch a police officer to canvas the area. A phone interview was conducted on [DATE] at 3:51 PM with Police Officer #1 who had been dispatched to canvas the area and look for the 911 caller on [DATE] at approximately 9:07 PM. The police officer stated he had went to the facility at approximately 9:07 PM and knocked on the front door and rang the bell for the intercom system at the front door for several minutes. The officer stated there was no response from the staff inside of the building and no one came to the door of the facility to let the officer in. The officer stated due to lack of response at the door of the facility he left the facility and continued to canvas the area looking for the 911 caller. The officer stated he responded back to the 911 dispatch service at approximately 9:07 PM he was unable to locate the 911 caller, and no one had responded to the door at the facility. An interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 4:27 PM. The NA stated Resident #1 had been on her assignment on [DATE]. The NA stated the resident's family had visited the resident approximately between 5:00 PM and 7:00 PM on [DATE] and had brought the resident Chinese food for dinner. The NA stated she had last seen the resident some time in between 8:00 PM and 8:30 PM. The NA stated she had intentions of returning to the resident but there were several other residents requiring care and she was unable to return to the resident. The NA stated she was going to go to Resident #1's room and Resident #1's call light was on, but there was another resident in another room who was hollering very loudly, and the NA stated she provided care for the resident who was hollering. The NA was unable to recall the time she had seen the call light on for Resident #1 when she went to the resident's room who was hollering. The NA stated when was entering the room of the resident who was hollering she had seen the call light was on for Resident #1 but did not check on the resident. NA #1 stated she had not seen Resident #1's call light on earlier when she was providing care for the other residents. The NA stated the next time she had entered the room was when CPR efforts was being conducted on the resident. Review of the City of High Point Entity Report, dated [DATE] and timed 8:50 PM revealed the cellular phone number was registered to Resident #1 and her family, and the address listed was for [NAME]ville, NC. At approximately 9:12 PM an officer with the [NAME]ville Police Department was sent to the address listed for Resident #1. A phone interview was conducted with Resident #1's family on [DATE] at 6:05 PM. The phone interview revealed a police officer had come to his house after 9:00 PM and had informed him a 911 call had been made from a cellular phone registered to him and Resident #1. The family member further stated the police officer had informed him they were unable to locate Resident #1 and was unaware she was residing at the Meridian Center. A review was completed of the City of High Point Entity Report, dated [DATE] and timed 9:40 PM. The report documented Resident #1's family had called the City of High Point 911 dispatch service and informed them Resident #1 was a resident of Meridian Center, he gave the room number, the floor, and the access code to gain entry to the facility. In addition, the resident's family stated he had tried to call the resident's phone and the facility phone number and there was no answer for either phone number. A review was completed of the High Point Police Department Incident/Investigation Report dated [DATE] and timed 9:40 PM. Police Officer #2 documented he went to Meridian Center to conduct a welfare check on Resident #1 at approximately 10:07 PM. The officer documented he went to the resident's room and Nurse #1 had asked if he needed assistance when she had seen the officer in the hall. The officer responded a female in room [ROOM NUMBER] had called in and said she could not breath. The nurse and the officer entered the room and discovered the resident laying on the bed, not breathing, and was unresponsive. The officer documented the resident was discovered to not have a pulse and the resident's legs and torso were still warm. The resident was lowered to the ground Cardio [MEDICAL CONDITION] Resuscitation (CPR) was initiated. The officer documented the nursing staff and himself conducted CPR until Emergency Medical Services (EMS) arrived and took over resuscitative efforts. The officer documented after over 30 minutes of life saving efforts, the resident was confirmed as deceased . The officer further documented he called the number which had been the original number belonging to the original 911 call at approximately 8:50 PM and the phone on the resident's bedside table started to ring. The officer documented the phone at the bedside table was the phone the resident had used to originally call 911. Review of the High Point Police Incident/Investigation Report dated [DATE] and timed 9:40 PM the Reporting Officer's Narrative documented Officer #3 had interviewed NA #1. The officer documented NA #1 was the last person to have seen Resident #1 alive at approximately 8:00 PM. The NA informed the officer earlier in the day, the resident had complained of having had a hard time breathing, she had reported it to the nurse, and the nurse had administered a breathing treatment to the resident. The NA stated she had went back to visit the resident later and the resident was observed to have been doing breathing exercises and had reported to the NA she had not felt the breathing treatment was very effective. In addition, the officer interviewed Nurse #1 and the nurse had told the officer she had remembered Resident #1's call light having been on during her medication pass but had not known how long the call light was on and had not checked on the resident. Time of death for the resident was documented as 10:46 PM. A review was completed of the Guilford County EMS incident report pertaining to the EMS call for Resident #1 on [DATE]. The review revealed Resident #1 was found to be not breathing and did not have a pulse at approximately 10:07 PM. The resident was lowered to the floor and CPR was initiated. EMS was documented to have arrived and at 10:15 PM the resident was documented as having been unresponsive, had a warm core, cool extremities, lips/face purple in color, skin was pale, pupils were dilated and non-responsive, lung sounds were absent, and CPR was in progress. At 10:16 PM CPR was taken over by the High Point Fire Department. The EMS responders contacted the High Point Regional Hospital Emergency Department and updated their physician on the resident's status at 10:46 PM and the physician advised to discontinue all lifesaving efforts. Resuscitation efforts were discontinued at 10:46 PM and the resident was found to not have a pulse or breathing. The narrative portion of the report documented Nurse #1 had seen the call light for Resident #1 was on while she was conducting her medication pass. The nurse was documented as stating she continued to conduct her medication pass and she did not know how long the resident's call light had been on. Review of the nurses' notes for Resident #1 revealed a nurses' note written by Nurse #1, dated [DATE], timed 3:21 PM, and was typed as a Late Entry. The note described the events which took place the evening of [DATE]. The note documented the nurse had administered a breathing treatment at 5:45 PM and the resident's oxygen saturation measured 96%, pulse was 87, and the resident's vital signs were stable after the breathing treatment. The nurse documented the resident had been observed to have been sleeping at 7:30 PM. It was then documented at 10:05 PM a High Point Police Department officer was observed in the hallway outside of Resident #1's room. The nurse documented the officer informed the nurse there was a concern regarding the resident's condition and when the two of them entered the resident's room the resident was discovered unresponsive and cool to the touch. The nurse documented the officer radioed for Emergency Medical Services (EMS), Code Blue (facility term for an emergency situation) was called over the intercom of the facility, and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was initiated at 10:10 PM. It was documented EMS arrived at 10:20 PM and took control of the resuscitative efforts. The nurse documented EMS made multiple attempts to access the resident's intravenous (IV) system to administer medications but was unsuccessful. The nurse documented CPR efforts were continued by EMS until 10:46 PM when the doctor communicating with the EMS personnel from the emergency room (ER) communicated to the EMS personnel to stop resuscitative efforts based on feedback regarding the resident's condition and the time of death was called at 10:46 PM. An interview was conducted with Nurse #1 on [DATE] at 3:49 PM. The nurse stated Resident #1 had been on her assignment on [DATE]. The nurse stated she had given the resident a breathing treatment at approximately 5:45 PM because the resident had had some complaints of shortness of breath. The nurse stated at the end of the breathing treatment the resident's vital signs were stable. The nurse stated the resident had a lot of anxiety and some shortness of breath which was normal for the resident. The nurse stated she had again checked on the resident at 7:30 PM and the resident was resting in bed with her eyes closed. The nurse stated she started her medication pass at about 8:00 PM. The nurse stated she did not recall if Resident #1's call light was on while she was conducting her medication pass. The nurse also stated she did not remember the phone ringing repeatedly or for an exceptionally long time that evening. The nurse stated at approximately 10:00 PM she had come out of a resident's room and she had seen a police officer standing outside the door of Resident #1's room. The nurse stated the officer explained the reason for her being at the facility and the two of them proceeded to enter Resident #1's room. The nurse stated she believed the resident's call light was on at the time she observed the officer outside of the resident's room. The nurse stated when they entered the resident's room the resident was discovered to be unresponsive. It was determined Resident #1 was a full code and with the assistance of the responding police officer and other facility staff the resident was lowered to the floor and CPR efforts were initiated. A second interview was conducted with Nurse #1 on [DATE] at 6:48 PM and Resident #1 body was warm to the touch when she had initially discovered the resident to have been unresponsive on [DATE]. A third interview was conducted with Nurse #1 via phone on [DATE] at 10:01 AM. The nurse stated she did not know if Resident #1's call light was on the whole time (during her med pass) or not, on [DATE] from approximately 8:00 PM to the point she had seen the officer outside of the resident's room. The nurse stated she did remember the call light having been on during her med pass, but it could have been turned on, turned off, and then turned back on. The nurse stated the only time she had remembered the call light flashing was when the bed had been moved to transfer the resident out of the bed onto the floor due to the resident having had been on air mattress. The nurse stated the call light has not been pulled out of the wall prior to her and the officer entering the room and discovering the resident to have been unresponsive. The nurse stated she did not remember the time of day when the call light may have been on. The nurse stated she was in and out of other resident rooms conducting her medication pass. Review of the Certificate of Death for Resident #1 revealed the documented immediate cause of death was listed as Cardiopulmonary Arrest. An interview conducted with Nurse #2 on [DATE] at 1:58 PM revealed Resident #1 was alert and oriented, able to communicate needs, and was able to use the call light. An interview was conducted with Nursing Assistant (NA) #2 on [DATE] at 2:09 PM. The NA stated the resident could feed herself, use the phone, use the call light, use her arm, and use the remote control for the television. The NA stated the resident used the call light to let the nursing staff know she needed care. The NA further stated the resident was able to take care of her own [MEDICAL CONDITION] care. An observation and interview were conducted with the facility receptionist on [DATE] at 6:39 PM. The receptionist stated the front door was locked with a magnetic lock which engaged automatically at either 4:00 PM or 5:00 PM depending on daylight savings time. The receptionist stated there was a code which could be punched into a keypad and there was a keypad located on the inside of building next to the door and on the outside of the building located next to the door. The receptionist stated she would get up and let people in the door if they did not know the code and the door was locked. The receptionist stated she usually left at 5:00 PM and after she left there was an intercom system which rang at the nurses' station and then whoever was at the nurses' station could come and let the individual in. An observation conducted at the front door on [DATE] at 6:43 PM revealed two sets of double doors to enter the facility. One set of double doors were on the outside which had no magnetic lock, a small breezeway, and a second set of double doors between the breezeway and the facility, which were locked with a separate magnetic lock on each door. There was an observed touch pad to disengage the magnetic lock system with numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, *, 0, and # inside the breezeway and inside of the facility. The intercom system observed during the observation was not the same intercom system present when the officer attempted to gain entry the evening of [DATE]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 7:25 PM. The DON stated the current intercom system was installed ,[DATE] weeks ago, after [DATE]. The DON stated prior to the current intercom system, there was a button which could be pressed in the breezeway and it would to one South nurses' station. The DON stated the front door was locked in the evenings because of the facility's urban location and proximity to the emergency room , which was right across the street. The DON stated they had tried to keep someone at the nurses' station to answer the phone or intercom from the front door, but it was not always possible. An interview was conducted with the Administrator on [DATE] at 8:26 PM. The Administrator stated she had interviewed NA #1 and the NA had told her she was on her way to Resident #1's room the evening of [DATE] and was aware Resident #1's call light was on, but there was another resident in another room who was screaming and the NA chose to address the resident who was screaming instead of answering the call light. The Administrator stated she had interviewed Nurse #1 and the nurse stated she had seen the call light was on for Resident #1 but had seen the NA go down the hall and she had thought the NA had answered the call light for Resident #1. The Administrator stated she had determined through her interviews she had determined the resident's call light was on when the police arrived inside the facility and the police officer and Nurse #1 discovered Resident #1 to be unresponsive. The Administrator stated she had never received any concerns regarding a problem for anyone getting into the facility. The Administrator stated she had not received concerns from the police department or EMS regarding them not being able to get into the building at night. The Administrator further stated the front door to the facility was locked in the evening for security reasons, the facility was in the inner city, and the hospital ER is right across the street. The Administrator stated if a police officer came to the facility and could not get into the facility there were several options for the police officer to gain entry to the facility. Some of the options the Administrator explained were the police officer could call the facility, knock on the door, or call the police department because the police department had the Administrator's cellular phone number. The Administrator stated each phone at all 5 nurses' stations rang when someone would call the facility. A second interview was conducted over the phone with the DON on [DATE] at 10:35 AM. The DON stated there was a brown box located outside of the facility which the Fire Department had access to. Inside of the brown box was information (a code to disengage the magnetic lock) and keys to access the facility. The DON stated during emergency situations in the past EMS, the police department, and the fire department would all be called to respond to the facility. The DON stated if the fire department had been called to respond to the emergency situation or any other emergency situation they would have been able to gain entry to the facility. The Administrator was informed of Immediate Jeopardy on [DATE] at 11:13 AM. On [DATE] at 8:40 PM, the facility provided the following Credible Allegation of Immediate Jeopardy Removal: ALLEGATION OF IMMEDIATE JEOPARDY REMOVAL Facility respectfully submits the below allegation of compliance for F684 Quality of Care, Professional Standards of Practice: Identify and provide care and services to include Emergency Services. 1. Police Officer came to center and knocked on door at front entrance, Facility staff did not hear or respond to this. He then rang bell and called center, without a response from the center. Police Officer then left the center. Facility staff failed to answer the front door, answer outside call and call bell, in response to resident # 1 Emergency needs. Facility staff were responding to call bells on the unit as they were able. Facility staff did not hear a phone call come in during this time frame. Resident # 1 with [DIAGNOSES REDACTED]. CPR was initiated by facility staff and police officer. EMS arrived on site at approximately 10:15 and the EMS team assumed responsibility for continuation of CPR and AED, until hospital physician called the code at 10:46 pm. Body was released to funeral home. Facility was later informed on [DATE], by an external source that a police man had arrived at the center earlier, and was unable to enter the center or get the center on the telephone. Upon receipt of this external report, the facility Administrator initiated an immediate investigation on [DATE] and developed an action plan which was completed on [DATE]. Staff that were on during the ,[DATE] shift on [DATE] have been questioned through the investigation process and re-educated regarding the process for afterhours entry to facility and prompt response to call bells, as well as answering call bells. 2. Education initiated by Nurse Practice Educator and Director of Nursing on [DATE] for all staff in all departments regarding process for emergency personnel getting in the center after hours, this includes: that staff will answer the intercom system and/or doorbell promptly which ring on both nurses stations. This system is audible throughout the units. Education also included answering of call bells and incoming calls timely. As of [DATE] at 12:34 p.m. over 99 % of the staff have completed the education via phone or in person by the Nurse Practice Educator, Center Nurse Executive and Center Executive. The remaining staff shall not work until they have completed this education, this will be ensured by the Executive Director. The Executive Director or Center Nurse Executive will personally be at the facility on the next scheduled shift for the remaining staff members to ensure that they receive the education prior to starting their shift, if they have not returned phone call for education prior to that time. 3. 100% audit completed by the Regional Nurse, to ensure no other residents have been impacted by a delay in emergency personnel getting into the facility over the last 30 days. This audit included review of Nurses Notes, and documentation of transfers. No other issues were noted. Audit was completed on [DATE]. Facility Executive Director developed an ADH[NAME] QAPI Plan on [DATE] to address the delay in Emergency Personnel getting into center. Audits were completed over the weekend (total of 11) by the Interdisciplinary Team to ensure compliance. Audits reviewed time to answer doorbell/intercom and time to answer phone calls. All bells and phone calls answered in under 2 minutes. An Audit was completed by Nursing Administration on [DATE] to ensure call lights responded to promptly. No concerns noted. Facility has purchased and put into place additional cordless phones to allow for each hallway to have a cordless phone to facilitate prompt response time to incoming calls. These were put in use on [DATE] with phone lines for these additional lines have been implemented. Facility has added a door bell to the front entrance in addition to the already existing intercom system, on [DATE]. Both the door bell and intercom system have been set up to ring at both nurses stations, where in the past the intercom system only rang on one unit. Door Bell system is audible throughout the units. Executive Director requested that the Fire Marshall visit the center on [DATE] to ensure that center had all necessary information to enter the facility in the emergency box in the front entry to ensure emergency personnel have access. Fire Marshall had no concerns upon his exit. The above will be monitored through the daily audits described in number 4 below. There is no ability to record missed calls or call bell response time at this center. 4. The Interdisciplinary Team will conduct after hour's audits of front door and telephone and call bell response times and record the time it takes for staff to respond accordingly to doors, phone calls and call bells. The audits will be conducted by team members making phone calls, ringing bell at front entrance and testing call bell response times. These audits will be conducted daily (including weekends) X 3 weeks, then weekly x 4 weeks, and then randomly thereafter, with the Executive Director responsible for monitoring outcomes and compliance. The Center Nurse Executive or Assistant Director of Nursing will review all EMS transfers for the next 30 days to ensure prompt/timely response to resident change of condition and EMS arrival and entry to center. It is the policy of the Fire Department not to give a key to the lock box at the center entry. (the lock box at the facility entry is provided by the local fire department so that they can get in in the event of a fire emergency). Facility has contacted the Police Chief regarding this policy and have provided the code to the front door. This was completed on [DATE] at 3:35 p.m. The Quality Assurance and Performance Improvement Committee met on [DATE] to discuss the findings identified by the external report and by the surveyor and the action plan. The Quality Assurance and Performance Improvement Committee will review and discuss monthly. 5. Allegation of compliance [DATE] at 8:40 pm. Center Executive Director is responsible for the implementation of this plan. The credible allegation was verified on [DATE] at 3:00 PM as evidenced by staff interviews and an observation of call lights being answered timely, and observation with demonstration of the new intercom system from the front door to the two first floor nurses' stations. The intercom system was demonstrated to facilitate communication between a visitor in the breezeway and either of the first-floor nurses' stations. Staff education was initiated on [DATE] regarding the process for emergency personnel getting in the center after hours, which included: that staff will answer the intercom system and/or doorbell promptly which ring on both nurses' stations. This system is audible throughout the first-floor units. Education also included answering of call bells and incoming calls timely. All staff interviewed (nursing staff and administrative staff) stated they were aware of the importance of responding to the intercom system at the two first floor nurses' stations, or to an individual who was knocking at the front door when the magnetic lock was engaged. In addition, the interviewed staff stated the importance of answering incoming phone call and answering call lights in a timely manner. Verification of education for staff regarding the education regarding answering call lights, responding to the intercom or visitors knocking at the front door, and answering the telephone was completed on [DATE].

Based on record review, resident interview, physician interview, and staff interviews, the facility failed to honor the resident's decision and request to go to the hospital which resulted in delayed medical treatment for [REDACTED].#1). Findings included: The resident was admitted on [DATE], discharged to the hospital 10/2/17 and readmitted to the facility on [DATE]. The facility [DIAGNOSES REDACTED]. Resident #1's 14-day MDS dated [DATE] revealed the resident had an intact cognition, was not feeling depressed, and there was no [MEDICAL CONDITION] or behavior. The resident was on scheduled and as needed pain medication regimen. The resident had frequent pain. Resident #1 had a care plan dated 9/5/17 that included goals and interventions for pain. The pain was to be assessed each shift and pain medication administered as scheduled and as needed. Pain medication orders were: [MEDICATION NAME] 300 milligrams 3 times a day ordered on [DATE] [MEDICATION] used for nerve pain); [MEDICATION NAME] 4 milligrams every 6 hours as needed for muscle spasm; Tylenol 1000 milligrams every 12 hours ordered on [DATE] (non-narcotic pain reliever); and [MEDICATION NAME] 800 milligrams 3 times a day ordered on [DATE] (anti-[MEDICAL CONDITION]). Nurses' note dated 9/29/17 at 12:51 pm revealed Resident #1 had a pain assessment of 10 out of 10 almost constantly (level scale of 1 to 10 with 10 being the worst pain). The pain made it hard to sleep at night and caused limited day-to-day activities. The pain was documented as being new. The resident was not satisfied with his current level of pain. Nurses' note dated 9/30/17 at 2:30 am Resident #1 was provided [MEDICATION NAME] HCL 6 mg as needed for back pain (muscle relaxer). Nurses' note dated 10/1/17 at 2:29 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses' note dated 10/1/17 at 6:56 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses' note dated 10/1/17 at 7:36 am Resident #1 complained he can't stand the pain and requested to go to the hospital. Nurse Practitioner (NP) progress note dated 10/1/17 revealed she received a voice mail from the facility at 7:26 am that Resident #1 requested to be sent to the hospital because of his back pain. The NP documented she returned the call at 9:13 am and ordered a urinalysis, urine culture and sensitivity, a back x-ray, and to be called when the results were available. Nurses' note dated 10/1/17 at 5:01 pm revealed the family called to state Resident #1 was crying in pain on the phone and the facility was not doing anything about his pain. The family was informed there was an order for [REDACTED]. Nurses' note dated 10/1/17 at 5:18 pm revealed Resident #1's family arrived. The resident stated he was going to the hospital (signed himself out and left the building). Nurses' note dated 10/1/17 at 5:23 pm revealed there were no orders to transfer to the hospital upon call back from the NP. The NP was notified at 5:24 pm that the resident signed himself out (to go to the ED) due to pain. The NP replied ok. NP progress note dated on 10/1/17 at 6:22 pm revealed the NP received a voice mail at 5:22 pm that Resident #1 was once again threatening to leave and go to the hospital due to his back pain. NP called the facility at 5:23 pm and was informed that the resident signed himself out and his family took him to the hospital. The note indicated the back x-ray and urinalysis had not been completed yet (in the facility). A review of the 24-hour shift report for day shift dated 10/1/17 revealed the resident complained of lower back pain and as needed pain medications were given on night shift. At the end of night shift the resident stated he can't stand the pain and wants to go to the hospital. The on-call Physician's Assistant was called and left a message. Staff was awaiting a call back. A review of the Emergency Department's (ED) record dated 10/1/17 revealed Resident #1 was diagnosed with [REDACTED]. The resident was treated for [REDACTED]. The neurosurgeon was consulted and a magnetic resonance image (MRI: scan of the body) of the lumber spine was ordered for the next morning. A review of Resident #1's hospital record dated 10/2/17 revealed the resident had a magnetic resonance imaging (MRI: scans inside of the body) which reported a lumbar [MEDICATION NAME] abscess [MEDICAL CONDITION] (infection in the blood). The resident was admitted to the hospital and treated for [REDACTED]. A review of the NP progress note dated 10/2/17 revealed the family took Resident #1 to the Emergency Department (ED) for intractable back pain 10/1/17. The resident received [MEDICATION NAME], and [MEDICATION NAME], had blood cultures drawn, and an order for [REDACTED]. On 11/28/17 at 2:00 pm an interview was conducted with Resident #1. Resident #1 stated that he had several days of uncontrolled pain. The resident informed the nurse, the NP and his family about the increased pain. The resident stated on 10/1/17 during the early morning the pain had gotten unbearable. The resident stated that he requested to go to the hospital several times because he knew something was wrong. The resident was informed the NP refused to send him to the hospital after waiting all day for an answer. The resident called his family crying in pain to take him. The resident stated that his family took him to the hospital on [DATE] in the evening. On 11/28/17 at 4:00 pm an interview was attempted with the NP. The NP had resigned shortly after the 10/1/17 incident and was not available. On 11/28/17 at 4:15 pm an interview was conducted with the Medical Director (MD). The MD stated that he was not familiar with Resident #1 and would need to review his medical record. The MD stated that Resident #1 could go to the ED if he wanted to. The NP made a judgement call to treat in the facility. On 11/28/17 at 4:30 pm an interview was conducted with Nurse #1. Nurse #1 stated that she was assigned to Resident #1 on 9/28/17 the evening shift (3:00 pm to 11:30 pm). Nurse #1 stated that she was very familiar with the resident. Nurse #1 informed the NP at 11:59 pm that Resident #1 was having back pain 8 out of 10 scale that was not relieved with his regular scheduled medication. The NP ordered [MEDICATION NAME] 800 milligrams now one dose which was administered. Nurse #1 stated that she was assigned to Resident #1 on 10/1/17 day shift (7am - 3:30 pm). The NP was called at 7:35 am and informed that the resident had increased acute back pain 10 out of 10 scale and this was a change. Nurse #1 stated that she received a call back from the NP toward the end of her day shift. The NP had ordered labs, back x-ray, and urinalysis and culture/sensitivity. Nurse #1 stated she informed the NP that the resident wanted to go to the hospital. According to Nurse #1, the NP replied, I am not sending him to the hospital, he just wants more pain medication. Nurse #1 stated she informed the resident of the NP orders and the resident cursed and had become angry. Nurse #1 stated the resident informed her he was not going to wait anymore and was going to call his family to take him (to the ED). Nurse #1 stated that the resident had a right to go to the ED if he wanted. Nurse #1 stated that she had not waited almost an entire shift for a response from an NP in the past. Nurse #1 stated that she did not like to send a resident to the ED without an order. Nurse #1 stated that the Unit Manager was available 24 hours a day and she could have called her. Nurse #1 stated she would send a resident to the ED in an emergency via ambulance without an order if necessary. The next day during report Nurse #1 was informed that the resident's family came and took the resident to the ED. On 11/28/17 at 5:28 pm an interview was conducted with the Medical Director (MD). The MD stated that he had reviewed Resident #1's record and remembered him. The resident had pain management issues secondary to polysubstance abuse. The MD stated the NP was called on 10/1/17 because of the resident's increased back pain. The NP ordered labs, urinalysis, and back x-ray and chose not to transfer to the ED. The MD felt this plan was reasonable. The MD stated that it was a resident's right to go to the ED and that if the facility staff felt the resident had a significant change they could send the resident without an order. The MD agreed that if the resident was to go to the ED himself there would be no medical information from the facility provided. On 11/28/17 at 6:35 pm an interview was conducted with Nursing Assistant #1 (NA). The NA stated she was assigned to Resident #1 on 10/1/17 evening shift (3pm - 11:30 pm). The NA stated that the resident was hurting real bad and this was unusual for him. The NA stated that she was present when the resident's wife came to the facility and stated she was taking the resident to the ED. On 11/28/17 at 6:45 pm an interview was conducted with the Administrator. The Administrator stated that if a resident requested to go to the hospital it was his/her right to choose to go.

Based on record review, resident interview, physician interview, and staff interviews, the facility failed to notify the physician of the resident's significant change in condition which resulted in a delay of treatment for [REDACTED].#1). Findings included: The resident was admitted on [DATE], discharged to the hospital 10/2/17 and readmitted to the facility on [DATE]. The facility [DIAGNOSES REDACTED]. Resident #1's 14-day MDS dated [DATE] revealed the resident had an intact cognition, was not feeling depressed, and there was no [MEDICAL CONDITION] or behavior. The resident was on scheduled and as needed pain medication regimen. The resident had frequent pain. Resident #1 had a care plan dated 9/5/17 that included goals and interventions for pain. The pain was to be assessed each shift and pain medication administered as scheduled and as needed. A review of the 24-hour shift report dated 10/1/17 revealed the resident complained of lower back pain and as needed pain medications were given on night shift. At the end of night shift the resident stated he can't stand the pain and wants to go to the hospital. The on-call Physician's Assistant (which is the Nurse Practitioner) was called and left a message. Staff was awaiting a call back. Nurses' noted dated 10/1/17 at 7:25 am revealed Resident #1 was complaining of increased back pain and had requested to go to the hospital. The Nurse Practitioner was called and left a message about the pain and that the resident wanted to go to the hospital. A review of the telephone/verbal order signature details dated 10/1/17 at 2:10 pm revealed the NP ordered an x-ray of the lower back and lumbar spine. Nurses' note dated 10/1/17 at 5:23 pm revealed there were no orders to transfer to the hospital upon call back from the NP. The NP was notified at 5:24 pm that the resident signed himself out (to go to the ED) due to pain. The NP replied ok. Nurse Practitioner (NP) progress note dated on 10/1/17 at 6:22 pm revealed the NP received a voice mail at 5:22 pm that Resident #1 was once again threatening to leave and go to the hospital due to his back pain. NP called the facility at 5:23 pm and was informed that the resident signed himself out and his family took him to the hospital. A review of the Emergency Department's (ED) record dated 10/1/17 revealed Resident #1 was seen and diagnosed with [REDACTED]. A review of the NP progress note dated 10/2/17 revealed the family took Resident #1 to the Emergency Department (ED) for intractable back pain 10/1/17. On 11/28/17 at 2:00 pm an interview was conducted with Resident #1. Resident #1 stated that he had several days of uncontrolled pain. The resident stated on 10/1/17 during the early morning the pain had gotten unbearable. The resident stated that he requested to go to the hospital several times because he knew something was wrong. The resident was informed by Nurse #1 the NP refused to send him to the hospital after waiting all day for an answer. The resident called his family crying in pain to take him. The resident stated that his family took him to the hospital on [DATE] in the evening. On 11/28/17 at 4:30 pm an interview was conducted with Nurse #1. Nurse #1 stated that she was assigned to Resident #1 on 10/1/17 day shift (7am - 3:30 pm). Nurse #1 stated that she was very familiar with the resident. The NP was called at 7:35 am and left a message that the resident had increased back pain and this was a change. Nurse #1 stated that she received a call back from the NP toward the end of her day shift. Nurse #1 stated that she had not waited almost an entire shift for a response from an NP in the past. Nurse #1 stated that she did not like to send a resident to the ED without an order. Neel #1 stated that the Unit Manager was available 24 hours a day for concerns and she could have called her for further instructions. Nurse #1 stated she would send a resident to the ED in an emergency via ambulance without an order if necessary. On 11/28/17 at 5:28 pm an interview was conducted with the Medical Director (MD). The MD stated that he had reviewed Resident #1's record and remembered him. The MD stated the NP was called on 10/1/17 because of the resident's increased back pain. The MD stated that it was a resident's right to go to the ED and that if the facility staff felt the resident had a significant change they could send the resident without an order. The MD agreed that if the resident was to go to the ED himself there would be no medical information from the facility provided. The MD stated that any clinician should call back as soon as possible when called by facility staff. The MD felt the facility staff should call the clinician back if there was no response in a reasonable amount of time or call other medical staff. The MD stated that five hours was not acceptable to respond to the facility.

Based on record review, resident interview, physician interview and staff interviews, the facility failed to initiate medical treatment for [REDACTED].#1). Findings included: Resident #1 was admitted on [DATE], discharged to the hospital 10/2/17 and readmitted to the facility on [DATE]. The facility [DIAGNOSES REDACTED]. Resident #1 ' s 14-day MDS dated [DATE] revealed the resident had an intact cognition, was not feeling depressed, and there was no [MEDICAL CONDITION] or behavior. The resident was on scheduled and as needed pain medication regimen. The resident had frequent pain. Resident #1 had a care plan dated 9/5/17 that included goals and interventions for pain. The pain was to be assessed each shift and pain medication administered as scheduled and as needed. Nurses ' note dated 9/29/17 at 12:51 pm revealed Resident #1 had a pain assessment of 10 out of 10 almost constantly (level scale of 1 to 10 with 10 being the worst pain). The pain made it hard to sleep at night and caused limited day-to-day activities. The pain was documented as being new. The resident was not satisfied with his current level of pain. Pain medication orders were: [MEDICATION NAME] 300 milligrams 3 times a day ordered on [DATE] [MEDICATION] used for nerve pain); [MEDICATION NAME] 4 milligrams every 6 hours as needed for muscle spasm; Tylenol 1000 milligrams every 12 hours ordered on [DATE] (non-narcotic pain reliever); and [MEDICATION NAME] 800 milligrams 3 times a day ordered on [DATE] (anti-[MEDICAL CONDITION]). A review of the medication administration record (MAR) for September and October 2017 revealed the resident was administered the [MEDICATION NAME], Tylenol and [MEDICATION NAME] as ordered. The pain assessment documented on the MAR was as follows: 9/28/18 at 9:00 am 0 level pain and 10:00 pm 8 level pain; 9/29/17 at 9 am 5 level pain and 10:00 pm 8 level pain; 9/30/17 at 9:00 am 10 level pain and 10:00 pm 4 level pain; and 10/1/17 at 9:00 am 10 level pain and 10:00 pm 8 level pain Nurses ' note dated 9/29/17 at 10:30 pm revealed Resident #1 complained of migrating back pain with spasms and numbness to finger tips. The NP was made aware and ordered for continued use of newly scheduled pain medications ([MEDICATION NAME]: anti-[MEDICAL CONDITION]). Nurses ' note dated 9/30/17 at 2:30 am Resident #1 was provided [MEDICATION NAME] HCL 6 mg as needed for back pain (muscle relaxer). Nurses ' note dated 10/1/17 at 2:29 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses ' note dated 10/1/17 at 6:56 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses ' note dated 10/1/17 at 7:36 am Resident #1 complained he can ' t stand the pain and requested to go to the hospital. Nurse Practitioner (NP) progress note dated 10/1/17 revealed she received a voice mail from the facility at 7:26 am that Resident #1 requested to be sent to the hospital because of his back pain. The NP called the facility back at 9:13 am and ordered a urinalysis, urine culture and sensitivity, and a back x-ray and to be called when the results were available. A review of the telephone/verbal order signature details dated 10/1/17 at 2:10 pm revealed the NP placed the order for x-ray of the lower back and lumbar spine. NP progress note dated on 10/1/17 at 6:22 pm revealed the NP received a voice mail at 5:22 pm that Resident #1 was once again threatening to leave and go to the hospital due to his back pain. NP called the facility at 5:23 pm and was informed that the resident signed himself out and his family took him to the hospital. The note indicated the back x-ray and urinalysis had not been completed yet (in the facility). A review of Resident #1 ' s hospital record dated 10/2/17 revealed the resident had a magnetic resonance imaging (MRI: scans inside of the body) which reported a lumbar [MEDICATION NAME] abscess [MEDICAL CONDITION] (infection in the blood). The resident was admitted to the hospital and treated for [REDACTED]. A review of the NP progress note dated 10/2/17 revealed the family took Resident #1 to the Emergency Department (ED) for intractable back pain 10/1/17. The resident received [MEDICATION NAME] (strong narcotic pain reliever), [MEDICATION NAME] (steroid to reduce acute inflammation), and [MEDICATION NAME] (strong prescription anti-[MEDICAL CONDITION]), had blood cultures drawn, and an order for [REDACTED]. The resident informed the NP that he was crying like a baby because the pain was so bad, he could not take it anymore. On 11/28/17 at 2:00 pm an interview was conducted with Resident #1. Resident #1 stated that he had several days of uncontrolled pain. The resident informed the nurse, the NP and his family about the increased pain. The resident stated on 10/1/17 during the early morning the pain had gotten unbearable. The resident stated that he requested to go to the hospital several times because he knew something was wrong. The resident was informed by Nurse #1 that the NP refused to send him to the hospital after waiting all day for an answer. The resident called his family crying in pain to take him. The resident stated that his family took him to the hospital on [DATE] in the evening. On 11/28/17 at 4:30 pm an interview was conducted with Nurse #1. Nurse #1 stated that she was assigned to Resident #1 on 9/28/17 the evening shift (3:00 pm to 11:30 pm). Nurse #1 stated that she was very familiar with the resident. Nurse #1 informed the NP at 11:59 pm that Resident #1 was having back pain 8 out of 10 scale that was not relieved with his regular scheduled medication. The NP ordered [MEDICATION NAME] 800 milligrams now one dose which was administered. Nurse #1 stated that she was assigned to Resident #1 on 10/1/17 day shift (7am - 3:30 pm). The NP was called at 7:35 am and informed that the resident had increased acute back pain 10 out of 10 scale and this was a change. Nurse #1 stated that she received a call back from the NP toward the end of her day shift. The NP had ordered labs, back x-ray, and urinalysis and culture/sensitivity. Nurse #1 stated she informed the NP that the resident wanted to go to the hospital. According to Nurse #1, the NP replied, I am not sending him to the hospital, he just wants more pain medication. Nurse #1 stated she informed the resident of the NP orders and the resident cursed and had become angry. Nurse #1 stated the resident informed her he was not going to wait anymore and was going to call his family to take him (to the ED). Nurse #1 stated that the resident had a right to go to the ED if he wanted. Nurse #1 stated that she had not waited almost an entire shift for a response from an NP in the past. Nurse #1 stated that she did not like to send a resident to the ED without an order. Nurse #1 stated that the Unit Manager was available 24 hours a day and she could have called her. Nurse #1 stated she would send a resident to the ED in an emergency via ambulance without an order if necessary. The next day during report Nurse #1 was informed that the resident ' s family came and took the resident to the ED. On 11/28/17 at 4:50 pm an interview was conducted with Nurse #2. Nurse #2 stated she could not remember Resident #1 and his complaints of increased back pain. Nurse #2 stated she was on duty on 9/29/17 evening and night shifts (3:00 pm to 7:00 am) responsible for the hall where Resident #1 resided. Nurse #2 stated that she was frequently assigned to different halls. On 11/28/17 at 5:28 pm an interview was conducted with the Medical Director (MD). The MD stated that he had reviewed Resident #1 ' s record and remembered him. The resident had pain management issues secondary to polysubstance abuse. The resident was on heavy medications: [MEDICATION NAME], and [MEDICATION NAME]. The MD stated the NP was called on 10/1/17 because of the resident ' s increased back pain. The NP ordered labs, UA, and back x-ray and chose not to transfer to the ED. The MD felt this plan was reasonable. The resident had ongoing back pain and was difficult to assess. The resident would be up and smoking or sitting in his bed and not complaining of pain when the NP saw him on 9/28/17 and 9/29/17. The MD stated that it was a resident ' s right to go to the ED and that if the facility staff felt the resident had a significant change they could send the resident without an order. The MD agreed that if the resident was to go to the ED himself there would be no medical information from the facility provided. On 11/28/17 at 6:35 pm an interview was conducted with Nursing Assistant #1 (NA). The NA stated she was assigned to Resident #1 on 10/1/17 evening shift (3pm - 11:30 pm). The NA stated that the resident was hurting real bad and this was unusual for him. The resident had more pain than was previously seen and this was a change. The NA did not see the NP on evening shift. The NA stated that she was present when the resident ' s wife came to the facility and stated she was taking the resident to the ED. On 11/28/17 at 6:45 pm an interview was conducted with the Administrator. The Administrator stated that if a resident chose and requested to go to the hospital it was his/her right to be sent.

Based on record review, resident interview, physician interview, and staff interviews, the facility failed to provide the resident requested care and services which resulted in uncontrolled pain management and a delay in medical treatment for [REDACTED].#1). Findings included: The resident was admitted on [DATE], discharged to the hospital 10/2/17 and readmitted to the facility on [DATE]. The facility [DIAGNOSES REDACTED]. Resident #1's 14-day MDS dated [DATE] revealed the resident had an intact cognition, was not feeling depressed, and there was no [MEDICAL CONDITION] or behavior. The resident was on scheduled and as needed pain medication regimen. The resident had frequent pain. Resident #1 had a care plan dated 9/5/17 that included goals and interventions for pain. The pain was to be assessed each shift and pain medication administered as scheduled and as needed. Pain medication orders were: [MEDICATION NAME] 300 milligrams 3 times a day ordered on [DATE] [MEDICATION] used for nerve pain); [MEDICATION NAME] 4 milligrams every 6 hours as needed for muscle spasm; Tylenol 1000 milligrams every 12 hours ordered on [DATE] (non-narcotic pain reliever); and [MEDICATION NAME] 800 milligrams 3 times a day ordered on [DATE] (anti-[MEDICAL CONDITION]). A review of the September and October 2017 Medication Administration Record [REDACTED] 9/28/18 at 9:00 am 0 level pain and 10:00 pm 8 level pain; 9/29/17 at 9 am 5 level pain and 10:00 pm 8 level pain; 9/30/17 at 9:00 am 10 level pain and 10:00 pm 4 level pain; and 10/1/17 at 9:00 am 10 level pain and 10:00 pm 8 level pain (level scale of 1 to 10 with 10 being the worst pain). Nurses' note dated 9/29/17 at 12:51 pm revealed Resident #1 had a pain assessment of 10 out of 10 almost constantly. The pain made it hard to sleep at night and caused limited day-to-day activities. The pain was documented as being new. The resident was not satisfied with his current level of pain. Nurses' note dated 9/29/17 at 10:30 pm revealed Resident #1 complained of migrating back pain with spasms and numbness to finger tips. The NP was made aware and ordered for continued use of newly scheduled pain medication ([MEDICATION NAME]). Nurses' note dated 9/30/17 at 2:30 am Resident #1 was provided [MEDICATION NAME] HCL 6 mg as needed for back pain (muscle relaxer). Nurses' note dated 10/1/17 at 2:29 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses' note dated 10/1/17 at 6:56 am Resident #1 was provided as needed [MEDICATION NAME] HCL 6 mg for back pain. Nurses' note dated 10/1/17 at 7:36 am Resident #1 complained he can't stand the pain and requested to go to the hospital. Nurse Practitioner (NP) progress note dated 10/1/17 revealed she received a voice mail from the facility at 7:26 am that Resident #1 requested to be sent to the hospital because of his back pain. The NP called the facility back at 9:13 am and ordered a urinalysis, urine culture and sensitivity, and a back x-ray and to be called when the results were available. A review of the telephone/verbal order signature details dated 10/1/17 at 2:10 pm revealed the NP placed the order for x-ray of the lower back and lumbar spine. NP progress note dated on 10/1/17 at 6:22 pm revealed the NP received a voice mail at 5:22 pm that Resident #1 was once again threatening to leave and go to the hospital due to his back pain. NP called the facility at 5:23 pm and was informed that the resident signed himself out and his family took him to the hospital. The note indicated the back x-ray and urinalysis had not been completed yet (in the facility). A review of the Emergency Department (ED) record dated 10/1/17 revealed Resident #1 was diagnosed with [REDACTED]. The resident was treated for [REDACTED]. The neurosurgeon was consulted and a magnetic resonance image (MRI: scan of the body) of the lumber spine was ordered for the next morning to determine the cause of the back pain. A review of Resident #1's Hospital record dated 10/2/17 revealed the resident had an MRI which reported a lumbar [MEDICATION NAME] (spinal canal) abscess [MEDICAL CONDITION] (infection in the blood). The resident was admitted to the hospital and treated for [REDACTED]. A review of the NP progress note dated 10/2/17 revealed the family took Resident #1 to the ED for intractable back pain 10/1/17. The resident received [MEDICATION NAME] and [MEDICATION NAME] (pain medications) and an order for [REDACTED]. On 11/28/17 at 2:00 pm an interview was conducted with Resident #1. Resident #1 stated that he had several days of uncontrolled pain. The resident informed the nurse, the NP and his family about the increased pain. The resident stated on 10/1/17 during the early morning the pain had gotten unbearable. The resident stated that he requested to go to the hospital several times because he knew something was wrong. The resident was informed the NP refused to send him to the hospital after waiting all day for an answer. The resident called his family crying in pain to take him. The resident stated that his family took him to the hospital on [DATE] in the evening. On 11/28/17 at 4:30 pm an interview was conducted with Nurse #1. Nurse #1 stated that she was assigned to Resident #1 on 9/28/17 the evening shift (3:00 pm to 11:30 pm). Nurse #1 stated that she was very familiar with the resident. Nurse #1 informed the NP at 11:59 pm that Resident #1 was having back pain 8 out of 10 scale that was not relieved with his regular scheduled medication. The NP ordered [MEDICATION NAME] 800 milligrams now one dose which was administered. Nurse #1 stated that she was assigned to Resident #1 on 10/1/17 day shift (7am - 3:30 pm). The NP was called at 7:35 am and informed that the resident had increased acute back pain 10 out of 10 scale and this was a change. Nurse #1 stated that she received a call back from the NP toward the end of her day shift. The NP had ordered labs, back x-ray, and urinalysis and culture/sensitivity. Nurse #1 stated she informed the NP that the resident wanted to go to the hospital. According to Nurse #1, the NP replied, I am not sending him to the hospital, he just wants more pain medication. Nurse #1 stated she informed the resident of the NP orders and the resident cursed and had become angry. Nurse #1 stated the resident informed her he was not going to wait anymore and was going to call his family to take him (to the ED). Nurse #1 stated that the resident had a right to go to the ED if he wanted. Nurse #1 stated that she had not waited almost an entire shift for a response from an NP in the past. Nurse #1 stated that she did not like to send a resident to the ED without an order. Nurse #1 stated that the Unit Manager was available 24 hours a day and she could have called her if there was a concern. Nurse #1 stated she would send a resident to the ED in an emergency via ambulance without an order if necessary. The next day during report Nurse #1 was informed that the resident's family came and took the resident to the ED. On 11/28/17 at 5:28 pm an interview was conducted with the Medical Director (MD). The MD stated that he had reviewed Resident #1's record and remembered him. The resident had pain management issues secondary to polysubstance abuse. The MD stated the NP was called on 10/1/17 because of the resident's increased back pain. The NP ordered labs, urinalysis, and back x-ray and chose not to transfer to the ED. The resident had ongoing back pain and was difficult to assess. The MD stated that it was a resident's right to go to the ED and that if the facility staff felt the resident had a significant change they could send the resident without an order. The MD agreed that if the resident was to go to the ED himself there would be no medical information from the facility provided. On 11/28/17 at 6:35 pm an interview was conducted with Nursing Assistant #1 (NA). The NA stated she was assigned to Resident #1 on 10/1/17 evening shift (3pm - 11:30 pm). The NA stated that the resident was hurting real bad and this was unusual for him. The resident had more pain than was previously seen and this was a change. The NA did not see the NP on evening shift. The NA stated that she was present when the resident's wife came to the facility and stated she was taking the resident to the ED. On 11/28/17 at 6:45 pm an interview was conducted with the Administrator. The Administrator stated that if a resident chose and requested to go to the hospital it was his/her right to be sent.

Based on record review and staff interviews the facility failed to notify the physician of elevated blood sugar for 1 of 1 resident (Resident #1) resulting in a blood sugar level above 600 milligrams per deciliter (mg/dl), unresponsiveness, and an emergent admission to the hospital. Findings included: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital from the facility on 3/27/17. Active [DIAGNOSES REDACTED]. A review of the admission physician's orders [REDACTED]. Review of the resident's comprehensive admission Minimum Data Set assessment dated for 3/17/17 documented the resident had severely impaired cognition. Review of resident's active care plan dated for 3/23/17, revealed Resident #1 was an insulin dependent diabetic. The resident's goal for this problem was to be free of all signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar levels) for 90 days. Interventions listed on care plan included: labs as ordered and report results to physician, and monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and report abnormal findings to the physician. A review of blood sugar levels from 3/25/17 to 3/26/17 revealed the resident's blood sugar levels normally ranged from 148 mg/dl to 157 mg/dl. On 3/27/17 Nurse #1 documented the resident's blood sugar to be 415 mg/dl at 10:10 AM and the regularly scheduled 25 units of [MEDICATION NAME] 100 UNIT/ML (a long acting insulin that starts to work several hours after injection) was administered. A review of nursing notes revealed a nursing note written on 3/27/17 at 11:02 PM by Nurse #2 that documented the nurse entered the room to obtain the resident's blood sugar level and found the resident non-responsive to verbal prompts and sternal stimulation and blood sugar level was above 600. The nurse notified the Nurse Practitioner on call and was given a verbal order to send the resident to the hospital. The nurse also documented she notified a family member of the transport. During an interview on 4/19/17 at 11:20 AM, Nurse #1 stated she worked on the resident's unit on 3/27/17 from 7:00 AM to 11:00 AM due to a call out. When asked about the blood sugar level of 415 mg/dl documented on 3/27/17, she stated she did not remember documenting a blood sugar level that high. After she reviewed the MAR (Medication Administration Record) and confirmed that she documented the blood sugar of 415 mg/dl, Nurse # 1 stated that she hadn't reported it to the physician. When asked about what she should have done in that situation, she stated she should have reported the result to the physician. During an interview on 4/19/17 at 1:30 PM with Nurse #2, when asked about the day the resident was transported to the hospital, she stated she relieved Nurse #1 for an 11:00 AM shift. She stated the resident's blood sugar was over 600 so she notified the on call Nurse Practitioner, his family, and arranged transportation to the hospital. During an interview on 4/19/17 at 3:05 PM with the director of nursing (DON), she stated that she expected staff to report abnormal blood sugar levels. She stated that there were no standing orders and it was per physician and their orders. When asked if she would expect a blood sugar level of 415 mg/dl to be reported when the previously obtained blood sugar was 148 mg/dl, she stated that the physician should have been notified of that result. During an interview on 4/19/17 at 3:15 PM with the on call Nurse Practitioner that ordered the transport to the hospital, he stated he couldn't remember the specifics of the situation but that based on the information given he would have had the resident sent to the hospital. When asked he stated he would expect a blood sugar level of 400 mg/dl or greater to be called into him and he would order short acting insulin, have staff recheck in one hour, and have that result called back to him. During an interview on 4/19/17 at 3:37 PM with the Medical Director he stated that he would expect that levels below 60 or above 400 mg/dl to be reported to the physician or on call provider. He stated he was new to the facility and did not realize that there were no standing orders in place for reporting these results to providers, and that he ensured standing orders would be in place as soon as possible.

Based on record review and interviews with staff, physician and nurse practitioner, the facility nurse neglected to notify the physician and the on-coming shift nurse of an elevated blood sugar. The facility staff neglected to recheck the blood sugar and assess the resident for abnormal blood sugar levels for 1 of 1 resident (Resident #1) resulting in a critical blood sugar level above 600 milligrams per deciliter (mg/dl), unresponsiveness, and an emergent admission to the hospital. Findings included: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital from the facility on 3/27/17. Active [DIAGNOSES REDACTED]. A review of the admission physician's orders [REDACTED]. Review of the resident's comprehensive admission Minimum Data Set assessment, dated 3/17/17, documented the resident had severely impaired cognition. Review of the resident's active care plan dated for 3/23/17, revealed Resident #1 had insulin dependent diabetes. The resident's goal for this problem was to be free of all signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar levels) for 90 days. Interventions listed on the care plan included: labs as ordered and report results to physician, and monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and report abnormal findings to the physician. A review of blood sugar levels from 3/25/17 to 3/26/17 revealed the resident's blood sugar levels normally ranged from 148 mg/dl to 157 mg/dl. On 3/27/17 Nurse #1 documented the resident's blood sugar to be 415 mg/dl at 10:10 AM and the regularly scheduled 25 units of [MEDICATION NAME] 100 UNIT/ML (a long acting insulin that starts to work several hours after injection) was administered. A review of nursing notes, written on 3/27/17 at 11:02 PM by Nurse #2, revealed the nurse entered the room to obtain the resident's blood sugar level and found the resident non-responsive to verbal prompts and sternal stimulation and his blood sugar level was above 600. The nurse notified the Nurse Practitioner on call and was given a verbal order to send the resident to the hospital. The nurse also documented she notified the family of the transport. During an interview on 4/19/17 at 11:20 AM with Nurse #1, she stated she worked on the resident's unit on 3/27/17 from 7:00 AM to 11:00 AM due to a call out. When asked about the blood sugar level of 415 mg/dl documented on 3/27/17, she stated she did not remember documenting a blood sugar level that high. Then, Nurse #1 accessed the Medication Administration Record (MAR) to determine if she was the one who documented that level. Once Nurse #1 confirmed that she was the nurse that documented the resident had a blood sugar of 415 mg/dl on 3/27/17, she stated she had not reported it to the physician. When asked about what she should have done in that situation, she stated she should have reported the result to the physician, followed orders given, and rechecked the blood sugar. When asked if she had noticed any abnormal signs or symptoms on the resident during her shift, she stated that she had not observed any changes in his behavior and that he had no issues taking his crushed medication. She also stated that she was relieved at 11:00 AM by Nurse #2 and did not report the abnormal blood sugar result to the oncoming nurse. During an interview on 4/19/17 at 1:30 PM with Nurse #2, when asked about the day the resident was transported to the hospital, she stated she relieved Nurse #1 for an 11:00 AM shift. She stated that she had first seen the resident that night, that he was unresponsive, his chest was rattling, his blood pressure was around 90 systolic, and that she remembered his heart rate was in the 120's, and his blood sugar was over 600 so she notified the on call Nurse Practitioner, family, and arranged transportation to the hospital. When shown the MAR where no initials were present representing that the blood sugar level had been checked at 5:00 PM as scheduled, she observed the MAR and stated If it's not documented then I must have missed it. During an interview on 4/19/17 at 3:05 PM with the director of nursing (DON), when asked about what her expectation for reporting abnormal blood sugar levels, she stated that there were no standing orders and it was per physician and their orders. When asked if she would expect a blood sugar level of 415 mg/dl to be reported when the previously obtained blood sugar was 148 mg/dl, she stated that the physician should have been notified of that result. During an interview on 4/19/17 at 3:15 PM with the on call Nurse Practitioner that ordered the transport to the hospital, he stated he couldn't remember the specifics of the situation but that based on the information given he would have had the resident sent to the hospital. When asked he stated he would expect a blood sugar level of 400 mg/dl or greater to be called into him and he would order short acting insulin, have staff recheck in one hour, and have that result called back to him. During an interview on 4/19/17 at 3:37 PM with the Medical Director he stated that he would expect that levels below 60 or above 400 mg/dl to be reported to the physician or on call provider. He stated he was new to the facility and did not realize that there were no standing orders in place for reporting these results to providers, and that he ensured standing orders would be in place as soon as possible.

Based on record review and interviews with staff, physician and nurse practioner, the facility failed to notify physician and reassess abnormal blood sugar levels for 1 of 1 resident (Resident #1) resulting in a critical blood sugar level above 600 milligrams per deciliter (mg/dl), unresponsiveness, and an emergent admission to the hospital. Findings included: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital from the facility on 3/27/17. Active [DIAGNOSES REDACTED]. A review of the admission physician's orders [REDACTED]. Record review of the resident's comprehensive admission Minimum Data Set assessment, dated 3/17/17, documented the resident had severely impaired cognition, required one to two persons extensive to total assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and required supervision for eating meals. The resident had functional limitation in range of motion for upper and lower extremities for one side and required a wheelchair. Review of the resident's active care plan dated for 3/23/17, revealed Resident #1 was an insulin dependent diabetic. The resident's goal for this problem was to be free of all signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar levels) for 90 days. Interventions listed on care plan included: labs as ordered and report results to physician, and monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and report abnormal findings to the physician. A review of blood sugar levels from 3/25/17 to 3/26/17 revealed the resident's blood sugar levels normally ranged from 148 mg/dl to 157 mg/dl. On 3/27/17 Nurse #1 documented the resident's blood sugar to be 415 mg/dl at 10:10 AM and the regularly scheduled 25 units of [MEDICATION NAME] 100 UNIT/ML (a long acting insulin that starts to work several hours after injection) was administered. A review of a nursing note, written on 3/27/17 at 11:02 PM by Nurse #2, revealed the nurse entered the room to obtain the resident's blood sugar level and found the resident non-responsive to verbal prompts and sternal stimulation and blood sugar level was above 600. The nurse notified the Nurse Practitioner on call and was given a verbal order to send the resident to the hospital. The nurse also documented she notified the family of the transport. During an interview on 4/19/17 at 11:08 AM, Nursing Assistant (NA) #1 was asked if she had observed any changes in the resident. She stated that the resident was moved from another place to a new room and she felt that he was taken out of his element, he refused to get out of bed most of the time and that she had noticed he had started sleeping more. During an interview on 4/19/17 at 11:20 AM with Nurse #1, she stated she worked on the resident's unit on 3/27/17 from 7:00 AM to 11:00 AM due to a call out. When asked about the blood sugar level of 415 mg/dl documented on 3/27/17, she stated she did not remember documenting a blood sugar level that high. Then, Nurse #1 accessed the Medication Administration Record (MAR) to determine if she was the one who documented that level. Once Nurse #1 confirmed that she was the nurse that documented the resident had a blood sugar of 415 mg/dl on 3/27/17, she stated she had not reported it to the physician. When asked about what she should have done in that situation, she stated she should have reported the result to the physician, followed orders given, and rechecked the blood sugar. When asked if she had noticed any abnormal signs or symptoms on the resident during her shift, she stated that she had not observed any changes in his behavior and that he had no issues taking his crushed medication. She also stated that she was relieved at 11:00 AM by Nurse #2 and did not report the abnormal blood sugar result to the oncoming nurse. During an interview on 4/19/17 at 1:30 PM with Nurse #2, when asked about the day the resident was transported to the hospital, she stated she relieved Nurse #1 for an 11:00 AM shift. She stated that she had first seen the resident that night, that he was unresponsive, his chest was rattling, his blood pressure was around 90 systolic, and that she remembered his heart rate was in the 120's, and his blood sugar was over 600 so she notified the on call Nurse Practitioner, family, and arranged transportation to the hospital. When shown the MAR where no initials were present representing that the blood sugar level had been checked at 5:00 PM as scheduled, she observed the MAR and stated If it's not documented then I must have missed it. During an interview on 4/19/17 at 3:05 PM with the director of nursing (DON), when asked about what her expectation for reporting abnormal blood sugar levels, she stated that there were no standing orders and it was per physician and their orders. When asked if she would expect a blood sugar level of 415 mg/dl to be reported when the previously obtained blood sugar was 148 mg/dl, she stated that the physician should have been notified of that result. During an interview on 4/19/17 at 3:15 PM with the on call Nurse Practitioner that ordered the transport to the hospital, he stated he couldn't remember the specifics of the situation but that based on the information given he would have had the resident sent to the hospital. When asked he stated he would expect a blood sugar level of 400 mg/dl or greater to be called into him and he would order short acting insulin, have staff recheck in one hour, and have that result called back to him. During an interview on 4/19/17 at 3:37 PM with the Medical Director he stated that he would expect that levels below 60 or above 400 mg/dl to be reported to the physician or on call provider. He stated he was new to the facility and did not realize that there were no standing orders in place for reporting these results to providers, and that he ensured standing orders would be in place as soon as possible.

Based on facility staff interviews, dermatology office staff and Medical Director interviews, and record reviews, the facility failed to arrange a dermatology consultation (a specialty branch of medicine that deals with the [DIAGNOSES REDACTED].#2) reviewed for the provision of medically-related Social Services. The findings included: Resident #2 was admitted to the facility on [DATE] from the community. His cumulative [DIAGNOSES REDACTED]. A review of Resident #2 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #2 was independent for transfers, walking in his room and corridor, locomotion off the unit, and eating. He required supervision for all of his other Activities of Daily Living (ADLs). On 10/2/16, a Change in Condition-Skin form indicated Resident #2 had a rash/dermatological disorder. Notes indicated he had a skin rash to his entire back, with redness and raised areas. A Nursing Communication form dated 10/2/16 also noted the problem was observed, reporting the resident ' s entire back and surrounding skin areas were reddened and had some sort of rash or break out. The form indicated Resident #2 complained of itching. He was given 25 milligrams (mg) of diphenhydramine (an antihistamine) with relief of itching. However, the rash remained. A handwritten note on the Nursing Communication form dated 10/5/16 read, (name of Medical Doctor or MD) Assessed 10/3/16. Further review of the resident ' s medical record revealed a Physician order [REDACTED]. An order was also written for 100 mg doxycycline (an antibiotic) to be given by mouth twice daily for 14 days due to a rash. On 10/17/16, a Nurse Practitioner (NP) progress note revealed the resident was seen for evaluation of a rash which had been a problem for the past 2 weeks. The plan of care included the use of hydrocortisone cream to be applied to the affected areas twice daily; and, a request for a dermatology consult. A review of Resident #2 ' s medical record revealed a Physician order [REDACTED]. The Physician order [REDACTED]. Nurse #2 ' s signature on the form indicated she was the nurse who received the Physician order [REDACTED]. On 10/28/16, Resident #2 was seen again by the NP. The NP progress notes indicated the chief complaint was dermatitis. The NP notes indicated the resident had an appointment scheduled with dermatology. New orders included 40 mg prednisone for 10 days for a primary [DIAGNOSES REDACTED]. Resident #2 ' s medical record included a Report of Consultation with Dermatologist dated 12/6/16. The dermatologist indicated the resident had Crusted Scabies and initiated 3 medications. The medications included: 3 mg Ivermectin (a medication used to treat parasitic infestations) to be given as 6 tablets by mouth at once on days 1, 2, 8, and 9; 5% Elimite (a topical anti-parasitic medication) with instructions to apply the topical cream to the entire body (neck down) on days 1 and 8; and, 0.1% triamcinolone acetonide cream (a topical steroidal cream) with instructions to apply the cream topically twice daily to the affected areas as needed for itching. A telephone interview was conducted on 3/8/17 at 2:22 PM with a staff member of the Dermatology office where Resident #2 had been seen for treatment on 12/6/16. The Dermatology office confirmed the resident was seen for an appointment once on 12/6/16. The records at their office revealed this appointment was arranged by the facility on 11/17/16 and scheduled for 12/6/16 at that time. An interview was conducted on 3/9/17 at 12:28 PM with Nurse #2. During the interview, Nurse #2 confirmed she had verified the order for the dermatology consult written on 10/17/17. Upon inquiry, Nurse #2 reported that after verifying the order, she would have called the scheduler for the facility and informed her of the need to arrange the dermatology consult. An interview was conducted on 3/9/17 at 12:55 PM with the facility ' s Unit Secretary. The Unit Secretary reported she was the scheduler for outside appointments and consultations. Upon inquiry, she reported that she was notified of requests for outside consults from the physician, the hall nurse, or upon receipt of a copy of the computer Order Entry or physician order. Once received, the Unit Secretary stated she would gather the paper work needed and fax it to the consulting office. She reported after the paper work was completed, she would telephone the consulting office and ask for the first available appointment. When asked how long it would take to begin this process once the consultation order was received, the Unit Secretary reported the process would be initiated by the next business day. During the interview, Resident #2 ' s referral for a dermatology appointment was discussed. The Unit Secretary was asked why it took one month from when the order was written (on 10/17/16) until 11/17/16 to arrange the dermatology appointment (scheduled for 12/6/16). The Unit Secretary reported she would need to look back at a few records to answer the question appropriately. A follow-up interview was conducted on 3/9/17 at 3:00 PM with the Unit Secretary. During the interview, the Unit Secretary stated she confirmed with the dermatology office that the appointment made for Resident #2 on 12/6/16 was arranged on 11/17/16. Upon further reflection, the secretary reported she was not certain when or how she had been notified of the resident ' s need for a dermatology consult ordered for him on 10/17/16. She recalled there was a need for additional information to be sent to the dermatology office regarding the resident ' s insurance. When asked how long this may have taken, she stated, probably not more than a couple of days. The Unit Secretary reported she thought a communication issue was likely the cause of the delay between when the order was written for a dermatology consult on 10/17/16 until the appointment was arranged on 11/17/16. A telephone interview was conducted on 3/10/17 at 3:10 PM with the facility ' s Medical Director. During the interview, concerns were discussed regarding the one month delay between when the order for a dermatology consult was written and when the appointment was arranged for Resident #2. When the Medical Director was asked what his thoughts were about this delay, he stated, We write the order, we expect it to be carried out. An interview was conducted on 3/10/17 at 3:30 PM with the facility ' s Director of Nursing (DON). During the interview, concerns were discussed in regards to the delay in arranging a dermatology consult for Resident #2. Upon inquiry, the DON stated her expectation would be for the consultation order to be given to the Unit Secretary when it ' s ordered, and for the Unit Secretary to arrange the appointment either the day the order was written or the next business day.

Based on observations, staff and resident interviews the facility failed to follow the care plan for interventions to prevent weight loss for three of six sampled residents on supplements (Residents #9, #7 and # 10.) The findings included: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #9 had long and short memory problems, required meal set up and was independent with eating. The resident's weight was 85 pounds and no weight loss had occurred. Review of the care plan dated 2/1/17 included a problem of nutritional concern related to her diagnoses, and a Body Mass Index (BMI) that was less than 19. (This indicated a nutritional risk for malnutrition) The stated goal indicated the resident would consume of at least 75% of most meals, increase protein intake with current diet order and she would maintain a stabilized weight with no significant changes through next review. The interventions were as follows: evaluate for proper consistency of diet, offer/encourage fluids of choice, weight per policy and alert dietitian and physician to any significant loss or gain, monitor for changes in nutritional status (changes in intake, unplanned weight loss/gain) and report to food and nutrition/physician as indicated, provide diet as ordered, house supplement as ordered and offer alternate food choices if less than 50% consumed at mealtime. Observation upon entry on 3/8/17 at 5:15 AM revealed a tray of supplements for residents was sitting on the conference room table. The supplements were warm to touch and included Resident #9 for the dates of 3/5/17 and 3/6/17. There were two cartons dated 3/5/17 and three cartons for 3/6/17. The Director of Nursing was observed removing the tray and taking it to the kitchen on 3/8/17 at 5:44 AM. Review of Resident #9's Kardex information dated 3/8/17 included the aides were to provide diet and house supplements as ordered. Interview on 3/9/17 at 9:31 AM with the Dietary Manager indicated supplements were placed on trays labeled 1, 2, & 3 and then delivered from the kitchen to 4-nourishment room refrigerators by 10:00 AM and 2:00 PM. The supplements placed in nourishment rooms at approximately 9:00 AM. The 8:00 PM supplements were placed in the nourishment rooms between 1:00 and 2:00 PM. Interview with Resident #9 on 3/9/17 at 9:54 AM revealed she didn't like eggs and had refused them. The tray ticket indicated the eggs were a double portion provided for protein. Further interview revealed she didn't like the house supplement and indicated she did not like the vanilla flavored supplement. During the interview, Resident #9 explained she had not been asked if she would prefer a different flavor. If she could have something different, she would like strawberry. Interview with Nursing Assistant #4 on 3/9/17 at 9:55 AM revealed Resident #9 had refused the eggs and asked him to remove them. A substitute was not offered in exchange for the double portion eggs for protein. Interview with Nurse #4 on 3/9/17 at 12:00 PM revealed she worked on 3/6/17 day shift. The documentation of the supplement would have been from the aide's report to her. When explained the supplements were found on 3/8/17 at 5:30 AM in the conference room, on a tray, unopened, she replied in the conference room. No explanation could be provided as to why the supplements had not been provided. Interview with the unit manager on 3/9/17 at 4:01 pm revealed the house supplements would be ordered by the physician. Dietary would be sent the supplements for the time it was ordered. The aide usually passed the snack/supplement. For the supplement it would be documented on the Medication Administration Record (MAR) by the nurse. The nurse would document the percentage consumed by the resident. It was not the expectation the nurse would give the supplement. If a resident did not like it/refused it, the nurse should notify the unit manager or dietician of the refusal or dislike. No one had informed her she did not like the supplement and/or refused it. Either the aides were not reporting it or the nurses were not asking the aides about amount consumed. Interview with the DON on 3/9/17 at 4:49 PM revealed her expectation of nursing to provide supplements would be for the staff to provide them to the resident, and the nurse would document the percentage after it had been consumed. The DON did not know why the tray of supplements had been in the conference room or why they were not given to the residents. The DON explained a weight should have been obtained on 3/6/17 and it was not obtained. She further explained the same staff was not obtaining the weights and errors had occurred. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's weight on admission was 108 pounds. Review of the care plan dated 11/28/16 included problems of requiring assistance/dependent for activities of daily living. The interventions for the problem included to provide the resident with one person extensive assistance for eating. The care plan identified a problem for nutritional risk related to his diseases and a pressure ulcer. The stated goals indicated Resident #7 would maintain a stabilized weight with no significant changes and consume at least 75% of most meals daily through next review. The interventions included diet as ordered, a dysphagia pureed with nectar-like liquids, house supplement as ordered, weigh per policy and alert dietitian and physician to any significant loss or gain, monitor for changes in nutritional status, changes in intake, ability to feed self, unplanned weight loss/gain, or abnormal labs and report to nutrition/physician as indicated. Review of the physician orders [REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 had short and long term memory impairment, required extensive assistance of one person for eating and he was receiving hospice services. The MDS assessed his weight as 110 pounds with no significant weight change. Review of a nurse's note dated 3/6/17 at 12:55 by nurse #5 revealed . no refusals. House Supplement three times a day for Body Mass Index (BMI) <19. Review of the March Medication Administration Record (MAR) for Resident #7 revealed documentation by the nurse the house supplement was given three times a day at 10:00 AM, 2:00 PM and 8:00 PM on 3/5/17 and 3/6/17. The supplement was documented as 100% for 3/9/17 at 10:00 AM. Observations upon entry on 3/8/17 at 5:15 AM revealed a tray of supplements for residents was sitting on the conference room table and included Resident #7 for the dates of 3/5/17 and 3/6/17. There were two cartons dated 3/5/17 and three cartons for 3/6/17. The Director of Nursing was observed removing the tray and taking it to the unclean side of the kitchen on 3/8/17 at 5:44 AM. Interview on 3/9/17 at 9:31AM with the Dietary Manager indicated supplements were placed on trays labeled 1, 2, & 3 and then delivered from the kitchen to 4-nourishment room refrigerators by 10:00 AM and 2:00 PM supplements placed in nourishment rooms at approximately 9:00 AM. The 8:00 PM supplements were placed in the nourishment rooms between 1-2:00 PM. Observation of the supplement for Resident #7 on 3/9/17 at 11:30 AM revealed the shake was in the trash with the name of the resident and the date of 3/9/17 and snack 1 (10:00 AM snack). The carton was half full. Interview on 3/9/17 at 11:45 AM with nurse #5 revealed she did not give the supplement to Resident #7. The nursing assistant #6 gave it to the resident. She further explained, to document 100% consumed the carton would have been completely empty. She explained the carton for 10:00 AM was not empty and would not be 100%. The nursing assistants would inform her of the percentage after giving it to the resident. She could not remember who told her it was 100%. Interview with the nursing assistant #6 on 3/9/17 at 11:50 AM revealed she had not given the supplement to the resident. Nursing assistant #6 stated it must have been the hospice aide/nurse. Interview with the unit manager on 3/9/17 at 4:01 pm revealed the house supplements would be ordered by the physician. Dietary would be send the supplements for the time it was ordered. The aide usually passed the snack/supplement. For the supplement it would be documented on the Medication Administration Record (MAR) by the nurse. The nurse would document the percentage consumed by the resident. It is not the expectation the nurse would give the supplement. If a resident did not like it/refused it, the nurse should notify the unit manager or dietician of the refusal or dislike. No one has informed her she did not like the supplement and/or refused it. Either the aides are not telling or the nurses are not asking. Interview with the DON on 3/9/17 at 4:49 PM revealed her expectation of nursing to provide supplements would be for the staff to provide them to the resident, and the nurse would document the percentage after it had been consumed. The DON did not know why the tray of supplements had been in the conference room or why they were not given to the residents. 3. Resident # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 had short and long term memory impairment and required set up and supervision of one staff for eating. His weight was 100 pounds with no loss in the past 30 days. The care plan dated 1/20/17 for a problem of nutritional concern related to history of weight loss, cognitive impairment, difficulty in chewing/swallowing and refuses weights at times. The stated goal included Resident #10 would maintain weight with no significant weight changes through next review. The interventions included for staff to encourage him to consume all fluids during meals, provide diet as ordered, supervise and cue or assist as needed with meals. Review of the diet order dated 1/20/16 indicated the diet was a regular/liberalized diet, dysphagia puree texture, thickened liquids of nectar consistency. Review of the dietician note of 2/22/17 revealed she added double portions to the diet order and also nectar thick milk with meals in order to increase caloric intake. Observation of Resident #7's tray on 3/10/17 at 9:20 AM revealed he had orange juice to drink and no milk. Interview with nursing assistant #6 on 3/10/17 at 9:36 AM revealed he delivered the tray, but did not set up the tray with the drinks. NA #6 stated the nursing assistants worked together to set up trays, and one of the other aides set up the drinks. Nursing assistant #6 explained there was thickened orange juice on the tray, but there was no milk. Interview with nursing assistant #7 on 3/10/17 at 9:42 AM revealed she followed the tray ticket to add the drinks to the tray. The tray ticket was reviewed with the nursing assistant #7 and she explained the thickened milk on the right side of the tray ticket let them know he would receive thickened milk when provided. This nursing assistant further explained, she would know if he was to have something at each meal, by the middle section of the tray ticket. If Resident #10 was to have milk at each meal, it would be in the middle section and say at each meal. Interview with the Dietary Manager on 3/10/17 at 9:53 AM revealed the drinks that should be provided at each meal are under the notes on the right side of the tray ticket. The nectar thick milk should be provided at each meal. The other section (middle section) was for dislikes. He was not aware the nursing assistants did not know how to read the tray ticket correctly.

Based on facility staff interviews, dermatology office staff and Medical Director interviews, and record reviews, the facility failed to evaluate and effectively treat a resident's itching skin condition due to a delay in the scheduling of a dermatology consultation (a specialty branch of medicine that deals with the [DIAGNOSES REDACTED].#2) reviewed for the provision of care to maintain well-being. This resulted in delayed treatment and prolonged discomfort for the resident. The findings included: Resident #2 was admitted to the facility on [DATE] from the community. His cumulative [DIAGNOSES REDACTED]. A review of Resident #2 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #2 was independent for transfers, walking in his room and corridor, locomotion off the unit, and eating. He required supervision for all of his other Activities of Daily Living (ADLs). On 10/2/16, a Change in Condition-Skin form indicated Resident #2 had a rash/dermatological disorder. Notes indicated he had a skin rash to his entire back, with redness and raised areas. A Nursing Communication form dated 10/2/16 also noted the problem was observed, reporting the resident ' s entire back and surrounding skin areas were reddened and had some sort of rash or break out. The form indicated Resident #2 complained of itching. He was given 25 milligrams (mg) of [MEDICATION NAME][MEDICATION NAME] (an [MEDICATION NAME]) with relief of itching. However, the rash remained. A handwritten note on the Nursing Communication form dated 10/5/16 read, (name of Medical Doctor or MD) Assessed 10/3/16. Further review of the resident ' s medical record revealed a Physician order [REDACTED]. An order was also written for 100 mg [MEDICATION NAME] (an antibiotic) to be given by mouth twice daily for 14 days due to a rash. Resident #2 ' s medical record included additional Change in Condition-Skin Follow-up forms dated 10/4/16 and 10/5/16. The rash continued to be present. A Physician order [REDACTED]. The resident ' s medical record included an additional Change in Condition Follow-up form completed on 10/6/16. The rash was reported to be present at the time of the assessment. A Skin Check form was completed on 10/17/16. The rash was reported to be present at the time of this skin check. On 10/17/16, a Nurse Practitioner (NP) progress note revealed the resident was seen for the evaluation of a rash which had been a problem for the past 2 weeks. The resident was reported to describe the rash as moderately pruritic (itchy). The resident ' s history was negative for the addition of a new medication or use of a new detergent (which indicated these were not likely causes for the rash). The NP notes reported the resident had [MEDICAL CONDITION] with a red raised diffuse rash on his back. The plan of care included the use of [MEDICATION NAME] cream to be applied to the affected areas twice daily; and, a request for a dermatology consult. A review of Resident #2 ' s medical record revealed a Physician order [REDACTED]. The Physician order [REDACTED]. Nurse #2 ' s signature on the order form indicated she was the nurse who received the Physician order [REDACTED]. The resident ' s medical record revealed a Skin Check form was completed on 10/24/16. No skin injuries/wounds were noted. The presence of a rash was not reported on the skin check. On 10/28/16, Resident #2 was seen again by the NP. The NP noted, .He presents with [MEDICAL CONDITION] .I am seeing this patient for a sick visit at the request of the patient. Notations from the visit also included the following: .He is complaining of itching to his back. The patient has diffuse [MEDICAL CONDITION] to his back, [MEDICATION NAME] cream has provided some relief of the itching, but symptoms still persist. (Resident #2) has an appointment scheduled with dermatology . New orders included 40 mg [MEDICATION NAME] for 10 days for a primary [DIAGNOSES REDACTED]. A review of the resident ' s medical record included a Nursing Note dated 10/31/16 at 5:52 AM. The note indicated a skin check was performed. A description of the rash reported: Back rash for entire back and near shoulders and upper arm area. Treatment in place. Dermatologist consult. Resident #2 ' s medical record included a Skin Check form completed on 11/14/16. The presence of a rash previously reported was noted on this skin check. A review of another Skin Check form dated 11/21/16 revealed the form was blank; no information was provided on the form. Resident #2 ' s medical record included documentation of the dermatology consultation visit on 12/6/16. Information on the visit report noted the resident ' s symptoms as itch with moderate severity. A Report of Consultation with Dermatologist dated 12/6/16 was also reviewed. The report indicated Resident #2 had a very itchy rash all over. The rash was noted as widespread, with burrows in between fingers and on his trunk. Testing indicated live mites and eggs were present, and the dermatologist noted the resident had Crusted Scabies. Three medications were initiated and included: 3 mg Ivermectin (a medication used to treat parasitic infestations) to be given as 6 tablets by mouth at once on days 1, 2, 8, and 9; 5% [MEDICATION NAME] (a topical anti-parasitic medication) with instructions to apply the topical cream to the entire body (neck down) on days 1 and 8; and, 0.1% [MEDICATION NAME] cream (a topical steroidal cream) with instructions to apply the cream topically twice daily to the affected areas as needed for itching. Further review of the resident ' s medical record included a Nursing Note dated 12/7/16 at 11:06 PM. The nursing note indicated Resident #2 ' s rash was on his back/bilateral arms with increased itchy skin; now being treated by dermatology. Resident #2 ' s medical record included nursing notes dated 12/9/16 and 12/10/16 which reported the status of the resident ' s condition as improved. A nursing note dated 12/10/16 at 1:41 AM revealed the resident had no complaints of itching. A telephone interview was conducted on 3/8/17 at 2:22 PM with a staff member of the Dermatology office where Resident #2 had been seen for treatment on 12/6/16. The Dermatology office confirmed the resident was seen for an appointment once on 12/6/16. The records at their office revealed this appointment was arranged by the facility on 11/17/16 and scheduled for 12/6/16 at that time. An interview was conducted on 3/9/17 at 12:28 PM with Nurse #2. During the interview, Nurse #2 confirmed she had verified the order for the dermatology consult written on 10/17/17. Upon inquiry, Nurse #2 reported that after verifying the order, she would have called the scheduler for the facility and informed her of the need to arrange the dermatology consult. An interview was conducted on 3/9/17 at 12:55 PM with the facility ' s Unit Secretary. The Unit Secretary reported she was the scheduler for outside appointments and consultations. Upon inquiry, she reported that she was notified of requests for outside consults from the physician, the hall nurse, or upon receipt of a copy of the computer Order Entry or physician order. A follow-up interview was conducted on 3/9/17 at 3:00 PM with the Unit Secretary. During the interview, the Unit Secretary stated she confirmed with the dermatology office that the appointment made for Resident #2 on 12/6/16 was arranged on 11/17/16. The Unit Secretary reported she thought a communication issue was likely the cause of the delay between when the order was written for a dermatology consult on 10/17/16 until the appointment was arranged on 11/17/16. A telephone interview was conducted on 3/10/17 at 3:10 PM with the facility ' s Medical Director. During the interview, concerns were discussed regarding the one month delay between when the order for a dermatology consult was written and when the appointment was arranged for Resident #2. When asked what the Medical Director ' s thoughts were about this delay, he stated, We write the order, we expect it to be carried out. An interview was conducted on 3/10/17 at 3:30 PM with the facility ' s Director of Nursing (DON). During the interview, concerns were discussed in regards to the delay in arranging a dermatology consult for Resident #2. Upon inquiry, the DON stated her expectation would be for the consultation order to be given to the Unit Secretary when it ' s ordered, and for the Unit Secretary to arrange the appointment either the day the order was written or the next business day.

Based on observations, record reviews, resident and staff interviews the facility failed to provide diet interventions for weight loss prevention for 1 of 6 sampled residents (Residents # 9) when house supplements were not provided and failed to review the interventions and make changes in the interventions for 1 of 6 residents (Resident #9) when she refused the supplement and continued to have unintended weight loss. The facility failed to provide diet interventions of supplements to assist in maintaining their weight for 2 of 6 sampled residents (Residents #7 and 10). The findings included: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Nutritional Assessment dated 1/25/17 indicated Resident #9 weighed 85.2pounds on admission, and her Body Mass Index (BMI) was 18.1. The prescribed diet was regular/liberalized with a dysphagia puree texture. The Nutrition History included in part, the puree diet was due to holding food in her mouth, her intake was fair, she was able to feed herself with set up assistance, was on weekly weights and had an adjusted BMI due to the left AKA. This assessment indicated Resident #9 had increased protein needs required for wound healing due to open area on top of the left thigh, right lower surgical incision and left AKA surgical incision. The interventions included to provide meals and snacks as ordered, staff to encourage good intake with a goal to promote wound healing and maintain weight with no significant changes through next review. Review of the physician orders [REDACTED]. A nutrition progress note dated 2/28/17 indicated a wound review was made of an unstageable right heel pressure ulcer. Resident #9 had an oral intake that improved and she was eating 50-100% of meals. Resident #9 was also receiving supplementation: house shake TID (three times a day) which provides additional 600 kilocalories and 18 grams protein. Currently meeting/exceeding calorie/protein needs in order to promote wound healing . The Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #9 had long and short memory problems, required meal set up and was independent with eating. The resident ' s weight was 85 pounds and no weight loss had occurred. Review of the care plan dated 2/1/17 included a problem of nutritional concern related to her diagnoses, and a BMI that was less than 19. This is an indicator for nutritional risk for malnutrition. The stated goal indicated the resident would consume of at least 75% of most meals, increase protein intake with current diet order and she would maintain a stabilized weight with no significant changes through next review. The interventions were as follows: evaluate for proper consistency of diet, offer/encourage fluids of choice, weight per policy and alert dietitian and physician to any significant loss or gain, monitor for changes in nutritional status (changes in intake, unplanned weight loss/gain) and report to food and nutrition/physician as indicated, provide diet as ordered, house supplement as ordered and offer alternate food choices if less than 50% consumed at mealtime. Review of the weight for 2/1/17 was 83.6 pounds. Review of a physician order [REDACTED]. Add lean meat, eggs, yogurt, beans, low fat dairy or protein shakes. A nutrition progress note dated 2/28/17 indicated a wound review was made of an unstageable right heel pressure ulcer. Resident #9 had an oral intake that improved and she was eating 50-100% of meals. Resident #9 was also receiving supplementation: house shake TID (three times a day) which provides additional 600 kilocalories and 18 grams protein. Currently meeting/exceeding calorie/protein needs in order to promote wound healing . Interview with the DON on 3/10/17 at 2:00 PM revealed Resident #9 may have had weight loss from a cast that was removed from her arm. A date of 2/13/17 was provided for the removal of the cast. Review of the 30 day MDS dated [DATE] indicated Resident #9 had improvements in her cognition with no long or short term memory problems. Review of the Medication Administration Record [REDACTED]. The documented intake varied from 25% to 100% of the house supplement. Review of the meal intake for the month of February revealed breakfast and lunch was 50% consumed with 14 days not documented, and supper intake was from 25% to 100%. Review of the weight for 2/20/17 (after the cast was removed) was 85.8 pounds (no documented method for weighing). This indicated Resident #9 had a gain of 0.2 pounds after the cast was removed. The next weight was obtained on 3/3/17 with a weight of 77.8 pounds (use of a wheelchair for weighing). The weight loss for one month was 9.3%. Review of the March Medication Administration Record [REDACTED]. Observations upon entry on 3/8/17 at 5:15 AM revealed a tray of supplements for residents was sitting on the conference room table. The supplements included Resident #9 for the dates of 3/5/17 and 3/6/17.There were two cartons dated 3/5/17 and three cartons for 3/6/17. The Director of Nursing was observed removing the tray and taking it to the kitchen on 3/8/17 at 5:44 AM. Review of Resident #9 ' s Kardex information dated 3/8/17 included the aides were to provide diet and house supplements as ordered. Observations on 3/9/17 revealed dietary delivered the Snacks/supplements to the floor at 9:47 AM. The supplements were placed in a refrigerator in the nourishment room. Interview with Resident #9 on 3/9/17 at 9:54 AM revealed she didn ' t like eggs and had refused them. The tray ticket indicated the eggs were a double portion provided for protein. Further interview revealed she didn ' t like the house supplement and indicated she did not like the vanilla flavored supplement. During the interview, Resident #9 explained she had not been asked if she would prefer a different flavor. If she could have something different, she would like strawberry. The tray ticket included dislikes of cottage cheese and yogurt, likes of bacon and scrambled egg, and she was to have double protein. Observations during interview with Resident #2 ' s breakfast tray revealed she ate dry cereal with milk and bacon. Interview with Nursing Assistant #4 on 3/9/17 at 9:55 AM revealed Resident #9 had refused the eggs and asked him to remove them. A substitute was not offered in exchange for the double portion eggs for protein. Interview with Nurse #4 on 3/9/17 at 12:00 PM revealed she worked on 3/6/17 day shift. The documentation of the supplement would have been from the aides report to her. When explained the supplements were found on 3/8/17 at 5::30 AM in the conference room, on a tray, unopened, she replied in the conference room. No explanation could be provided as to why the supplements had not been provided. Interview with Nursing Assistant #4 on 3/9/17 at 1:04 PM revealed he had passed out the supplements to the residents ' rooms that morning. For Resident #9, he attempted to offer the supplement, but she refused. He had not informed the nurse or documented the refusal. Review of the MAR for Resident #9 revealed the house supplement was recorded as 100% at 10:00 AM by Nurse #4. Interview with the dietician on 3/9/17 at 3:09 PM revealed the process for obtaining weekly weights included the unit manager providing a list on Mondays for the nursing assistants. The aide assigned to that resident would obtain the weight. The unit nurse manager would document the weights in the computer and would let her know about the weights. For new admissions, the weights were obtained weekly for four weeks. If significant weight loss was noted, the weights would continue to be obtained weekly for four more weeks. The re- weights would be obtained if there was a (+ or –) 5 pound difference from the previous weight. The person responsible for reviewing the weights and requesting a re-weight would be the unit nurse manager. The unit nurse managers were responsible for monitoring the weight changes. The dietician further explained information about weight changes would not come to her on a weekly basis. She would review month to month of any changes in weights. She had not reviewed March ' s weights yet. If there was a significant weight loss, the unit manager would let her know. The dietician was asked if a resident refused the supplements or meals, would she be made aware. She explained the aides and nurses would tell her and they were good about letting her know the residents ' likes and dislikes. The communication was verbal and not documented. Further interview revealed she would review the nurses ' documentation on the MAR indicated [REDACTED]. Interview with Resident #9 on 3/9/17 at 9:54 AM revealed she didn ' t like eggs and had refused them. The tray ticket indicated the eggs were a double portion provided for protein. Further interview revealed she didn ' t like the house supplement and indicated she did not like the vanilla flavored supplement. During the interview, Resident #9 explained she had not been asked if she would prefer a different flavor. If she could have something different, she would like strawberry. Interview on 3/9/17 at 4:01 pm with Nurse #5 (unit manager) revealed the nursing assistants were responsible for obtaining the weights on the residents they were assigned to for that day. The weight obtained on 3/3/17 was taken on a Friday. The re-weight was taken on 3/4/17 a Saturday. She worked on Monday, but as a floor nurse and had not reviewed the weights. A re-weigh would have been done on Tuesday if she had been working. Those (re-weights) were done if the weight change was plus or minus 5 pounds from the previous weight. For Resident #9, the nurse manager explained she thought the 3/4/17 weight was incorrect. Further explanation provided indicated she thought the nursing assistant had not subtracted the weight of the wheelchair after weighing the resident. The problems with Resident #9 ' s weights had not been discussed with the dietician. Interview with Nurse #5 on 3/9/17 at 4:05 PM revealed the house supplements were passed by the nursing assistants. The nurse would document the percentage that had been consumed from a verbal report from the nursing assistant. If a resident did not like the supplement, that should be reported to the dietician or unit manager. Further interview revealed she had not been informed Resident #9 did not like the supplement and/or refused it. Nurse #5 further explained Either the aides are not telling or the nurses are not asking. Interview on 3/9/17 at 4:30 PM with the Director of Nursing (DON) revealed weights would be reviewed in the daily stand up meeting. The DON was not aware of Resident #9 ' s weight changes on 3/3/17 and again on 3/4/17 with a recorded weight of 114.8 pounds. Interview with the DON revealed a re-weight should have been done and she checked the re-weight sheet for the re-weights. An explanation provided indicated if the unit manager was not available, either she or the Assistant Director of Nursing would review the weights and requested a re-weight. The re-weight would have been done on Monday 3/6/17. Reviewing the re-weight sheet with the DON revealed a weight was not obtained on 3/6/17. The DON requested a re-weight to be obtained for Resident #9 on 3/9/17. Interview with the DON on 3/9/17 at 4:49 PM revealed Resident #9 was just re- weighed at 4:45 PM on 3/9/17 and was 78.4 pounds. This weight indicated Resident #9 had experienced a 7.7% weight loss from 2/20/17 to 3/10/17. Further interview revealed the residents were not weighed by the same person, the same way and errors had occurred. Her expectation of nursing to provide supplements would be for the staff to provide them to the resident, and the nurse would document the percentage after it had been consumed. The DON did not know why the tray of supplements had been in the conference room or why they were not given to the residents. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s weight on admission was 108 pounds. Review of the care plan dated 11/28/16 included problems of requiring assistance/dependent for activities of daily living. The interventions for the problem included to provide the resident with one person extensive assistance for eating. The care plan identified a problem for nutritional risk related to his diseases and a pressure ulcer. The stated goals indicated Resident #7 would maintain a stabilized weight with no significant changes and consume at least 75% of most meals daily through next review. The interventions which included diet as ordered, a dysphagia pureed with nectar-like liquids, house supplement as ordered, weigh per policy and alert dietitian and physician to any significant loss or gain, monitor for changes in nutritional status, changes in intake, ability to feed self, unplanned weight loss/gain, or abnormal labs and report to nutrition/physician as indicated. Review of the physician orders [REDACTED].>Review of a Nutrition Assessment dated 12/12/16 indicated Resident5 #7 ' s weight was 109.6 pounds on 12/6/16, his Body Mass Index (BMI was 16.2). Resident #7 ' s diet type was Regular Liberalized, with a texture of dysphagia puree and nectar liquids. A house supplement was provided three times a day. The assessment was completed due to a significant change assessment secondary to receiving hospice/comfort care on 12/2/16. Resident #7 was assessed with [REDACTED]. He continued to be dependent on staff for feeding assistance with meals and ate in his room. The house shake provided additional 600 kilocalories (kcal) and 18 grams of protein daily. The resident should be able to meet daily nutritional requirements based on current intake and supplementation. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 had short and long term memory impairment, required extensive assistance of one person for eating and he was receiving hospice services. The MDS assessed his weight as 110 pounds with no significant weight change. Review of the subsequent monthly weights revealed the following: 12/28/16 105 pounds, 1/3/17 106 pounds, 2/17/17 99.2 pounds, 3/4/17 118.8 pounds and 3/9/17 99 pounds. A nutrition progress note dated 2/28/17 revealed the resident was seen due to significant weight loss in 30 days and monthly wound care review. His wound was a stage 2 sacral pressure ulcer. He continued to have good intake of 50 to 100%. House shake three times a day provided additional 600 kcal and 18 grams of protein. The dietician did not place him on weekly weights due to receiving hospice comfort care. Review of a nurse ' s note dated 3/6/17 at 12:55 by nurse #5 revealed . no refusals. House Supplement three times a day for BMI <19. Review of the March Medication Administration Record [REDACTED]. The supplement was documented as 100% for 3/9/17. Observations upon entry on 3/8/17 at 5:15 AM revealed a tray of supplements for residents was sitting on the conference room table. The supplements were warm to touch included Resident #7 for the dates of 3/5/17 and 3/6/17.There were two cartons dated 3/5/17 and three cartons for 3/6/17. The Director of Nursing was observed removing the tray and taking it to the unclean side of the kitchen on 3/8/17 at 5:44 AM. Observation of the supplement for Resident #7 on 3/9/17 at 11:30 AM revealed the shake was in the trash with the name of the resident and the date of 3/9/17 and snack 1 (10:00 AM snack). The carton was half full. Interview on 3/9/17 at 11:45 AM with nurse #5 revealed she did not give the supplement to Resident #7. The nursing assistant #6 gave it to the resident. She further explained, to document 100% consumed the carton would have been completely empty. She explained the carton for 10:00 AM was not empty and would not be 100%. The nursing assistants would inform her of the percentage after giving it to the resident. She could not remember who told her 100%. Interview with the nursing assistant #6 on 3/9/17 at 11:50 AM revealed she had not given the supplement to the resident. It must have been the hospice aide/nurse. Interview with nurse #5 on 3/9/17 at 12:00 PM revealed she worked on 3/5/17 and 3/6/17 day shift. The documentation of the supplement would have been from the nursing assistants report to her. The resident does not always drink the supplement, it varies. When explained the supplements were found on 3/8/17 at 5::30 AM in the conference room, on a tray, unopened, she replied in the conference room. No explanation could be provided as to why the supplements had not been provided and her documentation had a percentage of an amount consumed for those dates. Interview with the dietician on 3/9/17 at 3:40 PM revealed he received shakes three times a day to provide the additional calories and protein. She did the goal and care plan for Resident #7 ' s nutritional needs. The goal for this resident would not usually be achievable, normally she would put normal weight loss to be expected. When he first came in the facility, he was eating 100% of meals, and the family had him on hospice for a very long time prior to admission to this facility. There had not been communication to her over the past week of any change in his intake or condition. Interview with the DON on 3/9/17 at 4:49 PM revealed Resident #7 was just re- weighed at 4:45 PM on 3/9/17 and was 99 pounds. Further interview revealed the residents were not weighed by the same person, the same way and errors had occurred. The weight of 118 pounds on 3/4/17 was not accurate. Her expectation of nursing to provide supplements would be for the staff to provide them to the resident, and the nurse would document the percentage after it had been consumed. Nurse #5 should have documented the actual percentage, and not what she thought the resident would consume. The DON did not know why the tray of supplements had been in the conference room or why they were not given to the residents. 3. Resident # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 had short and long term memory impairment and required set up and supervision of one staff for eating. His weight was 100 pounds with no loss in the past 30 days. The care plan dated 1/20/17 for a problem of nutritional concern related to history of weight loss, cognitive impairment, difficulty in chewing/swallowing and refuses weights at times. The stated goal included Resident #10 would maintain weight with no significant weight changes through next review. The interventions included for staff to encourage him to consume all fluids during meals, provide diet as ordered, supervise and cue or assist as needed with meals. Review of the diet order dated 1/20/16 indicated the diet was a regular/liberalized diet, dysphagia puree texture, thickened liquids of nectar consistency. Review of the dietician note of 2/22/17 revealed she added double portions to the diet order and also nectar thick milk with meals in order to increase caloric intake. Observations of Resident #7 ' s tray on 3/10/17 at 9:20 AM revealed he had orange juice to drink and no milk. Interview with nursing assistant #6 on 3/10/17 at 9:36 AM revealed he delivered the tray, but did not set up the tray with the drinks. The nursing assistants work together to set up trays, and one of the other aides set up the drinks. Nursing assistant #6 explained there was thickened orange juice on the tray, but there was no milk. Interview with nursing assistant #7 on 3/10/17 at 9:42 AM revealed she and nursing assistant #8 usually work on Resident #10 ' s hall. They follow the tray ticket, ask residents before breakfast what they want to drink and give them a choice. Resident #10 receives thickened liquids and would have milk at lunch. She further explained milk was his favorite (beverage). The tray ticket was reviewed with the nursing assistant #7 and she explained the thickened milk on the right side of the tray ticket lets them know he would receive thickened milk when provided. He can have milk at breakfast if he wants it. This nursing assistant further explained, she would know if he was to have something at each meal, by the middle section of the tray ticket. If Resident #10 was to have milk at each meal, it would be in the middle section and say at each meal. Interview with the Dietary Manager on 3/10/17 at 9:53 AM revealed the drinks that should be provided at each meal are under the notes on the right side of the tray ticket. The nectar thick milk should be provided at each meal. The other section (middle section) was for dislikes. He was not aware the nursing assistants did not know how to read the tray ticket correctly.