Every finding on record at Pembroke Center

Based on observation, record review, and staff interviews, the facility failed to obtain a physician's order for the initiation of oxygen therapy for 1 of 1 resident reviewed for respiratory services (Resident #1).Findings included:Resident #1 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and congestive heart failure. Review of the hospital Discharge summary dated [DATE] revealed no order for nasal cannula oxygen upon Resident #1's return to the facility. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. He received oxygen therapy and had shortness of breath when at rest and lying flat. During an observation on 5/19/26 at 3:00 PM, Resident #1 was observed in his room wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at 1 liter per minute. Resident #1 was resting with his eyes closed and showed no signs of acute distress.During an observation and interview on 5/20/26 at 10:00 AM, Resident #1 was again observed wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at 1 liter per minute. Resident #1 was oriented to self and situation. When asked by the surveyor if he experienced shortness of breath at rest or with exertion, Resident #1 stated that he did.Review of Resident #1's electronic medical record on 5/20/26 revealed no current physician's order for supplemental oxygen. Review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated May 2026 revealed no order for oxygen therapy. The MAR did show that Resident #1's oxygen saturation (how much oxygen the blood is carrying) was monitored once daily from 5/10/26 through 5/12/26 then twice daily from 5/13/26 through 5/21/26 with readings ranging from 95-99% (Normal ranges 95-100%). A care plan revised 5/20/26 revealed Resident #1 was at risk for respiratory complications related to asthma and recent hospitalization. Interventions included to administer oxygen via nasal cannula as ordered. During an interview on 5/20/26 at 10:00 AM, Nurse #1 stated that Resident #1 had been receiving oxygen via nasal cannula since returning from the hospital on 5/5/26. Nurse #1 looked at the oxygen concentrator and stated Resident #1 was currently on one (1) liter per minute. She reported she did not know the ordered flow rate and would check the order. Nurse #1 later (approximately 12:00 pm) confirmed there was no oxygen order in Resident #1's electronic medical record and stated she was unsure what flow rate he should be receiving. She reported she would notify the Unit Manager.During an interview on 5/20/26 at 12:00 PM, the Unit Manager stated she could not locate an order for nasal cannula oxygen for Resident #1. She reported she had just notified the Nurse Practitioner and obtained a new order for nasal cannula oxygen at 2 liters per minute. The Unit Manager stated Resident #1 returned from the hospital on 5/5/26 on nasal cannula oxygen and that the admission nurse should have clarified the oxygen order since it was not on the hospital discharge summary. She stated she had not received any reports of Resident #1 experiencing shortness of breath or respiratory distress. An attempt was made to contact Nurse #2 who was the admission nurse on 5/5/26, and there was no response. During an interview on 5/21/26 at 11:00 AM, the Director of Nursing (DON) stated the oxygen order should have been clarified upon Resident #1's readmission by the admitting nurse and entered into the electronic medical record. The DON confirmed that oxygen therapy should not have been initiated or continued without a valid physician's order.

Based on record review, observation, and resident, staff, Physician and Wound Physician interviews, the facility failed to administer two prescribed medications, ketoconazole 2% shampoo (an antifungal shampoo used to reduce scalp flaking, scaling, and itching) and fluocinonide 0.05% topical solution (a topical steroid used to relieve inflammation and itching) in accordance with the physician's orders. This failure occurred for 1 of 3 residents reviewed for significant medication errors (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including seborrheic dermatitis (an inflammatory skin disorder affecting the scalp, face, upper chest, upper back, and skin folds. It presents as patches or plaques with inflammation, redness, and yellow, flaky scales that cause itching, burning, and irritation). A physician's order from the Dermatologist's office dated 11/6/25 for Resident #1indicated an active order for ketoconazole 2% shampoo, to be applied twice weekly with good lather to the scalp and face, left in place for 2-5 minutes, then rinsed, for treatment of seborrheic dermatitis. A physician's order from the Dermatologist's office dated 11/6/25 for Resident #1 also indicated an active order for fluocinonide 0.05% topical solution (a high-potency topical corticosteroid used to reduce inflammation, redness and itching for skin conditions such as eczema, dermatitis, psoriasis and allergic rashes), to be applied to the affected scalp twice daily as needed for seborrheic dermatitis. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from 11/22/25 through 4/24/26 revealed no order for the ketoconazole shampoo. The fluocinonide order was listed on the MAR with no documentation that the as needed topical corticosteroid solution was administered to Resident #1. Review of nursing progress notes from 11/22/25 through 4/24/26 revealed no documentation indicating administration of either treatment or documentation indicating whether treatment was needed for Resident #1. Resident #1 was transported to the emergency department on 4/24/26 for an unrelated condition. Hospital records documented multiple thick, yellow white crusted patches extending across the crown and back of the scalp. The hospital documentation did not indicate whether treatment was provided. Resident #1 was discharged back to the facility on 5/5/26. The Minimum Data Set (MDS) discharge return anticipated assessment dated [DATE] indicated Resident #1 had moderately impaired cognition and skin tears. Review of Resident #1's electronic medical record on 5/20/26 showed that ketoconazole shampoo and the as needed fluocinonide topical solution remained active orders upon return from the hospital on 5/5/26. Review of the MAR and TAR from 5/5/26 through 5/20/26 again revealed no documented administration of the ketoconazole shampoo and no documented use of the as needed fluocinonide topical solution for Resident #1. Review of the nursing progress notes from 5/5/26 through 5/20/26 revealed no documentation of treatment administration and no documentation indicating whether treatment was needed for Resident #1. An observation conducted on 5/20/26 at 10:00 AM with Nurse #1 and Nurse Aide #2 revealed Resident #1 lying in bed, and alert and oriented to self and situation. Resident #1 had thick, yellow white crusted patches extending across the crown and back of the scalp, with redness and irritation noted along the posterior hairline. During an interview on 5/20/26 at 10:00 AM, Resident #1 was unable to state whether any scalp treatments had been administered. He reported that his scalp was itchy and sore. During an interview on 5/20/26 at 10:05 AM, Nurse #1 stated she routinely provided care to Resident #1 but was not aware of any scalp issues or of the orders for ketoconazole shampoo or as needed fluocinonide. She reported she was unaware of any plaque buildup or irritation on his scalp. She stated Nurse Aides were responsible for shampooing residents' hair, but she did not know whether medicated shampoo was used.During an interview on 5/20/26 at 10:15 AM, Nurse Aide #2 stated she routinely cared for Resident #1 and indicated she did not recall if Resident #1's scalp had multiple scaly patches prior to his hospitalization on 5/5/26 but she had noticed irritation on his scalp at times including this morning, but she was not aware of any treatment and had never used medicated shampoo when washing his hair. Nurse Aide #2 indicated she had not reported this to Nurse #1 yet today, but she was planning to. During an interview on 5/20/26 at 11:00 AM, the Unit Manager stated Resident #1 had a chronic skin condition and previously received scheduled fluocinonide twice daily for symptom management. She stated the dermatologist changed the order to as needed on 11/6/25. The Unit Manager reported she was not aware that Resident #1 had multiple crusted scalp patches when sent to the hospital on 4/24/26 and was not aware he continued to have scalp issues. She stated the ketoconazole shampoo should have been administered twice weekly and the fluocinonide used when needed. The Unit Manager indicated that she or the assigned nurse would enter new orders into the electronic medical record but could not recall if she worked on 11/6/25 to enter new medication orders. During a phone interview on 5/21/26 at 9:00 AM, the Physician stated he was not aware of any concerns regarding Resident #1's scalp. He confirmed Resident #1 was followed by dermatology and stated medications should be administered as ordered. During an interview on 5/21/26 at 10:30 AM the Wound Physician stated ketoconazole shampoo and fluocinonide topical solution would be effective treatment for seborrheic dermatitis if they had been used. The Wound Physician stated the medications should have been administered to Resident #1. During an interview on 5/21/26 at 11:00 AM, the Director of Nursing (DON) confirmed the as needed fluocinonide order was active and should have been administered to Resident #1 when symptoms were present. She also confirmed that the ketoconazole shampoo was an active order and should have been administered twice weekly as prescribed and acknowledged this was not done. The DON indicated that the ketoconazole shampoo wasn't transcribed from the dermatologist orders that were received on 11/6/25 and entered into Resident #1's electronic medical record, and the as needed fluocinonide was on the MAR as and was not administered. The DON stated the nurse on duty on 11/6/25 should have entered the ketoconazole into Resident #1's electronic medical record and that was not done. The DON stated the fluocinonide should have been administered when Resident #1 was symptomatic but that was not done. The DON stated the assigned nurse, or the Unit Manager, were responsible for entering new orders.

Based on record reviews, and interviews with staff, Director of Nursing, Pharmacist, Administrator, and the Medical Director, facility failed to verify right patient before administering insulin, which resulted in an insulin injection being administered to a resident with the same last name without an insulin order for 1 of 1 resident reviewed for significant medication errors (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses of influenza, pneumonia, and did not include diabetes (DM).Resident #19's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact. Resident #19's physician orders for January/2026 listed: Oxygen at 3 liters nasal cannula, albuterol, digoxin, and metoprolol. The physician orders did not include an order for insulin. Review of Resident #19's Electronic Medication Administration Record (E-MAR) dated January 2026 revealed no order listed for insulin.A nursing note dated 01/12/26 at 7:24 PM for Resident #19 revealed on 01/12/26 at 4:30 PM the resident was given 10 units of Lispro insulin and was not on insulin. Resident #19 was given glucose by doctor's order. Resident's blood glucose on 01/12/26 at 6:28 PM was 149. Patient's blood sugar levels were monitored and remained within normal limits, with patient stable. (Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours.) (Normal blood sugar levels for non-diabetic adults range from 70 to 140). A Medical Director order dated 01/12/26 at 5:00 PM for Resident #19 revealed to administer one tube (24 grams) of Insta-glucose gel stat, which was given. (Insta-glucose gel is a fast-acting glucose used to treat very low blood sugar.) An interview was conducted on 01/14/26 at 9:10 AM with Nurse #1. The nurse said on 01/12/26 around 4:30 PM she was working on the medication cart on the 300-hall. She said she administered 10 units of Lispro (insulin) to Resident #19 instead of intended resident with the same last name. She said she immediately reported the medication error to the Unit Manager, who notified the Nurse Practitioner, who ordered glucose gel to be administered, vital signs and assessment done, along with 15-minute blood glucose levels check, which she did. Nurse #1 stated resident's blood sugar remained within normal limits and Resident #19 had no side effects. She said the Medical Director and resident's Responsible Party (RP) were informed of the medication error. Nurse #1 said she gave the insulin in error, was distracted, and should have paid closer attention to giving out medications to residents with the same last name.An interview was conducted on 01/13/26 at 3:48 PM with Unit Manager #2. She said on 01/12/26 around 4:30 PM she was working on the 400 short hall. She said Nurse #1 came to her and said she gave 10 units of insulin to the wrong resident. The Unit Manager said she immediately checked Resident #19's blood sugar which was 100, then reported the incident to the Director of Nursing and the Nurse Practitioner, who ordered glucose gel to be administered, vital signs and assessment done, along with blood glucose levels checked. Unit manager stated resident's blood sugar remained within normal limits and Resident #19 had no side effects from the insulin. Resident #19's blood sugar levels: 01/12/25 at 5:02 PM - 100, 01/12/25 at 5:18 PM - 114, 01/12/25 at 6:28 PM - 149, 01/12/25 at 9:00 PM - 100, 01/12/25 at 11:00 PM - 115, and 01/13/25 at 1:19 AM - 103.An interview was conducted on 01/13/26 at 3:25 PM with Resident #19. The resident stated on 01/12/26 just before dinner she was given an insulin injection in her right arm by Nurse #1. She stated after the injection, she asked the nurse what she gave her and was told her evening insulin. The resident told the nurse that she was not diabetic and was not on insulin. Resident #19 stated she had no reactions from the insulin, and soon after getting the injection, she was given glucose gel and was monitored by nursing staff. An interview was conducted on 01/14/26 at 9:36 AM with the Director of Nursing (DON). She stated it was her expectation that Nurse #1 followed their policy on medication errors and to have verified the right resident, the right medication, the right dose, and right route; before she administered the 10 units of Lispro (insulin) to Resident #19.An interview was conducted on 01/14/26 at 9:55 AM with the facility's Pharmacist. She confirmed Resident #19 received 10 units of Lispro insulin in error on 01/12/26 around 5:15 PM. The Pharmacist indicated Nurse #1 mistakenly gave the insulin to the wrong resident and noted the resident who was prescribed the insulin and Resident #19 both had the same last name. She said the only possible drug interaction was that of metoprolol, which could mask the effects of hypoglycemia. However, Resident #19 only received one 10-unit low dose of insulin, and was taking metoprolol in the mornings, which most likely wouldn't have this masking effect. The Pharmacist said the resident's blood sugar was closely monitored for about 2 hours after the 10-unit insulin administration, with no drug interactions. The Pharmacist stated a normal adult's blood sugar was 80 to 90, and that Resident #19 blood sugar checks after the one dose insulin administration was never below 100 and remained above the normal adult blood sugar range. An interview was conducted on 01/13/26 at 3:20 PM with the Medical Director. He confirmed on 01/12/26 at approximately 4:30 PM Resident #19 was accidentally administered 10 units of Lispro (insulin) that was intended for another resident with the same last name during medication pass. He said the nurse notified her unit manager; resident was assessed with vital signs and blood sugar check, was given glucose per order, and remained stable with blood sugar of 100, with no aftereffects, and no harm. A follow-up Medical Director progress note for Resident #19 dated 01/14/26 at 10:57 AM stated: [Resident #19] was noted to have received on 01/12/26 insulin Lispro (generic Humalog) 10 units in error. [Resident #19] sustained no adverse effect. Indeed, 10 units is not considered a high dose, and in this case, the likelihood of any adverse effects was nil. Moreover, the actions of the staff member in administering glucose gel, further ensured that any adverse effects were not likely to occur. Therefore, the likelihood for harm in this case was nil. An interview was conducted on 01/14/26 at 9:49 AM with the Administrator. She stated it was her expectation that Nurse #1 followed their policy on medication errors and to have verified the right resident, before she administered the 10 units of insulin to Resident #19, which she did not do.

Based on observations, record review, staff interviews, Physician and Consulting Pharmacist interviews, the facility administered an expired medication that was stored in the medication cart to Resident #10 via enteral tube feeding for 9 days for a total of 18 doses. Resident #10 was sent to the Emergency Department and had no adverse outcome as a result of receiving this expired medication. Findings included:Resident # 10 was admitted to the facility on [DATE]. Diagnoses included stroke with aphasia (a language disorder that affects a person's ability to communicate), gastrostomy (tube feed) and gastroenteric reflux disease (GERD). Review of a physician's order written on 12/27/24 for Pantoprazole Sodium Oral (also known as Protonix) Suspension 4 milligrams/milliliter. Give 10 milliliters enterally (via tube feed) two times a day for GERD. The Minimum Data Set admission assessment dated [DATE] revealed Resident #10 was coded as severely impaired and was coded as having a feeding tube. A hospital emergency department note dated 01/19/25 revealed, in part, per nursing facility staff, resident was given his daily dose of Protonix this morning and it was noted after administering that the medication had expired 9 days ago (01/10/25). Resident was currently resting comfortably, nonverbal but able to answer questions by nodding or shaking his head and had no acute complaints. Resident's Responsible Party requested that resident be sent to the emergency department to make sure resident was okay after receiving the expired medication. The hospital course indicated the only side effect from this expired medication would be that it may not be as effective as usual. Resident was discharged back to the facility. Review of the January Medication Administration Record revealed Resident #10 received the Protonix medication twice daily from 01/11/25 through 01/19/25 to include a total of 18 doses. Review of a grievance concern form dated 07/01/25 filed by the Responsible Party (RP) revealed Resident#10 received medications that were expired. The investigation was addressed to the Director of Nursing on 07/01/25 and the action taken for this concern was that education was provided to all nursing staff during an all-staff meeting. A written summary was attached and addressed to the RP stating, in part, we are contacting you to notify of the outcome to your concern regarding [Resident #10] receiving an expired medication. [Resident #10] had no adverse effects from the medication being given and 72-hour charting was completed to ensure there were no signs or symptoms of adverse effects. As a facility, we have measures in place to ensure this does not happen again. We have educated the staff and will be conducting medications cart checks for expired medications. Education in-service record dated 07/01/25 revealed the nursing staff were in serviced to ensure expired medications were discarded and not given to residents. The in-service included checking expiration dates on medications and discard any expired medications to avoid the administration of expired medications. Each of the nurses who administered the expired medication signed the in-service sheet. An interview with the Director of Nursing (DON) on 10/02/25 at 3:00 PM revealed she had started working at the facility in March of 2025. She stated on 07/01/25 she was made aware via a grievance from the Responsible Party of Resident #10 that he received expired medications that had occurred in January 2025. She stated she initiated an in-service with each nurse who signed off that they administered the medication from 01/11/25 through 01/19/25 on 07/01/25 and began medication cart audits. The DON stated she did not know what the previous DON did when this error occurred back in January 2025. A phone interview with Consulting Pharmacist #1 on 11/18/25 at 2:36 PM revealed the ordered liquid Protonix had a shortened expiration date because it was a compound (mixed with another medication) medication, so it did not have a long shelf life. Consulting Pharmacist #1 stated nursing staff should be monitoring the expirations on all medications before administration. She stated she was not sure about the adverse effects of receiving the medication, but that the expired medications could have been contaminated due to the short shelf life. An interview with the Physician on 11/17/25 at 1:10 PM revealed there would be no adverse effects from receiving the expired medication, but that nursing staff needed to follow the regulations and ensure there were no expired medications on the medication carts to avoid the administration of expired medications.

Based on observations, record review, resident and staff interviews, the Consultant Pharmacist, and the Medical Director interviews the facility failed to have effective safeguards and systems in place to prevent drug diversion of discontinued narcotic pain medication (Hydrocodone-Acetaminophen oral tablet 5-325 milligrams) which resulted in a total of 20 missing tablets. This occurred for 1 of 1 resident (Resident #3) reviewed for misappropriation of medications. Findings included: Resident #3 was re-admitted to the facility on [DATE] with diagnoses including a stage IV and stage II pressure wounds. A hospital physician's order dated [DATE] for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for up to 5 days. A second hard copy physician's order dated [DATE] for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 mgs. Give 1 tablet by mouth every 6 hours as needed for pain for 14 days (56 tablets). This order was not entered into the electronic medical record. A packing slip and proof of delivery from the dispensing pharmacy dated [DATE] revealed the hospital physician's order was filled with a delivery of 11 tablets of Hydrocodone-Acetaminophen oral tablets 5-325 mgs for Resident #3 was received in the facility on [DATE]. The delivery was signed as received by Nurse #7. A packing slip and proof of delivery from the dispensing pharmacy dated [DATE] revealed the facility's physician's order was filled with a delivery of Hydrocodone-Acetaminophen oral tablets 5-325 mg and a total of 54 tablets for Resident #3 was received in the facility on [DATE]. The delivery was signed as received by Nurse #7 and Nurse #5. The declining count sheet for the 11 tablets of Hydrocodone-Acetaminophen 5-325 mgs ordered on [DATE] by the hospital physician and the Medication Administration Record (MAR) dated [DATE] included corresponding information indicating that the medication was signed by nursing staff as administered to Resident #3 from [DATE] through [DATE] with zero tablets remaining. The MAR had a stop date of [DATE]. The declining count sheet for the [DATE] order for the 54 tablets of Hydrocodone-Acetaminophen 5-325 mgs ordered by the facility's physician and Resident #3's MAR were reviewed. The July and [DATE] MARs revealed the hard copy order from the facility physician's dated [DATE] was not entered on Resident #3's MAR. The declining count sheet and the MAR revealed the following information related to this Hydrocodone-Acetaminophen order: - [DATE] at 2:00 PM: On the declining count sheet one tablet was signed as administered by Nurse #9 with 53 pills noted as remaining. This was documented on the MAR on the 5-day under the order given by the hospital physician on [DATE]. - [DATE] at 8:00 PM: On the declining count sheet one tablet was signed as administered by Nurse #7 with 52 pills noted as remaining. There was no documentation on the MAR corresponding to the declining count sheet. - [DATE] with no time documented: On the declining count sheet one tablet was signed out by a nurse whose name was not legible with 51 pills noted as remaining. There was no documentation on the MAR corresponding to the declining count sheet. A new physician's order dated [DATE] for Resident #3 revealed Hydrocodone-Acetaminophen 5-325 mgs 1 tablet by mouth every 6 hours as needed for pain for 14 days. This order was on the MAR with a stop date of [DATE]. The [DATE] as needed order for Hydrocodone-Acetaminophen was signed out as administered on the declining count sheet from the [DATE] order for the 54 tablets delivered by the pharmacy on [DATE]. The declining count sheet and the September MAR revealed the following information: - [DATE] at 8:50 AM one tablet was signed as administered by Nurse #9 and documented on the September MAR. There were 50 pills remaining. - [DATE] at 4:20 PM one tablet was signed as administered by Nurse #9 and documented on the September MAR. There were 49 pills remaining. - [DATE] at 7:00 AM one tablet was signed as administered by Nurse #10 and was not documented on the September MAR. There were 48 pills remaining. - [DATE] at 7:00 AM one tablet was signed as administered by Nurse #10 and was not documented on the September MAR. There were 47 pills remaining on the 54-count card. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 was cognitively intact. He received scheduled and as needed opioid medications with occasional pain. An investigation report completed by the Administrator dated [DATE] revealed an order for Hydrocodone-Acetaminophen 5-325 mgs was given by the hospital. Eleven tablets were delivered to the facility on [DATE] and signed in by Nurse #7 and Nurse #5. Nurse Practitioner #1 placed an additional order on [DATE] and 54 tablets were delivered on [DATE] and signed in by Nurse #9. The 11 Hydrocodone-Acetaminophen 5-325 mgs were completed on [DATE]. The descending count for the 2nd card of 54 tablets was 49 on [DATE]. On [DATE] Nurse #10 discovered the count on the narcotic sheet had been changed to 27 noting 20 missing tablets and reported this to the Director of Nursing (DON). The DON then directed Nurse #10 to check the medication cart to ensure the pills were missing. Nurse #10 confirmed the pills were missing. Nurse #10 was directed to count the medication versus the count sheet to ensure there were no other discrepancies, and none were found. On [DATE] Resident #3's discontinued Hydrocodone-Acetaminophen was removed from the medication cart. On [DATE] the DON directed all nursing staff to complete an audit of all narcotics versus count sheets with no issues found. On [DATE] the DON contacted the local police to report the missing narcotics who stated he would notify the detective for further investigation. On [DATE] the State Agency and the Pharmacy was notified. On [DATE] while conducting nursing interviews Nurse #10 confirmed that when she last counted on [DATE] the count was correct at 47 of the 54 doses remaining on the medication card. Other staff interviewed stated they could not recall the count number. Interviews were conducted with both the agency night shift nurse on [DATE] and the agency day shift nurse on [DATE]. One nurse stated the count was correct and the other nurse stated he could not remember. The facility substantiated the allegation of misappropriation of residents property. During an interview on [DATE] at 1:30 PM Resident #3 was lying in bed. He was alert and oriented to person, place, and time. Resident #3 was in no distress and stated he received Hydrocodone as scheduled and there had not been any time that his pain medication was not available to him. Resident #3 stated the Hydrocodone relieved his pain and he had no concerns with his medications. During an interview on [DATE] at 10:00 AM Nurse #10 stated she was an agency nurse and knew for certain the count was right when she last counted the Hydrocodone doses on [DATE], which was the last time she worked before [DATE]. She stated on [DATE] she and Nurse #7 were counting the controlled medications during shift change and the medication declining count sheet from the original 54 doses had been tampered with and it looked as if someone had marked through the amount remaining of 48 pills on [DATE] and put 28, then marked through the amount remaining of 47 pills on [DATE] and put 27. The 27 remaining pills were removed from the cart on [DATE] and returned to pharmacy. Nurse #10 stated she did not know who removed the missing pills. Nurse #10 stated the Hydrocodone- Acetaminophen 5-325 mgs written [DATE] should have ended after 14 days and the medication card with the remaining tablets returned to pharmacy but that did not occur. Nurse #10 stated when she reported that the count was accurate as of [DATE] that was during shift count and the card was still on the medication cart. Nurse #10 indicated she did not verify that an active order was in place on [DATE]. During an interview on [DATE] at 10:45 AM the Director of Nursing (DON) stated the medication discrepancy was reported to her by Nurse #10 when she and the oncoming nurse were doing the end of shift count on the morning of [DATE]. Nurse #10 stated there was an issue with the declining count. The count of 47 had been marked out and changed to 27. Audits were done of the controlled medications immediately on all carts and the police were notified and the State Agency was notified. The DON stated the medication rooms were also audited to see if the medications had been misplaced. During the investigation she interviewed all nurses who had worked since [DATE], which was when Nurse #10 confirmed there were 47 pills at that time and the count was correct. All nurses were interviewed who had worked the medication cart, but no other nurse could remember how many pills were on the cart. The DON stated they were unable to determine who took the medications. When asked why the Hydrocodone-Acetaminophen order dated [DATE] from the facility's physician was not entered into Resident #3's electronic medical record the DON stated in [DATE] they discovered that the orders that the Nurse Practitioner entered weren't showing up in the electronic medical record and since that time the Nurse Practitioner no longer entered orders, the orders are given to the nurse. The Nurse Practitioner told the DON she could not remember which nurse she gave the order to. There was no order entered for the Hydrocodone - Acetaminophen 54 count. The DON stated the process failed when the order was not entered into Resident #3's medical record, and the nurses not accurately verifying the order associated with the medication card, as well as accurately counting the controlled medications at the end of each shift. The Hydrocodone- Acetaminophen order should have been entered into the electronic medical record, then after the 14-day period ended any doses remaining on the medication card should have been returned to pharmacy for destruction. The medication card should have been taken off the cart at that time, and the process failed with removing the card from the medication cart. The DON stated a night shift nurse (Nurse #5), and the Unit Managers were responsible for removing any discontinued medication cards from the medication cart. During an interview on [DATE] at 1:30 PM Unit Manger #2 stated before [DATE] there was no process in place to pull medications from the medication cart. She stated since the incident was found she was now required to check the medication carts for discontinued medications. Unit Manger #2 stated she had received in-service training during the facility investigations. During a phone interview on [DATE] at 2:15 PM the current Consultant Pharmacist #1 stated she began as the facility's Consultant Pharmacist in [DATE] and had not been to the facility since October. She stated she was told about the drug diversion. She stated the pharmacist is not here daily to remove medication cards and it should be done by the facility. She stated she did periodically conduct controlled card audits and will notify the nurse and DON if any concerns. Consultant Pharmacist #1 stated she selected one controlled medication card to audit per visit. During the audit she looks at the controlled medication book, looks at the medication cards, looks for expiration dates, and expired, or shortened order dates. She did not review Resident #3 during the October audit. During a phone interview on [DATE] at 2:30 PM with Consultant Pharmacist #2 who was the consultant during July through [DATE]. She stated she did random audits on the controlled medications and randomly selected 4 or 5 cards for auditing. She stated she looked at documentation, final counts, and verified that the card and order match. Consultant Pharmacist #2 stated a note was sent to the DON regarding Resident #3's Hydrocodone-Acetaminophen remaining on the medication cart on the August report. During a phone interview on [DATE] at 6:00 PM Nurse #5 stated she was a night nurse and did check the controlled medications at times, but she did not work every night. Nurse #5 stated the Unit Managers were responsible for checking the medication carts daily. During an interview on [DATE] at 4:13 PM Unit Manager #1 stated she started auditing medication carts last week. She stated all nurses were tasked with removing medications from the cart if an order was discontinued. Unit Manager #1 stated the nurse should have pulled the medication and the medication card, signed with a second nurse and returned the card to pharmacy who picks up several times a day and that was not done. During an interview on [DATE] at 1:00 PM the Medical Director stated he was made aware of the missing Hydrocodone-Acetaminophen for Resident #3. He stated Resident #3's pain was controlled with his pain medications and no further concerns had been reported to him regarding Resident #3. During an interview on [DATE] the Administrator indicated a full investigation was conducted regarding the missing Hydrocodone tablets. They were unable to determine who took the missing medications. The decision was made on [DATE] to monitor controlled medications and put it in their Quality Assurance (QA) program.

Based on observations, record review, and staff interviews, the facility failed to 1) secure an unattended medication cart that was facing the hallway for 13 minutes during which time 3 staff members and a resident propelling himself in a wheelchair passed the unattended opened medication cart for 1 of 1 medication carts observed (400 hall medication cart), and 2) remove loose and unsecured pills (200 hall cart), label inhalation breathing medication vials with an open date and store the vials according to manufacturer guidelines (300 hall cart) for 2 of 4 medication carts and failed to discard expired over the counter (OTC) stock medication from 1 of 2 medication storage rooms (200 hall medication room) that were reviewed for medication storage.Findings included: 1) A continuous observation of the 400-hall medication cart on 10/02/25 from 10:10 AM to 10:23 AM revealed the medication cart was noted to be unlocked as evidenced by the lock base not being pushed in flush with the drawer and was unattended and facing the hallway. Three staff members were noted to walk past the medication cart during this observation and one resident who was self-propelling in a wheelchair was noted to pass by the unlocked medication cart. An interview was conducted with Unit Manager #2 on 10/02/25 at 10:23 AM. The Unit Manager exited a resident's room and approached the 400-hall medication cart. At this time, she locked her medication cart. Unit Manager #2 stated she did not realize she left the medication cart unlocked until she came out of the residents' room. She stated she forgot to lock it before she walked away from it. An interview was conducted with Director of Nursing (DON) on 11/18/25 at 10:43 AM. The DON stated she would expect all the nursing staff to keep their medication carts locked if they were out of direct line of site and all medication carts should be secured for resident safety. 2. An observation of the 200-hall medication cart was conducted with Nurse #8 on 10/1/25 at 10:10 AM. The observation revealed 11 loose pills of various shapes, colors, and sizes in the bottom of the medication drawers. An interview was completed with Nurse #8 on 10/1/25 at 10:15 AM. Nurse #8 stated the nurses and medication aides (MA) were responsible for cleaning and checking the med carts every shift. She indicated there was not supposed to be any loose pills in the med cart drawers. An interview was completed with the Director of Nursing (DON) on 11/18/25 at 2:52 PM. The DON stated the nurses and medication aides were all responsible for keeping the med carts clean and orderly. She indicated there should not be any loose pills in the med cart drawers. She stated she expected med carts to be clean and free from loose pills. 3. An observation of the 200-hall medication storage room was completed with Unit Manager #1 and Nurse #8 on 10/1/25 at 10:17 AM. A bottle of the over the counter (OTC) stock Vitamin B6 50 milligrams (mg) tablets was available for use with an expiration date of 8/25. An interview was completed with Unit Manager #1 on 10/1/25 at 10:25 AM. Unit Manager #1 stated there should not be any expired medications on the shelf available for use in the medication storage rooms. An interview was completed with the DON on 10/2/25 at 10:30 AM. The DON stated there should not be any expired medications available for use in the medication storage rooms. 4. An observation of the 300-hall med cart was conducted on 10/2/25 at 10:13 AM with the Wound/Treatment Nurse. The observation revealed 20 vials of ipratropium bromide inhalation solution in an open foil package with no label or date opened. The manufacturer's instructions included discarding the medication 2 weeks after opening. An interview was completed with the Wound/Treatment Nurse on 10/2/25 at 10:25 AM. The Wound/Treatment Nurse stated she was unaware the vials expired 2 weeks after opening and it should have had an opened date. An interview was completed with the DON on 10/2/25 at 10:30 AM. The DON stated she was not aware that the vials expired 2 weeks after opening. She indicated all medications should have a label and an opened date.

Based on observations, record review, and staff interviews the facility failed to 1.) implement the infection control policy and procedures for special contact and droplet precautions for a resident (Resident #68) who was positive for COVID 19. Nurse Aide # 9 was observed walking into Resident# 68's room without wearing gloves or a gown and moved the mechanical lift that was used to transfer Resident # 68 from her bed. Nurse Aide #9 rolled the mechanical lift into the hallway without cleaning it, placed it against the wall, and left the lift unattended. Nurse Aide # 9 went back into Resident #68's room without donning gloves and a gown and moved the bedside table, picked up Resident #68's water cup and handed it to the resident. 2.) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to a resident with an indwelling urinary catheter (Resident #28). Nurse Aide #9 and Nurse Aide #10 were observed in Resident #28's room wearing gloves and no gown while bathing and repositioning Resident #28. 3.) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident (Resident #10) with a gastrostomy (enteral tube feeding site), and a resident (Resident #8) with a pressure ulcer when a Nurse Aide (Nurse Aide #1) was providing resident care without wearing the appropriate personal protective equipment (PPE), and failed to properly dispose of soiled linens that were observed on the floor of Resident #10's room. This occurred for 3 of 6 staff members (Nurse Aide #9, Nurse Aide #10, and Nurse Aide #1) who were observed for infection control practices. Findings included: 1.) The facility's Infection Control Policy revised 2/24/25 for Special Contact and Droplet Precautions revealed in part: Special Contact and Droplet precautions were used to prevent the transmission of infectious organisms that can be spread via pathogens that spread through the air or by direct person to person respiratory transmission. An example of a disease requiring special contact and droplet precautions is SARS-CoV (COVID 19). The process included in part; to wear personal protective equipment (PPE) including mask, gown, and gloves prior to entering the room of residents that required special contact and droplet precautions. During an observation on 9/30/25 at 11:20 AM Resident #68 was observed lying in her bed. A sign was observed on Resident #68's door that read: special droplet and contact precautions. A supply cart was located across the hall with gloves, gown, and masks on the cart. At approximately 11:25 AM Nurse Aide # 9 was observed going into Resident #68's room without donning gloves or a gown, she was wearing a mask and moved the mechanical lift into the hallway and placed it against the wall and walked away. Nurse Aide #9 was observed using alcohol-based hand rub (ABHR) for hand hygiene after walking away from the mechanical lift. Nurse Aide #9 then returned and entered Resident #68's room again without donning gloves or a gown and was observed moving the bedside table closer to the resident then handing Resident #68 her water cup. Nurse Aide #9 then left the room and applied ABHR. At approximately 11:30 AM on 9/30/25 Unit Manager #1 instructed Nurse Aide #9 to move the mechanical lift from the hallway into the dirty utility room and clean it. Nurse Aide #9 complied. Observations revealed the mechanical lift had not been used for other residents during the time it was left in the hallway by Nurse Aide #9. During an interview on 9/30/25 at 11:30 AM Unit Manager #1 stated Resident #68 was on special contact and droplet precautions due to testing positive for COVID 19. She stated Nurse Aide #9 should have applied gloves and a gown before going into a residents room who was COVID positive. Unit Manager #1 stated dirty equipment was stored in the dirty utility room and Nurse Aide #9 should not have left the lift sitting in the hallway without it being cleaned. During an interview on 9/30/25 at 11:55 AM Nurse Aide # 9 stated she forgot to put on gloves and a gown when she went into Resident #68's room. She indicated she gets confused at times on the difference between special droplet and contact precautions and enhanced barrier precautions. Nurse Aide #9 stated she should have put on gloves and a gown before entering Resident #68's room, and should have cleaned the mechanical lift before leaving it in the hallway. Nurse Aide #9 stated the mechanical lift should have been cleaned and taken to the storage room on the hall where they keep the equipment. She stated she had received infection control training on special contact and droplet precautions. During an interview on 9/30/25 at 12:10 PM the Director of Nursing (DON) stated staff were expected to wear the appropriate PPE when going into resident rooms and Nurse Aide #9 should have put on gloves and a gown along with her mask before going into Resident #68's room. The DON stated the mechanical lift should have been taken to the storage room and cleaned instead of being left dirty on the hallway especially after coming from a room of a COVID positive resident. During an interview on 10/2/25 at 1:00 PM the Infection Control Preventionist Nurse stated Resident #68 tested positive for COVID on 9/21/25 and was on special droplet precautions at the time of the observations. 2.) The facility's Infection Control Policy revised 12/16/24 revealed in part: Enhanced Barrier Precautions (EBP) were designed to reduce the transmission of multidrug resistant organisms (MDRO) and employed targeted personal protective equipment (PPE) to include gown and glove use during high contact resident care activities. EBP was indicated for residents with wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a MDRO. During an observation on 9/30/25 at 11:45 AM Nurse Aide #9 was observed along with Nurse Aide #10 providing a bed bath and repositioning Resident #28. Resident #28 had a urinary catheter in place. Nurse Aide #9 and Nurse Aide #10 were both wearing gloves but no gown while providing direct care. During an interview on 9/30/25 at 11:55 AM Nurse Aide # 9 stated she forgot to put on a gown when she went into Resident #28's room to give his bath. She indicated she knew Resident #28 was on enhanced barrier precautions due to having a urinary catheter. Nurse Aide #9 stated she should have put on a gown before providing care to Resident #28. She stated she had received infection control training on enhanced barrier precautions. During an interview on 9/30/25 at 12:00 PM Nurse Aide # 10 indicated she knew Resident #28 was on enhanced barrier precautions due to having a urinary catheter. Nurse Aide #10 stated she should have put on a gown before providing care to Resident #28. She stated she had received infection control training on enhanced barrier precautions. During an interview on 9/30/25 at 12:10 PM the Director of Nursing (DON) stated all staff have had infection control training including recent infection control training since the COVID outbreak that started on 9/8/25. She stated staff were expected to wear the appropriate PPE when going into resident rooms to provide care. During an interview on 10/2/25 at 1:00 PM the Infection Control Preventionist Nurse stated she was new to the role of the Infection Control Nurse but stated all staff had received training on special droplet precautions and enhanced barrier precautions. She stated staff had received recent infection control training due to the COVID outbreak that started on 9/8/25. She stated there were adequate supplies of PPE and staff were expected to wear the appropriate PPE when providing care to residents. 3). The facility policy dated 12/16/24 titled, Enhanced Barrier Precautions an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms. It employs targeted personal protective equipment (PPE) used during high contact resident activities to include, in part, dressing, bathing, providing hygiene, changing linens or briefs. High contact residents included, in part, wound care; any skin opening requiring a dressing, and enteral feeding tubes. a. An observation of resident care was conducted with Nurse Aide (NA) #1 on 10/01/25 at 10:00 AM. A sign was posted on the front of the door to indicate Resident #10 was on Enhanced Barrier Precautions and to apply PPE to include gloves and gowns before providing contact care. The PPE was noted to be in the hallway in an enclosed cart to include gloves and gowns. Upon entering Resident #10's room, NA #1 was noted to be wearing gloves only while providing a bath for Resident #10 who had a gastrostomy (tube feeding) site. An interview was conducted with NA #1 on 10/01/25 at 10:00 AM. NA #1 stated, when asked why she did not apply a gown during resident contact care, she just came in the room and got started on incontinent care and to give Resident #10 a bath. NA #1 added, she should have put a gown on since Resident #10 had a tube feeding site. b. An observation on 10/01/25 at 10:00 AM of Resident #10's room revealed NA #1 had placed all the soiled linens on the floor to include bathing towels, bed sheets and the resident's hospital gown. An interview was conducted with NA #1 on 10/01/25 at 10:00 AM. NA #1 stated she should not have put the soiled linens on the floor and instead should have put them in a plastic bag. NA #1 stated she was trained to follow the EBP precautions and to place soiled linens in a trash bag and not on the floor. NA #1 stated she had come in the room and got started with care and did not bring an extra plastic bag to put the soiled linens in. c. An observation of resident care was conducted with NA #1 on 10/01/25 at 11:00 AM. A sign was posted on the front of the door to indicate the Resident #8 was on Enhanced Barrier Precautions and to apply PPE to include gloves and gowns before providing contact care. The PPE was noted to be in the hallway in an enclosed cart to include gloves and gowns. Upon entering Resident #8's room, NA #1 was noted to be wearing gloves only while providing incontinent care for Resident #8 who had pressure ulcers to his right heel. An interview was conducted with NA #1 on 10/01/25 at 11:00 AM. NA #1 stated she knew she was supposed to wear a gown according to the EBP sign hanging on Resident #8's door due to his pressure ulcers. NA #1 stated she was rushing to get the resident to dialysis and forgot to apply a gown. An interview was conducted with the Staff Development Coordinator (SDC) on 10/02/25 at 3:30 PM. The SDC stated training was provided to NA #1 upon hire regarding following the EBP signs and to not put dirty / soiled linens on the floor. The SDC stated she would provide additional training to all her staff regarding infection control. An interview with the Director of Nursing (DON) on 10/02/25 at 3:30 PM revealed she would have expected the staff member to apply the appropriate PPE to include a gown whenever she was providing care to a resident with a tube feed and to a resident with an open wound. She stated the Enhanced Barrier Precaution policy was in place to protect other residents and staff members from infection and that more education needed to be given to the staff.

Based on observations, record review, and staff and resident interviews, the facility failed to honor a resident's right to make choices when a nurse aide (NA) turned off a resident's (Resident #21) air conditioning after she told them not to turn it off. This deficient practice occurred for 1 of 4 residents reviewed for choices. Findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left side, cerebral infarction (stroke), and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact with no rejection of care behaviors in the lookback period. Resident #21's range of motion was impaired on both sides of the upper and lower extremities, she was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene.The care plan revised 7/24/25 revealed Resident #21 had a self-care deficit in performing activities of daily living (ADL) related to a stroke with hemiplegia and hemiparesis. The care plan interventions included Resident #21 was dependent on the assistance of two staff members with mechanical lift for all transfers. An interview and observation with Resident #21 occurred on 9/30/25 at 2:50 PM. Resident was crying and tearful during the interview. Resident #21 reported she had a terrible night last night. She indicated that she had turned on her call light after her tv show was over at 9:30 PM to request assistance getting ready for bed and that she needed incontinence care for her soiled brief. She stated the two NA's (NA #4 and NA#5) on the 3:00 PM to 11:00 PM shift had refused to provide care to her, because she told them not to turn her air conditioner off. She further stated that she was always hot and she liked her room temperature to be cool. Resident #21 stated the NAs had turned her air conditioner off after she told them not to turn it off. She explained the NAs had refused to provide care for her because she had said a curse word when they turned off her air conditioner. Resident #21 stated her room was her home and NA #4 and NA#5 should have respected her right to have the air conditioner turned on. An interview with NA #5 was completed on 9/30/25 at 4:30 PM. NA #5 stated that she had been the NA assigned to care for Resident #21 last night. She further stated that at around 10:30 PM Resident #21 had requested to be assisted to bed and incontinence care be provided. NA #5 indicated that she asked NA #4 to help her with the mechanical lift to transfer Resident #21 to bed. She stated that when they came into the room with the mechanical lift the temperature in the room was cold, so they asked Resident #21 if they could turn off the air conditioner, and she told them no. NA #5 indicated she turned the air conditioner off anyway and Resident #21 had said a curse word and told them to turn the air conditioner back on. She stated that when Resident #21 cursed at them, she and NA #4 decided to leave the room, because they didn't want to argue with her. NA #5 indicated they left the room and reported the incident to the nurse. NA #5 further stated she had been a NA for approximately 1 year and that she had received training regarding resident rights. An interview with NA #4 occurred on 9/30/25 at 4:45 PM with NA #5 present. NA #4 stated that she was asked by NA #5 to help her assist Resident #21 to bed at approximately 10:30 PM last night. She further stated that she was only there to assist NA #5 and that she was just trying to help. NA #4 indicated that she was not the NA assigned to care for Resident #21. She stated when they entered the room to provide care for Resident #21 it was cold and they had asked her if they could turn off the air conditioner and she had stated no. NA #4 indicated that NA #5 had turned the air conditioner off and that the resident had said a curse word. She stated she didn't have to put up with anybody talking to her like that and that they had refused to provide care to Resident #21, and they had left the room. NA #4 stated she didn't feel like she had done anything wrong because she was not assigned to care for Resident #21. She further stated she had been a NA for approximately 3 months and that she had received training regarding resident rights to make their own choices. Resident #22 was admitted to the facility on 3/24 25 and her quarterly MDS assessment dated [DATE] revealed she was cognitively intact.An interview with Resident #22 was completed on 10/1/25 at 12:24 PM. Resident #22 stated she was Resident #21's roommate and was present when the incident occurred on 9/29/25 at approximately 9:30 PM between Resident #21 and NA #4 and NA #5. She stated that when NA #4 and NA #5 came into the room, they had asked Resident #21 if they could turn off the air conditioner and she had told them no. Resident #22 indicated that one of the NAs turned off the air conditioner anyway, and Resident #21 had said a curse word. She stated that the NAs told Resident #21 they didn't have to put up with anyone talking to them like that and disrespecting them. An interview with Nurse #7 who was working the 7:00 PM to 7:00 AM shift on 9/29/25 occurred on 10/2/25 at 1:29 PM. Nurse #7 indicated she was unaware that the NA had turned Resident #21's air conditioner off without her permission. An interview was completed with the Director of Nursing (DON) on 11/18.25 at 3:15 PM. The DON stated NA #5 should not have turned off Resident #21's air conditioner without her permission. She further stated the NAs should have provided the care that Resident #21 requested, regardless of her use of a curse word. The DON stated she expected the nursing staff to respect the residents' rights to choices. An interview was conducted with the Administrator on 11/18/25 at 3:55 PM. The Administrator stated the facility was Resident #21's home and NA #5 should not have turned off Resident #21's air conditioner after she told her not to turn it off. She stated that she expected the staff to provide care for the residents, regardless of the residents' behavior. The Administrator indicated that it was a resident right to make choices regarding their care.

Based on record review, staff interviews, and Nurse Practitioner (NP) interview, the facility failed to notify the provider of significant weight gain for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) for 1 of 1 sampled resident reviewed for notification of change. (Resident #62) Findings included: Resident #62 was admitted to the facility on [DATE] with a cumulative diagnosis including atrial fibrillation (A-fib), hypertension (HTN), congestive heart failure (CHF), and peripheral vascular disease (PVD).A physician order dated 04/28/25 revealed an order to weigh Resident #62 every day, with start date of 04/28/2025. Give Furosemide (a diuretic medication) oral tablet 40 milligrams (MG),1 tablet by mouth one time a day for HTN, with a start date of 4/10/2025. Give Spironolactone (a diuretic medication) oral tablet 25 MG,1 tablet by mouth in the morning for CHF.Review of Resident #62's weekly/monthly weights revealed: 09/09/25 was 220.2 pounds (lbs).09/28/25 was 247 lbs. a weight gain of 26.8 lbs. in 19 daysFurther review of Resident #162's medical record on 09/29/25 revealed there were no additional weights, and no documentation the physician was notified of the significant weight gain.An interview was conducted on 09/30/25 at 3:55 PM with the Director of Nursing (DON). She revealed it was her expectation that Resident #62's physician should have been notified by his nurse of the Resident's greater than 5% weight gain, given the Resident's history of CHF.An interview was conducted on 10/01/25 at 9:20 AM with the Nurse Practitioner (NP) The NP stated this was the first time she heard of Resident #62's nineteen-day weight gain of 26.8 pounds since admission. She stated no staff had reported to her any weight concerns. The NP expected she or the medical director to be notified if Resident #62's weekly/monthly weights were greater than 5 lbs. from the previous weight, since the resident had a diagnosis of CHF. The NP said she expected the MD to have been notified, in order to treat the weight gain and to determine if it was related to CHF, and if additional medication was to be ordered or a change in treatment needed. An interview was conducted on 10/01/25 at 2:00 PM with the Nursing Unit Manager #1. She stated on 09/28/25 she entered Resident #62's weight of 247 lbs. into the electronic medical record. She said she noticed when she entered the weight that the weight number entered had turned red indicating a significant weight gain, but she did not check resident's previous weight to determine how significant of a weight gain it was and should have. The nurse stated she did not notify the MD or RD because she did not compare the two weights to confirm resident's weight gain was greater than 5% in one month. She said it was her fault for not comparing previous weights to the ones she was entering for significant weight changes, especially with residents with edema or CHF.

Based on record review and staff interviews, the facility failed to provide written grievance summaries for 2 out of 2 residents reviewed (Resident #10 and #62). Findings included: Review of facility policy dated 10/15/24 titled Center Operations Policies and Procedures Grievance/Concern read in part: The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process including receiving and tracking grievances through their conclusion, issuing written grievance decision to the resident with a date the written resolution was issued with the purpose to assure prompt receipt and resolution of resident and representative grievance/concern. 1. Resident #10 was admitted to the facility on [DATE]. The Minimum Data Set quarterly assessment dated [DATE] revealed resident #10 was severely cognitively impaired. A review of the facility's grievance log since 11/21/24 revealed a grievance dated 03/31/25 for Resident #10 by the Responsible Party (RP) regarding a concern that Resident #10 had an appointment and the RP stated his nails were very long and needed trimming. The action taken to investigate the grievance was that the Director of Nursing checked residents' nails, Nurse Aide clipped his nails and shaved his face with a recommended correction action to include providing nail care and rounds to inspect nail care needs. The resolution of the grievance under Written notification provided on (insert date) was noted to be blank. The Administrator signed the grievance. An undated grievance written by the Responsible Party was reviewed for Resident #10. The grievance/concern was that Resident #10 had an appointment and was sent to the appointment without being dressed properly. The recommended correction action was education provided to all staff during an all staff meeting by the Director of Nursing. The resolution of the grievance under Written notification provided on (insert date) was noted to have a date of 07/01/25. On the bottom page of the grievance read, Additional methods that may have been used to discuss resolution with the resident/representative, was checked written. The attached written summary was dated 07/01/25, however it did not correspond to the concern regarding being sent to appointment without being dressed properly. The grievance was signed by the Administrator. An interview with the Administrator on 09/30/25 at 2:10 PM revealed she should have sent a written response to the Responsible Party regarding both concerns. She stated the letter dated 07/01/25 was a written response to a grievance that was filed on 07/01/25 and did not relate to the concern of being sent to appointment without being dressed properly. 2. Resident #62 was admitted to the facility on [DATE]. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #62 was severely cognitively impaired. A review of the facility's grievance log revealed a grievance from Resident #62 for needing help transferring to bathroom. On the bottom page of the grievance dated 05/27/25 read, Date written notification provided, was left blank. Also, on the bottom page of the grievance read, Additional methods that may have been used to discuss resolution with the resident/representative, was checked Face to face. The grievance/concern form reviewed had no back page summary or findings/recommended corrective action(s) filled out. An interview was conducted on 10/01/25 at 10:30 AM with the Director of Nursing (DON). The DON stated she did not know the resident/representative needed to receive a written summary of their grievance resolutions. The DON acknowledged Resident #62 should have been provided with a written resolution and summary. An interview was conducted on 10/01/25 at 10:40 AM with the Administrator. The Administrator confirmed Resident #62 did not receive a written grievance summary of the resolution. An interview on 10/02/25 at 8:17 AM with the Social Worker (SW) revealed that she did not know until today that she needed to provide a written grievance summary to the resident or representative who filed the concern. The SW stated she thought the verbal summary was okay. The SW stated before today, she had only called or verbally spoken to the complainant in person and verbally summarized the grievance, with nothing given to them in writing. The SW added, now she knows to provide a written grievance summary to complainants.

Based on observations, record review, and interviews with residents and staff, the facility failed to protect a resident's right to be free from neglect when two nurse aides (NA) on the 3:00 PM to 11:00 PM shift refused a dependent resident's (Resident #21) requests for transferring her to bed and incontinence care. Resident #21 was left sitting up in her electric wheelchair in her room that had a strong odor resembling bowel incontinence. When Resident #21's incontinence care was provided her brief was heavily soiled with a bowel movement that was caked and dried on her skin. Resident #21 was in a semi-private room, and she stated she was embarrassed and humiliated in front of her roommate by the NAs refusal of care. The deficient practice occurred for 1 of 4 residents reviewed for neglect. Findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left side, cerebral infarction (stroke), and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact with no rejection of care behaviors in the lookback period. Resident #21's range of motion was impaired on both sides of the upper and lower extremities, she was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene.The care plan revised 7/24/25 revealed Resident #21 had a self-care deficit in performing activities of daily living (ADL) related to a stroke with hemiplegia and hemiparesis. The care plan interventions included Resident #21 was dependent on the assistance of two staff members with mechanical lift for all transfers. An interview with Resident #21 occurred on 9/30/25 at 2:50 PM. Resident #21 reported she had a terrible night last night. She stated that she was a smoker and that she usually gets ready for bed after she goes outside for the last supervised smoke break scheduled at 8:30 PM. Resident #21 indicated that she had turned on her call light after her tv show was over at 9:30 PM to request assistance getting ready for bed and that she needed incontinence care for her soiled brief. She stated the two NA's (NA #4 and NA#5) on the 3:00 PM to 11:00 PM shift had refused to provide care to her. She further stated that she had to wait until after 12:30 AM to finally get changed and to go to bed. Resident #21 explained the NAs had refused to provide care for her because she had said a curse word when they turned off her air conditioner. She stated the NAs turned around with the mechanical lift and said they were not going to provide care for anyone who was cursing them and being disrespectful to them. Resident #21 stated she was left in her electric wheelchair in her room facing the tv. Resident #21 indicated that she was in a semi-private room and that the NAs had embarrassed her and humiliated her in front of her roommate, by treating her like a child. She stated that the incident had made her sad and mad at the same time. The Administrator was immediately notified on 9/30/25 at 3:30 PM of Resident #21's allegation of neglect involving NA #4 and NA#5. The Administrator stated she was immediately suspending NA #4 and NA #5 pending the investigation and she was filing a report with the state agency.An interview with NA #5 was completed on 9/30/25 at 4:30 PM. NA #5 stated that she had been the NA assigned to care for Resident #21 last night. She further stated that at around 10:30 PM Resident #21 had requested to be assisted to bed and incontinence care be provided. NA #5 indicated that she asked NA #4 to help her with the mechanical lift to transfer Resident #21 to bed. She stated that when they came into the room with the mechanical lift the temperature in the room was cold, so they asked Resident #21 if they could turn off the air conditioner, and she told them no. NA #5 indicated she turned the air conditioner off anyway and Resident #21 had said a curse word and told them to turn the air conditioner back on. She stated that when Resident #21 cursed at them, she and NA #4 decided to leave the room, because they didn't want to argue with her. NA #5 further stated that she felt like she was disrespected by Resident #21 and that is why she had refused to provide her care. She indicated they left the room and reported the incident to the nurse. NA #5 stated that she and NA #4 left the facility at 11:00 PM without providing care for Resident #21. NA #5 further stated she had been a NA for approximately 1 year and that she had received training on abuse/neglect. An interview with NA #4 occurred on 9/30/25 at 4:45 PM with NA #5 present. NA #4 stated that she was asked by NA #5 to help her assist Resident #21 to bed at approximately 10:30 PM last night. She further stated that she was only there to assist NA #5 and that she was just trying to help. NA #4 indicated that she was not the NA assigned to care for Resident #21. She stated when they entered the room to provide care for Resident #21 it was cold and they had asked her if they could turn off the air conditioner and she had stated, no. NA #4 indicated that NA #5 had turned the air conditioner off and that the resident had said a curse word. She stated she didn't have to put up with anybody talking to her like that and that they had refused to provide care to Resident #21, and they had left the room. NA #4 stated she didn't feel like she had done anything wrong because she was not assigned to care for Resident #21. She stated that she and NA #5 clocked out at 11:00 PM and left the building without providing care to Resident #21. NA #4 further stated she had been a NA for approximately 3 months and that she had received training regarding abuse/neglect.Resident #22 was admitted to the facility on 3/24 25 and her quarterly MDS assessment dated [DATE] revealed she was cognitively intact.An interview with Resident #22 was completed on 10/1/25 at 12:24 PM. Resident #22 stated she was Resident #21's roommate and was present when the incident occurred on 9/29/25 at approximately 9:30 PM between Resident #21 and NA #4 and NA #5. She stated that when NA #4 and NA #5 came into the room, they had asked Resident #21 if they could turn off the air conditioner and she had told them no. Resident #22 indicated that one of the NAs turned off the air conditioner and Resident #21 had said a curse word. She stated that the NAs told Resident #21 they didn't have to put up with anyone talking to them like that and disrespecting them. Resident #22 indicated the NAs had taken the mechanical lift out of the room and left Resident #21 sitting in her wheelchair. She stated that according to the time on her cell phone it was around 12:30 AM when the 1100 PM to 7:00 AM NAs got Resident #21 into bed and provided care. An interview was completed with NA #6 on 10/1/25 at 11:16 AM. NA #6 stated she was supposed to be at work at 11:00 PM on 9/29/25 but that she arrived about an hour late. She further stated that when she went to Resident #21's room she was still up in her wheelchair waiting to go to bed. NA #6 stated she and NA #7 transferred Resident #21 to bed at approximately 12:30 AM. She indicated that Resident #21 was incontinent with bowel and it looked like it had been there for a while because it was caked and dried on her skin. NA #6 stated that Resident #21 was usually in bed when she came in at 11:00 M and that was the first time she had to put her to bed on 11:00 PM to 7:00 AM shift. She further stated that Resident #21 informed her that the NA from 3:00 PM to 11:00 PM shift had refused to provide care for her. She indicated Resident #21 was very upset about the incident and she was crying. NA #6 stated Resident #21 had never been disrespectful or rude to her. An interview with Nurse #7 who was working the 7:00 PM to 7:00 AM shift on 9/29/25 occurred on 10/2/25 at 1:29 PM. Nurse #7 stated she recalled the incident with Resident #21 and NA #4 and NA #5 occurred on 9/29/25 at approximately 10:30 PM. She stated the NAs reported to her that Resident #21 had cursed them when they went into her room to transfer her to bed. Nurse #7 further stated that she had told the NA's she would speak to Resident #21 about the incident. She indicated she was unaware that NA #4 and NA #5 were not going to provide Resident #21 care prior to them leaving their shift. Nurse #7 explained that one of the NAs on the 11:00 PM to 7:00 AM shift was late for work on 9/29/25 and Resident #21 was not assisted to bed until around 12:30 AM. She stated that the NA's had not asked her to assist them with transferring Resident #21 to bed or providing incontinence care. Nurse #7 indicated she was unaware that Resident #21 had a bowel movement and needed incontinence care. An interview was completed with NA #7 on 10/2/25 at 8:10 AM. NA #7 stated that she was working the 11:00 PM to 7:00 AM shift on 9/29/25. She further stated that there was only 2 NA assigned to the 300 and 400 halls at night, and that NA #6 was approximately an hour late for work on 9/29/25. NA #7 indicated Resident #21 was still up in her electric wheelchair when she came on shift at 11:00 PM. She stated that Resident #21 was very upset and was crying that she was left up in her wheelchair and she needed incontinent care. NA #7 further stated that she and NA #6 did transfer Resident #21 to bed and provide incontinence care at approximately 12:30 AM. She explained that she had not asked Nurse #7 to assist her with transferring Resident #21 to bed because she was busy with new admissions and other work. An interview was completed with the Director of Nursing (DON) on 11/18/25 at 3:15 PM. The DON stated that NA #4 and NA #5 were suspended pending an investigation on 9/30/25 after becoming aware of the allegation of neglect for Resident #21. She further stated the NAs should have provided the care that Resident #21 requested, regardless of her use of a curse word. The DON stated the facility did not tolerate the type of unprofessional behavior that was displayed by the NAs. An interview was conducted with the Administrator on 11/18/25 at 3:55 PM. The Administrator reported that NA #4 and NA #5 were suspended on 9/30/25 after she was made aware of the allegation of neglect involving Resident #21. She stated that she expected the staff to provide care for the residents, regardless of the residents' behavior. The Administrator stated that the police were notified and a report was filed with the state. She indicated that the facility took allegations of abuse and neglect very seriously and an investigation was conducted.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD-referring to the last day of the observation period for 2 of 22 residents sampled for assessments (Resident #17 and Resident #21).Findings included:1a. Resident #17 was admitted to the facility on [DATE].Review of Resident #17's MDS assessments revealed that quarterly assessment with an ARD of 7/10/25 and the completion date was 7/30/25.b. Resident #21 was admitted to the facility on [DATE].Review of Resident #21's MDS assessments revealed a quarterly MDS assessment with an ARD of 7/23/25 and it was completed on 8/20/25.An interview with the MDS Clinical Reimbursement Coordinator (CRC) occurred on 11/16/25 at 9:19 AM. The MDS CRC stated that she knew several residents' quarterly MDS assessments had been completed late. She further stated that she worked for the company and traveled between several facilities and was not always able to get the assessments completed on time. The MDS CRC indicated the facility had hired a full-time MDS CRC a few weeks ago and that the assessments would be completed on time in the future. An interview with the Director of Nursing (DON) was completed on 11/18/25 at 2:52 PM. The DON stated she was aware that the MDS assessments were not being completed on time. She further stated she expected the assessments to be completed on time.An interview with the Administrator was completed on 11/18/25 at 3:55 PM The Administrator stated that the reason the MDS assessments were late was due to a vacant MDS CRC position. She further stated the MDS assessments should be completed on time.

Based on observations, record review, and interviews with resident and staff, the facility failed to provide incontinence care to a dependent resident for 1 of 4 residents reviewed for activities of daily living (ADL) care (Resident #21). Findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left side, cerebral infarction (stroke), and anxiety disorder.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact with no rejection of care behaviors in the lookback period. Resident #21 was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene.The care plan revised 7/24/25 revealed Resident #21 had a self-care deficit in performing ADL related to a stroke with hemiplegia and hemiparesis. The care plan interventions included Resident #21 was dependent on the assistance of two staff members with the mechanical lift for all transfers and to provide incontinence care as needed. An interview with Resident #21 occurred on 9/30/25 at 2:50 PM. Resident #21 reported that two nurse aides (NA) on the 3:00 PM to 11:00 PM shift had refused to transfer her to bed and provide incontinence care for her. She stated that she had turned on her call light around 9:30 PM and requested assistance getting ready for bed and that she needed incontinence care for her soiled brief. Resident #21 indicated that the two NAs (NA #4 and NA #5) had refused to provide care for her, because she had said a curse word when they turned off her air conditioner without her permission. She stated she had to wait until approximately 12:30 AM for the NAs on the 11:00 PM to 7:00 AM shift to transfer her to bed and provide incontinent care. An interview with NA #5 was completed on 9/30/25 at 4:30 PM. NA #5 stated that she had been the NA assigned to care for Resident #21 last night. She further stated that at around 10:30 PM Resident #21 had requested to be assisted to bed and incontinence care be provided. NA #5 indicated that she asked NA #4 to help her with the mechanical lift to transfer Resident #21 to bed. She stated that when they came into the room with the mechanical lift the temperature in the room was cold, so they asked Resident #21 if they could turn off the air conditioner, and she told them no. NA #5 indicated she turned the air conditioner off anyway and Resident #21 had said a curse word and told them to turn the air conditioner back on. She stated that when Resident #21 cursed at them, she and NA #4 decided to leave the room, because they didn't want to argue with her. NA #5 further stated that she felt like she was disrespected by Resident #21 and that is why she refused to provide care for her.An interview with NA #4 occurred on 9/30/25 at 4:45 PM with NA #5 present. NA #4 stated that she was asked by NA #5 to help her assist Resident #21 to bed at approximately 10:30 PM last night. She further stated that she was only there to assist NA #5 and that she was just trying to help. NA #4 indicated that she was not the NA assigned to care for Resident #21. She stated when they entered the room to provide care for Resident #21 it was cold and they had asked her if they could turn off the air conditioner and she had stated, no. NA #4 indicated that NA #5 had turned the air conditioner off and that the resident had said a curse word. She stated she didn't have to put up with anybody talking to her like that and that they had refused to provide care to Resident #21, and they had left the room. An interview was completed with NA #6 on 10/1/25 at 11:16 AM. NA #6 stated she was supposed to be at work at 11:00 PM on 9/29/25 but that she arrived about an hour late. She further stated that when she went to Resident #21's room she was still up in her wheelchair waiting to go to bed. NA #6 stated she and NA #7 transferred Resident #21 to bed at approximately 12:30 AM. She indicated that Resident #21 was incontinent with bowel and it looked like it had been there for a while because it was caked and dried on her skin. NA #6 stated that Resident #21 was usually in bed when she came in at 11:00 M and that was the first time she had to put her to bed on 11:00 PM to 7:00 AM shift. She further stated that Resident #21 informed her that the NA from 3:00 PM to 11:00 PM shift had refused to provide care for her. An interview with Nurse #7 who was working the 7:00 PM to 7:00 AM shift on 9/29/25 occurred on 10/2/25 at 1:29 PM. Nurse #7 stated she recalled the incident with Resident #21 and NA #4 and NA #5 occurred on 9/29/25 at approximately 10:30 PM. She stated the NAs reported to her that Resident #21 had cursed them when they went into her room to transfer her to bed. Nurse #7 further stated that she had told the NA's she would speak to Resident #21 about the incident. She indicated she was unaware that NA #4 and NA #5 were not going to provide Resident #21 care prior to them leaving their shift. Nurse #7 explained that one of the NAs on the 11:00 PM to 7:00 AM shift was late for work on 9/29/25 and Resident #21 was not assisted to bed until around 12:30 AM. She stated that the NA's had not asked her to assist them with transferring Resident #21 to bed or providing incontinence care. Nurse #7 indicated she was unaware that Resident #21 had a bowel movement and needed incontinence care. An interview was completed with NA #7 on 10/2/25 at 8:10 AM. NA #7 stated that she was working the 11:00 PM to 7:00 AM shift on 9/29/25. She further stated that there was only 2 NA assigned to the 300 and 400 halls at night, and that NA #6 was approximately an hour late for work on 9/29/25. NA #7 indicated Resident #21 was still up in her electric wheelchair when she came on shift at 11:00 PM. She stated that Resident #21 was very upset and was crying that she was left up in her wheelchair and she needed incontinent care. NA #7 further stated that she and NA #6 did transfer Resident #21 to bed and provide incontinence care at approximately 12:30 AM. She explained that she had not asked Nurse #7 to assist her with transferring Resident #21 to bed because she was busy with new admissions and other work. An interview was conducted with the Director of Nursing on 11/18/25 at 3:15 PM. The DON stated that it was unacceptable that NA #4 and NA #5 had refused to transfer Resident ##21 to bed and provide incontinent care for her when she requested. She further stated that she expected the nursing staff to provide care for residents, regardless of the residents' use of a curse word. The DON explained that it was their job to provide ADL care for residents.An interview was completed with the Administrator on 11/18/25 at 3:55 PM. The Administrator stated that NA #4 and NA #5 were wrong for not providing ADL care for Resident #21. She indicated that she expected the staff to provide care for the residents, regardless of the residents' behavior. The Administrator stated that NA #4 and NA #5 should have provided ADL care for Resident #21 when she requested their assistance.

Based on observations, record review, staff interviews, the Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident (Resident #6) reviewed for quality of care. Based on observations, record review, staff interviews, the Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident reviewed for quality of care. Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia. A care plan dated 4/9/25 revealed Resident #6 was at nutritional risk related to frequent hospitalizations, multiple chronic disease processes, history of weight gain and fluid retention, cognitive impairment, therapeutic diet order with restrictions, prescribed diuretics (high risk of weight fluctuations), significant weight loss, and history of increased nutrient needs with pressure areas. Interventions included in part: weigh per policy. A physicians order dated 4/5/25 for Resident #6 revealed Furosemide Solution 20 milligrams per milliliter (mg/ml) intramuscularly (IM) one time now for fluid overload. A physician's order dated 4/07/25 for Resident #6 was to obtain weekly weights for four weeks then monthly weights. A physicians order dated 4/11/25 for Resident #6 revealed Furosemide Solution 20 mgs/ml intramuscularly (IM) one time for excessive fluid. A physicians order dated 4/12/25 for Resident #6 revealed Furosemide 40 milligrams (mg) give one tablet as needed for edema. A physicians order dated 4/17/25 for Resident #6 revealed Furosemide 40 milligrams (mg) one time daily for edema. A physician's order dated 4/24/25 for Resident #6 was to obtain weekly weights for four weeks then monthly weights. A physicians order dated 4/29/25 for Resident #6 revealed Furosemide 40 milligrams (mg) one time daily for congestive heart failure (CHF). A nutritional assessment dated [DATE] completed by the Registered Dietician for Resident #6 revealed in part; Resident #6 had a history of weight gain and loss due to edema, recent hospitalization and poor appetite. She received a consistent carbohydrate and No Added Salt (NAS) diet, with regular texture, and thin liquids. Resident #6 eats independently after tray set up. Pressure ulcers noted to (sacrum, heel, coccyx). Pertinent medications included Furosemide (a diuretic used to treat fluid retention) medication. She remained on 1.5 liter fluid restrictions. Weight loss was 15% over 1 month. Nutrition Recommendations: Reorder Med Pass (nutrition supplement) three times a day. Monitor: Weights, labs, skin, and meal intake. A nutritional assessment dated [DATE] completed by the Registered Dietician for Resident #6 revealed in part; history of weight fluctuations 160 - 200 lbs. (intermittent edema and diuretics), history of intermittent poor appetite due to illness and hospitalizations. No new recommendations at this time. Monitor and evaluate weights, labs, skin, and meal intake. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. She had no rejection of care. She had weight gain and received a therapeutic diet. Resident #6 required staff assistance with activities of daily living (ADLs) and supervision with eating. Review of Resident #6's electronic medical record revealed the following weights recorded using the mechanical lift: 4/08/25: weight 205.0 4/16/25: weight 194.0 4/20/25: weight 174.0 5/08/25: weight 172.0 6/20/25: weight 147.6 7/15/25: weight 146.2 8/03/25: weight 146.0 8/06/25: weight 154.4 9/09/25: weight 152.6 During an interview on 10/01/25 at 2:00 PM Unit Manager #1 stated Resident #6's significant weight changes noted in the medical record should have had a re-weigh done within 24 hours and that was not done. Unit Manager #1 stated the nurse aides obtained the ordered weights and then gave the weights to her and she entered the weights into the residents electronic medical record. Unit Manager #1 stated she did not always check the previous weight to identify any significant weight gain or loss which was an error on her part. She stated the facility policy was that with any weight increase or decrease a reweigh should be done at that time for accuracy and she had not been directing staff to do the reweighs. Unit Manager #1 stated she should have asked for Resident #6 to be reweighed for accuracy to determine if Resident #6 had a 10 to 20 pound weight loss to verify accuracy. A phone interview was conducted on 10/01/25 at 9:20 AM with Nurse Practitioner #1 who stated it was her expectation that residents with significant weight changes get reweighed. She stated that a reweigh was to be done on all weight loss or gain greater than 5% within a month, or greater than 10% in six months, so in order to make the necessary treatment recommendations. During an interview on 10/2/25 at 10:00 AM Nurse Aide #10 stated she received a list each morning of which residents needed weights. She completes the weights and gives the results to Unit Manger #1. Nurse Aide #10 indicated she would not know to reweigh a resident unless a nurse or the Unit Manger instructed her to do so, then she would reweigh the resident. During an interview on 11/19/25 at 1:00 PM the Physician stated some of the weights documented in Resident #6's medical record could not be accurate because it was impossible for her to have a 20 pound loss in 4 days. The Physician stated that staff had not reported any change in condition and there were no concerns with Resident #6. He stated accurate weights should be documented in the medical record in order to make the appropriate treatment decisions. During a phone interview on 11/19/25 at 2:00 PM the Director of Nursing (DON) stated weights were to be reviewed and compared to the previous weight and if any significant increase or decrease then another weight should be obtained at that time. The DON stated the staff were to verify the accuracy of weights and report any changes to the physician if significant changes.

Based on record review, staff interviews, and the Wound Care Physician's interview, the facility failed to complete initial wound assessments upon admission to include the wound descriptions with measurements and obtain wound care orders upon admission and when the wound vac (vacuum assisted closure (vac), negative pressure wound therapy that uses suction to aid in wound healing) was not available in the facility for a resident admitted with multiple pressure wounds and osteomyelitis (infection of the bone tissue) requiring intravenous and oral antibiotics. This occurred for 1 of 6 residents (Resident #86) reviewed for wound care. Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including a Stage IV pressure ulcer of the left ischium (the lower and back portion of the hip bone), Stage IV pressure ulcer on the sacrum, Stage IV pressure ulcer of the right hip, Stage II pressure ulcer on the right buttock, a deep tissue injury of the left heel, osteomyelitis (an infection of the bone tissue) of the vertebra, sacral, coccyx region, and left thigh, and paraplegia (paralysis of the lower extremities). Review of the hospital discharge instructions dated 3/15/25 for Resident #86 revealed to follow up with the wound center. There were no further wound treatment orders listed on the discharge instructions. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Piperacillin Sodium Tazobactam (a broad-spectrum antibiotic used to treat moderate to severe bacterial infections). Use 3.375 grams intravenously every 8 hours for osteomyelitis for 18 days in 100 milliliters 0.9% Sodium Chloride. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Vancomycin (an antibiotic used to treat severe infections) intravenous solution. Use 1 gram intravenously two times a day for osteomyelitis until 04/03/25. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Sulfamethoxazole-Trimethoprim oral antibiotic tablets 800-160 milligrams. Give 1 tablet by mouth one time a day for osteomyelitis. Review of Resident #86's electronic medical record from 3/15/25 through 3/17/25 revealed no documented admission assessment of the wounds and no documented physician orders for wound care until 3/17/25. A progress note dated 3/17/25 at 9:48 PM documented by Unit Manager #1 revealed in part: admission assessment, Resident #86 was alert and oriented to person, place, and time. He was noted with multiple opened wounds to his buttocks, left ischium, right buttocks, left posterior upper thigh and buttock fold, sacral wound, right hip wound, and right heel DTI. The Physician (previous Medical Director) was notified 3/17/25. Treatment orders and intravenous orders were clarified with new orders received. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order with a start date of 3/17/25 for Wound Vac application (vacuum assisted closure (vac), negative pressure wound therapy that uses suction to aid in wound healing). Gently irrigate the wound to the left ischium with normal saline and pat dry. Apply skin prep to peri wound and let dry. Window pane peri wound with clear wound vac drape. Apply black foam to the wound bed and cover with vac drape then apply Wound VAC with 125 mm/hg (millimeters of mercury) continuous pressure 3 times a week every day shift on Monday, Wednesday, Friday. Review of Resident #86's Treatment Administration Record (TAR) and Medication Administration Record (MAR) from 3/17/25 through 3/20/25 revealed the wound vac was not applied to Resident #86. The Wound Vac order was discontinued on 3/20/25 by the Wound Care Physician. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order dated 3/17/25 to apply saline wet to dry dressings to the left ischium every day until the wound vac is available. This order was not signed as administered on 3/17/25. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order with a start date of 3/18/25 to cleanse the left ischium with normal saline, apply wet to dry saline moist gauze and cover with foam dressing until the Wound Vac arrives then discontinue. This order was signed as administered on 3/18/25. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order dated 3/17/25 to cleanse open area to right hip with normal saline and apply wet to dry saline gauze and cover with foam dressing as needed. This order was not signed as administered on 3/17/25. The order was changed on 3/18/25 to every day shift and was signed as administered on 3/18/25. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order dated 3/17/25 to cleanse open area to sacrum and apply Calcium Alginate (a wound dressing used for moderate to heavy exuding wounds to create a moist healing environment, absorbs drainage and controls minor bleeding), and cover with foam dressing as needed. This order was changed to every day shift on 3/18/25 and signed as administered on 3/18/25. Review of the Treatment Administration Record (TAR) for Resident #86 revealed an order dated 3/17/25 to cleanse open area to upper left thigh/buttock fold with normal saline and apply Calcium Alginate dressing and cover with foam dressing as needed. This was not administered, and the order was changed to every day shift on 3/18/25 and signed as administered on 3/18/25. A physicians order dated 3/18/25 for Resident #86 revealed to mop right heel DTI (deep tissue injury) with sure prep every day shift. This order was signed as administered on 3/18/25. A care plan dated 3/18/25 revealed Resident #86 had a stage IV pressure ulcer on the left hip, a stage IV pressure ulcer on the right hip, a stage IV pressure ulcer on the sacrum, and a stage II pressure ulcer on the right buttock with the risk of further skin breakdown related to decreased activity, frail fragile skin, incontinence, and limited mobility. Interventions included in part; to provide wound care. A progress note dated 3/18/25 at 2:19 PM written by Unit Manager #1 revealed Skin Issue: #1: Sacrum - Stage 4 pressure ulcer with full thickness skin and tissue loss. The wound was present on admission. The length was 4.2 centimeters (cm), width 1.9 cm, and depth 1.1 cm. There was no undermining (separation of the wound edge from the surrounding tissue), and no tunneling (a deep tract or channel that goes into the tissue). Wound #2 on the right gluteus was a stage III pressure ulcer with full thickness skin loss. The wound was present on admission. No signs and symptoms of infection. The length was 4.2 cm, width 3.7 cm, depth 0.1 cm. There was no undermining or tunneling. Wound #3: Rear left trochanter (Hip) pressure ulcer present on admission. Length 4.5 cm, width 5.5 cm, depth 1.4 cm with undermining length 1.7 cm. The left ischium pressure ulcer measured 2.0 x 1.3 x 1.3 cm. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #86 was cognitively intact, with no behaviors and no rejection of care. He had three stage IV pressure ulcers, and one stage II pressure ulcer present on admission. Resident #86 received pressure wound care including intravenous (IV) antibiotics. He required extensive 1-to-2-person assistance with activities of daily living (ADLs). During an interview on 11/18/25 at 2:00 PM Unit Manager #1 stated Resident #86 admitted on Saturday 3/15/25. He admitted with stage IV pressure wounds. She stated the initial skin assessments were to be completed by the assigned nurse within the first 24 hours of admission. Unit Manager #1 stated when she returned to work on 3/17/25 she realized the wound care orders were not entered and she called the Medical Director at that time to get new wound care orders while waiting on the wound vac supplies to arrive. Unit Manager #1 stated the weekend nurse should have completed the initial skin assessments upon Resident #86's admission or at least within 24 hours and obtain new wound care orders while waiting on the wound vac, and that did not occur. Unit Manager #1 received new wound care orders on 3/17/25 when she notified the Physician and the wound treatments were administered beginning the following day on 3/18/25. Unit Manager #1 indicated Medication Aide #1 was assigned to the hall that Resident #86 was admitted to on 3/15/25 but Medication Aide #1 would not be responsible for managing wound care or treatment orders. The responsible day shift and night shift nurses on 3/15/25 and 3/16/25 were agency staff and were no longer employed by the facility. Unit Manger #1 stated she entered Resident #86's wound treatment orders into the residents electronic medical record on 3/17/25, and she conducted the initial wound assessments with measurements on 3/18/25 and that should have been done by the admission nurse on 3/15/25. During a phone interview on 11/18/25 at 7:00 PM Medication Aide #1 stated she would not have been responsible for wound care treatments and did not have any information regarding Resident #86's wound care on 3/15/25 or 3/16/25. During an interview on 11/19/25 at 8:15 AM the wound treatment nurse stated Resident #86 was compliant with wound care. She stated that she began working in the facility around the time Resident #86 was admitted but she did not work full-time, and the floor nurses were responsible for daily wound care. She stated she was not working on the weekend of 3/15/25 when Resident #86 was admitted . During a phone interview on 11/19/25 at 10:00 AM the Wound Care Physician stated her initial evaluation of Resident #86 was done on 3/20/25, then weekly until he discharged from the facility. She stated Resident #86 admitted with four significant pressure wounds. At the time of his admission there was no dedicated wound nurse, and she could not attest to how often the wound care was getting done. The Wound Physician stated she last evaluated Resident #86 on 5/23/25 before he discharged and at the time of discharge the sacrum was more necrotic, and the left hip fascia was exposed with muscle. She stated the worsening of Resident #86's wounds during his stay in the facility was multifactorial, and also due to not offloading, possible missed wound treatments, osteomyelitis, and other comorbidities. The Wound Physician indicated initial wound assessments should have been completed on admission, and the wound vac supplies were usually easily accessible and should have been available. The Wound Physician stated she discontinued the wound vac due to it not being available when she initially evaluated Resident #86. The Wound Physician indicated Resident #86 discharged to the hospital May 2025 unrelated to wound care and did not return to the facility. During a phone interview on 11/19/25 at 1:00 PM the Director of Nursing (DON) stated the weekend nurse on 3/15/25 should have completed the initial wound assessments with measurements which was to be done within the first 24 hours of admission. The DON stated when Resident #86 admitted on [DATE] and the wound vac was not available the nurse should have clarified the treatment orders in order to get daily treatments started due to Resident #86's significant wounds. The DON indicated wound treatments should have been initiated sooner than 3/18/25 and that did not occur.

Based on observations, record review, and staff interviews the facility failed to provide care in a safe manner when Nurse Aide #8 provided incontinence care to a resident (Resident #39). This resulted in Resident #39 rolling off of the bed onto the floor sustaining a fracture to the first cervical vertebrae (C1) of the cervical spine. This occurred for 1 of 5 residents reviewed for accidents (Resident #39). Resident #39 was admitted to the facility on [DATE]. Her diagnoses included cerebral vascular accident (CVA), hemiplegia (paralysis or weakness on one side of the body), and dementia. A care plan dated 4/18/25 revealed Resident #39 required assistance with activities of daily living (ADLs) including bed mobility due to having limited mobility related to cerebral vascular accident (CVA) with hemiplegia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. She had no falls at the time of the assessment. Her weight was 168 pounds. She required extensive two-person assistance with bed mobility, and activities of daily living. A fall incident report dated 9/7/25 at 10:10 PM written by Nurse #9 revealed Nurse Aide #8 yelled for help. Nurse #9 entered the room and Resident #39 was lying on the floor on her side and partially on her stomach. A puddle of blood was noted under Resident #39's head. Nurse #9 applied pressure to the area to slow the bleeding. No other injuries were observed other than the laceration to the top of the forehead where the blood was coming from and possible guarding of the right arm. Emergency Medical Services (EMS) was immediately notified. Nurse #9 stayed with Resident #39 until EMS arrived. Resident #39 was unable to give a description of what happened. The Physician, Director of Nursing, and the Responsible Party were notified. Resident #39 was transported to the hospital for evaluation. The hospital summary dated 9/7/25 at 11:52 PM revealed Resident #39 presented to the emergency department after a witnessed fall. According to the report Resident #39 rolled off the bed while being changed. Resident #39 had a history of CVA and dementia at baseline. Computed Tomography (CT) of the cervical spine showed a nondisplaced fracture on the lateral margin of C1 (first cervical vertebrae) with no other abnormalities involving the cervical spine. A cervical collar was placed. The CT also revealed a midline frontal scalp soft tissue laceration with no underlying fracture. Resident #39 was transferred to a tertiary care facility (provides highly specialized medical services) for further evaluation. The hospital summary from the tertiary care facility revealed Resident #39 admitted on [DATE] and discharged back to the skilled nursing facility on 9/8/25. Resident #39's diagnoses was C1 fracture of the cervical spine with no surgical interventions needed. A progress note dated 9/8/25 at 3:36 PM written by Unit Manager #1 revealed a call was received from the hospital. Resident #39 was returning back to the facility with a C1-nondisplaced fracture with no neurosurgical involvement. Resident #39 was to wear the cervical collar at all times and follow up in 4 weeks. The facility investigation report dated 9/8/25 revealed on 9/7/25 at approximately 10:30 PM Nurse Aide #8 stated while providing care for Resident #39 she positioned Resident #39 who was severely cognitively impaired on her left side to begin washing her because of a bowel movement. Nurse Aide #8 began to change the sheets while providing care. Nurse Aide #8 had one hand placed on Resident #39 and the other hand was used to make the bed. Resident #39 began to wiggle and fell off the bed on to her left side. Nurse Aide #8 immediately called for help never leaving the residents side. Nurse #9 ran into the room and assisted in providing emergency care. Nurse #9 called for the charge nurse and they both stayed with Resident #39 to provide care until EMS arrived. Resident #39 was observed with blood pooling from her head from a laceration and guarding of her right arm. First Aide was rendered to stop the bleeding. The on-call physician was notified. Resident #39 was transferred to the hospital for evaluation. The hospital report revealed a nondisplaced fracture of C1 (first vertebrae of cervical spine). A written statement dated 9/8/25 made by the Regional Corporate Consultant during the facility's investigation revealed Nurse Aide #8 was called to return to the facility to perform a return demonstration of Resident #39 sliding out of the bed onto the floor. This writer along with the Director of Nursing and the Administrator assisted Nurse Aide #8 to room [ROOM NUMBER]. Nurse Aide #8 stated she went into Resident #39's room to provide incontinence care. Nurse Aide #8 explained that Resident #39 was positioned on her back, and she assisted her to her left side and began to provide incontinence care. Nurse Aide #8 stated during care Resident #39 began to move to the edge of the bed. Bolsters (a long cylindrical pillow used for support, which also acts as a safety barrier) were in place on both sides of the bed. While on her left side Resident #39 rolled off of the bed onto the floor. Nurse Aide #8 was unable to prevent her from sliding off of the bed. Resident #39 landed on her right side. Nurse Aide #8 immediately called for help and staff responded. When questioned if Nurse aide #8 checked the Kardex (a resident care guide that shows essential information including transfer status and bed mobility) prior to providing care Nurse Aide #8 stated she did not. Nurse Aide #8 also stated she knew Resident #39 required two-person assistance for bed mobility because she had cared for her many times prior to the incident. Resident #39's Kardex (a quick reference of a residents care needs) revealed Resident #39 required two-person assistance with bed mobility, transfers and activities of daily living, prior to the fall including the day of the fall on 9/7/25. A written statement from Nurse Aide #8 was obtained by the facility on 9/8/25 during their investigation. Nurse Aide #8'written statement stated: while she was providing incontinence care and changing Resident #39's bed sheet, Resident #39 fell off of the bed. She immediately yelled for the nurse who ran into the room and quickly assessed Resident #39. The nurses stayed with Resident #39 until EMS arrived. Attempts were made on 9/30/25 at 3:39 PM, 10/1/25 at 2:00 PM and 10/1/25 at 7:00 PM to contact Nurse Aide #8. There was no response. A phone interview was conducted on 9/30/25 at 6:30 PM with Nurse #9. She stated she was the assigned nurse on duty on 9/7/25 the night Resident #39 fell. Nurse #9 stated she had just assisted Nurse Aide #8 in the room adjacent to Resident #39 who also required two-person assistance. Once they were done in the other residents room Nurse Aide #8 went one way and Nurse #9 went the other way. Nurse #9 stated not long after she heard Nurse Aide #8 yelling for help, and she ran down to check on her. When she entered the room Resident #39 was lying on her side and partially on her stomach on the side of the bed near the window. Resident #39 had dementia and was yelling out. EMS was immediately notified due to the resident having a lot of blood on her forehead. Nurse #9 stated she did not move Resident #39 and stayed with her and placed support under her head until EMS arrived and transported her to the hospital. Nurse #9 stated she did not know that Nurse Aide #8 was going in to assist Resident #39 and Nurse Aide #8 did not ask her to go in and assist her with changing Resident #39. Nurse #9 stated she would have assisted Nurse Aide #8 and there were other staff on duty that night that would have assisted her, but Nurse Aide #8 did not ask anyone for help. Nurse #9 stated that Nurse Aide #8 reported to her that she thought she could do it herself. Nurse #9 stated Nurse Aide #8 was agency staff but had provided care to Resident #39 in the past and knew Resident #39 required two staff members to assist with care. During an observation on 9/30/25 at 11:30 AM Resident #39 was observed in her room lying in bed with a cervical collar in place. She was oriented to person only and could not engage in dialogue. She was in no distress. During an interview on 10/1/25 at 2:30 PM the Director of Nursing stated Resident #39 sustained a fall with injury on 9/7/25 when Nurse Aide #8 was providing incontinence care and did not have a second person to assist her. Resident #39 rolled off of the bed. She was transported to the hospital. She sustained a cervical fracture and forehead laceration. An investigation was initiated on 9/8/25 and Nurse Aide #8 was suspended pending the investigation. The DON indicated the root cause analysis determined Nurse Aide #8 failed to follow Resident #39's Kardex and care plan that showed Resident #39 required two-person assistance for bed mobility which resulted in the injury. The DON stated a corrective action plan was initiated on 9/8/25, and the decision was made on 9/8/25 to monitor residents requiring two-person assistance during care and to put it into their Quality Assurance (QA) program for ongoing monitoring. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 9/7/25, at approximately 10:30 PM, Nurse Aide #8 stated was providing care to Resident #39. She positioned her on her left side and Nurse Aide #8 began to change the sheets while providing care. Nurse Aide #8 had one hand placed on Resident #39 and the other hand making the bed when Resident #39 began to wiggle and fell off of the bed onto the left side. Nurse Aide #8 immediately called for help never leaving the resident's side. Nurse #9 ran into the room, quickly assessed the scene and assisted in providing emergency care. Nurse #9 called for the Nurse in Charge to assist. She arrived, as well as two other aides. The two nurses prepped Resident #39 and stayed at the bedside to provide care until the paramedics arrived. Nurse #9's observation revealed Resident #39 to have blood pooling from her head from a laceration, and she had guarding of the right arm. On 9/7/25 at 10:43 PM the on-call Physician was notified by Nurse #9, and an order was received to send Resident #39 to the local hospital for evaluation. Resident #39's Responsible Party was attempted to be notified via phone. A chart review was completed by the Director of Nursing on 9/8/25. The chart indicated a Bed Safety Evaluation was completed on 8/24/25 for Resident #39. The evaluation indicated Resident #39 was able to move her upper and lower extremities independently, however she was unable to turn side to side, move up and down in the bed, or pull herself up from laying to sitting position independently. Resident #39's Kardex at the time of the fall indicated to provide two-person assistance with bed mobility. Resident #39's care plan indicated to provide two-person assistance with bed mobility. Nurse Aide #8 was placed on administrative leave pending the facility investigation. On 9/8/25 at 6:39 AM the hospital note indicated Resident #39 presented to the emergency department after a witnessed fall. Per the report, Resident #39 was being changed and rolled off the bed. Resident #39 had a nondisplaced fracture through the lateral margin of the cervical spine with no other bony abnormalities involving the cervical spine. A root cause analysis was conducted on 9/8/25 and based on the findings, the facility found that Nurse Aide #8 failed to properly position Resident #39 prior to providing care and failed to follow the Kardex and care plan which stated to provide two-person assistance with bed mobility. Resident #39 was evaluated by the facility Medical Director on 9/8/25 with no new orders received. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The center recognizes all residents that require assistance with bed mobility have the potential to be affected by the noncompliance. On 9/8/25, the Director of Nursing completed a review of all current resident's Kardex and Care Plans to ensure accuracy. On 9/8/25 licensed nurses completed skin assessments on all cognitively impaired residents with no concerns identified. On 9/8/25 the Social Services Director interviewed a sample of alert and oriented residents with no concerns identified. On 9/8/25 the Director of Nursing and designee completed transfer assessments for residents residing in the facility. On 9/8/25, resident care plans and Kardex's were reviewed and updated to reflect resident transfer assessments by licensed nurses and the DON. On 9/8/25 the Director of Nursing and designee conducted an audit of all falls in the last 30 days to ensure no falls with injury were due to improper assistance provided by nursing staff. There were no concerns noted during the audit. On 9/8/25 the Director of Nursing and designee-initiated education to all nursing staff on safe handling of the residents, the location of the Kardex, when to review the Kardex, and the importance of following the Kardex when providing resident care, and the abuse and neglect policy. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning 9/8/25, licensed nurses and certified nursing assistants to include agency licensed nurses and agency certified nursing assistants were provided education by the DON and Nurse Educator on resident safe handling, location of the Kardex, when to review the Kardex, and the importance of following the Kardex when providing resident care. All new staff and new agency staff will be educated in the new hire orientation program and before the next scheduled shift. Beginning 9/8/25, education was provided to all facility staff, to include agency staff, by the Nurse Educator on the abuse policy with an emphasis on neglect. Any staff identified as not receiving abuse and neglect education by 9/8/25 will not be allowed to work before receiving education on the facility's abuse policy. All newly hired staff, to include new agency staff, will be educated on the facility's abuse prohibition policy in the new hire orientation program. Post tests were completed beginning on 9/8/25 for validation of understanding of abuse reporting timeframe, the requirements and reporting any allegations or witnessed abuse to the facility Administrator immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Effective 9/9/25, the Director of Nursing and designee will review all incidents and accidents through the Risk Management System in the morning clinical meeting 5 times weekly for 12 weeks to ensure the Kardex and care plans were followed with bed mobility and transfers to ensure resident safety. Effective 9/9/25, the Director of Nursing or Nurse Manager will conduct random audits through observations of 5 staff per week for 12 weeks to ensure safe bed mobility and transfers were maintained. An ADHOC Quality Assurance Performance Improvement (QAPI) meeting was conducted on 9/8/25 in collaboration with the Medical Director to discuss the root cause analysis of the deficient practice, to formulate a plan to include monitoring beginning on 9/8/25, and to ensure resident safe handling and residents bed mobility were followed during care as outlined in the patient's care plan. The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety for 3 months. The improvement-monitoring schedule will be modified based on the findings of monitoring. The facility's alleged compliance date of the corrective action plan was 9/10/25. The corrective action plan was validated on 10/2/25. The following documentation was reviewed along with staff interviews and observations: Validation included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. Staff members interviewed stated they had received training. In-service training included safe handling during resident care, the importance of reviewing the residents Kardex, and the abuse and neglect policy. Inservice logs were verified, and the initial and ongoing audits were verified. An observation of incontinence care was conducted of a resident who required two-person assistance with bed mobility and activities of daily living. There were no concerns identified. The compliance date of 9/10/25 was validated.

Based on record review, staff interviews, Nurse Practitioner (NP), and Registered Dietitian (RD) interviews, the facility failed to determine the accuracy of a weight when a resident had a significant weight gain of 26.8 pounds in 19 days and failed to communicate the significant weight gain to the Registered Dietitian for a nutritional assessment for 1 of 5 residents reviewed for nutrition (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE] with a cumulative diagnosis including right above the knee amputation (AKA), atrial fibrillation (A-fib), hypertension (HTN), congestive heart failure (CHF), and peripheral vascular disease (PVD). A physician order dated 04/28/25 revealed an order to weigh Resident #62 every day shift every 1 month(s) starting on the 28th for 2 day(s), with start date of 04/28/2025. A review of Medication Administration Record (MAR) dated 09/15/25 for Resident #62 revealed: Eliquis (treat Atrial fibrillation), Entresto (treat chronic heart failure), iron, Lasix (treat fluid retention), metformin (treat diabetes), metoprolol (treat high blood pressure), and spironolactone (treat edema and heart failure). Resident #62's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severe cognitive impairments and required extensive assistance with activity for daily living (ADL) and had a weight of 218 pounds. Resident #62's care plan goals dated 07/23/25 revealed the resident exhibits or is at risk for fluid volume excess as evidence by edema (a condition where excess fluid accumulates in the body's tissues, causing swelling) of left lower extremity. Interventions include assessing and monitoring symptoms of edema, shortness of breath, weight gain, and weigh resident per policy and alerting dietitians and physicians to any significant loss or gain. A nursing note dated 09/29/25 at 2:52 PM by Unit Manager #1 for Resident #62 revealed a weight of 247.0 pounds. on 09/28/25 at 3:03 PM for Resident #62, utilizing a mechanical lift. Review of Resident #62's weekly/monthly weights revealed: 04/08/25 hospital weight was 207.2 pounds (lbs.)04/28/25 was 209.4 lbs.04/29/25 was 209.2 lbs.05/28/25 was 208 lbs.06/28/25 was 211.6 lbs.07/28/25 was 218.6 lbs.08/29/25 was 218 lbs.09/09/25 was 220.2 lbs.09/28/25 was 247 lbs. a weight gain of 26.8 lbs. in 19 daysAn interview was conducted on 10/01/25 at 2:00 PM with Unit Manager #1. She stated Resident's weight significant change from 09/09/25 - 220.2 lbs. to 09/28/25 - 247 lbs. should have had a re-weight done on 09/28/25 (within 24 hours) and wasn't. She said she entered the 247 lb. weight into their electronic medical record on 09/28/25 but did not review resident's previous weights, which she stated she should have. She stated that when she entered resident's weight of 247 lbs., the electronic medical record flagged the resident's weight gain in red numbers signifying Resident #62's weight gain was significant, and that she should have then asked the nursing aids to do a reweight and didn't. Further review of Resident #62's medical record on 09/29/25 revealed there were no additional weights.An interview on 10/01/25 at 9:20 AM with the Nurse Practitioner (NP) revealed it was her expectation that Resident #62's significant weight of 247 lbs. on 09/28/25 should have had a reweight done. She said a reweight was to be done on all weight loss/gain weights greater than 5% within a month, or greater 10% in six months, so she could make the necessary treatment recommendations. The NP added it was her expectation for nursing staff to follow the facility's policy on weights and to follow resident's care plan protocols. An interview was conducted on 10/01/25 at 2:00 PM with Unit Manager #1. She stated Resident's weight significant change from 09/09/25 - 220.2 lbs. to 09/28/25 - 247 lbs. should have had a re-weight done on 09/28/25 (within 24 hours) and wasn't. She said she entered the 247 lb. weight into their electronic medical record on 09/28/25 but did not review resident's previous weights, which she stated she should have. She stated that when she entered resident's weight of 247 lbs., their electronic medical record flagged resident's weight gain in red numbers signifying Resident #62's weight gain was significant, and that she should have then asked the nursing aids to do a reweight and didn't. An interview was conducted on 09/30/25 at 3:15 PM with the Registered Dietitian (RD) revealed a reweight should be done the same day on all weight loss/gain weights greater than 5% within a month, or greater 10% in six months, so he would be able to make the necessary dietary changes. The RD was made aware on 09/30/25 by the Surveyor of Resident #62's weight gain. An interview on 09/30/25 at 4:00 PM with the Director of Nursing (DON) and Market Clinical Advisor revealed they confirmed Resident #62's last two documented weights were: 09/09/25-220.2 lbs., and 09/28/25-247 lbs. DON said it was her expectation that with the weight discrepancy between the two weights she would have expected her nursing staff to have done a reweight within 24 hours.

Based on record review and staff interviews, the facility failed to complete a performance review every 12 months for 1 of 1 nursing assistant (Nurse Aide #4) reviewed to ensure in-service education was designed to address the outcome of the performance review.Findings included:Nurse Aide #4's personnel file was reviewed and revealed the date of hire of was 7/30/24. The personnel file for Nurse Aide #4 did not include evidence that a performance review had been completed for Nurse Aide #4.An interview was conducted on 11/19/25 at 9:00 AM with the Administrator who stated the Director of Nursing (DON) was responsible for conducting the annual performance review for all Nurse Aides and she was aware the DON had not conducted the annual performance reviews.An interview was conducted on 11/19/25 at 9:05 AM with Nurse Aide #4. During the interview, Nurse Aide #4 stated her annual performance evaluation was due in 7/30/25 and she had not received a performance evaluation in the last year by the Director of Nursing (DON) and should have.A phone interview was conducted on 11/19/25 at 10:25 AM with the Director of Nursing (DON). During the interview, the DON stated since being hired at the facility in March 2025, she had not conducted a performance review for the facility's Nurse Aide staff. The DON did not provide a reason as to why she had not conducted an annual performance review for Nurse Aides.

Based on record review, staff interviews, and the Consultant Pharmacist's interview the facility failed to act on the Pharmacist's recommendation to remove a residents (Resident #3) discontinued narcotic pain medication (Hydrocodone- Acetaminophen 5-325 milligrams) from the medication cart. This resulted in 20 missing tablets. This occurred for 1 of 6 residents (Resident #3) reviewed for medication administration.Findings included:Resident #3 was re-admitted to the facility on [DATE] with diagnoses including a stage IV pressure wound and osteomyelitis (infection of the bone). A hospital physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for up to 5 days beginning 7/14/25. This order was administered to Resident #3 from 7/15/25 through 7/19/25 and completed. A second hard copy physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for pain for 14 days (56 tablets). A packing slip and proof of delivery from the dispensing pharmacy dated 7/15/25 revealed the facility physician's order was filled with a delivery of Hydrocodone-Acetaminophen oral tablets 5-325 mg and a total of 54 tablets for Resident #3 was received in the facility on 7/15/25. The delivery was signed as received by Nurse #7 and Nurse #5. The declining count sheet for the 54 tablets of Hydrocodone-Acetaminophen 5-325 mgs for Resident #3 was signed out by nursing staff as needed during the month of July 2025 and signed as administered one time in August 2025. Review of the Consultant Pharmacist's Controlled Substance Random Audit form dated 8/14/25 conducted by Consultant Pharmacist #2 revealed Resident #3 was selected for a random medication audit. The Pharmacist noted that Resident #3's Hydrocodone-Acetaminophen 5-325 mg order had been discontinued in July 2025 and to pull the medication card from the cart and return to pharmacy. An investigation report completed by the Administrator dated 11/5/25 revealed in part; On 11/5/25 Nurse #10 discovered the count on the narcotic sheet noting 20 missing tablets of Hydrocodone-Acetaminophen and reported this to the Director of Nursing (DON). During a phone interview on 11/18/25 at 2:30 PM the Consultant Pharmacist (#2) who was the consultant during July through September 2025 stated she did random audits on the controlled medications and randomly selected 4 or 5 cards for auditing at each visit. She stated she looked at documentation, final counts, and verified that the card and the order matched. The Consultant Pharmacist stated a note was sent to the Director of Nursing (DON) regarding Resident #3's Hydrocodone - Acetaminophen 5-325 mgs that remained on the medication cart on the August 2025 pharmacy report. The Consultant Pharmacist stated the note read to pull the Hydrocodone - Acetaminophen 5-325 mg for Resident #3 from the medication cart and return to the Pharmacy for disposal because the order was discontinued on 7/29/25 after 14 days. She stated she typically did not go back and review the previous months recommendations that were sent to the Director of Nursing (DON) and just expected the recommendations would be followed. During an interview on 11/18/25 at 10:45 AM the Director of Nursing (DON) indicated she was responsible for acting on the monthly pharmacy reports. She stated she received the Consultant Pharmacist's medication audit reports each month and would complete the necessary recommendations when she received the report. The DON indicated that the Pharmacist's note to pull Resident #3's discontinued medication from the medication cart on the 8/14/25 review was missed in error. The DON stated had the Hydrocodone- Acetaminophen been removed after the order was discontinued or at least removed after the Consultant Pharmacists recommendations the missing medications would not have occurred.

Based on record review, staff interviews, the Pharmacy District Director, and the Wound Physician interviews, the facility failed to administer two intravenous (IV) antibiotics (Piperacillin Sodium Tazobactam - a broad-spectrum antibiotic used to treat moderate to severe bacterial infections and Vancomycin - an antibiotic used to treat severe infections) prescribed for the treatment of osteomyelitis (infection of the bone) following admission for a resident (Resident #86). This resulted in 4 missed doses of the Piperacillin and 4 missed doses of the Vancomycin. This occurred for 1 of 6 residents reviewed for medication administration. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Piperacillin Sodium Tazobactam. Use 3.375 grams intravenously every 8 hours for osteomyelitis for 18 days. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Vancomycin intravenous solution. Use 1 gram intravenously two times a day for osteomyelitis until 04/03/25. Resident #86 was admitted to the facility on [DATE] with diagnoses including a Stage IV pressure ulcer of the left ischium (the lower and back portion of the hip bone), Stage IV pressure ulcer on the sacrum, Stage IV pressure ulcer of the right hip, Stage II pressure ulcer on the right buttock, a deep tissue injury of the left heel, osteomyelitis of the vertebra, sacral, coccyx region, and left thigh, and paraplegia (paralysis of the lower extremities). Review of the Medication Administration Record (MAR) dated March 2025 for Resident #86 revealed the first dose of Piperacillin Sodium scheduled for every 8 hours was not administered until 3/17/25 at midnight, the second dose was administered at 8:00 AM on 3/17/25, the third dose was administered at 8:00 PM on 3/17/25. Review of the Medication Administration Record (MAR) dated March 2025 for Resident #86 revealed the first dose of Vancomycin to be administered two times a day for osteomyelitis was not administered until 3/17/25 at 8:00 PM. Review of Resident #86's progress notes on 3/15/25 and 3/16/25 revealed no documentation as to why the antibiotics were not administered. A progress note was entered by the Social Worker on 3/15/25 at 1:34 PM indicating Resident #86 was in the facility at that time. Review of Resident #86's Vancomycin trough level (the lowest concentration of Vancomycin in the blood, measured just before the next dose is administered. Monitoring the trough level helps to ensure the drug is effective while minimizing the risk of toxicity) that was ordered on 3/17/25 then weekly showed Resident #86 was in therapeutic range. During a phone interview on 11/18/25 at 10:30 AM Unit Manager #1 stated Resident #86 admitted on Saturday 3/15/25 with stage IV pressure wounds and orders for IV antibiotics. Unit Manager #1 indicated the nurses could enter physician orders, but she was responsible for reviewing that the admission orders were entered. She realized the antibiotic orders had not been entered into Resident #86's electronic medical record upon admission on [DATE]. Unit Manager #1 stated she at times entered orders from home and she was the one that entered the antibiotic orders for Resident #86 and that was why the antibiotic orders did not populate on the MAR to be administered until 3/17/25. She stated the admitting nurse should have sent the antibiotic orders to the pharmacy and entered the antibiotic orders on 3/15/25 the day of admission, but that did not occur. Unit Manager #1 indicated Medication Aide #1 was assigned to the hall that Resident #86 was admitted to on 3/15/25 and 3/16/25. The responsible day shift nurse (Nurse # 12) and night shift nurse (Nurse #11) on 3/15/25 and 3/16/25 were agency staff and were no longer employed by the facility. During a phone interview on 11/18/25 at 7:00 PM Medication Aide #1 stated the nurse in charge would have handled IV medications, but she did not recall what medications Resident #86 received. During a phone interview on 11/21/25 at 11:30 AM the Pharmacy District Director stated they provided 24-hour services 7 days a week to the facility. If IV medications were ordered over the weekend the medications would be delivered over the weekend. She stated Resident #86's Vancomycin order was not received in the pharmacy until 3/16/25 at 9:32 PM and it was delivered to the facility Monday 3/17/25. The Piperacillin order was received in the pharmacy on 3/16/25 at 3:31 AM and delivered to the facility on 3/16/25. During a phone interview on 11/21/25 at 12:30 PM the Wound Physician stated missing doses of Vancomycin and Piperacillin in the treatment of osteomyelitis was significant and could delay wound healing. The Wound Physician stated she could not say the missed doses caused any worsening of the infection regarding Resident #86 but missed doses could lead to subtherapeutic levels causing the antibiotic to be less effective. During a phone interview on 11/21/25 at 1:00 PM the Director of Nursing (DON) stated the orders for Resident #86's IV antibiotics should have been entered into the electronic medical and sent to Pharmacy on 3/15/25 the day of admission. The DON indicated that the IV antibiotics should have been administered to Resident #86 sooner.

Based on record review, and staff , Psychiatrist, Nurse Practitioner, and the Medical Director's interviews the facility failed to protect a residents right to be free from resident-to-resident abuse when Resident #1 hit and scratched Resident #2 on her left arm resulting in multiple areas of bruising and abrasions. This occurred for 1 of 4 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, and bilateral below the knee amputation. Review of the care plan dated 12/28/24 revealed Resident #1 required assistance with activities of daily living. There was no care plan in place regarding Resident #1 having behavioral disturbances. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact. She had no physical or verbal behavioral symptoms directed toward others at the time of assessment. She required extensive two-person assistance with activities of daily living (ADL) and total dependence with transfers. Resident #2 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident. A physician's order dated 9/12/23 for Resident #2 revealed Eliquis (blood thinner) 5 milligrams twice a day for atrial fibrillation. Review of the care plan dated 3/18/25 revealed Resident #2 required assistance with activities of daily living. There was no care plan in place regarding Resident #2 having behavioral disturbances. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #2 was cognitively intact. She required extensive two-person assistance with activities of daily living. She had no physical or verbal behavioral symptoms directed toward others at the time of assessment. The facility investigation report dated 5/23/25 revealed: On 5/23/25 a nurse aide (Nurse Aide #4) was passing by the residents room (Resident #1 and Resident #2) and heard a resident yell for help. Nurse Aide #4 immediately attempted to separate the residents but neither resident would let go of the privacy curtain. Nurse Aide #4 stayed at the doorway and called for Nurse #2. Both residents were immediately separated. Resident #1 was placed on 1 to 1 supervision for safety. The Police, Adut Protective Services, the Ombudsman, the Physician, the Responsible Party, and the State Agency were notified. The police arrived and spoke with both residents. The on-call Psychiatric provider was notified for an emergency psychiatric evaluation of Resident #1. A skin assessment of Resident #2 revealed a hematoma (a collection of blood underneath skin), bruising, and minimal bleeding noted to the top left hand with scratch marks and minimal bleeding to the left arm, and a small bruise to the right hand. A skin assessment of Resident #1 revealed no new skin breakdown; blood was noted under the middle three digits of Resident #1's right hand. Resident #2 was transferred to the hospital for further evaluation. Resident #1 was later transferred to the hospital for a psychiatric evaluation. On 5/24/25 Resident #2 returned from the hospital. Imaging obtained revealed a fracture of the fifth metacarpal (finger) and a splint was placed. Resident #2 had abrasions and a hematoma to the left hand, with no significant open wounds. An orthopedic follow-up appointment was scheduled for 5/30/25. Involuntary commitment paperwork was filed for Resident #1, and she was notified of immediate discharge while she was at the hospital. Resident #1 did not appeal and stated she wanted to be discharged home. Resident #1 did not return to the facility. A change in condition report dated 5/23/25 at 5:43 PM documented by Nurse #2 revealed Resident #2 had an altercation with her roommate (Resident #1) in their room. The residents were arguing regarding the privacy curtain being pulled. Nurse #2 was unable to say how the injury occurred. Both of Resident #2's hands were noted to be bruised with scratches and minimal bleeding to the left hand. The Physician responded to send Resident #2 to the emergency department for evaluation. A progress note dated 5/23/25 at 6:33 PM documented by Nurse #2 revealed the police were in the facility to talk with the residents due to resident-to-resident altercation. Resident #2 was alert and oriented to person, place, and time and was able to show the officers her injuries to both hands. Resident #2 was made aware that she would have a room change today and that she was being sent to the emergency department for evaluation due to hematoma and bruises to her hands. Resident #2 was in agreement with going to the hospital for evaluation and requested not to remain in the room with her roommate. Resident #2 will be moved to another room upon return from the hospital. A progress note dated 5/23/25 at 7:10 PM documented by Nurse #2 revealed Resident #2 was transferred to the emergency department. A progress note dated 5/24/25 at 3:25 AM documented by Nurse #7 revealed Resident #2 returned to the facility at this time accompanied by two emergency medical technicians. Her vital signs were within normal limits. She had no complaints of pain or discomfort at the time. The hospital Discharge summary dated [DATE] revealed Resident #2 was evaluated today with concern of a large hematoma on the left side of her dorsal (top) hand. She stated that she was in an altercation with her nursing home roommate. Reportedly Resident #2 was trying to keep a room privacy curtain closed and her roommate did not want it closed and therefore smacked her hand. Resident #2 was on a blood thinner for Atrial fibrillation and has a large hematoma present on arrival. Resident #2 has some pain in the left hand. The final impression revealed: Displaced fracture of the neck of the fifth metacarpal (finger) bone, on her left hand, with referral to Orthopedic Surgery. A hematoma of the left hand and abrasion of right hand. A splint was applied to the left hand. Resident #2 was discharged back to the facility on 5/24/25 at 2:50 AM. A physician's order dated 5/24/25 for Resident #2 revealed Hydrocodone-Acetaminophen oral tablet 5-325 milligrams. Give 1 tablet by mouth every 6 hours as needed for pain for 14 days. Review of the Medication Administration Record (MAR) dated May 2025 revealed Resident #2 was administered Hydrocodone-Acetaminophen oral tablet 5-325 milligrams for pain level of 6 on a scale from 1-10 on 5/24/25 at 9:17 PM, 5/25/25 at 8:20 PM, and 5/26/25 at 10:22 PM. No further doses were administered. Review of the orthopedic surgeons note from the follow up appointment dated 5/30/25 revealed Resident #2 had soft tissue trauma of the left hand, with no obvious fracture. She had opened wounds on her left hand that needed dressing changes and antibiotics. Orders were written for Keflex (antibiotic) 500 milligrams twice a day for 1 week. Daily dressing changes to the left hand for 1-2 weeks. Apply nonstick dressing and ace wrap. Daily occupational therapy to prevent stiffness. Keep splint on and remove only for showers. An interview was conducted on 6/4/25 at 12:00 PM with Resident #2. She was observed lying in bed and was alert and oriented to person, place, and time. She stated the incident occurred on Friday evening 5/23/25. She stated her roommate Resident #1 had been out of the room for most of the day. Resident #1 returned to the room around 5:00 PM and the privacy curtain was pulled and Resident #1 whose side was near the window wanted the privacy curtain opened. Resident #2 stated she wanted the curtain pulled for privacy. Resident #1 then tried to open the curtain and Resident #2 used her reacher (tool used to pick up hard to reach items) to grab the curtain to keep it closed. She stated Resident #1 grabbed the reacher so at that point both of them had a hold of it. Resident #1 then proceeded to pull on the reacher while Resident #2 was still holding on to it. She stated Resident #1 proceeded to claw at her left arm and hand with her long fingernails. She stated the clawing and scratching caused a lot of bleeding and blood was all over her bed. Resident #1 started yelling out for a staff member. While they were waiting on a staff member Resident #1 continued to scratch and claw at her left arm and hand leaving deep scratches that ended up with swelling and bruising. She stated when staff finally came into the room they decided to send her to the hospital for evaluation. She went out to the hospital shortly afterward and returned to the facility around 2:30 AM the following morning. She stated she had only been roommates with Resident #1 for two days prior to the incident. Until that time she had not had any altercations or incidents with her. She stated when the incident occurred she did not feel scared or frightened she was just very mad that it had occurred. She stated when she returned from the hospital they moved her to another room and notified her that Resident #1 had been discharged from the facility. She stated she currently felt safe in the facility since Resident #1 was no longer there. An attempt was made on 6/4/25 at 1:00 PM to contact Resident #1. The phone number on file was not a valid number. Attempts were made on 6/4/25 at 1:15 PM and 2:35 PM and 6/5/25 at 9:00 AM to contact Nurse Aide #4 who entered the room to separate the residents on 5/23/25. There was no response. A witness statement obtained by the facility from Nurse Aide #4 during the investigation on 5/23/25 revealed she was making rounds and heard the residents yelling for help in the room. Both residents were pulling and fighting over the privacy curtain and neither resident was willing to let go. The nurse came in to assist. The residents were separated and were checked for bruising or scars. Resident #2 had a large scratch and bruising. During an interview on 6/4/25 at 2:10 PM Nurse #2 stated she was the assigned nurse on 5/23/25. She stated she was called to the residents room. When she arrived Nurse Aide #4 was taking Resident #1 out of the room and Resident #2 was still in bed with blood on her hand. She was told the residents were arguing over the privacy curtain being pulled. Both residents had a reacher but denied hitting each other. Resident #1 clawed Resident #2 with her fingernails. The residents were separated. The police were notified and came out and talked with both residents. Resident #1 did not deny scratching but denied hitting Resident #2. Resident #1 was moved to a room down the hall and placed on 1 to1 supervision. Resident #2 was sent to the hospital for evaluation of her injuries. She stated Resident #2 was confused at times, but she was very aware. Nurse #2 stated she left after the end of her shift around 7:00 PM that evening, and Resident #1 was sent out to the hospital later that night. She reported that Resident #1 was a bilateral amputee and in a wheelchair during the incident, and Resident #2 was lying in her bed during the incident. During an interview on 6/4/25 at 3:00 PM the Director of Nursing (DON) stated she was walking up to the nurses station when Nurse Aide #4 was standing at the door of the residents room yelling for Nurse #2. Both the DON and Nurse #2 went down to the room. As she came down the hall Nurse Aide #4 was pushing Resident #1 out of the room in her wheelchair. She went into the room and asked Resident #2 who was lying in bed what happened. She noticed the hematoma and scratch marks on her left hand and a small bruise on her right hand. She stated Resident #2 was calm about everything and said she wanted the curtain pulled one way and Resident #1 wanted it another way. After she spoke with Resident #2 and did the skin evaluation she went and spoke with Resident #1. Resident #1 reported the same thing. Resident #1 wanted to see out of the door and did not want the curtain pulled and they got in a scuffle. She assessed Resident #1, and she had blood under her fingernails. At that time, she was moved to another room and placed on 1 to 1 supervision. Resident #2 was sent to the hospital, and they called for an emergency psychiatric visit, but the psychiatrist was unable to come until the next day. The police came out and spoke with both residents prior to Resident #2 going to the hospital and Resident #2 wanted to press charges. Resident #1 was recently moved into Resident #2's room the day before on 5/22/25. Neither resident had complained to staff prior to this incident and had no prior altercations with each other. She stated Resident #1 had an incident with another resident at one time when another resident with dementia hit Resident #1 and Resident #1 reacted by hitting her back but there were no injuries. Resident #2 had never had any altercations with other residents. She stated Resident #1 was later sent out to the hospital that same night for a psychiatric evaluation since the Psychiatrist could not do an emergency visit that evening. The hospital called later and informed staff they could not do a psychiatric evaluation due to not having a psychiatric provider on staff that night. Later at 4:30 AM the hospital called the facility and stated Resident #1 did not need a psychiatric evaluation and they were sending her back to the facility. The facility had to sign a petition for involuntary commitment so that Resident #1would not return to the facility before being evaluated by a Psychiatrist. She stated Resident #1 never returned to the facility but indicated she thought Resident #1 discharged home. A progress note dated 5/27/25 documented by the Psychiatrist who provided services at the facility, revealed Resident #2 was evaluated for follow up after an altercation with her roommate. Resident #2 stated Resident #1 hit and scratched her hand while she attempted to keep the privacy curtain pulled. Resident #2 did have a fracture. Resident #2 stated she felt safe now that Resident #1 was discharged . She denied depressed mood or anxiety. During a phone interview on 6/4/25 at 4:50 PM the Psychiatrist stated she was made aware of the incident on 5/23/25 between the residents but was not clear on all of the details. She stated she would be evaluating Resident #2 again on her next visit later this week. She stated Resident #1 had confusion at times but was alert and oriented to person, place, and time. She stated Resident #1 was not on an antipsychotic medication, but she did receive the antidepressant medication Trazadone nightly for insomnia. She stated she did not feel Resident #1 was a threat to other residents and had she returned to the facility she would have made medication changes. She indicated Resident #2 was evaluated by her following the incident. She was not on any psychotropic medications and there had been no incidents involving Resident #2 prior to this incident of which she was aware. During a phone interview on 6/4/25 at 5:15 PM the Medical Director stated he was made aware of the incident that occurred on 5/23/25 between the residents. He stated he was aware the Orthopedic surgeons report read no fracture although the hospital diagnosed Resident #2 with a fracture of the 5th digit. He stated he trusted the Orthopedic surgeon over the hospital impressions but indicted he was uncertain if an x-ray was done at the orthopedist office. He stated he would reevaluate Resident #2 on his next visit and refer her back to Orthopedics for follow up. During an interview on 6/5/25 at 10:00 AM the Social Worker stated she spoke with Resident #2 on Saturday 5/24/25 the day after the incident. She stated Resident #2 reported to her that she was not fearful and not in danger since Resident #1 had been removed from the facility. She stated there were no prior incidents between the two residents. She stated she continued to check in with Resident #2 several times a week and she was doing well. She had no complaints with her new roommate. The Social Worker stated she went to the hospital on Saturday 5/24/25 to visit Resident #1. She stated Resident #1 listened to what she said but would not speak to her about the incident. An observation of Resident #2's left hand and forearm was conducted 6/5/25 at 1:30 PM along with the Nurse Practitioner. Resident #2 stated she felt better today, and the wounds were healing. The left hand and forearm were noted to have scattered scabbed areas with bruising in various stages of healing. There was no drainage or swelling noted and no complaints of pain at the time. Resident #2 stated she was receiving an antibiotic and daily dressing changes since the orthopedic visit. During an interview on 6/5/25 at 1:30 PM the Nurse Practitioner stated x-rays were not done at the orthopedic office on 5/30/25. She stated she was uncertain whether Resident #2 had a finger fracture or not. She stated on today's exam she was able to move her hand and fingers without pain or discomfort. She indicated they would refer her back to the orthopedic surgeon to determine for certain whether a fracture occurred or not. The progress note dated 6/5/25 documented by the Nurse Practitioner revealed Resident #2 was evaluated for follow up. The hospital left hand x-ray questioned avulsed fragment at the medial aspect of the fifth metacarpal (finger). The Orthopedic consult on 5/30/25 stated no obvious fracture. Discussed case with the Medical Director who recommended referral back to the orthopedic surgeon for reevaluation of fracture versus no fracture to the left hand. Continue antibiotic for infection prevention. An interview was conducted on 6/5/25 at 5:30 PM with the Administrator along with the Director of Nursing (DON). The DON stated following the resident-to-resident altercation a plan of correction was initiated on 5/23/25 which included skin assessments, interviews of residents and staff, education, and discussions in Quality Assurance (QA). The Plan of Correction (POC) initiated on 5/23/25 with a compliance date of 5/28/25 included the following: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/23/25 (Nurse Aide #4) was passing by the room and heard a resident yell for help. Nurse Aide #4 immediately attempted to separate the residents but neither resident would let go of the privacy curtain. Nurse Aide #4 stayed at the doorway and called for Nurse #2. Both residents were immediately separated. Resident #1 was placed on 1 to 1 supervision for safety. The Police, Adut Protective Services, the Ombudsman, the Physician, the Responsible Party, and the State Agency were notified. The police arrived and spoke with both residents. The on-call Psychiatric provider was notified for an emergency psychiatric evaluation of Resident #1. A skin assessment of Resident #2 revealed a hematoma (a collection of blood underneath skin), bruising, and minimal bleeding noted to the top left hand with scratch marks and minimal bleeding to the left arm, and a small bruise to right hand. A skin assessment of Resident #1 revealed no new skin breakdown; blood was noted under the middle three digits of her right hand. Resident #2 was transferred to the hospital for further evaluation. Resident #1 was later transferred to the hospital for a psychiatric evaluation. On 5/24/25 Resident #2 returned from the hospital. Imaging obtained revealed a fracture of the fifth metacarpal (finger) and a splint was placed. Resident #2 with abrasions and hematoma to the left hand, with no significant open wounds. An orthopedic follow-up appointment was scheduled for 5/30/25. Involuntary commitment paperwork was filed for Resident #1, and she was notified of immediate discharge while she was at the hospital. Resident #1 did not appeal and stated she wanted to be discharged home. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/23/25 skin assessments were conducted on non-alert and oriented residents by nursing staff. There were no new findings as a result of the skin assessments. On 5/24/25 the Director of Nursing conducted staff interviews to inquire if staff had knowledge of the incident. Staff identified no behaviors. On 5/23/25 education was initiated and provided to staff by the Administrator and the Director of Nursing on resident abuse, behaviors, management of symptoms, and ensuring resident safety by identifying, reporting, and managing behavioral symptoms. The Director of Nursing will ensure all new staff and agency staff will be educated on the abuse policy, and all staff education will be conducted prior to their next shift. On 5/24/25 the Social Worker interviewed alert and oriented residents regarding abuse. There were no negative findings. On 5/26/25 residents with roommates were interviewed by facility staff to ensure roommate compatibility. There were no concerns identified. On 5/26/25 grievances from the last 90 days were audited by facility staff to ensure no additional concerns existed that rose to the level of suspected resident abuse. There were no negative findings. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 5/23/25 the Administrator and Director of Nursing initiated and provided education to current staff on abuse, neglect, and recognizing signs and symptoms of abuse, and reporting abuse. Education forms were signed by trained staff for the verbal education that was provided. All new staff to include new agency staff will be educated by the DON on the facilities abuse prohibition policy in the new hire orientation program prior to working their first scheduled shift. All staff education will be conducted by the Administrator and DON prior to their next scheduled shift. Abuse education was initiated on 5/23/25, and provided on 5/24/25, 5/25/25, and 5/27/25. 4.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility made the decision to incorporate the plan of correction and audits into their Quality Assurance and Performance Improvement (QAPI) committee on 5/26/25. The Administrator will interview five residents with a brief interview of mental status of eight or greater per week for twelve weeks to inquire if they have felt abused or have witnessed or suspected abuse or neglect. The Administrator will review all grievances on a daily basis for twelve weeks to ensure no concerns rise to the level of suspected abuse. Facility staff will interview five residents with roommates twice a week for six weeks to ensure appropriate roommate compatibility and to ensure no concerns related to resident abuse exist between roommates. Immediate action will be taken for any positive findings. Results of these audits and interviews will be brought before the Quality Assurance and Improvement Committee (QAPI) monthly with the QAPI committee responsible for ongoing compliance. An Ad HOC QAPI meeting with the interdisciplinary team was held on 5/26/25 at 11:00 AM to discuss the resident-to-resident altercation that occurred on 5/23/25. In the monthly QAPI meeting the Interdisciplinary team will review all resident-to-resident abuse allegations to ensure appropriate interventions are in place and the care plans were updated for eight weeks. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to assure compliance is maintained. The QAPI committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained. A root cause analysis discussed in QAPI determined the cause was due to the residents involved in the altercation were not compatible roommates. The facility alleged a compliance dated of 5/28/25. Validation of the corrective action plan was completed on 6/5/25. This included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. Inservice training records were verified and included staff signatures. The initial audits including the weekly audits were verified. The minutes from the QAPI meeting held on 5/26/25 were reviewed. There were no concerns identified. The compliance date of 5/28/25 was validated.

Based on observations, record review, and interviews with residents, staff, medical doctor, nurse practitioners, and law enforcement, the facility failed to protect a female (who was deemed an incompetent person by the North Carolina Clerk of Court) resident's (Resident #1), right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 05/15/24 Resident #1 was naked from the waist down in her bed when Nursing Assistant (NA) #1 observed Resident #2 in Resident #1's bed with his face between Resident #1's legs. Resident #1 was incapable of giving consent for Resident #2 to touch her. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma. Additionally, the facility failed to protect Resident #2 from resident to resident physical abuse. Example #2 was cited at a scope and severity of D. This deficient practice affected 2 of 4 residents reviewed for abuse. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, dementia with other behavioral and psychotic disturbance, muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic pain syndrome, depression, anxiety disorder, muscular dystrophy, and bed confinement status. A review of the State of North Carolina Letters of Appointment Guardian of the Person document revealed Resident #1 was deemed an incompetent person before the Clerk of The General Court of Justice Superior Court Division on 07/27/23. A review of Resident #1's annual Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was severely cognitively impaired. A review of Resident #1's Care Plan, last updated 02/07/24, revealed she exhibits or has the potential to demonstrate verbal and physical behaviors related to cognitive loss/dementia and indicated she preferred to wear facility gowns versus her own clothing and had tendencies to expose herself while lying in her bed without privacy precautions. The Care Plan indicated she had a Brief Interview for Mental Status (BIMS) score of 3 and noted it fluctuated at times. The Care Plan specified Resident #1 had impaired/decline in cognitive function or impaired thought processes related to vascular dementia and acute encephalopathy and exhibits or is at risk for alterations in functional mobility related to cerebrovascular vascular accident (stroke) with left-sided flaccid hemiplegia. The Care Plan indicated Resident #1 met Preadmission Screening and Resident Review (PASRR) II Level of determination secondary to serious mental illness. A review of Resident #1's quarterly MDS, dated [DATE], revealed that Resident #1 was cognitively intact, had the ability to make herself understood, had the ability to understand others, and had no behaviors. The MDS indicated that Resident #1 was dependent on staff for oral hygiene, toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, cognitive communication deficit, mental disorder not otherwise specified, depression, anxiety disorder, and muscle weakness. A review of Resident #2's quarterly MDS, dated [DATE], indicated that Resident #2 was moderately cognitively impaired with clear speech and the ability to make himself understood and to understand others. The MDS indicated Resident #2 had no behaviors and required the extensive assistance of one staff for bed mobility and transfers, had no impairment with his upper and lower extremities, and used a wheelchair as a mobility device. A review of Resident #2's Care Plan, last updated on 03/15/24, revealed Resident #2 had the tendency to exhibit sexually inappropriate behaviors related to cognitive loss and dementia (initiated on 01/11/23), and had impaired and/or declined cognitive function or impaired thought processes related to dementia. An interview was conducted with Resident #3 on 05/23/24 at 8:15 a.m. Resident #3 was assessed as severely cognitively impaired on 02/27/24. Resident #3 asked if this interview was about the incident involving her roommate (Resident #1) and Resident #2 that had occurred a few nights ago or the one a while back. When asked to explain, she said one weekend not too long ago (referring to the 05/11/24 incident), she said she had left her room and when she returned, she saw Resident #2 trying to get in the bed with Resident #1. She said she immediately left the room to find the nurse (Nurse # 1) and report him to her. Resident #3 said the nurse came to the room and threatened to call the law if he would not leave the room. Resident #3 said Resident #2 was always in her & Resident #1's room, day or night, because Resident #1 always wanted him to bring her a soda. She said as far as she knew, the two of them never had a sexual relationship but they did have a friendship and he spent a lot of time in their room bringing her sodas and talking to her. A review of Resident #2's Progress Notes revealed he had been discovered by Nurse #1 on 05/11/24 entering a female resident's room and attempting to get in the bed with her. An interview was conducted with Nurse #1 on 05/22/24 at 1:15 p.m. Nurse #1 indicated on Saturday, 05/11/24, around 1:00 p.m. - 2:00 p.m., Resident #3 was observed standing in the doorway to her and Resident #1's room and called for the nurse. Nurse #1 stated she went to the room and observed Resident #2 attempting to get into Resident #1's bed. Nurse #1 stated she had never known Resident #2 to display any inappropriate sexual behaviors with Resident #1 or any other resident. She explained that Resident #1 and Resident #2 have always had a friendship and he often brought her sodas; however, on that day, she observed Resident #2 to have placed his wheelchair beside Resident #1's bed and had one of his knees on the side of her bed as if he was trying to climb into the bed with her. Nurse #1 stated Resident #1 told her, he's not doing anything and that Resident #2 did not say anything. Nurse #1 stated she then removed Resident #2 from the room, returned him to his room, and put him into his bed. Nurse #1 explained she called the Director of Nursing (DON) to get the telephone number of the new Assistant Director of Nursing (ADON) who was their on-call admin that day. She further explained she informed the DON of the incident who instructed her to call the ADON. She did so and was told by the ADON to document the incident and because she had already removed Resident #2 from Resident #1's room, there had been no further instructions. An interview was conducted with the ADON on 05/22/24 at 1:50 p.m. The ADON explained she had received a phone call from Nurse #1 on 05/11/24 about Resident #2 attempting to get in bed with Resident #1. The ADON further explained, stating that because Nurse #1 had already removed Resident #2 from Resident #1's room and had placed him in his bed, she said she instructed the nurse to continue to monitor. The ADON stated she failed herself in that she had not asked the nurse if Resident #1 was in her bed at the time Resident #2 was attempting to get in the bed as she assumed he was just trying to get into the bed. When asked if this incident had been discussed with the Interdisciplinary Team during their Monday morning meeting, she indicated it may have been since it had been a change in Resident #2's condition, however she did not have any notes from that particular meeting. Review of the facility's Initial Allegation Report, completed by Nurse #3 on 05/15/24, revealed an allegation of resident abuse on 05/15/24. The facility became aware of this allegation on 05/15/24 at 4:30 a.m. The allegation stated that a male resident (Resident #2) was found in a female resident's (Resident #1) room and that the male resident was noted to be performing oral sex on the female resident. The report indicated the facility reported the incident to law enforcement on 05/15/24 and to the State agency on 05/15/24. The witness statement from NA #1 was reviewed. It read, .Patient [Resident #2] was addressed several times from getting in and out of bed. Patient was then placed up front to desk. Patient stated he was ready to go to bed. Patient was placed in bed. Patient was watched for 20 minutes and I started my rounds. I heard bell ringing and step into hall. I went to answer call light and saw [Resident #2] with his face between [Resident #1's] legs with her diaper off. Nurse was notified ASAP [as soon as possible]. Nurse responded ASAP. [Resident #1] stated that nothing happened. I saw [Resident #2] with his mouth on [Resident #1's] private part. An interview was conducted with NA #1 on 05/21/24 at 12:13 p.m. NA#1 confirmed she worked the 11:00 p.m. to 7:00 a.m. shift that began on 05/14/24 and ended on 05/15/24 and had been assigned to care for both Resident #1 and Resident #2 during her shift. NA #1 explained Resident #1 was alert and able to make her needs known and required the extensive assistance of staff to being fully dependent on staff for her care needs. She explained that Resident #1 frequently removed her adult diaper and hospital gown so to find her in a stage of undress was not unusual for her. NA #1 explained Resident #2 had never displayed inappropriate sexual behaviors and admitted that he was known for frequent masturbation, however that act was always performed when he was in his own room. She stated that she had never known Resident #2 to make inappropriate sexual remarks or display inappropriate sexual behaviors towards other residents or staff. NA #1 stated that the rooms of each resident, on the morning of the incident, were located on opposite sides of the same hall however not quite directly across from each other. NA #1 explained that Resident #2 had been up and down all night and had required frequent redirection that night, which had been unusual for him as he typically stayed in his bed, in his room, at night. NA #1 stated she was not sure what had been going on with Resident #2 that particular night, but because he had been restless, she had given him a shower and placed him at the nurses' station in his wheelchair. She explained that he sat at the nurses' station for a couple of hours while she continued to make rounds on her other residents. She stated she had noticed Medication Aide (MA) #1 had taken him back to his room because he had wanted to lie down and stated she continued making rounds. Around 3:30 a.m. - 4:00 a.m. (05/15/24), she noticed the call light for Resident #1's room had come on and she went to the room to respond to it. Upon arriving to the room, the door to the room was shut and she had not been able to open it fully as Resident #2's wheelchair was blocking the door from opening all the way. NA #1 explained she was able to push open the door enough so as to allow her head into the room and stated when she looked in, she noticed Resident #2's wheelchair was positioned near the foot of Resident #1's bed (with the wheelchair facing the head of Resident #1's bed), between the wall and the left side of Resident #1's bed however it blocked the door to the room fully opening. She stated she observed Resident #2's right foot on the floor and his left leg and upper torso was in the bed with Resident #1, with his face between Resident #1's legs and his mouth on Resident #1's vagina. She noted that he was dressed in a t-shirt and pajama bottoms while Resident #1 was observed in a hospital gown which had been pulled off one of her shoulders and the bed covers were pulled up to her chest but pulled away from the lower half of Resident #1's body leaving her exposed from the waist down. She stated Resident #1's adult diaper had been taken off and was noticed on the floor beside the bed. NA #1 indicated Resident #1's breasts were not exposed. NA #1 explained she and Resident #1 made eye contact but Resident #1 did not say anything at that time. She stated Resident #2 seemed unaware he was being observed. NA #1 stated she asked them, what are y'all doing? at which time Resident #2 became aware of her presence and looked at her but did not say anything. NA #1 stated she then took a step back, away from the doorway but still in sight of the residents, and immediately called for Nurse #4 who had been standing in an area by the front of the nurses' station. NA #1 stated Nurse #4 immediately came to the room. NA #1 heard Resident #1 tell the nurse that nothing happened. The witness statement from Nurse #4 was reviewed. It read, [Resident #2] has made multiple attempts entering [Resident #2's] room. He was put to bed multiple times with himself transferring back the bed and attempting to enter her room again. He sat with us at the nurses' station for a while until he stated he was ready to lay down. After 20 minutes of no signs trying to get up again, me and the CNA [certified nursing assistant] [NA #1] was doing her rounds. She went into [Resident #2's] room to do care and found [Resident #1] with his head between her legs performing oral sex. She immediately informed me and resident [Resident #2] was removed from room. Unit Manager was called. DON [director of nursing] was called. Administrator was called with no answers. I then called [name of an Administrator from a sister facility who was assisting the facility while the facility's Administrator was out on leave] for further instructions. He directed me to call both resident's families and ask if they feel they are capable of making decisions. Placed [Resident #2] on 1:1 supervision, perform skin check on female resident. I got in contact with [Resident #2's] RP [responsible party], left a voicemail for [Resident #1's] RP to call the facility back at her earliest convenience. Got statements from all involved. Female stated nothing happened, male could not give coherent statement. An interview was conducted with Nurse #4 on 05/21/24 at 3:47 p.m. Nurse #4 confirmed she worked on 05/14/24 from 7:00 p.m. until 7:00 a.m. (05/15/24) and had been assigned to care for Resident #1 and Resident #2. She explained she had noticed Resident #2 was awake, in his wheelchair, and that he kept trying to enter Resident #1's room and that he had to be frequently redirected. She said this was abnormal behavior for him; around 12:30 a.m. - 1:00 a.m. (05/15/24), he had been brought to the nurses' station where he stayed for approximately an hour. She stated around 3:30 a.m., the resident started nodding off, so he was brought to his room, assisted back into his bed and that once he started to fall asleep, she left. The nurse said around 15 minutes later, NA #1 informed her that Resident #2 was in Resident #1's bed and stated she immediately went to the room but once there, she could not fully open the door as his wheelchair was blocking it from inside the room. Since he was already back in his wheelchair, she pushed open the door wide enough for her to shimmy her way in there and immediately removed him from the room. Because of what NA #1 had told her, she returned to Resident #1's room and performed a skin assessment which included her perineal area (the area between the anus and vulva in females) which did not reveal any signs of trauma. After that, Nurse #4 stated she began making phone calls to the administrative staff which included the Administrator, the DON and the Unit Manager. When she did not get an answer, Nurse #4 called the Administrator from a sister facility (who had been assisting their facility during the absence of the facility's Administrator) who instructed her on what the next steps would be to begin an investigation of the incident. She stated she called the Responsible Party (RP) for Resident #2 and spoke with her. She stated she then called the guardian of Resident #1 (as she is a ward of the State) and left a message for her to return the call. Nurse #4 stated the guardian returned her call while and explained that Resident #1 was not able to give consent for a sexual act. Nurse #4 stated after that, the Unit Manager (Nurse #2) had arrived and had been the one to call local law enforcement who came to the facility and interviewed the staff. Nurse #4 stated she provided the police officer a copy of the statements she had taken from Resident #1 and Resident #2. Nurse #4 stated Medication Aide (MA) #1 witnessed her conversations with the Resident #2's RP and with Resident #1's guardian. An interview was conducted with MA #1 on 05/22/24 at 8:49 a.m. MA #1 confirmed she worked on 05/14/24 from 7:00 p.m. until 7:00 a.m. She stated she had worked at the facility for as long as both residents had resided there and had never known Resident #2 to display any inappropriate sexual behaviors before. She also said it was the first time that she could recall seeing Resident #2 up in the middle of the night. MA #1 explained she had been charting at the desk at the nurses' station when she observed Resident #2 going into Resident #1's room, estimating the time to be before 4:00 a.m. but was unsure of the exact time. MA #1 further explained she took Resident #2 out of Resident #1's room and brought him to the nurses' station where he sat for approximately 15-20 minutes and then he was brought to his room. She stated after another 15-20 minutes or so, the call light for Resident #1's room came on, explaining it had been Resident #1's roommate (Resident #3) who had pressed the call light. MA #1 said she saw NA #1 go to the room to respond to the light and then heard NA #1 yell for Nurse #4 to go to the room. MA #1 said when NA #1 returned to the nurses' station, she described to her what she had witnessed in the room - that Resident #2 was in bed with Resident #1 and had his head between her legs. MA #1 clarified that she had not written a statement about the incident as she did not witness anything herself, however, she did witness the statements Nurse #4 had taken from the two resident's responsible parties. An interview was conducted with Resident #3 on 05/23/24 at 8:15 a.m. Resident #3 said the other night (referring to the 05/15/24 incident), Resident #2 probably would not have come into the room if Resident #1 had not invited him in. She said she was awake and although the curtain between the two beds was pulled and she could not see anything, she could hear the two of them whispering back and forth. Resident #3 said she could not really hear what they were whispering about, but she was adamant that Resident #1 never hollered out while Resident #2 was in the room. She said she pushed the call light button so someone would come and get him out of her room at that time of morning. An interview was conducted with Resident #1 on 05/21/24 at 11:10 a.m. She was observed sitting up in her bed and wearing a hospital gown. After introductions, Resident #1 asked, is this about [Resident #2]? and then, before any further conversation, Resident #1 said, I told him not to ever come back in here because he tried to come get in the bed with me. I had to hit him on the side of his head, and I stopped him from trying to get in bed with me. When asked if she had invited Resident #2 into her bed, she stated she had not and remarked that he had tried to go up under the covers and touch her leg and repeated what she had said moments before. Resident #1 then became focused on various body aches and pains and wanted to see her nurse and did not want to discuss the incident any further, therefore, the interview was stopped at this time. A second interview with Resident #1 was conducted on 05/21/24 at 1:42 p.m. during which she was more receptive to questions and conversation about the incident of 05/15/24. Resident #1 was adamant that Resident #2 did not sexually assault her and stated that he did try to touch her leg under her bed covers and wanted to talk with her however, she could not understand what he was saying and she had told him to get out of her room and to never come back. Resident #1 stated Resident #2 did not touch her vagina with his hands, mouth or tongue. She stated he would bring her red sodas and admitted he was not her friend nor was she afraid of him. Resident #1 acknowledged the fact that she prefers to wear hospital gowns and stated she frequently removes them because they are aggravating. She also said she has to wear an adult diaper however, the tabs come undone which is also aggravating, so she will take it off frequently. Resident #1 remarked that she did not want Resident #2 to get in trouble for trying to touch her and said, what's done is done. An interview with Resident #2 was conducted on 05/21/24 at 1:59 p.m. He was observed sitting in his wheelchair assisting the Activities Director who had been assigned to stay with him during his 1 on 1 observation that day. Resident #2 admitted that he and Resident #1 were friends and that he would occasionally buy her a red soda and bring it to her in her room. When asked, Resident #2 stated he did recall the 05/15/24 incident. He explained when he was in Resident #1's room, she encouraged him to perform oral sex on her when she pulled the covers back and had her legs open. Resident #2 stated he did not have intercourse with her and said that she was so nice that he had wanted to treat her like a girlfriend. He also stated that Resident #1 did not tell him to stop or get out of the room and that she did not hit him. He stated after the incident, he was moved to another room on the other side of the facility and that Resident #1 had been moved to another facility. An interview was conducted with the Unit Manager (Nurse #2) on 05/22/24 at 9:11 a.m. She confirmed that she worked on 05/15/24 from 7:00 a.m. until 6:00 p.m. Nurse #2 stated she had been made aware of an incident involving Resident #1 and Resident #2 when Nurse #4 called her at home, prior to her arrival to the facility. She indicated that she had spoken with the Administrator from their sister facility who had given her instructions related to the investigation of this incident. She explained she had called the police around 7:00 a.m. and that they had come to the facility right away and interviewed staff, but she does not think they spoke with either resident. Nurse #2 further explained she had moved Resident #2 across the building to another room on 05/15/24 and that Resident #1 was moved to a private room close to the nurses' station on 05/16/24. Nurse #2 stated she had never known Resident #2 to exhibit any inappropriate sexual behaviors, but that he often bought sodas for Resident #1 as well as other residents. She stated she had never known Resident #1 to have inappropriate sexual behaviors but did recall a time in the past where she appeared to have a fond relationship with a male resident (who no longer resided in the facility). Nurse #2 explained Resident #1 did like to undress and would frequently remove her hospital gown and adult diaper. She said she talked with Resident #1 on the day of the incident and denied anything of a sexual nature had taken place with Resident #2; she said Resident #1 told her that she told him to get out of her room after he tried to get into her bed that morning. When asked about the difference in Resident #1's Brief Interview for Mental Status (BIMS) assessment scores, Nurse #2 stated she had been completing the Brief Interview for Mental Status (BIMS) assessments since the facility did not have a social worker on staff until recently. She confirmed she completed the 03/28/24 assessment on Resident #1 (which resulted in a score of 13) but had not done the January 2024 assessment (which had a score of 3). Nurse #2 explained that because of the discrepancy between the two assessment scores in such a relatively short period of time (as well as Resident #1's other varied BIMS scores), she had repeated the March assessment with a second nurse present and the score remained 13; she said she completed another BIMS assessment on Resident #1 on 05/15/24 and her score was 12. A recreation of the room Resident #1 resided in on 05/15/24 was conducted on 05/23/24 at 8:00 a.m. with NA #1 who witnessed the incident of 05/15/24. Resident #1 had resided with Resident #3 in a semi-private room. Resident #1's bed had been the A bed, which was the bed closest to the door. The A bed remained empty, and the facility had placed a mannequin in the bed so administration could re-create the scene from the incident the evening prior to this observation. At the time of this observation, the mannequin was still in place and according to NA #1, the room was set up just as it had been the morning of the incident. The door to the room was closed; the bed divider curtain was pulled between bed A and bed B, a 4-drawer dresser was observed in the space between the wall and the left side of Resident #1's bed, and a wheelchair representing Resident #2's wheelchair had been placed at the foot of the bed, facing the head of the bed as it had been during the discovery of the incident. NA #1 demonstrated how she had only been able to lean into the room after pushing the door open approximately 12 inches (as measured by NA #2 with a tape measure as he was present during this room observation). The bed was in a low position, approximately 18 inches from the floor. The mannequin had been placed in the bed to represent Resident #1 and it was lying on its back with its legs spread open at the hips and bent at the knees. NA #1 described how she had observed the positions of both Resident #1 and Resident #2 and stated the light over the head of the bed illuminated the area well enough for her to visualize Resident #1's vagina and clearly see Resident #2 performing oral sex on Resident #1. Based on the surveyor's observation made during this reenactment, it was verified NA #1 would have been able to visualize the position and actions of the residents (Residents #1 and #2) as she described. An interview was conducted with Resident #1's legal guardian on 05/22/24 at 10:39 a.m. The guardian explained she is Resident #1's Guardian Representative while the Director of the [name of] County Department of Social Services is the resident's guardian. The Guardian Representative explained she was informed of the 05/15/24 incident involving Resident #1 and Resident #2 on 05/15/24 and stated it was procedure for her to go to the facility and talk with Resident #1 after an allegation such as this. She spoke with Resident #1 at 1:22 p.m. on 05/15/24 and during her conversation with her, Resident #1 was adamant nothing happened, and that the resident told her that a man tried to get on the bed with her, that she slapped him on the side of his head and told him to get out. During her interview with Resident #1, she stated that she discussed consent with her and asked her what it meant to give consent. The Guardian Representative stated Resident #1 was able to give an accurate definition of consent. The Guardian Representative explained the resident told her she and Resident #2 were not in a relationship, however, they were friends and that he often brought her sodas and they would talk. She said the resident also told her that she and Resident #2 had never talked about sexual activity before and that he had never tried to get into her bed before. The Guardian Representative stated after a bit of talking with Resident #1 that the resident told her she was tired of talking about it and began to pretend cry and repeated I told you, nothing happened. The Guardian Representative explained when she had talked with Nurse #4 earlier that day, she had informed the nurse that Resident #1 was not able to give consent; however, after interviewing Resident #1 herself, she felt that the resident was indeed able to give consent for a sexual act if she wanted that type of relationship. She explained in the past, Resident #1 had been deemed an incompetent adult by the Clerk of Court and said that she informed Nurse #4 of this during their phone conversation. However, after talking with Resident #1, she had been able to name all of her body parts, she knew what sexual activity was, and she knew what consent meant. The Guardian Representative stated that she believed a sexual act between Resident #1 and Resident #2 did occur and stated she felt that Resident #1 denied it because she was embarrassed and scared she might get in trouble. A review of Resident #2's Nurse Practitioner (NP) progress note, dated 05/15/24, revealed he had been seen for inappropriate sexual behavior towards a female resident. The note indicated that Resident #2 was witnessed by staff members in a female resident's room at his own will. Staff witnessed this resident giving oral sex to a female resident .this resident was immediately removed from the female resident's room and a sitter was in place. During my assessment, [Resident #2] verbalized to me that he thought he and the female resident were in a relationship. He stated that he assumed this was his girlfriend because he takes her [soda] almost every day. He admitted that he rolled himself into her room. He stated, 'I put my mouth in her private area.' I asked [Resident #2] if she was in agreement. He said, 'Yes.' He said that was when staff caught him in her room .I educated [Resident #2] that this type of behavior cannot occur in this environment. He was educated on the reason why a sitter was in place and why staff changed his room. He did understand . Diagnosis, Assessment and Plan: Inappropriate behavior - sexual inappropriate behavior, including touching, towards a female resident; one-to-one staff at bedside; new room on a different wing . Dementia with behavior problem - .[name of psych nurse practitioner] made aware .; I did report to unit coordinator that resident was able to recall and admit being in a female resident's room. An interview was conducted with the Nurse Practitioner (NP) on 05/22/24 at 10:08 a.m. The NP stated she assessed both Resident #1 and Resident #2 on 05/15/24. She explained she did a head-to-toe assessment on Resident #1 (which included her external genitalia) and there were no signs of trauma. During her examination, she asked Resident #1 questions about the incident, trying to keep the conversation casual. She stated the resident was able to tell her that a bald-headed man in a wheelchair came into her room; she then asked the resident if she had invited him into her room and the resident said no, that he had come in on his own. The NP said she then asked her if the man had touched her and she said no, that he did not touch her or do anything to her. The NP said Resident #1 began to get anxious and she stopped the conversation. The NP clarified that she did not feel Resident #1 was able to consent to a sexual act due to her history with cerebrovascular accident (stroke), dementia, anxiety, depression and a scattered thought process. During her assessment with Resident #2, the NP explained she asked him open-ended questions. The NP stated Resident #2 recalled the police coming to the facility and that he had self-propelled himself into Resident #1's room (who he thought was his girlfriend) and said he put his mouth on her private area. The NP stated she asked Resident #2 if Resident #1 had been in agreement with what he did and said he said yes. The NP stated she explained to Resident #2 that type of behavior was not allowed and explained to him why he had been moved to another room across the building and also that he would have to have a sitter. The NP stated Resident #2 appeared to understand his actions and their consequences and had even asked if Resident #1 was in her right mind. She stated she asked him if Resident #1 had invited him into her room and he told her that he went in on his own. The NP stated Resident #2 is cognitively impaired and is alert and oriented to name and situation but has poor judgment. After completing assessments on both residents, the NP stated she referred both of them to the psychiatric nurse practitioner. A review of Resident #2's psychiatric follow-up evaluation, conducted on 05/15/24 by a behavioral health nurse practitioner (NP), revealed he had been seen per staff request [TRUNCATED]

Based on observations, record review and physician, resident, and staff interviews, the facility failed to provide care safely to a dependent resident when a resident (Resident #1) fell out of bed during care on 05/29/23 resulting in a fall with fracture to the right leg and an abrasion to his right knee with bleeding. Resident #1 was hospitalized and no surgical treatment was provided to treat the fracture due to paralysis of his right leg. After the 05/29/23 fall, the facility implemented a corrective action plan that included an intervention to follow the care plan for two staff assistance with bed mobility and to turn the resident toward the care giver during care instead of away from them to prevent from any further falls out of bed. The facility failed to consistently implement this corrective action plan and on 06/23/23, Resident #1 sustained another fall with no injury when care was provided by one staff and that staff member did not turn and reposition Resident #1 toward them while providing care for 1 of 3 residents reviewed for accidents. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include, in part, anemia, aphasia, stroke with weakness, osteopenia, paraplegia and neurogenic bladder with urinary catheter. A care plan updated on 12/15/22 revealed a plan of care for at risk for falls related to immobility, fall without injury, and stroke with right sided hemiparesis. Interventions included to utilize low bed, provide verbal cures for safety and energy conservation techniques, place call light within reach at all times and all personal items within reach. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and demonstrated no behaviors. Resident #1 required two person assistance with extensive assistance with bed mobility, dressing, toileting , personal hygiene, and bathing and he had impairment to both sides to upper and lower extremities. Resident had an indwelling urinary catheter and was incontinent of bowel. Resident #1 had no falls during this look back period assessment and was not receiving anti coagulants (medication to thin blood). Review of an incident report completed by Nurse #1 for a fall on 05/29/23 revealed nurse aide (Nurse Aide #1) was in with Resident #1 giving activity of daily living (ADL) care. The nurse aide rolled the resident to the left side and resident missed the side of the bed to maintain his balance and fell off the left side of the bed. A head to toe assessment was completed per hall nurse (Nurse #1). Resident complained of right knee pain, with swelling noted to same, small laceration noted to the right lateral knee. Small skin tear to left big toe. Resident stated his pain was 1 (barely noticeable, very mild) out of 10 (worst pain possible) on the pain scale. Resident was assisted back to bed and a dressing placed to right knee per wound protocol. The on call provider was contacted and orders were obtained to transfer resident to the emergency department. An interview was conducted with Nurse Aide (NA) #1 on 07/20/23 at 2:00 PM. NA #1 stated she worked with Resident #1 often as she was most often assigned to his hall. NA #1 stated on 05/29/23, she was giving Resident #1 his bath, and told him to hold on to the dresser on the side of his bed when she turned him on to his left side and his hand slipped off the dresser and he fell on the floor. NA #1 stated she could not stop him from falling. NA #1 stated Nurse #1 arrived at the room and assessed him and at the time he was not complaining of pain. NA #1 stated she and three other staff members (the nurse, another aide, and the physical therapist) assisted him back to bed using the mechanical lift. She stated after about 15 minutes, Resident #1 reported to her that his leg hurt and Nurse #1 assessed him again and he was sent to the hospital. NA #1 stated after 05/29/23, Resident #1 required two people to do his care and she was educated to make sure two staff were doing his care at all times. She stated she had always done Resident #1's care by herself up until 05/29/23 and he had never fallen. NA #1 added that he had the ability to hold on to the side table when he was turned on his side. An interview was conducted with Nurse #1 on 07/19/23 at 4:36 PM. Nurse #1 reported Resident #1 required two staff to do his bathing and incontinence care because of his paraplegia, contractures, and the way he would sometimes have jerky movements after the 05/29/23 fall. She stated nursing aide staff had been providing care to Resident #1 by themselves before the 05/29/23 fall, but since he had a recent fall, it was required that he should have two staff assisting him with ADLs. She stated on 05/29/23, when NA #1 was rolling Resident #1 away from her to clean him, he had kept rolling and fell off the bed. Nurse #1 reported staff notified her that Resident #1 fell out of the bed and when she went to assess Resident #1, he told her to get him off the floor. She stated we used a mechanical lift with assist of four staff (NA #1, another nurse aide, and a Physical Therapist) to get him back to bed. Nurse #1 reported he had no complaints of pain at that moment, but he did have an abrasion to his right knee that was bleeding. She stated after they transferred him back to bed he complained of pain of a 1 out of 10 on the pain scale. She stated his knee was still bleeding and she had to put another dressing on it. She stated, it was not a very large abrasion. A review of the hospital records dated 05/29/23 revealed [Resident #1] presented to the emergency department via emergency medical service from the facility after slipping out of bed during a sponge bath. An x-ray of the right knee indicated a comminuted (a bone broken in at least two places) fracture of the right femur. The hospital record indicated the resident would be admitted under inpatient status due to requiring admission for complicated urinary tract infection and was at risk for decompensation given the age and comorbidities. A review of the fall investigation completed by the Director of Nursing (DON) dated 05/29/23 revealed the root cause of Resident #1's 05/29/23 fall was determined that Resident #1 required two staff assistance with bed mobility. Staff education was provided on 05/29/23 on use of two person assistance with larger residents with poor bed mobility and trunk control and when turning and repositioning [Resident #1] to be sure staff turned the resident toward the caregiver during ADL care. A care plan updated on 05/29/23 included at risk of falls related to fall with injury with a goal that resident would have no falls with injury for 90 days. The new interventions included, in part, staff education provided for turning and repositioning of Resident #1 related to fall 05/29/23 and staff to utilize two person assist with bed mobility. The plan of care included Resident #1 required assistance and was dependent for mobility related to right femur fracture and would be able to be safely moved from side to side in the bed with staff assistance. An orthopedic consult dated 05/30/23 during Resident #1's hospitalization recommended a knee immobilizer with no surgical intervention at this time due to immobility and bedbound. The orthopedic assessment and plan stated, in part, there was question of the chronicity of the fracture, but the patient denied any other falls or injuries in the last 6 months. The resident's hemoglobin (red blood cells that carry oxygen to the tissues) was noted to be 9.9 (range is 13.2 to 16.6 grams for men) in the emergency department on 05/29/23 and had decreased during his hospital stay to 5.3 on 05/31/23 and he required 4 units of pack red blood cells. The hospital records indicated acute blood loss anemia from trauma. Resident #1 was discharged from the hospital on 06/05/23 with a goal to have hemoglobin at 8. The record indicated the iron panel was consistent with anemia of chronic disease. A review of in-services dated 05/29/23 was conducted regarding accidents/incidents and fall management. The in services included to identify risk for falls and minimize the risk of recurrent falls, to ensure the resident centered care plan was reviewed and resident centered interventions were being implemented according to individual risk factors in the residents' plan of care. Education was provided by the Director of Nursing (DON) to all nursing staff and included NA #1 who turned (Resident #1) away from herself while providing the resident with care. Education included that all nursing staff would care for residents as guided by the care plan, staff were educated on turning and repositioning and demonstrated competency by the DON, and nursing staff would not care for residents alone that required assistance of two staff members. An interview was conducted with the Director of Nursing (DON) on 07/20/23 at 2:17 PM. The DON reported after the first fall on 05/29/23 the training and education and audits were done on all nursing staff by the DON to be sure to follow the care plan to have two staff assisting with bathing and incontinence care, and bed mobility for dependent residents requiring two assist. Additionally, the intervention to turn the resident toward the staff while doing care was implemented. The DON stated the plan of correction that was put in place after the 05/29/23 fall was ineffective because many staff were not savvy in navigating the computer system to read the care plan and further education was required. Resident #1 was readmitted to the facility on [DATE] after a discharge to the hospital on 05/29/23 with diagnoses of right femur fracture, urinary tract infection, and acute blood loss from trauma. The MDS admitting assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired and demonstrated no behaviors and required total dependence with 2 staff physical assistance with bed mobility, dressing, personal hygiene, bathing, and toileting. Resident had an indwelling urinary catheter and was incontinent of bowel and was coded as having a fall with fracture. A review of an incident report completed by Nurse #2 dated 06/23/23 revealed Nurse Aide (NA #2) informed this writer (Nurse #2) that resident fell on the floor. Resident was having peri-care performed and resident started to scratch himself on his back, he propelled forward while scratching himself on his back and fell on the floor. When this writer (Nurse #2) entered the room, the resident was on the floor face down. Resident did not hit his head per NA (NA #2). Resident was asked if he hit his head and resident denied hitting his head. Resident denied any injuries, pain, or discomfort. Resident informed this writer (Nurse #2) he wanted to go to the hospital. Resident initially reported he would like to be transferred to the hospital and later declined. On call provider was notified and left a message that resident wanted to go to the emergency room (ER), but now he was refusing to go to the ER. Resident was asked again and he refused to go the ER. Responsible Party called and informed of all the above information. Resident continued to deny pain, deny injuries, and deny discomfort. A phone interview was conducted with NA #2 on 07/19/23 at 9:26 PM. NA #2 reported she received education on 05/29/23 regarding how many people were required when doing ADL care on dependent residents who required two assist. She stated she was aware Resident #1 required two staff assistance with bed mobility including bathing and incontinence care. She stated she received education on 05/29/23 on turning and repositioning and to be sure staff were turning the resident toward themselves during care to prevent him from rolling off the bed. She stated on 06/23/23, she went in to change Resident #1 and as she was changing him, she turned him away from her and he began to scratch himself on his back and he lifted up his hip and rolled off the bed. She stated she was the only one in the room providing care and she should have asked the nurse to help her, but she was doing her medication pass and she did not want to bother her. NA #2 stated if she had turned the resident toward her she could have prevented the fall. NA #2 stated Resident #1's care could be done with one person safely if the staff member turned the resident toward them instead of away from them. NA #2 could not say why she turned him away from her instead of toward her. A phone interview was conducted with Nurse #2 on 07/20/23 at 6:00 AM. Nurse #2 reported on 06/23/23, NA #2 informed her Resident #1 had a fall. She stated she went to assess him. He was lying on the floor. He had no complaints of pain and no injuries and was assisted off the floor with 4 staff using the mechanical lift back to bed. She stated she asked him to go to the hospital, but he refused. She stated she called the provider and responsible party and notified them of the fall with no injury and that he was refusing to go to the hospital. Nurse #2 stated the nursing staff received education on 05/29/23 regarding making sure to use the appropriate number of staff required whenever doing ADL care for dependent residents. She stated Resident #1 required two staff with his bathing and incontinence care per the education that was provided on 05/29/23. She stated NA #2 did not ask her to assist with Resident #1 and if she had, she would have helped. An observation of Resident #1 on 07/19/23 at 12:17 PM revealed an alert and oriented Resident lying in his bed. The bed was noted to be an oversized bed with no side rails. He had an end table on either side of the bed and it was in low position. He had contractures to his upper extremities but was able to move his arms. Resident #1 had an immobilizer on his right leg. An interview with Resident #1 on 07/19/23 at 12:17 PM revealed he had no complaints of pain. He reported he had a bed bath this morning with Nurse Aide #3 and she completed his bed bath by herself. He reported that more often than not, his care was done by one aide and not two. Resident #1 stated he felt safe with one staff member providing his care. Resident #1 reported on 06/23/23, the nurse aide turned him to side and he rolled off the bed, but he did not have any injury. He reported he was scratching his back and not holding on to the table. An interview with Nurse Aide #3 on 07/19/23 at 2:30 PM revealed she was assigned to Resident #1 on 07/19/23. NA #3 stated she was assigned to Resident #1 often and usually provided care to Resident #1 alone. She reported she bathed him and changed him. She stated when she turned him she made sure there was enough room on the bed so he would not roll over and made sure he was not too close to the edge. She stated she kept a hand on him while doing care and he was facing her while she washed his back. She stated she was made aware of the new interventions to ask for assistance with turning and reposition, but she bathed Resident #1 alone and provided incontinence care on him alone and she should have gotten help. She added, she was able to do his bath alone as she had done in the past, so she did it alone. NA #3 stated as long as Resident #1 was facing her during the care and he was, she would have been able to stop him from falling. A phone interview was conducted with the facility Physician on 07/20/23 at 1:45 PM. The Physician recalled the hospital record for Resident #1 and stated sometime during his hospital stay from 5/29/23 through 6/5/23, his hemoglobin dropped from 9.9 in the emergency department on 05/29/23 to 5.3 and he required a blood transfusion. The Physician stated he could not say with 100% certainty that the blood loss was a result of the fall. The Physician added he had never seen a resident who was not receiving anti coagulants (blood thinning medication) require 4 units blood as a result of a fall with fracture but confirmed the hospital record indicated it was a blood loss from trauma. An interview was conducted with the Director of Nursing (DON) on 07/20/23 at 2:17 PM. The DON stated after the fall on 06/23/23 additional training and coaching was reiterated with Nurse Aid #2. The DON stated after the 06/23/23 fall for Resident #1, he created a paper list on 06/23/23 of all the residents who required two staff assistance and posted it in the nutrition rooms, the employee lounge, at the time clock, the nursing station assignment books, and provided a list to the all the nurses to attach to their clipboards that they used during their shift. An observation of the paper lists was conducted with the DON on 07/20/233 at 2:30 PM and confirmed the paper list was in each location with Resident #1's name on the list. The DON reported Nurse Aide #3 should have followed the care plan and used two staff to assist with bathing Resident #1 on 07/19/23. The DON added, more education and audits would need to be done to make sure the staff understand and follow the expectation to prevent falls.

Based on observations, record review and interviews with the physician, resident, and staff, the Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and effective monitoring of interventions to ensure residents were provided with the necessary supervision to prevent accidents (F689). This deficiency was cited on the recertification and complaint survey of 07/06/21, the revisit and complaint survey of 06/29/23, and the current revisit and complaint survey of 07/20/23. The continued failure during 3 federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. During the current survey of 07/20/23 it was determined Resident #1 was not provided with the necessary supervision to prevent accidents as evidenced by 2 falls out of bed during care with one of the falls resulting in a fracture to the right leg and an abrasion to his right knee. Findings included: This tag is cross referenced to: F689: Based on observations, record review and physician, resident, and staff interviews, the facility failed to provide care safely to a dependent resident when a resident (Resident #1) fell out of bed during care on 05/29/23 resulting in a fall with fracture to the right leg and an abrasion to his right knee with bleeding. Resident #1 was hospitalized and no surgical treatment was provided to treat the fracture due to paralysis of his right leg. After the 05/29/23 fall, the facility implemented a corrective action plan that included an intervention to follow the care plan for two staff assistance with bed mobility and to turn the resident toward the care giver during care instead of away from them to prevent from any further falls out of bed. The facility failed to consistently implement this corrective action plan and on 06/23/23, Resident #1 sustained another fall with no injury when care was provided by 1 staff and that staff member did not turn and reposition Resident #1 toward them while providing care for 1 of 3 residents reviewed for accidents. During the recertification and complaint survey of 07/06/21, the facility failed to provide safety interventions as ordered. During the revisit and complaint investigation survey of 06/29/23, the facility failed to follow a physician order for fall mats at both sides of the bed for a resident with a history of falls. An interview with the Administrator on 07/20/23 at 2:20 PM revealed the Quality Assurance and Performance Improvement (QAPI) plan for providing supervision to prevent accidents was ineffective and more education, audits and monitoring would need to be conducted.

Based on record review and staff interview, the facility failed to follow a physician order for fall mats at both sides of the bed for a resident with a history of falls for 1 of 1 resident (Resident #3) sampled for supervision to prevent accidents. The findings included: Resident #3 was admitted to the facility on [DATE]. His diagnoses included: dementia and unsteady gait. A review of Resident #3's physician order dated 11/14/22 revealed to place a fall mat to both sides of bed and to check for placement every shift. This order was placed on the Treatment Administration Record (TAR). Resident #3's active care plan, dated 06/16/23, included a focus area for risk for falls due to cognitive loss, lack of safety awareness and impaired mobility. The interventions included fall mats to both sides of the bed that was initiated on 11/14/22. A review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had moderately impaired cognition and required limited to extensive assistance with Activities of Daily Living (ADLs). A wheelchair was used for mobility. Resident #3 was coded with 8 falls since the last MDS assessment dated [DATE]. Observations were made on 06/27/23 at 10:45 AM, 06/28/23 at 7:45 AM, and 06/29/23 at 8:05 AM of Resident #3 in bed without a fall mat to both sides of bed. An interview was conducted with Nursing Aide #2 on 06/29/23 at 10:02 AM. She said she was assigned to Resident #3 that day. She said she was familiar with Resident #3 and had worked with him before. She said he would try to get up by himself and that it was easy to re-direct him to keep him from falling. She said she had seen fall mats by his bed before but could not remember when they were there or what happened to them. She said the nurses would know what happened to them, because the nurses were responsible for checking on them. She said she did not see them, nor was it her responsibility to make sure they were by the resident's bed. A phone interview was conducted with Nurse #6 on 06/29/23 at 10:16 AM. She stated she was familiar with Resident #3 and that he had a fall mat on the floor next to the right side of his bed but did not have a fall mat on the left side of his bed. She said she could not remember if his fall mat order was for one or two. She said Resident #3's fall mat placement was to be checked every shift with documentation to be completed on the TAR. She indicated she worked with Resident #3 on 06/26/23, 06/27/23, and 06/28/26 during the 1st shift but was unable to explain why Resident #3 had only one fall mat, which was placed on the floor on the left side of his roommate's bed. An interview was conducted with Nurse #1 on 06/29/23 at 8:38 AM. She stated she was familiar with Resident #3 and that he had an order for his fall mat to be checked for placement every shift. She revealed that Resident #3 had two fall mats in the past. Nurse #1 stated she worked with Resident #3 on 06/29/23 during the 1st shift. She was unable to explain why a fall mat was not next to both sides of Resident #3's bed. An interview was conducted with the Director of Nursing (DON) on 06/29/23 at 8:40 AM. He stated that fall mat monitoring for placement was to be completed and documented on the TAR once on every shift. He stated that his expectation was for physician's ordered 2-fall mats to be in place and that monitoring documentation to be fully completed.

Based on observations, record review and interviews with the physician, resident, and staff, the Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and effective monitoring of interventions to ensure residents were provided with the necessary supervision to prevent accidents (F689). This deficiency was cited on the recertification and complaint survey of 07/06/21, the revisit and complaint survey of 06/29/23, and the current revisit and complaint survey of 07/20/23. The continued failure during 3 federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. During the current survey of 07/20/23 it was determined Resident #1 was not provided with the necessary supervision to prevent accidents as evidenced by 2 falls out of bed during care with one of the falls resulting in a fracture to the right leg and an abrasion to his right knee. Findings included: This tag is cross referenced to: F689: Based on observations, record review and physician, resident, and staff interviews, the facility failed to provide care safely to a dependent resident when a resident (Resident #1) fell out of bed during care on 05/29/23 resulting in a fall with fracture to the right leg and an abrasion to his right knee with bleeding. Resident #1 was hospitalized and no surgical treatment was provided to treat the fracture due to paralysis of his right leg. After the 05/29/23 fall, the facility implemented a corrective action plan that included an intervention to follow the care plan for two staff assistance with bed mobility and to turn the resident toward the care giver during care instead of away from them to prevent from any further falls out of bed. The facility failed to consistently implement this corrective action plan and on 06/23/23, Resident #1 sustained another fall with no injury when care was provided by 1 staff and that staff member did not turn and reposition Resident #1 toward them while providing care for 1 of 3 residents reviewed for accidents. During the recertification and complaint survey of 07/06/21, the facility failed to provide safety interventions as ordered. During the revisit and complaint investigation survey of 06/29/23, the facility failed to follow a physician order for fall mats at both sides of the bed for a resident with a history of falls. An interview with the Administrator on 07/20/23 at 2:20 PM revealed the Quality Assurance and Performance Improvement (QAPI) plan for providing supervision to prevent accidents was ineffective and more education, audits and monitoring would need to be conducted.

Based on observations, record review and interviews with the physician, resident, and staff, the Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and effective monitoring of interventions to ensure residents were provided with the necessary supervision to prevent accidents (F689). This deficiency was cited on the recertification and complaint survey of 07/06/21, the revisit and complaint survey of 06/29/23, and the current revisit and complaint survey of 07/20/23. The continued failure during 3 federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. During the current survey of 07/20/23 it was determined Resident #1 was not provided with the necessary supervision to prevent accidents as evidenced by 2 falls out of bed during care with one of the falls resulting in a fracture to the right leg and an abrasion to his right knee. Findings included: This tag is cross referenced to: F689: Based on observations, record review and physician, resident, and staff interviews, the facility failed to provide care safely to a dependent resident when a resident (Resident #1) fell out of bed during care on 05/29/23 resulting in a fall with fracture to the right leg and an abrasion to his right knee with bleeding. Resident #1 was hospitalized and no surgical treatment was provided to treat the fracture due to paralysis of his right leg. After the 05/29/23 fall, the facility implemented a corrective action plan that included an intervention to follow the care plan for two staff assistance with bed mobility and to turn the resident toward the care giver during care instead of away from them to prevent from any further falls out of bed. The facility failed to consistently implement this corrective action plan and on 06/23/23, Resident #1 sustained another fall with no injury when care was provided by 1 staff and that staff member did not turn and reposition Resident #1 toward them while providing care for 1 of 3 residents reviewed for accidents. During the recertification and complaint survey of 07/06/21, the facility failed to provide safety interventions as ordered. During the revisit and complaint investigation survey of 06/29/23, the facility failed to follow a physician order for fall mats at both sides of the bed for a resident with a history of falls. An interview with the Administrator on 07/20/23 at 2:20 PM revealed the Quality Assurance and Performance Improvement (QAPI) plan for providing supervision to prevent accidents was ineffective and more education, audits and monitoring would need to be conducted.

Based on record review and staff and physician interviews, the facility failed to notify the physician when Resident #1 developed an opened area the size of a nickel on his scrotum with significant amounts of pus or drainage. Resident #1 had a history of Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1 was assessed for abscesses at the emergency department of Hospital #1 and transferred to Hospital #2 for urology care. Hospital #2 operated on the scrotal abscess and debrided the Fournier's gangrene. Resident #1's post operative stay was complicated by continuing sepsis and end organ dysfunction (damage occurring in major organs fed by the circulatory system). This deficient practice occurred for 1 of 3 residents reviewed for notification of change (Resident #1). Immediate jeopardy began on [DATE] when the physician was not notified of a new open area Resident #1's scrotum. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective and the completion of staff education. Findings included: Resident #1 was admitted to the facility on [DATE]. His medical history in the facility medical record included paraplegia, presence of urogenital implants, necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. His active diagnoses included wound infection, anemia, hypertension, heart failure, neurogenic bladder, diabetes mellitus, paraplegia and multiple sclerosis. He was documented to have an indwelling catheter and colostomy. During an interview on [DATE] at 10:21 AM Nurse #4 stated she provided wound care for Resident #1 on [DATE] and noted no skin breakdown areas to his scrotum. The nurse did not indicate there was any swelling or raised areas. During an interview on [DATE] at 11:28 AM Nurse #2 stated on [DATE] during the morning around 6:00 AM she went to administer a medication injection to Resident #1's stomach and when she pulled the sheets back, she thought they were wet with urine. She noted his indwelling catheter was kinked under his thigh. She unkinked the tubing, got urine flow, and she was able to give him his medicine. She indicated she informed him the nurse aides were going to clean him up. A short time later the nurse aides (Nurse Aides #1 and #2) told her Resident #1 had an open area to his scrotum that needed to be assessed. She stated she then went down to assess him and said, I heard you have something on your scrotum I need to look at, and he responded, no. She told him she needed to see it to make sure he was okay, and he told her You can look at it but don't touch it. She stated she visualized his scrotum, and there was an open area the size of a nickel with no bleeding or drainage. Resident #1 then covered it up, so she only had a brief look at it, and she told him they needed to take care of it. He indicated they could take care of it later. Nurse #2 reported she told Resident #1 she would let the oncoming nurse know about the area as the day shift provided wound care. She stated this was around 6:00 - 6:15 AM and the next shift started at 7:00 AM. She stated she then told Nurse #1 about the area at change of shift report. She concluded since she could not examine the wound, she did not have anything to report to the physician so she did not notify the physician as the day shift would do that when they completed wound care. During an interview on [DATE] at 10:55 AM Nurse Aide (NA) #1 stated Resident #1 needed to be cleaned up on [DATE] in the early morning and he often would refuse care. Both she and Nurse Aide #2 entered Resident #1's room. She stated they thought it was urine that had leaked everywhere when they first entered and assumed something had happened to his catheter. Resident #1 had a suprapubic catheter and when they removed a towel, which was on top of his scrotum, they noted it was not urine but fluid leaking from what appeared to be an open area to his scrotum. The right side of his scrotum appeared to have ruptured open leaving black tissue and yellow drainage to the area. The area covered the right side of his scrotum and was very alarming which they indicated to the nurse. She stated they ensured his comfort and then notified Nurse #2 to assess the area. NA #1 stated about 5 minutes later Nurse #2 came to her and indicated Resident #1 had refused to let her assess the area. NA #1 then told Nurse #2 that she was very concerned about that area and that he needed to be assessed as soon as possible as it was a very pressing issue. Nurse #2 then walked away, and NA #1 thought she was going back to Resident #1, so she did not report the concern to the oncoming nurse aide. This all happened around 6:00 AM and her shift ended at 7:00 AM. During an interview on [DATE] at 11:50 AM Nurse Aide #2 stated she cared for Resident #1 on night shift (7:00 PM to 7:00 AM) on [DATE] and [DATE]. On the night shift of [DATE] no concerns were noted with Resident #1 and his scrotum during her activities of daily living care that shift. The morning of [DATE] Nurse #2 came to her and requested she clean the resident as he had gotten urine all over himself. She stated this was unusual as he had a suprapubic catheter as well as a colostomy. She stated she went and got Nurse Aide #1 and went to the room to clean him up. They took his gown off and began cleaning him up and when they removed his brief to clean his groin area, they noted from his waist down to his knees the fluid did not have the appearance of urine but instead had the appearance of pus or drainage. She stated they continued to clean him up and on the right side of his scrotum there was area about the size of a dime that appeared slightly swollen but was not black but flesh colored and as they cleaned it, they noted that the drainage was coming from that open area and there was so much drainage that they had to use a brief like pad on the front part of his scrotum to keep him from becoming soaked again in drainage. She stated she then went and let Nurse #2 know that Resident #1 was cleaned up but had a new open area to his scrotum and they had cleaned up pus and drainage but no urine. The nurse indicated she was passing medications but then would go in and check on the resident after, so NA #2 did not report the concern to the oncoming nurse aide. She concluded her shift ended and she had no further involvement with Resident #1 and did not know if the nurse assessed the resident or not. During an interview on [DATE] at 10:13 AM Nurse Aide #3 stated she took report that morning, on [DATE], from Nurse Aide #2 and the nurse aide indicated Resident #1 had a bath and she had emptied his catheter and colostomy bags. Nurse Aide #2 did not mention anything which indicated Resident #1 had a change to his scrotum, so Nurse Aide #3 did not have a reason to visualize Resident #1's scrotum or request the nurse assess it. During an interview on [DATE] at 9:06 AM Nurse #1 stated she was his regular nurse. She further stated it was important to know Resident #1 had no feeling to his groin and scrotum so he could not tell if something was hurting him there. She stated on [DATE] she worked a 12-hour shift beginning at 7:00 AM. She was not notified of any concerns from Nurse #2 with Resident #1 during change of shift report, so she had no reason to assess or contact the physician regarding Resident #1. She worked her shift as normal and completed her medication passes and then was doing wound care around 6:00 PM that day when she was going in to provide wound care for Resident #1. She set up her equipment and pulled back his sheet and removed his brief. Nurse #1 stated Resident #1's scrotum had the appearance of an abscess that had ruptured and the best way she could describe it was to imagine boiling an egg and when the egg cracks, the white of the egg comes out. But in this case what came out was black and not normal looking tissue. She stated Resident #1 had Fournier's gangrene before and the tissue observed on [DATE] had a similar appearance. She reported she got the Director of Nursing (DON) to observe the area and they agreed Resident #1 needed to be sent out to the hospital. Nurse #1 stated she notified the on-call provider and the on-call provider ordered for the resident to be sent out to the hospital. Resident #1 was discharged from the facility at 6:50 PM. Nurse #1 denied that Nurse #2 reported the area to her at change of shift that morning. She indicated Nurse #2 should have called the physician when she was informed of the area from the nurse aides. She added that the physician should have been informed of the resident's refusal for treatment so that a decision could be made to send the resident out to be assessed. Nurse #1 concluded Resident #1 was discharged from the facility at 6:50 PM, and at no time did he ever have a temperature, other abnormal vital signs, or indicators of distress during her shift including as he discharged . Review of Hospital #1's records dated [DATE] revealed Resident #1 presented to the emergency department with an abscess to the groin and scrotum. General surgery was consulted for plan of care or transfer. The Consulting Surgeon wrote, they were consulted for scrotal and penile abscess and Resident #1 had a history of drainage of penile abscess, scrotal abscess, and debridement of Fournier's gangrene by urology at a different hospital a few years ago. The physical exam revealed the scrotum was swollen and had signs and symptoms of an infection. The wound had spread to the left side of the scrotum and penis and there was an abscess on the left side of the penis draining pus. The assessment noted dead tissue as well. The Consulting Surgeon documented the treatment was beyond the scope of his practice and recommended transfer to urology at Hospital #2. Review of Hospital #2's records revealed a history and physical dated [DATE] that noted Resident #1 had a history of multiple sclerosis, paraplegia, and prior debridement for Fournier's gangrene in April of 2022. The Physician noted Resident #1 was transferred from an outside hospital with hypotension and purulent drainage from his scrotum, penis and perineum concerning for Fournier's gangrene. Resident #1 was taken to the operating room on [DATE] for debridement (surgical procedure to remove dead or infected tissue) of scrotal abscess and Fournier's gangrene. The discharge summary dated [DATE] revealed Resident #1's post operative stay was complicated by continuing sepsis and end-organ dysfunction, and he was transferred to hospice and expired on [DATE]. Attempts to contact physician at the hospital #1 were made on [DATE] at 2:20 PM, 2:44 PM, and 3:45 PM, and further attempts made on [DATE] at 9:52 AM and again on [DATE] at 5:18 PM. These attempts were unsuccessful. During an interview on [DATE] at 12:58 PM Physician #1 stated he was Resident #1's primary physician at the facility. He further stated he was not made aware of the open area on Resident #1's scrotum until after he had been hospitalized , and to his knowledge it was not reported to any on call provider until later that day, [DATE]. Even though Nurse #2 was unable to assess the area as the resident did sometimes refuse, she should have notified him or the on-call physician of the open area and the extent of the drainage. He concluded it was hard to say if Resident #1's outcome would have been different had the physician been notified earlier that day about the drainage and abscess, but he would have sent the resident out immediately upon being made aware of an open area on his scrotum with drainage even if the resident did not allow a full assessment. During an interview on [DATE] at 12:53 PM the Administrator stated the nurse should have notified the physician as soon as she was made aware of a new skin opening and drainage from Resident #1's scrotum by the nurse aide. He concluded the nurse and nurse aides should have reported the new open area to the oncoming shift. During an interview on [DATE] at 9:52 AM the Director of Nursing stated Nurse #2 should have attempted to assess the area or notify someone that Resident #1 was not allowing an assessment of the area. Nurse #2 should have notified the oncoming shift of the area, lack of assessment, and not having notified the doctor. Nurse #2 should have notified the doctor of the lack of assessment and of the new area when it was brought to her attention by the nurse aides. The Administrator was notified of the immediate jeopardy on [DATE] at 2:01 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to notify the Physician of a change of condition for Resident #1 in a timely manner and failed to have effective systems in place for Nursing staff to know what changes need to be reported and what needs to be reported immediately. The Director of Nurses and/or designee conducted a 30 look back to review other residents identified with a change in condition to verify Physician and/or Provider was notified in a timely manner. This review was completed by [DATE] and consisted of a thorough review of 24-hour reports, progress notes, and change of condition assessments. No additional concerns 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 The Nurse Practice Educator and/or designee re-educated Licensed Nurses on Notification of Changes in Condition with emphasis on changes that require immediate physician notification and documentation by [DATE]. Changes requiring prompt notification include a significant change in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The EInteract Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nurses and/or designee will review changes in condition by reviewing the 24-hour report, progress notes, change in condition assessments, and stop and watch alerts in the morning Clinical Meeting to verify prompt and/or immediate notification is communicated to the Physician and/or Provider. Removal of Immediate Jeopardy is [DATE] The credible allegation for immediate jeopardy removal with a compliance date of [DATE] was validated on [DATE], as evidenced by staff interviews and in-service record reviews. The in-services included information on notification of the physician or on call provider of changes in residents, communication of change of conditions in residents between staff, and documenting the change in condition as well as who was notified. The facility's immediate jeopardy removal date of [DATE] was validated.

Based on record review and staff and physician interviews, the facility failed to identify the seriousness of an open area on the scrotum that nurse aides reported had significant amounts of pus or drainage and failed to seek urgent medical attention once the resident refused an assessment. Resident #1 had paraplegia, had no feeling in his groin/scrotum area, and had a history of prior debridement for Fournier's gangrene. Fournier's gangrene is a type of flesh-eating disease (necrotizing fasciitis) that destroys the soft tissue of the scrotum, penis and perineum and is associated with a high mortality rate and requires immediate medical attention. Resident #1 was sent to Hospital #1's emergency department (ED) for evaluation. The ED Physician noted a scrotal abscess and drainage which were concerning for necrotizing infection as well. It was determined Resident #1 needed to be transferred to urology at Hospital #2 for continued care and surgical intervention. Resident #1 had surgery on [DATE] and his post operative stay was complicated by continuing sepsis and end-organ dysfunction (damage occurring in major organs fed by the circulatory system). He was transferred to hospice and expired on [DATE]. This occurred for 1 of 3 residents reviewed for notification of change (Resident #1). Immediate Jeopardy began on [DATE] when a high risk resident did not receive urgent medical attention. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective and the completion of staff education. Findings included: Resident #1 was admitted to the facility on [DATE]. His medical history in the facility medical record included paraplegia, presence of urogenital implants, necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. His active diagnoses included wound infection, anemia, heart failure, hypertension, neurogenic bladder, diabetes mellitus, paraplegia and multiple sclerosis. The MDS indicated Resident #1 had a suprapubic catheter and colostomy. Resident #1's care plan dated [DATE] revealed he was care planned to be at risk for skin breakdown and has actual skin breakdown which included being sent to the emergency room for a ruptured abscess to groin. The interventions included providing preventative treatments as ordered, observe for verbal and nonverbal signs of pain related to wound or wound treatment, wound treatment and medication as ordered, and weekly skin assessments by licensed nurse. Review of a progress note completed by Nurse #1 dated [DATE] revealed a head-to-toe skin check was completed. Resident #1 had previously identified skin issues noted, and no concerns were identified with Resident #1's scrotum at that time. During an interview on [DATE] at 9:06 AM Nurse #1 stated she did a skin check on Resident #1 on [DATE] and found no new areas to his skin, just the already identified wounds to his sacrum, right foot, and left calf. During an interview on [DATE] at 10:21 AM Nurse #4 stated she provided wound care for Resident #1 on [DATE] and noted no skin changes to his scrotum. Record review for [DATE] revealed Nurse #2 did not document any concerns for Resident #1. During an interview on [DATE] at 11:28 AM Nurse #2 stated on [DATE] around 6:00 AM she went to administer a medication injection to Resident #1's stomach and when she pulled the sheets back, she thought they were wet with urine. She noted his indwelling catheter was kinked under his thigh. She unkinked the tubing, got urine flow, and she was able to give him his medicine. She indicated she informed him the nurse aides were going to clean him up. In the middle of her medication pass a short time later the nurse aides (Nurse Aides #1 and #2) told her Resident #1 had an open area to his scrotum that needed to be assessed. She stated she went down to assess him and said, I heard you have something on your scrotum I need to look at, and he responded, no. She told him she needed to see it to make sure he was okay, and he told her You can look at it but don't touch it. She stated she visualized his scrotum, and there was an open area the size of a nickel with no bleeding or drainage. Resident #1 then covered it up, so she only had a brief look at it, and she told him they needed to take care of it. He indicated they could take care of it later. Nurse #2 reported she told Resident #1 she would let the oncoming nurse know about the area as the day shift provided wound care. She stated this was around 6:00 - 6:15 AM and the next shift started at 7:00 AM. She stated she continued to complete her medication pass and then told Nurse #1 about the area at change of shift report. She concluded since she could not examine the wound, she did not have anything to report to the physician so she did not notify the physician as the day shift would do that when they completed wound care. During an interview on [DATE] at 10:55 AM Nurse Aide (NA) #1 stated Resident #1 needed to be cleaned up on [DATE] in the early morning and he often would refuse care. Both herself and Nurse Aide #2 entered Resident #1's room and she thought it was urine that had leaked everywhere when they first entered and assumed something had happened to his catheter. Resident #1 had a suprapubic catheter and when they removed a towel, which was on top of his scrotum, they noted it was not urine but fluid leaking from what appeared to be an open area to his scrotum. The right side of his scrotum appeared to have ruptured open leaving black tissue and yellow drainage to the area. The area covered the right side of his scrotum and was very alarming, which they indicated to the nurse. She stated they ensured his comfort and then notified Nurse #2 to assess the area. NA #1 stated about 5 minutes later Nurse #2 came to her and indicated Resident #1 had refused to let her assess the area. NA #1 then told Nurse #2 that she was very concerned about that area and that he needed to be assessed as soon as possible as it was a very pressing and acute issue. Nurse #2 then walked away, and NA #1 thought she was going back to Resident #1, so she did not report the concern to the oncoming nurse aide. This all happened around 6:00 AM and her shift ended at 7:00 AM. During an interview on [DATE] at 11:50 AM Nurse Aide #2 stated she cared for Resident #1 on night shift (7:00 PM to 7:00 AM) on [DATE] and [DATE]. On the night shift of [DATE] no concerns were noted with Resident #1's scrotum during her activities of daily living care that shift. The morning of [DATE] Nurse #2 came to her and requested she clean the resident as he had gotten urine all over himself. She stated this was unusual as he had a suprapubic catheter as well as a colostomy. She stated she went and got Nurse Aide #1 and went to the room to clean him up. They took his gown off and began cleaning him up and removed his brief to clean his groin area. NA#2 stated there was fluid from his waist to his knees and it did not have the appearance of urine but instead had the appearance of pus or drainage. She stated they continued to clean him up and on the right side of his scrotum there was an area about the size of a dime that appeared slightly swollen but was not black but flesh colored. As they cleaned it, they noted that the drainage was coming from that open area and there was so much drainage that they had to use a brief like pad on the front part of his scrotum to keep him from becoming soaked in drainage again. She stated she let Nurse #2 know that Resident #1 was cleaned up but had a new open area to his scrotum and they had cleaned up pus and drainage but no urine. Nurse #2 indicated she was passing medications but would go in and check on the resident after, so she did not report the concern to the oncoming nurse aide. She concluded her shift ended and she had no further involvement with Resident #1 and did not know if Nurse #2 assessed the resident or not. During an interview on [DATE] at 10:13 AM Nurse Aide #3 stated she took report that morning, on [DATE], from Nurse Aide #2 and the nurse aide indicated Resident #1 had a bath and she had emptied his catheter and colostomy bags. Nurse Aide #2 did not mention anything which indicated Resident #1 had a change of his scrotum, so Nurse Aide #3 did not have a reason to visualize Resident #1's scrotum or request the nurse assess it. Review of a progress note dated [DATE] at 7:05 PM revealed Nurse #1 went to Resident #1's room to provide wound care to resident and while attempting to turn the resident onto his left side, the nurse observed that Resident #1's scrotum was swollen and appeared to have an abscess that was ruptured. The on-call provider was contacted at 6:22 PM and made aware of the situation and an order was given to send to the emergency department for evaluation and treatment. The nurse contacted 911 at 6:24 PM. During an interview on [DATE] at 9:06 AM Nurse #1 stated she remembered Resident #1 and was his regular nurse. She further stated it was important to know Resident #1 had no feeling to his groin and scrotum so he could not tell if something was hurting him there. She stated on [DATE] she worked a 12-hour shift beginning at 7:00 AM. She was not notified of any concerns from Nurse #2 with Resident #1 during change of shift report, so she had no reason to assess or contact the physician regarding Resident #1. She worked her shift as normal and completed her medication passes. Around 6:00 PM it was time to provide wound care for Resident #1. She set up her equipment and pulled back his sheet and removed his brief. Nurse #1 stated Resident #1's scrotum had the appearance of an abscess that had ruptured and the best way she could describe it was to imagine boiling an egg and when the egg cracks, the white of the egg comes out. But in this case what came out was black and not normal looking tissue. She stated Resident #1 had Fournier's gangrene before and the tissue observed on [DATE] had a similar appearance. She reported she got the Director of Nursing (DON) to observe the area and they agreed Resident #1 needed to be sent out to the hospital. She added that the physician should have been informed of the resident's refusal for treatment so that a decision could be made to send the resident out to be assessed. Nurse #1 stated she notified the on-call provider and the on-call provider ordered for the resident to be sent out to the hospital. Resident #1 was discharged from the facility at 6:50 PM. Review of Hospital #1's records dated [DATE] revealed an emergency department (ED) Provider note that indicated Resident #1 had a history of necrotizing fasciitis and presented with a severe scrotal abscess with purulent foul-smelling drainage which were concerning for necrotizing infection as well. The Provider noted Resident #1 had no sensation to this area. A sepsis work up was ordered in addition to IV (intravenous) antibiotics and fluid resuscitation (due to hypotension). General surgery was consulted for plan of care or transfer. The Consulting Surgeon documented the entire scrotum was red and swollen and there was a large area, approximately 7 centimeters (cm) by 5 cm, on the right side of the scrotum that was necrotic (dead tissue) and draining foul smelling pus. The underlying testicle was exposed and appeared to be draining pus as well. It was also noted the left side of the penis had an abscess that was draining pus. The Consulting Surgeon documented Resident #1 had a history of drainage of penile abscess, scrotal abscess, and debridement of Fournier's gangrene by urology at a different hospital a few years ago. The assessment noted dead tissue as well. The Consulting Surgeon documented the treatment was beyond the scope of his practice and recommended transfer to urology at Hospital #2. Review of Hospital #2's records revealed a history and physical dated [DATE] that noted Resident #1 had a history of multiple sclerosis, paraplegia, and prior debridement for Fournier's gangrene in April of 2022. The Physician noted Resident #1 was transferred from an outside hospital with hypotension and purulent drainage from his scrotum, penis and perineum concerning for Fournier's gangrene. Resident #1 was taken to the operating room on [DATE] for debridement (surgical procedure to remove dead or infected tissue) of scrotal abscess and Fournier's gangrene. The discharge summary dated [DATE] revealed Resident #1's post operative stay was complicated by continuing sepsis and end-organ dysfunction, and he was transferred to hospice and expired on [DATE]. Attempts to contact physician at Hospital #1 were made on [DATE] at 2:20 PM, 2:44 PM, and 3:45 PM, and further attempts made on [DATE] at 9:52 AM and again on [DATE] at 5:18 PM. These attempts were unsuccessful. During an interview on [DATE] at 12:58 PM Physician #1 stated he was Resident #1's primary physician at the facility. He further stated he was not made aware of the open area with drainage on Resident #1's scrotum until after he had been hospitalized , and to his knowledge it was not reported to any on call provider until later that day, [DATE]. Even though Nurse #2 was unable to assess the area as the resident did sometimes refuse, she should have notified him or the on-call physician of the open area and the extent of the drainage. He concluded it was hard to say if Resident #1's outcome would have been different had the physician been notified earlier that day about the drainage and abscess, but he would have sent the resident out immediately upon being made aware of an open area on his scrotum with drainage even if the resident did not allow a full assessment. During an interview on [DATE] at 12:53 PM the Administrator stated Nurse #2 should have notified the physician as soon as she was made aware of a new skin opening and drainage from Resident #1's scrotum by the nurse aides and was unable to assess the area. He concluded the nurse and nurse aides should have reported the new open area to the oncoming shift. During an interview on [DATE] at 9:52 AM the Director of Nursing stated Nurse #2 should have attempted to assess the area or notify someone that Resident #1 was not allowing an assessment of the area on his scrotum. Nurse #2 should have notified the oncoming shift of the area, lack of assessment, and not having notified the doctor. Nurse #2 should have notified the doctor of the lack of assessment and of the new area when it was brought to her attention by the nurse aides. The Administrator was notified of the immediate jeopardy on [DATE] at 2:01 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to conduct an assessment of Resident #1 and take appropriate actions when Resident #1 refused an assessment. The Director of Nurses and/or designee conducted a 30 look back to review other residents identified with a change in condition to verify a thorough assessment was completed by a Licensed Nurse. This review was completed by [DATE], and consisted of a thorough review of 24-hour reports, progress notes, and change of condition assessments. No additional concerns were identified. The Licensed Nurses and/or designee completed a skin assessment on all residents to identify skin changes in condition and verify the Physician and/or Provider was notified of changes by [DATE]. No additional residents were identified with necrotizing fasciitis and Fournier's gangrene. 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 Nurse Practice Educator and/or designee will provide education to Licensed Nurses on necrotizing fasciitis and Fournier's gangrene with specific emphasis on how rapidly it can progress, how detrimental it can be, and the seriousness/urgency of seeking immediate medical attention by [DATE]. A post-test has been created and is in progress to validate knowledge and/or comprehension of education. The Director of Nurses and/or Nurse Practice Educator will track and verify no Licensed Nurse (s) will be allowed to return to work with scheduled time off, on leave of absence (FMLA), vacation, or PRN until they have successful completed the education/training and post-test. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee will educate Licensed Nurses on the importance of conducting a thorough assessment, documenting the assessment, and on specific measures to take if a patient refuses an assessment to include notifying the Responsible Party, and Physician/Provider, and educating the resident on the importance of allowing an assessment to be completed, and re-approach by [DATE]. The Director of Nursing and/or Nurse Practice Educator will track and verify Licensed Nurses with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee re-educated Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The EInteract Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nurses and/or designee will review changes in condition by reviewing the 24-hour report, progress notes, change in condition assessments, in the morning Clinical Meeting to verify a thorough assessment has been completed. Removal of Immediate Jeopardy is [DATE] The credible allegation for Immediate Jeopardy removal with a compliance date of [DATE] was validated on [DATE], as evidenced by staff interviews and in-service record reviews. The in-services included information on identification of changes in residents, importance of assessments, documenting assessments, and measures to take if a resident refused an assessment. The education further included information on necrotizing fasciitis and Fournier gangrene with a focus on the speed at which it can cause a decline and requires emergent medical attention. The facility's Immediate Jeopardy removal date of [DATE] was validated.

Based on record review and Physician and staff interviews the facility failed to provide care for a diabetic by failing to obtain and monitor blood sugar (BS) levels for 1 of 1 residents (Resident #171) which resulted in the resident being admitted to the hospital for Diabetic Ketoacidosis (DKA). DKA is the formation of a toxic chemical in the blood caused by prolonged high blood sugar which can be life threatening. Resident #171 was also admitted to the hospital with hyperosmolar [CONDITION(S)] (a complication from high blood sugar for a long period of time that causes severe dehydration and confusion). Immediate Jeopardy began on 02/22/21 when Resident #171 was readmitted to the facility with sliding scale insulin orders and parameters to administer insulin but no orders directing the monitoring of Resident #171's blood sugar and no sliding scale insulin was administered. Immediate Jeopardy was removed on 06/14/21 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #171 was readmitted to the facility from the hospital on 02/22/21 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge orders dated 02/22/21 were for novolog insulin inject under the skin as needed for high blood sugar. The 02/22/21 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #171 was also ordered Novolog insulin to be injected on a sliding scale subcutaneously as needed. The parameters for administration of the insulin were: if BS was between 201-250 administer 2 units of insulin, if BS was between 251-300 administer 4 units of insulin, if BS was between 301-350 administer 6 units of insulin, if BS was between 351-400 administer 8 units of insulin, and if BS was greater than 400 administer 10 units of insulin and call the physician. The order did not direct how often to monitor Resident #171's BS. A BS less than 140 mg/dL (milligrams/deciliter) is considered to be normal. There were no orders for administration of insulin on a regular basis noted. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Progress Note dated 02/23/21 revealed Resident #171 was being seen by the physician after readmission to the facility from the hospital. The plan was to monitor Resident #171's BS and adjust the medication as indicated. The 02/23/21 orders revealed that Resident #171's insulin was changed from Novolog to [MEDICATION(S)] insulin with the same parameters. The order did not list how often to monitor Resident #171's BS. The 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #171 was moderately impaired in cognitive skills for daily decision making. The resident had an indwelling catheter. Resident #171 received no injections and no insulin during the seven day look back period. The Care Plan reviewed 03/01/21 revealed that Resident #171 had diabetes. Interventions included to access and record blood sugar levels as ordered, to obtain laboratory work as ordered and to report the results to the physician, and to monitor any signs and symptoms of infection. The 03/24/21 e-MAR (electronic-Medication Administration Record) Progress Note documented at 9:39 AM, revealed Nurse #6 notified the physician that Resident #171's BS would not read on the meter and she was instructed to administer 20 units of insulin. The Change in Condition Evaluation dated 03/24/21, and documented by Nurse #6, revealed that Resident #171 experienced a hyperglycemic (high BS) episode that started the morning of 03/24/21. There were no mental or functional status changes observed. The physician was notified and an order to give 20 units of insulin with fluids was received. Hourly BS testing was also to be done. The 03/24/21 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital ED notes dated 03/24/21 revealed that Resident #171 presented as alert, calm and in no acute distress. The ED laboratory results dated [DATE] revealed that Resident #171 had a serum glucose level of 568 mg/dL (milligrams/dLiter) with a laboratory reference range of 75-110 mg/dL. Resident #171's Hemoglobin A1C was 9.6% with a laboratory reference range of 4.7-5.6%. Hemoglobin A1C is an average measurement and 9.6% would indicate that his blood sugar was consistently >240 mg/dL. The B-hydroxybuterate level was 16.6 mg/dL with a laboratory reference range of 0.2-2.8 mg/dL. Resident #171's sodium level was 149 mmol/L (millimoles/Liter) with a laboratory reference range of 135-153 mmol/L. The BUN (blood, urea, nitrogen) was 34 mg/dL with a laboratory reference range of 8-21 mg/dL. Resident #171's creatinine level was 1.5 mg/dL with a laboratory reference range of 0.5-1.4 mg/dL and the anion gap level was 17 mmol/L with a laboratory reference range of 5-16 mmol/L. These laboratory values are relevant as they contributed to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Internal Medicine Progress Note dated 03/25/21 revealed that Resident #171 presented with Mild Diabetic Ketoacidosis (DKA) when admitted on [DATE]. His BS level was improving and the BS reading that morning was 336 mg/dL. Resident #171's sodium was 155 mmol/L, BUN was 19 mg/dL, and creatinine was 1.1 mg/dL. The 03/26/21 Hospital Discharge revealed a primary discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the hospital admission Resident #171 required intravenous (IV) antibiotics, IV fluids, IV insulin and potassium supplementation. An attempted telephone interview was conducted on 05/16/21 with the nurse who created the SSI order for Resident #171. No contact was able to be made. In a telephone interview on 05/16/21 at 3:29 PM Nurse #1, who worked with Resident #171 on 03/23/21 on the 7:00 AM-3:00 PM shift and the 3:00 PM-11:00 PM shift stated that Resident #171 was not sedated when he worked with him. He indicated that Resident #171 did not complain of thirst and that he could eat whatever he wanted. Nurse #1 stated that if a resident was on SSI then BS needed to be checked. He stated that if the nurse did not know the BS reading, they would not know how much SSI to give. Nurse #1 indicated that normally BS for SSI was checked before meals but if it was not on the order, the order should have been clarified. He indicated that he had not called the physician to clarify how often Resident #171's BS needed to be monitored. In a telephone interview on 05/16/21 at 2:31 PM Nurse #6, who was assigned to care for Resident #171 when he was sent to the hospital on 03/24/21, stated she could not remember what was going on with Resident #171 on the morning of 03/24/21. She indicated that something did not seem right with the resident and that she asked another nurse to come into the room. Nurse #6 indicated that she thought it was Nurse #3 who came into the room and suggested she check Resident #171's BS. She stated that she had not received any information in report that Resident #171 was acting any differently than he usually did. Nurse #6 stated she injected 20 units of whatever type of insulin was in the medication cart for him to the resident. She indicated she did not document that the insulin was administered because she thought someone else was going to do that as she was busy. Nurse #6 stated she took BS readings several times that morning and it kept reading high instead of providing a number. She indicated that the family decided to send Resident #171 to the hospital after being informed about what was going on. Nurse #6 stated that in order to tell how much SSI to administer to a resident she would need to know what their BS was. She indicated that to know what the BS reading was she would have to test the resident's blood. Nurse #6 stated that BS should be checked as often as the order said and if it was not listed then the physician should be called, and the order clarified. She indicated that she had not called the physician to clarify the SSI order. In a telephone interview on 05/16/21 at 3:07 PM Nurse #3 confirmed that she had helped Nurse #6 with Resident #171 on 03/24/21. She indicated that she could not really remember what had been happening with Resident #171 but that he seemed fatigued, sedated, and weak. Nurse #3 stated they took Resident #171's BS and it read High. The physician was notified and a new order for insulin administration was received. She indicated she did not document that the insulin was administered. Nurse #3 stated that BS should be taken before meals and should be included on the order. She indicated that if it was not on the order you would not know how much SSI to give. Nurse #3 indicated that the order should have been clarified to see when the physician wanted Resident #171's BS to be taken for monitoring. She indicated that she had not called the physician to clarify how often Resident #171's BS was to be monitored. In a telephone interview on 05/17/21 at 1:32 PM the Director of Nursing (DON) stated that if a resident was ordered SSI, she expected BS to be monitored as per the order. She indicated that if the order did not include times to monitor the BS, such as before meals, the physician would need to be called and the order clarified. The DON indicated that a BS reading of high would be defined as > 600. She indicated that any type of steroid or an active infection could increase a resident's BS which would make BS monitoring that much more important. The DON indicated that she felt the monitoring of Resident #171's BS was just left off the order, was not clarified, and was just an error. The DON indicated that she felt that if Resident #171's BS had been monitored, he probably would not have had to be admitted to the hospital for high BS with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In a telephone interview on 05/17/21 at 1:59 PM Resident #171's Physician stated that BS monitoring for SSI should be performed before meals and at bedtime. He indicated that if the times for monitoring were not included in the order, that someone should have called him to clarify the order. The Physician indicated that he expected his orders to be followed and if there were any questions he should be notified, and the orders clarified. He indicated that an active infection such as a UTI or taking steroids of any kind could increase BS levels and monitoring the BS levels would be even more important. He stated that if monitoring of BS was not done it was a significant problem and probably contributed to Resident #171 being sent out to the hospital and being diagnosed with a UTI and DKA. The Administrator was notified of the Immediate Jeopardy by telephone on 06/24/21. Immediate Jeopardy Removal Plan [NAME] Center June 25, 2021 Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: 1. Resident # 171 was admitted to Genesis [NAME] Center on 2/22/21. Resident #171 did not have any fingersitcks done from admission through 3/24/21, but did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 171 has a medical history significant for diabetes mellitus. On 3/24/21 a fingerstick was obtained that could not be read due to the value being too high (>600). Resident # 171 was sent to the ER at that time. Resident was admitted to the hospital where he was diagnosed with mild diabetic ketoacidosis, acute kidney injury. Resident # 171's attending physician failed to identify and write routine orders for Blood Glucose Monitoring. Resident # 171 had a prn order for Blood Glucose Monitoring but not routine monitoring. Consultant Pharmacist failed to identify that Resident # 171 did not have routine monitoring of Blood Glucose Levels. The Charge nurse who completed resident # 171's admission, failed to clarify orders. This Charge Nurse is no longer employed at the center. Within 30 days of admission to [NAME], Resident #171 developed components of diabetic ketoacidosis and hyperosmolar [CONDITION(S)], due to failure of the center to monitor Blood Glucose levels. Resident # 171 discharged from Genesis [NAME] Center on 4/23/2021 to another SNF. All residents who receive scheduled or as needed insulin have potential to be affected. The Director of Nursing completed an audit of all current residents with orders for scheduled and as needed insulin on 6/11/2021 to ensure that these residents were having routine Blood Glucose Monitoring and that the orders were being carried out and monitored appropriately. Director of Nursing continues to audit of all new admissions to ensure that any newly admitted residents with orders for scheduled or as needed insulin have orders for Blood Glucose Monitoring and that the orders are being carried out and monitored appropriately. Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: On 6/09/2021 Education was initiated for all licensed nurses on Policy of Monitoring Blood Glucose Levels, by the Director of Nursing. Education included FT, PT, PRN and agency staff. This education was completed on 6/14/21. No staff shall work until this education is received. This education will be included for all new hires. The Director of Nursing (DON) and ADON will review all new medication orders as part of the Clinical Morning Meeting to ensure that any new orders for Insulin have appropriate Glucose Monitoring orders in place. All new Admissions and Readmissions will be reviewed by the DON and ADON to ensure that any residents with orders for scheduled or as needed insulin have appropriate orders in place for Glucose Monitoring. All of the above is reviewed in morning meeting by pulling up PCC on computer for review of orders, as well as new admission charts are brought to the morning meeting for review by the clinical team. As part of the review in PCC the clinical team will pull up the resident's eMAR to ensure that the orders are in place appropriately. Alleged date Immediate Jeopardy was removed, 6/14/2021. Administrator is responsible for the implementation of this plan. The Removal Plan of Immediate Jeopardy was validated on 06/30/21 at 2:15 PM. A sample of staff that included licensed nurses and the Director of Nursing (DON) were interviewed regarding in-servicing related to the deficient practice. Nine nurses including the DON all stated they had been in-serviced prior to the validation process. The in-servicing was done verbally in person and also conducted over the telephone. The topics included diabetes management, [CONDITION(S)] protocol, lab processes and the components of a drug order. Training included all nurses, both staff and agencies. A review of all documents developed to correct the deficient practice was completed. A review of audit forms that were developed to ensure that in-services presented to all staff were understood was conducted. Immediate Jeopardy was removed on 06/14/21.

Based on record review and Physician, Urology nurse, and staff interviews the facility failed to obtain and monitor blood sugar (BS) levels and failed to obtain laboratory results which caused a delay in treatment for 1 of 1 residents (Resident #171) which resulted in the resident being admitted to the hospital for Diabetic Ketoacidosis (high blood sugar) and a Urinary Tract Infection (UTI). Findings included: The Care Plan created 04/14/20 revealed that Resident #171 had diabetes. Interventions included to access and record blood sugar levels as ordered, to obtain laboratory work as ordered and to report the results to the physician, and to monitor any signs and symptoms of infection. The Care Plan created 08/06/20 revealed that Resident #171 required an indwelling supra pubic catheter. It was initiated on 03/11/21 that Resident #171 had been to the urologist that day and the suprapubic catheter was changed. An intervention of obtaining a urinalysis and culture and sensitivity (UA C&S) was recommended. There was also an intervention of monitoring labs as ordered on the Care Plan. The electronic Blood Sugar (BS) record revealed Resident #171 had a BS of 88 on 02/09/21. The next BS reading was recorded as 145 on 03/26/21. There were no BS readings listed between those dates. Resident #171 was readmitted to the facility from the hospital on 02/22/21 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/22/21 orders revealed that Resident #171 was to use a [MEDICATION(S)] inhaler (a steroid) every day for shortness of breath. Resident #171 was also ordered Novolog insulin to be injected on a sliding scale subcutaneously as needed. The parameters for administration of the insulin were: if BS was between 201-250 administer 2 units of insulin, if BS was between 251-300 administer 4 units of insulin, if BS was between 301-350 administer 6 units of insulin, if BS was between 351-400 administer 8 units of insulin, and if BS was greater than 400 administer 10 units of insulin and call the physician. The order did not direct how often to monitor Resident #171's BS. The Medication Administration Record (MAR) for 02/22/21-03/23/21 revealed no documentation that BS monitoring had been completed or that any sliding scale insulin (SSI) had been administered. The 02/23/21 orders revealed that Resident #171's insulin was changed from Novolog to [MEDICATION(S)] insulin with the same parameters. The order did not list how often to monitor Resident #171's BS. The Physician's Progress Note dated 02/23/21 revealed Resident #171 was being seen by the physician after readmission to the facility from the hospital for a UTI. The plan was to continue and complete the course of antibiotic therapy. In addition, the plan was to monitor Resident #171's BS and adjust the medication as indicated. The 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #171 was moderately impaired in cognitive skills for daily decision making. The resident had behavioral symptoms directed toward others 1-3 days but did not reject care. Resident #171 needed the extensive assistance of one staff member for bed mobility and was dependent on one staff member for dressing, hygiene and bathing and needed the extensive assistance of one staff member for toilet use. The resident had an indwelling catheter. Resident #171 received no injections and no insulin during the seven day look back period. The Urologist Report of Consultation dated 03/11/21 revealed that Resident #171 had his suprapubic catheter changed in the office. Resident #171 became agitated when the catheter was removed and upon reinsertion of the catheter. The Urologist requested urine be obtained for a culture and sensitivity. The 03/11/21 MAR revealed that a UA C&S was collected at the facility at 6:13 PM by Nurse #8. The urine culture final result dated 03/14/21 at 7:12 AM revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The colony count was >100,000 CFu/mL (Colony Forming units/milliliter). There were multiple Gram-Negative Bacilli present- 3 or more non-predominant species. It was noted that the presence of three or more species of bacteria suggests contamination. If a repeat culture is indicated, please submit a clean catch or catheterized specimen. The laboratory results revealed the specimen taken date was 03/11/21 at 6:13 PM. The specimen was received in the lab on 03/12/21 at 6:40 PM (greater than 24 hours after obtaining) and resulted on 03/14/21 at 7:12 AM. The facility was unable to provide any follow-up on this lab result. The 03/24/21 e-MAR (electronic-Medication Administration Record) Progress Note documented at 9:39 AM, revealed Nurse #6 notified the physician that Resident #171's BS would not read on the meter and she was instructed to administer 20 units of insulin. The Change in Condition Evaluation dated 03/24/21, and documented by Nurse #6, revealed that Resident #171 experienced a hyperglycemic (high BS) episode that started the morning of 03/24/21. The assessment revealed that the last BS taken was 02/09/21 and was 88. There were no mental or functional status changes. The physician was notified and an order to give 20 units of insulin with fluids was received. Hourly BS testing was also to be done. The 03/24/21 MAR revealed the box for BS contained NA (not applicable) instead of a number and in the PRN (as needed) box was a U signifying unknown for how many units of insulin was given. There was no documentation that 20 units of insulin was administered to Resident #171 prior to transfer to the Emergency Department (ED) or that hourly BS readings were done. The Hospital Emergency Department (ED) lab results revealed that Resident #171 had a glucose level of 568 mg/dL (milligrams/deciliter) and a Hemoglobin A1C of 9.6. The Hospital Internal Medicine Progress Note dated 03/25/21 revealed that Resident #171 presented with Mild Diabetic Ketoacidosis (DKA) when admitted on [DATE]. His BS level was improving and the BS reading that morning was 336. The 03/26/21 Hospital Discharge revealed primary discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the hospital admission Resident #171 required intravenous (IV) antibiotics, IV fluids, and IV insulin. In a telephone interview on 05/16/21 at 2:31 PM Nurse #6, who was assigned to care for Resident #171 when he was sent to the hospital on 03/24/21, stated she could not remember what was going on with Resident #171 on the morning of 03/24/21. She indicated that something did not seem right with the resident and that she asked another nurse to come into the room. Nurse #6 indicated that she thought it was Nurse #3 who came into the room and suggested she check Resident #171's BS. She stated that she had not received any information in report that Resident #171 was acting any differently than he usually did. Nurse #6 stated she injected 20 units of whatever type of insulin was in the medication cart for him to the resident. She indicated she did not document that the insulin was administered because she thought someone else was going to do that as she was busy. Nurse #6 stated she took BS readings several times that morning and it kept reading high instead of providing a number. She indicated that the family decided to send Resident #171 to the hospital after being informed about what was going on. Nurse #6 stated that in order to tell how much SSI to administer to a resident she would need to know what their BS was. She indicated that to know what the BS reading was she would have to test the resident's blood. Nurse #6 stated that BS should be checked as often as the order said and if it was not listed than the physician should be called, and the order clarified. She indicated that she had not called the physician to clarify the SSI order. In a telephone interview on 05/16/21 at 3:07 PM Nurse #3 confirmed that she had helped Nurse #6 with Resident #171 on 03/24/21. She indicated that she could not really remember what had been happening with Resident #171 but that he seemed fatigued, sedated, and weak. Nurse #3 stated they took Resident #171's BS and it read High. The physician was notified and a new order for insulin administration was received. She indicated she did not document that the insulin was administered. Nurse #3 stated that BS should be taken before meals and should be included on the order. She indicated that if it was not on the order you would not know how much SSI to give. Nurse #3 indicated that the order should have been clarified to see when the physician wanted Resident #171's BS to be taken for monitoring. She indicated that she had not called the physician to clarify how often Resident #171's BS was to be monitored. In a telephone interview on 05/16/21 at 3:29 PM Nurse #1, who worked with Resident #171 on 03/23/21 on the 7:00 AM-3:00 PM shift and the 3:00 PM-11:00 PM shift stated that Resident #171 was not sedated when he worked with him. He indicated that Resident #171 did not complain of thirst and that he could eat whatever he wanted. Nurse #1 stated that if a resident was on SSI then BS needed to be checked. He stated that if the nurse did not know the BS reading, they would not know how much SSI to give. Nurse #1 indicated that normally BS for SSI was checked before meals but if it was not on the order, the order should have been clarified. He indicated that he had not called the physician to clarify how often Resident #171's BS needed to be monitored. In a telephone interview on 05/17/21 at 11:17 AM Nursing Assistant (NA) #7, who worked with Resident #171 on the 11:00 PM-7:00 AM shift on 03/23/21, stated that she did not recall that night. In a telephone interview on 05/17/21 at 11:32 AM Nurse #7, who was assigned to Resident #171 on 03/23/21 on the 11:00 PM-7:00 AM shift, stated she remembered Resident #171 but not the night in question. In a telephone interview on 05/17/21 at 1:32 PM the Director of Nursing (DON) stated that if a resident was ordered SSI, she expected BS to be monitored as per the order. She indicated that if the order did not include times to monitor the BS, such as before meals, the physician would need to be called and the order clarified. She indicated that any type of steroid or an active infection could increase a resident's BS which would make BS monitoring that much more important. The DON indicated that she felt the monitoring of Resident #171's BS was just left off the order, was not clarified, and was just an error. She stated that the urine for the UA C&S that the Urologist ordered on 03/11/21 was sent from his office to the lab and not completed at the facility as documented on the March 2021 MAR by the nurse. The DON indicated that the facility had not received a report of Resident #171's UA C&S from the lab and had not been contacted by the urology office for any medications that may have been needed as a result of the urine testing or if a new specimen needed to be sent. The DON indicated that she felt that if Resident #171's BS had been monitored; he probably would not have had to be admitted to the hospital for high BS with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In a telephone interview on 05/17/21 at 1:59 PM Resident #171's Physician stated that BS monitoring for SSI should be performed before meals and at bedtime. He indicated that if the times for monitoring were not included in the order, that someone should have called him to clarify the order. The physician indicated that he would be okay with the Urologist ordering a UA C&S but would expect the Urologist to make the physician aware of the results so he could decide on a course of treatment. He indicated he could not recall if he had been informed of the results of Resident #171's 03/11/21 UA C&S by either the facility or the Urologist. The Physician indicated that he expected his orders to be followed and if there were any questions he should be notified, and the orders clarified. He indicated that an active infection such as a UTI or taking steroids of any kind could increase BS levels and monitoring the BS levels would be even more important. He stated that if monitoring of BS was not done it was a significant problem and probably contributed to Resident #171 being sent out to the hospital and being diagnosed with a UTI and DKA. In a telephone interview on 05/21/21 at 11:35 AM Nurse #8, who initialed the 03/11/21 MAR that the UA C&S was completed at 6:13 PM by her, stated that she no longer worked at the facility, had no access to Resident #171's medical record, and did not remember anything about a urine sample. In a telephone interview on 05/21/21 at 11:56 AM the Urology Nurse stated that Resident #171 came in for a catheter change on 03/11/21. She indicated that the urine sample was collected from the catheter in the office. The Urology Nurse stated that the process was for the office nurse to call the facility and let them know if the Urologist wanted to order a medication or if he wanted the sample to be recollected for some reason. When asked, the Urology Nurse indicated that she did not know if the facility had been notified of the result of the urine culture or if the Urologist had seen the results. She indicated she did not know if the Urologist wanted the sample recollected or if he wanted to order a medication for the UTI. She indicated she would find out the information and call back. A request to speak with the Urologist was made and was not acknowledged. No further information from the Urology practice was received.

Based on observation, physician interview, resident interview, staff interview, and record review the facility failed to individualize the securement of Resident #110 by achieving angulation of the seat belt across the resident as specified in the owner's manual for 1 of 1 sampled residents (Resident #110) who sustained injury in the facility transportation van. The resident slid out of her wheelchair during transport and landed on the floor of the van sustaining a hematoma, skin tears, swelling, and bruising. Based on observation, staff interviews and record review the facility also failed to maintain water temperatures below the acceptable temperature of 116 degrees Fahrenheit for 1 (short hall) of 3 halls. The immediate jeopardy (IJ) began on 04/20/17 when the facility transporter applied brakes and swerved to avoid a head-on collision, causing the resident to slide out of her wheelchair and sustain injuries when she hit the floor of the van. The IJ was removed on 05/05/17 at 12:05 PM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its new procedure for individualizing the wheelchair securement of residents in the facility transportation van. The facility also remained out of compliance because of hot water issues also cited at F323, but with a scope and severity of E. Findings included: 1. The facility's 2017 transit van owner's manual documented, Position the safety belt height adjuster so that the safety belt rests across the middle of your shoulder. Failure to adjust the safety belt correctly could reduce its effectiveness and increase the risk of injury in a crash. Review of a Vehicle Safety Competency, dated 03/21/17, revealed the facility transporter passed the competency and met safety standards and procedures for: preparing residents for loading, loading/unloading residents on a lift, understanding and following manufacturer's guidelines for weight limits/safety precautions/maintenance, proper placement of resident wheelchairs in the van, proper securement of resident wheelchairs with tie downs, proper placement of the seat belts to secure residents in their wheelchairs, and utilizing precautions and following safety guidelines. The form revealed the transporter was evaluated by the maintenance manager (MM). Record review revealed Resident #110 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. Review of a 04/20/17 Pre-Trip Vehicle Safety Inspection Checklist revealed the facility transporter checked off Seat belts and wheelchair tie-downs work properly for driver and passengers and All passengers must wear seat belts and, if in wheelchair, must also have wheelchair tie-down prior to transporting Resident #110 in the facility's 2017 transit van. A 04/20/17 7:49 PM progress note documented, During transport from dialysis to facility transport vehicle was run off the road by an on-coming vehicle at 5:35 PM. Transport driver called 911 to have them come to evaluate the resident. When brakes applied to swerve out of way of on-coming vehicle, the resident fell from the chair with seatbelt still on. Res (Resident) had skin tear to right hand and right cheek as well as a lump to her right forehead about marble size. Res remained alert and oriented and stated she was in no pain. Transport driver then called facility to inform us of description of incident. ____ (name of primary physician) was then notified at 5:45 PM. The family (name provided) was then notified at 5:50 PM. Res was transported to ____ (name of hospital). When transport arrived back at center the van was inspected by maintenance to verify proper placement of equipment. 04/20/17 emergency department notes documented, .Large hematoma noted to pt's (patient's) right orbit (eye socket). Bleeding controlled. Primary [DIAGNOSES REDACTED]. Computed tomography (CT) and x-rays ruled out fractures to the head, spine, feet, and hands. A 04/20/17 statement from the transporter as taken by the police department, after the transporter returned to the facility, documented, .A car in the opposite lane was passing another car and coming at us head on. I had to swerve to prevent them from hitting us head on (Resident #110) fell out of the wheelchair onto the floor, her wheelchair did not move nor did her seat belt come loose. They both were safely secured. She fell on the side of her face. I immediately checked to see if (Resident #110) was ok, then called 911, she was bleeding on the side of her face and on her hand. She was alert and talking to me. I was keeping an eye on her physical appearance and providing emotional support until the ambulance arrived. When the ambulance arrived they checked (Resident #110) who was still bleeding and alert, took her to the hospital In this statement the transporter reported she was traveling at about 35 miles per hour at the time of the van incident. A 04/21/17 3:03 AM change in condition follow-up note documented, Right eye purple swollen shut. 2nd and 3rd fingers right hand from tips to 2nd knuckles purple in color. Monitored for mental status changes. c/o (complaints of) pain refused any pain meds. A 04/21/17 10:20 PM progress note documented, .right eye closed and swollen and entire right side of face bruised, discolored, and swollen. Pts (Patient's) right hand and fingers swollen black and blue middle finger and index fingers. Pt able to move all fingers and extremities well On 04/21/17 Resident at risk for falls r/t (related to) limited mobility and weakness. 04/20/17 fall with injury and ER (emergency room ) visit with bruising and swelling to rt (right) eyes, skin tears to rt hand and rt cheek was identified as problem in Resident #110's care plan. Interventions for this problem included involvement of physical therapy and occupational therapy to help improve the resident's strength and mobility. The resident's 04/26/17 admission minimum data set (MDS) documented her cognition was moderately impaired, she exhibited no behaviors including resistance of care, and she required extensive assist by two staff members with transfers. The assessment also documented Resident #110 was not steady during transitions/transfers and walking, she had no impairment in her range of motion, she utilized a walker and a wheelchair for mobility, she had skin tears and moisture associated skin damage, and she was receiving occupational and physical therapy. At 10:45 AM on 05/3/17 Resident #110 stated she remembered van brakes being applied and the van swerving off the road, but she could not remember how or if she was secured in the van on 04/20/17 when the transporter picked her up from dialysis to return her to the nursing home. However, she commented if she was belted in as required she did not understand how she could have come out of her wheelchair. She recalled being on the floor of the van on her side. At 10:45 AM on 05/03/17 the facility's supply clerk/transporter stated she assumed the transporter position on 04/04/17. She reported she received training from the MM (on 03/21/17) before she transported any residents. She commented most of the training was hands-on, but she did get some written information to refer to also. According to the transporter, the MM showed her the proper technique for securing wheelchairs with tie downs and for applying seat belts. She also commented the MM reviewed the Pre-Trip Vehicle Safety Inspection Checklist, the vehicle operation and routine operation of van features, and the need to carry a first aid kit and disinfectant spray. She explained that before she could begin transporting residents she had to perform acceptable return demonstration of loading and unloading residents, wheelchair securement, seat belt placement, and completion of the inspection checklist. The transporter stated on 04/20/17 Resident #110's wheelchair was secured at four points, her wheelchair was locked, and her seatbelt (combination belt across shoulder and lap) was fastened. She reported she completed the Pre-Trip Vehicle Safety Inspection Checklist before pulling away from the dialysis center. The transporter stated she had begun slowing down on a two lane road to make a turn, but as she looked ahead she saw a car coming at the van head on as it was trying to pass another vehicle. She reported she had to swerve off the road and apply brakes to prevent a head-on collision. When the van came to a complete stop the transporter commented she observed Resident #110 on her right side on the floor. She stated the wheelchair was still secured at four points and the seatbelt was still fastened, but the resident had come out of the wheelchair. She reported the resident was bleeding from her right hand and right cheek. She commented she called 911 first and then the facility. According to the transporter, the resident was still alert and oriented and did not complain of any pain, but the ambulance arrived at the accident site and took the resident to the hospital. She commented the police did not come to the site of the accident because they reported there was no crash. She stated once the resident was taken away to the hospital, she returned to the nursing home where the MM was waiting on her. She reported the MM immediately inspected the van, including the seatbelt and wheelchair tie downs, and the resident wheelchair which was still secured in the van at four points, but found nothing wrong. She stated the MM requested that she secure him in a wheelchair, and required that she demonstrate how she loaded and secured Resident #110 in the van. She commented the MM took her out driving, remaining secured in the wheelchair, making her apply breaks, swerve, and make turns. She reported the MM remained secured in the wheelchair without any problems during the entire trip. At 11:02 AM on 05/03/17 the administrator of the facility at the time of the 04/20/17 van incident stated the van was a brand new 2017 transit van, received by the facility in October 2016. She reported Resident #110 was the only resident transported in the facility van on 04/20/17. She commented the facility thought Resident #110 would be hospitalized overnight for observation after the van incident, but four or five hours after the incident the emergency room (ER) contacted the facility, informing them that the resident was ready for discharge. According to the administrator at the time of the incident, the facility's transit van was used to pick Resident #110 up from the ER. She explained that the MM had found no problems during his post-incident van inspection, and the facility did not want to bother the resident's family by asking them to pick the resident up from the hospital. (Review of transit records also revealed the facility van was used to transport Resident #110 back and forth to dialysis on 04/25/17, 04/27/17, and 05/02/17). According to the administrator, she also had the MM take the van to a certified mechanic who verified the seat belts and wheelchair tie downs were in good working condition. (A copy of the auto service invoice was reviewed). She commented after the incident she had the MM interview all alert and oriented residents who had been transported in their wheelchairs in the van recently, and all of them reported the transporter used a seat belt and four point tie downs to secure them in their wheelchairs. None of the residents had concerns about their safety. The administrator stated during facility interviews with Resident #110 the resident mentioned she thought maybe the transporter missed a turn and that was why she applied brakes and swerved so the facility made pictures of the incident scene which showed no tire tracks in the road and undisturbed grass where the transported pulled off the road. As a precaution the administrator also reported the transporter passed an on-line defensive driving course on 04/26/17. (A copy of the course transcript was reviewed). At 11:36 AM on 05/03/17 the MM stated during the transporter's initial competency she had to demonstrate safe driving skills and safe securement of residents in wheelchairs by using the seat belt and four point tie downs. He reported he also did monthly inspections of the transport van to make sure the seat belts and tie downs were in good working condition, and there had been no problems discovered. (These monthly inspections were reviewed with the last inspection taking place on 03/31/17). At 1:12 PM on 05/03/17 during an observation the facility transporter secured Resident #64 in the facility transit van. The resident was in her personal wheelchair, and the transporter secured her in the van using a seat belt and four point tie downs. The seat belt crossed the resident's shoulder at the mid-point (the resident had broad shoulders), and fit securely around the resident's body. (On 05/04/17 Resident #64's weight summary documented she was 64 inches tall and weighed 197 pounds). The resident was still secured safely in her wheelchair when the van arrived at the doctor's office after the transporter maneuvered curves, hair pin turns, and broken pavement. At 3:50 PM on 05/03/17 physical therapist (PT) #1 stated she was currently working with Resident #110 to improve her lower extremity strength, balance, ambulation, transfers, and wheelchair mobility. She reported the resident was making good progress. She commented, for example, the resident was now able to ambulate 250 feet with contact guard and a rest break, was able to endure 20 minutes of cardio exercising, and her trunk stability was good when sitting up. According to PT #1, she was not the PT who completed the resident's initial evaluation, but she thought she remembered the resident being very weak from a hospitalization for pneumonia. At 9:25 AM on 05/04/17 an electronic search revealed the van manufacturer reported no recalls on the model being used by the facility. At 10:16 AM on 05/04/17, during a telephone interview, a customer service representative for the company which manufactured the securement system in the facility transport van stated if the van was being used to transport a large number of residents with varying body types it was very important to individualize seat belt placement to achieve the safest angle at which the seat belt crossed the residents' bodies. He reported the standard was for the seat belt to cross the middle of the residents' shoulders which maximized the belt's ability to keep the residents seated. He commented he thought this standard was documented in the owner's manuals which accompanied the vans when they were purchased. According to the representative, it was difficult to achieve these effective seat belt angles without some type of device to regulate the height at which the seat belt began its decent across the resident's body. (The facility's 2017 transit van owner's manual documented, Position the safety belt height adjuster so that the safety belt rests across the middle of your shoulder. Failure to adjust the safety belt correctly could reduce its effectiveness and increase the risk of injury in a crash.) At 10:32 AM on 05/04/17 the administrator at the time of the van incident stated the facility van did not have any device to help regulate the angle at which the seat belt crossed resident bodies, and she was not aware that devices such as height adjusters were available. She explained the facility received the van in October 2016 from corporate so the facility had no interaction with the dealership where they might have mentioned devices that could be purchased to make securement more effective. At 11:18 AM on 05/04/17 the facility transporter secured Resident #110 in the transport van. The resident was in her personal wheelchair, and the transporter secured her in the van using a seat belt and four point tie downs. The seat belt crossed the resident below her shoulder, just below the mid-upper arm. The transporter confirmed that this was the way Resident #110 was secured on 04/20/17. (A 04/25/17 entry in Resident #110's weight summary documented she was 62 inches tall and weighed 108.5 pounds.) The resident had very small, thin, raised shoulders. The MM attempted to improve the angle at which the seat belt crossed the resident's body by moving the four point tie downs, but then the seat belt either cut into the resident's neck or fell completely off her shoulder. The MM stated he did not have the angulation problem when the transporter secured him in the van on 04/20/17, but he was about 70 inches tall and weighed about 204 pounds. The MM reported he had never observed Resident #110 secured in the facility van. At 12:35 PM on 05/04/17 the administrator at the time of the van incident stated the facility had not placed Resident #110 in the transport van to observe how she was secured as they were formulating their 04/20/17 post-incident action plan. At 1:30 PM on 05/04/17 PT #2, who completed Resident #110's initial physical therapy evaluation, stated during a telephone interview that she completed the initial eval before the resident left for dialysis on 04/20/17. She reported the resident was very weak, could only stand holding onto a rollator, and was unable to walk any at all. She explained that at this point in time it would have been necessary to transport the resident in her own wheelchair in the facility van. At 3:32 PM on 05/04/17 Resident #110's primary physician stated he was informed of the van incident on 04/20/17, and assessed the resident on 04/26/17. (The physician's progress note was reviewed). He reported upon observation of the resident she had a small hematoma, bruising, and skin tears. He commented the resident's swelling was minimal by the time he observed her. The physician stated he thought the resident's injuries looked worse than what they really were because the resident was on Plavix (A 04/19/17 physician order [REDACTED]. He reported Resident #110 did not complain to him or the staff about uncontrolled pain after the 04/20/17 van incident. At 3:45 PM on 05/04/17 the facility's social worker stated Resident #110 would be discharged from the facility on 05/09/17, and she would either be going home or to an assisted living facility. Between 9:32 AM and 10:00 AM on 05/05/17 4 of 7 residents identified by the facility as being alert and oriented and transported via wheelchair in the facility van from 04/20/17 to 05/04/17 were interviewed (Resident #64 and #110 were not re-interviewed, and one resident had since been discharged from the facility). All residents stated they were secured by the transporter using a seat belt and four point tie down system. All reported they thought the seat belt crossed their bodies about mid-shoulder, and they had no concerns about their safety when in the van. (Resident #24's cognition was intact per a 03/01/17 admission MDS, and was 71 inches tall and weighed 155.5 pounds on 05/04/17. Resident #35's cognition was moderately impaired per a 04/17/17 admission MDS, and was 67 inches tall and weighed 141.5 pounds on 05/04/17. Resident #40's cognition was severely impaired per a 04/09/17 quarterly MDS, and she was 66 inches tall and weighed 222.5 pounds on 05/04/17. Resident #69's cognition was moderately impaired per a 03/31/17 quarterly MDS, and was 66 inches tall and weighed 194 pounds on 05/04/17). On 05/04/17 at 12:25 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 05/05/17 at 11:50 AM: Affected Resident 1. Facility will provide Resident #110 with contracted transport services as needed effective 05/04/17. Other Residents with the Potential to be Affected 1. Facility will provide contracted transport services for all residents until facility transport van is back in service. 2. Resident census reviewed by DON, ADON and appointment scheduler to identify residents that require transportation on the facility van on 05/04/17 at 2:00 PM. 3. Manufacturer of van safety equipment customer service was contacted on 05/04/17, and will be sending to the facility the following items: height adjuster, new straps, decal which provides visual example of proper application of safety restraints, and training video. E-mail from representative acknowledged a Monday arrival date 05/08/17. 4. All new parts, height adjuster, new straps will be installed by local auto service technician. Scheduled for 05/09/17. 5. Prior to providing resident transportation staff involved in the transportation of residents will view the training video provided by manufacturer of van safety equipment on the proper fitting and application of all safety restraints. The maintenance director will be responsible for developing a hands-on training with return demonstration competencies based on the manufacturer's guidelines. This will be completed on an annual basis or with the new hire of van drivers by the maintenance director. 6. Van driver will complete a safety restraint checklist for all residents who utilize the facility van for transportation. The van driver will monitor for proper application. Residents will be evaluated utilizing safe seat belt practices that include: shoulder belt crosses between the shoulder and neck, lower back against seating device, lap belt on upper thighs and knees bent at edge of seat, to maintain proper securement. Visual aide will be posted inside van on the van interior wall showing proper placement of safety restraints prior to starting ignition. The validation of the credible allegation was completed on 05/05/17 at 12:05 PM by doing the following: At 11:35 AM on 05/04/17 the MM demonstrated his understanding of the angle at which the seat belt needed to cross resident bodies to ensure safe securement in the facility van. At 4:08 PM on 05/04/17 the contract with the facility's contracted transportation services was reviewed and validated. At 11:55 AM on 05/05/17 the list of 22 residents who required transport in the facility van was reviewed and validated. At 11:57 AM on 05/05/17 an e-mail from the securement system customer representative was reviewed which estimated arrival date of parts, decal, and training video as 05/08/17. At 11:59 AM on 05/05/17 it was verified with the MM that an appointment had been set up with local auto service to install new van securement parts on 05/09/17. At 12:02 PM on 05/05/17 ad-hoc quality assurance meeting notes were reviewed from 05/05/17 which included re-education about establishing the root cause of incidents/accidents. At 12:04 PM on 05/05/17 the facility van keys were observed stored in the new administrator's office drawer where they could not be obtained by other staff. 2. The facility Logbook Documentation for Water Temps was reviewed for January, February, March and April 2017. No temperatures above 116 degrees Fahrenheit were recorded. On 05/01/17 from 11:00 AM - 12:00 PM the following water temperatures that were above the acceptable temperature of 116 degrees Fahrenheit were taken by the Dietary Manager using the facility self-calibrating air thermometer: Room Temperature 308 120 306 122 300 121 301 120 310 122 303 122 The facility placed barrier duct tape across the top of all sinks and posted signs not to use the hot water. All residents residing in the above mentioned rooms were not able to access their bathrooms or sinks without staff assistance. On 05/01/17 from 3:00 PM - 4:25 PM the following water temperatures that were above the acceptable temperature of 116 degrees Fahrenheit were taken by the Dietary Manager and the Administrator using the facility manual thermometer that was calibrated in ice water to 32 degrees Fahrenheit: Room Temperature 308 118 306 119 300 119 301 119 310 119 303 119 In an Interview on 05/01/17 at 4:45 PM with the Maintenance Supervisor and the Administrator, the Maintenance Supervisor stated there were no mixing valves on the hot water heaters, only recirculating pumps. He said he turned off the recirculating pumps to cool down the water. He revealed the hot water heaters were already at the lowest setting and could not be further adjusted without the installation of a mixing valve. The Administrator stated she didn't know there wasn't a mixing valve on the hot water heaters. She said she thought these days everyone had a mixing valve. She said the hot water heater was only five weeks old. An observation was made at 5:30 PM on 05/01/17 that plumbers had arrived and installed a mixing valve. On 05/02/17 at 2:40 PM the temperature of the water in room 310 was observed to be 120 degrees Fahrenheit taken by the Maintenance Supervisor using the facility thermometer. The Maintenance Supervisor stated he was going to adjust the mixing valve. An observation on 05/02/17 at 3:45 PM of the water temperatures taken by the Maintenance Supervisor using the facility thermometer calibrated in ice water to 32 degrees Fahrenheit revealed that no temperatures were above the acceptable temperature of 116 degrees Fahrenheit: Room Temperature 101 107 102 108 107 108 110 105 201 110 207 110 210 108 211 110 300 112 303 109 306 110 310 110 401 109 402 110 In addition, the 100 Hall Shower Room temperature was 110 degrees Fahrenheit. On 05/04/2017 at 10:05 AM the facility Logbook Documentation for Water Temps was reviewed and all temperatures recorded were below 116 degrees Fahrenheit. In an Interview with Nurse #1 at 10:15 AM on 05/04/17 she stated that she had not experienced the water being too hot and had never known of anyone at the facility to be burned or injured by hot water. In an interview with CNA #1 at 10:20 AM on 05/04/17 she stated the water temperatures had not been too hot. Said she never knew of any resident who had been burned or injured from hot water in the facility.

Based on observation, physician interview, resident interview, staff interview, and record review the facility failed to provide sufficient training to the transporter and her supervisor, the maintenance manager (MM), regarding the individualization of resident securement in the facility van. Lack of training concerning the adjustment of the seat belt angulation based on resident height, weight, and body type resulted in 1 of 1 sampled residents involved in a van incident (Resident #110) receiving a hematoma, skin tears, swelling, and bruising. The immediate jeopardy (IJ) began on 04/20/17 when the facility transporter did not safely secure Resident #110 using a seat belt per instructions in the transit van owner's manual causing the resident to slide out of her wheelchair and sustain injuries when the transporter applied brakes and swerved to avoid a head-on collision. The IJ was removed on 05/05/17 at 12:05 PM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its new procedure for individualizing the wheelchair securement of residents in the facility transportation van. Findings included: Cross Refer to F323: Based on observation, physician interview, resident interview, staff interview, and record review the facility failed to individualize the securement of Resident #110 by achieving angulation of the seat belt across the resident as specified in the owner's manual for 1 of 1 sampled residents (Resident #110) who sustained injury in the facility transportation van. The resident slid out of her wheelchair during transport and landed on the floor of the van sustaining a hematoma, skin tears, swelling, and bruising. A corporate Vehicle Safety policy, effective 02/01/12 and reviewed on 07/15/15, documented the maintenance manager (MM) was responsible to educate authorized drivers on use of the company vehicle(s). The purpose of the policy included, To provide safe and reliable transportation for patients/residents. At 12:11 PM on 05/04/17 the facility transporter stated during her initial competency completed on 03/21/17 the MM taught her to verify residents had their seat belts fastened and their wheelchairs secured using a four point tie down system before transporting them in the facility van. However, she reported she never received any instruction about individualizing resident securement so that a safe angulation of the resident's seat belt was achieved. At 3:18 PM on 05/04/17 the MM stated the facility had provided him with no specialized training in transporting residents. He reported his training consisted of instruction from the maintenance manager at another facility about the importance of making sure seat belts were fastened, and demonstration about how to secure wheelchairs in the facility van using the tie down system. According to the MM, the facility had not provided him with information about how the seat belts should fit across secured van residents that he could pass on to the facility transporter. He explained he thought residents were safe if they were belted in, and did not realize that accidents could happen if the seat belts did not pass across the mid-shoulder of residents. On 05/04/17 at 12:25 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 05/05/17 at 11:50 AM: Affected Resident 1. Facility will provide Resident #110 with contracted transport services as needed effective 05/04/17. Other Residents with the Potential to be Affected 1. Facility will provide contracted transport services for all residents until facility transport van is back in service. 2. Resident census reviewed by DON, ADON and appointment scheduler to identify residents that require transportation on the facility van on 05/04/17 at 2:00 PM. 3. Manufacturer of van safety equipment customer service was contacted on 05/04/17, and will be sending to the facility the following items: height adjuster, new straps, decal which provides visual example of proper application of safety restraints, and training video. E-mail from representative acknowledged a Monday arrival date 05/08/17. 4. All new parts, height adjuster, new straps will be installed by local auto service technician. Scheduled for 05/09/17. 5. Prior to providing resident transportation staff involved in the transportation of residents will view the training video provided by manufacturer of van safety equipment on the proper fitting and application of all safety restraints. The maintenance director will be responsible for developing a hands-on training with return demonstration competencies based on the manufacturer's guidelines. This will be completed on an annual basis or with the new hire of van drivers by the maintenance director. 6. Van driver will complete a safety restraint checklist for all residents who utilize the facility van for transportation. The van driver will monitor for proper application. Residents will be evaluated utilizing safe seat belt practices that include: shoulder belt crosses between the shoulder and neck, lower back against seating device, lap belt on upper thighs and knees bent at edge of seat, to maintain proper securement. Visual aide will be posted inside van on the van interior wall showing proper placement of safety restraints prior to starting ignition. The validation of the credible allegation was completed on 05/05/17 at 12:05 PM by doing the following: At 11:35 AM on 05/04/17 the MM demonstrated his understanding of the angle at which the seat belt needed to cross resident bodies to ensure safe securement in the facility van. At 4:08 PM on 05/04/17 the contract with the facility's contracted transportation services was reviewed and validated. At 11:55 AM on 05/05/17 the list of 22 residents who required transport in the facility van was reviewed and validated. At 11:57 AM on 05/05/17 an e-mail from the securement system customer representative was reviewed which estimated arrival date of parts, decal, and training video as 05/08/17. At 11:59 AM on 05/05/17 it was verified with the MM that an appointment had been set up with local auto service to install new van securement parts on 05/09/17. At 12:02 PM on 05/05/17 ad-hoc quality assurance meeting notes were reviewed from 05/05/17 which included re-education about establishing the root cause of incidents/accidents. At 12:04 PM on 05/05/17 the facility van keys were observed stored in the new administrator's office drawer where they could not be obtained by other staff.

Based on observation, physician interview, resident interview, staff interview, and record review the facility failed to identify the root cause of an accident utilizing its quality assessment and performance improvement (QAPI) process and a performance improvement plan (PIP) which it developed for 1 of 1 sampled residents (Resident #110) who sustained injuries in a van incident. The resident slid out of her wheelchair during transport and landed on the floor of the van sustaining a hematoma, skin tears, swelling, and bruising. Because the facility did not identify the root cause of the 04/20/17 incident, Resident #110 was not safely secured utilizing a seat belt in the facility's transportation van when she was picked up from the emergency roiagnom on the night of 04/20/17 and when she traveled back and forth between [MEDICAL TREATMENT] on 04/25/17, 04/27/17, and 05/02/17. The immediate jeopardy (IJ) began on 04/20/17 when the facility transporter applied brakes and swerved to avoid a head-on collision, causing the resident to slide out of her wheelchair and sustain injuries when she hit the floor of the van. The IJ was removed on 05/05/17 at 12:05 PM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its new procedure for individualizing the wheelchair securement of residents in the facility transportation van and to educate its QAPI committee members about root cause analysis. Findings included: Cross Refer to F323: Based on observation, physician interview, resident interview, staff interview, and record review the facility failed to individualize the securement of Resident #110 by achieving angulation of the seat belt across the resident as specified in the owner's manual for 1 of 1 sampled residents (Resident #110) who sustained injury in the facility transportation van. The resident slid out of her wheelchair during transport and landed on the floor of the van sustaining a hematoma, skin tears, swelling, and bruising. Review of minutes from a 04/24/17 Performance Improvement meeting revealed the facility developed a PIP regarding the 04/20/17 van incident involving Resident #110. Recommendations made in this meeting included having the transporter stay at the incident scene until the highway patrol arrived, having the transporter complete a defensive driving course, making pictures of the incident scene, completion of a police report, having the transporter complete another driving competency after the incident, obtaining emergency room reports for Resident #110, and inspecting the seat belt and tie downs in the facility van. At 11:02 AM on 05/03/17 the administrator at the time of the 04/20/17 van incident stated the 04/24/17 PIP was used as a tool to investigate the cause for Resident #110's injuries. She reported the facility found the van transporter had not done anything wrong, and determined the resident accidentally slipped under the seat belt and into the van floor. At 2:50 PM on 05/04/17 the director of nursing (DON) stated because of the resident's extensive injuries from the 04/20/17 van incident the facility did not want to disturb her or cause her more pain post-accident by asking her if they could observe her wheelchair securement in the facility transport van. At 3:32 PM on 05/04/17, during a telephone interview, Resident #110's primary physician and facility medical director stated he attended the monthly quality assurance (QA) meetings, but was not able to be present for the ad-hoc (called for an immediate and special purpose) QA meeting on 04/24/17. However, he reported the facility informed him of the van incident involving the resident within an hour of it happening. He commented he was told the QA committee would be developing a PIP. According to the medical director, the purpose of investigating incidents/accidents was to determine their root cause and how to change facility processes to make sure similar accidents did not happen in the future. During a follow-up interview with the administrator at the time of the 04/20/17 van incident she stated the PIP was the facility's form of root cause analysis. She reported if the facility had extended their investigation a little further by observing Resident #110 when she was secured in the facility van the QAPI committee might have seen that the seat belt did not cross the resident's body at an effective angle to keep the resident safe. She commented the medical director was informed of the 04/24/17 Performance Improvement meeting, but was unable to attend. According to the administrator, the medical director was asked for his post-incident input, and his main focus was addressing the resident's pain/comfort and psychosocial needs. On 05/04/17 at 12:25 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 05/05/17 at 11:50 AM: Affected Resident 1. Facility will provide Resident #110 with contracted transport services as needed effective 05/04/17. Other Residents with the Potential to be Affected 1. Facility will provide contracted transport services for all residents until facility transport van is back in service. 2. Resident census reviewed by DON, ADON and appointment scheduler to identify residents that require transportation on the facility van on 05/04/17 at 2:00 PM. 3. Manufacturer of van safety equipment customer service was contacted on 05/04/17, and will be sending to the facility the following items: height adjuster, new straps, decal which provides visual example of proper application of safety restraints, and training video. E-mail from representative acknowledged a Monday arrival date 05/08/17. 4. All new parts, height adjuster, new straps will be installed by local auto service technician. Scheduled for 05/09/17. 5. Prior to providing resident transportation staff involved in the transportation of residents will view the training video provided by manufacturer of van safety equipment on the proper fitting and application of all safety restraints. The maintenance director will be responsible for developing a hands-on training with return demonstration competencies based on the manufacturer's guidelines. This will be completed on an annual basis or with the new hire of van drivers by the maintenance director. 6. Van driver will complete a safety restraint checklist for all residents who utilize the facility van for transportation. The van driver will monitor for proper application. Residents will be evaluated utilizing safe seat belt practices that include: shoulder belt crosses between the shoulder and neck, lower back against seating device, lap belt on upper thighs and knees bent at edge of seat, to maintain proper securement. Visual aide will be posted inside van on the van interior wall showing proper placement of safety restraints prior to starting ignition. The validation of the credible allegation was completed on 05/05/17 at 12:05 PM by doing the following: At 11:35 AM on 05/04/17 the MM demonstrated his understanding of the angle at which the seat belt needed to cross resident bodies to ensure safe securement in the facility van. At 4:08 PM on 05/04/17 the contract with the facility's contracted transportation services was reviewed and validated. At 11:55 AM on 05/05/17 the list of 22 residents who required transport in the facility van was reviewed and validated. At 11:57 AM on 05/05/17 an e-mail from the securement system customer representative was reviewed which estimated arrival date of parts, decal, and training video as 05/08/17. At 11:59 AM on 05/05/17 it was verified with the MM that an appointment had been set up with local auto service to install new van securement parts on 05/09/17. At 12:02 PM on 05/05/17 ad-hoc quality assurance meeting notes were reviewed from 05/05/17 which included re-education about establishing the root cause of incidents/accidents. At 12:04 PM on 05/05/17 the facility van keys were observed stored in the new administrator's office drawer where they could not be obtained by other staff.

Based on observation, record reviews and staff interviews, the facility failed to provide treatment to a resident who had pressure ulcers on both feet, which resulted in an infection for 1 of 2 sampled residents (Resident #5). Findings included: Review of the facility guideline titled "Skin Integrity/Wound Care Guideline April 2009 Update" provided by Nurse #5 indicated as a guideline for heel ulcer prevention and management staff would "Monitor area for any evidence of infection including [DIAGNOSES REDACTED], warmth, pain, swelling, fever and drainage." Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] indicated the resident had no impairment with cognition or decision making ability and was totally dependent with one person physical assist for personal hygiene. Resident #5 was coded as having two Stage 2 pressure ulcers and two Stage 4 pressure ulcers. Review of Resident #5 hospital records dated 5/28/10 indicated Resident #5 "Underwent debridement of both calcaneous (heel bone) ulcers with abscess on 5/23/10. The hospital history and physical dated 5/28/20 also indicated the pathology report was positive for acute osteo[DIAGNOSES REDACTED] and wound cultures showed evidence of Proteus and [MEDICAL CONDITION]-resistant Staphylococcus aureus. The resident was placed on [MEDICATION NAME] and [MEDICATION NAME] while in the hospital." Review of the hospital discharge summary dated 7/19/10 indicated "Initially she was continued on a Wound Vac, however, this was subsequently discontinued and she was placed on dressing changes to both heels, which consisted of cleansing with SAF-Clens Monday, Wednesday, and Friday to both lower extremities. The patient continued to be noncompliant during her hospital stay. She was refusing medications at times. She was refusing blood draws at times, but overall, she did improve to the point where her wounds have good granulation tissue. No other complications were noted during her stay. Plans were made for discharge to nursing home in Pembroke." Review of the hospital discharge orders dated 7/19/10 indicated the resident was "Stable" . There was no mentioning of an active infection, foul odor from wounds or discharge antibiotics. Review of the nursing facility admission history and physical assessment dated [DATE] completed by the nursing home physician did not indicate a foul odor, active infection and/or ordered antibiotics upon admission. Review of the nursing admission assessment dated [DATE] indicated the resident was admitted with wounds to both feet that measured 7?5 centimeters (right heel) and 8?5.5 centimeters (left heel). Both wounds were indicated as "Unstage." The skin description indicated "Pink, warm and skin turgor with no tenting (within normal parameters that it takes for the skin to return to normal position). The resident was documented as "Having pain and was currently receiving pain medications." No foul odor was indicated. Review of the "Pressure Ulcer/Vascular Log" revealed the following measurements: Left Heel (Pressure Ulcer) ? 8/4/10 resulted 8?5.5 centimeters ? 8/25/10 resulted 8?6.0 centimeters Left Foot (Vascular Ulcer) ? 8/18/10 resulted 4?6.5?0.2 centimeters ? 8/25/10 resulted 4?6.5?0.2 centimeters Right heel (Pressure Ulcer) ? 8/4/10 resulted 7?5.0 centimeters ? 8/25/10 resulted 8?6.5 centimeters The wound care notes dated 8/7/10 and 8/11/10 indicated the resident ulcers had a foul odor. The last wound care note dated 8/18/10 did not mention a foul odor to ulcers on both feet. Review of the last completed skin assessment dated [DATE] did not mention a foul odor to ulcers on both feet. The wound care note indicated "Right heel wound measures 8 ? 7.5 centimeters with no depth, moderate to heavy drainage noted. Drainage soaked through dressing as well as serosanguious drainage noted on the bed. Wound on left heel measures 7.5 ? 6.5 centimeters and wound at top of foot measures 4.0 ? 6.5 centimeters and resident complaint of pain during dressing changes." Resident #5's Resident Assessment Protocol Summary (RAPS) dated 7/27/10 indicated a problem area checked for pressure ulcers and was addressed in the care plan. RAP worksheet dated 7/27/10 indicated "Will monitor for signs/symptoms of infection and will follow up with MD (medical doctor) as needed for sign/symptoms of infection." Care plan dated 7/27/10 indicated as an intervention for impaired skin integrity related to pressure ulcers to heels of the feet staff would keep skin clean and dry and perform weekly skin assessments. Review of the treatment record for August1st-August 31 2010 indicated resident #5 received the following treatment "Cleanse both lower extremities with wound cleanser, pat dry, cover wound bed with [MEDICATION NAME] AG followed by hydrofoam and wrap with kerlix and tape every Monday-Wednesday-Friday." The last treatment done was on 9/1/10 as indicated on the treatment record. Review of the obtained laboratory results of the white blood cell count indicated: ? 7/13/10 resulted 7.4 normal values (4.5-12.5) ? 7/5/10 resulted 5.9 normal values (4.5-12.5) ? 6/28/10 resulted 5.3 normal values (4.5-12.5) Observation on 9/1/10 at 11:15 am revealed the left heel, bottom of the left feet and right heel ulcerations had a foul odor with yellow slough and brownish drainage on the kerlix gauze to each wound. The resident displayed facial grimace during treatment provided by Nurse #5. The wounds were cleaned and dressed according to the treatment order. Interview on 9/1/10 at 11:10 am with Resident #5 indicated the wounds to both feet had a foul odor for 1 month and she sometimes experienced pain and the nurses medicated her when she requested. She indicated she refused the pain medication when offered by the nurse during the morning med pass. Interview on 9/1/10 at 2:25 pm with Nurse #5 (Unit Manager) indicated the wounds had a foul odor since admission (7/19/10). She further indicated on admission the resident was not admitted with any orders for antibiotics. She stated she had not notified the resident's physician since admission regarding the foul odor. Interview on 9/1/10 at 2:45 pm with the Director of Nursing (DON) indicated she was notified 2 days ago that Resident #5's room mate had complained of a foul odor in the room. She indicated that she was notified on 8/31/10 regarding the foul odor to the resident's feet. The DON further indicated she expected nurses to notify the resident's physician of any foul odor when first noticed, so labs could be ordered and the resident's physician can direct how to care for the foul odor to the wounds. Interview on 9/1/10 at 3:05 pm with Nurse #6 indicated she had noticed the foul odor since the resident was admitted . She indicated she had not reported the odor to the unit manger, director of nursing or the resident's physician but had discussed the odor with the nurse aides. Interview on 9/1/10 at 3:10 pm with NA #7 indicated she had noticed the foul odor about 3-4 weeks ago and did not report it because she was assured that the nurses were already aware. Interview on 9/1/10 at 3:15 pm with NA #8 indicated she noticed the foul odor 2 days ago. NA #9 indicated she noticed the foul odor 2 weeks after the resident's admission into the facility. Both NA's indicated they did not report the foul odor to anyone because they assume that all staff was aware. Interview on 9/1/10 at 3:20 pm with Nurse #9 indicated she noticed a foul odor during the past weekend Saturday and Sunday and upon admission into the facility. She further indicated she did not notify any one because it was expected considering the resident's wound history. Interview on 9/1/10 at 4:50 pm with the resident's physician indicated he expected to be notified as soon as the foul odor was noted to both foot ulcers. He further indicated he was notified today and gave orders for the resident to start on [MEDICATION NAME]-[MEDICATION NAME] (antibiotic) 800-160 mg tablet one by mouth twice daily for 10 days and for staff to obtain a wound culture and sensitivity to feet ulcers of both feet due to the foul odor of the ulcers. Review of the laboratory report titled "Microbology/Routine Culture specimen/source: Abscess/Right heel" dated 9/3/10 revealed: ? GRAM (final) Gram Positive Cocci Few Squamous [MEDICATION NAME] Cells ? CULT (Final) Mixed Flora ? ISO1 (Final) 4+ Proteus mirabilis ? ISO2 (Final) 3+ Coagulase Negative Staphylococcus

Based on record review, resident interview, and staff interviews, the facility failed to prevent pests in 2 of 5 sampled residents' rooms where resident #6 and resident #7 were bitten by ants. Findings include: 1. Resident #6 was admitted on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had no short or long term memory problems. The MDS revealed no impairment in cognitive skills for daily decision making. The MDS revealed the resident was totally dependent on staff for all activities of daily living (ADLS) except eating. The MDS revealed the resident was bedfast all or most of the time. Record review of the facility's 24 hour report dated 8/23/10 revealed an entry for resident #6 which read "ant bites R (right) thigh." A Pest Sighting Memo dated 8/23/10 at 9:00AM read in part "Pest sighted: ants, Location: 211,213, 215, 214, under beds, behind beds and they were in bed biting residents." In an interview on 9/1/10 at 8:30AM, NA (nursing assistant)#1 stated she made rounds every 2 hours to assess the residents. NA#1 stated if pests were observed, she would report to the nurse or Maintenance Director. NA#1 stated she had not observed any pests in the facility. NA#1 stated ants had been reported several weeks ago on the 200 hall. NA#1 stated the affected rooms had been sprayed. In an interview on 9/1/10 at 8:56AM, NA#2 stated ants had been reported the week before, on Saturday 8/21/10. NA#2 stated she had observed ants in rooms 211, 213, 214, and 215, which included resident #6's room, on Saturday 8/21/10. NA#2 stated she observed the ants crawling around the air conditioning (AC) units and along the baseboards in those rooms. NA#2 stated she reported to the nurse and unit manager at that time. NA#2 stated the ants were still there the next day. NA#2 stated the staff told her that resident #6 had received bites from the ants. NA#2 stated she examined resident #6 and observed "9 or 10 bites" on her right thigh. NA#2 stated she reported the bites to the nurse. In an interview on 9/1/10 at 9:35AM, the unit manager (nurse #1) stated the weekend supervisor reported finding ants in rooms 211, 213, and 215 on Saturday, 8/21/10. She stated the resident in room 211 was moved to another room and later returned. She stated ants had been observed crawling in resident #6's bed. She was unsure if resident #6 had received any bites from the ants. She stated the nursing staff should have documented any findings in the nursing notes. The unit manager stated she notified the Director of Nursing (DON) on 8/21/10 but had not notified the Maintenance Director. In an interview on 9/1/10 at 11:20AM, the Maintenance Director stated he was responsible for pest control. The Maintenance Director stated if the staff observed any pests, they completed a Pest Sighting Memo and reported to him. The Maintenance Director stated he would spray the affected rooms immediately and call the pest control vendor. He stated the vendor received copies of the memos to help identify problem areas. He stated the vendor usually responded the same day and would also come on the weekend if called. He stated the vendor came the first Wednesday of every month for routine treatment. The Maintenance Director stated since it was the weekend, he was not in the facility on 8/21/10 when the ants were reported on 200 hall. He stated no one called or notified him. He stated he would expect to be called on the weekend if pests were discovered. In an interview on 9/1/10 at 12 Noon, resident #6 stated she had been bitten by ants while in bed recently, but didn't recall the exact date. The resident stated she reported the bites to her CNA (certified nursing assistant), who then notified the nurse. The resident stated she was bitten multiple times on her right leg. She stated the staff removed her from bed, sprayed her room, and put her back to bed several hours later. She stated the staff applied cream to the bites, which relieved the itching. She stated her room was treated by pest control later, but she wasn't sure when. In telephone interview on 9/1/10 at 1:37PM, NA#3 stated she worked the third shift and came in around 10:30PM. NA#3 stated she checked resident #6 when making rounds and discovered ants in the bed. NA#3 stated she got resident #6 up, stripped the bed, and sprayed around the bed. NA#3 stated she notified the nurse on duty. NA#3 stated she saw ants around the resident's AC unit and around the baseboard. NA#3 stated she checked the room for food or crumbs but found none. NA#3 stated she observed 3 or 4 bites on the resident's right upper leg. NA#3 stated a stock cream was applied on the resident's bites. The Maintenance Director provided copies of the pest control vendor's reports. The report dated 6/2/10 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around window seals in residents' rooms." The report dated 7/710 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around window seals in residents' rooms." The report dated 7/16/10 read in part "Structural Deficiencies: cracks around baseboarding & window seals in residents' rooms." The report dated 7/22/10 read in part "Structural Deficiencies: cracks around AC units in resident rooms allowing for pest entry. Summary and Recommendations: Suggest caulking around units and screening around units on exterior." The report dated 8/9/10 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around AC units in resident rooms." In an interview on 9/1/10 at 3:15PM, the Maintenance Director stated he was responsible for completing the structural repairs identified by the pest control vendor. The Maintenance Director stated he had started to make some repairs but had not completed them. He stated he had not done any repairs on the 200 hall. In a telephone interview on 9/1/10 at 4:00PM, Nurse #3 stated he was the weekend supervisor for all halls. Nurse #3 stated the staff didn ' t notify him of the ants in residents' rooms until about 3:00PM on 8/21/10. Nurse #3 stated he questioned the nurses to determine what had been done. Nurse #3 stated he called the DON to be sure she had been notified. Nurse #3 stated "I think it was reported to the Maintenance Director." Nurse #3 stated the pest control vendor did not come to the facility that weekend. Nurse #3 stated he was unaware that resident #6 had been bitten until Sunday the 22nd. In an interview on 9/1/10 at 4:30PM, the DON stated she was not aware of resident #6 having ants in her room until later. She stated there should have been documentation on the weekend report, 24 hour report, or change of condition report. The DON stated she wasn't aware that resident #6 had received any bites from the ants. In an interview on 9/1/10 at 4:46PM, the DON stated the facility was under contract with a pest control company and received routine service and inspections. She stated the Maintenance Director would be notified immediately, including weekends, of any signs of pests. The DON stated she was made aware of the ants on 200 hall on 8/20/10 and 8/21/10. She stated she didn't know why the Maintenance Director had not been called. In an interview on 9/1/10 at 5:14PM, the Administrator stated the facility received service from a pest control company monthly and as needed. The Administrator stated she could review the vendor's reports but they were usually reviewed and filed by the Maintenance Director. The Administrator stated the weekend staff had not called the Maintenance Director to notify him of the ants on 200 hall. The Administrator stated the Maintenance Director was notified on Monday the 23rd. The Administrator stated the Maintenance Director was asked to call pest control, and to spray and deep clean the affected rooms. The Administrator stated the increased heat and rainfall had increased pests and she didn't think screening or caulking would help. She stated cleaning, spraying, and removing items attractive to ants would have more impact. When asked if she expected the Maintenance Director to follow the pest control vendor's recommendations, the Administrator stated "if it would help and be feasible for us." 2. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed the resident had short and long term memory problems and severly impaired cognitive skills for daily decision making. The MDS revealed the resident was totally dependent on staff for all ADLS. Record review of the facility's 24 hour report dated 8/20/10 revealed an entry for resident #7 which read "ants in room/bed, ant bites on resident." An entry dated 8/21/10 read "ant bites 8/20/10 3-11 (3PM-11PM shift) Red blistered areas to Rt (right) arm & abd (abdominal) area, [MEDICATION NAME] ([MEDICATION NAME]) Admin (administered)." Record review of a Change of Condition Documentation form dated 8/20/10 revealed an entry at 10:30PM which read in part "CNA making rounds for diaper change (symbol) Found ants on pt (patient)/in bed c (with) pt. Ant bites noted to R (right) upper/lower extremities, abdomnial region. VO (verbal order) [MEDICATION NAME] 25mg (milligram) po (by mouth) q6 (every 6 hours) prn (as needed)." Record review of Interdisciplinary Progress Notes dated 8/21/10 revealed an entry at 8:10AM which read in part "resident continues to have redness & rashes to Rt (right) arm & abd [MEDICATION NAME] 25mg admin x (times) 1 for rashes & itching." A Pest Sighting Memo dated 8/23/10 at 9:00AM read in part "Pest sighted: ants, Location: 211,213, 215, 214, under beds, behind beds and they were in bed biting residents." In an interview on 9/1/10 at 8:30AM, NA #1 stated she made rounds every 2 hours to assess the residents. NA#1 stated if pests were observed, she would report to the nurse or Maintenance Director. NA#1 stated ants had been reported several weeks ago on the 200 hall. NA#1 stated the affected rooms had been sprayed. In an interview on 9/1/10 at 8:56AM, NA#2 stated ants had been reported the week before, on Saturday 8/21/10. NA#2 stated she had observed ants in rooms 211, 213, 214, and 215, which included resident #7's room. NA#2 stated she observed the ants crawling around the air conditioning units and along the baseboards in those rooms. NA#2 stated she reported to the nurse and unit manager at that time. NA#2 stated the ants were still there the next day. In an interview on 9/1/10 at 9:35AM, the unit manager (nurse #1) stated the weekend supervisor reported finding ants in rooms 211, 213, and 215. She stated a nurse had reported to her on Saturday 8/21/10 that resident #7 had received bites from the ants. The unit manager stated she had notified the Director of Nursing (DON) but had not notified the Maintenance Director. Nurse #1 stated she did not know when the exterminator was called. She stated the nursing staff should have documented any findings in the nursing notes. In an interview on 9/1/10 at 11:20AM, the Maintenance Director stated he was responsible for pest control. The Maintenance Director stated if the staff observed any pests, they completed a Pest Sighting Memo and reported to him. The Maintenance Director stated he would spray the affected rooms immediately and call the pest control vendor. He stated the vendor received copies of the memos to help identify problem areas. He stated the vendor usually responded the same day and would also come on the weekend if called. He stated the vendor came the first Wednesday of every month for routine treatment. The Maintenance Director stated since it was the weekend, he was not in the facility on 8/21/10 when the ants were reported on 200 hall. He stated no one called or notified him. He stated he would expect to be called on the weekend if pests were discovered. The Maintenance Director provided copies of the pest control vendor's reports. The report dated 6/2/10 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around window seals in residents' rooms." The report dated 7/710 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around window seals in residents' rooms." The report dated 7/16/10 read in part "Structural Deficiencies: cracks around baseboarding & window seals in residents' rooms." The report dated 7/22/10 read in part "Structural Deficiencies: cracks around AC units in resident rooms allowing for pest entry. Summary and Recommendations: Suggest caulking around units and screening around units on exterior." The report dated 8/9/10 read in part "Structural Deficiencies: holes around pipes in laundry & food prep area. Cracks around AC units in resident rooms." In an interview on 9/1/10 at 3:15PM, the Maintenance Director stated he was responsible for completing the structural repairs identified by the pest control vendor. The Maintenance Director stated he had started to make some repairs but had not completed them. He stated he had not done any repairs on the 200 hall. In a telephone interview on 9/1/10 at 4:00PM, Nurse #3 stated he was the weekend supervisor for all halls. Nurse #3 stated the staff didn't notify him of the ants in residents' rooms until about 3:00PM. Nurse #3 stated resident #7 had received bites from the ants. Nurse #3 stated he questioned the nurses to determine what had been done. Nurse #3 stated the rooms were sprayed. Nurse #3 stated [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) were ordered for resident #7. Nurse #3 stated he called the DON to be sure she had been notified. Nurse #3 stated "I think it was reported to the Maintenance Director." Nurse #3 stated the pest control vendor did not come to the facility that weekend. In an interview on 9/1/10 at 4:46PM, the DON stated the facility was under contract with a pest control company and received routine service and inspections. She stated the Maintenance Director would be notified immediately, including weekends, of any signs of pests. The DON stated she was made aware of the ants on 200 hall on 8/20/10 and 8/21/10. She stated she didn't know why the Maintenance Director had not been called. In an interview on 9/1/10 at 5:14PM, the Administrator stated the facility received service from a pest control company monthly and as needed. The Administrator stated she could review the vendor's reports but they were usually reviewed and filed by the Maintenance Director. The Administrator stated the weekend staff had not called the Maintenance Director to notify him of the ants on 200 hall. The Administrator stated the Maintenance Director was notified on Monday the 23rd. The Administrator stated the Maintenance Director was asked to call pest control, and to spray and deep clean the affected rooms. The Administrator stated the increased heat and rainfall had increased pests and she didn't think screening or caulking would help. She stated cleaning, spraying, and removing items attractive to ants would have more impact. When asked if she expected the Maintenance Director to follow the pest control vendor's recommendations, the Administrator stated "if it would help and be feasible for us." In a telephone interview on 09/03/10 @ 1:40PM, NA #4 stated she discovered ants on resident #7 and in the bed when making rounds about 10:30PM on 8/20/10. NA #4 stated she notified the nurse immediately. NA #4 stated she, the nurse, and another NA got the resident out of bed and assessed her. NA #4 stated she observed bites on resident #7's side. NA #4 stated resident #7 could not verbalize her needs. The nurse (#4) on duty at the time the ants were discovered in resident #7's bed was unavailable for interview. Attempts to contact her were unsuccessful.