Every finding on record at Pelican Health at Charlotte

Based on record review and resident and staff interviews, the facility failed to treat Resident #1 with dignity and respect when staff engaged in a verbal argument with the resident utilizing profanity and yelling at the resident. The resident reported she felt angry with the way staff treated her. This deficient practice affected 1 of 1 resident reviewed for dignity (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE].An annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact and was not coded with behaviors.Resident #1's active care plan, last revised on 1/19/2026, had a focus area regarding Resident #1 having mood symptoms and poor coping strategies due to past trauma including emotional and physical abuse. The goals included Resident #1 maintaining the ability to seek out social contact and not experiencing any acute anxiety or depressed mood through the review period. The interventions included encouraging continued family involvement; encouraging Resident #1 to participate in conversation with staff and other residents daily; helping Resident #1 to identify stressors and remove the stressors when possible; providing Resident #1 with as many opportunities as possible to give Resident #1 control over Resident #1's environment and care delivery; and providing opportunities for Resident #1 to communicate feelings. An Investigation Report dated 4/8/2026 indicated that Resident #1 reported on 4/2/2026 at approximately 6:30 PM that Nurse Aide (NA) #1 called her names and cursed her using foul language. Resident #1 stated that NA #2 yelled down the hallway, [f***] your Daddy when Resident #1 stated she was calling her father. Resident #1 stated NA #1 called her a [b****] and said repeatedly [f***] you. NA #1 and NA #2 both said, that was why she [Resident #1] was slapped by another NA, referring to an alleged incident on 3/6/2026. Both NA #1 and NA #2 were suspended pending the investigation. Interviews with staff witnesses indicated that Resident #1, NA #1 and NA #2 were cursing back and forth down the hallway. Staff witnesses indicated NA #1 and NA #2 discussed Resident #1 where other residents could hear their conversation. NA #1 and NA #2 were terminated from employment. The Investigation Report was signed by the former Administrator.The Local Law Enforcement Records Department was contacted on 4/27/2026 at 11:59 AM but the officer did not file a report for the incident. Voice mails were left for the responding officer on 4/27/2026 at 12:15 PM and 4/28/2026 at 3:10 PM. An email was sent to the responding officer on 4/29/2026 at 10:21 AM. Attempts to contact the responding officer were unsuccessful.An interview with Resident #1 was conducted on 4/27/2026 at 2:30 PM. Resident #1 stated on 4/2/2026 during the evening shift, NA #1 arrived to perform her (Resident #1's) shower. Resident #1 reported she was telling NA #1 her shower preferences and NA #1 became annoyed. Resident #1 told NA #1 she wanted someone else to assist her with her shower. Resident #1 stated NA #1 started calling her a b**** and saying f*** you. Resident #1 reported she called NA #1 names and cursed as well but could not recall exactly what she said but remembered she called NA #1 nasty, a b**** and told NA #1 to get the f*** out of my room. Resident #1 stated NA #2 came down the hallway and attempted to get NA #1 to leave her (Resident #1's) room. Resident #1 reported she (Resident #1) said she was going to call her father about how she was being treated and NA #2 yelled down the hallway, f*** your daddy. Resident #1 stated Nurse #1 and the Restorative Aide also arrived in her room within approximately 3 to 4 minutes as they had heard the yelling and tried to deescalate the situation. NA #1 and NA #2 left the room but then NA #1 came back to the room within a few minutes and started yelling and cursing again at her (Resident #1) saying I'm sick and tired of this b****', that b**** is always finding a reason to cuss us out and nobody did anything to you. Resident #1 stated NA #1 referred to an incident on 3/6/2026 when Resident #1 alleged another NA had slapped her. (The 3/6/2026 incident was investigated but did not result in a deficiency). Resident #1 indicated she wished the NAs would stop talking about the incident on 3/6/2026 as Resident #1 felt the NAs were taunting her. Resident #1 went on to say that Nurse #1 and the Restorative Aide sent NA #1 out of the room a second time and the situation calmed down. Resident #1 expressed she was angry at the way NA #1 and NA #2 treated her and felt it was very disrespectful. Resident #1 stated she had not seen either NA #1 or NA #2 working in the facility since that night.A written statement dated 4/6/2026 from NA #1 indicated NA #1 believed Resident #1 made up stories when she didn't get her way. NA #1 indicated she was preparing to shower Resident #1 when Resident #1 asked where her purse was and became agitated. NA #1 reported Resident #1 stated she wanted someone else to give her a shower and called NA #1 a name and said NA #1 was nasty. Resident #1 was screaming and cursing so NA #1 stated she left Resident #1's room to answer other call lights. NA #1 indicated she put Resident #1 to bed later that night. NA #1 stated she did not ever curse at Resident #1.A telephone interview with NA #1 was attempted on 4/28/2026 at 10:24 AM. NA #1 asked if speaking with the surveyor would assist her in getting her job back at the facility. When told, No, NA #1 stated she declined to answer any questions and disconnected the call.A telephone interview with NA #2 was conducted on 4/27/2026 at 1:57 PM. NA #2 stated on 4/2/2026 Resident #1 and NA #1 began to loudly argue and curse at each other which NA #2 could clearly hear where she was sitting at the nurse's station. NA #2 went to the room to separate Resident #1 and NA #1. NA #1 walked out of Resident #1's room back to the nurse's station and stated to NA #2 that this b**** get on my nerve and this b**** don't want me to give her a shower. NA # 2 stated NA #1 told her Resident #1 requested another staff member provide her with a shower. NA #2 stated NA #1 was being verbally aggressive toward Resident #1 and calling her a b****. NA #2 denied the allegation that she was talking about Resident #1 to NA #1 in an inappropriate manner in front of other residents. NA #2 stated she only responded to Resident #1 when Resident #1 was calling for the nurse by telling Resident #1 the nurse was off the hall at that moment. NA #2 stated Nurse #1 and the Restorative Aide came to the resident's room to deescalate the situation. NA #2 indicated at that time, NA #1 went back to the room and resumed yelling and cursing at Resident #1 and called her a b**** and said she was sick and tired of her. NA #2 went again to ask NA #1 to come back to the nurse's station and stop the interaction which NA #1 agreed to do.A telephone interview with Nurse #1 was conducted on 4/28/2026 at 9:38 AM. Nurse #1 stated that she was on break outside on 4/2/2026 and heard yelling back and forth between NA #1 and Resident #1. Nurse #1 reported she came inside and headed to Resident #1's room to deescalate the argument. Nurse #1 indicated that the Restorative Aide was also going to the room and they arrived together to send NA #1 out of the room. Nurse #1 reported NA #2 came to the room and pulled NA #1 out of the room. Nurse #1 went on to say that NA #1 returned to the room a few minutes later and resumed the argument with Resident #1. Nurse #1 stated she and the Restorative Aide sent NA #1 out of the room again. Nurse #1 indicated she closed the door to Resident #1's room to stop the argument and proceeded to talk with Resident #1 to calm her down as Resident #1 had been yelling back at NA #1 and NA #2 and was very upset/angry about how she felt she had been treated by NA #1 and NA #2. Resident #1 expressed to Nurse #1 that she should have been able to have someone else provide her shower without issue when she decided she did not want to work with NA #1. Nurse #1 reported she advised Resident #1 that she was working on the morning of 4/3/2026 and she would assist her with a shower at that time. Nurse #1 stated Resident #1 was agreeable with that plan and was assigned a different NA for the remainder of the shift.An interview with the Restorative Aide was conducted on 4/28/2026 at 12:04 PM. The Restorative Aide reported that she was walking with a resident on 4/2/2026 when she heard loud yelling and cursing. The Restorative Aide stated that she asked the resident she was walking to sit down to rest while she went to the hallway to investigate the disturbance. The Restorative Aide indicated Nurse #1 was also headed toward Resident #1's room and they both arrived at the same time. The Restorative Aide observed NA #1 and Resident #1 yelling and cursing at one another. The Restorative Aide asked NA #1 to stop arguing with Resident #1 and leave the room. The Restorative Aide indicated NA #2 had come to the room and took NA #1 to the nurse's station. The Restorative Aide reported that she and Nurse #1 were trying to calm Resident #1 down as Resident #1 was upset about how NA #1 and NA #2 had treated her when NA #1 returned to the room and started yelling and cursing at Resident #1 again, calling her a b****. NA #1 was sent out of the room a second time. The Restorative Aide indicated Nurse #1 had control of the situation and she needed to return to the resident she was walking. As she passed the nurse's station, the Restorative Aide indicated she heard both NA #1 and NA #2 talking about Resident #1 being a b**** and being a difficult resident. NA #1 and NA #2 were talking where other residents could hear their conversation.A telephone interview with the Former Director of Nursing (DON) was conducted on 4/28/2026 at 2:51 PM. The Former DON indicated the Former Administrator handled most of the investigation regarding the incident on 4/2/2026 between Resident #1, NA #1 and NA #2 but she was familiar with the incident. The Former DON expressed that NA #1 and NA #2 should not have yelled and cursed at the resident. The Former DON reported NA #1 should have stopped care and left Resident #1's room to end the interaction and reported to the nurse what had occurred. The Former DON indicated NA #1 and NA #2 were both terminated.A telephone interview was conducted on 4/28/2026 at 10:22 AM with the Former Administrator. The Former Administrator indicated that she investigated the incident on 4/2/2026 between Resident #1, NA #1 and NA #2. The former Administrator stated NA #1 should have stopped care when Resident #1 became agitated and not engaged in an argument. Based on the investigation and staff interviews, the former Administrator stated the allegation of verbal abuse from NA #1 and NA #2 toward Resident #1 was substantiated. The former Administrator reported NA #1 and NA #2 were terminated.The facility provided a corrective action plan that was not accepted by the State Agency.

Based on observations, record review and interviews with the resident, staff, Responsible Party (RP), Wound Nurse Practitioner, and Medical Director, failed to recognize the severity of the injury, the extent of bleeding, and the resident's increased risk for bleeding due to her daily anticoagulant medication (helps prevent blood from forming clots). On 01/20/26 Nurse Aide #1 pulled Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. Resident #25 reported a pain scale of 10 on a scale of 1 to 10 (0 being no pain and 10 being the worst possible pain. Nurse #1 observed a 1-inch laceration to the residents left lower extremity, applied pressure for 5 minutes to stop the bleeding and applied a pressure dressing. Despite this known risk factor and the presence of active bleeding Emergency Medical Services (EMS) were not initiated by facility staff. The resident's RP arrived at the facility after being called by the resident who reported pain and the RP observed blood on the outside of the pressure dressing and called EMS. Resident #25 was subsequently transported to the hospital emergency department (ED) for evaluation and treatment. The ED physician noted Resident #25 had a large soft tissue hematoma (a localized collection of clotted or partially clotted blood, trapped in tissue caused by a ruptured blood vessel from an injury) measuring 16.2 centimeters (6.3 inches) to her left lower extremity. Laboratory studies demonstrated a decline in hemoglobin from 11.1 to 7.3 (normal range 11.5 to 15) over the first two days of hospitalization, consistent with acute blood loss anemia, necessitating transfusion of packed red blood cells. Subsequently, the skin overlying the hematoma became necrotic (dead or dying tissue), requiring operative evacuation (surgically removing a collection of blood from inside of the body) of the hematoma and surgical debridement of the necrotic tissue, with placement of a wound vacuum-assisted closure (VAC) device. The facility's failure to assess the severity of the injury, consider the impact of anticoagulant therapy, and initiate emergency medical intervention placed Resident #25 at risk for serious complications related to acute blood loss. Resident #25 was discharged back to the nursing facility on 02/05/26 with orders for oxycodone 5 milligrams (mg) one tablet every 6 hours as needed for severe pain and wound care orders. This deficient practice affected 1 of 3 residents reviewed for quality of care (Resident #25).Immediate Jeopardy began on 01/20/26 when Nurse #1 failed to recognize the severity of the injury and Resident #25's increase risk of bleeding due to her use of an anticoagulant. Immediate Jeopardy was removed on 02/25/26 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure the monitoring systems put into place are effective and education is completed. The findings included:Resident #25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, fracture of the right tibia, hypertension, muscle weakness, osteoporosis, history of a deep vein thrombosis (DVT- a medical condition in which a blood clot (thrombus) forms in one or more of the deep veins of the body), and physical debility. A physician's order dated 11/02/25 revealed an order for Eliquis 5 milligrams, one tablet by mouth twice a day, for the prevention of deep vein thrombosis (DVT), a medical condition in which a blood clot (thrombus) forms in one or more of the deep veins of the body. Eliquis is a blood thinning medication that reduces blood clotting. Manufacturer's guidelines for the medication Eliquis 05/2025 indicated the medication can cause serious side effects including bleeding which could be serious and may lead to death. The guidelines further stated to call your healthcare provider with any severe bleeding. A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 was cognitively intact and dependent upon two staff members for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. Resident #25 was coded for receiving an anticoagulant during the assessment period.A care plan revised on 01/19/26 revealed a focus area related to anticoagulant usage. Resident #25 was noted to be at risk for bleeding and bruising related to use of an anticoagulant. The goal was for the resident to have no complications related to anticoagulant usage through the next review date. Interventions included observing for any abnormal bleeding or bruising. On 02/23/26 at 12:54 PM, an interview and observation were conducted with Nurse Aide (NA) #1. During the interview, she stated she was responsible for Resident #25 on 01/20/26 during the 7:00 AM to 3:00 PM shift. NA #1 explained she was assisting Resident #25 with a bed bath when the resident requested to get up to her wheelchair. She explained that after placing Resident #25 in her wheelchair, with both feet positioned on pillows on top of the wheelchair leg rests, she turned the wheelchair and pulled it backward along the side of the bed. While NA #1 was pulling Resident #25's wheelchair backward along the side of the bed and the resident's left lower leg hit the corner of the footboard. She stated the bed was in a low position and Resident #25 began to yell out in pain. NA #1 indicated she realized Resident #25's left leg had hit the corner of the footboard and had begun to bleed. NA #1 re-enacted this action to the surveyor by pulling the resident's wheelchair backward along the side of the bed. NA #1 explained obtained paper towels from the sink and placed them on the resident's leg in an attempt to stop the bleeding. She stated, It was bleeding bad. NA #1 the paper towels were saturated, so she then placed a regular bath towel over the leg and yelled for Nurse #1, who entered the room, applied pressure, and placed a dressing on the wound. She stated after Nurse #1 placed the dressing on the resident's leg the resident remained in her wheelchair with her legs elevated. NA #1 did not go back into the room until EMS arrived and she assisted the resident onto the stretcher. NA #1 stated she did not see blood on the dressing when she assisted with the transfer of Resident #25. A Situation, Background, Assessment, Recommendation assessment dated [DATE] at 11:30 AM, written by Nurse #1, revealed Resident #25 had received a skin tear to her left lower leg. A dressing was applied, and the Wound Nurse, Nurse Practitioner, or Medical Director were to evaluate. Recommendations included that Resident #25 be sent to the Emergency Department. New orders documented included: Patient to Emergency Department per her request related to skin tear to left leg. Vital signs included the following: blood pressure 132/77 (normal 120/80), pulse 97 (normal range 60-90), respiration 22 (normal range 12/20), temperature 98.2 (normal range 97-99.0), pulse oximetry 97% (normal range >92%) on room air. A pain scale was not included in the documentation.A late entry nursing progress note dated 01/20/26 at 3:00 PM, written by Nurse #1, revealed the note was a late entry for 11:30 AM. Nurse #1 was informed Resident #25's leg was bumped during transfer. Resident #25 was assessed and noted to have a one-inch slit in the middle of her left leg. The resident's anticoagulant was held at that time. Increased bleeding was noted related to Resident #25's anticoagulant therapy. Pressure was applied to the injury site for a duration of five minutes, and then a pressure dressing was applied.A late entry nursing progress note dated 01/20/26 at 3:29 PM, written by Nurse #1, revealed Resident #25's Responsible Party (RP) was present in the facility. Upon the RP's arrival, Resident #25 began to scream and yell, I'm hurting. Nurse #1 left the resident's room to check physician orders and obtain medication. Upon returning, the RP stated, I called 911 services for Resident #25. Resident #25 stated, I want to go to the hospital. Bleeding was noted to have stopped. Emergency Medical Services (EMS) arrived at the facility at 1:35 PM. A mechanical lift was used with two staff members to transfer Resident #25 onto the stretcher for EMS.On 02/23/26 at 1:45 PM, an interview was conducted with Nurse #1. She stated she was an agency nurse working in the facility for the first time 01/20/26. She recalled NA #1 calling for assistance on 01/20/26 around 11:30 AM and entering the room to find Resident #25's left leg bleeding with a one-inch laceration located on her left lower leg. Due to the increased bleeding that saturated a towel NA #1 applied, she applied pressure for approximately 5 minutes to stop the bleeding, applied a pressure dressing, and notified the Wound Nurse and Nurse Practitioner #1. She stated, I didn't think she needed to go to the hospital; I just notified Nurse Practitioner #1. She explained she did not recall if she administered pain medication to Resident #25 but if she put it into her written note from that date then she would have given pain medication. She didn't know why it wasn't on the MAR. Nurse #1 stated because she was an agency nurse it was difficult to remember the situation and all of the specific details and to refer to her notes of what occurred on 01/20/26.On 02/23/26 at 1:10 PM, an interview was conducted with Resident #25. She confirmed NA #1's account of events and stated NA #1 was slowly pulling her wheelchair backward when her left leg hit the footboard because she got too close to the footboard of the bed. She stated her legs were elevated on pillows and positioned outward. She stated immediately when her leg hit the footboard she screamed in pain because it hurt and her leg began to bleed. NA #1 tried to assist her by placing towels onto her left lower leg and got the Nurse (Nurse #1) who entered the room and applied a dressing. She stated both staff members left the room, and she called her Responsible Party who came to the facility, and she told him she felt like she needed to go to the hospital. Resident #25 explained her Responsible Party then called 911. She stated it had been several weeks since the injury and she was still experiencing a lot of pain. Resident #25 described the pain as like no other she had experienced stating, it's on and off, sharp pain. She explained she had received daily wound care and felt like her injury on her lower leg was improving.On 02/23/26 at 3:14 PM, an interview was conducted with NA #4. She stated she worked both first and second shift on 01/20/26. NA #4 assisted with transferring Resident #25 onto the EMS stretcher. She reported Resident #25 was yelling in pain and that her legs remained straight and did not bend.On 02/23/26 at 2:10 PM, an interview was conducted with Resident #25's Responsible Party. He stated Resident #25 called him on 01/20/26 and reported a Nurse Aide had hit her leg on the footboard while the NA was backing up her wheelchair beside the bed. During the call Resident #25 did not complain of pain but asked him to come. Upon arrival, he observed red blood on a white dressing on her left lower leg and stated, The facility wasn't sending her, so I called 911. The interview revealed there was no blood noted in the room when he arrived other than on the resident's dressing and Resident #25 was complaining of pain. EMS arrived shortly after he called and transported her to the hospital.Emergency Medical Services (EMS) records dated 01/20/26 revealed EMS was called at 1:27 PM arrived at Resident #25's bedside at 1:42 PM. The nurse reported to EMS that Resident #25 was transferred from her, wheelchair to her bed when her leg was hit on a rounded corner, causing a 1 to 2-inch laceration to her left lower leg. Nurse #1 stated to EMS she had controlled the bleeding with gauze and tape and had administered pain medication. The resident's RP arrived approximately 30 minutes after the incident and requested Resident #25 be transported to the hospital for further evaluation. Resident #25 was noted to be in emotional distress due to pain with bilateral lower extremity swelling. Resident #25's left lower leg was noted to have bruising and swelling where she was injured but no obvious deformity. EMS did not remove Resident #25's dressing to her left lower extremity. of Vital signs revealed an elevated blood pressure of 182/110 (normal 120/80) and an elevated heart rate of 123 (normal 60-90). Resident #25 continued to complain of pain to her left lower extremity while en route to the hospital with a pain level of 10, on a 0-10 scale (0 being no pain, 10 being the worst pain). She was administered pain medication (acetaminophen) along with a diuretic (torsemide), and muscle relaxant (methocarbamol). Hospital records dated 01/20/26 revealed Resident #25 presented to the Emergency Department (ED) from the nursing facility for evaluation of a hematoma and laceration to the left lower leg. She reported moderate to severe pain. The ED note indicated difficulty controlling bleeding at the nursing facility, and due to swelling, she was referred for further evaluation. Assessment of the left lower extremity revealed a 2 cm skin tear with a small amount of drainage coming from the area. She also had an associated large hematoma measuring approximately 4 x7 inches distally a small distance from the laceration. A picture 01/20/26 was taken while Resident #25 was in the Emergency Department. The picture shows Resident #25 lying in bed with her left leg elevated on a pillow. Blood was observed under her left knee pooled onto the bed and also on the pillow under the residents left leg. Ice was placed to assist with pain and swelling along with 2mg of morphine (a strong opioid pain medication use to treat moderate to severe pain) administered intravenously. Blood is also visualized on the residents left surrounding the laceration. Upon admission on [DATE], she was noted to have a large superficial soft tissue hematoma measuring 16.2 cm (6.38 inches). Laboratory studies demonstrated a decline in hemoglobin from 11.1 to 7.3 over the first two days of hospitalization, consistent with acute blood loss anemia, necessitating transfusion of packed red blood cells. Subsequently, the skin overlying the hematoma became necrotic, requiring operative evacuation of the hematoma, surgical debridement of necrotic tissue, and placement of a wound vacuum-assisted closure (VAC) device. Resident #25 was discharged back to the nursing facility on 02/05/26 with orders for oxycodone 5 milligrams (mg) one tablet every 6 hours as needed for severe pain and acetaminophen 650 mg every 8 hours as needed for pain. Wound care discharge instructions included daily dressing changes to the left lower extremity with petroleum gauze an abdominal pad and gauze wrap.A nursing note dated 02/05/26 at 2:17 PM revealed Resident #25 had arrived back at the facility at 1:00 PM. The resident was assessed by the nurse, with a wound noted to her left lower leg. Resident #25 denied any pain or discomfort at that time.A physician progress note written by the Medical Director on 02/06/26 revealed Resident #25 was evaluated on this date for a new admission following a recent hospitalization. The note revealed she was admitted into the hospital on [DATE] through 02/05/26 for a left leg hematoma and laceration. Resident #25 had sustained the left lower leg injury during a transfer at the nursing facility resulting in a laceration and large hematoma measuring 16.2 cm. Orders included to continue daily dressing changes with petroleum gauze, abdominal pad, and a gauze wrap per discharge wound care instructions.A Wound Care NP note dated 02/10/26 revealed wound care was reestablished for Resident #25 due to a new hematoma to the left lateral lower leg. Resident #25 was hospitalized from [DATE] through 02/05/26 for a large laceration and hematoma to the left leg. Surgical evacuation of the hematoma was completed on 01/30/26 due to necrosis and a wound VAC was placed. The Wound Vac was removed at discharge from the hospital. During the assessment Resident #25 reported that pain in the left leg was worse with dressing changes and improved with rest and pain medication. The area to Resident #25's left lower leg measured 15.5 cm in length, 8.8 cm in width and 0.5 cm in depth with an overall 136.4 cm surface area. Orders included cleanse area with normal saline, pat dry, apply Santyl to necrotic areas of the wound, followed by 1/4 strength Dakin's moistened gauze fluffed and filled into the wound bed. Apply an abdominal pad and kerlix. Change the wound daily and as needed.A Wound Care NP note dated 02/17/26 revealed the hematoma to Resident #25's left lower extremity was improving. She did report pain with dressing changes, but the pain improved with rest. The area to Resident #25's left lower leg measured 15.2 cm in length, 8.5 cm in width and 0.4 cm in depth with an overall 129.2 cm surface area. Orders for the dressing change included to cleanse with wound cleanser, pat dry, apply xeroform, cover with an abdominal pad and kerlix. The dressing was changed daily and as needed.Review of the Medication Administration Record dated February 2026 revealed Resident #25 received an order for oxycodone HCL (a strong prescription opioid pain reliever used for moderate to severe pain) oral tablet 5 mg, give one tablet by mouth every 6 hours as needed for pain, initiated on 02/05/26 and discontinued on 02/23/26. An order for oxycodone HCL oral tablet 5 mg, give one tablet by mouth every day shift (give with AM wound care to left lower extremity) was initiated on 02/24/26. An order for acetaminophen 8-hour tablet extended release 650mg by mouth every 8 hours as needed for pain initiated on 02/05/26. A 0-10 pain scale was documented on the MAR with 0 being no pain and 10 being the worst pain experienced. Resident #25 was documented as received acetaminophen 650mg for having a level 4 on 2/7, level 2 on 2/10, level 8 on 2/14, level 8 on 2/16, level 1 on 2/18, level 8 on 2/20, level 8 on 2/21, level 5 on 2/22 and level 8 on 2/23. Resident #25 received oxycodone 5 mg on 13 of the 17 days reviewed. Resident #25 received oxycodone 5mg on 2/6 at 10:57 AM (pain level of a 4) and at 6:59 PM (pain level of a 5). On 2/7 at 8:05 PM for a pain level of 4, on 2/8 at 6:16 PM for a pain level of 7, on 2/10 at 9:48 AM for a pain level of 4 and again at 8:50 PM for a pain level of 10. On 2/12 at 10:24 AM for a pain level of 5, and at 4:32 for a pain level of 6. On 12/13 at 10:45 AM for a pain level of 5, On 2/14 at 12:43 PM for a pain level of 7, on 2/15 at 11:17 PM for a pain level of 10. She received oxycodone 5mg for a pain level of 6 on 2/16 at 3:52 PM, on 2/17 at 5:11 AM for a pain level of 7 and at 11:13 for a pain level of 8, at 4:44 PM for a pain level of 3. Also, on 2/19 at 5:23 AM for a pain level of 0, and at 4:37 PM for a pain level of 5. She received an additional dose on 2/20 at 1:23 AM for a pain level of 6.On 02/24/26 at 1:30 PM an interview was conducted with Nurse Practitioner #1. During the interview she stated she was not in the facility on 01/20/26 and by the time she was notified of the situation to give orders to hold the residents anticoagulant Resident #25 was already at the hospital per Family Member #1's request. Nurse Practitioner #1 explained she did not know how the injury to Resident #25's leg had occurred.On 02/24/26 at 8:45 AM, a telephone interview was conducted with the Medical Director. He stated Resident #25 was prescribed a high dose of an anticoagulant (Eliquis), which contributed to the blood loss following the incident. He explained anticoagulation increased her risk of bleeding. He stated he was not aware a Nurse Aide had struck Resident #25's leg on the footboard and had only been told about the injury, not how it occurred. He stated he would have sent her to the hospital on [DATE] due to her increased bleeding risk however, it sounded like she was sent out anyway due to a Responsible Party request for her to be evaluated so the outcome would have been the same. On 02/25/26 at 11:50 AM, a follow-up in person interview was conducted with the Medical Director. He stated the facility could perform in-house testing (such as x-rays) and assess whether hospital transfer was necessary. He explained he could have, put in a stitch if necessary, due to the laceration and increased bleeding. He stated, Most patients do not need to be sent out initially unless there is a red flag, and noted decisions vary on a case-by-case basis. A red flag would have been any obvious change in her medical status such as blood pressure, increased bleeding and pain. On 02/24/26 at 9:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that, from her recollection, NA #1 had transferred Resident #25 to her wheelchair on 01/20/26 and the resident's leg struck either the wheelchair or bed. She was notified of the incident by Nurse #1 after it occurred. The DON stated Nurse #1 had called Nurse Practitioner #1 and obtained orders to hold the anticoagulant. The DON explained it was her understanding Resident #25 did not need to go to the hospital and the DON wanted orders to hold the next dose of anticoagulant for that night. She stated, everything just happened so quickly. The interview revealed the DON was in the facility on 01/20/26 when the incident occurred however she did not go into the room nor did she look at the wound to Resident #25's left lower extremity. The DON stated, based on what had occurred with Resident #25's leg hitting the footboard, she wouldn't have sent her to the hospital immediately. The DON stated it was her understanding Nurse #1 had the bleeding controlled however, the Responsible Party insisted she be sent out. The DON stated the main focus when she learned of the incident was getting an order to hold the resident's anticoagulant dose for that evening. However, by the time Nurse #1 notified Nurse Practitioner #1 and received orders to hold the medication and to monitor the residents' left leg she realized Resident #25 was already sent to the hospital per the Responsible Parties request. On 02/23/26 at 2:27 PM, an interview was conducted with the Administrator. She stated she was notified after staff had addressed the incident on 01/20/26. She was informed that NA #1 had bumped Resident #25's leg on the footboard. She stated the Nurse Practitioner was notified and a pressure dressing was applied.On 02/24/26 at 10:17 AM, an interview was conducted with the Wound Care Nurse Practitioner. She stated she had evaluated Resident #25 weekly after the resident's discharge from the hospital on [DATE]. She confirmed Resident #25 sustained a hematoma requiring surgical intervention at the hospital. She explained large hematomas can result in pooled blood, which may become necrotic. After reviewing hospital records, she stated the hospital monitored the area for several days before surgically evacuating the hematoma, debriding necrotic tissue, and applying a wound VAC. Once Resident #25 returned to the facility she had received daily wound care with weekly evaluations. The Wound Care Nurse Practitioner stated the wound was improving; however, it would be difficult to fully heal due to the surface area. She stated she was considering an allograft (a type of tissue taken from a donor to replace damaged tissue) to cover the area to the residents left lower leg since it remained an open area and probability of skin healing was low.The Administrator was notified of the immediate jeopardy on 02/24/25 at 2:00 PM.The facility provided the following credible allegation of immediate jeopardy removal.F684 Credible Allegation: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Resident #25 (on anticoagulant therapy) suffered a serious adverse injury following the incident when the resident sustained a significant skin tear resulting in significant bleeding and hematoma to left lower leg on 1/20/26. While Nurse Aide (NA) 1 was maneuvering resident's wheelchair, NA #1 bumped residents' left leg on the foot board of the bed. NA #1 immediately applied pressure to the laceration on left lower leg and notified Nurse #1 of the incident. Nurse #1 assessed wound, applied pressure dressing and notified Nurse Practitioner (NP) #1. NP #1 gave order for anticoagulant to be held and to monitor skin tear. Nurse #1 reported to NP #1 that resident received a skin tear to left lower leg on 01/20/26. Nurse #1 did not recognize the severity of the injury and the need to transfer Resident #25 to a higher level of care. NP #1 was notified on 1/20/26 by Nurse #1 of the skin tear Resident #25 obtained. Resident #25 notified her own Responsible Party (RP) via phone that she received an injury to her lower leg on 01/20/26. Responsible party arrived at facility and discussed with nurse prior to resident going out via Emergency Medical Services (EMS). Resident #25 was sent to the Emergency Department and admitted on [DATE]. Resident #25 was admitted to the hospital from [DATE]-[DATE]. Resident #25's RP notified EMS of the need for transfer to the hospital. Nurse #1 notified NP #1 that resident was transferred to ED at the request of RP on 01/20/26. Other residents on anticoagulants were at risk of serious adverse outcomes (e.g., uncontrolled bleeding, significant bruising) due to the identified practice gaps. On 2/24/26 the Assistant Director of Nursing (ADON) completed an audit of the electronic health record order listing report to identify all residents receiving anticoagulant therapy. 21 residents were noted to receive anticoagulant therapy. This is an ongoing audit that is updated with each admission. The Director of Nursing (DON) completed an audit of all incident and accident reports for the past 30 days on 2/24/26 to ensure that any incident that resulted in an injury received timely and appropriate treatment. No concerns were identified. A facility wide skin assessment of all residents was completed by Licensed Nurses on 02/24/2026 for all residents receiving anticoagulant therapy to ensure no other residents exhibited excessive bruising or bleeding associated with anticoagulant use. Results of the skin assessments found no additional residents affected by this deficient practice. Skin assessments are maintained in the residents electronic health care record. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: A root cause Analysis was completed on 2/24/26 by the facility Administrator and DON. It was determined that the cause of the deficient practice was the lack of recognition by Nurse #1 to identify the need for Resident #1 to be transferred to ED for a higher level of treatment. Nurse #1 was an agency nurse that did not follow the policy on anticoagulants, or significant change in conditions, which includes monitoring individuals on anticoagulation therapy who show signs of excessive bruising and bleeding to discuss the situation with the physician. An ad hoc QAPI was held on 2/24/26 with facility Administrator, DON, ADON, Medical Director, and Nurse Managers to review the deficient practice plan of correction.On 2/24/2026, the Administrator reviewed the facilities policy and clinical protocol for anticoagulation and change in condition with no changes warranted. On 2/24/26 the Director of Nursing began education for all licensed nurses, including agency nurses, on the recognition and assessment of abnormal bruising and bleeding (including excessive, uncontrolled bleeding) for residents receiving anticoagulant therapy. Education consisted of utilizing the e-interact tools (a specialized clinical workflow tool to assist facilities in identifying, assessing, and managing resident conditions) to identify residents that may need a higher level of treatment, notifying the Medical Director (MD) or Nurse Practitioner (NP) for residents that receive anticoagulant therapy that have sustained an injury, and to seek higher level of treatment for any resident on anticoagulant therapy that has continued bleeding after 15 minutes of applying pressure with a pressure dressing. Education was provided in person and via electronic education system. After 2/24/26 newly hired nursing staff including agency nurses will receive this education during the orientation process by the DON or designee also via electronic education at onboarding. The DON/ADON will be responsible for tracking and maintaining education record to ensure that staff receive this education prior to start of their next shift. The DON was made aware of this responsibility by the Administrator on 2/24/26.Education began with all nurse aids on 2/24/26 by the DON on recognizing changes in resident conditions, including excessive bleeding. Education included utilization of the Stop and Watch Tool, an early warning tool that prompts Nurse Aids to alert nursing staff to a change in a resident's condition. Education included completion of the tool and providing it to the Licensed Nurse immediately. All newly hired nursing staff, including agency, will be educated on this process in orientation by the DON or designee. The DON was made aware by the Administrator of this responsibility on 2/24/26. The Administrator is responsible for the execution of this plan of Credible Allegation. Date of IJ removal: 2/25/26The facility's credible allegation of immediate jeopardy removal was validated on 3/02/26. An interview conducted with the Assistant Director of Nursing (ADON) indicated she completed full body skin assessments for all residents receiving anticoagulant medications on 2/24/26 and no concerns were identified. A review of the skin assessments revealed they were completed on 2/24/26 for all residents receiving anticoagulant medications and no abnormal bruising or new skin concerns were identified. Interviews conducted with licensed nurses revealed they received education on the importance of completing a thorough assessment for residents receiving anticoagulant medication that sustained an injury, identifying the need for a higher level of treatment when there was uncontrolled bleeding, notifying the Medical Director or NP of changes in condition and reporting the full extent of any resident injury. The facility's immediate jeopardy removal date of 2/25/26 was validated on 3/02/26.

Based on observations, record review, and interviews with the resident, staff, Responsible Party, Wound Nurse Practitioner, and Medical Director, the facility failed to provide care in a safe manner and ensure a resident's environment remained free of an accident hazard for a dependent resident on Eliquis (an anticoagulant medication that prevents blood from clotting). On 01/20/26 Nurse Aide (NA) #1 transferred Resident #25 using a mechanical lift from the bed to the Resident's wheelchair. Nurse Aide #1 proceeded to pull Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. Resident #25 complained of a pain, on a scale of 10 with 10 being the worst possible pain. She sustained a 1-inch laceration to the leg. Resident #25 was transported to the hospital on [DATE]. Upon evaluation, she was noted to have a large superficial soft tissue hematoma (a localized collection of clotted or partially clotted blood, trapped in tissue caused by a ruptured blood vessel from an injury) measuring 16.2 centimeters (6.3 inches) to the left lower extremity. Hospital laboratory studies demonstrated a decline in hemoglobin from 11.1 to 7.3 (normal range 11.5 to 15.1) over the first two days of hospitalization, consistent with acute blood loss anemia, necessitating transfusion of packed red blood cells. Subsequently, the skin overlying the hematoma became necrotic (dead or dying tissue), requiring operative evacuation (surgically removing a collection of blood from inside of the body) of the hematoma and surgical debridement of the necrotic tissue, with placement of a wound vacuum-assisted closure (VAC) device. Resident #25 was discharged back to the facility on [DATE]. The facility staff also allowed a resident to use a grab bar that was not secure resulting in a fall in the shower room (Resident #20), the facility failed to follow their smoking policy and allowed residents to keep their smoking materials on their person and in their rooms rather than locked up at the nurses' station (Resident #8, Resident #18 and Resident #65). The deficient practice affected 5 of 8 residents reviewed for supervision to prevent accidents (Resident #25). Immediate Jeopardy began on 01/20/26 when Nurse Aide #1 hit Resident #25's outer lower left leg against a damaged footboard. Immediate Jeopardy was removed on 02/25/26 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the monitoring systems put into place are effective and education is completed.Example 2, 3, 4, 5 are being cited a lower scope and severity of an E. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, fracture of the right tibia, hypertension, muscle weakness, osteoporosis, history of a deep vein thrombosis (DVT- a medical condition in which a blood clot (thrombus) forms in one or more of the deep veins of the body), and physical debility. A care plan dated 09/05/25 revealed a focus area related to Activities of Daily Living (ADL) care. Resident #25 required assistance with her ADLs. The goal was for the resident to maintain their current level of function through the next review date. Interventions included two staff member assistance with transfers. A physician's order dated 11/02/25 revealed an order for Eliquis 5 milligrams (mg), one tablet by mouth twice a day, for the prevention of deep vein thrombosis (DVT), Manufacturer's guidelines for the medication Eliquis 05/2025 indicated the medication can cause serious side effects including bleeding which could be serious and may lead to death. The guidelines further stated to call your healthcare provider with any severe bleeding. A Physical Therapy evaluation dated 11/14/25 signed by Physical Therapist #1 revealed Resident #25 demonstrated decreased bilateral lower extremity range of motion due to contractures and weakness. She demonstrated decreased functional with bed mobility and wheelchair mobility. Resident #25 was noted to be limited by contracture and malalignment of the right lower extremity due to a chronic break. The assessment revealed Resident #25 did not tolerate upright positioning for long and was unable to sit in a wheelchair without bilateral lower extremities elevated on pillows and leg rests. On 02/25/26 at 5:00 PM, an interview was conducted with Physical Therapist #1. During the interview, she stated she had worked with Resident #25 during sessions in November 2025 and December 2025. She explained Resident #25's range of motion was severely decreased in bilateral lower extremities and her legs remained elevated on pillows and leg rest. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and dependent upon two staff members for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. Resident #25 was coded as having no impairment to the upper or lower extremities and no use of mobility devices during the assessment period. Resident #25 was coded as receiving anticoagulants during the assessment period. On 02/23/26 at 12:54 PM, an interview and observation were conducted with Nurse Aide (NA) #1. During the interview, she stated she was responsible for Resident #25 on 01/20/26 during the 7:00 AM to 3:00 PM shift. NA #1 explained she was assisting Resident #25 with a bed bath when the resident requested to get up to her wheelchair. She explained that after placing Resident #25 in her wheelchair, with both feet positioned on pillows on top of the wheelchair leg rests, she turned the wheelchair and pulled it backward along the side of the bed. While NA #1 was pulling Resident #25's wheelchair backward along the side of the bed the resident's left lower leg hit the corner of the damaged footboard. She stated the bed was in a low position and Resident #25 began to yell out in pain. NA #1 indicated she realized Resident #25's left leg had hit the corner of the footboard and had begun to bleed. NA #1 re-enacted this action to the surveyor by pulling the resident's wheelchair backward along the side of the bed. NA #1 explained obtained paper towels from the sink and placed them on the resident's leg in an attempt to stop the bleeding. She stated, It was bleeding bad. NA #1 stated the paper towels were saturated, so she then placed a regular bath towel over the leg and yelled for Nurse #1, who entered the room, applied pressure, and placed a dressing on the wound. She stated after Nurse #1 placed the dressing on the resident's leg the resident remained in her wheelchair with her legs elevated. NA #1 did not go back into the room until Emergency Medical Services (EMS) arrived and she assisted the resident onto the stretcher. NA #1 stated she did not see blood on the dressing when she assisted with the transfer of Resident #25. A Situation, Background, Assessment, Recommendation assessment dated [DATE] at 11:30 AM, written by Nurse #1, revealed Resident #25 had received a skin tear to her left lower leg. A dressing was applied, and the Wound Nurse, Nurse Practitioner, or Medical Director were to evaluate. Recommendations included that Resident #25 be sent to the Emergency Department. New orders documented included: Patient to Emergency Department per her request related to skin tear to left leg. Vital signs included the following: blood pressure 132/77 (normal 120/80), pulse 97 (normal range 60-90), respiration 22 (normal range 12/20), temperature 98.2 (normal range 97-99.0), pulse oximetry 97% (normal range >92%) on room air. A pain scale was not included in the documentation. A late entry nursing progress note dated 01/20/26 at 3:00 PM, written by Nurse #1, revealed the note was a late entry for 11:30 AM. Nurse #1 was informed Resident #25's leg was bumped during transfer. Resident #25 was assessed and noted to have a one-inch slit in the middle of her left leg. The resident's anticoagulant was held at that time. Increased bleeding was noted related to Resident #25's anticoagulant therapy. Pressure was applied to the injury site for a duration of five minutes, and then a pressure dressing was applied. The Wound Nurse was informed and aware of the situation. A late entry nursing progress note dated 01/20/26 at 3:29 PM, written by Nurse #1, revealed Resident #25's Responsible Party (RP) was present in the facility. Upon the RP's arrival, Resident #25 began to scream and yell, I'm hurting. Nurse #1 left the resident's room to check physician orders and obtain medication. Upon returning, the RP stated, I called 911 services for Resident #25. Resident #25 stated, I want to go to the hospital. Bleeding was noted to have stopped. Emergency Medical Services (EMS) arrived at the facility at 1:35 PM. A mechanical lift was used with two staff members to transfer Resident #25 onto the stretcher for EMS. On 02/23/26 at 1:45 PM, an interview was conducted with Nurse #1. She stated she was an agency nurse working in the facility for the first time 01/20/26. She recalled NA #1 calling for assistance on 01/20/26 around 11:30 AM and entering the room to find Resident #25's left leg bleeding with a one-inch laceration located on her left lower leg. Due to the increased bleeding that saturated a towel NA #1 applied, she applied pressure for approximately 5 minutes to stop the bleeding and notified the Wound Nurse and Nurse Practitioner #1. She stated, I didn't think she needed to go to the hospital; I just notified Nurse Practitioner #1. She explained she did not recall if she administered pain medication to Resident #25 but if she put it into her written note from that date then she would have given pain medication. She didn't know why it wasn't on the Medication Administration Record (MAR). Nurse #1 stated because she was an agency nurse it was difficult to remember the situation and all of the specific details and to refer to her notes of what occurred on 01/20/26. On 02/23/26 at 2:10 PM, an interview was conducted with Resident #25's Responsible Party. He stated Resident #25 called him on 01/20/26 and reported a Nurse Aide had hit her leg on the footboard while the NA was backing her wheelchair beside the bed. During the call Resident #25 did not complain of pain but asked him to come. Upon arrival, he observed red blood on a white dressing on her left lower leg and stated, The facility wasn't sending her, so I called 911. The interview revealed there was no blood noted in the room when he arrived other than on the resident's dressing and Resident #25 was complaining of pain. EMS arrived shortly after he called and transported her to the hospital. On 02/23/26 at 3:14 PM, an interview was conducted with NA #4. She stated she worked both first and second shift on 01/20/26. NA #4 assisted with transferring Resident #25 onto the EMS stretcher. She reported Resident #25 was yelling in pain and that her legs remained straight and did not bend. The interview revealed assisting with the transfer onto the EMS stretcher was the first time NA #4 had been in Resident #25's room during the shift. Emergency Medical Services (EMS) records dated 01/20/26 revealed EMS was called at 1:27 PM and arrived at Resident #25's bedside at 1:42 PM. The nurse reported to EMS that Resident #25 was transferred from her, wheelchair to her bed when her leg was hit on a rounded corner, causing a 1 to 2-inch laceration to her left lower leg. Nurse #1 stated to EMS she had controlled the bleeding with gauze and tape and had administered pain medication. The resident's RP arrived approximately 30 minutes after the incident and requested Resident #25 be transported to the hospital for further evaluation. Resident #25 was noted to be in emotional distress due to pain with bilateral lower extremity swelling. Resident #25's left lower leg was noted to have bruising and swelling where she was injured but no obvious deformity. EMS did not remove Resident #25's dressing to her left lower extremity. Vital signs revealed an elevated blood pressure of 182/110 (normal 120/80) and an elevated heart rate of 123 (normal 60–90). Resident #25 continued to complain of pain to her left lower extremity while en route to the hospital with a pain level of 10, on a 0-10 scale (0 being no pain, 10 being the worst pain). She was administered pain medication (acetaminophen) along with a diuretic (torsemide), and muscle relaxant (methocarbamol). Hospital records dated 01/20/26 revealed Resident #25 presented to the Emergency Department (ED) from the nursing facility for evaluation of a hematoma and laceration to the left lower leg. She reported moderate to severe pain. The ED note indicated difficulty controlling bleeding at the nursing facility, and due to swelling, she was referred for further evaluation. Assessment of the left lower extremity revealed a 2 cm skin tear with a small amount of drainage coming from the area. She also had an associated large hematoma measuring approximately 4 x7 inches distally a small distance from the laceration. A picture 01/20/26 was taken while Resident #25 was in the Emergency Department. The picture shows Resident #25 lying in bed with her left leg elevated on a pillow. Blood was observed under her left knee pooled onto the bed and also on the pillow under the residents left leg. Ice was placed to assist with pain and swelling along with 2mg of morphine (a strong opioid pain medication use to treat moderate to severe pain) administered intravenously. Blood is also visualized on the residents left surrounding the laceration. Upon admission on [DATE], she was noted to have a large superficial soft tissue hematoma measuring 16.2 cm (6.38 inches). Laboratory studies demonstrated a decline in hemoglobin from 11.1 to 7.3 over the first two days of hospitalization, consistent with acute blood loss anemia, necessitating transfusion of packed red blood cells. Subsequently, the skin overlying the hematoma became necrotic, requiring operative evacuation of the hematoma, surgical debridement of necrotic tissue, and placement of a wound vacuum-assisted closure (VAC) device. Resident #25 was discharged back to the nursing facility on 02/05/26 with orders for oxycodone 5 milligrams (mg) one tablet every 6 hours as needed for severe pain and acetaminophen 650 mg every 8 hours as needed for pain. Wound care discharge instructions included daily dressing changes to the left lower extremity with petroleum gauze an abdominal pad and gauze wrap. On 02/25/26 at 10:02 AM an interview was conducted with the Maintenance Director. During the interview he stated he had been working in the facility since April 2025. He explained he was notified by the Administrator on 02/23/26 of an issue with Resident #25's footboard. Once in the room he observed the outer layer of laminate was gone exposing the press board. He stated that was not how the beds were supposed to be and immediately changed the footboard. The interview revealed the facility kept extra footboards in stock and he had received no work orders or mention of the damaged footboard from staff. On 02/24/26 at 8:45 AM, a telephone interview was conducted with the Medical Director. He stated Resident #25 was prescribed a high dose of an anticoagulant (Eliquis), which contributed to the blood loss following the incident. He explained anticoagulation increased her risk of bleeding. He stated he was not aware a Nurse Aide had struck Resident #25's leg on the footboard and had only been told about the injury, not how it occurred. He stated he would have sent her to the hospital on [DATE] due to her increased bleeding risk however, it sounded like she was sent out anyway due to a Responsible Party request for her to be evaluated so the outcome would have been the same. On 02/24/26 at 9:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that, from her recollection, NA #1 had transferred Resident #25 to her wheelchair on 01/20/26 and the resident's leg struck either the wheelchair or bed. She was notified of the incident by Nurse #1 after it occurred. The DON stated Nurse #1 had called Nurse Practitioner #1 and obtained orders to hold the anticoagulant; however, Resident #25 was already at the hospital per the Responsible Parties request to send the resident to the hospital. The DON explained it was her understanding Resident #25 did not need to go to the hospital and she wanted orders to hold the next dose of anticoagulant for that night. She stated, everything just happened so quickly. The interview revealed the DON was in the facility on 01/20/26 when the incident occurred however she did not go into the room nor did she look at the wound to Resident #25's left lower extremity. On 02/23/26 at 2:27 PM, an interview was conducted with the Administrator. She stated she was notified after staff had addressed the incident on 01/20/26. She was informed that NA #1 had bumped Resident #25's leg on the footboard. She stated the Nurse Practitioner was notified and a pressure dressing was applied. On 02/24/26 at 10:17 AM, an interview was conducted with the Wound Care Nurse Practitioner. She stated she had evaluated Resident #25 weekly after the resident's discharge from the hospital on [DATE]. She confirmed Resident #25 sustained a hematoma requiring surgical intervention at the hospital. She explained large hematomas can result in pooled blood, which may become necrotic. After reviewing hospital records, she stated the hospital monitored the area for several days before surgically evacuating the hematoma, debriding necrotic tissue, and applying a wound VAC. Once Resident #25 returned to the facility she had received daily wound care with weekly evaluations. The Wound Care Nurse Practitioner stated the wound was improving; however, it would be difficult to fully heal due to the surface area. She stated she was considering an allograft (a type of tissue taken from a donor to replace damaged tissue) to cover the area to the residents left lower leg since it remained an open area and probability of skin healing was low. On 02/25/26 at 11:11 AM an observation was conducted of Resident #25's wound to the left lower leg. Resident #25 was observed to have a large reddened open area to her left lower extremity with areas of black (necrotic) tissue. Resident #25 was pre-medicated with pain medication prior to the wound care observation. The Wound Nurse was observed cleansing the left lower leg with normal saline solution, patting the area dry with gauze and applying santyl (a prescription medication used to remove dead tissue and promote healing) ointment to the necrotic areas of the wound, followed by moisten gauze with dakins (antiseptic cleaning agent for wounds) solution. The area was covered with an abdominal pad and wrapped with kerlix. The Administrator was notified of the immediate jeopardy on 02/24/25 at 2:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. F689 Credible Allegation: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #25 (on anticoagulant therapy) suffered a serious adverse injury following the incident on 1/20/26. Nurse Aide (NA) #1 completed a 1-person mechanical lift transfer prior to injury. While Nurse Aide (NA) #1 was maneuvering resident's wheelchair, NA#1 bumped residents' left leg on the foot board (that was damaged and the outer layer of material was gone and press board was exposed) of the bed causing a laceration, hematoma and pain to Resident #25's left lower leg. NA #1 received 1 on 1 education on 2/24/26 by the Director of Nursing (DON) on the expectation of following the mechanical lift policy that includes utilizing 2-person assistance with all mechanical lift transfers and safe movement of residents in their room and environment. NA #1 immediately (1/20/26) applied pressure to the laceration on Resident #25's left lower leg and notified Nurse #1 of the incident. Nurse #1 assessed the wound, applied pressure dressing and notified Nurse Practitioner (NP) #1. NP #1 gave order for anticoagulant to be held and to monitor laceration on 1/20/26. NP #1 was notified on 1/20/26 by Nurse #1 of the incident. Resident #25 notified her own Responsible Party (RP) via phone on 1/20/26 that she received an injury to her lower leg. Responsible party arrived at facility and discussed with nurse prior to resident going out via Emergency Medical Services (EMS). Resident #25 was sent to the Emergency Department and admitted on [DATE]. Resident #25 was admitted to the hospital from [DATE]-[DATE]. Resident #25's RP notified EMS of the need for transfer to the hospital. Nurse #1 notified NP #1 that resident was transferred to ED at the request of RP on 1/20/26. Other residents on anticoagulants were at risk of serious adverse outcomes (e.g., uncontrolled bleeding, significant bruising) due to the identified practice gaps. On 2/24/26 the Assistant Director of Nursing (ADON) completed an audit of the electronic health record order listing report to identify all residents receiving anticoagulant therapy. 21 residents were noted to receive anticoagulant therapy. This is an ongoing audit that is updated with each admission. All residents requiring mechanical lift transfers were at risk for serious injury due to a failure of staff to consistently perform required two person assist procedures and inadequate staff adherence to safe transfer practices prior to corrective actions. 100% audit of Resident Kardex (an electronic reference to individualized plan of care, to include method of transfer) was conducted by the Assistant Director of Nursing on 2-24-2026 to determine the residents who required a Mechanical lift and 35 residents were identified. Transfer status is evaluated by the Inter Disciplinary Team upon admission, readmission, significant change, and quarterly to establish safe transfer method at which time the resident care plan is updated as needed and populated to the Kardex by the Minimum Data Set Nurse (MDS) or designee. A review of all incidents and accident log was conducted on 2/24/26 for the last 30 days by the DON to identify any other residents that may have sustained an injury while being maneuvered in their wheelchair in their environment. No other incidents were identified. Resident #25's care plan was reviewed by MDS Nurse, Administrator, and DON on 2/24/26. No changes were needed at this time. On 02/24/2026, the Maintenance Director inspected resident furniture for all residents —including the bed frame and bedside table—to ensure no rough edges or hazardous surfaces were present. No concerns were noted with any other bed frames or footboards. Resident #25's footboard was replaced on 2/23/26 by the Maintenance Director. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: A Root Cause Analysis was completed on 2/24/26 that included the DON, ADON, Administrator and MDS Coordinator. It was identified that NA #1 did not follow facility policy with 2-person mechanical lift transfers as well as lack of education with safely maneuvering residents in their environment. NA #1 had received prior education on the policy for 2 person mechanical lift transfer, however, continued to proceed with the transfer independently. 02/24/2026: All nursing staff, including nurses, nursing assistants as well as therapy department, and agency nurses and nurse aides, were in-serviced by the Director of Nursing (DON) on safe transfer requirements, emphasizing the mandatory two person assist for all mechanical lift transfers. All staff who did not receive education on 2-24-2026 will be educated prior to their next shift by the DON or designee. Education was provided in person and via electronic education system. New staff will be educated during orientation by the DON or designee. The DON was made aware of this responsibility on 2/24/26 by the Administrator. Education was provided using facility policy on Safe Lifting of Residents. Education included safe maneuvering of residents in wheelchairs while in their room with a focus on environmental surroundings and the ability to avoid bumping furniture in room, awareness of recognizing potential in room hazards, such as poor condition of furniture (exposed pressboard, sharp edges on furniture). Education was also provided on 02/24/26 on by the DON reporting any potential hazards or need for equipment changed via the TELS system (an electronic platform for reporting environmental and maintenance concerns directly to Maintenance Director). Once the Maintenance Director has received the TELS notification via electronic alert on cellular device, lap top and or desk top, as well as verbal communication of TELS entry, completion of repair is expected within the same day if it involves a resident safety concern. Hoyer Lift competencies were completed on 02/24/2026 for all on duty nursing staff (nurses and Nurse Aides) by the DON and Rehab Director. Any staff not present on 02/24/2026 are required to complete their competency prior to their next scheduled shift. Competency Evaluations will be completed by DON, ADON and Unit managers. DON/ADON will be responsible for tracking and maintaining education record to ensure that staff receive this education prior to start of their next shift. The DON and ADON were made aware of this responsibility on 2/24/26 by the Administrator. NA #1 was re-educated on the Kardex with emphasis on location of resident transfer on 2/24/26. Education was provided by the DON. All Na's, including agency, were educated on 2/24/26 by the DON on where to locate the Kardex in the Point of Care platform that details resident care specific information, including transfer status, and reviewing of Kardex at the beginning of their shift. All NA's not educated on 2/24/26, including agency and new hires, will be educated prior to the start of their next shift and during the orientation process by the DON, ADON, or Unit Manager. The DON was made aware of this responsibility by the facility Administrator on 2/24/26. The DON made ADON and Unit Manager aware of this responsibility on 2/24/26. An ad hoc QAPI was held on 2/24/26 with the facility Administrator, DON, Medical Director, and Nurse Managers to review the deficient practice and plan of correction. Maintenance will be responsible for assessing, repairing, or replacing damaged foot boards with visible hazards of press board immediately upon notification via TELS. The Administrator notified Maintenance Director of this responsibility on 2/24/26. The Administrator is responsible for the execution of this plan of Credible Allegation. Date of IJ removal: 2-25-2026 The facility's credible allegation of immediate jeopardy removal was validated on 3/02/26. An interview conducted with the DON revealed she and the Rehabilitation Director provided education to nurses and NAs on the facility's policy regarding safe resident transfers and had them perform return demonstration using the mechanical lift to ensure all competencies were met on the skills checklist which included reviewing the Kardex to verify a resident's transfer status, review of the mechanical lift skills checklists that were completed for nurses and NAs on 2/24/26 revealed all competencies were marked as met and no concerns were identified. Interviews conducted with nurses and NAs revealed they received education on the facility's safe resident transfer policy and were observed performing return demonstrations using the mechanical lift. An interview conducted with the Maintenance Director revealed on 2/23/26 and 2/24/26 he completed an audit of all the residents' rooms and any furniture that was damaged or broken was immediately replaced. Observations conducted in the residents' rooms revealed no broken or damaged headboards or footboards on the beds, the furniture was in good repair, and there were no safety concerns identified. An observation conducted of two NAs transferring a resident using the mechanical lift revealed the facility's safe transfer policy was followed and no concerns were identified. The facility's IJ removal date of 2/25/26 was validated on 3/02/26. 2. Resident #20 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, generalized muscle weakness and diabetes mellitus. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 was cognitively intact. Resident #20 was her own responsible party. Resident #20 required supervision to minimum assistance with bathing, dressing and transfers from bed to wheelchair. Resident #20 used a wheelchair for mobility and could propel herself independently. Resident #20's care plan dated 4/23/2025 had a focus area which indicated Resident #20 had a risk to fall due to impaired physical mobility, lower extremity weakness, psychoactive medication (medication that can alter mood, cognition, and behavior and can cause sedation or altered consciousness) use and visual impairment. Goals included Resident #20 would not have any falls through the review period. Interventions included staff to anticipate Resident #20's needs as able (hunger, thirst, toileting, and temperature), keep the bedside table/personal items within reach, place the bed in low position, and remind Resident #20 to use the call light when assistance was needed. An interview on 2/22/2026 at 2:12 PM with Resident #20 revealed she had worked with Physical Therapy (PT) and Occupational Therapy (OT) during April 2025 while preparing for discharge to the community. On 4/24/2025, she went to the shower room on the East hallway of the facility with OT #1 and PT #1 to be checked off on showering as part of her discharge goals. Resident #20 did not recall the exact time but knew the shower took place in the morning approximately around 10:00 AM. Resident #20 stated the shower had been going well and PT #1 left to go get Resident #20's clothes from her room just down the hallway. OT #1 asked Resident #20 to stand to rinse off. Resident #20 reported when she touched the shower grab bar it moved a little and she stated to OT #1, This is loose. Resident #20 stated OT #1 did not respond and asked her to rinse off. Resident #20 stood up and when she pulled on the shower grab bar, the bar moved quite a bit which scared her and she fell back, hit the edge of the shower chair with her buttocks and then slid onto the floor onto her buttocks. Resident #20 stated she could not get up with the help of OT #1 and PT #1 due to chronic knee/leg weakness and the floor was wet and slippery. The therapists notified nursing of the fall. The therapists used the mechanical lift to get her up and into her wheelchair. Resident #20 stated she finished the therapy session in her room and was able to dress herself. Resident #20 reported she did not feel any new pain at the time of the fall as she had chronic knee, leg and back pain until later in the day. Resident #20 went to the hospital on 4/24/2025 for an evaluation. Resident #20 indicated she had a sprain in her knee but no fractures. Resident #20 stated after the fall she was scared to use the [

Based on observations and staff interviews, the facility failed to close the trash receptacle door, remove loose garbage, boxes, and debris and failed to prevent standing water from around 1 of 1 trash receptacle and 1 of 1 recycling receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests and rodents.The findings included:An observation of the outdoor trash receptacle area with the Head [NAME] on 2/22/26 at 11:30 AM revealed three used disposable gloves and one clear trash bag which contained trash on the ground to the left of the trash receptacle and one clear trash bag which contained small amounts of trash hanging out of the open trash receptacle door. There were five collapsed cardboard boxes that were floating in standing water approximately 5 inches deep in the trash and recycling receptacles area, which was approximately 15 to 20 feet wide. One blue trash bag which contained trash was floating in the standing water between the trash receptacle and the recycling receptacle. One empty carboard carton was observed under the front of the recycling receptacle. An interview with the Head [NAME] on 2/22/26 at 11:33AM revealed many staff members at the facility used the dumpster area and staff continuously forgot to close the receptacle doors. She stated that when it rained, water pooled under the dumpster area and didn't drain, which caused the standing water. A second observation of the outdoor trash receptacle area was completed on 2/23/26 at 11:57 AM. One used purple glove was observed on the ground to the left of the trash receptacle. The trash receptacle door was open and one clear trash bag which contained trash hung out of the receptacle. Two collapsed cardboard boxes were floating in standing water approximately 3 inches deep (approximately 6 feet wide) between the trash receptacle and the recycling receptacle and one empty carton was observed under the front of the recycling receptacle. An interview with Regional Housekeeping Supervisor on 2/23/26 at 2:10 PM revealed many staff members in multiple departments used the dumpster area and staff were continually reminded to keep the doors closed to the trash receptacle. She also stated the trash pick-up service which came a couple times a week caused a lot of the materials to fall out of the receptacles such as the collapsed cardboard boxes that were observed. A tour and third observation of the trash receptacle area was completed with the Dietary Manager and Administrator on 2/23/26 at 2:53 PM and included interviews. The trash receptacle was not full, and the door was open and one clear trash bag which contained trash hung out of the door. Two collapsed cardboard boxes were observed in approximately an inch of standing water next to the recycling receptacle and an empty carton was under the front of the recycling receptacle. The Administrator stated she was not aware of the standing water, and she would have the area cleaned up to see if there was a drain present under the receptacles. The Administrator expected the area to be maintained by all staff who took out trash. The Dietary Manager revealed the trash pick-up company dumped items out of the dumpster when they picked up the trash and the items were not placed back in the receptacles by the trash pick-up company.

Based on observation, record review and resident and staff interviews, the facility failed to honor a resident's request to return to bed after arrival to the facility from dialysis services. The resident stated to a staff member that waiting for over an hour for assistance to return to bed after dialysis treatment made her feel lightheaded and even more tired. This deficient practice affected 1 of 4 residents reviewed for choices (Resident #22). The findings included: Resident #22 was readmitted to the facility on [DATE]. Her diagnoses included chronic kidney disease stage 4 with hemodialysis and type 2 diabetes mellitus. Resident #22's physician order dated 8/12/25 revealed Resident #22 received hemodialysis every Tuesday, Thursday, and Saturday. Resident #22 had a dialysis care plan in place dated 8/12/25 which revealed she was at risk for complications requiring hemodialysis; dialysis treatment days were scheduled every Tuesday, Thursday, and Saturday. Resident #22's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22 was dependent on staff for transfers via mechanical lift. The MDS further indicated that it was very important for Resident #22 to choose her bedtime. Resident #22 was coded as receiving dialysis An interview was conducted on 2/22/26 (a non-dialysis treatment day) at 11:59 AM with Resident #22. Resident #22 stated she would typically return to the facility around 10:50 AM from dialysis services. She stated she would notify staff when she returned from dialysis services as she passed the nurses' station or the dialysis transport driver would inform the staff that she (Resident #22) was back from dialysis services if staff were not at the nurses' station. Resident #22 explained she pressed her call light to notify staff she was ready to return to bed. Resident #22 verbalized she gauged the time while watching The Price is Right (a television program that started at 11:00 AM and ended at 12:00 PM) or by looking at the clock on her personal cell phone. Resident #22 also had a clock on her wall next to the bathroom door that she gauged time with. Resident #22 stated there were times she would wait until after lunch (between 12:30 PM and 1:30 PM) to be placed back into bed after her return from dialysis treatment. Resident #22 voiced that her day began at 2:00 AM in preparation for her dialysis treatment. Resident #22 expressed that after her dialysis treatments, she was extremely tired and ready to return to bed once she arrived back at the facility. On 2/24/26 at 10:40 AM, a continuous observation was conducted of Resident #22 returning from dialysis services via external transportation. Once Resident #22 was delivered to her room, the call light was activated by Resident #22 at 10:43 AM. Resident #22's call light was turned off by Nurse Aide (NA) #10 at 10:45 AM. At 10:51 AM, an interview was completed with Resident #22. Resident #22 stated NA #10 entered her room and deactivated her call light, then informed Resident #22 that she was completing rounds and would return. Resident #22 verbalized that she did not have a chance to let NA #10 know what she required or needed. Resident #22's call light remained off. At 11:25 AM, the call light was reactivated by Resident #22. At 11:28 AM, NA #7 answered the call light and deactivated it. At 11:34 AM, NA #7 attempted to assist Resident #22 but needed another nurse aide or staff person to assist her during a mechanical lift transfer. NA #7 verbalized to Resident #22 that she had requested assistance from another staff member. At 11:40 AM, the call light was reactivated by Resident #22. At 11:43 AM, the call light was turned off by the Certified Occupational Therapist Assistant (COTA) #1 and NA #7 as they returned to Resident #22's room. COTA #1 and NA #7 were observed transferring Resident #22 with the mechanical lift with no concerns back to bed.On 2/24/26 at 2:55 PM an interview was conducted with Nurse Aide #10. NA #10 stated she was assigned to Resident #22 that day and was responsible for assisting with upper and lower body bathing and dressing. NA #10 stated she answered Resident #22's call light after she returned from dialysis and Resident #22 voiced that she was ready to lay down. NA #10 stated she was in the process of assisting another resident located on a different hall with dressing and transferring to a wheelchair at that time. NA #10 acknowledged that she did not notify or request assistance from other staff members. NA #10 explained that, as an agency nurse aide, she had a designated assignment and stated it was not the responsibility of other staff members to address needs for residents on her assignment. NA #10 stated she completed walking rounds at the beginning of her shift; however, she was not aware of any request or preference that Resident #22 should be placed in bed upon returning from dialysis services. NA #10 revealed she did not receive a full report prior to taking the hall and beginning her assignment and did not recall receiving report regarding Resident #22. NA #10 stated she did not return to Resident #22's room after she assisted another resident on a different hall. On 2/24/26 at 2:29 PM an interview was conducted with Nurse Aide #7. NA #7 revealed she answered the call light initially and turned off call light. NA #7 indicated she explained to Resident #22 that she needed to get someone to assist her with the mechanical lift transfer. NA #7 explained that it was normal to have two staff members present with mechanical lift transfers. NA #7 then proceeded to come out of Resident #22's room to get someone to assist her, which was COTA #1. NA #7 stated that Resident #22 expressed that she was tired from dialysis treatment. Resident #22 also stated to NA #7 that she had waited a little minute, but NA #7 could not give a definite time frame. NA #7 stated that the nurse aides were aware that when Resident #22 returned from dialysis treatment she liked to go to bed as soon as possible. NA #7 confirmed that the nurse aides who were usually scheduled on the unit were aware of Resident #22's request and would put her to bed upon her return to the facility from dialysis treatment. NA #7 added, if the aides were in the middle of something, then it would typically be 10 to 15 minutes (depending on what they were completing) to assist her to bed. NA #7 was not certain why it took so long to assist Resident #22 back to bed after her dialysis treatment and return to the facility.On 2/24/26 at 2:22 PM, an interview was completed with the Certified Occupational Therapy Assistant (COTA) #1 who stated she worked at the facility for approximately 6 years. She confirmed that Resident #22 was on Occupational Therapy (OT) caseload and no other therapies at the time. COTA #1 explained she responded to Resident #22's call light around 11:40 AM and went to look for NA #10 to assist with getting Resident #22 back into bed. NA #10 verbalized she needed assistance with another resident, so COTA #1 assisted NA #10 with the resident NA #10 was working with and then returned to Resident #22's room to assist with getting her back to bed. COTA #1 stated NA #7 assisted with putting Resident #22 back to bed via mechanical lift per Resident #22's transfer status. COTA #1 verbalized that Resident #22 informed her she was very tired and lightheaded from her dialysis treatment. Resident #22 also informed COTA #1 that she had been waiting over 45 minutes. COTA #1 stated staff was aware that when Resident #22 returned from dialysis treatment she liked to go to bed. COTA #1 explained that because a different nurse aide was assigned to the hall, Resident #22's routine and preferences must not have been communicated with NA #10. On 2/24/26 at 2:42 PM, an interview was conducted with the Unit Manager. The Unit Manager stated that nurse aides were to respond immediately to call lights and notify staff if any additional assistance was required. The Unit Manager further explained that staff were aware that Resident #22 preferred to go to bed upon return to the facility after dialysis treatments. The Unit Manager stated Resident #22 should not have had to wait over an hour to be assisted back to bed and that NA #10 should have anticipated Resident #22's need and made sure she was put to bed immediately upon her return from dialysis treatment. If NA #10 could not assist Resident #22 then NA #10 should have requested assistance from other staff on the unit that were available. On 2/25/26 at10:10 AM, an interview was completed with the Director of Nursing (DON). The DON confirmed Resident #22 was alert, oriented and could clearly communicate regarding her preferences and choices. Resident #22 could make the request to return to bed after she arrived back at the facility after dialysis treatment. The DON indicated NA #10 was not aware of Resident #22's preferences as she was agency staff. The DON further stated that if NA #10 was in the middle of care with another resident, then the appropriate process would have been to return to Resident #22 as soon as possible or NA #10 should have followed up and provided an update as to when she would be able to assist her. The DON explained that the facility attempted to accommodate Resident #22's preferences and choices when she returned from dialysis treatment to be placed back to bed. On 2/25/26 at 4:33 PM, an interview with the Administrator revealed that staff should have responded to Resident #22's call light immediately or within 5 minutes to 10 minutes at maximum to assist with Resident #22's request. The Administrator stated that waiting 45 minutes to go to bed after dialysis services was not acceptable and staff should have acknowledged Resident #22's request by returning her to bed after dialysis treatment.

Based on observation, record review, and staff interviews, the facility failed to maintain the footboards on beds in a resident room in good repair (Residents #25 and #27). The deficient practice affected 1 of 21 rooms on 1 of 4 halls observed for a safe and homelike environment. The findings included:An observation conducted on 2/23/26 at 1:15 PM in the shared room of Residents #25 and Resident #27 revealed that the footboards on both residents' beds were in disrepair. Resident #25's footboard was missing the banding which left an exposed, rough area of particle board approximately 3 to 4 inches in length. Resident #27's footboard exhibited multiple damaged areas, each approximately 6 inches long, with rough, exposed particle board. The laminate covering was missing from the footboard. A review of the facility's online maintenance work order system from March 2025 to February 2026 revealed no documented requests for repair of the bed footboards for Resident #25 or Resident #27. An interview and observation were conducted with Nurse Aide (NA) #1 on 2/23/26 at 12:54 PM revealed that the outer coating on Resident #25's bed footboard was missing, which exposed a rough area of particle board. She confirmed that the footboards for both Resident #25 and Resident #27 had exposed particle board. The interview revealed both footboards had been damaged for some time, but she had not notified any staff members. An interview with Nurse #4 on 2/24/26 at 11:36 AM revealed she had observed damage to the outer coating of Resident #25's and Resident #27's bed footboard. She reported that, as an agency staff member, she assumed Maintenance was already aware of the issue. Nurse #4 stated she did not know how long the footboard had been in that condition but had observed the damage a couple of weeks earlier. An interview with the Maintenance Director on 2/24/26 at 10:02 AM revealed he had been at the facility since April of last year and on 2/23/26, he stated the Administrator called him on 02/24/26 and notified him of an issue with the footboards in a resident room. He stated he noticed the laminate covering had been rubbed off on the bottom of Resident #25 and Resident #27 footboards. He stated Resident #27's bed was replaced and Resident #25's bed, looked like the banding was coming off and the particle board was exposed. The Maintenance Director stated that was not how the beds were supposed to look and it was warranted for the footboards to be changed. He stated when he was notified about the situation, verbally by the Administrator, he immediately went and changed them as he keeps extra footboards and headboards in the maintenance shop. The Maintenance Director stated if staff saw beds in disrepair, he expected them to put in a work order to have it changed out. The interview revealed he was not aware of the damage to the footboards until the Administrator called him. A combined telephone interview with the Director of Nursing (DON) and Administrator occurred on 2/26/26 at 10:36 AM. The DON stated she had the expectation that all nursing staff to put in a work order for anything that needs to be repaired by maintenance. The Administrator stated NAs have access in their point of care system to request any maintenance concerns 24 hours a day. The Administrator stated there were many items in the facility which needed attention and some had been marked as urgent requests. The Administrator stated maintenance, checked Resident #25 and Resident #27's beds and did not find anything on them that was rough and he did not see anything urgent in replacing them until after the State Surveyor pointed out the concern. The footboards were replaced by the maintenance department on 2/24/26. The Administrator and DON both stated they were not aware of any damage to Resident #25 or Resident #27's footboards until it was brought to their attention during the survey on 02/24/26.

Based on observations, record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of range of motion and mobility devices for 1 of 21 sampled residents (Resident #25).The findings included:Resident #25 was admitted to the facility on [DATE] with diagnoses of fracture of the right tibia, muscle weakness and physical debility. A care plan dated 09/05/25 revealed a focus area related to Activities of Daily Living (ADL) care. Resident #25 required assistance with her ADL. The goal was for the resident to maintain their current level of function through the next review date. Interventions included two staff member assistance using a mechanical lift with transfers. A Physical Therapy evaluation dated 11/14/25 signed by Physical Therapist #1 revealed Resident #25 demonstrated decreased bilateral lower extremity range of motion due to contractures and weakness. She demonstrated decreased function with bed mobility and wheelchair mobility. Resident #25 was noted to be limited by contracture and malalignment of the right lower extremity due to a chronic break. The assessment revealed Resident #25 did not tolerate upright positioning for long and was unable to sit in a wheelchair without bilateral lower extremities elevated on pillows and leg rests. On 02/25/26 at 5:00 PM, an interview was conducted with Physical Therapist #1. During the interview, she stated she had worked with Resident #25 during sessions in November 2025 and December 2025. She explained Resident #25's range of motion was severely decreased in her bilateral lower extremities and her legs remained elevated on pillows and leg rests with use of a wheelchair as a mobility device.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and dependent upon two staff members for personal and toileting hygiene, showering/bathing and upper and lower body dressing. Resident #25 was coded as having no range of motion impairment to the upper or lower extremities and no use of mobility devices during the assessment period. An interview with the MDS Coordinator was conducted on 02/25/26 at 4:58 PM. She confirmed she had completed Resident #25's 11/24/25 MDS. She indicated after reviewing the Physical Therapy notes from 11/14/25 Resident #25 did have bilateral lower extremity impairment and did use a wheelchair as a mobility device. The MDS Coordinator explained that the MDS was completed incorrectly and should have been coded for use of a wheelchair and bilateral lower extremity range of motion impairment.An interview conducted with the Administrator on 03/02/26 at 10:00 AM revealed Resident #25's MDS should have been coded to accurately reflect her range of motion and mobility devices.

Based on observations, record review and resident, staff and Nurse Practitioner interviews, the facility failed to secure medications found at the bedside for 1 of 2 residents reviewed for medication storage (Residents #8). The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses which included acute systolic heart failure.An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact.A review of Resident #8's physician's orders revealed an order dated 2/10/26 for a 20 milliequivalents (mEq) potassium oral capsule (Potassium Citrate) one time a day for hypokalemia. Additionally, Resident #8 did not have any past or current physician's orders to self-administer medications.A review of Resident #8's Electronic Medical Record (EMR) revealed no care plan areas or assessments for self-administering medications.An observation on 2/22/26 at 12:02 PM revealed a large white pill in a cup on the bedside table to the left of Resident #8's bed. Resident #8 was lying in bed at the time of the observation. An observation and interview with Nurse #3 on 2/22/26 at 12:08 PM revealed she was the medication nurse for Resident #8 and had administered Resident #8's medications that morning. She observed the medication cup with the large white pill on Resident #8's bedside and stated Resident #8 took all her other pills, but she wanted to wait a little bit on this one. Nurse #3 verified the large white pill was the potassium citrate capsule. Nurse #3 stated Resident #8 liked to take it later. Nurse #3 stated she did not normally leave the pill by the bedside and would always take the remaining pill back to her medication cart. Nurse #8 stated another staff member called her for a concern that morning and she left the pill next to Resident #8's bedside. An interview with Resident #8 on 2/22/26 at 12:15 PM revealed she didn't like to take the large white pill with all her other medications, so she left it for later and Nurse #3 did not take it away. An interview with the Nurse Practitioner (NP) on 2/24/26 at 1:57 PM revealed Resident #8 didn't like to take the potassium citrate, and she typically did not like to take a lot of medications at the same time. She stated Resident #8 has never had an order to self-medicate and she would not be able to self-medicate. The NP stated Nurse #3 should not have left the pill at Resident #8's bedside and the pill should have been returned to the medication cart when Resident #8 didn't take it. She stated no medications should ever be left at the bedside.A combined telephone interview with the Director of Nursing (DON) and the Administrator on 2/26/26 at 10:44 AM revealed the Administrator had the expectation that Nurse #3 should have taken the pill back to the medication cart to be destroyed after Resident #8 refused it. The DON indicated Resident #8 did not have an order to self-medicate although she had a history of asking staff to leave her medications at her bedside all the time. The Administrator stated she had the expectation for Nurse #3 to follow the protocol for medication refusal, and the medication should have been destroyed and the DON notified.

Based on observations, record review, and staff interviews, the facility failed to keep a fire compression tank clean of debris and keep the floor grout lines clean of greasy residue and food debris. These practices occurred in 1 of 2 food preparation areas and had the potential to affect food served to residents.The findings included:An initial tour of the main kitchen occurred 2/22/26 at 11:10 AM with the Head Cook. The following concerns were identified:-Visible dirt and grime build-up present on a large fire suppression tank and its tubing. The tank and the associated equipment were attached to the wall and ceiling in a food preparation area above the toaster. -Visible food debris and grease build-up was present in the grout lines of the floor tiles in front of the cooking range.An interview with the Head [NAME] occurred on 2/22/26 at 11:25 AM. She stated the housekeeping department oversaw the cleaning of the floors in the kitchen, however, she was unsure of the cleaning schedule. The Head [NAME] stated grease and food debris would build up in the grout around the floor tiles and she was unaware of the visible dirt and grime build-up on the fire suppression tank. An interview with the Housekeeping Supervisor was conducted on 2/23/26 at 2:10 PM. The Housekeeping Supervisor stated the kitchen floor was pressure washed on 2/20/26 and a new degreasing cleaning product was ordered with a new cleaning supply company. The Housekeeping Supervisor stated the old degreasing cleaning product they used didn't get everything as clean as it needed to be. A telephone interview with the Administrator on 2/26/26 at 10:57 AM revealed the kitchen floors had just been pressure cleaned and the new cleaning products were ordered but had not come in yet.

Based on record reviews, observations and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #4 did not wear Personal Protective Equipment (PPE) while providing urinary catheter care for Resident #5. In addition, Nurse Aide (NA) #9 failed to wear PPE while providing urinary catheter care and transferring Resident #33 from wheelchair to bed. These deficiencies occurred for 2 of 10 staff members observed for infection control practices (Nurse #4 and NA #9). The findings included:A review of the facility's policy that was undated titled Enhanced Barrier Precautions, indicated: Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. High-contact activities included dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, Peripherally Inserted Central Catheter (PICC) lines, midline catheters, and wound care if deemed chronic by a medical provider or if MDRO was present. a. An observation of urinary catheter care for Resident #5, provided by Nurse #4, was made on 2/25/2026 at 12:10 PM. Resident #5's room had an Enhanced Barrier Precautions (EBP) sign posted on the front of the door, and personal protective equipment (PPE) was hanging behind the door. The EBP sign located on Resident #5's door revealed gloves and a gown should be worn when providing high- contact care such as urinary catheter care. Nurse #4 entered the room without wearing a gown. She cleansed her hands with hand sanitizer gel and put on gloves. After completing Resident #5's urinary catheter care, she discarded any unused supplies and her gloves, then proceeded to wash her hands with soap and water at the sink.An interview with Nurse #4 on 2/25/2026 at 12:30 PM revealed she was aware that Resident #5 was on Enhanced Barrier Precautions. Nurse #4 stated she was not aware she needed to wear a gown while providing urinary catheter care.b. An observation of NA #9 transferring Resident #33 and emptying his urinary catheter was completed on 2/25/2026 at 1:35 PM. Resident #33's room had an Enhanced Barrier Precautions sign posted outside the door stating that staff should wear a gown and gloves for high-contact activities such as urinary catheter care and transfers. PPE was hanging on the back of Resident #33's door. NA #9 applied hand sanitizer to both hands and placed gloves on her hands. She did not put on a gown. NA #9 assisted Resident #33 with a stand-pivot transfer from his wheelchair to his bed. She then moved Resident #33's urinary catheter bag from the wheelchair to a hook on the side of the bed. NA #9 emptied the urinary catheter bag into a urinal and disposed of the urine in the toilet. She cleaned the urinal, disposed of her gloves, and washed her hands.An interview with NA #9 at 2:00 PM on 2/25/2026 was completed. NA #9 stated she was not aware that Resident #33 was on Enhanced Barrier Precautions. She stated she did not notice the sign on Resident #33's door because it was a dark gray printed sign, and she was accustomed to the light blue Enhanced Barrier Precautions signs with red stop signs. NA #9 reported she was not aware that a gown was required to transfer and provide care for residents with urinary catheters.An interview with the Director of Nursing (DON)/Interim Infection Preventionist was completed on 2/25/2026 at 3:52 PM. The DON stated that all employees were trained on infection control and proper use of PPE during orientation upon hire, and agency staff received infection control training online prior to working in the facility. The DON stated that staff should wear the appropriate PPE according to the enhanced barrier precaution signs posted for each resident.An interview with the Administrator was completed on 2/25/2026 at 4:12 PM. The Administrator stated she expected all staff members to use the appropriate PPE according to the enhanced barrier precaution signs posted for each resident.

Based on observations, record review, and Nurse Practitioner, staff and resident interviews, the facility failed to provide a safe transfer using a mechanical lift for Resident #43. On 3/9/24 Nurse Aide (NA) #1 and NA #2 were transferring Resident #43 with the mechanical lift when a strap that was frayed on the left side of the lift pad broke, and Resident #43 fell approximately 3 feet to the tile floor hitting her head and landing on her right side. Resident #43 was assessed by Nurse #3 and was observed to have a huge hematoma (collection of blood underneath the skin) to the back right side of her head and reported her whole right side hurt. Resident #43 was transported to the Emergency Department (ED) for further evaluation. Computed tomography (CT) scans and x-rays obtained in the ED were negative for fracture or injury. While in the ED Resident #43 experienced acute respiratory insufficiency related to rib pain and/or narcotic administration. Resident #43 returned to the facility on [DATE]. Resident #43 was not receiving an anticoagulant (blood thinner). Most recently on 1/15/25 Resident #43 was transferred with the mechanical lift for a shower and suffered a panic attack because she was scared of the mechanical lift. There was a high likelihood of a serious adverse outcome or injury when one of the straps on the lift pad broke when Resident #43 was being transferred with the mechanical lift. Additionally, the facility failed to secure the mechanical lift brake when transferring Resident #76. This deficient practice occurred for 2 of 6 residents (Resident #43 and Resident #76) reviewed for accidents. Immediate jeopardy began on 3/09/24 when Resident #43 was transferred using a mechanical lift and fell to the floor when the strap on the lift pad broke. Immediate jeopardy was removed on 3/10/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 is being cited a scope and severity of D. The findings included: 1. A review of the manufacturer's instruction manual for the mechanical lift provided by the facility read in part: The operator shall inspect the mechanical lift before each use checking all bolts for tightness, checking the sling hardware, making sure all lift parts are in place and checking the lift sling for any wear. Resident #43 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, chronic kidney disease and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 was cognitively intact and dependent on staff for transfers. The care plan dated 2/06/24 revealed Resident #43 had a problem area related to activities of daily living self-care performance deficit and the intervention was to use a mechanical lift and two-person assistance for transfers. A review of the facility incident report dated 3/09/24 at 3:34 PM written by Nurse #3 revealed Resident #43 was being transferred with the mechanical lift when one of the left side straps on the lift pad snapped in half and Resident #43 flipped out of the lift pad and landed on the floor. Resident #43 was observed lying on the floor at the base of the mechanical lift, had a blank stare and was only responding to painful stimuli for approximately 1 minute. Resident #43 reported hitting her head and was complaining of pain to her whole right side. Resident #43 was assessed for injury and noted to have a huge hematoma to the back right side of her head. Nurse #1 called Emergency Medical Services (EMS), notified the Nurse Practitioner (NP) and Resident Representative (RR), and Resident #43 was transferred to the ED for further evaluation. A review of NA #1's statement dated 3/11/24 indicated on 3/09/24 NA #2 assisted her with transferring Resident #43 to a shower chair. The 4 straps on the lift sling were secured to the hooks on the mechanical lift. During the transfer one of the sling straps broke and Resident #43 fell to the floor hitting her head and landing on her right side. Several attempts were made to call NA #1 were unsuccessful. A review of NA #2's statement dated 3/11/24 revealed on 3/09/24 she was assisting NA #1 to transfer Resident #43 to a shower chair using the mechanical lift. When they began lifting Resident #43 one of the straps on the sling broke and she slipped out of the sling, fell to the floor and hit her head. An interview with NA #2 on 1/29/25 at 8:21 AM revealed on 3/09/24 she assisted NA #1 with transferring Resident #43 to a shower chair using the mechanical lift sometime after lunch. She stated NA #1 placed the lift sling under Resident #43 and hooked the sling straps to the mechanical lift before she entered the room, so she was unsure if NA #1 inspected the sling to ensure it was in good condition. NA #2 indicated they were supposed to check the lift slings before every use to make sure the sling was in good condition and the straps were not frayed or torn. NA #2 revealed when they were lifting Resident #43 from the bed one of the straps on the lift sling snapped and Resident #43 slid out of the sling and fell approximately 3 feet to the floor hitting her head. She indicated they immediately called out for help, Nurse #3 responded and assessed Resident #43 for injury. NA #2 stated she did not recall which strap on the lift sling broke nor did she look at the sling following the incident. A review of the Nurse Practitioner note dated 3/09/24 indicated Resident #43 fell to the floor from approximately 3 feet hitting her head and landing on her right side. Nurse #3 reported Resident #43 had a blank stare for one minute and was complaining of head pain and pain to her right side. EMS was called and Resident #43 was sent to the ED for further evaluation. A review of the hospital records revealed Resident #43 was evaluated in the ED on 3/09/24 due to falling from a mechanical lift and was complaining of pain to her head, right leg and hip. Computed tomography (CT) scans of the head, chest and spine were obtained as well as x-rays of the pelvis, right leg and hip. The CT scan results showed no acute trauma, and the x-rays were negative for fractures. Resident #43 experienced acute respiratory insufficiency while in the ED, suspected to be related to rib pain and/or narcotic administration. Resident #43 was admitted to the hospital on 3/09/24 for observation and discharged back to the facility on [DATE] with no new orders. An interview conducted with Resident #43 on 1/29/25 at 4:30 PM revealed she did not recall the date, but during a transfer with the mechanical lift from her bed to the shower chair a strap on the lift sling broke and she fell to the floor. She indicated she fell left out of the sling, flipped as she fell to the floor landing on her right side and hitting her head. Resident #43 indicated her head and whole right side hurt and the nurse responded and called EMS. She revealed she was transferred to the ED for further evaluation but did not have any injuries or fractures. Resident #43 stated she had to use the mechanical lift to be transferred to a shower chair and only received a few showers since the incident because she was scared to use the mechanical lift. She stated staff were giving her bed baths, but she really enjoyed taking a shower once or twice a week. Resident #43 indicated the few times she received a shower and was transferred with the mechanical lift she had a panic attack. An interview conducted with Nurse #3 on 1/29/25 at 9:54 AM indicated she was assigned to Resident #43 on 3/09/24. She revealed she heard NA #1 and NA #2 yelling for help and responded to Resident #43's room and observed her lying on the floor. She stated NA #1 and NA #2 reported they were using the mechanical lift to transfer Resident #43 when one of the straps on the lift sling snapped and Resident #43 fell to the floor and hit her head. Nurse #3 revealed she assessed Resident #43 but did not recall if she had any visible injuries. She stated because Resident #43 hit her head she immediately called EMS, notified the NP and Resident #43 was transferred to the ED for further evaluation. Nurse #3 revealed she did not recall which of the 4 straps on the lift sling broke, but she observed the sling after the incident and the broken strap was frayed which caused it to rip in half. An interview conducted with the NP on 1/30/25 at 12:47 PM revealed she was notified by Nurse #3 that Resident #43 had a fall to the floor from approximately 3 feet and hit her head. The NP stated Resident #43 was transferred to the ED for further evaluation. She indicated CT scans and x-rays obtained in the ED were negative for acute injury or fractures. The NP revealed she was not immediately aware that Resident #43 fell during a transfer with the mechanical lift, however that would not have changed the course of treatment. She revealed when a resident falls and hits their head they were at risk for suffering injuries including a concussion or brain bleeding and standard protocol was to transfer them to the ED for further evaluation. The NP stated she could not comment on the safety measures that staff should take when using a mechanical lift to transfer a resident. An attempt was made to call the Former Director of Nursing, but the phone number was no longer in service. An interview with the Former Director of Maintenance on 1/31/25 at 3:45 PM revealed he inspected all the mechanical lifts and lift slings once a month to ensure they were in good repair. He stated the nursing staff were responsible for inspecting the lift slings before every use. He stated he was aware of the incident on 3/09/24 involving Resident #43 falling from the mechanical lift due to a strap on the lift sling breaking. The Director of Maintenance indicated he did not recall observing any lift slings during his monthly inspections prior to the incident on 3/09/24 that were damaged or had frayed or torn straps. An interview was conducted with the Former Administrator on 1/29/25 at 12:58 PM. He stated on 3/09/24 he was notified that NA #1 and NA #2 were using a mechanical lift to transfer Resident #43 when one of the straps on the lift sling broke and Resident #43 fell to the floor. He revealed he initiated an investigation that day and determined the lift sling that NA #1 used to transfer Resident #43 was damaged and she did not inspect it prior to use. The Former Administrator indicated when staff were using the mechanical lift to transfer a resident, they should inspect the lift sling prior to every use for damage and ensure it was in good repair. The Administrator was notified of immediate jeopardy on 1/29/25 at 6:00 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the noncompliance: On 03/09/2024, Resident #43 experienced a fall during a transfer using a mechanical lift. The loop on the sling that connects to the mechanical lift tore resulting in the resident falling to the floor. The Licensed Nurse immediately assessed the resident, found unresponsive to vocal stimulation for about one minute, but responded to painful stimuli. The Licensed Nurse also observed a hematoma on the right side of the back of her head and the resident reported pain to her full right side but denied pain to her neck or back. The Nurse Practitioner was notified of the incident. Resident #43 was subsequently transferred to the hospital via EMS for further evaluation. The hospital evaluation resulted in no fractures reported from the performed imaging and the CT scan of chest, abdomen, pelvis, and spine did not show acute trauma. The resident returned to the facility on [DATE] with no new orders. On 03/09/2024 the Nurse Aide initially removed the damaged sling from Resident #43's room after the incident occurred and was inspected by the Maintenance Director and Nurse Aide. The sling was immediately thrown in the trash after it was inspected. Residents at risk of experiencing similar adverse outcomes would include those who rely on mechanical lifts for transfers. A facility-wide audit of all mechanical lift slings was conducted on 03/09/2024 by the facility Maintenance Director with the assistance of a nurse aide. The audit's purpose was to identify residents at risk. The lift slings were thoroughly inspected for rips, tears, and frays. No other lift slings were found to have been defective. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed: On 3/9/24 one on one competency assessments were completed for the two nurse aides involved in the incident by Licensed Charge Nurse with emphasis on safety procedures including how to inspect lift slings for rips, tears, and frays, and to immediately remove any slings that are defective. The two nurse aides demonstrated correct usage of the mechanical lift. On 3/9/24 in-person education was provided to all nurse aides and licensed nurses on duty by the Maintenance Director on proper lift usage and safety procedures including how to inspect lift slings for rips, tears, and frays before each use, as well as to immediately remove any slings from use if they are defective and take them to their immediate supervisor. The in-person training was continued after 3/9/24 for all direct care staff, including agency staff, for the rest of the month for those not on duty the day of the incident. All agency staff were in-serviced during facility orientation. The Director of Nursing was responsible for tracking the staff that required education and for providing the education. Staff were not allowed to work until education was completed. New hires, including agency staff, are required to complete education during orientation. Alleged date of immediate jeopardy removal: 03/10/24 The facility's credible allegation of immediate jeopardy removal was validated on 1/31/25. Observations conducted of the facility's lift slings revealed they were in good repair and there were no slings observed to have frayed straps or other damage. An observation conducted of a resident being transferred with a mechanical lift revealed the NA inspected the lift sling prior to use, it was observed to be in good condition and was used per the manufacturer's instructions. An interview conducted with NA #2 indicated she received education on how to inspect mechanical lifts and lift slings prior to every use for damage, removing damaged equipment immediately from service and then reporting equipment concerns to administration. NA #2 revealed she also received education on performing a safe resident transfer using the mechanical lift and then completed a return demonstration. Interviews conducted with nurses and nurse aides revealed they received education on how to properly inspect mechanical lifts and lift slings prior to every use, immediately removing equipment from service that was damaged, and reporting equipment concerns to administration. An interview conducted with the Former Director of Maintenance indicated he completed safety inspections of all the mechanical lifts and lift slings, and no concerns were identified. Additionally, it should be noted that the facility was unable to locate the initial audit completed on 03/09/24 of all of the facility's mechanical lifts nor was the facility able to locate the audit completed on 03/09/24 of all the lift slings that were inspected for rips, tears, and frays. The facility was also unable to provide any ongoing monitoring that had occurred since the 03/09/24 incident. The facility's immediate jeopardy removal date of 03/10/24 was validated on 1/31/25. 2. A review of the mechanical lift manufacturer's instructions provided by the facility read in part: Operating instructions: Preparation before lifting - widen the base and engage the caster (wheel) brake. Resident #76 was admitted to the facility 8/15/24 with diagnoses including: Right tibia fracture, muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #76 was severely cognitively impaired and required substantial to maximal assistance with transfers. The care plan dated 11/26/24 revealed Resident #76 had a problem area related to activities of daily living self-care performance deficit. The intervention was to provide substantial to maximal assistance with transfers but did not include the use of a mechanical lift. An observation was conducted on 1/29/25 at 11:50 AM of Nurse Aide (NA) #2 and NA #3 using the mechanical lift to transfer Resident #76 from her bed to the wheelchair. Nurse Aide (NA) #2 positioned the base of the mechanical lift under the bed while NA #3 locked the brake on the bed. NA #2 did not secure the wheel brake on the base of the mechanical lift. NA #2 was operating the mechanical lift and when she was raising Resident #76 from the bed the base of the lift moved and shifted to the right. After Resident #76 was raised from the bed NA #2 moved the mechanical lift from the bed to the wheelchair while NA #3 guided Resident #76 in the lift sling positioning her over the wheelchair. NA #3 made sure the wheelchair brakes were locked and NA #2 lowered Resident #76 into the wheelchair. NA #2 did not secure the wheel brake on the mechanical lift before lowering Resident #76. An interview was conducted with NA #3 on 1/29/25 at 3:30 PM. She stated she was assisting NA #2 to transfer Resident #76 with the mechanical lift. NA #3 indicated she was not operating the mechanical lift during the transfer, and it was the responsibility of the person operating the lift to ensure the wheel brake was secured prior to lifting the resident. NA #3 revealed she did not notice that the brake on the mechanical lift was not secured prior to Resident #76 being lifted from the bed and she was unsure as to why NA #2 did not secure the brake. A phone interview with NA #2 on 1/30/25 at 1:18 PM revealed when using the mechanical lift to transfer a resident, the wheel brake on the mechanical lift should be secured prior to lifting or lowering the resident. NA #2 stated when she was using the mechanical lift to transfer Resident #76 on 1/29/25 she did not recall that the wheel brake on the mechanical lift was not secured when she was lifting and lowering Resident #76 and she thought she had secured the brake. A phone interview was conducted with the Director of Nursing (DON) on 1/30/25 at 8:40 AM. She stated when staff were transferring a resident with the mechanical lift they should operate the lift per the manufacturer's guidelines. The DON further stated if the manufacturer's guidelines indicated the wheel brake on the mechanical lift should be secured prior to lifting or lowering the resident then staff should secure the wheel brake accordingly. A phone interview was conducted with the Administrator on 1/31/25 at 9:30 AM. He stated nursing staff should operate the mechanical lifts per the manufacturer's guidelines including securing the wheel brake on the mechanical lift prior to lifting or lowering a resident to ensure the resident was transferred safely.

Based on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with the following diagnoses, cerebral infarction (stroke), obesity and stress incontinence. A review of Resident #64's comprehensive care plan dated 12/24/24 included the following interventions, she was bedfast all or most of the time, she required hands on dependent assistance with perineal hygiene and she was not toileted. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #64 was cognitively intact. Resident #64 had no impairment of her upper extremities and had impairment to both lower extremities. Resident #64 was incontinent of both bowel and urine. She had no pressure ulcers but had moisture association skin damage. On 1/26/25 at 1:00 PM the initial interview and observation was conducted with Resident #64. She stated staff would run out of the correct size brief and staff would use a smaller brief on her. It was observed that Resident #64 had a bariatric bed and mattress. On 1/28/25 at 1:53 PM a second interview was conducted with Resident #64. She stated that since admission to the facility, the facility often runs out of the 2X briefs, and the staff will use a smaller brief on her. The smaller brief was very uncomfortable and left red marks on her inner thighs. Resident #64's family member now brings in a supply of 2X briefs and wipes, so she has what she needs. Resident #64 stated that sometimes the staff will come in and ask to borrow some of her personal supplies because they can't find any large briefs. Resident #64 stated that recently she had no fitted sheet on her bed and was told by staff they ran out of linens. Resident #64 had a bariatric mattress, and stated they run out of the sheets for this type of bed often. A daily staffing sheet dated 10/25/24 for the 11PM-7AM shift stated there was no linen. On 1/27/25 at 3:30 PM an interview was conducted with Nurse Aide (NA) #4. NA #4 stated she worked the 7am-7pm shift. She stated she did not think there were sufficient supplies, especially bariatric briefs. She stated the supply clerk quit four weeks ago. NA #4 stated she knows her residents' needs and will ration out supplies. She stated that once supplies are gone, they are gone, and the staff wait until the next shipment. NA #4 stated she recently reported the supply issue but had not noticed any changes. NA #4 stated she had often run out of bariatric briefs and had no choice but to use a smaller brief. She stated linens were also an issue and often ran out of linens such as sheets. NA #4 stated that when there was no linen, she would need to make do with what she had. Sometimes using a smaller sheet for a bariatric bed, which did not work well or no sheet at all. On 1/29/25 at 10:01 AM an interview was conducted with NA #5. NA #5 stated that there had been several times the facility didn't have enough briefs. NA #5 stated that sometimes the shipment doesn't come in as planned and she felt Central Supply was not ordering enough briefs. On 1/29/25 at 10:25 AM an interview was conducted with NA #6. NA #6 stated she had found the facility was short on briefs a couple times each week. She stated that there had been times when the supply closet had no briefs, and she had to search all over the facility to find briefs. NA #6 stated the last two months had been worse with the facility not having enough briefs and she had to use smaller briefs on bariatric residents. NA #6 also stated the facility runs out of linens as well. NA #6's understanding of the process was the first and second shift would get a linen cart but not the third shift. NA #6 stated she worked the 7AM to 7 PM shift. She stated that sometimes when she comes in to start her shift, she will find that some of her assigned residents had no fitted sheet on their bed and was informed they had no linen for the bariatric beds. On 1/26/25 at 3:25 PM an interview was conducted with Nurse #1. She stated the clean linen was brought up in the evening around 4:00 - 5:00 PM from the laundry room. She stated that often times there was not a sufficient amount of linens and it was an ongoing issue. On 1/27/25 at 3:20 PM an interview was conducted with Nurse #4. The nurse worked the 7am-7pm shift and stated there were not enough linen. The cart will come up full and quickly be gone. On 1/26/25 at 3:25 PM an observation was made of the linen/supply closet. There were no linens or towels in the closet. On 1/27/25 at 3:30 PM a 2nd observation was made of the 100-unit linen closet. The linen closet had no linens of any kind. It did have three shelves of incontinent briefs, several boxes of gloves and one package of wipes. On 1/29/25 at 10:26 AM an interview was conducted with the Regional Housekeeping Director. She stated that the third shift does have a linen cart that was kept in her office and the third shift staff just need to come down to get it, but they never do. She felt the facility had enough linen. 2. Resident #28 was admitted to the facility on [DATE] with the following diagnoses, morbid obesity, chronic kidney disease and amyotrophic lateral sclerosis. The MDS dated [DATE] revealed that she was cognitively intact, she had impairment on one side of her lower extremity and was frequently incontinent of bowel and urine. A review of Resident #28's comprehensive care plan dated 11/12/24 included the following interventions, use disposable briefs after each incontinent episode, allowing her to place insert (high absorbency pad) in brief per her request and preference and she required extensive assistance of one for toileting. On 1/28/25 at 2:58 PM an interview was conducted with Resident #28. She stated that every week the staff run out of 2X briefs, and the staff had to use a smaller size. The smaller brief is uncomfortable and left redness on her upper thighs. Resident #28 stated that once you see staff handing out three briefs per resident that was a sign that they were running low on supplies. Resident #28 stated that staff also ran out of wipes and had to carry wipes from room to room. Resident #28 had linen with holes in it and once went without a fitted sheet. On 1/28/25 at 3:03 PM an interview was conducted with NA #7. She stated that the facility runs out of large briefs often and sometimes will need to use a smaller size brief on a resident. NA #7 has done care for both Resident #64 and Resident #28 and had to use smaller briefs on both residents due to not having the correct size. NA #7 stated they also run out of fitted sheets and some of the sheets have holes in them. NA #7 stated that unfortunately there had been times the residents went without any fitted sheets because the facility did not have anything to use. On 1/29/25 at 2:37 PM an interview was conducted with the Administrator. He stated the facility just hired a new company to purchase briefs. The facility is trying to figure out what is needed so they can order the correct amount and the correct sizes. The facility also ordered more linens. The Administrator agreed that the residents should have supplies and sheets on their beds to accommodate resident needs.

Based on record review, observations, staff interviews and resident interviews, the facility neglected to provide a sufficient quantity of linens and size 2x incontinent briefs for 2 of 2 residents who required bariatric goods (Resident #64 and Resident #28). The findings included: Cross refer to tag F558. Based on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28).

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 29 of 389 days reviewed for sufficient staffing. The findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 2, 2024 (January 1 - March 31, 2024) revealed the facility had no RN coverage on 1/06/2024, 1/20/2024,1/21/2024, 2/03/2024, 2/04/2024, 2/10/2024, 2/11/2024, 2/17/2024, 2/18/2024, 3/02/2024, 3/10/2024, 3/16/2024 and 3/30/2024. Review of the PBJ Staffing Data Report Fiscal Year - Quarter 3, 2024 (April 1 - June 30, 2024) revealed the facility had no RN coverage on the following dates: 5/12/2024, 5/18/2024, 6/08/2024 and 6/15/2024. Review of the PBJ Staffing Data Report Fiscal Year - Quarter 4, 2024 (July 1 - September 31, 2024) revealed the facility had RN coverage for 8 consecutive hours per day, 7 days a week during the report period. The facility's daily assignment schedules from 10/01/2024 to 1/31/2024 revealed the facility failed to provide 8 hours of RN coverage on the following dates: 10/05/2024, 10/06/2024, 10/20/2024, 10/27/2024, 11/03/2024, 11/16/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/17/2024, and 12/20/2024. An interview with the Staff Scheduler on 1/31/25 at 3:30 PM indicated he scheduled an RN daily to work at least 8 consecutive hours. He stated if the RN was scheduled to work on a weekday and called out the MDS Coordinator or Wound Care Nurse were able to fill in as the RN on duty. The Staff Scheduler further stated if the RN scheduled to work on a weekend day called out there was not usually another RN in the building to fill in and they had difficulty finding a replacement. He indicated they were actively working to hire nurses including RNs and currently used three different staffing agencies to fill vacant shifts. A phone interview was conducted with the Administrator on 1/31/25 at 9:30 AM. He stated the facility came under new ownership 12/16/2024 and they had a corporate recruiter that was working on hiring nursing staff including RNs. He indicated he was unable to provide records that an RN worked on the dates identified both on the PBJ Staffing Data Reports and the facility's daily assignment schedules that there was no RN coverage. The Administrator stated the facility should have an RN scheduled at least 8 consecutive hours per day, 7 days a week.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of functional abilities (Resident #76) and discharge status (Resident #82) for 2 of 2 residents reviewed for accuracy of assessments. The findings included: 1. Resident #76 was admitted to the facility 8/15/24 with diagnoses including right tibia fracture, muscle weakness and cognitive communication deficit. A review of the weekly nursing summary dated 10/26/24 completed by Nurse #5 revealed Resident #76 was totally dependent on staff for transfers. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #76 required substantial to maximal assistance with transfers. The care plan dated 11/26/24 revealed Resident #76 had a problem area related to activities of daily living self-care performance deficit. The intervention was to provide substantial to maximal assistance with transfers but did not include the use of a mechanical lift. A phone interview was conducted with Nurse #5 on 1/31/25 at 8:46 AM indicated she was the primary nurse that worked with Resident #76 on 1st shift (7AM - 7PM). Nurse #5 stated since Resident #76 was admitted to the facility she was dependent on staff for transfers and required the use of a mechanical lift. A phone interview conducted with the MDS Nurse on 1/31/25 at 9:10 AM revealed when completing a resident MDS assessment she pulled information from the point of care which provided the NAs documentation of the level of assistance a resident required to complete activities of daily living (ADL). The MDS Nurse revealed she also interviewed direct care staff to verify the resident's level of functioning. She indicated she was unable to pull up the point of care information used to complete Resident #76's MDS dated [DATE] and did not recall if she interviewed the direct care staff concerning her transfer status. She stated if a resident was transferred with a mechanical lift, the transfer status should be coded as dependent on the MDS. The MDS Nurse revealed she was unsure why she did not code Resident #76's transfer status as dependent. A phone interview with the Director of Nursing on 1/31/25 at 11:21 AM indicated a resident that was transferred with a mechanical lift was dependent on staff for transfers and the transfer status should be coded as dependent on the MDS assessment. 49366 2. Resident #82 was admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82 was discharged to a general hospital. Review of a nursing progress note dated 11/22/24 indicated Resident #82 was discharged home with family. An interview with the MDS Nurse on 1/29/25 at 2:20 PM was conducted. She stated the discharge MDS for Resident #82 dated 11/22/24 should have been coded as discharged home. She explained the Social Worker (SW) had inaccurately coded the MDS. A telephone interview with the SW on 1/30/25 at 10:49 AM revealed she was responsible for coding certain areas of the MDS for all residents, which included the Identification Information section which included discharge status. An interview with the Director of Nursing (DON) on 1/29/25 at 4:35 PM revealed residents' discharge MDS should accurately reflect their discharge location and the MDS Nurse should update the MDS. During an interview with the Administrator on 1/29/25 at 5:16 PM he indicated the MDS should be completed accurately.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of Hospice for 1 of 1 resident reviewed for Hospice (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe) and respiratory failure. Review of a significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact and received hospice services. A review of Resident #29's comprehensive care plan did not reveal a care plan in the area of Hospice. In an interview with the MDS Nurse on 01/28/25 at 1:51 PM revealed she looked for Resident #29's Hospice care plan in her record and stated she did not have one. She stated she was responsible for completing the comprehensive care plan and missing the Hospice care plan was an oversight. An interview with the Director of Nursing (DON) on 01/28/25 at 1:53 PM revealed the MDS nurse was ultimately responsible for developing comprehensive care plans. She was unaware Resident #29 did not have a care plan to address Hospice services. An interview with the Administrator was conducted on 01/29/25 at 4:45 PM. The Administrator stated he was not aware Resident #29 did not have a Hospice care plan.

Based on observations, record review, and staff interviews, the facility failed to obtain a physician's order for the use of supplemental oxygen for 1 of 3 residents reviewed for oxygen use (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe) and respiratory failure. Review of a significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact and received oxygen therapy. Review of Resident #29's physician's orders revealed there were no orders for supplemental oxygen. An observation and interview was conducted on 01/26/2025 at 12:05 PM with Resident #29. Resident #29 was observed lying in bed with oxygen on at 3.5 liters per minute via nasal canula. She stated 3.5 liters per minute was her normal setting and she had been on supplemental oxygen for over a year. An observation was conducted on 01/27/2025 at 3:27 PM of Resident #29. Resident #29 was observed lying in bed with oxygen on at 3.5 liters per minute via nasal canula. An observation was conducted on 01/28/2025 at 2:08 PM of Resident #29. Resident #29 was observed lying in bed with oxygen on at 3.5 liters per minute via nasal canula. An interview was conducted on 01/28/2025 at 1:23 PM with Nurse #2. Nurse #2 stated if a resident was on oxygen, there should be an order in the resident's medical record. Nurse #2 stated Resident #29 had been on oxygen since admission and stated she was unsure why she did not have an order. Nurse #2 stated Resident #29 should have had an order for oxygen. An interview was conducted on 01/28/2025 at 1:32 PM with Unit Manger #1. Unit Manager #1 stated if a resident was on oxygen there would be an order in the resident's medical record and would sign off that oxygen was in use on the Medication Administration Record (MAR). Unit Manager #1 stated she was not aware Resident #29 did not have an order for oxygen and stated she should have. An interview was conducted on 01/28/2025 at 1:53 PM with the Director of Nursing (DON). The DON stated if a resident required oxygen there should be an order in the resident's chart. The DON stated she was not sure why Resident #29 did not have an order for oxygen and stated she should have.

Based on observations, record review, and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions during high-contact care and hand hygiene when Nurse #1 performed wound care for a resident with a full-thickness wound without wearing a gown and failed to perform hand hygiene after removing a soiled dressing, cleaning a wound, and before applying a new wound dressing for Resident #20. The deficient practice occurred for 1 of 1 staff member (Nurse #1) observed during wound care. The findings included: The facility's Enhanced Barriers policy approved 03/28/24 revealed it is the policy of this facility to use enhanced barrier precautions (EBP) based on guidance from the Center for Disease Control (CDC). Enhanced barrier precautions refer to the infection control intervention aimed at reducing transmission of multi-resistant organisms (MDROs) through the targeted use of gown and gloves during high-contact resident care activities. High-contact resident care activities requiring EBP include wound care (any skin opening requiring a dressing). The Hand Hygiene policy last revised July of 2024 revealed staff were to perform hand hygiene before performing dressing care or touching wounds of any kind, after handling dressings, urinals, catheters, bedpans, contaminated tissues, linen, etc. The policy also stated hand hygiene should be performed after removing gloves. The Clean Dressing Change policy effective July 2024 revealed staff were to complete the following: - Wash hands and put on clean gloves. - Place a barrier cloth or pad next to the resident, under the wound to protect the bed and body sites. - Loosen the tape and remove the existing dressing. - Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacles. - Wash hands and put on clean gloves. - Cleanse the wound as ordered. Pat dry with gauze. - Wash hands and put on clean gloves. - Apply topical ointments or creams and dress the wound as ordered. - Secure dressing. [NAME] with initials and date. - Discard disposable items and gloves into appropriate trash receptable and wash hands. An observation was conducted on 1/29/2025 at 9:26 AM while Resident #20 received wound care. Nurse #1 was observed entering Resident #20's room without a gown, laying wound supplies on the bedside table and applied clean gloves without performing hand hygiene. Nurse #1 removed a soiled dressing from Resident #20's sacrum and changed gloves without performing hand hygiene. Nurse #1 cleaned the wound on Resident #20's sacrum and placed a clean dressing on the wound. Nurse #1 then removed her gloves and washed her hands prior to exiting Resident #20's room. An interview was conducted on 1/29/2025 at 9:36 AM with Nurse #1. Nurse #1 stated Resident #20 was not on Enhanced Barrier Precautions. Nurse #1 stated EBP were used when a resident had an indwelling medical device and was unsure if it was needed for wounds. Nurse #1 stated she did not sanitize or wash her hands between removing the old dressing, cleaning the wound, and placing the new dressing on Resident #20's wound because she had just forgotten and was doing the best that she could. Nurse #1 stated after the surveyor brought the EBP to her attention she then noticed the EBP sign located at the head of the resident's bed on the wall. Nurse #1 stated there should be gowns on the outside of the resident room so she would have known he was on EBP. The interview revealed Nurse #1 typically did not complete wound care in the facility however, the Wound Care Nurse had called out on the date observed and she was asked to complete all dressing changes for the day. An interview was conducted on 1/29/2025 at 10:25 AM with the Director of Nursing (DON). The DON stated she served as the Infection Control Nurse for the facility since January 2025. The DON stated staff received education about infection control during orientation and annually. The DON stated when staff performed wound care, they should wash their hands and change gloves before removing the old dressing and then perform hand hygiene and glove changes in between steps. The DON stated Nurse #1 should have changed gloves and performed hand hygiene after she removed the dirty dressing, after cleaning, and before applying a new dressing. The DON stated residents with a wound, required EBP. The DON stated she was not sure why Resident #20's EBP sign was not located on the resident's door or have gowns outside of the room for staff. The DON stated she was still new to the facility and would be keeping a closer eye on EBP.

Based on record review and staff interviews, the facility failed to maintain a record of the daily posted nurse staffing sheets for 472 of 519 days of the period reviewed from September 1, 2023 through January 31, 2025. The findings included: The daily nurse staffing sheets for September 2023 revealed no information was available for the days of 9/01/2023 through 9/30/2023. The daily nurse staffing sheets for October 2023 revealed no information was available for the days of 10/01/2023 through 10/31/2023. The daily nurse staffing sheets for November 2023 revealed no information was available for the days of 11/01/2023 through 11/30/2023. The daily nurse staffing sheets for December 2023 revealed no information was available for the days of 12/01/2023 through 12/31/2023. The daily nurse staffing sheets for January 2024 revealed no information was available for the days of 1/01/2024 through 1/31/2024. The daily nurse staffing sheets for February 2024 revealed no information was available for the days of 2/01/2024 through 2/29/2024. The daily nurse staffing sheets for March 2024 revealed no information was available for the days of 3/01/2024 through 3/31/2024. The daily nurse staffing sheets for April 2024 revealed no information was available for the days of 4/01/2024 through 4/30/2024. The daily nurse staffing sheets for May 2024 revealed no information was available for the days of 5/01/2024 through 5/31/2024. The daily nurse staffing sheets for June 2024 revealed no information was available for the days of 6/01/2024 through 6/30/2024. The daily nurse staffing sheets for July 2024 revealed no information was available for the days of 7/01/2024 through 7/31/2024. The daily nurse staffing sheets for August 2024 revealed no information was available for the days of 8/01/2024 through 8/31/2024. The daily nurse staffing sheets for September 2024 revealed no information was available for the days of 9/01/2024 through 9/30/2024. The daily nurse staffing sheets for October 2024 revealed no information was available for the days of 10/01/2024 through 10/31/2024. The daily nurse staffing sheets for November 2024 revealed no information was available for the days of 11/01/2024 through 11/30/2024. The daily nurse staffing sheets for December 2024 revealed no information was available for the days of 12/01/2024 through 12/15/2024. A phone interview with the Scheduler on 1/30/2025 at 8:54 AM indicated he was responsible for completing the daily posted nurse staffing sheets and maintaining a record of the sheets for 18 months. He stated due to the facility's ownership changing on 12/16/2024 they did not have access to the posted nurse staffing sheet records prior to that date. A phone interview with the Administrator on 1/31/2025 at 9:30 AM indicated the facility's ownership changed on 12/16/2024 and there were no records of the daily posted nurse staffing sheets available prior to that date. He stated records of the daily posted nurse staffing should be maintained for 18 months.

Based on observation, record reviews and staff interviews, the facility failed to ensure Medication Aide (Agency MA #1) and other nursing staff were trained and competent in cleaning and disinfecting glucometers (blood glucose machine) according to manufacturer recommendations using an Environmental Protection Agency (EPA) approved disinfectant cloth, between resident usage. Agency MA #1 was observed not cleaning and disinfecting a shared glucometer between use with three residents (Resident #28, Resident #30, and Resident #57). Interviews with Nurse #2, Nurse #6 and Nurse #10 revealed each nurse was unable to describe glucometer disinfection procedures. This deficient practice involved four of four nursing staff. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (Agency MA #1) demonstrated she was not competently disinfecting a shared glucometer between resident use per manufacturer's recommendations. The immediate jeopardy was removed on 8/23/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: Cross refer to tag F 880. Based on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). This practice affected 3 of 4 residents on the assigned unit and could potentially affect 17 residents in the facility who required glucose monitoring. A review of Agency MA #1's employee training records from the nursing home and staffing agency revealed there was no medication aide training to include cleaning and disinfecting of a glucometer. An interview with Medication Aide (MA #1) with the DON present on 8/20/23 at 1:30 PM revealed she acknowledged was previously shown glucometers should be cleaned and disinfected between resident use, however, she stated she rushed to obtain blood glucose monitoring before the residents received their lunch trays and did not take the time to clean and disinfect the shared glucometer. MA #1 was also unable to verbalize the correct procedure to use with the EPA approved disinfecting wipes. An interview with Nurse #10 who was working the East Wing Cart #2 at 4:50 PM revealed she was responsible for obtaining blood glucose monitoring and aware the glucometers should be cleaned between residents but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. An interview with Nurse #2 who was working the [NAME] Wing Cart #1 at 4:53 PM revealed he was responsible for obtaining blood glucose monitoring and aware the glucometers should be cleaned between residents but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. A telephone interview with Nurse #6 on 8/21/23 at 8:55 AM revealed she had last worked in the facility as an agency nurse on Thursday 8/17/23. Nurse #6 had been responsible for blood glucose monitoring and was aware the glucometers were required to be cleaned and disinfected between each resident use but was unable to recall the correct procedure for performing this task or the correct kill time for the EPA wipes used in the facility. An interview with the Director of Nursing (DON) on 8/20/23 at 1:30 PM revealed DON verified she was responsible for all staff training because the facility did not have a staff development coordinator. She also explained MA #1 had no education/training on how to clean and disinfect the glucometers by the facility or the staffing agency which she was hired as a nurse aide. MA #1 had received Nurse Aide competencies in the facility, but no medication aide training to include glucometer cleaning and disinfecting. The DON stated the facility did not currently have a system in place to verify credentials and competencies of agency staff and relied on the staffing agency to verify these. A telephone interview with the Medical Director on 8/29/23 at 9:49 AM revealed he would expect all staff to perform care in a manner to prevent potential cross contamination of bloodborne illnesses. An interview with the Administrator on 8/24/23 at 1:09 PM revealed he was new to the facility and left all training of nursing personnel to the DON, but he would have expected the glucometer to be cleaned and disinfected before and after use to decrease the spread of any potential illness. Facility administration (Administrator and Director of Nursing) was notified of immediate jeopardy on 8/22/23 at 12:09 PM. The facility provided the following plan for IJ removal. Noncompliance Allegation: Based on observation, record reviews, and staff interviews, the facility failed to ensure Medication Aide #1 and other nursing staff were trained on how to thoroughly clean and disinfect a glucometer (blood glucose machine) according to manufacturer guidelines using an EPA- approved disinfectant cloth, between resident usage. This occurred for 3 of 3 residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57). Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Observation, record review, resident, and staff interviews completed by the surveyor on 8/20/23 identified the facility failed to ensure training was provided to nursing staff for glucometer cleaning according to manufacturer guidelines using an EPA-approved disinfectant cloth between each resident usage. This occurred for 3 residents who were required to have their blood glucose levels checked (Resident #28, Resident #30, and Resident #57). Clinical staff failed to use the appropriate procedure to clean and disinfect a shared glucometer. On 8/20/23 and 8/21/23 the Director of Nursing and Unit Managers conducted interviews to evaluate understanding of the facility's glucometer disinfectant procedure prior to providing education with 25 Licensed Nurses- 11 of 25 are facility employees and 14 of 25 are agency nurses It was determined there was a knowledge deficit related to the facility process for disinfecting glucometers and Licensed Nurses were unable to recall previous training. No documentation of previous glucometer disinfection training during the last 3 months was identified by the Director of Nursing after reviewing completed training logs. Re-education of the facility process for disinfecting glucometers was initiated immediately by the Director of Nursing and Unit Managers. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and Administrator educated the Unit Managers regarding the Glucometer Disinfection policy and procedures for using fingerstick blood glucose checks, managing glucometers and cleaning requirements. This was completed on 8/21/23. Current Licensed Nurses have received training from the Director of Nursing and Unit Managers: o The purpose for following the cleaning checklist process, for glucometers due to the likelihood of cross-contamination and the spread of bloodborne pathogens among residents. o The importance of cleaning and disinfecting the glucometer per manufacturer's guidelines, using the training/education checklist for Cleaning Glucometers that includes the process of cleaning and includes observation and return demonstration. o This includes cleaning and disinfecting the individually issued glucometers that are stored at the residents' bedside. o On 8/22/23 return demonstration of process was observed by the Director of Nursing and Unit Managers to validate understanding. The Director of Nursing and Unit Managers completed this education for current Licensed Nurses, including those working for agencies, on 8/21/23. This education was provided verbally with written documents for reference and a return demonstration completed by the Director of Nursing and Unit Managers. The orientation for new hires and agency staff will be updated to include the procedure for cleaning glucometers after use. The Director of Nursing approves all new Nursing Department hires and will maintain a log of all Licensed Nurses to ensure no staff are allowed to work without receiving this training. The facility alleges the removal of Immediate Jeopardy on 8/23/23. On 8/24/23, the facility's immediate jeopardy removal plan effective 8/23/23 was validated by the following: Staff interviews revealed all nurses were able to verbalize they had received training on the proper cleaning procedure to clean and disinfect the glucometer before and after each use using an EPA approved disinfectant wipe and allow it to dry the appropriate amount of time based on the wipe used. Inservice training records of return demonstrations and of the updated policy were reviewed.

Based on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). This practice affected 3 of 4 residents on the assigned unit and could potentially affect 17 residents in the facility who required glucose monitoring. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (MA #1) hired through an agency was observed to perform blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's guidelines. The immediate jeopardy was removed on 8/22/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: The facility policy titled, Glucometer Disinfection (a blood glucose meter) dated 11/1/20 indicated 1) facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2)If the manufacturers are unable to provide information specifying how glucometers should be cleaned and disinfected then the meter should not be used for multiple patients. 3)The glucometer should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C, and Hepatitis B virus. 4) Glucometers should be cleaned and disinfected after each use and according to manufacturers' instructions regardless of whether they are intended for single resident use or multiple resident use. The blood glucose meter manufacturer's instructions for cleaning and disinfecting page 47-48 of the booklet indicated healthcare workers should wear gloves when cleansing the meter. Option 1) Wash hands after gloves are doffed. Contact with blood products presents a potential infection risk. We suggest cleaning and disinfecting between each use. Many wipes function as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; one wipe to clean and a second wipe to disinfect. The wipes container which was in the bottom drawer of the medication cart located on the East Wing read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for 3 minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. An observation was made on 8/20/23 at 11:28 AM and revealed a Medication Aide (MA#1) carried a glucometer from the medication cart to the dining room located just adjacent to the nurses' station on the East Unit where Resident #28 was sitting in his wheelchair. MA #1 performed a task with her back to the door, then exited the dining room holding a used blood glucose test strip, the glucometer, and a used lancet in her right hand. When she arrived near the medication cart, she discarded the used lancet in the sharps box and then removed the used test strip from the glucometer and discarded it and her gloves in the trash can located on the medication cart. MA #1 then documented the blood glucose reading for Resident #28 on a piece of paper located on the medication cart before leaving the medication cart. MA #1 was not observed to clean the glucometer after usage. MA #1 left the medication cart to speak to another staff member and then returned at 11:33 AM. A continuous observation on 8/20/23 from 11:33 AM to 11:45 AM revealed MA #1 retrieved a bottle of glucose test strips and a lancet from the top drawer of the medication cart then, pick up the glucometer which had been used on Resident #28 and walked down the hallway to locate Resident #30 outside the facility at the main lobby entrance along with other residents and visitors. MA #1 then applied gloves and performed a fingerstick using the lancet and obtained blood from Resident #30 on the blood glucose test strip. Once she got a reading on the monitor, MA #1 left Resident #30 outside and entered the building (both hands remained gloved) carrying the glucometer with the test strip and soiled lancet in her right hand. MA #1 then removed her right glove and the test strip from the meter and the lancet in her left hand. MA #1 was observed to carry the glucometer to the medication cart in her ungloved hand where she laid the glucometer again on a white towel located on the top of the medication cart and discard the used lancet and test strip in the sharps box and soiled gloves in the trash can. MA #1 was not observed to perform hand hygiene or disinfect the glucometer before she reached into the top drawer of the medication cart and retrieved a clean blood glucose test strip from a bottle and a clean lancet. MA #1 closed the top drawer, picked up the glucometer from the white towel on the cart and rapidly walked down the hall towards Resident #57's room. MA #1 retrieved a pair of gloves from the hallway outside Resident #57's room and entered the room. She approached Resident #57 who was lying in her bed, and she placed the test strip in the glucometer before sitting it on Resident #57's bedside table to apply her gloves. The surveyor attempted to stop MA #1 from performing any further contamination and asked MA #1 to stop and exit the room. MA #1 demanded the surveyor to come there instead and again turned to Resident #57 and lifted her right-hand pricked Resident #57's finger. The surveyor again told MA #1 to stop before she picked up the glucometer and the MA #1 grabbed the glucometer, test strip and lancet and briskly walked past the surveyor who was standing in the doorway without acknowledging the surveyors questions, hurried toward the medication cart, and placed the glucometer on the cart on the same white towel. The surveyor asked MA #1 about cleaning and disinfecting the glucometer between resident use. Without answering MA #1, grabbed a container of disinfecting wipes from the bottom drawer of the cart and wiped the glucometer for approximately 3-5 seconds and walked off from the surveyor without answering any further questions. Following the observation and attempt of interview, the Director of Nursing (DON) was made aware of the observation and request for interview. An interview with Medication Aide (MA #1) with the DON present on 8/20/23 at 1:30 PM revealed she acknowledged she performed blood glucose monitoring on multiple residents at both 7:30 AM and at 11:00 AM using the multi-use glucometer located in the top drawer of the medication cart. MA #1 verified she did not clean and disinfect the glucometer between each resident using an EPA approved disinfecting wipe. She stated during the lunch time observations, she wanted to make sure she obtained the blood glucose level before each resident received their lunch and did not take the time to clean the monitor or perform hand hygiene between each resident. She stated she had always used a multi-use glucometer on all residents in the facility when obtaining fingerstick blood glucose monitoring and had never used individually assigned glucometers in this facility. An interview with the Director of Nursing (DON) on 8/20/23 at 1:30 PM revealed she had no knowledge MA #1 had performed fingerstick glucose checks on multiple residents without disinfecting the device between use until the surveyor notified her. The DON indicated the glucometer device should have been disinfected between usage and MA #1 should not perform blood glucose checks without proper cleaning and disinfecting using approved EPA wipes. The facility was unable to determine if any residents who resided in the facility had a bloodborne pathogen illness during the survey. An observation of the East Wing Cart #1 (the medication cart where Resident #28, Resident #30, and Resident #57 resided) and interview with Nurse #5 on 8/20/23 at 4:45 PM revealed a multi-use glucometer in the top drawer of the medication cart along with a partially used bottle of glucose test strips. Nurse #5 stated the procedure had changed on 8/20/23 and all residents at that time, now had their own glucometers stored in their room and the multi-use glucometer observed should not have been on the medication cart and available for potential usage. Using a gloved hand, the glucometer and test strips were removed from the cart and taken to the DON who was in her office. An observation of the East Wing Cart #2 at 4:50 PM revealed no multi-use glucometers on the cart and an interview with Nurse #10 revealed she was aware each resident was now assigned their own glucometers which was kept in their rooms but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. An observation of the [NAME] Wing Cart #1 at 4:53 PM revealed no multi-use glucometers on the cart and an interview with Nurse #2 revealed he was aware each resident was now assigned their own glucometers which were kept in their rooms but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. A telephone interview with Nurse #6 on 8/21/23 at 8:55 AM revealed she had last worked in the facility as an agency nurse on Thursday 8/17/23. Nurse #6 stated she had been assigned to work on each unit and had always used a multi-use glucometer from the top drawer of each medication cart when she worked at this facility. Nurse #6 was aware the glucometer required to be cleaned and disinfected between each resident use but was unable to recall the correct procedure for performing this task or the correct kill time for the EPA wipes used in the facility. A telephone interview with the Local Health Department Nurse on 08/22/23 at 12:15 PM revealed she was notified about Medication Aide #1 obtaining blood glucose checks on Resident #28, Resident #30, and Resident #57 while not cleaning and disinfecting the shared glucometer meter on 8/20/23. The Local Health Department Nurse indicated she had advised the facility to obtain a Hepatitis Panel (lab to test for Hepatitis B, Hepatitis C) and a Human Immunodeficiency Virus (HIV) lab, review the three resident's immunization records, notify the medical provider, residents, and Resident Representatives (RP) of the occurrence and monitor for any adverse effects. A review of labs presented by the facility for Resident #28 and Resident #30 revealed the facility drew labs to assess immunity instead of the Hepatitis Panel originally requested by the local health department. When the facility was notified, the facility presented a letter from the local health department dated 8/29/23 that indicated since MA #1 used a clean lancet and a clean test strip, the local health department no longer considered it to be a potential transmission and labs no longer needed to be drawn to determine each resident's health status for Hepatitis B, Hepatitis C or HIV. A telephone interview with the facility Nurse Practitioner (Nurse Practitioner #1) on 8/28/23 at 3:53 PM revealed she became aware of the potential for transmission of a bloodborne illness involving Resident #28, Resident#30, and Resident #57 which occurred on 8/20/23 when she arrived the at facility in the afternoon on Monday, 8/21/23 by the DON. The NP #1 indicated the DON notified her MA #1 had not thoroughly cleaned and disinfected the blood glucose monitoring device between residents when blood sugar levels were obtained on 8/20/23. The NP did not understand why the labs had been ordered because she said she would not have drawn labs without one of the residents having a known bloodborne communicable disease diagnosis listed in the medical record. A telephone interview with the Medical Director on 8/29/23 at 9:49 AM revealed he had not been made aware of the occurrence where a single glucometer was used on multiple residents without disinfecting. He stated he would expect all staff to perform care in a manner to prevent potential cross contamination of bloodborne illnesses. An interview with the Administrator on 8/24/23 at 1:09 PM revealed he learned about the occurrence on 8/20/23 when MA #1 performed fingerstick glucose checks using a single glucometer without cleaning and disinfecting it between residents which placed the residents at risk for a bloodborne illness. The Administrator indicated he would have expected the glucometer to be cleaned and disinfected before and after use to decrease the spread of any potential illness. Facility administration (Administrator and Director of Nursing) was notified of immediate jeopardy on 8/20/23 at 5:02 PM. The facility provided the following plan for IJ removal. Noncompliance Allegation: The facility has been found noncompliant in ensuring that the glucometer was cleaned according to manufacturer guidelines using an EPA approved disinfectant cloth between each resident usage. This has resulted in potential exposure to bloodborne pathogens for the residents who were required to have their blood glucose levels checked. The noncompliance was identified through observation, record review, resident, and staff interviews, and is specifically attributed to a Certified Medication Aide failing to follow the proper procedure for cleaning and disinfecting a shared glucometer. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Observation, record review, resident, and staff interviews completed by the surveyor on 8/20/23 identified the facility failed to ensure a glucometer was cleaned, according to manufacturer guidelines using an EPA approved disinfectant cloth, between each resident usage. This occurred for 3 residents who were required to have their blood glucose levels checked (Resident #28, Resident #30, and Resident #57). Clinical staff failed to use the appropriate procedure to clean and disinfect a shared glucometer. Every resident that receives a fingerstick blood glucose level is at risk. On 8/20/23 the Director of Nursing and Unit Managers completed an audit of all current residents and identified those with physician's orders requiring blood glucose levels. On 8/21/23, the Director of Nursing and Unit Managers ensured that each resident requiring fingerstick blood glucose levels was assigned an individual use glucometer stored at their bedside. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Administrator and Director of Nursing changed the facility's policy and procedure to include a new process to assign completion of blood glucose levels to only Licensed Nurses as well as issuing individual glucometers to each resident requiring blood glucose levels. On 8/20/23 the Director of Clinical Services educated the Director of Nursing and the Administrator regarding the new process for obtaining blood glucose levels by only assigning Licensed Nurses and the revisions to the Glucometer Disinfection policy and procedures including cleaning and disinfecting of each device and the management of glucometers by issuing individual glucometers to each resident requiring blood glucose levels. The Director of Nursing and Administrator educated the Unit Managers regarding the revisions to the Glucometer Disinfection policy and procedures including cleansing and disinfecting of each device and the management of glucometers by issuing individual glucometers to each resident requiring blood glucose levels. The Unit Managers were also educated regarding the change in process to allow only Licensed Nurses to complete blood glucose levels. This was completed on 8/21/23. On 8/21/23, responsible parties (RP) for residents and those residents that receive fingerstick blood glucose levels have been notified by the Director of Nursing or Unit Manager of the potential exposure of bloodborne pathogens due to not properly disinfecting a shared glucometer. They were informed that we will now be using individual glucometers for each resident. RPs and Residents were informed that the local Health Department had been notified and we will be following any recommendations that they provide regarding the potential exposure to blood borne pathogens. Current Licensed Nurses have received training by the Director of Nursing and Unit Managers on the following: o Only Licensed Nurses will perform blood glucose levels beginning 8/21/23. In the event a Medication Aide is assigned to administer medications to a resident requiring a blood glucose level, the Medication Aide will notify the Licensed Nurse for completion of the blood glucose level. o The purpose for following a cleaning checklist process, for disinfecting glucometers due to the likelihood of cross-contamination and the spread of bloodborne pathogens among residents o The importance of cleaning and disinfecting the glucometer per manufacturer's guidelines, using the training/education checklist for Cleaning Glucometers that includes the process of cleaning and includes observation and return demonstration. o This includes cleaning and disinfecting the individually issued glucometers that are stored at the residents' bedside. o The glucometer cleaning process is as follows: Upon entering the resident's room with 2 EPA approved disinfectant wipes, wash hands and don clean gloves. Obtain the resident's individual glucometer from the bedside table. Insert a test strip into glucometer, complete fingerstick using a lancet, and collect a small amount of blood on the sample test strip. Wait for the results of the sample to appear. Remove the test strip and dispose of the lancet and test strip in the sharps container on the med cart. Use one EPA approved disinfectant wipe to wipe the glucometer of any visible materials covering all surfaces. Remove soiled gloves and don clean gloves. Use the second wipe to allow the glucometer to remain moist for 3 minutes and allow to air dry, return to storage case and place case in the bedside drawer. Remove gloves, wash hands well. Record Blood Sugar result in the electronic record. On 8/21/23 Licensed Nurses were notified by the Director of Nursing and Unit Managers that extra glucometers are available in the Nurses Medication Room to ensure new admissions or residents with new orders for blood glucose levels have their own glucometer assigned. This education was completed for current Licensed Nurses including those working for agencies on 8/21/23 by the Director of Nursing and Unit Managers. This education was provided verbally with written documents for reference and a return demonstration completed by the Director of Nursing and Unit Managers. The Director of Nursing will maintain a log of all Licensed Nurses to ensure no staff are allowed to work without receiving this training. On 8/21/23, the Administrator and Director of Nursing notified the county Health Department Nurse and the Physician of the concerns identified regarding a Medication Aide failing to use the appropriate procedure to disinfect a shared glucometer for 3 residents and requested guidance for follow-up for possible exposure to bloodborne pathogens. Recommendations were completed by the Director of Nursing and Unit Managers. On 8/21/23, the Director of Nursing and Unit Managers ensured that each resident requiring fingerstick blood glucose levels was assigned an individual use glucometer stored at their bedside. This was completed on 8/21/23. Current Medication Aides have received training from the Director of Nursing and Unit Managers that only Licensed Nurses will perform blood glucose levels beginning 8/21/23. Medication Aides will no longer be assigned to perform blood glucose levels. In the event a Medication Aide is administering medications on an assignment with residents requiring blood glucose levels the Medication Aide will notify the Licensed Nurse for completion. The facility alleges removal of Immediate Jeopardy 8/22/23. On 8/24/23, the facility's immediate jeopardy removal plan effective 8/22/23 was validated by the following: Staff interviews revealed all nurses were able to verbalize they had received training that medication aides were no longer allowed to perform fingerstick glucose monitoring, each resident who required blood glucose monitoring had been assigned an individual glucometer which would be kept in the residents' room and the proper cleaning procedure to clean and disinfect the glucometer before and after each use using an EPA approved disinfectant wipe and allow it to dry the appropriate amount of time based on the wipe used. Inservice training records of return demonstrations and of the updated policy were reviewed and observation of glucometers in each individual resident's room were made.

Based on record reviews and interviews with resident, staff, Pharmacist, Nurse Practitioner (NP #2) and the Medical Director (MD), the facility failed to acquire medications ordered for administration resulting in multiple doses of the prescribed controlled substance medication being missed for 1 of 1 resident reviewed for the provision of pharmaceutical services to meet a residents' needs (Resident #33). As a result of this deficient practice, Resident #33 had to be sent to the emergency department where she required 3 days of treatment for benzodiazepine (class of medications used to treat anxiety) withdrawal with delirium symptoms. The findings included: Resident #33 was admitted to the facility on [DATE]. Her cumulative diagnoses included depression, anxiety, and bipolar disorder. Review of the physician's orders revealed an order dated 09/25/21 which indicated Resident #33 was to receive Xanax (Alprazolam) 0.5 milligram (mg): Give one (1) tablet by mouth three (3) times a day for anxiety disorder. Review of Resident #33's electronic Medication Administration Record (MAR) for October 2022 revealed she had not received Xanax as ordered on the following dates: On 10/15/22 at 10:00 PM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/15/22 in the medical record that mentioned Resident #33 not receiving her Xanax. An interview with Nurse #18 on 8/23/23 at 6:09 PM revealed she recalled a day last fall where she came on shift and Resident #33 was already upset because she had been told the facility was out of her Xanax and was unable to refill the medication due to the provider not sending a new prescription to the pharmacy. Nurse #18 indicated Resident #33 called the police once if not twice that night on her shift due to not having her medication available. Nurse #18 stated she attempted to contact the on-call provider but was unable to obtain a new prescription for Resident #33 on her shift due to the provider being unfamiliar with the resident and the medication requested being a controlled substance. Nurse #18 stated she recalled Resident #33 experienced some delusions that shift, but later learned Resident #33 possibly had a urinary tract infection (UTI). Nurse #18 stated she had been taught nurses were to notify the provider between 3-5 days before a resident should run out of a controlled substance and day shift nurses should notify the provider who is in the facility daily during the week when inventory is low to prevent any residents from being without their routine ordered medications. A nurses' note dated 10/16/22 at 5:18 AM indicated during the 7P- 7A shift, Resident #33 had made telephone calls to 9-1-1 for various things to include: staff withholding medications. The note did not mention Resident #33 not receiving her Xanax. On 10/16/22 at 8:00 AM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/16/22 in the medical record that mentioned Resident #33 not receiving her Xanax. On 10/16/22 at 2:00 PM, the MAR showed no dose of Xanax was administered. A chart code of 5 was documented on the MAR to indicate hold/see nurses' notes. There were no notes for 10/16/22 in the medical record that mentioned Resident #33 not receiving her Xanax. An interview with Medication Aide #2 on 8/24/23 at 9:36 AM revealed she no longer worked in the facility and could not recall Resident #33 or why did not receive her scheduled medication. MA #2 verified her initials were who had signed the MAR as the medication not administered at 8 AM and 2 PM on 10/16/22. MA #2 stated if the medication is in the cart and ordered, she gives the medication as ordered. On 10/16/22 at 10:00 PM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/16/22 in the medical record that mentioned Resident #33 not receiving her Xanax. An interview with Nurse #18 on 8/23/23 at 6:09 PM revealed she worked on night shift (7P-7A) on 10/16/22 and recalled she was unable to obtain Resident #33's medication due to a new prescription required by pharmacy. On 10/17/22 at 8:00 AM, the MAR showed a dose of Xanax was administered. On 10/17/22 at 2:00 PM, the MAR showed no dose of Xanax was administered. No reason provided as the time was left blank. There were no notes for 10/17/22 in the medical record that mentioned Resident #33 not receiving her Xanax. An interview with Nurse #17 on 8/26/23 at 9:46 AM revealed she worked day shift (7AM -7 PM) on 10/17/23. Nurse #17 stated she could not recall the exact date but recalled an event last fall where Resident #33 called the police accusing her and other nurses of not giving her medication that was not available or it was not time to receive the next dose. She did state there had been times with various residents where medications were out of stock and was not available for pharmacy to dispense due to the medication being a controlled substance and the on-call providers not being willing to refill the medication because they were not familiar with the resident. On 10/17/22 at 10:00 PM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/17/22 in the medical record that mentioned Resident #33 not receiving her Xanax. An interview with Nurse #4 on 8/24/23 at 9:03 AM revealed she worked on 10/17/22 on night shift and could not recall why Resident #33 did not receive her medications on 10/17/22; however, she stated if she realized Resident #33 did not have her medications available, she was first to contact the pharmacy to see if it could be dispensed. If the pharmacy was unable to dispense for reasons of a new prescription needed, she was to contact the on-call provider to obtain one. Nurse #4 stated that due to Resident #33's medication being a controlled substance, her experience with the on-call providers was that they were not comfortable providing a prescription because they were unfamiliar with the resident and the resident would have to go without her medication regardless of potential side effects or adverse reactions Resident #33 might experience until the routine provider was on duty during the weekdays (Monday through Friday). On 10/18/22 at 8:00 AM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/18/22 in the medical record that mentioned Resident #33 not receiving her Xanax; however, a note written at 7:40 AM mentioned Resident #33 had confusion related to her ex-husband's death and having increase anxiety over the weekend. The facility was unable to identify the initials of the staff member who signed the MAR on 10/18/22 at 8 AM and therefore this staff member was unable to be interviewed during the investigation. On 10/18/22 at 2:00 PM, the MAR showed no dose of Xanax was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses' notes. There were no notes for 10/17/22 in the medical record that mentioned Resident #33 not receiving her Xanax. A provider progress note written by NP #2 on 10/18/22 indicated Resident #33 reported to her that she had not been given her Xanax since Friday 10/14/22 because the nurses didn't request a refill despite NP asking medicating nurses to check the stock each Friday and was assessed to be very anxious with jerky motions, a facial tick and slight elevation in her blood pressure from her baseline. It further indicated Resident #33 was known to have been without her Xanax for the last 4 days. A nurses note dated 10/18/22 at 10:55 PM indicated Resident #33 was transferred to the emergency room for evaluation at the request of Resident #33's son due to increase anxiety, delusions, and inability to keep Resident #33 comfortable. An after-visit summary report dated 10/21/22 revealed Resident #33 was seen in the emergency department on 10/18/22 for benzodiazepine withdrawal with delirium due to not receiving anti-anxiety medications as ordered. The document indicated she was evaluated by psychiatric services and discharged to the facility on [DATE]. A provider progress note written by NP #2 on 10/25/22 revealed that Resident #33 was sent to the emergency room for 2 nights due to benzodiazepine withdrawal due to failure of nursing to give Xanax for approximately 4 days. Resident #33 was kept for psychiatric evaluation and possible involuntary commitment. Resident #33 was found to be stable and did not require admission. The note further indicated Resident #33 was assessed to be mentally stable without presentation of psychosis at her baseline and plan would be to continue Xanax and current plan of care. An interview with NP #2 on 8/29/23 at 11:26 AM revealed she was familiar with Resident #33 under the Longevity program's care (special needs program where care is directed by additional medical staff who are onsite during the week in addition to traditional facility medical providers). NP #2 stated she did not wish to add any further information regarding the facility's nursing staff failing to alert her to Resident #33 being without her medication and stated, I detailed it all clearly in my notes on 10/18/22 and 10/25/22- refer to those notes for my evaluation of the situation. An interview with the Director of Nursing on 8/23/23 at 5:00 PM revealed she was not the DON at the time and was unable to locate Resident #33's narcotic controlled monitoring forms for September and October 2022 and therefore was not sure why the medications had not been administered as ordered. The DON stated she expected medications to be given as ordered. An interview with the Administrator on 8/24/23 at 1:09 PM revealed he was not the Administrator of the facility during October 2022 and was not sure why Resident #33 would have not received her medications; however, he expected all medications to be ordered from pharmacy and administered as ordered by the provider.

Based on observations, record review and staff, Nephrologist, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to schedule and continue [CONDITION(S)] services for Resident #6. As a result, he missed 3 consecutive [CONDITION(S)] appointments ([DATE], [DATE], [DATE]) and was scheduled for a non-emergent [CONDITION(S)] treatment on [DATE] and died [DATE]. This occurred for 1 of 4 sampled residents reviewed for [CONDITION(S)] (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] after a hospitalization for abdominal ascites. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital discharge summary dated [DATE] indicated Resident #6 to continue with [CONDITION(S)]. The discharge summary did not specify which days to continue with [CONDITION(S)] and when he last received [CONDITION(S)]. An Admission Skin assessment dated [DATE] was conducted by Nurse #1 and revealed Resident #6's left arm had a bruised [CONDITION(S)] shunt. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident#6 had mild cognitive impairment. He required extensive assistance with bed mobility and personal hygiene; he was totally dependent on staff for bathing, toileting, and dressing. The MDS did not identify [CONDITION(S)]. A Care Plan dated [DATE] did not indicate [CONDITION(S)] for Resident #6. A Nurse Practitioner (NP) progress note dated [DATE] indicated she examined Resident #6 as a new admission into the facility after hospitalization and he was alert and oriented at baseline. She further indicated he had a skin tear to his left forearm, fistula to his left upper arm, and denied pain or acute distress. The Resident was to continue [CONDITION(S)] 3 days per week for CKD Stage 5. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #6 as a new admission to the facility after a hospitalization . He further revealed the Resident was alert, oriented with confusion and denied pain or distress. Resident's lungs were non-labored and mild ascites was noted. Resident #6 was to continue [CONDITION(S)] on a schedule of 3 days a week. All medications and records were reviewed. A Registered Dietician progress note dated [DATE] indicated Resident #6 received routine hemodialysis 3 days per week and some weight changes were expected. A Nursing Progress Note dated [DATE] revealed Nurse #2 spoke with the NP regarding Resident #6 [CONDITION(S)] status. Resident #6 had no signs or symptoms of any respiratory distress. Respirations were even and non-labored. Skin was warm and dry to touch, [CONDITION(S)] catheter patent no signs or symptoms of any bleeding noted and there was no [CONDITION(S)] noted. A new order was given to send Resident #6 to the emergency room the following morning for non-emergent [CONDITION(S)]. Nurse #2 called the emergency room to inform them that Resident #6 would be sent over for [CONDITION(S)] in the morning. The [CONDITION(S)] schedule was to be set up once [CONDITION(S)] was completed in the am. The Director of Nursing (DON) was made aware of the new order. A Social Services assessment dated [DATE] indicated Resident #6 was dependent on renal [CONDITION(S)]. A death certificate for Resident #6 revealed he died on [DATE] and cause of death was [CONDITION(S)]. A phone interview with the hospital discharge Social Worker (SW) on [DATE] at 1:40 PM revealed she first contacted the facility on [DATE] and spoke with the Assistant Business Office Manager (ABOM) who accepted Resident #6 for rehabilitation. She provided the ABOM with the name, location of the [CONDITION(S)] center and days. The initial referral packet was sent via Care Port (referral portal) for the facility to review. On [DATE] she updated the ABOM that the Resident's discharge changed due to not being medically eligible for discharge. On [DATE] the SW communicated through Care Port that Resident #6 was ready to be discharged to the facility and the acceptance was contingent on the facility's ability to provide transportation to [CONDITION(S)]. The Resident was discharged to the facility on [DATE]. An interview with the ABOM on [DATE] at 12:58 PM indicated she utilized Care Port to review hospital discharges for possible admissions to the facility. She printed out Resident #6's history & physical, medication list, clinical notes, and progress notes, then gave it to the DON, who reviewed and approved the admission. The approval meant the facility could provide transportation to [CONDITION(S)]. A post-it note regarding the Resident's [CONDITION(S)] days and location was placed on the discharge paperwork and was given to the DON. On [DATE] the ABOM communicated with the hospital discharge SW through Care Port about the name and location of the [CONDITION(S)] center, then accepted the Resident. After the Resident arrived, the nurses should have communicated the information to the receptionist who provides transportation. She further indicated she uploaded the updated hospital DC Summary into the electronic medical record (EMR) and provided a copy to the DON. The ABOM stated she made announcements during the interdisciplinary morning meetings about possible admissions or new admissions that had arrived. She further stated, since the incident related to Resident #6 missing [CONDITION(S)] days after he was admitted to the facility, the Admissions Coordinator entered more specific information on the admission form (such as [CONDITION(S)] or oxygen status) before providing the DON with the form. A phone interview with Nurse #1 on [DATE] at 3:45 PM, who no longer worked at facility, revealed she admitted Resident #6 on [DATE]. She could not recall conducting a skin assessment, although she entered the assessment into the EMR. She stated she last worked at the facility one week prior and she could only recall working the night Resident #6 died . She further stated she barely remembered admitting him. An interview with the Rehabilitation Director on [DATE] at 3:45 PM indicated the Speech Therapist informed her on [DATE] that Resident #6 needed [CONDITION(S)]. She then mentioned it in the morning meeting the same day ([DATE]) and the DON and Unit Manager #1 stated they would take care of it. She further indicated the DON usually set up the [CONDITION(S)] and the receptionist provided transportation to [CONDITION(S)] appointments. An interview with the NP on [DATE] at 2:49 PM revealed she examined Resident #6 on [DATE] who presented with no symptoms and said he felt ok. She was unaware at the time of her assessment that he was not getting [CONDITION(S)] as ordered. The NP further revealed nursing staff contacted her on [DATE] and reported Resident #6 had not been dialyzed since his admission to the facility. She expected nursing staff to set up the [CONDITION(S)] schedule when he was admitted from the hospital. She gave an order to go to ER the following day [DATE] to be dialyzed, since he presented with no symptoms such as fluid overflow or shortness of breath. The Unit Manager usually set up the [CONDITION(S)] schedule and it had not been done. He missed at least 3 [CONDITION(S)] days since his admission to the facility. An interview with the Medical Director (MD) on [DATE] at 9:42 PM indicated he examined Resident #6 on [DATE] and he was alert and oriented. He did not understand how Resident #6 could have missed [CONDITION(S)]. He further indicated he and his NP were made aware of it and agreed that the Resident was okay when they examined him. However, they were troubled that at least 20 people encountered the Resident before his death but did not detect he missed [CONDITION(S)]. The MD stated he reviewed the Resident's discharge summary before he examined him. He stated that he mainly focused on his medications. The MD was unsure whether the Resident would have survived even if he had [CONDITION(S)] during those days missed. In the MD's opinion, the Resident probably had a failed arrythmia (sudden heart episode). The MD expected nursing staff would have transposed the [CONDITION(S)] information from the hospital discharge summary. He stated the Resident had several medical issues that could have caused his death. He further stated he placed the initial diagnosis, which was end-stage renal disease on the Resident's death certificate. During an interview on [DATE] at 11:00 AM Nurse #2 stated she worked 7am- 11pm on the west unit and was assigned to Resident #6 on [DATE] and [DATE]. She further indicated while administering medications, she noticed he was bleeding on his right arm. She informed the treatment nurse, who performed a skin assessment and noticed there was a [CONDITION(S)] catheter. Nurse #2 went to the east unit of the facility where the Resident had transferred from the previous day and inquired with nursing staff about the Resident's [CONDITION(S)] catheter and [CONDITION(S)] status. Nursing staff on the east unit were unaware of the Resident's [CONDITION(S)] status. She then stated she went to the DON's office and inquired about the Resident's [CONDITION(S)] status. She further stated the DON was unaware that Resident #6 should have been receiving [CONDITION(S)] since he was admitted to the facility on [DATE]. Nurse #2 then asked Resident #6 if he was on [CONDITION(S)]. He stated he usually went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays. It was determined that Resident #6 missed at least three [CONDITION(S)] visits between [DATE] and [DATE]. The NP was contacted and informed of the Resident's need for [CONDITION(S)]. The NP informed Nurse #2 that if the Resident was not showing any symptoms, he could go to the emergency room in the morning [DATE] for non-emergent [CONDITION(S)] treatment. The nearest hospital was contacted, and the plan was for the Resident to be transported the following morning for [CONDITION(S)], since the assigned [CONDITION(S)] center could not service the Resident on short notice. Interviews with the DON on [DATE] at 6:11 PM and [DATE] at 10:55 AM revealed she was unaware Resident #6 was supposed to have [CONDITION(S)]. On [DATE] Nurse #2 informed her that the Resident was supposed to go to [CONDITION(S)] 3 days per week and had not gone since he was admitted to the facility 8 days prior ([DATE]). The [CONDITION(S)] center was also contacted, and they were unable to accept the Resident that day. Instead, they recommended an emergent [CONDITION(S)] at the emergency room . The DON further revealed she and Nurse #2 contacted the NP, who stated since the Resident was asymptomatic and the emergency room would not dialyze him until the morning, the Resident could be sent to the emergency room the following morning [DATE]. The DON stated that usually, the discharging hospital would contact the admitting facility to provide report. The Admissions Coordinator would print the discharge summary and provide her with a copy. The DON further stated she would usually review the discharge summary and set up [CONDITION(S)]. She then stated she failed to set up [CONDITION(S)] and it was a big miss on the facility's part. Since then, it was determined that an admission audit of the Resident needs was not completed. She in-serviced the charge nurses who admitted residents and created an admission audit tool. A phone interview with the Nephrologist on [DATE] at 10:34 AM indicated Resident #6 had been his patient since 2010. The Resident started with [CONDITION(S)] in [DATE] and had been a [CONDITION(S)] patient since that time. He went from his home to the hospital, and he had a primary care team. The Nephrologist further indicated the Resident was still a patient with the [CONDITION(S)] center at the time he was discharged from hospital to the facility on [DATE]. Per hospital records he was last dialyzed on Tues [DATE]. His nephrology group saw him throughout his hospital stay. The Administrator, the DON, the Regional Nurse Consultant, and the Regional Director of Operations were informed of Immediate Jeopardy on [DATE] at 8:37 PM. The facility provided the following corrective action plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #6 was admitted [DATE] after a hospitalization for abdominal ascites from [DATE]-[DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to schedule and continue [CONDITION(S)] services for, Resident #6, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, he missed 3 consecutive [CONDITION(S)] appointments. All residents who have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the Director of Nursing (DON)/ Regional Director of Clinical Services (RDCS) completed an audit of all new admissions and readmissions from the previous 60 days to ensure that no further residents missed [CONDITION(S)] orders/treatments. No further missed [CONDITION(S)] orders/treatments were identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On [DATE], the Regional Director of Clinical Services (RDCS) educated the Director of Nursing (DON), Nurse Manager, and the Administrator regarding the clinical morning meeting process for the DON to run and review the Order Listing report and compare it to the discharge summary of any new admission/readmissions to ensure [CONDITION(S)] orders have been entered for new admissions and readmissions for [CONDITION(S)] services and [CONDITION(S)] treatments are scheduled. On [DATE], the DON and Nurse Manager were educated regarding this process and the use of the New Admission Audit tool. On [DATE], the Administrator notified the Admission Coordinator of the new process using the New Referral Admission Sheet and provide to the DON for review. Information for new referrals requiring [CONDITION(S)] orders/treatments will be reviewed by the DON prior to admission. On [DATE], the Director of Nursing re-educated the Licensed Nurses and Nurse Manager including agency staff, to review hospital discharge orders for new admissions and readmissions to identify [CONDITION(S)] treatment orders, to notify Nurse Practitioner/Physician of admission of [CONDITION(S)] resident, and to place the discharge summary in the Physician/Nurse Practitioner book. The Licensed Nurses were educated to enter these orders in the electronic record and notify the DON at time order entry; if the DON isn't in the building, the nurse will call her at the number provided for after hours. The Physician will be notified of new admissions or readmissions requiring [CONDITION(S)] treatments by the Licensed Nurse and/or the DON. The Nurse Manager will coordinate scheduling of [CONDITION(S)] with the Director of Nursing. The Director of Nursing will ensure no new licensed nursing staff will work without receiving this education. Any new hires, including nursing agency staff will receive education prior to the start of their shift. Measures will be put in place/systemic changes made to ensure that the deficient practice will not recur On [DATE], the Administrator began reviewing all admissions/readmissions data provided by the DON/Nurse Manager in the morning meeting using the New Admission Audit tool that indicates the need for [CONDITION(S)] treatment/orders. DON/Nurse Manager will conduct an audit of all admissions/readmissions daily to validate that [CONDITION(S)] treatment/orders have been entered into the electronic medical record and [CONDITION(S)] treatments have been scheduled. On [DATE], the Administrator notified the DON/Nurse Manager on this responsibility. How facility plans to monitor its performance to ensure that solutions are sustained All admissions/readmissions will be reviewed to ensure [CONDITION(S)] orders/treatments received at weekly QAPI meeting x 3 months. Administrator will monitor the review of new admissions at weekly QAPI meeting x 3 months to ensure that [CONDITION(S)] orders/treatments were followed. The DON will provide all audits for the QAPI committee to review and make recommendations. Effective [DATE] the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. The facility's alleged correction date of [DATE] was verified by the following: On [DATE], the facility's corrective action plan with correction date of [DATE] was validated on-site by observations, interviews with residents and staff and record review. Six residents were admitted /readmitted to the facility after [DATE] who required [CONDITION(S)] services. These residents received coordination of [CONDITION(S)] services on admission/readmission to the facility based on observations of transportation to/from [CONDITION(S)], record review of hospital discharge summaries, admission assessments, physician orders, and care plans. Interviews with facility nursing staff and staff contracted to provide [CONDITION(S)] and transportation services were also conducted. No concerns related to the coordination of [CONDITION(S)] services were identified. Interviews with nursing staff from all shifts revealed they had been re-educated per the documentation of in-services provided related to coordinating [CONDITION(S)] services on admission/readmission to the facility. Interviews with alert and oriented residents revealed nursing staff coordinated [CONDITION(S)] services upon admission/readmission to the facility. Review of in-service records revealed on [DATE], the Administrator and Director of Nursing completed re-education via phone and in-person in-services on providing [CONDITION(S)] services on admission/readmission to the facility. Review of a sample of nursing staff who worked after [DATE] revealed re-education prior to the start of their shift. Review of monitoring tools revealed the management staff had completed audits and monitoring per the audit tools and monitoring documentation provided. Alleged Date of IJ Removal: [DATE]

Based on resident, staff, nurse practitioner, physician and Nephrologist interviews, and record review, the facility failed to administer anti-anxiety medication to 1 of 3 sampled residents who received psychoactive medications (Resident #3). The omissions of the anti-anxiety medication caused Resident #3 to refuse [MEDICAL TREATMENT] which resulted in emergency room treatment for [REDACTED]. The findings included: Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's admission Minimum Data Set ((MDS) dated [DATE] documented an assessment of intact cognition. The MDS indicated Resident #3 received [MEDICAL TREATMENT] treatments. The care plan for Resident #3 dated 06/19/2020 indicated interventions for [MEDICAL TREATMENT] care included scheduled [MEDICAL TREATMENT] treatment and administration of medications as ordered. The care plan indicated Resident #3 required encouragement to go for [MEDICAL TREATMENT] treatment. A Nurse Practitioner (NP) note dated 07/06/2020 documented Resident #3 experienced anxiety and required [MEDICATION NAME] (an anti-anxiety medication) to aid in compliance with [MEDICAL TREATMENT] treatment. The NP continued the use of [MEDICATION NAME] 0.5 milligrams (mg.) one tablet every 12 hours as needed for anxiety for 14 days. On 07/16/2020, the NP documented Resident #3 continued to experience anxiety. The NP increased the frequency of the [MEDICATION NAME] 0.5 mg. to every 8 hours as needed for anxiety with reevaluation to occur in 14 days. A NP note dated 07/23/2020 documented Resident #3 requested an increase in dosage for continued anxiety. The NP increased the [MEDICATION NAME] to 1 mg. every 8 hours as needed for anxiety for 14 days with reevaluation to occur in 14 days. A hospital discharge summary dated 08/08/2020 documented Resident #3 was hospitalized from [DATE] to 08/08/2020 for treatment of [REDACTED]. Resident #3 received [MEDICAL TREATMENT] during his hospital stay. Discharge medications included [MEDICATION NAME] 0.5 mg. every 12 hours for 14 days. Resident #3's August 2020 electronic Medication Administration Record [REDACTED]. A nursing note dated 08/12/2020 as late entry for 08/08/2020 documented the admitting nurse, Nurse #3, informed Unit Manger (UM) #1 of the change of frequency of the [MEDICATION NAME] dose. UM #1 documented the NP gave verbal orders to discontinue the [MEDICATION NAME]. Resident #3's physician's orders did not contain an order to discontinue the [MEDICATION NAME]. Nurse #3 did not return telephone calls and was not able to be interviewed. Interview with UM #1 on 08/12/2020 at 1:45 PM revealed the NP was contacted upon Resident #3's readmission on 08/08/2020 and discontinued the [MEDICATION NAME] order. UM #1 could not provide a reason for the lack of a written order to discontinue the [MEDICATION NAME]. Telephone interview on 08/13/2020 at 9:46 AM with the NP specified in the readmission note of 08/08/2020 revealed the NP was not contacted by the facility on 08/08/2020. The NP explained she was not aware of Resident #3's 08/02/2020 hospitalization until 08/12/2020. The NP reported she did not discontinue the [MEDICATION NAME] on 08/08/2020. A nursing note dated 08/10/2020 written by Nurse #2 documented Resident #3's transportation to [MEDICAL TREATMENT] did not arrive. Nurse #2 informed Unit Manager (UM) #2 and notified the NP. The NP directed Resident #3 to receive [MEDICAL TREATMENT] either at the [MEDICAL TREATMENT] treatment center or the hospital. A late entry nursing note dated 08/12/2020 for 08/10/2020 documented UM#2 notified the NP of Resident #3's rescheduled [MEDICAL TREATMENT] appointment on 08/11/2020 at 9:30 AM. A nursing note dated 08/11/2020, written by Nurse #4, documented Resident #3 refused [MEDICAL TREATMENT] because he could not receive [MEDICATION NAME]. Nurse #4 documented Resident #3 did not have an [MEDICATION NAME] order. The NP received notification and ordered an emergency room evaluation. The emergency room evaluation dated 08/11/2020 revealed Resident #3 received treatment for [REDACTED]. The physician documented [MEDICAL CONDITION] with a potassium level of 6.1 Millimoles per liter (mmol/L) with a normal reference range of 3.5 mmol/L to 5.1 mmol/L. Resident #3's EKG (electrocardiogram) had no significant changes. Resident #3's blood pressure measured 204/92 millimeters of mercury. (mmHg.). Resident # 3 received oral medications to lower the potassium level, blood pressure and anxiety. Resident #3 returned to the facility. During an interview with Resident #3 on 08/12/2020 at 8:51 AM, Resident #3 explained he became extremely anxious on [MEDICAL TREATMENT] days. Resident #3 reported the [MEDICATION NAME] enabled him to go to [MEDICAL TREATMENT]. Resident #3 explained he needed the [MEDICATION NAME] and did not understand the refusal by nurses to administer the medication. Interview with Nurse Aide (NA) #1 on 08/12/2020 at 8:46 AM revealed Resident #3 refused to go to [MEDICAL TREATMENT] if [MEDICATION NAME] was not administered. NA #1 reported Resident #3's [MEDICAL TREATMENT] refusal due to lack of [MEDICATION NAME] to Nurse #2 on 08/10/2020 and to Nurse #4 on 08/11/2020. Interview with Nurse #2 on 08/12/2020 at 11:15 AM revealed Resident #3 requested [MEDICATION NAME] the morning of 08/10/2020. Nurse #2 explained to Resident #3 that there was not an order for [REDACTED].#2 reported Resident #3 had [MEDICATION NAME] available for administration but did not have an order. Continued interview with Nurse #2 revealed NA #1 informed her at approximately 1:00 PM or 1:30 PM on 08/10/2020 that transportation did not arrive to take Resident #3 to [MEDICAL TREATMENT]. Nurse #2 reported she did not know Resident #3's refusal of [MEDICAL TREATMENT] was connected to the [MEDICATION NAME]. At the direction of UM #2, Nurse #2 notified the NP. Nurse #2 reported the NP directed her to send Resident #3 to the hospital for [MEDICAL TREATMENT] if the [MEDICAL TREATMENT] center could not dialyze Resident #3 that day (08/10/2020). Nurse #2 informed UM #2 of the NP's order. Nurse #2 reported Resident #3 had not gone to [MEDICAL TREATMENT] when she left duty at 3:00 PM on 08/10/2020. Telephone interview with Nurse #4 on 08/13/2020 at 11:52 AM revealed NA #1 informed her of Resident #3's refusal of [MEDICAL TREATMENT] transportation due to not receiving [MEDICATION NAME] on 08/11/2020. Nurse #4 explained there was no [MEDICATION NAME] ordered on the eMAR for Resident #3. Nurse #4 notified the NP of Resident #3's refusal of [MEDICAL TREATMENT] and Nurse #4's inability to determine the most recent date of [MEDICAL TREATMENT] treatment. The NP ordered emergency room evaluation. A telephone interview with the NP on 08/12/2020 at 1:06 PM revealed Resident #3 should have received the [MEDICATION NAME] as ordered on the discharge summary dated 08/08/2020. The NP explained she did not know Resident #3's refusal of [MEDICAL TREATMENT] was connected to the [MEDICATION NAME] when notified on 08/10/2020. The NP explained she ordered an emergency room evaluation on 08/11/2020 when informed of Resident #3's missed [MEDICAL TREATMENT] sessions and request for [MEDICATION NAME]. The NP reported the nurse (Nurse #4) could not be precise in the number of missed sessions so the NP did not want to order [MEDICATION NAME] until after Resident #3 received the emergency room evaluation. During an interview with UM #2 on 08/12/2020 at 11:59 AM, UM #2 explained he did not know Resident #3 refused [MEDICAL TREATMENT] because of [MEDICATION NAME] omission until 08/11/2020. UM #2 did not know Resident #3's discharge summary contained an order for [REDACTED]. Interview with the interim Director of Nursing (DON) on 08/12/2020 at 12:17 PM revealed Resident #3 should have received the [MEDICATION NAME] as ordered. The interim DON explained Resident #3 required the [MEDICATION NAME] prior to [MEDICAL TREATMENT] treatments. The interim DON described Resident #3 as extremely anxious on [MEDICAL TREATMENT] days. Telephone interview with Resident #3's physician on 08/12/2020 at 12:45 PM revealed Resident #3 should have received [MEDICATION NAME] as ordered especially since the omissions caused [MEDICAL TREATMENT] refusal and emergency room evaluation. A telephone interview was conducted with Resident #3's Nephrologist on 08/13/2020 at 2:32 PM. The Nephrologist explained omission of [MEDICAL TREATMENT] caused elevated potassium but could not be certain if Resident #3's elevated potassium was due to the omitted session on 08/10/2020. The Nephrologist reported Resident #3 should have received the [MEDICATION NAME] as ordered.

Based on physician and staff interviews and record review the facility failed to notify the physician when as needed pain medication was not effective for a resident in severe pain for 1 of 5 sampled residents (Resident #64). The findings included: Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) prior to Resident #64's fractured femur was dated 10/31/14 and specified the resident had moderately impaired cognition and was on a pain medication regimen. Review of Resident #64's physician orders [REDACTED]. - [MEDICATION NAME] 1 tablet every 6 hours as needed for moderate generalized pain dated 02/25/14 - [MEDICATION NAME] 2 tablets every 6 hours as needed for severe generalized pain dated 02/25/14 Further review of Resident #64's medical record revealed nurses' entries made by Nurse #1. On 12/25/14 at 8:50 AM Nurse #1 documented that Resident #64 complained of bilateral leg pain and was given 1 tablet of [MEDICATION NAME] for moderate pain. Additional entries made by Nurse #1 were: - On 12/25/14 at 9:19 AM Resident #64 refused Restorative therapy services due to pain - On 12/25/14 at 9:21 AM Resident #64 complained of pain during morning care provided by nurse aide #1 - On 12/25/14 at 1:58 PM Resident #64's pain medication was ineffective After Nurse #1 documented that Resident #64's pain medication was ineffective, shift change occurred and Nurse #2 provided care for Resident #64. On 12/25/14 at 6:34 PM Nurse #2 gave Resident #64 2 [MEDICATION NAME] tablets for severe pain and documented the following: - On 12/25/14 at 6:34 PM Resident #64 was refusing to eat and get out of bed related to pain - On 12/25/14 at 9:04 PM Resident #64's pain medication was ineffective - On 12/25/14 at 11:43 PM Resident #64 lying in bed all day complaining of pain and moaning and groaning. Pain medications given and not effective. Emergency Medical Services (EMS), physician and family were notified. On 07/15/15 at 10:50 AM Nurse #1 was interviewed and reported that her usual process for managing a resident with pain was to determine the severity of the pain either by asking them using a 1 to 10 pain scale or for non-verbal residents looking at facial expressions. She explained that once medication was given she waited an hour to see if the medication was effective. If the medication was not effective, she would review the physician orders [REDACTED]. Nurse #1 stated that if a resident presented with severe unexplained pain and appeared in distress then she would immediately contact the physician. Nurse #1 added that Resident #64 took scheduled pain medications that controlled his pain but on occasion required additional pain medication that was ordered for as needed. Nurse #1 stated that was assigned to work 7 AM to 3 PM on 12/25/14 as Resident #64's nurse. Nurse #1 stated that on 12/25/14 Resident #64 started to complain of leg pain that morning and she gave him pain medication and couldn't recall if it was effective and could not describe the resident's pain. Nurse #1 reviewed Resident #64's medical record and the entries she made that specified Resident #64's pain medication was ineffective. The Nurse stated that she would have given more medication and called the physician if it was also ineffective. Nurse #1 stated that she could not recall if she contacted the physician. Nurse #2 was no longer employed at the facility and was unable to be reached. On 07/16/15 at 3:30 PM the Director of Nursing (DON) was interviewed and stated that he would expect nurses to administered pain medication as needed, assess for effectiveness, re-administer medications if ordered and then contact the physician if the resident was still in pain. He stated that Nurse #1 should have contacted the physician prior to the end of her shift when she documented that the resident's pain medication was ineffective. On 07/16/15 at 2:40 PM the medical director was interviewed and stated that he would expect a nurse to contact the physician when an as needed pain medication was ineffective. He explained that a sudden onset of newly developed pain that was unexplained he would expect the nurse to contact the physician right then because the resident would need to be sent to the Emergency Department for evaluation.

Based on observations, staff, physician, transportation driver and [MEDICAL TREATMENT] nurse interviews and record review the facility failed to intervene when pain medication was ineffective for a resident in severe pain for 1 of 4 sampled residents (Resident #64) and the facility failed to maintain communication with an outside [MEDICAL TREATMENT] center for 1 of 2 sampled residents who receive [MEDICAL TREATMENT] care (Resident #73). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) prior to Resident #64's fractured femur was dated 10/31/14 and specified the resident had moderately impaired cognition, had no behaviors, required 2 person extensive assistance with bed mobility and transfers; walking did not occur and the resident was not steady with balance and only able to stabilize with staff assistance. The MDS also specified Resident #64 was on a pain medication regimen and occasionally had pain in the last 5 days. Resident #64 had a care plan to address pain discomfort initiated on 11/19/13 and updated quarterly but not dated that specified to administer pain medication as ordered and utilize pain monitoring tool to evaluate effectiveness of interventions. On 07/14/15 at 12:30 PM Resident #64 was observed in his wheelchair and showed no signs of pain that included pained facial expressions, verbalization of pain, strenuous breathing or body language that would suggest pain. Review of Resident #64's physician orders [REDACTED]. - [MEDICATION NAME] 1 tablet every 6 hours as needed for moderate generalized pain dated 02/25/14 - [MEDICATION NAME] 2 tablets every 6 hours as needed for severe generalized pain dated 02/25/14 Review of Resident #64's Medication Administration Record [REDACTED]. Further review of Resident #64's medical record revealed nurses' entries made by Nurse #1. On 12/25/14 at 8:50 AM Nurse #1 documented that Resident #64 complained of bilateral leg pain and was given 1 tablet of [MEDICATION NAME] for moderate pain. Additional entries made by Nurse #1 were: - On 12/25/14 at 9:19 AM Resident #64 refused Restorative therapy services due to pain - On 12/25/14 at 9:21 AM Resident #64 complained of pain during morning care provided by nurse aide #1 - On 12/25/14 at 1:58 PM Resident #64's pain medication was ineffective After Nurse #1 documented that Resident #64's pain medication was ineffective, shift change occurred and Nurse #2 provided care for Resident #64. On 12/25/14 at 6:34 PM Nurse #2 gave Resident #64 2 [MEDICATION NAME] tablets for severe pain and documented the following: - On 12/25/14 at 6:34 PM Resident #64 was refusing to eat and get out of bed related to pain - On 12/25/14 at 9:04 PM Resident #64's pain medication was ineffective - On 12/25/14 at 11:43 PM Resident #64 lying in bed all day complaining of pain and moaning and groaning. Pain medications given and not effective. Emergency Medical Services (EMS), physician and family were notified. A documented titled Hospital Discharge Summary dated 12/27/14 specified Resident #64 was admitted to the hospital 12/25/14 and diagnosed with [REDACTED].#64 right proximal femur fracture was the result of a fall on 12/25/14 at the nursing facility. The decision was made to proceed with non-operative management due to extensive history of comorbidities and that Resident #64 had been non-ambulatory prior to hospital admission. On 07/15/15 at 10:50 AM Nurse #1 was interviewed and reported that her usual process for managing a resident with pain was to determine the severity of the pain either by asking them using a 1 to 10 pain scale or for non-verbal residents looking at facial expressions. She explained that once medication was given she waited an hour to see if the medication was effective. If the medication was not effective, she would review the physician orders [REDACTED]. Nurse #1 stated that if a resident presented with severe unexplained pain and appeared in distress then she would immediately contact the physician. Nurse #1 reported that she was regularly assigned to care for Resident #64 and that due to the resident's [MEDICAL CONDITION] (unable to speak) he was difficult to understand but made some verbalizations that she was able to understand. She added that she could tell when the Resident was in pain from facial expressions and some words. Nurse #1 added that Resident #64 took scheduled pain medications that controlled his pain but on occasion required additional pain medication that was ordered for as needed. Nurse #1 stated that was assigned to work 7 AM to 3 PM on 12/25/14 as Resident #64's nurse. Nurse #1 stated that on 12/25/14 Resident #64 started to complain of leg pain that morning and she gave him pain medication and couldn't recall if it was effective. She added that when she returned to work on 12/26/15 she was notified that Resident #64 had fallen and had a fractured leg. Nurse #1 stated that she did not get report that Resident #64 fell on [DATE] while she was assigned to him. Nurse #1 was able to recall that nurse aide #1 was assigned to Resident #64 on 12/25/14 from 7 AM to 3 PM and never reported to her any incidents during the shift. Nurse #1 reviewed Resident #64's medical record and the entries she made that specified Resident #64's pain medication was ineffective. The Nurse stated that she would have given more medication and called the physician if it was also ineffective. Nurse #1 stated that she could not recall if she contacted the physician. Nurse #1 also stated that she did not document that she assessed Resident #64's legs for the new complaint of bilateral leg pain. Nurse #1 was unable to recall any other details that occurred on 12/25/14. Nurse aide #1 was no longer employed at the facility and unable to be reached for an interview. Nurse #2 was no longer employed at the facility and unable to be reached for an interview. On 07/15/15 at 12:50 PM the Director of Nursing (DON) was interviewed and reported that he was on vacation on 12/25/14 but received a phone call from the facility that Resident #64 was being sent to the Emergency Department. The DON stated that the former Administrator investigated Resident #64's fractured femur. The DON reported that he was told the results of the investigation revealed that on 12/25/14 nurse aide #1 attempted to transfer Resident #64 and the resident started to fall, nurse aide #1 caught him, returned the resident to the chair and never reported the incident to Nurse #1. Resident #64 started to complain of pain after morning care. The DON did not know if Resident #64 was lowered to the ground and he was unable to answer any other questions surrounding the circumstances of the incident. The DON did not know what level of assistance Resident #64 required for transfers on 12/25/14. On 07/16/15 at 3:30 PM a second interview was conducted with the DON who reviewed Resident #64's medical record and nurses' entries that specified the resident complained of pain at 8:50 AM and was not given effective medication and the physician was not contacted when it was identified the pain medication was ineffective and the resident had a fractured femur. The DON stated that he would expect nurses to administered pain medication as needed, assess for effectiveness, re-administer medications if ordered and then contact the physician if the resident was still in pain. On 07/16/15 at 2:40 PM the medical director was interviewed and stated that he would expect a nurse to contact the physician when an as needed pain medication was ineffective. He explained that a sudden onset of newly developed pain that was unexplained he would expect the nurse to contact the physician right then because the resident would need to be sent to the Emergency Department for evaluation. 2. Review of the facility's [MEDICAL TREATMENT] guidelines revised 2013 revealed communication between the facility and [MEDICAL TREATMENT] center is essential for continuity of care. The guideline specified communication should include: a written communication form with review of daily weights, any changes in condition or mood, identification of the type of vascular access and issues with patency or signs of infection. Review of the facility's communication form revealed instructions for staff to complete the top portion of the form prior to resident's [MEDICAL TREATMENT] treatment and send with resident each treatment. The form contained sections for vital sign measurements, fasting blood sugar measurement with insulin dosage, description of access site, and condition changes in the last 24 to 48 hours. The form contained a section for the [MEDICAL TREATMENT] unit to complete at end of the resident's treatment. This section included pre and post [MEDICAL TREATMENT] vital sign measurements and weights with any additional changes. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #73's annual Minimum Data Set ((MDS) dated [DATE] revealed an assessment of moderately impaired cognition. The MDS indicated Resident #73 received [MEDICAL TREATMENT] treatment. Review of Resident #73's care plan revealed Resident #73 received [MEDICAL TREATMENT] treatment three days a week. Interventions included an assessment before and after [MEDICAL TREATMENT] treatment. Review of Resident #73's electronic Medication Administration Record [REDACTED]. Resident #73's finger stick blood sugars at 8:00 AM from 07/1/15 to 0/7/14/15 ranged from 135 to 500. Nurse #1 documented administration of 14 units of [MEDICATION NAME](a medication used to lower blood sugar) with physician notification. There were no new orders and there was no documentation of a repeat finger stick blood sugar. Observation on 07/15/15 at 9:46 AM revealed Resident #73 seated in a high back wheelchair in the hallway outside the main dining room. A transportation company driver gave Resident #73 a bag lunch. Interview with the transportation company driver on 07/15/15 at 9:48 AM revealed he regularly transported Resident #73 to the [MEDICAL TREATMENT] center. The driver explained he always went to the kitchen to obtain a bag lunch for Resident #73 before leaving. Observation on 07/15/15 at 9:50 AM revealed the transportation company driver transported Resident #73 to the van without paperwork and drove away from the facility. Interview on 07/16/15 at 8:21 AM with the East Wing Unit Manager revealed the facility communicated with the [MEDICAL TREATMENT] center with each [MEDICAL TREATMENT] treatment. The East Wing Unit Manager reported the hall nurse completed and placed the [MEDICAL TREATMENT] form in the resident's [MEDICAL TREATMENT] binder. This binder accompanied the resident to [MEDICAL TREATMENT]. The East Wing Unit Manager could not provide written [MEDICAL TREATMENT] communication forms or a binder for Resident #73. Interview with Nurse #1 on 07/16/15 at 9:11 AM revealed she did not complete the [MEDICAL TREATMENT] communication form for Resident #73. Nurse #1 explained she did not see Resident #73 leave for [MEDICAL TREATMENT] yesterday (07/15/15). Nurse #1 reported could not recall the last time Resident #73's [MEDICAL TREATMENT] communication binder had been used. Nurse #1 reported she should complete the form and list the high blood sugar but could not recall the last time she used the form. Nurse #1 reported she did not inform the [MEDICAL TREATMENT] center of the blood sugar reading of 506. A second interview with the East Wing Unit Manager on 07/16/15 at 9:11 AM revealed Resident #73's [MEDICAL TREATMENT] communication binder could not be located. The East Wing Unit Manager reported the binder was not in the facility, at the [MEDICAL TREATMENT] center or in the transportation company's van. Telephone interview on 07/16/15 at 10:02 AM with the [MEDICAL TREATMENT] nurse revealed the [MEDICAL TREATMENT] center contacted the facility by telephone with critical issues. The [MEDICAL TREATMENT] nurse reported the [MEDICAL TREATMENT] was not aware of Resident #73's blood sugar measurement of 506. The [MEDICAL TREATMENT] nurse reported Resident #73 did not come to the center with a binder but occasionally brought a form for the center to complete. Interview with the Director of Nursing (DON) on 07/16/15 at 10:17 AM revealed the facility nurse should complete an assessment with documentation on a communication form prior to each [MEDICAL TREATMENT] treatment in order to communicate with the [MEDICAL TREATMENT] center. The DON reported communication of a critical nature would be conducted by telephone or facsimile.

Based on staff interviews and record review the facility failed to safely transfer a resident that was lowered to the floor and sustained a leg fracture and failed to keep fall precautions in place for a resident with a history of falls for 2 of 4 sampled residents (Resident #64 and #78). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) prior to Resident #64's fractured femur dated 10/31/14 specified the resident had moderately impaired cognition, had no behaviors, required 2 person extensive assistance with bed mobility and transfers; walking did not occur and the resident was not steady with balance and only able to stabilize with staff assistance. The MDS also specified Resident #64 had not fallen. Resident #64 had a care plan to address the resident's risk for falls initiated on 11/19/13 and updated quarterly that specified education given to staff regarding proper transfer technique for this resident. The care plan did not specify what the proper transfer technique for Resident #64 was. Resident #64's Care Sheet (an instruction sheet for nurse aides to use when caring for residents), not dated, specified Resident #64 required 2 person assistance with transfers. Review of Resident #64's medical record revealed nurses' entries made by Nurse #1. On 12/25/14 at 8:50 AM Nurse #1 documented that Resident #64 complained of bilateral leg pain and was given 1 tablet of Norco for moderate pain. On 12/25/14 at 9:20 Nurse #1 documented that Resident #64 was unable to participate in Restorative therapy due to leg pain. On 12/25/14 at 1:58 PM Nurse #1 documented that Resident #64's pain medication was ineffective. Further review of Resident #64's medical record revealed that on 12/25/14 at 11:43 PM Nurse #2 documented that the resident was lying in bed all day complaining of pain and moaning and groaning. Pain medications given and not effective. Emergency Medical Services (EMS), physician and family were notified. A documented titled Hospital Discharge Summary dated 12/27/14 specified Resident #64 was admitted to the hospital 12/25/14 and diagnosed with [REDACTED].#64's right proximal femur fracture was the result of a fall on 12/25/14 at the nursing facility. The decision was made to proceed with non-operative management due to extensive history of comorbidities and that Resident #64 had been non-ambulatory prior to hospital admission. On 07/15/15 at 10:50 AM Nurse #1 was interviewed and reported that she was Resident #64's nurse on 12/25/14 from 7 AM until 3 PM. She explained that after nurse aide (NA) #1 provided morning care Resident #64 complained of bilateral leg pain. She gave the resident as needed pain medication for moderate pain in his legs. Nurse #1 reported that NA #1 had provided morning care for Resident #64 and had not reported any incidents or falls to her on 12/25/14. Nurse #1 stated that she could not recall any other details of that day and added she would have documented in the medical record any incidents or assessments that occurred during her shift. Nurse #1 explained that she returned to work on 12/26/14 at 7 AM and was notified that Resident #64 was hospitalized due to fractured femur from a fall in the facility. Nurse #1 could not recall what level of assistance Resident #64 required on 12/25/14 for transfers. Nurse aide #1 was no longer employed at the facility and unable to be reached for an interview. Nurse #2 was no longer employed at the facility and unable to be reached for an interview. Attempts were made to contact nurse aides that had cared for Resident #64 on or around 12/25/14 and they did not return messages. On 07/15/15 at 12:50 PM the Director of Nursing (DON) was interviewed and reported that he was on vacation on 12/25/14 but received a phone call from the facility that Resident #64 was being sent to the Emergency Department. The DON stated that the former Administrator investigated Resident #64's fractured femur. The DON reported that he was told the results of the investigation revealed that on 12/25/14 nurse aide #1 attempted to transfer Resident #64 and the resident started to fall, nurse aide #1 caught him, returned the resident to the chair and never reported the incident to Nurse #1. Resident #64 started to complain of pain after morning care. The DON did not know if Resident #64 was lowered to the ground and he was unable to answer any other questions surrounding the circumstances of the incident. The DON did not know what level of assistance Resident #64 required for transfers on 12/25/14. On 07/16/15 at 9:45 AM the MDS Coordinator was interviewed and stated she was not familiar with Resident #64 and his level of assistance. The MDS Coordinator reviewed Resident #64's MDS dated [DATE] and reported that he required 2 person extensive assistance with transfers and that nurse aides should use two persons when transferring him unless that changed. She explained that nurse aides used care sheets that were developed by the Unit Managers for instructions on how to care for residents. On 07/16/15 at 12:20 PM the East Wing Unit Manager was interviewed and reported that he developed and updated care sheets daily and the sheets were given to nurse aides for instructions on residents' individualized needs. He stated that Resident #64 had always required 2 person assistance with transfers for safety because of the Resident's dependent state and hemiparesis. He stated that it was possible Resident #64 could stand but needed additional assistance due to his hemiparesis. On 07/16/15 at 11:30 AM the former Administrator was interviewed on the telephone and reported that she was notified Resident #64 had been admitted to the hospital for a fractured femur. She stated that she immediately started an investigation to determine the cause of the fracture. She explained that she conducted interviews with every staff member that had cared for Resident #64 48 hours prior to 12/25/14. The former Administrator added that NA #1 reported that while providing morning care on 12/25/14 he attempted to transfer Resident #64 from the bed to wheelchair, the resident started to fall, the nurse aide lowered Resident #64 to the floor, assisted Resident #64 off the floor and placed the resident in the wheelchair. The former Administrator stated that NA #1 did not report the incident to the nurse. The former Administrator stated that to her knowledge Resident #64 was able to stand and pivot for transfers and that it was acceptable for NA #1 to attempt to transfer the resident alone. The former Administrator reported that she concluded from her investigation Resident #64's fractured femur was a result of the incident on 12/25/14 during morning care. She added that NA #1 was re-educated on reporting all incidents to the nurse immediately. 2. Resident #78 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Medical record review and review of incident reports revealed Resident #78 fell in his room from his wheel chair on 01/13/15 and from his bed on 06/30/15. He was uninjured. A care plan reviewed May 2015 and a nurse aide communication tool updated 07/16/15 recorded to keep floor mats at the bedside while the resident was in bed. Resident #78 was observed in a low bed on 07/15/2015 at 08:51 AM and on 07/16/15 at 08:30 AM with a fall mat to the floor on the left side of the bed. A second fall mat was observed folded against the wall. An interview with nurse aide (NA) #3 occurred on 07/16/15 at 8:55 AM. NA #3 stated that she used the NA communication tool to know how to care for the residents she was assigned. NA #3 stated that staff kept the bed for Resident #78 in it lowest position, a tabs alarm in place and fall mats to the floor on both sides of his bed, because Resident #78 made attempts to self transfer and may fall due to a history of falls. NA #3 confirmed that both fall mats should have been on the floor while Resident #78 was in bed, but had no explanation as to why both fall mats were not on the floor. During an interview on 07/16/15 at 09:15 AM, the west wing unit manager confirmed that Resident #78 was at risk for falls and nursing staff should place fall mats to both sides of his bed while he was in bed and check for placement each shift.