Every finding on record at Piedmont Hills Center for Nursing and Rehab

Based on record review and interviews of the staff, Family Member, Responsible Party, Paramedic, Nurse Practitioner (NP), Psychiatry NP, and Medical Director, the facility failed to identify the seriousness of new behaviors and increased confusion and complete and document thorough on-going assessments of a resident which delayed medical interventions and treatment. On 10/2/25 nursing staff were aware Resident #1 was undressing, which was a change for the resident and as the day progressed, he became more confused and agitated. A family member visited that evening and found the resident naked on the floor in his room. The family member reported to the nurse that the undressing was out of character for the resident, and he was agitated. The family member told the nurse she felt like something was wrong and asked the nurse to call 911. The nurse checked the resident's temperature, pulse and respirations which were within normal limits and told the family member they would take care of it. The family member returned at approximately 11:00 PM and found the resident naked on the floor again and called 911. Emergency Medical Services (EMS) transported Resident #1 to the hospital where he was diagnosed with acute encephalopathy (any disorder or disease affecting brain function), acute respiratory failure (a life- threatening impairment of oxygenation, carbon dioxide elimination or both) with hypoxia (low levels of oxygen in body tissue), hypotension (low blood pressure), lactic acidosis (excessive buildup of lactic acid in the blood), acute kidney injury (abrupt decrease in kidney function), and transaminitis (liver enzymes elevated), septic shock (a serious medical condition that occurs when an infection leads to extremely low blood pressure and organ failure) and aspiration pneumonia (an infection caused by inhaling food, liquid, saliva or stomach contents into the lungs). The resident was admitted to the intensive care and required fluid resuscitation and medication to maintain his blood pressure, antibiotic treatment, and 3 days of ventilator life support. Resident #1 was discharged from the hospital on [DATE]. In addition, the facility failed to complete thorough and ongoing assessments including neurological checks (a series of neurological observations and neurological system checks conducted by nursing staff to identify any signs or symptoms of a potential neurological abnormality) after a fall occurred which caused a delay in receiving further medical evaluation and treatment. The deficient practices affected 2 of 3 residents reviewed for professional standards and hospitalization (Resident #1 and Resident #5).The findings included:1. Resident #1 was admitted on [DATE] with the diagnoses of metabolic encephalopathy (the brain does not function properly) from poly pharmacy (many different medications), dysphagia and stroke. Resident #1 had NP notes documented for 9/26/25 and 9/29/25. The notes documented the resident was alert to self and situation and was able to answer questions. The resident was participating in therapy. There were no behaviors reported. The NP was interviewed on 10/21/25 at 11:20 am. The NP stated she saw Resident #1 on 9/26/25 and 9/29/25 as a new admit. The resident had intermittent confusion but was dressed and appropriate and able to answer questions. Staff reported the resident was cooperative. There was no report of him taking his clothing off, refusing care with combativeness, or wandering. There were no behaviors. The NP stated if the behaviors were new and not baseline, she would be concerned about infection and start testing. If the resident was not stable, she would send him out to the hospital. A nurses' note dated 9/27/25 at 5:42 pm written by the Unit Manager documented Resident #1 had vital sign results for temperature 97.5 (normal value 96 to 99), pulse 74 (normal value 60 to 100) and regular, respirations 19 (normal value 12 to 20), and blood pressure was 121/68 (normal value 120/80). His oxygen saturation was 97.0 % (normal value 90 to 100%) on room air. The resident was alert with intermittent confusion. He had short term memory loss and usually understands and was understood. The resident had normal chest respirations, and his lungs were clear. The Unit Manager was interviewed on 10/21/25 at 10:50 am. The Unit Manager stated she was assigned to Resident #1 on 9/27/25 during the day shift (7:00 am to 3:00 pm). The resident had intermittent confusion. The Unit Manager stated she had not recalled the resident removing his clothing, refusing care, or being combative. The resident was appropriate and cooperative. There was no nursing assistant (NA) report of confusion, combativeness, or clothing removal. A nurses' note dated 9/29/25 at 7:17 pm by Nurse #1 documented Resident #1's vital sign results were temperature 97.2, pulse 73 and regular, respirations 8 and blood pressure 110/62. His oxygen saturation was 96.0 % on room air. The resident was alert with intermittent confusion. He had short term memory loss and usually understands and was understood. The resident had normal chest respirations, and his lungs were clear. Nurse #1 was interviewed on 10/21/25 at 10:00 am. Nurse #1 stated she was assigned to Resident #1 on 9/29/25 during the evening shift (3:00 pm to 11:00 pm). He was a new admit and was oriented to self and situation. He was wearing his clothes. The admission Minimum Data Set for Resident #1 dated 9/30/25 documented he had moderate cognitive impairment, clear speech, understands, and was understood, was feeling down, and had trouble falling asleep. Toileting required moderate/maximal assistance. The resident's diagnoses were stroke, hemiplegia (one sided weakness, communication/speech language deficit following stroke, and dysphagia. Resident #1's care plan dated 9/30/25 documented the resident was a high risk for falls and had an actual fall with no injury. The interventions were to round frequently and offer care and a reminder for use of the call light. The resident had a swallowing deficit, and the interventions were for small bites and sips, no straws, and check after meals for food pocketing. Resident #1's Psychiatric NP visit note dated 9/30/25 documented he was seen for an initial assessment. The resident was alert and oriented x 2 (self and situation) and calm and cooperative. He was new to the facility after hospital discharge for acute encephalopathy and had a history of cognitive communication deficit and insomnia. The resident was sitting in his room at the bedside. He reported feeling hopeless and down due to his health and being in a facility. The resident reported he had been engaging in activities at the facility and had been interacting with his roommate. The nursing staff had not reported any behavioral concerns. The resident had been seen by therapy. The Psychiatric NP was interviewed on 10/22/25 at 11:10 am. The Psychiatric NP stated Resident #1 was wearing his clothing on 9/30/25 and there was no report from nursing about behaviors or the resident removing his clothing. The resident was oriented to person and situation, appropriate, and able to answer questions. The Occupational Therapist note (OT) note dated 10/1/25 documented Resident #1 participated in upper and lower body exercises. The resident continued to need assistance and was compliant with skilled interventions. On 10/22/25 at 1:52 pm an interview was conducted with the OT. The OT stated she was assigned to Resident #1 on 10/1/25 in the morning. His diagnoses were a stroke with spastic hemiplegia. The resident was alert and oriented to self and situation. He was dressed and appropriate. The OT indicated Resident #1 was able to follow commands and participate but was limited in answering questions and he seemed a little agitated. Resident #1 had an admission progress dated 10/2/25 (time was not indicated on the note) written by the Medical Director. The progress note documented that the resident had a history of metabolic encephalopathy (the brain does not function properly) from medication and being found unresponsive by his roommate. The resident was alert but appeared confused after returning from therapy. There was no report from nursing of any complaints or concerns. The resident's judgement and insight was appropriate with a normal affect (facial expression). The resident is well developed (physical attributes are normal), in no acute distress, and lying in bed resting comfortably. Resident #1's nurses' note 10/2/25 at 5:00 pm written by Nurse #1 documented Resident #1's vital sign results were temperature 97.4, pulse 74 and regular, and respirations 18. He was oriented to person and place with intermittent confusion. Nursing assistant (NA) #1 reported the resident disrobed and did not want to get dressed. There was no oxygen saturation documented in the record. On 10/20/25 at 11:50 am the Family Member was interviewed. The Family Member stated she visited Resident #1 on 10/2/25 at 7:00 pm. Upon entering the resident's room, he was found naked, and the resident reported to the Family Member the nurse was asked to help him get dressed, but the assigned nurse (Nurse #1) replied she was not going to help him get dressed. The Family Member stated the resident was not acting his normal self. The Family Member asked Nurse #1 and she (Nurse #1) commented that the resident was not his normal self and the NA was asked to assist with the clothes. The Family Member informed Nurse #1 the resident had changed behavior, and undressing was out of character for him. The Family Member further reported something was wrong, he was agitated, and up and down. The Family Member reported to Nurse #1 she was going to call 911 and Nurse #1 asked family not to call 911, that the staff would take care of it. The Family Member indicated that she left and went home. The Family Member stated she discussed the resident's change in behavior with other Family Members, and they decided to return to the facility about 11:00 pm. The resident's door was closed and upon entry the resident was on the floor naked. He appeared to be asleep but was squirming on the floor. The resident answered to his name but was very confused. The Family Member called out to the nurse, the resident was on the floor and called 911. Staff assisted the resident back to the bed. This was the second time family found the resident naked that day. Emergency Medical Services (EMS) evaluated the resident, and he had a low oxygen level and was barely breathing. EMS informed the family they thought Resident #1 had an infection. The Family Member stated EMS informed her he would have died during the night if EMS had not been called. On 10/21/25 at 10:00 am Nurse #1 was interviewed. Nurse #1 stated she was assigned to Resident #1 on 10/2/25 evening shift from 3:00 pm to 11:00 pm. Nurse #1 stated early in the shift the family visited, and NA #1 would put the resident's clothes on, and the resident took his clothes off repeatedly. Nurse #1 stated she received nothing in report about this behavior. The resident was alert and verbal. When the family came in to visit around 4:00 pm the resident was different. The resident appeared mad and agitated versus anything being wrong with his mentation. Nurse #1 stated she took the resident's vital signs, and they were normal. Nurse #1 stated when she asked the resident about his clothing he replied, I don't want them on. Nurse #1 stated she had not thought the resident had a change in mental status. Nurse #1 indicated the resident was swatting their hands when he did not want something and had limited verbal communication which was a change for him. On 10/22/25 at 2:37 pm Nurse #1 was interviewed again. Nurse #1 stated the family member came to visit Resident #1 on 10/2/25 at dinner time during her evening shift. The resident was not himself and the family member was concerned. The family member requested the resident be sent out to the hospital. Nurse #1 stated she took the resident's vital signs, and they were stable, and Nurse #1 decided not to report the family's concerns or request to medical staff. The family member reported to Nurse #1 that, the resident wasn't right and the family member went home. After dinner NA #1 informed Nurse #1 that the resident was more confused and agitated. Nurse #1 further stated this information was not provided to medical staff. Nurse #1 reported off to Nurse #2 the resident's behavior and that the family was in to visit. On 10/21/25 at 1:40 pm NA #1 was interviewed. NA #1 stated she was assigned to Resident #1 on 10/2/25 from 3:00 pm to 11:00 pm and this was her first time having the resident. The resident was taking his clothing off and was not cooperative when she tried to put his clothing back on and took his clothing back off. NA #1 indicated, I heard another NA talking about the resident taking his clothes off on day shift (7:00 am to 3:00 pm) on 10/2/25, I received nothing in a formal report. NA #1 revealed the resident appeared very confused and was unable to follow directions and this was reported to Nurse #1 who was assigned to the resident. The family came in to visit at dinner time and was informed the resident had taken his clothing off. Nurse #1 took vital signs. NA #1 stated she was not familiar with the resident's mentation and was unsure if there was a change. The NA stated she reported the resident's behavior to the medication aide assigned also. The Medication Aide was interviewed on 10/21/25 at 9:27 am. The Medication Aide stated he remembered Resident #1 taking his clothes off on 10/2/25 during day shift and night shift NA #3 (10/1/25) reported the same. At the beginning of day shift (7:00 am to 7:00 pm) on 10/2/25 the resident was alert and oriented. He was eating and taking his medications. Later in the shift the resident was less oriented, taking off his clothes, coming out to the hallway and taking off his undergarment. This behavior was similar to what was reported 10/2/25 from night shift on 10/1/25 from 7:00 pm to 7:00 am. The Medication Aide indicated he had not interacted with the family, did not see the family, and there were no reports that there were concerns about the resident's mentation. The resident was able to make his needs known but seemed confused and less verbal at the end of his shift at 7:00 pm. The Medication Aide stated he thought the increased confusion was the resident's baseline and there was no change in mentation for the resident documented in the nurse 24-hour report. Did the Medication Aide report the highlighted to you? If so would need to documented this way. Yes, changed Attempts to interview NA #3, who was assigned to Resident #1 on 10/1/25 night shift 7:00 pm to 7:00 am, were unsuccessful. Resident #1 had a nurses' note dated 10/3/25 at 3:59 am written by Nurse #2. Nurse #2 documented while in the hallway she heard yelling coming from Resident #1's room by the family member man on the floor at approximately at 11:06 pm. Nurse #2 noted Resident #1 on the floor next to his bed and was alert to self with signs and symptoms of confusion. The resident had no complaints about pain or discomfort. Emergency Medical Services (EMS) was contacted by staff, and the family member had called on his personal cell phone before notifying staff. The EMS arrived at around 11:15 pm and left with the resident at 11:30 pm on the stretcher with the family following behind. Nurse #2 was notified by NA #1 at around 10:50 pm that resident refused care and assistance with putting on his night grown. Nurse #2 also had the same issue with the resident at around 10:00 pm. Nurse #2 noted the resident was sitting on his bed without clothing. Nurse #2 tried to help the resident to lay down in bed by assisting his legs and he kicked and was shaking his head. The resident refused clothing also. The resident was left sitting in bed with the bed in the lowest position. On 10/21/25 at 2:20 pm Nurse #2 was interviewed. Nurse #2 stated she was assigned to Resident #1 on 10/2/25 from 11:00 pm to 7:00 am. This was her first assignment with Resident #1. Nurse #2 received in report from evening shift that the resident had some confusion and had taken his clothes off, the family had visited, and to watch the resident closely. The resident had not allowed staff to provide care or to redress on Nurse #2's night shift. Nurse #2 indicated that NA #1 reported around 10:15 pm the resident was a little combative and confused during the evening shift. Nurse #2 stated she was not sure if the refusal of care, removing clothing and being combative for the NA during care was new. Nursing was responsible for determining a resident's orientation from the prior day if there was an altered mental status. Nurse #2 commented that some people have good or bad days, and she would need to return to evaluate the resident again when the resident was new. Staff would need to start monitoring a resident's mental status and talk to staff that may have had the resident previously or read notes to determine the resident's mental status. Nurse #2 revealed she had not looked back at the resident's record to determine his orientation and I did what I could in the timeframe. EMS documentation dated 10/2/25 indicated they responded to a 911 call by the family for Resident #1 at the facility. Arrival time was 11:23 pm. The resident had signs and symptoms of an altered mental status, restlessness and agitation, and sepsis. The resident had a fall from the bed with no injury. Upon arrival the blood pressure was 96/54, pulse 100, respirations 12, and pain score by facial expression 6 (0 to 10 with 10 being the worst). EMS asked the resident what was wrong, and he responded dying. At 11:45 pm oxygen was administered by nasal cannula and pulse oximetry result was 95%. Sepsis treatment of fluid resuscitation and oxygen began at the facility and continued while enroute to the hospital. On 10/22/25 at 2:20 pm an interview was conducted with the EMS paramedic. The paramedic stated she was called to the facility on [DATE] around 11:00 pm. The family member had called 911 when he found Resident #1 on the floor unresponsive at the facility. The family member informed Nurse #2 that he had not wanted to wait because the family had visited earlier at 5:00 pm and notified nursing there was something wrong. The facility called 911 after the family member had called. The resident was non-verbal, difficult to arouse, hypotensive (low blood pressure), and dyspneic (difficulty breathing). The resident met the protocol for sepsis (infection of the blood). The resident had sepsis treatment imitated by EMS and was transported to the Emergency Department (ED). The resident responded the one-word response when asked what was wrong, dying. A review of Resident #1's ED record revealed he arrived at the ED on 10/3/25. His ED record documented that he was found to have acute encephalopathy, acute respiratory failure with hypoxia, hypotension, lactic acidosis, acute kidney injury, and transaminitis. The resident had an unwitnessed fall at the facility and an altered mental status. The resident had a chest x-ray and was found to have aspiration pneumonia and a lab result of elevated white blood cells 12.9 (showing infection and/or inflammation, normal range 6-10), and a workup for sepsis. The resident had septic shock and required fluid resuscitation and medication to maintain his blood pressure, antibiotic treatment, intensive care, and 3 days of ventilator life support. Computed Tomography (CT) Scan (computerized x-ray imaging process) of the resident's chest on 10/3/25 showed moderate to advanced emphysema with diffuse bronchial inflammation and debris within the left mainstem bronchus (from aspiration). The resident's sepsis and pneumonia were resolved, and he was transferred to another facility 10/8/25. On 10/21/25 at 1:06 pm an interview was conducted with the Medical Director. The Medical Director stated he saw Resident #1 on 10/2/25 early in the day and wrote a progress note. The resident had slight confusion but was able to answer questions. Nursing had not reported to the Medical Director that the resident had taken his clothes off and that he had new behavior. The Medical Director stated if a resident had a change in behavior or an altered mental status, he expected staff to take vital signs and check the blood glucose. If these values were normal for Resident #1, the staff would be expected to call the medical staff because this resident had a medication reaction previously with metabolic encephalopathy. The Medical Director stated he was not informed that the family visited in the evening and had concern the resident was undressing and confused, not himself, and asked that the resident be evaluated or that the resident had fallen and was sent to the hospital with an altered mental status that night. The Medical Director stated he expected the staff to notify him or the on-call provider for altered mental status, disrobing (new behavior) and be notified if the family felt there was a change in the resident's status and wanted him sent out to the hospital. On 10/22/25 at 2:20 pm an interview was conducted with the Administrator. The Administrator stated she was not aware of Resident #1's mental status change reported by the family until after he was discharged to the hospital. She had no comment regarding the failure to report this to medical staff. 2. Resident # 5 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, abnormal findings on diagnostic imagining of skull and head, and dementia with behavioral disturbances. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required partial/moderate staff assistance when attempting to stand from a sitting position. Review of Resident #5's care plan created on 8/27/25 with revision dates of 9/1/25 and 9/3/25 revealed a focus area for actual fall with no injury related to poor balance, poor communication/comprehension, and unsteady gait. Initial interventions included anticipated resident needs, place call light within reach, provide prompt response to resident needs, and ensure resident had appropriate footwear in use when ambulating/mobilizing in wheelchair. On 9/1/25 an intervention was added to encourage Resident #5 to be up and out of bed before breakfast for supervision. A review of the incident report dated 9/3/25 at 11:30 AM, written by Nurse #3, revealed Resident #5 had an unwitnessed fall in his room and was observed laying on the floor next to his bed with no injuries noted. Resident #5 was unable to describe the incident and was assessed and assisted back to the wheelchair. A review of nursing progress note dated 9/3/25 at 12:12 PM, written by Nurse #3, revealed Resident #5 was found lying on the floor next to the bed with no apparent injuries. Resident #5 was noted to have good range of motion to all extremities; no complaints of pain or discomfort were noted. Nurse #3 notified the Nurse Practitioner (NP) and Responsible Party (RP). Review of Resident #5's Neurological Flow Sheet dated 9/3/25, completed by Nurse #3 revealed neurological checks (a series of neurological observations and neurological system checks conducted by nursing staff to identify any signs or symptoms of a potential neurological abnormality) and vital sign checks were initiated at 11:30 AM. The flow sheet indicated vital signs, and neurological checks were to be completed as follows: Every 15 minutes for 1 hour; Every 30 minutes for 1 hour; Every hour for 4 hours; Every 4 hours for 24 hours. The flow sheet revealed neurological checks were completed on 9/3/25 at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:15 PM and 5:15 PM. The flow sheet also revealed that Resident #5 experienced a low pulse of 56 beats per minute (bpm) (normal range between 60 bpm and 100 bpm) at 12:00 PM and again at 12:15 PM. A review of the NP's progress note dated 9/3/25 at 1:00 PM revealed Resident #5 was seen in the facility for a follow up due to a fall. The progress note indicated nursing staff reported Resident #5 was found lying on the right side of the floor by the bed. Resident # 5 was assisted to the wheelchair, was alert and nonverbal which was his baseline. The NP indicated she performed passive range of motion (ROM) with all extremities, no signs of acute pain, swelling or bruising were noted, pupils equal, round, reactive to light and accommodation, resident was not on an anticoagulant, no reported nausea, no change in appetite, resident remained restless, and neurological checks were initiated by nursing staff per facility's protocol. The NP's progress notes further revealed the following vital signs dated 9/2/25 at 11:02 AM were reviewed: pulse of 72 beats per minute (bpm), systolic blood pressure of 122 and diastolic blood pressure of 68, oxygen saturation 95 at room air, 97.6 temperature and respiratory rate of 16 breaths per minute. An interview was conducted with the NP on 10/22/25 at 11:08 AM. The NP indicated that it was her understanding that the facility's post fall protocol was for the nurse to initiate neurological and vital sign checks every 15 minutes for 1 hour; every 30 minutes for 1 hour; every hour for 4 hours; every 4 hours for 24 hours and to notify the provider of any changes or concerns. The NP recalled assessing Resident #5 after his first fall on 9/3/5 around lunchtime and was not made aware that Resident #5 had a low pulse rate at 12:00 PM and again 12:15 PM. The NP further revealed that she could not recall if she was notified of Resident #5's 2nd fall but she would have wanted to have been aware of the change in vital signs at that time so she could have assessed Resident #5 further and determine if additional medical interventions were needed. A review of nursing progress note dated 9/3/25 at 1:00 PM, written by Nurse #3 revealed Resident #5 was at the nursing station in a wheelchair and reached for the floor when he fell out of the wheelchair. Resident # 5 had no loss of consciousness, no complaints of pain, and his pupils were equal and reactive. No injuries were observed, and the NP and RP were notified. A review of the incident report dated 9/3/25 at 1:00 PM, written by Nurse #3 revealed Resident #5 had an unwitnessed fall and was at the nurse's station trying to pick something up off the floor when he fell forward out of the wheelchair and striking the left side of his head. The progress note further revealed Resident #5 was assessed and had no injury, signs or symptoms of pain, skin was intact, and the NP and RP were notified. A second Neurological Flow Sheet was initiated on 9/3/25 at 1:00 PM by Nurse #3. The flow sheet revealed neurological checks, and vital signs were completed by Nurse #3 at 1:00 PM, 1:15 PM, 1:30 PM, 1:45 PM, 2:15 PM, and 2:45 PM and the results indicated Resident #5 was fully conscious, hand grasps were equal and strong, had movement in all 4 extremities, and pupil reaction was brisk. Resident #5's pulse rating was documented to be within normal limits. Resident #5's speech was noted to be rambling which was his baseline. An interview was conducted with Nurse #3 on 10/21/25 at 2:24 PM. Nurse #3 explained that the facility's protocol for monitoring a resident post fall was to follow the falls/incident form which instructs the nurse to complete a fall assessment, pain assessment, skin assessment, neurological checks for all witnessed and unwitnessed falls, update the care plan with a fall intervention, collect witness statements, update the 24-hour report and notify the RP, the provider, the Director of Nursing . Nurse #3 further explained that the nurses were trained to complete the facility's Neurological Flow sheet which directs the nurse to complete neurological checks and vital sign checks. Nurse #3 indicated she was the assigned nurse for Resident #5 on 9/3/25 from 7:00 AM to 3:00 PM. Nurse #3 indicated Nurse #4 took over for her at the end of her shift but could not recall what time the transition took place. Nurse #3 indicated Resident #5 had 2 falls that occurred during her shift on 9/3/2025 and this was reported to Nurse #4. She stated that the first fall occurred in Residents #5's room at 11:30 AM and it was unwitnessed. Nurse #3 recalled observing Resident #5 on the floor on the side of his bed. Nurse #3 indicated Resident #5 was fully assessed , had no injuries and the Director of Nursing , NP and the RP were notified. She also indicated that the NP was in the facility at the time of the first fall and was able to assess Resident #5 between the 1st and 2nd falls. The 2nd fall occurred on 9/3/25 at 1:00 PM and was witnessed either by Nurse #4 or the Staff Development Coordinator (SDC) who was the unit manager at that time and Nurse #3 recalled Nurse #4 reporting the incident to her. Nurse #3 indicated that she thought Nurse #4 completed the post fall assessment and Resident #5 was already assisted to the wheelchair when she was notified of the 2nd fall. Nurse #3 revealed she noted on the incident report that the 2nd fall was unwitnessed in error and that she did not obtain witness statements and did not report a low pulse rate of 56 at 12:00 PM and again at 12:15 PM to the medical provider at that time. Nurse #3 could not explain why she did not notify the NP of the low pulse rate, but it should have been reported to the provider at that time. A telephone interview was conducted with the SDC on 10/23/25 at 12:30 PM and she did not recall witnessing Resident #5's falls on 9/3/35 or completing any documentation related to a fall. An interview was conducted with the RP on10/21/25 at 5:00 PM. The RP revealed she was notified of both Resident #5's falls that occurred on 9/3/25 and came to the facility at approximately 3:00 PM on 9/3/25 to check on the resident. The RP indicated upon her arrival Resident #5 was observed seated in his wheelchair at the nurse's station for monitoring and she did not observe any head injury at that time. The RP further explained that she assisted Resident #5 back to the room and did not recall any staff members that came to Resident #5's room to check on him between the hours of 3:00 PM and 5:00 PM and neither Nurse #3 or Nurse #4 had not come into the room to complete any neurological or vital sign checks from 3:00 PM until Resident #5 was sent to the hospital. The RP indicated that around 5:00 PM she had observed a large bump that had formed over Resident #5's left eye and slightly swollen lip and notified Nurse #4 when he entered Resident #5's room. The RP indicated that around 5:00 PM she requested Nurse #4 notify someone in charge that she wanted to speak to them as she felt that the staff had not been monitoring Resident #5 and may require hospitalization. The RP revealed the Director of Nursing (DON) came to Resident #5's room around 6:30 PM to discuss h

Based on record review, staff interviews, Responsible Party interview, On-Call Nurse Practitioner interview, Nurse Practitioner interview, and Medical Director interview, the facility failed to notify the physician immediately after Resident #5 exhibited a change in condition related to a fall. Resident #5 had a low pulse during vital sign checks after the fall and Resident #5's Responsible Party identified a hematoma on the resident's head later in the day and requested he be sent to the hospital. The deficient practice affected 1 of 3 residents reviewed for accidents (Resident #5). The findings Included: Resident # 5 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, abnormal findings on diagnostic imagining of skull and head, and dementia with behavioral disturbance.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was severely cognitively impaired. A review of the incident report dated 9/3/25 at 11:30 AM, written by Nurse #3 revealed Resident #5 had an unwitnessed fall in his room and was observed laying on the floor next to his bed with no injuries noted. Resident #5 was unable to describe the incident and was assessed and assisted back to the wheelchair.Review of Resident #5's Neurological Flow sheet dated 9/3/25, completed by Nurse #3 revealed neurological checks (a series of neurological observations and neurological system checks conducted by nursing staff to identify any signs or symptoms of a potential neurological abnormality) and vital sign checks were initiated at 11:30 AM. The flow sheet indicated vital signs, and neurological checks were to be completed as follows: Every 15 minutes for 1 hour; Every 30 minutes for 1 hour; Every hour for 4 hours; Every 4 hours for 24 hours. The flow sheet revealed neurological checks were completed on 9/3/25 at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:34 PM, 1:15 PM and 5:15 PM. The flow sheet also revealed that Resident #5 experienced a low pulse of 56 beats per minute (bpm) (normal range between 60 bpm and 100 bpm) at 12:00 PM and again at 12:15 PM. Resident #5 was noted to have a blood pressure of 100 (systolic-heart contracting)/50 (diastolic-heart relaxed) (normal blood pressure would be 120/80) at 1:15 PM and refused the remaining blood pressure checks.An interview was conducted with Nurse #3 on 10/21/25 at 2:24 PM. Nurse #3 explained that the facility's protocol for monitoring a resident post fall was to follow the falls/incident form which instructs the nurse to complete a fall assessment, pain assessment, skin assessment, neurological checks for all witnessed and unwitnessed falls, update the care plan with a fall intervention, collect witness statements, update the 24-hour report and notify the Responsible Party (RP), the provider (the physician or physician extender such as a Nurse Practitioner (NP) or Physician's Assistant (PA), and the Director of Nursing . Nurse #3 further explained the nurses were trained to complete the facility's Neurological Flow sheet which directed the nurse to complete neurological checks and vital sign checks and to notify the provider of any change in condition. Nurse #3 further revealed she should have notified the provider when Resident #5 had a change in condition related to a low pulse rate of 56 beats per minute (bpm) that occurred on 9/3/25 at 12:00 PM and again at 12:15 PM. She explained she was not sure why it had not been done and that she must have just missed it.A review of the incident report dated 9/3/25 at 1:00 PM, written by Nurse #3 revealed Resident #5 had an unwitnessed fall and was at the nurse's station trying to pick something up off the floor when he fell forward out of the wheelchair and striking the left side of his head. The progress note further revealed Resident #5 was assessed and had no injury, signs or symptoms of pain, skin was intact, and the NP and RP were notified.A review of the Nurse Practitioner's (NP) progress note dated 9/3/25 at 1:00 PM revealed Resident #5 was seen in the facility for a follow up due to a fall. The progress note indicated that nursing staff reported Resident #5 was found lying on the right side of the floor by the bed with no injuries. The NP's progress notes further revealed the following vital signs dated 9/2/25 at 11:02 AM were reviewed: pulse of 72 beats per minute (bpm), systolic blood pressure of 122 and diastolic blood pressure of 68, oxygen saturation 95 at room air, 97.6 temperature and respiratory rate of 16 breaths per minute. There was no mention of the resident's low pulse readings of 56 bpm at 12:00 PM and 12:15 PM on 9/3/25.An interview was conducted with the NP on 10/22/25 at 11:08 AM. The NP indicated that it was her understanding that the facility's post fall protocol was for the nurse to initiate neurological and vital sign checks every 15 minutes for 1 hour; every 30 minutes for 1 hour; every hour for 4 hours; every 4 hours for 24 hours and to notify the provider of any changes or concerns. The NP recalled assessing Resident #5 after his first fall on 9/3/5 around lunchtime and was not made aware that Resident #5 had a low pulse rate at 12:00 PM and again 12:15 PM The NP further revealed that she would have wanted to have been aware of the change in vital signs at that time so she could have assessed Resident #5 further and determine if additional medical interventions were needed.A telephone interview was conducted 10/23/25 at 10:12 AM with Medication Aide #1 who was assigned to Resident #5 on 9/3/25. Medication Aide #1 recalled going to Resident #5's room around 5:00 PM and the RP was present. The RP made him aware of the bump that had developed over Resident #5's left eye and he immediately notified Nurse #4.An interview was conducted with the RP on10/21/25 at 5:00 PM. The RP revealed she was notified of both Resident #5's falls that occurred on 9/3/25 and came to the facility at approximately 3:00 PM on 9/3/25 to check on the resident. The RP indicated that around 5:00 PM she had observed a large bump that had formed over Resident #5's left eye and slightly swollen lip and notified Nurse #4 when he entered Resident #5's room. The RP indicated that around 5:00 PM she requested Nurse #4 notify someone in charge that she wanted to speak to them as she felt that the staff had not been monitoring Resident #5 and the resident may require hospitalization. The RP revealed the Director of Nursing (DON) came to Resident #5's room around 6:30 PM to discuss her concerns and Resident #5 was sent to the hospital at approximately 7:45 PM.Multiple attempts were made to interview Nurse #4, but attempts were not successful.A telephone interview was conducted with the On-Call Nurse Practitioner (NP) on10/22/25 at 10:50 AM. The On-Call NP indicated that she began her shift on 9/3/25 at 5:00 PM and was notified by the facility on 9/3/25 at 7:06 PM that Resident #5 had a fall with a head injury around 1:00 PM and developed a large bump over his left eye. She further revealed she was told the family had requested Resident #5 to be sent to the hospital, and she agreed Resident #5 required hospitalization for further evaluation and treatment. The On-Call NP indicated that if the nurse had contacted her when the facility first became aware of the bump over Resident #5's eye she would have recommended hospitalization at that time.A telephone interview was conducted with the Medical Director on 10/23/25 11:09 AM and he would have wanted the nursing staff to notify the provider at the time a change of condition occurred so the provider could further evaluate and determine if further medical intervention was needed at that time.An interview was conducted with the Director of Nursing (DON) on 10/23/25 at 12:10 PM. The DON indicated she recalled being summoned to Resident #5's room by Nurse #4 around 6:40 PM on 9/3/25. The DON revealed when she entered Resident #5's room she observed a bump over Resident #5's left eye and spoke to the RP for about 10 minutes. The DON indicated that during the conversation they discussed hospice and hospitalization. The DON also indicated she would have wanted Nurse #3 to notify the provider at the time when Resident #5's pulse dropped below 60 bpm and would have wanted Nurse #4 to notify the On-Call NP immediately when Nurse #4 observed the injury to Resident #5's head.An interview was conducted with the Administrator 10/23/25 12:55 PM. The Administrator indicated Nurse #3 and Nurse #4 should have notified the provider immediately of any change in condition.

Based on observations, record review, and staff, Medical Director and Nurse Practitioner interviews, the facility failed to ensure the necessary supervision was provided to a severely cognitively impaired resident to prevent an avoidable accident. Resident #1 was prescribed a puree diet and had a history of choking. On 3/19/25 Resident #1, who was known to have poor safety awareness, had a choking episode in the main lobby. Staff performed a back blow that produced a piece of bread from his mouth. He was assessed by the Nurse Practitioner (NP) and determined to return to his baseline. Following the 3/19/25 choking incident, all facility staff were educated on the importance of providing residents with diets per the physician order. On 4/22/25, while dinner trays were being picked up by the staff, Resident #1 took a hot dog off an unattended meal cart, put part of it in his mouth, and began to choke. Staff provided abdominal thrusts and were unable to dispel the food. Cardiopulmonary Resuscitation (CPR) was started when the resident became unresponsive and was pulseless. Emergency Medical Services (EMS) was called and were unable to revive Resident #1 who was pronounced deceased at 8:01 PM. The deficient practice affected 1 of 2 residents reviewed for supervision to prevent accidents (Resident #1). The findings included: A hospital Discharge summary dated [DATE] ordered a level 1 dysphagia diet (all food are pureed smooth to a pudding consistency to ensure easy swallowing) and honey thick liquid with close supervision and assistance with feeding. Resident #1 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), cerebrovascular accident (stroke), weakness to both legs, and aphasia (difficulty or inability to express with language). Review of the facility physician orders for 1/25/ 2025 revealed a diet of honey thickened fluids and pureed texture. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired with no refusal of care. He had a therapeutic diet due to difficulty with swallowing and was independent with eating after setting up meal tray. He used a wheelchair for mobility and required supervision to stand. A care plan was initiated on 2/20/2025. It focused on Resident #1's swallowing problem related to coughing or choking during meals. The goal was for no aspiration (when something you swallow goes down the wrong way and enters your airway [trachea or windpipe] or lungs) injury, maintain weight and nutrition and no choking episodes with eating. Interventions included all staff to be informed of Resident #1's special dietary and safety needs. There were no interventions related to supervision during meals. An interview conducted on 6/5/25 at 5:22 PM with the MDS Coordinator revealed Resident #1's safety needs in the care plan were about supervising him and preventing him from accessing food he should not eat. He propelled in his wheelchair and looked for food, he exhibited behaviors of hunger by gestures. Information was on the electronic Kardex (care guide) for the nursing staff. The MDS Coordinator explained that the Kardex was deleted after the resident was discharged so the information on the Kardex was no longer available. The discharge speech therapy note revealed dated 3/14/2025 revealed Resident #1 refused treatment. Discharge recommendations from speech therapy was a nectar thick liquid with swallowing strategies implemented. Mechanical soft/ground textures (with strategies implemented). Strategies were alternate liquids and solids. Small bites, tuck the chin during swallowing. Upright posture thirty (30) minutes after meals. His goal was not met, and he remained on a honey-thick liquids and a pureed diet. An interview with the Speech Therapist (ST) on 6/4/2025 at 2:04 PM revealed Resident #1 was able to eat a mechanical soft/ground diet if he used strategies. His diet was honey thick liquids and pureed diet and he was not upgraded because of noncompliance with the exercises to strengthen the muscles in his throat. The ST indicated Resident #1 was able to feed himself and propelled himself in a wheelchair. Resident #1 comprehended directions and he understood his diet and not eating foods that were not pureed. The ST stated Resident #1 He was discharged from speech therapy because he refused treatment. She stated she was not aware of his seeking food outside his prescribed diet. On 6/4/2025 at 6:10 PM the Rehab (Rehabilitation) Manager indicated Resident #1 was able to walk short distances. He refused to do the swallowing exercises during meals and tore up the strategies the speech therapist had given him. The Rehab Manager stated Resident #1 He had awareness and was able to follow cues and instructions. His diet was not advanced, and he remained on his original ordered diet. The Activities Assistant was interviewed on 6/5/2025 at 11:56 AM. She revealed she had been sitting in the dining room watching television with Resident #1 on 3/19/2025 and did not recall the time. Resident #1 was taken out by an unidentified nurse aide. The Activities Assistant stated she did not provide Resident #1 with any food on 3/19/25 because she was not allowed to give residents food. The interview further revealed the Activities Assistant had no idea how or when Resident #1 had gotten food on 3/19/25. Interview on 6/5/25 at 11:40 AM with Unit Manager #2 revealed on 3/19/25 she came off the elevator and entered the lobby and Resident #1 was on the floor and had a blank look on his face. She was not familiar with this resident. She did not recall what time it was or who was present except Nurse #50. Resident #1 was on his left side when Nurse #50 reached into his mouth and pulled out bread. Resident #1 was no longer in distress. An interview with Nurse #50 on 6/5/2025 at 11:12 AM revealed on 3/19/25 he was working on the hall on first floor, and he saw a commotion in the lobby. He walked to the lobby and Resident #1 was lying on the floor. Nurse #50 did not recall which staff were present. He stated Resident #1 looked scared and he did a quick assessment, turned Resident #1 to his left side and did a back blow, and a piece of bread fell out of his mouth. The Nurse Practitioner assessed Resident # 1, then the EMS paramedics did an assessment. Resident #1 was back to his baseline and Nurse #50 helped Resident #1 back to his chair and returned to his hall. A Nurse Practitioner note dated 3/19/25 with no time, revealed Resident #1 had choked on food in the lobby. Food was removed by finger sweep and Resident #1 returned to baseline. A telephone interview on 6/9/2025 at 3:39 PM revealed the Nurse Practitioner indicated she responded to the choking episode on 3/19/2025. Resident #1's lungs were clear, and he was at his baseline. A nursing note documented by Unit Manager (UM) #1 dated 3/19/2025 at 11:50 AM revealed Resident #1 had an episode where he was sliding out of the wheelchair with seizure like symptoms in the main lobby. He was lowered to the floor by a nurse aide and assessed by a nurse (not identified) and observed to have food in his mouth. The food was removed from his mouth, Emergency Medical Services responded. The Nurse Practitioner was in the building and was notified. Resident #1 returned to his baseline Record review of the report dated 3/19/2025 identified as Incident Description, Nursing Description Resident pushed by CNA (unidentified Nurse Aide) from dining room to hallway and noted he was sliding from wheelchair. CNA was assisting residents to the floor and noted resident having seizure-like activity. Immediate Action Taken: Assessment completed resident actively coughing piece of bread noted in his mouth. Resident turned to his side, a slight strike on back and resident spit out a piece of bread. No loss of consciousness, respiratory status remains stable. NP (Nurse Practitioner) notified and evaluated, lungs clear and resident is no (sic) distress. EMS arrived and evaluated with same findings. Resident refused to transfer to the hospital. This document was completed by the Director of Nursing (DON). An interview on 6/5/2025 at 11:05 AM with UM #1 indicated she could not recall which Nurse Aide (NA) wheeled Resident #1 out of the dining room on 3/19/25. UM #1 stated she saw Nurse #50 turn Resident #1 on his side and struck him on the back which produced the piece of bread out of his throat. Resident #1 returned to baseline and the Nurse Practitioner assessed him. Resident #1 refused to go to the hospital. The facility provided education to all staff, to provide the correct diet after the 3/19/25 choking incident. An interview on 6/5/2025 11:05 AM Unit Manager #1 revealed she saw Resident #1 was returning from activities into the main lobby and he was coughing. An NA (could not remember who) was pushing the wheelchair, and Resident #1 was sliding down. Unit Manager #2 and Nurse #50 observed this, and they put him on the floor and turned him to the left side. Nurse #50 struck Resident #1 on the back and a piece of bread fell out of his mouth. He never lost consciousness, and he fully recovered to his baseline. He was assisted back to his wheelchair. Emergency Medical Services arrived, Nurse Practitioner listened to his lung sounds and she asked him to go to the hospital, and he refused. An interview on 6/5/2025 at 12:40 PM with the Administrator revealed that activity staff had been educated by the Staff Development Coordinator (SDC) on the importance of providing the correct diet and the Activity Director was given the changes to residents' diets during the morning stand-up meeting after Resident #1's 3/19/25 choking incident. A record of training titled, Resident Diets conducted on 3/18/25 (sic) was conducted by the SDC. The training enforced the importance of providing residents with special diets as prescribed by the physician or other delegated provider. The provided signature sheet dated 3/19/2025 had the activity department personnel signatures and two nursing assistants. The facility produced further sign off sheets and identified them as training that occurred for all staff for the 3/19/2025 event. An interview with the Activity Director by phone on 6/5/25 at 12:24 PM revealed the Activity Assistant was not permitted to give food to residents. The activity department had been educated on the diets of residents. The Activity Director stated she was not present when the episode occurred on 3/19/25. The SDC conducted education with the Activity Department on the importance of providing the correct diet. The Activity Director explained she was responsible for knowing each resident's diet order and the Activities Assistant was allowed to distribute food and fluids to residents once the Activity Director determined what was appropriate. An Incident Description report dated 4/22/2025 revealed Nursing Description CNA (unidentified nurse aide) noted resident with a hot dog bun in his hand with a bite out of it. Resident actively coughing and a piece of hot dog bun coughed out. Immediate Action Taken: Resident assessed, (staff not identified) actively coughing with strong cough and noted to cough out a piece of hot dog bun. Resident noted to become distressed and unable to produce a strong cough and face became red. Heimlich (abdominal thrusts) initiated and 911 called. Mouth sweeps unable to produce the remainder of bun. Resident became weak and placed on floor and Heimlich continued. Resident became unresponsive and breathless and cardiopulmonary resuscitation initiated until EMS arrived. Predisposing factors were impaired safety awareness and impaired memory. Injuries Report Post Incident, No injuries observed post incident. This was documented by the DON. The dinner menu on 4/22/2025 included chili dogs. A telephone interview was conducted on 6/4/2025 at 4:48 PM with NA #1. She stated Resident #1 comprehended what he was told and followed directions. NA #1 stated Resident #1 was supervised because he was impulsive and stood up without warning. She stated on 4/22/2025 she had taken some bread from Resident #1 while she was picking up trays and she told him to go to his room. NA #1 indicated she went into room [ROOM NUMBER] and was held up. NA #1 recalled she came out of room [ROOM NUMBER] and observed NA #4 doing abdominal thrusts on Resident #1 while he was seated in his wheelchair. Then NA #4 got on the phone with 911 and she (NA #1) took over the abdominal thrusts then NA #5 did the abdominal thrusts. NA #1 said they passed Resident #1 from person to person and Resident #1 was not responding to the thrusts and was put onto the floor. NA #1 explained she did abdominal thrusts while she straddled Resident #1. Nurse #1 had NA #1 stop and checked for his pulse and Nurse #1 had NA #1 start chest compressions. Nurse #1 took over from NA #1 and did the chest compressions and then she (NA #1) took over chest compressions until EMS arrived. NA #1 stated she had never observed Resident #1 take food from a meal cart. During a follow up interview on 6/5/2025 at 2:20 PM NA #1 stated she never saw a hot dog in Resident #1's hand, only bread. An interview was conducted with NA #2 on 6/4/2025 at 5:13 PM. NA #2 stated on 4/22/25, she was assigned to monitor another resident on a one-to-one basis and was seated in the hall outside of room [ROOM NUMBER]. NA #2 stated Resident #1 was monitored because he was impulsive and stood up from his wheelchair. He usually stayed by his door or in the lobby and he liked to watch TV. On 4/22/25 dinner was late, and Resident #1 was pointing at the kitchen indicating he was hungry. NA #2 indicated Resident #1 received and ate his meal on 4/22/25 and did not ask for other food. NA #2 recalled she and NA #3 were picking up meal trays and the meal cart was close to Resident #1's room (which was behind her). NA #2 observed Resident #1 propelling himself to room [ROOM NUMBER] and looked like he was choking. His eyes were wide, and his face was purple. Resident #1 handed her a piece of hot dog then he coughed up a piece of hot dog and he was choking. NA #2 indicated she yelled up to the nurses' station for help. NA #4 came down the hall from the nurse's station and NA #4 did abdominal thrusts. NA #1 came out of room [ROOM NUMBER] to the hallway outside of room [ROOM NUMBER], stood up Resident #1, and took over the abdominal thrusts while NA #4 called 911 on her cell phone. Then NA# 5 took over abdominal thrusts. The Director of Nursing checked his mouth for food and stated she didn't see anything else. During an interview on 6/6/2025 at 10:24 AM NA #3 indicated that Resident #1 was supervised during his meals. In the past he had grabbed his roommate's food. She indicated that all staff were aware to watch Resident #1 when the meal carts were on the floor because he got food off the cart. On 4/22/2025 Resident #1 had his dinner in the dining room. NA #3 recalled she and NA #1 had gone into room [ROOM NUMBER] and when they came out of the room with the meal trays Resident #1 was in the hallway near NA #2 and Resident #1's face was purple. NA #3 and NA #2 yelled to Nurse #1 who was at the nursing station that Resident #1 was choking, and his face was purple. NA #5 tried abdominal thrusts and then NA #4 did abdominal thrusts. NA #5 took over abdominal thrusts and NA #4 called 911. The 911 dispatch was on the phone and NA #4 relayed what they said. NA #3 stated Resident #1 went limp, and the dispatch said to put him on the floor and do abdominal thrusts. NA #3 indicated NA #1 continued to do abdominal thrusts. NA #3 said she sat at Resident #1's head. The DON got the oxygen and put a nasal cannula on him. Then EMS arrived and took over. A telephone interview was conducted on 6/5/2025 at 3:47 PM. NA #4 indicated that she had clocked in at 6:50 PM on 4/22/2025 and was at the nurse's station. NA #2 yelled something was wrong with Resident #1. She stated that NA #1 and NA #3 said they had told Resident #1 to get out of the meal cart on 4/22/25. NA #4 stated we all knew Resident #1 took food off meal carts. NA #4 stated that she called 911 on her cell phone and NA #7 had also called 911 from the nursing station. Record review of the timecard punches on 4/22/25 confirmed NA # 4 had clocked in for work at 6:53 PM. An interview with NA #5 was conducted on 6/4/2025 at 4:00 PM. NA #5 revealed while the trays were being picked up from dinner on 4/22/25, Resident #1 was standing, and NA #1 did abdominal thrusts. NA #5 stated she tried abdominal thrusts and Resident #1 became unresponsive and was laid down on the floor. Nurse #1 started cardiac pulmonary resuscitation, and NA #4 called 911. NA #5 indicated she had never observed Resident #1 taking food from another resident and she did not know how Resident #1 got food on 4/22/25. A telephone interview with Nurse #1 was conducted on 6/4/2025 at 4:28 PM. Nurse #1 stated she was at the nurses' station when NA #2 told her that something was wrong with Resident #1 on 4/22/25. Nurse #1 indicated she went down the hallway to Resident #1 and he pointed to his chest, was not able to speak, and was choking. NA #1 was administering abdominal thrusts. Then NA #5 took over and administered the abdominal thrusts. Resident #1 went limp and was lowered to the floor and NA #1 continued to administer abdominal thrusts. Nurse #1 stated she had NA #1 stop the abdominal thrusts and the pulse was checked. She felt no pulse and they switched to doing chest compressions until Emergency Medical Services took over. Nurse #1 indicated she had not ever seen Resident #1 take food off the meal cart or a resident's tray. Record review of the late entry nursing note dated 4/22/25 authored by the Director of Nursing (DON) indicated at about 6:40 PM staff were observed in the hallway assisting the resident (Resident #1) who was in a standing position while abdominal thrusts were being performed. The staff informed the DON that while the staff were going room to room collecting trays Resident #1 had reached into the closed food cart and had taken a hot dog and bit a piece of it. A nurse aide coming out of a room realized he needed help and asked him to cough and spit out the food, but a piece of food was still lodged in his throat. Heimlich was immediately begun and 911 was called. While waiting, abdominal thrusts continued until the resident became unresponsive and chest compressions were started. EMS arrived and took over; the resident regained pulse and respirations on two separate occasions but vital signs were unable to be sustained. Resident #1 was pronounced dead at 8:08 PM. An interview on 6/5/2025 at 9:02 AM revealed the Director of Nursing indicated that initially Resident #1 stayed in his room and after he had completed his occupational and physical therapy, he propelled his wheelchair. She had never observed him at the meal cart, and he had never asked her for food. The nursing staff have a Kardex (care guide) that included the type of diet for each resident. They were accessible by computer and a paper copy was at the nursing station. The Kardex was updated as the care plan was updated or after a change of the resident. The DON stated she was in the office with the SDC on 4/22/2025 (unable to recall time) and heard commotion on the hall. She observed NA #1 doing abdominal thrusts and Nurse Aide #4 was on the phone with 911. Nurse #1 did the mouth sweep and got a small piece of food. The DON recalled 911 had them put Resident #1 on the floor and continue abdominal thrusts. Nurse #1 started chest compressions and EMS arrived. Training was completed with nursing staff again after the 4/22/25 choking incident and currently no food carts were left unattended while meals were passed or trays picked up. Meal carts were brought up to the nursing station and the doors faced the wall until the carts were returned to the kitchen. On 6/5/2025 at 1:42 PM during a follow up interview, the DON stated on 4/22/25 the doors of the food carts were closed to keep the heat on the food. She stated her investigation, determined he opened the door of the meal cart and took the hot dog, and it was a fluke. He had never tried to open the meal cart doors to her knowledge. A telephone interview on 6/9/2025 at 3:39PM revealed the Nurse Practitioner indicated Resident #1 was very social. The NP stated the facility was aware of the possibility that he may choke. The facility educated the staff and had put interventions in place after the choking event in March to follow the residents' diets. The NP further stated Resident #1 understood directions and followed direction, but he did not realize the consequences of his actions. The Emergency Medical Services (EMS) report dated 4/22/2025 revealed a call was received at 7:00 PM for a cardiac arrest from choking. EMS resuscitation services began at 7:08 PM. Initial assessment at 7:10 PM revealed Resident #1 was on his left side with no pulse or respirations. Suctioning at 7:13 PM and removal of foreign body air obstruction revealed no solid obstruction in the airway. Resident #1 had liquidized bread in the airway. Suction removed the material and intubation was successful at 7:16 PM. Resuscitation efforts continued until 8:01 PM when Resident #1 was pronounced deceased . The Medical Examiner death certificate dated 4/27/2025 revealed the cause of death was accidental and caused by an occlusion by a bolus (a blockage caused by a ball like mixture of food and saliva) of food. An interview by telephone on 6/5/2025 at 4:11 PM Medical Director revealed speech therapy assessed Resident #1 and this was the diet that was followed. The Medical Director indicated Resident #1 was able to comprehend and follow direction and it was the facility's responsibility that Resident #1 did not have access to food that caused him to choke. The interview further revealed Resident #1 was compliant with his diet and the Medical Director was not aware of Resident #1 looking for foods he should not eat. The Medical Director stated Resident #1 was at high risk to choke. The Administrator was notified of immediate jeopardy at 6/5/2025 at 7:13 PM. The facility provided the corrective action plan with a completion date of 4/26/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was admitted on [DATE] with diagnoses of, but not limited to, cerebral infarction (stroke), acute cerebral vascular insufficiency, hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of the body), altered mental status, depression, hypertension, congestive heart failure, and cardiomyopathy. The resident had a diagnosis of dysphagia (difficulty swallowing) and had a diet order of puree texture and honey thickened liquids consistency. The resident's score on the Brief Interview for Mental status indicated severe cognitive impairment. The resident was able to self-propel in the wheelchair. The resident had aphasia, but the speech therapist was unable to evaluate the degree of aphasia. In addition, the speech therapist notes increased impulsivity. On 3/19/25 while NA began to push Resident #1 from the dining room into the hallway where Nurse #50 was walking down the hall and noted the resident sliding out of his wheelchair. NA informed Nurse #50 that the resident was having a seizure. NA #1 and Nurse #50 lowered the resident to the floor and turned him on his side. Nurse #50 assessed the resident and noted a piece of bread in his mouth. Nurse #50 called out to Unit Manager #1. When Unit Manager #1 arrived, the resident was lying on the floor on his side and no seizure activity was noted; however, noted Resident #1 was actively coughing. Unit Manager #1 noted Nurse #50 slightly hit the resident on his back and the resident spit out a piece of bread. The resident did not lose consciousness and respiratory status remained intact. The Nurse Practitioner was paged to the lobby to assess the resident. EMS arrived at the facility stating they were called for seizure activity. NP and EMS assessed resident noting lungs remained clear and resident was in no distress. Resident declined to go to the hospital. Resident's responsible party notified. Education was provided by the Director of Nursing and Staff Development Coordinator to the activities department regarding activities involving food to ensure that they provide food textures as ordered. In addition, activities were educated on ensuring that a thorough clean-up is completed post a food activity either by themselves or the environmental services department. On 4/22/25 at approximately 5:00 pm dinner carts were delivered to the first floor, where Resident #1 resided. The food served for dinner that evening was a chili cheese dog on a bun. Resident #1 was in his room sitting on his bed in preparation for eating. Nurse Aide (NA) #1 provided his tray. The tray delivered was a pureed meal with honey-thick liquids per physician's order. At approximately 6:00 pm NAs began to collect the trays of residents who were finished eating. At approximately 6:15 pm NA #1 picked up Resident #1's tray. The resident was noted to have eaten 75-100% of his meal. NA #1 placed the tray on the meal cart and closed the cart door with the latch in place to secure the door in the closed position. This was the only cart on the hall near the resident's room. At approximately 6:40 pm NA #2 noticed Resident #1, who was in his wheelchair, was actively coughing and trying to expel something. NA #3 noted Resident #1 had a hot dog with a bun with a bite out of it in his hand. When Resident #1 saw NA #3 approaching, he immediately dropped the hotdog on the floor. NA #3 went to Resident #1 and stayed with him, while encouraging him to actively cough. The resident did spit out some pieces of bun. Several staff members (NAs) observed Resident #1 coughing and went to the aid of Resident #1. Resident #1 then became distressed unable to produce a strong cough and red faced. NA #4 stood him up and begun the Heimlich maneuver in an attempt to dispel what the resident was choking on. NA #1 took over the Heimlich and NA #4 called 911 from her personal cell phone exact time is unknown. Nurse #1 and #2 arrived to assist Resident #1 and Nurse #2 attempted to sweep the mouth, to remove what the resident was choking on, without success. Resident #1 became weak; staff placed him on the floor and continued the Heimlich. A small piece of bun/hotdog was expelled. However, Resident #1 continued to be in distress as evidenced by his limp body and facial color change to a blue-gray. Resident #1 then became unresponsive and breathless. A code blue, indicating a resident requiring immediate resuscitation, was yelled and then called over the intercom system. Nurse #1, NA #1, and NA #5 initiated cardiopulmonary resuscitation (CPR) with chest compressions and breaths an ambu bag (a device used to force air into a person's lungs). There was no pulse or respirations noted at this time. Staff continued CPR, chest compressions and breaths for two minutes. They were able to get air into the resident's lungs as evidenced by the rise of the chest during breaths provided with the ambu bag. At 7:08pm Emergency Medical Services (EMS) arrived and relieved the staff by taking over CPR. EMS began attempts to resuscitate with the use of the LUCAS compression system, a device that provides mechanical chest compression to residents in cardiac arrest. EMS attempted suction to remove the obstruction without success. EMS was able to intubate the resident. EMS continued with attempts of resuscitation for approximately 8 cycles of CPR. All efforts of resuscitation ceased at approximately 8:15pm. Resident #1 was announced dead at this time. The cause of death on the death certificate was cardiac arrest. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Residents with altered diets, including pureed, mechanically altered, and thickened liquids, have the potential to be affected by the deficient practice. On 4/22/25 the Director of Nursing initiated an audit of resident diets to determine what residents were on altered diets, are ambulatory or can self-propel in a wheelchair, and potential food seekers. One resident was identified as a potential food seeker. This resident was placed on supervision during mealtimes until the meal trays were removed from the unit and during activities with food involvement. The resident has a roommate with a regular textured diet. The roommate does not have snacks stored in her room nor does she have the ability to purchase snacks. The supervision will be provided by the NA assigned to the resident during the presence of food for either the resident or the roommate, in the event there is more than one resident needing supervision for an NA, department heads will be assigned to supervise residents. The NA receives an assignment for supervision from the charge nurse at the beginning of the shift. This supervision was put into place on 4/23/25. Tray cart doors are to remain closed during tray pass and pick up except for when the staff member is taking or putting the tray away. When the tray cart is not in direct contact with a staff member, the tray cart door will be pushed up against the wall. This education was provided to staff by the Staff Development Coordinator and Director of Nursing, which was initiated on 4/22/25. Food availability is from meals, food activities or the vending machines. Snacks are kept in the nourishment rooms behind the nurses' station. Residents would need to have money to access food from the vending machines. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 4/22/25 the Staff Development Coordinator and the Director of Nursing initiated education with facility staff to include nursing, dietary, environmental services and therapy department staff regarding monitoring of tray carts when they were out on the units to ensure the doors remain closed, cart against the wall, and monitoring residents who received alternate diets/thickened liquids and were ambulatory or were able to self-propel in a wheelchair to ensure they are not attempting to get in the tray cart or showing food seeking behaviors. The education included making sure residents who were on alternate/thickened liquids diet were not consuming inappropriate foods. Snacks are kept in the nourishment room accessible by staff. Staff who do not receive the education by 4/25/25 will not be allowed to work until the education is completed. Newly hired staff will receive the education during orientation from the Staff Development Coordinator. The Director of Nursing will be responsible for ensuring the education is complete for current staff and new hires. If a staff member identifies a resident with a food consistency they do not have ordered, the staff member will go to the resident and encourage them to spit it out while simultaneously calling for assistance. The IDT review diet orders during morning stand up and determines the residents that need monitoring. The Unit Managers deliver any new information to the charge nurse, who assigns the NA that will be responsible for monitoring the resident at risk. The Director of Nursing and Administrator are the second check to ensure the monitoring has been put in place. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. On 4/25/25 the facility had an ad hoc Quality Assurance Performance Improvement (QAPI) meeting, including the Interdisciplinary Team consisting of the Administrator, Director of Therapy, Unit Manager First Floor, Unit Manager Second Floor, Staff Development Coordinator, Environmental Services Director, Dietary Manager, MDS nurse, Director of Nursing, Regional Nurse Consultant. The Medical Director was notified via telephone. During the meeting it was determined the Director of Nursing, or the Administrator will conduct audits of residents who receive altered diets and are able to ambulate or self-propel in the wheelchair for monitoring during mea[TRUNCATED]

Based on record review, observation and interviews with staff and the Medical Director, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On [DATE] Resident #1 requested incontinence care and Nurse Aide (NA) #1 gathered supplies and raised the level of the bed to provide care. NA #1 asked Resident #1 to turn on her side away from NA #1. NA #1 stated she had her right-hand touching Resident #1 and while the resident was turning the brief fell on the floor. NA #1 took her hand off Resident #1 when she bent down to pick up the brief and Resident #1 rolled off the bed onto floor hitting her head. Nurse #1 was called to the room and assessed Resident #1 and noted she was incoherent and unable to answer questions. When Nurse #1 palpated Resident #1's head she yelled out in pain her head and neck hurt. Resident #1 yelled out in pain when Nurse #1 assessed her upper extremities. Resident #1 was sent to the emergency room (ED) on [DATE] and results of x-rays completed on [DATE] revealed fractured left 6th and 7th ribs and the CT scan (computed tomography scan is a medical imaging procedure that uses x-rays to create detailed images) of the head noted an acute on chronic bilateral subdural hematomas (collection of blood on the surface of the brain) that had increased in size from compared with prior imaging on [DATE] and a possible trace acute subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect the brain). On [DATE] Resident #1 had a neurological change (a change in the function of the brain, spinal cord, or nerves) to include expressive aphasia (condition that makes it difficult to speak or write) with right-sided weakness, seizure activity, and admission to Intensive Care Unit (ICU). On [DATE] Resident #1's neurological status worsened due to an increase in subdural hematoma. On [DATE] Resident #1 was made comfort care and died on [DATE] at 5:00 pm. The Death Certificate indicated the immediate cause of death for Resident #1 was complications of blunt force injury to the head. Immediate jeopardy began on [DATE] when Resident #1 rolled out of bed to the floor while incontinence care was provided. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE], with a diagnosis that included dialysis dependent end stage renal disease (ESRD), metabolic encephalopathy, hypertension, congestive heart failure, diabetes, history of seizures, venous sinus thrombosis ,d+[DATE] (rare form of a stroke), and history of pulmonary embolism. Physician orders dated [DATE] included Eliquis (blood thinner used to prevent blood clots and stroke) 5 mg (milligrams) one tablet by mouth two times a day related to thrombosis and remained current until the resident was discharged to hospital on [DATE]. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, with no behaviors, with a height of 65 inches and weighed 213 pounds Resident #1 required partial/moderate assistance (helper does less than half the effort, Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with roll left and right (the ability to roll from lying back to left and right side, and return to lying on back on the bed.) The facility did not provide a care plan that focused on Resident #1's functional abilities (self-care and mobility). Review of ED provider notes dated [DATE] revealed Resident #1 was transferred to the hospital for evaluation due to an episode of hypotension (abnormally low blood pressure) and altered mental status after being found unresponsive at the facility. The resident was awake and at her baseline and had normal blood pressure by the time she got to the ED. She did not remember passing out. The initial CT scan completed on [DATE] showed bilateral subdural calvarial convexities (subdural hematomas) which were likely subacute to chronic with some acute component not excluded. Laboratory tests were unremarkable. It was noted she had not had any falls and had no subdural hematomas on her scans last month. Neurosurgery recommended a repeat CT scan in 8 hours. The resident was admitted given her episode of syncope, hypotension and new onset subdural hematomas. The hospital discharge summary note dated [DATE] indicated that resident was discharged in stable condition with active problems, end stage renal disease on hemodialysis, hypotension and subdural hematoma. It was noted the follow up CT head scan was done with no acute changes and per neurology department and Resident #1 should have a neurological outpatient follow up to determine duration of anticoagulation and follow-up CT scan. Eliquis 5 mg twice daily was listed as a medication to be continued. Physical Therapy (PT) evaluation for start of care dated [DATE], indicated that Resident #1 was worried about falling. The functional mobility assessment on the PT evaluation report revealed that Resident #1 required partial/moderate assistance to roll left and right during bed mobility. It also showed that the mobility function score (ranges from ,d+[DATE]; 12 being the highest function) was a 3. The self-care performance assessment indicated on the PT evaluation revealed that Resident #1's self-care function score (score ,d+[DATE]; 12 being the highest function) was a 0. The musculoskeletal system assessment on the PT evaluation indicated that Resident #1 had impaired right and left lower extremity strength. Occupational Therapy (OT) evaluation for start of care [DATE], indicated that Resident #1 required substantial/maximal assistance with toileting hygiene, and bed mobility. The mobility function score (ranges form ,d+[DATE];12 being the highest function) was a 1. The musculoskeletal system assessment on the OT evaluation revealed that Resident #1 had impaired right and left upper extremity strength, and impaired right upper extremity shoulder, elbow, forearm and wrist. An interview with the Rehabilitation Director was conducted on [DATE] at 11:58 am. The Rehabilitation Director confirmed that Resident #1 required minimum to moderate staff assistance with bed mobility to include rolling left and right. Rehab Director indicated that Resident #1 was never independent with bed mobility but required assistance with bed mobility to include rolling left and right while in bed. The facility Transfer/Mobility Evaluation Assessment completed by Unit Manager #1, on [DATE] was reviewed. The resident evaluation/functional ability section indicated that Resident #1 was non-ambulatory, had unsteady gait, with difficulty standing and required partial support to sit on bedside. The assessment further indicated that resident was able to sit on bedside with partial support (rail or person). Interview was conducted with Unit Manager #1 on [DATE] at 2:54 pm. Unit Manager #1 confirmed that she completed the transfer/mobility evaluation assessment. Unit Manager #1 indicated that Resident #1 required assistance with bed mobility and could not turn side to side in bed without assistance. Daily skill assessment completed on [DATE] by Nurse #3 was reviewed. Assessment indicated that Resident #1 required total assistance of one person with bed mobility. Multiple attempts were made to reach Nurse #3 for an interview were unsuccessful. Facility Incident report dated [DATE] completed by Nurse #1 at 1:28 am indicated under the nursing description; nurse aide [NA #1] states the resident [Resident #1] fell from bed when she rolled resident over to clean her bottom. The report revealed that Resident #1 had an injury to the back of head, left shoulder and top of scalp with occasional moaning or groaning, low level of speech with a negative quality and facial grimacing. The report also mentioned that upon the initial assessment immediately after the fall, Resident #1 could not answer questions and staff had to say Resident #1's name and physically stimulate Resident #1 to get a response. As time passed while waiting for emergency medical services (EMS), Resident #1 became more coherent but seemed to become more lethargic. The level of consciousness reflected on the incident report indicated Resident #1 was responsive only to vigorous stimulation after fall. NA #1's signed statement dated [DATE] indicated the incident occurred on Sunday [DATE] and NA #1 had seen Resident #1 about 6:00 pm when picking up the dinner tray from and Resident #1 was watching TV (television). NA #1 was doing rounds between 7:30 pm and 7:45 pm and Resident #1 requested to be changed. NA #1 gathered her supplies, raised the bed up and the brief fell on the floor. NA #1 she bent down to pick up the brief, and [Resident #1] rolled over to the window and rolled off the bed. A chair was by the air conditioner and NA #1 was unsure whether Resident #1 hit the chair. NA #1 indicated was screaming and she called for a nurse and called NA #2 on her cell phone. NA #1 requested NA #2 to send a nurse to Resident #1's room. Nurse #2 entered the room and immediately asked about how high the bed was but did not evaluate Resident #1. Nurse #1 came in and helped and assessed Resident #1. NA #1 Nurse #1 and NA #2 remained with Resident #1 and did not move the resident until EMS arrived. Resident #1 was talking and knew the day and time. Initially Resident #1 refused to go to the hospital, and her family was called and helped convince her to go. EMS transferred Resident #1 to the hospital. An interview with NA #1 was conducted on [DATE] at 4:06 pm. NA #1 revealed that Resident #1 was under her care from 7:00am, until she finished her shift at about 8:56 pm, on [DATE]. NA #1 confirmed that Resident #1 was able to make her needs known. NA #1 indicated that at around 7:15 pm, she went to check on Resident #1 and Resident #1 requested assistance with incontinence care. NA #1 indicated that she gathered her supplies which included a brief, wash clothes and towels to assist Resident #1 with incontinence care. NA #1 explained that once she entered the room, she got a basin of water, washcloths, brief and soap to provide care. NA #1 then confirmed that she raised the height of the bed to where she did not have to bend at all. NA #1 indicated that the height of bed was approximately at her chest level. NA #1 emphasized that she did not think the bed was too high, because she always brought it up that high. NA #1 revealed that after she completed washing Resident #1's perineal area, she told Resident #1 could you turn over there. NA #1 stated she was pointing Resident #1 towards the window, which was away from NA #1. NA #1 confirmed that she was standing to the left of Resident #1, facing the window. NA #1 further explained that prior to asking Resident #1 to turn from her back towards her right side, NA #1 did not move Resident #1 towards Resident #1 left side first, to ensure that Resident #1 was not close to the to the edge of the bed when she turned. NA #1 stated she did not recall how Resident #1 was positioned on the bed prior to requesting her to turn. NA #1 indicated the brief fell just when she had completed telling Resident #1 to turn towards the window, away from NA #1. NA #1 indicated that Resident #1 turned over, and then NA #1 turned from Resident #1 to bend down and pick up the fallen brief off the floor. NA #1 stated that Resident #1 fell off the bed onto the floor. NA #1 stated that she thought Resident #1 fell because, when the brief fell to the floor next to the bed, and she (NA #1) went to get it, she (NA #1) let go of Resident #1 and Resident #1 fell . NA #1 indicated that she did not touch Resident #1 while she turned /rolled over and Resident #1 turned herself to the side. NA #1 explained that she had her right-hand touching Resident #1 after Resident #1 was on her side. NA #1 continued to explain that when she went bent down to get the brief from the floor, she took her right hand off the resident. NA #1 stated when she picked up the brief off the floor, and stood up, it was too late for her to stop Resident #1 from falling because she was already falling off the bed, and she (NA #1) could not reach her at that point. NA #1 stated that Resident #1 fell , hit her head on the floor with a loud thud. NA #1 stated that she (NA #1) started screaming asking for assistance. NA #1 repeatedly stated that Resident #1 rolled too far and fell . NA #1 further stated that she did not leave Resident #1 alone, but sat with her on the floor, while screaming for help. NA #1 continued to state that NA #2 was at the nursing station and notified Nurse #1 and Nurse #2 about the incident. NA #1 indicated that both Nurse #1 and Nurse #2 came into Resident #1's room. NA #1 revealed that Nurse #1 asked her what happened. NA #1 explained to Nurse #1 that she was changing Resident #1 and Resident #1 fell . NA #1 revealed that while Resident #1 was on the floor, she was trying to talk to Nurse #1. NA #1 explained that when EMS arrived at the facility, Resident #1 has initially refused to go to the hospital, because she did not want anyone to take her television. NA #1 indicated that EMS convinced Resident #1 to go to the hospital. Nurse #1 contacted Resident #1's family member, who stated that Resident #1 was not in her right mind at the moment due to the fall. NA #1 indicated that Resident #1 was then lifted off the floor, onto the stretcher by EMS, Nurse #1 and NA #1. NA #1 indicated that the facility Administrator typed out a statement about the incident and told her to sign. NA #1 explained she was trying to write a statement on the day of the incident, but was told that the facility did not have any paper for her to use. NA #1 indicated that she never wrote a statement. Progress note written by Nurse #1 on [DATE] at 12:48 am which referenced Resident #1 stated at approximately 7:35 pm, while receiving shift report from off-going nurse, writer responded to nursing assistant [NA#1] calling out for help in Resident #1's room. Upon entering the room, the resident observed lying on the floor on her left side with the back of her head on the ac/heating unit. The NA stated the resident fell off bed when being rolled over to have her bottom cleaned. Nurse #1 noted the bed was significantly elevated. Upon assessment, resident was somewhat incoherent and unable to answer questions appropriately. Resident noted to have dazed look in her eyes and tremoring of lips. While palpating the resident's head and attempting to move head off ac/heating unit, the resident yelled out in pain stating her head and neck hurt. No further attempts were made to move neck or head but placed pillow for comfort. While assessing upper extremities, resident also yelled out in pain, especially during manipulation of left extremity. Neurological checks (assessment to check change in the function of the brain, spinal cord, or nerves) revealed change of LOC (level of consciousness), movement of upper extremities. Lower extremities were not assessed due to the resident's increasing pain. While writer was assessing resident, off-going nurse notified the on-call provider of fall and resident's use of Eliquis. An order given to send resident to ER. EMS was called and family was notified of events. When EMS arrived, resident initially refused to be transported to hospital. EMS called the resident's family and explained that they could not take resident if she did not want to be transported. Eventually, EMS and staff were able to encourage resident to go to hospital to be evaluated. At 8:15 pm, EMS left the facility and transported the resident to the ED. Family was notified of transport to the ED. The Director of Nursing was notified of fall and transport to hospital. A phone interview with Nurse #1 was conducted on [DATE] at 4:40pm. Nurse #1 indicated that she worked from 7:00 pm on [DATE] to 7:00 am on [DATE]. Nurse #1 stated that she was at the nursing station, having completed taking report from the outgoing Nurse #2 when NA #1 called out for help. Nurse #1 indicated that NA #1 came out to the hallway outside Resident #1's room and shouted, [Resident #1] is not responding. Nurse #1 indicated she immediately ran to Resident #1's room and upon entering Resident #1's room, Nurse #1 observed the bed was raised to the highest level. Nurse #1 further stated NA #1 explained to her that she raised the bed up to give Resident #1 care and when she rolled Resident #1 over to wipe her back side, she realized she did not have the diaper and wipes. NA #1 indicated she turned around to get the supplies and when she let go of Resident #1, she fell over. Nurse #1 added that NA #1 also stated that she rolled over Resident #1 too far. Nurse #1 indicated she observed Resident #1 on the floor with the back of her head against the air conditioning unit. Nurse #1 further revealed that Resident #1 was lying on the floor on her left side and her left arm was over her head. Nurse #1 indicated she rubbed Resident #1's head and Resident #1 made a groaning noise like it hurt. Nurse #1 informed NA #1 and Nurse #2 that they could not move Resident #1, but they had to notify provider and EMS as Resident #1 required immediate medical attention. Nurse #1 revealed that when she attempted to talk to Resident #1, resident was super dazed as if she was knocked out and not focused. Nurse #1 emphasized that if NA #1 did not let go of Resident #1, Resident #1 would not have fallen out of the bed. Nurse #1 stated Resident #1 could make her needs known but could not turn to her side without assistance. Nurse #1 repeated this statement NA #1 did it. She let her go. She did not hold onto to her, and she did not have the stuff next to the bed. Nurse #1 indicated that the bed was high to its maximum height, a height that she had never seen before. Nurse #1 further stated that NA #1 kept saying I had to raise the bed high. Nurse #1 indicated that she notified Resident #1's family member of the incident and also stayed with Resident #1 until EMS arrived. Statement provided by facility with no date or signature was reviewed. The Administrator indicated in the document that she typed out, that she (Administrator) told Nurse #2 to sign it, and Nurse #2 refused. The statement documented indicated fell [Resident #1] about 7:30pm. Aide yelled down hall for the nurse. 'She's not responding.' Me [Nurse #2] and Nurse #1 were sitting at the nurses' station getting report. [NA #1] ran screaming '[Resident #1] is not responding.' We got to the room. [NA #1] said she was changing her, turned back to get something off the nightstand. Grabbed brief or wipe or 'something.' Resident #1 was between heater and bed on her left side. I left the room and printed the paperwork to go to ED for Nurse #1. She was responsive. She was not talking. I did not assess Resident #1. The other nurse was in the room. 'Resident #1 eyes were fixed. Looked like she was having a seizure. 'I told aide 'why is the bed so high?' The aide explained she was giving patient care and turned around to get something. I left the room about 7:32 pm. A phone interview was conducted with Nurse #2 on [DATE] at 10:00am. Nurse #2 indicated that she worked from 7:00 am to 7:00 pm on [DATE]. Nurse #2 explained that after she had completed giving report to oncoming Nurse #1, NA #1 came out of a room into the hallway and said [Resident #1] was not responding. Nurse #2 indicated that she thought Resident #1 had become unresponsive and required cardiopulmonary resuscitation (CPR). Nurse #2 stated she ran into Resident #1's room and the first thing she noted was the bed was at its highest level. Nurse #2 indicated that she was 5 feet 3 inches tall, and the bed was all the way up to her chest. Nurse #2 indicated that the bed was raised to its highest position. Nurse #2 indicated that she asked NA #1 what happened, and NA #1 stated she was changing Resident #1, turned around to grab something off the dresser, and Resident #1 fell on the floor. Nurse #2 indicated that Nurse #1 was in the room as well. Nurse #2 stated that Nurse #1 requested that EMS and the provider be notified. Nurse #2 then left the room, notified the provider, called EMS and prepared the discharge paperwork. Nurse #2 revealed that she had cared for Resident #1 multiple times and indicated that Resident #1 was able to make her needs known and required extensive assistance from staff with turning in bed. Nurse #2 indicated she explained the incident to the Administrator but was not allowed to write a statement. Nurse #2 indicated the Administrator typed a statement and asked Nurse #2 to sign it. Nurse #2 confirmed that she refused to sign the statement the Administrator typed because she did not agree with what was written on the form about the incident. Nurse #2 indicated the Administrator had changed her words to imply something else had happened and that is why she refused to sign it. Resident #1's emergency department (ED) provider note dated [DATE] indicated she had a history of ESRD with hemodialysis, recent venous sinus thrombosis on Eliquis, recent seizures on Keppra, and diabetes mellitus. Resident #1 reported she was being changed when she rolled about 3 feet off the bed, landing on the floor on her right side. She was not sure if she lost consciousness. The ED physician noted per chart review Resident #1 was admitted [DATE] through [DATE] following a syncopal episode and was found to have a new subdural hematoma and was restarted in Eliquis prior to discharge. Results of x-rays completed on [DATE] revealed fractured left 6th and 7th ribs and the CT scan of the head noted an acute on chronic bilateral subdural hematomas that had increased in size from compared with prior imaging and a possible trace acute subarachnoid hemorrhage. Neurosurgery was consulted due to worsening of the prior subdural hematomas and possible new acute subarachnoid hemorrhage. The Neurosurgeon recommended a follow-up CT scan in 6 hours and to hold Eliquis. Hospital progress notes dated [DATE] through [DATE] revealed on [DATE] while boarding in the ED neurological changes were noted including expressive aphasia with right-sided weakness. The repeat head CT scan revealed an increase in the left subdural hematoma without a midline shift (shift of the brain past its center line due to bleeding or swelling). Neurology was consulted and recommended admission to the intensive care unit for frequent neurological checks and Eliquis reversal. An Internal Medicine consultation note dated [DATE] indicated serial CT scans were now showing increase in the size of the subdural hematomas with a new midline shift measuring 3 mm (milliliters). The consulting Physician also noted that during the exam that morning Resident #1 appeared to be actively seizing. Neurology was paged urgently and intravenous Keppra (antiepileptic drug) was given. On [DATE] hospital progress notes indicated that Resident #1 had a worsened neurological status due to increase in subdural hematoma. On [DATE] Resident #1 was made comfort care and died on [DATE] at 5:00 pm. Certificate of Death, dated [DATE], from North Carolina vital records, indicated that the immediate cause of death for Resident #1 as complications of blunt force injury to the head. An interview with the Director of Nursing (DON) was conducted on [DATE] at 3:35 pm. DON indicated that she was notified by Unit Manager #1 on [DATE] at 7:45 pm that Resident #1 fell out of the bed while receiving care from NA #1. DON indicated that she then contacted the Administrator about the incident. DON indicated that Resident #1 was receiving care from NA #1, who did not use the proper positioning technique to assist the resident onto her side, and thus Resident #1 fell out of the bed. DON indicated that Resident #1 needed assistance to be turned to her side. An interview was conducted with the facility Administrator on [DATE] at 3:35 pm. The Administrator indicated she interviewed NA #1 on [DATE]. The Administrator explained that NA #1 was able to show a return demonstration of what happened during care with Resident #1, while in the Administrator's office. The Administrator stated that NA #1 demonstrated that she (NA #1) had her right hand on Resident #1 and her left hand was not touching Resident #1. The Administrator continued to state that NA #1 indicated that the brief fell to the floor, and NA #1 demonstrated that she turned to pick up the brief from the floor and her right hand moved away from Resident #1. The Administrator added that NA #1 confirmed that once she moved her right hand away from Resident #1 and went to pick up the brief form the floor, Resident #1 fell out of the bed onto the floor. The Administrator stated that NA #1 was not able to indicated how high the bed was raised. A phone interview with the Medical Director was conducted on [DATE] at 4:39pm. The Medical Director confirmed that he did not examine or see Resident #1 upon readmission on [DATE]. The Medical Director indicated that he was scheduled to assess Resident #1 on [DATE], but the resident was out of facility. The Medical Director stated that he had reviewed the discharge summary from the acute care hospital dated [DATE]. The Medical Director stated that with the combination of the fact that Resident #1 was on Eliquis the fall did contribute to the increase in the subdural hematoma. The Medical Director revealed the head injury sustained from the fall off the bed, contributed to increased hemorrhage in combination with the use of Eliquis. The Administrator was notified of immediate jeopardy on [DATE] at 4:30 pm. The facility provided the following plan for IJ removal. * Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was admitted to the facility on [DATE] with diagnoses that included a recent venous sinus thrombosis, and a chronic bilateral hematoma. She was ordered anticoagulation prior to admission to the facility for the venous sinus thrombosis. The Resident was discharged to the hospital on [DATE]. She was readmitted on [DATE]. On [DATE] at 7:20 p.m. Resident #1 requested incontinent care. Nursing Assistant (NA) #1 prepared supplies, that included a brief, and began by raising the bed to hip height, per recommended care safety guidelines for staff. The brief fell to the floor and NA #1 bent over to pick up the brief. NA #1 did not have her hands on Resident #1 when she picked up the brief and Resident #1 rolled over to face the window, on the right side of the bed, and rolled off the bed. NA #1 immediately responded to the Resident by walking to that side of the bed and called for assistance from NA #2. NA #2 notified Nurse #1 that there was a fall. Nurse #1 responded to the fall immediately, observed Resident #1 on the floor on the right side of the bed. Nurse #1 called for assistance from Nurse #2. Nurse #2 finished the assessment while Nurse #1 contacted Emergency Medical Services (EMS) to transport Resident #1 to an acute care hospital. While EMS was in route to the facility, Nurse #2 continued to conduct assessments that included neurological examinations, vital signs, and a skin assessment. Nurse #2 reported there were no visible signs of broken skin. Resident #1 was admitted to the hospital on [DATE]. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] Nurse #2 notified the unit manager that Resident #1 had a fall from the bed during care. The Unit Manager (UM) notified the Director of Nursing (DON) and the Administrator. The intervention included Resident was to be seen at the acute care hospital and for the fall to be discussed in the morning clinical risk meeting on [DATE]. On [DATE] Resident #1's care plan was updated to indicate she would require two staff assistance during care related to most recent fall. Following interview with CNA #1, it was determined that CNA #1 removed her hand from Resident #1 in order to pick up the brief from the floor and resident rolled away from CNA #1. On [DATE] an audit was conducted by the DON, Regional Nurse Consultant (RNC), and the Minimum Data Set (MDS) nurse, to identify any residents at risk for falls utilizing fall risk analysis report and Morse Scale report. The Activities of Daily Living (ADL) care plans of the residents who are at risk for falls and/or have had falls in the past 30 days were reviewed to ensure they included if the resident required a level of assistance of minimum, moderate, or maximum assistance with bed mobility. This audit included residents who currently have devices care planned to ensure the device is in place. Kardex updates automatically in Point Click Care (PCC) when the intervention is updated in the care plan, which CNAs can review under their documentation system of Point of Care (POC). The DON identified 2 items related to Dycem and a weighted blanket. These two items were corrected immediately by DON and/or SDC. This audit was completed on [DATE]. On [DATE] the Staff Development Coordinator (SDC) began education on turning and repositioning during care, utilizing the appropriate level of care required, maintaining resident safety during care by maintaining physical contact, and utilizing any assistive devices are according to resident's care plan/Kardex. Education was conducted in person with staff with an observed return demonstration completed to SDC. The education included an emphasis on the procedure for turning and repositioning resident when providing care, obtaining assistance when needed, maintaining resident's safety during care by maintaining physical contact, and repositioning a resident to the center of the bed when care is completed. SDC observed return demonstration included answering any questions, and/or re-educating 1:1. The education will be completed by [DATE] for clinical staff currently working and will continue with staff who provide care to residents including nurses, nurse aides, therapy. Those who were not educated by [DATE] will be educated and provide return demonstration prior to beginning their next scheduled shift. Newly hired staff including nurses, nurse aides, and therapy will receive the education from the SDC or designee and provide return demonstration to SDC, DON, or UMs during orientation and this will be conducted by the SDC or DON. On [DATE] the Activities Director conducted interviews with residents that had a Brief Interview for Mental Status (BIMS) > 12, to identify any resident concerns related to turning and repositioning during care. Interviews were completed by [DATE]. No concerns were identified. On [DATE] the DON conducted observations of residents and resident rooms identified to be at risk for falls to ensure the fall interventions placed on the plan of care were in place. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Date of immediate jeopardy removal: [DATE] Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The facility's initial plan audit was verified and signature sheet for education reviewed with no concerns. Facility nurses and nursing assistants were interviewed and were aware of turning and repositioning during care, utilizing the appropriate level of care required, maintaining resident safety during care by maintaining physical contact, obtaining assistance when needed, repositioning a resident to the center of the bed when care is completed and utilizing any assistive devices are according to resident's care plan/Kardex. The facility's immediate jeopardy removal date of [DATE] was validated.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for a newly admitted resident that required assistance with bed mobility for 1 of 3 residents reviewed for supervision to prevent accidents. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE], with a diagnosis that included dialysis dependent end stage renal disease (ESRD), metabolic encephalopathy, hypertension, congestive heart failure, diabetes, history of seizures, venous sinus thrombosis 12/2024 (rare form of a stroke), and history of pulmonary embolism. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. The assessment also indicated Resident #1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with roll left and right (the ability to roll from lying back to left and right side, and return to lying on back on the bed.) Care Area Assessment (CAA) worksheet for functional abilities (Self-Care and Mobility was triggered for admission MDS assessment dated [DATE] and completed on 1/11/25). Review of the worksheet revealed that the triggering conditions included but were not limited to, brief interview for mental status (BIMS) summary was 14 (intact cognition), while activities of daily living (ADL) was required at partial/moderate assistance for toileting hygiene, upper body dressing, roll left and right, sit to lying, lying to sitting on side of bed and toilet transfer. Analysis of findings indicated that Resident #1 needed assistance with self-care and mobility items due to physical limitation, weakness, limited range of motion, poor coordination, poor balance, visual impairment, pain etc. CAA worksheet indicated that functional abilities (self-care and mobility) functional status would be addressed in the care plan. The facility did not provide a care plan that focused on Resident #1's functional abilities (self-care and mobility) functional status care plan. Interview with the MDS Nurse was conducted on 1/30/25 at 10:57 am. The MDS nurse confirmed that Resident #1 required assistance with self-care and mobility and did not have a functional abilities (self-care and mobility) functional status care plan. The MDS Nurse further stated that Resident #1 should have a care plan that addressed self-care and mobility. An interview was conducted with the facility Administrator on 1/30/25 at 3:35 pm. The Administrator indicated that care was to be provided according to the plan of care.

Based on record review and staff interviews, the facility failed to accurately assesses residents in the area of accidents (Resident #76, Resident #42, Resident #58) and failed to complete the functional abilities and goals section (Resident #12) for 4 of 13 residents reviewed for Minimum Data Set (MDS) accuracy. The findings included: 1a. Resident #76 was admitted to the facility on [DATE]. A Smoking assessment dated [DATE] indicated Resident #76 required supervision while smoking. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was cognitively intact and was coded as not being a current tobacco user. An interview with the MDS Coordinator on 12/4/24 at 2:37 PM revealed Resident #76 was admitted to the facility as a smoker. Upon review of Resident #76's annual MDS assessment, the MDS Coordinator stated Resident #76 should have been coded as a current tobacco user. 1b. Resident #42 was admitted to the facility on [DATE] with diagnoses that included tobacco use. Review of a Smoking assessment dated [DATE] indicated Resident #42 was a tobacco user and was identified as safe to smoke unsupervised. Review of Resident #42's annual MDS assessment dated [DATE] revealed he was coded as not being a current tobacco user. An interview with the MDS Coordinator on 12/5/24 at 2:31 PM revealed Resident #42 used tobacco/smoked. Upon reviewing Residet #42's MDS assessment, she stated it was not coded for current tobacco use and should have been. 1c. Resident #58 was admitted to the facility on [DATE] with diagnoses that included tobacco use. Review of Resident #58's annual MDS assessment dated [DATE] revealed he was coded as not being a current tobacco user. An interview with the MDS Coordinator on 12/5/24 at 2:31 PM revealed Resident #58 used tobacco/smoked. Upon reviewing Resident #58's MDS assessment, she stated it was not coded for current tobacco use and should have been. An interview conducted with the Administrator and Director of Nursing on 12/5/24 at 3:33 PM revealed they would expect the MDS to accurately identify a resident that currently used tobacco. Resident #76, Resident #42 and Resident #58 MDS assessments should have coded the residents as tobacco users. 38920 2. Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included stage 4 kidney disease and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. While reviewing the section of the MDS titled functional abilities and goals, the section for self-care was observed not to be completed. Further reviews of subsequent quarterly MDS assessments were observed to have the self-care section filled out. During an interview with MDS Nurse #1 on 12/3/24 at 2:48pm, the MDS Nurse explained she had been hired as the MDS Nurse in September 2024 and prior to that the facility relied on an outside contract company to complete the residents' MDS assessments. She explained the contract company continues to assist with completing MDS assessments. The MDS Nurse reviewed Resident #12's MDS assessment for 1/18/24 and confirmed the self-care section under functional abilities and goals was not completed. She also confirmed Resident #12 had not been hospitalized which she stated would have caused this section to be marked not assessed and/or not completed. MDS Nurse #1 stated she did not know why the section had not been filled out and explained it should have been. The Director of Nursing (DON) was interviewed on 12/4/24 at 9:42am. The DON explained the facility had been without an in-house MDS Nurse and had been utilizing a remote MDS company to help complete/review MDS assessments. She stated she had not known about Resident #12 not having the self-care portion of the section titled functional abilities and goals completed on her quarterly MDS assessment dated [DATE]. The DON commented that the self-care section should have been completed for Resident #12. An interview with the Administrator occurred on 12/5/24 at 1:30pm. The Administrator explained the facility always had an MDS Nurse but not always an MDS Nurse in-house. She stated in January 2024 there was a remote contracted MDS service completing the MDS assessments and explained she began working at the facility in January 2024 so she was not aware of who would have been reviewing the MDs assessments for accuracy. The Administrator stated she could not comment on why Resident #12 did not have her self-care assessment section completed on her quarterly MDS assessment dated [DATE]. She did state the self-care section should have been completed.

Based on record reviews, and resident and staff interviews, the facility failed to offer a resident the opportunity to participate in his care plan meetings for 1 of 1 sampled resident reviewed for care planning (Resident #32). Findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses which included: diabetes mellitus with diabetic peripheral angiopathy, vascular dementia, and major depressive disorder. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #32 was cognitively intact. During an interview on 12/02/24 at 10:34 a.m., when asked about his care plan meetings, Resident #32 stated he had resided at the facility for two years and no one had ever explained or discussed anything with him. There was no documentation in the medical record or provided by the social worker indicating Resident #32 attended or refused to attend his care plan meetings. An interview with the Director of Social Work (SW) on 12/04/24 at 1:39 p.m., revealed she began working at the facility in January 2024, and her responsibilities included scheduling the quarterly care plan meetings for all the facility's residents. She stated that in preparation for the quarterly meetings, she would send a generalized letter with her phone number to the residents' families informing them of the upcoming care plan meetings encouraging them to attend and to schedule a date and time. Two weeks after the letter, she would telephone the families/responsible parties of residents who were scheduled for a care plan meeting with the scheduled date and time of the resident's meeting. If the family/responsible party had a conflict scheduled date and time, then she would discuss a better date/time convenient for them. The SW stated she would also verbally notify the alert and oriented residents the day before or on the day of the meeting as well as the unit manager to ensure the resident was out of bed and dressed. The SW stated that Resident #32, his wife (via telephone) and/or his son (on-site) have attended the resident's care plan meeting in the designated room in the facility and sometimes in the resident's room. The SW was unable to recall the date of Resident #32's last care plan meeting. After further review of facility records, the SW revealed there was no documentation available indicating a care plan meeting for Resident #32 was held in October 2024 but acknowledged there should have been. She stated the most recent documented care plan meeting held for Resident #32 was on 3/23/23.

Based on observation, record review, and staff interview and physician interviews, the facility failed to follow physician orders for oxygen administration for 2 of 4 sampled residents reviewed for respiratory care (Resident #40 and Resident #14). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), respiratory failure and vascular dementia. Physician order dated 5/16/24 stated continuous oxygen at 2 liters via nasal cannula (NC) and as needed (PRN) to maintain {oxygen} saturation (SATS) greater than 90%. Care plan last revised 6/15/24 stated Resident #40 had oxygen therapy. The goal stated Resident #40 would have no signs or symptoms of poor oxygen absorption. The interventions included provide oxygen per physician order. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 had moderate cognitive impairment and received oxygen. She required extensive assistance with bed mobility and had no rejection of care coded during the look back period. Review of Resident #40's vital signs for 12/2/24, 12/3/24 and 12/4/24 revealed her oxygen SATS to be greater 90%. Resident #40 was observed on 12/2/24 at 10:27 AM. She was observed to be laying in bed and receiving oxygen via NC. The oxygen concentrator was observed to be set at .5 liters. Resident #40 had no signs or symptoms of respiratory distress. Resident #40 was observed on 12/3/24 at 3:44 PM revealed Resident #40 to have oxygen via NC. The oxygen concentrator was observed to be set at .5 liters. During the observation, Resident #40 showed no signs or symptoms of respiratory distress. Resident #40 was observed on 12/4/24 at 8:54 AM. She was observed to laying in bed and receiving oxygen via NC. The oxygen concentrator was observed to be set at .5 liters. Resident #40 had no signs or symptoms of respiratory distress. Interview with Nurse #2 on 12/4/24 at 11:00 AM indicated she had entered Resident #40's room in the morning of 12/4/24. She stated she observed Resident #40's oxygen to be set at .5 liters. She stated when she observed the oxygen was not set according to the physician order, she adjusted Resident #40's oxygen concentrator to 2 liters. Nurse #2 further stated Resident #40 would not be able to adjust her oxygen setting independently. Interview with the Director of Nursing (DON) on 12/4/4 at 11:00 AM revealed nurses should check supplemental oxygen settings daily. In a follow up interview with DON on 12/5/24 at 3:28 PM revealed nursing staff should ensure residents oxygen orders were followed as written by the physician. Interview with the Physician on 12/5/24 at 2:59 PM stated it was his expectation that staff follow physician orders as written until they were modified or discontinued. He stated Resident #40 had no STATS lower than 90% due to receiving .5 liters of oxygen. 39613 2. Resident #14 admitted to the facility on [DATE]. Resident #14's diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure, and anxiety disorder. Resident #14 had a physician order in place dated 11/27/2023 which read in part: continuous oxygen at 2 liters. Resident #14 had a care plan in place revised on 4/24/2024 related to oxygen therapy for COPD. Interventions included oxygen settings via nasal cannula at 2 liters per minute continuously. Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, no mood or behaviors indicated and received oxygen therapy. An observation on 12/02/2024 at 10:26 AM revealed Resident #14 sitting edge of bed. Resident #14 had her nasal cannula (NC) in her nares. An observation completed of the in-room oxygen concentrator revealed the oxygen setting at 3.5 liters (L). No signs or symptoms of distress observed. A follow up observation of Resident #14 was completed on 12/02/2024 at 12:36 PM which revealed Resident #14's in-room oxygen concentrator setting remained at 3.5L. Resident #14 was eating lunch at this time. No signs or symptoms of distress noted. Resident #14 was observed at breakfast on 12/03/2024 09:38 AM which revealed her in-room oxygen concentrator remained at 3.5L. No signs or symptoms of distress noted. An interview with Medication Aide (MA) #5 was completed on 12/04/2024 at 10:08 AM. MA #5 stated Resident #14 received supplemental oxygen and was compliant with her supplemental oxygen. MA #5 further stated Resident #14 did not adjust her in-room oxygen concentrator settings at will. MA #5 verbalized Resident #14 should be on 2 or 3 liters of supplemental oxygen. MA #5 verified the physician order in the electronic medication administration record (eMAR) which revealed Resident #14 was ordered continuous oxygen at 2L via nasal cannula. An observation with Medication Aide (MA) #5 was completed on 12/04/2024 at 10:11 AM. MA #5 observed the in-room oxygen concentrator setting at 3.5L. MA #5 was observed to adjust the in-room oxygen concentrator setting to 2L per the physician order. MA #5 explained nurse aides (NA) do not adjust oxygen settings. Nurses or the assigned MA were responsible for checking and ensuring the residents were on the correct ordered liter. MA #5 stated her process was to check the settings when delivering medications and if the resident verbalized they were not feeling any air flowing. MA #5 did not recall when she last checked Resident #14's in-room oxygen concentrator settings. An interview was completed with Resident #14 on 12/04/2024 at 10:15 AM. Resident #14 verbalized she had received supplemental oxygen for a long time since being at the facility. She stated the oxygen setting should have been at 2L and was not certain when the setting changed. Resident #14 verbalized that she did not manipulate her in-room oxygen concentrator settings. An interview with Unit Manager #1 on 12/04/2024 10:30 AM revealed nurses should be monitoring their residents on supplemental oxygen and ensuring the in-room oxygen concentrators were on the correct ordered liter. NAs were not responsible for manipulating oxygen settings or monitoring. Nurses should be checking the in-room oxygen concentrators every shift to make sure the correct ordered liter was still in place for their residents on supplemental oxygen. Unit Manager #1 verbalized she had not seen Resident #14 manipulate her oxygen settings on her in-room oxygen concentrator. An interview with the Director of Nursing (DON) on 12/04/2024 at 11:00 AM stated nurses should be checking supplemental oxygen settings daily to ensure residents were on the correct ordered liter. An interview with the Physician was completed on 12/05/2024 at 3:17 PM. The Physician explained Resident #14's in-room oxygen concentrator should have been set at the correct ordered liter. The Physician continued to state if Resident #14 required an increase, then he could have assessed her.

Based on observations, record review, and staff interviews, the facility failed to provide foot care and arrange podiatry services for 1 of 10 dependent residents reviewed for activities of daily living (ADL) care. Resident #5 was discovered to have long and jagged toenails on both feet that extended 1/4 to 1/2 beyond the tip of her toes (Resident #5). The findings included: Resident #5 was admitted on [DATE] with the diagnoses included diabetes and dementia. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #5 was cognitively intact, and dependent (helper does all the effort) on staff for personal hygiene. Resident #5's comprehensive care plans, last revised on 09/29/24, did not include interventions that addressed her need for assistance with activities of daily living. Review of the podiatry schedules on 7/31/24, 9/5/24, and 11/5/24 revealed no consultation report or notation was made in Resident #5's chart that she had been seen by the podiatrist or had been scheduled to be seen. A review of Resident #5's electronic medical record from 6/14/24 through 12/5/24 revealed no documentation that indicated Resident #5 had received toenail trimming by staff or podiatry. Review of Resident #5's skin assessments done by nursing on the following dates 10/3/24, 10/26/24, 11/9/24, 11/16/24 revealed there was no information documented on the assessment about the condition of Resident #5's toenails. An observation and interview were conducted on 12/2/24 at 10:40 AM, Resident #5 was in her room lying in bed with her bare feet exposed. The toenails on both feet were jagged and had grown approximately 1/4 to 1/2 inch beyond the tip of her toes. Resident #5 indicated that she would like to have her toenails cut but nobody had done it. A follow-up observation was conducted on 12/4/24 at 9:02 AM. Resident #5 was lying in bed and there was no change of condition of Resident #5's toenails An interview was conducted on 12/4/24 at 9:52 AM, with NA #2. She stated she had worked with Resident #5 on a regular basis, and she recalled reporting to a nurse that Resident #5's toenails were long and needed to be seen by the podiatrist. NA #2 was not able to recall the name of the staff member she reported to or how long ago it was reported. An interview was conducted with Social Worker (SW) #1 on 12/4/24 at 10:06 AM and indicated she was responsible for coordinating the podiatry list and did not recall receiving a podiatry referral from nursing staff for Resident #5. She also indicated that podiatry referrals can be given to her verbally or in writing by the nursing staff. Once she receives the referral for podiatry she would contact the podiatry provider with the referral information. An interview was conducted on 12/5/24 at 9:17 AM, with Nurse #1 who stated she had completed the skin checks for Resident #5 on 11/2/24, 11/9/24, and 11/16/24 and did not notice if foot care was needed and must have been an oversight. She further revealed she thought Resident #5 had already been referred to podiatry as she was a diabetic and would have needed a podiatrist to provide the appropriate foot care. An interview was conducted on 12/4/24 at 3:59 PM, with the Director of Nursing (DON) who stated the podiatrist was scheduled every 3 months and it was expected that any residents who needed podiatry service be added to the schedule. She said the nurse aides were responsible for reporting to nursing when resident's toenails were extremely long or sharp, and/or needed podiatry to trim/cut the nails. The DON further stated the nurses were responsible for completing the weekly full body assessments which would include the condition of resident's toenails. The interview further revealed the nurses were responsible for notifying the SW verbally or in writing when a resident required podiatry services. The DON further revealed that Resident #5 was a diabetic and therefore should have been referred to the podiatrist for services and felt it was an oversight by the nursing staff.

Based on record review, observation, and resident and staff interviews, the facility failed to protect a resident's right to be free from neglect when Nursing Assistant (NA) #3 and the dietary staff did not ensure Resident #12 received lunch. This occurred for 1 of 4 residents (Resident #12) reviewed for food preferences. The findings included: This tag is cross referenced to: F806 Based on observation, record review, and resident and staff interviews, the facility failed to provide a resident with an alternate preference during the lunch meal for 1 of 4 residents (Resident #12) reviewed for food preferences.

Based on observation record review and staff interview, the facility failed to develop a comprehensive care plan for the areas of smoking (Resident #76) and Activities of Daily Living (ADL) (Resident #5) for 2 of 18 residents whose care plans were reviewed. The findings included: 1. Resident #76 was admitted to the facility on [DATE]. A facility smoking assessment dated [DATE] indicated Resident #76 required supervision while smoking. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was cognitively intact and was coded as not being a current tobacco user. The smoking assessment dated [DATE] indicated Resident #76 did not require supervision while smoking and was considered an unsupervised smoker. Review of Resident #76's care plans were reviewed and did not include a care plan or interventions in the area of tobacco use/smoking. An interview with the MDS Coordinator/Nurse #1 on 12/4/24 at 2:37 PM revealed Resident #76 was a smoker when she was admitted to the facility. The MDS Coordinator stated Resident #67 did not have a care plan identifying smoking as an area of concern and one should have been developed. Resident #76 was interviewed on 12/4/24 at 3:34 PM. She stated she was a smoker and had smoked at the facility since admission. An interview with the Director of Nursing and the Administrator on 12/5/24 at 3:35 PM revealed Resident #76 was a tobacco user/smoker since her admission. They indicated Residet #76 should have had a care plan developed with interventions due to her tobacco use. 46725 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had intact cognition and required substantial to maximum assistance with toileting hygiene, personal hygiene, shower/bathing, upper/lower body dressing, putting on/taking off footwear, bed mobility, and transfers. Review of the Care Area assessment dated [DATE] revealed Resident #5 triggered to have ADL function care planned. Resident #5's comprehensive care plans, last revised on 09/29/24, did not include a plan that addressed her need for assistance with ADL care. Multiple attempts were made to interview the previous MDS Nurse #2 but attempts were unsuccessful. An interview was conducted with MDS Nurse #1 on 12/4/24 at 10:14 AM. She indicated that when a resident is coded to require assistance with ADL care and the CAA is triggered to proceed to the care plan then an ADL care plan should be developed and implemented at that time. During an interview on 12/4/24 at 3:59 PM, the Director of Nursing reviewed Resident #5's care plan and confirmed the care plan did not include interventions relating to care needs, so that staff would know what level of care to provide. The DON stated it was an oversight, and Resident #5's ADL care plan should have reflected her care needs. During an interview on 12/5/24 at 2:45 PM, the Administrator stated she would expect care plans to be developed to accurately reflect the resident's needs.

Based on record review and staff interviews, the facility failed to update a care plan for 1 of 3 residents (Resident #12) reviewed for care plans. The findings included: Resident #12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. Upon reviewing Resident #12's care plan, it was observed that Resident #12's care plan had not been reviewed since 7/3/24. There was documentation under the care plan section of the electronic medical record for Resident #12 to have her care plan reviewed on 10/22/24. During an interview with MDS Nurse #1 on 12/3/24 at 2:48pm, the MDS Nurse explained she would have been responsible for ensuring Resident #12's care plan had been reviewed but stated she had not been placed in the MDS Nurse role until September 2024. The MDS Nurse stated she would not have reviewed the care plan in October 2024 as indicated in Resident #12's record unless there was a change in condition. She explained she only reviews care plans annually and/or if there is a change in condition. The Director of Nursing (DON) was interviewed on 12/4/24 at 9:42am. The DON discussed being the DON for only 3 months. She explained that she had been reviewing residents' care plans and had realized there were residents' who had not had a review of their care plans. She explained it was the responsibility of the MDS Nurse to track when care plan reviews were due. The DON stated residents should have their care plans reviewed every 3 months and/or if there was a change in the residents' condition. She stated she was unaware of Resident #12's care plan not being reviewed since July 2024. An interview with the Administrator occurred on 12/5/24 at 1:30pm. The Administrator discussed resident care plans should be reviewed when there is a change in condition and/or every 3 months. She explained the interdisciplinary team would review the care plan first and then the Social Worker would schedule the care plan meeting. The Administrator stated she did not know why Resident #12's care plan had not been reviewed since July 2024.

Based on record review, and staff, and Physician interview, the facility staff failed to confirm residents had taken their medication and left the medication on their meal tray. The medication was found by dietary staff. This occurred for 2 of 2 residents (Resident #12 and Resident #58) reviewed for medication storage. The findings included: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes and congestive heart failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. Resident #58 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia and hemiparesis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact. Review of the facility's timeline revealed on 8/16/24 the Administrator was sent pictures by the previous Dietary manager of medication that were left on Resident #58's meal tray. Again on 8/18/24 the Administrator received pictures from Medication Aide (MA) #4 of medication that was left on Resident #12's meal tray. The only other information present on the timeline was that education was provided to the two MAs (MA #4 and MA #3). Resident #12 was interviewed on 12/2/24 at 10:51am. Resident #12 stated she had not left any of her medication on her meal tray that she could remember. She explained the MAs would often leave her medication on her meal tray for her so she could take them during her meal but said she did not remember ever leaving her medication on her meal tray without taking them. Resident #58 was interviewed on 12/4/24 at 9:30pm. Resident #58 stated he could not remember if he had ever left medication on his meal tray. During an interview with Dietary Aide (DA) #3 on 12/2/24 at 2:25pm, DA #3 stated she recalled the medication being found on resident trays two times in August 2024. She stated she did not find the medication but saw DA #4 with them in her hand. DA #3 explained DA #4 gave the medication each time to the previous Dietary Manager. She stated she did not know what the previous Dietary Manager did with the medication. A telephone interview occurred with the previous Dietary Manager on 12/2/24 at 2:54pm. The Previous Dietary Manager recalled two times in August 2024 when meal trays were returned to the kitchen with medication on the trays. He stated he recalled one resident was Resident #12 and the other was Resident #58. The previous Dietary Manager explained he immediately called the Administrator both times who he said told him to give the medication to the Unit Manager each time. He stated he gave the medication to the previous Staff Development Coordinator (SDC), who he said was also acting as Unit Manager. During a telephone interview with the previous SDC on 12/2/24 at 3:48pm, the previous SDC stated she recalled one of the incidences when medication was found on a meal tray in August 2024. She explained she had received a call at home (could not remember from who) that there was medication found on a meal tray in the kitchen. The previous SDC stated she came back to the facility immediately and looked at the medication that was in the previous Dietary Managers possession to see if any of the medications were narcotics. She explained she did not remember who the medications belonged to, nor did she know what the previous Dietary Manager did with the medication. The previous SDC stated she never took the medication from the previous Dietary Manager. She explained the next thing she did was to check all the resident rooms to ensure no other medication was left in a resident room. The previous SDC stated that was all she could remember but said there should be an investigation file in the Administrator's office. An interview occurred with the Regional Consultant, Regional Nurse Consultant and the Director of Nursing (DON) on 12/3/24 at 9:40am. The Regional Consultant explained the previous SDC had not completed an investigation. She stated the only thing completed was a disciplinary action form for MA #3. The Regional Consultant. Regional Nurse Consultant, and the DON all stated they did not know what happened to the medication that was found and that there was never an investigation completed as to what happened to the medication, audits, further education with staff, or follow up with the residents who did not receive their medication. The DON discussed a timeline that had been completed by the Administrator. The Regional Consultant explained in November 2024, the DON realized there had been a systemic problem with medications being left at the bedside and that the DON began a performance improvement plan. A telephone interview occurred on 12/4/24 at 12:31pm with MA #3. MA #3 remembered leaving medication on Resident #58's meal tray. She explained when she was passing the medication, Resident #58 requested his medication be left on his tray. MA #3 stated when she returned to his room, the meal and the medication were gone. She stated Nurse #7 came to her and explained the dietary department had told her there were medications left on Resident #58's meal tray. MA #3 discussed later that day in August 2024, Unit Manager (UM) #1 counseled her and supervised one medication pass. She explained she never saw the medication that was left on the meal tray and did not know what was done with the medication after it was found by the dietary department. During a telephone interview with MA #4 on 12/5/24 at 2:25pm, MA #4 recalled the incident in August 2024 when there were medications left on a meal tray. She explained they belonged to Resident #12. MA #4 discussed never sending any photos to management regarding the medication. MA #4 explained she worked night shift (11:00pm to 7:00am) and never passed any medication but said management believed she had left them on Resident #12's meal tray. She stated management had given her a talking to about leaving medications on a meal tray. During an interview with UM #1 on 12/4/24 at 1:00pm, UM #1 stated she did not recall anyone ever telling her that there had been medication left on a meal tray back in August 2024. She also stated she did not recall ever counseling MA #3. DA #4 was interviewed on 12/4/24 at 1:23pm. DA #4 explained she remembered there had been two times in August where she found medications left on meal trays. She stated she could not remember the residents but stated she gave the cup of medications each time to the previous Dietary Manager. DA #4 discussed not knowing what the previous Dietary Manager did with the medications. A telephone interview occurred with Nurse #7 on 12/5/24 at 9:18am. Nurse #7 stated she did not recall any incidences of medication being left on meal trays or receiving any medications from dietary. The Medical Director was interviewed on 12/5/24 at 2:37pm. The Medical Director explained he was never made aware of the incident where medications had been left on meal trays two times in August 2024. He stated staff should have identified what the medications were and notified himself or the Nurse Practitioner to see if there would have been any consequences to the resident not taking their medications. The Medical Director stated he should have been informed of the situation.

Based on observation, record review, and resident and staff interviews, the facility failed to provide a resident with an alternate preference during the lunch meal for 1 of 4 residents (Resident #12) reviewed for food preferences. The findings included: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included stage 3 pressure ulcer and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact and was independent with eating. Resident #12 was documented as being on a therapeutic diet. Resident #12 was interviewed on 12/2/24 at 10:32am. The resident discussed not liking the food at the facility. She explained she would often ask for an alternate meal or a sandwich and would not receive any alternate or sandwich. Resident #12 stated that is why I keep food in my room and pointed to a shelf that had canned food. The lunch meal was observed with Resident #12 on 12/2/24 at 12:15pm. Nursing Assistant (NA) #3 was observed to provide Resident #12 with her lunch tray. Resident #12 requested a ham and cheese sandwich because she did not like her meal. NA #3 was observed telling Resident #12 she would go to the kitchen and get her sandwich. At 2:55pm on 12/2/24 Resident #12 was observed in the hallway in her wheelchair. Resident #12 stated she never received any lunch today and was hungry. The resident explained the sandwich she had asked for was never brought to her, so she had nothing to eat for lunch. During an interview with NA #3 on 12/2/24 at 3:00pm, the NA confirmed she had been the NA who had requested the sandwich from the kitchen for Resident #12. She explained she went to the kitchen right after Resident #12 told her that she wanted a ham and cheese sandwich and informed one of the dietary aides. She stated she could not remember who the dietary aide was. NA #3 stated she was unaware Resident #12 never received her lunch and thought the kitchen staff would have brought the resident her sandwich. An interview with Dietary Aide #1 occurred on 12/2/24 at 3:15pm. Dietary Aide stated he was the one who was told Resident #12 wanted a ham and cheese sandwich for lunch. Dietary Aide #1 produced the wrapped ham and cheese sandwich that he stated he made for Resident #12. He explained he thought NA #3 would come back and deliver the sandwich to Resident #12 and was unaware this did not happen until now. Dietary Aide #1 stated he was also unaware Resident #12 did not receive anything for lunch and questioned the surveyor if he should offer Resident #12 something to eat now. The surveyor informed Dietary Aide #1 Resident #12 was hungry, so Dietary Aide #1 was observed to approach Resident #12 and asked the resident if she wanted her sandwich. Resident #12 was heard telling Dietary Aide #1 she would like her sandwich because she was hungry. Observation of Resident #12 occurred on 12/2/24 at 3:30pm. Resident #12 was observed eating her sandwich she had requested. The Administrator was interviewed on 12/2/24 at 3:18pm. The Administrator discussed the floor staff and dietary staff working together to ensure that residents received requested food items. She stated she would have expected the floor staff to ensure the residents receive a lunch meal. During an interview with the Assistant Dietary Manager on 12/5/24 at 10:18am, the Assistant Dietary Manager explained if a resident wanted an alternate meal, then the NA or a dietary staff would ask the resident what they wanted and if the kitchen had the food available, they would fix the resident what they requested. She further explained, once the food was prepared the Dietary Aide or the Assistant Dietary Manager would deliver the requested food items to the resident. The Assistant Dietary Manager stated when NA #3 requested the ham and cheese sandwich for Resident #12, the NA did not provide the Dietary Aide with the information of who the sandwich was for, so they were unable to provide the meal to Resident #12.

Based on record review, observations, and resident and staff interviews, the facility failed to maintain walls or baseboards in good condition for 6 of 13 rooms (room [ROOM NUMBER], #213, #215, #217, #218 and #222). This occured for 1 of 2 halls (200 hall) reviewed for clean, comforatble, homelike environment. The findings included: 1. A continuous observation on 12/5/24 from 10:45 AM until 11:00 AM revealed the following: a. Resident room # 213 was observed to have baseboard that was not affixed to the wall. The baseboard could be observed leaning from the wall with dry wall exposed behind the baseboard. b. Resident room [ROOM NUMBER] to have baseboard missing from the wall under the TV under bed B. c. Resident room [ROOM NUMBER] revealed baseboard to missing beside the bathroom and baseboard was observed to be lyying on the floor by bed B. d. Resident room [ROOM NUMBER] was observed was observed to have missing baseboard by bed A. Bed B had a section of baseboard lyying directly on floor. Review of the facility work orders from October 2024 through December 2024 revealed no work orders regarding baseboard repair. A continuous observation and interview was conducted with the Maintenance Assistant on 12/5/24 from 2:00 PM until 2:15 PM. He stated recently the facility began using an electronic system (TAILS) to document and track items that were in need of repair about a month ago. Prior to implementing the electronic tracking system staff would communicate concerns verbally. He revealed he was unaware of the missing baseboard in resident room [ROOM NUMBER]. He stated if he was made aware he would have fixed the baseboard. He indicated he would only need glue to put the baseboard back in place. During observation of Resident room [ROOM NUMBER], the Maintenance Assistant stated he was not made aware and measured the missing baseboard in room [ROOM NUMBER] to be 6 feet. An observation in Resident room [ROOM NUMBER] with the Maintenance Assistant revealed about 4 feet of baseboard was missing and in need of repair to Resident room [ROOM NUMBER]. Interview with the Administrator on 12/5/24 at 3:37 PM revealed it would be her expectation that staff report missing or loose baseboards to the Maintenance Director or Maintenance Assistant. The Administrator indicated the facility had been without a Maintenance Director for some time. During the time the facility was without a Maintenance Director the facility was not using the electronic tracking system and were using word of mouth to communicate items in the facility that needed repair. 38920 2. room [ROOM NUMBER] was observed on 12/2/24 at 10:28am. The observation revealed red/orange splatter on the wall across from the bathroom, the door leading to the hall had black marks on the inside above the door handle, and there were black marks on her bathroom door also above the door handle. The Resident in room [ROOM NUMBER] was interviewed on 12/2/24 at 10:30am. The Resident stated housekeeping did not clean her room daily. On 12/4/24 at 10:52am a walk around occurred with the Housekeeping Manager and Administrator. Upon entering room [ROOM NUMBER], there was red/orange splatter on the wall across from the bathroom, the door leading to the hall had black marks on the inside above the door handle, and there were black marks on her bathroom door also above the door handle. The Housekeeping Manager was interviewed on 12/4/24 at 11:11am. The Housekeeping Manager explained that the assigned housekeeper would wipe down any touch areas, dust, clean the bathroom, and sweep/mop the floor daily. She also explained she performed walk around twice a week. The Housekeeping Manager stated if the housekeeper saw spillage or dirt on the walls/doors they were responsible for cleaning the area. During an interview with Housekeeper #1 on 12/4/24 at 11:22am, Housekeeper #1 discussed he was aware residents' walls were dirty and stated he had informed his supervisor. He explained due to the time constraint to get to each resident room, there was not enough time to clean all the areas and their walls. The Administrator was interviewed on 12/5/24 at 1:50pm. The Administrator stated she was not made aware of the issues until the walk around. 3. An observation of room [ROOM NUMBER] occurred on 12/2/24 at 12:28pm. The observation revealed holes in the wall behind and below both resident's headboards. The resident by the window had 2 holes behind her bed right below the headboard and the resident by the door had 1 hole behind her headboard and 1 hole right below the headboard. During an interview with both both residents in room [ROOM NUMBER] on 12/2/24 at 12:29pm, both residents stated the holes in their wall had been there at least 1 year. A walk around occurred with the Maintenance Assistant and the Administrator on 12/4/24 at 10:52am. The Maintenance Assistant measured the holes for the resident by the window with the following results: 1. 3.5 by 8 inches and 2. 7.5 by 10 inches. Upon measuring the holes for the resident by the door the results were: 1. 7 by 7 inches and 2. 19 by 10 inches. The Maintenance Assistant was interviewed on 12/4/24 at 11:08am. The Maintenance Assistant stated they do not complete walk around on a consistent basis. He explained they rely more on housekeeping and Nursing Assistants to complete work orders in their computerized system. The Maintenance Assistant stated he was unaware of the holes in the wall because no one had entered the issue into the computerized system. He explained that anyone can enter an issue into the computerized system which then sends an alert to his phone. The Maintenance Assistant stated once the issue has been fixed, he logs into the computerized system and marks the issue as completed. The Administrator was interviewed on 12/5/24 at 1:50pm. The Administrator stated she was not made aware of the issues until the walk around.

Based on record reviews and staff interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 30 sampled residents (Resident #109) reviewed for submission of MDS assessments. The findings included: Resident #109 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation and diabetes mellitus. The admission MDS dated [DATE] indicated Resident #109 was cognitively intact. Review of the medical record revealed the self-care and mobility section of Resident #109's quarterly MDS with the assessment reference date of 11/19/24 was not completed as of 12/4/24. During an interview on 12/05/24 at 9:58 a.m., the MDS Coordinator revealed she was on emergency leave from the facility on 11/25/24 to 12/2/24. She stated the self-care and mobility section of Resident #109's quarterly MDS should have been completed and submitted into the CMS system (Centers for Medicare and Medicaid Data Base System) by 12/3/24 by one of the facility's contracted remote MDS nurses.

Based on observations, record review, Nurse Practitioner and staff interviews, the facility failed to verify competency for cleaning and disinfecting glucometers according to the manufacturer's instructions. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same shared glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. MA #1 was interviewed and reported she worked at the facility for approximately 2 years and her competencies for cleaning and disinfecting glucometers per the manufacturer's instructions had never been verified. She stated she never cleaned and disinfected the glucometer between residents. This was for 1 of 1 Medication Aide reviewed. The Immediate Jeopardy began on 7/10/24 when the failure to verify the competency of MA #1 on the cleaning and disinfecting of a glucometer resulted in the MA's failure to clean and disinfect a shared glucometer between residents when conducting FSBS checks. Immediate Jeopardy was removed on 7/12/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems is put in place and to complete employee in-service training. Findings included: Cross refer to tag F-880: Based on record reviews, observations, and staff and Nurse Practitioner (NP) interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. This occurred while there were no residents with known bloodborne pathogens, such as Hepatitis and Human Immunodeficiency Virus (HIV), in the facility. Failure to clean and disinfect the shared glucometer per manufacturer's instructions after use on each resident has the high likelihood of exposing residents to the spread of bloodborne pathogens. The deficient practice occurred for 4 of 4 residents observed for finger stick blood sugar monitoring. During an interview on 7/10/24 at 4:55 pm, MA #1 revealed she was not trained on cleaning and disinfecting glucometers per the manufacturer's instructions in the facility. She stated she had always wiped down her cart and the glucometer with 2 wipes. One wipe was used to clean and the other wipe to disinfect. She indicated nobody watched her perform the process of cleaning and disinfecting glucometers while she worked in the facility. During an interview on 7/11/24 at 9:15 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) revealed she just started her job three months ago and she was not sure what had been taught to the medication aides regarding cleaning and disinfecting the glucometers. She could not find orientation checklists for the MAs including MA #1 and was having to come up with her own orientation checklists which included cleaning and disinfecting glucometers. She said she did an in-service about infection control and disinfecting glucometers in April 2024 based on the facility's policy. She had staff sign rosters when doing an in service. She stated she was not sure if MA #1 attended the in-service. She was not able to provide a roster for the in-service in April 2024. The SDC/IP stated she was not sure if the medication aides' competencies were verified or how they were verified. She revealed she could not find the training folders. The SDC/IP stated in the future, she would ask the nurse and MA's to demonstrate the cleaning and disinfecting of glucometers per manufacturer's instruction to make sure they understood when she trained them. After the interview on 7/11/24 with the SDC/IP, evidence of training and verification of competencies for cleaning and disinfecting glucometers for MA #1, MA #2, MA #3, MA #4 and MA #5 was requested from the SDC/IP. As of the survey's exit, no evidence was provided. During an interview on 7/11/24 at 9:27 am, the Director of Nursing (DON) revealed she started her job in April 2024. The DON explained the MA not cleaning and disinfecting the glucometer between resident use was an example of not having a strong training and a good orientation program which she observed in the facility when she first got the job in April 2024. She could not find training folders, or the staff folders did not have records regarding training, such as infection control, in them. The DON stated they had an in service on checking blood glucose and the cleaning and disinfection of glucometers in April of 2024. She did not know if MA #1 was at the April in service. She could not find any evidence the nurses and the MAs' competencies were verified. She stated she hired the SDC/IP and trained her. She also hired two Unit Managers to help with training and educating staff. The DON was hoping to structure the orientation program and streamline the education. The constraint to the effective training program was the staffing shortage. She stated the SDC/IP and the Unit Managers who she was hoping to help train were getting pulled to work the carts. The DON stated she was trying to create processes and improve their training program and had made strides since she started. On 7/11/24 at 10:03 am, an interview was conducted with the Administrator, in the presence of the DON. The Administrator revealed she just started at the facility in January 2024 as the administrator. She revealed there were a lot of improvements that needed to be made at the facility and she was working closely with the DON to ensure improvements were made. During an interview on 7/11/24 at 2:05 pm, the Regional Nurse Consultant stated the Chief Nursing Officer sent an email to the DON regarding the use of glucometers in April and the staff had the in-service on checking blood sugars and cleaning and disinfecting the glucometers. She revealed MA #1 told her on 7/11/24 that nobody in the facility trained her on the cleaning and disinfecting of glucometers in between residents per manufacturer's instructions. The Administrator was notified of Immediate Jeopardy on 7/11/24 at 1:50 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. On 7/10/2024 at 4:45 p.m., Medication Aide (MA) #1 performed a fingerstick blood glucose check on Resident #1, #2, #3, and #4. MA #1 failed to perform glucometer fingersticks on 4 residents utilizing each resident's personal glucometer and instead used one (1) glucometer for the 4 residents. MA #1 failed to cleanse and disinfect the glucometer according to glucometer manufacturer and EPA-registered disinfectant germicidal wipes recommendations. MA #1 did not follow the facility process and manufacturer and disinfected product guidelines despite having received proper training Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 7/10/2024 at 5:10 p.m., The Medical Director was notified of the incident by the interdisciplinary team (IDT). The IDT discussed education and systems to put into place to prevent future staff competency issues related to blood glucose monitoring. These systems included education to MA #1, all nurses, and medication aides. On 7/10/2024, SDC #2 was notified by Nurse Consultant #1 of her responsibility to conduct education with nurses and medication aides regarding residents' personal glucometers for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The education will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation process for newly hired nurses and medication aides. On 7/10/2024 at 5:10 p.m. the IDT team reviewed the manufacturer instructions to obtain the manufacturer recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included germicidal disposable wipes (EPA 9480-4). The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow the surface to remain wet for two minutes. Let air dry. On 7/10/2024 at 5:15 p.m., SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacture guidelines for the glucometer and the germicidal wipe recommendations to clean and then disinfect with two minutes of wet contact time. The SDC then in-serviced all nurses and medication aides working. SDC then began in-servicing all nurses and medication aides not currently working at the facility. All staff were instructed to see the Director of Nursing (DON) and/or SDC before their next shift for a return demonstration. The SDC will educate all newly hired nurses, medication aides and agency staff before receiving an assignment. The SDC will be responsible for keeping up with the newly hired staff and new agency staff. The new staff will be in-serviced on glucometer disinfection prior to working on a medication cart and will be required to perform a return demonstration for the DON or SDC before the next assignment. The glucometer policy was placed on every medication cart and reads: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. 2. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. Don gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) disinfectant wipes from container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, according to the glucometer manufacturer's instructions. Follow the germicidal directions for the dry time. Allow the glucometer to air dry. 11. Discard disinfectant wipes in waste receptacle. 12. Perform hand hygiene. On 7/11/2024 the IDT made the decision to move all resident glucometers into the corresponding resident's room to be stored at the bedside. The glucometers were moved by the Unit Managers on 7/11/2024 and education on the location of the glucometers was provided to all nurses and Medication Aides working on this shift. Any nurse, medication aide, or agency staff that were not working on 7/11/2024 will receive education prior to starting the next scheduled shift. This education will be conducted by SDC #2. Alleged date of Immediate Jeopardy removal is 7/12/24. The credible allegation for immediate jeopardy removal was validated on 07/17/24. Education for nurses and medication aides was confirmed as completed. The education included obtaining capillary blood glucose sampling and cleaning/disinfecting glucometers per the manufacturer's instructions before and after each resident or to use individual glucometers. Review of the facility audits revealed nurses and medication aides had been observed by Director of Nursing (DON), and Staff Development Coordinator (SDC) performing blood checks and cleaning/disinfecting the glucometers. The audits documented there were no issues. During this survey both licensed nurses and medication aides were interviewed and revealed knowledge of education and training to show competency to provide care and disinfect residents' glucometers and knowledge that all residents have their personal glucometers in their rooms. Education for licensed nurses and unlicensed staff was confirmed with observations of staff providing glucose blood checks on each hall and the glucometers were cleaned/disinfected with no issues identified during this survey. The immediate jeopardy removal date of 07/12/24 was validated.

Based on record reviews, observations, and staff and Nurse Practitioner (NP) interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. This occurred while there were no residents with known bloodborne pathogens, such as Hepatitis and Human Immunodeficiency Virus (HIV), in the facility. Failure to clean and disinfect the shared glucometer per manufacturer's instructions after use on each resident has the high likelihood of exposing residents to the spread of bloodborne pathogens. The deficient practice occurred for 4 of 4 residents observed for finger stick blood sugar monitoring. Immediate Jeopardy began on 7/10/24 when MA #1 failed to clean and disinfect the shared glucometer in between residents when conducting FSBS checks. Immediate Jeopardy was removed on 7/12/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility's policy entitled Glucometer Disinfection last revised 12/1/23 read in part as follows: 1. The facility will ensure glucometers will be cleaned and disinfected according to manufacturer's instruction for multi-resident use . 3. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective against HIV, Hepatitis C, and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The manufacturer's User Guide for cleaning and disinfecting the glucometer read in part, Blood glucose meters are at high risk for becoming contaminated with bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV). Transmission of these viruses has been documented due to a contaminated blood glucose device. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of these viruses through indirect contact .Blood glucose meters need to be cleaned and disinfected after each use for individual resident care . Disinfecting can be accomplished with an EPA registered disinfectant detergent or germicide that is approved for healthcare settings . On 7/10/24 from 4:45 pm through 4:55 pm, a continuous observation of MA #1 performing FSBS on the 1 North unit was conducted. At 4:45 pm, MA #1 put on gloves and obtained the glucometer from a compartment in the top drawer of her medication cart. She completed a FSBS check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. In between each resident, the MA returned to the cart to change gloves and use hand sanitizer. At 4:55 pm, the MA was observed to place the glucometer back in the compartment of the top drawer after checking Resident #4's blood sugar without cleaning and disinfecting the glucometer. During an interview on 7/10/24 at 4:55 pm, MA #1 revealed she cleaned the glucometer with disinfectant wipes when she started her shift (MA #1 worked 7:00 am to 7:00 pm according to the schedule on 7/10/24). The MA explained she wiped down her cart and the glucometer when she came in with two disinfecting wipes each time, one was to clean, and the other was to disinfect. The MA said she then wiped down the cart again including the glucometer before the end of her shift. The MA said she had worked at the current facility for about 2 years but, she was trained by another medication aide at another facility years ago to wipe down the cart and the glucometer at the start and end of each shift. She stated not every resident had their own glucometer. MA #1 explained she did not clean and disinfect glucometer in between residents; she just cleaned and disinfected the glucometer before and after her shift with disinfectant wipes. MA #1 stated the glucometer was not technically touching the resident and she made sure she did not put the glucometer down in the resident's room. The MA said there was a 5th resident who she would have completed a FSBS check on, but the resident was at dialysis. An observation of 1 North medication cart and interview of MA #1 was conducted on 7/11/24 at 10:00 am. There were five individual bags containing glucometers labeled with residents' names, including Resident #1, Resident #2, Resident #3, Resident #4, and the dialysis resident that were seen at the bottom drawer of the medication cart. There was a plastic container with a purple top containing disinfectant wipes inside another bottom drawer. Medication Aide #1 stated she did not see the residents' individual glucometers on 7/10/24. She further stated she used the disinfecting wipes in the purple top container to wipe down the glucometer and her cart at the start and end of her shift. The observed disinfectant wipes brand was listed as one of the accepted disinfectant wipes from the glucometer manufacturer. Review of the purple top container containing the disinfectant wipes label indicated it contained germicidal disposable wipes effective against bacteria, viruses, fungi, and blood borne pathogens when used as directed. The label specified blood borne pathogens such as Hepatitis B Virus, Hepatitis C Virus, and HIV among others. Attempts to interview the Unit Manager, who was supervising MA #1, for 1 North during the survey were unsuccessful. During an interview on 7/11/24 at 9:15 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) revealed the facility used disinfecting wipes in a purple top plastic container. The staff used the first wipe to clean the glucometer and used the second wipe to disinfect. The staff had to wait for the disinfectant to dry for about 5 to 6 minutes and then the glucometer could be used on another resident or put them back in the individual bags if they were done checking blood sugars. During an interview on 7/16/24 at 10:55 am, NP #1 revealed she was made aware on 7/11/24 by the facility about the glucometer not being cleaned and disinfected in between residents on 7/10/24. The NP said the cleaning and disinfecting of the glucometer was to prevent the transmission of blood borne pathogens to the residents. She stated that was the standard and staff had to follow it. During an interview on 7/11/24 at 9:27 am, the Director of Nursing (DON) revealed the facility had individual glucometers for residents needing to have their blood glucose monitored. She stated MA #1 was not familiar with the 1 North medication cart. She revealed she spoke with MA #1 this morning and informed her the glucometers for individual residents were at the bottom of the cart. The DON said the MAs and the nursing staff should be cleaning and disinfecting the glucometers before and after each use on each resident using the disinfectant wipes as per their policy for disinfecting glucometers. On 7/11/24 at 10:03 am, an interview was conducted with the Administrator, in the presence of DON. The Administrator revealed she just started at the facility in January as the administrator. The MA should have cleaned and disinfected the glucometer in between the residents. MA #1 should have used the resident's individual glucometer. She stated they expected staff to follow their policies and procedures. During a discussion on 7/11/24 at 2:05 pm, the Regional Nurse Consultant stated MA #1 should have cleaned and disinfected the glucometer in between residents according to the facility's policy and manufacturer's instructions. The Administrator was informed of the Immediate Jeopardy on 7/11/24 at 12:34 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. On 7/10/2024 at 4:45 p.m., Medication Aide (MA) #1 performed a fingerstick blood glucose check on Resident #1, #2, #3, and #4. The MA removed a glucometer for a recently discharged resident (Resident #5) from the medication cart. The MA did not cleanse or disinfect the glucometer, according to glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions, prior to testing, between each resident, or upon completion. All residents that required blood glucose monitoring were identified on the 7/10/2024 census and added to the potentially affected resident list. No residents that receive glucometer blood glucose monitoring were identified to have blood borne pathogens. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 7/10/2024 at 5:10 p.m., The Medical Director was notified of the incident by the interdisciplinary team (IDT). The IDT discussed education and systems to put into place to prevent future staff competency issues related to blood glucose monitoring. These systems included education to MA #1, all nurses, and medication aides. The education will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation to newly hired nurses and medication aides. On 7/10/2024 at 5:10 p.m. the IDT team reviewed the manufacturer's recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included suggested manufacturer germicidal disposable wipes. The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow the surface to remain wet for two minutes. Let it air dry. On 7/10/2024 at 5:15 p.m., SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacture guidelines for the glucometer and the germicidal wipe recommendations to clean and then disinfect with two minutes of wet contact time. SDC then in-serviced all nurses and medication aides working. SDC then began in-servicing all nurses and medication aides not currently working at the facility on the telephone. All nursing staff and medication aides were instructed to see the Director of Nursing (DON) and/or SDC before their next shift for a return demonstration of blood glucose monitoring cleansing and disinfection process. The SDC will educate all newly hired nurses, medication aides and agency staff regarding cleaning and disinfection of glucometers, before receiving an assignment. On 7/10/2024, SDC #2 was notified by Nurse Consultant #1 of her responsibility to conduct education with nurses and medications aides regarding resident's personal glucometer for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The SDC will be responsible for keeping up with the newly hired staff and new agency staff. The new staff will be in-serviced on glucometer disinfection prior to working on a medication cart and will be required to perform a return demonstration for the DON or SDC before the next assignment. On 7/10/2024 at 5:15 p.m. the Unit Manager removed the glucometer of the discharged Resident (Resident #5) and discarded the glucometer. On 7/10/2024 the Director of Nursing and Unit Manager assessed, cleansed, and disinfected all glucometers according to the manufacturer recommendations for glucose disinfection and the germicidal disposable wipes directions. On 7/10/2024, an audit was conducted by Nurse Consultant #1 and Unit Manager to verify that residents had personal glucometers on the medication carts, bagged, and labeled. The audit revealed 100% of residents that required glucose monitoring had individualized glucometers available. The Administrator notified [NAME] County Department of Health of the incident on 7/11/2024. The Health Department had no initial recommendations but requested a summary of the event. The Health Department responded to the summary with recommendations to conduct laboratory blood work on all diabetics that receive blood glucose monitoring to screen for blood borne pathogens. Medical Director was notified on 7/11/2024 of [NAME] County Department of Health recommendations. On 7/11/2024, the physician orders were entered into the laboratory system by the DON or designee. The DON will be responsible for ensuring orders are implemented, the laboratory order is completed, and communicate results to the health department and Medical Director. The glucometer policy was placed on every medication cart by the Assistant Nursing Home Administrator on 7/10/2024 and reads: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. 2. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. Don gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) disinfectant wipes from container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, according to the glucometer manufacturer's instructions. Follow the germicidal directions for the dry time. Allow the glucometer to air dry. 11. Discard disinfectant wipes in waste receptacle. 12. Perform hand hygiene. On 7/11/2024 the IDT team made the decision to move the glucometers off the medication carts and into each resident's room. Education was provided by the Unit Managers to all Nurses and Medication Aides working on 7/11/2024 regarding the location of the glucometers in the rooms and this education will be provided to all nursing and MA staff prior to working the next shift, by the SDC. Any nurse or medication aide found to be sharing glucometers will be subject to disciplinary action. The alleged date of Immediate Jeopardy removal was 7/12//24. The facility's credible allegation of immediate jeopardy removal was validated on 7/17/24. Documentation of the County Health Department, physician, and residents' Responsible Party notification was provided and reviewed. Evidenced by observations of nurses and medication aides and interviews conducted on each hallway with regards to the required infection control practices for the use of glucometers. All nurses and medication aides who were interviewed reported they had received the required in-service training. This training included the importance of using an approved disinfectant wipe and disinfecting a glucometer with the procedures in accordance with the manufacturer's instructions for the disinfectant. Observations were conducted on each hallway as blood glucose checks were conducted and glucometers were disinfected. All residents observed had their own personal glucometers. Multiple observations also confirmed EPA-approved disinfectant wipes were stored on each medication cart. The immediate jeopardy removal date of 07/12/24 was validated.

Based on record review, observations, and staff, Pharmacist and Nurse Practitioner (NP) interviews, the facility failed to send expired or discontinued narcotic medications back to the pharmacy for 2 of 4 medication carts. Findings included: 1. On 7/10/24 at 11:45 am, the medication cart on 2 North was reviewed with Medication Aide (MA) #2. The following were discovered during the review: a. Eighteen lorazepam 0.5 mg tablets in a pill card labeled with the order to administer one tablet by mouth twice a day for anxiety or restlessness to Resident #7. Thirty lorazepam 0.5 mg tablets were in a second pill card labeled with the same order to administer one tablet by mouth twice a day for anxiety or restlessness to Resident #7. Resident's EMR was reviewed with MA #2. The medical records revealed Resident #7 died on [DATE]. MA #2 stated the two pill cards should have been sent back to the pharmacy by the nurse on 6/14/24. b. Twenty oxycodone-acetaminophen 5-325 mg tablets in a pill card labeled with the order to administer one tablet every four hours as needed to Resident #8. The pill card was delivered on 7/8/23 and was labeled to discard after 7/6/24. Review of Resident #8's EMR was reviewed with MA #2. Resident #8 did not have a current order for the narcotic medication. The medication was discontinued on 9/19/23. Review of the narcotic sheet did not indicate Resident #8 received any of the expired medication. MA #2 stated the nurse should have sent the pill card back to the pharmacy when the medication was discontinued on 9/19/23. c. Nine tablets of alprazolam 0.25 mg tablets in a pill card labeled with the order to administer one tablet once a day as needed for anxiety for Resident #9. The pill card was delivered on 5/15/23 and was labeled to discard after 5/14/24. Review of Resident #9's EMR with MA #2 revealed no current order for alprazolam. The medication was discontinued on 5/29/23. Review of the narcotic sheet indicated no expired medication was administered to Resident #9. d. Twenty-eight tramadol hydrochloride (hcl) 50 mg tablets in a pill card labeled with the order to administer one tablet by mouth every six hours as needed for moderate and severe pain for Resident #10. The pill card was delivered on 6/30/23 and was labeled to discard after 6/27/24. Review of Resident #10's EMR with MA #2 revealed no active order for tramadol. Review of the narcotic sheet indicated no expired medication was administered to Resident #10. During an interview on 7/10/24 at 11:50 am, MA #2 stated the nurses were supposed to check their medication carts for expired medications and send them to the pharmacy to be discarded. She was not sure how often they were supposed to do it. 2. On 7/10/24 at 12:20 pm, the medication cart on 2 East was reviewed with MA #3. The following was discovered during the review: a. One tramadol hcl 50 mg tablet in a pill card labeled with the order to administer one tablet every six hours as needed for pain to Resident #11. The pill card was delivered on 6/7/23 and labeled to discard after 6/3/24. Review of Resident #11's EMR with MA #3 revealed a current order for the medication. Review of the narcotic sheet indicated Resident #11 did not receive any of the expired medication. MA #3 stated the nurse should have checked the cart and sent expired narcotics to the pharmacy. b. One tramadol hcl 50 mg tablet in a pill card labeled with the order to administer one tablet every six hours as needed for moderate to severe pain to Resident #12. The pill card was delivered on 5/30/23 and labeled to discard on 5/26/24. Review of Resident #12's EMR with MA #3 revealed a current order for the medication. Review of the narcotic sheet indicated Resident #12 received eight expired medications on 6/5/24, 6/17/24, 6/18/24, 6/19/24, 6/20/24, 6/22/24, 6/24/24, and 6/29/24. c. Eight hydrocodone acetaminophen 5-325 mg tablet in a pill card labeled with the order to administer one tablet by mouth every six hours as needed for pain to Resident #13. The pill card was delivered on 4/11/23 and labeled to discard on 4/5/24. Review of Resident #13's EMR with MA #3 revealed a current order for the medication. Review of the narcotic sheet indicated Resident #13 received two expired medications on 4/14/24 and 5/4/24. During an interview on 7/10/24 at 12:25 pm, MA #3 stated the nurses were supposed to be checking their medication carts. She revealed the day shift nurse who used to check the carts had been gone for a while and nobody was checking on the carts. She stated two nurses had to count off if a narcotic had to be sent back to the pharmacy. They scanned the narcotic code into the pharmacy system, entered the amount, and put the narcotic medications in a paper bag with the narcotic sheet and taped the bag. The nurse put the taped bag in a red box inside the medication room for the pharmacy to pick up. During an interview on 7/10/24 at 12:15 pm, Nurse #1 stated she monitored the medication aides on the second floor. The nurses and unit managers checked the medication carts for expiration dates routinely. She said they do not have set dates or days to check the carts. It varied. She could not remember the date the last time she checked the carts. She revealed the pharmacy also came and checked the carts to do their audit for the medication stocks. During an interview on 7/10/24 at 2:00 pm, Unit Manager #1 revealed the nurses should be checking the medication carts and pull out the expired or discontinued medications and send them back to the pharmacy. Third shift nurses were supposed to be checking for expiration dates in the medication room and the carts every night. All the nurses and medication aides were supposed to check the medication rooms. During an interview on 7/11/24 at 9:15 AM the Staff Development Coordinator (SDC) revealed she had been in that position for three months. She stated all the nurses and MAs should be checking for expiration dates before they did their medication pass. During an interview on 7/11/24 at 12:35 pm, the Pharmacist stated that nursing staff should have sent the expired medication back to the pharmacy so they could be discarded. There may not be side effects on the residents that received the expired medication. However, the Pharmacist revealed there were some drugs that were time sensitive especially if the medications were repacked and heat sealed. The pill cards were repacked and were heat sealed so the facility had to discard those medications right after the expiration date. That was the best practice. During an interview on 7/11/24 at 9:43 am, NP #2 stated if a narcotic medication expired and it was administered close to that date, it should not have any side effects on the residents. The expiration dates were more of an approximation or suggestion, but the nursing standard was not to administer any kind of medications after the expiration date. During an interview on 7/11/24 at 9:27 am, the Director of Nursing (DON) revealed she started her job in the facility in April. The nurses and MA's should be checking for medication expiration dates all the time. If a medication was discontinued or if a resident got discharged , the medications should be sent back to the pharmacy. During an interview on 7/11/24 at 10:03 am, the Administrator stated she started her job in January. She revealed that there were a lot of things that needed to improve in the facility including medication storage. The nursing staff working on the carts should be checking for expiration dates before their medication administration. The Administrator said she would continue working with the DON in improving the facility. She stated she expected staff to follow policies and procedures accordingly.

Based on observation, record review, and staff interviews, the facility failed to submit a 24-hour and 5-day report to the State Agency when the facility became aware of an allegation of misappropriation of property by a staff member on 7/5/24 for 1 of 3 residents reviewed for misappropriation of resident property (Resident #2). Findings included: A review of the facility's undated Abuse, Neglect and Exploitation policy defined Alleged Violation as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Under Reporting/Response, the policy stated A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the investigation when final within 5 working days of the incident, as required by state agencies. Review of the initial investigation documents provided by the facility on 7/11/24 revealed a letter from the North Carolina Board of Nursing (NCBON) dated 7/8/24. The letter indicated a complaint had been received alleging Nurse #2 may have diverted controlled substances on or about 7/6/24. Another document indicated Nurse #2 voluntarily underwent drug testing on 7/8/24. The initial result indicated the urine specimen collected was negative for oxycodone. Review of Resident#2's pain medication oxycodone 10 milligram (mg) narcotic sheet on 7/11/24 revealed: The narcotic sheet was labeled with Resident #2's identifier and a current order that stated, take 1 tablet by mouth every six hours as needed. The narcotic count on 7/2/24 revealed there were 28 tablets as of 7:39 am. On 7/2/24 at 1:39 pm, Nurse #2 administered 1 tablet and documented there were 27 tablets remaining. On 7/2/24 at 73 pm, Nurse #2 administered 1 tablet and documented there were 26 tablets remaining. On 7/2/24 at 1930, Nurse #2 documented she administered a tablet and documented there were 25 tablets remaining. At the bottom of the narcotic sheet was a section to record waste and spoilage. One oxycodone 10 mg tablet was wasted by Nurse #2 as indicated by her signature on 7/2/24. There was no time documented. Nurse #2 wrote wrong time under the description/detail column. There was not a second signature to witness the waste under the column for signature #2. The documented wasting of the oxycodone 10 mg tablet on 7/2/24 was marked out by a single line. At the end of the line, Nurse #2 wrote wrong medication and the Nurse #2's initials above it. The documented narcotic count for Oxycodone 10 mg on 7/5/24 at 4:09 am revealed there were 14 tablets. Medication Aide (MA) #1 administered a tablet on 7/5/24 at an undetermined time. The time documented was marked over and was ineligible to read. MA #1 documented the remaining amount was 13 on the narcotic sheet. Nurse #2 documented she administered a tablet on 7/5/24 at 10:00 am and documented the remaining amount was 12. On 7/5/24 at 6:36 pm, Nurse #2 documented the corrected count was eight tablets. Under the record of waste and spoilage, another entry by Nurse #2 as indicated by her signature dated 7/5/24 indicated she wasted oxycodone tablets. The entry under the quantity wasted was illegible. The area under signature #2 column had been blotted out. During an interview on 7/10/24 at 5:50 pm, Resident #2 stated she was receiving her pain medications as scheduled and did not have any issues with her pain medications. During an interview on 7/10/24 at 4:55 pm, MA #1 stated she worked 7:00 am to 7:00 pm on 7/5/24. She revealed there was an issue with the wasted oxycodone tablets for Resident #2 when she was counting off at 7:00 pm with MA #7. She remembered administering 1 oxycodone 10 mg tablet at 10:00 am on 7/5/24 to Resident #2. She explained that there were 13 tablets left when she counted off with Nurse #2 for her lunch break at around 12 noon. MA #1 said she went out to monitor the residents that smoked after supper. She counted off with Nurse #2 again and said there were still 13 oxycodone tablets. At around 6:00 pm, Nurse #2 called her to fix the narcotic count. She revealed Nurse #2 told her there were 3 oxycodone tablets that fell from Resident #2's oxycodone pill card and wanted to waste it with her. MA #2 said Nurse #2 did not produce the three pills that she wanted to waste so she refused to sign as a witness. Nurse #2 told her she threw the 3 pills down the toilet and wanted her to sign. She explained to Nurse #2 that she was not comfortable, so she did not sign the narcotic sheet as a witness. When MA #1 was counting off with MA #7 on 7/5/24 at 7:00 pm, they both noticed there were only 8 oxycodone tablets left for Resident #2 as it was documented on the narcotic sheet. MA #1 informed MA #7 that there were 3 pills wasted by Nurse #2 earlier so the count should have been 10 oxycodone tablets. She also noticed the 10:00 time she entered earlier that day was marked over and was rendered ineligible. In addition, Nurse #2 had documented that she administered another tablet at 10:00 am. Both MA #1 and MA#7 both decided the total should have been 9 oxycodone tablets remaining in the pill card. Both MA's notified Nurse #3 and explained there was a discrepancy in Resident #2's oxycodone count. Nurse #3 called Nurse #2 to explain what went on. Nurse #2 told Nurse # 3 that she and MA #1 wasted 5 tablets earlier. MA #1 explained to the nurses and MA #7 that Nurse #2 told her she wasted 3 tablets, but she did not see the actual pills to waste. Nurse #2 had already wasted it, so she refused to sign. MA #1 revealed somebody scrawled all over the signature #2 line for 7/5/24 making it look like she signed and blotted off her signature. MA #1 stated she never signed as a witness and left the signature #2 space blank. She revealed Nurse # 3 contacted the Administrator and reported Nurse #2 and the missing narcotics. The Director of Nursing (DON) called back and instructed Nurse #3 to get statements from the MAs and the nurses. During an interview on 7/11/24 at 7:50 am, Nurse #3 stated MA #1 counted off with night shift MA #7 on 7/5/24 at 7:00 pm. Both MAs noticed a discrepancy with Resident #2's oxycodone count, so they called her. Nurse #3 revealed Nurse #2 documented 3 pills were wasted on the narcotic sheet. When Nurse #2 came, she told MA #1 remember I wasted it, and I told you that's why I asked you to sign? MA #1 responded, saying that she did not see the pills and she did not sign as a witness. Nurse #3 revealed the witness signature on the narcotic sheet was blotted over but MA #1 insisted she never signed, and that it was a blank space earlier. Nurse #3 said that was not the first time Nurse #2 was involved in a discrepancy. Nurse #3 revealed Nurse #2 wasted a narcotic medication and did not have any witnesses that signed with her on 7/2/24. Nurse #2 also had signed out oxycodone tablets twice at 7:30 pm on 7/2/24 for Resident #2. Nurse #2 revealed she looked at the medication administration record (MAR) to recheck the time of administration but there were no entries by Nurse #2 on 7/2/24. She stated she notified DON on 7/4/24 about 7/2/24 but thought there was nothing done about it. Nurse #3 said she called the Administrator on 7/5/24 at around 7:30 pm and reported Nurse #2 and the missing narcotics. The administrator told Nurse #3 that she would call her back, but it was the DON who called her back and instructed her to get statements from the nurses and the MAs. The DON also told Nurse #3 to make a copy of the narcotic sheet and to take a picture and send it to her. A telephone interview with Nurse #2 was conducted on 7/11/24 at 2:20 pm in the presence of the Regional Nurse Consultant. Nurse #2 stated she was not at work today due to an investigation. She said she administered the narcotic medications she pulled from the medication carts. She stated she was not sure why the narcotic medications she administered were not in the electronic MAR. She explained she could not enter the narcotic medications into the MAR if the MA was logged in on the computer on the cart. She said she went back to the computer on the desk to log the narcotic administration. Nurse #2 claimed she was not aware her entries were not in the MAR until she was notified on 7/8/24 by the DON. She thought the system was not saving what she entered. She stated she signed out the narcotics from the narcotic sheet as soon as she pulled them and administered them immediately to the residents. Nurse # 2 stated she must have a witness whenever she was wasting a narcotic medication. She revealed on 7/5/24 there were no missing pills. She explained that there were 5 oxycodone tablets in the pill card that were popped open at the back, so she had to waste it with MA #1. She claimed MA #1 witnessed her waste the pills and signed as the witness. Nurse #2 stated she counted with MA #1 and made sure that there were correct medications remaining in the pill card. She was not aware of the time that was marked over on the narcotic sheet for 7/5/24. She added that she did not waste an oxycodone tablet on 7/2/24. She marked off what she had documented on Resident #2's narcotic sheet when she realized she wasted another resident's medication. An interview was conducted on 7/11/24 at 10:15 AM with the Administrator and the DON. The Administrator revealed Nurse #3 called her Sunday night (7/7/24) she thought and notified her of a discrepancy involving Nurse #2. She said that was the first time she was made aware of any narcotic discrepancy. Nurse #3 told her she previously reported another discrepancy with the same nurse to the DON. The Administrator called and asked the DON to reach out to Nurse #3 and request statements. The DON stated she requested the Staff Development Coordinator to educate the nurses and medication aides on the accounting of narcotics medications. The DON reached out to Nurse #2 on 7/8/24 and did an investigation. The DON stated she notified the Administrator and the Chief Nursing Officer. She also talked to the North Carolina Board of Nursing (NCBON) investigator, but no one came by to investigate. The Administrator revealed she did not notify the state agency because we have not determined that's not what happened. She said Nurse #2 did not work on Monday, but she worked Tuesday and Wednesday to assist with computer assessments. The Administrator revealed there was a meeting with the CNO and the nursing team the morning of 7/11/24 and removed Nurse #2 from the schedule while the investigation was ongoing. During a follow up interview on 7/12/23 at 4:10 pm, the Administrator clarified that she was not the one who notified NCBON. She revealed that Nurse #2 called her on 7/8/24 at around 1:00 pm and reported that she received notification from NCBON about a complaint. She stated it was the DON that called the nurse investigator to consult and follow up with her regarding the complaint. She stated Nurse # 3 called her on 7/5/24 and not Sunday night (7/7/24). Nurse #3 told her that she had concerns about Nurse #2 and the narcotic count. Nurse #3 told her that she had previously discussed her concerns about Nurse #2 and narcotics with the DON so she called the DON to follow up with Nurse #3. The Administrator asked the DON to put together all the statements on 7/8/24. She revealed she did not report it to the state agency because it was just a suspicion, and she did not have a documented proof that it happened. She stated it was more of a conversation with Nurse #3 and not an accusation. On 7/12/24 at 4:40 pm, the Administrator and the Director of Nursing called back to clarify that the report from Nurse #3 on 7/5/23 was not an allegation. The Administrator stated it was more of a discussion that Nurse #2 wasted narcotics and that somebody signed as a witness then it was marked off. The DON stated she started an investigation right that moment and notified the management team within 2 hours. She took statements to look at what was going on. The Administrator stated Nurse #2 called her on 7/8/24 informing her that she was reported to the NCBON about the narcotics. She had Nurse #2 forward the email from the NCBON to the DON. The DON revealed she talked to the NCBON investigator and obtained guidance on how to proceed. She was told to continue gathering statements and to send the NCBON investigator copies of the statements. The Administrator stated she did not report to the state agency when she was notified by Nurse #2 about her being reported to the NCBON for diversion of controlled substances. The Administrator stated she would consult with the corporate office and would call the surveyor back when she was asked what her training was on notification if she received reports of alleged violations. The Administrator did not call back on 7/12/24.

Based on record review, observations, resident interview, staff interviews, Nurse Practitioner (NP) interview and Medical Director interview, the facility staff failed to implement a pain management program that included pharmacological and non-pharmacological approaches for Resident #518 who was admitted with chronic pain syndrome. Resident #518 was not thoroughly assessed for pain, a plan for pain management was not initiated, pain medication was not ordered, care continued to be delivered to Resident #518 in the presence of pain described at 9 out of 10. Pain interfered with sleep, mobility, and provision of activities of daily living. Resident #518 exhibited verbal and nonverbal cues of pain that included facial grimacing, groaning, and holding tightly onto the grab bars during incontinence care and bed mobility. A diagnostic x-ray was not implemented stat (rush) as ordered. Resident #518 was diagnosed with osteoarthritis following the results of the x-ray. This deficient practice occurred for 1 of 1 resident reviewed for pain management (Resident #518). Immediate jeopardy began on 11/20/2023 when Resident #518 experienced pain at a 10 out of 10 level according to the occupational therapy treatment encounter notes, indicated to the Nurse Practitioner (NP) she was not sleeping well due to the pain and had no orders for pain management. The immediate jeopardy was removed on 12/1/23 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to pain management. Findings included: Resident #518's Medication Administration Record (MAR) from the Hospital, indicated the resident was hospitalized on [DATE]. Resident #518's hospital MAR indicated she received Cymbalta DR (antidepressant) 30 milligram (mg) capsule two times a day by mouth starting 11/6/23 to 11/13/23, Lamictal 200mg 1 tablet by mouth a day starting 11/6/23 to end 11/6/23 and Lamictal 25mg 1 tablet by mouth daily starting 11/13/23 to 11/17/23. Resident #518 was admitted to the facility on [DATE], with diagnosis that included chronic pain syndrome, disorder of thyroid, adult failure to thrive, bipolar disorder, constipation, anorexia, hypothyroidism, and spondylosis. Resident #518 physician order dated 11/18/23 revealed resident was to receive Lamictal (mood stabilizer) 25 milligram (mg) one tablet, by mouth one time a day. Occupational therapy treatment encounter notes for Resident #518 dated 11/20/23 indicated that resident reported 10/10 global pain affecting function. NP progress notes dated 11/20/23, revealed that resident underwent psychiatry evaluation, and it was determined that resident's decreased appetite is due to hypothyroidism and not a psychiatric issue. Resident states today that she is in the rehabilitation facility because she is unable to move secondary to bilateral arm and leg pain and numbness. Resident states she is not sleeping well due to the pain. On 11/30/23 at 1:07 pm, a telephone interview was conducted with the NP. The NP progress notes for 11/20/23 were reviewed with NP where she indicated Resident #518 had chronic pain and had undergone psychiatric evaluation. A continued review of the NP progress notes further indicated Resident #518 had bilateral arm and leg pain and numbness, and complained she could not sleep because of pain. The NP indicated, after reviewing her notes, that she did not address Resident #518's pain on 11/20/23 because Resident #518 had a diagnosis of bipolar disorder and she wanted Resident #518 to take her medication (Lamictal) first, before the NP would be able to do anything about the resident's pain. The NP further indicated the medication needed time to kick in before she could address the pain. Resident #518's care plan initiated 11/21/23 did not address resident's pain and did not have any care plan in reference to behaviors or refusal of medication. Medical Director's progress notes for Resident #518 dated 11/22/23 indicated that resident has pain and numbness in bilateral arms and legs. An in-person interview was conducted on 11/30/23 at 4:04 pm with the Medical Director (MD). The MD indicated Resident #518 did not complain of pain. The MD indicated the review of systems in his progress notes was from the history and physical and Resident #518 did not have anything acute. The MD indicated the resident was on Lamictal (a medication used to treat epilepsy and bipolar disorder.) which would usually take at least 4 to 6 weeks to be therapeutic, but he would not expect for a medical provider to wait 4 to 6 weeks or to wait until a medication was therapeutic to address any resident's pain and he would have initiated a pain medication such as Tylenol, or an anti-inflammatory medication such as aspirin. The MD further indicated pain was not dependent on a resident's psychiatric status, especially when dealing with a resident who did not have any dependency concerns with pain medication. Physical therapy treatment encounter notes for Resident #518 dated 11/22/23 indicated that resident reported pain all over body and limiting resident's ability to scoot. Occupational therapy treatment encounter notes for Resident #518 dated 11/22/23 indicated that resident reporting ongoing pain and discomfort all over. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #518 was cognitively intact with no behaviors or rejection of care and no pain and required moderate assistance with bed mobility and was dependent on toileting hygiene. Physical therapy treatment encounter notes dated 11/27/23 indicated that resident with reports of pain all over, facial grimacing and groaning. An interview was conducted with NA #5 on 11/29/23 at 3:12 pm. NA #5 indicated that she worked with Resident #518 on 11/27/23 during the day shift (7:00 am to 3:00 pm shift). NA #5 indicated that Resident #518 did complain of shoulder pain (could not validate which shoulder) during care on 11/27/23, and she notified Nurse #3 and Medication Aide (MA) #2. On 11/29/23 at 3:19 pm, an interview was conducted with Nurse #3. Nurse #3 indicated that the NA #5 did not notify her on 11/27/23 that Resident #518 was complaining of pain. Interview with Medication Aide (MA)#2 was conducted on 11/30/23 at 10:04 am. MA#2 indicated that on 11/28/23 she was working day shift (7:00 am to 3:00 pm) and was in training. MA #2 stated she went to provide Resident #518 her medication in her room, and during medication administration, Resident #518 made groaning noises while she was moving in bed. MA #2 indicated she did not ask Resident #518 about her pain and stated Resident #518 did not state she was in pain. MA #2 indicated she did not report this to the nurse. Physical therapy treatment encounter notes dated 11/28/23 indicated that physical therapy assistant requested patient to be provided pain medication prior to session to prevent pain limiting progression. Resident refused her medication and pain pills and reported pain all over her body. Physical therapist assistant talked with Director of rehabilitation about patients increase pain levels and limitation. Resident #518 Medication Administration Record starting 11/17/23 through 11/29/23, revealed that resident had not refused to take any medication. Physician orders starting 11/17/23 through 11/29/23, revealed that resident had no pain medications ordered. Resident #518 MAR starting 11/17/23 through 11/29/23, revealed that resident had no pain medication order. Resident #518 did not have any standing orders. An interview with the Director of Nursing on 11/30/23 at 4:15 pm revealed Resident #518 did not have any standing orders. DON further indicated that standing orders are usually on a case-to-case basis. Review of Resident #518 occupational therapy treatment encounter notes dated 11/28/23 indicated that resident with increase pain today. Resident #518's Medication Administration Record (MAR) revealed no pain medication physician orders from 11/17/2023. There was also no refusal of medication by Resident #518. On 11/30/23 at 10:54 am, an interview was conducted with Certified Occupational Therapist Assistant (COTA). The COTA indicated that Resident #518 had limited mobility due to pain that was getting worse. The COTA indicated she had communicated multiple times to nursing staff about Resident #518's pain for more than a week. The COTA indicated the resident had complained about her shoulder pain for about a week. The COTA indicated Resident #518 could not lift her arm during shoulder flexion due to shoulder pain. The COTA indicated she had asked nursing to administer pain medications to Resident #518 prior to rehabilitation treatment on 11/27/23 and 11/28/23. At 11:17 am, on 11/30/23 the COTA further indicated Resident #518 was clearly in pain and Resident #518 had been indicating her shoulder hurts. The COTA indicated she was seeing more signs of pain with Resident #518 that progressed. The COTA indicated Resident #518 had received therapy on 11/28/23, during which time, the nurse (unknown) was asked to medicate Resident #518 with pain medication after lunch, prior to her rehabilitation therapy treatment. The nurse (unknown) indicated to therapy the resident had refused to take her medication and refused to take her pain medication on 11/28/23. The COTA indicated the facility did have a diathermy machine (a medical device that uses high-frequency electric current to produce heat deep inside a targeted tissue through the skin to the area that is causing pain) that was used as a non-medication pain regime, but it was not used on the resident, because she did not go to the therapy room for treatment. On 11/29/23 at 5:13 am, an observation of incontinence care was made with Resident #518 and NA #3. As NA #3 was moving resident, Resident #518 complained of right shoulder pain. NA #3 continued to proceed with providing incontinence care. Resident #518 was observed holding onto both her grab bars, making nonverbal signs of pain (facial grimacing, groaning) while NA #3 was providing incontinence care. Resident #518 also verbalized pain while NA #3 was providing incontinence by saying that hurts and NA #3 continued to provide incontinence care. NA #3 stated to Resident #518 that her perineal area was red and appeared to be irritated and infected. The observation revealed that the resident's perineal area was reddened. NA #3 turned the resident over to her right side to continue incontinence care. Resident #518 verbally complained of pain and indicated her right shoulder was in pain. NA #3 continued to provide incontinence care.NA # 3 completed incontinence care and indicated to Resident #518 that she was going to get another aide to assist her with moving Resident #518 up in her bed. NA #3 returned to the room a few minutes later with NA #4 to assist resident with bed mobility. NA #3 asked Resident #518 to cross both her arms on her chest. Resident #518 indicated to both NA #3 and NA #4 that her right shoulder was hurting. NA #3 and NA #4 continued to assist Resident #518 with bed mobility by moving her up in the bed even after Resident #518 indicated that she was having right shoulder pain. NA #3 and NA #4 used the draw pad/linen protector to move the resident up in the bed with their hands positioned in the mid chest area of the resident. An interview was conducted with NA #3 on 11/29/23 at 5:40 am. NA #3 indicated her shift started on 11/28/23 at 3:00 pm, and she was doing a double shift(3:00 pm to 7:00 am), which would end on 11/29/23 at 7:00 am. NA #3 indicated she notified Nurse #1 at about 3:30 pm on 11/28/23 , after she had completed her first round of incontinence care on Resident #518, that the resident was complaining of pain in her perineal area and all over. NA #3 indicated that she did not stop providing perineal care, because she wanted to clean the area first. Resident #518 was interviewed on 11/29/23 at 5:49 am. Resident #518 indicated that she notified a nurse (Unknown) a couple of days prior, about her perineal area pain and irritation, and her right shoulder pain upon moving. Resident #518 indicated that the Nurse (unknown) came back to her room and applied A and D ointment (skin protectant) to her perineal area and did not offer anything to relieve her right shoulder pain. Resident #518 indicated that she would take Tylenol (analgesic) medication when she was home and did not use any opioid medication. On 11/29/23 at 3:34 pm, an interview was conducted with Nurse #1. Nurse #1 confirmed that she worked with Resident #518 on 11/27/23 and 11/28/23. Nurse #1 indicated she did not work with the resident often and stated that the resident never reported pain to her. Nurse #1 indicated that she did not recall NA #3 reporting Resident #518 having right shoulder pain. At 5:57 am on 11/29/23, an interview was done with Nurse #2. Nurse #2 confirmed that she was the regular night shift nurse for Resident #518 and stated the resident did not report pain to her. Nurse #2 indicated NA # 3 and NA #4 never notified her about Resident #518's pain and that she would go and assess Resident #518. A follow up interview was done with Nurse #2 at 6:15 am on 11/29/23, and she indicated upon assessment of Resident #518, the resident complained of right shoulder pain. Nurse #2 indicated that she would notify the medical provider of Resident #518's right shoulder pain. On 11/29/23 at 3:19 pm, an interview was conducted with Nurse #3. Nurse #3 indicated that the outgoing nurse on 11/29/23 (11:00 pm to 7:00 am), Nurse #2 reported to her during shift report, that Resident #518 was assessed to have right shoulder pain. Nurse #3 further indicated that she notified the NP who was in the facility. Nurse #3 indicated the NP did not initiate anything for Resident #518's pain. An observation of incontinence care was made on 11/30/23 at 10:07 am with NA #5 and Resident #518. Resident #518 complained of right shoulder pain and was observed holding tightly on her grab bars and having facial grimacing while NA #5 continued to provide incontinence care. NA #5 asked Resident #518 to turn to her right side, and Resident #518 informed NA #5 that her right shoulder and perineal area were in pain. An interview with Resident #518 was conducted on 11/30/2023 at 10:09 am while she received perineal care from NA #5. Resident #518 was asked to rate her pain related to her right should and perineal area, on a scale of 1 to 10 and the resident indicated that her pain was 9 out of 10 during perineal care and moving. An interview with NA #5 was conducted on 11/30/23 at 10:10 am. NA #5 indicated she could not stop providing care but would notify the nurse of Resident #518's right shoulder pain, after she had completed incontinence care. On 11/30/23 at 10:11 am an interview was conducted with Nurse #1. The Surveyor informed Nurse #1 that Resident #518 complained of right shoulder pain during observation of incontinence care, and Resident #518 held tightly to her grab bars, with facial grimacing during perineal care and bed mobility. Nurse #1 indicated she would assess the resident. At 10:15 am on 11/30/23, Nurse #1 indicated that she would notify the medical provider about Resident #518's right shoulder pain of 9 out of 10 and she would recommend an X-ray to rule out fracture. Nurse #1 indicated that Resident #518 had a history of falls prior to admission to the facility, and the pain could be related to that. Nurse #1 indicated that Resident #518 did not have any medication for pain. An interview was conducted on 11/30/23 at 10:47 am. Nurse #1 indicated that she had received a new physician order for Resident #518 to start Tylenol (non-opioid analgesic) 500milligrams two tablets by mouth twice a day and Voltaren gel (dermatological anti-inflammatory analgesic) 2 grams for right shoulder. She also indicated the medical provider ordered for a right shoulder X ray to rule out fracture. The physician order dated 11/30/23 revealed a STAT order for a right shoulder X ray to rule out fracture. The physician's order dated 11/30/23 revealed an order for Tylenol 500mg two tablets by mouth twice a day for right shoulder pain. On 11/30/23 at 1:07 pm, a telephone interview was conducted with the NP. The NP indicated she assessed Resident #518 on 11/29/23 while in the facility. The NP indicated Resident #518 did not complain of pain upon her assessment on 11/29/23. The NP indicated that nursing staff did notify her on 11/29/23 of Resident #518's right shoulder pain but she had not addressed the pain due to Resident #518's psychiatric issues and she wanted to make sure the pain was real. Interview was conducted with Nurse #1 on 11/30/23 at 3:52 pm. Nurse #1 indicated that the STAT Xray ordered for Resident #518 at 10:30 am on 11/30/23 had not been initiated. Nurse #1 did not know why the Xray had not been initiated. At 4:15 pm on 11/30/23 an interview was conducted with the Director of Nursing (DON). DON indicated STAT x-rays had not been implemented because the company that was contracted to provide diagnostic testing, did not consider STAT physician orders to be within 4 hours, but could be done in a day or two or later. DON indicated that if a resident verbalized pain or had any nonverbal signs of pain during peri care, she would require the nursing assistants to complete providing peri care first, and tell the residents Sorry it hurts, but they would need to complete care and after completion of care, the nurse aide would notify the nurse. DON further indicated that if resident verbalizes pain or has any nonverbal signs of pain noted before or during bed mobility, she would require the nursing assistants to stop moving the resident and notify the nurse. Resident #518's Xray to right shoulder was completed after the surveyor's intervention 11/30/23. The result of Xray revealed no fracture but showed mild osteoarthritis. The administrator was notified in person of the immediate jeopardy on 11/30/23 at 5:40 pm. On 12/2/23 on the facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident was admitted to facility on 11-17-23 status post hospitalization with chronic pain syndrome. Resident was witnessed experiencing pain on 11-30-23 in the presence of staff. Interviews identified the resident had been experiencing pain for greater than one week with facility staff aware of the situation. During these periods of pain, the facility failed to identify the pain, properly assess for location and severity, and put proper interventions in to place to manage the pain. The CNA that was providing care was educated on 11/30/23 by the Regional Nurse Consultant regarding identifying pain and immediately ceasing care being provided to notify nurse of the pain. The Regional Clinical Nurses and the Director of Nursing conducted a full-house pain interview and assessment by using verbal and non-verbal signs. This was completed on 11-30-23. The total of in-house residents is 108. Notification was given to the hall nurse for any resident who reported pain at that time and an intervention was put into place. o 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. Resident was assessed for pain immediately after the surveyor issued the template on 11/30/23 by the Director of Nursing. Resident reported her pain was a 7/10 and that the Tylenol she received earlier was helping. The nurse offered to call for more pain medication and the resident voiced that she would only take Tylenol. The nurse administered 2-500mg tablets of Tylenol as ordered. Also, Voltaren was applied to the right shoulder. Resident expressed some relief. The X-ray company was notified and completed the order at 7:00 pm. The x-ray results showed no fracture but did show mild osteoarthritis acromioclavicular and glenohumeral joints. Pain assessment has been added to Resident MAR for monitoring every shift. Tylenol has been scheduled three times a day, Voltaren gel has been scheduled three times a day and Meloxicam has been scheduled to assist with controlling resident's pain. Pain will continue to be assessed by the nurse and documented on the MAR. Tylenol has been scheduled three times a day to help with pain management and relief during therapy sessions. Care plan updated to reflect a goal of normal activities will not be interrupted secondary to pain. Interventions include anticipating the resident's need for pain relief and respond immediately to any complaint of pain. Care plan was reviewed and updated by the Regional Nurse Consultant on 11/30/23. The non-pharmaceutical intervention of repositioning was added for pain relief and comfort. The direct care staff were informed on 11/30/23 by the Unit Managers and Staff Development Coordinator to respond to the resident's complaint of pain timely and encourage the use of her ordered pain medications. Education on identifying and reporting pain to staff (to include licensed nurses, certified nursing assistants, medication aides, all department heads, housekeeping, dietary, laundry and therapy) was initiated on 11-30-23 and conducted by the Unit Managers, wound nurse, and Staff Development Coordinator. The education included identifying pain through verbal and nonverbal cues (grimacing, screaming, guarding, etc.) then reporting to the resident's nurse or Director of Nursing. The nurse is to then complete an assessment of the resident's pain and put the proper intervention in to place. Nurses were educated on completing a pain assessment and documenting on the medical record. Any staff who did not receive this in service by 11-30-23 were not allowed to work until this was completed. The Director of Nursing and Staff Development Coordinator are responsible for maintaining records of staff who need the in-service prior to their next shift. All licensed nurses were educated in following up on x-ray orders. This education was initiated on 11-30-23 by the Unit Managers, wound nurse, and Staff Development Coordinator. Any licensed nurse who did not receive this education by 11-30-23 was not allowed to work until completed. The Director of Nursing and Staff Development Coordinator are responsible for maintaining records of all licensed staff who need the in-service prior to their next shift. This education was added to the new hire orientation by the Director of Nursing on 11-30-23. Facility alleges removal of the immediate Jeopardy as 12-1-23. Validation of the immediate jeopardy removal plan was conducted in the facility on 12/4/23. The facility's initial plan audit was verified and signature sheet for education reviewed with no concerns. Facility nurses were interviewed and were aware of the pain management protocol, how and when to assess pain, and how to appropriately respond to a resident's request or nonverbal signs of pain. Facility medication aides, nurse aides, dietary staff, housekeeping staff and rehabilitation staff were also aware of the pain protocol and how to observe for nonverbal signs of pain and how to respond to resident's request or nonverbal signs of pain. The facility's immediate jeopardy removal date of 12/1/23 was validated.

Based on record review, observations, resident interview and staff interviews the facility failed to maintain a resident's continence status for 1 of 2 residents who were continent to both bowel and bladder (Resident #518). Findings included: Resident #518 was admitted to the facility on [DATE], with diagnosis that included chronic pain syndrome, disorder of thyroid, adult failure to thrive, bipolar disorder, constipation, anorexia, hypothyroidism, and spondylosis. Review of Resident #518 admission assessment progress note by Nurse #3, dated 11/17/23, revealed the resident was continent of both bowel and bladder. An interview with Nurse #3 was conducted on 11/29/23 at 3:19pm. Nurse #3 admitted resident on 11/17/23 and indicated upon her assessment, Resident #518 was continent of both bowel and bladder. Nurse #3 indicated that resident required the nurse aide to offer a bed pan for toileting. Nurse #3 was not aware that Resident #518 was asked to wear a brief by staff. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #518 was cognitively intact with no behaviors or rejection of care and frequently incontinent of both bowel and bladder. An interview with MDS Nurse #1 on 11/30/23 at 3:05pm, indicated that she worked remotely to assist the facility with completing the MDS assessments. MDS Nurse #1 indicated she had never assessed or met with Resident #518 in person because she worked remotely and used the medical record to gather information. Resident #518's care plan initiated 11/21/23 did not address the resident's incontinence. On 11/29/23 at 5:13am, an observation of incontinence care was made with Resident #518 and NA #3. Resident #518 was noted to be wearing a brief that was soaking wet of urine. Resident #518 did not have a bedpan in the bathroom or room. Resident #518 was interviewed on 11/29/23 at 5:49am. Resident #518 indicated she was continent of both bowel and bladder but was asked by staff to wear a brief since admission (11/17/23) because she could not walk to the bathroom and use the restroom. Resident #518 indicated she used her call light to ask for toileting assistance, but staff would not respond, and she would go on herself. Resident #518 indicated she was able to tell when she needed to be toileted. Resident #518 indicated the facility did not offer her a bed pan to use while in bed and just placed her in briefs. Resident #518 indicated she had used a bed pan and bedside commode while at an acute care hospital prior to being admitted to facility. On 11/29/23 at 3:34pm, an interview was conducted with Nurse #1. Nurse #1 indicated Resident #518 was continent to both bowel and bladder but not able to transfer safely or walk to the bathroom. Nurse #1 further indicated Resident #518 required the nurse aide to offer a bed pan for toileting. Nurse #1 was not aware that Resident #518 was asked to use brief by staff. An interview was conducted on 11/30/23 at 10:07am while NA #5 provided incontinence care to Resident #518. NA #5 indicated she worked with Resident #518 regularly, and she had never offered a bed pan to Resident #518 because the resident was wearing a brief since admission (11/17/23), and she assumed Resident #518 was incontinent. On 11/30/23 at 10:54am, an interview was conducted with Certified Occupational Therapist Assistant (COTA). The COTA indicated Resident #518 was not able to use the bathroom commode or bedside commode for toileting because she was not safe with transfers, but she was able to use a bed pan, because her bed mobility was decent. COTA was not aware that Resident #518 was not offered a bed pan. An interview was conducted with the Director of Nursing (DON) on 12/1/23 at 10:30am. The DON indicated if a resident was admitted and continent of both bowel and bladder, but they were not able to walk to the bathroom, she would require staff to offer the resident a bedpan for toileting. DON was not aware that Resident #518 was not offered bed pan. On 12/1/23 at 11:30am an interview was conducted with the Administrator. The administrator indicated if a resident was admitted as being continent of both bowel and bladder and could not safely transfer, she would require staff to maintain continence by offering the resident a bed pan while in bed for toileting. Administrator was not aware that Resident #518 was not offered bed pan.

Based on resident and staff interviews and record reviews, the facility failed to transfer a resident safely from her bed to a wheelchair while using a total mechanical lift for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 experienced a fall when two staff members failed to securely attach the sling to the lift which resulted in the sling jarring loose as the lift was moved and with the resident falling to the floor. Resident #1 was sent out to the hospital for evaluation / treatment with severe pain and was found to have a comminuted (a bone that is broken in at least two places) and displaced (where the bones are not in alignment) scapular body (shoulder blade) fracture, rib fractures involving the second through fifth right ribs. Immediate Jeopardy began on 11/13/22 when Resident #1 was being transferred with a total mechanical lift and one of the four loops from the resident's sling detached from the lift, resulting in the resident falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 11/23/22 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's instructional video for the facility's total mechanical lift included directions for staff members using the lift. As the video demonstrated a lift being used to transfer a resident from a bed to a wheelchair, the narrator stated, As the resident is being raised (slightly off of the bed), confirm the secure attachment of the sling to the cradle. A review of the Food and Drug Administration (FDA) Patient Lifts Safety Guide included a compilation of best practices and general safety recommendations that when followed, can help mitigate the risks associated with patient lifts. The safety recommendations included the following sections, in part: -- Place Patient in Sling. A cautionary note read, ! Using the wrong sling or attaching the sling incorrectly may cause serious injury to the caregiver or patient. The steps included, Ensure all clips or loops are secure and will stay attached as patient is lifted. --Perform Safety Check. This section provided the following instructions: Before lifting the patient, perform safety check: Examine all hooks and fasteners to ensure they will not unhook during use. Double-check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. -- Lift the Patient. The recommendations included: Lift patient two inches off the surface to make sure patient is secure. Check the following: Sling straps are confined by guard on sling bar and will not disengage. Weight is spread evenly between straps. Patient will not slide out of sling or tip backward or forward. Resident #1 was admitted to the facility on [DATE]. Her cumulative diagnoses included multiple [CONDITION(S)] (MS) and [CONDITION(S)] (paralysis of the legs and lower body). The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #1 had intact cognition. She required extensive assistance with two plus (2+) persons physical assist for transfers. The resident was 65 inches tall and weighed 191 pounds (#). The resident's Care Plan included the following area of focus, in part: --Resident has an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, [CONDITION(S)], impaired balance, MS (Date Initiated: 12/6/20; Revision on: 8/16/22). The care plan interventions indicated the resident was totally dependent on and was transferred by a total mechanical lift with 2 staff members. (Date Initiated: 12/6/20). The resident's electronic medical record (EMR) included a Situation-Background-Assessment-Recommendation (SBAR) Summary dated 11/13/22 at 10:45 AM and authored by Nurse #1. The Summary indicated Resident #1 had a fall. Her Primary Care Provider was notified and an order received to send the resident to the hospital for evaluation. An interview was conducted with Resident #1 on 11/21/22 at 12:28 PM. The resident was awake, alert, and oriented as she was lying on her bed. When asked about the fall she sustained while being transferred with a total mechanical lift, the resident reported two veteran nurse aides (NAs) came in to transfer her from the bed to her wheelchair using a total mechanical lift. She was able to identify the two NAs who transferred her (NA #1 and NA #2). Resident #1 reported she had been transferred with the total mechanical lift for several years and thought all would be well because these two aides had worked with her several times in the past. She stated there was a problem with the pad (the lift's sling) not being hooked up right. Upon further inquiry, she stated she was raised above the bed just fine. However, when the lift moved towards the wheelchair, she was flipped out off of the sling and dropped onto the floor. At the time of her fall, she reported she thought both of the NAs were standing behind the lift (not within reach of her). The resident stated, It all happened very quickly. She reported she thought she hit her back on the base of the lift when she landed on the floor. Immediately after the fall, Resident #1 reported she was in a great deal of pain and could hardly breathe. The hall nurse (Nurse #1) came in, assessed her, and the facility called 911. The paramedics transferred her from the floor to the stretcher, then took her to the hospital. The resident reported she has been in a considerable amount of pain since sustaining the fall on 11/13/22. She stated the NAs told her they were sorry about the incident. A telephone interview was conducted on 11/22/22 at 6:48 PM with NA #1. NA #1 was identified as one of the nurse aides who was transferring Resident #1 with the total mechanical lift when she fell on [DATE]. During the interview, the NA recalled she was working on obtaining weights for the residents on that date. The NA stated she already had the total mechanical lift with her when a coworker wanted to borrow it to get Resident #1 up in her wheelchair. I told her we would get her in the chair and get the weight at the same time. NA #1 stated the resident was already laying on the sling on her bed and was ready for the transfer. NA #2 assisted her and was on the resident's left side with NA #1 on the right side. She recalled both sides of the bottom part of the sling were hooked up to the lift using the blue loops while both sides of the top part of sling were hooked up to the lift using the orange loops. The NA reported, I had the controls. I proceeded to move the (brand name of mechanical lift). She stated the lift's legs were open and when the lift was moved, it jerked a little because it got caught on a wire under the bed. She stated, So we proceeded to move her and when we moved her, the lift's pad (sling) on the top right hand side gave way and she (Resident #1) yelled. She reported that Resident #1 fell in such a way that she was lying on the legs of the total mechanical lift. NA #2 ran and got Nurse #1 while she stayed with the resident. The telephone interview continued on 11/22/22 at 6:48 PM with NA #1. During the interview, the NA was asked if she looked at the resident's sling after the fall. She stated, No, I didn't. When asked if she had any reason to believe there was a problem with the sling, the NA only stated that she threw the sling away in the garbage after the fall just in case there had been a problem with it. NA #1 reported she recalled hearing a pop during the lift transfer but stated she did not know where the noise came from. The NA was also asked if either of the NAs had a hand on the resident to provide guidance to her body during the transfer. She reported they did not. NA #1 stated she had the control and was turning the lift while NA #2 had come around the foot of the bed as she was getting the wheelchair ready for transfer. An interview was conducted with NA #2 on 11/22/22 at 3:54 PM. NA #2 was identified as one of the nurse aides who was transferring Resident #1 with the total mechanical lift when she fell on [DATE]. As the NA recalled the incident, she reported NA #1 was planning to weigh the resident prior to transferring her to the wheelchair and NA #2 was going to assist her. The NA recalled Resident #1 had her own sling and she remembered examining the sling (straps and loops) to make sure everything was in order before using it. NA #2 stated she started out on the resident's left side with the other NA on the right side of the bed with the control for the lift. She recalled each of the NAs hooked the orange color-coded loop on the top of the sling to the lift; and each hooked the blue color-coded loop at the bottom of the sling to the lift. She noted these were the loops typically used to for Resident #1. NA #2 stated after the loops were hooked to the lift, she came around to the right side of the bed to help straighten the resident onto the middle of both the bed and the sling. NA #1 started to lift the resident up with the mechanical lift, then pulled the lift backwards. As she came backwards with the lift, NA #2 turned and grabbed the wheelchair to position it for the transfer. NA #1 turned the lift towards the wheelchair while NA #2 was grabbing the wheelchair. NA #2 stated, That's when the resident started to lean backwards in the sling. She reported at the time when the resident was leaning backwards, there was no one touching her. The resident continued to go backwards and fell directly on the base (legs) of the lift. The NA recalled it all happened very quickly. After Resident #1 fell , the NA recalled she went outside, called the nurse, and the nurse called 911. The interview continued with NA #2 on 11/22/22 at 3:54 PM. During the interview, the NA was asked if there was a problem with the sling. She stated, I don't think there was. I didn't understand how the fall happened. NA #2 reported she looked at the sling after the fall and did not see a problem with it. She stated NA #1 told her the loop came off and she actually said it broke. Upon further inquiry, NA #2 stated she looked at the loop on the sling and did not see a break in the loop. When asked, the NA reported she did not hear anything unusual (any noises) from the lift or sling during Resident #1's transfer to indicate there may be a problem. The NA was also asked if at least one person would have typically had a hand on the resident to provide guidance to her body during the transfer. The NA responded by saying, Sometimes we do .both of us normally have a hand on her right side because she tends to lean in that direction. A telephone interview was conducted on 11/23/22 at 8:19 AM with Nurse #1. Nurse #1 was identified as the nurse who was assigned to care for Resident #1 on 11/13/22 (the date of her fall). As the nurse recalled the incident, she stated she was at the medication cart in the hall close to Resident #1's room. Immediately after hearing a loud noise and scream, she went to the room. Resident #1 was crying and moaning from pain. The nurse noticed her head was laying on the leg of the lift and said right away she needed to go to the hospital due to the resident hitting her head. The nurse reported the resident's vital signs were obtained and her physician was called. An order was received to send the resident out to the hospital. The nurse reported the resident continued to be alert and oriented. She did not complain of head pain but did have some shortness of breath. Nurse #1 administered a dose of the resident's [MEDICATION(S)] (an opioid pain medication ordered to be given to Resident #1 on an as needed basis). When asked, the nurse reported she did not have any additional conversations with the NAs regarding the fall. She was also asked if she examined the resident's sling after the fall. The nurse stated she did not. A Nursing Note dated 11/13/22 at 11:08 AM and authored by Nurse #1 reported the resident was transferred to the hospital for evaluation after the fall due to right shoulder pain. Resident #1's hospital record indicated the resident arrived in the Emergency Department (ED) on 11/13/22 at 11:25 AM. The ED Triage Notes read in part: Per EMS patient was in (brand name of mechanical lift) at a height of 4 - 5 ft (feet) in the air and fell out of the sling. Patient fell on R (right) shoulder and hit head. Patient denies loss of consciousness. The resident's history reported, they were moving her when they dropped her onto her right side onto the floor. The resident reported having severe sharp [NAME] pain 9 out of 10 in her right shoulder which does not radiate is worse anytime she tries to move it and she reports she did hit her head and has a mild right-sided headache and some neck pain .She does not take any anticoagulation. They gave her [MEDICATION(S)] at the facility with minimal improvement in the pain. The history is provided by the patient and the EMS personnel. Findings from the 11/13/22 hospital x-ray and computerized tomography (CT) radiology indicated the resident had a comminuted and displaced scapular body fracture, a nondisplaced fracture of the right anterior (located towards the front of the body) second rib, a nondisplaced fracture of the right lateral (located towards the side of the body) third rib, and minimally displaced right lateral fourth and fifth rib fractures. Orthopedics was consulted. The physician noted, .She has advanced MS, is wheelchair-bound, and unfortunately this is her primary functional upper extremity. She can use her fingers wrist and hand, and can even use her shoulder if she can tolerate, but I doubt she will be able to do much. Plan for nonsurgical management and follow-up in the office in 1 to 2 weeks. Additional pain control was provided and a sling recommended for comfort. The resident was transferred back to the facility on [DATE]. A Nursing Note dated 11/13/22 at 6:00 PM (authored by Nurse #1) reported Resident #1 returned from the hospital and was reported to be pain free at that time. The resident continued to receive the following pain medications as previously ordered: 50 milligrams (mg) [MEDICATION(S)] to be given as two tablets by mouth every 6 hours as needed for pain (Start Date 8/21/21); and 325 mg acetaminophen to be given as two tablets by mouth every 8 hours as needed for mild to moderate pain (Start Date 9/16/21). The resident's level of pain was reported to range from 0 to 8 on a scale of 0 - 10 (with zero indicative of no pain) on 11/13/22 and 11/14/22. A physician's order was received on 11/15/22 for 5 mg / 325 mg [MEDICATION(S)] / acetaminophen (a combination opioid pain medication) to be given as one tablet by mouth every 6 hours as needed for moderate to severe pain. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting/Four Point Plan of Correction Agenda and Summary dated 11/14/22 was provided by the facility for review. This Summary identified an opportunity for improvement with the following description: On 11/13/22, a resident fell during a 2-person (brand name of mechanical lift) transfer and sustained a closed rib fracture and a scapula fracture. After a thorough investigation, incident reenactment and staff interviews the facility determined the root cause of resident fall was related to staff failure to properly secure sling loops which allowed resident to fall during transfer. 1) The Corrective Action in the Action Plan reported the total mechanical lift was verified as properly functioning and sling size and condition was good. The results of the root cause analysis determined that while nurse aide (NA) was knowledgeable on performing a proper lift transfer, they did not ensure proper loop securement. 2) Residents who require use of a total mechanical lift were identified as being at risk. 3) The Systemic Changes made based on results of the root cause analysis noted the facility would ensure nursing staff were knowledgeable and competent of the proper use of total mechanical lifts and the facility would monitor compliance of total mechanical lift transfers by making rounding observations of identified residents and staff during transfers. All licensed nurses and nurse aides were to be educated on the proper use of total mechanical lifts during transfers. This education would also be included in orientation and at least annually. 4) Monitoring of the Plan of Correction would be done by completing audits of staff observations during care to ensure proper technique with total mechanical lift transfers and reporting results of the audits to during QAPI monthly meetings. The Four Point Plan of Correction did not specify a date as to when the plan would be fully implemented. A review of the facility's In-Service education records on (Brand name of mechanical lift) Lift Safety provided for nurses and nurse aides was completed. This review revealed the following: --On 11/15/22, 19 nursing staff members (nurses, medication aides or MAs, and nurse aides) worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/16/22, 13 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/17/22, 21 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/18/22, 20 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/19/22, 25 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/20/22, 21 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. An interview was conducted on 11/21/22 at 2:35 PM with NA #3. NA #3 was assigned to care for Resident #1 during 1st shift on 11/21/22. During the interview, the NA reported she was new to the facility. She stated she was an Agency NA (temporary staff) who started at the facility 2-3 days ago. When asked how she would know if a mechanical lift was required to safely transfer a resident, the NA stated she primarily relied on colleagues to tell her about the residents' needs for assistance and care when she received report at the change of shift. If no one was available for additional questions she may have, the NA stated she could look in the resident's Kardex (an electronic overview of the individual resident's care needs). When asked if she received any orientation to the facility when she first started, she reported orientation was primarily provided by her Agency. Upon inquiry regarding Resident #1, NA #3 reported the resident preferred not to get out of bed today. An interview was conducted on 11/21/22 at 4:55 PM with the facility's DON. During this interview, the DON discussed Resident #1's fall from the total mechanical lift. She reported two NAs were transferring the resident from her bed to the wheelchair when the fall occurred. From her investigation, she believed the NAs were using the correct lift sling for the resident. The facility ultimately concluded the NAs did not properly hook the sling onto the total mechanical lift. The DON reported the facility took additional measures to ensure the safety of transfers using a total mechanical lift. Resident #1's sling was discarded and an audit was done to assess the condition of all lift slings in the facility. She reported a total of three slings were discarded as a result of the audit and new slings were ordered. As the interview continued on 11/21/22 at 4:55 PM, the DON provided two in-service sign-in sheets from a (Brand name of mechanical lift) Lift Safety In-Service. The signature list included NAs, MAs, and nurses. At that time, the DON was told the 1st shift NA assigned to care for Resident #1 on this date (11/21/22) had been interviewed. Review of the documentation of the (Brand name of mechanical lift) Lift Safety in-services did not indicate NA #3 had received this education. The DON reported the in-services on (Brand name of mechanical lift) Lift Safety were initiated on 11/13/22 (the day Resident #1 experienced her fall). When asked, the DON stated all nursing staff should have received the (Brand name of mechanical lift) Lift Safety in-service before the start of their shift. Upon their request, an interview was conducted on 11/22/22 at 9:49 AM with the facility's Administrator and DON. During the interview, the Administrator and DON reported the facility had two total mechanical lifts currently in use. New slings were ordered last week (specifically for their brand of total mechanical lift) to replace all of the older slings in the facility. The new slings were delivered on 11/21/22 and distributed on this date (11/22/22) along with staff educated on the proper use of the slings. An interview was conducted on 11/22/22 at 11:00 AM with the facility's Staff Development Coordinator (SDC). During the interview, the SDC reported she was working at the facility on 11/13/22 (the day Resident #1 had a fall). She recalled interviewing and reenacting the total mechanical lift transfer with NA #1 and NA #2 on that date. The SDC reported concerns were identified at that time regarding the need to make sure the loops of the sling were properly clamped (secured) into place. The SDC reported she started education with the nursing staff on 11/13/22 and it was on-going since then. When asked about the content of the education, she stated the in-service placed an emphasis on making sure two staff members were always used for total mechanical lifts so one person would be available to guide the resident's feet, ensuring either the DON or Administrator were notified of any holes or fraying on a sling so it could be promptly replaced, and making sure the color-coded loops on the sling were hooked up properly to the lift. The SDC explained staff were educated to make sure the color-coded loops on the sling matched on each side so the two loops at the top would be the same color and the two loops at the bottom of the sling would be the same color. She reported it was concluded that either the color-coded loops of the sling were not matched up on each side or they weren't clamped down all the way and secured on the lift when Resident #1 fell on [DATE]. She reported if the loop to the sling was not hooked all the way under black locking piece on each side of the lift's cradle, the loop could dislodge. The SDC stated, Something dislodged. As the interview continued on 11/22/22 at 11:00 AM, The SDC further described the in-service education provided on (Brand name of mechanical lift) Lift Safety consisted of verbal information, printed material, and the manufacturer's instruction video for the lift (viewed by some of the staff). She noted that some nursing staff members also performed a return demonstration. When asked, the SDC reported she had in-serviced nurses, NAs, and management staff who worked directly with the residents. She stated the goal was to provide this education to the nursing staff before the start of his/her shift. The SDC reported although the in-service documentation did not indicate NA #3 received the in-service education, she recalled the NA actually had been in-serviced (but was unsure of the date). When asked if she had been able to in-service all nursing staff members before the start of their shift, the SDC stated, Yes .for the most part. On 11/22/22 at 11:43 AM, the SDC used a total mechanical lift and sling to demonstrate the key points emphasized in the (Brand name of mechanical lift) Lift Safety in-service. The SDC reported each resident had his/her own sling kept in their room with extra slings stored in the laundry department. A follow-up interview was conducted with the SDC on 11/22/22 at 12:15 PM. At that time, a partial review of the (Brand name of mechanical lift) Lift Safety in-service documentation was compared to the nursing staff schedule for 11/15/22 to 11/20/22. The SDC acknowledged there were several nursing staff members who worked a shift on these dates prior to receiving the in-service education. The Administrator was notified of immediate jeopardy on 11/22/22 at 2:00 PM. The facility provided an acceptable credible allegation on 11/23/22 at 8:03 AM. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to transfer Resident #1 safely from surface to surface while using a total mechanical lift. While transferring a resident with a total mechanical lift, two Nurse Aides did not hook the sling to the lift according to manufacturer's instruction resulting in the sling jarring loose when moving the resident in the lift and Resident #1 falling to the floor. Root Cause Analysis was conducted as a result of the investigation. The factors that were identified were as follows; Certified Nursing Aide #1 did not ensure the right shoulder strap was secured to the cradle before operating mechanical lift. Certified Nursing Aide #1 proceeded to operate mechanical lift while Certified Nursing Aid #2 was located at the foot of the bed. Certified Nursing Aid #2 was not located in the proper position to help guide the resident. On 11/14/2022, the Director of Nursing assessed current residents using the mechanical lift to ensure residents were safely transferred without incident by interviewing the alert and oriented residents with a BIMs score of > 12. Residents with BIMs score < 12 the residents received a range of motion assessment to ensure no new onset of pain. On 11/14/2022, there were no other residents involved in any other incidents that were transferred with the mechanical lift. Currently the 18 other residents are being transferred using the total mechanical lift. 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 Staff Development Coordinator, Director of Nursing, and Unit Managers educated the Licensed Nurses and the Certified Nursing Aides on the process of how to properly transfer using the mechanical lift using a video provided by the mechanical lift company and written information in a classroom setting. Education included ensuring the sling is the appropriate size for the resident. Staff are to ensure the colors of the straps match at the shoulder and at the head. They are to check the straps in the cradle to ensure they are seated properly and secure before the certified nursing aide operates the mechanical lift. Once this is completed the second certified nursing aide will position themselves on the same side of the bed as the mechanical lift to guide the resident in the completion of the transfer. The Director of Nursing will ensure no Licensed Nurse and Certified Nursing Aide will work without receiving this education. Any new hires, including agency staff, will receive education prior to providing resident care. Education will be completed by 11/22/2022 by the Staff Development Coordinator, Director of Nursing, and Unit Managers. The staff members will document the date and time on the education form to show education was provided prior to providing resident care. The Director of Nursing and/or designee will observed 2 residents that are transferred using the mechanical lift on random shifts 3 times weekly (including weekends) x 4 weeks to ensure proper usage for safely transferring residents. Effective 11/22/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance Alleged Date of IJ Removal: 11/23/2022 The facility's credible allegation of Immediate Jeopardy removal was validated on 11/23/22. The validation was evidenced by observations of lift transfers using a total mechanical lift and an interview with the Staff Development Coordinator regarding the system put into place to ensure nursing staff were provided the necessary in-service education prior to working their shift. Multiple interviews with both licensed nursing staff and non-licensed nursing staff (NAs) currently working at the facility were conducted. The nursing staff consistently reported they received in-service education on (Brand name of mechanical lift) Lift Safety and were able to verbalize key measures necessary to ensure a resident's safety during the lift transfers, including ensuring the sling's color-coded loops were securely attached to the total mechanical lift. Immediate Jeopardy was removed on 11/23/22 at 12:00 PM.

Based on record review and interviews with staff, Physician Assistant and the Medical Director, the facility failed to implement an order from the hospital discharge summary to test blood sugar twice daily for Resident #72. The facility administered injectable and oral diabetes medication to Resident #72 who was diagnosed with diabetes without monitoring the resident's blood sugar from admission to the facility until admission to the hospital. On 8/13/22, Resident #72's blood sugar registered HI on the glucometer. Resident #72 was sent to the emergency department (ED) due to being lethargic and staff were unable to obtain vital signs. At the hospital, Resident #72 ' s blood sugar was recorded as 764 milligrams per deciliter (mg/dl) and the Resident received insulin via intravenous method to lower blood sugar levels. Resident #72 was diagnosed with Diabetic Ketoacidosis (a buildup of acids in your blood that can lead to diabetic coma or even death) /Hyperosmolar [CONDITION(S)] (an extremely high blood sugar level). This deficient practice occurred for 1 of 3 sampled residents reviewed for diabetes care (Resident #72). Immediate jeopardy began on 4/21/22 when the facility failed to monitor blood sugars for Resident #72 who had diabetes and received injectable and oral diabetes medications. The hospital discharge summary included orders to monitor the resident ' s blood sugars twice a day. The facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy was removed on 8/18/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: A review of Resident #72 ' s hospital discharge (d/c) summary dated 4/17/2022 revealed orders to test blood sugar twice daily. Resident #72 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse # 1 documented the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/17/22 at 2:08 pm with Nurse #1 it was indicated she was not completely sure if she had put the orders in the computer from the hospital d/c summary on admission, however she indicated she was the nurse that day. She indicated if it was documented on the discharge summary for Resident #72 to have blood sugar checks done that then there should have been an order to do so. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had cognitive impairment received insulin during the assessment period. A review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) was 6.6% (A level of 6.5% indicates diabetes.) and will check blood sugars before meals and at bedtime. A review of medical record revealed blood sugar was obtained after a fall on 4/29/22 and was 88 mg/dl. A review of the Basic Metabolic Panel dated 5/16/22 revealed the sugar result was high at 220 mg/dl, reference range is 70-99 mg/dl. A review of medical record revealed a blood sugar was obtained on 6/23/22 and was 155 mg/dl. A review of a Progress notes by Nurse #2 dated 8/13/22 read, in part, Resident #72 was found to be severely lethargic, skin cool to touch and staff were unable to obtain vital signs. Blood sugar registered HI, which per the glucometer manufacture information indicates a result of HI is over 600 mg/dl. Spouse was present & agreed with nurse to transfer Resident to hospital ED for evaluation and treatment. Call was placed to on-call Nurse Practitioner and was made aware. A call was placed to 911 to transfer Resident to hospital and emergency medical service arrived and transferred resident to hospital. An interview with Director of Nursing (DON) 8/17/22 at 3:05 pm was conducted and she indicated she was not aware Resident #72 had orders on admission for blood sugar checks. She stated the facility should have verified the orders for the blood sugar checks On 8/17/22 at 3:19 pm an interview with Physician Assistant who indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated if blood sugar checking was on the orders from the hospital, then the blood sugar should have been checked as ordered. During an interview with the Medical Director (MD) on 8/18/22 at 4:49 pm it was indicated the facility had issues with orders that were not being transcribed as ordered. He indicated for Resident #72 the blood sugar checks were missed and the facility should have been doing the checks as they were ordered. He indicated if the facility had been doing the blood sugar checks, then staff could ' ve seen his blood sugar was rising ahead of time and modified his medications. A review of the EMS report dated 8/13/22 at 7:48 pm revealed upon arrival to facility Resident #72 was responsive to verbal stimuli by name only and blood sugar was obtained, and results read HI. According to the hospital ED documentation dated 8/13/22, Resident #72 had a blood sugar of 764 mg/dl in the ED and was diagnosed with Diabetic Ketoacidosis/Hyperosmolar [CONDITION(S)] and remained in the hospital at the time of the survey. The Resident presented to the ED with altered mental status and was admitted for further management. He was started on an insulin drip for severe [CONDITION(S)]. The Administrator was notified of immediate jeopardy on 8/17/22 at 5:06 pm. On 8/18/2022 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 complete an evaluation of residents #72 medication regimen that identified the need to monitor insulin administration and anti-diabetic medications. Resident #72 medication regimen review did not identify the inadequate monitoring of insulin administration and anti-diabetic medication. Resident #72 received weekly insulin and daily anti-diabetic medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. A review of the pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 revealed no identification of inadequate monitoring of insulin administration and anti-diabetic medication. On 8/17/2022 the Regional Director of Clinical Services (RDCS), reviewed residents with diabetic medication to ensure residents are receiving blood sugar checks. On 8/17/22 the RDCS notified the Nurse Managers of any opportunities identified during this audit and explained their responsibility to correct by 8/17/2022. On 8/17/2022 the Regional Director of Clinical Service (RDCS), reviewed 30 days of admissions to ensure accuracy of orders. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers educated the Licensed Nurses regarding the process for verifying new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse is to call the medical doctor and/or nurse practitioner to verify orders on the discharge summary prior to entering the orders into the residents ' electronic medical record. When the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing will ensure no licensed nurse will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 8/17/2022 by the Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers. The Regional Director of Clinical Services educated the Director of Nursing and Nurse Managers regarding the validation of new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This education was completed on 8/17/2022. Effective 8/17/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance Alleged Date of Immediate Jeopardy Removal: 8/18/2022 On 8/19/22 the credible allegation of immediate jeopardy was validated by onsite verification. Record reviews and interviews were conducted which verified the audits were completed. Interview with the Regional Clinical Nurse Consultant revealed when a new admission was admitted to the facility, the nurse needed to call the Medical Director or Nurse Practitioner to verify discharge summary orders prior to entering the orders into the resident ' s medical record. She also indicated when admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the audits revealed all residents ' orders were reviewed and any discrepancies were corrected. A review of the education training revealed education was provided to staff as stated in the credible allegation. Interview was conducted with staff on 8/19/2022 at 10:52 am who indicated knowledge of what to do for new admission residents and entering the new orders. Interview was conducted with staff on 8/19/2022 at 11:00 am who indicated knowledge of what to do for new admission residents and entering the new orders from the hospital. Interview was conducted with Unit Manager on 8/19/2022 at 11:45 am who indicated knowledge of the process implemented to verify orders from the d/c summary from the hospital for all new patients. Interview was conducted with Staff Development Coordinator on 8/19/2022 at 11:58 am and it was indicated she had the knowledge of how to complete the medication reconciliation for new admissions, and she also indicated a new checklist that was implemented for the completion of new admissions. Interview with the DON on 8/19/2022 at 12:00 pm revealed the new admission audit will help the nurses complete a full assessment of residents ' needs. All medications and treatments will be reviewed for the residents during the admission process. Interviews with staff revealed that education was provided. The immediate jeopardy removal date of 8/18/2022 was validated.

Based on record review, Consultant Pharmacist, Medical Director and staff interviews, the facility failed to complete an evaluation of Resident #72's medication regimen that identified the need to monitor injectable and oral diabetes medications for 4 of 4 medication regimen reviews. Resident #72 received weekly injectable and daily oral diabetes medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. This deficient practice occurred for 1 of 6 sampled residents reviewed for medication regimen review (Resident #72). Immediate Jeopardy began on 4/27/22 when the facility failed to complete an evaluation of Resident #72 ' s medication regimen that identified the need to monitor injectable and oral diabetes medications and failed to identify the inadequate monitoring of injectable and oral diabetes medication as ordered to test blood sugar tests twice daily. The Immediate Jeopardy was removed on 8/19/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: A review of Resident #72 ' s hospital discharge (d/c) summary dated 4/17/2022 revealed orders to test blood sugar twice daily. Resident #72 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, Parkinson ' s disease, and dementia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had cognitive impairment received insulin during the assessment period. Review of physician orders revealed orders dated 4/21/22 included [MEDICATION(S)] (an antihyperglycemic injectable medication used to control high blood sugar) 1.5 milligrams (mg)/0.5 milliliters (ml) subcutaneously in the morning every Monday and [MEDICATION(S)] (an oral diabetes medication) 1000 mg give 1 tablet by mouth one time a day. Nurse # 1 documented the admission orders. No order documented for blood sugar monitoring. Manufacturer precautions for [MEDICATION(S)] and [MEDICATION(S)] indicate Check blood glucose levels regularly. A review of pharmacy medication regimen review for the month of April dated 4/27/2022 by Pharmacist #1 revealed a review of Resident #72 ' s medical record which included discharge summary, vital signs, weight, labs, progress notes, Physician/Nurse Practitioner notes were done, and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of May dated 5/27/22 by Pharmacist #1 revealed a review of Resident #72 ' s blood sugar dated 4/29/22 was 88 mg/dl and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of June dated 6/28/22 by Pharmacist #2 revealed a review was completed of Resident #72 ' s medical record including: orders, available labs, progress notes and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of July dated 7/18/22 by Pharmacist #2 revealed a review was completed for Resident # 72 ' s medical record including: orders, available labs, progress notes and no recommendation were made related to blood sugar monitoring. A review of Progress note dated 8/13/22 read, in part, Resident #72 was found to be severely lethargic, skin cool to touch and staff were unable to obtain vital signs. Blood sugar registered HI. (The glucometer manufacturer ' s information indicates HI displays if the result is over 600 mg/dl.) Spouse was present and agreed with nurse to transfer Resident to hospital emergency department (ED) for evaluation & treatment Call placed to 911 and Resident transferred to ED by emergency medical services. According to the review of hospital ED documentation dated 8/13/22, Resident #72 had a blood sugar of 764 milligrams per deciliter (mg/dl) in the ED and was diagnosed with Diabetic Ketoacidosis (a buildup of acids in your blood that can lead to diabetic coma or even death) /Hyperosmolar [CONDITION(S)] (an extremely high blood sugar level) and remained in the hospital at the time of the survey. The Resident presented to the ED with altered mental status and was admitted for further management. He was started on an insulin drip for severe [CONDITION(S)]. On 8/18/2022 at 9:35 am an interview was conducted with Pharmacist #1, and she indicated she was no longer the Pharmacy consultant for the facility, however, was for the months of April and May 2022. She stated she was not able to see any documentation for Resident #72 due to no longer having access to the facility records, however she stated in general she would look at the d/c summary and the orders in the computer that the Nurse entered in the computer. She indicated it was usually the facility ' s protocol to verify orders with the Physician and then enter the orders in the computer. She stated it was her understanding that the orders in the system were accurate. She indicated residents that have the diagnosis of diabetes would not necessarily have blood sugars monitored daily, but she would rather review their A1c because it was a more accurate marker of how residents ' diabetes are controlled verses a blood sugar check that can fluctuate. She indicated if the resident would have had an incident that would warrant her to recommend blood sugar checks, then she would have recommended it to be done. During an interview on 8/18/2022 at 11:50 am with Pharmacist #2, it was indicated she noted from the Physicians June progress note that Resident #72 had a recent A1c of 6.6%, and June fingerstick blood sugar was 155, which indicated to her a stable blood sugar. She indicated Resident #72 had no issues whatsoever and was a stable diabetic from what she reviewed starting in June 2022. She also indicated Resident had no previous concerns by the other Pharmacist. She indicated she wasn ' t concerned and had in her notes to follow-up with another A1c in September 2022, which she indicated was 3 months from the June Physician progress note with the 6.6 % A1c result. She stated when she last reviewed Resident #72 ' s medications he was a stable diabetic with no signs of diabetic issues. She indicated she reviewed Resident #72 ' s medications on 8/18/2022 and noted Resident had started [MEDICATION(S)] (ordered for an appetite stimulant) on 8/8/22 and it could have possibly been the cause of his blood sugar to have increased. She stated [MEDICATION(S)] and [MEDICATION(S)] are not medications that need blood sugar monitoring, and she would not have known the Resident had orders on admission for blood sugar monitoring as she was not the Pharmacist for the facility at the time of his admission. During an interview with the Medical Director (MD) on 8/18/22 at 4:49 pm it was indicated the facility had issues with orders that were not being transcribed as ordered. He indicated for Resident #72 the blood sugar checks were missed and the facility should have been doing the checks as they were ordered. He indicated if the facility had been doing the blood sugar checks, then staff could ' ve seen his blood sugar was rising ahead of time and modified his medications. The Administrator was notified of immediate jeopardy on 8/18/2022 at 1:22 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 because of the noncompliance. The facility failed to complete an evaluation of residents #72 medication regimen that identified the need to monitor insulin administration and anti-diabetic medications. Resident #72 medication regimen review did not identify the inadequate monitoring of insulin administration and anti-diabetic medication. Resident #72 received weekly insulin and daily anti-diabetic medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. A review of the pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 revealed no identification of inadequate monitoring of insulin administration and anti-diabetic medication. On 8/18/2022 the Regional Director of Clinical Services (RDCS), reviewed residents with diabetic medication pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 to ensure residents have been reviewed for orders that were not transcribed from the discharge summary to the resident ' s medical record, to ensure residents that are receiving diabetic medication has blood sugar checks and address any concerns. Pharmacy medication regimen reviews did not include the discharge summaries. On 8/18/2022, nurse management reviewed 30 days of admissions to ensure accuracy of transcribing medications from the discharge summary to the residents ' medical records. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Regional Director of Clinical Services educated the facility pharmacist on reviewing the resident ' s admission orders to ensure orders from the discharge summaries are implemented as ordered, as well as diabetics that are reviewed monthly to identify any monitoring of blood glucose checks for resident insulin and/or anti-diabetic medications. This education was completed on 8/18/2022. Education will be provided to the new pharmacist if the facility has a change by the Regional Director of Clinical Services (RDCS). Effective 8/18/2022 the Regional Director of Clinical Services will review the pharmacy monthly medication regimen on new admissions for 3 months to ensure accuracy from the discharge summary to include medications and interventions. Effective 8/18/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy Removal: 8/19/2022 On 8/19/22 the credible allegation of immediate jeopardy was validated by onsite verification which included record reviews and interviews which verified the audits and education were completed. An interview with the Regional Clinical Nurse Consultant revealed they will review the pharmacy monthly medication regimens on new admissions for 3 months to ensure accuracy of orders from the discharge summary to include medications and interventions. The facility's immediate jeopardy removal date of 8/19/2022 was validated on 8/19/2022.

Based on record review, observation and interviews of the staff, nurse practitioner, and family member, the facility failed to assess and provide wound care for both heel pressure ulcers upon admission which resulted in deep tissue injury and open wounds (Resident #28) and failed to consistently complete pressure ulcer care as ordered (Residents #28, 32 and 19) for 3 of 3 sampled residents. Findings included: 1. Resident #28 ' s FL2 (cognition and body assessment form) from the hospital dated 10/4/21 provided nursing notes of resident's skin assessment which documented right heel slightly blistered area of red 5 cm (centimeters) by 4 cm and left heel slightly blistered faint purple 3 x 6 cm. Resident #28 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Nursing admission note dated 10/14/21 documented Resident #28 had a blister on his right foot (heel) and a skin tear on his right buttock. There was no documentation that the left heel was assessed. There were no physician orders for pressure ulcer care and/or pressure relieving interventions implemented on admission documented. Resident #28 ' s admission Minimum Data Set (MDS) dated [DATE] documented he had clear speech, understood/understands and had severely impaired cognition. He required total dependence for all activities of daily living (ADL). He had two stage 2 pressure ulcers. Resident #28 ' s care plan dated 10/22/21 documented he had an ADL self-care performance deficit and potential for pressure ulcer. Resident #28 ' s nurses' note dated 10/25/21 documented right and left heels are dark purple, non-blanchable, boggy, with uneven edges. There was a small open area to the sacrum. Resident #28 ' s progress note dated 10/25/2021 resident representative stated resident had bilateral breakdown (blister) to heels and sacrum (open area) while in hospital (10/14/21). Note was written by the Director of Nursing. Resident #28 ' s progress note dated 10/26/2021 for skin/wound: Foam dressing applied to bilateral heels, old sacral wound and area was cleaned, and dressing applied for added protection. Resident representative was informed regarding wounds and the wound care specialist will evaluate tomorrow. Note was written by the Treatment Nurse. On 12/20/21 at 3:10 pm an interview was conducted with the Director of Nursing (DON). She stated Resident #28 had blisters on his heels on admission. Only the right heel was documented. FL2 documented by the hospital revealed the resident had slight blister to both heels. The DON stated that there was no documentation or orders for care or pressure relief boots for the heels from admission 10/14/21 until 10/25/21 when the wound care Nurse Practitioner was notified, assessed the resident, and provided orders. The resident ' s blisters had opened and were now stage 2. The DON stated that a blister was considered a stage 2 pressure ulcer. On 10/25/21 the heels were now open, and an order was obtained for treatment. The wound care Nurse Practitioner assessed the heels, and they were documented as deep tissue injury (DTI). Resident #28 ' s physician order documented right heel paint DTI with skin prep each day started 10/28/21 and discontinued on 11/11/21. Resident #28 ' s physician order documented left heel paint DTI with skin prep each day started 10/28/21 and discontinued on 11/24/21. Resident #28 ' s physician order documented 11/11/21 right heel stage 2 pressure ulcer (PU) cleanse wound with cleanser, pat dry, apply silver alginate, and place a dry sterile dressing (DSD) each day. Resident #28 ' s physician order documented left heel stage 2 PU cleanse wound with cleanser, pat dry, apply [MEDICATION(S)], and apply DSD each day. Resident #28 ' s October, November, and December 2021 treatment administration record (TAR) documentation had missing nursing initials for both right and left heel pressure ulcer care for dates: 10/28 – 31/21, 11/1 - 3/21, 11/12/21, 11/18/21, 11/19/21, 11/22/21, 11/28/21, 11/29/21 and 12/6/21. On 10/27/2021 Resident #28 ' s progress note dated 10/27/21 by Nurse Practitioner wound care specialist documented initial assessment of wounds. Resident had the following wounds: Left heel DTI measures 3.6 x 6 centimeter (cm); Right heel DTI measures 5 x 6.5 cm; Right lateral foot wound measures 3 x 1.2 cm (new). Treatment recommendation was given to paint wounds with skin prep daily followed by dry dressing. Sacral area was resolved with noted scarred tissue. On 12/13/21 at 10:30 am an interview was conducted with Resident #28 ' s resident representative/family member. She stated that the resident had acquired a small blister to both of his heels while he was in the hospital. She stated the resident had no dressing on his heels or protection for pressure at the facility. She observed that the blisters opened and got larger and were draining with no dressing in place. She stated that staff placed shoes on the resident ' s feet with open, heel wounds and no dressing. There was drainage in his shoes. She stated that she informed the Administrator that the heels were not being taken care of and he had no protection to the heels. She stated that the Administrator had the staff place a dressing and boots to prevent pressure. She stated that the staff had not changed the resident ' s dressing. The dressing had an old date (not the day before) and was falling off. She stated after informing the Administrator, the problems got better about 3 weeks after admission. On 12/7/21 at 11:30 am an interview was conducted with the facility Nurse Practitioner. He stated that if a pressure ulcer was not dressed and provided pressure relief, the fragile tissue would become damaged and increased in size. The ulcer also had the possibility to become infected. He stated he was not aware that Resident #28 ' s pressure ulcer was missed on admission. The facility had used agency nurse staff, they were not familiar with the resident, and could not provide him a resident update. On 12/7/21 at 12:05 pm an interview was conducted with the Unit Supervisor (US) #1. The US #1 stated that she, the wound care nurse and Infection Preventionist were required to carry a phone for on-call nursing assignment. When there was a nurse call out that could not be filled, one of the three staff were expected to take turns to cover the assignment. The US #1 stated that when the wound care nurse was pulled to a nursing assignment, she and the staff were not always informed until later in the day (when residents were up in their wheelchair and decline care) or not at all and wound care was not completed. She stated there was a break-down in communication. US #1 also stated that when a nurse had to cover 1 unit/2 halls with a medication aide, there was not enough time to complete wound care when the wound care nurse was not available. US #1 stated that there was a staffing shortage. Resident #28 ' s risk meeting note dated 11/18/2021 documented resident reviewed for healing pressure wounds to both feet. Resident was seen by the wound care Nurse Practitioner on 11/17/21 for assessment and treatment recommendation. The Nurse Practitioner documented the resident ' s right lateral foot DTI had resolved. Resident ' s left heel DTI measures 3 x 4.8 cm. Treatment plan for skin prep to wound daily followed by dry dressing. Resident ' s right heel stage 2 pressure wound measures 3 x 2.6 x 0.1cm with 100% granulation and moderate serosanguinous exudate. Treatment continues with silver alginate to wound bed daily secured with dry dressing. Resident #28 ' s skin/wound note dated 12/2/21 documented the resident was seen by the wound care Nurse Practitioner for assessment and treatment recommendation of wounds to both feet. The Nurse Practitioner ' s assessment documented DTI to left heel is now a stage 2 pressure injury. New treatment order for [MEDICATION(S)] to wound bed followed by dry dressing daily. Stage 2 pressure wound to right heel will continue with daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 ' s skin/wound note dated 12/8/2021 documented the resident was seen by the wound care Nurse Practitioner today for assessment and treatment recommendations. The resident has stage 2 pressure injury to both heels. The left heel wound measured 2 x 1.6 x 0.1cm with 100% granulation tissue and moderate serosanguinous exudate. Treatment continues as, [MEDICATION(S)] to wound bed followed by dry dressing daily. The right heel wound measured 2 x 1.3 x 0.1cm with 100% granulation tissue and moderate serosanguinous Exudate. Treatment continued with [MEDICATION(S)] to wound bed followed by silver alginate, secured with dry dressing daily. On 12/6/21 at 10:10 am an interview was conducted with the wound care nurse (WCN). The WCN stated that she had started her position in July 2021 and was responsible for all resident wounds with dressings except minor skin tears. The WCN stated she was required to carry a phone and be responsible to float into a nurse assignment rotating with 2 other staff when there was not enough staff 7 days a week. The WCN stated when she worked on the weekend, she would have weekday(s) off (which depended on whether she worked both weekend days). The WCN stated when she was not available to provide wound care, the assigned nurse was responsible to provide wound care for that day. The WCN stated that the DON was responsible to inform nursing staff to complete wound care when the WCN was not available. The WCN had not audited the resident TAR for completed wound care. The WCN stated that she had noticed on a couple of occasions the resident ' s wound dressing date was not the day before, but older (day or two). The WCN stated she informed the DON of the missed dressing changes. On 12/7/21 at 9:35 am an interview was attempted with the wound care Nurse Practitioner. A detailed message was left for return call. On 12/8/21 at 10:00 am an observation was attempted for Resident #28 ' s pressure ulcer of the heels. The resident declined. On 12/13/21 at 4:50 pm an interview was conducted with the wound care Nurse Practitioner. She stated that she was not aware that wound care was not completed as ordered. She stated that failing to provide wound care as ordered could cause a set-back for the wound. When exudate (wound drainage) sits on the wound and surrounding skin there can be tissue breakdown and bacterial growth (infection). 2. Resident #32 was admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #32 ' s quarterly Minimum Data Set (MDS) dated [DATE] documented he had 1 stage 4 pressure ulcer and was dependent for all activities of daily living. Resident #32 ' s care plan dated 5/14/21 documented problem and interventions for pressure ulcer. Resident #32 ' s wound care note dated 8/17/21 measured the stage 4 left hip at (length x width x depth) 0.3 x 1.3 x 0.1 centimeters (cm). Resident #32 ' s wound care note dated 8/25/21 measured the stage 4 left hip at 0.3 x 2 x 0.1 cm. Resident #32 had a physician order dated 8/3/21 left hip clean wound, apply hydrogel to wound bed, apply dry sterile dressing (DSD) each day. Resident #32 ' s August 2021 TAR was missing nursing initials wound care completed for dates 8/8/21, 8/11 – 14/21, 8/18 – 20/21, 8/25/21 and 8/27/21. Resident #32 ' s wound care note dated 9/15/21 measured the stage 4 left hip at 1.6 x 3.5 x 0.2 cm. Surrounding tissue had maceration (skin breakdown from moisture). Resident #32 ' s progress note dated 9/22/21 measured the stage 4 left hip at 1.2 x 3 x 0.2 cm Resident #32 ' s September 2021 TAR was missing nursing initials wound care completed for dates 9/6/21, 9/9/21, 9/16/21, 9/20/21, 9/27/21, and 9/30/31. Resident #32 had a physician order dated 9/16/21 clean the wound, pat dry, apply collagen to wound bed, followed by silver alginate and secure with DSD each day. Resident #32 ' s progress note dated 10/20/21 measured the stage 4 left hip at 0.7 x 2 x 0.1cm. Resident #32 ' s October 2021 TAR was missing nursing initials wound care completed for dates 10/1/21 10/4/21 10/7/21 10/14/21, 10/22/21. Order ended on 10/27/21 no initials for 10/27 – 30/21. Next order was 11/4/21. Resident #32 had a physician order dated 11/4/21 cleanse with dakin ' s solution, apply [MEDICATION(S)] to wound bed, cover with silver alginate, and cover with DSD each day. Resident #32 ' s progress note dated 11/4/21 measured the stage 4 left hip at 1.2 x 2.5 x 0.2 cm. The wound had moderate drainage. Resident #32 ' s progress note dated 11/18/21 measured the stage 4 left hip at 0.8 x 2 x 0.2 cm. The wound had moderate drainage. Resident #32 ' s November 2021 TAR was missing nursing initials care completed for dates 11/5/21, 11/10/21, 11/11/21, 11/18/21, 11/19/21, 11/2821 and 11/29/21. Resident #32 ' s December 2021 TAR was missing nursing initials care completed for dates 12/1/21 and 12/6/21. On 12/7/21 1:55 pm an interview was conducted with the wound treatment nurse (TN). She stated she started at the facility July 2021 and was responsible for all wounds (except skin tears) Monday through Friday. Nursing staff assigned to a resident with a wound was responsible for care on the weekends and when the TN was absent. She stated that she was responsible to be on call for licensed nursing call outs. She carried a phone and was called 7 days a week, rotating with other staff. The TN stated when she was floated to a nursing staff position, the nursing staff who had residents with wounds were responsible to provide wound care on their shift. The TN stated if she was required to cover a nursing shift on the weekend, she would have day(s) off during the week. The TN noted that on some weekends there were no initials that wound care was completed. The TN stated that she signed the TAR for all the days that she completed wound care and did not know why there were multiple blanks for the initial block. TN stated that she never looked back at the TAR to see if wound care was documented as completed. TN had received no communication that care was not completed. TN stated that the DON and Unit Manager communicated to nursing staff when the TN was not available to complete the resident wound care on their assignment. TN stated that she had noted a couple of times in November the date on the resident's wound dressing was not dated the day before. She assumed the care had not been completed and informed the DON. TN could not remember which days the wound dressing had an older date. TN stated she rounded each Wednesday with the wound care Nurse Practitioner. On 12/7/21 at 3:46 pm an interview was conducted with the Administrator. She stated that the DON, wound treatment nurse, staff development coordinator, and unit manager all were on call/rotate to cover licensed nursing call outs. The four staff rotate. She stated she knew that the treatment nurse carried an on-call phone and was required to be pulled to a nursing assignment any day of the week. She stated that she knew the treatment nurse had weekdays off when required to work on the weekend. The Administrator was informed that since July 2021 to December 2021 there were multiple omissions of nursing signature for wound care treatment not completed on the TAR and that the treatment nurse was interviewed and stated she signed for all the wound care she completed. The Administrator stated that a failure to clean and change the dressing for a wound would cause infection and decline. 12/8/21 at 10:40 am an observation was done of the resident's sacral decubitus care by the treatment nurse. She followed the order and infection control. There were no concerns observed. On 12/8/21 at 11:00 am an interview was conducted with the facility Nurse Practitioner. He stated that he was not aware that residents ' wound care was not being completed as ordered. Resident #32 now had a new open area abrasion to his inner thigh due to contracture pressure. He stated that there has been a problem with staffing. There was not enough staff and contract staff do not know the residents. He stated when he would ask a contract nurse for the history of a resident, the nurse would state I don't know, I have only been here 1 day. He stated that if a resident had not received wound care on average 7 days per month since August 2021 there would be infection and/or wound decline. On 12/8/21 at 11:10 am an interview was conducted with Unit Supervisor #1. The US was aware that the wound care was not completed as ordered due to staffing shortage and staff getting behind in their work then unable to complete wound care. She stated the treatment nurse (TN) was floated to an assignment and staffing assigned were responsible to perform wound care for that day. Staff was not always informed when the TN was not available and wound care needed to be completed by staff assigned. There was a communication problem/breakdown. She stated that on the second-floor unit when there were 2 medication aides and 1 nurse assigned, there were too many residents that required wound care to be completed by 1 nurse on day shift. She stated nurses work 12 hours and the second shift had not completed the wound care and she did not know why. She stated that later in the day she would inform the Director of Nursing (DON) that wound care was not completed when the TN was not available. The DON was not informed of each occurrence. She stated she was not auditing the resident TAR for missed care and had not known how many occurrences per month. The problem had been going on for a couple of months. 3. Resident # 19 was admitted to the facility 10/6/21. Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 19 was cognitively intact and required limited assistance with 1-person physical assist with bed mobility, dependent assistance with 2-person physical assist with transfers, dependent assistance with 1-person physical assist with toilet use, bathing. Skin conditions included a stage 3 pressure ulcer that was present on admission. Resident #19 ' s physicians orders were reviewed. On 10/14/21, there was a physician ' s order to clean stage 3 occipital head wound with wound cleanser, pat dry, apply Medi honey to open area followed by a dry dressing daily for wound treatment. A care plan dated 10/18/21 revealed Resident #19 had potential for pressure ulcer development related to immobility. Interventions included administer treatments as ordered and monitor for effectiveness. A review of the treatment record (TAR) for the months of October, November and December 2021 revealed missing nursing initials for treatment to occipital head wound for dates as follows: 10/14/21, 10/18/21, 10/22/21, 10/27/21, 10/28/21, 10/30/21, 10/31/21, 11/1/21, 11/2/21, 11/5/21, 11/8/21, 11/10/21, 11/11/21, 11/18/21, 11/19/21, 11/23/21, 11/26/21, 11/28/21, 11/29/21, 11/30/21, 12/1/21, and 12/6/21. On 12/05/21 at 1:55 PM Resident #19 indicated wound care was not being treated consistently. Resident #19 indicated wound was getting treated daily then approximately 2/12 weeks ago wound care stopped. Resident #19 stated it was reported to Nursing staff wound care was not being done. An observation of wound care nurse (WCN) perform wound care was conducted on 12/8/21 at 6:51 AM. WCN performed wound care to occipital wound. WCN removed old bandage with date of 12/7/21 with small amount of tan drainage to dressing. WCN cleaned wound with wound cleanser, dried with dry gauze, applied skin prep, and placed a dry dressing to area. No concerns were identified with wound care provided. Observation of occipital wound revealed an approximately nickel sized superficial wound without drainage. On 12/6/21 at 10:10 am an interview was conducted with the wound care nurse (WCN). The WCN stated she had started her position in July 2021 and was responsible for all resident wounds with dressings except minor skin tears. The WCN stated she was required to carry a phone and be responsible to float into a nurse assignment rotating with 2 other staff when there was not enough staff 7 days a week. The WCN stated when she worked on the weekend, she would have weekday(s) off (which depended on whether she worked both weekend days). The WCN stated when she was not available to provide wound care, the assigned nurse was responsible to provide wound care for that day. The WCN stated that the DON was responsible to inform nursing staff to complete wound care when the WCN was not available. The WCN indicated she had not audited the resident TAR for completed wound care. The WCN stated that she had noticed on a couple of occasions the resident ' s wound dressing date was not the day before, but older (day or two). The WCN stated she informed the DON of the missed dressing changes. On 12/14/17 at 3:25 PM, the Director of Nursing was interviewed and stated she expected staff to follow physician orders for pressure ulcer care.

Based on record review, observation and interviews of staff, nurse practitioner and family member, the facility failed have sufficient nursing staff to provide wound care as ordered (Residents #28, 32, and 73) for 3 of 3 sampled residents. Cross refer: F686: Based on record review, observation and interviews of the staff, nurse practitioner, and family member, the facility failed to assess and provide wound care for both heel pressure ulcers (Resident #28) and failed to consistently complete pressure ulcer care as ordered (Residents #28, 32 and 19) for 3 of 3 sampled residents. Findings included: On 12/7/21 at 3:46 pm an interview was conducted with the Administrator. She stated that the Director of Nursing (DON), wound treatment nurse, staff development coordinator, and unit manager were all on-call/rotate to cover licensed nursing call outs. She stated she knew that the treatment nurse carried an on-call phone and was required to be pulled to a nursing assignment any day of the week. She stated that she knew the treatment nurse had weekdays off when required to work on the weekend. The Administrator was informed that since June to date there were multiple omissions of nursing initials for wound care treatment on the resident ' s treatment administration record (TAR) and that the treatment nurse was interviewed and stated she signed for all the wound care she completed. The Administrator stated she was not aware that wound care was not completed as ordered. On 12/8/21 at 2:10 pm an interview was conducted with the infection preventionist (IP). The IP stated there was a high turnover of nursing staff, she had to wear many hats to cover, and was pulled to a nursing assignment when there was staffing shortage. The facility had hired two new unit managers and was phasing out the assistant director of nursing to help fill the gap. The facility also used agency staff for nursing shortage. On 12/8/21 at 3:30 pm an interview was conducted with the Director of Nursing (DON). The DON stated that there was a shortage of nursing staff due to resignations. The facility was using agency staff. When there was a call-out that could not be filled, the wound care nurse, unit supervisor or myself were responsible to cover the assignment. Nursing staff worked 12-hour shifts, and there were 2-day and 2-night shift, full-time nursing positions open. The DON stated that the shortest staffed and hardest to cover was Sunday staffing.

Based on observations, record review, staff interview, and physician interview, the facility neglected a resident by not following physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility neglected residents by not providing wound care for two days for 2 of 3 residents who were supposed to have daily treatments as ordered by the physician (Resident #4 and Resident #5). Immediate jeopardy for Resident #2 began on [DATE] when Resident #2 blood glucose registered HI on the glucometer (blood glucose was more than 600 mg/dL.) and the resident was showing signs of lethargy, low blood pressure, vomiting, and unusual bowel incontinence. EMS was not immediately initiated and nursing did not continue to assess the resident. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The facility is also out of compliance at the D scope and severity for Resident #4 and Resident # 5. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set ((MDS) dated [DATE] revealed that Resident #2 was cognitively intact and required supervision with the physical assistance of one person with activities of daily living (ADL), was independent with walking and dressing, was not steady but able to stabilize without staff assistance and utilized a wheelchair as a mobility device when needed. It also revealed that he was occasionally incontinent of bladder and was continent of bowel. A review of the care plan dated [DATE] revealed Resident #2 had Diabetes Mellitus with interventions to include: diabetes medication as ordered by doctor, observe/document for side effects and effectiveness, Fasting Serum Blood sugar as ordered by doctor, observe/ document/report prn (as needed) any sign/symptoms of [MEDICAL CONDITION]; increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul (deep and labored breathing associated with diabetes) breathing, [MEDICATION NAME] breath, stupor and coma. A review of the medical records revealed progress/nursing notes, CBG level order changes and insulin regimen changes: A physician order [REDACTED].= 1 ([MEDICATION NAME]) unit; 211 - 270 = 2 units; 271 - 330 = 3 units; 331 - 390 = 4 units; 391 - 450 = 5 units; notify MD (physician) if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. Review of Resident #2 handwritten physician order [REDACTED]. New SSI (sliding scale insulin) for patient (resident) with meals ,[DATE]=2 units, ,[DATE]=3 units, ,[DATE]=5 units, ,[DATE]=7 units, ,[DATE]=9 units, ,[DATE]=11 units, if greater than 450 call MD. Review of the Medication Administration Record [REDACTED]. The transcribed [MEDICATION NAME] SSI order was the following: [MEDICATION NAME] solution 100unit/ml, inject as per sliding scale: if ,[DATE]=1 unit, ,[DATE]=2 units, ,[DATE]=3 units, ,[DATE]=4 units, ,[DATE]=5 units. Notify MD if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. Order date [DATE]. Review of the [DATE] MAR indicated [REDACTED] MAR date [DATE] at 6:30 AM, CBG 71. MAR date [DATE] at 11:30 AM, CBG 508. Code 8 was written which meant other/see progress note. No written progress note or order found in the medical record. On [DATE] at 11:10 AM, an interview was conducted with Nurse #8 who worked with Resident #2 on [DATE] and documented the blood glucose of 508 mg/dL at 11:30 AM. The nurse confirmed that the resident blood glucose was 508 and stated she received an order for [REDACTED]. MAR date [DATE] at 4:30 PM, CBG 271, 3 units given instead of 5 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 220, 2 units given instead of 3 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 83. MAR date [DATE] at 11:30 AM, CBG 180, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 206, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 209, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 570, Code 8 was written which meant other/see progress note. No written progress note or order found in the medical record. Review of the Nursing Note dated [DATE] at 5:37AM revealed CBG was 570. There was no documentation of sliding scale insulin given or if the physician was notified. The nurse that wrote the note was not available for interview because he was out of the country at the time of investigation. MAR date [DATE] at 11:30 AM, CBG 168, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 414, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 431, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 6:30AM, CBG 74. MAR date [DATE] at 11:30 AM, CBG 270, 2 units given instead of 5 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 310, 3 units given instead of 7 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 176, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 123. MAR date [DATE] at 11:30 AM, CBG 440, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 335, 4 units given instead of 7 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 154, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 143. MAR date [DATE] at 11:30 AM, CBG 68. MAR date [DATE] at 4:30 PM, CBG 225, 2 units given instead of 3 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 158, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 436, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 11:30 AM, CBG 254, 2 units given instead of 5 units as ordered on [DATE]. An interview on [DATE] at 1:15 PM with Director of Nursing (DON) and Administrator revealed that they did not know why the physician order [REDACTED]. It was the expectation that every order was written on the physician's orders [REDACTED]. Review of the current physician orders [REDACTED]. [MEDICATION NAME] Solution 100 UNIT/ML, inject as per sliding scale: If CBG 150 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 11 units, notify MD if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. On [DATE] at 4:55 PM, Nurse #1 and Nurse #3 were interviewed. Nurse #1 was a unit manager/administrative nurse and Nurse #3 was a MDS nurse. Nurse #1 and Nurse #3 said on [DATE], three nurses called in sick on the first shift. The facility called Nurse #1 and Nurse #3 to come in and work on the 100 hall, where Resident #2 resided. They both came around 8 AM and worked from around 8 AM to 3 PM. Nurse #1 and Nurse #3 manned the carts on 100 Hall. Resident #2 was doing okay on their shift. He was a brittle diabetic. On [DATE] at 11:23 AM, an interview was conducted with NA #1 who worked on [DATE] from 7 AM to 3 PM. She worked on the 100 Hall and was responsible for Resident #2's care. The resident was his usual self except he slept in during the last two mornings. On the morning of [DATE], he shaved and showered and he said he felt like a million bucks after that. He usually wheeled himself in the wheelchair. He ate well that morning and he ate well for lunch. A review of the Nursing Note, written by Nurse #2, dated [DATE] at 9:25 PM, revealed at 4 PM on [DATE], Nurse #2 walked in Resident #2's room and noticed that the resident was not responding properly. His skin was cool and clammy. His blood glucose was checked using a glucometer (a machine used to measure how much glucose (a type of sugar) is in the blood). The glucometer registered HI (the glucometer registered HI when blood glucose was more than 600 mg/dL.) Vital signs were checked and blood pressure was low. Nurse #2 called Physician #1 and she gave an order to give 17 units of [MEDICATION NAME] and 4 mg of [MEDICATION NAME] every 8 hours for nausea. At 7 PM, Nurse #2 checked the resident's blood glucose again and the glucometer registered HI. Nurse #2 called Physician #2 and she received a verbal order to give 14 units of [MEDICATION NAME] and if the resident's status did not get better then to send to the hospital. Resident's condition did not improve. He was incontinent of bowel and bladder and remained lethargic. The resident's family was notified of the resident's status and agreed to send him to the hospital. 911 was called. The resident complained of an ache in his abdomen. Resident was sent to the hospital. Vital signs were as follows: temperature 98.3 Fahrenheit, blood pressure was ,[DATE], heart beat 82/minute, respiration 20, O2 saturation 92%. Review of the Emergency Medical Service (EMS) report revealed EMS was called at 8:25 PM on [DATE]. The EMS personnel checked the resident blood glucose and it registered HI on their glucometer. The resident was not alert to surrounding but was alert to verbal stimuli to person, time, and event. It was also noticed the resident's pupils were pin point and not reactive to light. Multiple attempts were made without success to administer intravenous (IV) fluids. A telephone interview was conducted with Nurse #2 on [DATE] at 11:19 AM. Nurse #2 said she usually worked from 7 PM to 7 AM. But on [DATE], the facility called her and asked her to work from 3 PM to 7 PM on the 100 Hall. It was busy. At around 4 PM, she went to Resident #2's room. The resident was in bed which was unusual for him. He was lethargic. His speech was slurred and he had vomitus dried up on his face and in the trash can. The nurse asked him what was wrong, he told her he was not feeling well. She checked his vital signs. His blood pressure was low and his blood sugar registered high on the glucometer so she called physician #1 and notified him of the resident's condition, including the HI blood glucose, lethargy, nausea, slurred speech, unusual incontinence, and unresponsiveness. The physician told her to give the resident 17 units of insulin and [MEDICATION NAME] for nausea. The resident was able to swallow the [MEDICATION NAME] pill and she gave him the insulin injection. The nurse said she did not go back to check on the resident until 15 minutes till 7 PM. Nurse #2 checked the blood glucose and it still registered HI. She called physician #2 (On call) and the physician ordered 14 more units of sliding scale insulin and to recheck blood glucose in 30 minutes and send him to the hospital if not improved. When she came back to check on him, he had a bowel movement on himself which was unusual for him. She sent the aide to clean him up. Nurse #2 said usually she was able to complete her tasks if nothing came up out of the ordinary. She said she did not have enough time to take care of the resident. When asked what prevented her from checking on the resident after she gave him insulin around 4 PM, she said she was trying to get a change of shift report, stock the medication cart, check on tube feeding, talk about taking over medication cart of the other hall, had to get [MEDICATION NAME] and needed to document in residents' medical record. She had been employed at the facility for only three months and she did not know how to put in a physician order [REDACTED]. An interview with NA #4 on [DATE] at 12:35 PM revealed she usually worked from 3 PM -11 PM. She stated, on average, she had ,[DATE] residents which was a manageable load. On [DATE], it was different with a lot of things going on. There were a lot of staff assignment changes. New staff started that day and they were confused about where they worked. There were one new nurse and the other nurse was not familiar with the residents on the hall. NA #4 stated she did not work with the resident. She just took him his tray. He was in bed and he told her he did not feel like eating and he would not eat. It was around 6 or 6:30 PM. She reported to the nurse that he would not eat. The nurse said okay. On [DATE] at 5:15 PM, Physician #1 was interviewed. The physician stated the resident had a history of [REDACTED]. He was a brittle diabetic (the person experiences frequent, extreme swings in blood glucose levels). The resident wanted to go home. The physician was shown the [DATE] Nursing Note written by Nurse #2 regarding the resident's change in condition. The physician stated she did not remember being called on [DATE] about this resident and she did not remember giving the order for 17 units of insulin. The physician said I was never called. She said if they called her and told her the resident had vomiting, slurred speech, lethargic and blood glucose registering HI, she would have sent the resident right away to the hospital because the nursing home could not manage the resident in that condition. The physician repeated this statement more than one time. The physician said no way I would have kept the patient without intravenous fluids. The physician said she reviewed the resident's hospital record and his blood glucose was 1123 mg/dL at the hospital and he died of [MEDICAL CONDITION] infarction. Review of the hospital emergency room department (ED) dated [DATE] revealed laboratory test results from the resident's urine sample collected on [DATE] at 10:44 PM were as follows: Resident's urine glucose was more than 1000 mg/dL (reference range was negative). The urine [MEDICATION NAME] was 15 mg/dL (reference range was negative). The ED laboratory test results of blood collected on [DATE] at 11:43 PM were as follows: Blood glucose was 1123 mg/dL, The resident died on [DATE] at 12:55 AM. The administrator was notified of the immediate jeopardy on [DATE] at 12:18 PM. The administrator provided the following credible allegation of compliance effective [DATE] at 2:47 PM. Residents identified to be affected by the alleged deficient practice. At 4:00 PM on [DATE] Nurse #2 went into Resident #2 room and noticed that he was not responding as usual. His skin was cool and clammy. His Blood glucose was checked and read HI with no value on the monitor. The manufacturer insert for this glucometer stated that a reading of HI indicated a blood glucose value of greater than 600 mg/dL. The Physician was notified and orders were received to administer 17 units of [MEDICATION NAME] one time and [MEDICATION NAME] 4 mg every 6 hours for nausea. At approximately 4:30 PM NA#3 entered room to check on Resident #2 who was resting in bed with no new changes. At approximately ,[DATE]:30 PM, NA #4 delivered Resident #2 his dinner tray. Resident #2 reported he was not feeling good and didn't want to eat. NA#4 stated this was then reported to Nurse #2. Resident #2 remained in the bed and the tray was set up. At 7:00 PM, Nurse #2 rechecked the resident blood sugar and it again read HI. Nurse #2 notified the Physician and received orders to administer 14 units of [MEDICATION NAME] and instructions to transport to the hospital if not improved. Resident status did not improve. Resident was incontinent of bowel and bladder and remained lethargic. Resident complained of an ache in his abdomen. Family was notified of resident status, 911 was called at 8:25 PM, and resident arrived at the hospital at 9:26 PM. The nurse reported she was too busy to check on the resident more frequently to reassess following insulin administration for a HI blood sugar reading with nausea and a low blood pressure and that she did not communicate with a manager that she was not able to recheck on the resident. Nurse #2 has received education on [DATE] from the Director of Nursing and Staff Development Coordinator regarding the facility policy for identification and assessment of changes in condition, management of residents with diabetes including monitoring of residents following intervention implementation, and physician notification. Nurse #2 is no longer an employee and will not receive education about initiating EMS. Residents with the potential to be affected by the alleged deficient practice. All residents with changes in condition have the potential to be affected by the alleged deficient practice. On [DATE], the Director of Nursing and Nurse Managers conducted an audit of current diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days and reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented according to the physician's orders [REDACTED]. Systemic Measures Beginning [DATE] the Director of Nursing and Nurse Managers will review those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms have been assessed, interventions were initiated as ordered or care planned, and the attending physician was notified. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Licensed Nurses beginning [DATE] regarding the facility's existing policy for identification and assessment of changes in condition, Diabetic Management including monitoring of residents following intervention implementation, and physician notification. Education included clarification of existing policy: Beginning [DATE] of the following: - When a resident's blood sugar read HI on the glucometer, Residents will be re-assessed with [REDACTED]. -physician's orders [REDACTED]. - Identification of an obvious critical acute change in condition, and appropriate response and physician notification. - Ensuring staff awareness that failure to provide care and services, including when to initiate EMS, can constitute resident neglect. - EMS will be imitated by physician order [REDACTED]. Licensed nursing staff, and agency licensed nursing staff will not be allowed to work until this training is complete. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Certified Nursing Assistants beginning [DATE] regarding reporting an observation of a resident's change of condition to the Nurse immediately. Nursing assistants will not be allowed to work until this training is complete. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted education with Licensed Nursing staff and nurses aides on Abuse and Neglect Prevention on [DATE] including prompt response to resident's change of condition. Beginning [DATE]nd, Licensed Nursing staff, nurses' aides and Agency Licensed nursing staff will not be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide care and services, including when to initiate EMS, can constitute resident neglect. Beginning [DATE] Licensed nursing staff and Agency Licensed nursing staff will not be allowed to work until the training for Abuse and Neglect Prevention, including prompt response to resident's change of condition is completed. This education also includes ensuring staff awareness that failure to provide care and services, including when to initiate EMS, can constitute resident neglect. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Resident Care Management Director. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. Date of Immediate Jeopardy Removal: [DATE]. On [DATE] at 1:27 PM, the credible allegation of compliance was validated to ensure the facility implemented their corrective actions to remove the immediate jeopardy. The facility provided evidence of an audit, on [DATE], of current insulin dependent diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days. The facility reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented. Record reviews of diabetic residents were reviewed to ensure that they received care to manage diabetes as ordered by the physician. The facility provided evidence of inservice training to nursing staff on how to manage diabetic residents. This was validated by interviews with nurses and nursing assistants. On [DATE] at 1:27 PM, 4 nurses and 4 nursing assistants were interviewed regarding their knowledge of neglect and change of condition. One of the nurses was an agency nurse. Nurses and nursing assistants confirmed that they received inservices regarding neglect and change in condition in the last few two days and they were all able to identify what constituted neglect and what to do when a resident has a change in condition. 2. Record review showed that resident #4 re-entered the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the most recent care plan on [DATE] documented that the resident had a pressure area to her right hip and her right heel. Interventions included to apply dressings per orders, complete labs as ordered, monitor intake, assist to turn and reposition on rounds and prn, provide supplements as ordered, and see the wound care doctor as scheduled. The most recent MDS dated [DATE] indicated the resident had (2) facility acquired Stage 4 pressure ulcers, pressure reducing devices for her chair and bed, and nutrition and hydration intervention to manage skin problems. Cognition was intact. The most recent physician orders [REDACTED]. 1. Apply to right hip Dakins Solution 0.25% wet to moist dressing twice daily 2. Apply Santyl Ointment to right heel topically every day shift 3. Multivitamin one tab daily 4. House Shakes 4 ounces at lunch and dinner 5. Pro Stat Liquid 30ml twice daily 6. House 2.0 Med Pass 120cc three times daily 7. Geri-Sleeves to both arms Review of the most recent wound care specialist progress notes dated [DATE] documented that there was no change in wound healing progress for either wound on that date. Further review revealed that both wounds are smaller in size and have improved. Wound care for resident #4 was observed on [DATE] at 2:40 PM. Care was provided by Nurse #6. Proper hand washing and glove donning was observed. Clean technique was used. It was observed that the old dressing removed from the Stage 4 right hip pressure ulcer was dated [DATE]. The dressing was malodorous with a large amount of brown exudate present. The skin surrounding the wound was reddened. The wound was packed with gauze soaked in Dakins Solution 0.25% and covered with a dry dressing as ordered by the physician. Nurse #6 then removed the old dressing from the resident's Stage 4 pressure ulcer on her right heel. The old dressing was dated [DATE]. It was malodorous with a large amount of brown exudate. The skin surrounding the wound was white. Santyl ointment was applied to the wound and a dry dressing was applied. The used dressings were disposed of properly. In an interview with Nurse #6 on [DATE] at 2:50 PM she revealed that she had called out on [DATE] and [DATE]. She stated that the nurses working the hall were responsible for doing the dressing changes in her absence. She agreed that the dressings had not been changed and the wounds were not treated on [DATE] and [DATE]. Nurse #1 was also present and agreed that the dressings were not changed and the wounds were not treated on [DATE] and [DATE]. In an interview with Nurse #7 on [DATE] at 2:30 PM she stated that she had care for resident #4 on [DATE] during the day shift. She said that the day had been very busy. She stated that her first priority was to keep the residents safe and give out the medicines. She revealed that she had looked at the dressings on wounds to make sure everything was intact but did not have time to do the treatments on her assignment. She revealed that it was her intention to do the treatments but that there was too much going on during the day shift to get everything done. 3. Record review shows that resident #5 re-entered the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ( MDS) assessment dated [DATE] documented that the resident had venous, arterial, and [MEDICAL CONDITION]. Cognition was documented as intact. He was extensive assist for bed mobility, personal hygiene and toilet use. He was totally dependent for dressing and bathing. The assessment indicated that he did not walk. Care plan interventions on [DATE] included to apply dressings per orders, complete labs as ordered, monitor intake, assist to turn and reposition on rounds and prn, provide supplements as ordered, and see the wound care doctor as scheduled. The physician orders [REDACTED]. 1. Decubi-Vite Capsule (2) daily 2. Ensure air mattress is functioning properly with setting locked at 5 every shift 3. Pro Stat sugar free liquid 30cc twice daily 4. Cleanse top of left foot with Normal Saline, dry, apply Silver Sulfa Cream 1%, apply 4 x 4, wrap with Kerlix daily 5. Apply Santyl Ointment 250 unit/gm to outer LLE topically every day 6. Apply Mupirocin Ointment 2% to left great toe topically every day shift for skin alteration 7. Apply [MEDICATION NAME] to left heel Stage 2 venous wound every 3 days Review of the most recent wound care specialist progress notes dated [DATE] documented that there was no change in the wound healing progress for the (2) arterial and (1) venous wounds on that date. Further review revealed that the measurements for all wounds have remained the same since [DATE]. An observation on [DATE] at 4:45 PM revealed that the dressing on the left foot and left lower extremity of Resident #5 were dated [DATE]. The surveyor was unable to observe wound care because the resident refused treatment until he was medicated for pain and it became effective. In an interview with Nurse #6 on [DATE] at 4:50 PM she revealed that she had called out on [DATE] and [DATE]. She stated that the nurses working the hall were responsible for doing the dressing changes in her absence. She agreed that the dressings had not been changed and the wounds were not treated on [DATE] and [DATE]. In an interview with Nurse #1 and Nurse #3 on [DATE] at 5:15 PM they stated that they had worked together on the 100 Hall on [DATE] day shift. They both stated that they did not have time to do the treatments and had passed the duty on to the second shift nurse. In an interview with Nurse #2 on ,[DATE]//17 at 11:20 AM she revealed that she had cared for resident #5 on [DATE] from 3:00 PM to 11:00 PM. She stated that she did not get report when coming on shift. She said she did not do the treatments on her shift because she had too much to do. She said for part of the shift she was caring for forty-two residents until 11:00 PM when she was relieved by an Agency Nurse. In an interview with the Director of Nursing on [DATE] at 5:00 PM she stated that she expected the treatments to be done as ordered by the physician.

Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility failed to follow physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility failed to provide wound care for two days for Resident #5 who was supposed to have daily treatments as ordered by the physician for 1 of 1 sampled residents with wounds. Immediate jeopardy for Resident #2 began on [DATE] when Resident #2 blood glucose registered HI on the glucometer (blood glucose was more than 600 mg/dL.) and the resident was showing signs of lethargy, low blood pressure, vomiting, and unusual bowel incontinence. EMS was not immediately initiated and nursing did not continue to assess the resident. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The facility is also out of compliance at the D scope and severity for Resident # 5. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set ((MDS) dated [DATE] revealed that Resident #2 was cognitively intact and required supervision with the physical assistance of one person with activities of daily living (ADL), was independent with walking and dressing, was not steady but able to stabilize without staff assistance and utilized a wheelchair as a mobility device when needed. It also revealed that he was occasionally incontinent of bladder and was continent of bowel. Review of the Medical Orders for Scope of Treatment (MOST) dated [DATE] revealed the resident/family wanted the resident to be DNR (not to attempt resuscitation), and comfort measure only (keep clean and dry, do not transfer to the hospital unless comfort needs cannot be met in current location). A review of the care plan dated [DATE] revealed Resident #2 had Diabetes Mellitus with interventions to include: observe/document the resident/family's current level of understanding about the disease process, diabetes medication as ordered by doctor, observe/document for side effects and effectiveness, Fasting Serum Blood sugar as ordered by doctor, observe/ document/report prn (as needed) any sign/symptoms of [MEDICAL CONDITION]; increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul (deep and labored breathing associated with diabetes) breathing, [MEDICATION NAME] breath, stupor and coma. A review of the medical records revealed the following: A physician order [REDACTED].= 1 ([MEDICATION NAME]) unit; 211 - 270 = 2 units; 271 - 330 = 3 units; 331 - 390 = 4 units; 391 - 450 = 5 units; notify MD (physician) if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. A physician order [REDACTED]. A physician order [REDACTED]. A Nursing Note dated [DATE] at 2:48 PM read CBG 407 at 1130 AM, insulin given per MD orders. A Nursing Note dated [DATE] at 7:37 AM revealed CBG was 71. A Nursing Note dated [DATE] at 8:16 AM revealed CBG was 74. The resident stated that was low for him. Review of Resident #2 handwritten physician order [REDACTED]. 1. Start Toujeo 24 units at bedtime on [DATE]. Do not give [DATE] AM dose of 12 units. 2. New SSI (sliding scale insulin) for patient (resident) with meals ,[DATE]=2 units, ,[DATE]=3 units, ,[DATE]=5 units, ,[DATE]=7 units, ,[DATE]=9 units, ,[DATE]=11 units, if greater than 450 call MD. Review of the Medication Administration Record [REDACTED]. The transcribed [MEDICATION NAME] SSI order was the following: [MEDICATION NAME] solution 100unit/ml, inject as per sliding scale: if ,[DATE]=1 unit, ,[DATE]=2 units, ,[DATE]=3 units, ,[DATE]=4 units, ,[DATE]=5 units. Notify MD if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. Order date [DATE]. Review of the [DATE] MAR indicated [REDACTED] MAR date [DATE] at 6:30 AM, CBG 71. MAR date [DATE] at 11:30 AM, CBG 508. Code 8 was written which meant other/see progress note. No written progress note or order found in the medical record. On [DATE] at 11:10 AM, an interview was conducted with Nurse #8 who worked with Resident #2 on [DATE] and documented the blood glucose of 508 mg/dL at 11:30 AM. The nurse confirmed that the resident blood glucose was 508 and stated she received an order for [REDACTED]. MAR date [DATE] at 4:30 PM, CBG 271, 3 units given instead of 5 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 220, 2 units given instead of 3 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 83. MAR date [DATE] at 11:30 AM, CBG 180, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 206, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 209, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 570, Code 8 was written which meant other/see progress note. No written progress note or order found in the medical record. Review of the Nursing Note dated [DATE] at 5:37 AM revealed CBG was 570. There was no documentation of sliding scale insulin given or if the physician was notified. The nurse that wrote the note was not available for interview because he was out of the country at the time of investigation. MAR date [DATE] at 11:30 AM, CBG 168, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 414, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 431, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 74. MAR date [DATE] at 11:30 AM, CBG 270, 2 units given instead of 5 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 310, 3 units given instead of 7 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 176, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 123. MAR date [DATE] at 11:30 AM, CBG 440, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 4:30 PM, CBG 335, 4 units given instead of 7 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 154, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 143. MAR date [DATE] at 11:30 AM, CBG 68. MAR date [DATE] at 4:30 PM, CBG 225, 2 units given instead of 3 units as ordered on [DATE] MAR date [DATE] at 9:00 PM, CBG 158, 1 unit given instead of 2 units as ordered on [DATE] MAR date [DATE] at 6:30 AM, CBG 436, 5 units given instead of 11 units as ordered on [DATE] MAR date [DATE] at 11:30 AM, CBG 254, 2 units given instead of 5 units as ordered on [DATE]. An interview on [DATE] at 1:15 PM with Director of Nursing (DON) and Administrator revealed that they did not know why the physician order [REDACTED]. It was the expectation that every order was written on the physician's orders [REDACTED]. Review of the current physician orders [REDACTED]. [MEDICATION NAME] Solution 100 UNIT/ML, inject as per sliding scale: If CBG 150 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 11 units, notify MD if CBG is greater than 450, subcutaneously before meals and at bedtime for DM. [MEDICATION NAME] Solution Cartridge 100 UNIT/ML, inject 4 unit subcutaneously with meals for DM. ToujeoSolo Star Solution Pen-injector 300 UNIT/ML, inject 10 unit subcutaneously once a day for DM Review of the resident's Medication Administration Record [REDACTED] 6:30 AM: CBG ranged from 43 - 450 mg/dL. Sliding scale insulin was administered 11 times during the month. 11:30 AM: CBG ranged from 71 - 564 mg/dL. Sliding scale insulin was administered 23 times during the month. 4:30 PM: CBG ranged from 68 - 535 mg/dL. Sliding scale insulin was administered 18 times during the month. 9:00 PM: CBG ranged from 67 - 450 mg/dL. Sliding scale insulin was administered 19 times during the month. Review of the Nursing Note on [DATE] revealed the CBG was 530 at 11:30 AM. Nursing staff administered 11 units of sliding scale insulin and the nurse practitioner (NP) was notified. No new orders were given. Review of the Nursing Note dated [DATE] revealed the resident CBG was 200 in the morning, 284 at noon and 397 in the evening. Medication was administered as ordered. No adverse reaction was noted. Review of the resident's Medication Administrator Record revealed the following range of CBG readings and number of days the resident received insulin during the period of [DATE]-8, 2017: 6:30 AM: CBG ranged from 96 - 375 mg/dL. Sliding scale insulin was administered 5 times during the month. 11:30 AM: CBG ranged from 64 - 400 mg/dL. Sliding scale insulin was administered 7 times during the month of May. 4:30 PM: CBG ranged from 202 - 430 mg/dL. Sliding scale insulin was administered 7 times during the month. 9:00 PM: CBG ranged from 114 - 320 mg/dL. Sliding scale insulin was administered 5 times during the month of May. Review of Nursing Note dated [DATE] revealed the resident's CBG was 56. The resident was unresponsive and diaphoretic. [MEDICATION NAME] was administered and CBG was rechecked in 15 minutes and it was 106. The resident ate lunch after the incident. Review of the progress notes dated [DATE] revealed the resident has increased participation in activities and he attended social events. Review of Nursing Note dated [DATE] revealed the resident's CBG was 354 at 6 AM. The resident was alert and responsive with confusion. Medication was given whole with water. There was no noted distress. On [DATE] at 4:55 PM, Nurse #1 and Nurse #3 were interviewed. Nurse #1 was a unit manager/administrative nurse and Nurse #3 was a MDS nurse. Nurse #1 and Nurse #3 said on [DATE], three nurses called in sick on the first shift. The facility called Nurse #1 and Nurse #3 to come in and work on the 100 hall, where Resident #2 resided. They both came around 8 AM and worked from around 8 AM to 3 PM. Nurse #1 and Nurse #3 manned the carts on 100 Hall. Resident #2 was doing okay on their shift. At 6:30 AM his blood glucose was 375. He was given 11 units of insulin as sliding scale and 4 scheduled units of insulin. At noon time his blood glucose was 288, and he was given 5 units of sliding scale insulin and 4 scheduled units of insulin with meals. He was a brittle diabetic. On [DATE] at 11:23 AM, an interview was conducted with NA #1 who worked on [DATE] from 7 AM to 3 PM. She worked on the 100 Hall and was responsible for Resident #2's care. The resident was his usual self except he slept in during the last two mornings. Resident was independent with toileting and was able to stand and take himself to the bathroom. On the morning of [DATE], he shaved and showered and he said he felt like a million bucks after that. He usually wheeled himself in the wheelchair. He ate well that morning and he ate well for lunch. He had a good appetite. The aide said typically there were 4 to 6 aides on the 100 hall which was about ,[DATE] residents. She would not say if there was any care that was not provided, however, she said it was very busy and it was too much. A review of the Nursing Note, written by Nurse #2, dated [DATE] at 9:25 PM, revealed at 4 PM on [DATE], Nurse #2 walked in Resident #2's room and noticed that the resident was not responding properly. His skin was cool and clammy. His blood glucose was checked using a glucometer (a machine used to measure how much glucose (a type of sugar) is in the blood). The glucometer registered HI (the glucometer registered HI when blood glucose was more than 600 mg/dL.) Vital signs were checked and blood pressure was low. Nurse #2 called Physician #1 and she gave an order to give 17 units of [MEDICATION NAME] and 4 mg of [MEDICATION NAME] every 8 hours for nausea. At 7 PM, Nurse #2 checked the resident's blood glucose again and the glucometer registered HI. Nurse #2 called Physician #2 and she received a verbal order to give 14 units of [MEDICATION NAME] and if the resident's status did not get better then to send to the hospital. Resident's condition did not improve. He was incontinent of bowel and bladder and remained lethargic. The resident's family was notified of the resident's status and agreed to send him to the hospital. 911 was called. The resident complained of an ache in his abdomen. Resident was sent to the hospital. Vital signs were as follows: temperature 98.3 Fahrenheit, blood pressure was ,[DATE], heart beat 82/minute, respiration 20, O2 saturation 92%. Review of the Emergency Medical Service (EMS) report revealed EMS was called at 8:25 PM on [DATE]. The EMS personnel checked the resident blood glucose and it registered HI on their glucometer. The resident was not alert to surrounding but was alert to verbal stimuli to person, time, and event. The EMS report revealed that throughout the day, and despite insulin coverage, the resident was not acting his norm, which was alert, sitting up and talking without being lethargic. The report revealed the resident was hypotensive. It was also noticed the resident's pupils were pin point and not reactive to light. Multiple attempts were made without success to administer intravenous (IV) fluids. A telephone interview was conducted with Nurse #2 on [DATE] at 11:19 AM. Nurse #2 said she usually worked from 7 PM to 7 AM. But on [DATE], the facility called her and asked her to work from 3 PM to 7 PM on the 100 Hall. When she came at 3 PM, tube feeding bags were empty, tube feeding pumps were going off, she needed to flush feeding tubes, and that put her behind. One resident had his feeding tube pulled out so she had to put it back in. It was busy. At around 4 PM, she went to Resident #2's room. The resident was in bed which was unusual for him. He was lethargic. His speech was slurred and he had vomitus dried up on his face and in the trash can. The nurse asked him what was wrong, he told her he was not feeling well. She checked his vital signs. His blood pressure was low and his blood sugar registered high on the glucometer so she called physician #1 and notified him of the resident's condition, including the HI blood glucose, lethargy, nausea, slurred speech, unusual incontinence, and unresponsiveness. The physician told her to give the resident 17 units of insulin and [MEDICATION NAME] for nausea. The resident was able to swallow the [MEDICATION NAME] pill and she gave him the insulin injection. The nurse said she did not go back to check on the resident until 15 minutes till 7 PM. At that time, the incoming nurse and Nurse #2 counted the medications. Nurse #2 asked the incoming nurse to look at the resident with her. The resident condition did not improve and the incoming nurse verified that he was not right. Nurse #2 checked the blood glucose and it still registered HI. She called physician #2 (On call) and the physician ordered 14 more units of sliding scale insulin and to recheck blood glucose in 30 minutes and send him to the hospital if not improved. When she came back to check on him, he had a bowel movement on himself which was unusual for him. She sent the aide to clean him up. Nurse #2 said usually she was able to complete her tasks if nothing came up out of the ordinary. She said that day on [DATE], one of the nurses that was working from 3 PM to 6 PM wanted her to take over the carts for two hall. That took some time discussing and going back and forth. That also put her behind. The other nurse ended up not leaving until 15 minutes till 7 PM. She said with all of this going on, she did not have enough time to take care of the resident. When asked what prevented her from checking on the resident after she gave him insulin around 4 PM, she said she was trying to get a change of shift report, stock the medication cart, check on tube feeding, talk about taking over medication cart of the other hall, had to get [MEDICATION NAME] and needed to document in residents' medical record. She had been employed at the facility for only three months and she did not know how to put in a physician order [REDACTED]. A telephone interview was conducted on [DATE] at 3:01 PM with NA #3 who took care of the resident from 3 PM to 7 PM on [DATE]. The resident was usually independent and mobile. He was cognitively alert and did not need a lot of assistance. He can use the call bell if he needed help or he would ambulate or wheel himself and let the staff know of his needs. On [DATE], the aide stated that her assignment changed 2 times due to staffing. She had to wait for a while for the facility staff to figure out staffing. The aide said she did rounds at about 3:30 PM to 4 PM and saw the resident. She did not see any vomiting on the resident. He was asleep, which was normal for him. She did not go back any more because she was busy taking care of other residents. She did not deliver his meal tray since she was feeding other residents in the dining room. On [DATE] at 8:54 AM, a telephone interview was conducted with NA #2 who provided care to the resident on [DATE] from 7 PM to 7 AM. She said usually she worked from 11 PM through 7 AM. But she was called that day on [DATE] to come early. She said that usually she did not have a permanent assignment but she was assigned wherever was needed. On [DATE], she went to the resident room shortly after she started her shift, she saw the resident mumbling. She asked him how he was feeling, he told her he was not feeling well. She said he usually fed himself but the meal tray was not touched. When she asked him if he was going to eat his dinner, he told her he did not feel well and he did not want to eat but he wanted unsweetened tea. The aide said she went and told the nurse, then she came back and cleaned the resident from a bowel movement. The nurse called EMS and the resident was sent to the hospital. The resident usually was up in his wheelchair and moving around. But when she came to the facility he was in bed which was unusual for him. An interview with NA #4 on [DATE] at 12:35 PM revealed she usually worked from 3 PM -11 PM. She stated, on average, she had ,[DATE] residents which was a manageable load. On [DATE], it was different with a lot of things going on. There were a lot of staff assignment changes. New staff started that day and they were confused about where they worked. There were one new nurse and the other nurse was not familiar with the residents on the hall. NA #4 stated she did not work with the resident. She just took him his tray. He was in bed and he told her he did not feel like eating and he would not eat. It was around 6 or 6:30 PM. She reported to the nurse that he would not eat. The nurse said okay. On [DATE] at 5:15 PM, Physician #1 was interviewed. The physician stated the resident had a history of [REDACTED]. He was a brittle diabetic (the person experiences frequent, extreme swings in blood glucose levels). The resident wanted to go home. The physician was shown the [DATE] Nursing Note written by Nurse #2 regarding the resident's change in condition. The physician stated she did not remember being called on [DATE] about this resident and she did not remember giving the order for 17 units of insulin. The physician said I was never called. She said if they called her and told her the resident had vomiting, slurred speech, lethargic and blood glucose registering HI, she would have sent the resident right away to the hospital because the nursing home could not manage the resident in that condition. The physician repeated this statement more than one time. The physician said no way I would have kept the patient without intravenous fluids. The physician said she reviewed the resident's hospital record and his blood glucose was 1123 mg/dL at the hospital and he died of [MEDICAL CONDITION] infarction. An interview was conducted on [DATE] at 10:44 AM with the nurse practitioner (NP), she stated orders were written on the physician order [REDACTED]. Review of the hospital emergency room department (ED) dated [DATE] revealed laboratory test results from the resident's urine sample collected on [DATE] at 10:44 PM were as follows: Resident's urine glucose was more than 1000 mg/dL (reference range was negative). The urine [MEDICATION NAME] was 15 mg/dL (reference range was negative). The ED laboratory test results of blood collected on [DATE] at 11:43 PM were as follows: Blood glucose was 1123 mg/dL, The ED note revealed on [DATE] at 12:50 AM, the resident's heart rate was at 27 beats per minute and blood pressure was ,[DATE]. The resident was having agonal (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations) breathing ,[DATE] times a minute. The resident was lying still with pale skin color. The resident died on [DATE] at 12:55 AM. The administrator was notified of the immediate jeopardy on [DATE] at 5:00 PM. The administrator provided the following credible allegation of compliance effective [DATE] at 6:30 PM. Residents identified to be affected by the alleged deficient practice. At 4:00 PM on [DATE] Nurse #2 went into Resident #2 room and noticed that he was not responding as usual. His skin was cool and clammy. His Blood glucose was checked and read HI with no value on the monitor. The manufacturer insert for this glucometer stated that a reading of HI indicated a blood glucose value of greater than 600 mg/dL. The Physician was notified and orders were received to administer 17 units of [MEDICATION NAME] one time and [MEDICATION NAME] 4 mg every 6 hours for nausea. At approximately 4:30 PM NA#3 entered room to check on Resident #2 who was resting in bed with no new changes. At approximately ,[DATE]:30 PM, NA #4 delivered Resident #2 his dinner tray. Resident #2 reported he was not feeling good and didn't want to eat. NA#4 stated this was then reported to Nurse #2. Resident #2 remained in the bed and the tray was set up. At 7:00 PM, Nurse #2 rechecked the resident blood sugar and it again read HI. Nurse #2 notified the Physician and received orders to administer 14 units of [MEDICATION NAME] and instructions to transport to the hospital if not improved. Resident status did not improve. Resident was incontinent of bowel and bladder and remained lethargic. Resident complained of an ache in his abdomen. Family was notified of resident status, 911 was called at 8:25 PM, and resident arrived at the hospital at 9:26 PM. The nurse reported she was too busy to check on the resident more frequently to reassess following insulin administration for a HI blood sugar reading with nausea and a low blood pressure and that she did not communicate with a manager that she was not able to recheck on the resident. Nurse #2 has received education on [DATE] from the Director of Nursing and Staff Development Coordinator regarding the facility policy for identification and assessment of changes in condition, management of residents with diabetes including monitoring of residents following intervention implementation, and physician notification. Residents with the potential to be affected by the alleged deficient practice. All residents with changes in condition have the potential to be affected by the alleged deficient practice. On [DATE], the Director of Nursing and Nurse Managers conducted an audit of current diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days and reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented according to the physician's orders [REDACTED]. Systemic Measures On [DATE], the Director of Nursing and Nurse Managers will review those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms have been assessed, interventions were initiated as ordered or care planned, and the attending physician was notified. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Licensed Nurses beginning [DATE] regarding the facility's existing policy for identification and assessment of changes in condition, Diabetic Management including monitoring of residents following intervention implementation, and physician notification. Education included clarification of existing policy: - When a resident's blood sugar read HI on the glucometer, Residents will be re-assessed with [REDACTED]. -physician's orders [REDACTED]. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Certified Nursing Assistants beginning [DATE] regarding reporting an observation of a resident's change of condition to the Nurse. Beginning [DATE] Licensed nursing staff and Agency Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Resident Care Management Director. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. Date of Immediate Jeopardy Removal: [DATE] On [DATE] at 6:30 PM, the credible allegation of compliance was validated to ensure the facility implemented their corrective actions to remove the immediate jeopardy. The facility provided evidence of an audit, on [DATE], of current insulin dependent diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days. The facility reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented. Record reviews of diabetic residents were reviewed to ensure that they received care to manage diabetes as ordered by the physician. The facility provided evidence of inservice training to nursing staff on how to manage diabetic residents. This was validated by interviews with nurses and nursing assistants. 2. Record review shows that resident #5 re-entered the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the most recent MDS assessment dated [DATE] documented that the resident had venous, arterial, and [MEDICAL CONDITION]. Cognition was documented as intact. He was extensive assist for bed mobility, personal hygiene and toilet use. He was totally dependent for dressing and bathing. The assessment indicated that he did not walk. The care plan interventions on [DATE] included to apply dressings per orders, complete labs as ordered, monitor intake, assist to turn and reposition on rounds and prn, provide supplements as ordered, and see the wound care doctor as scheduled. Physician orders [REDACTED]. 1. Decubi-Vite Capsule (2) daily 2. Ensure air mattress is functioning properly with setting locked at 5 every shift 3. Pro Stat sugar free liquid 30cc twice daily 4. Cleanse top of left foot with Normal Saline, dry, apply Silver Sulfa Cream 1%, apply 4 x 4, wrap with Kerlix daily 5. Apply Santyl Ointment 250 unit/gm to outer LLE topically every day 6. Apply Mupirocin Ointment 2% to left great toe topically every day shift for skin alteration 7. Apply [MEDICATION NAME] to left heel Stage 2 venous wound every 3 days Review of the most recent wound care specialist progress notes dated [DATE] documented that there was no change in the wound healing progress for the (2) arterial and (1) venous wounds on that date. Further review revealed that the measurements for all wounds have remained the same since [DATE]. An observation on [DATE] at 4:45 PM revealed that the dressing on the left foot and left lower extremity of Resident #5 were dated [DATE]. The surveyor was unable to observe wound care because the resident refused treatment until he was medicated for pain and it became effective. In an interview with Nurse #6 on [DATE] at 4:50 PM she revealed that she had called out on [DATE] and [DATE]. She stated that the nurses working the hall were responsible for doing the dressing changes in her absence. She agreed that the dressings had not been changed and the wounds were not treated on [DATE] and [DATE]. In an interview with Nurse #1 and Nurse #3 on [DATE] at 5:15 PM they stated that they had worked together on the 100 Hall on [DATE] day shift. They both stated that they did not have time to do the treatments and had passed the duty on to the second shift nurse. In an interview with Nurse #2 on ,[DATE]//17 at 11:20 AM she revealed that she had cared for resident #5 on [DATE] from 3:00 PM to 11:00 PM. She stated that she did not get report when coming on shift. She said she did not do the treatments on her shift because she had too much to do. She said for part of the shift she was caring for forty-two residents until 11:00 PM when she was relieved by an Agency Nurse. In an interview with the Director of Nursing on [DATE] at 5:00 PM she stated that she expected the treatments to be done as ordered by the physician.

Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility failed to provide sufficient staffing to deliver care and services, including emergency medical services (EMS), to an insulin dependent brittle diabetic who was having critical capillary blood glucose (CBG) above 600 mg/dL (milligram/deciliter) and symptoms of distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility failed to have sufficient staffing to provide wound care for two days for Resident #4 and Resident #5 who were supposed to have daily treatments as ordered by the physician for 1 of 3 sampled residents with wounds. Immediate jeopardy for Resident #2 began on [DATE] when the facility did not have sufficient staffing and Resident #2 blood glucose registered HI on the glucometer (blood glucose was more than 600 mg/dL.) and the resident was showing signs of lethargy, low blood pressure, vomiting, and unusual bowel incontinence. EMS was not immediately initiated and nursing did not continue to assess the resident. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The facility is also out of compliance at the D scope and severity for Resident #4 and Resident # 5. This tag was cross referenced to tags F224, F309 and F314. Findings included: 1. Cross referenced at F224: Based on observations, record review, staff interview, and physician interview, the facility neglected a resident by not following physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility neglected residents by not providing wound care for two days for 2 of 3 residents who were supposed to have daily treatments as ordered by the physician (Resident #4 and Resident #5). 2. Cross referenced at F309: Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility failed to follow physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility failed to provide wound care for two days for Resident #5 who was supposed to have daily treatments as ordered by the physician for 1 of 1 sampled residents with wounds. 3.Cross referenced at F314: Based on observations, staff interviews and record review, the facility failed to provide pressure ulcer care for two days for a resident who was supposed to have daily treatments as ordered by the physician for 1 of 2 sampled residents with pressure ulcers (Resident #4.) The administrator was notified of the immediate jeopardy on [DATE] at 5:00 PM. The administrator provided the following credible allegation of compliance effective [DATE] at 6:30 PM. Residents identified to be affected by the alleged deficient practice. At 4:00 PM on [DATE] Nurse #2 went into Resident #2 room and noticed that he was not responding as usual. His skin was cool and clammy. His Blood glucose was checked and read HI with no value on the monitor. The manufacturer insert for this glucometer stated that a reading of HI indicated a blood glucose value of greater than 600 mg/dL. The Physician was notified and orders were received to administer 17 units of [MEDICATION NAME] one time and [MEDICATION NAME] 4 mg every 6 hours for nausea. At approximately 4:30 PM NA#3 entered room to check on Resident #2 who was resting in bed with no new changes. At approximately ,[DATE]:30 PM, NA #4 delivered Resident #2 his dinner tray. Resident #2 reported he was not feeling good and didn't want to eat. NA#4 stated this was then reported to Nurse #2. Resident #2 remained in the bed and the tray was set up. At 7:00 PM, Nurse #2 rechecked the resident blood sugar and it again read HI. Nurse #2 notified the Physician and received orders to administer 14 units of [MEDICATION NAME] and instructions to transport to the hospital if not improved. Resident status did not improve. Resident was incontinent of bowel and bladder and remained lethargic. Resident complained of an ache in his abdomen. Family was notified of resident status, 911 was called at 8:25 PM, and resident arrived at the hospital at 9:26 PM. The nurse reported she was too busy to check on the resident more frequently to reassess following insulin administration for a HI blood sugar reading with nausea and a low blood pressure and that she did not communicate with a manager that she was not able to recheck on the resident. Nurse #2 has received education on [DATE] from the Director of Nursing and Staff Development Coordinator regarding the facility policy for identification and assessment of changes in condition, management of residents with diabetes including monitoring of residents following intervention implementation, and physician notification. Residents with the potential to be affected by the alleged deficient practice. All residents have the potential to be affected by the alleged deficient practice. The Administrator and Director of Nursing have reviewed the schedule for the next 7 days ending [DATE] to validate dedicated Nursing Supervision is scheduled for all 3 shifts each day including the weekend. Nursing Supervision includes the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Manager or Shift Supervisor. 3. The Administrator has secured contracts with multiple Staffing Agencies since December of 2016 to fill staffing needs as required. The Administrator and Director of Nursing have the authority to contact the staffing agency to fill vacant shift for Licensed Nurses and Certified Nursing Assistants. The Nursing Supervisor will notify the Administrator or Director of Nursing of a staffing need and authority to contact the staffing agency to fill vacancies may be delegated to the Nursing Supervisor at the discretion of the Administrator or Director of Nursing. The Administrator and Director of Nursing with the Interdisciplinary Team including input from Nursing Staff completed a root cause analysis regarding coverage for vacant shifts a utilizing Agency staff, offering shift bonuses to current staff and scheduling dedicated Nursing Supervision daily for all shifts by [DATE]. Based on this review it was determined that multiple Nurses had called out for 3 shifts on [DATE] requiring Administrative Nursing staff to cover these shifts and therefore reducing the amount of available Nursing Supervision. The Administrator and Director of Nursing have reviewed the schedule for the next 7 days ending [DATE] to validate dedicated Nursing Supervision is scheduled for all 3 shifts each day including the weekend. The Administrator and Director of Nursing will conduct a daily meeting to review Nursing and Certified Nursing Assistant staffing and scheduling for each day to ensure adequate coverage to include a dedicated Supervisor for each shift. All attempts to assign familiar caregivers to maintain continuity of care for high risk residents will be discussed during this meeting. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Licensed Nurses beginning [DATE], in the event the Nursing Supervisor is required to move to a resident care assignment as a result of a staffing shortage the Administrator and Director of Nursing will be notified immediately to make further staffing adjustments as necessary. If a Nurse is feeling overwhelmed with completing the tasks due on their current assignment the Nurse will report to the Supervisor for assistance. In the event the Nursing Supervisor has a resident care assignment the Director of Nursing will be notified. Beginning [DATE] Licensed nursing staff and Agency Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Resident Care Management Director. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education On [DATE] at 6:30 PM, the credible allegation of compliance was validated to ensure the facility implemented their corrective actions to remove the immediate jeopardy. The facility provided evidence of an audit, on [DATE], of current insulin dependent diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days. The facility reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented. Record of diabetic residents were reviewed to ensure that they received care to manage diabetes as ordered by the physician. The facility provided evidence of inservice training to nursing staff on how to manage diabetic residents and regarding sufficient staffing. This was validated by interviews with nurses and nursing assistants.

Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility's administration failed to ensure care and services, including emergency medical services (EMS), were provided to an insulin dependent brittle diabetic who was having critical capillary blood glucose (CBG) above 600 mg/dL (milligram/deciliter) and signs of distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility administration failed to ensure wound care was provided for two days for Resident #4 and Resident #5 who were supposed to have daily treatments as ordered by the physician for 1 of 3 sampled residents with wounds. Immediate jeopardy for Resident #2 began on [DATE] when the facility did not have sufficient staffing and Resident #2 blood glucose registered HI on the glucometer (blood glucose was more than 600 mg/dL.) and the resident was showing signs of lethargy, low blood pressure, vomiting, and unusual bowel incontinence. EMS was not immediately initiated and nursing did not continue to assess the resident. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The facility is also out of compliance at the D scope and severity for Resident #4 and Resident # 5. This tag is cross referenced to tags F224, F309, F314 and F353. Findings included: 1. Cross referenced at F224: Based on observations, record review, staff interview, and physician interview, the facility neglected a resident by not following physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility neglected residents by not providing wound care for two days for 2 of 3 residents who were supposed to have daily treatments as ordered by the physician (Resident #4 and Resident #5). 2. Cross referenced at F309: Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility failed to follow physician orders [REDACTED]. The resident was also showing signs of lethargy, low blood pressure, unusual bowel incontinence, and vomiting. The facility failed to initiate emergency medical services (EMS) for the resident when he became in distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility failed to provide wound care for two days for Resident #5 who was supposed to have daily treatments as ordered by the physician for 1 of 1 sampled residents with wounds. 3. Cross referenced at F314: Based on observations, staff interviews and record review, the facility failed to provide pressure ulcer care for two days for a resident who was supposed to have daily treatments as ordered by the physician for 1 of 2 sampled residents with pressure ulcers (Resident #4.) 4. Cross referenced at F353. Based on observations, record review, staff interview, Nurse Practitioner (NP) interview and physician interview, the facility failed to provide sufficient staffing to deliver care and services, including emergency medical services (EMS), to an insulin dependent brittle diabetic who was having critical capillary blood glucose (CBG) above 600 mg/dL (milligram/deciliter) and symptoms of distress. This was evident in 1 of 3 diabetic residents (Resident #2). The resident was sent to the hospital and shortly died of a [MEDICAL CONDITION]. The facility failed to have sufficient staffing to provide wound care for two days for Resident #4 and Resident #5 who were supposed to have daily treatments as ordered by the physician for 1 of 3 sampled residents with wounds. The administrator was notified of the immediate jeopardy on [DATE] at 5:00 PM. The administrator provided the following credible allegation of compliance effective [DATE] at 6:30 PM. Residents identified to be affected by the alleged deficient practice. At 4:00 PM on [DATE] Nurse #2 went into Resident #2 room and noticed that he was not responding as usual. His skin was cool and clammy. His Blood glucose was checked and read HI with no value on the monitor. The manufacturer insert for this glucometer stated that a reading of HI indicated a blood glucose value of greater than 600 mg/dL. The Physician was notified and orders were received to administer 17 units of [MEDICATION NAME] one time and [MEDICATION NAME] 4 mg every 6 hours for nausea. At approximately 4:30 PM NA#3 entered room to check on Resident #2 who was resting in bed with no new changes. At approximately ,[DATE]:30 PM, NA #4 delivered Resident #2 his dinner tray. Resident #2 reported he was not feeling good and didn't want to eat. NA#4 stated this was then reported to Nurse #2. Resident #2 remained in the bed and the tray was set up. At 7:00 PM, Nurse #2 rechecked the resident blood sugar and it again read HI. Nurse #2 notified the Physician and received orders to administer 14 units of [MEDICATION NAME] and instructions to transport to the hospital if not improved. Resident status did not improve. Resident was incontinent of bowel and bladder and remained lethargic. Resident complained of an ache in his abdomen. Family was notified of resident status, 911 was called at 8:25 PM, and resident arrived at the hospital at 9:26 PM. The nurse reported she was too busy to check on the resident more frequently to reassess following insulin administration for a HI blood sugar reading with nausea and a low blood pressure and that she did not communicate with a manager that she was not able to recheck on the resident. Nurse #2 has received education on [DATE] from the Director of Nursing and Staff Development Coordinator regarding the facility policy for identification and assessment of changes in condition, management of residents with diabetes including monitoring of residents following intervention implementation, and physician notification. Residents with the potential to be affected by the alleged deficient practice. All residents have the potential to be affected by the alleged deficient practice. The Administrator and Director of Nursing have reviewed the schedule for the next 7 days ending [DATE] to validate dedicated Nursing Supervision is scheduled for all 3 shifts each day including the weekend. Nursing Supervision includes the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Manager or Shift Supervisor. 3. The Administrator has secured contracts with multiple Staffing Agencies since December of 2016 to fill staffing needs as required. The Administrator and Director of Nursing have the authority to contact the staffing agency to fill vacant shift for Licensed Nurses and Certified Nursing Assistants. The Nursing Supervisor will notify the Administrator or Director of Nursing of a staffing need and authority to contact the staffing agency to fill vacancies may be delegated to the Nursing Supervisor at the discretion of the Administrator or Director of Nursing. The Administrator and Director of Nursing with the Interdisciplinary Team including input from Nursing Staff completed a root cause analysis regarding coverage for vacant shifts a utilizing Agency staff, offering shift bonuses to current staff and scheduling dedicated Nursing Supervision daily for all shifts by [DATE]. Based on this review it was determined that multiple Nurses had called out for 3 shifts on [DATE] requiring Administrative Nursing staff to cover these shifts and therefore reducing the amount of available Nursing Supervision. The Administrator and Director of Nursing have reviewed the schedule for the next 7 days ending [DATE] to validate dedicated Nursing Supervision is scheduled for all 3 shifts each day including the weekend. The Administrator and Director of Nursing will conduct a daily meeting to review Nursing and Certified Nursing Assistant staffing and scheduling for each day to ensure adequate coverage to include a dedicated Supervisor for each shift. All attempts to assign familiar caregivers to maintain continuity of care for high risk residents will be discussed during this meeting. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted training with Licensed Nurses beginning [DATE], in the event the Nursing Supervisor is required to move to a resident care assignment as a result of a staffing shortage the Administrator and Director of Nursing will be notified immediately to make further staffing adjustments as necessary. If a Nurse is feeling overwhelmed with completing the tasks due on their current assignment the Nurse will report to the Supervisor for assistance. In the event the Nursing Supervisor has a resident care assignment the Director of Nursing will be notified. Beginning [DATE] Licensed nursing staff and Agency Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Resident Care Management Director. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. The Administrator along with input from the Director of Nursing will oversee and make adjustments to the staffing patterns and scheduling within the facility to meet the residents' needs. The Administrator will ensure staffing resources are allocated appropriately. District Director of Clinical Services and /or the District Director of Operations will provide oversight of the administration to ensure implementation of the credible allegation, by providing on site visits to the facility every week x 4 weeks, and then a minimum of bimonthly visits X 6 months to ensure implementation of all credible allegations. On [DATE] at 6:30 PM, the credible allegation of compliance was validated to ensure the facility implemented their corrective actions to remove the immediate jeopardy. The facility provided evidence of an audit, on [DATE], of current insulin dependent diabetic residents who have had an acute change in condition related to high blood glucose levels in the last 30 days. The facility reviewed their corresponding documentation to validate that a nursing assessment has been completed and interventions were implemented. Record of diabetic residents were reviewed to ensure that they received care to manage diabetes as ordered by the physician. The facility provided evidence of inservice training to nursing staff on how to manage diabetic residents and regarding sufficient staffing. This was validated by interviews with nurses and nursing assistants.

Based on record review, and staff interviews, the facility failed to provide therapy recommended assistance for 1 of 3 residents (Resident #1) that were assessed as being a high risk for falls. The resident had a fall which resulted in a fractured left hip. Findings included: Resident #1 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A review of a nursing note dated 12/31/15 at 7:55 PM read, in part, admitted from home with family present. Resident ambulatory with slightly unsteady gait, alert and oriented to family with periods of confusion. Will require supervision when ambulating due to unsteady gait at times. A review of a nursing note dated 1/1/16 at 7:23 PM read, in part, Resident was noted to be wandering down hallway with unsteady gait. The note further indicated the resident was redirected and encouraged to use the walker, but the resident was non-compliant due to mental status. A review of the nursing notes dated 1/8/16, 1/9/16, 1/10/16, and 1/11/16 revealed Resident #1 had 1 to 1 (1:1) observation for wandering behavior. No further entries related to (r/t) 1:1 observation after 1/11/16. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had no vision, speech or hearing deficits, was severely cognitively impaired, displayed inattention and disorganized thinking constantly, wandering-with significant risk to the resident occurred daily, and had no limb impairment. All activities of daily living (ADLs) required supervision except dressing which required extensive assistance. Resident #1 was unable to perform transitions and walking without staff assistance related to (r/t) not being steady without assistance. Active [DIAGNOSES REDACTED]. A review of the physical therapy (PT) notes revealed Resident #1 received PT beginning on 1/1/16 and therapy ended on 1/14/16. A note dated 2/3/16 revealed Resident #1 was discharged from PT on 1/14/16 r/t Goal met. The PT note indicated the resident needed stand by assistance (SBA)/supervision for safe transfers, sit to stand and stand pivot due to the resident's impaired cognition and subsequent poor safety awareness. The clinical impression entered by PT #1 read, Nursing staff have been educated in patient assist (assistance) level for transfers and ambulation(walking)-including (the) need for CGA (contact guard assistance-actually touching the resident) with ambulation, hand held assistance and need for SBA for transfers-and high fall risk. A review of the care plans dated 1/20/16 included a care plan r/t Impaired neurological status r/t Alzheimer's disease. The goal was to be free from injury. Interventions included assistance in mobility as needed. An additional care plan dated 1/20/16 was present r/t a physical functioning deficit r/t a mobility impairment. Interventions included assistive devices as needed, locomotion assistance as needed, and walking assistance as needed. A care plan for falls r/t a new environment and no safety awareness dated 1/20/16 was implemented and revealed a goal of no falls through the next review. The interventions listed were: call light or personal items (to be) available and in easy reach; keep (the) environment well lit and free of clutter; and observe for side effects of medications. A progress note dated 2/4/16 and timed 5:14 PM read, Social Services spoke to RP (Responsible Party) to inform her about the resident's (Resident #1) wandering behavior. The resident will be placed on one to one (1:1). A review of the staffing sheets dated 2/4/16 revealed no entries for 1:1 assignment r/t Resident #1. A nursing note dated 2/4/16 at 7:27 PM read, in part, 6 PM, during dinner, 2 staff members heard the resident fall on the floor on her right side, when staff approached the resident to assess for injuries the resident rolled over onto her left side and became physically aggressive with the nurse. Unit manager was called to the unit to assist with assessing the resident and the resident began to scream at the staff stating, 'Don't touch me my leg hurts.' Resident remains on the floor. Unable to assess ROM (range of motion). 6:10 PM- 911 was called by the unit manager. 6:15 PM- Resident's family members were called and message was left for both to call facility. 6:15 PM- the Director of Nursing (DON) responded to the dining room attempting to convince the resident to allow the staff to assist her off the floor. Resident remains resistant and continues to scream and yell at staff. The nursing note further indicated: 6:30 PM- Resident's family member returned call. Informed regarding fall. 7:00 PM- 911 called a second time. 7:10 PM- resident's family member arrived at the facility and was able to calm the resident down. 7:20 PM- EMS (Emergency Medical Services) arrived and resident out to (hospital name) ER (emergency room ) for evaluation and treatment. A review of the hospital radiology report dated 2/4/16 revealed Resident #1 sustained a left femur (thigh bone) fracture with displacement and angulation. There was no evidence of significant degenerative changes. An interview was conducted with nursing assistant #1 (NA) on 5/5/16 t 3:55 PM. She stated she was assigned to the dining room on 2/4/16 when Resident #1 fell . She also stated, I was helping another resident and I heard (Resident #1) yell out, 'Help, help.' When I turned around she was on the floor. She required supervision because she walked around herself. She was 1:1 at the time, but I wasn't assigned to her. The DON will have us do 1:1 for some residents and that means you care for that specific resident only. The DON assigned someone to be 1:1 with (Resident #1) that night because of her Alzheimer's, but it wasn't me. An interview was conducted with Nurse #4 on 5/5/16 at 4:05 PM. She stated she was assigned to the hall where Resident #1 resided on 2/4/16 and Resident #1 was 1:1 at that time. She also stated a NA assigned 1:1 with a resident was to stay with the resident they were assigned to only. She could not state who was assigned to Resident #1 on 2/4/16. A nursing note dated 2/5/16 labeled Late entry read, Falls Management Meeting: Resident (Resident #1) noted with increased agitation with restlessness and exit seeking behavior requiring 1:1 care. Noted (on 2/4/16) ambulating in (the) dining room reorganizing table cloths prior to staff hearing resident scream. Resident transferred to the hospital. Upon return to the facility will place low impact mattress (falls mat) and therapy referral. The care plans were updated on 2/11/16. Goals were modified to reduce the number of falls through the next review. Interventions were modified to include: footwear to prevent slipping as needed, monitor the resident frequently and keep in a highly visible area, a therapy referral per physician order, toilet schedule as needed, and transferred to the hospital-upon return will place low impact mattress to floor and therapy referral. A nursing note dated 3/11/16 at 4:55 PM was labeled Late entry and read, Resident (Resident #1) attempted self-transfer. Found on floor at bedside after lunch. Staff re-educated to provide rest periods after each meal, and continue to keep in highly visible area. Care plans were revised on 3/18/16. Goals were modified to no falls through the next review. Interventions were modified and included: keep the resident in a highly visible area, and re-educate (staff) to provide rest periods after each meal. A nursing note dated 5/3/16 at 2:59 AM revealed Resident #1 had made several attempts to get out of bed, with her legs hanging over the assist rail of the bed. Repositioning was attempted but was not successful. Resident #1 was placed in a Geri-chair. A nursing note dated 5/4/16 at 5:00 PM read, Observed on floor by staff. History of falls, altered safety awareness, Alzheimer's disease. A nursing note dated 5/4/16 at 7:08 PM read, Observed with legs hanging over assist rails attempting to get OOB (out of bed). Resident placed in Geri-chair by staff to promote safety. Placed in hallway. Constant viewing of resident performed by all staff members. At 8:10 PM resident placed in bed. An interview with NA #2 was conducted on 5/5/16 at 3:10 PM. She stated, She (Resident #1) had a fall out of bed yesterday. I was walking up the hall and saw her feet under the curtain. I looked behind it and she was sitting on the floor. I went to her nurse (Nurse #8) and told she had fallen, she said okay and continued to pass her medications in other resident rooms. Nurse #8 was not available to be interviewed. An interview with the Director of Nursing (DON) was conducted on 5/5/16 at 10:30 AM r/t a fall Resident #1 had on 5/4/16 at 5:00 PM. She stated her understanding was NA #2 saw the resident's (Resident #1) feet under the curtain in her room. When NA #2 entered she saw the resident sitting on the fall mat on the floor with her back against the assist rail. An interview with NA #3 was conducted on 5/5/16 at 10:55 AM. She stated, The call light was going off for the resident (Resident #1). I went down to the room and the nurse was already in there. She asked me for help because the resident had both legs hanging over the bed between the assist rail and foot board. An interview with the rehabilitation director was conducted on 5/5/16 at 12:25 PM. She stated stand by assistance (SBA) meant someone was standing beside the resident to give assistance if needed. There was no physical contact with the resident unless the resident was going to lose their balance or possibly fall. She stated Resident #1 needed varying levels of assistance from day to day. Recommendations were made to the medical staff and resident, if the resident was able to understand, r/t assistance needs. She stated the cognitive level of Resident #1 did not allow for education because, She couldn't remember what we talked about. So we educated the nurses. An interview was conducted on 5/6/16 at 10:10 AM with Physical Therapist (PT) #1. She stated, In my opinion she was never not a high risk for falls. PT recommended a level of contact guard assistance (CGA) which is more hands on than SBA. It was a difficult therapy with (Resident #1) because it's hard to convince someone with her cognitive deficits (to follow directions). She required more encouragement and was easily distracted, and she did benefit from increased observation, or 1 to 1 observation as it's sometimes called. An interview with Nurse #3 was conducted on 5/4/16 at 10:20 AM. She stated if a NA was assigned a resident for 1:1 observation the NA was to stay with the assigned resident for the length of the shift. If an NA was assigned a resident for 1:1 observation she could not be pulled to any other assignment. She also stated 1:1 assignments were noted on the daily assignment sheets. Nurse #3 said when their assigned resident was in the dining room, the NA assigned to that resident assisted other residents at the same table, but could not walk away from their assigned resident. An interview was conducted with the administrator on 5/5/16 at 4:30 PM. She stated, We utilize 1:1 if needed. If an NA is assigned 1:1 she isn't supposed to be pulled to another assignment. So if an NA is assigned increased supervision (1:1) the NA will finish that shift as 1:1 with that resident. An additional interview with the administrator was conducted on 5/6/16 at 10:30 AM. The administrator stated, She (Resident #1) was 1:1 at the time of her fall r/t wandering. All nursing home residents are falls risks. How are we supposed to monitor all of them? I'd love to make everyone 1:1 but that's impossible. She was on increased observation (1:1) for wandering not falls.

Based on interviews with staff and record review the facility failed to transfer Resident#2 using a 2 person (staff) assist and mechanical lift resulting in a lower left leg fracture. This was evident in 1of 3 residents in the survey sample reviewed for accidents. (Resident#2) Findings included: A review of the facility medical record indicated Resident #2 was admitted on [DATE] and discharged on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) dated 7/5/11 revealed the resident had moderately impaired cognition, vision impairment, balance was not steady when sitting and only able to stabilize with human assistance, and transfers were extensive assistance with a 2 person assist. A review of the " Immediate Plan Of Care " dated 6/22/11 revealed Resident #2 was at risk for falls. The interventions included to make the call light available and assist the resident with transfer. On 7/20/11 new statements were added to the care plan under " problem " . The statements indicated the resident had a fall on 7/20/11 and an x-ray was done to the left lower leg. The interventions included inservicing the staff on the location and use of the care card, for the nursing assistants (NA) to call the nurse for assistance and for the staff to use two persons to assist the resident. A review of the nurses notes dated 7/20/11 at 3:29 pm revealed that the resident (Resident #2) was observed sitting on the floor and leaning over on left arm and left leg. The notes continued that ADL (activities of daily living) care was rendered by NA #1 and according to NA#1 Resident #2 was placed in a sitting position on the side of the bed, then she (NA #1) attempted to place the wheelchair closer when Resident #2 started to slide off the bed. The notes continued to read that NA #1 was unable to help Resident #2 back in bed, no mechanical lift was used. No visible injury noted. Resident #2 complained of pain to the left side and the NP (Nurse Practioner) was informed and ordered x-rays. Resident #2 was sent to the hospital. Review of the Mobile x-ray results dated 7/20/11 revealed a fracture to the left lower leg. A phone message left for NA #1 and was unavailable for an interview. A phone message left for NA#2 that was working with NA #1 was unavailable for an interview. A review of a " CHANGE IN CONDITION REPORT - POST FALL/TRAUMA " , dated 7/20/11 at 11:00 (am or pm?). Under " INTERVENTIONS USED PRIOR TO FALL " , for Resident #2 revealed the following: ? bedrails, change in footwear, toileting schedule, restorative program, wheelchair positioning, bed in low position, Mechanical lift for transfer, Safety cues/ reinforcement/reminder, call light within reach. " The report also indicated under IDT, (Interdisciplinary Team Review) and recommendations were to inservice the staff on the location and use of the care card, for the nursing assistants (NA) to call the nurse for assistance and for the staff to use two persons to assist the resident. An interview conducted on 8/4/11 at 2:50 pm with the physical therapist (PT) revealed the NAs ' were not required to do heavy lifting as the facility was a " No Lift Facility. " The PT continued to state, " The staff was required to utilize a mechanical lift for all transfers for (Resident #2). " The PT indicated that Resident #2 had safety awareness impairment and only if someone (meaning Therapy) was with Resident #2 she could sit on the edge of the bed. When asked about the accident on 7/20/11 the PT stated, " (Resident #2) was being transferred without the mechanical lift. When a new resident has an order for [REDACTED]. The PT will communicate this information to the staff and family members. (Resident #2) was dependent on staff for transfer from bed to wheelchair and vice versa using a mechanical lift with the assistance of 2 persons. The incident that happened (7/20/11) was that NA#1 did not follow the care needs or she was unaware of what was needed for this resident. (Resident #2) was not to be sat on the edge of the bed without a therapist present due to her extreme left sided weakness. " On 8/5/11 at 10:00 am an interview with the OT (Occupational Therapist) revealed she looked at Resident #2 ' s self care skills (feeding, hygiene, etc.) and upper extremities including the upper left extremity which was affected by the stroke. She further indicated that she looked at the visual (ability to see), cognition (safety awareness skills), ADLs (activities of daily living), and abilities to transfer (toileting, shower and bathing transfers) compared to the PLOF (Prior Level Of Function). The OT continued that she focused on the upper left extremity during the evaluation. " I talked to NA that that was assigned to her that day (meaning 6/22/11 admitted ). I told her the mechanical lift was to be used for transfers to the chair and the bed. " The OT continued to state, " During the initial evaluation (Resident #2) was sat on the edge of the bed which indicated her postural control (ability to sit up) was impaired. Sitting on the side of the bed was not appropriate for (Resident #2). (Resident #2) was never deemed appropriate to sit on the edge of the bed, only with a therapist present. The only thing we (NA and OT) discussed was using a mechanical lift and positioning the left upper extremity to make sure she was not sitting on her left upper extremity. " When the OT was asked about the accident on 7/20/11 she stated, " I read the incident report and (Resident #2) was not approved to be sat on the edge of the bed for transfer purposes. " On 8/4/11 at 4:00 pm an interview with the Staff Development Coordinator (SDC) revealed she conducted an in-service on 7/20/11. A review of the in-service record dated 7/20/11 indicated the " Subjects Covered: " No lift Facility. " The content of the in-service included the " Golden Living Lift Program " which indicated mechanical lifts ' should be used when a resident cannot stand or pivot. Staff were expected to report individualized resident care provided that day on and off (beginning and end of shift) to peers and to each charge nurse. The SDC was asked if she inserviced staff regarding care cards, she said " no. " On 8/5/11 at 11:05 am an interview with the DON (Director of Nurses) revealed she was not in the facility on 7/20/11 (date of accident). " I received a call at home that (Resident #2) had fallen and complained of pain and was sent to the hospital. I came in and talked to the NA #1 and NA #2 that were assigned to (Resident #2). The NA#1 (orientee) said she sat (Resident #2) on the side of the bed and waited for help. (Resident #2) slid off the bed and landed on the floor. NA #2 that was orientating the new NA #1 and I felt she (NA#2 assigned to the orientee) should have been with the orientee. All orientees are told about the care card. You look at the care card which tells the current status of the resident. " The DON continued to state that she was not aware that (Resident #2) was not to be sat on the edge of the bed. " The in-service was provided that day (7/20/11) and my expectation is that everyone attends. " The in-service sheet was presented to the DON and she stated, " I do not see NA #1 and NA #2 listed on the in-service sheet for the day of the in-service (7/20/11) and I did not in-service the 2 NAs ' . My expectation is that the 2 NAs ' involved should have attended. " The DON continued, " NA #1 involved on 7/20/11 was in-serviced on proper use of care cards by the Administrator on the day of the accident, and I spoke to her (NA #1) one on one explaining that this is a no lift facility which means any resident that is unable of pivoting/standing is to be transferred by a mechanical lift. My expectation is that NA #1 was to have the lift in (Resident #2 ' s) room prior to getting (Resident #2) up out of bed and use a 2 person assist. When the DON was asked for the Care Cards regarding Resident #2 she stated that the care cards were updated daily and there was no record as to what care was supposed to be given to Resident #2. An untitled document dated 7/20/11 read, " Interview with the CNA (NA #1) revealed the NA #1 was aware of using the NA Care Card to guide the care given to the residents ' . NA #1 also stated that she had been in-serviced as to using the NA Care Cards. At this point, I again educated NA #1 as to where to find the Care Cards and how to use the care Cards. NA #1 stated she understood where to find the Care Cards and how to use them. She further stated that she understood she was to ask her charge nurse if she could not find the Care Cards. " This document was signed by the Administrator.