Every finding on record at Northchase Nursing and Rehabilitation Center

Based on observations and staff interviews, the facility failed to discard expired medications on 2 of 4 medication (med) carts observed (200 hall and 100 hall med carts) and date medications when they were opened to allow for the determination of their shortened expiration date for medications stored on 3 of 4 med carts (100 hall, 200 hall, and 400 hall) med carts reviewed for medication storage. Findings included: 1 a. An observation was conducted on 6/11/25 at 9:46 AM of the 200 hall med cart in the presence of Nurse #8. The observation revealed the following medications were stored on the cart. - An opened box of ipratropium bromide 0.5 milligrams (mg) and albuterol sulfate 3 mg (inhaled medications used to treat chronic obstructive pulmonary disease (COPD) nebulizer treatments containing 3 vials dispensed for Resident #23 with an opened date 2/6/25. The manufacturer's instructions included discarding medication 2 weeks after it was opened. - An open bottle of floor stock zinc sulfate (a supplement) 50 mg tablets with a manufacturer's expiration date of 1/25. - An opened box of ipratropium bromide 0.5 mg and albuterol sulfate 3mg (inhaled medications used to treat COPD) 7 vials dispensed for Resident #8 with an opened date of 2/1/25. The manufacturer's instructions included discarding medication 2 weeks after opening. 1 b. An observation of the 100 hall med cart was conducted on 6/11/25 at 10:15 AM in the presence of Nurse #9. The observation revealed the following medication was stored on the cart. - An opened box of ipratropium bromide 0.5 mg and albuterol sulfate 3 mg (inhaled medications used to treat symptoms of COPD) containing 7 nebulizer vials dispensed from the pharmacy for Resident #13 with an opened date of 2/4/25. The manufacturer's instructions included discarding the medication 2 weeks after opening. 2 a. An observation of the 200 hall med cart was conducted on 6/11/25 at 9:46 AM in the presence of Nurse #8. The observation revealed the following medications were stored on the med cart. - An opened umeclidinium 62.5 mcg powder inhaler (medication used to treat symptoms of COPD) with 17 out of 30 doses left dispensed for Resident #23 with no opened date. - An opened box with 3 vials of ipratropium bromide 0.5 mg and albuterol sulfate 3mg dispensed to Resident #11 were laying out of their package with no date opened on the package. - An opened package of fluticasone furoate 10 mcg (a powdered corticosteroid used to treat allergies) inhaler dispensed to Resident #23 on 5/28/25 with no date opened on the package. The manufacturer's instructions included discarding the medication 6 weeks after opening. 2 b. An observation of the 100 hall medication cart was conducted on 6/11/25 at 10:15 AM in the presence of Nurse #9. The observation revealed the following medications were stored on the cart. - An opened package containing 6 vials of ipratropium bromide 0.5 mg and albuterol 3 mg (medication used to treat symptoms of COPD) dispensed for Resident #110 with no opened date. The manufacturer's instructions included discarding the medication 6 weeks after opening. - An opened inhaler of fluticasone furoate 10 micrograms (mcg) inhalations powder with 24 of 30 doses remaining dispensed on 5/28/25 for Resident #13 had no date opened on the package. The manufacturer's instructions included discarding 6 weeks after opening. 2 c. An observation of the 400 hall med cart occurred on 6/11/25 at 10:50 AM in the presence of Nurse #10. The observation revealed the following medication was stored on the cart. - An opened inhaler containing fluticasone furoate 110 mg and vilanterol 25 mcg (medication used to treat symptoms of COPD) inhalation powder with 20 of 30 doses remaining was without a label and no dated opened. An interview was conducted with the Director of Nursing (DON) on 6/12/25 at 3:45 PM. The DON stated she expected the nursing staff to label and date medications when they were opened and to discard them before their expiration date. She further stated she expected the nursing staff to follow manufacturer's instructions for labeling and storage of medications An interview was completed with the Administrator on 6/12/25 at 4:15 PM. The Administrator stated she expected the nursing staff to properly label and store medications and to dispose of medications prior to their expiration date.

Based on record review, observations and staff interviews, the facility failed to remove expired food items stored for use in 1 of 1 walk-in refrigerator and 1 of 2 nourishment rooms and failed to label and date leftover food in 1 of 2 nourishment rooms observed (Rehabilitation Hall nourishment room). This deficient practice had the potential to affect the food served to the residents. The findings included: 1. An observation in the kitchen on 6/9/25 at 11:00 AM revealed the following items in the walk-in refrigerator: - an opened bag of Swiss cheese with no opened date. - a metal container with pureed mixed fruit with no label and no opened date. - a metal container with stewed tomatoes with an opened date of 5/28/25 and a use by date of 5/29/25. - a metal container with pimentos with a label with an open date of 6/4/25. - an opened plastic bag of deli turkey with no opened date. - an opened plastic bag of deli ham with no opened date. - an opened half full box of muffins with no opened date. - an opened carton of honey thick tea with no opened date. - an opened carton of honey thick orange juice with an opened date of 5/29/25. The manufacturer label for the honey thick tea and orange juice indicated the products were good for 7 days after they were opened if stored in the refrigerator. An interview was conducted with the Dietary Manager on 6/9/25 at 11:00 AM. The Dietary Manager stated she expected all items to be labeled with an opened date and expired items to be discarded. The Dietary Manager stated it was challenging to keep up with ensuring that all items were dated due to frequent staff turnover in the dietary department. The Dietary Manager stated she tried to conduct audits of the refrigerator and freezer to check dates and labeling of food items, but she had fallen behind on this. An interview was conducted with the Administrator on 6/12/25 at 4:00 PM. The Administrator indicated that she expected that all food items in the kitchen would be labeled and dated properly and that foods that were passed the used by date would be discarded. 2. An observation of the Rehabilitation Hall nourishment room on 6/9/25 at 11:30 AM with the Dietary Manager present revealed the following: - an opened carton of a nutritional supplement with no opened date. - an opened carton of a nutritional supplement with an opened date of 5/30/25. - a glass bowl of rice and vegetables with no date. - a large plastic bag with leftover food in it dated 5/8/25. - a plastic bag with a plastic container and a foil container with unidentifiable, food items with no name or date. - an opened plastic container of hummus with no name or date that it was opened. The manufacturer label for the nutritional supplement indicated the product was good for 4 days after it was opened if stored in the refrigerator. An interview was conducted with the Dietary Manager on 6/9/25 at 11:30 AM revealed she observed the expired food items in the plastic bags and stated she did not know why the expired items were in the nourishment room refrigerator and that they should have been discarded. The Dietary Manager stated that the dietary staff checked the nourishment room refrigerators daily, made sure they were clean and stocked them with items such as juice and soda for the residents. The Dietary Manager stated the dietary staff should have discarded the expired items and informed the nursing staff that there were items in the refrigerator that were not labeled with the resident name and date they were brought in. An interview was conducted with the Administrator on 6/12/25 at 4:00 PM. The Administrator stated she expected that items in the nourishment room refrigerators would be labeled with a resident name and the date when the item was brought in. The Administrator indicated that she expected that expired items would be discarded. The Administrator revealed the refrigerators should be free from expired items. The Administrator further stated she expected that all out-of-date items would be discarded immediately.

Based on record review, and staff and family interviews, the facility failed to honor a resident's choice to receive a shower for 1 of 1 resident reviewed for choices (Resident #172). Findings included: Resident #172 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, anxiety, depression, and insomnia. The Minimum Data Set admission assessment dated [DATE] revealed Resident #172 was moderately cognitively impaired and demonstrated no behaviors or refusals of care. She required substantial / maximal assistance with one staff physical assistance with bed mobility and transfers, and substantial / maximal assistance with one staff physical assistance with personal hygiene. She had no functional impairments with range of motion, used a walker and a wheelchair and required one staff physical assistance with bathing/showering. Resident #172 was frequently incontinent of bowel and bladder. A review of Resident #172's care plan dated 06/04/25 revealed a plan of care for Activities of Daily Living/Personal Care will be completed with staff support as appropriate to maintain or achieve highest practical functioning through the next review. Resident required substantial/maximal assistance with personal hygiene. An observation was conducted on 06/09/25 at 12:33 PM of Resident #172' s shower schedule posted on her wall which revealed she was to be offered a shower on Wednesdays and Sundays during the 7:00 PM to 7:00 AM shift. Review of the Activity of Daily Living (ADL) shower sheet from 06/01/25 through 06/08/25 revealed there was no evidence that Resident #172 had received a shower since admission to the facility on [DATE]. The documentation revealed the following: - 06/01/25 no documentation of bathing - 06/02/25 bed bath - 06/03/25 no documentation of bathing - 06/04/25 no documentation of bathing - 06/05/25 full bed bath documented by Nurse Aide #9 - 06/06/25 full bed bath documented by Nurse Aide #9 - 06/07/25 no documentation of bathing - 06/08/25 no documentation of bathing Review of the nursing progress notes from 06/01/25 through 06/08/25 revealed there was no documentation to support the nurse aides offered Resident #172 a shower and she refused. An observation of Resident #172 on 06/09/25 at 12:33 PM revealed an alert resident sitting upright in her chair at the bedside. She was appropriately dressed, was without odors, and appeared to be well groomed. An interview was conducted with Resident's # 172's family member on 06/09/25 at 12:33 PM. The Family Member stated she arrived at the facility at 7:30 AM and stayed with Resident #172 until 11:30 PM every day since her admission. The Family Member stated she did not understand why Resident #172 has not had a shower since her admission. The Family Member stated that since the resident arrived on 06/01/25 she was present when Resident #172 got a bed bath on 06/02/25. The Family Member stated she requested to a staff member (unknown) that Resident #172 would like a shower and the staff member told her that Resident #172's shower days were Wednesday (06/04/25) and Friday (06/06/25) during the 7:00 PM to 7:00 AM shift. The Family Member stated on Wednesday evening 06/04/25 she asked the Nurse Aide assigned to Resident #172 (Nurse Aide #9) if the resident was going to get her shower today and she stated that Nurse Aide #9 replied Resident #172 would get a shower on 06/05/25. The Family Member stated on 06/05/25, Resident #172 did not receive her shower during her stay up until 11:30 PM. The Family Member stated she was told by Nurse Aide #9 that Resident #172 would get a shower on 06/06/25. She stated 06/06/25 came and went and Resident #172 was not offered nor did she receive a shower. The Family Member stated on 06/07/25 a staff member (Nurse Aide #12) provided her with a shower schedule of when Resident #172 should receive a shower and posted the shower schedule in the resident's room. The schedule revealed Resident #172 should get a shower on Wednesday and Sundays. The Family Member stated it had been 9 days since her admission and she knew that Resident #172 would really like a shower. An interview was conducted with Nurse Aide #12 on 06/09/25 at 1:10 PM. Nurse Aide #12 reviewed the shower schedule and confirmed Resident #172 was to get a shower on Wednesdays and Sundays on the 7:00 PM to 7:00 AM shift. She stated she provided a schedule to the Resident and the family on 06/07/25 and posted the schedule in her room on 06/07/25. Nurse Aide #12 reported that whenever she gave showers, she would document in the electronic record if a shower or bed bath was given to a resident and would let the nurse know if the resident refused. An interview was conducted with Nurse Aide #9 via phone on 06/11/25 at 4:45 PM. Nurse Aide #9 stated she did not recall her work activities on Wednesday 06/04/25. She stated if Resident #172 did not get a shower, there was a reason and she would have documented it in the electronic record and let the nurse know. The ADL sheet was reviewed with Nurse Aide #9 which indicated no shower or bed bath was given on 06/04/25 or 06/05/25 and she stated she did not recall giving Resident #172 a shower on 06/04/25 or 06/05/24. The shower schedule was reviewed with Nurse Aide #9 and revealed the Resident was scheduled to be offered a shower on third shift beginning on Wednesday 06/04/25 and ending on Thursday 06/05/25. Nurse Aide #9 stated if Resident #172 got a shower she would have documented it in the electronic record. Nurse Aide #9 stated if she did not document that the resident received a shower then the resident did not get one. Nurse Aide #9 stated she could not remember all her activities and conversations with residents that occurred during her shifts. An interview was conducted with the Director of Nursing on 06/12/25 at 4:00 PM. The Director of Nursing stated she expected her nursing staff to be offering and giving showers to all residents according to the shower schedule. The Director of Nursing stated if a resident refused the shower, the nurse aides should be notifying their nurse to see if the nurses could encourage the resident to have a shower and document any continued refusals. The Director of Nursing stated it was important to make sure residents were at least being offered a shower to maintain their personal hygiene.

Based on record review, and staff, Nurse Practitioner (NP), Medical Director interviews, and Consultant Pharmacist interviews, the facility failed to protect a resident's right to be free from neglect, when a nurse (Nurse #1) disregarded a severe drug-to drug interaction alert sent from the pharmacy to the resident's electronic medical record (EMR), regarding a newly prescribed antibiotic and a heart medication the resident (Resident #30) was currently prescribed. Nurse #1 neglected to read a severe drug-to-drug interaction alert received from the pharmacy regarding a newly prescribed antibiotic and did not notify the physician of the alert. The resident was administered the antibiotic by the nurse and there was no significant harm to the resident. This deficient practice occurred for 1 of 1 resident reviewed for neglect. The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), obstructive pulmonary disease (COPD), lymphedema, kidney disease, Stage 3, and paroxysmal atrial fibrillation (a type of atrial fibrillation (Afib) (irregular heart rhythm episodes that are intermittent and short lived), hypertension (high blood pressure), and history of transient ischemic attacks (TIA's are often a warning sign that a major stroke may occur). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact, and she was receiving oxygen therapy as needed. Her primary diagnosis was listed as congestive heart failure (CHF). The care plan for Resident #30 dated 2/5/25 revealed a plan of care for risk for cardiac complications related to diagnoses that included peripheral vascular disease, hypertension, history of transient ischemic attacks, and paroxysmal atrial fibrillation. Interventions included administering oxygen as needed, monitoring for signs and symptoms of respiratory distress. An Encounter note written by the NP on 5/30/25 at 1:00 PM read in part the visit to Resident #30 was to evaluate her pulmonary status due to an acute episode of dyspnea (shortness of breath) at rest with associated increased oxygen demands and wheezing on 5/28/25. The note read that a chest x-ray was obtained on 5/29/25 and the results revealed she had consolidation in the right lower lung. The NP diagnosed Resident #30 with right lower lobe pneumonia due to infectious organism and ordered ceftriaxone 1 gram intramuscularly times one dose, then azithromycin 250 mg for 5 days. The physician's orders for Resident #30 revealed the following orders: 1. An order dated 5/30/25 at 12:42 PM for azithromycin (antibiotic prescribed for bacterial infections) 250 milligrams (mg) tablets. Give 500 mg by mouth one time a day for infection for one day and then a 250 mg tablet one time a day for 4 days. 2. An order dated 3/14/25 for amiodarone hydrochloride tablet 200 mg. Give one tablet by mouth one time a day for abnormal heart rhythm. Review of Resident #30's EMR revealed a Physician's Order Note alert was sent by the Pharmacy to the nursing staff on 5/30/25 at 3:11 PM. The note read in part, The order you have entered azithromycin 250 mg tablet, give 500 mg by mouth one time a day for infection for 1 day then give 250 mg one time a day for infection for 4 days has triggered the following drug protocol alerts/warnings: Drug-to-drug interaction. The system has identified a possible drug interaction with the following orders: Amiodarone 200 mg, give one tablet by mouth one time a day for abnormal heart rhythm. Severity: Severe. Interaction: additive QT interval prolongation may occur during coadministration of azithromycin, a moderate-risk QT-prolonging agent and amiodarone hydrochloride oral tablet 200 mg, a high-risk QT prolonging agent. The alert was acknowledged by Nurse #1. According to Resident #30's MAR the first dose of Azithromycin 250 mg, give 500 mg by mouth one time day for infection day 1 was administered on 5/31/25 at 8:00 AM by Nurse #1. An interview was completed with Nurse #1 on 6/11/25 at 11:53 AM. Nurse #1 stated that the NP entered the orders herself on 5/30/25 for the ceftriaxone and the azithromycin. She further stated that the NP usually entered her own orders. Nurse #1 indicated that she thought it was the responsibility of the NP to check allergies and contraindications. Nurse #1 indicated that she had seen the alert for the azithromycin, but she had just acknowledged it without reading it. She stated that Resident #30 was acting like herself on both 5/30/25 and 5/31/25. Nurse #1 further stated that Resident #30 was outside smoking most of the day and her vital signs were within normal limits on both days. An interview with the Consultant Pharmacist was conducted on 6/12/25 at 12:50 PM. The Consultant Pharmacist stated that when the pharmacy received the order for azithromycin for Resident #30 on 5/30/25, the pharmacy had immediately sent an electronic alert to Resident #30's EMR concerning the severe drug-to-drug interaction for azithromycin and amiodarone. He indicated the alert must be acknowledged by the nurse prior to administering the medication ordered. The Consultant Pharmacist stated that the nurses were supposed to read the pharmacy alerts and notify the physician of the drug-to-drug interaction to check if the Provider wanted the medication administered or wanted to prescribe a different medication. An interview was completed with the Director of Nursing (DON) on 6/12/25 at 3:31 PM. The DON stated she expected the nurses to read the pharmacy alerts regarding medication interactions and to notify the provider to see if they still wanted the medication to be given. An interview with the Medical Director was conducted remotely on 6/23/25 at 1:30 PM. The Medical Director stated that the drug-to-drug interaction regarding the azithromycin should have been identified by the nurse that received the alert. He further stated that Nurse #1 should not have administered the azithromycin without notifying the provider and obtaining a baseline electrocardiogram (EKG) and close monitoring for irregular heart rhythms. The Medical Director indicated that another option would have been to order a different antibiotic for Resident #30. The facility did provide a plan of correction to the state agency, but it was not accepted due to being unable to validate on site.

Based on record review and interviews with staff, Consultant Pharmacist, and Pharmacy Manager, the facility failed to prevent misappropriation of a resident's controlled medication (30 hydrocodone/acetaminophen 5-325 milligrams (mg) pills and 30 oxycodone hydrochloride 10 mg pills) prescribed by the physician for pain for 1 of 1 resident reviewed for misappropriation of property (Resident #267). Findings included: Resident #267 was admitted to the facility on [DATE] with diagnoses to include dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and mood disturbance, history of falls, atrial fibrillation. She was receiving hospice care at the time of the misappropriation. The physician's orders for Resident #267 included: - Hydrocodone/Acetaminophen 5-325 mg oral tablet every 8 hours for pain ordered on [DATE]. - Oxycodone hydrochloride oral tablet 10 mg. Give 10 mg by mouth every 6 hours as needed (PRN) for pain ordered on [DATE]. The pharmacy packing slips for Resident #267's controlled medications were reviewed and revealed the following information: 1. On [DATE] 30 oxycodone 10 mg tablets were delivered from the pharmacy. 2. On [DATE] 90 hydrocodone-acetaminophen 5-325 mg tablets and 30 oxycodone tablets were delivered from the pharmacy. 3. On [DATE] 30 oxycodone 10 mg tablets were delivered from the pharmacy. Review of Resident 267's [DATE] Medication Administration Record (MAR) from [DATE] through [DATE] revealed she was administered 93 doses of scheduled hydrocodone-acetaminophen 325 mg and 32 doses of PRN oxycodone 10 mg. Review of Resident #267's February 2025 MAR from [DATE] through [DATE] (the record indicated Resident #267 expired in the facility on [DATE]) revealed she was administered 65 doses of scheduled hydrocodone-acetaminophen 325 mg tablet and 32 doses of PRN oxycodone 10 mg. A telephone interview was conducted with the Consultant Pharmacist on [DATE] at 12:50 PM. The Consultant Pharmacist stated the pharmacy received a refill request for Resident #267's for hydrocodone-acetaminophen 5-325 mg tablets from the facility on [DATE]. He further stated the pharmacy delivered a 30-day supply of 90 pills on [DATE]. The Pharmacist indicated that on [DATE] the pharmacy had faxed a notification to the facility that it was too early to dispense the medication. He further indicated that [DATE] was the earliest the pharmacy would have refilled the medication. An Initial Allegation report dated [DATE] at 4:59 PM revealed the facility became aware of the possible misappropriation of a controlled medication for Resident #267 and a proactive investigation was initiated to determine if there were missing pills of hydrocodone/acetaminophen due to an early refill request that was sent by the facility to the pharmacy on [DATE]. The facility re-ordered the medication at the facility's expense and no missed doses were identified. Law Enforcement was notified on [DATE] at 4:40 PM. An Occurrence Investigation Report Summary for drug diversion dated [DATE] completed by the Director of Nursing (DON) was provided by the facility. The report revealed that on [DATE] the nurse on the 500-hall noted that Resident #267's hydrocodone-acetaminophen was not delivered yet, the pharmacy and the Hospice Provider were contacted. The facility was notified by the pharmacy Resident #267's hydrocodone-acetaminophen was ordered too early. Facility staff were utilizing the emergency kit to ensure Resident #267 was administered her pain medication. An investigation was initiated by the DON. On [DATE] the facility received 90 hydrocodone-acetaminophen tablets and the three medication blister packs were added to the shift count sheet by the assigned nurse. On [DATE] card #1 was initiated and completed on [DATE]. Card #3 of 3 was initiated on [DATE]. Between [DATE] and [DATE] 10 doses were documented on the MAR as given but no declining count sheet was found for card #2 of 3 and potentially 30 hydrocodone-acetaminophen pills were unaccounted for. The facility Nurse Practitioner (NP) then electronically prescribed hydrocodone-acetaminophen to replace the missing medications that were valued at $13.85 and paid for by the facility. Appropriate regulatory agencies were contacted to include the state, Adult Protective Services (APS), law enforcement and the Drug Enforcement Agency. During the investigation it was also noted that the resident had unaccounted for oxycodone 10 mg tablets. On [DATE] the resident received a new refill of oxycodone 10 mg tablets and another refill on [DATE] for an additional 30 tablets were received from the pharmacy. The oxycodone refill for [DATE] was requested by Nurse #7. Multiple attempts were made to contact Nurse #7 but were unsuccessful. It was determined that 24 doses were documented on the MAR as given from [DATE] and believed they were given from the refill delivered on [DATE]. There was no declining count sheet to review, and no evidence the medication was returned to the pharmacy. There was no evidence that any medication was administered from the oxycodone card filled on [DATE] and no return of drug or declining count sheet were available for review. By reviewing declining count sheets and staff schedules, both staff members (Nurse #5 and Nurse #7) noted to last be in possession of the medication and were suspended pending an investigation. Resident #267 was assessed for pain to ensure the pain regimen in place was effective with no negative findings. There was no harm to the resident because she did not go without pain medication. After a thorough investigation the facility was unable to determine the root cause of missing medications, the allegation of misappropriation was not substantiated. A new system process was initiated for monitoring receiving/returning controlled substances and shift to shift count. Review of the Nursing Assignment Sheets on [DATE] revealed Nurse #7 was the nurse working the 500 hall on the 7:00 PM to 7:00 AM and Nurse #5 was the nurse working the 7:00 AM to 7:00 PM shift 500 hall on [DATE]. A telephone interview was completed with Nurse #7 on [DATE] at 12:50 PM. Nurse #7 stated that she didn't know anything about missing medications at the facility. She further stated that she had stopped working at the facility in February 2025. Nurse #7 indicated due to personal issues she was unable to return to work. Nurse #7 stated she was never contacted by the Director of Nursing (DON) in regard to missing narcotic medications. She further stated that she was not aware she was terminated from the facility. Nurse #7 stated she couldn't remember anything about Resident #267's narcotic medication. An interview was conducted with Nurse #5 on [DATE] at 3:15 PM. Nurse #5 stated she had worked at the facility for 2 years. Nurse #5 stated that she had suspected Nurse #7 of diverting narcotics and had reported it to the DON on [DATE] right before Nurse #7 never came back to work. She further stated she and Nurse #7 were the 2 nurses involved in the investigation for missing medications. Nurse #5 indicated that the narcotic counts were always right. She indicated that on [DATE] she was not aware of the missing declining narcotic count sheets and missing medications. Nurse #5 further indicated she was allowed to return to work when the facility was unable to reach Nurse #7 after she left for personal reasons. Nurse #5 stated she was not the person who diverted the narcotic medications. The Investigation Report submitted to the stated agency on [DATE] completed by the DON revealed Resident #267 did not miss any doses of medication. A declining count sheet could not be located to verify the sign out of meds for hydrocodone/acetaminophen and oxycodone. The facility will replace unaccounted for medications. The report further read that an audit of controlled substance count sheets, audit of declining count sheets, audit of packing slips from pharmacy, audits of returned medication, witness statements, state registry check, education to all nurses on drug diversions and narcotic process. A telephone interview with the Pharmacy Manager occurred on [DATE] at 2:30 PM. The Pharmacy Manager stated he was aware of an incident that occurred at the facility on [DATE]. He further stated the facility had reached out for invoice slips and the names of the nursing staff who ordered the medication. An interview was completed with the DON on [DATE] at 1:26 PM. The DON confirmed Nurse #5 had come to her [DATE] with some concerns regarding narcotic medication and Nurse #7. She further stated before she could begin an investigation to confirm the allegation, she was notified by the Unit Manager working on the 500 hall on [DATE] that Resident #267's narcotic medication had not been delivered to the facility that evening. She further stated she instructed the nurse to obtain the medications from the emergency kit, so Resident #267 would receive her scheduled medication. The DON stated the next day she had started an investigation as to why the medication was not delivered. She indicated that she had tried to order the medication from the pharmacy and was told it was too early. The DON stated she had requested the packing slips and the names of the staff ordering the medication. During the investigation they discovered the narcotic shift change sheet and the declining pill count sheet for Resident #267's narcotic medications were missing from the narcotic book on the 500 hall and a new count sheet had been started by Nurse #7 on [DATE]. She further stated that one of the blister packs containing 30 hydrocodone-acetaminophen 5-325 mg tablets and the declining count sheet and the blister pack for 30 oxycodone 10 mg tablets delivered by the pharmacy on [DATE] were missing. The DON indicated that a refill of 30 oxycodone 30mg tablets were delivered on [DATE] and Nurse #7 had requested a refill for the medication on [DATE]. She stated that Nurse #7 had started a new declining count sheet, and the old one was missing. She further indicated that Nurse #7 left a note under her door on the morning of [DATE] stating she was out of state for personal reasons. The DON indicated Nurse #7 never returned to the facility after [DATE]. She stated she had tried to call and text message Nurse #7 multiple times, but the only response she received was that Nurse #7 was busy with personal issues. The DON indicated that the facility was unable to prove who took the medication, but they did substantiate that drug diversion occurred for Resident #267's narcotic medication. The DON stated Resident #267 never missed any scheduled narcotic medication doses. She further stated the facility had initiated pain assessments on non-alert residents for signs and symptoms of pain and interviews were conducted with alert and oriented residents to ensure they were not experiencing pain. The DON indicated the facility reviewed 60 days of packing slips, narcotic shift change sheets, narcotic declining count sheets and return of drug forms, and an audit of the residents' Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication carts. She further stated they had inspected the blister packs for evidence of tampering and none was noted. The DON indicated an audit of all nurses' and medication aides license verification was completed and with no negative findings. She further stated the facility conducted in-services with all the nurses and medication aides regarding Controlled Substance Diversion and initiated a Narcotic Management Process. The DON indicated they facility was continuing to perform audits and reconciliation of all the narcotics in the facility. An interview was completed with the Administrator on [DATE] at 4:13 PM. The Administrator stated she expected no misappropriation from the staff regarding medications, especially narcotic medications. The facility provided a Plan of Correction (POC) that was not acceptable to the state agency, due to there was no evidence of how the facility would prevent future misappropriatoin, and it did not address the suspicion that the nurse diverted the medication and was not reported to the Board of Nursing.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Preadmission Screening and Resident Review (PASRR) for 2 of 26 residents reviewed for MDS assessments (Resident #14 and #16). Findings included: 1. Resident #14 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, and bipolar disorder. Review of Resident #14's electronic health record revealed Resident's PASARR was completed on 02/12/21 and indicated Resident #14 was screened as Level II (a person centered evaluation that is completed for residents identified as having a mental illness diagnoses. It helps to determine appropriate placement and the need of specialized services). A review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was not coded as a Level II PASRR. A review of Resident #14's care plan dated 05/29/25 revealed a plan of care for a Level II Preadmission Screening and Resident Review (PASRR) recommendations related to mental illness diagnoses of bipolar disorder, anxiety and depression and treated with psychotropic medications. The goal for the plan of care was that the Resident would receive recommended care and/or services as determined appropriate by Level II Preadmission Screening and Resident Review (PASRR) through next review. Interventions included provide a referral for new and updated PASSR as indicated, psychiatric services, close observation and assessments with corresponding documentation due to medications, provide daily care related to severe medical conditions which are debilitating or chronic illness and that cannot be given adequately at lower care levels, behavioral problems related to a medical condition (Depression, Anxiety, Bipolar), and requires treatment or observation by skilled professional personnel, to extent deemed appropriate for a nursing facility. An interview was conducted with the Social Worker on 06/11/25 at 4:22 PM. The Social Worker stated she had a list of the residents that were Level II PASRR and she answered the question on the MDS assessments regarding PASRR. The Social Worker stated she did not know why Resident #14 was not coded as a Level II PASRR on the 12/08/24 annual MDS assessment. The Social Worker stated she must have missed it. An interview was conducted with the Administrator on 06/12/25 at 4:00 PM. The Administrator indicated that she expected that the MDS assessments would be completed accurately and this included the coding of PASRR status for each resident. 2. Resident #16 was admitted to the facility on [DATE]. The resident's diagnoses included psychosis and hallucinations. Review of Resident #16's electronic health record revealed the resident had a PASARR screening completed on 3/7/21 and Resident #16 was screened as a Level II (a person-centered evaluation that is completed for residents identified as having a mental illness diagnosis. It helps to determine appropriate placement and the need for specialized services). A review of Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was not coded as a Level II PASRR. A review of Resident #16's care plan revealed a plan of care dated 6/10/25 for a Level II Preadmission Screening and Resident Review (PASRR) with recommendations related to psychoses and hallucinations. The goal for the plan of care was that the residents would receive recommended care and/or services as determined appropriate by Level II Preadmission Screening and Resident Review (PASRR) through next review. Interventions included provide a referral for new and updated PASSR as indicated, psychiatric services, close observation and assessments with corresponding documentation due to medications, provide daily care related to severe medical conditions which are debilitating or chronic illness and that cannot be given adequately at lower care levels, behavioral problems related to a medical condition ( psychoses and hallucinations) and requires treatment or observation by skilled professional personnel, to extent deemed appropriate for a nursing facility. An interview was conducted with the Social Worker on 06/11/25 at 4:22 PM. The Social Worker stated she had a list of the residents that were Level II PASRR, and she answered the question on the MDS assessments regarding PASRR. The Social Worker stated she did not know why Resident #16 was not coded as a Level II PASRR on the 12/5/24 annual MDS assessment. The Social Worker stated she must have missed it. An interview was conducted with the Administrator on 06/12/25 at 4:00 PM. The Administrator indicated that she expected that the MDS assessments would be completed accurately and this included the coding of PASRR status for each resident.

Based on record review and staff and Nurse Practitioner (NP), and Consultant Pharmacist interviews, the facility failed to prevent the administration of unnecessary medication when a resident (Resident #30) a) received a dose of ceftriaxone (an antibiotic used to treat bacterial infections) as a one-time dose by intramuscular injection. Resident #30 had a documented allergy to ceftriaxone documented on the allergy list in the electronic medical record (EMR) and b) administered azithromycin ( an antibiotic used to treat bacterial infections) that had a drug to drug interaction alert not to be administered with amiodarone without a baseline electrocardiogram (EKG is a test that measures the electrical impulses in the heart for abnormal rhythms because of risk of long QT syndrome (prolonged QT interval on the EKG (which increases the risk of a dangerous heart rhythm). This deficient practice occurred for 1 of 6 residents reviewed for medication errors. The findings included: a).The hospital discharge summary sent to the facility on 1/30/25 for Resident #30 listed her allergies as: 1. Sulfa drugs with the reaction listed as 12/22/22 script for Bactrim (sulfa antibiotic) led to severe thrombocytopenia. She also received a dose of ceftriaxone. 2. Ceftriaxone with the reaction listed as 12/22/22 dose of ceftriaxone led to severe thrombocytopenia but could not exclude that it was from the sulfa antibiotic script given the same day. We would need to review her prior exposure to antibiotics and balance risks/benefits. 3. Statins (cholesterol reduction inhibitor) with the reaction of feeling faint and jittery. 4. Theophylline (medication used to treat symptoms of chronic obstructive pulmonary disease [COPD]) with the reaction of restlessness, and insomnia. Resident #30 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), obstructive pulmonary disease (COPD), lymphedema, kidney disease, Stage 3, and paroxysmal atrial fibrillation (a type of atrial fibrillation (Afib) where the irregular heart rhythm episodes are intermittent and short lived), peripheral vascular disease (PVD), hypertension (high blood pressure), and history of transient ischemic attacks (TIA's are often a warning sign that a major stroke may occur). An interview was completed with the Unit Manager on 6/12/25 at 2:02 PM. The Unit Manager stated she was the nurse that entered the allergies into the EMR for Resident #30 when she was admitted to the facility. She further stated that she had obtained the information from the discharge summary sent by the hospital. She indicated that she had documented the allergies from the allergy section, but she had not seen the reactions listed for the allergies on a different page. The Unit Manager stated she had just read the top section of the summary but didn't read the reactions. She further stated that when the allergies were entered into the electronic medical record (EMR) they would show up in the banner in the record and they were transmitted automatically to the pharmacy and added to the medication administration record (MAR) screen. The Unit Manager indicated that it was important for the nursing staff to know the residents' allergies prior to the administration of medication. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact, and she was receiving oxygen therapy as needed. Her primary diagnosis was listed as congestive heart failure (CHF). The care plan for Resident #30 dated 2/5/25 revealed a plan of care for risk for cardiac complications related to diagnoses that included peripheral vascular disease, hypertension, history of transient ischemic attacks, and paroxysmal atrial fibrillation. Interventions included administering oxygen as needed, monitoring for signs and symptoms of respiratory distress. An Encounter note written by the NP on 5/30/25 at 1:00 PM read in part the visit to Resident #30 was to evaluate her pulmonary status due to an acute episode of dyspnea (shortness of breath) at rest with associated increased oxygen demands and wheezing on 5/28/25. The note further read that the chest x-ray obtained on 5/29/25 results revealed she had consolidation in the right lower lung. The NP diagnosed Resident #30 with right lower lobe pneumonia due to infectious organism and ordered ceftriaxone 1 gram intramuscularly times one dose, then azithromycin 250 mg for 5 days. An interview was conducted with the NP on 6/12/25 at 2:18 PM. The NP stated that her process for entering orders involved using the EMR and putting the orders in herself or by giving a nurse a verbal order. She further stated that she had to list the name of the medication, the route, dosage, and the frequency of the medications or the pharmacy would not accept the order. The NP indicated that she usually checked the residents' allergies by clicking on the tool bar in the EMR. She stated that if she forgot to check the allergies and the resident was allergic to a medication she would expect the nursing staff to call and confirm the medication. She stated that the order for ceftriaxone 1 gm for Resident #30 was ordered in error. She further indicated that it was also contraindicated to administer azithromycin and amiodarone at the same time. The NP stated that she would have expected the nurse who received the alert from the pharmacy would call her to clarify the order. The physicians' orders for Resident #30 revealed an order dated 5/30/25 at 12:42 PM written by the NP for ceftriaxone one gram (gm) intramuscularly times one dose for pneumonia. An interview was completed with Nurse #1 on 6/11/25 at 11:53 Nurse #1 stated she was the nurse who signed off the order dated 5/30/25 at 12:42 PM written by the NP for ceftriaxone one gram intramuscularly times one dose for pneumonia for one day. Nurse #1 further stated that the NP entered the orders in the computer herself on 5/30/25 for the ceftriaxone and the azithromycin. She further stated that the NP usually entered her own orders. Nurse #1 indicated that she thought it was the responsibility of the NP to check the allergies. Nurse #1 indicated she was not aware of Resident #30's allergy to ceftriaxone when she had signed the order off. She further indicated that she had obtained the ceftriaxone from the emergency kit and filled out a slip and faxed it to the pharmacy. Nurse #1 stated she had attempted to give Resident #30 the ceftriaxone injection, but that she had refused to come inside from smoking to get the injection. She further stated that she was not the nurse that administered the medication and that Nurse #6 administered the injection on the next shift beginning at 7:00 PM. Nurse #1 stated that since she had obtained the ceftriaxone from the emergency kit, it had not triggered an alert stop from the pharmacy. She stated she had not checked Resident #30's allergies prior to removing the ceftriaxone from the emergency supply kit. The May 2025 Medication Administration Record (MAR) for Resident #30 revealed she was administered ceftriaxone sodium injection by intramuscular injection by Nurse #6 on 5/30/25 at 9:45 PM. An interview with Nurse #6 was completed on 6/12/25 at 4:37 PM. Nurse #6 stated that she was given report on the residents on 5/30/35 at 7:00 PM by Nurse #1. She further stated that Nurse #1 had informed her that she had received an order for Resident #30 for ceftriaxone 1 gm intramuscularly and she had pulled the medication from the emergency kit. Nurse #6 indicated that Nurse #1 had not administered the medication because Resident #30 had refused to come into the facility while she was outside smoking. She further indicated that she didn't believe she had received an alert from the pharmacy indicating Resident #30 had an allergy to the ceftriaxone. Nurse #6 stated that she usually does check for allergies prior to administering a medication. She further stated that it was a mistake that she hadn't checked the allergies prior to administering the medication. An interview with the Consultant Pharmacist was conducted on 6/12/25 at 12:50 PM. The Consultant Pharmacist stated that when the ceftriaxone was ordered for Resident #30 on 5/30/25 the pharmacy had sent a faxed alert to the facility concerning the allergy to ceftriaxone. He further stated that since the medication was removed from the emergency kit, the nurse would have to fill out a slip listing the residents' name, date, time, and the medication removed from the emergency kit and fax it to the pharmacy, so the medication could be replaced. The Consultant Pharmacist indicated that the reason the nurses faxed it to the pharmacy was so the resident could be charged and the medication that was used could be replaced the next day. The Consultant Pharmacist stated the pharmacy would have called the facility if the reaction listed was anaphylaxis but that was not listed as a reaction on her allergies list. An interview was conducted with the Medical Director on 6/12/2025 at 2:42 PM. The Medical Director stated that he was aware of the medication error related to Resident #30 receiving ceftriaxone and she had a documented allergy to it. He further stated that she was also administered a sulfa medication at the same time that the allergic reaction occurred and it had not been determined which medication had caused the reaction, which was thrombocytopenia (low platelets). The Medical Director stated that it would take longer than one day to develop thrombocytopenia He indicated that they didn't know if she truly had an allergy to ceftriaxone. The Medical Director acknowledged that the medication should not have been ordered because she was possibly allergic An interview was completed with the Director of Nursing (DON) on 6/12/25 at 3:31 PM. The DON stated that during the review of the chart on 6/2/25 they had discovered Resident #30 was administered a medication that she had a documented allergy to. The DON indicated that an investigation was conducted regarding the issue. She further indicated that the facility had noted that she was administered sulfa medication at the same time an allergic reaction had occurred, and that it was undetermined which medication had caused the reaction. The DON stated that she was unaware if the facility had received a fax alert from the pharmacy on the date it was ordered. She indicated that she expected the nurses to check the resident's allergies prior to administering a medication and to respond appropriately to pharmacy alerts regarding medications. The DON further indicated that the nurses should call the provider and verify the allergies and medication prior to administering the medication. She stated that the chart was reviewed on Monday 6/2/25 and that was how the error was discovered. The DON indicated the facility had immediately enacted a plan of correction involving a 100% check of all the allergies for every resident. She further indicated that they had entered the allergic reaction to the medications if they were able to identify them from the record or their former provider. The DON stated the all the nurses had received education and in-services regarding checking residents' allergies prior to administration of medications. She further stated that the facility had conducted an ad hoc Quality Assessment and Performance (QAPI) meeting regarding the medication error and that the facility was continuing to monitor and audit the charts for medication errors. An interview was conducted with the Administrator on 6/12/25 at 4:11 PM. The Administrator stated that she expected the nurses to check the allergies prior to administering a medication, especially new medications. The facility provided the following corrective action plan with a completion date of 6/4/25. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 6/2/25, during the morning QAPI Meeting the resident's chart was reviewed. Resident #30 received a medication she had potential sensitivity to. An investigation revealed Resident #30 was experiencing a change in condition with cough and decreased oxygen saturation on room air on 5/28/25. The Provider was notified and an order for a chest x-ray. The chest s-ray was obtained on 5/29/25 and resulted in the diagnosis of pneumonia. The resident was evaluated by the facility NP on 5/30/25 and she was prescribed ceftriaxone for this change in condition. The provider entered the order for the ceftriaxone and the day nurse confirmed the order. The medication was administered on the night of 5/30/25 by the night shift nurse with no side effects or adverse signs and symptoms noted. Resident #30 was at baseline the following day and was noted by staff throughout the day, up and out of bed and went outside multiple times to smoke. Upon review of the allergies in EPIC (hospital electronic medical record sofware) the allergy for ceftriaxone was added as precaution from a health event in 2022 and downgraded from severe. Allergies were validated with alert and oriented residents and there were no concerns from the audit. Residents' families were contacted to validate allergies of non-alert and oriented residents. A care plan audit was completed of all allergies and no concerns were identified. A 30-day look back of progress notes was performed and any concerns were addressed with the doctor. Medication allergies and policy changes were provided for both providers and nursing staff. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/3/25, the Social Worker and Unit Manager initiated interviews with all alert and oriented residents regarding allergies including medication allergies. The purpose of the interviews was to ensure the allergy is reflected in Point Click Care (PCC) and in the care plan. The Social and Unit Manager updated the resident's clinical record accordingly for all identified areas of concern. The interviews were completed on 6/3/25. On 6/3/25, the Quality Improvement (QI) Nurse from a sister facility initiated interviews with all residents' representatives for non-alert and oriented residents regarding allergies, including medication allergies. The purpose of the interviews was to ensure the allergy was reflected on the residents' dashboard in PCC and in the care plan. The QI Nurse updated the residents' clinical records accordingly for all areas of concern identified. The interviews were completed on 6/3/25. On 6/3/25, the Pharmacy Manager obtained a list of facility notifications of drug alerts from pharmacy in the past 7 days. The purpose of the audit was to ensure the physician was notified of the alert with documentation in the clinical record. The Pharmacy Manager notified the physician of all identified areas of concern. The audit was completed on 6/3/25. On 6/3/25, the Director of Nursing from a sister facility initiated 100% audit of all current residents' medication allergies listed on the resident's dashboard in the EMR including ceftriaxone and the residents' care plans. All residents' medications allergies were compared to the residents' physician orders to ensure the resident was not receiving any medication that may cause an allergic reaction. The facility's DON contacted the physician for all identified areas of concern. The audits were completed on 6/3/25. On 6/3/25, the DON from a sister facility initiated an audit of all residents' progress notes for the past 30 days to identify any documented acute change in condition that may have been related to the resident receiving the medications with known allergies. The purpose of audit was to ensure the acute change was addressed to include physician notification. The audits were completed on 6/3/25. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur. On 6/3/25, an in-service was initiated with 100% of all nurses, medication aides, Medical Director regarding the following: 1. Nurses are to check all admission paperwork for resident's allergies upon admission. 2. Nurses are to ensure all resident allergies are reflected on the resident's dashboard in PCC and on the care plan upon admission 3. The residents' allergies should be reviewed on the dashboard in the EMR or the MAR for allergies every time a new medication is ordered. This should be done prior to nurses or medication aides administrating new medications. 4. If the provider orders medication and the resident has a known allergy on the dashboard in the EMR or the MAR to the medication, immediately contact the provider to verify whether they intend to proceed with the order or want an alternative. 5.The provider must be immediately notified of all fax or verbal allergy notices received from the pharmacy. 6. When a medication is entered into PCC and an alert is received from the pharmacy regarding an allergy, the nurse must immediately contact the provider to verify whether they intend to proceed with the order or want an alternative. Indicate how the facility plans to monitor its performance to make sure the solutions are sustained. On 6/3/25, the DON delegated the Unit Managers to audit all new residents' orders 5x per week times 4 weeks then monthly times 1 month and compare them to the resident's allergies on the dashboard in the EMR to ensure the resident is not receiving any medications that may cause an allergic reaction utilizing an allergy/order audit tool. The DON will notify the physician of any identified areas of concern. The Administrator or DON will review and initial the audits weekly times 4 weeks then monthly times 1. The QAPI committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need for additional monitoring. The POC for allergies will be presented at the QAPI meeting on 6/17/25. The facility implemented all corrective actions and was in compliance on 6/4/25. As part of the validation process on 6/12/24, the plan of correction was reviewed and included a sample of nursing staff, the Unit Managers, Administrator, and Medical Director regarding in-services and training related to deficient practice. The nursing staff verified the education and in-service training. The Unit Managers confirmed the audits and monitoring tools. The Medical Director confirmed that nursing staff were to notify him or the NP to verify orders if an allergy was identified. The Administrator stated that the investigation would be included in the QAPI meeting on 6/17/25. The completion date of 6/4/25 was validated. b). An Encounter note written by the NP on 5/30/25 at 1:00 PM read in part the visit to Resident #30 was to evaluate her pulmonary status due to an acute episode of dyspnea (shortness of breath) at rest with associated increased oxygen demands and wheezing on 5/28/25. The note further read that the chest x-[NAME] obtained on 5/29/25 results revealed she had consolidation in the right lower lung. The NP diagnosed Resident #30 with right lower lobe pneumonia due to infectious organism and ordered ceftriaxone 1 gram intramuscularly times one dose, then azithromycin 250 mg tablets for 5 days. An interview was conducted with the NP on 6/12/25 at 2:18 PM. The NP stated that her process for entering orders involved using the EMR and putting the orders in herself or by giving a nurse a verbal order. She further stated that she had to list the name of the medication, the route, dosage, and the frequency of the medications or the pharmacy would not accept the order. The NP stated that it was contraindicated to administer azithromycin and amiodarone at the same time. The NP stated that she would have expected the nurse who received the alert from the pharmacy to call her to clarify the order. She further stated that if the nurses had called her about the pharmacy alert and the drug-to-drug interaction she would have obtained a baseline EKG and then another one in about a week to compare for changes or ordered another antibiotic. The physician's orders for Resident #30 revealed the following orders: 1. An order dated 5/30/25 at 12:42 PM for azithromycin (antibiotic prescribed for bacterial infections) 250 milligrams (mg) tablets. Give 500 mg by mouth one time a day for infection for one day and then 250 mg tablet one time a day for 4 days. 2.An order dated 3/14/25 for an amiodarone hydrochloride tablet 200 mg. Give one tablet by mouth one time a day for abnormal heart rhythm. According to Resident #30's MAR she received the initial dose of Azithromycin 250 mg, give 500 mg by mouth one time day for infection day one, and it was administered on 5/31/25 at 8:00 AM by Nurse #1. Review of Resident #30's EMR revealed a Physician's Order Note alert was sent by the Pharmacy to the nursing staff on 5/30/25 at 3:11 PM. The note read in part, The order you have entered azithromycin 250 mg tablet, give 500 mg by mouth one time a day for infection for 1 day then give 250 mg one time a day for infection for 4 days has triggered the following drug protocol alerts/warnings: Drug to drug interaction. The system has identified a possible drug interaction with the following orders: Amiodarone 200 mg, give one tablet by mouth one time a day for abnormal heart rhythm. Severity: Severe. Interaction: additive QT interval prolongation may occur during coadministration of azithromycin, a moderate-risk QT-prolonging agent and amiodarone hydrochloride oral tablet 200 mg, a high-risk QT prolonging agent. The alert was acknowledged by Nurse #1. An interview was completed with Nurse #1 on 6/11/25 at 11:53 AM. Nurse #1 stated that the NP entered the orders herself on 5/30/25 for the ceftriaxone and the azithromycin. She further stated that the NP usually entered her own orders. Nurse #1 indicated that she thought it was the responsibility of the NP to check allergies and contraindications. Nurse #1 indicated that she had seen the alert for the azithromycin, but she had just acknowledged it without reading it. She stated that Resident #30 was acting like herself on both 5/30/25 and 5/31/25. Nurse #1 further stated that Resident #30 was outside smoking most of the day and her vital signs were within normal limits on both days. An interview with the Consultant Pharmacist was conducted on 6/12/25 at 12:50 PM. The Consultant Pharmacist stated that when the pharmacy received the order for azithromycin for Resident #30 on 5/30/25, the pharmacy had immediately sent an electronic alert to Resident #30's EMR concerning the severe drug-to-drug interaction for azithromycin and amiodarone. He indicated the alert must be acknowledged by the nurse prior to administering the medication ordered. The Consultant Pharmacist stated that the nurses were supposed to read the pharmacy alerts and notify the physician of the drug-to-drug interaction to check if the Provider wanted the medication administered or wanted to prescribe a different medication. An interview was completed with the DON on 6/12/25 at 3:31 PM. The DON stated she expected the nurses to read the pharmacy alerts regarding medication interactions and to notify the provider to see if they still wanted the medication to be given. A follow-up interview with the DON was conducted remotely on 6/23/25 at 9:26 AM. The DON stated the facility had a plan of correction for Nurse #1 failing to read the drug-to-drug interaction alert the pharmacy sent to Resident #30's EMR regarding the azithromycin and the amiodarone. She further stated that the audits for the drug-to drug interaction and education were completed at the same time as the audits were conducted regarding Resident #30's drug allergy. The DON indicated the facility had conducted audits of the charts to identify any alert notifications of drug interactions sent by the pharmacy. She stated education was provided regarding nurses responding to drug notifications sent from the pharmacy to the EMR. An interview with the Medical Director was conducted remotely on 6/23/25 at 1:30 PM. The Medical Director stated that the drug-to-drug interaction regarding the azithromycin should have been identified by the nurse that received the alert. He further stated that Nurse #1 should not have administered the azithromycin without notifying the provider and obtaining a baseline electrocardiogram (EKG) and close monitoring for irregular heart rhythms. The Medical Director indicated that another option would have been to order a different antibiotic for Resident #30. The facility provided the following corrective action plan with a completion date of 6/4/25. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice On 6/2/25, during the morning QAPI Meeting the resident's chart was reviewed. Resident #30 received a medication that had a severe drug-to-drug interaction alert with a medication she was currently prescribed. An investigation revealed Resident #30 was experiencing a change in condition with cough and decreased oxygen saturation on room air on 5/28/25. The Provider was notified, and she ordered a chest x-ray. The chest s-ray was obtained on 5/29/25 and resulted in the diagnosis of pneumonia. The resident was evaluated by the facility NP on 5/30/25 and she prescribed azithromycin for this change in condition. The provider entered the order for the azithromycin and the day nurse confirmed the order. The nurse received a Pharmacy severe drug-to-drug interaction alert on 5/30/25 and she acknowledged it without reading it. The medication was administered on the morning of 5/31/25 by the nurse with no side effects or adverse signs and symptoms noted. Resident #30 was at baseline the following day and was noted by staff throughout the day, and up and out of bed. A review of the residents EMR's was conducted for drug interaction alerts sent by the pharmacy to ensure the physician was notified of the alert. Audits of all pharmacy alerts for the last 30 days were completed to ensure the physician was notified of all drug-to-drug interactions alerts, and no concerns were identified. Drug-to-drug interaction education and policy changes were provided for both providers and nursing staff. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/3/35, the DON from a sister facility initiated an audit of all residents' electronic medical records for the past 30 days to identify any alert notifications of drug interactions. The purpose of the audit was to ensure the physician was notified of the alert. The physician was notified by the facility's DON with documentation in the clinical record for all identified areas of concern. The audits were completed on 6/3/25. On 6/3/25, the Pharmacy Manager obtained a list of facility notifications of drug interaction alerts from pharmacy in the past 7 days. The purpose of the audit was to ensure the physician was notified of the alert with documentation in the clinical record. The Pharmacy Manager was to notify the physician of all identified areas of concern. The audits were completed on 6/3/25 On 6/3/25, the Staff Development Coordinator (SDC) from a sister facility initiated quizzes with 100% of nurses to ensure knowledge and understanding of what to do when there was an alert of a drug interaction. All nurses that do not successfully pass the quiz after 3 attempts will be retrained and removed from the schedule until they achieve a passing score. The quizzes were completed on 6/3/35 for all nurses that worked. The DON will monitor staff completion. After 6/3/25 any nurse that has not worked or received the quiz will complete it upon starting their next scheduled work shift. This was completed on 6/3/25. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur. On 6/3/25, an in-service was initiated by the SDC from a sister facility with 100% of all nurses and the Medical Director regarding drug interactions: 1.When an order is entered into the EMR and an alert is triggered for a drug interaction (physicians order risk note) the nurse must immediately contact the provider to verify whether they intend to proceed with the order or want analternative. 2. The provider must immediately be notified of all fax or verbal drug interaction notifications received from the pharmacy. 3. Do not administer medications with a severe level alert drug interaction without first speaking to the physician. The in-service will be completed by 6/3/25 for all nurses that worked. The DON and/or the Administrator will monitor staff completion. After 6/3/25 any nurse who has not received the in-service will complete upon starting their next scheduled work shift. All newly hired nurses will receive education during orientation. Indicate how the facility plans to monitor its performance to make sure the solutions are sustained. On 6/3/25, the Unit Managers will audit the physician order risk notes 5 times per week for 4 weeks, then monthly for 1 month to ensure the physician was notified of all drug interaction alerts with documentation in the clinical record utilizing a drug interaction tool. The Unit Manager will notify the physician of any identified areas of concern. The Administrator or DON will review and initial audits weekly for 4 weeks then monthly for one month to ensure all areas of concern were addressed appropriately. The QAPI committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need for additional monitoring. The POC for drug interactions will be presented at the QAPI meeting on 6/17/25. The facility implemented all corrective actions and was in compliance on 6/4/25. As part of the validation process on 6/12/24, the plan of correction was reviewed and included a sample of nursing staff, the Unit Managers, Administrator, and Medical Director regarding in-services and training related to deficient practice. The nursing staff verified the education and in-service training. The Unit Managers confirmed the audits and monitoring tools. The Medical Director confirmed that nursing staff were to notify him or the NP to verify orders if a drug-to-drug interaction alert was identified. The Administrator stated that the investigation would be included in the QAPI meeting on 6/17/25. The completion date of 6/4/25 was validated.

Based on observations, record review, resident and staff interviews, the facility failed to honor a resident's food preferences. This deficient practice was for 1 of 3 residents reviewed for food preferences (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE]. A physician order dated 02/12/21 revealed Resident #14 had an order to receive a regular diet, with regular texture, and thin consistency. A diet communication slip dated 05/15/25 revealed resident requests grits in the morning and no orange juice. This slip was signed by Nurse #11. Review of a nursing note written on 05/17/25 by Nurse #11, revealed Resident approached nurse and stated that she needed nurse to go to the kitchen and reiterate that she wants grits for breakfast every morning and no orange juice. This nurse let resident know that she wrote a dietary slip the other day, as resident requested, and handed it to the kitchen staff herself. Nurse will again let kitchen know the residents' request. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #14 was cognitively intact and was independent with eating. Resident #14 received a regular diet and had no weight loss or gain. An interview was conducted with Resident #14 on 06/09/25 at 11:10 AM. Resident #14 stated she has been at the facility for 4 years and she did not ask for much. She stated she had been requesting to the staff to get a bowl of grits every morning and no orange juice for over 3 weeks and every morning she received orange juice on her tray and had to ask for a bowl of grits because it was never served on her tray. Resident #14 stated she preferred to have just a bowl of grits in the morning and was frustrated that she had to ask a staff member every single morning for her grits. Resident #14 stated this morning on her food tray she received orange juice, scrambled eggs, bacon and 1 piece of toast. A diet communication slip dated 06/09/25 (unsigned) revealed Grits for breakfast, and no OJ (orange juice). An interview with Resident #14 on 06/10/25 at 12:17 PM revealed she was not served grits again this morning and had to ask for them and she was given orange juice again. An observation of Resident #14's breakfast tray on 06/11/25 at 8:35 AM revealed she had no grits on her tray and was served orange juice. Resident stated she did not understand why she was not getting what she preferred served to her and then would have to wait for the staff to bring her what she wanted even though the kitchen was informed. Resident #14 stated she cannot drink orange juice and yet it was put on my tray every morning. Review of the dietary slip provided on Resident #14's meal tray on 06/11/25 at 8:35 AM revealed: prefers sausages, likes boiled and scrambled eggs, 1 piece of toast, prefers lemonade and dislikes cranberry juice. While reviewing and discussing Resident #14's likes and dislikes, Nurse Aide #7 entered the room and Resident #14 requested a bowl of grits at this time and reminded the Nurse Aide she did not like orange juice. Nurse Aide #7 removed the tray and stated she would get Resident #14 a bowl of grits. An observation of Resident #14's breakfast tray on 06/12/25 at 8:15 AM revealed she received grits on her meal tray with eggs and sausage and 1 piece of toast. She was also served apple juice. An interview with the Dietary Manager on 06/12/25 at 8:50 AM revealed she reviewed the dietary communication slips that were in a pile in her desk drawer and located the slips that were written on 05/15/25 and 06/09/25. She stated she used to have a system whereby she would initial the slip after she entered the information in the electronic record for meal trays to know that preferences were updated. She stated she stopped doing that and probably should not have because both of these slips were over looked. She stated she changed the revised the breakfast likes and dislikes on the evening of 06/11/25 to prefers grits, sausage, scrambled eggs, and 1 piece of toast and dislikes OJ after Nurse Aide #7 returned Resident #14's breakfast tray on 06/11/25 and stated Resident #14 just wanted grits and no orange juice. The Dietary Manager stated she would visit Resident #14 today and discuss her likes and dislikes again since it had been almost a year since she updated her preferences. An interview with the Administrator on 06/12/25 at 4:10 PM revealed she would expect the Dietary Manager to have a system in place to ensure resident preferences were being updated and the residents' choices were being honored.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the area of nutrition for 4 of 11 residents whose MDS assessments were reviewed for nutrition (Residents #107, #12, #19, # 69). Findings included: 1. Resident #107 was admitted on [DATE] with diagnosis which included adult failure to thrive and diabetes. Review of Resident #107's electronic health record revealed the following weights were recorded: 10/2/2023- 207.3 pounds (Lbs.) 11/10/2023- 205.1 Lbs. 12/5/2023- 194.2 Lbs. 1/19/2024- 181.8 Lbs. 1/30/2024- 177.1 Lbs. 2/9/2024- 172.5 Lbs. 3/26/2024- 147.6 Lbs. 4/2/2024 1:14 PM- 152.3 Lbs. 4/10/2024 2:35 PM- 158.1 Lbs. Review of Resident #107's weights recorded revealed resident had a 47.1-pound weight loss in180 days (22.92 percent). Review of Resident #107's 4/12/24 quarterly Minimum Data Set (MDS) indicated resident had a mild cognitive impairment. Resident #107's weight was 158 pounds and resident was coded as had no weight loss or weight gain of 5 percent in the past 30 days or 10 percent in the past 180 days. An interview was conducted on 5/16/24 at 3:15 PM with MDS Coordinator #1. MDS Coordinator #1 stated the MDS Coordinator was responsible for the completion of the nutrition section of the MDS assessments. MDS Coordinator #1 stated Resident #107's 4/12/24 quarterly MDS should have been coded for a significant weight change. MDS Coordinator #1 further revealed the computer usually gave a warning when a resident had a significant weight change but it had not been giving the warnings so that may have contributed to the error. MDS Coordinator #1 indicated she was aware of how to calculate a weight change per the Resident Assessment Instrument (RAI) manual, but she had not done it. An interview was conducted on 5/16/24 at 4:35 PM with the Director of Nursing (DON). The DON stated she expected that the MDS assessments would be coded accurately, that the weight changes would be calculated, and she did not know why the resident had lost weight. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the MDS assessments to be completed accurately. The Administrator further stated it was important for the MDS assessments to be accurate for the resident care plans to be accurate and reflect the resident's current condition. 2. Resident #12 was admitted on [DATE] with diagnosis which included in part end stage renal disease. Review of Resident #12's electronic health record revealed the following weights were recorded: 9/28/23- 224 pounds (Lbs.) 2/27/24- 222.2 Lbs. 3/26/24- 199.1 Lbs. Review of Resident #12's weights recorded revealed resident had a 23-pound weight loss in 30 days (10.4%) and 25-pound weight loss in 180 days (greater than 10%). Review of Resident #12's 3/26/24 quarterly Minimum Data Set (MDS) assessment revealed the resident had severe cognitive impairment. Resident #12 was coded as having a weight of 199 pounds with no weight loss or weight gain of 5 percent in the past 30 days or 10 percent in the past 180 days. An interview was conducted on 5/16/24 at 3:15 PM with MDS Coordinator #1. MDS Coordinator #1 stated the MDS Coordinator was responsible for the completion of the nutrition section of the MDS assessments and Resident #12's MDS should have been coded for a significant weight change. MDS Coordinator #1 revealed the computer usually gave a warning when a resident had a significant weight change but it had not been giving the warnings so that may have contributed to the error. MDS Coordinator #1 indicated she was aware of how to calculate a weight change per the Resident Assessment Instrument (RAI) manual but she had not done it. An interview was conducted on 5/16/24 at 4:35 PM with the Director of Nursing (DON). The DON stated she expected that the MDS assessments would be coded accurately. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the MDS assessments to be completed accurately. The Administrator further stated it was important for the MDS assessments to be accurate for the resident care plans to be accurate and reflect the resident's current condition. 3. Resident #19 was admitted to the facility on [DATE] with diagnosis which included diabetes and hypertension. Review of Resident #19's electronic health record revealed the following weights were recorded: 11/29/2023- 156.5 pounds (Lbs.) 12/1/2023- 156.5 Lbs. 12/5/2023- 150.7 Lbs. 12/12/2023- 148.4 Lbs. 12/21/2023- 143.7 Lbs. 12/29/2023- 143.0 Lbs. 1/11/2024- 147.3 Lbs. 1/30/2024- 142.2 Lbs. 2/9/2024- 140.0 Lbs. 3/7/2024- 141.6 Lbs. 3/12/2024- 135.0 Lbs. 4/9/2024- 178.0 Lbs. 4/9/2024 incorrect documentation 4/9/2024- 178.0 Lbs. Review of Resident #19's weight record revealed resident had a 43-pound weight gain in 30 days (24.16 percent) and a 21.5-pound weight gain in 180 days (13.74 percent). Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was coded as had a weight of 178 pounds. The MDS assessment indicated Resident #19 had no weight loss or weight gain of 5 percent in 30 days or 10 percent in 180 days. An interview was conducted on 5/16/24 at 3:15 PM with MDS Coordinator #1. MDS Coordinator #1 stated the MDS Coordinator was responsible for the completion of the nutrition section of the MDS assessments. MDS Coordinator #1 stated Resident #19's 4/11/24 quarterly MDS should have been coded for a significant weight change. MDS Coordinator #1 further revealed the computer usually gave a warning when a resident had a significant weight change but it had not been giving the warnings so that may have contributed to the error. MDS Coordinator #1 indicated she was aware of how to calculate a weight change per the Resident Assessment Instrument (RAI) manual. MDS Coordinator #1 stated she had not calculated the weight change and the computer populated the assessment with the weight, so she had not checked it. MDS #1 stated maybe she should have questioned the weight that entered on Resident #19's assessment and reviewed the weights more carefully. An interview was conducted on 5/16/24 at 4:35 PM with the Director of Nursing (DON). The DON stated she expected that the MDS assessments would be coded accurately, and the weight change would be calculated. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the MDS assessments to be completed accurately. The Administrator further stated it was important for the MDS assessments to be accurate for the resident care plans to be accurate and reflect the resident's current condition. 37673 4. Resident #69 was admitted to the facility on [DATE] with diagnoses that included: End stage renal disease, mild protein calorie malnutrition, dependence on renal dialysis, and Type 2 Diabetes Mellitus. Review of the MDS assessment for Resident #69 dated 03/29/24 documented he had intact cognition. He weighed 169 pounds. He had no weight gain in six months. Review of the recorded weights for Resident #69 revealed he weighed 135.3 pounds on 09/29/23 and 169 pounds on 03/29/24 showing a weight gain of 24.91 percent. In an interview with the DON and the Administrator on 05/16/24 at 8:45 AM they both stated they expected the MDS assessment to be coded correctly to reflect that Resident #69 had a weight gain during the six month assessment look back period. In an interview with MDS Nurse #1 on 05/16/24 at 13:51 PM she stated the MDS assessment dated [DATE] was coded incorrectly documenting the resident did not have a 10% or more weight gain in the previous six months because he did have a weight gain of 24.91 percent during this period. She did not know why the assessment had been coded incorrectly.

Based on record review, and staff and resident interviews, the facility failed to update the comprehensive care plan to reflect changes in care interventions in the areas of mobility and nutrition. This was for 3 of 11 residents whose care plans were reviewed (Resident #107, Resident #12, and Resident #19). Findings included: 1.Resident #107 was admitted on [DATE] with diagnosis which included: stroke with hemiparesis, adult failure to thrive and diabetes. a. Review of Resident #107's nutrition care plan last revised on 1/31/2024 revealed a problem of state of nourishment more than body requirement characterized by weight gain, obesity, excessive appetite related to: increased caloric and fat intake, and sedentary lifestyle. The goal indicated the resident would adhere to a prescribed diet, would eat food only from their own plate, and would eliminate snacking between meals. The care plan did not include a goal of a desired weight to be achieved. Interventions included avoiding using food as a reward, using other means of positive encouragement, and referring to the dietitian for evaluation/recommendations. Review of Resident #107's record revealed the following weights and physician orders were recorded: 10/2/23- 207.3 pounds (lb.) 11/10/23-205.1 lb. 12/5/23- 194.2 lb. 1/19/24- 181.8 lb. 1/26/2024 a physician order was written for [brand name] nutritional supplement three times per day with meals and regular diet with enriched meals for Resident #107 due to weight loss. 1/30/24- 177.1 lb. 2/9/24- 172.5 lb. 3/26/24- 147.6 lb. 3/26/24 a physician order for Resident #107 to have weekly weights measured. 4/2/24- 152.3 lb. 4/10/24- 158.1 lb. Review of Resident #107's quarterly Minimum Data Set (MDS) dated [DATE] noted her weight was 158 pounds and had no weight loss or weight gain. An interview was conducted on 5/15/24 at 11:30 AM with the Registered Dietitian (RD). The RD revealed she was in the position since January 2024, her role was to complete a clinical review of the nutritional status of the residents, and she was not involved in the care planning process. The RD stated she was aware Resident #107 was not eating well and had lost a significant amount of weight. An interview was conducted on 5/16/24 at 3:10 PM with MDS Coordinator #1. MDS Coordinator #1 stated she was responsible for updating resident care plans and it was an error that Resident #107's care plan was not revised to reflect the weight loss and current interventions. She explained this had been an oversight. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the care plans would be accurate and up to date, including current information and interventions. b. Review of Resident #107's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she had impaired range of motion of the upper and lower extremities on one side, required extensive assistance with transfers, was noted as dependent for wheelchair mobility, and walking was coded as not applicable. A review of Resident #107's mobility care plan last reviewed on 4/26/24, included a focus of requires assistance for potential to restore or maintain maximum function of self-sufficiency for mobility characterized by the following functions: positioning, locomotion and ambulation related to at risk for limitation of range of motion in upper and lower extremities. The goal indicated resident will walk 50 feet with a hemi walker (a walker for a resident with the use of only 1 hand or arm) and left ankle brace through next review. Interventions included providing verbal cues and minimal assist of 1 person for ambulation of 50 feet with hemi walker and left ankle brace. An interview on 5/16/24 at 10:15 AM with the Rehabilitation Director revealed Resident #107 last received therapy from January 2024 through April 2024 to address mobility, positioning, and transfers. The Rehabilitation Director stated Resident #107 was non-compliant with splints, was non-ambulatory, and did not progress well with therapy. An interview was conducted on 5/16/24 at 3:10 PM with MDS Coordinator #1. MDS Coordinator #1 stated she was responsible for updating resident care plans and it was an error that Resident #107's care plan was not revised to reflect her current non ambulatory status. She explained this had been an oversight. An interview was conducted on 5/17/24 at 9:35 AM with Nurse #1. Nurse #1 indicated she was assigned to Resident #107 frequently and was familiar with her care. She explained Resident #107 had not walked or worn a leg brace for a long time. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the resident care plans to be revised to reflect changes in condition and interventions. 2. Resident #12 was admitted on [DATE]. Resident's diagnoses included in part end stage renal disease and dependence on renal dialysis. Review of Resident #12's nutrition care plan last revised on 1/24/23 indicated a problem for state of nourishment related to diagnosis of obesity, diabetes mellitus, increased protein needs and on therapeutic diet. Interventions indicated cardiac diet, regular texture, supplement as ordered, monitor weight, and notify physician as indicated. The resident had actual weight loss, received a renal carbohydrate-controlled diet and was on dialysis which was not updated/included in this nutrition care plan. Review of Resident #12's record revealed the following weights were recorded: 9/28/23- 224 pounds (lb.) 2/27/24- 222.2 lb. 3/26/24- 199.1 lb. Review of the weights recorded revealed resident had a 23-pound weight loss in 30 days (10.4%) and 25-pound weight loss in 180 days (greater than 10%). Review of Resident #12's 3/26/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #12 was coded as having a weight of 199 pounds with no weight loss or weight gain and received a therapeutic diet. Review of Resident #12's record revealed a physician order dated 3/29/24 for renal carbohydrate-controlled diet regular texture. Review of Resident #12's record revealed a 4/19/24 Registered Dietitian (RD) progress note which indicated resident's nutritional status was reviewed due to dialysis. The note indicated resident received a renal carbohydrate-controlled diet with regular texture and thin liquids and had a weight decrease of 14.5# (6.7 percent) over 30 days. An interview was conducted on 5/15/24 at 11:05 AM with the Registered Dietitian (RD). The RD stated she had been in the position since January 2024 and was following Resident #12 regarding the significant weight change. The RD stated she was not involved with the resident care plans. An interview was conducted on 5/16/24 at 3:10 PM with MDS Coordinator #1. MDS Coordinator #1 stated she was responsible for updating resident care plans and it was an error that Resident #12's care plan was not revised to reflect her current nutritional status. She explained this had been an oversight. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the resident care plans would be accurate, person centered and revised as needed. 3. Resident #19 was admitted to the facility on [DATE] with diagnosis which included diabetes. Review of Resident #19's record revealed the following weights were recorded: 11/29/2023- 156.5 pounds (lb.) 12/5/23- 150.7 lb. Review of Resident #19's current nutrition care plan indicated a problem last revised on 12/11/23 which indicated state of nourishment more than body requirement characterized by weight gain, obesity, excessive appetite related to overweight, diabetes, and heart disease. The goals indicated Resident #19 would adhere to the prescribed diet, would eat food only from her own plate, would eliminate snacking between meals and total intake would meet resident's nutritional needs as evidenced by weight stability. Interventions included avoiding using food as a reward, using other means of positive reinforcement, consistent carbohydrate/no added salt diet, regular texture, refer to dietitian for evaluation/recommendations, and weigh per facility protocol. Review of Resident #19's record revealed the following weights were recorded: 12/12/23- 148.4 lb. 1/11/24- 147.3 lb. 2/9/24- 140.0 lb. 3/7/24- 141.6 lb. 3/12/24- 135.0 lb. 4/9/24- 178.0 lb. A 4/12/24 physician order indicated Resident #19 received a consistent carbohydrate diet pureed texture with nectar consistency liquids. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a weight of 178 pounds with no weight loss or weight gain and they received a mechanically altered diet. A review of Resident #19's electronic health record revealed a 4/11/24 physician order for daily weights for 2 weeks then weekly due to 43-pound weight gain in 1 month. 4/12/24- 138.4 lb. 4/19/24- 132.4 lb. A 4/19/24 physician order indicated Resident #19 was to receive [brand name] nutritional supplement one time a day for additional calories and protein and a regular diet. 5/14/24- 129.7 lb. A 5/14/24 Nurse Practitioner progress note indicated Resident #19 was evaluated due to unintentional weight loss. The note indicated Resident #19's diet was advanced to regular diet to increase intake. An interview was conducted with the Registered Dietitian (RD) on 5/15/24 at 11:10 AM. The RD stated she was in the position since January 2024, her role was to complete clinical reviews of the residents' nutrition and she was not involved in the care planning process. The RD indicated Resident #19 had significant weight loss. An interview was conducted on 5/16/24 at 3:10 PM with MDS Coordinator #1. MDS Coordinator #1 stated it was an error that Resident #19's care plan was not updated regarding the weight loss and current interventions. She explained she was responsible for the completion of the nutrition focus in the care plan and Resident #19's care plan should have been revised when she began losing weight. MDS Coordinator #1 also explained that the previous RD who left in December updated and revised the nutrition care plans but the new RD did not. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the resident care plans would be accurate and revised to reflect changes in condition and interventions.

Based on observations, record review, staff, and the Nurse Practitioner interviews the facility failed to 1.) obtain blood pressure readings or heart rate prior to administering the antihypertensive medication Metoprolol which had parameters to hold the medication if the systolic blood pressure was less than 110 mmHg (millimeters of mercury) or heart rate less than 60 beats per minute. (Resident #17) and 2.) obtain physician ordered weekly weights for a resident with congestive heart failure. (Resident #44). This occurred for 2 of 2 residents (Resident #17, Resident #44) reviewed for quality of care. Findings included. 1.) Resident #17 was admitted to the facility on [DATE] with diagnoses including hypertension, and end stage renal disease. A care plan dated 02/10/23 with a target date of 06/18/24 revealed Resident #17 had end stage renal disease, received hemodialysis and was at risk for complications. Interventions included to monitor vital signs. A physician's order dated 04/02/24 for Resident #17 revealed Metoprolol Succinate extended release 50 milligrams (mgs). Give one tablet by mouth daily for hypertension. Hold for systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute. Review of Resident #17's Medication Administration Record (MAR) dated April 2024 revealed Metoprolol Succinate extended release 50 milligrams was scheduled for administration daily at 8:00 AM. The medication was signed as administered on the following dates with no corresponding blood pressure or heart rate recorded. 04/19/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/20/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/21/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/22/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/24/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/26/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/28/24 at 8:00 AM with no blood pressure or heart rate recorded. 04/29/24 at 8:00 AM with no blood pressure or heart rate recorded. Review of Resident #17's progress notes dated 04/19/24 through 04/29/24 revealed no blood pressure or heart rate recordings that corresponded to the Metoprolol administration time. Review of Resident #17's Medication Administration Record (MAR) dated May 2024 revealed Metoprolol Succinate extended release 50 milligrams was scheduled for administration daily at 8:00 AM. The medication was signed as administered on the following dates with no corresponding blood pressure or heart rate recorded. 05/03/24 at 8:00 AM with no blood pressure or heart rate recorded. 05/04/24 at 8:00 AM with no blood pressure or heart rate recorded. 05/05/24 at 8:00 AM with no blood pressure or heart rate recorded. 05/08/24 at 8:00 AM with no blood pressure or heart rate recorded. 05/10/24 at 8:00 AM with no blood pressure or heart rate recorded. 05/12/24 at 8:00 AM with no blood pressure or heart rate recorded. Review of Resident #17's progress notes dated 05/03/24 through 05/12/24 revealed no blood pressure or heart rate recordings that corresponded to the Metoprolol administration time. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had moderately impaired cognition. She had no rejection of care and received hemodialysis. A progress note documented by the Nurse Practitioner dated 05/15/24 revealed in part; Resident #17 was alert and oriented to person, place, and time. She was sitting in her wheelchair at the nurses station in no distress. She was appropriate and not drowsy. Her blood pressure was 116/76 (systolic/diastolic), pulse rate was 88 beats per minute. The cardiovascular exam indicated Resident #17 was at her baseline. During an interview on 05/17/24 at 12:45 PM Resident #17 was observed in her wheelchair in the hallway. She was alert and oriented to person, place, and time. She was pleasant and easily engaged in conversation. She stated she was doing okay today and voiced no concerns. She indicated that she had no concerns with her medications and was not aware of the times her medications were scheduled for administration. During an interview on 05/17/24 at 2:00 PM the Director of Nursing stated Nurse #4 and Nurse #5 who administered the Metoprolol on the dates with no blood pressures or heart rate recorded were not available for interview. She stated Nurse #4 was away on vacation and she made attempts today to contact Nurse #5 and there was no response. She stated the Medical Director was unavailable for interview due to a family emergency. She indicated a blood pressure and heart rate should have been obtained and recorded prior to administering the Metoprolol. She acknowledged there were no corresponding blood pressures and heart rate recorded in Resident #17's medical record during the time the medication was administered for the dates listed. She indicated education would be provided to nursing staff regarding medication administration and monitoring blood pressures and heart rate. During a phone interview on 05/17/24 at 3:30 PM the Nurse Practitioner stated she routinely evaluated Resident #17 and last examined her on 05/15/24. She indicated she was not aware that Resident #17 was not having her blood pressure taken prior to Metoprolol administration. She stated the Metoprolol was prescribed to Resident #17 to control high blood pressure and her blood pressure reading on 05/15/24 was 116/76 (systolic/diastolic). She stated her blood pressures have been okay. She indicated Resident #17 received hemodialysis and her blood pressures fluctuated at times which was why parameters were in place to hold the medication if the blood pressure or heart rate was low. She stated there had been no reports to her regarding a change of condition and blood pressures and heart rate should be obtained prior to administering the medication. 2.) Resident #44 was admitted to the facility on [DATE] with diagnoses including congestive heart failure. A physician's order dated 02/16/24 for Resident #44 revealed Furosemide (diuretic) 40 milligrams (mgs). Give one tablet by mouth daily for congestive heart failure. A physician's order dated 02/16/24 for Resident #44 revealed Aldactone (a potassium sparing diuretic) 25 milligrams (mgs). Give one tablet by mouth daily for hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #44 was cognitively intact. She had no rejection of care. A physician's order dated 03/20/24 for Resident #44 revealed to obtain weekly weights for congestive heart failure. Review of Resident #44's electronic medical record from 03/20/24 through 05/17/24 revealed the following weights recorded: 03/27/24 the recorded weight was 196.1 Lbs. (pounds) 04/02/24 the recorded weight was 201.5 Lbs. 04/23/24 the recorded weight was 202.5 Lbs. 05/14/24 the recorded weight was 207.0 Lbs. During an interview on 05/17/24 at 1:23 PM the Nurse Practitioner stated she was not aware Resident #44 was not getting weekly weights according to the order. She stated weekly weights were ordered to monitor fluid retention due to congestive heart failure. She stated Resident #44 had no change in condition and she expected weekly weights to get done according to the order. During an interview on 05/17/24 at 1:48 PM Resident #44 was observed sitting in her wheelchair. She was alert, and oriented to person, place, and time. She stated weekly weights have not been done, but she did get weighed 2 or 3 days ago. She stated she did not refuse care and wanted her weight monitored. During an interview on 05/17/24 at 2:00 PM the Director of Nursing stated upon reviewing Resident #44's Medication Administration Record (MAR) the order for weekly weights was on the MAR but it had an x on the MAR each day and therefore it would not populate on the MAR to obtain a weekly weight. She indicated the error was due to the way the order was entered into the electronic medical record that prevented it from populating on the MAR to obtain the weight weekly. She indicated if it had shown on the MAR the nurse would have informed a nurse aide to obtain the weight. She stated it would be corrected immediately. She stated Resident #44 was weighed on 05/14/24 and was evaluated by the Registered Dietician on 05/15/24. She stated she expected weight orders to be entered into the electronic medical record correctly and education to nursing staff would be provided.

Based on record review, observations and staff, resident and Nurse Practitioner interviews, the facility failed to provide physician ordered nutritional supplements on meal trays and failed to obtain physician ordered weights for 2 of 10 residents reviewed for nutrition (Resident #107 and Resident #19). 1.Resident #107 was admitted on [DATE]. Resident's medical diagnosis included stroke, failure to thrive, protein calorie malnutrition and diabetes. Review of Resident #107's electronic health record revealed the following weights were recorded: 10/2/2023- 207.3 pounds (Lbs.) 11/10/2023- 205.1 Lbs. 12/5/2023- 194.2 Lbs. 1/19/2024- 181.8 Lbs. 1/30/2024- 177.1 Lbs. 2/9/2024- 172.5 Lbs. 3/26/2024- 147.6 Lbs. 4/2/2024- 152.3 Lbs. 4/10/2024- 158.1 Lbs. 4/16/2024- 158.0 Lbs. 4/23/2024 No weight recorded. 4/30/2024 No weight recorded. 5/7/2024- 161.3 Lbs. 5/14/2024- 157.8 Lbs. Review of Resident #107's electronic health record revealed a 1/26/2024 physician order for Mighty Shake nutritional supplement three times per day with meals and regular diet with enriched meals. A 3/12/24 Nurse Practitioner (NP) progress note indicated resident continued with decreased appetite with stable decline in weight. Review of Resident #107's electronic health record revealed a 3/26/2024 physician order for weekly weights. Review of Resident #107's 4/12/24 quarterly Minimum Data Set (MDS) indicated resident had a mild cognitive impairment. Resident #107's weight was 158 pounds and the resident was coded as had no weight loss or weight gain of 5 percent in past 30 days or 10 percent in past 180 days. A 4/24/24 NP progress note indicated resident was seen due to poor appetite and weight loss. The progress note indicated to continue with the enriched meal diet, nutritional supplement and encourage intake. The progress note did not indicate Resident #107 was receiving end of life care. Observation of Resident #107's lunch meal tray card on 5/13/24 at 12:40 PM revealed resident was to receive enriched meals, double vegetables, 2 bowls of soup, a peanut butter and jelly sandwich and a Mighty Shake nutritional supplement. The meal tray card further indicated disliked fish, spaghetti squash, zucchini, rice, pasta, and vegetables. Observation of the meal tray revealed Resident #107 did not receive double vegetables, soup, a sandwich, or a Mighty Shake nutritional supplement on the meal tray. Resident #107's meal tray consisted of 2 chicken tenders, a single serving of macaroni and cheese and a single serving of coleslaw. Observation of Resident #107's lunch meal tray on 5/14/24 at 12:40 PM revealed resident did not receive a Mighty Shake nutritional supplement on her meal tray. An interview was conducted on 5/14/24 at 12:45 PM with Resident #107. Resident #107 stated she did not receive a milk shake on her meal tray. Resident stated she would really like a milk shake. An interview was conducted on 5/15/24 at 11:30 AM with the Registered Dietitian (RD). The RD revealed she completed a clinical review of the resident's nutritional status and did not routinely observe or interview the residents. The RD stated she was aware Resident #107 was not eating well and was losing weight. The RD stated she was not sure why Resident #107 continued to lose weight. The RD further stated she was not aware that Resident #107 had not received her nutritional supplement. An interview was conducted on 5/16/24 at 3:30 PM with the Nurse Practitioner (NP). The NP indicated she expected that residents would receive nutritional supplements as ordered and weekly weights would be completed as ordered. An interview was conducted on 5/17/24 at 9:50 AM with the Dietary Manager. The Dietary Manager stated she expected that supplements would be on the meal trays as ordered. The Dietary Manager stated she received the order for the nutritional supplement from nursing and then it is put on the meal tray card along with the likes and dislikes and any special items the resident was to receive. The dietary aides were responsible for placing the supplements on the trays. The Dietary Manager stated sometimes she ran out of supplements including Mighty Shakes. The Dietary Manager stated she currently had the Mighty Shake supplement in stock. The Dietary Manager stated it was an oversight that Resident #107 did not receive her Mighty Shakes as ordered and that the extra items were not on her lunch tray on 5/13/24. The Dietary Manager stated she had a lot of new staff, and it was hard to get them to pay attention to the meal tray cards. The Dietary Manager further stated she had a lot of staff turnover, and she was constantly trying to train new staff and trying to make sure they were doing things properly. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the residents to receive nutritional supplements as ordered and weekly weights were to be completed as ordered. The physician was not available for interview on 5/17/24. 2. Resident #19 was admitted to the facility on [DATE] with diagnosis which included diabetes and hypertension. Review of Resident #19's electronic health record revealed the following weights were recorded: 11/29/2023- 156.5 pounds (Lbs.) 12/1/2023- 156.5 Lbs. 12/5/2023- 150.7 Lbs. 12/12/2023- 148.4 Lbs. 12/21/2023- 143.7 Lbs. 12/29/2023- 143.0 Lbs. 1/11/2024- 147.3 Lbs. 1/30/2024- 142.2 Lbs. 2/9/2024- 140.0 Lbs. 3/7/2024- 141.6 Lbs. 3/12/2024- 135.0 Lbs. 4/9/2024- 178.0 4/9/2024- 178.0 documented as incorrect documentation. 4/9/2024- 178.0 Lbs. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident had a weight of 178 pounds. The MDS assessment indicated Resident #19 had no weight loss or weight gain of 5 percent in 30 days or 10 percent in 180 days. A review of Resident #19's electronic health record revealed a 4/11/2024 physician order for daily weights for 2 weeks then weekly due to 43-pound weight gain in 1 month. 4/12/2024- 138.4 Lbs. 4/13/2024- 136.2 Lbs. 4/13/2024- 136.2 Lbs. 4/14/2024- 135.6 Lbs. 4/15/2024- 133.2 Lbs. 4/16/2024- 133.9 Lbs. 4/17/2024- 132.6 Lbs. 4/18/2024- 132.2 Lbs. 4/19/2024- 132.4 Lbs. 4/20/2024 No weight recorded. 4/21/2024 No weight recorded. 4/22/2024- 133.3 Lbs. 4/23/2024- 133.4 Lbs. 4/24/2024- 131.5 Lbs. 4/25/2024- 134.7 Lbs. 5/2/2024 No weight recorded. 5/6/2024- 132.6 Lbs. 5/13/2024 No weight recorded. 5/14/2024- 129.7 Lbs. A physician order dated 4/17/2024 indicated regular diet. A 4/19/2024 physician order indicated Resident #19 was to receive Magic Cup supplement one time a day for additional kilocalories and protein. Observation of Resident #19's meal tray ticket on 5/13/2024 at 12:45 PM indicated resident received a regular cardiac consistent carbohydrate diet. The meal ticket also indicated Resident #19 was to receive a Magic Cup. Observation indicated a Magic Cup was not on resident's tray. Observation of Resident #19's meal tray on 5/14/2024 at 12:45 PM revealed no Magic Cup was observed on the meal tray. Interview with Resident #19 on 5/14/2024 at 12:45 PM revealed she could not eat the lunch meal that was served today as it did not look appetizing to her. Resident #19 stated she thought she had lost weight and that she often had crackers and juice for lunch. Observation indicated Resident #19 had a large cooler in her room of foods that her family had brought in. A 5/14/24 Nurse Practitioner (NP) progress note indicated resident was evaluated due to unintentional weight loss over the last 6 months and it appeared to be from the dislike of the taste of the food at the facility. Diet was advanced to regular diet. The progress note did not indicate that Resident #19 was receiving end of life care. An interview was conducted with the Registered Dietitian on 5/15/2024 at 11:10 AM. The RD stated she was following Resident #19 for significant weight loss. The RD stated Resident #19 had a nutritional supplement ordered and she had not heard of any issues with the resident not receiving it. The RD stated she mainly completed a chart review to evaluate the resident's nutritional status and did not observe the meal trays or interview the resident. The RD stated not receiving the nutritional supplement would contribute to continued weight loss. Observation of Resident #19's meal tray on 5/16/2024 at 12:45 PM revealed no Magic Cup was observed on the meal tray. An interview was conducted on 5/16/2024 at 3:30 PM with the Nurse Practitioner (NP). The NP indicated if a resident had an order for a nutritional supplement, she expected the resident to receive the supplement as ordered. The NP further stated resident weights were to be obtained as ordered. An interview was conducted on 5/16/2024 at 4:30 PM with the Director of Nursing (DON). The DON stated she expected the residents to receive nutritional supplements as ordered and resident weights to be obtained as ordered. An interview was conducted on 5/17/2024 at 9:50 AM with the Dietary Manager. The Dietary Manager stated she expected that supplements would be on the meal trays as ordered. The Dietary Manager stated she received a diet slip from nursing with orders for a nutritional supplement and changes in the diet. The Dietary Manager stated she put the nutritional supplement on the meal tray ticket along with the likes and dislikes and any special items the resident received. The dietary aides were responsible for placing the supplements on the meal trays. The Dietary Manager stated sometimes she ran out of nutritional supplements including the Magic Cups but currently she had them in stock. The Dietary Manager stated it was an oversight that Resident #19 did not receive her Magic Cup as ordered this week. The Dietary Manager stated she had a lot of new staff, and it was hard to get them to pay attention to the meal tray cards. The Dietary Manager further stated she had a lot of staff turnover, and she was constantly trying to train new staff and trying to make sure they were doing things properly. An interview was conducted on 5/17/2024 at 1:50 PM with the Administrator. The Administrator stated she expected the residents to receive nutritional supplements as ordered and resident weights to be obtained as ordered.

Based on record review, and resident, staff and Nurse Practitioner interviews, the facility failed to ensure a resident had an appointment scheduled for a physician ordered mammogram (Resident #22) for 1 of 1 resident sampled for medically related social services. Findings included: Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included diabetes and history of left breast keloid (thick scar tisssue resulting from excessive growth of fibrous tissue). Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. Review of the facility grievance log revealed a grievance form dated 12/4/23 completed by the resident received by the Director of Nursing/ Assistant Administrator. The grievance was regarding Resident #22's request for a referral for a mammogram. Resident #22 stated she had requested an appointment for a mammogram, and it had not been scheduled. The outcome of the grievance indicated an appointment for a mammogram was to be made for Resident #22. Findings of the grievance indicated Resident #22 had a history of a partial resection of the left breast keloid with request for a mammogram. The grievance indicated follow up was to be made with the provider regarding the request for a mammogram. Grievance resolution was issued to the resident on 12/6/23. Review of a 12/6/23 letter addressed to Resident #22 indicated resident requested an appointment for a mammogram. After an appropriate investigation supervised by the grievance official it was determined that follow up would be made with the provider about the request for a mammogram. Review of a 2/14/24 physician progress note revealed Resident #22 requested a mammography appointment. The progress note indicated the physician would write an order to schedule a mammogram. Review of Resident #22's physician orders revealed a 2/14/24 physician order to schedule a mammography appointment. Review of Resident #22's electronic health record revealed a 2/26/24 Nurse Practitioner progress note which indicated resident again requested a referral for a mammogram. The order was previously written to schedule the mammogram. An interview was conducted on 5/13/24 at 12:04 PM with Resident #22. Resident #22 stated she requested an appointment for a mammogram, and it had not been scheduled. Resident #22 stated she had a history of a cyst in her breast and had not had a mammogram for several years. A following up interview was conducted on 5/16/24 at 12:26 PM with Resident #22. Resident #22 stated she filed a grievance in December 2023 regarding her request for a mammogram to be scheduled and the appointment had still not been scheduled. Resident #22 further indicated she had breast pain and was concerned about the appointment for the mammogram. Resident #22 stated she was aware that the Nurse Practitioner had written a referral several months ago for the appointment, but it had not been scheduled. An interview was conducted on 5/15/24 at 12:10 PM with the Transportation Specialist. The Transportation Specialist stated she was responsible for scheduling appointments and transportation for the residents and was in the position for the past year. The Transportation Specialist stated she was informed of referrals by the nursing staff, family members and the providers. The Transportation Specialist stated she had not made any appointments lately for Resident #22. She stated she was informed a while back that Resident #22 required an appointment for a mammogram. The Transportation Specialist stated she was still working on trying to get an appointment for the resident for a mammogram. The Transportation Specialist stated she was not sure how Resident #22 needed to be transported and it was difficult to obtain stretcher transportation. An interview was conducted on 5/15/24 at 1:45 PM with the Unit Manager. The Unit Manager stated she was not aware of a referral for Resident #22 to have a mammogram written by the provider in February. The Unit Manager indicated the Transportation Specialist should have been notified of the physician order written in February to schedule a mammogram for Resident #22. An interview was conducted on 5/16/24 at 3:25 PM with the Nurse Practitioner (NP). The NP revealed she would expect to be notified if the facility was not able to schedule an appointment or if there was a delay in obtaining an appointment for a mammogram. The NP indicated a screening mammogram was indicated for Resident #22 and should have been scheduled when the order was written in February. The NP stated the NP that evaluated Resident #22 in February no longer worked at the facility. An interview was conducted on 5/17/24 at 12:20 PM with the Administrator. The Administrator stated Resident #22 had filed a grievance in December regarding the appointment for a mammogram and the resolution of the grievance was that administration would follow up. The Administrator stated she expected the appointment would be made when an order was written, and 5 months was too long to wait to obtain an appointment. The Administrator stated she did not know why there was a breakdown in the process to obtain the appointment for the mammogram following the grievance.

Based on record review, and staff, Pharmacy Consultant, and Nurse Practitioner interviews the facility failed to 1a.) administer the antihypertensive medication Metoprolol prescribed to lower blood pressure, the oral diabetic medication Tradjenta prescribed to lower blood sugar , a phosphate binder Sevelamer (a medication prescribed to lower the amount of phosphorus in the blood when receiving dialysis), and Cymbalta prescribed for neuropathy to a hemodialysis resident after returning from dialysis treatments. This resulted in the resident (Resident #17) not receiving a total of 15 doses of Metoprolol, 15 doses of Tradjenta, 15 doses of Sevelamer, and 8 doses of Cymbalta. 1b.) administer the full course of the oral antifungal Diflucan prescribed for treatment of vaginitis according to the physicians order (Resident #17). This resulted in 2 of the 3 doses of Diflucan not administered. This occurred for 1 of 5 resident reviewed for medication administration (Resident #17). Findings included. 1a.) Resident #17 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, end stage renal disease, and neuropathy. A physician's order dated 03/26/24 for Resident #17 revealed Hemodialysis on Tuesday, Thursday, Saturday at 6:00 AM. A physician's order dated 04/02/24 for Resident #17 revealed Metoprolol Succinate extended release 50 milligrams (mgs). Give one tablet by mouth daily for hypertension. Review of Resident #17's Medication Administration Record (MAR) dated April 2024 revealed Metoprolol Succinate extended release 50 milligrams was scheduled for administration daily at 8:00 AM. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 04/02/24 (Tuesday) 8:00 AM: out of the facility. 04/04/24 (Thursday) 8:00 AM: out of the facility. 04/06/24 (Saturday) 8:00 AM: out of the facility. 04/09/24 (Tuesday) 8:00 AM: out of the facility. 04/11/24 (Thursday) 8:00 AM: out of the facility. 04/16/24 (Tuesday) 8:00 AM: out of the facility. 04/18/24 (Thursday) 8:00 AM: out of the facility. 04/23/24 (Tuesday) 8:00 AM: out of the facility. 04/25/24 (Thursday) 8:00 AM: out of the facility. Review of Resident #17's Medication Administration Record (MAR) dated May 2024 revealed Metoprolol Succinate extended release 50 milligrams was scheduled for administration daily at 8:00 AM. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 05/02/24 (Thursday) 8:00 AM: out of the facility. 05/07/24 (Tuesday) 8:00 AM: out of the facility. 05/09/24 (Thursday) 8:00 AM: out of the facility. 05/11/24 (Saturday) 8:00 AM: out of the facility. 05/14/24 (Tuesday) 8:00 AM: out of the facility. 05/16/24 (Thursday) 8:00 AM: out of the facility. A physician's order dated 04/04/24 for Resident #17 revealed Tradjenta 5 milligrams. Give one tablet once daily for diabetes. Review of Resident #17's Medication Administration Record (MAR) dated April 2024 revealed Tradjenta 5 mgs give one tablet once daily for diabetes was scheduled for administration daily at 8:00 AM. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 04/04/24 (Thursday) 8:00 AM: out of the facility. 04/06/24 (Saturday) 8:00 AM: out of the facility. 04/09/24 (Tuesday) 8:00 AM: out of the facility. 04/11/24 (Thursday) 8:00 AM: out of the facility. 04/16/24 (Tuesday) 8:00 AM: out of the facility. 04/18/24 (Thursday) 8:00 AM: out of the facility. 04/23/24 (Tuesday) 8:00 AM: out of the facility. 04/25/24 (Thursday) 8:00 AM: out of the facility. 04/30/24 (Tuesday) 8:00 AM: out of the facility. Review of Resident #17's Medication Administration Record (MAR) dated May 2024 revealed Tradjenta 5 mgs give one tablet once daily for diabetes was scheduled for administration daily at 8:00 AM. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 05/02/24 (Thursday) 8:00 AM: out of the facility. 05/07/24 (Tuesday) 8:00 AM: out of the facility. 05/09/24 (Thursday) 8:00 AM: out of the facility. 05/11/24 (Saturday) 8:00 AM: out of the facility. 05/14/24 (Tuesday) 8:00 AM: out of the facility. 05/16/24 (Thursday) 8:00 AM: out of the facility. A physician's order dated 04/02/24 for Resident #17 revealed Sevelamer 800 milligrams. Give 2 tablets three times a day for Hypophosphatemia. Review of Resident #17's Medication Administration Record (MAR) dated April 2024 revealed Sevelamer 800 mgs. Give 2 tablets three times a day for Hypophosphatemia was scheduled for administration three times a day at 8:00 AM, 12:00 PM, and 4:00 PM. The 8:00 AM dose had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. The 12:00 PM and 4:00 PM doses were signed as administered. 04/02/24 (Tuesday) 8:00 AM: out of the facility. 04/04/24 (Thursday) 8:00 AM: out of the facility. 04/06/24 (Saturday) 8:00 AM: out of the facility. 04/09/24 (Tuesday) 8:00 AM: out of the facility. 04/11/24 (Thursday) 8:00 AM: out of the facility. 04/16/24 (Tuesday) 8:00 AM: out of the facility. 04/18/24 (Thursday) 8:00 AM: out of the facility. 04/23/24 (Tuesday) 8:00 AM: out of the facility. 04/25/24 (Thursday) 8:00 AM: out of the facility. Review of Resident #17's Medication Administration Record (MAR) dated May 2024 revealed Sevelamer 800 mgs. Give 2 tablets three times a day for Hypophosphatemia was scheduled for administration three times a day at 8:00 AM, 12:00 PM, and 4:00 PM. The 8:00 AM dose had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. The 12:00 PM and 4:00 PM doses were signed as administered. 05/02/24 (Thursday) 8:00 AM: out of the facility. 05/07/24 (Tuesday) 8:00 AM: out of the facility. 05/09/24 (Thursday) 8:00 AM: out of the facility. 05/11/24 (Saturday) 8:00 AM: out of the facility. 05/14/24 (Tuesday) 8:00 AM: out of the facility. 05/16/24 (Thursday) 8:00 AM: out of the facility. A physician's order dated 04/25/24 for Resident #17 revealed Cymbalta 60 milligrams (mgs) oral capsules delayed release. Give 30 mgs by mouth in the morning for neuropathy. Review of Resident #17's Medication Administration Record (MAR) dated April 2024 revealed Cymbalta 60 mgs oral capsules delayed release. Give 30 mgs by mouth in the morning for neuropathy was scheduled for administration at 9:00 AM daily. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 04/25/24 (Thursday) 9:00 AM: out of the facility. 04/30/24 (Tuesday) 9:00 AM: out of the facility. Review of Resident #17's Medication Administration Record (MAR) dated May 2024 revealed Cymbalta 60 mgs oral capsules delayed release. Give 30 mgs by mouth in the morning for neuropathy was scheduled for administration at 9:00 AM daily. The MAR had chart code 3 documented on the following dates indicating the medication was not administered due to Resident #17 was out of the facility. 05/02/24 (Thursday) 9:00 AM: out of the facility. 05/07/24 (Tuesday) 9:00 AM: out of the facility. 05/09/24 (Thursday) 9:00 AM: out of the facility. 05/11/24 (Saturday) 9:00 AM: out of the facility. 05/14/24 (Tuesday) 9:00 AM: out of the facility. 05/16/24 (Thursday) 9:00 AM: out of the facility. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had moderately impaired cognition. She had no rejection of care and received hemodialysis. A progress note documented by the Nurse Practitioner dated 05/15/24 revealed in part; Resident #17 was alert and oriented to person, place, and time. She was sitting in her wheelchair at the nurses station in no distress. She was appropriate and not drowsy. Her blood pressure was 116/76 (systolic/diastolic), pulse rate was 88 beats per minute. Her blood sugar was 144 mg/dl (milligrams per deciliter). The cardiovascular exam indicated Resident #17 was at her baseline. Neuropathic pain of stumps (bilateral below knee amputation) to thighs and right hand were minimal. She had no tremors. During an interview on 05/17/24 at 1:00 PM Medication Aide #1 stated on the days Resident #17 was at dialysis she documented code 3 indicating Resident #17 was out of the facility at the time the medications were due. She stated once she documented that the resident was out of the facility the medication would not show up again on the MAR. She stated the medications were not given once Resident #17 returned from dialysis because it did not show on the MAR as needing to be administered. During an interview on 05/17/24 at 2:00 PM the Director of Nursing stated Nurse #4 and Nurse #5 who documented Resident #17 was out of the facility for the dates the medication was not administered in April and May 2024 were not available for interview. She stated Nurse #4 was away on vacation and she made attempts today to contact Nurse #5 and there was no response. She stated the Medical Director was unavailable for interview due to a family emergency. She stated the medication times should have been adjusted to administer to Resident #17 after she returned from dialysis and that was not done. During a phone interview on 05/17/24 at 3:30 PM the Nurse Practitioner stated she routinely evaluated Resident #17 and last examined her on 05/15/24. She indicated she was not aware that Resident #17 was not receiving her morning medications on dialysis days. She stated the Metoprolol was prescribed to Resident #17 to control high blood pressure and her blood pressure reading on 05/15/24 was 116/76 (systolic/diastolic). She indicated her blood pressures have been okay. She stated the Tradjenta was prescribed to Resident #17 for additional protection for diabetes and she also received sliding scale insulin. She stated her blood sugars were stable. She indicated the Cymbalta was prescribed for neuropathy and there had been no reports of increased pain or adverse symptoms. She stated Sevelamer was prescribed to Resident #17 due to being on dialysis and was a phosphate binder. She indicated her phosphorus levels were within normal limits and no abnormal phosphorus levels had been reported from dialysis staff. She stated Resident #17 was alert, oriented, and typically in her wheelchair throughout the day. She stated there had been no reports to her regarding a change of condition and the medication times should have been adjusted to account for dialysis. She indicated Resident #17 had not exhibited any significant outcome from not receiving the Metoprolol, Tradjenta, Cymbalta, or Sevelamer daily. 1b.) A physician's order dated 04/30/24 for Resident #17 revealed Diflucan 150 milligrams. Give one tablet by mouth in the morning every other day for vaginitis. Review of the Medication Administration Record (MAR) dated May 2024 for Resident #17 revealed Diflucan 150 milligrams. Give one tablet by mouth in the morning every other day for vaginitis was scheduled to be administered at 9:00 AM beginning 05/01/24. The medication had chart code 10 documented on the following dates indicating the medication was not available. The MAR read as follows: 05/01/24 9:00 AM 10 medication not available. 05/03/24 9:00 AM 10 medication not available. 05/05/24 9:00 AM the medication was signed as administered. A progress note documented by the Nurse Practitioner dated 05/15/24 revealed in part; Resident #17 was evaluated for urinary tract infection. She was alert and oriented to person, place, and time. She was sitting in her wheelchair at the nurses station in no distress. She was positive for urinary tract infection and would start Gentamycin 80 mgs IM (intramuscular) daily for 7 days. During a phone interview on 05/17/24 at 9:30 AM the Consultant Pharmacist stated the order for Diflucan was received at the Pharmacy on 04/30/24 at 7:00 PM. The Pharmacy dispensed 3 tablets on 05/01/24. She stated Diflucan was also kept in the e-kit (kit located in the facility containing extra doses of medications for backup use) in the facility. Her record showed 6 doses of Diflucan were available on 05/01/24 in the e-kit at the facility. She reported they should have had the full course of the medication available for administration on 05/01/24. She indicated she was not aware of any adverse effects from Resident #17 not receiving the full course of treatment. During an interview on 05/17/24 at 2:00 PM the Director of Nursing stated Nurse #4 and Nurse #5 who documented the medication was not available on 05/01/24 and 05/03/24 were not available for interview. She reported that Nurse #4 was away on vacation, and she had made attempts today to contact Nurse #5 and there was no response. During a phone interview on 05/17/24 at 3:30 PM the Nurse Practitioner stated she was not aware that Resident #17 did not get the 3 doses of Diflucan. She stated it was prescribed for vaginitis and one dose (150 mgs) of Diflucan could be sufficient. She stated she prescribed 3 doses to effectively clear her symptoms. She stated she evaluated Resident #17 on 05/15/24 for symptoms of urinary tract infection (UTI) and prescribed Gentamycin IM (intramuscular) for UTI treatment. She indicated although Resident #17 was positive for urinary tract infection it was not necessarily a direct result from not getting the full course of Diflucan for vaginitis. During an interview on 05/17/24 at 4:00 PM the Director of Nursing (DON) stated 10 on the MAR indicated the medication was not available. She stated the Nurse should have checked the e- kit while waiting for the medication to come from the Pharmacy. She indicated once the medication was available the MAR was not adjusted to account for the missed doses. She stated education had already been started on medication administration last night when she was made aware of the concern with Diflucan. She stated the full course of the Diflucan should have been administered according to the physicians order.

Based on observation, record review, resident and staff interview, the facility failed to ensure food was palatable and served at an appetizing temperature for 4 of 8 residents reviewed for food palatability and temperature (Residents #22, #116, and #107) and 5 of 5 Resident Council members in attendance at a Resident Council meeting (Residents #23, #119, #14, #75 and #41). Findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnosis which included diabetes. Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #22 on 5/13/24 at 12:00 PM. Resident #22 revealed the food was cold and not appetizing or cooked well. Resident #22 stated she wished she could make a choice about what she received to eat. Meal observation of Resident #22's lunch tray on 5/13/24 at 12:30 PM revealed resident received 2 chicken tenders, a scoop of potato salad and a scoop of macaroni and cheese. Resident refused the meal and stated the macaroni and cheese was dry and the chicken tenders were hard. Resident #22 requested 2 grilled cheese sandwiches. Resident received 1 grilled cheese sandwich. An interview was conducted on 5/14/24 at 9:12 AM with Resident #22. Resident #22 indicated the food was frequently not hot when it was served, and it was not palatable. Resident #22 stated she had received cold food and food that did not look or taste good for a while. An interview was conducted on 5/17/24 at 9:50 AM with the Dietary Manager. The Dietary Manager stated she was not aware that Resident #22 had any food complaints. The Dietary Manager indicated Resident #22 preferred grilled cheese for lunch and dinner recently and the kitchen provided them per resident's preference. An interview was conducted on 5/17/24 at 12:20 PM with the Administrator. The Administrator stated she was not aware of Resident #22 having any concerns about cold food. 2. Review of Resident #116's 3/19/24 quarterly Minimum Data Set (MDS) assessment revealed resident was cognitively intact. . Interview on 5/13/24 at 1:47 PM with Resident #116 indicated the food often does not look or taste good. Resident #116 stated she frequently drinks a nutritional supplement provided by her family instead of eating due to the meals being cold and not palatable. Resident #116 stated her meals were always cold, not reheated and she often could not eat it because of this. Meal observation on 5/14/24 at 12:45 PM indicated Resident #116 had her lunch meal tray in front of her which consisted of chicken and dumplings, carrots and mashed potatoes and gravy. Resident #116 indicated she had tried a few bites of her meal but could not eat it. Resident #116 stated the meal did not look appetizing and did not taste good. Resident was observed drinking a nutritional supplement that she received on her meal tray. Resident #116 indicated she was drinking her supplement instead because she could not eat the meal that was served. Resident #116 stated she could ask for an alternate, but it was usually a peanut butter and jelly sandwich, and she could not eat that since she had diabetes. An interview was conducted with the Registered Dietitian (RD) on 5/15/24 at 11:15 AM. The RD stated she was in the position at the facility for 5 months. The RD stated she was not aware of any issues with the food that was served. The RD stated she was not involved with the menu or the diet. The RD stated her main role was to provide a clinical review of the resident's record and this did not involve interview of the resident or observation of the meals. The RD stated Resident #116 had significant weight loss. The RD stated she was not aware Resident #116 was not eating the meals due to concerns with the food temperature and palatability. The RD did not indicate that she would follow up with the Dietary Manager. 3. Resident #107 was admitted on [DATE]. Review of Resident #107's electronic health record revealed a Nurse Practitioner progress note which indicated resident was evaluated on 3/5/24 due to staff concerns that resident's appetite was poor and resident was not eating the meals. The progress note indicated Resident #107 informed the Nurse Practitioner that the food was no good. The progress note further stated the resident had a poor appetite with a down trend in weights. The progress note did not indicate that resident was receiving end of life care. Interview with Resident #107 on 5/13/24 at 11:07 AM revealed the food was not good. Resident #107 stated she kept snacks in her room that her family supplied. Resident #107 stated the food frequently was not hot or palatable. Resident #107 indicated the staff were aware she did not like the food, and they added the extra items that sometimes she received and sometimes she did not. Observation of the lunch meal on 5/13/24 at 12:30 PM revealed Resident #107's meal tray ticket indicated resident was to receive a regular enriched meal program diet with double vegetables, 2 bowls of soup, a peanut butter and jelly sandwich, and a sugar free milk shake supplement. Observation of Resident #107's meal tray revealed resident received a Styrofoam container which contained 2 chicken tenders, a scoop of potato salad, and a scoop of macaroni and cheese. Resident was observed not eating the meal that was provided. Resident had a container with food that her family had provided that she was eating. Interview with Resident #107 indicated the chicken was cold and hard and the macaroni and cheese was cold and dry. Observation of Resident #107's lunch meal tray on 5/14/24 at 12:40 PM revealed resident received two bowls of soup, a peanut butter and jelly sandwich and a foam container which contained chicken and dumplings, carrots and mashed potatoes and gravy. An interview was conducted with Resident #107 on 5/14/24 at 12:40 PM. Resident #107 stated the meal she received was not hot and not palatable. Resident #107 stated the chicken and dumplings looked sloppy and messy with the chicken ground up and it was cold. An interview was conducted with Resident #107 on 5/15/24 at 12:45 PM. Resident #107 stated she ate a peanut butter and jelly sandwich for lunch. Resident #107 stated she did not think she should eat peanut butter and jelly sandwiches every day because she was diabetic, but the meals were not good, and she often just could not eat it. 4. Review of the Resident Council meeting minutes from December 2023 through May 2024 revealed the following food concerns: - 1/3/24 Concern was voiced regarding food thrown on trays and not hot enough. The grievance follow up indicated dietary staff were educated by the manager on food presentation and food temperatures were to be checked prior to leaving the kitchen. The grievance follow up indicated staff were to work on delivering the food quicker to ensure appropriate temperatures on arrival for the residents. - 3/6/24 Concern was voiced regarding vegetables being served mushy. The grievance follow up indicated the Dietary Manager explained that vegetables were sometimes mushy due to cooking a large quantity. - 5/1/24 Concern was voiced that food was not hot when served in Styrofoam trays and meals were repeated frequently. The grievance follow up indicated foam containers were used due to a recent dishwasher fire and they would resume normal meal service once the new dishwasher is installed. During the survey a Resident Council meeting was held on 5/14/24 at 2:30 PM and was attended by the Resident Council President (Resident #23) and a sample of other cognitively intact residents (Resident #119, #14, #75 and #41). The sample of residents in the Resident Council meeting stated the food had been discussed in the Resident Council meetings for months and they continued to receive cold food. The sampled residents stated they received meals that were not palatable and food that did not look or taste good. The residents stated the food was a big concern in the facility. An interview was conducted on 5/16/24 at 4:35 PM with the Director of Nursing (DON). The DON stated the facility needed to work on a system for residents to receive an alternate meal and to ensure the residents received a hot, palatable meal. The DON indicated food service and meal delivery was an area that needed to be investigated more closely. An interview was conducted on 5/17/24 at 9:50 AM with the Dietary Manager. The Dietary Manager stated she was not aware that the residents had any food complaints. The Dietary Manager stated she was not informed of any grievances filed regarding the food. The Dietary Manager stated that she had new staff, and it was hard to get them trained and to pay attention to how the meals were served. The Dietary Manager indicated she had a high turnover of staff and was constantly training staff. The Dietary Manager further stated she had some insulated meal carts, but not enough to deliver all the meals. The Dietary Manager indicated she obtained likes and dislikes from the residents on admission but did not make routine rounds to update these or receive feedback regarding the food. The Dietary Manager stated she was told by the Administrator to improve the food and the food temperatures, but she did not think there was anything she could do. An interview was conducted on 5/17/24 at 12:20 PM with the Administrator. The Administrator stated she expected that the food would be palatable and served at an appropriate temperature per resident preferences. The Administrator further stated she expected that staff would offer alternate meals if a resident did not like what was served and would take the meal to the kitchen to be reheated if it was cold.

Based on observations, record review and staff and resident interviews, the facility failed to provide alternative meals for 6 out of 8 residents reviewed for nutrition (Resident # 7, Resident #21, Resident #22, Resident #116, Resident #107, and Resident #19). Findings included: 1a. Resident #7 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set assessment dated [DATE] for Resident #7 documented he had intact cognition. In an interview with Resident #21 on 05/16/24 at 12:08 PM he stated when he gets his food it's cold, dried out and hard. He stated he was not aware he could ask for an alternate meal if he did not like what was served to him. 1b. Resident #21 was admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] documented Resident #21 had intact cognition. An observation of the lunch meal served to Resident #21 included fried shrimp. In an interview with Resident #21 on 05/13/24 at 2:00 PM she stated she did not eat anything that came out of the ocean, and she was not going to eat the lunch that was served. She stated she had not told dietary about the seafood dislike, but they did know she did not eat eggs or sausage and sometimes she was served both. She reported that she had a dinner that her roommate's family had brought in for her and that was what she planned on eating. She stated she was not offered an alternative. She noted that in the past a staff member came around and reviewed the menu for the week and asked her to choose which meal she preferred. She stated that lasted about 2 weeks and after that no one had been around to offer her an alternate meal choice. She noted she ate food brought in a lot because half the time the food she was served she either didn't like or it was cold when it was served to her. Two examples of documentation for resident meal choices were reviewed. For the week of 04/15/24 documentation showed that residents were asked which meal or alternate was preferred each day beginning on Wednesday, 04/17/24. Residents were not interviewed regarding the menu on 04/15/24 or 04/16/24 of that week. The week of 5/13/24 documentation showed that residents were asked which meal or alternate was preferred each day beginning on Thursday, 05/16/24. Residents were not interviewed regarding the menu on 05/13/24, 05/14/24, or 05/15/24 the week of 05/13/24. In an interview with the Administrator on 05/17/24 at 11:23 AM she stated she did expect the residents to have a choice for meal preferences. She explained she did not know why residents were not interviewed this week on 05/13/24, 05/14/24 or 05/15/24 regarding meal choices and were not interviewed on 04/15/14 and 04/16/14 for the week of 04/15/24. She stated the evening receptionist was given a menu for the week. She then was to interview each resident who was able to be interviewed to obtain meal preferences. She stated this process started in April 2024. Prior to that menus were put on each unit and the aides would go around daily and ask each resident what they preferred. She explained that process failed because the aides didn't have time to do that and complete their other duties. In an interview with Receptionist #3 on 05/17/24 at 11:21 AM she stated she had only gone around with the menus and interviewed residents for meal preferences one time and that was this Wednesday. She explained because she wasn't given the menu until Wednesday, she could only interview for preferences beginning with Thursday's menu (05/16/24). In an interview with Receptionist #1 on 05/17/24 at 12:56 PM she stated she had in the past went around and asked residents what meal they wanted for a week at a time. It used to be that a list of residents was made and if any resident wanted something different that day it would be documented and given to the kitchen. She stated that currently it was done weekly. She explained the last time she did this she only asked 9 residents what they preferred to eat each day because it took too long to interview and circle the choices on the menu. She said she was supposed to ask all alert and oriented residents what their preferences were, but she could not get to everyone. She explained after the residents were interviewed the menus would then be given to the kitchen so that meal preferences could be honored each day. She explained the last time she did go around with the weekly menus she could only do Wednesday through Sunday because the menu for the week wasn't given to her until Tuesday evening. In an interview with Receptionist #2 on 5/17/24 at 2:48 PM she stated the process currently in place was to obtain menu preferences for a week at a time. She thought this process had been in place for 2 or 3 months. Prior to that she would go to the halls and ask the nurses which residents were alert and oriented and those were the residents she would interview and review the menu with them. She would circle the resident's choices and return the menus to the kitchen. Usually on Mondays and sometimes Tuesdays no choice were given because the receptionist would not get the menu in time to go around, plus whichever day they went around to inquire about choices would start the following day, not that day. She stated she had been employed since [DATE] and had completed choice menus plenty of times. She noted that recently the main receptionist thought it took too much time away from the receptionist answering the phone and had talked to the Dietary Manager about having someone else go around and interview the residents. In an interview with the Dietary Manager on 05/17/24 at 10:31 AM she stated she had worked at the facility for 2 years. She explained the process was for the receptionists to go around and interview residents for meal preferences. When the kitchen received the menus each meal ticket would be adjusted for residents who wanted something other than the main meal. She stated this process had been in place for about a month. She noted the main menus were posted on halls 300, 500, and 700. She explained alternate menu choices are not posted. She noted that any resident who did not get a choice was because the residents were not in their rooms when staff went around to ask. She reported that she was responsible for providing the receptionist with the menu each week. She did not know why for the week of 5/13/24 that residents were not asked what they wanted to eat on 05/13/24, 05/14/24, and 05/15/24 or for the week of 4/15/24 for 04/15/24 and 04/16/24 because the menu was out. She stated she wasn't sure why the process was not working but that it was a work in progress. She stated alternates were available from the everyday menu that included the following choices: cheeseburger, chef salad, cold cut sandwich, grilled cheese, or the chef's daily choice. All entrees except the chef's salad came with chips and the vegetable of the day. 45711 c. Resident #22 was admitted to the facility on [DATE]. Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #22 on 5/13/24 at 12:00 PM. Resident #22 stated she wished she could make a choice about what she received to eat. An interview was conducted on 5/14/24 at 9:12 AM with Resident #22. The resident indicated the only thing she was offered as an alternate was a grilled cheese sandwich. A meal observation conducted on 5/16/24 at 12:26 PM revealed Resident #22 was in bed with the head of the bed elevated feeding herself a pasta take out meal. Resident stated she ordered take out as she did not like the lunch and did not want a grilled cheese sandwich again. Resident #22 stated the staff used to take the orders for the meals and offer the meal or an alternate prior to the meal but they had not been doing that for a long time. An interview was conducted on 5/17/24 at 9:50 AM with the Dietary Manager. The Dietary Manager stated she was not aware of Resident #22 having any food complaints. The Dietary Manager stated she had items available for alternate meals. The Dietary Manager indicated the facility was asking the residents about alternate meals, but it had not been done recently. An interview was conducted on 5/17/24 at 12:20 PM with the Administrator. The Administrator further stated she expected food preferences to be honored, residents to be served meals according to their preferences and alternate meals to be provided. d. Resident #116 was admitted to the facility on [DATE] with diagnosis which included in part chronic obstructive pulmonary disease and diabetes. Review of Resident #116's electronic health record revealed a physician order dated 1/22/24 for a consistent carbohydrate diet. Review of Resident #116's 3/19/24 quarterly Minimum Data Set (MDS) assessment revealed resident was cognitively intact. Interview on 5/13/24 at 1:47 PM with Resident #116 indicated the food often did not look or taste good and she was not aware of an alternate meal other than a peanut butter and jelly sandwich. Resident #116 stated she frequently drank a nutritional supplement provided by her family instead of eating. Meal observation on 5/14/24 at 12:45 PM revealed Resident #116 was sitting on the side of her bed with her lunch tray in front of her. Resident #116 had not eaten any of the lunch. Resident was observed drinking her nutritional supplement. Interview on 5/14/24 at 12:45 PM with Resident #116 revealed she was drinking a nutritional supplement instead of eating the meal. Resident #116 stated she did not like the meal and was not aware of a list of alternate meals. Resident #116 stated she knew that she could get a peanut butter and jelly sandwich, but she could not eat that since she was a diabetic. e. Resident #107 was admitted on [DATE] with diagnosis which included stroke and diabetes. Interview with Resident #107 on 5/13/24 at 11:07 AM revealed the food was not good and she mostly ate snacks supplied by her family. Resident #107 was not aware of alternate options at meals. Meal observation on 5/13/24 at 12:30 PM revealed Resident #107's was in bed with the head of the bed elevated with her meal tray in front of her. Resident #107 had not eaten from the meal tray but instead was eating from a container of food that her family had provided. An interview was conducted with Resident #107 on 5/14/24 at 12:40 PM. Resident #107 stated the meal she received was not hot and not palatable and she was not offered an alternate. An interview was conducted with Resident #107 on 5/15/24 at 12:45 PM. Resident #107 stated she ate a peanut butter and jelly sandwich for lunch. Resident #107 stated she was told you get what you get for your meals. Resident #107 stated she did not like to eat peanut butter and jelly sandwiches every day because she was diabetic. Resident #107 stated the food was not good, she often just could not eat it and was not offered an alternate meal. f. Resident #19 was admitted to the facility on [DATE] with diagnosis which included diabetes and hypertension. Review of Resident #19's 4/11/24 quarterly Minimum Data Set (MDS) assessment indicated resident was cognitively intact. Interview with Resident #19 on 5/14/24 at 12:45 PM revealed she could not eat the lunch meal that was served as it was not appetizing. Resident #19 stated sometimes staff stated they did not have an alternate meal available. An interview was conducted on 5/17/24 at 9:35 AM with Nurse #1. Nurse #1 stated the facility used to give copies of the menu and asked the residents if they wanted the meal or an alternate, but it had not been done for a while. An interview was conducted on 5/17/24 at 1:50 PM with the Administrator. The Administrator stated she expected the residents to receive alternate meals. The Administrator stated she did not know what the breakdown was with the alternate meals.

Based on record review, staff interviews, and Nurse Practitioner (NP) interview the facility failed to notify the provider of significant weight gain greater than 3-pounds (lbs.) in 24-hours (hrs.), or 5-lbs. in a week, for a resident that required weight gain monitoring for possible cardiac fluid overload due to resident's history of Congestive Heart Failure (CHF). This deficient practice occurred for 1 of 11 sampled residents reviewed for notification of change. (Resident #20) Findings included: Resident #20 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF). A physician order written to start on 05/01/24 revealed daily weights times 2-weeks and notify provider of 3-lb. weight gain in 24-hours or 5-lbs. in a week, then weekly during day shift for CHF for 14-days, with start day 05/01/24. Review of Resident #20's Medical Administration Record (MAR) dated 05/01/24 through 05/14/24 revealed to obtain daily weights and report weight gain greater than 3-lbs. in 24-hours or 5-lbs. in a week (started 05/01/24). Recorded weights in Resident #20's MAR were recorded daily and signed off as completed as evidenced by nursing initials and a check mark daily up to 05/14/24. Review of Resident #20's daily weight: On 05/06/24 was 182.5 lbs. and his daily weight on 05/07/24 was 190-lbs. a weight gain of 7.5-lbs. in 1-day. On 05/09/24 was 189-lbs. and his daily weight on 05/10/24 was 191-lbs. a weight gain of 3-lbs. in 1-day. On 05/11/24 was 184-lbs. and his daily weight on 05/14/24 was 189.3-lbs. a weight gain of 5.3-lbs. in 3-days. Further review of the medical record for Resident #20 revealed there was no evidence the physician was notified of weight changes as ordered. An interview was conducted on 05/16/24 3:20 PM with the Nurse Practitioner (NP). The NP stated this was the first time she or MD had heard of Resident #20's one day weight gain of 7.5-pound from 05/06/24 through 05/07/24, and the three-day weight gain of 5.3-lbs. from 05/11/24 through 05/14/24, or the other 3 lb. one day weight gain 05/09/24 through 05/10/24. She stated no staff had reported to her any weight concerns. The NP expected the MD to be notified if Resident #20's daily weights were greater than 3-lbs. in one day or 5-lbs. in a week related to resident having a diagnosis of CHF. NP said she was not made aware or notified by nursing staff of resident's weight gain and should have. NP said Resident #20's weight gains had no health outcome, but could have, and she expected the MD to have been notified, per order, to treat the weight gain to determine if related to CHF, and if additional medication needed to be ordered or change in treatment adjusted. An interview on 05/16/24 at 4:30 PM with the Director of Nursing (DON) revealed it was her expectation that Resident #20's MD should have been notified of resident's greater than 3-lb. weight gain in a day or 5-lb. weight gain in a week, per physician's order. She said she did not know why the MD was not notified and should have per MD order.

Based on record review and staff interviews the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification who required the provision of the SNF-ABN form (Resident #126 and #129). Findings included: a. Resident #126 was admitted to the facility on [DATE]. Review of Beneficiary Notices - Residents discharged Within the Last Six Months form revealed Resident #126 Medicare Part A skilled services ended on 01/29/24. She remained in the facility with benefit days remaining, per Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123). Record review revealed that Resident #126 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN). b. Resident #129 was admitted to the facility on [DATE]. Review of Beneficiary Notices - Residents discharged Within the Last Six Months form revealed Resident #129 Medicare Part A skilled services ended on 02/12/24. She remained in the facility with benefit days remaining, per Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123). Record review revealed that Resident #129 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN). An interview was conducted on 05/15/24 at 11:50 AM with the Social Services Director (SW#1). The SW #1 indicated she or SW #2, who was new, should have provided Residents #126 and #129 with the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form, but was unable to provide documentation that they were provided. An interview was conducted on 05/16/2024 at 2:00 PM with the Administrator and she revealed it was her expectation that the residents at the facility or Responsible Party (RP) should be provided appropriate notices prior to being discharged from Medicare.

Based on observations, record review, resident and staff interviews the facility failed to provide tray set-up and assistance with eating to maintain resident's ability to feed themselves for 3 of 3 residents (Resident #112, #126, and #131) reviewed for activities of daily living (ADL). The findings included: 1. Resident #112 was admitted [DATE] with diagnoses that included: dysphagia, dementia, and mild protein calorie malnutrition. Resident #112 was receiving palliative care through hospice services. The resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate to severe cognitive impairments and required supervision and set up only for meals during the assessment period. Resident #112's care plan dated 03/26/24 revealed a potential for fluid volume deficit related to anemia, with nourishment less than body requirement, inadequate intake, and decreased appetite. A nursing note dated 05/10/24 at 10:41 AM for Resident #112 revealed the resident had triggered a 110% weight loss over the last 180-days. The Resident's Health Care Provider and Responsible Party (RP) was notified with no new orders at that time. The resident continued Hospice services and continued to receive Med-Pass (a nutritional supplement) 120 mL by mouth twice per day, and enriched meals with staff encouragement. A Registered Dietitian (RD) note dated 05/10/24 at 1:37 PM for Resident #112 revealed the resident continued to receive hospice care, with mechanical soft texture diet and thin liquids. Her by mouth intake reflects 50-75%, occasionally more, with added med-pass supplement two times per day. An interview and observation were conducted on 05/14/24 at 8:45 AM with Resident #112. She said her breakfast tray was not set up and should have been. She was observed trying to punch a hole into her juice container with a plastic straw and failed to puncture the aluminum lid and dropping the broken straw onto the floor. She said with only one hand she was not able to open her mighty shake, milk carton, or juice, or cut her sausage or French toast. An interview was conducted on 05/14/24 at 9:15 AM with the Rehabilitation Director. She said all resident meal trays should be set-up by facility staff if the residents were not independent. She said Resident #112 was in Hospice and needed tray set-up assistance with meals. On 05/14/24 at 12:40 PM Resident #112 was observed sitting up in bed with her lunch tray in front of her. The Nursing Aide (NA) was not present. Resident #112 made several attempts to put a straw in the lid of a juice cup and was unsuccessful. She was observed trying to grasp and open her milk carton with her fingers and failed. An interview was conducted on 05/15/24 at 11:30 AM with the Registered Dietitian. She said all residents' meal trays should be set up unless they specifically requested to set-up their meal tray themselves. An interview was conducted on 05/15/24 at 2:06 PM with the Director of Nursing. She said all residents who needed partial/moderate assistance with meals means tray set-up and additional help if needed. She further stated Residents' meal trays should be set up unless they specifically requested to set-up their meal tray themselves. An interview was conducted on 05/16/24 at 3:20 PM with the Nurse Practitioner. She expected most of the resident meal trays to be set up by the NAs, unless the resident specifically requested to set-up their own meal tray. She said it is good nursing practice to do so, by improving meal intake, encouraging eating, and by getting to know residents likes and dislikes, and time to offer alternates. An interview was conducted on 05/17/24 at 9:45 AM with Nursing Aide (NA#2). NA#2 stated, she only worked part-time and could not remember which residents on the 500-hall (the hall where Resident #112 resided) needed their meal trays to be set-up or not. She was not aware Resident #112 received assistance with her meals. She said she rarely worked on the 500-hall and wasn't told which residents needed meal tray set-up or assistance with feeding. She said she could not remember anything about that day. 2. Resident #126 was admitted to the facility on [DATE] with diagnoses that included diabetes, congestive heart disease, adult failure to thrive, and anemia. Resident #126's Minimum Data Set (MDS) dated [DATE] revealed resident had had no cognitive impairments and needed supervision with eating. Resident #126's care plan dated 04/30/24 revealed: Potential for or Actual fluid volume deficit due to: 1500ml fluid restriction, daily diuretic use. State of nourishment; more than body requirement characterized by weight gain. Ms. [NAME] required assistance with the activities of Daily Living/Personal Care due to weakness, adult failure to thrive and congestive heart failure. Interventions included: Eating (oral intake): Set-up/clean-up assistance. An interview and observation were conducted on 05/14/24 at 8:50 AM with Resident #126. She said her breakfast tray was not set up and should have been. She was observed holding up a fork with a round sausage patty stuck to the end, eating around the edges of the sausage. She was also observed not able to open her milk or juice container and was unable to use the knife and fork together to cut her French toast into smaller pieces which would have been easier to eat. An interview was conducted on 05/14/24 at 9:15 AM with the Rehabilitation Director. She said all resident meal trays should be set-up by facility staff if the residents were not independent. She said Resident #126 was receiving Physical Therapy (PT) in her room and needed tray set-up assistance with meals. An interview was conducted on 05/17/24 at 9:45 AM with Nursing Aide (NA#2). NA#2 stated, she only worked part-time and could not remember which residents on the 500-hall (the hall where Resident #126) needed their meal trays to be set-up or not. She was not aware #126 received assistance with her meals. She said she rarely worked on the 500-hall and wasn't told which residents needed meal tray set-up or assistance with feeding. She said she could not remember anything about that day. 3. Resident #131 was admitted [DATE] with diagnoses that included hemiplegia, dysphagia, cerebral infarction (stroke), and diabetes. The resident's Minimum Data Set (MDS) dated [DATE] indicated the resident had no cognitive impairments and needed supervision with eating. Resident #131's care plan dated 04/08/24 revealed a potential for fluid volume deficit related to anemia, with nourishment less than body requirement, inadequate intake, and decreased appetite. Interventions included: Provide assistance with meal as indicated, with set-up/clean-up assistance, due to hemiplegia/hemiparesis following cerebral infarction affecting left non-dominant side. An interview was conducted on 05/14/24 at 8:15 AM with Resident #131. She said her breakfast tray was not set up and should have been. She said with only one hand she was not able to open her mighty shake, milk carton, or juice, or cut her sausage or French toast. An interview was conducted on 05/14/24 at 8:30 AM with Nurse #3. She said Resident #131 could only use her right hand due to a stroke and needed Nursing Aides (NAs) to set-up her tray and assist with her meals. The nurse said she did not know why the NAs did not set up Resident #131 meal tray.

Based on record review, observation, and resident, staff and Nurse Practitioner interviews, the facility failed to obtain an appointment with an ophthalmologist for evaluation of vision for 1 of 1 resident (Resident # 22) reviewed for vision. Findings included: Resident # 22 was admitted to the facility on [DATE]. Resident #22's medical diagnoses included cataracts and diabetes. Review of the facility grievance log revealed a grievance form dated 12/4/23 completed by Resident #22 was received by the Director of Nursing (DON) and the Assistant Administrator. The grievance was regarding Resident #22's request for a referral to an eye doctor for cataracts. Resident #22 stated the request had previously been made to the hall nurse. The outcome was that referrals and appointments were to be made. Findings of the grievance indicated that the DON stated Resident #22 sees the in-house eye care provider for her eye care and was last seen on 12/6/22. The grievance indicated an annual visit was tentatively scheduled for January 2024. The grievance further indicated Resident #22 would be placed on the list for the next in- house eye care visit. If the resident did not want to wait for the in-house provider, the grievance indicated will discuss an outside referral with the provider. The grievance resolution was issued to the resident on 12/6/23. Review of a 12/6/23 letter addressed to Resident #22 indicated resident requested a referral to see an eye doctor. The letter stated after an appropriate investigation supervised by the grievance official, it was determined that the resident sees the in-house eye care provider for eye care for annual eye exams. The letter indicated the resident would be informed of the next visit with the eye care company. Review of a 2/14/24 physician progress note revealed Resident #22 was evaluated and requested an ophthalmologist appointment regarding cataracts. The physician progress note indicated an order was written for referral to an ophthalmologist. Review of Resident #22's 2/14/24 physician orders revealed an order for follow up with ophthalmology regarding cataracts. Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, had impaired vision and did not have glasses. Review of Resident #22's electronic health record revealed a 2/26/24 Nurse Practitioner progress note which indicated the resident required a referral for ophthalmology. The progress note indicated an order was written for the referral. Review of Resident #22's Nurse Practitioner progress note dated 3/7/24 indicated resident was asking about the ophthalmology appointment which was previously requested. The progress note indicated awaiting the scheduling of the ordered appointment. Review of Resident #22's care plan revealed a focus last revised on 3/7/24 for impaired vision and risk for complications. The goal indicated Resident #22 would use compensatory mechanisms for decreased vision through next review. Interventions indicated ensure eyeglasses are clean, appropriate and being worn by resident, and obtain eye exam consultation for resident to ensure appropriate medications and compensatory mechanisms are in place. An interview was conducted on 5/13/24 at 12:04 PM with Resident #22. Resident #22 stated she still had not received an eye doctor appointment. Resident #22 stated she thought her eyesight was getting worse and she was concerned since she had a diagnosis of diabetes and cataracts. A following up interview was conducted on 5/16/24 at 12:26 PM with Resident #22. Resident #22 stated no one had talked to her this week about her request to see an ophthalmologist. Resident indicated the Social Worker had not talked to her. Resident stated she was concerned about obtaining the appointments as she had not seen the eye doctor in over a year. Resident #22 stated she filed a grievance in December and still had not received the requested appointment. An interview was conducted on 5/15/24 at 12:10 PM with the Transportation Specialist. The Transportation Specialist stated she was responsible for scheduling appointments and transportation for the residents. She stated she was in the position for the past year. The Transportation Specialist stated she was informed of referrals by the nursing staff, family members and the providers. The Transportation Specialist stated she had not made any appointments lately for Resident #22. She stated she was informed a while back that Resident #22 required an appointment with an ophthalmologist. The Transportation Specialist stated she was still working on arranging the appointment but had not recently tried. She stated when she had extra time, she called ophthalmologist offices to see if they would see the resident. She stated the last time she tried calling was a few weeks ago. The Transportation Specialist stated she did not have any notes indicating what offices she called, when and what the outcome was. The Transportation Specialist stated she was not sure how Resident #22 needed to be transported and it was difficult to obtain stretcher transportation. The Transportation Specialist stated she was not involved in the grievance that Resident #22 filed in December 2023 and was not made aware of the request to schedule the appointment in December 2023. An interview was conducted on 5/15/24 at 12:30 PM with Social Worker (SW) #1. SW#1 stated she had been in the position since December 2023. SW #1 stated she arranged the ophthalmologist visits with the in-house provider. SW #1 stated the last in-house ophthalmologist visit at the facility was in August 2023. Resident #22 was not seen in August 2023. SW #1 indicated Resident #22 was not seen by the in-house eye care provider since December 2022. SW #1 did not know why Resident #22 was not seen in August 2023. SW #1 stated the in-house eye care provider should be seeing residents at the facility in August 2024. SW #1 stated if a resident had a concern or needed to be seen by an ophthalmologist sooner than the annual visit, she could reach out to the company and request a visit to be arranged sooner. SW #1 stated she was not informed Resident #22 had a physician order for a referral in February 2024 to be seen by ophthalmology. SW #1 stated she went on maternity leave in February 2024, and she may have been gone when the referral was written in February. SW #1 stated she would talk to Resident #22 about obtaining a visit with the in-house ophthalmologist. An interview was conducted on 5/15/24 at 12:40 PM with Social Worker (SW) #2. SW #2 stated she was new to the position having started in January 2024. SW# 2 stated she was not notified of the physician order written in February 2024 for Resident #22 to see the ophthalmologist. An interview was conducted on 5/15/24 at 1:45 PM with the Unit Manager. The Unit Manager stated she was not aware of a physician order for a referral for Resident #22 to see the ophthalmologist written by the provider in February 2023. The Unit Manager further stated she was not aware of a grievance that was filed by Resident #22 in December 2023 regarding her request to see an ophthalmologist. An interview was conducted on 5/16/24 at 3:30 PM with the Nurse Practitioner. The NP indicated a resident with a diagnosis of cataracts required evaluation at least annually. The NP stated the facility used a company that comes into the facility to provide ophthalmology care. The NP stated she expected to be notified if the facility did not complete a referral for an appointment. An interview was conducted on 5/17/24 at 4:30 PM with the Director of Nursing (DON). The DON stated they should have arranged the appointments for Resident #22 but there was a problem with the resident's payor source. An interview was conducted on 5/17/24 at 12:20 PM with the Administrator. The Administrator stated Resident #22 expressed a concern about having an ophthalmology appointment scheduled. The Administrator stated Resident #22 was not eligible to be seen by the in-house ophthalmologist that came in August 2023 since it wasn't a year since her last exam. The Administrator stated she guessed they could have tried to obtain the appointment with an outside provider. The Administrator stated there had been a delay in finding a provider that would accept the resident's insurance, but 5 months was a long time and maybe they could have tried to obtain the appointment sooner. The Administrator stated it was her understanding the only reason the resident wanted the appointment with the ophthalmologist was so she could see her iPad.

Based on observations, record review, and staff and resident interviews, the facility failed to provide a safe transfer when a resident (Resident #1) fell from a mechanical lift while being transferred by Nurse Aide #1 and Nurse Aide #2 and sustained a 10-centimeter laceration to the right ankle requiring 9 sutures, a contusion to the left wrist and left shoulder, and pain as a result of the fall for 1 of 3 residents observed for falls. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 had a diagnoses of congestive heart failure and hypoxia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and demonstrated no behaviors. Resident #1 required total dependence with two person physical assistance with transfers and did not receive anticoagulant (blood thinner) medication. Resident #1's weight was recorded as 199 pounds. A review of Resident #1's care plan dated 09/21/23 revealed Resident #1 had a plan of care for activities of daily living/personal care with a goal that care would be completed with staff support as appropriate to maintain or achieve highest practical level of functioning. Interventions included, in part, two staff assistance required with extra-large mechanical lift and extra-large lift pad. A plan of care was also in place for at risk for falls with a goal that Resident #1 would be free of fall related injuries. Interventions included, in part, to observe and intervene for factors causing falls such as bowel and bladder needs, mobility, and transfers. The MDS quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact, demonstrated no behaviors and was coded as having one fall with injury (not major). A review of a nursing progress note written by Nurse #1 on 09/29/23 at 7:21 PM revealed this nurse was called to the resident's room by the nursing assistant. Resident was noted lying on the floor next to the bathroom door with the mechanical lift pad under her. Resident was alert and talking and she stated she was having pain on her left side, which was the side she was laying on. There was blood around the resident's lower leg and it was noted that the resident had a laceration above the right ankle. A pressure dressing was applied to stop the bleeding. The resident was repositioned to make her more comfortable. The Nurse Practitioner ordered the resident to be sent to the hospital. Resident #1's responsible party and the Director of Nursing were notified. Review of the Emergency Department (ED) visit dated 09/29/23 revealed, in part, Resident #1 presented with a laceration. The note indicated per Emergency Medical Services the resident was coming from a nursing home facility where staff were attempting to transfer her using a mechanical lift. The lift broke, resident fell and landed on her left side and sustained a laceration on the right lower leg. Resident was not on blood thinners and denied hitting her head. The Emergency Department Course and Medical Decision Making section revealed, in part, x-ray results were discussed with the resident and family and there were no signs of fractures. Resident was noted to have a 10 centimeter laceration to the right ankle, a contusion to the left wrist and left shoulder. Area to the right ankle was sterilely prepped and draped and anesthetized (numbed) with 1% lidocaine (a numbing medication) and 9 sutures were placed. The note indicated Resident #1 tolerated the procedure without any problems and was given pain medication and antibiotics. Resident was discharged back to the facility on [DATE] on antibiotics and instructions to keep the ankle area clean and dry and watch for any signs of infection and remove sutures in 10 days. A nursing progress note written on 09/30/23 at 3:44 AM by Nurse #2 revealed Resident #1 returned from hospital ED via emergency medical services' transport. She was alert and oriented. No complaints of pain and moved all extremities at baseline. Dressing was intact to right ankle laceration. A follow up visit note from the Nurse Practitioner written on 10/01/23 revealed, in part, follow-up evaluation post fall of laceration to right ankle and pain. Resident reports she was sore on her left side from the mechanical lift fall and continued to have right knee pain and discomfort to right ankle laceration area. Will schedule hydrocodone-acetaminophen (narcotic pain reliever) 5-325 milligrams (mg) twice daily. Dressing was intact with no bleeding noted and she was followed by the wound nurse. An investigation was initiated on 09/29/23. The summary written by the Administrator included Resident #1 had just finished dinner and requested to go to bed. Resident #1 was sitting in her wheelchair at the end of her bed facing the door at the time. Nurse aide (NA) #1 got the extra-large mechanical lift and the extra-large lift pad to transfer Resident #1. Before transferring Resident #1, NA #1 asked NA #2 to assist and spot her during the transfer. NA #1 hooked all the straps up and NA #2 used the remote control. NA #1 turned the resident slightly to guide her toward the bed. The NAs and Resident #1 heard a loud pop and Resident #1 began sliding out of the lift with her left shoulder going first toward the floor. NA #2 immediately called for the hall nurse. Nurse #1 entered the room and saw the resident laying on the floor on her left side and called a code green (a code to indicate a fall had occurred). The Unit Manager (UM) and Director of Nursing (DON) responded. The UM went to get the Nurse Practitioner (NP) to assess the resident immediately. Nurse #1 noted blood coming from the back of the resident's right leg above her ankle. The NP ordered a pressure dressing to be applied. Resident #1 had no complaints of pain. Resident #1 stated she did not hit her head. Range of motion of upper and lower extremities were within normal limits. The NP ordered Resident #1 to be sent out to the Emergency Department (ED) to address the laceration on her lower right leg. Resident #1 went to the ED and received 9 sutures. Resident #1 received x-rays at the ED and was negative for any fractures. Resident #1 was transferred back to the facility around 3:50 AM on 09/30/23 with a new order for Keflex (antibiotic) for infection prevention. Resident #1 did complain of pain/soreness on the morning of 09/30/23 and was given Hydrocodone. After review of the resident's record, interviews with Resident #1 and staff, and observations of return demonstration, it was determined the loop of the lift pad came out of the ring and resident slid out of the lift pad backwards. Resident #1 related she was able to catch herself with her left hand and lower herself to the floor. This action did cause a contusion of the left shoulder and wrist. Review of a written statement by Nurse #1 written on 09/29/23 revealed I was called to [Resident #1's] room by the nurse aide. When I arrived to the room, I observed the resident lying on the floor next to the bathroom door with the mechanical lift pad underneath her. Resident was observed to be alert and talking. She stated she was having pain on her left side. The side she was laying on. There was blood around the resident's lower leg and it was found that the resident had a laceration above the right ankle. A pressure dressing was applied to stop the bleeding. The resident was repositioned to make her more comfortable. The NP ordered the resident to be sent to the hospital The DON was notified and she notified the responsible party. A phone interview was conducted with Nurse #1 on 01/03/24 at 1:21 PM. Nurse #1 reported he went to Resident #1's room and she was laying on the floor. He stated he assessed her and she was having pain on her left side. He added he applied pressure to her bleeding right ankle with towel. Nurse #1 stated after it happened there was a meeting to discuss the root cause. He stated he had understood that one of the straps to the lift pad had popped out of the ring that it would get secured too. Review of a written statement by the Wound Treatment Nurse written on 09/29/23 revealed I responded to the code green in the resident's room. Resident was supine [on her back] on the floor with nurse [#1] holding residents' right leg in his hands holding pressure to a laceration. No equipment or other items were near the resident. The NA stated that resident fell out of the mechanical lift when I asked how she fell . [Nurse #1] and I wrapped the wound with 4 X 4 pads and gauze. Resident was alert and responsive. Review of a written statement by Nurse Aide (NA) #1 written on 09/29/23 revealed I went in the room to spot [NA #2] with the transfer of [Resident #1]. We placed the straps on to the mechanical extra-large lift. We proceeded to lift her and I lifted her out of the wheelchair. I was instructed to lift her a little higher and the lift seemed to hesitate a little so then I gave [NA #2] the control to the lift to lift [Resident #1] higher and as we pulled her back to go to the bed, we all heard a snap and [Resident #1] was falling. My first instinct was to grab her/break the fall but it was absolutely an uncontrollable situation. She slipped out of the mechanical lift pad. I called the nurse and the nurse called EMS. An addendum to NA #1's statement written on 09/29/23 included: I observed [Resident #1] in her room about 30 minutes prior to the fall awaiting to get back into bed. I was in the room for the fall as a spotter to assist [NA #2] with the transfer. Prior to the fall she had nonskid socks on with no clutter or wetness observed on the floor. During the fall we were using the mechanical extra-large lift on [Resident #1]. A phone interview was conducted with NA #1 on 01/03/24 at 1:42 PM. NA #1 reported she had gone in to spot NA #2 with transferring Resident #1 from her wheelchair to the bed with the extra-large mechanical lift. NA #1 stated she and NA #2 secured the straps of the lift pad to the hooks on the mechanical lift. NA #1 stated she was standing beside Resident #1 spotting her and NA #2 proceeded to lift Resident #1 with the remote control. NA #1 stated she had asked NA #2 to lift Resident #1 a little higher from her wheelchair and the lift seemed to hesitate a little so NA #2 gave her the remote control. NA #1 stated NA #2 pulled the lift away from the wheelchair and began to roll her towards the bed. She stated at that time, she and NA #2 and the resident heard a snap and Resident #1 started falling out of the lift pad on her left side. NA #1 stated her first instinct was to grab Resident #1 to prevent her from falling but it was absolutely out of her control and Resident #1 slipped out of the lift pad. NA #1 stated she was certain the straps were secured to the rings on the mechanical lift and was not certain how the resident could have fallen out of the lift. NA #1 stated she had been educated on how to safely transfer a resident when she was first hired on 09/05/23. NA #1 stated she received additional education with return demonstrations after this happened with Resident #1. Review of a written statement by NA #2 written on 09/29/23 revealed Around 6: 00 PM [NA #1] came in to spot me with the transfer of [Resident #1] from her wheelchair to the bed with the mechanical lift. We placed the straps onto the lift. We proceeded to lift her and I was spotting her when she was being lifted from the wheelchair. I asked [NA #1) to go a little higher. The lift seemed to hesitate a little so [NA #1] gave me the remote control. [NA #1] pulled her back toward the bed. We all, including the resident, heard a snap and [Resident #1] was falling. Our first instinct was to grab her from falling but it was absolutely out of our control. [Resident #1] slipped out of the lift pad. [NA #1] called for the nurse and I called for a code green. Nonskid socks were on, the floor was free of clutter and dry. I was using the mechanical extra-large lift with resident and another aide when she fell . A phone interview was conducted with NA #2 on 01/03/24 at 1:27 PM. NA #2 reported Resident #1 was in her wheelchair and she and NA #1 hooked her up to the extra-large mechanical lift and while she was going up NA #2 was right next to her and NA #1 was lifting her up slowly with the remote control and they heard a snap and noticed that one of the sides of the lift pad fell off and Resident #1 was dangling out of the lift pad. NA #2 stated Resident #1 was not very high up from her chair, and added, her buttocks was level with the wheelchair arm. NA #2 explained that the straps on the lift pad have upper support straps that support the back and lower support straps that supports the legs. NA #2 stated there were rings that she would hook the strap too and the strap hook would get secured in the ring. NA #1 stated somehow the top left strap of the lift pad had snapped off while Resident #1 was on the lift and she fell out onto her left side. NA #2 stated her legs were still secured, but she slipped out and fell to the floor. NA #2 stated she did not know how it happened and swore she had secured the hooks in the rings. NA #2 stated it all happened so fast, she did not know if it was the actual lift malfunctioning or the lift pad, but somehow the lift pad got loose. NA #2 believed the laceration to the right ankle may have been caused by hitting the bottom of the lift legs when Resident #1 went down. NA #2 stated both aides, the Unit Manager and the DON tried to figure out what happened. There was no disrepair noted to the extra-large mechanical lift or the extra-large lift pad, but the DON took that mechanical lift off the floor to be checked out. NA #2 added, Resident #1 was in the appropriate extra-large lift pad. She was assigned to a green pad with a black stripes. NA #2 stated she received her yearly education regarding safe resident handling on 06/09/23 and was again in serviced on 09/30/23 with a return demonstration. An interview was conducted with Resident #1 on 01/03/24 at 11:40 AM. Resident #1 was alert and oriented and was lying in bed. She reported on 09/29/23 there were two aides in the room transferring her from the wheelchair with the mechanical lift to get her back to bed. Once she was in the mechanical lift and was raised up she heard a snap or a pop and she fell out to left side of the lift. She stated they used a green pad with black stripes which fit her and that was the pad they always used. She stated she did not fall straight down and that she actually fell out of the pad to her left side and put her left arm out to break the fall. She stated the mechanical lift did not fall, in fact, it did not even budge. She stated they quickly got the nurse and she had a wound to her right ankle but she was not certain how she got the wound which required 9 sutures and was bleeding. She stated she had never fallen from the mechanical lift before. She stated she did not have any pain to her ankle at that time, but her left side hurt and they put a pillow under my head for comfort. Resident reported she did not know what happened or how it happened. Resident #1 stated the two aides were not rushing while they were trying to transfer her. An observation of a transfer with the extra-large mechanical lift on Resident #1 was done on 01/03/24 at 2:00 PM with NA #3 and the Unit Manager. NA #3 was observed placing the green pad with a black stripes labeled extra-large under Resident #1 while she was lying in bed. The lift pad showed no signs of poor condition. The Unit Manager and NA #3 rolled the mechanical lift which was numbered 0 to position over Resident #1. NA #3 crissed crossed the lower straps and secured each hook noted on the end of the strap to a ring on the mechanical lift. NA #3 then raised the right strap by the Resident's shoulder and secured the hook on the end of the strap to a ring on the mechanical lift and repeated the same way with the left strap. The hooks were noted to lock in place and the rings were noted to only be moved inward toward the mechanical lift frame. Once the hook was in the ring, the ring would not move outward - away from the mechanical lift frame. Resident #1 was noted to fit in the lift pad securely. The Unit Manager used the remote control to raise Resident #1 and once she was above the bed, she moved the lift away from the bed and toward the secured wheelchair next to the bed while NA #3 guided Resident #1 with her hands holding on to the resident and the lift pad. The UM and NA #3 positioned Resident #1 over the wheelchair and the UM began to slowly lower her in the wheelchair while NA #3 guided the resident into position. Once seated, the hooks were unhooked from the rings on all four corners. An interview was conducted with the Assistant Maintenance Director on 01/03/24 at 2:00 PM. The Assistance Maintenance Director stated he did lift inspections to all lifts monthly which included cleaning the hair out of the wheels, checking the wheels for any damage, ensuring the guards (protective case) were on all the wheels, checked the remote to ensure it was in working order and the up and down buttons were working, making sure the battery was charging, and making sure all the rings that the straps were hooked on to were intact and not loose on all 4 points of the lift. The Assistant Maintenance Director stated he kept a log to ensure all the lifts were inspected and each of the 10 mechanical lifts were numbered. He stated after this event happened with Resident #1, the lift and the lift pad were immediately removed the floor so that he could inspect them. The Assistant Maintenance Director reported he inspected mechanical lift numbered 0 which was brand new in July 2023 and he could not find anything wrong with it. There was nothing noted to be in disrepair. The Assistant Maintenance Director stated he placed weighted materials on the lift pad, and secured the straps to the rings as though a resident was in the lift pad. He stated he raised the lift pad all the way up with the remote control and the straps remained secured in the rings. During this interview, the number 0 mechanical lift was inspected with the Assistant Maintenance Director and there was no disrepair to the mechanical lift noted. The rings that the mechanical lift straps clip into were noted to go inward and were not able to fold outwardly. The Assistant Maintenance Director stated the only way the strap would come out is if it was not securely clipped in. A maintenance log from June 2023 to September 2023 revealed monthly inspections of each numbered mechanical lift were being done. The dates the inspections were done were: 06/08/23, 07/25/23 (indicating lift number 0 was new), 08/07/23, 09/25/23, 10/02/23, 11/08/23 and 12/14/23. An interview as conducted with the Administrator on 01/03/24 at 3:13 PM. She stated she was in the facility when Resident #1 fell from the mechanical lift. She stated she, the Unit Manager and the DON went to Resident #1's room immediately to see what had happened. She added, she immediately took the mechanical lift out of service and had the Assistant Maintenance Director do a full inspection. She stated at that time he had also checked all the other mechanical lifts to be sure they were in working order. The Administrator stated after reenacting the event the only conclusion they could come up with was that the lift pad hook was not fully secured in the ring. The Administrator added, the ring would not pull out and would only push in with the force of putting the strap inside. She stated the mechanical lift was brand new in July and there were no signs of disrepair to the mechanical lift or the lift pad. The Administrator stated she brought both NAs into the room and had them show her how they hooked up Resident #1 and the process they went through. She stated, based off the reenactment it looked like they did everything correctly which was why we thought the actual strap did not get secured in the ring. The Administrator stated the lift pad went with Resident #1 when she was sent to the hospital and it was never returned back, but stated she looked over the lift pad and there were no rips or knots noted in the pad. The Administrator stated she initiated a plan of correction immediately to include education on safe handling and movement and return demonstrations. The Administrator stated we closed it out in December but continue to do random competency checks utilizing the questionnaire and return demonstration. The facility provided the following corrective action plan: F689 Failure to provide supervision to prevent accidents: 1. The facility identified how correction action will be accomplished for those residents to have been affected by the deficient practice: Resident #1 sustained a fall from a mechanical lift on 09/29/23. Resident was immediately assessed by Nurse #1, the Nurse Practitioner, and the Wound Treatment Nurse. Resident #1 was noted to have a laceration to her right ankle and a pressure dressing was ordered and applied. Resident #1 was sent to the Emergency Department for further evaluation. Resident #1 returned to facility with 9 sutures to her right ankle and was started on an antibiotic for infection prevention and pain medicine for pain control. The mechanical lift used for the transfer and all the other mechanical lifts were removed from the floor and immediately inspected by the Assistant Maintenance Director. Nurse Aide #1 and Nurse Aide #2 were provided additional in servicing regarding safe resident handling and provided a return demonstration for understanding on 09/30/23. 2. The facility identified other residents having the potential to be affected by the same deficient practice: Review of documentation to ensure there were no mechanical lift accidents in the past 30 days. An audit was completed of all mechanical lifts and lift pads. There were no issues identified. An audit of all falls were conducted. There were no falls related to mechanical lifts. Care plans were updated for all residents to include independent residents, stand by assist residents and one or two person assist residents for all transfers indicating the use of a mechanical lift, the type of mechanical lift and size of the lift pad. A 100 % skin assessment audit on non-alert and oriented residents was completed. A resident questionnaire was utilized for the alert and oriented residents regarding using a lift during transfers and if there had been any concerns. No concerns were noted. This was completed on 09/30/23. 3. The facility implemented systemic changes to ensure that the deficient practice will not recur: The Administrator and Director of Nursing conducted in services on safe resident handling and movement with return demonstration for all nursing staff. The in services and demonstration would be completed by 09/30/23. After 09/30/23, nursing staff who did not receive in services and provide return demonstration will have this completed prior to the start of their shift. Additional education was provided by the DON on 09/30/23 regarding mechanical lifts safe handling to include always ensure the mechanical lifts are in proper working order and the lift pad was intact before using the mechanical lift, make sure the straps were secured in the ring, always use the proper size lift pad, and refer to the care plan before transferring a resident. A staff questionnaire was provided to all staff to ensure understanding. All nursing staff were in serviced as of 10/02/23. 4. The facility plans to monitor its performance to make sure that solutions are sustained: Weekly monitoring for 4 weeks and then monthly for 1 month was conducted for observations of mechanical lift use to include the resident name, date, type of lift, if the care guide was reviewed prior to transfer, if the transfer was done properly and if there was reeducation needed. The Administrator and the Director of Nursing would review the transfer audit tools weekly for 4 weeks then monthly for 1 month for completion and to ensure that any areas of concern were addressed. The Administrator and DON will forward the results of the transfer audit tools to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for 2 months. The QAPI committee will meet monthly for 2 months to review the transfer audit tools to determine trends and or issues that may need further interventions put into place and to determine the need for additional monitoring (NOV/DEC). Validation of the corrective action was completed on 01/03/24. This included staff interviews with nurses, nurse aides, and medication aides. Return demonstration of a mechanical lift transfer with nursing staff. Observation of all the current mechanical lifts and lift pads to ensure no disrepair. Review of other residents' medical records who required a mechanical lift for transfers to ensure there were no falls with injury with the lift. Care plans were reviewed to ensure they were updated to reflect residents' care. A review of the signature sign in sheets to affirm all nursing staff received education regarding utilizing mechanical lifts safely. The facility's alleged compliance date of 10/02/23 was validated.

Based on observations, record review, staff interviews and the Family Nurse Practitioner (FNP) and Physician interviews, the staff failed to transfer a resident using the required mechanical lift as listed on the Resident Care Guide for 1 of 3 residents (Resident #1) reviewed for accidents. Staff manually transferred Resident #1 using stand and pivot from his wheelchair to his bed which led to his right ankle becoming twisted underneath the bed. As a result, Resident #1 experienced right ankle pain and swelling. An x-ray showed that Resident #1 had a closed fracture of his right distal fibula. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include; history of [MEDICAL CONDITIONS], peg tube placement, [MEDICAL CONDITION], and [MEDICAL CONDITION] (inability to speak). The Minimum Data Set (MDS) annual assessment dated [DATE] indicated Resident #1 had severely impaired daily cognition skills. He was nonverbal but could understand others. He had adequate vision and hearing. He exhibited no behaviors and no rejection of care. He required two-person extensive assistance with bed mobility, transfers, and activities of daily living. He had impaired range of motion on one side of his upper and lower extremities and used a wheelchair for mobility. A review of the care plan revised 04/19/20 revealed Resident #1 required assistance with activities of daily living related to a decline in functional mobility due to his history [MEDICAL CONDITION] left side [MEDICAL CONDITION] (paralysis on one side of body) and the presence of contractures to his left upper extremities. The goal of care was to provide care with staff support to maintain or achieve the highest practical level of functioning through the next review. The interventions included in part; to transfer Resident #1 using total mechanical lift with two-person assistance and using a large sling. A nursing progress note dated 07/27/20 at 4:54 PM documented Resident #1 had complaints of right lower extremity pain. The right ankle was observed with swelling and warm to the touch. No swelling noted on right foot, pedal pulses were palpable. The posterior ankle and malleolus were tender to the touch and was able to move toes without difficulty. The Nurse Practitioner was notified and assessed the resident; an x-ray was ordered. Mobile x-ray was notified, and the residents RP (Responsible Party) was notified. A physician progress notes [REDACTED].#1's x-rays demonstrated acute right fibula fracture that was nondisplaced. A review of the facility's investigation revealed an investigation was conducted beginning 07/27/20 through 7/29/20 regarding Resident #1's right fibula fracture (occurring 07/26/20) due to improper transferring. The facility investigation summary included review of clinical records, ADL (activities of daily living) documentation, the Medication Administration Record [REDACTED]. The facility's investigation revealed the following: at approximately 6:30 PM on 07/26/20 Nurse Aide (NA) #3 and NA #4 manually transferred Resident #1 via total assistance stand and pivot transfer. NA #3 assisted resident on the left side and NA #4 assisted the right side. Resident #1 was assisted to a standing position with total support for NA #3 and NA #4. In the process of turning, the resident's right foot was in plantar flexion position (extension or flexion of the foot at the ankle) under the bed. The position of the foot was observed when Resident #1 was seated on the side of the bed. NA #4 moved the right foot from the plantar flexion position to a non-plantar flexion position. Resident #1 had no complaints of pain or facial grimacing while repositioning the right foot. Resident #1 was provided incontinent care with no complaints of pain. At approximately 7:00 PM, Nurse #2's shift began. At approximately 8:00 PM NA #3 observed Resident #1 pointing to his head. The nurse was notified, and incontinent care was performed. There were no signs or symptoms of pain. At approximately 9:00 PM, Nurse #2 administered medications to Resident #1 without difficulty and no complaints of pain. At 9:30 PM incontinent care was provided with no complaints of pain. At 10:30 PM incontinent care was provided with no complaints of pain. At 11:00 PM NA #5's shift began and at 11:30 PM NA #5 observed Resident #1 lying in bed with eyes closed. On 07/27/20 the investigation summary revealed: at approximately 12:00 AM, 2:00 AM, and 4:00 AM, incontinent care was provided with no complaints of pain. At 4:05 AM the nurse administered pain medication for complaints of headache. At 4:45 AM Resident #1 communicated to the nurse that the pain medication was effective. At 6:00 AM incontinent care was provided with no complaints of pain. At 8:00 AM Resident #1 was resting in bed with eyes closed. At approximately 10:30 AM on 07/27/20, NA #6 was providing incontinent care and a bed bath. Resident #1 pointed to his right ankle indicating pain. The nurse was notified. At 10:30 AM the nurse assessed Resident #1 and noted pain and swelling to his right ankle. Pedal pulses were present and increased pain was noted when (the right) foot was flexed. The nurse administered scheduled pain medication. At 10:40 AM the Nurse notified the FNP in the facility. The FNP assessed Resident #1 and ordered an x-ray of the right ankle. No additional pain medications were ordered Resident #1 received [MEDICATION NAME] 5/325mg (milligrams) three times a day for chronic pain and [MEDICATION NAME] 5/325 mg every six hours as needed for pain. At 11:00 AM (07/27/20) mobile x-ray was called. At 11:30 AM the facility notified Resident #1's Responsible Party (RP) of the new orders for an x-ray. At 5:00 PM on 07/27/20 the x-ray was completed. At 5:45 PM the RP was notified of the completed x-ray. On 7/28/20 the investigation summary revealed; at 7:05 AM the facility received the x-ray report stating acute nondisplaced [MEDICAL CONDITION] fibula with no focal bone [MEDICAL CONDITION]. The alignment was anatomic. There was no soft tissue swelling or foreign body identified. At 7:11 AM the nurse notified the on-call physician. New orders were received for an orthopedic consult. At 7:15 AM the RP was notified of the x-ray result and orthopedic consult. At 12:00 PM the FNP assessed Resident #1 to follow up on the fracture. Resident #1 reported pain on palpation. A new order was received for an immobilizer boot and to continue pain medications. At 3:15 PM the facility notified Resident #1's RP of the x-ray results and new orders. A review of the witness statement obtained by the facility with Nurse Aide #3 documented; On 7/26/20 at approximately 6:30 PM I was assisting Nurse aide #4 an agency NA to complete a transfer. I had never seen this resident out of bed before tonight. I was unsure of his transfer status. I did not know how to access the care guide. I was not oriented on the IPAD when I started at the facility. Resident (#1) was in the Geri chair prior to transfer. NA #4 and I went to transfer the resident. I was on the right side and NA #4 was on the left. We placed our arms under the resident's arms and grabbed the back of his pants to stand and pivot transfer. Once the transfer began the resident was pivoted to the right towards the bed. The resident was seated on the side of the bed. NA #4 noticed the resident's right foot was in a vertical position plantar flexion towards the floor position. I bent down and moved the right foot to its normal position. The resident had no facial grimacing when I moved his foot. I asked the resident if he had pain and he nodded no. I did not report this to the nurse as it did not appear noteworthy. This resident was not my assigned patient. That was the last time I saw Resident #1 during my shift. A follow up witness statement obtained by the facility with NA #3 documented; I helped NA #4 put Resident #1 in bed. We could not find a lift or sling. We assisted him to bed. I took one side he took the other side. He did not fall. His foot got stuck under the bed a little and we pulled it out. We asked if he was hurting and he said (nodded) no. It was his right foot. I did not let the nurse know because he acted like it didn't hurt and I didn't see bruising or lumps. We assisted him to bed between 6:00-7:00 PM. A review of the witness statement obtained by the facility with Nurse Aide #4 documented; I worked with Resident #1 on 7/26/20 on the 3:00-11:00 PM shift. When I came to work, I began my rounds at approximately 3:00 PM. Resident #1 was in the wheelchair at the time. At approximately 5:00 PM Resident #1 remained in the wheelchair and wished to stay there a little while longer. At approximately 6:00 PM I was delivering meal trays and stopped in resident #1's room. Between 6:00 -7:00 PM I transferred him back to his bed with NA #3. We placed the wheelchair facing the middle of the bed. I had the left side and NA #3 had the right side under his arms. When we stood him up and were in the process of turning him his right foot went underneath the bed getting stuck underneath the horizontal bar. We got his foot unstuck and continued to transfer him to the bed. I asked him if he was okay and he nodded yes. He was given incontinent care around 7:00 PM, and during that time showed no signs or symptoms of pain. At 8:00 PM I rounded on Resident #1 again and provided incontinent care, Resident #1 then pointed to his head. I notified the nurse and the nurse said that meant he had a headache. Around 9:30 PM I completed incontinent care on Resident #1 with no signs or symptoms of pain. Around 10:30 PM, I completed my final round and completed incontinent care with no signs or symptoms of pain. My shift ended at 11:00 PM. An interview was conducted with Nurse Aide #4 on 12/16/20 at 2:50 PM. He stated he was an agency nurse aide and worked at the facility for four months. He recalled the incident with Resident #1. He stated when he transferred Resident #1 on 7/26/20 it was the first day he had ever worked at the facility. He reported that Resident #1 was sitting in his chair and he asked Nurse Aide #3 to help him transfer Resident #1, and stated he wasn't sure about how they transferred him. He stated Nurse Aide #3 was an agency aide and she no longer worked at the facility. He reported he looked for a lift and didn't see one. He indicated he worked that night from 3:00 PM - 11:00 PM and was on the 600 hall and all lifts were on the 100 hall at that time. He stated he pivoted Resident #1 and his ankle was caught under the bed. He reported Resident #1 had no complaints of pain at that time and he thought he was okay. He stated he kept going in his room throughout the shift and he seemed normal all night but did have complaints of a headache during the night, and he reported that to the nurse. He stated he didn't report the transfer to the nurse because he didn't think it was anything reportable and stated it was nothing dramatic and thought Resident #1 was not injured. He acknowledged that the Resident Care Guide indicated Resident #1 required the mechanical lift with two-person assistance for transfers. An interview was conducted on 12/15/20 at 3:40 PM with Nurse #1 who was the assigned nurse when Resident #1 began exhibiting swelling and pain of the right ankle on 07/27/20. She stated Resident #1 was complaining of ankle pain one morning. She assessed his ankle and noted pain and swelling and immediately had the facility Nurse Practitioner assess him. She reported an x-ray was ordered which showed the fracture and Resident #1's RP was notified. An interview was conducted on 12/15/20 at 4:00 PM with the facility Nurse Practitioner. She stated Resident #1 had sudden complaints of ankle pain, and she ordered an x-ray. She reported Resident #1 was referred to orthopedics, and an immobilizer boot was placed. She reported he received ongoing follow up evaluations due to continued complaints of pain. A follow up phone interview was conducted on 12/16/20 at 4:40 PM with the facility Nurse Practitioner. She indicated the fracture sustained by Resident #1 resulted from being transferred without using the mechanical lift. In a phone interview with the facility Medical Director on 12/17/20 at 10:04 AM, he stated he was made aware of Residents #1's fracture that occurred on 7/26/20 and reported the facility Nurse Practitioner assessed him at the time he began exhibiting signs and symptoms and continued to evaluate Resident #1 in the days immediately following the incident. He stated he evaluated residents routinely every 10-12 weeks and evaluated Resident #1 in August 2020 without any acute concerns. The physician stated the x-ray report dated 7/27/20 revealed an acute nondisplaced fracture of distal fibula. He acknowledged that Resident #1 had no diagnoses of [MEDICAL CONDITION] or osteopenia and indicated there was no pathologic etiology for the fracture. During an interview on 12/16/20 at 3:11 PM with the Director of Nursing she reported she was not working at the facility during the incident regarding Resident #1's fracture and had no knowledge of the specific details although she was aware that he had sustained a fracture. She indicated that Resident #1 required a mechanical lift for transfers and the nurse aides were expected to review the Resident Care Guide to determine how a resident was to be transferred. She reported that NA #3 was an agency NA and no longer worked at the facility. During an interview on 12/16/20 at 10:00 AM the Administrator reported he was aware that Resident #1 sustained a fibula fracture, but he was not working at the facility during the time of the incident or during the time the corrective action plan was implemented. During a phone interview on 12/17/20 at 5:30 PM with the Corporate Nurse Consultant she reported she assisted the DON with implementing the corrective action plan including conducting some of the in-service training. She confirmed the completion date was 07/30/20. The corrective action for noncompliance with a completion date of 07/30/20 was as follows: A thorough investigation was initiated on 07/29/20 to determine the root cause regarding Resident #1 sustaining a [MEDICAL CONDITION] fibula. The facility investigation included; record review and obtaining witness statements. On 07/29/20, 100% resident questionnaires were completed by the Social Worker and the unit manager with all alert and oriented residents regarding any concerns with transfers or injuries with transfers that were not reported or addressed. There were no concerns during the interviews. On 07/29/20 100% of all residents were assessed by the unit manager to ensure no residents had a fracture that had not been addressed. An audit was completed on 07/30/20 with no identified concerns. On 07/29/20 a 100% audit was conducted by the DON and QA (Quality Assurance) nurse to locate all mechanical lifts in the facility. Nine mechanical lifts were in the facility during the audit. On 07/29/20 a 100% audit of all incident reports and progress notes was completed by the DON from 06/29/20 -07/29/20 to include Resident #1 to identify any injuries related to improper transfer techniques. There were no additional injuries related to improper transfers. The DON and the Corporate Nurse Consultant provided statements from staff that were working on 07/26/20 through 07/28/20. The DON and Nurse Consultant completed in services beginning 07/28/20 and provided education to the nursing staff and nurse aides regarding signs and symptoms of fractures, including causes, nurse responsibilities, and prevention. Inservice's on 07/28/20 were conducted on transferring residents and accessing the Resident Care Guide, and reporting any incident occurring during transfers immediately to the nurse. Staff not in attendance were mailed via certified mail the in-service material, this was verified by signatures on the certified mail receipt. Monitoring was conducted by the Nurse Consultant and DON weekly for 8 weeks through return demonstrations of locating resident care guides, and transfers using the appropriate equipment. The DON would bring outcomes of compliance to the facility monthly Quality Assurance (QA) meeting for three months beginning August 2020. The facility alleged full compliance with the plan of correction effective date 07/30/20. As part of the validation process on 12/17/20 the plan of correction was reviewed which included dates and content of the in-services that were conducted, and interviews with the nurses and nurse aides to ensure their understanding and knowledge of transfers using the required mechanical lift and accessing the resident care guides. During the investigation direct care staff were interviewed regarding training that was conducted and knowledge of accessing the resident care guide and using the mechanical lifts for transfers. Observations were conducted of resident transfers during the investigation. All nurses and nurse aides interviewed were able to verbalize how to access the resident care guide. The facility's alleged compliance date of 07/30/20 was validated.

Based on record review, staff and resident interviews and Adult Protective Services (APS) interview the facility failed to protect a resident ' s right to be free of sexual and physical abuse for 1 of 2 residents (Resident #6) reviewed for abuse. Resident #4 was observed naked while standing over Resident #6 ' s bed with both of his hands between her legs and inside her brief. Resident #6 said Resident #4 grabbed her vagina and slapped her face and the incident made her scared and very angry. Findings included: Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4 ' s hospital expected discharge record written on 12/12/19 revealed a note by the hospital Social Worker which specified the resident no longer required a tele sitter (a computer camera device used to monitor a resident who required continued observation) at the hospital since 11/27/19 at 8:34 PM. An interview was conducted with the Administrator on 01/02/20 at 4:20 PM. The Administrator reported she and the Admissions Coordinator went to the hospital just prior to Resident #4 being discharged and observed the resident in his hospital room sitting up in a recliner and he was noted to be pleasant. The Administrator reported he was not on 1 to 1 (staff to resident monitoring) and he seemed appropriate to be admitted to the facility. The Administrator reported the Director of Nursing (DON) reviewed the resident ' s admission record, and the DON felt the resident was appropriate for this facility. The Administrator and the Admissions Coordinator could not provide documentation to support why Resident #4 was requiring a tele sitter while hospitalized . The Administrator stated according to the discharge records, the tele sitter was discontinued on 11/27/19. Resident #4 ' s baseline care plan dated 12/12/19 revealed a plan of care was in place for chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. The intervention included to allow and encourage resident to make choices. Additionally, a plan of care was in place for at risk for falls characterized by history of falls/actual falls, injury, multiple risk factors related to impaired balance, impaired cognition, impaired mobility and wandering. The Minimum Data Set ((MDS) dated [DATE], 5-day assessment revealed Resident #4 was severely cognitively impaired. Resident #4 presented with moods and behaviors such as physical behaviors including hitting, kicking, pushing, scratching and abusing others sexually for 1-3 days, refused care and wandered. The resident required limited assistance with one staff physical assistance with toileting and walked in and out of his room. Resident #4 received 4 days of antipsychotic medication and 3 days of antidepressant medication. An interview was conducted with Nurse #7 on 01/03/20 at 12:42 PM. Nurse #7 indicated on 12/12/19 when the resident was admitted around 1:30 PM from the hospital, she did not receive any report or information from the nurse at the hospital about Resident #4. Nurse #7 stated the Nursing Assistants (NAs) put the resident in bed because she was in the middle of a medication pass when he arrived. Nurse #7 stated, after a short while, she went to Resident #4 ' s room to introduce herself and let him know that she would be back shortly to assess him. The nurse reported while she was at her medication cart, she noticed he had come into the hallway wearing only a brief and she redirected him back to his bed. Nurse #7 stated this happened a couple more times and she knew she was going to need to get some help with this resident. Nurse #7 reported Resident #4 was easily directed, however, he was persistent with disrobing and coming out to the hallways. Nurse #7 stated she went to the Quality Assurance (QA) Nurse and together they observed the resident, and he was, again, wearing only his brief and wandering in the hallway. Nurse #7 stated she asked the QA nurse to get a staff member to sit with him until she was able to get her med pass done and try to get the resident more settled. Nurse #7 stated she obtained an order for [REDACTED].#7 stated she went back to Resident #4 ' s room to complete her assessment and obtain vital signs and she indicated the resident was not mean in demeanor, but pleasant, but he was calling out he needed help, refusing care when you tried to help, and became sexually inappropriate verbally. Nurse #7 stated NA #4 left at 4:00 PM and reported to her he was sleeping. Nurse #7 reported she went back to his room about 4:45 PM, assisted him into a Geri chair (reclining chair on wheels) and brought him to the nurse ' s station where the Evening Nurse Supervisor watched him until 7:00 PM. Nurse #7 reported she would not have considered the resident to be an actual 1 to 1, but she just needed sometime to help get him situated and keep him safe. An interview was conducted with NA #4 on 01/03/20 at 11:15 AM. NA #4 stated when she went into Resident #4 ' s room on 12/12/19 he was pleasant, but he was saying sexually inappropriate things to her and Nurse #7 and making sexual hand gestures while touching his private areas. NA #4 stated he settled down and she covered him up and went to sleep. NA #4 stated she was in the room for about 2 hours and at 4:00 PM he was sleeping and it was time for her to leave. She stated Nurse #7 was down the end of the hall and she told Nurse #7 she was leaving, but she did not know if she heard her. NA #4 stated that no other staff member relieved her, but she felt safe leaving him at that time. NA #4 stated Resident #4 was just admitted and very disoriented and she was told she would be sitting with him until he settled down. An interview with the Evening Nursing Supervisor (ENS) was conducted on 01/03/20 at 12:56 PM via phone. The ENS reported on the evening of 12/12/19, Nurse #7 brought Resident #4 to him in a Geri chair and asked that he keep an eye on him and explained that the was disrobing, getting out of bed and wandering upon admission. The ENS reported Resident #4 was confused and called out for help during the time he monitored him, but he was not combative, wandering or uncooperative and he was easily reassured and redirected. The ENS stated he monitored the resident from about 5:00 PM to 7:00 PM and at that time, NA #5 took him to his room to do care. An interview was conducted with NA #5 via phone on 01/03/20 at 1:20 PM. NA #5 revealed when she arrived on 12/12/19 at 3:00 PM, she was told Resident #4 had been disrobing, wandering out of his room and being verbally sexually inappropriate with staff. NA #5 reported the resident was sitting with the ENS until about 7:00 PM when she took him to his room to do care. NA #5 stated he was verbally sexually inappropriate to her but she ignored what he was saying. NA #5 indicated she assisted the resident back into the Geri chair and placed him at the nurse ' s station so the staff could keep an eye on him. NA #5 reported at about 9:30 PM, she brought the resident to his room to complete incontinent care and get him ready for bed. NA #5 stated the resident continued to be verbally sexually inappropriate toward her and she reported that to the ENS. NA #5 reported he went to sleep and there were no further issues for the remainder of the 3:00 PM – 11:00 PM shift. A behavior monitoring sheet for Resident #4 revealed there were no behaviors during the night shift starting on 12/13/19 and throughout the day on 12/13/19. Behaviors were documented on 2nd shift on 12/14/19. A nursing behavior note, written by Nurse #4 on 12/14/19 at 4:40 PM revealed, in part, Resident #4 wandered into Resident #6 ' s room. Resident #4 was redirected and a wander guard was placed on Resident #4 ' s left ankle. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE] revealed the resident was cognitively aware and she did not exhibit any behaviors. Resident #6 required extensive assistance with one staff physical assistance with bed mobility. She had impairment to one side to the lower extremity and used a wheelchair. A review of the physician orders [REDACTED]. An interview was conducted with Resident #6 on 01/03/20 at 3:15 PM. Resident #6 revealed on the afternoon of 12/14/19 she was sitting up in her wheelchair when a man came into her room wearing just a brief, walked around her wheelchair and sat on her bed and began to eat her popcorn. Resident #6 stated she told the man he did not belong there, and he stated he was cold. Resident #6 stated a visitor had arrived to see her and asked who was this man sitting on her bed? Resident #6 reported she called out to Nurse #4 that there was a man in her room in her bed. Resident #6 stated NA #5 came in and escorted him out of the room. Resident #6 reported Resident #4 did not say anything inappropriate to her and she and the visitor thought it was kind of funny that he came into the room and sat on the bed and ate her popcorn. Resident #6 stated she had never seen Resident #4 before and she did not see him again until the early morning hour the next day (about 5:00 AM or so). Resident #6 reported she woke up to this man standing naked next to her bed who pulled back her covers and stated I want to see your old pussy. Resident #6 stated she tried to push him away and he slapped her in the face. Resident #6 reported Resident #4 put his hands under her brief and felt her vagina, but he did not penetrate her. Resident #6 stated she yelled for help and Nurse #3 came in and took Resident #4 out of the room. Resident #6 stated Nurse #2 also came into the room to talk with her and reassured her everything was okay and she was safe. Resident #6 reported she was scared after the incident occurred and very angry and she reported her face hurt. Resident #6 stated the police came and took a report and Nurse #2 asked if she could contact anyone for her, but she declined at this time to have family notified because she needed to process what just happened and she was embarrassed. An interview was conducted with NA #5 via phone on 01/03/20 at 1:20 PM. NA #5 reported on 12/14/19 at around 3:45 PM she had heard Resident #6 yelling help me, there is a man in my bed. NA #5 stated she went into Resident #6 ' s room and noted Resident #6 was sitting in her wheelchair while Resident #4 was sitting on her bed wearing only a brief and eating popcorn. NA #5 reported Resident #6 rolled her wheelchair to the doorway and notified Nurse #4. NA #5 redirected Resident #4 out of Resident #6 ' s room and brought him to his room which was located directly beside Resident #6 ' s room. NA #5 stated Resident #4 did not say anything to Resident #6 while she escorted him out of the room and he remained in his room for the rest of the evening shift and she checked on him every 30 minutes. NA #5 reported he was not wandering throughout the shift, but he was demonstrating behaviors by being verbally sexually inappropriate with her (NA #5) when she was providing care throughout the evening. NA #5 stated she reported the behaviors to Nurse #2. A review of a written statement by Nurse #4 revealed at 3:45 PM at 12/14/19, Nurse #4 and NA #5 were alerted by Resident #6 that a man was in her room. NA #5 redirected Resident #4 out of the room. The written statement indicated Nurse #4 applied a wander guard to Resident #4 at this time. Nurse #4 indicated in her statement Resident #6 was sitting in her wheelchair when Resident #4 entered the room and sat on her bed. An interview was attempted with Nurse #4 via phone, but she was unable to be reached after 2 attempts on 01/03/20 and 01/04/20. An interview was conducted with Nurse #2 via phone on 01/02/20 at 5:00 PM. Nurse #2 revealed on 12/14/19 when she arrived for her shift from 7:00 PM – 7:00 AM, she had been told by the day shift Nurse #4 Resident #4 had wandered into Resident #6 ' s room. Nurse #2 stated she was on a medication cart and was assigned to the hall that Resident #4 and Resident #6 resided on until 11:00 PM. Nurse #2 stated during the 7:00 PM – 11:00 PM shift, Resident #4 slept and had no further wandering behaviors on 12/14/19. Nurse #2 reported staff was keeping an eye on Resident #4 during rounds every 2 hours and as they passed his room from the hall. An interview was conducted with Nurse #3 via phone on 01/03/20 12:30 PM. Nurse #3 revealed when she came in at 11:00 PM on 12/14/19, Nurse #2 reported to her that Resident #4 was sleeping. Nurse #3 stated she had no knowledge of what happened on 12/14/19 when Resident #4 entered Resident #6 ' s room during the day shift. Nurse #3 stated Resident #4 had no behaviors during the night shift until about 5:20 AM on 12/15/19 when she heard a scream from down the 400 hall. She stated she ran toward the scream and found Resident #6 ' s door closed, she opened the door and found Resident #4 naked, standing over Resident #6 ' s bed with both hands between her legs inside her brief and Resident #6 was trying to push Resident #4 away. Nurse #3 stated she removed Resident #4 from the room and instructed NA #6 to get him dressed, put him in a Geri chair, and to monitor him 1 to 1. Nurse #3 stated she assessed Resident #6. She reported Resident #6 was nervous and scared and knew she had been violated and wanted to know why and how. Nurse #3 noted Resident #6 ' s face had redness to the left side of her face and Resident #6 reported to the nurse Resident #4 had slapped her when she told him to stop touching her and get out. Nurse #3 stated Resident #4 remained on 1 to 1 until she obtained an order by the physician to send him to the hospital for further evaluation. Nurse #3 stated Emergency Medical Services arrived at 11:51 AM on 12/15/19 and transferred him to the hospital. An interview with NA #6 via phone on 01/03/20 at 1:15 PM revealed she was assigned to the hall that Resident #4 and Resident #6 resided on. NA #6 reported when she came on to her shift for the 11:00 PM – 7:00 AM shift on 12/14/19 going into 12/15/19, she did not get report from anyone and did not know Resident #4 had behaviors such as wandering. NA #6 stated she worked as an agency NA and usually did not get report from the previous NA when she worked at the facility. NA #6 reported she rounded on Resident #4 every 2 hours and the last round she completed was about 5:00 AM. NA #6 stated Resident #4 had no behaviors during the night. NA #6 stated when she saw Resident #4 come out of Resident #6 ' s room with Nurse #3, he had no brief on and she knew she had just put a clean one on him. A review of the police report revealed the report was dated 12/15/19 at 6:15 AM. The crime incident noted on the report was simple assault with minor injury noted to Resident #6. An attempt to interview the officer on scene was attempted on 01/04/20 at 9:55 AM. There was no answer and a voice mail message was left. An interview was conducted with the Adult Protective Services (APS) staff member on 01/02/20 at 2:45 PM. The APS staff member stated the officer, who was on the scene at the facility on 12/15/19, reported to her that according to the Magistrate and the District Attorney, Resident #4 was not of sound mind and would be given a citation for assault on a female and was given a date to appear in court. An interview was conducted with the Administrator on 01/04/20 at 9:20 AM. The Administrator reported what happened to Resident #6 while living in her home was horrific. The Administrator stated Resident #4 was confused when he arrived at the facility on 12/12/19, and he ended up settling down once he was situated. The Administrator reported Resident #4 did not have any behaviors again until 12/14/19 when he wandered into Resident #6 ' s room and the nurse put a wander guard on him but no other interventions were put in place to keep him from entering other resident rooms. The Administrator stated after Resident #4 wandered into Resident #6 ' s room on 12/14/19, he slept until the following morning. The Administrator added, the facility had no way of knowing such a thing could happen and expected her staff to keep all the residents safe from harm and abuse. A corrective action plan for noncompliance dated 12/15/19 was as follows: 1. The immediate corrective action by the facility on 12/15/19 was Resident #4 was brought out of the Resident #6 ' s room by Nurse #3 and NA #6 dressed the resident and put him in Geri chair and he was placed on 1 to 1 at the nurse ' s station. Resident #6 was assessed by the Nurse #3. A physician's order [REDACTED].#4 was sent to the hospital for further evaluation on 12/15/19 at 11:51 AM. The Administrator, Director of Nursing, and Assistant Director of Nursing were notified immediately after the incident and were in the facility within 30 minutes. Police were notified and completed a report. The facility completed the 24-hour initial report and submitted it to Department of Health Care Registry via fax within 2 hours and initiated the 5 –day investigation report. The corrective action for the affected resident included notifying the physician, notifying the Social Worker at PACE (Program for All-inclusive Care for the Elderly) where the resident attended 3 times per week and was seen by the PACE Social Worker once per week, frequent visits from the facility ' s Social Worker to assess wellbeing and any post-traumatic stress, a psychiatric consult was ordered on [DATE] and family was notified when the resident allowed permission to do so. The corrective action for residents with the potential to be affected included the DON, ADON and Staff Development Coordinator (SDC) Nurse completed 100% skin assessments of all non-alert and oriented residents for signs and symptoms of sexual abuse on 12/15/19. The facility Social Worker completed a 100% resident questionnaire for all alert and oriented residents regarding anyone wandering into their room on 12/15/19. The questionnaire was expanded on 12/16/19 and completed by the Social Worker to include the question regarding has anyone touched you inappropriately that has not been reported and addressed. 2. Measures implemented to assure deficient practice would not reoccur included 100% audit of all progress notes for the last 30 days for any resident that had wandered into another resident ' s room unwanted or uninvited was completed on 12/15/19 by the DON. On 12/15/19, The DON also reviewed admissions for the past 30 days to ensure that no other residents had any documented inappropriate behaviors to include requiring a sitter, sexual behaviors, violent behaviors, or were given as needed antipsychotics without justifiable diagnoses. The SDC Nurse completed 100% in services to staff to include nurses, nursing assistants, med aides, dietary staff, housekeeping staff, therapy staff, ancillary staff and the Administrator on 12/15/19 regarding resident abuse and residents that wander into other resident ' s rooms unwanted or uninvited which included how to intervene with residents who wander uninvited to other resident ' s room or make inappropriate sexual comments or display inappropriate sexual actions. In services were completed by 12/17/19. 3. The outcome of compliance with the plan of action will be monitored by the DON, ADON, Nursing Supervisors, QA Nurse and SDC Nurse and includes 100% review of progress notes 5 days per week for 4 weeks monitoring for wandering and inappropriate behaviors to include implementing interventions and updating the care plan to prevent reoccurrence by utilizing the Behavior Interdisciplinary (IDT) tool. The initial Quality Assurance (QA) meeting to review the plan of correction was held on 12/15/19. The Behavior IDT tool, which will aid in determining trends or concerns that required further interventions, will be utilized and forwarded to the executive QA committee monthly X 1 month. The executive QA committee will meet and review the Behavior IDT tool to determine the need for further and or frequency of monitoring. The facility alleges full compliance with the plan of correction effective 12/18/19. As part of the validation process on 01/04/20 the plan of correction was reviewed which included dates and content of the in services that were conducted, dates and content of the audits that were completed. A review of dates and content of the questionnaires for the alert and oriented residents regarding anyone wandering into their rooms or making inappropriate sexual comments or action, and the skin assessments for all non-alert and oriented residents for signs and symptoms or abuse and review of the Behavior IDT audit. The Abuse Prohibition Review was completed to determine if residents, direct care staff, and front line supervisors were provided education regarding the abuse policy and procedures to include screening potential new hires, training of employees, prevention policies and procedures, identification of possible incident or allegations which need investigation, investigation of incidents and allegations, protection of residents during investigation and the reporting of incidents, investigations, and the facility response to the results of their investigations. On 01/04/20, the facility ' s compliance date of 12/18/19 was validated.

Based on staff interviews, physician interview and record review the facility neglected to seek medical treatment for [REDACTED].#45) reviewed for accidents. Staff observed a bruise on Resident #45's arm for 4 days before seeking medical treatment and obtaining an x-ray which showed the resident had a right humerus fracture. Findings included: Resident #45 was admitted on [DATE]. [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] quarterly assessment revealed there was no cognitive assessment completed. Resident #45 exhibited no mood or behaviors. Resident #45 required extensive assistance with one staff physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. Resident #45 was not steady and only able to stabilize with staff assistance. Resident #45 had impairments to both sides to upper and lower extremities and used a wheelchair. The resident was always incontinent of bowel and bladder and had no falls or skin concerns recorded. Resident #45 received no anticoagulants (blood thinners). A review of the care plan for Resident #45 updated on 05/03/19 revealed there was a plan of care in place for at risk for skin breakdown related to impaired mobility and incontinence. Interventions included, in part, to inspect skin and notify nurse of abnormal changes. A plan of care for potential for skin tears related to fragile skin was in place with interventions to include, in part, observe skin daily and notify nurse of new skin tears, and a weekly evaluation/assessment with notification of physician of changes as necessary. Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/09/19. An interview was conducted with Nurse #3 via phone on 07/18/19 at 6:00 AM. Nurse #3 stated no staff member had reported a bruise on Resident #45 ' s arm during the night shift on 07/09/19. A weekly skin check assessment completed on 07/09/19 at 1:44 PM by Nurse #2 revealed the resident had a skin check done and the present skin integrity issue was the right toe with an intervention for lower extremity bridging/floating. The skin assessment did not indicate there was a bruise to the right upper extremity. An interview was conducted with Nurse #2 on 07/18/19 at 11:59 AM. Nurse #2 reported when she completed the skin check assessment on 07/09/19 for Resident #45, she only identified the area on the resident ' s right toe. Nurse #2 stated she did not see a bruise on the resident ' s arm. An interview was conducted with Nursing Assistant (NA) #4 on 07/17/19 at 12:16 PM. NA #4 reported Resident #45 was on her assignment and she worked from 7:00 AM to 11:00 PM. NA #4 stated skin checks were usually done when a resident got a complete bed bath or shower. NA #4 stated Resident #45 would get her shower on the night shift early in the morning. NA #4 stated when she started her shift on 07/09/2019, the resident was already up and dressed and sitting up in the chair. NA #4 stated she transferred her to the bed to change her and she did not recall the resident showing any signs or symptoms of pain. NA #4 stated if she had seen a bruise, she would have notified the nurse immediately. Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/10/19. An interview was conducted with NA #3 via phone on 07/18/19 at 6:00 AM. NA #3 reported he worked the night of 07/10/19 going into 07/11/19. NA #3 reported Resident #45 was on his assignment and when he went to give her a bed bath and was undressing her, he noticed bruising on the right arm from the upper forearm area to the shoulder. NA #3 described the bruise as black and blue and purple and it covered the upper arm. NA #3 stated he told Nurse #1, and she told him that she would tell Nurse #4 because Nurse #1 was usually on the 500/600 hall. NA #3 stated Nurse #1 assessed the bruise. NA #3 stated he finished giving Resident #45 her bath and kept her in bed. NA #3 reported the resident did not show any signs of pain like grimacing or moaning. NA #3 stated he left the resident in bed so the day nurse (Nurse #4) could look at her. NA #3 reported the resident did not try to get out of bed. She was cooperative with care and had no falls. He stated he did not know how the resident got the bruise and he was not aware of the bruise prior to starting his shift. He stated whenever he saw a change in condition be it skin, mental status, pressure ulcer, an abnormal vital sign or injury of unknown origin, the facility protocol was to notify the nurse. An interview was conducted with Nurse #1 on 07/17/19 at 7:15 AM. Nurse #1 stated during the night shift on the night of 07/10/19 going into 07/11/19, NA #3 reported to her there was a bruise on Resident #45. Nurse #1 stated she assessed the bruise and noted it was on her right upper forearm and it was yellowish in color and about the size of her hand. Nurse #1 stated she moved the shoulder and arm around and the resident showed no signs or symptoms of pain. Nurse #1 stated she spoke with Nurse #4 on the day shift the morning of 07/11/19 because the bruise looked old to Nurse #1. Nurse #1 stated Nurse #4 stated she had no prior knowledge about a bruise on Resident #45. Nurse #1 reported that she was not told in report on the start of her shift on 07/10/19 going into 07/11/19 Resident #45 had a bruise. Nurse #1 stated after she assessed the bruise, she did not do anything else except report it to the oncoming nurse (Nurse #4). Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/11/19. An interview was conducted with Nurse #4 on 07/19/19 at 11:55 AM. Nurse #4 reported she recalled Nurse #1 reporting to her on the morning of 07/11/19 Resident #45 had a bruise. Nurse #4 stated she went and assessed the bruise and it was on her upper forearm and it was small and purple. Nurse #4 stated it was not yellow or green to indicate it looked old. Nurse #4 reported she looked at the bruise again later on her shift and the resident had no complaints of pain. Nurse #4 stated she did not report or document on it because it was so small. An interview was conducted with NA #6 on 07/17/19 at 4:00 PM. NA #6 reported she was assigned to Resident #45 for the day shift on 07/11/19. NA #6 stated she did not see Resident #45 ' s arm on 07/11/19. NA #6 reported the night shift would get the resident up because she was on restorative therapy. NA #6 stated while caring for Resident #45 during her shift, the resident had no complaints of pain or signs or symptoms of pain. NA #6 stated no one had reported to her Resident #45 had a bruise on her arm. An interview was conducted with the Restorative Aide (RA) on 07/19/19 at 2:00 PM. The RA reported she worked with Resident #45 when she was assigned as a restorative aide. She stated the resident was on restorative therapy for range of motion, transfers, and eating. The RA reported the resident was compliant with restorative therapy and would not refuse or resist care. She stated recently she had been working as a NA instead of a RA and had not done any restorative therapy on the resident. She stated when she did restorative therapy the resident was usually up and dressed when she came into the room in the morning. She stated the resident ' s restorative included range of motion of the upper extremities and included raising the resident ' s arms. The RA reported, at times Resident #45 could follow commands, but most of the time the RA performed the range of motion. The RA reported she tolerated the therapy well and had no signs of pain such as grimacing. An interview was conducted with NA #7 via phone on 07/19/19 at 10:43 AM. NA #7 reported he was assigned to Resident #45 on 07/11/19 during the evening shift. NA #7 stated when he arrived, Resident #45 was already in bed and in her gown. NA #7 reported he did not see her arm throughout the shift and only did incontinent care on her. An interview was conducted with Nurse #1 on 07/17/19 at 7:15 AM. Nurse #1 stated when she came in for her shift on 07/11/19 going into 07/12/19, she palpated the bruise and performed range of motion and the resident had no complaints of pain or any signs or symptoms of pain. Nurse #1 stated there was no change in the bruise on 07/12/19. Nurse #1 stated there was a policy in place for abuse and neglect which included injury of unknown origin, and if staff identified an injury of unknown origin, they were to notify the supervisor or Director of Nursing (DON) immediately, complete an incident report and an incident note, and notify the on call physician and the Responsible Party (RP). Nurse #1 stated she did not report it or document on it because it looked old. Nurse #1 stated the bruise was faded and had yellow edges and she did not know how the resident got the bruise. Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/12/19. An interview was conducted with NA #1 on 07/16/19 at 5:20 PM. NA #1 reported she had seen the bruise to Resident #45 ' s upper arm on 07/12/19 during the night shift. NA #1 reported NA #2 had asked her to come and look at Resident #45 ' s arm. NA #1 stated the right upper forearm was bruised. It was a large bruise and it was black and purple in color. NA #1 stated she told NA #2 to report it to the nurse. An interview was conducted with NA #2 on 07/17/19 at 7:00 AM. NA #2 reported the early morning (night shift) staff was responsible for getting Resident #45 up and ready. NA #2 stated she worked the night shift on 07/12/19 and when she removed Resident #45 ' s robe, she noticed a bruise that was black and blue on the right upper forearm going up to her shoulder. NA #2 stated she did not see any open areas and the resident had no signs of pain. NA #2 stated she showed the bruise to NA #1 and NA #1 instructed her to report it to the nurse. NA #2 stated she covered the resident up and called Nurse #1 and stated she needed to come and see Resident #45. NA #2 reported Nurse #1 asked her if it was about the bruise and NA #2 said yes. NA #2 stated Nurse #1 stated she was already aware of it because NA #3 had already informed her from a previous night. NA #2 reported that no staff member had reported anything about a bruise on Resident #45 to her. NA #2 stated she proceeded to get Resident #45 up and get her ready and put her in the chair. She stated the resident did not express any pain. She did not grimace or flinch. NA #2 stated the resident could not verbally make her needs known. An interview was conducted with NA #6 on 07/17/19 at 4:00 PM. NA #6 reported she was assigned to Resident #45 for the day shift on 07/12/19. NA #6 stated she did not see Resident #45 ' s arm on 07/12/19. NA #6 stated while caring for Resident #45 during her shift, the resident had no complaints of pain or signs or symptoms of pain. NA #6 stated no one had reported to her Resident #45 had a bruise on her arm. Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/13/19. An interview was conducted with NA #7 via phone on 07/19/19 at 10:43 AM. NA #7 reported he was assigned to Resident #45 on 07/12/19 going into 07/13/19. NA #7 stated when he arrived at 7:00 PM, Resident #45 was already in bed and in her gown. NA #7 reported he did not see her arm throughout the shift and only did incontinent care on her. NA #7 stated NA #10 gave the resident her shower on the morning of 07/13/19. An interview was conducted with NA #10 via phone on 07/19/19. NA #10 reported on the morning of 07/13/19 (during the night shift hours) she gave Resident #45 a shower. NA #10 stated the resident was brought into the shower room, she removed the splint she wore on her right arm, and she removed the resident ' s gown and gave her a complete shower. NA #10 reported she did not see a bruise on the resident ' s right arm. NA #10 stated if she had seen a bruise, she would have reported it to Nurse #3. NA #10 stated Nurse #3 did not do a skin check on Resident #45 because one had been done on 07/09/19. NA #10 stated she did not notice any bruising or swelling on Resident #45 and the only skin issue she observed was on her right toe. An interview was conducted with Nurse #3 via phone on 07/18/19 at 6:00 AM. Nurse #3 stated she worked from 7:00 PM - 7:00 AM on both 07/12/19 and 07/13/19 and no staff member reported to her a bruise on Resident #45. Medical record review revealed there were no issues documented that Resident #45 had any bruising on 07/13/19. An interview was conducted with NA #5 on 07/19/19 at 12:36 PM. NA #5 reported Resident #45, who was assigned to the resident on day shift on 07/13/19, wore a splint on her hand and a soft splint on her arm/elbow to keep the arm in place. He reported he did not really work with her that much on 07/13/19 except to do incontinent care. NA #5 stated she was already dressed and up when he started his shift and he was not made aware of a bruise on her arm. NA #5 reported the resident was smiling like she always does. An interview with NA #21 who worked the evening shift and the night shift of 07/13/19 going into 07/14/19 was attempted via phone on 07/20/19 at 9:20 AM. The phone number was disconnected. The DON was asked if there was another number and she reported the NA #21 was terminated and she had no other phone number for her. An interview with the night shift charge nurse (NSCN) was conducted via phone on 07/20/19 at 6:45 AM. She stated on Sunday morning on 07/14/19 during the night shift hours, she was made aware of Resident #45 by NA #21 who stated the resident had a bruise on her arm and NA #2, who was nearby, who stated she told the nurses a few days ago. The NSCN stated once she learned of it, she was told it had been reported to other nurses so she thought the bruise was addressed. NSCN stated NA #21 told her the bruise was yellowed. The NSCN stated she received training regarding abuse and the types of abuse which included neglect, and injury of unknown origin. The NSCN reported if there was an injury of unknown origin, the policy was to notify the physician right away, do an incident report, document, and call the family. The NCSN stated she did not report the bruise because she was told other nurses were aware of the bruise and she thought it had been addressed. An interview was conducted with NA #1 on 07/16/19 at 5:20 PM. NA #1 stated on 07/14/19, she came in for the evening shift and was assigned to Resident #45. NA #1 stated she went into the resident ' s room to do her care and observed her arm. NA #1 stated it looked worse than it did on the 07/12/19. NA #1 stated when she looked at her arm, it looked swollen and the bruise was darker in color and had spread up to the shoulder. NA #1 stated she reported the bruise to Nurse #2 immediately. NA #1 stated Nurse #2 had not known anything about the bruise and stated this was the first time she had seen it. NA #1 stated the nurse got an x-ray on 07/14/19 and found out the right arm was fractured. NA #1 stated she took care of Resident #45 throughout the shift and she was comfortable through the night. NA #1 stated she did not grimace or flinch or show signs of pain when she did her care. NA #1 stated she did not know how the bruise happened. She reported the resident did not have a fall and she did not attempt to get out of bed. NA #1 stated she would stay in one position all day if you let her. NA #1 stated the resident was very quiet and would sometimes answer yes or no questions. An interview was conducted with Nurse #2 on 07/18/19 at 11:59 AM. Nurse #2 reported on 07/14/19 at 4:00 PM she was taking care of another resident when NA #1 came up to her and asked her if she had seen Resident #45 ' s arm. Nurse #2 stated she said no. Nurse #2 reported NA #1 stated it looked a lot worse than the other day and she would have thought the nurse would have heard about the bruise in report. Nurse #2 stated she went to the resident ' s room and removed her shirt and she had a huge bruise on her right arm. Nurse #2 stated she was shocked! Nurse #2 reported she left immediately and told the Day Supervisor (Day S/V) at the nurse ' s station. Nurse #2 stated the Day S/V was on the phone with the Nurse Practioner (NP) at this time so she told her to tell the NP about the bruise and that she needed an order for [REDACTED].#2 stated she was resting in bed and had no signs or symptoms of pain. Nurse #2 stated NA #1 reported she saw the bruise on Resident #45 ' s arm a few days ago and it looked worse and that it was not swollen like it was today (07/14/19). Nurse #2 reported there was swelling and the bruise went from her forearm up to shoulder and was dark purple and green with yellowing edges and a lump in the upper forearm. Nurse #2 stated the resident did not appear to be in pain when she assessed the bruise. A review of a progress note written by Nurse #2 on 07/14/19 at 7:56 PM revealed Nurse #2 was made aware by NA #1 that the bruise to the right upper extremity for Resident #45 was reported to NA #1 a few days ago by NA #2 from the night shift. The note indicated NA #2 informed NA #1 Resident #45 had a bruised shoulder of unknown origin. The note indicated NA #1 stated she had not worked with Resident #45 since (07/12/19) until today (07/14/19) and noticed it was much more swollen. The progress note indicated NA #1 came and asked Nurse #2 about it and thought she should evaluate her because it looked so much worse than the last time she saw it. Nurse #2 noted she was not aware of this injury, but evaluated the resident and immediately reported it to her day supervisor, contacted the NP, obtained orders for a right shoulder x-ray, and called the x-ray provider. An interview with the night shift charge nurse (NSCN) was conducted via phone on 07/20/19 at 6:45 AM. The NSCN reported when she came back to work that evening on 07/14/19, the Day S/V had told her in the pre shift meeting that she looked into the injury of unknown origin and there was no documentation found and nothing had been done about the bruise. The NCSN stated she was told by the Day S/V the NP was notified and an x-ray was ordered for 07/14/19. An interview was conducted with Nurse #3 via phone on 07/18/19 at 6:00 AM. Nurse #3 reported on 07/14/19, Sunday evening, Nurse #2 reported off to her and told her Resident #45 had a bruise on her right arm. Nurse #3 stated Nurse #2 informed her the x-ray technician would be coming at 8:00 PM and to wait for the results. Nurse #3 stated at 8:10 pm, the x-ray was completed and the results were called in around 10:50 PM. Nurse #3 reported the result was a fractured right humerus. Nurse #3 stated once she obtained the faxed result she reported it to the Night Shift Charge Nurse (NSCN) and she waited to see what the NSCN was going to do. Nurse #3 stated she believed the NSCN called the DON and the RP. Nurse #3 reported the resident did not have any signs or symptoms of pain, but once she obtained the x-ray results she medicated her with Tylenol because she could not verbalize she had pain and Nurse #3 wanted to make sure she was comfortable. A review of an x-ray of the right arm for Resident #45 taken on 07/14/19 and revealed Resident #45 had an acute fracture to the humeral head and neck with impaction. An interview was conducted with the Restorative Aide (RA) on 07/19/19 at 2:00 PM. The RA reported she had no knowledge of a bruise to her right extremity until she learned of the bruise on Monday, (MONTH) 15, 2019, when she observed the resident in bed and her gown was hanging slightly off her shoulder and she saw the bruise. The RA reported she went to the nurse, but saw that the nurse was preparing to send her to the hospital because of the bruise so she did not report it to the nurse. The RA stated she did not look any closer at the bruise by removing the gown. She stated all she could see was black and blue with some yellow on the shoulder. The RA stated she did not touch the resident. An interview was conducted with the facility physician on 07/18/19 at 4:15 PM. The physician stated when he came into the facility the morning of 07/15/19 and saw the x-ray result for Resident #45, he asked why the resident was still here and to get her to the ER now. The physician stated the staff noticed an injury on the resident, knew to get an x-ray to identify if anything was going on, obtained the result and saw that there was an abnormal result. The physician stated he would have expected the nurse to send the resident to theER on ce she was made aware of the result. The physician stated it was unknown what had happened and when the bruising had actually occurred, but the nurse who first identified the bruising on 07/11/19 should have notified him and he would have had her sent to the ER if he was the physician on call. The physician stated he did not believe the fracture could worsen from 07/14/19 (when the x-ray showed a fracture) until 07/15/19 (when she was sent to the ER). The physician stated, however, no one actually knew when she fractured it or how. An interview was conducted with Nurse #4 on 07/19/19 at 11:55 AM. Nurse #4 stated when she came back on Monday, 07/15/19, the bruise on the resident ' s arm was way worse than 07/11/19 and the x-ray showed there was a fracture. Nurse #4 stated she was sent to the emergency room (ER) that morning. A review of the hospital record from 07/15/19 revealed in the summary of the history and physical, in part, resident presented with right humeral fracture of undetermined age, but probably occurred about 5 - 6 days ago given the size of the bruise which appeared to be old. The x-ray result indicated acute impacted displaced proximal right humerus fracture involving the right humeral head and neck and bones were osteoporotic and demineralized. A review of the hospital discharge summary on 07/19/19 indicated the resident had [MEDICAL CONDITION] humerus approximately one week old. Orthopedics recommended non-surgical management with no need for splint and will use sling to limit right upper extremity movement. An interview was conducted with the SDC (Staff Development Coordinator) Nurse on 07/19/19 at 1:15 PM. The SDC nurse reported that all staff were oriented to the abuse policy and procedure upon hire, annually and as needed. The SDC nurse stated reporting an injury of unknown origin was included in the abuse training. The DON reported her expectation of the nursing staff would have been to assess the bruise once they were made aware of it, document their assessment, complete an incident report and report the concern to the physician, the DON and the RP so the management team could begin the investigation process for the injury of unknown origin. The DON reported the investigation process for the injury of unknown origin was initiated on 07/15/19.

Based on observation, record review, staff and physician interviews the facility failed to evaluate the effectiveness of the facility wound treatment protocol and seek further treatment after the deterioration of a pressure ulcer on the right gluteal fold from a stage II to an unstageable wound and failed to conduct a weekly wound assessment with measurements on an unstageable pressure ulcer to assess for deterioration for 1 of 7 sampled residents with pressure ulcers which resulted in a stage IV pressure ulcer with loss of muscle tissue, the development of a stage II pressure ulcer on the right buttock, and the development of a stage III sacral ulcer. (Resident #50) Findings included: Resident #50 was admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. He did not receive palliative or comfort care measures. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #50 had severely impaired cognition. He was able to make his needs known. He required extensive two person assist with bed mobility and transfers. There were no pressure ulcers on admission. Review of the weekly skin assessment dated [DATE] documented a small area of abraded skin was noted on the left buttocks, apply barrier cream with brief changes. A QA (quality assessment) note dated 06/03/2019 documented; right gluteal fold open area, resident #50 gets up approximately 10:30 AM every day and goes back to bed between 7-8 PM. Resident had lift pad under him in the wheelchair. Resident was care planned to remove the lift pad from underneath him while he is sitting up in the wheelchair. Review of the weekly skin assessment dated [DATE] documented the right gluteal fold with 6.8 cm (centimeter) in length x 8.4 cm in width, stage II with yellow drainage, red base with defined edges. Cleanse with Calcium Alginate and cover with dry dressing, with preventative interventions to include; repositioning, foam mattress, and a foam cushion for wheelchair. A Dietician note dated 6/6/19 documented; a wound assessment indicated resident #50 had a stage II area to the right gluteal fold, his weight on 6/5/19 was 250.5 lbs. (pounds). Resident consumes 100% of meals per intake records and received a regular diet with double portions. Medications included; Vitamin C and Vitamin D. Interventions in place to aid in wound healing. A review of the electronic medical record dated (MONTH) 2019, documented resident #50 received Zinc 220 milligrams for 14 days beginning 5/22/19, and Vitamin C daily beginning 5/22/19 to promote wound healing for 30 days. Review of the weekly skin assessment dated [DATE] documented right gluteal fold with 7.5 cm in length x 8.4 cm in width, stage II with moderate serous exudate (drainage), no tunneling, no undermining, no infection, apply Calcium Alginate and cover with dry dressing daily and weekly assessments. Review of the weekly skin assessment dated [DATE] documented; right gluteal fold with 9cm in length x 10.8 cm in width, unstageable, with no tunneling, undermining or odor, 90% eschar, to apply Calcium alginate dressing daily and weekly assessments. There was no skin assessment that included weekly wound measurements documented for the week of 6/24/19. Review of the skilled nursing notes from 6/24/19 through 7/1/19 revealed no documentation that a weekly wound measurement was conducted. A nursing progress note dated 6/24/19 at 3:36 PM written by Nurse #1 documented; to cleanse the right inferior gluteal fold and upper thigh with NS (normal saline), apply Santyl (a [MEDICATION NAME] agent) and cover with dry dressing daily, every day shift. The resident refused to go back to bed after lunch. He remained up at this time. The hall nurse said she would do the treatment when he went to bed. Spoke to RP (responsible party) about resident #50's wound. He is non-compliant, he was asked to return to bed. He refused. Review of the weekly skin assessment dated [DATE] documented the right gluteal fold with 7.5 cm x 11.4 cm, unstageable, with no tunneling, undermining or odor, 90% eschar. Cleanse with Santyl, cover with dressing. A review of the facility wound protocol updated on 5/22/18 indicated for stage III ulcers, Santyl may be utilized if an area does not respond to other treatments. A physician order [REDACTED]. A physician's orders [REDACTED]. Review of the weekly skin assessment dated [DATE] documented the right gluteal fold with 14 cm x 11.5 cm x 3.8 cm, unstageable, with no tunneling, undermining or odor, 90% eschar. Cleanse with Dakins wet to dry, and weekly assessments. A Dietary supplement review note dated 7/11/19 for Resident #50 documented; residents nutritional needs for weight maintenance, skin integrity, healing, and protein stores was calculated due to areas of breakdown. His intake of meals averaged 83%. His body weight was down 9lbs or 3.4% over one month and has fluctuated over two months with no significant change. Wounds are worse, continue to monitor. A physician's orders [REDACTED]. A review of the weekly skin assessment dated [DATE] documented a newly identified stage III pressure ulcer to the sacrum which measured 5cm x 2.5 cm x 3 cm. Review of the care plan revised on 7/17/19 documented, actual skin integrity impairment; pressure ulcers to sacrum, and right thigh. Goals included; will show positive healing of skin integrity and impairment as evidenced by smaller size, and resolution of eschar. Interventions included; ensure appropriate pressure relieving devices are in place during repositioning, nutritional supplements as ordered, observe for and monitor changes in skin integrity or skin impairment and notify physician as necessary, provide treatment as ordered, monitor for nonhealing or infection. Refer to wound clinic, turn and reposition patient frequently. In an observation on 7/17/19 at 9:40 AM with the wound treatment nurse (Nurse #1), wound care was performed for Resident #50. Three areas, a right gluteal fold stage IV pressure ulcer, a stage II pressure ulcer on the left buttocks, and a stage III pressure ulcer on the sacrum was observed. Each of the three pressure wounds were cleansed with Dakin ' s solution and covered with a bandage. Resident #50 voiced no complaints of pain. In an interview on 7/17/19 at 10:00 am with the wound treatment nurse (Nurse #1), she stated all wounds were assessed and measured weekly, and if the wounds worsened the facility physician or nurse practitioner would be notified. She stated Resident #50 had an appointment to be seen at the wound clinic the following week around (MONTH) 25th. Nurse #1 stated the stage III pressure ulcer to the sacrum was just identified on 7/16/19, and when the wound was measured and identified as a stage III, she began the facility wound protocol which included a wound cleansing solution and covering with a dry dressing. Nurse #1 stated that resident #50 would stay up in his wheelchair by choice all day and the staff would have to make him go back to bed to relieve the pressure on the wounds. She stated he was able to turn and reposition himself while in the bed, he had a pressure reducing cushion in his wheelchair, and they no longer leave the lift pad underneath the resident when he is sitting in the wheelchair. A phone interview was conducted on 7/17/19 at 12:30 PM with the wound clinic to confirm resident #50's appointment on (MONTH) 25th. The clinic confirmed that it takes approximately two weeks to get appointments scheduled due to the volume of patients that come to the clinic. In a follow up interview on 7/17/19 at 12:40 PM with the wound treatment nurse (Nurse#1), she stated she didn't know there was no documentation to show that Resident #50's wounds were not measured for deterioration during the week of (MONTH) 24, 2019. She stated she may have done the measurements but didn't document it, then stated she was not sure. In an interview on 7/17/19 at 12:55 PM with the facility Nurse Practitioner, she stated that the treatment nurses handled the wound care and reported to her or the physician as needed. She indicated she had not assessed Resident #50's pressure wounds on that day and would follow up. A follow up wound treatment observation was conducted on 7/18/19 at 10:05 AM with the wound treatment nurse (Nurse #1) and with the facility physician present. The wounds were measured, the right gluteal fold was 9 cm in length x 13 cm in width x 4 cm depth with loss of muscle tissue, a stage II left buttocks pressure wound measured 2.4 cm x 6.2 cm, with no depth, and the stage III sacrum measured 4.5 cm x 3cm x 4 cm. The physician acknowledged the wounds needed debridement which would be done during the upcoming wound clinic appointment. An interview was conducted with the facility physician on 7/18/19 at 10:20 AM. He stated the wound treatment nurses were to follow the facility wound treatment protocol and notify him when the wounds worsened, or if wounds failed to respond to treatment, and he would change the treatment order or refer the resident to the wound clinic. He stated he trusted that the nurses in the facility were notifying him regarding worsening signs or symptoms of wounds. He acknowledged that the right gluteal wound had declined and stated a referral was made to send the resident to the wound clinic. He indicated that the resident was in the wheelchair during the day and was non-compliant with staying off the wound. In an interview on 7/20/19 at 1:12 PM with the second facility wound treatment nurse (Nurse #2) she confirmed that all wounds were to be assessed and measured weekly in order to notify the physician if the wounds had worsened. Nurse #2 stated they (Nurse #1 and Nurse #2) needed to be more proactive with wound care. In an interview conducted on 7/20/19 at 1:38 PM with the Director of Nursing (DON), she stated weekly weight and wound meetings were conducted every Friday which included the DON, Quality Improvement nurse, the wound nurse, the MDS nurse, and a member of the therapy department. She stated when the nurses notify the physician, they usually receive phone orders for treatments, or referrals for the wound clinic She stated the wound nurses are expected to monitor wounds through weekly wound assessments with measurements and are expected to notify the physician of new or worsening wounds.