Every finding on record at Mill Creek Center for Nursing and Rehabilitation

Based on observations and staff interviews, the facility failed to maintain a clean and homelike environment in 3 of 36 resident rooms on 1 of 2 halls reviewed for a safe, comfortable, and homelike environment (Resident #2, Resident #5, Resident #22, Resident #24, Resident #40, and Resident #41). The findings included: a. An observation of Resident #41/Resident #22's room on 5/26/26 at 10:48 AM revealed all corners and baseboards of the bathroom had a heavy buildup of dirt, hair, food particles, and raised brown matter. A dark brown stain around the entire toilet base was observed; the seal around the toilet base was absent. Red and brown matter were seen on the wall above the commode grab bar. During the same observation, heavy buildup of dust, hair, and paper particles were noted in all corners of the room. A small round metal item and yellow particles were observed on the floor under the window. Three graham crackers were seen on the floor along the wall next the Bed A. The room was occupied but the residents were unable to be interviewed. b. An observation of Resident #40/Resident #5's room on 5/26/26 at 11:02 AM revealed a heavy layer of dirt, hair, and dust on the baseboard to the right side of Bed A. Brown, raised matter was observed on the wall just above the baseboard. There was a thick layer of dust on the top and bottom surfaces of the baseboard throughout the room. A raised, sticky debris was noted under the bed. A large amount of white matter in a splatter pattern was observed on the back of the room door. Behind the entry door there was heavy hair, dirt buildup that extended along all the baseboards, particularly in all corners. Yellow debris was noted on the floor under the window. Under the air conditioning unit, a large amount of dirt and brown and white particles were seen. During the same observation, in the bathroom a heavy buildup of hair and dirt was observed in all corners. A raised yellow and brown residue was present along the baseboard under the sink extending behind the toilet and surrounding the toilet base. Raised red and brown matter was noted on the wall above the towel rack and on the glove box mounted on the wall. The room was occupied but the residents were unable to be interviewed. c. An observation of Resident #24/Resident #2's room on 5/26/26 at 11:15 AM revealed a heavy layer of dirt and dust behind along the baseboards and corners throughout the room. An area of raised red matter was noted along the baseboard behind Bed B. The wardrobe for Resident #2 was observed to have heavy hair, dust, and paper particles built up along the entire base. An approximately 2-foot section of the baseboard was missing to the left of the window, exposing an open area packed with dust, hair, food, and paper particles. To the right of the window an approximately 2-foot section of baseboard was pulled away from the wall; raised debris was observed above this area. Food particles and heavy dust build up were observed in 5 of 10 louvered vents and around the controls of the air conditioning unit. During the same observation, in the bathroom, heavy buildup of dirt, hair, and dark brown debris were observed under the sink and behind the toilet. All corners of the bathroom had heavy, raised dirt and hair buildup. The residents occupying the room were unable to be interviewed. An interview was conducted with Housekeeper #1 on 5/26/26 at 3:43 PM. She stated that her shift was 8:00 AM to 4:00 PM, five days a week with a permanent assignment on the 200 hallway. She shared she had been assigned to the 200 hallway on 5/26/26. She explained her daily responsibilities for each room included pulling trash from rooms and replacing the liner, cleaning the bathroom floor, sink, toilet, and mirror, dusting blinds, wiping down light switches, bed frames, and grab bars, and cleaning the floors in the room. She stated that floor cleaning included sweeping and mopping under the beds, pulling out and cleaning behind dressers and under the window units. Housekeeper #1 stated a deep cleaning of each room was scheduled on a monthly basis and her supervisor did audits following the deep cleaning. She confirmed the daily cleaning in Resident #2, Resident #5, Resident #22, Resident #24, Resident #40 and Resident #41's rooms had been completed on 5/26/26. An observation of the rooms of Resident #41/Resident #22, Resident #40/Resident #5 and Resident #24/Resident #2's rooms was conducted with Housekeeper #1 at 3:50 PM. Issues observed in the morning were still present. The Housekeeper stated she does the best she can, but she lacks a proper mop to remove debris buildup. She shared she had told her supervisor this was a concern. The Housekeeper stated she felt the debris in Resident # 40 and Resident # 5's bathroom was firmly in place, but she was able to remove it with a scraping tool from her cart and a rag. An interview and observations of the rooms of Resident #41/Resident #22, Resident #40/Resident #5 and Resident #24/Resident #2's rooms were conducted with the Administrator on 5/27/26 PM at 3:43 PM as the Housekeeping Director was on vacation and unavailable during the survey period. The Administrator stated daily responsibilities for housekeepers included trash removal from each room, cleaning the overbed tables tops and legs, cleaning the bathrooms, wiping the nightstands if needed, sweeping under each bed, and mopping from the window to door. The Administrator shared she did not conduct monthly room inspections but relied on reports from the Housekeeping Director who conducted monthly inspections of every room. She further stated if substandard work was observed, the assigned housekeeper should redo the room. During this observation of Resident #41/Resident #22, Resident #40/Resident #5 and Resident #24/Resident #2's rooms the Administrator stated the cleanliness did not meet the standards of facility. She indicated she was not aware that Resident #2, Resident #5, Resident #22, Resident #24, Resident #40, and Resident #41's rooms were not clean, and it was unacceptable to have dirty resident rooms. The Administrator stated she did not know why the Housekeeping Director was unaware. She further stated if substandard work was observed, the assigned housekeeper should redo the room.

Based on record review and staff interview, the facility failed to provide information to residents regarding the residents' right to accept or refuse medical/surgical treatment when formulating an advanced directive for 4 of 6 sampled residents reviewed for advanced directives (Residents #15, #25, #29, #39). Findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. The most recent Minimum Data Set assessment dated [DATE] indicated Resident #15 was cognitively intact. Review of the physician's order dated 2/4/25 documented Resident #15's Advance Directive status as Full Code. There was no documentation in Resident #15's medical record indicating the resident was provided information about his right to accept or decline medical or surgical treatment prior to making a Advance Directive decision. During an interview on 4/2/25 at 8:40 a.m., the Social Worker acknowledged the facility did not inform or have any documentation indicating Resident #15 had the right to accept or decline medical or surgical treatment. 2. Resident #25 was admitted to the facility on [DATE]. The most recent Minimum Data Set assessment dated [DATE] indicated Resident #25 was severely cognitively impaired. Review of the physician's order dated 2/27/24 documented Resident #25's Advance Directive status as Full Code. There was no documentation in Resident #25's medical record indicating the resident or the resident's responsible party were provided information about the right to accept or decline medical or surgical treatment prior to making an Advance Directive decision. During an interview on 4/2/25 at 8:40 a.m., the Social Worker acknowledged the facility did not inform or have any documentation indicating Resident #25 had the right to accept or decline medical or surgical treatment. 3. Resident #29 was admitted to the facility on [DATE]. The most recent minimum data set assessment dated [DATE] indicated Resident #29 was Review of the physician's order dated 1/23/25 documented Resident #29's Advance Directive status as Full Code. There was no documentation in Resident #29's medical record indicating the resident and the resident's responsible party were provided information about the right to accept or decline medical or surgical treatment prior to making an Advance Directive decision. During an interview on 4/2/25 at 8:40 a.m., the Social Worker acknowledged the facility did not inform or have any documentation indicating Resident #29 had the right to accept or decline medical or surgical treatment. 4. Resident #39 was admitted to the facility on [DATE]. The most recent Minimum Data Set assessment dated [DATE] indicated Resident #39 was severely cognitively impaired. Review of the physician's order dated 12/24/24 documented Resident #39's Advance Directive status as Do Not Resuscitate. There was no documentation in Resident #39's medical record indicating the resident and the resident's responsible party were provided information about the right to accept or decline medical or surgical treatment prior to making an Advance Directive decision. During an interview on 4/2/25 at 8:40 a.m., the Social Worker acknowledged the facility did not inform or have any documentation indicating Resident #39 had the right to accept or decline medical or surgical treatment.

Based on staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Prevnar 20 (pneumococcal conjugate vaccine (PCV20) in accordance with nationally recognized standards for 4 of 5 residents reviewed for pneumococcal immunizations (Resident #16, #10, #15, and #36). Findings include: The Center for Disease Control and the Advisory Committee on Immunization Practices (ACIP), last reviewed on 10/26/24, now recommends routine vaccination against pneumococcal infection for all adults aged [AGE] years or older and 19-64 with certain underlying medical conditions. Beginning June 8, 2021, for persons aged [AGE] years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown, they should receive 1 dose of PCV15 or 1 dose of PCV20. Review of the facility's immunization policy last revised in 2019 stated that all residents would be offered a pneumococcal vaccine upon admission; brand unspecified. A. Record review revealed Resident #16 was admitted to the facility on [DATE] and was over [AGE] years of age at the time of admission. Review of the pneumococcal immunizations, provided by the facility, indicated Resident #16 received a pneumococcal PPSV23 vaccine on 10/28/24. There was no documentation that the resident received a PCV20 vaccine prior to admission or since the last recertification on 11/16/2023. B. Record review revealed Resident #10 was admitted to the facility on [DATE] and was over [AGE] years of age at the time of admission. Review of the pneumococcal immunizations, provided by the facility, indicated Resident #10 declined to receive a pneumococcal PPSV23 vaccine. There was no documentation on the declination form that the resident had specifically been offered a PCV20 vaccine. There was no documentation that the resident received a PCV20 vaccine prior to admission or since the last recertification on 11/16/2023. C. Record review revealed Resident #15 was admitted to the facility on [DATE] and was over the age of 65. Review of the pneumococcal immunizations, provided by the facility, indicated Resident #15 declined to receive a pneumococcal PPSV23 vaccine. There was no documentation on the declination form that the resident had specifically been offered a PCV20 vaccine since the last recertification on 11/16/2023. There was no documentation that the resident received a PCV20 vaccine prior to admission. D. Record review revealed Resident #36 was admitted to the facility on [DATE] and was over [AGE] years of age at the time of admission. Review of the pneumococcal immunizations, provided by the facility, indicated Resident #36 declined to receive a pneumococcal PPSV23 vaccine. There was no documentation on the declination form that the resident had specifically been offered a PCV20 vaccine since the last recertification on 11/16/2023. There was no documentation that the resident received a PCV20 vaccine prior to admission. During an interview with the Staff Development Coordinator/Infection Preventionist (IP) on 4/4/2025 at 10:05 AM, she stated that the facility offers PPSV23 (Pneumovax 23) to all residents. The IP stated that, as far as she was aware of, the facility had never offered the Prevnar 20 vaccine. The IP reported she was not aware of the regulation that stated the facility should follow the ACIP recommendations. During an interview with the Director of Nursing on 4/4/2025 at 3:00 PM, she reported the facility offered the pneumococcal PPSV23 vaccine to all residents upon admission and she was unaware that the facility also needed to offer the Prevnar 20 vaccine.

Based on observations, record reviews, and resident and staff interviews, the facility failed to respect a resident's right to dignity when Resident #212 requested incontinence care and it was not provided until after all the meals trays were passed on the hall for 1 of 1 resident reviewed for dignity (Resident #212). The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses including bowel and bladder incontinence due to impaired mobility, and osteomyelitis. Resident #212's self-care deficit care plan dated 3/13/25 indicated staff were to aid with bowel and bladder incontinence related to immobility. The admission Minimum Data Set (MDS) dated [DATE] specified that Resident #212 was cognitively intact and dependent on toileting, dressing, bathing, transfers, and mobility care. The MDS also determined that the Resident required a mechanical lift for transfers. There were no indications of behaviors exhibited. The MDS indicated Resident #212 was frequently incontinent of bowel and bladder. An observation was conducted in conjunction with an interview with Resident 212 on 4/1/25 at 8:30 AM. When approaching Resident 212's room a strong odor of feces was noted. Upon entrance to Resident 212's room it was discovered the odor was coming from Resident #212's room. Resident #212 was interviewed, he stated he needed to be changed and had been waiting since before light (outside). The Resident stated they brought him his breakfast tray, but he had them remove it because he could not eat in that mess. Nurse Aide (NA) #1 was notified of Resident #212's request for incontinence care. An observation of incontinence care and an interview occurred with NA #1 and NA #2 on 4/01/25 at 8:40 AM. NA #1 stated they found him like that every time they work, and the 11:00 PM to 7:00 AM shift always leaves him (Resident #212) for us to clean up. When the NAs were asked why they didn't round on the resident earlier in their shift, they stated they were not supposed to do patient care while the trays were out. NA #1 further indicated the residents should be cleaned up by the 11:00 PM to 7:00 AM shift and ready for breakfast. NA #1 also stated the trays came out right after they arrived at 7:00 AM, and Resident #212 always needed cleaning up first thing in the morning, but they could not do patient care while the trays were being passed. On 4/01/25 at 9:06 AM, a follow-up interview with Resident #212 revealed that he turned his call light on and had asked the third shift (11:00 PM to 7:00 AM) aide, NA #5, to clean him up. He said NA #5 answered his light, turned it off, said she would return to provide incontinence care, left the room, and did not return. Resident #212 stated this treatment had been going on since his admission. He further said it was still dark outside when he rang for NA #5 but could not recall the exact time. Resident #212 noted the next shift (7:00 AM to 3:00 PM) NA came into his room around 7:00 AM with his breakfast tray, but did not provide care; it was light outside by this time. The resident recalled that NA #1 came in with his breakfast tray and told him she would clean him up after all the trays were passed. Resident #212 stated that he felt disgusted about sitting in this mess and being expected to eat breakfast like that. He asked NA #1 to put the tray back on the cart until he was cleaned up. The tray was removed by NA #1 and placed back on the cart until he was cleaned up. The resident further stated he was left in his soiled brief until after the breakfast trays were passed. He said, I can do bad at home by myself. Attempts were made to interview NA #5 by phone, but she did not return calls. An interview on 4/02/25 at 10:00 AM with Nurse # 4 (Unit Manager) revealed that the 11:00 PM to 7:00 AM shift should have the residents clean and dry for breakfast because the trays came out around 7:00 AM. An interview with the Director of Nursing (DON) on 4/04/25 at 9:45 AM revealed the staff should ensure the residents are clean and dry before breakfast on the first shift. She stated it was unacceptable for the residents to lie in soiled briefs while being expected to eat. She further noted that if a resident needed incontinence care, the staff should leave their tray on the cart and give incontinence care so they will be clean for the meal. The DON indicated the staff should treat the residents with dignity and not allow them to feel sad or like the staff did not care about them.

Based on record review, observations, and resident and staff interviews, the facility failed to assess and document the ability of a resident to self-administer medications for 1 of 2 residents (Resident #38) reviewed for medication self-administration. Findings included: Resident #38 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #38 was cognitively intact. On 4/1/25 at 9:53 am, an observation was made of fluticasone propionate nasal spray (a steroid nasal spray to treat allergic rhinitis) sitting on Resident #38's bedside table. During an interview with Resident #38 on 4/1/25 at 10:35 am he stated that he used the nasal spray a couple times a day when he needed to for his stuffy nose. Resident #38 reported he couldn't remember who gave the nasal spray to him but he had been using it for a month or two. A care plan last revised on 2/18/25 revealed Resident #38 did not have a care plan to address self-administration of medications. A review of physician orders for Resident #38 there was no order for fluticasone propionate nasal spray. During an interview with Nurse #2 on 4/1/25 at 10:40 am, she stated she was assigned to Resident #38 often but had never noticed the nasal spray on his bedside table before. She reported she was unsure if he had been assessed to self-administer any medications. During an interview on 4/1/25 at 11:00 am with the Director of Nursing (DON), she stated Resident #38 had never been assessed for self-administration of any medication. The DON reported if a resident wanted to have medications at their bedside there should be an order and an assessment for self-administration of medications.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure the accessibility of a wheelchair for 1 of 1 resident (Resident #1) reviewed for reasonable accommodations of needs. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: osteomyelitis, cerebral infarction, and diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact; and was totally dependent on staff and a mechanical lift for transfers. During an observation and interview on 3/31/25 at 1:20 p.m., Resident #1 revealed he had not attended the out of room group activities because he had not seen his wheelchair since his return from the hospital (2/18/25). The resident stated that prior to his hospitalization he would use the wheelchair to propel himself to the group activities. An observation of the resident's room and bathroom revealed there was no wheelchair in Resident #1's room or bathroom. On 4/3/25 at 1:50 p.m., Resident#1 was observed awake, lying in his bed. There was no wheelchair in the resident's room or bathroom. An interview was conducted on 4/3/25 at 3:00 p.m. with Nursing Assistant (NA) #8 who stated she had been working at the facility approximately 2 to 3 months during second shift (3:00 PM to 11:00 PM). NA #8 stated Resident #1 had never requested to get out of bed but acknowledged she never asked the resident if he wanted to get out of his bed to his wheelchair. The NA #8 indicated she was not aware there was no wheelchair in the resident's room or bathroom. During an interview on 4/3/25 at 3:05 p.m., NA #9 stated the resident currently required the use of the mechanical lift and two nursing assistants for transfers in and out of bed. Resident #1 did not like the use of the mechanical lift and would refuse to get out of bed. She recalled the resident's wheelchair had not been in his room for approximately three weeks, when the resident's room was deep cleaned. On 4/3/25 at 3:46 p.m., NA #7 stated that she worked every other weekend and whenever needed during second shift. NA#7 stated that she last worked with Resident #1 approximately two months ago. She revealed the resident used to get out of bed and was able to propel himself in his wheelchair. NA #7 indicated Resident #1 never requested to get out of bed since his return from the hospital. NA #7 acknowledged she never asked the resident if he wanted to get out of the bed and was not aware there was not a wheelchair in the resident's room or bathroom. During an interview on 4/4/25 at 10:07 a.m., the Interim Rehabilitation Director stated that on 4/1/25 she attempted to work with Resident #1 for out of bed tolerance for sitting on the side of his bed for activities of daily living and unsupported sitting balance on the side of his bed but the resident refused. The Interim Rehabilitation Director did not recall observing the resident's wheelchair in his room. On 4/4/25 at 10:12 a.m., during a follow-up interview, the Interim Rehabilitation Director stated that after the interview with this Surveyor, she was able to locate Resident#1's bariatric wheelchair on the second floor, in the empty therapy room which was used by the facility as a storage room. She revealed the bariatric wheelchair was labeled with the resident's name. The Interim Rehabilitation Director further stated she went to Resident#1's room and asked if he wanted to get out of his bed to his wheelchair. The resident replied yes, after his meal. She stated she informed the nursing staff.

Based on observation and staff interviews, the facility failed to protect the private health information for 3 of 3 sampled residents by posting confidential medical information in an area accessible to the public (Resident #11, Resident #22, and Resident #158). Findings included: During observations on the 100 and 200 halls on 4/1/25 at 9:51 a.m. and 9:52 a.m., one 8.5 inch x 11-inch white sheet of paper with the updated date of 3/12/25 was posted on the wall with tape located behind and next to 2 of 2 nurses' stations. The signs were documented with Resident #11, Resident #22, and Resident #158's names and medical information concerning the residents' dialysis treatments. The documentation on the signs was in large print, typed and had additional handwritten notes about each dialysis resident. The signs included the residents' names, days of the week each resident was scheduled for dialysis treatment, departure times from the facility, and dialysis procedure times. The posted signs on the walls were visible and readable to residents and visitors from the front of each of the nurses' station countertops. During an interview on 4/1/25 at 10:02 a.m., the Director of Nursing acknowledged and stated residents' medical information was displayed on the signs posted on the wall next to the nurses' stations on the 100 and 200 halls in full view of residents and visitors to the facility. She indicated the signs should not have been posted in areas for anyone other than nursing staff to view due to Health Information Portability and Accountability Act (HIPAA) violations.

Based on observations, and staff interviews, the facility failed to ensure an electrical outlet was securely covered in room [ROOM NUMBER] and failed to ensure resident's clothing was clean and stored neatly in sufficient storage spaces for two residents on the 200 hall. The deficient practice occurred on 1 of 2 halls observed for a clean and homelike environment (200 hall). Findings included: 1. An observation in room [ROOM NUMBER] and interview of Resident #1 was conducted on 3/31/25 at 1:23 p.m. An electrical outlet cover located behind and to the left side of the head of Resident #1's bed was observed partially separated from the wall. There were two electrical cords inserted in the electrical outlet (attached to the bed and the air mattress on the bed) and both attached devices were functioning. The resident revealed he had not been out of his room since his return from the hospital (2/18/25). He indicated he was not aware of the condition of the electrical outlet. During a follow-up observation in room [ROOM NUMBER] on 4/03/25 at 1:50 p.m., the electrical outlet cover located behind and to the left side of the head of Resident #1's bed continued to be partially separated from the wall. On 4/03/25 at 1:50 p.m. during an observation of the electrical outlet cover in room [ROOM NUMBER] and an interview, the Environmental Services Director stated it appeared as if the electrical outlet cover was missing screws and should have been reported by the nursing staff and/or housekeeping staff when observed while cleaning the room An interview was conducted on 4/03/25 at 2:30 p.m. with the facility's Maintenance Director. He revealed none of the facility staff reported the outlet's condition in room [ROOM NUMBER] to the maintenance department. He explained that the facility's protocol for reporting maintenance repair needs was for them to be communicated to him via the Tels Program (an application on the facility's computers as well as the nursing assistants' automatic tasks and service access machine). The Maintenance Director indicated all facility staff were trained to input maintenance work order requests into the program in the computer. During an interview on 4/03/25 at 3:05 p.m., Nursing Assistant (NA) #9 revealed she was aware the outlet next to Resident #1's bed was partially pulled out from the socket and reported this to the staff nurse (no longer worked at the facility) in February 2025. 2.a. During an observation of room [ROOM NUMBER] on 4/01/25 at 10:51 a.m., there was an overflowing large, clear plastic bag of clothes on the floor, beneath the vanity which was visible from the room's open doorway. Resident #29 revealed there were dirty clothes in the plastic bag and she would prefer the dirty clothes to be placed in some sort of container/laundry bag. On 4/03/25 at 1:51 p.m., a follow-up observation of room [ROOM NUMBER] was conducted with the Environmental Services Director. The large clear, plastic bag of clothing remained on the floor beneath the vanity. The Environmental Services Director revealed residents' clothes were washed and dried in the facility's laundry room twice each week (Tuesdays and Saturdays) and whenever needed. He further stated that if the nursing assistants brought residents' dirty clothes to the laundry room, there would not be dirty clothes piled in overflowing bags and stored on the floor beneath the vanity. During a third observation on 4/04/25 at 12:43 p.m. room [ROOM NUMBER] a large, clear, plastic bag of clothing continued on the floor beneath the vanity. b. On 4/3/25 at 1:55 p.m., an observation of room [ROOM NUMBER] from the opened doorway revealed multiple large, clear, plastic bags of clothing on the floor beneath the vanity and piles of clothing scattered on top of the vanity. Resident #15 resided in room [ROOM NUMBER] was in the hospital at the time of the observation. discharged to the hospital prior to the observation. On 4/4/25 at 1:55 p.m., during a follow-up observation of room [ROOM NUMBER] clear, a large plastic bag of clothing continued on the floor beneath the vanity and piles of clothing continued to be on top of the vanity. During an interview on 4/4/25 at 1:25 p.m., Nursing Assistant (NA) #10 revealed the nursing assistants were required to sign up for the shower assistant team which included taking residents' dirty laundry to the laundry room.

Based on record review and staff interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 2 sampled residents (Resident #39) reviewed for hospice services. Findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses which included: dementia and chronic obstructive pulmonary disorder. Resident #39 was admitted to Hospice Services on 2/22/25 with the diagnosis of Alzheimer's disease with late onset. A review of the MDS assessments revealed a Significant Change in Status MDS Assessment was not completed after Resident #39 was admitted to hospice services. During an interview on 4/4/25 at 9:54 a.m., the facility's Administrator revealed the MDS Coordinator was not available. The Administrator acknowledged that a Significant Change MDS should have been completed within fourteen days of Resident #39's admission to Hospice Services.

Based on observations, record review, and resident and staff interviews, the facility failed to provide incontinence care to a resident upon request for 1 of 1 dependent resident reviewed for activities of daily living (ADL) (Resident #212). The findings included: Resident #212 was admitted to the facility on [DATE] with a diagnosis that included osteomyelitis (bone infection) and bowel and bladder incontinence due to impaired mobility. The admission Minimum Data Set, dated dated dated [DATE] specified that Resident # 212 was cognitively intact and dependent for toileting, dressing, bathing, transfers, and mobility care. The MDS also determined that the Resident required a mechanical lift for transfers. There were no indications of behaviors exhibited. The MDS indicated Resident #212 was frequently incontinent of bowel and bladder. Resident #212's self-care deficit care plan dated 3/13/25 indicated staff were to provide assistance with bowel and bladder incontinence related to immobility. An observation was conducted in conjunction with an interview with Resident 212 on 4/1/25 at 8:30 AM. When approaching Resident 212's room a strong odor of feces was noted. Upon entrance to Resident 212's room it was discovered the odor was coming from Resident #212's room. Resident #212 was interviewed, he stated he needed to be changed and had been waiting since before light (outside). Nurse Aide (NA) #1 was notified of Resident #212's request for incontinence care. An observation of incontinence care and an interview occurred with NA #1 and NA #2 on 4/01/25 at 8:40 AM. The Resident had a saturated brief with a large amount of soft stool from the front to the back and upwards. The stool was not dry and was not stuck to Resident #212's skin and the skin in his sacral area was pink and intact. The bottom sheet had stool on it, but it was not observed that the bottom sheet was wet with urine. NA #1 stated that they find him like this every time they work, and that the 11:00 PM to 7:00 AM shift always leaves him for us to clean up. When the NAs were asked why they didn't round on the resident earlier in their shift, they stated they were not supposed to do patient care while the trays were out. NA #1 further indicated that the residents should be cleaned up and ready for breakfast by the 11:00 PM to 7:00 AM shift. She also stated the trays came out right after they got there at 7:00 AM. On 4/01/25 at 9:06 AM, a follow-up interview with Resident #212 revealed that he turned his call light on and had asked the third shift (11:00 PM to 7:00 AM) aide, NA #5, to clean him up. He said NA #5 answered his light, turned it off, said she would return to provide incontinence care, left the room, and did not return. He said that this treatment had been going on since his admission. He further stated it was still dark outside when he rang for NA #5 but could not recall the exact time. The resident noted that the next shift (7:00 AM to 3:00 PM) came in his room but did not change him; instead, they passed out his breakfast tray around 7:00 AM, and it was light outside by this time. The resident said that NA #1 came in and told him she would get him cleaned up as soon as all the trays were passed. The resident stated he was left in his soiled brief until after the breakfast trays were passed. He said, I can do bad at home by myself. NA# 5 was unable to be interviewed and did not return phone calls. An interview with the Director of Nursing (DON) on 04/04/25 at 09:45 AM revealed the staff should ensure the residents were clean and dry before the first shift. She stated that it was unacceptable for the residents to lie in soiled briefs for long periods. The DON further stated she felt the staff members understanding was to pass all trays no matter what and not to stop and clean up a resident who had not had a meal served and needed a brief change.

Based on observations, record review and staff interviews, facility failed to secure a spray cleaner and spray deodorizer inside a housekeeping cart with a working lock for 1 of 2 housekeeping carts (the 2nd floor housekeeping cart) observed for accidents hazards. The findings included: An observation of the housekeeping cart occurred on 3/31/25 at 1:17 PM on the second floor of the facility outside of a resident's room. The side door of the cart was partially ajar. The cart did not have a lock. There were three residents seen nearby the cart. There were no staff members near the cart at the time of observation. During an observation and interview with Housekeeper #1 on 3/31/25 at 1:25 PM, she stated she had a spray cleaner, and a spray deodorizer inside the cart. Houskeeper #1 reported the cart used to have a lock but it broke sometime over the weekend (3/28/25-3/30/25). She explained she reported it to the Environmental Manager but it had not been fixed yet. Housekeeper #1 stated she was aware the cart should have a working lock, but it was the only cart on the floor. Housekeeper #1 stated she was keeping it close to her as she was going from one resident's room to another. Review of the Safety Data Sheet issued 10/26/18 for the spray cleaner read, in part, all components are considered non-hazardous and proprietary in their quantities. The SDS indicated the cleaner could cause eye irritation and to wash any contacted parts of the body after handling with soap and water thoroughly. Review of the Safety Data Sheet issued 3/6/18 for the spray deodorizer revealed it contained propanol (a colorless alcohol) and was flammable. The SDS also indicated it could cause irritation to the eyes, nose, and throat and to wash any contacted parts of the body after handling with soap and water thoroughly. During an interview with the Housekeeping Manager on 3/31/25 at 3:40 PM, he stated he had been at the facility for two weeks. The Housekeeping Manager stated he had been made aware by Housekeeper #1 that the lock had broken off over the weekend but he had not had a chance to let maintenance know yet. During an interview with the Administrator on 4/4/25 at 4:10 PM, she verbalized the importance of having a working lock on all housekeeping carts due to the cleaning chemicals stored inside.

Based on observations, record review, and resident and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen (O2) was in use and to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #6). The findings included: Resident #6 was admitted to the facility 7/15/24 with diagnoses including chronic lung disease and hypertension. Resident #6's care plan last revised on 1/18/25 addressed potential for breathing issues related to his lung disease and specified to administer oxygen at 3 liters per minute by nasal canula. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact and used oxygen therapy. Review of Resident #6's physician orders showed there was no active order for continuous oxygen therapy. Observation of Resident #6 in his room on 4/1/25 at 9:45 AM revealed he had an oxygen concentrator by his bedside delivering 3 liters of continuous oxygen via nasal canula. There was no cautionary signage outside of Resident #6's room indicating there was oxygen in use inside. During an interview with Resident #6 on 4/1/25 at 9:45 AM, he stated that he had been on oxygen continuously for a while. He reported he had seen his lung specialist last week with no changes. Resident #6 reported that he saw a specialist outside of the facility who takes care of his oxygen needs. During an interview with Nurse #2 on 4/1/25 at 10:55 AM she stated Resident #6 moved to a new room the day before (3/31/25) and the oxygen in use sign was inadvertently not moved with him. During an interview with the Director of Nursing (DON) on 4/4/25 at 2:35 PM, she stated that she was unaware Resident #6 did not have an active order for oxygen use. She stated he previously had one for as needed use but that was discontinued at the end of last year. The DON reported Resident #6 should have had a physician order entered into the facility system for continuous oxygen and that would also include instructions for the flowrate. The DON explained that initiating continuous oxygen therapy based on orders from an outside physician was appropriate, but the facility physician also needed to be notified to write an order. The DON also explained that there should be a cautionary sign on the outside of each resident's room who was on oxygen indicating there was oxygen in use.

Based on record review and staff interviews, the facility failed to maintain ongoing communication with the dialysis treatment center for 2 of 3 residents reviewed for dialysis (Resident #22 and Resident #11). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter wastes and water from the blood). Resident #22 had an active physician order dated 8/21/23 for dialysis on Monday, Wednesday, and Friday. Review of Resident #22's care plan last reviewed 1/13/25 revealed the need for dialysis related to renal failure with an intervention to communicate with the dialysis center by the dialysis communication form. Review of Resident #22's electronic medical record showed completed dialysis communication forms last scanned into her chart on 11/20/24. Review of Resident #22's dialysis communication forms, located in medical records dated 11/13/24 through 3/28/25 revealed the facility was only able to locate 23 dialysis communications forms. Of the 23 forms located, 5 were incomplete with no documentation by the dialysis facility. There were no communication forms located for the month of December 2024. During an interview with Nurse #3 on 4/3/25 at 1:30 PM, she stated that she fills out the top part of the dialysis sheets, which included vital signs, and sends that form with the resident to her dialysis appointments. Nurse #3 then stated, she would assess the resident when she returned (vital signs and site assessment) and document the information on the resident's medication administration record. Nurse #3 reported that the dialysis center sends their own printed copy of post dialysis information instead of filling out the bottom portion of the facility provided form. Nurse #3 stated both dialysis communication papers (the partial facility and the dialysis center) go to medical records. Nurse #3 reported no dialysis sheets were kept on the floor that she was aware of. The Medical Records staff member was unavailable for interview. During an interview with the Director of Nursing (DON) on 4/4/25 at 2:08 pm she stated the facility was responsible for completing the dialysis communication form prior to the resident being sent to dialysis center and for making sure the dialysis center provides post dialysis information either by completing the bottom portion of the facility form or by providing their own printout. The DON stated she did not know why the facility had been unable to locate complete dialysis communication sheets or why they were not scanned into the chart. The DON explained it was the responsibility of medical records staff to scan completed dialysis communication forms into the electronic medical record. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and dependence on dialysis. Resident #11 had an active physician order dated 8/21/23 for dialysis on Monday, Wednesday, and Friday. Review of Resident #11's care plan last reviewed 12/18/24 revealed the need for dialysis related to renal failure with an intervention to communicate with the dialysis center by the dialysis communication form. Review of Resident #11's electronic medical record showed completed dialysis communication forms last scanned into his chart on 11/22/24. Review of Resident #11's dialysis communication forms, located in medical records dated 11/8/24 through 3/28/25 revealed the facility was only able to locate 3 completed forms for the month of January 2025 and only 4 completed forms for the month of February 2025. During an interview with Nurse #3 on 4/3/25 at 1:30 PM, she stated that she fills out the top part of the dialysis sheets, which included vital signs, and sends that form with the resident to her dialysis appointments. Nurse #3 then stated, she would assess the resident when she returned (vital signs and site assessment) and document the information on the resident's medication administration record. Nurse #3 reported that the dialysis center sends their own printed copy of post dialysis information instead of filling out the bottom portion of the facility provided form. Nurse #3 stated both dialysis communication papers (the partial facility and the dialysis center) go to medical records. Nurse #3 reported no dialysis sheets were kept on the floor that she was aware of. The Medical Records staff member was unavailable for interview. During an interview with the Director of Nursing (DON) on 4/4/25 at 2:08 pm she stated the facility was responsible for completing the dialysis communication form prior to the resident being sent to dialysis center and for making sure the dialysis center provides post dialysis information either by completing the bottom portion of the facility form or by providing their own printout. The DON stated she did not know why the facility had been unable to locate complete dialysis communication sheets or why they were not scanned into the chart. The DON explained it was the responsibility of medical records staff to scan completed dialysis communication forms into the electronic medical record.

Based on observation, record reviews, and resident and staff interview, the facility failed to provide dental services as ordered by the physician for 1 of 2 sampled residents (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE] diagnoses which included: COPD (chronic obstructive pulmonary disease), adult failure to thrive, diabetes mellitus, and Crohn's disease (chronic inflammatory bowel disease). Resident #18's most recent periodic oral evaluation was on 11/30/23. The oral exam showed the resident's oral tissue was red and inflamed, with heavy plaque buildup. The resident had no dental pain. The Dentist's recommendation included: dental cleaning and for the facility staff to remind/assist Resident #18 to brush her teeth twice daily, focusing at gum line. Also, dental follow-up, when needed. The review of the physician's order dated 1/29/24 documented a dental referral for Resident #18 due to a diagnosis of cavities. Review of the clinical record revealed Resident #18 was examined by the Nurse Practitioner (NP) on 3/15/24 due to a reported toothache. The examination showed the resident had cavities to several of her molars, several cracked/broken teeth, and excessive plaque. The resident's upper and lower posterior gingiva (gums) were mildly inflamed. The resulting diagnosis was oral cavity pain and poor oral hygiene. The treatment plan included: continue with (11/30/22) Tylenol (acetaminophen) as prescribed; continue (1/30/24) chlorhexidine (antiseptic) 0.12% swish and swallow; continue to (2/2/24) brush teeth twice daily and as needed; (3/15/24) Cefdinir (antibiotic) 300 mg (milligram) twice a day for seven days, refer to dentist. The review of Resident #18's March 2024 physician's orders included a dental referral for a toothache dated 3/15/24. The follow-up NP's note dated 3/19/24 revealed the cavity on the lower left side of Resident #18's mouth caused the resident to complain of pain when attempting to touch the gum area around that tooth. The dental referral was discussed along with the antibiotics for possible abscessed tooth. There was no documentation in Resident #18's clinical record indicating the resident was referred to or seen by a dentist as re-ordered on 3/15/24. It was originally ordered on 1/29/24. The quarterly minimum data set assessment dated [DATE] indicated Resident #18 was cognitively intact. During an interview on 3/31/25 at 11:38 a.m., Resident #18 revealed she had two cavities. She stated last year, during her last dental visit, she was informed the teeth required extraction. The resident recalled that x-rays of her teeth and gums were completed but she had not received any follow-up. Resident #18 acknowledged she had no oral pain and was able to chew her food without discomfort. A telephone interview was conducted on 4/14/25 at 10:01 a.m. with Nurse #4 who revealed she worked as the Unit Manager on the first floor but was familiar with Resident #18 who resided on the second floor in the facility. She indicated she would often see and speak with the resident, but Resident #18 did not complain of tooth or gum pain. Nurse #4 explained the facility's practice was for the physician to document the medication or referral order in the que (standby) of the electronic health record for signed confirmation by a facility nurse (including a unit manager). If the physician's order was a referral order, the nurse was required to print the order then deliver the order to the Appointment Scheduler via the Scheduler's mailbox or in person. She revealed during the time period of the referral order dated 3/15/24, the physician placed the order for Resident #18 into the que of Resident #18's electronic health, then confirmed the order, herself. Nurse #4 stated that because the physician did the confirmation process, the nurses were not aware of the Resident #18's dental referral and it would not appear on the medication administration record as the medications would. An interview with the Administrator on 4/2/25 at 3:06 p.m. revealed the facility had not had onsite dental services in six months. She further explained that if or when a resident had dental requests/needs, the resident's nurse would notify the physician who would write a referral order for dental services. The approved order would then be given to the Appointment Scheduler/Receptionist to schedule the dental appointment to an offsite dental service. During an interview on 4/03/25 at 10:24 a.m., the Appointment Scheduler stated she maintained documentation of all referrals and scheduled appointments for three years. The nurse would inform her and give her a copy of the physician's order. She revealed Resident #18 had been seen by the dentist during previous onsite facility visits. After she reviewed documentation of Resident #18's referrals, the Appointment Scheduler acknowledged there were no dental referrals for this resident throughout 2024. During an interview on 4/03/25 at 10:55 a.m., the Administrator stated the nurse failed to follow through on giving the physician's dental referral order to the Appointment Scheduler. During follow-up telephone interview on 4/14/25 at 9:36 a.m., the Administrator revealed Resident #18's most recent routine on-site dental examination was on 11/30/23. She stated that after reviewing the resident's medical record, there was no documentation indicating Resident #18 complained of oral pain prior to her visit with the nurse practitioner on 3/15/24, and the resident did not complain of tooth pain during or after completion of her antibiotic treatment. The Administrator stated the routine dental on-site visit on 11/30/23 was the most recent dental examination prior to 3/15/24. The Administrator revealed the facility's practice for physician's referral orders was that once the physician entered the order for the dental referral for Resident #18 into the electronic health record, the staff nurse was to confirm the order, print the order and submit it to the Appointment Scheduler.

Based on observation, a Resident Council Meeting, and staff interviews, the facility failed to post the survey results in a location accessible to the residents. The findings included: While entering the facility on 04/02/25 at 8:00 AM, an observation revealed the survey results binder was in the lobby on a table. The facility's lobby area was enclosed and secured by a door requiring a code to be entered for staff and residents to access. The Resident Council meeting was held on 04/02/25 at 1:30 PM. During the meeting, Resident #9, Resident #28, Resident #35, and Resident #12 stated they were unaware that survey results were posted in the facility or where the results were located. The Resident Council President, Resident #18, attended the meeting and stated she was aware that survey results could be reviewed and that they were in the lobby. They all stated they were not able to access the lobby to review the survey binder. An interview with the Administrator on 04/02/25 at 2:39 PM indicated that the survey results binder was available to the residents in the lobby; they just needed to let someone know they would like to look at the survey results binder. The interview further revealed the door leading to the lobby was always locked and required a staff member to enter a code to unlock it.

Based on record review, and staff, Nurse Practitioner (NP) and physician interviews, the facility failed to notify the physician when an anticonvulsant medication was not administered for 1 of 1 resident reviewed for notification (Resident #1). The findings included: Resident #1 was admitted to the facility 11/27/24 with diagnoses that included stroke, nontraumatic subdural hemorrhage unspecified, and seizure disorder of epilepsy. Resident #1's Physician's orders included an order written 11/29/24 for Valproic Acid Oral Solution 250mg (milligrams)/5 ml (milliliters) solution to give 15ml by mouth every 8 hours for seizures. Resident #1's Medication Administration Records (MAR) for 11/2024 and 12/2024 were reviewed and revealed the following: Valproic Acid Oral Solution 250 mg/5ml solution was not signed on the MAR as given at 2:00 pm on 12/3/24, 12/5/24, 12/7/24, 12/10/24 and 12/12/24. Further review of the MARs revealed on 12/3/24 Nurse #3 documented Hold/See Nurse Notes, on 12/5/24 Nurse #2 documented LOA (leave of absence), on 12/7/24 Nurse #4 documented Other/See Nurse Notes, on 12/10/24 and 12/12/24 Nurse #1 documented Other/See Nurse Notes. Further review of Resident #1's medical record and nursing notes revealed there was no documentation the physician was notified on 12/3/24, 12/5/24, 12/7/24, 12/10, 24 or 12/12/24 of the Valproic Acid not being administered. Review of Resident #1's MAR on 12/3/24 at 2:00pm revealed Resident #1 did not receive Valproic Acid and Nurse #3 indicated hold/see nurse notes. Nurse #3's note on 12/3/24 at 3:16pm read in the dialysis. During a phone interview on 1/3/25 at 2:13pm, Nurse #3 revealed that she didn't remember Resident #1 and could not answer any questions. Review of Resident #1's MAR on 12/5/24 at 2:00pm revealed that Valproic Acid was not given, and Nurse #2 documented Resident #1 was on Leave of Absence (LOA). During a phone interview on 1/3/25 at 3:22pm, Nurse #2 revealed that she didn't remember Resident #1 well, but Valproic Acid was not given on 12/5/24 due to Resident #1 being at dialysis. Nurse #2 indicated she would have told the NP if medication was held, although she really didn't recall. Nurse #4's progress noted dated 12/7/24 at 1:20pm did not reveal why Valproic Acid was not administered. During a phone interview on 1/4/25 at 4:20pm, Nurse #4 revealed that she was fairly new to the facility, and she didn't recall Resident #1. Resident #1's MAR on 12/10/24 revealed Resident #1 did not receive Valproic Acid at 2:00pm and read other/see nurse notes. Resident #1'a MAR on 12/12/24 revealed Resident #1 did not receive Valproic Acid at 2:00pm and read other/see nurse notes. Nurse #1's progress note on 12/12/24 at 2:32pm read he is on dialysis. Nurse #1's progress note on 12/10/24 at 4:52pm revealed Resident #1 returned from dialysis at 4:45pm. During an interview on 1/3/25 at 11:38am, Nurse #1 confirmed that Valproic Acid was not administered on 12/10/24 and 12/12/24 and he wrote a progress note that Resident #1 was at dialysis. Nurse #1 indicated he didn't notify the physician because he wrote the note as he thought it was known that Resident #1 was at dialysis. During an interview on 1/3/25 at 10:08am, the Unit Manager revealed that Resident #1 missed the midday dose of Valproic Acid on 12/3/24, 12/5/24, 12/7/24, 12/10/24, and 12/12/24 due to being at dialysis. She was unsure if the physician was aware of missed doses. During an interview on 1/3/25 at 9:18am, NP revealed that she was not aware that Resident #1 missed several doses of his Valproic Acid that was scheduled while Resident #1 was at dialysis. The NP indicated the physician may have been aware of the missed doses and NP would have wanted Resident #1's medications given as ordered. During a phone interview on 1/3/25 at 10:47am the Physician revealed she was aware that Resident #1's midday Valproic Acid was scheduled during the time when Resident #1 would be at dialysis. During a phone interview with the Interim Director of Nursing on 1/6/25 at 4:30pm she indicated she expected medications to be given as ordered and if they were not given as ordered the physician needed to be notified. During a phone interview with the Administrator on 1/6/25 at 4:44pm she indicated that she expected medications to be given as ordered and if they were not given as ordered the physician needed to be notified.

Based on record review and staff, Pharmacist, Nurse Practitioner (NP) and Physician interviews, the facility failed to prevent a significant medication error when they failed to administer antiseizure medication as prescribed by the physician. As a result, Resident #1 missed 5 doses of antiseizure medication. This affected 1 of 3 sampled residents reviewed for assuring facility was free of medication errors (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included stroke, nontraumatic subdural hemorrhage unspecified, and seizure disorder or epilepsy. Resident #1's Care Plan dated 11/30/24 indicated he had a seizure disorder, and the interventions included administer seizure medication as ordered and monitor for effectiveness. Resident #1's Physician's orders included an order written 11/29/24 for Valproic Acid Oral Solution 250mg (milligrams)/5ml (milliliter) solution to give 15 milliliters by mouth every 8 hours for seizures. Resident #1's Medication Administration Records (MAR) for 11/2024 and 12/2024 were reviewed and revealed the following: Valproic Acid Oral Solution 250 mg/5ml solution was not signed on the MAR as given at 2:00 pm on 12/3/24, 12/5/24, 12/7/24, 12/10/24 and 12/12/24. Further review of the MARs revealed on 12/3/24 Nurse #3 documented Hold/See Nurse Notes, on 12/5/24 Nurse #2 documented LOA (leave of absence), on 12/7/24 Nurse #4 documented Other/See Nurse Notes, on 12/10/24 and 12/12/24 Nurse #1 documented Other/See Nurse Notes. Review of Resident #1's MAR on 12/3/24 at 2:00pm revealed Resident #1 did not receive Valproic Acid and Nurse #3 indicated hold/see nurse notes. Nurse #3's note on 12/3/24 at 3:16pm read in the dialysis. During a phone interview on 1/3/25 at 2:13pm, Nurse #3 revealed that she didn't remember Resident #1 and could not answer any questions. Review of Resident #1's MAR on 12/5/24 at 2:00pm revealed that Valproic Acid was not given, and Nurse #2 documented Resident #1 was on Leave of Absence (LOA). During a phone interview on 1/3/25 at 3:22pm, Nurse #2 revealed that she didn't remember Resident #1 well, but Valproic Acid was not given on 12/5/24 due to Resident #1 being at dialysis. Nurse #2 indicated she would have told the NP if medication was held, although she really didn't recall. Nurse #4's progress noted dated 12/7/24 at 1:20pm did not reveal why Valproic Acid was not administered. During a phone interview on 1/4/25 at 4:20pm, Nurse #4 revealed that she was fairly new to the facility, and she didn't recall Resident #1. Resident #1 MAR on 12/10/24 revealed Resident #1 did not receive Valproic Acid at 2:00pm and read other/see nurse notes. Nurse #1's progress note on 12/10/24 at 4:52pm revealed Resident #1 returned from dialysis at 4:45pm. Resident #1'a MAR on 12/12/24 revealed Resident #1 did not receive Valproic Acid at 2:00pm and read other/see nurse notes. Nurse #1's progress note on 12/12/24 at 2:32pm read he is on dialysis. During an interview on 1/3/25 at 11:38am, Nurse #1 confirmed that Valproic Acid was not administered on 12/10/24 and 12/12/24 and he wrote a progress note that Resident #1 was at dialysis. Nurse #1 indicated he didn't notify the physician because he wrote the note as he thought it was known that Resident #1 was at dialysis. During an interview on 1/3/25 at 10:08am, the Unit Manager revealed that Resident #1 missed the midday dose of Valproic Acid on 12/3/24, 12/5/24, 12/7/24, 12/10/24, and 12/12/24 due to being at dialysis. She was unsure if the Physician was aware of missed doses. A follow-up interview on 1/4/25 at 3:31pm with Unit Manager revealed Resident #1 went to dialysis on Tuesdays, Thursdays and Saturdays. Resident #1 had a chair time of 9:50am and was usually away from the facility between 5 - 6 hours. During an interview on 1/3/25 at 9:18am, NP revealed that she was not aware that Resident #1 missed several doses of Valproic Acid that were scheduled while Resident #1 was at dialysis and would have wanted Resident #1's Valproic Acid given as ordered. During a phone interview on 1/3/25 at 10:47am, Physician revealed she was aware that Resident #1's midday Valproic Acid was scheduled during the time when Resident #1 would be at dialysis. The interview further revealed she didn't feel like the missed medications were harmful to him and to her knowledge he didn't have any seizures at the facility. During a phone interview with the Pharmacist on 1/3/25 at 3:55pm she indicated that missing a dose of Valproic Acid would not have made Resident #1 subtherapeutic, Resident #1 would have had to have missed several doses in a row; Valproic Acid has 16-hour half-life. The interview further revealed missing one dose would not have caused Resident #1 to have a seizure. During a phone interview with the Interim Director of Nursing on 1/6/25 at 4:30pm she indicated Resident #1 didn't have any seizures while in the facility and she felt like the missed doses did not negatively affect Resident #1 in the short-term. The interview further revealed that she expected medications to be given as ordered and if they were not given as ordered the physician needed to be notified. During a phone interview with the Administrator on 1/6/25 at 4:44pm she indicated that she expected medications to be given as ordered and if they were not given as ordered the physician needed to be notified.

Based on observations, record review, and staff, Medical Director and Transportation Agent staff (Driver #1, Supervisor #1, Supervisor #2) interviews, the facility failed to have Resident #1 assessed by a medical professional before repositioning the resident after he was thrown forward out of his wheelchair while inside a contracted transportation van. On 03/20/24 Driver #1 for the Transportation Agent applied the van brakes suddenly to avoid a collision and Resident #1 slid out of his wheelchair onto the floor of the contracted transportation van. Driver #1 repositioned Resident #1 back into his wheelchair before the Resident was assessed by an emergency professional. Resident #1 complained of left knee pain 6 out of 10 (with 10 being the highest pain scale) and right foot pain, 10 out of 10 and was transferred to the hospital where he was diagnosed with an acute impacted oblique left femoral fracture (a break in the thighbone that occurs at an angle caused by direct trauma when the ends of the thighbone are jammed together) with edema (swelling) and bleeding around the left knee. This was for 1 of 3 residents reviewed for quality of care (Resident #1). Immediate jeopardy began on 3/20/24 when Resident #1 was repositioned into his wheelchair after a fall in the contracted transportation van without an assessment by a medical professional. Immediate jeopardy was removed on 5/25/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility 10/5/23 with diagnoses that included end stage renal disease, dependence on hemodialysis, diabetes mellitus, type 2, atherosclerotic heart disease, osteopenia, spinal stenosis, cervical disc degeneration and cerebrovascular accident. A 2/1/24 Transfer, Mobility Evaluation, assessed Resident #1 required the caregiver to perform 100% of the transfer task with the use of a mechanical lift because he was non-ambulatory, unable to stand, non-weight bearing and unable to sit at the bedside without full back and head support. A 3/1/24 quarterly Minimum Data Set assessment indicated Resident #1 expressed himself with clear speech, made himself understood, understood others, moderately impaired cognition with no acute changes in mental status, and used a wheelchair for mobility. Pain was assessed as almost constant pain that frequently interfered with activities and rated 10 out of 10. The facility's Appointment Schedule for 3/20/24, recorded Resident #1 had a 10:00 AM appointment. He was scheduled for transportation pick up at 9:30 AM on 3/20/24 by the Transportation Agent. A written statement by Driver #1 for the Transportation Agent, dated 3/20/24, recorded that on 3/20/24 at approximately 12:40 PM, Driver #1 was transporting Resident #1 to the facility while during transport she had to make a quick stop to avoid a collision. Because of the sudden stop, Resident #1 slid under his seat belt and landed partially on the floor of the van. Driver #1 pulled into the nearest driveway, Resident #1 was frightened and asked Driver #1 to help him up. Supervisor #1 for the Transportation Agent advised Driver #1 to call 911 and not to try to move Resident #1. Driver #1 recorded that she called 911. A 3/20/24 Emergency Medical Service (EMS) Report, recorded receipt of a call at 12:39 PM. EMS arrived on the scene at 12:55 PM, in response to injury from a fall for Resident #1. The EMS report documented once on the scene; Driver #1 directed EMS to Resident #1. The EMS Report recorded Resident #1 was alert to the event, person, place, and time, and he was found seated in a wheelchair. The Report recorded that to avoid a collision, Driver #1 slammed on the brakes and when this happened Resident #1 was thrown forward out of his wheelchair onto the floor. Resident #1 complained of left knee and right foot pain. Resident #1 complained his left knee was chronically painful, but he currently had increased pain. He reported his left knee pain was 6 out of 10 and his right foot was rated 10 out of 10. He was transported to the hospital at 1:19 PM on 3/20/24. An incident report dated 3/20/24 at 1:00 PM, recorded by the Regional Nurse Consultant, recorded the facility received a call from the Transportation Agent who reported that Resident #1 slid out of his wheelchair during transport, Driver #1 stayed with the Resident but did not attempt to move the Resident and called 911 immediately. A hospital History & Physical report dated 3/21/24 at 2:35 AM recorded Resident #1 presented for evaluation after he was riding in a wheelchair van when he tipped over, fell upon his left leg, and developed sudden severe left leg pain. Hospital x-ray results dated 3/21/24 revealed an acute impacted oblique left femoral fracture with swelling and bleeding around the left knee. A leg immobilizer was applied for non-surgical management due to a history of a blood clot in the same leg. Resident #1 discharged back to the facility on [DATE]. Driver #1 for the Transportation Agent was interviewed via phone on 5/22/24 at 10:05 AM with Supervisor #1. During the interview, Driver #1 stated that on 3/20/24 she transported Resident #1 to an appointment and on the way back to the facility suddenly a car cut right in front of the van such that she had to hit her brakes to keep from running into the car. Driver #1 continued that when she hit the brakes Resident #1 slid forward. She immediately pulled over into the parking lot of a restaurant not more than 200 feet away and Resident #1 kept repeating, I need to get up. The interview with Driver #1 on 5/22/24 at 10:10 AM continued in person and included an observation of the securement system on the contracted transportation van. During the observation and continued interview, Driver #1 stated that when she applied brakes, Resident #1 did not hit anything and that he did not come out of the wheelchair onto the floor. During a follow up phone interview with Driver #1 on 5/22/24 at 12:06 PM with the Administrator and Regional Nurse Consultant present in person, Driver #1 stated that Resident #1's bottom moved out of the wheelchair and hung partially off the seat, while the top of his body was held in the wheelchair by the restraint. Driver #1 stated Resident #1 repeated pull me up, pull me up and said he was in pain. Driver #1 stated she called her Supervisor (Supervisor #1, [NAME] President) who advised Driver #1 to call 911 and not to move Resident #1. Driver #1 stated she called 911 and then positioned Resident #1 back into his wheelchair. Driver #1 described that she reached her arms under the arms of Resident #1 and pulled his bottom back into to the chair. Driver #1 stated she positioned his bottom back into the wheelchair because he kept asking her to pull him up. Driver #1 described that Resident #1 was in a panic state and stated that his bottom hung off the seat of the wheelchair. Driver #1 stated I called my supervisor and he said to call 911 and not to move him, but I did move him because he was in a panic state and complained of pain and I did not know how long it was going to take medic {paramedics} to get there, I did not want him yelling in pain that whole time. Driver #1 stated that when EMS arrived Resident #1 was not in the same position he was in at the time of the accident and that she told the facility and Supervisor #1 that she did not move him. Driver #1 denied that Resident #1 was thrown out of his wheelchair to the floor of the contracted transportation van. A phone interview occurred on 5/22/24 at 8:41 AM with Supervisor #1 (Vice President) of the Transportation Agent. Supervisor #1 stated that Driver #1 called him on 3/20/24 after the van accident to let him know someone pulled out in front of the van, she had to brake quickly, when she did, Resident #1 slid forward in his wheelchair, he complained of pain, and she was unable to pull him up. Supervisor #1 said he told Driver #1 not to move Resident #1, but to call 911. Supervisor #1 said he contacted the facility, told the Administrator and Regional Nurse Consultant about the accident, that Resident #1 complained of pain, but that he told Driver #1 not to move Resident #1, but to call 911. A follow up phone interview occurred on 5/23/24 at 8:43 AM with Supervisor #1 (Vice President) who asked Supervisor #2 (President) of the Transportation Agent to join the call. During the interview, Supervisor #1 stated that Driver #1 called him to notify of the accident and that he provided instructions not to move the Resident but to call 911. Supervisor #1 and Supervisor #2 both stated they were not aware that Driver #1 moved the Resident before EMS arrived. Supervisor #1 stated, That was not the training she received and that moving a Resident could cause further injury. The Administrator and the Regional Nurse Consultant were both interviewed on 5/21/24 at 12:54 PM. The Regional Nurse Consultant stated that on 3/20/24 in the afternoon, the facility received a call from Supervisor #1 of the Transportation Agent. Supervisor #1 informed the facility that there was an incident with the contracted transportation van, someone pulled out in front of Driver #1 and when she applied her brakes Resident #1 slid down in his wheelchair. Supervisor #1 stated that Driver #1 pulled over immediately, she did not touch the resident and she called 911. During a follow up interview with the Administrator and Regional Nurse Consultant on 5/22/24 at 12:06 PM, the Regional Nurse Consultant stated that Driver #1 did not report that she moved the Resident but that she left him in place until EMS arrived. The Regional Nurse Consultant stated that the facility was not aware that Resident #1 was moved by Driver #1 before EMS arrived and that moving a Resident involved in a car accident if you are not clinically trained could cause further injury. The Regional Nurse Consultant further stated if Driver #1 had called the facility, she would have asked questions to assess the situation and given Driver #1 further instruction based on the situation. During an interview on 5/22/24 at 12:30 PM the Medical Director stated that he was not aware that Driver #1 moved Resident #1 before EMS arrived to assess him. He stated that Resident #1 should have remained in place to avoid the risk of further injury until EMS arrived to assess Resident #1. The Administrator was notified of immediate jeopardy on 5/23/24 at 3:15 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 3/20/24, Resident #1 was being transported back to the facility from dialysis appointment when the contracted Driver #1 quickly stepped on the brakes to avoid hitting a car that pulled out in front of her. Driver #1 pulled over at a safe location to check on the resident. At that time, Driver #1 observed that Resident #1's bottom slid to the edge of his wheelchair, he had a lap restraint that was positioned across his chest, both arms were positioned on the armrests, and both feet were off the footrests and his left leg bent. Resident #1 complained of pain to Driver #1. Resident #1 asked Driver #1 to reposition him back into his wheelchair. Driver #1 called her supervisor and received instruction not to move Resident #1, but to call 911. Driver #1 called 911 and then repositioned Resident #1 back into his wheelchair before paramedics arrived. When paramedics arrived, he expressed left knee pain that he rated 6 out of 10, and right ankle pain he rated 10 out of 10. Resident #1 was transferred to the emergency department for further evaluation and diagnosed with an acute left femoral fracture with soft tissue edema and bleeding around the left knee. Residents who require transportation services for outside physician services have the potential to be affected as a result of the lack of a full assessment for injury by Paramedics before a resident is moved does not allow for a thorough assessment of injury and places the resident at risk for further injury. 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. To ensure no other residents are affected, the involved contracted transportation company contract was terminated on 5/23/24 in writing by the facility administrator. Driver #1 originally wrote in her 3/20/24 statement that she did not touch the resident. However, on 5/22/24 she stated she moved the resident because Resident #1 was crying in pain and pleading that she reposition him. Education was provided in person by 5/23/24 by the Director of Plant Operations to the facility van driver and provided the education to the company-contracted van drivers to pull over, not move a resident if he/she slides down or falls out of their wheelchair, call 911, and wait for paramedics to assess the resident, as well as the risks of moving a resident prior to EMS arrival. A reiteration of education and return demonstration was completed again on 5/24/24 in the presence of the Director of Plant Operations. Questions regarding education may be directed to nursing administration. Drivers will not be allowed to transport any resident until education has been completed. Education will be tracked by the Director of Plant Operations or Maintenance Director with documented signatures. Newly hired transportation drivers will be required to receive the same education in orientation prior to any transportation. The alleged date of immediate jeopardy removal was 5/25/2024. The immediate jeopardy removal plan of 5/25/24 was validated on 5/29/24. Staff were interviewed regarding the training received not to move a resident prior to the assessment of a medical professional, but to call 911, and to wait for a medical professional to assess the resident due to the risk involved for the potential of further injury. Documentation of staff training was reviewed. Interviews with alert and oriented residents who were transported to appointments by the facility staff or by a Transportation Agent were conducted. The interviews included if the residents were assessed by a medical professional prior to being moved after an accident. The immediate jeopardy removal on 5/25/24 was validated.

Based on observations, record review, and staff, Medical Director, Regional Nurse Consultant and Transportation Agent (Driver #1, Supervisor #1 and Supervisor #2) interviews, the facility failed to utilize an occupant restraint system, complete with a shoulder restraint and lap belt, per manufacturer's instructions for Resident #1 who slid out of his wheelchair during transport in a contracted transportation van. Driver #1 applied a shoulder restraint under the armrest of the wheelchair and across the lap of Resident #1 for transport, but did not apply a lap restraint. When Driver #1 applied brakes to avoid hitting a car, Resident #1's buttocks slid out of his wheelchair with his left leg bent forward, and his right leg extended straight out in front. Resident #1 expressed pain to Driver #1. Driver #1 called 911 and when paramedics arrived, Resident #1 complained of left knee pain 6 out of 10 (with 10 being the highest pain scale) and right foot pain, 10 out of 10. Resident #1 was transferred to the hospital where he was diagnosed with an acute impacted oblique left femoral fracture (a break in the thighbone that occurs at an angle caused by direct trauma when the ends of the thighbone are jammed together) with edema (swelling) and bleeding around the left knee. The death certificate recorded Resident #1's date of death as 5/5/24 and the primary cause of death was due to complications from the left femoral fracture. This failure occurred for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). Immediate jeopardy began on 3/20/24 when Driver #1 failed to secure Resident #1 per manufacturer's instructions for safe transport. The immediate jeopardy was removed on 5/25/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: The June 2001 manufacturer's operation instructions for the securement system posted inside the contracted transportation van, recorded the following, in part. Attach the lap belt. Secure the occupant by attaching the ends of the lap belt around the occupant, threading down and through opening between wheelchair side panel and seat, or through gap between wheelchair back and seat. Attach the shoulder belt. Bring the triangular fitting of the shoulder belt over the shoulder and across the upper chest of occupant. For track anchored shoulder belts install the belt track fitting into the desired opening that provides proper extension and placement. Connect triangular fitting to the stud of the lap belt latch plate. Pull loose end of the belt through the adjuster to achieve firm, but comfortable fitting. Pull on the belt to ensure that all fittings are properly attached. Always ensure that the shoulder belt is properly extended over the shoulder and across the upper torso of the occupant. According to the manufacturer's website, https://sure-lok.com/products/occupant-restraints/, for standards of compliance, the occupant restraints should be properly used as a complete system to include the wheelchair tie-down, track and anchorages, lap belt and shoulder restraint and to always secure the occupant in the vehicle using the complete system. A Transportation Agreement, effective 3/23/21, recorded the Transportation Agent would provide wheelchair lift vehicles which met all government regulations, requirements, and licensing. The Transportation Agent would ensure that all vehicles had equipment that included 4 Wheelchair Restraints per chair transported, a shoulder strap and a lap safety belt. A manufacturer's securement systems Training Completion dated 4/9/22 and signed by Driver #1 for the Transportation Agent recorded in part, Note: We strongly recommend the use of lap and shoulder belts to reduce the possibility of impact with vehicle components. Resident #1 was admitted to the facility 10/5/23 with diagnoses that included end stage renal disease (ESRD), dependence on hemodialysis, diabetes mellitus, type 2 (DM2), atherosclerotic heart disease, spinal stenosis, osteopenia, cervical disc degeneration and cerebrovascular accident. A 3/1/24 quarterly Minimum Data Set assessment indicated Resident #1 expressed himself with clear speech, made himself understood, understood others, moderately impaired cognition with no acute changes in mental status, and used a wheelchair for mobility. The facility's Appointment Schedule for 3/20/24, recorded Resident #1 had a 10:00 AM appointment. He was scheduled for Transportation Agent pick up at 9:30 AM on 3/20/24. A written statement by Driver #1 for the Transportation Agent, dated 3/20/24, recorded that on 3/20/24 at approximately 12:40 PM, Driver #1 traveled with Resident #1 back to the facility when a car pulled in front of the van and Driver #1 had to make a quick stop to avoid a collision. The statement recorded that because of the sudden stop, Resident #1 slid under his seat belt and landed partially on the floor of the van. Driver #1 recorded that she pulled into the nearest driveway, Resident #1 was frightened and asked Driver #1 to help him up. Driver #1 recorded that Supervisor #1 (Vice President) for the Transportation Agent advised Driver #1 to call 911. Driver #1 recorded that she called 911, Resident #1 was transported to the hospital for further evaluation. A 3/20/24 Emergency Medical Service (EMS) Report, recorded receipt of a call at 12:39 PM and arrived on the scene at 12:55 PM, in response to injury from a fall for Resident #1. The EMS report documented once they arrived, Driver #1 directed EMS to Resident #1. The EMS Report indicated that Resident #1 was alert to the event, person, place, and time, found by EMS seated in his wheelchair and complained of left knee and right foot pain. The EMS Report documented Resident #1 described that his left knee was chronically painful, but due to the accident, he currently had increased pain. The EMS Report indicated that Resident #1 reported his left knee pain was 6 out of 10 and his right foot pain was rated 10 out of 10. The report documented that Driver #1 reported to EMS that to avoid a collision, Driver #1 slammed on the brakes when a car pulled out in front of the van and when this happened Resident #1 was thrown forward out of his wheelchair onto the floor of the van. The EMS Report documented that Resident #1 and Driver #1 both reported that during transport Resident #1 wore a seat belt, and the wheelchair was properly restrained. The Report documented that Resident #1 requested to be transferred to the hospital for further evaluation. The EMS Report documented Resident #1 was transported to the hospital at 1:19 PM on 3/20/24 for further evaluation. An incident report dated 3/20/24 at 1:00 PM, completed by Regional Nurse Consultant, recorded the facility received a call from the Transportation Agent who reported that Resident #1 slid out of his wheelchair during transport. The incident report recorded Resident #1 sustained a left femur fracture. A hospital History & Physical Report dated 3/21/24 at 2:35 AM recorded Resident #1 presented for an evaluation after he was riding in a wheelchair van when he tipped over, fell upon his left leg, and developed sudden severe left leg pain. Hospital Xray results dated 3/21/24 revealed an acute impacted oblique left femoral fracture with swelling and bleeding around the left knee. A leg immobilizer was applied for non-surgical management due to a history of a blood clot in the same leg. Resident #1 discharged back to the facility on [DATE]. A death certificate for Resident #1 recorded the date of death as 5/5/24 and the cause of death as complications from a left femur fracture. Driver #1 for the Transportation Agent was interviewed via phone on 5/22/24 at 10:05 AM with Supervisor #1 for the Transportation Agent present on the phone. During the interview, Driver #1 stated that on 3/20/24 she transported Resident #1 to an appointment and on the way back to the facility suddenly a car cut right in front of the van such that she had to hit her brakes to keep from running into the car. Driver #1 continued that when she hit the brakes Resident #1 slid forward and she immediately pulled over into the parking lot of a restaurant not more than 200 feet away. The interview with Driver #1 continued in person on 5/22/24 at 10:10 AM on the contracted transportation van. Driver #1 continued that she used the shoulder restraint equipped on the vehicle to transport occupants. She stated that to secure larger occupants, she applied the shoulder restraint per manufacturer's instructions, secured across the shoulder of the occupant, and for smaller occupants or occupants who could not maintain an upright position, she secured the shoulder restraint under both arm rests and across the lap of the occupant. Driver #1 stated that she secured the shoulder restraint attached to the contracted transportation van under both armrests and across the lap of Resident #1 for transport on 3/20/24 because she did not have a lap belt on the vehicle, he leaned forward as his usual position, and because that was her usual practice when securing Resident #1 for transport. Driver #1 stated that Resident #1 usually leaned forward as his typical posture during transport, so she did not secure the shoulder restraint across his shoulder according to the manufacturer instructions because she thought it would be a choking hazard for him. Driver #1 stated that when Resident #1 slid forward in his wheelchair, after she applied brakes to avoid hitting a car, he did not hit anything and that only his legs landed on the floor of the van, but that he did not come completely out of the wheelchair onto the floor. Driver #1 stated that when she applied brakes, Resident #1 slid forward until his bottom slid to the edge of his wheelchair, the shoulder restraint was across his chest, both arms remained on the armrests, both feet came off the footrests, his left leg was bent forward, and his right leg was straight out in front. Driver #1 said Resident #1 kept asking her to help him up because he said he was in pain. During a follow up phone interview with Driver #1 on 5/22/24 at 12:06 PM while the Administrator and Regional Nurse Consultant were present in-person, Driver #1 stated that Resident #1 was in a panic state, said he was in pain and that he wanted to go to the hospital. Driver #1 stated she called her supervisor (Supervisor #1); he advised her to call 911 and not to move Resident #1. Driver #1 stated she and Resident #1 both confirmed with paramedics that Resident #1 was wearing a seat belt and was properly restrained in his wheelchair during transport on 3/20/24. The Administrator and the Regional Nurse Consultant were both interviewed on 5/21/24 at 12:54 PM. The Regional Nurse Consultant stated that on 3/20/24 in the afternoon, the facility received a call from Supervisor #1 of the Transportation Agent. The Regional Nurse Consultant stated that Driver #1 came to the facility on [DATE] and wrote a statement and told the Regional Nurse Consultant and the Administrator about what happened. The Regional Nurse Consultant said that on 3/20/24, Driver #1 transported Resident #1 to an appointment, and on the way back to the facility, Resident #1 was the only passenger in the van, someone pulled out in front of the van and the Driver had to slam on brakes to keep from hitting the car. The Regional Nurse Consultant said the Driver described that when she slammed on brakes, Resident #1 slid forward in his wheelchair, but remained secured in the wheelchair with his arms on the arm rests. Driver #1 reported that she pulled into the parking lot nearby and called 911 immediately because Resident #1 said he was in pain. The Regional Nurse Consultant said when she read the EMS Report, it documented that Driver #1 and Resident #1 both reported that the wheelchair and the Resident were both secured properly. The Regional Nurse Consultant stated that the facility reviewed the manufacturer's instructions, for occupant securement and the wheelchair tie-down points, how to secure an occupant in the van, the Driver statement, the EMS Report and the hospital records to determine the root cause but could not identify what went wrong. The Regional Nurse Consultant reported that Driver #1 and Resident #1 both reported that he was wearing a seat belt that was secured properly and that his wheelchair was locked in place. The Administrator stated that when Resident #1 returned from the hospital, he was interviewed by the Administrator and he reported that he was coming from an appointment on 3/20/24, he was strapped in the wheelchair with a restraint, the wheelchair was tied down, during the transport, the driver pushed on the brakes hard and he slid forward. A follow up in-person interview with Driver #1 and an observation of the contracted transportation van occurred on 5/23/24 at 12:45 PM. Driver #2 from the Transportation Agent, the Administrator and the Regional Nurse Consultant were also present for this interview and observation. During this interview and observation, Driver #1 stated that she wanted to clarify her interview and the observation of the contracted transportation van that occurred on 5/22/24 at 10:10 AM. Driver #1 stated that the contracted transportation van observed on 5/22/24 at 10:10 AM was not the same contracted transportation van used to transport Resident #1 on 3/20/24, as previously stated, but that the contracted transportation van she currently had was the actual vehicle used to transport Resident #1 on 3/20/24. Driver #1 stated that the clarification was important because the occupant securement systems between the two contracted transportation vans were different. During the follow up in-person interview on 5/23/24 at 12:45 PM, Driver #1 and Driver #2 provided a demonstration of how Resident #1 was secured for transport on 3/20/24 in the actual van used to transport him on 3/20/24. The manufacturer's instructions for the occupant securement system were observed posted on the wall interior of the contracted transportation van. For the observation, Driver #2 sat in a wheelchair in the contracted transportation van while Driver #1 demonstrated that she centered the wheelchair between the floor tracks, applied the wheelchair brakes, applied the front tie-downs and secured them into the floor tracks of the contracted transportation van. Then Driver #1 applied the rear tie-downs and secured them into the floor tracks of the contracted transportation van. Driver #1 shook the wheelchair; it was observed not to move, and Driver #1 stated that the wheelchair was secure. While Driver #2 was seated in the wheelchair, Driver #1 was observed to thread the shoulder restraint (attached to the track on the wall of the van which was the difference in the occupant securement system of the two vans) under both arm rests of the wheelchair, securing it across the lap of Driver #2 rather than across the shoulder of Driver #2. Driver #1 stated she did not secure Resident #1 with a lap belt, because she did not have one available on the contracted transportation van at the time of transport, but rather used the shoulder restraint secured across the lap of Resident #1. Driver #1 stated that the contracted transportation van was equipped with a shoulder restraint but did not come equipped with a lap belt. The contracted transportation van was observed and did not have a lap belt attached, neither was a lap belt observed available for use. Driver #1 obtained a lap belt from Driver #2 for the demonstration. Driver #1 stated that she was trained to check the contracted transportation van before transport to ensure all parts of the wheelchair and occupant securement system were in place and functioning. Driver #1 stated she checked the van and occupant securement system on 3/20/24 before she transported Resident #1, she did not have a lap belt on the van but did not think she needed one because she usually used the shoulder restraint secured across the lap of Resident #1 for transport. Driver #1 stated that she did not routinely use both a shoulder restraint and lap belt to transport occupants, but when she did need a lap belt, she obtained a lap belt from Driver #2. A phone interview occurred on 5/22/24 at 8:41 AM with Supervisor #1 (Vice President) for the Transportation Agent. Supervisor #1 stated Driver #1 was employed as a driver with the Transportation Agent for the past two years with no prior driving experience. He described that she received two weeks of training, for a total of about 28 training hours. He stated that she drove with other experienced drivers to learn the routes, the global positioning system, loading/unloading residents in the vehicle, the wheelchair and occupant securement system, and required a competency evaluation with a return demonstration to a supervisor of these tasks for completion of the training. Supervisor #1 stated that Driver #1 called him on 3/20/24 to let him know someone pulled out in front of the van, she had to brake quickly, when she did, Resident #1 slid forward in his wheelchair, Resident #1 complained of pain, and that Driver #1 was unable to pull him up. Supervisor #1 said he told Driver #1 not to move the Resident, but to call 911. Supervisor #1 said he contacted the facility, told the Administrator and Regional Nurse Consultant about the accident, that Resident #1 complained of pain, and that he told Driver #1 to call 911. A follow up phone interview with Supervisor #1 occurred on 5/23/24 at 8:43 AM with Supervisor #2 (President) also on the phone. During the phone interview, Supervisor #2 stated that drivers were trained to routinely use either a lap restraint or a shoulder restraint based on the size of the occupant. He stated drivers were trained to typically use a lap restraint for a smaller framed person and the shoulder restraint for a larger framed person. He stated that both a shoulder restraint and a lap belt were used together as needed for occupants who could sit in an upright position, but that a shoulder restraint was not used for passengers who could not maintain an upright position due to the risk of the restraint presenting a choking hazard, but rather a lap belt was used to make sure there was no movement across the waist. Supervisor #1 described that the driver should thread the lap belt under both armrests of the wheelchair so that it fits snuggly around the occupant's waist and attach each end of the lap restraint to the floor latch. During a follow-up phone interview on 5/24/24 at 1:45 PM with Supervisor #1 and Supervisor #2 both on the phone, Supervisor #1 and Supervisor #2 stated they did not realize Driver #1 did not have both a shoulder restraint and lap belt on the van to transport Resident #1 on 3/20/24. Supervisor #2 stated when the contracted transportation van was purchased, it came equipped with a shoulder restraint but not a lap belt. Supervisor #2 stated the lap belt was purchased later and all contracted transportation vans should have both a shoulder restraint and a lap belt on the van for use during transportation. Supervisor #2 stated that for occupants who leaned forward and did not sit upright in the wheelchair, a shoulder restraint could present a choking hazard, so it was left to the driver's discretion in these situations to determine which restraint to use. Supervisor #2 stated that the contracted van used to transport Resident #1 on 3/20/24 had the shoulder restraint attached to a tracking device on the wall interior of the van and should be adjusted to the occupant for comfort and safety. Supervisor #2 stated that drivers were trained to conduct weekly safety checks on the assigned vehicles to check all items necessary for the wheelchair and occupant securement system and if anything was needed the driver should advise a supervisor. An interview with the Medical Director (MD) occurred on 5/21/24 at 2:39 PM. The MD stated that he was notified that on 3/20/24, during transportation in a contracted transportation van, Resident #1 sustained an acute left femur fracture with bleeding around the fracture because the muscle was also injured that was treated with non-operative management due to a history of a blood clot in the same leg. The MD stated he was told that a car pulled out in front of Driver #1, and she had to hit the brakes, but that according to the Resident and to the Driver, Resident #1 was properly secured in the van. The MD described Resident #1 was at high risk for fractures due to a history of fractures, advanced age, heart failure, DM2, and demineralized bones from ESRD. The MD stated that given everything considered Resident #1 was at high risk for spontaneous pathological fractures, due to his weakened bones. The MD stated that fractures in the case of Resident #1 could occur with or without impact, and if there was impact, the impact did not have to be of great force. The Administrator was notified of immediate jeopardy on 5/23/24 at 3:15 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 3/20/24, Resident #1 was being transported back to the facility from dialysis when the contracted Driver #1 quickly stepped on the brakes to avoid hitting a car that pulled out in front of her causing Resident #1 to slide forward from the wheelchair with the lap restraint positioned across his chest, both arms positioned on the armrests, both feet were off the footrests, and his left leg was bent. Driver #1 pulled over at a safe location to check on the resident. When EMS arrived, it was noted in the report that the resident was properly secured in a seat belt and the wheelchair was properly restrained. However, it was discovered that Driver #1 was not following the restraint manufacturer's guidelines during the surveyor observation reenactment on 5/23/24. Resident #1's normal posture was to lean forward. Driver #1 stated she applied a lap restraint but did not apply a shoulder restraint as per her training before transporting Resident #1. Driver #1 stated that she applied the shoulder restraint as a lap restraint, and she did not have an additional lap restraint available for use. It was discovered at the hospital that Resident #1 was diagnosed with an acute left femoral fracture with soft tissue edema and bleeding around the left knee. Residents who require dialysis and external physician services being transported by the facility and contracted drivers have the potential to be affected as a result of noncompliance with properly securing residents in the vehicle which may cause risk for serious injury or death. 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 To ensure no other residents are affected, the involved contracted transportation company contract was terminated by the facility on 5/23/24 in writing for noncompliance with not using an effective restraint system to safely secure a resident. Education of proper securement per manufacturer guidelines was provided to the one facility van driver on 5/22/24 by the Director of Plant Operations who is knowledgeable of the manufacturer guidelines for the single facility vehicle. A return demonstration was also completed on 5/22/24 to show full compliance and understanding. Other contracted van drivers will be educated by 5/23/24 by their company management who is knowledgeable on their specific vehicle's manufacturing guidelines. Re-education and return demonstration was completed on 5/24/24 by the facility and contracted van drivers by the Director of Plant Operations. Education included following the manufacturer's guidelines for the specific vehicle being used to prevent this event from reoccurring. Drivers will not be allowed to transport any resident until education has been completed. Newly hired transportation drivers will be required to receive the same education provided by the Director Plant Operations or Maintenance Director during orientation. The Administrator will be responsible for tracking the education. Facility will require return demonstrations of correct securement per the manufacturer's guidelines before transport and monitored by the Maintenance Director or designee. If stretcher transport is required, the facility will utilize the services of a medical transport company that specializes in stretcher transport. Residents with poor center of gravity will utilize the appropriate equipment for safe securement following the manufacturer guidelines. The alleged date of immediate jeopardy removal was 5/25/2024. The immediate jeopardy removal plan of 5/25/24 was validated on 5/29/24. Observations were made of staff securing residents for transport according to the manufacturer instructions which included the use of both a shoulder restraint and a lap belt. Staff were interviewed regarding training received on securing residents for transport according to the manufacturer instructions and the use of both a shoulder restraint and a lap belt. Documentation of staff training was reviewed. Interviews with alert and oriented residents who were transported by the facility or by a Transportation Agent were conducted and revealed residents were secured for transport with both a shoulder restraint, a lap belt and that the wheelchair was secured to the floor with tie-down restraints. The immediate jeopardy removal on 5/25/24 was validated.

Based on observations, staff and Medical Director interviews, and record reviews, 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 2 of 6 residents whose blood glucose levels were checked (Residents #168 and #58). 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 of the glucometer creates a high likelihood of exposing residents to the spread of blood borne infections. Immediate Jeopardy began on 11/14/2023 when Nurse #1 was observed during blood glucose testing for three residents on her assigned hall using a shared glucometer between the three residents but did not follow the manufacturer's instructions to allow for the wet contact time as specified for the disinfectant to be effective. Immediate Jeopardy was removed on 11/15/2023 when the facility provided and 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: A review of the facility's policy entitled, Glucometer Disinfection (revised 5/2023) read: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. The guidelines included, in part: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human immunodeficiency virus (HIV) or Hepatitis B or Hepatitis C virus. 4. The glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands. c. Explain the procedure to the resident. d. Provide privacy. e. Put on gloves. f. Obtain capillary blood glucose sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting the room. h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. l. Discard disinfectant wipes in waste receptacle. m. Perform hand hygiene. The manufacturer instructions for the glucometer used at the facility indicated the cleaning and disinfection procedure should be performed after each use on a resident. The disinfecting procedure was needed to prevent the transmission of blood borne pathogens. These instructions read in part, The (Brand Name) meter should be cleaned and disinfected between each patient. A review of the manufacturer instructions for the disinfectant wipes used to disinfect individual-resident glucometers at the facility read, in part, Allow treated surface to remain wet for two (2) minutes. Let air dry. A continuous medication administration observation was conducted with Nurse #1 on 11/14/2023 at 11:30 a.m. The Nurse opened the medication cart, and a single glucometer was observed to be sitting in the top drawer. The glucometer was not labeled with a name and was stored without a covering in the cart. Nurse #1 removed the glucometer, two alcohol wipes, and one lancet from the cart. She placed the supplies on top of the medication cart, performed hand hygiene, and donned a pair of gloves. The Nurse then took the supplies and entered Resident #167's room. She conducted hand hygiene, donned a pair of gloves, cleaned the Resident's finger, placed a droplet on the test strip of the glucometer, and waited for the test results. The glucometer was placed on a bedside table and then on a refrigerator. She then exited the room with the supplies and glucometer. She placed the glucometer on the Medication Cart, discarded the trash she had removed from the room, removed her gloves, conducted hand hygiene, and removed a disinfectant wipe and placed it on the glucometer. The disinfectant wipe touched a portion of the top of the glucometer and did not touch the sides or the underside of the device. She picked up the glucometer and wiped the entire surface for 15 seconds. She placed the device on top of the medication cart to dry. Based on the clock it was allowed to dry for 1 minute. She picked up the device and placed it back in the top drawer of the medication cart. At 11:59 a.m. Nurse #1 removed the glucometer and a container of testing strips from the medication cart, gathered supplies for a blood glucose procedure, conducted hand hygiene, donned a pair of gloves, and entered the room for Resident # 168. She placed the glucometer and the testing strips on the bedside table. She cleansed the Resident's finger with an alcohol wipe, used the lancet to prick the skin, placed a droplet of blood on the testing strip of the glucometer. When the test was completed, she picked up the glucometer and the testing strips and then she exited the room. She placed the glucometer and the testing strips on the medication cart, threw the trash away, removed her gloves, removed a disinfectant wipe from the container, and wiped the glucometer for 30 seconds. She then allowed the glucometer to air dry. Based on the clock it was dry in less than one minute. At 12:01 p.m. Nurse #1 had gathered additional glucose testing supplies and went to enter Resident #58's room to perform a blood glucose test. The surveyor stopped the nurse as she was entering the room. An interview was conducted with Nurse #1 on 11/14/2023 at 12:01 p.m. When asked how long the disinfectant wipe needed to be in contact with the glucometer device, Nurse #1 responded that the disinfectant required two minutes for the solution to be effective. She revealed she was unsure if she had allowed two full minutes. She then reviewed the time she had entered the previous room for Resident #168 and the time she was entering Resident #58's room. She stated the time difference was only two minutes. She added the reason the facility utilized a shared glucometer system was because they had so many residents that come and go quickly and would find peoples blood pressure cuffs and other devices in a new resident's room, so the nurses decided to use only one glucometer. She revealed she received training upon hire at the facility on proper blood glucose cleansing and disinfection of the device. An interview was conducted with the Administrator on 11/14/2023 at 1:47 p.m. and she revealed the facility's practice was for each resident to have their own glucometer. She was unsure why the nurses had made the decision to share a glucometer. An interview was conducted with the Staff Development coordinator/Facility infection preventionist (SDC) on 11/15/2023 at 10:32 a.m. and she revealed the facility policy was to clean a glucometer after each use with an EPA-approved wipe and then use a second wipe for disinfection. The wet contact time should be according to the manufacturer's guidelines. She added this information was provided to all clinical staff that conduct blood glucose readings upon hire and on yearly re-education. She provided a copy of the education provided upon hire, to Nurse #1, dated 11/24/2021. An interview was conducted with the Medical Director on 11/16/2023 at 2:10 p.m. and he revealed every resident at the facility should have their own glucometer device. He added that sharing a device placed the Residents at risk of contracting a blood borne pathogen like HIV, Hepatitis B, or Hepatitis C. He added it was his expectation that all residents have their own device, and he was not asked if it would be acceptable to share the devices. A review of the electronic medical record for the medical diagnoses of all current residents at the facility was conducted and no blood borne pathogens were identified. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy (IJ) on 11/14/2023 at 4:47 p.m. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 11/14/2023, Nurse #1 checked resident #168 blood sugar without cleaning and disinfecting the device according to manufacturer's recommendations prior to testing. Nurse #1 began walking toward resident #58's room to check blood sugar with a glucometer that was not cleaned and disinfected according to manufacturer's recommendations but was stopped by the surveyor prior to testing. The current census as of 11/14/2023 was printed and any residents that required blood sugar finger sticks were added to the potential affected resident list. Root cause analysis: Based on the interview of Nurse #1 she was nervous when the surveyor was standing in observation and did not disinfect the glucometer with 2 disinfectant wipes for the full 2 minutes as indicated by the manufacturer's guide before using it for another resident. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 11/14/2023, The Director of Nursing and Staff Development Coordinator began in-servicing all nurses and medication aides on the policy and procedure of cleaning and disinfecting glucometers. All nurses and medication aides that were not in the building at the time of the in-service were called and educated verbally on 11/14/2023. All staff were instructed to see the Director of Nursing and Staff Development Coordinator before their next shift for a return demonstration education. The Staff Development Coordinator arranges all new hire nurses and medication aides. The Staff Development Coordinator will be responsible in keeping up with new staff and they will be in-serviced on glucometer disinfection prior to working on a medication cart and be required to perform a return demonstration by the Director of Nursing or the Staff Development Coordinator. The county health department was contacted, and messages left. The Medical Director was notified of the incident and affected residents and gave no new orders on 11/14/2023. Nurse #1 was immediately educated verbally and by demonstrating with return demonstration by the Regional Clinical Director, Director of Nursing, and Staff Development Coordinator, on 11/14/2023 on the following: The glucometer policy was put on every medication cart and shows the following procedure: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. 2. Perform Hand Hygiene 3. Explain the procedure to the resident. 4. Provide privacy. 5. Don gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) disinfectant wipes from container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions for the dry time. Allow the glucometer to air dry. 11. Discard disinfectant wipes in waste receptacle. 12. Perform hand hygiene. Education was provided to nurses and medication aides by the Director of Nursing on 11/14/2023 that each resident with a blood sugar order is to have their own individual glucometer. Any nurse or medication aide found to be sharing glucometers is subject to disciplinary action. The Staff Development Coordinator and Unit Managers bagged and labeled the 8 residents without personal glucometers and placed them on their side of the room. Completed on 11/14/2023. The immediate jeopardy was removed on 11/15/2023. The facility's credible allegation of immediate jeopardy removal was validated on 11/15/2023. The validation was evidenced by nurse observations and interviews conducted that include the required infection control practices for the use of glucometers. All nurses who were interviewed reported they had received the required in-service training and were made aware of the facility's policy to use individually assigned glucometers for each resident requiring blood glucose monitoring. The education included review of the facility's infection control policy, manufacturer instructions related to glucometer disinfection, and a return demonstration. The nurses reported they were informed each resident's individual glucometer was now stored in his or her room. The credible allegation was validated, and the immediate jeopardy was removed on 11/15/2023.

Based on resident, staff and physician interviews and record reviews the facility transferred a resident from the bed to the wheelchair in a lift. During this transfer the resident received a laceration on her leg that required stitches for 1 of 3 sampled residents. (Resident #1) The findings included: Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of two staff for transfers. Review of the Incident/Accident report, dated 1/25/19 and completed by LPN #1 at 2:00 pm revealed Resident #1 was transferred to a wheelchair by 2 (two) staff members using a mechanical lift when the resident's right leg bumped the foot pedal and sustained a laceration to right lower extremity (leg). Resident #1 was assessed by the facility physician then transported by Emergency Medical Services (EMS) to the hospital. Review of the care plan dated 2/27/18 and the Bedside Kardex for Resident #1 revealed the resident required a mechanical lift with 2 staff to move between surfaces and used a wheelchair for mobility. Review of the hospital emergency room record dated 1/25/19 revealed Resident #1 presented to the hospital emergency room with a semicircular shaped laceration inside the right lower leg, 18 centimeters long, which was closed with 19 sutures. Photos of the laceration before sutures were placed were included. An interview with Resident #1 was conducted on 2/13/19 at 11:00 am and 2/14/19 at 8:40 am. She stated she was transferred from her bed to the wheelchair by two nurse aides (NA) and a mechanical lift on 1/25/19. One NA was in front operating the lift and NA #1 was on the resident's right side. Resident #1 stated she was assisted into the lift from the bed and as she was being lowered into the wheelchair, she was slightly swaying back and forth. She then felt pressure and yelled out. During the transfer, her right leg hit something which resulted in a cut to her right lower leg. Resident #1 stated she did not see what caused the cut to her leg. She stated the doctor was in the building and he came to look at her leg. She was transported to the hospital emergency room (ER) where her leg was sewed up. Resident #1 stated the pedals on the W/C were out to the side and the metal part of the foot rest hit her leg. She shared photos of the C-shaped laceration with sutures noted. An interview with NA #1 was conducted on 2/13/19 at 2:57 pm. NA #1 was one of 2 nurse aides who transferred Resident #1 at the time of the injury. NA #1 stated the facility requires 2 (two) people to transfer a resident using a mechanical lift. NA#1 stated that she and another NA got Resident #1 up using the mechanical lift. Resident #1 was positioned into the wheelchair and then repositioned while still in the sling. When Resident #1 was lowered back into the wheelchair is when the laceration of the right lower leg occurred. NA #1 stated she was not sure what cut Resident #1's leg. NA #1 stated that prior to the incident, she was verbally instructed to make sure the area was clear when Resident #1 was transferred. NA #1 stated that after the incident, she attended training which instructed her how to transfer Resident #1 using a mechanical lift. On 2/13/19 at 6:15pm, a call was made to the second nurse aide, who assisted NA #1 with the transfer of Resident #1 on 1/25/19. The second nurse aide failed to return the call. An interview with the Director of Nursing (DON) was conducted on 2/14/19 at 9:07 am. The DON stated she reviewed the incident report. The DON further stated that, during the facility's investigation, she checked the lift and maintenance checked the wheelchair. The DON nor maintenance saw any blood anywhere on the wheelchair to indicate what the resident's leg hit. The DON stated that after the incident, she initiated a Performance Improvement Plan which instructed the nurse aides not to obstruct a transfer when using a mechanical lift. The DON stated the resident's leg hit something that caused the injury during the transfer. The DON stated this was an isolated event and she had not identified anything that the staff could have done differently to have prevented the injury. An interview with RN #1, who was working the unit at the time of the incident, was conducted on 2/14/19 at 9:30 am. RN #1 confirmed she completed the incident report but did not witness the incident. An interview with the facility physician was conducted on 2/14/19 at 11:14 am. He confirmed he was familiar with Resident #1 and he assessed the laceration shortly after the incident occurred. The physician stated that Resident #1 denied she felt anything touch her leg when the injury occurred. Resident #1 has a [DIAGNOSES REDACTED]. He stated the contact with the resident's lower leg had to have been very quick with a sharp or [MEDICATION NAME] object. He stated that the incident was accidental and, with Resident #1's diagnosis, the injury was the result of pressure and her leg coming into contact with something that caused the laceration. The physician further stated that the patient is very vocal and observant and there was no indication or warning that this injury could occur. An interview with the Administrator was conducted on 2/14/19 at 1:00 pm. The Administrator stated they had completed an investigation of the incident that occurred on 1/25/19 and determined that they were not able to identify how the resident was injured and that the incident was an accident.

Based on record review, staff interviews and resident interview the facility failed to prevent neglect by not providing mental health services for 1 of 1 residents (Resident #189) who voiced feelings of depression and exhibited signs and symptoms of anxiety. Findings included: Resident #189 was admitted to the facility initially on 4-25-18 and then readmitted [DATE] after a 5-day hospital stay. Resident #189 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that resident #189 was moderately cognitively intact and had feelings of depression 12-14 days, feeling tired 7-11 days and a poor appetite 7-11 day. During an interview with Resident #189 on 5-15-18 at 10:21am she expressed feeling helpless because she was no longer as independent. The resident was tearful and stated she cried every day. She denied speaking to anyone about her feelings since she was admitted to the facility. An interview with the nursing assistant (NA#3) occurred on 5-16-18 at 10:10am and she stated that Resident #189 cried a lot and that the resident seemed anxious. The NA stated when she observed those behaviors she reported them to the nurse. Resident #189 was observed on 5-17-18 at 9:40 where she was found to be fidgeting in her bed, eyes were darting around the room and she was complaining of not being able to breath. The nurse (#4) was interviewed on 5-17-18 at 9:43am and she stated the resident's oxygen level was at 98% and that Resident #189 yells out all day she cannot breathe. The nurse went on to state she felt the resident was having psychological issues but denied that a mental health consultation was ever ordered. Nurse #4 also stated she had been informed by the nursing assistant of the resident crying at times and that she would talk with the resident and try to help her. She stated she or the nurse manager could have spoken to the physician and obtained an order for [REDACTED].>An interview with the Administrator occurred on 5-17-18 at 5:30pm who stated she expected her staff to follow the guidelines that were set by the Center for Medicare and Medicaid services and provide appropriate services to the residents.

Based on record review, staff interviews and resident interview the facility failed to provide mental health services for 1 of 1 residents (Resident #189) who voiced feelings of depression and exhibited signs and symptoms of anxiety. Findings included: Resident #189 was admitted to the facility initially on 4-25-18 and then readmitted [DATE] after a 5-day hospital stay. Resident #189 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that resident #189 was moderately cognitively intact and had feelings of depression 12-14 days, feeling tired 7-11 days and a poor appetite 7-11 day. The care plan dated 5-15-18 did not reveal any goals or interventions for mental health services. During an interview with Resident #189 on 5-15-18 at 10:21am she expressed feeling helpless because she was no longer as independent. The resident was tearful and stated she cried every day. She denied speaking to anyone about her feelings since she was admitted to the facility. The MDS nurse was interviewed on 5-15-18 at 10:30am and she stated the resident should have been care planned for mental health services by the Social Worker. Resident #189's medical record did not reveal any order or consultation for mental health services. An interview with the nursing assistant (NA#3) occurred on 5-16-18 at 10:10am and she stated that Resident #189 cried a lot and that the resident seemed anxious. The NA stated when she observed those behaviors she reported them to the nurse. In an interview on 5-16-18 at 12:00pm, the Social Worker stated she just started at the facility and was unaware of the resident's issues but that she would talk with the resident. Resident #189 was observed on 5-17-18 at 9:40 where she was found to be fidgeting in her bed, eyes were darting around the room and she was complaining of not being able to breath. The nurse (#4) was interviewed on 5-17-18 at 9:43am and she stated the resident's oxygen level was at 98% and that Resident #189 yells out all day she cannot breathe. The nurse went on to state she felt the resident was having psychological issues but denied that a mental health consultation was ever ordered. Nurse #4 also stated she had been informed by the nursing assistant of the resident crying at times and that she would talk with the resident and try to help her. She stated she or the nurse manager could have spoken to the physician and obtained an order for [REDACTED].>An interview with the Administrator occurred on 5-17-18 at 5:30pm who stated she expected her staff to follow the guidelines that were set by the Center for Medicare and Medicaid services and provide appropriate services to the residents.

Based on record review, staff interviews, and physician interviews, the facility failed to accurately transcribe a physician's order resulting in a significant medication error for 1 of 3 sampled residents receiving [MEDICATION NAME] (Resident #64), an oral anticoagulant medication. Immediate Jeopardy began on 8/18/15. At that time, Resident #64 re-entered the facility after a short hospital stay. Upon his return to the facility, [MEDICATION NAME] was omitted during the reconciliation and transcription of orders from the hospital discharge medication list. Resident #64 had been on chronic anticoagulation due to a history of [MEDICAL CONDITION] embolism. At the time of the survey investigation, the omission of [MEDICATION NAME] had not yet been identified by the facility. Immediate Jeopardy was removed on 10/8/15 at 7:15 PM. The facility remained out of compliance at a lower scope and severity of (D), an isolated deficiency with potential for more than minimal harm, while the facility completed the staff training required. The facility was in the process of monitoring the implementation of their correction action. The findings included: Resident #64 was admitted to the facility on [DATE] from an acute care hospital. His cumulative [DIAGNOSES REDACTED]. A review of the 8/6/15 admission orders [REDACTED]. A review of Resident #64 ' s medical record included the following Physician ' s Notes which read, in part: 8/10/15 (Authored by the Nurse Practitioner or NP): PLAN: [MEDICAL CONDITION] embolism and infarction, other continue [MEDICATION NAME] as ordered, adjust dosage based on INR (International Normalized Ratio) results, goal 2-3, monitor PT ([MEDICATION NAME] time)/INR weekly. 8/12/15 (Authored by the Medical Doctor or MD): History of Present Illness (HPI): [MEDICAL CONDITION]: The patient developed painful red rash behind his right knee. He was on [MEDICATION NAME]. He was placed on IV Abs (intravenous antibiotics) and transitioned to POs (oral medications). He is here for rehab (rehabilitation) and continued chronic disease management. PTE (pulmonary [MEDICAL CONDITION] embolism) in 2008 and placed on lifelong [MEDICATION NAME]. PLAN: Personal history of [MEDICAL CONDITION] embolism. Will monitor. No change in current treatment plan. A review of the Resident #64 ' s Admission MDS dated [DATE] revealed the resident had intact cognitive skills for daily decision making. He required extensive assistance with all Activities of Daily Living (ADLs) with the exception of supervision with eating. The assessment indicated Resident #64 received an anticoagulant on 7 of 7 days during the look back period. A review of the resident ' s 8/13/15 Care Area Assessments included the topic of Circulatory/Heart and a notation which read, History of PE in 2008 on chronic anticoagulation Resident #64 ' s Care Plan dated 8/13/15 included an area of focus entitled Bleeding Risk. The Care Plan problem addressed the resident ' s risk for increased bleeding, bruising or injury related to the use of anticoagulant therapy and noted the resident was receiving [MEDICATION NAME]. Further review of Resident #64 ' s medical record revealed laboratory results were collected and reported on 8/14/15. The lab work included an INR = 5.35. This value was noted as a critical result. Review of the resident ' s medical record revealed a Physician Orders was received on 8/14/15 which instructed, DC (discontinue) current [MEDICATION NAME]. PT/INR on 8/15/15. A review of Resident #64 ' s August 2015 Medication Administration Record [REDACTED]. Additional laboratory results were collected and reported on 8/15/15 as ordered. The lab work included an INR=5.94. A notation was hand-written on the lab report which read, Recheck PT/INR on 8/17/15. On 8/15/15, a Physician Order was received for a PT/INR to be completed on 8/17/15. A review of the Nursing Progress notes written on 8/16/15 at 5:25 PM revealed Resident #64 appeared to experience a change in behavior. The Nurse Practitioner was notified by telephone and a Physician ' s Order was received to send Resident #64 to the hospital emergency room (ER) for evaluation and treatment. A review of the Nursing Progress notes for Resident #64 included the following notation: 8/16/15 at 6:15 PM: EMT (Emergency Medical Team) arrived to the facility to take the Resident to the ER and the resident refused to go to the ER. The resident states he feels fine and he hates to go to the hospital. EMT talked with resident and evaluated him. Resident still refuses to go to the ER. Notified resident emergency contact that he refused. On 8/17/15, laboratory results were collected and reported as ordered by the physician. The resident ' s INR=2.28. A notation hand-written dated 8/18/15 was written on the lab report which read, Hospital. A review of the resident ' s Nursing Progress notes included the following, in part: 8/17/15 at 7:00 PM: . ' Resident ' s sister told the resident that she felt he should go to the ER to be evaluated. The resident told this nurse that he wanted to go to the ER. This nurse called the on-call NP and received NO (new order) to send resident to the ER for eval (evaluation) and treat (treatment) . 8/17/15 at 7:30 PM: Resident left the facility via stretcher and 2 EMT attendants. Resident #64 was admitted to the hospital on [DATE] at 8:35 PM with an altered mental status. He was discharged back to the facility on [DATE]. A review of the resident ' s 8/18/15 Hospital Records included the following, in part: Assessment and Plan: 2. History of PE in 2008, on chronic anticoagulation with [MEDICATION NAME] ([MEDICATION NAME]) at 14 mg per day based on the previous discharge. We will continue the patient on the [MEDICATION NAME] at 14 mg, check the daily PT/INRs. Today, the INR is 1.83. We will follow up the daily INR on the patient and increase the dose, or titrate the dose, to an INR of 2-3. Resident #64 returned to the facility on [DATE]. A review of the hospital ' s Discharge Medication list dated 8/18/15 instructed the resident to Continue these medications which have not changed, and included 14 mg [MEDICATION NAME] given once daily within this list of medications. The Discharge Medication list was signed by the NP and included a hand-written notation which read: Check PT/INR weekly. A review of Resident #64 ' s August 2015 MAR indicated [REDACTED]. The medical record revealed no orders had been transcribed for either the [MEDICATION NAME] or the weekly PT/INR checks on this date. A review of Resident #64 ' s medical record included the following Physician ' s Notes which read, in part: 9/7/15 (Authored by the MD): HPI: PTE in 2008 and placed on lifelong [MEDICATION NAME]. Plan: Personal history of [MEDICAL CONDITION] embolism: Will monitor. No change in current treatment plan. A review of Resident #64 ' s September 2015 and October 2015 MARs revealed [MEDICATION NAME] was not listed as a medication ordered or administered to the resident. A telephone interview was conducted on 10/6/15 at 8:17 AM with the resident ' s MD at the facility. After a review of the resident ' s history and stay at the facility, the physician acknowledged there was a failure to re-initiate [MEDICATION NAME] upon his return from the hospital on [DATE]. The MD stated the omission was likely due to a transcription error at the facility. Upon inquiry, the MD reported he had thought the resident was still on [MEDICATION NAME] to date and stated, The doctors before me recommended lifelong [MEDICATION NAME] and I did not mess with it. On 10/6/15, a Physician ' s Telephone Order was received from the resident ' s MD to re-initiate 14 mg [MEDICATION NAME] given once daily and to check his INR on 10/7/15. On 10/6/15 at 10:00 AM, an interview was conducted with Resident #64. During the interview, the resident stated when he came back from the hospital on [DATE] there was a problem with some of his medications, including [MEDICATION NAME]. However, he reported the problem had been resolved and all of his medications were re-started. When asked specifically about his [MEDICATION NAME], the resident stated he had a PE in 2008 and expected to be on [MEDICATION NAME] his entire life. The resident indicated he thought he was currently receiving [MEDICATION NAME] at the facility. An interview was conducted on 10/6/15 at 10:05 AM with Nurse #2. Nurse #2 assumed responsibilities as a Unit Coordinator for the facility. During the interview, the process followed for obtaining and transcribing re-admission orders [REDACTED]. Nurse #2 reported if the resident returning to the facility had been out to the hospital for less than 24-hours, the staff would not need to do a full admission upon his/her return. However, she stated the hospital may still have sent admission orders [REDACTED]. Upon inquiry, the Unit Coordinator stated that the nurse who admitted the resident back to the facility (the hall nurse) would be responsible for completing this task. Upon review of Resident #64 ' s medical record, the Unit Coordinator identified Nurse #6 as the nurse who was on duty at the time the resident came back into the facility on [DATE]. Upon further inquiry, the Unit Coordinator reviewed Resident #64 ' s chart and acknowledged the signed Discharge Medication list from the hospital dated 8/18/15 was intended to serve as the MEDICATION ORDERS FOR [REDACTED]. On 10/6/15 at 10:24 AM, Nurse #2 was joined by the Assistant Director of Nursing (ADON). At that time, both nurses reviewed Resident #64 ' s medical records, including his hospital discharge records, Nursing Progress notes, physician orders, and MARs. An interview was conducted with the ADON on 10/6/15 at 10:30 AM. When asked, the ADON stated her expectation would have been for the physician ' s order for [MEDICATION NAME] to have been verified by the nurse when the resident returned to the facility on [DATE]. She indicated the admission package from the hospital needed to be gone through thoroughly and any new orders transcribed and put on the MAR. The ADON said, The new order should have been transcribed, and specifically reported the [MEDICATION NAME] should have been re-initiated upon the resident ' s return to the facility on [DATE]. When asked what needed to be done now, the ADON stated the facility had received a Physician ' s Order earlier that morning to restart the resident ' s [MEDICATION NAME] (14 mg given once daily) and for a PT/INR. The ADON indicated she would need to inform the resident of the [MEDICATION NAME] omission which occurred upon his return from the hospital on [DATE]. On 10/06/15 at 12:12 PM, the facility ' s Administrator and Director of Nursing (DON) requested an interview to discuss the omission of [MEDICATION NAME] for Resident #64 ' s upon his return from hospital on [DATE]. During the interview, the Administrator stated, We realize this is a serious error. We had a system in place but we need to dig deeper now. Upon inquiry, the Administrator clarified the facility ' s process for resident admissions/re-admissions would need to be adjusted. A telephone interview was conducted on 10/6/15 at 12:14 PM with Nurse #6. Nurse #6 was the staff nurse assigned to care for Resident #64 when he returned from the hospital on [DATE]. The nurse reported she vaguely recalled accepting Resident #64 back from the hospital on that date and was unable to recall specifics related to the 8/18/15 readmission. Upon inquiry, the nurse discussed the general process employed to accept a resident back from a 24-hour hospital readmission. Nurse #6 reported when a resident came back from the hospital, she would take report from the hospital and review the paper work from EMS (Emergency Medical Service) to be sure there were no new orders for the resident. Upon inquiry, the nurse stated if there was a new medication order, the nurse would need to ensure it was written on the resident ' s MAR. A follow-up interview was conducted with Resident #64 on 10/7/15 at 9:00 AM. During the interview, the resident reported he was angry and disappointed about the situation. He indicated he was afraid the omission of [MEDICATION NAME] back in August and its re-initiation on 10/6/15 would postpone his anticipated discharge. The resident was scheduled to be discharged from the facility on 10/8/15. An interview was conducted on 10/7/15 at 2:30 PM with the DON. Upon inquiry, the DON reported a breakdown in the facility ' s process occurred after the hospital Discharge Medication list was faxed to the physician ' s office for verification. He indicated the medication list was signed but the order written for Resident #64 ' s [MEDICATION NAME] did not get transcribed into the resident ' s medical record or onto the MAR. During the interview, the DON also discussed the facility ' s process for reviewing or double-checking any new medication orders written for a resident. The DON reported he routinely completed a review of the Nursing 24-Hour Report, made notes on it, and gave it to the Unit Manager or staff nurse to follow-up and audit the chart as an accuracy check. On 8/19/15, the DON reported Nurse #8 was assigned to audit Resident #64 ' s re-admission orders [REDACTED]. He reported Nurse #8 was no longer employed by the facility; and, no contact information was available to reach Nurse #8 for an interview. Upon inquiry, the DON stated his expectation was that the staff would be educated on how to follow through the facility ' s process for accurately obtaining and transcribing medication orders. The facility ' s Administrator was notified of the Immediate Jeopardy on 10/6/15 at 3:30 PM. The following credible allegation of compliance was received on 10/8/15 at 3:39 PM: 1. A Medication Variance Report was completed by the Director of Nursing on 10/6/15 regarding [MEDICATION NAME] for Resident #64. Resident #64 and the Physician were notified of the Medication Variance Report by the Unit Manager on 10/6/15 and new orders were received for Resident #64 to begin [MEDICATION NAME] 14 mg daily and PT INR ordered for 10/7/15. A Skilled Nursing assessment was completed on 10/6/15 with no change in condition noted. Resident #64 is planning to discharge from the facility on 10/8/15 and Home Health has been arranged by the Director of Nursing to include PT INR monitoring. Resident #64 will receive medication as part of the orders for home health, including teaching and assessments, INR testing and education of resident utilizing own coagulant check machine and verification of accurate usage. 2. 100% of all resident records were audited by the Director of Nursing, Assistant Director of Nursing, and Unit Manager for significant medications as well as all medication transcriptions in order to validate accurate transcription of physician ' s orders including hospital admission and readmission orders [REDACTED]. There were no variances in the auditing process with all audits collected and readily available to be viewed. These resident records were audited by the Director of Nursing, Assistant Director of Nursing, or Unit Manager to validate accurate transcription of orders for [MEDICATION NAME] as well as any significant medication upon admission. The process forthcoming will be a two (2) nurse-nurse check of all admission orders [REDACTED]. This process will continue the medical record audit weekly by the DON, ADON, and/or Unit Manager with two person nurse to nurse check of orders validating accuracy and timeliness. 3. Beginning on 10/6/15 Licensed Nurses will be re-educated by the Director of Nursing, Assistant Director of Nursing or Unit Manager regarding transcription of physician ' s orders. No Licensed Nurse shall work after 10/6/15 without receiving this re-education. Beginning on 10/6/15, newly hired Licensed Nurses will be educated, prior to beginning work in the resident care area, by the Director of Nursing, Assistance Director of Nursing as well as pharmacy manager, regarding transcription of physician ' s orders. Education regarding transcription of orders will include the review of the physician ' s orders received from the hospital by the Physician or Nurse Practitioner to confirm and then these orders will be transcribed by the Charge Nurse to the Medication Administration Record. This will be completed daily with two person nurse check. All transcription orders reviewed in clinical meeting each morning with chart to clinical meeting and validation of two nurse signatures/initials ensuring accuracy and completion. The Director of Nursing or the Assistant Director of Nursing will be responsible for reviewing these orders daily as part of the medication reconciliation to validate accurate transcription completed by the Charge Nurse. The Director of Nursing will review at clinical meeting all new admissions as well as re-admissions for accuracy and chart will be brought to the clinical meeting for Nurse to Nurse review and IDT review at clinical meeting. The Director of Nursing, Assistant Director of Nursing, and Unit Manager will be aware of admissions and re-admissions from the hospital through the admission process which includes acceptance of a referral by the Director of Nursing, receipt of discharge orders and discharge summary, including medications from hospital, faxing or giving a copy to the physician and/or nurse practitioner for acceptance and verification of physician and/or nurse practitioner ' s approval. Upon receipt of orders faxed back to the facility, the orders will be then faxed over to pharmacy to be filled and brought to the facility. The Medication Administration Record [REDACTED]. On 10/8/15 at 7:15 PM, the credible allegation of compliance was validated. The survey team confirmed orders for the [MEDICATION NAME] management and monitoring with Home Health were in place; the facility implemented an auditing process to validate accurate transcription of hospital admission and readmission physician orders; and, had educated nursing staff on a two (2) nurse-nurse check of all admission and readmission orders [REDACTED]

Based on record reviews, staff interviews, consultant pharmacist and physician interviews, the consultant pharmacist failed to report an irregularity related to medication order transcription and the omission of Coumadin (an oral anticoagulation medication) prescribed for 1 of 3 residents reviewed receiving an anticoagulant (Resident #64). Immediate Jeopardy began on 8/18/15. Resident #64 re-entered the facility on 8/18/15 after a short hospital stay. Upon his return to the facility, Coumadin was omitted during the reconciliation and transcription of orders from the hospital discharge medication list. A Medication Regimen Review (MRR) completed by the consultant pharmacist on 9/11/15 failed to identify the transcription error and omission of Coumadin. Immediate Jeopardy was removed on 10/8/15 at 7:15 PM. The facility remained out of compliance at a lower scope and severity of (D), an isolated deficiency with potential for more than minimal harm. The facility was in the process of monitoring the implementation of their correction action. The findings included: A review of the facility ' s Pharmacy Consultant Agreement (Effective 4/1/2003) included a listing of consultant pharmacist ' s services which included, in part: Consultant shall perform monthly drug regimen reviews (also known as a Medication Regimen Review) and provide written reports of these reviews to the facility Administrator, Medical Director, Director of Nursing, and all residents' physicians. Such written reports must include a standardized monthly report (a form of which will be provided to consultant). The standardized monthly report will include documentation of compliance with federal regulations and guidelines, the outcome of a drug regimen review (e.g., review of unnecessary drug requirements, psychoactive drug use and compliance, medication laboratory orders, adverse drug reactions, interactions and allergies [REDACTED]. Resident #64 was admitted to the facility on [DATE] from an acute care hospital. His cumulative [DIAGNOSES REDACTED]. A review of the 8/6/15 admission orders [REDACTED]. A review of Resident #64 ' s medical record included the following Physician ' s Notes which read, in part: 8/10/15 (Authored by the Nurse Practitioner or NP): PLAN: Pulmonary embolism and infarction, other continue Coumadin as ordered, adjust dosage based on INR (International Normalized Ratio) results, goal 2-3, monitor PT (prothrombin time)/INR weekly. 8/12/15 (Authored by the Medical Doctor or MD): History of Present Illness (HPI): Cellulitis: The patient developed painful red rash behind his right knee. He was on Coumadin. He was placed on IV Abs (intravenous antibiotics) and transitioned to POs (oral medications). He is here for rehab (rehabilitation) and continued chronic disease management. PTE (pulmonary thrombotic embolism) in 2008 and placed on lifelong Coumadin. PLAN: Personal history of pulmonary embolism. Will monitor. No change in current treatment plan. Further review of the resident ' s medical record revealed the facility ' s consultant pharmacist completed an initial Medication Regimen Review (MRR) on 8/13/15. The review included a notation to check Resident #64 ' s INR. Further review of Resident #64 ' s medical record revealed laboratory results were collected and reported on 8/14/15. The lab work included an INR = 5.35. This value was noted as a critical result. Review of the resident ' s medical record revealed a Physician order [REDACTED]. PT/INR on 8/15/15. A review of Resident #64 ' s August 2015 Medication Administration Record [REDACTED]. Additional laboratory results were collected and reported on 8/15/15 as ordered. The lab work included an INR=5.94. A notation was hand-written on the lab report which read, Recheck PT/INR on 8/17/15. On 8/15/15, a Physician order [REDACTED]. On 8/17/15, laboratory results were collected and reported as ordered by the physician. The resident ' s INR=2.28. A notation hand-written dated 8/18/15 was written on the lab report which read, Hospital. Resident #64 was admitted to the hospital on [DATE] at 8:35 PM with an altered mental status. He was discharged back to the facility on [DATE]. A review of the resident ' s 8/18/15 Hospital Records included the following, in part: Assessment and Plan: 2. History of PE in 2008, on chronic anticoagulation with warfarin (Coumadin) at 14 mg per day based on the previous discharge. We will continue the patient on the Coumadin at 14 mg, check the daily PT/INRs. Today, the INR is 1.83. We will follow up the daily INR on the patient and increase the dose, or titrate the dose, to an INR of 2-3. Resident #64 returned to the facility on [DATE]. A review of the hospital ' s Discharge Medication list dated 8/18/15 instructed the resident to Continue these medications which have not changed, and included 14 mg Coumadin given once daily within this list of medications. The Discharge Medication list was signed by the NP and included a hand-written notation which read: Check PT/INR weekly. A review of Resident #64 ' s August 2015 MAR indicated [REDACTED]. The medical record revealed no orders had been transcribed for either the Coumadin or the weekly PT/INR checks on this date. A review of Resident #64 ' s medical record included the following Physician ' s Notes which read, in part: 9/7/15 (Authored by the MD): HPI: PTE in 2008 and placed on lifelong Coumadin. Plan: Personal history of pulmonary embolism: Will monitor. No change in current treatment plan. Further review of the resident ' s medical record revealed the consultant pharmacist completed an MRR on 9/11/15. The pharmacist ' s MRR indicated the resident was readmitted to the facility on [DATE]. The omission of Coumadin from the resident ' s medication regimen was not addressed with the text of the review. A review of Resident #64 ' s September 2015 and October 2015 MARs revealed Coumadin was not listed as a medication ordered or administered to the resident. A telephone interview was conducted on 10/6/15 at 8:17 AM with the resident ' s MD at the facility. After a review of the resident ' s history and stay at the facility, the physician acknowledged there was a failure to re-initiate Coumadin upon his return from the hospital on [DATE]. The MD stated the omission was likely due to a transcription error at the facility. Upon inquiry, the MD reported he had thought the resident was still on Coumadin to date and stated, The doctors before me recommended lifelong Coumadin and I did not mess with it. On 10/6/15, a Physician ' s Telephone Order was received from the resident ' s MD to re-initiate 14 mg Coumadin given once daily and to check his INR on 10/7/15. An interview was conducted on 10/6/15 at 3:15 PM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported the facility ' s consultant pharmacist did not make a Consultation Report with concerns or recommendations specific to Resident #64 in either August 2015 or September 2015. A telephone interview was conducted with the facility ' s consultant pharmacist on 10/6/15 at 3:58 PM. During the interview, the consultant pharmacist confirmed she had reviewed Resident #64 ' s pharmacy records for the months of August, September and October 2015. She reported the records showed Resident #64 had orders for Coumadin through 8/17/15; and, the Coumadin had not been re-ordered for the resident after 8/17/15. Upon inquiry, the pharmacist indicated she did not have a record of having made any recommendations specific to Resident #64 during her August 2015 or September 2015 consultation visits. The pharmacist indicated she apparently had missed the Coumadin transcription error at the time of her September 2015 review. A follow-up interview was conducted with the consultant pharmacist on 10/07/2015 at 10:08 AM. During the interview, the pharmacist stated she reviewed Resident #64 ' s medical record to identify how she had missed the Coumadin transcription error and omission of the medication at the time of her 9/11/15 review. The consultant reported she must have assumed the medications listed as continued on the 8/18/15 hospital Discharge Medication list were continued at the facility and indicated she apparently focused on the medications noted as changed. She concluded the Coumadin may have been overlooked since it was not listed as a medication change for the resident. An interview was conducted on 10/7/15 at 2:30 PM with the DON. Upon inquiry, he indicated his expectation as a DON was for the pharmacy (and consultant pharmacist) to help the facility put a process in place to promote the accuracy of medications administered to its residents. The DON stated he expected the pharmacy and pharmacist, To be our check and balance system and second set of eyes. The facility ' s Administrator was notified of the Immediate Jeopardy on 10/6/15 at 3:30 PM. The following credible allegation of compliance was received on 10/8/15 at 3:39 PM: 1. A Medication Variance Report was completed by the Director of Nursing on 10/6/15 regarding Coumadin for Resident #64. Resident #64 and the Physician were notified of the Medication Variance Report by the Unit Manager on 10/6/15 and new orders were received for Resident #64 to begin Coumadin 14 mg daily and PT INR ordered for 10/7/15. A Skilled Nursing assessment was completed on 10/6/15 with no change in condition noted. The Pharmacy consultant completed a review on 10/7/15 which outlines the events resulted in the Coumadin medication variance for Resident #64. The review record was faxed to the pharmacy manager at the provider company for his review and was re-faxed back to the facility with the pharmacy manager signature. 2. Current records for residents receiving Coumadin and significant medications will be audited by the Director of Nursing and the Consultant Pharmacist weekly to validate the completion of pharmacist review and recommendations regarding Coumadin and significant medication administration. This audit will be completed on 10/7/15. The Pharmacy Consultant ' s report was reviewed for accuracy by the Pharmacy Manager on 10/8/15 via faxsimile. 3. On 10/7/15 the Consultant Pharmacist was be re-educated by the District Director of Clinical Services regarding the requirements of F428, to include the review of residents receiving Coumadin and recommendations for monitoring. The facility investigation revealed that both the nurse and the pharmacy consultant did not discover the transcription error. The medication from the hospital have been compared and reviewed with the current medications with no changes noted. In investigating the process, it was discovered that the nurse as well as the pharmacy consultant had not noted the transcription error. The pharmacy consultant will review medications from the hospital as well as the current medications in the facility. Beginning on 10/7/15, all newly hired Pharmacy Consultants will be educated prior to beginning work in the resident care area, by the Director of Nursing and the pharmacy manager regarding the requirement of F428, to include the review of residents receiving Coumadin and recommendations for monitoring current medications and hospital information. The new pharmacy consultants will be educated by the facility Director of Nursing and/or designee as well as the pharmacy manager at the pharmacy provider office which will include review of hospital information. The Director of Nursing will be responsible to ensure the Pharmacy Manager reviews the Pharmacy Consultants recommendations for residents receiving Coumadin and significant medications weekly. The pharmacy consultant will being completing weekly reviews until the deficient practice is resolved. The Director of Nursing will fax weekly consulting pharmacy review and or recommendations to the pharmacy manager for review who will initial each pharmacy recommendation and review. Starting the week of October 12 and continuing weekly, it has been agreed and necessary that the pharmacy consultant visit the facility weekly until safe practice has been resolved and demonstrated. On 10/8/15 at 7:15 PM, the credible allegation of compliance was validated. The survey team confirmed Resident #64 ' s Pharmacist MRR dated 10/7/15 was reviewed and signed by the Pharmacy Manager; and, the facility and consultant pharmacist implemented an auditing process to validate completion of pharmacist reviews and recommendations regarding Coumadin and signification MEDICATION ORDERS FOR [REDACTED] .

Based on observations, record reviews, physician interview, and staff interviews the facility's Quality Assessment and Assurance Committee failed to implement, monitor and revise as needed the action plan developed for the recertification survey dated 11/6/14 and the complaint investigation dated 5/20/15 in order to achieve and sustain compliance. The facility had a pattern of repeat deficiencies on significant medication errors (F333) from the recertification survey of 11/6/14 and, again, on the current recertification survey. The facility also had a pattern of repeat deficiencies on the posting of nurse staffing information (F356) from the recertification survey of 11/6/14, a complaint investigation survey of 5/20/15, and again, on the current recertification survey. The findings include: Example 1) This tag is cross referenced to F333: Residents Are Free of Any Significant Medication Errors. Based on record review, staff interviews, and physician interviews, the facility failed to accurately transcribe a physician's orders [REDACTED].#64), an oral anticoagulant medication. Immediate Jeopardy began on 8/18/15. Resident #64 re-entered the facility on 8/18/15 after a short hospital stay. Upon his return to the facility, [MEDICATION NAME] was omitted during the reconciliation and transcription of orders from the hospital discharge medication list. Resident #64 had been on chronic anticoagulation due to a history of [MEDICAL CONDITION] embolism. At the time of the survey investigation, the omission of [MEDICATION NAME] had not yet been identified by the facility. Immediate Jeopardy was removed on 10/8/15 at 7:15 PM. The facility remained out of compliance at a lower scope and severity of (D), an isolated deficiency with potential for more than minimal harm, while the facility completed the staff training required. The facility was in the process of monitoring the implementation of their correction action. During the recertification survey of 11/6/14, the facility was cited for F333 for failing to administer [MEDICATION NAME] (an antiarrhythmic medication) to a resident as ordered by the physician; and, failing to administer the correct dosage of [MEDICATION NAME] (an antipsychotic medication) to a resident in accordance with the physician's order [REDACTED]. An interview was conducted on 10/8/15 at 5:37 PM with the facility ' s Administrator. The Administrator reported he assumed responsibility as the Quality Assessment and Assurance (QAA) contact person. He noted there has been a change of staff over the past few months and indicated that he started in his position approximately 3 months ago. The Administrator reported shortly after starting his position, a complaint investigation survey on 7/8/15 identified facility non-compliance for pressure sores (F314), complete and accurate records (F514), and QAA (F520). In response to this complaint investigation survey, the frequency of QAA committee meetings had been increased from monthly to weekly. This was expected to continue until the Plan of Correction and compliance was ensured for the issues identified at that time. However, upon inquiry, the Administrator reported he was not aware of continuous QAA involvement specifically focused on the issue of significant medication errors at the facility. The facility ' s Administrator was notified of the Immediate Jeopardy on 10/6/15 at 3:30 PM. The following credible allegation of compliance was received on 10/8/15 at 3:39 PM. 1. On 10/7/15, the District Director of Clinical Services conducted re-education for the Administrator on the facility ' s Quality Assurance and Performance Improvement Program including meeting schedules, identification of trends or patterns, submission of data, and initiation of quality improvement plans related to identified areas of opportunity. All members of the Quality Assurance and Performance Improvement Committee submit data related to each department and participate in the identification of areas in need of improvement. 2. On 10/7/15, the Administrator and the Quality Assurance Committee were retrained on the Quality Assurance & Performance Improvement Program. This training was completed by the District Director of Clinical Services and the District Director of Operations. . The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director 3. The Administrator and the Director of Nursing will present the results of all audits of transcription of physician's order [REDACTED]. The next Quality Assurance & Performance Improvement meetings will be conducted weekly for four weeks, then monthly with oversight by District Director of Clinical Services for three months. On 10/8/15 at 7:15 PM, the credible allegation of compliance was validated. The survey team confirmed the facility ' s Quality Assurance Committee completed re-education and re-training on the facility ' s Quality Assurance and Performance Improvement Program, including meeting schedules, identification of trends, submission of data, and initiation of quality improvement plans related to the identified areas. Example 2) This tag is cross referenced to: F356 Nurse staffing information. Based on observations and staff interviews, the facility failed to indicate the resident census on the daily nursing services staff posting for various dates for 6 months, which included May 2015 through October 8, 2015. This tag was cited at a Scope/Severity of C (a widespread deficiency that constitutes no actual harm with potential for no more than minimal harm). During the recertification survey of 11/6/14, the facility was cited for F356 for failing to post accurate nurse staffing information. On a complaint investigation survey of 5/20/15, the facility was recited for failing to include census information on the posted nurse staffing information. On the current recertification survey, the facility was again recited for failing to include the resident census data on the daily posting of nurse staffing information. An interview was conducted on 10/8/15 at 5:37 PM with the facility ' s Administrator. The Administrator reported he assumed responsibility as the Quality Assessment and Assurance (QAA) contact person. He noted there has been a change of staff over the past few months and indicated that he started in his position approximately 3 months ago. The Administrator reported shortly after starting his position, a complaint investigation survey on 7/8/15 identified facility non-compliance for pressure sores (F314), complete and accurate records (F514), and QAA (F520). In response to this complaint investigation survey, the frequency of QAA committee meetings had been increased from monthly to weekly. This was expected to continue until the Plan of Correction and compliance was ensured for the issues identified at that time. However, upon inquiry, the Administrator reported he was not aware of continuous QAA involvement specifically focused on the issue of significant medication errors at the facility.

Based on observation, record review, staff and physician interview, the facility failed to consistently assess a resident ' s skin integrity for a resident who developed a sacral pressure ulcer after being admitted to the facility (Resident #1), failed to assess and treat pressure ulcers for one of four residents (Resident #3) and failed to provide pressure ulcer treatment as ordered by the physician for two of four residents reviewed for pressure ulcers (Resident#3 and #5). The findings included: 1. Resident #1 was admitted to the facility from home on 3/31/15 and readmitted to the facility following a hospitalization [DATE] to 4/16/15. Cumulative diagnoses, on admission, included: debility, dementia, right BKA [MEDICAL CONDITION] with residual right sided weakness and [MEDICAL CONDITION] with suprapubic catheter (urinary catheter with opening in the abdomen). An Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was moderately impaired in cognition. He required extensive assistance of 2 people for bed mobility and transfers. Extensive assistance of one person was needed for dressing, toilet use and personal hygiene. Set up assistance was needed for eating. Total assistance was required for bathing. Balance impaired and only able to stabilize with staff assistance for moving on and off the toilet and surface to surface transfer. Resident had an indwelling catheter and was frequently incontinent of bowel. The assessment indicated he was not at risk for pressure ulcers and no unhealed pressure ulcers noted during the assessment period. A review of the nursing admission assessment dated [DATE] indicated admitting [DIAGNOSES REDACTED]. It was documented that Resident #1 had a pressure area to his sacral (buttocks) area and a wound to his left heel. An admission intake form for predicting pressure sore risk dated 4/16/15 indicated locations of skin conditions/ wounds as sacral area (closed) and left heel wound. A care plan dated 4/16/15 indicated Resident #1 had a stage 4 pressure ulcer ( necrotic tissue-black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges) to his left heel. Approaches included; apply pressure reduction mattress to bed; reposition in chair frequently for comfort and pressure reduction; turn and reposition while in bed frequently for comfort and pressure reduction. Measure and stage wound weekly using the pressure ulcer healing assessment form. Complete a full body check weekly and document. Pressure ulcer treatment as ordered. Weekly skin assessments were reviewed and revealed the following: 4/3/15 skin intact-yes; 4/17/15 skin intact-yes. No previously identified areas; 4/24/15 No mention of a pressure ulcer on the sacral/ coccyx area; 5/6/15 skin assessment noted an old area at the base of coccyx with no description of the area; 5/12/15 no mention of a pressure ulcer on the sacral/ coccyx area; 5/20/15 No skin assessment was documented. A nursing note dated 5/26/15 stated Resident ' s left heel was elevated, floating off mattress. The wound to the heel was odorous. A new order was noted and initiated due to wound to right and left buttocks. No further description of the wound to the right and left buttocks as documented. A physician order dated 5/26/15 indicated a buttock wound. Clean with normal saline. Apply (name) [MEDICATION NAME] ointment nickel thick and secure with dry dressing daily. A nursing note dated 5/27/15 stated Resident #1 had a decubitus ulcer on buttock with some blackened tissue. A physician wound care note 5/28/15 indicated Resident #1 was being followed for lower coccyx wound which the physician noted as unstageable (due to necrosis) of the lower coccyx of at least 1 day duration. Moderate serous exudate (drainage) was associated with the wound. The pressure area measured 10 centimeters (cm) x 10 cm. with 90% thick adherent devitalized necrotic (black) tissue and 10% granulation tissue (pink or red tissue with shiny, moist granular appearance). A physician order dated 5/28/15 indicated to cleanse the lower coccyx with normal saline. Apply (name) [MEDICATION NAME] ointment and calcium alginate with dry dressing daily and as needed. Air mattress. Gel cushion to chair. A review of the Medication Administration Records and treatment Administration Records revealed there were no preventative measures noted in April or May for the sacral/ coccyx area until the orders noted by the physician on 5/26/15. An observation of the pressure ulcers for Resident #1 was not conducted due to the fact Resident #1 was no longer at the facility. On 7/2/15 at 9:05AM, an interview was conducted with Nurse #1 who stated she was the nurse who readmitted Resident#1 on 4/16/15. She stated, when a resident was admitted to the facility, a body/ skin assessment is done and the findings were documented on the pressure sore risk form. She stated Resident #1 had a white/ pink area on his sacrum with unbroken skin on 4/16/15. On 7/2/15 at 9:2AM, nurse #2 stated Resident #1 was seen for his sacral pressure ulcer on 5/28/15 by the wound care physician who came to the facility. She stated she was the wound care nurse who went with the wound care physician when he made his weekly rounds. She stated she first saw Resident #1 ' s coccyx pressure ulcer on 5/28/15 when she viewed the area with the facility wound doctor. Nurse #2 stated the area was very reddened and large with black tissue noted. She staged the ulcer as a stage 4 pressure ulcer. She stated the nurses on the floor did the weekly skin checks and any areas of concern should be documented on the head to toe skin checks done weekly and also documented in the nursing notes. On 7/2/15 at 10:48AM, Administrative staff #1 stated the nurses on the floor were responsible for weekly skin checks. She said the nursing staff were expected to document skin assessments weekly; Administrative staff #1 stated she expected the nurse to notify the doctor and reach out to the wound care nurse for further assessment at the time the area was observed. On 7/2/15 at 11:48AM, a telephone interview was conducted with nurse #3. Nurse #3 stated she was responsible for the weekly skin assessments for Resident #1. She stated she did not perform a skin assessment the week of 5/20/15 and first saw the sacral pressure ulcer on 5/27/15. Nurse #3 did not indicate why she did not do the weekly skin assessment the week of 5/20/15. On 7/6/15 5:54PM, a telephone interview was conducted with the facility wound care physician. He stated he first saw the lower coccyx pressure ulcer on 5/28/15. The wound care physician stated he documented at least one day duration because that was the initial evaluation and that is how he documented the time frame. The wound care physician stated it would have been extremely unlikely that Resident 1 he would have developed an unstageable area in 24 hours and especially with the size of the area and the presence of necrotic (black) tissue. 2. a. Resident #3 was admitted to the facility 4/23/15 and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] indicated Resident #3 was severely impaired in cognition. He required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and total assistance with bathing. Resident #3 had impairment in functional range of motion for the lower extremities. He was frequently incontinent of urine and always incontinent of bowel. The resident was at risk for developing pressure ulcers and had two stage 3 pressure ulcers that were present upon admission, one stage 4 pressure ulcer that was present on admission, one unstageable pressure ulcer with slough and/or eschar (black tissue) that was present on admission and two unstageable deep tissue skin problems. The largest pressure ulcer which was staged as unstageable measured at 11.0 cm x 7.5 cm x 5.0 cm. Pressure ulcer care was checked as having been treated during the assessment period. A care plan dated 5/18/15 indicated Resident #3 had pressure ulcers of the sacrum/ bilateral ankles/ legs. Approaches included: reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinence episode, complete a full body check weekly and document, pressure ulcer treatment as ordered. The pressure ulcers on the heels was not specifically addressed in the care plan. A hospital discharge summary dated 6/8/15 indicated, in part, that Resident #3 had a stage 4 sacral pressure ulcer and stage 3 bilateral heel pressure ulcers. Discharge recommendations for the stage 4 sacral decubitus indicated to use (name) solution and (name) [MEDICATION NAME] ointment. No discharge treatment was recommended for the bilateral heel pressure ulcers. A Nursing admission intake form indicated Resident #3 was readmitted to the facility on [DATE]. A dry blister was noted to the side of the right great toe and bottom of the right great toe. Necrotic tissue was noted to the right ankle and inner left heel. Resident #3 had an ulcer on the right upper sacral area with a large area of beefy red tissue. [MEDICAL CONDITION] was noted in both feet. Physician ' s orders dated 6/8/15 indicated to use (name) solution and name ([MEDICATION NAME] ointment) to the sacral ulcer. No physician orders were noted for the treatment of [REDACTED]. Weekly pressure ulcer records of 6/9/15 were reviewed and revealed there was a pressure ulcer record completed on 6/9/15 for the sacral decubitus only. No weekly pressure ulcer record for the bilateral foot pressure ulcers on the heels and ankles was done on 6/9/15. A wound care physician note dated 6/16/15 stated Resident #3 had the following pressure ulcers: Unstageable (due to necrosis) of the left medial heel that measured 2.4 cm. x 2 cm. with light serous exudate with no change in the wound progress; stage 3 pressure wound of the right medial ankle that measured 0.9 cm x 0.7 cm x 0.1 cm depth with light serous exudate with wound improvement; stage 4 pressure wound of the left lateral ankle that measured 1.8 cm x 2.3 cm with light serous exudate with wound deterioration; stage 4 pressure wound of the coccyx that measured 8.8 cm x 4.4 cm x 4.2 cm depth with moderate serous exudate and 100% granulation tissue with improvement in wound; unstageable deep tissue injury of the right plantar foot that measured 1cm x 1.5 cm with wound progress unchanged; stage 3 pressure wound of the left plantar heel resolved on 6/16/15. The Medication Treatment Record and the Treatment Administration Record for June 2015 were reviewed and revealed no treatments were recorded until 6/16/15 when the wound doctor evaluated Resident #3 and ordered treatments for the bilateral foot ulcers (heels and ankles). An observation of pressure ulcer/ wound care was conducted on 7/1/15 at 2:10PM with Nurse #3. Resident #3 had a stage 4 sacral pressure ulcer, a stage 3 left ankle pressure ulcer, no open areas noted on the right heel and a stage 4 pressure ulcer on the left heel with black tissue and slough observed. During an interview on 7/2/15 at 2:45PM, Nurse #2 stated the expectation was that the nurse who identified any skin issues on admission should obtain the appropriate orders from the discharge summary. If there were no orders along with the discharge summary for the pressure ulcer area, they should contact the medical director and get orders and initiate treatment and interventions at that time. Nurse #2 stated she did an assessment on the coccyx on 6/9/15. Nurse #2 saw Nurse #4 ' s admission assessment on 6/9/15 and noted the bilateral foot ulcers (heels and ankles). She stated she informed Nurse #4 that she needed to follow through and obtain complete orders for what she had seen. Nurse #2 stated she realized there were no orders for treatment of [REDACTED]. Telephone attempts were made on 7/6/15, 7/7/15 and 7/8/15 to contact nurse #4 and were unsuccessful. Nurse #4 was no longer employed by the facility. b. Resident #3 was admitted to the facility 4/23/15 and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] indicated Resident #3 was severely impaired in cognition. He required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and total assistance with bathing. Resident #3 had impairment in functional range of motion for the lower extremities. He was frequently incontinent of urine and always incontinent of bowel. The resident was at risk for developing pressure ulcers and had two stage 3 pressure ulcers that were present upon admission, one stage 4 pressure ulcer that was present on admission, one unstageable pressure ulcer with slough and/or eschar (black tissue) that was present on admission and two unstageable deep tissue skin problems. The largest pressure ulcer which was staged as unstageable measured at 11.0 cm x 7.5 cm x 5.0 cm. Pressure ulcer care was checked as having been treated during the assessment period. A care plan dated 5/18/15 indicated Resident #3 had pressure ulcers of the sacrum/ bilateral ankles/ legs. Approaches included: reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinence episode, complete a full body check weekly and document, pressure ulcer treatment as ordered. The pressure ulcers on the heels was not specifically addressed in the care plan. A Nursing admission intake form indicated Resident #3 was readmitted to the facility on [DATE]. A dry blister was noted to the side of the right great toe and bottom of the right great toe. Necrotic tissue was noted to the right ankle and inner left heel. Resident #3 had an ulcer on the right upper sacral area with a large area of beefy red tissue. [MEDICAL CONDITION] was noted in both feet. A wound care physician note dated 6/16/15 stated Resident #3 had the following pressure ulcers: Unstageable (due to necrosis) of the left medial heel that measured 2.4 cm. x 2 cm. with light serous exudate with no change in the wound progress; stage 3 pressure wound of the right medial ankle that measured 0.9 cm x 0.7 cm x 0.1 cm depth with light serous exudate with wound improvement; stage 4 pressure wound of the left lateral ankle that measured 1.8 cm x 2.3 cm with light serous exudate with wound deterioration; stage 4 pressure wound of the coccyx that measured 8.8 cm x 4.4 cm x 4.2 cm depth with moderate serous exudate and 100% granulation tissue with improvement in wound; unstageable deep tissue injury of the right plantar foot that measured 1cm x 1.5 cm with wound progress unchanged; stage 3 pressure wound of the left plantar heel resolved on 6/16/15. Physician orders dated 6/16/15 stated the following orders for treatment of [REDACTED]. Apply (name) [MEDICATION NAME] ointment and calcium alginate daily to the sacral pressure ulcer. Physician orders dated 6/17/15 stated the wound was to the coccyx and not the sacral area. Cleanse with normal saline and apply (name) [MEDICATION NAME] ointment and calcium alginate daily. A review of the Treatment Administration Record (TAR) for July 2015 revealed the following: Coccyx-cleanse with normal saline, apply calcium alginate and (name) [MEDICATION NAME] ointment daily and as needed. On 7/1/15 at 2:10PM, an observation of pressure ulcer/ wound care for Resident #3 was conducted with Nurse # 3. Nurse #3 was observed to clean the coccyx pressure ulcer with normal saline. Nurse #3 applied the [MEDICATION NAME] ointment, packed the coccyx pressure ulcer with gauze and applied a foam dressing to the area. Nurse #3 did not apply the calcium alginate to the wound bed as ordered by the physician. On 7/2/15 at 11:46AM, Nurse #3 stated she did not apply calcium alginate to the coccyx pressure ulcer. She stated she thought the physician orders had been changed. Nurse #3 stated she always looked at the physician orders and treatments to make sure she did the treatment as ordered and thought she did the treatment as ordered. On 7/2/15 at 11:03AM, Administrative staff #1 stated she would complete a medication variance form and notify the doctor that the treatment was not done as ordered. She stated she expected nursing staff to do the treatment as the doctor has ordered. 3. Resident #5 was admitted to the facility 6/26/15. Cumulative [DIAGNOSES REDACTED]. A hospital discharge summary dated 6/26/15 stated, in part, that Resident #5 was discharged with a [DIAGNOSES REDACTED]. Change Wound Vac 3 x week (Monday-Wednesday-Friday). Clean ulcerations with antibacterial soap and water. Apply (name) [MEDICATION NAME] ointment ¼ inch thick to wound bed each dressing change prior to applying wound vac. A Nursing Admission intake form dated 6/26/15 stated Resident #5 had a Wound Vac to her right sacral area that was intact and had a small ulcer to her left elbow. An Interim care plan dated 6/26/15 indicated Resident #5 had a skin pressure ulcer due to mobility, history of ulcers, incontinence and nutritional impairment. Interventions initiated: provide wound care/ preventive skin care per order. Observe wound healing. Skin checks weekly per facility protocol, document findings. Notify physician of changes in wound or emerging wounds. Turn and reposition frequently to decrease pressure. A review of the medical record revealed there was not a Minimum Data Set (MDS) completed as of the time of the investigation. The Treatment records for June/ July 2015 were reviewed and revealed the following treatment for [REDACTED]. Change Monday-Wednesday-Friday to right buttocks. The treatment was noted as completed on 6/29/15, 7/1/15 and 7/3/15. On 7/6/15 at 10:37AM, an observation of pressure ulcer care was conducted with Nurse #5. Nurse #5 cleansed the area with normal saline and gauze pads. Then she applied foam padding and a closed clear plastic dressing before reapplying the Wound Vac at 125 mmHg negative pressure. Nurse #5 did not cleanse the area with antibacterial soap or apply [MEDICATION NAME] ointment prior to completing wound care. On 7/6/15 at 11:15AM, Nurse #5 stated nursing staff had been cleaning the ischial and sacral wounds with normal saline. She stated she did not realize the sacral wound had an order to cleanse with antibacterial soap and to [MEDICATION NAME] ointment. On 7/6/15 at 12:30PM, Administrative staff #1 stated she expected staff to check the treatment sheet prior to doing the treatment and to do what the order indicated. She said the nursing staff should have cleansed the area per physician order (antibacterial soap and water) and applied [MEDICATION NAME] ointment as ordered by the physician.

Based on observation, record review and staff interview, the facility ' s Quality Assessment and Assurance committee (QAA) failed to implement, monitor and revise as needed the action plan developed for the recertification survey dated 11/6/14 and the complaint investigation dated 5/20/15 in order to achieve and sustain compliance. The facility had a pattern of repeat deficiencies on pressure ulcer assessment and treatment (F314) on the recertification survey 11/6/14 and the complaint investigation 5/20/15. The facility also had a pattern of repeat deficiencies on maintaining complete and accurate treatment records on the follow-up/ complaint investigation survey dated 7/8/15 and the complaint investigation dated 5/20/15. The tag is cross referenced to F 314. Based on observation, record review, staff and physician interview, the facility failed to consistently assess a resident ' s skin integrity resulting in a resident sustaining a sacral pressure ulcer (Resident #1), failed to assess and treat pressure ulcers for one of four residents (Resident #3) and failed to provide pressure ulcer treatment as ordered by the physician for two of four residents reviewed for pressure ulcers (Resident#3 and #5). The tag is cross referenced to F 514. Based on medical record review and staff interview, the facility failed to maintain complete and accurate treatment records (TARS) for one of four sampled residents (Resident #2) as evidenced by treatments initialed as completed on the TAR but never completed. An interview was conducted with Administrative staff #1 on 7/2/15 at 11:03 AM. Administrative staff #1 stated she had given in-services regarding all aspects of care and treatment of [REDACTED]. She stated she had observed pressure ulcer care and stressed to the nursing staff the importance of checking the Treatment Administration Record (TAR) prior to administering care to ensure proper treatment was administered. Administrative staff #1 stated audits had been done for accuracy of documentation of pressure ulcer treatment care. She stated she did not know why the nursing staff failed to assess and/ or provide pressure ulcer care as ordered by the physician or obtain physician orders [REDACTED].

Based on record review, staff interviews, interviews with the Nurse Practitioner and the contracted Radiology Representative, the facility failed to obtain an X-Ray as ordered on [DATE] for the Right Hip. The facility X-Rayed the left hip when the order was to X-Ray the right hip. This was evident for 1 of 4 residents (Res. #3) who were reviewed. Findings include: Review of the closed record for Resident #3 indicated the resident was admitted to the facility on [DATE] for rehabilitation following a left hip replacement. Other admitting [DIAGNOSES REDACTED]. A staff interview was conducted on 3/20/13 at 4:40 PM with the Minimum Data Set(MDS) Coordinator. The MDS Coordinator indicated Resident #3 had short and long term memory problems. She understood others and was able to make herself understood. Review of the physician's orders [REDACTED].? tab by mouth Every 6 hours as needed for pain. Review of the Interdisciplinary Post Fall Review dated 3/4/13 indicated the resident had an unwitnessed fall on 3/3/13 at 12:30 AM. Description of the fall read," Resident ambulated from room to hall and fell in hallway. No injury noted. Neuro checks done due to unwitnessed fall." Telephone orders dated 3/3/13 read,"X Ray Right Hip Due to Fall. Rule Out [MEDICAL CONDITION]." Review of the Nursing Daily Skilled Summary dated 3/3/13 at 2:15 PM read, "Resting in bed with neurological checks continued as ordered without change in neurological status. Able to follow commands. Initially denying pain verbally without signs /symptoms. However, when the family member arrived the resident complained of general pain, with as needed Qxycodone given at 3:30 PM without further complaint of pain. " Review of the Nurses notes dated 3/4/13 at 10:00 AM read, "Visited the resident in room due to reports of fall on 3/3/13. Assisted Resident Care Specialist in placing pressure sensitive bed alarm. Resident indicated she had pain in the left hip. Spoke with the primary care nurse and requested the resident be given pain medication. Repositioned for comfort, using draw sheet and assist by the Resident Care Specialist." Pain medications were given as ordered. Review of the PRN (As needed) Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. New physician's orders [REDACTED]. The Pain Medication Record indicated the resident received the medication at 9:00 AM and 9:00 PM on 3/5/13, and at 9:00 AM on 3/6/13. Review of the Change of Condition form started 3/4/13 at 9:00 PM read," Per Physician's Assistant - Hip X-Ray Rule Out new Fracture Right Hip. X-Ray ordered 3/4/13." Review of the X-Ray dated 3/4/13 indicated,"Left hip prosthesis was in place without malalignment or acute fracture. " Review of the Physician's Progress Note dated 3/5/13 read: Chief Complaint: Left Hip Pain. History of Present Illness: Resident is seen today to evaluate Left hip Pain. The resident had a fall 3/3/13. X-Ray of the Left Hip indicated: Left hip prosthesis in place without no alignment, no acute fracture. The resident was on pain medication ([MEDICATION NAME]) 2.5 milligrams every 6 hours as needed. The family was concerned about increased pain. The resident is unable to participate in Rehabilitation today. Assessment and Plan: The resident has an appointment 3/6/13 at 2:00 PM with the Orthopedic Surgeon). The attending Physician increased the [MEDICATION NAME] to 5 milligrams twice daily until evaluated, and called to discuss the plan with the resident ' s family. The original Orthopedic appointment was 3/10/13. A call was placed to increase the Orthopedic appointment to 3/6/13. Physical and Occupational Therapy was held until evaluated by the Orthopedist. An attempt was made to contact the Orthopedic Surgeon's office on 3/20/13 at 4:15 PM. The call was unsuccessful. A staff interview was conducted on 3/20/12 at 3:30 PM with Nurse Practitioner who indicated, "I remember that the staff told me she was complaining of generalized pain. The results of the X-Ray indicated there was no misalignment and she was still complaining of pain. I called her Orthopedic Doctor. I called to get her appointment moved up, so she could be seen sooner, by the Orthopedist. I cannot recall which hip she was complaining of pain from." Review of a telephone order dated 3/5/13 indicated the resident, "Has an appointment with (the Orthopedic Surgeon) 3/6/13 at 2:00 PM. Increase [MEDICATION NAME] to 5 milligrams 1 tab by mouth twice daily." A Direct Care Staff Interview was conducted on 3/20/13 at 12:00 Noon with Nursing Assistant (NA) #1. NA #1 indicated, "She complained about her hip hurting. I just assumed it was the hip she had surgery on (Left Hip). She would ring for pain medicine, and was given pain medicine. " Review of the hospital record of 3/6/13 indicated Resident #3 was sent to the emergency room from the Orthopedic Doctor ' s office. X-Rays had been taken at the Orthopedic Doctor's office. The results of the X-Rays demonstrated the resident had a fractured right hip. The resident was admitted to the hospital 3/6/13 and scheduled for right hip surgery on 3/7/13. Interview with the contracted Radiology Representative was conducted on 3/20/13 at 11:00 AM. An inquiry was made about the procedure in obtaining X-Rays at the facility. The Radiology Representative indicated, " When we receive a call from a facility, we dispatch according to location and availability of a X-Ray Technologist. They (referring to the X-Ray Technologists) go to the nursing station according to the information given to us. They will collect and verify the Doctor ' s order and collect and verify the patient ' s face sheet for billing demographics. They then go to the patient ' s room, locate the patient, and do the X-Ray in the patient's room. " When asked which of Resident #3's hips were X-Rayed on 3/4/13, the Radiology Representative indicated, " The Left Hip was X-Rayed. We faxed the final results on 3/4/13 at 19:01 (7:01 AM).We did this as a stat (immediate) call for a possible fracture. " When asked if the X-Ray Technologist verified the Doctor ' s order on 3/4/13, the X-Ray Representative indicated, " When our Technologist arrives at the facility, they are taught to verify the Doctor's orders. The Technologist verified the Doctor's order which said Left Hip. " When asked if the Mobile X-Ray Department received a call from the facility on 3/3/13 with a request to X-Ray the Right Hip, the Radiology Representative indicated, " There is no record of a call from the facility on 3/3/13 to X-Ray the Right Hip. " A staff interview with the former Director of Nurses (DON) was conducted on 3/20/13 at 2:45 PM. The former DON was unable to provide any pertinent information related to the reason the facility did not follow the X-Ray orders on 3/3/13 to X-Ray Resident #3's Right Hip. Interview with the Regional Director on 3/20/13 at 2:50 PM indicated "(Resident #3) was complaining of left hip pain which she already had fractured and was here for rehabilitation after surgery on the left hip. She was complaining of pain in her left hip after the fall of 3/3/13. An X-Ray was done on 3/4/13 which was negative for the left hip. I was told she continued to point to the left hip per the DON, therefore they moved an appointment with the Orthopedist forward. The original appointment was for 3/18/13 and was moved forward to 3/6/13. When asked if the Regional Director had done anything with the X-Ray company. The Regional Director indicated, " I have not contacted the X-Ray company. I gave directions to the DON who no longer works here to contact the X-Ray company to investigate. The investigation was ongoing, and I cannot provide any documentation related to (Res. #3)'s case." During an interview on 03/20/13 at 3:15 PM with the Physical Therapist (PT) who cared for Resident #3 on 03/05/13, indicated this was the first time he cared for the resident. As he attempted to have her move he realized she was unable to participate or perform in therapy like she had been able to do so prior. He indicated she was unable to sit in the chair. She was complaining of pain in the pelvis. She did not have pain when she was lying still. He further indicated she was able to get herself out of bed prior to her fall on 3/3/13. He stated "She was in no way able to do what she was able to do prior to 3/3/13 fall. She was unable to stand up or bear weight on her Right leg. He was so concerned that he spoke with the Physician's Assistant and indicated the X-Ray was negative, but Resident #3 was is in a lot of pain and unable to move. The Physician's Assistant called the Orthopedist, who moved the appointment to the next day. He also indicated that he spoke with the Nursing Assistants (NA's) who cared for Resident #3 that morning. The NA stated the resident was not the same today. She (Resident #3) couldn't even stand up while we got her pants on. As soon as we (referring to the NA ' s) got her pants on we had to lay her back in bed because she was so uncomfortable. " The PT stated, " the word we got back from the appointment was that she had fractured the other hip with the fall." An attempt to contact the Orthopedic Surgeon's office on 3/20/13 at 4:15 PM. The call was not returned. A interview with the Administrator was conducted on 3/20/13 at 6:00 PM regarding his expectations of the facility regarding Resident #3. The Administrator indicated his expectations included, " That the X-Ray ordered 3/3/13 could have been done timely, and the resident assessed for pain and the location of the pain. Also the X-Ray done on the correct hip. "

Based on observations, record reviews and staff interviews the facility failed to ensure an incident which resulted in a fracture was reported for three days for 1 (Resident # 58) of 3 residents in the survey sample reviewed for accidents. The findings include: Resident # 58 had [DIAGNOSES REDACTED]. The 3/7/12 care plan revealed the resident had a potential for injury and impaired mobility related to predisposing factors which included end stage dementia. The care plan indicated the resident required use of a mechanical lift for transfers with 2 person assistance. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment, behavioral symptoms and was totally dependent on staff for all Activities of Daily Living including transferring and was not ambulatory. The MDS also indicated resident #58 had unclear speech, was rarely/never understood and unable to verbalize pain. The 5/7/12 Change of Condition Report noted that the resident #58's right leg/knee area was bruised and more swollen than the left leg. Review of Nurses' Notes dated 5/7/12 indicated the resident's family was phoned to inform them that the resident was being sent to the emergency room for an X-ray of the right lower extremity to rule out a fracture. The resident returned to the facility with EMS and was transferred from the stretcher to the bed. There was a soft boot on the right leg wrapped in ace bandage. Review of accident report dated 5/7/12 revealed nursing assistant (NA) #1 was showering resident #58 when she observed the right lower leg to be bruised and swollen. The resident was confused and unable to verbalize and an X-ray of the right leg was obtained. Review of the 5/7/12 radiology report revealed the resident had moderately severe diffuse osteopenia (low bone density) and an acute minimally displaced fracture involving the proximal tibial metaphysis (the top portion of the shin bone). The Disciplinary Action Record dated 5/8/12 and completed by the director of nursing (DON) noted that on 5/4/12 NA #4 did not follow her assignment to deliver care. Resident #58 was care planned for a mechanical lift for transfers. The NA attempted to transfer the resident with a gait belt and injured her right leg resulting in a fracture. NA #4 did not report the accident/incident until questioned on 5/8/12, 4 days later. She did not follow the "No Lift Policy." Observation of a transfer by a Physical Therapy Assistant (PTA) and NA #1 was conducted at 11:00 AM on 6/7/12. Resident #58 was transferred with a mechanical lift. A soft cast was in place on the right leg and both lower extremities were guarded by NA #1 during the transfer. An interview with NA #1 was conducted following the transfer and she stated that she has always transferred the resident with a mechanical lift. On 6/7/12 at 4:11 PM Nurse #1 revealed that on 5/7/12 NA #1 came to her and told her the resident had a bruise. She assessed the resident and her range of motion. The bruise was yellow and blue. She called the physician and obtained an order for [REDACTED]. An interview with the director of nursing (DON) at 5:30 PM on 6/7/12 revealed the bruise on resident #58 was identified on 5/7/12. Nurse #1 reported it to her about 7:30 - 8:00 AM. She began the accident report and called the family and the physician. The physician ordered the X-ray. The mobile X-ray report was inconclusive. She called the physician again and an order was obtained from the medical director to send the resident to the emergency room for an evaluation and X-ray. The resident was sent late in the afternoon and returned later at night with a soft cast on. The DON stated she called the weekend supervisor who told her that the resident was not out of bed all weekend. She then checked the assignment sheets and determined that the last time the resident was out of bed was 5/4/12. The NA (#4) who cared for the resident on 5/4/12 was interviewed by the DON and NA #4 told her that she transferred the resident from bed without the mechanical lift. When NA #4 looked down the hall and didn't see anyone in the hallway she decided to get the resident up on her own. She lifted her under her arms and tried to stand and pivot the resident. NA #4 told the DON that she did not drop her but sat her down hard in the chair. When the DON questioned NA #4 regarding not reporting the incident the NA said she did not report it to anyone because she looked at resident #58 and didn't see anything wrong with her. An interview with the assistant director of nursing (ADON) at 5:45 PM on 6/7/12 revealed he conducted inservices for mechanical lift transfers and assignment sheets after the incident. He completed no other inservices as of 6/7/12 because he thought those were the most important issues. On 6/7/12 at 6:00 PM the DON stated that inservices were conducted on the topics of mechanical lifts and assignment sheets. No other education was done as a follow up to resident #58's incident. On 6/8/12 at 2:45 PM interviews were conducted with the Administrator and DON. The Administrator stated that his expectation regarding changes or incidents was that the DON or unit nurse would be notified immediately. He also indicated that he expected to be notified if the DON was unavailable. The DON stated that she expected that all incidents would be reported immediately to a supervisor, the DON or ADON.

Based on observations, record reviews and staff interviews the facility failed to ensure a resident was transferred with a mechanical for 1 (resident # 58) of 3 residents reviewed for accidents. The findings include: Resident # 58 had [DIAGNOSES REDACTED]. The Physical Therapy Evaluation dated 3/5/12 revealed the resident should be transferred with a mechanical lift. The 3/7/12 care plan revealed the resident had a potential for injury and impaired mobility related to predisposing factors which included end stage dementia. The care plan indicated the resident required use of a mechanical lift for transfers with 2 person assistance. The Minimum (MDS) data set [DATE] indicated the resident had severe cognitive impairment, behavioral symptoms and was totally dependent on staff for all Activities of Daily Living including transferring and was not ambulatory. The Resident Care Specialist Assignment sheet dated 5/4/12 was reviewed and indicated the resident was to be transferred with a mechanical lift. The 5/7/12 Change of Condition Report noted that the resident #58's right leg/knee area was bruised and more swollen than the left leg. Review of Nurses' Notes dated 5/7/12 indicated the resident's family was phoned to inform them that the resident was being sent to the emergency room for an X-ray of the right lower extremity to rule out a fracture. The resident returned to the facility with EMS and was transferred from the stretcher to the bed. There was a soft boot on the right leg wrapped in ace bandage. Review of accident report dated 5/7/12 revealed nursing assistant (NA) #1 was showering resident #58 when she observed the right lower leg to be bruised and swollen. The resident was confused and unable to verbalize and an X-ray of the right leg was obtained. Review of the 5/7/12 radiology report revealed the resident had moderately severe diffuse osteopenia and an acute minimally displaced fracture involving the proximal tibial metaphysis (the top portion of the shin bone). The Disciplinary Action Record dated 5/8/12 and completed by the DON noted that on 5/4/12 NA #4 did not follow her assignment to deliver care. Resident #58 was care planned for a mechanical lift for transfers. The NA attempted to transfer the resident with a gait belt and injured her right leg resulting in a fracture. NA #4 did not report the accident/incident until questioned on 5/8/12, 4 days later. She did not follow the "No Lift Policy. " Observation of a transfer by a Physical Therapy Assistant (PTA) and NA #1 was conducted at 11:00 AM on 6/7/12. Resident #58 was transferred with a mechanical lift. A soft cast was in place on the right leg and both lower extremities were guarded by NA #1 during the transfer. An interview with NA #1 was conducted following the transfer and she stated that she has always transferred the resident with a mechanical lift. On 6/7/12 at 3:50 PM NA #2 stated she always transferred resident #58 with a mechanical lift and 2-4 people depending on the resident's behavior. She added that sometimes the resident yelled out more and she couldn't verbalize pain so they used an extra staff to transfer the resident. At 3:52 PM on 6/7/12 Nurse #1 stated that the resident was transferred with a mechanical lift and 2 people. She further stated that resident # 58 had been transferred with a mechanical lift since she was working there, almost 4 years, and the resident had never been able to bear weight. On 6/7/12 at 4:02 PM NA #3 revealed the resident was transferred with a mechanical lift and 2 people. She added that the resident could not stand or walk and use of the mechanical lift is identified on the assignment sheet. She had never transferred the resident without the mechanical lift and didn't know of anyone who had. On 6/7/12 at 4:11 PM Nurse #1 revealed that on 5/7/12 NA #1 came to her and told her the resident had a bruise. She assessed the resident and her range of motion. The bruise was yellow and blue. She called the physician and obtained an order for [REDACTED]. An interview with the director of nursing (DON) at 5:30 PM on 6/7/12 revealed the bruise on resident #58 was identified on 5/7/12. Nurse #1 reported it to her about 7:30 - 8:00 AM. She began the accident report and called the family and the physician. The physician ordered the X-ray. The mobile X-ray report was inconclusive. She called the physician again and an order was obtained from the medical director to send the resident to the emergency room for an evaluation and X-ray. The resident was sent late in the afternoon and returned later at night with a soft cast on. The DON stated she called the weekend supervisor who told her that the resident was not out of bed all weekend. She then checked the assignment sheets and determined that the last time the resident was out of bed was 5/4/12. The NA (#4) who cared for the resident on 5/4/12 was interviewed by the DON and NA #4 told her that she transferred the resident from bed without the mechanical lift. When NA #4 looked down the hall and didn't see anyone in the hallway she decided to get the resident up on her own. She lifted her under her arms and tried to stand and pivot the resident. NA #4 told the DON that she did not drop her but sat her down hard in the chair. The NA did not report it to anyone because she looked at resident #58 and didn't see anything wrong with her. She also said that she transferred the resident previously without using the mechanical lift. When the DON asked NA #4 if she looked at her assignment sheet she told her that she knew the resident was to be transferred with a mechanical lift. When the DON was asked what her expectations were regarding transferring of residents she replied that if the resident has been evaluated as needing a mechanical lift for transferring, the resident was to be transferred with the mechanical lift because it is the only safe method to transfer the resident. An interview with the assistant director of nursing (ADON) at 5:45 PM on 6/7/12 revealed he conducted inservices for mechanical lift transfers and assignment sheets since the incident. He further stated that no other inservices had been completed as he thought those were the most important issues. On 6/7/12 at 6:00 PM the DON stated that inservices were conducted on the topics of mechanical lifts and assignment sheets.