Every finding on record at Pine Acres Center for Nursing and Rehabilitation

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 13 of 30 days reviewed for staffing (6/19/26, 7/2/26, 7/5/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/13/26, 7/14/26, 7/15/26, 7/16/26, and 7/17/26). Findings included:Review of the facility's daily nurse staffing postings for 6/19/26 through 7/19/26 revealed there was not a RN scheduled for at least 8 hours a day on 6/19/26, 7/2/26, 7/5/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/13/26, 7/14/26, 7/15/26, 7/16/26, and 7/17/26.On 7/20/26 at 3:01 pm the 6/19/26 through 7/19/26 nurse staffing postings with assignments were provided by the Administrator and reviewed with the Director of Nursing (DON). The DON verified that the 0 on the schedule for RNs was correct, there was no RN available on those dates due to a lack of RN staff and she was aware.On 7/23/26 at 10:30 am an interview was conducted with the Administrator. The Administrator reviewed the daily nurse staffing postings during the interview. The Administrator stated the facility has open full time slots for RNs and there had been days with no 8 hours of RN coverage. The Administrator further commented the facility was actively recruiting RNs.

Based on record review, and staff and Medical Director interviews, the facility failed to ensure the Nursing Assistant (NA) and/or Medication Aide requested a nurse to assess a Resident who experienced a drop in oxygen saturation on room air to a level of 68 percent where a normal oxygen saturation ranges from 95-100 percent in healthy individuals but may be 90-100 percent in individuals with known respiratory conditions. The deficient practice occurred in 1 of 1 resident investigated for quality of life (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with hemodialysis three times per week, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder and anxiety disorder. Review of hospital records revealed Resident #1 was hospitalized from [DATE] through 12/17/25. A chest x-ray obtained on 12/13/25 revealed pulmonary interstitial edema (fluid in the lung tissues which can occur in the setting of respiratory acidosis or renal failure). Hospital records also indicated Resident #1 had a NSTEMI (NSTEMI stands for non-ST elevation myocardial infarction and occurs when an area of the heart does not get enough oxygen) on 12/14/25, which was likely due to demand ischemia (a sudden inability for the heart muscle to get enough oxygen) secondary to her respiratory acidosis and sepsis, workup revealed no further cardiac concern and no additional follow up was indicated. Discharge diagnoses included sepsis (a blood infection) resulting from a suspected direct inoculation of her dialysis fistula during hemodialysis, respiratory acidosis (a condition where the blood becomes too acidic rendering breathing difficult and which can result in a respiratory emergency if untreated) and acute respiratory failure (a respiratory emergency where the lungs are unable to oxygenate the body). Hospital records indicated Resident #1 declined the use of special positive pressure breathing machines that would have assisted with her respiratory acidosis and breathing, but her mental status remained stable. Hospital progress notes further indicated Resident #1 exhibited normal breathing effort and was oxygenating well on 2 liters of oxygen via nasal canula. Hospital records further indicated comprehensive work up and treatment courses by kidney specialists and infectious disease specialists and Resident #1 was discharged back to the facility in stable condition.Review of Resident #1's comprehensive care plan revised on 12/21/25 included focus areas for chronic obstructive pulmonary disease, chronic respiratory failure, obstructive sleep apnea and pneumonia. Ongoing goals included keeping oxygen saturation levels above 90 percent, maintaining normal breathing pattern as evidenced by normal respirations, normal skin color and maintaining a regular respiratory rate and pattern. Interventions for Resident #1's respiratory care plan included: Monitoring for signs and symptoms of respiratory distress and reporting to the physician any increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis or cough; Monitoring for pleuritic pain, accessory muscle usage or skin color changes to blue or grey; Monitoring, document and/or reporting abnormal breathing patterns to physician: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing or nasal flaring; Positioning resident with proper body alignment for optimal breathing pattern and providing relaxation training as appropriate to help normalize breathing patterns (for example, biofeedback, imagery, progressive muscle relaxation).A provider note dated 1/12/26 revealed Resident #1 had been hospitalized again from 12/27/25 through 1/2/26 for influenza and pneumonia following a chest x-ray showing right upper lung infiltrates (fluid in the lung). Resident #1 was started on antibiotic therapy and had since returned to the facility on said antibiotics. Records also indicated Resident #1 had a newer diagnosis of thrombocytopenia (a condition in which the blood does not have enough platelets which hinders blood clotting) which the provider was aware of and Resident #1 was being monitored for. A 1/8/26 re-entry Minimum Data Set (MDS) assessment revealed Resident #1 had moderate cognitive impairment. Diagnoses included COPD, obstructive sleep apnea, respiratory failure and pneumonia.Review of Resident #1's vital sign records from 1/2/26 through 1/13/26 revealed vital signs within Resident #1's baseline. Resident #1's oxygen saturation levels ranged from 90 percent to 96 percent. Some oxygen saturation readings were noted to be on room air and some were noted to be with Resident #1 wearing oxygen, in no discernable pattern. Vital sign readings were documented once daily at differing times of day. Review of Resident #1's vital sign readings on 1/14/26 revealed a respiratory count of 18 breaths per minute (normal range is 16-20 breaths per minute) at 5:30 PM. At 7:56 PM, remaining vital signs entered revealed a blood pressure of 176/98 (within Resident's baseline), a heart rate of 80 beats per minute (normal range is 60-100 beats per minute), a temperature of 97.7 degrees Fahrenheit (normal range is are 97.0-99.0 degrees Fahrenheit) and An oxygen saturation level of 68 percent on room air (normal range is 90-100 percent in individuals with known respiratory conditions). The 7:56 PM vital signs were entered by Nurse Aide #1. On 1/21/26 at 2:06 PM, an interview was conducted with Nurse Aide (NA) #1. NA #1 confirmed she worked from 6:00 PM on 1/14/26 until 6:00 AM on 1/15/26. NA #1 said at around 8:00 PM on 1/14/26, as she prepared to take Resident #1's vitals, the Medication Aide told her Resident #1 had been taking off her oxygen and the Medication Aide had already been in the room back and forth checking on her. NA #1 said Resident #1 could get anxious and she tended to yell out a lot, sometimes she could get confused but not always. NA #1 said Resident #1 liked to have company and was not as anxious when staff could stay in her room and talk with her more. NA #1 said when she entered Resident #1's room at around 8:00 PM, Resident #1 did not have her oxygen on and was yelling out and said she was anxious about her health issues and what was going to happen to her. NA #1 said she took Resident #1's vitals and her oxygen saturation level was 68 percent without her oxygen on. NA #1 said she notified the Medication Aide who was just outside the door and the Medication Aide came in immediately to assist. NA #1 said she helped Resident #1 put her oxygen back on and rechecked her oxygen level, which went back up to 91 or 92 percent after a few minutes. NA #1 said the Medication Aide also re-checked the Resident's oxygen saturation level with a manual oximeter (a hand-held machine used to check oxygen saturation levels) and her oxygen level was 92 percent with her oxygen on. NA #1 said she did not remember how much oxygen Resident #1 was on but she stayed with Resident #1 and talked with her and then Resident #1 became calmer. NA #1 said it took about 10 minutes for Resident #1 to become calmer and her oxygen level to come back up. NA #1 said Resident #1 otherwise looked normal, she didn't look pale or blue or anything. NA #1 said before Resident #1 went to the hospital the last time, she had oxygen if she needed it, and she had needed it more since she had come back. NA #1 stated every time she had taken care of Resident #1 since her last return from the hospital; she was always wearing her oxygen.An interview with the Medication Aide was conducted on 1/21/26 at 2:23 PM. The Medication Aide confirmed she worked from 6:00 PM on 1/14/26 to 6:00 AM on 1/15/26. The Medication Aide said Resident #1 had been yelling a lot that night, which was rather normal for her. The Medication Aide said Resident #1 had been removing her oxygen and at times would throw it down onto the floor. The Medication Aide indicated Resident #1 had used oxygen before, but she had needed it more since coming back from the hospital after being treated for the flu and pneumonia, the Resident #1 didn't seem like she had gotten used to wearing it more. The Medication Aide said she went in back and forth numerous times during her medication pass to keep checking on Resident #1 and re-educate the Resident about her oxygen and to replace her oxygen tubing. The Medication Aide said Resident #1 was confused sometimes. The Medication Aide said about 8:00 PM, NA #1 called her into Resident #1's room because she had gotten a low oxygen saturation level in the 60s. The Medication Aide said when she entered the room, NA #1 had already replaced Resident #1's oxygen and said the oxygen level was coming back up. The Medication Aide said she also checked Resident #1's oxygen with her manual oximeter and the reading was 91 or 92 percent with her oxygen on. The Medication Aide said she did not remember how much oxygen Resident #1 had on. The Medication Aide said Resident #1 had calmed down with them in the room with her. The Medication Aide said NA #1 also re-checked her vital signs and they were normal around 8:30 PM. The Medication Aide said she administered a scheduled breathing treatment to Resident #1 during that time as well. The Medication Aide said Nurse #1, who was Resident #1 primary nurse that night, was on a different hall passing medications for other residents at that time. The Medication Aide said she went back and forth and checked Resident #1 with her manual oximeter numerous times and everything seemed fine. The Medication Aide said Resident #1 looked pretty normal, she was not pale, her lips did not appear cyanotic (a blue or purple discoloration of the skin caused by low oxygen), her oxygen saturation at that time was 91or 92 percent with her oxygen on and she seemed calmer so she finished her medication pass and checked Resident #1 again right before 10:00 PM. The Medication Aide stated when she saw Nurse #1 shortly before 10:00 PM, she notified Nurse #1 of Resident #1's low saturation level and that the Resident seemed stable ever since and asked her to keep an eye on her. On 1/22/26 at 11:59 AM, a follow up interview with the Medication Aide was conducted. The Medication Aide said she last checked on Resident #1 at 9:56 PM right before she notified Nurse #1 of the low oxygen saturation. The Medication Aide said she spoke with Resident #1 at that time, and the Resident was calmer and appeared to be doing ok with her oxygen on. The Medication Aide said Resident #1's oxygen was about 92 percent right before 10:00 PM with her oxygen and she did not re-check complete vital signs. On 1/21/26 at 12:48 PM, an interview with Nurse #1 was conducted. Nurse #1 confirmed she was the primary nurse for Resident #1 on the evening of 1/14/26 from 6:00 PM to 6:00 AM on 1/15/26. Nurse #1 said that Resident #1 seemed her normal self when she started her shift at 6:00 PM and had rounded on Resident #1 and assessed her at the start of her shift. Nurse #1 said Resident #1 frequently yelled and called out which she was doing that evening as was usual for her and nothing seemed out of the ordinary. Nurse #1 stated she saw the Medication Aide had been in and out of Resident #1's room to help Resident #1 with her oxygen because the Resident kept removing her oxygen tubing but her readings were ok then. Nurse #1 said Resident #1 had oxygen before but since she had returned from the hospital about a week prior, she had been wearing it most of the time but would frequently remove it. Nurse #1 said at about 9:30 PM, she passed by Resident #1's room to visualize her and she was still awake and calling out but seemed calmer than before. Nurse #1 stated she did not go in to Resident #1's room at that time but visualized that she was awake and proceeded to administer medications to 2 of her other residents that were on her other hall and so she did not know about the low reading for a little while longer. Nurse #1 stated just before 10:00 PM, she was notified by the Medication Aide that Resident #1's oxygen saturation level had dropped to 68 percent on room air at about 8:00 PM but the oxygen saturation had gone back up to normal levels with her oxygen on. Nurse #1 indicated the Medication Aide told her she had checked on the Resident numerous times, had given her a breathing treatment and the Resident had since been calmer with normal vital signs. Nurse #1 said because the Medication Aide told her she had just checked on Resident #1 and the Resident was doing ok, she (Nurse #1) finished her current medication task and then made her way down to her other hall to Resident #1's room. On 1/22/26 at 11:48 AM, a follow up interview with Nurse #1 was conducted. Nurse #1 said if she had been notified earlier of the low oxygen saturation, she would not have done anything different because her Medication Aide had already checked the resident, re-applied the oxygen and the Resident had been doing better by the time she was notified. Nurse #1 said she would have done the exact same thing the Medication Aide had done. On 1/21/26 at 3:15 PM, an interview with the Medical Director was conducted. The Medical Director said Resident #1 had been very sick with her existing comorbidities and was recently being monitored for thrombocytopenia (a condition in which the blood does not have enough platelets which hinders blood clotting). The Medical Director said Resident #1 had had several recent hospitalizations and was most recently diagnosed with influenza and pneumonia. The Medical Director said the oxygen need for Resident #1 was on an as needed basis. The Medical Director said he was not aware that Resident #1 had desaturated (low blood oxygen saturation) to 68 percent on room air and would have expected the Resident to be checked at that time and to be notified of a new oxygen desaturation level. An interview with the Assistant Director of Nursing (ADON) was conducted on 1/21/26 at 3:30 PM. The ADON said if a resident experienced a changed in condition, staff would be expected to assess the resident and if initial corrective measures taken by nursing were successful, they were not required or expected to immediately notify the on call provider at night. An interview with the Administrator was conducted on 1/22/26 at 11:30 AM. The Administrator said when a resident experienced a change of condition, he would expect the nursing staff to assess a resident and notify the provider if need be, but if initial corrective measures by nursing staff were successful, nursing staff would not necessarily need to notify the provider immediately.

Based on record review, and staff and Medical Director interviews, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with hemodialysis three times per week, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder and anxiety disorder. Review of hospital records revealed Resident #1 was hospitalized from [DATE] through 12/17/25. Discharge diagnoses included sepsis (a blood infection) resulting from a suspected direct inoculation of her dialysis fistula during hemodialysis, respiratory acidosis (a condition where the blood becomes too acidic rendering breathing difficult and which can result in a respiratory emergency if untreated) and acute respiratory failure (a respiratory emergency where the lungs are unable to oxygenate the body). Hospital records indicated Resident #1 declined the use of special positive pressure breathing machines that would have assisted with her respiratory acidosis and breathing, but her mental status remained stable. Hospital progress notes further indicated Resident #1 exhibited normal breathing effort and was oxygenating well on 2 liters of oxygen via nasal canula. Resident #1 was discharged back to the facility in stable condition. Review of the medical record revealed no order for oxygen therapy for Resident #1. Review of Resident #1's comprehensive care plan revised on 12/21/25 included focus areas for chronic obstructive pulmonary disease, chronic respiratory failure, obstructive sleep apnea and pneumonia. Ongoing goals included keeping oxygen saturation levels above 90 percent, maintaining normal breathing pattern as evidenced by normal respirations, normal skin color and maintaining a regular respiratory rate and pattern. Interventions for Resident #1's respiratory care plan included: Monitoring for signs and symptoms of respiratory distress and reporting to the physician any increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis or cough. A provider note dated 1/12/26 revealed Resident #1 had been hospitalized again from 12/27/25 through 1/2/26 for influenza and pneumonia following a chest x-ray showing right upper lung infiltrates (fluid in the lung). Resident #1 was started on antibiotic therapy had since returned to the facility on said antibiotics. The provider note indicated Resident had a newer diagnosis of thrombocytopenia (a condition in which the blood does not have enough platelets which hinders blood clotting) which the provider was aware of and Resident #1 was being monitored for. The provider further summarized Resident #1's vital signs from the dates of 1/8/26 through 1/12/26 (excepting 1/9/26 where there was no entry listed) which showed on 1/8/26 the Resident's oxygen saturation was 96 percent on oxygen, on 1/10/26 the Resident's oxygen saturation was 96 on oxygen, on 1/11/26 the Resident's oxygen was 95 on oxygen and on 1/12/26 the Resident's oxygen saturation was 95 with oxygen. A 1/8/26 re-entry Minimum Data Set (MDS) assessment revealed Resident #1 had moderate cognitive impairment, noted respiratory diagnoses of COPD, obstructive sleep apnea, respiratory failure and pneumonia but no coding for oxygen use.On 1/21/26 at 2:06 PM, an interview was conducted with Nurse Aide (NA) #1. NA #1 confirmed she was the NA for Resident #1 on the evening of 1/14/26. NA #1 said when she entered Resident #1's room at around 8:00 PM to take vital signs, Resident #1 did not have her oxygen on. NA #1 said she took Resident #1's vitals and her oxygen saturation level was 68 percent without her oxygen on. NA #1 said she notified the Medication Aide who was just outside the door and the Medication Aide came in immediately to assist. NA #1 said she helped Resident #1 put her oxygen back on and rechecked her oxygen level, which went back up to 91 or 92 percent after a few minutes. NA #1 said she did not remember how much oxygen Resident #1 was on. NA #1 said before Resident #1 went to the hospital the last time, she had oxygen if she needed it, and she had needed it more since she had come back. NA #1 stated every time she had taken care of Resident #1 since her last return from the hospital; she was always wearing her oxygen. An interview with the Medication Aide was conducted on 1/21/26 at 2:23 PM. The Medication Aide confirmed she was the Medication Aide on Resident #1's hall on the evening of 1/14/26. The Medication Aide reported Resident #1 had been removing her oxygen and at times would throw it down onto the floor. The Medication Aide indicated Resident #1 had used oxygen before, but she had needed it more since coming back from the hospital after being treated for the flu and pneumonia. The Medication Aide stated that she did not remember how much oxygen Resident #1 had on. On 1/21/26 at 12:48 PM, an interview with Nurse #1 was conducted. Nurse #1 confirmed she was the primary nurse for Resident #1 on the evening of 1/14/26 from 6:00 PM to 6:00 AM on 1/15/26. Nurse #1 stated she saw the Medication Aide had been in and out of Resident #1's room to help Resident #1 with her oxygen because the Resident kept removing her oxygen tubing, but her readings were ok then. Nurse #1 said Resident #1 had used oxygen before but since she had returned from the hospital about a week prior, she had been wearing it most of the time but would frequently remove it. Nurse #1 said at about 9:30 PM, she passed by Resident #1's room to visualize her and she was still awake and her oxygen was on. Nurse #1 stated she did not remember how much oxygen Resident #1 was using.On 1/21/26 at 3:15 PM, an interview with the Medical Director was conducted. The Medical Director said Resident #1 had been very sick with her existing comorbidities and was recently being monitored for thrombocytopenia (a condition in which the blood does not have enough platelets which hinders blood clotting). The Medical Director said Resident #1 had had several recent hospitalizations and was most recently diagnosed with influenza and pneumonia. The Medical Director said the oxygen need for Resident #1 was on an as needed basis.

Based on record review, and staff, family, and Physician Assistant (PA) interviews, the facility failed to provide care safely to a dependent resident. Resident #76 had an impaired gait and she was unable to walk without assistance. On 01/11/25 Nursing Assistant (NA) #1 transferred Resident #76 from her bed to the floor for ambulation to the bathroom. The NA turned away from the resident to place the resident's brief in a trash can leaving the resident in a standing position with no staff support resulting in the resident falling. Resident #76 sustained a left wrist fracture and a left hip fracture. This was for 1 of 4 residents reviewed for accidents (Resident #76). Findings included: Resident #76 was admitted to the facility on [DATE] with diagnosis that included osteoporosis, [NAME] Lymphoma, breast cancer, history of humerus (the long bone that extends from the shoulder to the elbow) fracture, and history of falls. The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident #76's cognition was moderately impaired and she exhibited no behaviors. She required moderate assistance to ambulate 10 feet and maximal assistance for toileting hygiene, dressing, and transfers. Resident #76 was coded for receiving scheduled pain medications but no as needed pain medications. During the pain assessment, Resident #76 denied having pain. Resident #76 was not coded as receiving opioid, anticoagulant, or antiplatelet medications. Resident #76's admission care plan dated 12/19/24, included a focus that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to dementia and limited mobility. She was admitted following a hospitalization for a fall at her assisted living facility sustaining subdural hematoma (a pooling of blood between the brain's outermost protective layer and the brain itself) and right humerus fracture. The interventions included Resident #76 was dependent on two or more staff and the use of mechanical lift for transfers. The date this intervention was created and initiated was 12/19/24. Another focus indicated that Resident #76 was at risk for falls related to history of falls, gait/balance problems, incontinence, and that she was unaware of safety needs. The interventions included for staff to be sure her call light was within reach and encourage her to use it for assistance as needed. Resident #76 needs prompt response to all requests for assistance and to anticipate and meet her needs. A fall risk assessment (used to predict a patient's likelihood of falling) dated 01/06/25 indicated Resident #76 was categorized as a high risk for falling with a score of 55.0. (Fall scoring: high risk 45 and higher). Resident #76's risk factors included a history of falling, multiple diagnoses, she overestimated or forgets her limits, her gait was impaired, she could not walk without assistance, and she did not use ambulatory aids. Resident #76's pain assessments documented on the Medication Administration Record (MAR) from 01/01/25 through 01/10/25 revealed no pain. Resident #76's incident report dated 01/11/25 at 12:55 PM, completed by Nurse #1, indicated Resident #76 had a fall while being assisted to the bathroom by NA #1. Resident #76's brief was falling so NA #1 stopped the resident to remove the brief. NA #1 then turned around to throw the brief in the trash and when she turned back around to face Resident #76 she was falling to the floor. Nurse #1 entered the room and observed Resident #76 lying on her left side by the bed. Resident #76 complained of pain but stated she felt comfortable to be assisted back to bed. A skin tear was noted to her left elbow and a discolored/darkened area noted to her left forearm/wrist. The physician, Director of Nursing, and family were notified of the fall and complaints of left wrist pain. An interview was conducted on 05/21/25 at 9:27 AM with NA #1. NA #1 verified she was Resident #76's NA on 01/11/25 when she fell. She stated she had worked at the facility as a NA since December 2024. She indicated she did not know Resident #76 could not ambulate without assistance or that she was to be transferred via the mechanical lift. NA #1 stated 01/11/25 was the first time she had worked with Resident #76 and that other staff had told her she could ambulate with assistance. NA # 1 was unable to provide the names of those staff members. She explained she was assisting the resident to the bathroom by ambulating with her. The NA said Resident #76's brief was falling down so she stopped her, removed the brief, she let go of Resident #76 and turned to throw the brief in the trash can which was against the wall, and when she turned back around Resident #76 was observed losing her balance and falling before she could get to her. An interview was conducted on 05/21/25 at 9:10 AM Nurse #1. She verified she was Resident #76's nurse on 01/11/25 when she had a fall. She stated she was called to the room by NA #1 and was told that Resident #76 fell while being assisted to the bathroom by NA #1. She indicated a second staff member was not present. Upon entering the room Resident #76 was lying on the floor on her left side beside the bed. She also stated she completed an assessment of the resident to include vital signs, checked for range of motion to all extremities, deformities, and checked her skin. She then explained that Resident #76 complained of pain in her left wrist, denied any other pain, and showed no signs of pain during the initial assessment. Nurse #1 indicated Resident #76 did not give her a rating of pain and she offered pain medication which the resident refused and said, I'm fine. Resident #76 stated she wanted to get back in bed. Nurse #1 and NA #1 assisted Resident #76 back to bed. She had a skin tear noted to her left elbow and a discolored/darkened area noted to her left forearm/wrist, like a hematoma. She then explained she called the PA and received an order to obtain an x-ray of the left wrist and to apply ice as needed for 20 minutes at a time for 2 days. She stated throughout the morning Resident #76 began to complain of pain in the left hip and this was added to the x-ray order. Nurse #1 applied the ice packs to Resident #76's left hip and Resident #76 voiced that this was effective for her pain. She indicated she assessed her hip again, which did not reflect bruising, deformity, or leg shortening. When she called to place the order for the x-ray the company stated they had a high call volume and they would be there as soon as they could. She explained NA #1 told her she was assisting the resident to the bathroom by ambulating with her. The NA said Resident #76's brief was falling so she stopped her, removed the brief, turned around to throw it in the trash and when she turned back around the resident was observed losing her balance falling before she could get to her. Nurse #1 stated Resident #76 was to be transferred by 2 staff members via the mechanical lift due to her poor balance and unsteady gait. She explained that Resident #76 should not have been ambulating due to the risk of falling and she was non weight bearing on her left lower extremity. Review of the 5 whys worksheet (a structured tool for problem-solving that uses a series of why questions to uncover the root cause of a problem) completed by the Director of Nursing (DON) dated 01/11/25 revealed the problem was Resident #76 fell while being assisted to the bathroom. The resident sustained a skin tear to her left elbow and darkened left forearm/wrist. Staff were throwing the resident's brief away and when NA #1 turned back to Resident #76 she was falling. The worksheet provided the following information related to the 01/11/25 fall: 1. Why was it happening? Incontinent; 2. Why was that? Gait imbalance; 3. Why was that? Staff were not touching Resident #76 with assistance. The Whys under numbers 4 and 5 were not answered. The identified root cause was staff transferring. The action/plan to address the problem was neurological checks and reeducation to staff when transferring Resident #76. Review of a Situation, Background, Assessment, and Recommendation (SBAR) form dated 01/11/25 at 6:25 PM completed by Nurse #1 revealed a change of condition related to the resident's fall. Resident #76 was identified with discoloration to her skin, a skin tear, and pain. New orders were received for a left wrist x-ray and an ice pack to left wrist every 2 hours for 20 minutes as needed for 2 days related to a fall. Physician orders dated 01/11/25 for Resident #76 indicated an x-ray for the left forearm and wrist for a hematoma; an x-ray of the left hip for acute pain related to a fall; and an ice pack to the left wrist for 20 minutes every 2 hours as needed for 2 days for a hematoma. A progress note dated 01/12/25 at 6:32 AM by Nurse #8 revealed Resident #76 was alert and oriented to person, place, and situation with intermittent confusion noted. She complained of acute pain in her left wrist; swelling was observed and bruising noted related to her fall. As needed pain medications were given with effective results. Awaiting an X-Ray to be obtained. Multiple unsuccessful attempts were made to contact Nurse #8. Resident #76's pain assessment documented on the MAR for 01/13/25 during the day shift (6:00 AM to 6:00 PM) revealed a pain level of 07 (pain scale of 1-10 with 10 being the worst pain). Record review revealed Resident #76 received an x-ray on 01/13/25 with a report date of 01/13/25. The results for the left wrist and forearm included a fracture at the distal radius metaphysis (a break in the wider, flared end of the bone, located near the wrist joint). The results for the left hip x-ray were positive for intertrochanteric femur fracture (hip fracture). A progress note dated 01/13/25 at 3:50 PM by Unit Manager (UM) #2 revealed Resident #76 had a fall on 01/11/25. An x-ray of her hip and forearm were completed and showed a fractured hip upon assessment. Resident #76 was being sent to hospital via emergency medical services (EMS) for further evaluation. The hospital Discharge summary dated [DATE] revealed Resident #76 presented to emergency room on [DATE] with a left hip fracture and left wrist fracture. Resident #76 did not remember the fall and was not in pain. After discussion, the family ultimately opted for comfort measures only. Resident #76's pain was well controlled with oral agents and given her poor baseline there was felt to be no benefit in surgical repair. A phone interview was conducted on 05/18/25 at 11:22 AM with Resident #76's family member. The family member stated he was notified of the fall on 01/11/25 and that she was sent to the emergency room on [DATE] due to the x-ray results revealing a hip fracture and the wrist fracture. He stated he discussed the options with the hospital physician and decided on no surgical interventions. His main concern was to keep Resident #76 comfortable. He explained he came to the facility often and that during his visits Resident #76 did not complain or show signs of being in pain An interview was conducted on 05/21/25 at 3:20 PM with the Director of Nursing. She stated she expected the care plan to be followed. The DON indicated NA #1 should not have let Resident #76 go during ambulation due to her unsteady gait. She stated she thought this resident was care planned for extensive to total assistance by one plus staff members. She indicated she was not aware of her transfer status being changed to a mechanical lift. A phone interview was conducted on 05/21/25 at 3:34 PM with the Physician's Assistant (PA). He stated he recalled the fall in January with Resident #76. He explained that Resident #76 could stand but she was unsteady and was at a high fall risk. He expected the care plan to be followed and the goal was always to keep the residents safe and free of injuries. He stated Resident #76 was sent to the emergency room however she nor her family wanted to go through surgical interventions because they did not feel she was a good candidate. He further explained Resident #76 was not on a blood thinner and she stayed in bed most of the time.

Based on record review and staff interview, the facility failed to ensure a Nursing Assistant (NA) was trained and competent on utilizing the kardex (a concise, quick-reference system for resident care information) to identify the care needs that residents required prior to providing direct care to residents. This was for 1 of 5 staff reviewed for competency (NA #1). The findings included: This tag is cross-referred to: F689: Based on record review, staff, family, and Physician Assistant (PA) interviews, the facility failed to provide care safely to a dependent resident. Resident #76 had an impaired gait, and she was unable to walk without assistance. On 01/11/25 Nursing Assistant (NA) #1 transferred Resident #76 from her bed to the floor for ambulation to the bathroom. The NA turned away from the resident to place the resident's brief in a trash can leaving the resident in a standing position with no staff support resulting in the resident falling. Resident #76 sustained a left wrist fracture and a left hip fracture. This was for 1 of 4 residents reviewed for accidents (Resident #76). NA #1's hire date was 11/07/24. NA #1's orientation packet dated 01/01/25 was reviewed and revealed no evidence she was trained in accessing residents' kardex. During an interview with NA #1 on 05/21/25 at 9:27 AM she stated she began working at the facility in December 2024. She revealed she was not educated on what a kardex was or how to access it when she was hired or while being trained on the floor. She revealed she had no training on the kardex until after she was educated by Nurse #1 on 01/11/25. She indicated she would ask the residents and/or other staff about care needs of residents prior to learning about the kardex. NA #1 stated she has utilized the kardex since education was provided. She further stated she wished she would have known how to utilize it prior to the training because she should know how to safely assist and care for the residents. An interview was conducted on 05/21/25 at 9:10 AM Nurse #1 she verified on 01/11/25 NA #1 informed her she did not know how to access the kardex. She reported that she educated NA #1 immediately. Nurse #1 explained she educated NA #1 on what the kardex was and how it provided guidelines for resident care needs such as assistance required for safe transfers and other activity of daily living tasks. An interview was conducted on 05/21/25 at 3:20 PM with the Director of Nursing. She stated she expected NAs to look at the kardex prior to working with residents so the staff knew how to provide safe care for the resident. She stated she was not aware NA #1 did not know how to access the kardex until after she was trained by Nurse #1 on 1/11/25. She indicated new staff were trained in using the kardex during orientation and she thought NA #1 had been educated during orientation. She added that when staff were working on the floor other NAs trained new hires after orientation and that other NAs trained newly hired NAs on accessing the kardex when training on the floor after classroom/computer training was provided. NA #1's orientation packet was reviewed with the DON, and she verified there was no evidence she was trained on accessing the kardex during orientation. The DON stated they have a new Staff Development Coordinator and this training will be included in orientation.

4. Resident #85 was admitted to the facility 7/8/24 with diagnoses including heart failure and pulmonary embolism (a blood clot in the lungs). Review of the physician orders for Resident #85 revealed an order dated 3/13/25 that specified warfarin (a blood thinner used for blood clots) to be administered 5 milligrams (mg) on Tuesday, Thursday, and Saturday at 5:00 PM, and warfarin 6 mg to be administered Monday, Wednesday, Friday, and Sunday at 5:00 PM. Review of the medication administration record for March, April, and May 2025 revealed Resident #85 received warfarin as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #85 was not taking anticoagulant medications and was taking antibiotic medications. Review of the physician orders for Resident #85 did not have antibiotic medications prescribed. MDS Nurse #2 was interviewed on 5/21/25 at 3:03 PM and she reported that coding antibiotics for Resident #85 was a mistake. MDS Nurse #2 reviewed her handwritten worksheet and on the worksheet she had noted Resident #85 was taking anticoagulation medications. The Administrator was interviewed on 5/21/25 at 3:47 PM and he reported MDS Nurse #2 had mis-keyed the information for Resident #85 and he expected the MDS assessments to be accurate. Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of oxygen use (Resident #7), prognosis (Resident #62), diagnoses (Resident #6) and medications (Resident #85). This was for 4 of 25 residents whose MDS assessments were reviewed. The findings included: 1. Resident #7 was originally admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Resident #7 had a hospital stay from 4/17/25 to 4/21/25. Resident #7's physician orders included an order dated 4/21/25 for oxygen continuous at 3 liters per minute via nasal cannula. A review of the April 2025 Medication Administration Record (MAR) revealed that Resident #7 had oxygen at 3 liters per minute via nasal cannula on 4/21/25, 4/22/25 and 4/23/25. A review of a quarterly MDS assessment dated [DATE] indicated that Resident #7 was cognitively intact and was not coded for the use of oxygen. On 5/21/25 at 12:29 PM, an interview occurred with MDS Nurse #1. She reviewed Resident #7's quarterly MDS assessment dated [DATE] and verified that oxygen use was not coded. MDS Nurse #1 reviewed Resident #7's current physician orders as well as the April 2025 MAR and confirmed that Resident #7 was ordered oxygen on a continuous basis. She stated that oxygen use should have been coded for on the 4/23/25 MDS assessment and felt it was an oversight. An interview was completed with the Administrator on 5/21/25 at 1:52 PM and stated that he would expect the MDS assessment to be coded accurately. 2. Resident #62 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Review of a Hospice Certification of Terminal Illness dated 12/24/24 from the Hospice physician read, I recertify that this patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. The certification period was noted to be 12/26/24 through 3/25/25. A quarterly MDS assessment dated [DATE] indicated that Resident #62 was coded for hospice care but not marked for a condition or chronic disease that may result in a life expectancy of less than six months. On 5/21/25 at 12:29 PM, an interview occurred with MDS Nurse #1. She reviewed Resident #62's quarterly MDS dated [DATE] and indicated that the prognosis section for a condition or chronic disease that may result in a life expectancy of less than six months should have been marked as yes, as Resident #62 received hospice care. She felt this was an oversight. The Administrator was interviewed on 5/21/25 at 1:52 PM and stated that he would expect the MDS to be coded accurately. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia and hypertension. A record review indicated Resident #6 had an active diagnosis of hypertension since 07/01/22 and an active diagnosis for dementia since 08/03/23. The Nurse Practitioner note dated 02/04/25 read in part that Resident #6's Dementia with associated depression seems stable, no significant behaviors, on citalopram and hypertension was managed with diet only. Resident #6's blood pressure (BP) was monitored with six BPs documented during the 7 day look back period. The following BPs were obtained: 03/18/25 at 10:40 AM BP 136/88, 03/19/25 at 6:57 AM BP 126/78, 03/19/25 at 11:59 PM BP 118/62, 03/20/25 at 1:55 PM BP 112/64, and 03/24/25 at 4:55 PM BP 123/70. A weekly nursing summary dated 03/24/25 indicated Resident #6 was alert and oriented to person only and had episodic confusion. She also had short and long term memory problems and required total assistance with transfers and toilet use. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #6 had an active diagnosis of hypertension in the Heart/Circulation section or dementia in the Neurological section. An interview was conducted on 05/21/25 at 1:00 PM with Minimum Data Set (MDS) Nurse #2. She reviewed Resident #6's quarterly MDS assessment dated [DATE] and verified that hypertension in the Heart/Circulation section and dementia in the Neurological section were not coded. She stated she did not see any documentation of active diagnoses within the last 7 days in Resident #6's electronic medical record. She indicated it was an oversight that she did not see the documentation in the NPs notes or the vital signs area. She verified dementia and hypertension were included in the care plan. An interview was conducted on 05/21/25 at 2:52 PM with the Administrator. He stated he expected the MDS assessments to be coded accurately.

2. Resident #20 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including chronic obstructive lung disease (COPD) and respiratory failure. Physician orders for Resident #20 dated 4/26/25 specified oxygen flow rate to be administered at 3 liters per minute (LPM). The quarterly Minimum Data Set, dated [DATE] documented Resident #20 was cognitively intact and used oxygen. Review of the medication administration record for May 2025 indicated by the nursing initials that the oxygen flow rate of 3 LPM was checked by the nurse twice per day (once on each shift). Resident #20 was observed on 5/19/25 at 8:31 AM. She was in bed and had oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. Resident #20 reported she did not know the oxygen flow rate, but sometimes she felt like she was not getting enough oxygen. Resident #20 was observed on 5/20/25 at 11:06 AM in bed with an oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. On 5/21/25 at 8:50 AM, Resident #20 was observed in bed with an oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. Review of the medication administration record for 5/21/25 day shift revealed Nurse #2 initials that indicated she had checked the oxygen flow rate for Resident #20. Resident #20 was observed with Nurse #2 on 5/21/25 at 11:36 AM in bed with an oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. Nurse #2 reported the oxygen flow rate was supposed to be 2 LPM and 5 LPM was too much oxygen. Nurse #2 adjusted the oxygen flow rate to 2 LPM and then Nurse #2 checked the physician order and reported that she was wrong, and that Resident #20 should be receiving oxygen at 3 LPM. Nurse #2 returned to the room to correct the oxygen flow rate. When asked why the medication administration record indicated Nurse #2 had checked the flow rate on 5/21/25, Nurse #2 explained that she had checked the oxygen flow rate for residents in the past, but that she may have slacked off. The Unit Manager (UM) was interviewed on 5/21/25 at 11:45 AM and she reported the nurses should check oxygen flow rate for all residents receiving oxygen at least once per shift. The UM did not know why Resident #20's oxygen flow rate was set at 5 LPM. During an interview with the Director of Nursing on 5/21/25 at 3:30 PM, she reported that nurses are supposed to check the oxygen flow rate once per shift and that they documented in the medication administration record that the flow rate was correct. The DON reported she did not know why Resident #20's oxygen flow rate was set at 5 LPM and that the nurses should have corrected the flow rate to what the physician ordered. Based on record reviews, observations and interviews with resident, Physician Assistant and staff, the facility failed to obtain a Physician's order for a resident's use of oxygen (Resident #8) and failed to administer oxygen at the prescribed rate (Resident #20). In addition, the facility failed to apply signage indicating the use of oxygen outside the residents' rooms with supplemental oxygen (Residents #9 and #82). This deficient practice affected 4 of 6 residents reviewed for respiratory care. The findings included: 1. Resident #8 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure and asthma. She was recently hospitalized from [DATE] to 3/22/25 for norovirus and on 4/27/25 to 5/2/25 for cellulitis concerns. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact. She was not coded for the use of oxygen. A review of Resident #8's active care plan, last reviewed 4/1/25, had a focus area for oxygen therapy related to heart failure and COPD. The interventions included oxygen settings via nasal cannula per physician orders. Review of a physician's progress note dated 4/26/25 indicated oxygen was available as needed for shortness of breath for Resident #8. A review of Resident #8's April 2025 and May 2025 physician orders did not reveal any orders for the use of oxygen via nasal cannula. There was an order dated 1/21/25 to 3/21/25 for oxygen as needed at 2 liters per minute via nasal cannula for shortness of breath. On 5/18/25 at 10:15 AM, Resident #8 stated that she used 2 liters of oxygen via nasal cannula all the time. The oxygen concentrator was set at 2 liters flow and was in use by Resident #8. On 5/19/25 at 1:35 PM, Resident #8 was observed lying in bed watching TV. Oxygen was being used at 2 liters flow via a concentrator. Nurse #6 was interviewed on 5/20/25 at 10:05 AM and had been assigned to Resident #8 on 5/18/25. She stated she couldn't recall if Resident #8 had oxygen flowing on 5/18/25, however an oxygen concentrator was always available in her room within reach so she could place it on whenever she felt short of breath. Nurse #6 reviewed Resident #8's current physician orders and confirmed there was not an order for the use of oxygen and felt it had not been transcribed when Resident #8 had returned from one of her recent hospitalizations. Nurse #7 was interviewed on 5/20/25 at 1:11 PM and was assigned to care for Resident #8. She stated that Resident #8 has always had an oxygen concentrator in her room within reach that she would use when she felt short of breath. She verified that an order for the use of oxygen was not present for Resident #8 and felt it was not been reinstated when she had returned from her recent hospitalizations. The Physician Assistant (PA) familiar with Resident #8 was interviewed on 5/20/25 at 11:58 AM. He stated that Resident #8 had utilized oxygen in the past when she felt short of breath. He reviewed her current physician orders and verified an order for oxygen was not present. He stated that if Resident #8 was utilizing oxygen, then an order should have been present. The Director of Nursing (DON) was interviewed on 5/20/25 at 12:00 PM. She stated that Resident #8 had used oxygen as needed prior to her hospitalizations in March 2025 and April 2025. She verified there was no order for the use of oxygen when she was readmitted to the facility on [DATE] or 5/2/25 and felt it was an oversight. 3. Resident # 9 was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease. A physician's order for Resident # 9 dated 8/21/24 read oxygen continuous at 4 liters per minute via nasal canula. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 9 was cognitively intact and coded for the use of oxygen. During an observation on 5/18/25 at 10:52 AM of Resident #9's room, there was no signage for oxygen use found anywhere near Resident # 9's room entrance. Resident #9 was observed wearing oxygen via nasal cannula at 4 liters per minute (LPM). The oxygen concentrator was observed in Resident # 9's room. During an observation on 5/19/25 at 12:49 PM there was no signage for oxygen use found anywhere near the entrance of Resident # 9's room. Resident #9 was observed wearing oxygen via nasal cannula at 4 liters per minute (LPM). The oxygen concentrator was observed in Resident # 9's room. During an interview with Nurse #6 on 5/20/25 at 11:27 AM she stated that Resident #9 received oxygen continuously and nursing staff made sure oxygen was applied to Resident #9 and she was monitored. Nurse #6 further revealed that she did not know for sure why Resident #9 was missing the signage, but it should have been posted outside the door. An interview occurred on 5/20/25 at 11:42 AM with the Director of Nursing (DON). She stated it was the nursing staff's responsibility to put up the oxygen in use sign on the resident's door and if the signage is missing the nurse should have it replaced. An interview on 5/21/25 at 3:13 PM occurred with the Administrator. The Administrator indicated that Resident #9 should have had signage posted outside the room to indicate the use of oxygen. 4. Resident # 82 was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #82 was cognitively impaired and coded for the use of oxygen. A physician's order for Resident # 82 dated 3/25/25 read oxygen continuous at 3 liters per minute via nasal canula. During an observation on 5/18/25 at 11:01 AM of Resident #82's room, there was no signage for oxygen use found anywhere near Resident # 82's room entrance. Resident #82 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 82's room. During an observation on 5/19/25 at 12:52 PM there was no signage for oxygen use found anywhere near the entrance of Resident # 82's room. Resident #82 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 82's room. During an interview with Nurse #6 on 5/20/25 at 11:27 AM she stated that Resident #82 received oxygen continuously and nursing staff made sure oxygen was applied to Resident #82 and she was monitored. Nurse #6 further revealed that she did not know for sure why Resident #82 was missing the signage, but it should have been posted outside the door. An interview occurred on 5/20/25 at 11:42 AM with the Director of Nursing (DON). She stated it was the nursing staff's responsibility to put up the oxygen in use sign on the resident's door and if the signage is missing the nurse should have it replaced. An interview on 5/21/25 at 3:13 PM occurred with the Administrator. The Administrator indicated that Resident #82 should have had signage posted outside the room to indicate the use of oxygen.

Based on observations and staff interviews the facility failed to discard milk stored past the use by date in 1 of 1 reach-in cooler and failed to label, and date opened left food items in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: Observations during the initial tour of the main kitchen with Dietary Aide #1 on 05/18/25 at 9:56 AM, revealed the following: a. In the reach-in cooler the following leftover beverage was stored past the use by date: -one gallon of whole milk partially consumed with a use by date of 05/15/25. b. In the walk-in cooler the following items were observed on 05/18/25 at 10:02 AM with Dietary Aide #1. -two opened 5 pound bags of leftover shredded cheese with no label or date. An interview was conducted on 05/18/25 at 10:04 AM with Dietary Aide #1. She stated the milk should have been discarded by the use by date. She also stated when staff opened items the date should be written on the item including a use by date. c. In the walk-in cooler the following items were observed on 05/18/25 at 10:06 AM with the Dietary Manager. -One opened bag of hot dogs with no open date. -One 4 quart container of purple jelly like substance in it. Label read jelly with a use by date of 05/15/25. -One 4 pound roll of bologna with no open date. -One 2.5 pounds bag sliced cooked ham with a use by date of 05/15/25. An interview was conducted on 05/18/25 at 10:17 AM with the Dietary Manager. She stated she was responsible for monitoring the freezer and coolers for dated and labeled food items. She stated she had been on vacation since 05/13/25 and returned last night (05/17/25). She explained she checked the coolers and freezers on 05/12/25 prior to leaving the facility. She also explained that the facility Social Worker was making daily rounds in the kitchen using check off sheets that she provided to her while she was out. She then stated she expected Dietary Cooks and Aides to label and date items in the coolers and freezers according to regulations. An interview was conducted on 05/19/25 at 9:20 AM with the Social Worker (SW). She verified she made daily rounds in the kitchen from 05/13/25 through 05/16/25 using the check off sheets provided to her by the Dietary Manager. She stated on 05/14/25 she noted undated food in the walk-in-cooler and she notified kitchen staff at that time. She also stated on 05/15/25 she noted food that had not been labeled in the walk-in-cooler and she again notified the kitchen staff. The SW explained she did not see repeated undated, or items not labeled during the rounds. An interview was conducted on 05/20/25 at 11:02 AM with Dietary Aide #1. She verified she was working on 05/14/25 and 05/15/25 when the Social Worker (SW) was covering the kitchen. She stated the SW did tell her on 05/14/25 and 05/15/25 that there was an open food item that had no open date and there was a food item without a label. She stated the items had been opened on those days and she dated and labeled them according to regulation. An interview was conducted on 05/21/25 at 3:02 PM with the Administrator. He indicated he was unaware that dietary staff were not labeling or dating open food items and that they were not discarding opened food items within 7 days. He stated that he expected the Dietary Manager and kitchen staff to properly label, date, and discard prepared food items per regulations.

Based on observations, record review, and staff interviews, the facility failed to label enteral feeding formula for 1 of 2 residents reviewed for enteral feeding (method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) (Resident #79) and failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for 2 of 2 residents (Resident #79 and Resident #43) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination. The findings included: 1. Resident #79 was admitted to the facility 8/23/24 with diagnoses including anoxic brain injury. A physician order dated 4/10/25 specified for enteral feeding to be administered at 55 milliliters per hour via j-port (a tube that delivers enteral feeding directly into the small intestine) by pump. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #79 to be severely cognitively impaired. The MDS documented Resident #79 received enteral feedings and received 51% or more of calories by enteral feedings. a. Resident #79 was observed on 5/18/25 at 1:54 PM. The enteral tube feeding was infusing by j-port tube at 55 milliliters per hour. The enteral feeding was not labeled with the date or time the enteral feeding was changed. b. During the observation on 5/18/25 at 1:54 PM, the enteral feeding syringe was noted in a plastic bag with the plunger in the barrel of the syringe. Droplets of water were noted in the tip of the syringe and the interior of the plastic bag was noted to have droplets of water. Nurse # 3 was interviewed on 5/18/25 at 1:54 PM during the observation. Nurse #3 explained the enteral feeding was changed by night shift and she did not know why the bag of enteral feeding was not labeled with the date and time the feeding was changed. Nurse #3 reported the enteral feeding was changed when the bag was empty, and she didn't think there was a time limit on the feeding. Nurse #3 explained she was not aware the plunger for the enteral feeding syringe should be removed from the barrel and stored separately from the barrel. Nurse #3 reported she had used the syringe to administer medications by j-port tube to Resident #79 earlier in the day. The Director of Nursing (DON) was interviewed on 5/21/25 at 3:30 PM. The DON reported the enteral feeding came with a bag for the enteral feeding and a bag for the water hydration with one label to apply to the enteral feeding. The DON explained that the enteral feeding could hang for up to 24 hours before it needed to be discarded. The DON reported she did not know why the night shift nurse had not labeled the enteral feeding. The DON explained the plunger for the enteral feeding syringe should be removed from the barrel and stored separately from the barrel because of the potential for bacterial growth in the syringe tip when it was used for medication administration. The DON reported the enteral feeding should be labeled with the date and time it was hung, and the enteral feeding syringe should be stored with the plunger separated from the barrel. 2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and a history of a stroke. A review of Resident #43's physician orders included an order dated 12/21/23 to flush gastrostomy tube with 60 milliliters (ml) of warm tap water after each medication administration. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #43 was cognitively intact and received 51% or more of her total calories and more than 501 ml of fluids per day by enteral feedings. A review of Resident #43's Medication Administration Record (MAR) for 5/18/25 revealed she received medications and 60 ml of warm tap water after each medication administration at 8:00 AM and 9:30 AM on 5/18/25. During an observation of Resident #43 on 5/18/25 at 1:52 PM, the plastic syringe used to provide medications and flush her gastrostomy tube was noted in a plastic bag hanging from the feeding pump pole with the plunger in the barrel of the syringe. Droplets of a clear liquid were noted in the tip of the syringe and the interior of the plastic bag was noted to have droplets of a clear liquid. Nurse #5 was interviewed on 5/18/25 at 1:55 PM and explained she had provided Resident #43 with her medications and water flush via the gastrostomy tube that morning. She stated she was not aware the plunger should be removed from the barrel of the syringe and stored separately. The Director of Nursing (DON) was interviewed on 5/20/25 at 12:15 PM and stated the plunger for the enteral feeding syringe should be removed from the barrel and stored separately from the barrel because of the potential for bacterial growth in the syringe tip when it was used for medication administration.

Based on record review, resident, Pharmacist, and staff interviews, the pharmacy failed to label a medication blister package correctly, which resulted in the facility administering 18 doses of oxycodone (an opioid pain medication) to Resident #75 instead of ordered hydrocodone (an opioid pain medication). This was for 1 of 6 residents reviewed for medication administration. The findings included: Resident #75 was admitted to the facility 11/4/23 with diagnoses including stroke, chronic pain, and ovarian cancer. A physician order dated 2/28/24 specified for hydrocodone/acetaminophen 5/325 milligrams (mg) to be given by mouth every 4 hours as needed for pain. A facility incident report dated 4/5/24 and completed by Unit Manager (UM) #1 documented that on 4/5/24 it was discovered that Resident #75 received 18 doses of oxycodone/acetaminophen 5/325 mg instead of hydrocodone/acetaminophen 5/325 mg as the physician ordered. The incident report documented the tablets in the blister packet were scored, round, white tablets with the number 512 on them, and the labeling on the blister packet indicated the hydrocodone/acetaminophen tablets were oblong with M365 imprinted on the tablets. Resident #75 was notified of the medication error, and she reported that she had no adverse reactions to the oxycodone/acetaminophen. A progress note dated 4/5/24 documented the physician was notified of the medication packaging error. A nursing physical assessment was completed for Resident #75 on 4/5/24 at 1:19 PM and no issues were identified. A physician note dated 4/8/24 documented he was notified of the medication error, and this was not a significant medication error for Resident #75. The physician documented he had assessed Resident #75 who did not experience adverse effects from the medication error, and if she wanted to switch medication from hydrocodone to oxycodone, that would be fine. Review of the March 2024 and April 2024 medication administration record revealed that Resident #75 received oxycodone/acetaminophen 5/325 mg instead of hydrocodone on these dates: -3/27/24 at 5:18 AM, 12:26 PM, and 11:07 PM -3/28/24 at 1:14 PM, and 11:28 PM -3/29/24 at 11:11 AM -3/30/24 at 3:21 AM and 12:25 PM -3/31/24 at 1:08 PM -4/1/24 at 3:00 AM and 12:34 PM -4/2/24 at 12:11 AM and 12:42 PM -4/3/24 at 3:16 AM and 2:15 PM -4/4/24 at 3:32 AM and 12:18 PM 4/5/24 at 4:00 AM The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #75 was cognitively intact. The MDS documented Resident #75 took opioid medications. Resident #75 was interviewed on 5/18/25 at 11:20 AM and she reported that in April 2024, she was given the wrong medication. Resident #75 reported she did not recall the details of the error, but she did remember that she did not have good pain control during that time and felt that she needed medication more frequently. Resident #75 explained that the physician discussed the medication error with her and assessed her. Resident #75 reported that as far as she knew, no further medication errors had been made. UM #1 was interviewed on 5/21/25 at 11:39 AM. UM #1 explained that on 4/5/24 a nurse brought her a blister packet of medications labeled as hydrocodone/acetaminophen 5/325 mg. The nurse pointed out that the pills that were in the blister packet did not match the description of the pills on the pharmacy label and she thought the medications in the package were wrong. UM #1 described observing the medication blister package and calling the pharmacy to notify them the medication package was incorrect. The Director of Nursing (DON) was interviewed on 5/21/25 at 11:55 AM. The DON explained that a nurse discovered the medications packaged as hydrocodone/acetaminophen were incorrect, and the pharmacy was notified of the error. The DON reported a nurse consultant from the pharmacy was sent to the facility to check all narcotic medications and did not find any further mislabeled medications. The DON reported the facility audited all narcotics on all medication carts and did not find any other mislabeled medications. The DON reported the facility educated the nurses to examine the medications in the blister packaged to the description on the label to ensure the correct medications were packaged. The pharmacy Director of Operations was interviewed by phone on 5/22/25 at 1:58 PM. The Director of Operations reported that the pharmacy completed a root cause analysis to determine why the oxycodone/acetaminophen 5/325 mg was labeled with the hydrocodone/acetaminophen 5/325 mg label and they determined that a pharmacy technician grabbed the wrong blister packet, and the pharmacist had not double-checked the medication to ensure it was correct. The Director of Operations explained that the pharmacist was supposed to double-check the medications that the pharmacy technician brought to them for labeling, but this did not happen with this medication. The Director of Operations reported that the pharmacy discovered that they had a surplus of hydrocodone/acetaminophen and a shortage of oxycodone/acetaminophen when they did a weekly inventory check and the pharmacy was unable to determine where the error occurred, until the facility contacted the pharmacy on 4/5/24 and reported the error. The Director of Operations reported the pharmacy nurse consultant went to the facility and checked all narcotics in the building and did not find any other issues. The facility submitted the following plan of correction with a compliance date of 4/11/25: How corrective action will be accomplished for those residents found to have been affected by the deficient On 4/5/24 it was identified that Resident #75's hydrocodone did not have the same appearance as the usual pill. After researching the pills characteristics, it was identified that the medication had been packaged wrong at the pharmacy. The pharmacy had packaged Percocet in error. The pharmacy was notified by the Administrator. The Unit Manager completed a check of narcotics in the facility as soon as the issue was identified. In addition, the pharmacy sent a Nurse Consultant to the facility to conduct an audit of the narcotics. Resident #75 still resides in the facility and has had no further issues. Resident #75 had an assessment completed by the physician and no adverse reaction from the medication administered. Address how the facility will identify other residents having the potential to be affected by the same deficient. Residents residing in the facility have the potential to be affected by the deficient practice. The Unit Manager completed an audit of the five narcotic drawers on 4/5/25. The Nurse Consultant with Pharmacy Services completed an audit of the five narcotic drawers on 4/8/25 for residents' narcotics to ensure the dispensed medication matched the physician order. In addition, the medication label was matched to the medication dispensed. There were no issues identified. Address what measures will be put into place, or systemic changes made to ensure that the deficient practice will not occur. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was completed on 4/5/25 with the Administrator leading. The Administrator, the Regional Nurse Consultant, the Director of Public Relations, MDS nurse, Social Worker, Medical Records, Housekeeping Director, Activities Director, Admissions Director, Human Resources, the nurse at the time the incident was identified, and Medical Director were present for the meeting. The Director of Clinical Services at Polaris Pharmacy attended via telephone. The Director of Nursing was notified via telephone. The facility team collaborated with the pharmacy on an appropriate plan to avoid the incident happening again. The Team members present as well as the Director of Nursing approved the plan of correction and put it in to place. Education was completed by the Director of Nursing between 4/5/25 and 4/10/25 with the staff nurses regarding reconciliation of narcotics received to the physician order. The nurses were educated to match the paper delivery sheet to the pill, and to the physician order. The nurses were re-educated on using the description on the narcotic card to identify the pill. The nurse will check the label and description to the actual packaged product. Furthermore, the nurses were educated that the electronic health record has an area where they can see a picture of the pill if in question. Nurses that do not receive the education will not be able to start next shift until education is completed. Newly hired nurses will receive the education during orientation by the Director of Nursing. The pharmacy is using a process as follows: the technician types the order in, pharmacist checks the order and prints a label, technician labels the medication and pharmacist verifies. Pharmacist verifies that the label is correct and the medication being dispensed is what is packaged. A double check system is in place between technicians and pharmacists to check accuracy of label and medication. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision was made on 4/5/24 that the Director of Nursing or designee will audit narcotics on medication carts three times a week including weekends for four weeks, then one time a week including weekends for four weeks to ensure narcotics received from the pharmacy matched the physician order. The label is read to compare the packaged medication to the named medication on the label. The DON will read the label for the medication and description then compare to what the medication package looks like visually. On 4/5/24 during the ad hoc QAPI committee meeting it was decided the Director of Nursing or designee will forward the results of the audit to the QAPI committee for 3 months. The QAPI committee will review the audit to determine trends and/or issues that may need further interventions put into place and to determine the need for further and/or frequency of monitoring. The Administrator will be responsible for the plan of correction. Date of compliance 4/11/24. The plan of correction was validated on 5/22/25 by reviewing the education provided to the nurses, reviewing the audits conducted by the facility, interviewing the staff nurses about the process of accepting narcotics from the pharmacy and how to identify medications within the blister package, and reviewing the QAPI meeting notes. The compliance date of 4/11/24 was validated on 5/22/25.

Based on observation, record review, and staff interviews, the facility failed to post accurate nurse staffing forms for 5 of 8 posted daily posted nurse staffing forms reviewed (11/28/24, 3/14/25, 5/7/25, 5/17/25, and 5/18/25). The findings included: Posted nurse staffing forms for the following dates were reviewed: 7/20/24, 9/1/24, 11/28/24, 1/5/25, 3/14/25, 5/7/25, 5/17/25, and 5/18/25. a. The facility posted nurse staffing form was observed on 5/18/25 at 9:40 AM. The date on the staffing form was 5/16/25. The Receptionist was interviewed at the time of the observation, and she reported she did not know who was responsible for changing or updating the posted nurse staffing form. b. A posted nurse staffing form dated 11/28/24 was reviewed. The staffing form indicated 5 Licensed Practical Nurses (LPNs) were working 2nd shift (7:00 PM to 7:00 AM). The schedule indicated 4 LPNs were scheduled to work that shift. c. A posted nurse staffing form dated 3/14/25 indicated 9 Nursing Assistants (NA) were working 1st shift (7:00 AM to 7:00 PM). The schedule indicated 1 NA called out sick and 8 NAs were working that shift. d. The posted nurse staffing form dated 5/7/25 indicated no Registered Nurse (RN) worked 1st or 2nd shift, 10 NAs worked 1st shift. Review of timecards and the schedule for that date confirmed 1 RN worked 8 hours on day shift (8:30 AM to 4:30 PM) and 10.5 NAs worked 1st shift. e. The posted nurse staffing form dated 5/17/25 indicated 10 NAs worked 1st shift. Review of the schedule for that date, revealed 8.5 NA were working that date. An interview was conducted with the Scheduler on 5/21/25 at 12:34 PM. The Scheduler reported the RN should have been added to the nurse staffing form on 5/7/25 and she did not know why she was not added. The Director of Nursing was interviewed on 5/21/25 at 12:34 PM. The DON explained that some of the nursing staffing form errors may have been her responsibility, including adding the RN to the 5/7/25 posted nurse staffing form, but she was not certain. The DON explained that the nursing staffing form should be updated with any staffing changes. The Scheduler was interviewed again on 5/21/25 at 2:40 PM. The Scheduler reported she was making corrections to the nurse staffing forms during the week when she was in the building, and on the weekend, the receptionist was responsible, and she did not know why the receptionist had not updated the staffing form on 5/18/25.

2. Resident #64 was admitted to the facility 3/8/23 with the most recent readmission date of 4/26/25. Diagnoses for Resident #64 included respiratory failure and diabetes. a. A nursing note dated 2/25/25 documented Resident #64 had a change in condition and was transferred to the hospital. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident. A nursing note dated 3/1/25 documented Resident #64 returned to the facility after hospitalization. b. A nursing note dated 3/2/25 documented Resident #64 was transferred to the hospital after a change in condition. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident. A nursing note dated 3/4/25 documented Resident #64 returned to the facility after hospitalization. c. A nursing note dated 4/15/25 documented Resident #64 was transferred to the hospital after a change in condition. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident. A nursing note dated 4/26/25 documented Resident #64 returned to the facility after hospitalization. A significant change Minimum Data Set assessment dated [DATE] documented Resident #64 was severely cognitively impaired. The Responsible Party was not available for interview. An interview was conducted with the Director of Nursing (DON) on 5/20/25 at 9:30 AM. The DON reported the transfer form was sent with the resident when they were transferred to the hospital and the Responsible Party was notified of the transfer by phone. The DON explained that she was unaware the transfer notification was to be mailed to the Responsible Party and given to the resident. Based on record reviews and interviews with Responsible Party (RP) and staff, the facility failed to provide the RP written notification of the reason for a hospital transfer for 2 of 4 residents reviewed for hospitalization (Residents #7 and #64). The facility had no process in place to provide RPs with written notification which had the potential to affect all residents during transfers and discharges. The findings included: 1. Resident #7 was admitted to the facility on [DATE] and was noted to have a guardian for her medical and financial concerns. Resident #7 was transferred to the hospital on 1/7/25 for abdominal pain and on 4/17/25 for warmth and redness to a surgical site. On 5/20/25 at 9:30 AM, an interview occurred with the Director of Nursing (DON) who explained that when a resident was transferred to the hospital the transfer form was sent with the resident when they were transferred to the hospital and the RP was notified of the transfer by phone. The DON stated that Resident #7 had a guardian that the facility communicated with via phone regarding any changes or the need to transfer to the hospital. The DON stated she was unaware a written reason for a hospital transfer needed to be mailed to the RP. A phone interview was conducted with Resident #7's RP on 5/20/25 at 9:41 AM and stated that he was always informed by phone when Resident #7 was sent to the hospital but had not received anything in writing from the facility. The Administrator was interviewed on 5/21/25 at 1:52 PM, who had been employed at the facility since 3/17/25. The Administrator verified he was aware of the regulation regarding the need for written notice of transfer including the reason for the hospital transfer to be sent to the RP. He was unable to explain why this had not been completed for Resident #7 when she transferred to the hospital but stated a plan would be put into place going forward.

Based on record review, staff, resident, Emergency Service Services (EMS) Personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner, Medical Director, family, and Physician Assistant interviews the facility neglected to provide intravenous (IV) antibiotic medication as ordered for 14 days to a resident when his IV access became dislodged and neglected to direct him to a higher level of care, to replace the IV access line for 1 of 3 residents reviewed (Resident #244) for abuse/neglect. There was the the high likelihood of physical harm by not administering the IV antibiotic as ordered by the infectious disease clinic. The untreated bacterial infection had the high likelihood of causing loss of function to his extremities or possible amputation of his extremities. The facility also failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents reviewed for abuse/neglect (Resident #38). A cognitively intact male resident (Resident #241) was discovered in the bathroom of his room with a female resident (Resident #38), a severely cognitively impaired resident, with her pants off, brief off, and shirt pulled up near her breasts. During the facility's investigation in an interview, Resident #38 stated Resident #241 had stimulated and rubbed her breast(s) and stated she felt like she was being taken advantage of by Resident #241. Immediate jeopardy began on 07/14/23 when Resident #244's IV access become dislodged, and the facility neglected to re-establish his IV access or direct him to a higher level of care to ensure his IV access was restored and he could receive the IV medication he was prescribed. Immediate jeopardy was removed on 03/28/24 for Resident # 244 when the facility implemented a credible allegation of immediate jeopardy removal. Immediate jeopardy began on 2/13/24 for Resident # 241 and was removed on 2/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: 1. This tag is crossed referred: F684: Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. Resident #244 was discharged from the facility on 07/24/23 and followed up at the Infectious Disease office on 07/26/23, had his IV access restored and his IV antibiotics resumed at an outpatient infusion center. This deficient practice affected 1 of 2 residents reviewed for significant medication errors. F760: Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. During an interview with the Director of Nursing (DON) on 03/21/24 at 4:14 PM, she stated if the infectious disease office called on 07/14/23 and gave an order to send Resident #244 to the ER then they should have sent him to the ER. She explained that there was no documentation of Resident #244's refusal to go to the ER and she stressed the importance of documentation to the nursing staff all the time. The DON stated that it was not acceptable to not administer Resident #244's IV antibiotics as prescribed and they should have sent him to the ER so his IV access could be restored, and his IV antibiotics resumed. The Administrator was interviewed on 03/21/24 at 4:53 PM, she stated that Resident #244 was very difficult and extremely non complaint with staff, she further stated, What he did not want he did not want. She explained he pulled his PICC line out and the staff attempted to get vascular access and it was unsuccessful. The nursing staff spoke to Infectious Disease on 07/17/23 and made them aware that he was still receiving antibiotic by mouth and not receiving the IV antibiotic. The Administrator stated, I feel like we did everything we could have done, we notified the provider and did our due diligence. He refused everything. The Administrator was notified of the immediate jeopardy on 03/27/24. 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 neglected to provide intravenous antibiotics for 14 days to a resident when his intravenous access became dislodged. Administering the antibiotics was necessary to avoid physical harm. There was a high likelihood of serious hard or impairment when Resident #244's thoracis osteomyelitis (infection of the bone) and staphylococcus bacteremia (infection of the bloodstream left untreated for 14 days and the facility neglected to direct him to a higher level of care that could provide the ordered services. On 03/27/2024 the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. 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 03/27/2024 the Director of Nursing educated all licensed nurses on directing residents to a higher level of care if the needs of the resident cannot be met in the facility to avoid serious harm or impairment/ neglect of services needed. On 03/27/2024, the Director of Nursing educated all licenses nurses on following physician orders, notification of physician and documenting any barriers to IV antibiotic administration. On 03/27/2024 the Director of Nursing educated all certified nursing assistants on reporting changes in resident baseline, and any new acute observations to include observed IV issues. On 03/27/2024 the Director of Nursing educated all staff on heightened awareness of the definition of neglect, what constitutes neglect, and how to provide necessary care and services to the residents to ensure resident receive appropriate goods and services. On 03/27/2024, the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all staff revealed that they had been educated on neglect, what it was, how to identify it, and who and when to report it to. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated. 38904 2. Resident #241 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #241 was cognitively intact and required moderate assistance with walking and used a wheelchair and walker for ambulation. There were no behaviors documented on the MDS. Resident #241's Care Plan dated 2/9/2024 indicated he was independent but could require set-up assistance with transferring to his wheelchair. The Care Plan did not indicate he had behaviors. Resident #38 was admitted to the facility on [DATE]. Resident #38 cumulative diagnoses included: dementia, schizoaffective disorder, bipolar disorder, and posttraumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was severely cognitively impaired, she did not ambulate, and she required extensive assistance for transfers and toileting, she did not have any behaviors, and she was occasionally incontinent of bowel and bladder. Resident #38's Care Plan was reviewed and stated she had impaired cognitive function due to impaired thought process related to dementia, psychoactive medication use, and a history of head injury; she required care with all activities of daily living due to dementia, decreased balance, and limited mobility; and she had behaviors of wandering and decreased safety awareness. The Care Plan included interventions of monitoring and reporting any changes in cognitive function, providing a home like environment, and assisting with decision making for impaired cognitive function; assisting with activities of daily living such as showering, bathing and personal care as needed; providing medications as ordered, and anticipate the residents needs for behaviors. Resident #47 was admitted to the facility on [DATE] with diagnoses of stroke, mood disorder, and diabetes. A review of Resident #47's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. Resident #47's Care Plan dated 2/10/2024 indicated he did not have cognitive issues or behaviors. An interview was conducted on 3/21/2024 at 10:25 am with Resident #47, who was the roommate of Resident #241. Resident #47 stated Resident #241 pushed Resident #38 into their room on the evening of 2/13/2024 and they were watching television together. Resident #241 then wheeled Resident #38 into the bathroom and shut the door, and he knew that wasn't right. Resident #47 stated he put on his call light and Nurse Aide (NA) #1 answered. He stated he told Nurse Aide #1 that Resident #241 and Resident #38 were in the bathroom and Nurse Aide #1 went to get the Nurse. On 3/21/2024 at 5:03 pm Nurse Aide (NA) #1 was interviewed by phone and stated she answered Resident #47's (roommate for Resident #241) call light and he told her he thought his roommate, Resident #241, was trying to have sex with that lady (Resident #38) in the next room. Nurse Aide #1 stated she went to the next resident room and there was a resident in the room and then she checked the bathroom and there were no other residents in the bathroom, so she dismissed the allegation and did not look any further for the two residents. Nurse Aide #1 stated she might have told Nurse #2 about Resident #47's allegation but she was not sure if she told someone. During an interview with Resident #38 on 3/21/2024 at 6:28 pm she stated she could not remember what happened when she was found in the bathroom with Resident #241 on 2/13/2024. She stated she thought it was something unpleasant and she felt violated but was unable to verbalize any details of the incident and she did not remember if the incident happened in the facility or somewhere else. On 2/13/2024, during the facility's investigation into the allegation of sexual abuse, the Director of Nursing interviewed Resident #241's roommate, Resident #47, and he stated Resident #241 pushed Resident #38 into his bathroom and shut the door. Resident #47 stated when Nurse Aide #1 entered the room to answer his call light he mouthed the words that Resident #241 and Resident #38 were in the bathroom. The facility provided a copy of the statement Resident #241 gave on 2/13/2024 and he stated Resident #38 was complaining about her brief rubbing against her because it was too tight, and she could not break the tape on the brief, so he tore the tape and pushed the brief down for her. Resident #241 also stated during the statement that he did not touch her he just pushed the brief down. A phone interview was conducted 3/22/2024 at 1:03 pm with Resident #241 and he stated the facility had accused him of doing something to Resident #38. He stated they were friends and they held hands, and he bought her candy. He stated he went into the bathroom with Resident #38 because she needed to use the toilet and she could not remove her brief without assistance. Nurse #1 was interviewed by phone on 3/22/2024 at 9:33 am, she stated she worked for an agency staffing company, and she was Resident #241's nurse on 2/13/2024 on the 7:00 pm to 7:00 am shift. Nurse #1 stated she went into Resident #241's room at approximately 9:30 pm to give him his evening medications. She stated when she did not see Resident #241 in his room she went to the bathroom door, which was closed, and when she opened it, Resident #38 was sitting in her wheelchair, her brief was on the floor beside her wheelchair, her pants were pulled down to the floor, and her shirt was pulled up to just below her breasts. Nurse #1 stated Resident #241 was standing with his hands in front of his abdomen, he was fully clothed, and he told Nurse #1, Resident #38 was changing her brief and she was doing a good job. Nurse #1 stated she called for Nurse #2 to help her separate the residents. Nurse # 2 was interviewed by phone on 3/22/2024 at 9:15 am and she stated Nurse #1 called her to Nurse #2's unit and stated Resident #241 was with Resident #38 in his bathroom and she needed her assistance. She stated Resident #241 was standing at the door to the bathroom when she arrived at the room and did not want to let her in, and he stated he was helping Resident #38 change her brief. Nurse #2 stated Nurse #1 took Resident #241 out of the room and she assisted Resident #38 with dressing, and she spoke with Resident #38 after assisting Resident #241 out of the bathroom and Resident #38 told her Resident #241 stimulated her and touched her boobs. Nurse #2 further stated Resident #38 said Resident #241 did not hurt her, but it was not pleasurable, or painful. Nurse #2 stated Resident #38 did not act like she was upset and did not appear to be trying to get away from Resident #241 when she entered the bathroom. Review of Resident #38's Nurse's Progress notes revealed a note by the Director of Nursing (DON) on 2/13/2024 at 11:19 pm which stated she was notified by Nurse #2 of Resident #38 being discovered in Resident #241's bathroom and Resident #38 stated Resident #241 had touched her breasts and stimulated her. The DON's Progress Note further revealed the residents were separated; Resident #38's Responsible Party was notified of the situation; and an investigation was initiated. The DON's Progress Note also stated Resident #38 denied pain, stated she felt safe; and exhibited no distress. During a review of the facility's investigation after the incident the Director of Nursing and Social Worker interviewed Resident #38 and a written statement indicated Resident #38 stated she remembered she was not hurt or scared; it felt good; and she felt like he (Resident #241) was playing a game, and she was being taken advantage of. On 3/21/2024 at 1:34 pm the Director of Nursing (DON) was interviewed, and she stated she received a phone call from the Nurse #2 on 2/13/2024 at 9:30 pm. She stated during the phone call Nurse #1 told her Resident #38 was found in Resident #241's bathroom with Resident #241. When Resident #38 was found with Resident #241 she was undressed from the waist down, and Resident #241 stated he was helping her go to the bathroom. She stated she and the Social Worker began an investigation immediately and Resident #38 was calm and did not appear to be in distress. The DON stated they interviewed Nurse #1, Nurse #2, Nurse Aide #1, and Resident #47 after they interviewed Resident #38 and Resident #241. She stated Nurse #1 put Resident #241 on 1:1 observation and separated him from Resident #38. The DON stated Resident #47 requested a room change and he was moved to another room that evening. A Progress Note written by the Physician's Assistant (PA) on 2/14/2024 stated Resident #38 was seen due to an allegation of sexual assault by a male resident. The Progress Note stated staff reported Resident #38 was found with her pants and brief pulled down and a male resident grabbed her breast. The Progress Note further stated Resident #38 was severely cognitively impaired, had a history of bipolar disorder and suffered from post-traumatic stress disorder and her recall of events is limited. The PA's Progress Note stated a physical assessment was performed and no bruising, bleeding or other abnormal findings were found from the physical exam; no pain was reported; and the resident did not appear to be in acute distress. The Physician's Assistant (PA) was interviewed on 3/21/2024 at 11:59 am and she stated she was on call when Resident #38 was found in the bathroom with Resident #241 when her brief was off, and her pants were pulled down. The PA stated she saw Resident #38 the next day and she could recall some things but could not specify what had happened. The PA stated Resident #38 could remember a man in the bathroom. She stated she denied pain and her physical exam was normal. On 3/19/2024 at 4:30 pm a phone interview was conducted with the Family Member of Resident #38, and he stated the Administrator called him on the evening of 2/13/2024 and reported she was found Resident #38 in male resident's bathroom partially unclothed. He stated the facility had separated Resident #241 from Resident #38 and protected her from any further incidents. He stated Resident #38 was severely cognitively impaired and did not talk about the incident after it happened. On 3/22/2024 at 12:32 pm the Administrator was interviewed, and she stated the facility had completed a plan of correction for the allegation of sexual abuse on 2/13/2024 when Resident #38 was found sitting in her wheelchair with Resident #241, in his bathroom, with her shirt pulled up to below her breasts, her brief on the floor beside her wheelchair, and her pants pulled down to her ankles. She stated the Director of Nursing (DON) and Social Worker (SW) began interviewing the staff and residents involved. She stated Nurse #1 and Nurse #2 put Resident #241 on 1:1 observation and at Resident #47's request, they transferred him to another room. The Administrator further stated she and the DON began education about the facility's Abuse Prohibition and Reporting Policy on 2/13/2024 with all staff including the nursing department, dietary department, maintenance department, housekeeping department, therapy department and administration staff. She stated they educated all staff on the kinds of abuse, signs of abuse, and what to do if the staff suspect or have abuse reported to them. The Administrator stated they had continued to educate all new staff and they had taken the results of their monitoring to their monthly Quality Assurance Meetings. The Administrator was notified of the immediate jeopardy on 03/22/2024 at 7:55 pm. The facility provided the following credible allegation of immediate jeopardy removal for Resident #38: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On February 13, 2024, nurse #1 entered resident #241's room. Nurse #1 observed resident #38 in resident #241's bathroom with her pants down to her ankles with her brief off sitting in her wheelchair with resident #38 standing beside resident #241. Nurse #1 called for nurse #2. Nurse #1 immediately removed resident #241, who is cognitively intact, from resident #241's bathroom and stayed with him in the dayroom [ROOM NUMBER]:1 while nurse # 2 remained with resident #38. Nurse #2 assessed, dressed, and interviewed resident #38, who is severely cognitively impaired with a diagnosis of Dementia/Alzheimer's. Nurse #2 then removed resident #38 and returned her to her room. Nurse #2 notified the Director of Nursing (DON) of incident with resident #38 and resident #241. DON notified Administrator of incident with resident #38 and resident #241. The administrator notified social worker and treatment nurse and requested their assistance with incident in the building. On 2/13/2024, upon notification by phone of incident, the Director of Nursing (DON) and treatment nurse drove to the facility to meet with Resident #38, who was severely cognitively impaired, with a diagnosis of Dementia/Alzheimer and was assessed by the DON and treatment nurse for any injury on the residents' body as a result of the alleged abuse and incontinent care was provided for resident #38. The assessment revealed that resident #38 had no obvious bruising or redness on her body or genitals. 0n 2/14/2024 the psych provider was notified of incident with resident #38. On 2/20/2024 the psych provider visited with resident #38. On 2/13/2024, upon notification by phone of incident, the Administrator drove to the facility, it was determined that there was suspected abuse, notified police and adult protective services and submitted initial allegation report to State Survey Agency at 10:59 pm. The Administrator and DON notified Resident #38's responsible party and the on-call provider of the alleged abuse. The Administrator and police conducted an interview of resident #241, nurse #1, and nurse #2 regarding alleged abuse. Upon notification by phone the social worker drove to the facility to meet Resident #38 and conduct interview for alleged abuse. On 02/13/2024, the Social Worker and Director of Nursing interviewed resident #38 regarding alleged abuse. On 2/13/2024 at 10:00 pm resident #241's roommate was moved from room [ROOM NUMBER]B to 108B. Resident #241 was then taken back to his room by nurse remaining 1:1 until he discharged on [DATE]. On 02/14/2024, the Administrator concluded alleged abuse investigation and based on investigation findings, unsubstantiated the alleged abuse of resident #38. On 02/14/2024 at 1:59 am, the Administrator submitted an investigation report to the State Survey Agency. Resident # 241 was discharged from the facility on 02/14/2024. On 2/13/2024, social worker completed 100% interviews of alert and oriented residents for sexual abuse. On 02/13/2024 the treatment nurse completed 100% skin checks of cognitively impaired residents for signs of abuse. Findings included: No other residents affected by alleged abuse. 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 02/13/2024 the Director of Nursing began in-service of all full-time, part-time, and PRN (as needed) staff, administration, housekeeping, dietary, nursing, therapy and maintenance (including agency) on the abuse prohibition/reporting policy. This training will include all current staff including agency. This training included: Residents' right to be free from abuse, Abuse Types, screening of residents for red flags indicative of potential perpetrator behavior, identifying what constitutes abuse, recognizing signs of abuse, understanding behavioral symptoms of residents that may increase their risk of abuse and/or of being victimized, what to do if abuse is observed or suspected, and assuring resident safety. Staff were also educated to have heightened awareness, understanding and identifying resident #38 behaviors that placed her at an increased risk of abuse and monitoring, prohibiting and preventing abuse for resident #38. Staff were also asked if they were aware of any abuse occurring to any resident in the facility. No staff were aware of any other alleged abuse occurring in the facility. The Director of Nursing will ensure that any of the above-identified staff (all staff including agency) who do not complete the in-service training by 02/13/2024 will not be allowed to work until the training is completed. The Director of Nursing will ensure this training will be included in new hire orientation for any newly hired staff. Alleged date of IJ removal was 02/15/24. The facility provided evidence of correction of action accomplished for Resident #38 on 03/22/24. The facility provided documentation of Resident #241 being put on 1:1 observation immediately after the incident was discovered and continued until he was discharged from the facility on 2/14/24. The facility began an investigation by interviewing all staff involved on 2/13/2024. The facility also provided documentation of assessment of Resident #38 by Nurse #2 on 3/13/2024 and by the Nurse Practitioner on 3/14/2024. The facility provided evidence of actions accomplished for all other residents by providing skin assessments of all residents that were cognitively impaired and could not answer a questionnaire. They also provided documentation of questionnaires completed with any residents that were able to answer questions regarding any allegations of abuse and no issues were reported. The facility provided in-service education for all staff, for all departments, including agency and contracted staff regarding their abuse and neglect policy. The facility provided documentation of their monitoring, review of the monitoring, and their monthly Quality Assurance Committee meeting which included the review monitoring and in-servicing of all employees. The IJ removal date of 02/15/24 was validated.

Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. Resident #244 was discharged from the facility on 07/24/23 and followed up at the Infectious Disease office on 07/26/23, had his IV access restored and his IV antibiotics resumed at an outpatient infusion center. This deficient practice affected 1 of 2 residents reviewed for significant medication errors. Immediate jeopardy began on 07/14/23 when the Infectious Disease office instructed the facility staff to send Resident #244 to the ER to have his PICC line replaced so that he could resume his IV antibiotics and the facility failed to do so. Immediate jeopardy was removed on 03/28/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The finding included: Review of Resident #244's discharge summary from the local hospital dated 06/29/23 read in part, chronic left humeral fracture from a motor vehicle accident in 2018 with fixation with hardware and recurrent infection/osteomyelitis due to methicillin sensitive staphylococcus aureus (MSSA) status post recent left arm amputation 2 weeks ago. The discharge summary further indicated severe thoracic spinal stenosis with cord flattening, posterior disc bulging, vertebral abnormal marrow signal intensity possible osteomyelitis. Infectious disease on board and antibiotics were switched to daptomycin and ciprofloxacin to complete 8 weeks of antibiotic regimen. Resident #244's discharge medications included: Daptomycin (antibiotic) 500 milligrams (mg) intravenously (IV) daily and Ciprofloxacin (antibiotic) 750 mg by mouth twice daily. Both were to be given for a total of 8 weeks and were to be discontinued on 08/19/23. Resident #244 was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #244's diagnoses included thoracic osteomyelitis with spinal stenosis and left upper extremity amputation. Review of physician orders dated 06/30/23 read, Ciprofloxacin 750 mg by mouth twice a day until 08/19/23. Daptomycin 500 mg IV every day until 08/19/23. Review of the Medication Administration Record (MAR) dated July 2023 revealed that Resident #244's Ciprofloxacin was administered as prescribed during his time in the facility. The MAR further revealed that the Daptomycin was not given from 07/11/23 through 07/24/23. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #244 was cognitively intact with no rejection of care. The MDS further indicated he received IV medications and 7 days of antibiotic during the assessment reference period. A nurses note dated 07/11/23 at 7:24 PM read in part, nurse entered room to check on resident and his PICC line. Resident was digging in closet and nurse asked what was wrong and he stated his PICC line came out and PICC line noted on bedside table. This nurse requested resident to allow nurse to place pressure dressing on site and resident refused and stated it was fine. Nurse attempted to educate resident on need for pressure dressing and resident started cussing and threatening nurse. Resident told this nurse not to return to his room for any reason. No obvious signs of bleeding noted at the PICC line site with tip intact. The note was written by Nurse #3. Review of a physician order dated 07/12/23 read pulled IV out, unable to place new line. PICC line to be put in place by third party. Medication to be held until PICC line inserted. The order was entered by Nurse #4. The order was a verbal order from the Medical Director (MD). Review of a care plan initiated on 06/30/23 read, I have osteomyelitis/discitis of the vertebra and am receiving IV antibiotic therapy, unless otherwise specified this event will be resolved as of 08/22/23. The goal read, The resident will be free from complications related to infection through the review date. The interventions included, administer antibiotics as per MD order, follow facility policy and procedures for line listing summarizing and reporting infections, maintain universal precautions when providing care, monitor temperature/pulse as ordered, monitor and report signs of delirium. Review of a document from a third-party company dated 07/13/23 at 1:00 PM read in part, large red area to the inner side of right arm, patient pulled out at least 2 lines already maybe more. Right cephalic vein (superficial vein in arm) with good blood return but the guide wire (used to insert catheter) only went up 8 centimeters. Right brachial vein (another superficial vein in arm) good blood return by would not thread guidewire. Not a candidate for future PICC or midline access. The form was signed by the technician that attempted to reinsert the PICC line. Review of intraoffice communication from the Infectious Disease office dated 07/14/23 at 2:01 PM read, had a call today from {Unit Manager} stated that Resident #244's picc line was out that had someone to come there and try to put it in and they could not get it in. I called back and down there and talked to the nurse with him today {Nurse #10} and she said she was not given any orders for IV antibiotics. She was giving him the cipro. I told her she needed to take him to the ER and get the PICC line put back in. I told her if PICC line had been out it was 2 days he has gone without his medication. The Unit Manager was interviewed on 03/20/24 at 3:45 PM, she stated that she had worked at the facility for 9 months. She stated she did not recall calling Infectious Disease regarding Resident #244 and did not recall having any involvement with the Resident #244 or the situation. Review of intraoffice communication from the Infectious Disease office dated 07/17/23 read, I called the nursing home and spoke with {Nurse #11} to see if they took him to the hospital to have PICC line put in. she said no they had someone to come out there. They could not get it in. Said his arm was too sore. Nurse #11 was interviewed via phone on 03/20/24 at 3:05 PM. Nurse #1stated that she had received in report that Resident #244's PICC line was out, and he missed doses of his antibiotic. She stated that she had called the Infectious Disease office and made them aware that Resident #244's PICC line came out and that they tried to re-insert it and it was unsuccessful. She could not recall who gave her report that day or who she spoke to at the Infectious Disease office, but they did not give me any orders, or I would have put them in my notes. Nurse #11 stated she did recall speaking the facility NP or MD regarding Resident #244's PICC line or medication. Resident #244's family was interviewed via phone on 03/20/24 at 4:41 PM. The family member stated that after Resident #244 was discharged from the facility he had followed up at the Infectious Disease office and continued his antibiotic treatment. Nurse #10 was interviewed via phone on 03/21/23 at 9:01 AM. She stated that it had been a while since she had worked at the facility. She stated that she really did not recall Resident #244, she remember that she came to work one day, and someone did not have an IV line so she could not administer the IV antibiotic. It rings a bell that maybe I called to have the line replaced but it is odd that I did not make a note about it. Typically, I would have called the provider and told them that he did not have IV access and then carry out whatever orders they gave. If they would have told me to send Resident #244 to the hospital I would have done so because it is unacceptable to skip an antibiotic. A follow up interview was conducted with Nurse #10 on 03/21/24 at 3:38 PM. Nurse #10 confirmed that she did not receive a call with instructions to send Resident #244 to the ER. If she would have, she would put the order into the system, called Emergency Medical Services (EMS) and notified the management team. Finally, I would have documented in the medical record the situation. Nurse #6 was interviewed via phone on 03/22/24 at 10:43 AM, she stated that she had not worked at the facility for 6 months. She stated that she did not recall getting any orders from Infectious Disease or from the providers regarding Resident #244. She added that she was not able to give him his IV antibiotic because he did not have a PICC line in place. She stated she believed the staff tried to send him to the ER and when EMS came, they told them that the ER would not place a PICC line. She stated that EMS had called the ER, and the ER staff told them no they could not replace a PICC line. Nurse #6 stated that most of the time the pharmacy would come and replace the PICC line, and she believed they were contacted to come and replace the line. An interview was conducted with EMS personnel on 03/26/24 at 3:15 PM and they had no record of any run reports for Resident #244 at the facility from 07/11/23 through 07/24/23. The DON was interviewed on 03/20/24 at 5:07 PM who stated she recalled Resident #244 as he only had one arm and he pulled his PICC line out. She stated that he refused to have it reinserted as he wanted to go home. The DON stated that the Infection Disease office was notified on 07/17/24 that his line was out, and he had missed doses of the IV Daptomycin. When asked why she did not send Resident #244 to the emergency room (ER) for assistance in getting a PICC line or other line inserted for the antibiotic she replied, if we cannot get a line the ER cannot get a line. The ER cannot put a PICC line in because they do not have access people over there to do it. The ATB was placed on hold pending an appointment with Infection Disease. The DON stated, I do not when the appointment was it has been over a year ago. He only had one arm and if we could not get a line the ER could not get a line. She added that she had no contact with Infectious Disease office during this time. The DON stated that with no IV access the IV antibiotic could not be administered. The Infectious Disease Nurse Practitioner (NP) was interviewed via phone on 03/20/24 at 12;15 PM who stated that if Resident #244's PICC line was dislodged, or he did not have access and access was unable to be obtained then he should have been immediately sent to the ER so we could have restored his access. She explained that there were numerous other types of line access that they could have done for Resident #244 including a central line or tunneled PICC line in the groin. The NP stated, it is not reasonable to not receive antibiotics for a portion of time due to access issues. It is prudent of any skilled nursing facility if the PICC line is out and attempts to reinsert failed, then he should have been directed to higher level of care, not say oh well and not give for 2 weeks. The NP added, if the facility could not figure out how to work through the access issues we could have helped them. She added that Resident #244 had thoracic spinal osteomyelitis with spinal stenosis and staphylococcus bacteremia and untreated could lead to loss of limb function and he was already a left upper extremity amputee. The NP stated that Resident #244 was seen in the office 2 days after discharging from the facility on 07/26/23 and his access was restored, and we resumed his IV antibiotic at an outpatient infusion center and extended the duration to make up for the missed doses at the facility. The MD was interviewed via phone on 03/20/24 at 1:26 PM. He stated that he did not recall being made aware that his PICC line was out and that he had missed 14 doses of the IV antibiotic. The MD stated had he been aware that an attempt to reinsert the PICC line was unsuccessful, he would have directed the staff to send Resident #244 to the ER to have access regained. The MD stated, it was very concerning that he missed 14 doses of antibiotic. The facility NP #2 was interviewed via phone on 03/20/24 at 4:47 PM, she stated she recalled Resident #244 but stated she did not recall any issues with his PICC line or missing doses of his scheduled antibiotic. She explained that she was out of state on personal business during this time but had someone contacted her, she would have directed the staff to send Resident #244 to the ER. The Administrator was notified of immediate jeopardy on 03/27/24. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to send resident #244 to the hospital to have his intravenous access (IV) replaced, when his peripherally inserted central catheter became dislodged, as directed by the Infectious Disease provider on 07/14/2023. Resident #244 missed 14 doses of the IV antibiotics before being discharged from the facility, and then resuming his IV antibiotic course at a outpatient infusion center. There was a high likelihood of serious harm of impairment when resident #244 was not directed to a high level of care, and when attempts to restore his IV access were unsuccessful at the facility. On 03/27/2024, the Director of Nursing assessed all current residents receiving IV antibiotics for: IV access placement/ patency/ function, and orders for administration of IV antibiotic therapy course, to ensure residents are receiving their antibiotics as ordered by the physician, and do not require a higher level of care to meet resident current needs. 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 03/27/2024, the Director of Nursing educated licensed nurses on directing residents to a higher level of care, if the needs of the resident cannot be met in the facility to avoid serious harm or impairment. 03/27/2024, the Director of Nursing educated licenses nurses (to include agency) on following facility provider orders (to include consulting physicians and notification of facility provider/consulting physicians within the realm of practice) and documenting any barriers to IV antibiotic administration. On 03/27/2024, the Director of Nursing educated all certified nursing assistants on reporting changes in resident baseline, new acute observations; to include observed IV issues. On 03/27/2024, the Director of Nursing reviewed all current residents receiving IV antibiotics for: IV access placement/ patency/ function, and orders for administration of IV antibiotic therapy course; to ensure residents are receiving their antibiotics as ordered by the physician, and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses and agency nurses. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated.

Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. Immediate jeopardy began on 07/14/23 when Resident #244's PICC line become dislodged, and the facility failed to direct him to higher level of care to ensure he received the IV antibiotic he required. Immediate jeopardy was removed on 03/28/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Review of Resident #244's discharge summary from the local hospital dated 06/29/23 read in part, chronic left humeral fracture from a motor vehicle accident in 2018 with fixation with hardware and recurrent infection/osteomyelitis due to methicillin sensitive staphylococcus aureus (MSSA) status post recent left arm amputation 2 weeks ago. The discharge summary further indicated severe thoracic spinal stenosis with cord flattening, posterior disc bulging, vertebral abnormal marrow signal intensity possible osteomyelitis. Infectious disease on board and antibiotics were switched to daptomycin and ciprofloxacin to complete 8 weeks of antibiotic regimen. Resident #244's discharge medications included: Daptomycin (antibiotic) 500 milligrams (mg) intravenously (IV) daily and Ciprofloxacin (antibiotic) 750 mg by mouth twice daily. Both were to be given for a total of 8 weeks and were to be discontinued on 08/19/23. Resident #244 was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #244's diagnoses included thoracic osteomyelitis with spinal stenosis and left upper extremity amputation. Review of physician orders dated 06/30/23 read, Ciprofloxacin 750 mg by mouth twice a day until 08/19/23. Daptomycin 500 mg IV every day until 08/19/23. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #244 was cognitively intact with no rejection of care. The MDS further indicated he received IV medications and 7 days of antibiotic during the assessment reference period. Review of the Medication Administration Record dated July 2023 revealed that Resident #244 did not receive Daptomycin 500 mg IV from 07/11/23 through his discharge on 07/24/23. A nurses note dated 07/11/23 at 7:24 PM read in part, nurse entered room to check on resident and his PICC line. Resident was digging in closet and nurse asked what was wrong and he stated his PICC line came out and PICC line noted on bedside table. This nurse requested resident to allow nurse to place pressure dressing on site and resident refused and stated it was fine. Nurse attempted to educate resident on need for pressure dressing and resident started cussing and threatening nurse. Resident told this nurse not to return to his room for any reason. No obvious signs of bleeding noted at the PICC line site with tip intact. The note was written by Nurse #3. Review of a physician order dated 07/12/23 read pulled IV out, unable to place new line. PICC line to be put in place by third party. Medication to be held until PICC line inserted. The order was entered by Nurse #4. The order was a verbal order from the Medical Director (MD). Review of a Medication Administration Note dated 07/11/23 at 8:26 PM by Nurse #3, Daptomycin 500 mg every 24 hours until 08/19/23 hold pending PICC replacement. Review of a Medication Administration Note dated 07/12/23 at 9:48 PM read in part, placement of PICC line unsuccessful. The note was written by Nurse #5. Review of a document from a third-party company dated 07/13/23 at 1:00 PM read in part, large red area to the inner side of right arm, patient pulled out at least 2 lines already maybe more. Right cephalic vein (superficial vein in arm) with good blood return but the guide wire (used to insert the catheter) only went up 8 centimeters. Right brachial vein (another superficial vein) good blood return by would not thread guidewire. Not a candidate for future PICC or midline access. The form was signed by the technician that attempted to reinsert the PICC line. Review of a Medication Administration Note dated 07/13/23 at 7:58 PM read, attempts to replace PICC line this shift were unsuccessful. The note was written by Nurse #5. Review of intraoffice communication from the Infectious Disease office dated 07/14/23 at 2:01 PM read, had a call today from {Unit Manager} stated that Resident #244's picc line was out that had someone to come there and try to put it in and they could not get it in. I called back and down there and talked to the nurse with him today {Nurse #10} and she said she was not given any orders for IV antibiotics. She was giving him the cipro. I told her she needed to take him to the ER and get the PICC line put back in. I told her if PICC line had been out it was 2 days he has gone without his medication. Review of a Medication Administration Note dated 07/14/23 at 7:50 PM read, PICC line to be replaced. The note was written by Nurse #2. Review of a Medication Administration Note dated 07/15/23 at 9:52 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, no access. The note was signed by Nurse #6. Review of a Medication Administration Note dated 07/16/23 at 8:08 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, held until PICC line placed. The note was signed by Nurse #7. Review of intraoffice communication from the Infectious Disease office dated 07/17/23 read, I called the nursing home and spoke with {Nurse #11} to see if they took him to the hospital to have PICC line put in. she said no they had someone to come out there. They could not get it in. Said his arm was too sore. Review of a Medication Administration Note dated 07/17/23 at 8:36 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, hold pending infectious disease appointment and PICC placement. The note was signed by Nurse #3. Review of a nurses note dated 07/18/23 at 9:37 AM read in part, resident continues on therapy, IV antibiotic on hold due to unable to obtain line due to multiple attempts with resident pulling PICC lines out. On oral antibiotic to discharge home when complete. The note was signed by the Director of Nursing (DON). Nurse #3 was interviewed on 03/20/24 at 3:21 PM who stated that she recalled Resident #244 had rolled over in bed and pulled his PICC line out. She stated she found it on his bedside table. Nurse #3 stated that Resident #244 would not allow the area to be dressed and began cursing at Nurse #3. She stated she had called and got an order for reinsertion and to hold the IV antibiotic pending reinsertion. Resident #244's family was interviewed via phone on 03/20/24 at 4:41 PM. The family member stated that after Resident #244 was discharged from the facility he had followed up at the Infectious Disease office and continued his antibiotic treatment. The DON was interviewed on 03/20/24 at 5:07 PM who stated she recalled Resident #244 as he only had one arm and he pulled his PICC line out. She stated that he refused to have it reinserted as he wanted to go home. The DON stated that the Infection Disease office was notified on 07/17/24 that his line was out, and he had missed doses of the IV Daptomycin. When asked why she did not send Resident #244 to the emergency room (ER) for assistance in getting a PICC line or other line inserted for the antibiotic she replied, if we cannot get a line the ER cannot get a line. The ER cannot put a PICC line in because they do not have access people over there to do it. The ATB was placed on hold pending an appointment with Infection Disease. The DON stated, I do not know when the appointment was it has been over a year ago. He only had one arm and if we could not get a line the ER could not get a line. She added that she had no contact with Infectious Disease office during this time. The DON stated that with no IV access the IV antibiotic could not be administered. Nurse #2 was interviewed via phone on 03/22/24 at 9:58 AM. Nurse #2 stated she worked all the units and did not recall Resident #244's name or situation, she stated I see some of everyone. Nurse #6 was interviewed via phone on 03/22/24 at 10:43 AM, she stated she no longer worked at the facility for the last 6 months. She stated she was not able to administer Resident #244's IV Daptomycin because he did not have a PICC line. She stated she thought they had called the pharmacy to request a new PICC line be placed but after that she did not recall working with Resident #244 again. Nurse #7 was interviewed via phone on 03/22/24 at 11:00 AM. Nurse #7 stated that he did not work at the facility anymore and had been gone for approximately 2 months. He stated that he recalled Resident #244 was very particular about his PICC line dressing but did not recall much else about Resident #244 or the situation. He stated if his PICC line was out we should have held the medication and notified the Medical Director (MD) for orders to have the line replaced. Nurse #4 was interviewed via phone on 03/24/24 at 12:50 PM who stated she had not worked at the facility for almost a year and did recall Resident #244 or anything about the situation. An attempt to speak to Nurse #5 via phone was made on 03/24/24 at 3:38 PM and was unsuccessful. The Infectious Disease Nurse Practitioner (NP) was interviewed via phone on 03/20/24 at 12;15 PM who stated that if Resident #244's PICC line was dislodged, or he did not have access and access was unable to be obtained then he should have been immediately sent to the ER so we could have restored his access. She explained that there were numerous other types of line access that they could have done for Resident #244 including a central line or tunneled PICC line in the groin. The NP stated, it is not reasonable to not receive antibiotics for a portion of time due to access issues. It is prudent of any skilled nursing facility if the PICC line is out and attempts to reinsert failed, then he should have been directed to higher level of care, not say Oh well and not give for 2 weeks. The NP added, if the facility could not figure out how to work through the access issues we could have helped them. She added that Resident #244 had thoracic spinal osteomyelitis with spinal stenosis and staph bacteremia and untreated could lead to loss of limb function and he was already a left upper extremity amputee. The NP stated that Resident #244 was seen in the office 2 days after discharging from the facility on 07/26/23 and his access was restored, and we resumed his IV antibiotic at an outpatient infusion center and extended the duration to make up for the missed doses at the facility. The MD was interviewed via phone on 03/20/24 at 1:26 PM. He stated that he did not recall being made aware that his PICC line was out and that he had missed 14 doses of the IV antibiotic. The MD stated had he been aware that an attempt to reinsert the PICC line was unsuccessful, he would have directed the staff to send Resident #244 to the ER to have access regained. The MD stated, it was very concerning that he missed 14 doses of antibiotic. The facility NP #2 was interviewed via phone on 03/20/24 at 4:47 PM, she stated she recalled Resident #244 but stated she did not recall any issues with his PICC line or missing doses of his scheduled antibiotic. She explained that she was out of state on personal business during this time but had someone contacted her, she would have directed the staff to send Resident #244 to the ER. The Administrator was notified of the Immediate Jeopardy on 03/27/24 at 10:10 AM. The facility provide 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 administer an intravenous (IV) antibiotic for 14 days after the residents peripherally inserted central catheter was dislodged in 07/11/2023 (Resident #244). Resident #244 was discharged on [DATE] and was seen at the Infectious Disease office on 07/26/2023, access was restored, and his IV antibiotic was resumed. There was a high likelihood that Resident #244 would lose the function of his one remaining upper extremity without having the IV antibiotics as ordered. On 03/27/2024 the Director of Nursing assessed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. 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 03/27/2024 the Director of Nursing educated licensed nurses on directing residents to a higher level of care if the needs of the resident cannot be met in the facility to avoid serious harm or impairment. On 03/27/2024 the Director of Nursing educated medication aides on reporting to licensed nurses any observations of adversities to resident care that may indicate assessment by a licensed nurse to avoid serious harm or impairment. 03/27/2024 the Director of Nursing educated licenses nurses on following physician orders and notification of physician and documenting any barriers to medication administration. 03/27/2024 the Director of Nursing educated medication aides on following physician orders and notification to a licensed nurse any barriers to medication administration. On 03/27/2024 the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses and medication aides. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated.

Based on record review, staff, resident, and Physician's Assistant interviews the facility failed to immediately report an allegation of sexual abuse to the administrator for 1 of 3 residents reviewed for sexual abuse (Resident #38). A severely cognitively impaired female resident (Resident #38) was taken by a resident (Resident #241), a cognitively intact male resident, into the bathroom in his room. Resident #241's roommate, a cognitively intact male resident (Resident #47), used his call light to alert Nurse Aide (NA) #1 about Resident #241 and Resident #38. NA #1 did not report the allegation about Resident #241 and Resident #38 to a nurse. During this time when NA #1 did not report the allegation to a nurse, Resident #241 was in the bathroom with Resident #38. It was not until a nurse, who was coming to administer evening medications to Resident #241, discovered Resident #38 with her pants down, brief off, and shirt pulled up to below her breasts, as Resident #241 was standing in the bathroom with her. Findings included: A review of the facility's Abuse, Neglect and Exploitation Policy dated 10/20/2020 stated the facility's staff will report all alleged violations to the Administrator within specified timeframes: immediately if the events that caused the allegation involve abuse. Resident #241 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #241 was cognitively intact, had not had behaviors, and required moderate assistance with walking and used a wheelchair and walker for ambulation. Resident #38 was admitted to the facility on [DATE]. Resident #38's cumulative diagnoses included: dementia, schizoaffective disorder, bipolar disorder, and posttraumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was severely cognitively impaired and she required moderate assistance for transfers and toileting, she did not have any behaviors, and she was occasionally incontinent of bowel and bladder. The MDS assessment further indicated Resident #38 could roll herself in her wheelchair for 150 feet without assistance. Resident #47 was admitted to the facility on [DATE] with diagnoses of stroke, mood disorder, and diabetes. A review of Resident #47's most recent quarterly Minimum Data Set (MDS) assessment indicated he was cognitively intact. On 2/13/2024, during the facility's investigation into the allegation of sexual abuse, the Director of Nursing interviewed Resident #241's roommate, Resident #47, and he stated Resident #241 pushed Resident #38 into his bathroom and shut the door. Resident #47 stated when Nurse Aide #1 entered the room to answer his call light he mouthed the words that Resident #241 and Resident #38 were in the bathroom, and he stated Nurse Aide #1 got Nurse #1. An interview was conducted on 3/21/2024 at 10:25 am with Resident #47, who was the roommate of Resident #241. Resident #47 stated Resident #241 pushed Resident #38 into their room on the evening of 2/13/2024 and they were watching television together. Resident #241 then wheeled Resident #38 into the bathroom and shut the door, and he knew that wasn't right. Resident #47 stated he put on his call light and Nurse Aide (NA) #1 answered. Resident #47 told Nurse Aide (NA) #1 that Resident #241 and Resident #38 were in the bathroom and Nurse Aide #1 went to get the Nurse. On 3/21/2024 at 5:03 pm Nurse Aide (NA) #1 was interviewed by phone and stated she answered Resident #47's (roommate for Resident #241) call light and he told her he thought his roommate, Resident #241, was trying to have sex with that lady (Resident #38) in the next room. Nurse Aide #1 stated she went to the next resident room and there was a resident in the room and then she checked the bathroom and there were no other residents in the bathroom, so she dismissed the allegation and did not look any further for the two residents. Nurse Aide #1 stated she might have told Nurse #2 about Resident #47's allegation but she was not sure if she told someone. A phone interview was conducted with Nurse #1 on 3/22/2024 at 9:10 am and she stated no one reported to her there was an allegation by Resident #241's roommate (Resident #47) that Resident #241 pushed Resident #38 into his bathroom, and he thought they were going to have sex. She stated she found Resident #38 in the bathroom with Resident #241 when she went to Resident #241's room to give him his evening medication. Nurse #1 stated Resident #38 was sitting in her wheelchair beside the commode with her brief on the floor beside her wheelchair and her pants pulled down to the floor, and her shirt pulled up to just below her breasts. She further stated Resident #241 was standing with his hands around his abdomen, he was fully clothed, and he stated Resident #38 was changing her brief and was doing a good job. Nurse #2 was interviewed by phone on 3/22/2024 at 9:15 am and she stated she was called to Resident #241's room by Nurse #1 and Nurse #1 told her she found Resident #241 and Resident #38 in Resident #241's bathroom and her pants were pulled down, her brief was on the floor, and her shirt was pulled up to just below her breasts. She stated when she arrived at Resident #241's room Resident #38 was sitting in her wheelchair in front of the commode with her pants below her knees, her brief on the floor, and her shirt pulled up to just below her breasts. Nurse #2 was interviewed by phone again on 3/22/2024 at 9:56 am and she stated Nurse Aide #1 did not notify her of Resident #47's allegation, she was notified of the incident by Nurse #1 after she found Resident #241 and Resident #38 in the bathroom together. Nurse #2 stated if Nurse Aide #1 told her about the allegation she would have investigated immediately. The written statements gathered by the Social Worker and the Director of Nursing on 2/13/2024 indicated Nurse Aide #1 stated between 9:00 pm and 9:15 pm the roommate, Resident #47, put his call light on and when she answered the call light, he stated Resident #241 was in bed with the lady in the next room and he was being fresh (inappropriate) with her. The written statement by Nurse #2 stated she was called by Nurse #1 for assistance and when she entered the room at 9:25 pm with Nurse #1 Resident #38 was sitting in her wheelchair with her pants down to her ankles, her shirt pulled up to just below her breasts, and her brief on the floor beside the wheelchair. On 3/21/2024 at 1:34 pm the Director of Nursing (DON) was interviewed, and she stated she received a phone call from Nurse #2 on 2/13/2024 at 9:30 pm. The DON stated during the phone call Nurse #1 told her Resident #38 was found in Resident #241's bathroom with Resident #241. The DON stated Nurse #2 reported Resident #38 was found undressed from the waist down, and Resident #241 was helping her to go to the bathroom. The DON stated she was not aware Nurse Aide #1 had not reported to Nurse #1 or Nurse #2 that Resident #47, Resident #241's roommate had reported an allegation of abuse and Nurse Aide #1 had not reported it to either Nurse #1 or Nurse #2. The DON stated Nurse Aide #1 should have reported the allegation to the Nurse #1 immediately. On 3/22/2024 at 12:32 pm the Administrator was interviewed, and she stated the facility had completed a plan of correction for the reporting of the allegation of sexual abuse that occurred on 2/13/2024 when Resident #38 was found sitting in her wheelchair with Resident #241, in his bathroom, with her shirt pulled up to below her breasts, her brief in the floor beside her wheelchair and her pants pulled down to her ankles. The Administrator stated Nurse Aide #1 should have immediately reported the allegation to a Nurse and the Nurse would report to the Director of Nursing or her. The Administrator was notified of Immediate Jeopardy on 3/22/2024 at 11:25 am. On 3/22/2024 at 11:25 am the Administrator stated the facility had completed a plan of correction regarding reporting of abuse on 2/13/2024: Corrective action for resident(s) affected by the allegation of deficient practice: On February 13, 2024, between 9:00 pm and 9:15 pm Resident #241's roommate, Resident #47, notified Nurse Aide #1 that Resident #241 was in the bed with the lady in the next room and he was being fresh (inappropriate) with her. Nurse Aide #1 stated she checked the next room and its adjoining bathroom and there was only one resident in the next room. On February 13, 2024, Nurse #1 entered Resident #241's room to give him his medications at 9:30 pm and Nurse #1 observed resident #38 in Resident #241's bathroom with her pants down to her ankles with her brief off sitting in her wheelchair with Resident #241standing beside Resident #38. Nurse #1 called Nurse #2 for assistance and Nurse #2 immediately removed Resident #241, who was cognitively intact, and stayed with him to ensure Resident #38's and other resident's safety. Nurse #2 stayed with Resident #38, a severely cognitively impaired resident, and assessed her for injuries, dressed her, and interviewed her. Nurse #2 notified the Director of Nursing of the incident, and the Director of Nursing notified the Administrator. The Administrator notified the Social Worker and the Treatment Nurse and requested their assistance with the incident. On 2/13/2024 the Administrator notified the police, notified Adult Protective Services, and submitted an initial allegation report to the State Survey Agency at 11:59 pm. The Administrator and DON notified Resident #38's responsible party and the on-call provider of the alleged abuse. The Administrator and the Police conducted an interview with Resident #38, Nurse #1, and Nurse #2 regarding the alleged abuse. The Social Worker and Administrator interviewed Resident #38 and Resident #47 for alleged abuse on 2/12/2024. Resident #38 was returned to her room; Resident #47 was moved to another room and Resident #241 was returned to his room and remained on 1:1 with nursing staff until he discharged on [DATE]. On 2/14/2024 the Administrator concluded the investigation of allegation of abuse and based on investigation finding the allegation was unsubstantiated for the allegation of abuse of Resident #38. On 2/14/2024 at 1:59 am the administrator submitted the investigation report to the State Survey Agency. Corrective action for residents with the potential to be affected by the deficient practice: On 2/13/2024 the Social Worker completed interviews with 100% alert and oriented residents for sexual abuse. On 2/13/2024 the Treatment Nurse completed skin assessments for 100% of residents with cognitive impairments for any signs of abuse. Findings included no other residents were affected by the alleged abuse. Measure/systemic changes to prevent reoccurrence of alleged deficient practice: On 2/13/2024 the Director of Nursing began in-service education of all full-time, part-time, and prn (as needed) staff, administration, housekeeping, dietary, nursing, therapy, and maintenance (including agency) on the abuse prohibition/reporting policy. The training will include all current staff including agency. This training included: abuse types, reporting abuse allegations immediately to the nurse/Director of Nursing/ Administrator, what to do if abuse is observed or suspected, assuring residents safety, zero tolerance of retaliation of reporting allegations of abuse, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. Staff were also asked if they were aware of any abuse occurring to any residents in the facility and what to do if observed or suspected. No staff were aware of any other alleged abuse occurring in the facility. The Director of Nursing will ensure that any of the above identified staff (all staff including agency) who does not complete the in-service training by 2/14/2024 will not be allowed to work until the training had been completed. This training will be included in new hire orientation for any newly hired staff. Monitoring procedure to ensure the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements: Beginning the week of 2/14/2024, the Administrator or designee will monitor the abuse process to ensure residents are free from abuse and any abuse identified reported and addressed according to facility policy using the QA Tool for recognizing and reporting abuse. The Administrator or designee will interview 5 staff members to monitor if staff know the procedure for reporting alleged abuse and when and who to report to. The monitoring will be completed for 4 weeks and then monthly for 2 months or until resolved. Reports will be presented to the monthly Quality Assurance Committee by the Administrator or designee to ensure corrective action is initiated as appropriate. Compliance will be monitored, and on-going auditing program reviewed at month Quality Assurance Meeting. Immediate jeopardy removal date is 2/15/24. Date of Compliance is 2/15/24. Review of the Plan of Correction with compliance date of 2/15/2024: The facility provided documentation of interviews with staff who cared for Resident #38, Resident #241, and Resident #47 when Resident #47 reported an allegation of abuse to Nurse Aide #1 which she did not report. The Director of Nursing was notified, and the Director of Nursing notified the Administrator of the allegation of abuse and an investigation began on the evening of 2/13/2024. The Social Worker interviewed Resident #38 and all other residents that were cognitively intact regarding any abuse allegations on 2/13/2024 and there were no further allegations of abuse. The Wound Nurse completed skin assessments on all residents that were cognitively impaired, and no signs of abuse were identified on 2/13/2024. The Director of Nursing began in-service education on 2/13/2024 regarding the reporting of all types of abuse to the nurse/Director of Nursing/ Administrator; what to do if abuse is observed or suspected; assuring residents safety; zero tolerance of retaliation of reporting allegations of abuse, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. The facility also interviewed all staff to ensure they were not aware of any abuse that had occurred in the facility on 2/13/2024. The facility included the training in the orientation packet for all newly hired staff as of 2/13/2024. On 2/14/2024 the facility's Administrator began monitoring through interviews of 5 staff members a week for 4 weeks, then 5 staff members a month for 2 months to monitor through interviews if staff know the procedure for reporting alleged abuse and when and who to report to. The facility provided documentation of sign in sheets for education and staff were interviewed regarding their knowledge with no issues identified. The facility also provided documentation of the monitoring they had completed with no issues identified. The Plan of Correction compliance date of 2/15/24 was validated on 3/22/24.

Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective discharge planning process to ensure discharge needs and goals were identified with the resident and the interdisciplinary team (IDT) as active participants in the discharge plan in order to prepare the resident for an effective transition to post-discharge care for a resident who was a planned discharge. On 2/14/24 Resident #241 was discharged without the facility verifying his discharge location and if his care needs were able to be met. In addition, the resident was discharged without adaptive equipment required for ambulation (rolling walker). Resident #241 indicated he was dropped off at a homeless shelter where he continued to reside and felt unsafe and was fearful. These failures created a high likelihood of harm for Resident #241. This deficient practice affected 1 of 4 residents reviewed for discharge. Immediate jeopardy began on 02/14/24 when the facility initiated a planned discharge of a resident without verifying the discharge location and ensuring the resident's needs were able to be met. The immediate jeopardy was removed on 03/24/24 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 a 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. The findings included: Resident #241 was admitted to the facility on [DATE] following a hospital stay for a surgical hernia repair. He admitted with diagnoses that included hernia repair, Parkinson's disease, chronic obstructive pulmonary disease, hypertension, right lower quadrant pain, major depressive disorder, muscle weakness, lack of coordination. Resident #241's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #241 was coded as having the goal to discharge to the community. The assessment indicated no discharge planning was actively occurring. Resident #241 was coded as normally using a walker and wheelchair, required limited assistance with toileting hygiene, bathing, lower body dressing, personal hygiene, and picking up an object from the floor. He required supervision with rising from a seated position, moving from a chair to the bed and from the bed to a chair, toileting transfers, tub or shower transfer, walking 10 feet, walking 50 feet, and walking 150 feet. Resident #241 was coded as taking antidepressant medications. Review of Resident's #241's care plan initiated on 02/01/24 and last reviewed on 02/13/24, revealed a care plan for I wish to discharge to [assisted living facility] once able to do so. Interventions included evaluate and discuss with the resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits, and needs for maximum independence. Evaluate the resident's motivation to return to the community. Additional review of Resident #241's care plan revealed a care plan for Resident is (specify high, Moderate, Low) risk for falls related to gait or balance problems. Interventions included Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair and for physical therapy to evaluate and treat as ordered or as needed. Review of resident's medications revealed he was taking the following medications: Carbidopa-Levodopa ER Oral Tablet Extended Release for the treatment of Parkinson's disease Spiriva Respimat Aerosol, solution for the treatment of chronic obstructive pulmonary disease (COPD) Albuterol Sulfate HFA Aerosol, solution for wheezing or shortness of breath Diclofenac Sodium External Gel for pain management Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour for the treatment of depression Mirapex Tablet for the treatment of Parkinson's disease Trazodone HCl Oral Tablet for the treatment of insomnia Propranolol HCl Oral Tablet for the treatment of hypertension Trilogy Ellipta Inhalation Aerosol Powder Breath Activated for the treatment of COPD Carbidopa-Levodopa ER Oral Tablet Extended Release for the treatment of Parkinson's disease Atorvastatin Calcium Oral Tablet for the treatment of hyperlipidemia Baclofen Tablet for the treatment of muscle spasms Gabapentin Oral Capsule for the treatment of nerve pain On 02/13/24 Resident #241 was found in a bathroom with a female resident. The female resident was reportedly undressed from the waist down with her shirt pulled up to below her breasts. Review of Resident #241's progress notes revealed no notes or documentation related to discharge planning prior to 02/13/24 when the facility opened and began to complete a discharge summary. Review of Resident #241's discharge summary revealed it was created on 02/13/24 at 10:50 PM by the Social Worker. Resident #241's discharge summary indicated no transitional services or referrals were completed or recommended, and no durable medical equipment [wheelchair, walker, bedside commode, oxygen] was ordered. The discharge assessment indicated Resident #241 was independent with his activities of daily living and was cognitively intact. Physical therapy and occupational therapy referrals were completed but no home health services were recommended or ordered and there was no scheduled primary care physician appointment scheduled. The discharge summary did report a primary care physician of Doctor #1 with a provided phone number with instructions that read please follow-up with your primary care physician 1-2 weeks post discharge from facility. If you have any immediate medical needs, call 911. The discharge assessment indicated that Resident #241 discharged home, accompanied by agency and was ambulatory at the time of discharge and that no durable medical equipment (rolling walker) was ordered. The discharge assessment was completed on 02/14/24 and signed by the Social Worker, Nurse #8, Resident #241. Review of Resident #241's functional abilities and goals assessment completed on 02/14/24 revealed Resident #241 required the use of a walker prior to his admission, required supervision or touching assistance with toilet hygiene, bathing, was dependent on others for lower body dressing, and needed supervision with walking 50 and 150 feet. An interview with the Social Worker on 03/22/24 at 1:32 PM revealed Resident #241 had been admitted to the facility on [DATE] and subsequently discharged on [DATE]. She stated on the morning of 02/14/24, Resident #241 approached her and told her he wanted to leave She reported she asked him if he would stay until she could make it safe, and he reported that he would not and that he was going to leave that day. The Social Worker reported Resident #241 had approached him with his belongings packed. She proceeded to try and put as much post-discharge assistance in place as she could, as fast as possible but by the time she had contacted the Medical Director to notify him of the pending discharge and returned from trying to reach out to the physician, Resident #241 had already left the facility. She reported from the time Resident #241 reported he wanted to leave until the time he left, it was approximately 30 minutes or less. The Social Worker stated it was her understanding that Resident #241 had arranged for a ride share driver to pick him up from the facility. She stated she had no knowledge where Resident #241 had departed to and that he had previously mentioned he would go to stay with his spouse in a neighboring county and had assumed that was where he had gone. She reported she attempted to reach Resident #241 via telephone post discharge at the number in his medical record, but was unsuccessful. She also stated she could not recall if she coded the discharge as planned on the discharge summary. She reported she had processed the discharge as a planned discharge because she had been receiving pressure to ensure that all discharges were safe. She indicated that due to the hasty nature of Resident #241's discharge, it probably should have been treated more as an unplanned discharge against medical advice, instead of a planned, safe discharge. She also indicated there had been no active discharge planning prior to 02/13/24. Review of a progress note completed by Nurse #8 dated 02/14/24 at 4:47 PM read Resident has been discharged from facility, ambulating. [The] writer reviewed discharge summary and medications. No questions asked. Medications on cart were released to the resident and explained/educated and written on medicine card in detail the times to self-administer. No further questions. Transportation driver transported resident to destination. An interview with Nurse #8 on 03/25/24 at 10:15 AM revealed she remembered the discharge for Resident #241 on 2/14/24 and reported it did not seem like it was rushed or hurried. Nurse #8 did not indicate who informed her the resident was going to discharge on that date (2/14/24). Nurse #8 stated that she was able to educate Resident #241 on his medications and when and how to take them. She reported he never mentioned to her that he was asked or being forced to leave and that she believed he mentioned that he was either going to go to a friend's house or to the shelter. She reported the process was not different from any other planned discharges she had been involved with in the past. Nurse #8 also stated that she coded that resident was transported to his destination on her discharge progress note by the transportation driver because Resident #241 had set up his own transportation at discharge and since it was not family, she coded it as a transportation driver. Nurse #8 reported she did not recognize the transportation driver. Resident #241's discharge Minimum Data Set assessment dated [DATE] revealed he had a planned discharge from the facility back to the community with a return to the facility being unanticipated. An interview was conducted with Resident #241 on 03/22/24 at 1:03 PM via telephone. Resident #241 reported he used to live at the facility and was currently living in a homeless shelter. He stated He reported he was accused of molesting female resident at the facility on 02/13/24 and the staff told him he had to leave after the incident. Resident #241 was unable to provide the staff member's name but was able to provide a physical description. The physical description did not pinpoint the staff member as it corresponded with multiple staff members. He described the staff member that told him he had to leave as a Caucasian female with dark hair, approximately 5'9 and weight approximately 180 pounds but he could not recall her name. Resident #241 reported he did not want to go to the shelter because he thought he would be going to an assisted living facility, but stated he was not given a choice. Resident #241 reported he could not go live with his spouse because they were estranged and he did not want her to have to see him deteriorate as his Parkinson's disease progressed. He indicated he had not set up his own transportation as he did not want to leave the facility. Resident #241 stated he had been at the homeless shelter since he was dropped off and that he had not seen his physician since he left the facility. He explicitly stated that he did not feel safe and explained that a week prior to this interview a fight occurred at the shelter where knives were being thrown and he was pushed hard into a wall. He reported he was fearful he would be injured or hurt. When Resident #241 was asked if he was in pain, he stated I hurt from my ankles to the tips of ears. He indicated he was still at the shelter because he had nowhere else to go. During a follow-up interview with Resident #241 on 03/22/24 at 5:21 PM, he reported prior to his admission to the hospital for hernia repair, he was living in a different shelter. He stated he was admitted to a local hospital for hernia repair, and then was moved to the facility for aftercare and therapy. He stated he believed the plan was for him to go to an assisted living facility down the street from the facility he was in when he finished his therapy, but they kicked him out before that could happen. Resident #241 reported on 2/14/24 he was transported in an old ambulance type vehicle driven by and African American man. Resident #241 also indicated that he was not included in his discharge planning and that it surprised him. An interview with the Transportation Driver #1, who was the only transportation driver employed by the facility that matched the description provided by Resident #241 on 03/25/24 at 10:55 AM, revealed he had been at the facility since August 2022 and provided transportation in the facility's van for residents. He stated he remembered Resident #241 and stated he believed he had transported him to and from a couple appointments during his admission. Transportation Driver #1 reported he did not provide transportation services to Resident #241 at the time of his discharge (2/14/24). An interview with the Case Manager, who worked at the homeless shelter where Resident #241 was currently residing at, was conducted on 03/22/24 at 2:00 PM. She reported Resident #241 had been at the shelter approximately 2 months. She stated he arrived there straight from the facility. The Case Manager reported when Resident #241 arrived, he (Resident #241) indicated he was unsure why the facility had dropped him off at the shelter. She continued, stating that another staff member (Shelter Staff #1) from the shelter observed a facility labeled transportation van drop Resident #241 off at the shelter with his belongings and a whole bunch of medicine. She stated the shelter staff were helping Resident #241 with his medication management but stated they needed to find him a rolling walker as when he arrived, he did not have one and was having difficulty ambulating without a rolling walker. She also stated Resident #241 was able to continue to stay at the shelter for 120 days and then the shelter staff would have to reassess Resident #241 to determine if he would be allowed to stay longer. The Case Manger stated that Resident #241 was able to stay at the shelter through the day as he was paying a small amount of money while he was there. The Case Manager also reported Resident #241 was receiving some assistance with his activities of daily living from other residents such as tying his shoes and bathing as the shelter staff were unable to assist him. The Case Manager reported another resident at the shelter was able to provide Resident #241 with an extra rolling walker they had, and he was currently using it all the time when ambulating. An interview with Shelter Staff #1 on 03/27/24 at 3:48 PM revealed he worked on the evening of 02/14/24 from 5:00 PM until 10:00 PM. He stated he did not see the vehicle that Resident #241 arrived in but that when Resident #241 arrived he had only a bag of medicine and the clothes on his back. Shelter Staff #1 stated that Resident #241 had no wheelchair or walker and that the shelter staff had to scramble to find him a walker because Resident #241 walked with a shuffled gait and the shelter staff were concerned he would fall and seriously injure himself. Shelter Staff #1 stated Resident #241 currently used the walker the shelter provided at all times when he was ambulating. An interview with Shelter Coordinator on 03/26/24 at 8:23 AM revealed she had worked at the shelter for approximately 1 year. She reported she was familiar with Resident #241 and had processed his intake when he arrived (2/14/24). She reported when Resident #241 arrived, he had a box and a suitcase with only medications and clothing. She also stated he was confused when he arrived, stating he thought the plan was for him to go to an assisted living facility, but the facility had dumped him here. The Shelter Coordinator continued, stating the shelter cannot provide the care that Resident #241 needed and indicated if he was not such a nice guy, we would have had to discharge him due to not being able to take care of him. She did not provide information on the Resident #241's care needs. She stated that other residents at the shelter helped him when possible. She also provided information that Resident #241 was running out of medication and the Case Manager and Resident #241 had reached out to the facility (no specific facility staff member was identified) the previous week and requested assistance and were denied. The facility reported that since he no longer was a resident, they could not do anything to assist him. The Shelter Coordinator stated Resident #241 will most likely have to be sent to the hospital soon to get treatment and medication refills. She stated one medication he received was for tremors and when he runs out, it will become more difficult for him to care for himself. An interview with the Director of Therapy on 03/22/24 at 2:23 PM revealed Resident #241 was mostly independent with his activities of daily living at the time of his discharge. She reported he was walking more than 300 feet with the use of a rolling walker. She indicated that Resident #241 would require the use of a rolling walker to ambulate long distances. She indicated Resident #241 needed the rolling walker in order to ambulate long distances safely. The Therapy Director reported therapy last provided services to him on 02/13/24, the day before he discharged . She stated she was not included in the discharge planning process. She reported she did not know whether Resident #241 wanted to leave or if he was told to leave. The Director of Therapy reported she had no knowledge of where Resident #241 discharged to and indicated she had no knowledge if he had a rolling walker when he discharged but stated that was the recommendation at the time of discharge from therapy. An interview with Unit Manager #1 on 03/22/24 at 2:32 PM revealed she was assigned to be one on one with Resident #241 following an incident between him and another resident at the facility on 02-13-24. She reported the morning of 02/14/24, Resident #241 was quiet and reserved and stayed to himself. She reported prior to that day, Resident #241 was outgoing and friendly and spent most of his day out in the facility visiting with other residents. Unit Manager #1 reported he placed a few phone calls while she was providing 1:1 supervision, but she did not overhear what they were about. She also reported Resident #241 had mentioned to her once on 02/14/24 that he wanted to go home. She stated she could not recall if she observed Resident #241 packing his belongings. Unit Manager #1 reported around 3:00 PM or 4:00 PM, Resident #241 exited the facility via the front door and got into a vehicle and left. She reported she could not recall the type, color, make, or model of vehicle Resident #241 left in. Unit Manager #1 stated she did not know where Resident #241 discharged to. An interview with the Former Medical Director on 03/24/24 at 3:12 PM revealed he only saw Resident #241 one time during his admission. He stated when he saw Resident #241, he was using a wheelchair as a walker, had a shuffling gait, was being treated for Parkinson's disease and surgical aftercare. He reported he was not involved in the discharge of Resident #241 and that he did not know what the discharge goal for Resident #241 was after he completed his therapy. The Former Medical Director stated that Resident #241 had a shuffling gait and that he would have needed a rolling walker to ambulate. He also reported there would be some concern with Resident #241's involuntary movements from his Parkinson's disease worsening should he not take his medications or if they were unable to be filled. An interview with the Director of Nursing on 03/23/24 at 2:34 PM revealed she had returned to the facility on the evening of 02/13/24 after being informed of an incident between Resident #241 and another resident. She reported at that time, Resident #241 informed her he wanted to discharge immediately and requested some of his belongings that the facility had been storing for him in the medication room. The Director of Nursing reported she spoke with Resident #241 and encouraged him to stay since it was so late, and the weather was cold. She stated Resident #241 agreed to stay through the night but that he was adamant the following morning that he was going to discharge. The Director of Nursing reported Resident #241 discharged on his own accord on 02/14/24 and she had no knowledge of where he discharged to, if he had everything he needed, and whether where he was going was safe and could meet his needs. The Director of Nursing indicated she could not recall if she had contacted adult protective services and stated she did not call the Medical Director but thought the Administrator had notified him. An initial interview with the Administrator on 03/22/24 at 4:17 PM revealed she did not have a lot of information regarding Resident #241's discharge from the facility and that she felt they did what they could to make it as safe as possible. She reported her interdisciplinary team typically set up discharges and discharge planning began when residents stated they wanted to discharge. She reported she was not involved in the discharge process for Resident #241 and did not know where he went. She was unable to indicate what staff were involved with Resident #241's discharge process. The Administrator reported she was informed that Resident #241 voiced he wanted to discharge home and had planned to return to his spouse. She was unable to state who informed her or when she was informed. She stated it was her knowledge that he called a ride share company for transportation and left on his own accord. She was unable to explain where she received this knowledge from. The Administrator stated she did not believe the facility had transported Resident #241 to the homeless shelter as they did not provide discharge transportation services. She also reported that the facility's transportation van did not have any markings on it until 03/14/24 when they paid to have it wrapped in their facility's name. The Administrator reported there had been an incident between Resident #241 and another resident in the facility on the evening of 02/13/24 and that the police department had questioned him and notified him (Resident #241) that the other resident's family wanted to press charges and she wondered if that conversation may have scared him and made him want to leave to avoid the situation. Regarding Resident #241 being discharged without a rolling walker, she indicated that the facility routinely and provided equipment to discharging residents if there was an issue with backorders of equipment, or if needed equipment was not going to arrive before the scheduled discharge date . The Administrator reported she would have approved for Resident #241 to take a rolling walker with him had she been aware he needed one. She also reported that Resident #241 did not have a primary care physician and that he received a small income each month and stated he could utilize an urgent care physician if he needed and that he could also afford to pay for his own transportation. During a follow-up interview with the Administrator on 03/23/24 at 2:04 PM, she reported during Resident #241's 48-hour baseline care plan meeting, he voiced his desire to eventually discharge to an assisted living facility when he was able to. The Administrator continued, stating that Resident #241 had participated with therapy. She reported after the incident between him and another resident (2/13/24), he was informed that he would have to remain on one-to-one supervision but insisted that at no time during Resident #241's admission was he told he had to leave. The Administrator stated the discharge summary was opened on 02/13/24 because Resident #241 indicated that he wanted to leave that night, so the Social Worker began to prepare him for discharge from the facility. She continued, stating the Social Worker was eventually able to convince Resident #241 to stay until they could set up a safe and orderly discharge and the facility staff were under the impression on 02/13/24 that Resident #241 had agreed to stay until a safe and orderly discharge could occur. The Administrator reported the facility should have processed the discharge as leaving against medical advice instead of a safe discharge. She reported she had educated the Social Worker on how to better code discharges on the discharge assessment in the future. The Administrator reported a safe discharge would include a resident being prepared to go home or to another facility, with education received on care needs and medications. A safe discharge would include her interdisciplinary team and would now include knowing exactly where a resident will be discharging to. The Administrator and DON were notified of the Immediate Jeopardy on 03/22/24 at 5:22 PM. The facility provided the following IJ removal plan: F660 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 develop a discharge plan and implement a discharge plan to ensure resident #241's needs would be met. The facility did not ascertain how resident's needs would be met post discharge. The facility failed to ensure recommended adaptive equipment was available upon discharge. The facility did not follow up after discharge to see if resident #241's needs were being met. The facility failed to involve the IDT team in the discharge process. The Administrator made multiple attempts to contact resident #241 by phone with phone number provided by surveyor on 03/23/2024. The voicemail box was full and a message could not be left. The administrator sent a text message notifying of attempt to reach and voicemail being full, inquiring if resident was ok and if he had any current care need that I could help with and requested a return call. As of 3/24/2024 at 1:50 pm the Administrator has not received any follow up text or phone call from resident #241. In the event that resident #241 contacts administrator the administrator will inquire as to care needs of resident and attempt to provide assistance with current care needs. Residents discharging from the facility have potential to be affected by the same deficient practice. On 3/22/24 the Director of Nursing reviewed the last 30 days of planned discharges to community for development of a discharge plan that included: adaptive equipment, ensuring basic needs (food, shelter, water) were met, location was identified, physician appointments and discharge was safe and orderly. There were no issues identified during this review, regulatory criteria were met for safe discharge of all 13 residents reviewed. There were no issues identified during this review, regulatory criteria were met for safe discharge of all 13 residents reviewed. On 3/22/24 the Director of Nursing reviewed the last 30 days of un-planned discharges to community for documentation to support the voluntary revocation of all services without clearance or proper notice to implement a safe and orderly discharge. There were no issues identified during this review, regulatory criteria were met for unplanned discharge of all 2 residents reviewed. On 3/22/2024 the Administrator notified the interdisciplinary team of reviewing upcoming planned discharges daily in morning meetings to ensure the discharge planning process has been followed and resident care/ discharge needs are addressed prior to final discharge and to provide the medical director with information regarding upcoming discharges to ensure proper orders and discharge paperwork are implemented. The administrator also notified the interdisciplinary team they will meet weekly to review residents with goals to discharge from the facility to identify and address resident goals for care, treatment, preferences, barriers to discharge such as: care giver support, education, resident interests in any referrals made to local contact agency, post discharge needs such as nursing and therapy services, medical equipment or modification to the home or activities of daily living assistance. 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 3/22/2024 the Administrator completed education with the interdisciplinary team. Education included: the discharge planning processes for facility initiated and resident initiated discharges; determining when safe discharge planning is attainable and/or unsafe discharge/against medical advice. Education also included understanding the regulatory requirements for the discharge planning processes, in the State Operations Manual for F 660, to ensure the interdisciplinary team understands the intent of the regulation as follows and has discharge planning processes in place for residents prior to planned discharges. The discharge planning process will address each resident's discharge goals and needs including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan to ensure a safe discharge for those residents discharging from the facility. This will also include having knowledge of the discharge location, adaptive equipment as needed, ensuring basic needs (food, shelter, water) were met, location was identified, physician appointments, medications as needed, and discharge was safe and orderly. The Administrator will educate newly hired social workers and other newly hired IDT members in orientation. Education completed 3/22/24. Effective 3/22/24 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/24/2024 On 03/25/24, the credible allegation of Immediate Jeopardy removal was validated onsite by verification through facility staff interviews and record review. The interviewed staff across disciplines included nursing, administration, and therapy. The interviewed staff indicated they had received in-service training on discharge planning and processes and what constituted a safe and orderly discharge. The facility also reviewed previous discharges for the past 30 days to see if other residents had possibly been affected. The facility's alleged Immediate Jeopardy removal date of 03/24/24 was validated.

Based on record review, resident, and staff interviews the facility failed to treat a resident in a dignified manner when two Nurse Aides (NAs) were talking about the residents' wounds in front of her, but not to her, and were rough during incontinent care, and when the resident was screaming and crying in pain (Resident #35) they did not stop the care. The resident stated the interactions with the NAs made her feel angry and upset that they treated her that way for 1 of 1 resident reviewed for pain. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included: diabetes melilites, chronic obstructive pulmonary disease, respiratory failure, a pressure ulcer to left lower leg, and a pressure ulcer to the right lower leg. An observation and interview were conducted with Resident #35 on 03/18/24 at 12:01 PM. Resident #35 was resting in bed on her back and had a very flat affect, her voice was very soft in tone almost a whisper. Resident #35 stated that two Nurse Aides (NA) had just given her a bed bath, the one with short hair was very nice and the one with long hair was very rough. Resident #35 was asked to describe what rough meant, she stated that the long-haired NA, identified as NA #2 was giving her a bed bath and she was washing with a rag that was very rough and then the short haired NA identified as NA #3 came in and they turned me onto my side and I was in so much pain from my wounds on my bottom. Resident #35 stated that she was crying and hollering out in pain and both NAs kept saying we are sorry but just kept on wiping me. She added that NA #2 and NA #3 were talking to each other about the wounds on my bottom but not to me directly. Resident #35 stated it made her feel angry and upset that they treated me that way referring to the staff talking about her wounds but not her and then being in so much pain during incontinent care and the staff did not stop the care but continued to wipe her. Resident #10 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed that Resident #10 was cognitively intact. An interview with Resident #35's roommate (Resident #10) was conducted on 03/18/24 at 12:06 PM, she stated NA #2 came in and told Resident #35 she was going to give her a bed bath and got the basin and filled it with water and went to Resident #35's bedside to begin her bed bath. She stated she did pull the privacy curtain, but she heard the entire exchange of care being provided to her roommate. Resident #10 stated that she could hear NA #2 scrubbing Resident #35 and heard Resident #35 state to NA #2 that she was scrubbing her too hard. When NA #2 had completed washing the front of Resident #35 she went and got NA #3 to help turn her and wash her back side. Resident #10 stated that during the process both NA #2 and NA #3 were talking to themselves about how bad it was, and indicated they were referring to the size and color of Resident #35's sores on her bottom were but not talking to Resident #35. She stated the whole time NA #1 and NA #2 were washing her Resident #35 was crying and screaming saying it hurt. NA #2 was interviewed on 03/18/24 at 2:23 PM, she stated she had been coming to the facility for 4 days as agency staff. NA #2 confirmed she had given Resident #35 a bed bath earlier today. She stated that Resident #35 was in pain and crying especially when she rolled her over to her side. NA #2 stated, She is raw in her peri area and on her back side. NA #3 came in and helped turn Resident #35 onto her side to help wash her back side. NA #2 explained while washing Resident #35's other body parts she was fine and had no complaints of pain, but when she started washing her peri area and her back side, she began to cry but did not see real tears, but she was moaning and saying that it hurt. NA #2 stated, If you see it you will understand, referring to Resident #35's peri area and bottom. NA #3 was interviewed on 03/18/24 at 2:56 PM who confirmed she assisted NA #1 with completing Resident #35's bed bath. She stated that when she entered the room Resident #35 was resting on her back, NA #2 had washed and dried her front side and they turned Resident #35 onto her side to wash her peri area and her back side. She stated when they turned Resident #35 over, she was moaning and saying ouch and at one point put her hands over her face. The Director of Nursing (DON) was interviewed on 03/21/24 at 10:28 AM. She stated she expected the staff to treat each resident as though they are family and in a respectful and professional manner. She explained she did a lot of customer service training to remind staff on treating the residents in a dignified manner.

Based on record review, resident, roommate, staff, Wound Nurse Practitioner, and facility Nurse Practitioner interviews the facility failed to stop incontinent care when a resident (Resident #35) experienced pain and was crying and failed to report to the nurse so that her complaints of pain could be addressed for 1 of 1 resident reviewed for pain management. Resident #35 stated that during incontinent care and while being turned onto her side her pain was an 8 on a pain scale. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included: diabetes melilites, chronic obstructive pulmonary disease, respiratory failure, a pressure ulcer to left lower leg, and a pressure ulcer to the right lower leg. Review of a pain care plan for Resident #35 revised on 01/26/24 read in part, I am on pain medication therapy related to wound to lower extremities. The goal read, The resident will be free of any discomfort or adverse side effects from pain medication through the review date, and the interventions included: administer analgesic (pain medication) as ordered, monitor/document as needed adverse reactions to pain medications, and review pain medication for effectiveness. Review of a physician's order dated 03/21/23 read, Hydrocodone/Acetaminophen (controlled pain medication) 5/325 milligrams (mg) by mouth every 6 hours as needed for pain. Tylenol Extra Strength 500 mg give two tables by mouth every 8 hours as needed for discomfort. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #35 was cognitively intact and had no rejection of care. Resident #35 reported pain occasionally on a pain scale of a 6. The MDS also indicated that Resident #35 had moisture associated skin dermatitis and had 2 venous ulcers. Resident #35 received opioid medication during the assessment reference period. Review of the MAR dated March 2024 revealed on 03/18/24 no as needed Hydrocodone/Acetaminophen or Tylenol Extra Strength were administered. The MAR also revealed Resident #35 had reported pain on a pain scale of 5-6 at least every day during the month of March except for 03/13/24 and 03/18/24. Some days there were multiple doses of the Hydrocodone/Acetaminophen administered. An observation and interview were conducted with Resident #35 on 03/18/24 at 12:01 PM. Resident #35 was resting in bed on her back and had a very flat affect, her voice was very soft in tone almost a whisper. Resident #35 stated that two Nurse Aides (NA) had just given her a bed bath, the one with short hair was very nice and the one with long hair was very rough. Resident #35 was asked to describe what rough meant, she stated that the long-haired NA, identified as NA #2 was giving her a bed bath and she was washing with a rag that was very rough and then the short haired NA identified as NA #3 came in and they turned me onto my side and I was in so much pain from the wounds on my bottom. Resident #35 stated that she was crying and hollering out in pain and both NAs kept saying we are sorry but just kept on wiping me. Resident #35 stated that she would rate her pain at 8 at the time, once the staff were done and got her back onto her back, she stated her pain was better than before maybe down to a 5. She added that could not recall if this was the first time that NA #2 and NA #3 had taken care of her but stated they did put some cream on her sores on her bottom before they finished with her. She added that NA #2 and NA #3 were talking to each other about my wounds on my bottom but not to me directly. Resident #10 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed that Resident #10 was cognitively intact. An interview with Resident #35's roommate (Resident #10) was conducted on 03/18/24 at 12:06 PM, she stated NA #2 came in and told Resident #35 she was going to give her a bed bath and got the basin and filled it with water and went to Resident #35's bedside to begin her bed bath. She stated she did pull the privacy curtain, but she heard the entire exchange of care being provided to her roommate. Resident #10 stated that she could hear NA #2 scrubbing Resident #35 and heard Resident #35 state to NA #2 that she was scrubbing her too hard. When NA #2 had completed washing the front of Resident #35 she went and got NA #3 to help turn her and wash her back side. Resident #10 stated that during the process both NA #2 and NA #3 were talking to themselves about how bad it was, and indicated they were referring to the size and color of Resident #35's sores on her bottom were but not talking to Resident #35. She stated the whole time NA #2 and NA #3 were washing her Resident #35 was crying and screaming saying it hurt. She did overhear NA #2 say to Resident #35 I am sorry, and NA #3 apologized a couple of times, but they did not stop and get the nurse. She started that after NA #2 and NA #3 were finished and had left the room Resident #35 did calm down. NA #2 was interviewed on 03/18/24 at 2:23 PM, she stated she had been coming to the facility for 4 days as agency staff. NA #2 confirmed she had given Resident #35 a bed bath earlier today. She stated that Resident #35 was in pain and crying especially when she rolled her over to her side. NA #2 stated, She is raw in her peri area and on her back side. NA #3 came in and helped turn Resident #35 onto her side to help wash her back side. She stated Resident #35's wounds were not deep, and she had put cream (barrier cream) on them. NA #2 explained while washing Resident #35's other body parts she was fine and had no complaints of pain, but when she started washing her peri area and her back side, she began to cry but did not see real tears, but she was moaning and saying that it hurt. NA #2 stated she had not reported the interaction to the nurse and was not aware if Resident #35 had anything for pain or not. She added that everyone told me that her crying and fussing was her usual behavior and that was why she had not reported it to the nurse. NA #2 stated, If you see it you will understand, referring to Resident #35's peri area and bottom. NA #3 was interviewed on 03/18/24 at 2:56 PM who confirmed she assisted NA #2 with completing Resident #35's bed bath. She stated that when she entered the room Resident #35 was resting on her back, NA #2 had washed and dried her front side and they turned Resident #35 onto her side to wash her peri area and her back side. She stated when they turned Resident #35 over, she was moaning and saying ouch and at one point put her hands over her face. She stated she knew Resident #35 was hurting but she never asked us to stop and that was pretty normal behavior for her. NA #3 stated she had not let the nurse know that Resident #35 was hurting. Nurse #9 was interviewed on 03/19/24 at 9:09 AM. She stated Resident #35 did complain a lot of pain with her wounds, and they definitely gave her something for pain prior to any wound treatment. Nurse #9 stated outside of wound care it was hit or miss if Resident #35 requested something for pain, she explained the resident may take the pain medication once a shift and then may not take it for a day or so. Nurse #9 stated Resident #35 has pain when she is moved and there were times where she would refuse to turn because it hurt so bad. Nurse #9 stated she has told Resident #35 that she can have her pain medication but that she still has to get changed and the pain medication is effective until we move her again. When Nurse #9 does assess Resident #35's pain she explained it was usually a headache or pain in her bottom and sometimes her pain was a 6 or 7. If she was resistive to care the NAs would come and get me but nothing was reported to her yesterday regarding Resident #35's pain during incontinent care. Nurse #9 also confirmed she had not given Resident #35 anything for pain on 03/18/24. The facility NP was interviewed via phone on 03/19/24 at 4:57 PM, she stated the nurse had contacted her earlier on 03/19/24 and she was going to increase Resident #35's pain medication. She stated that recently her usage had increased and typically the pain medication was given with dressing changes. The NP explained the wounds on Resident #35's legs had been present for 5 years and were likely not going to heal. The NP stated although Resident #35 was starting to use her pain medication more frequently she did not think that she would need opioid medication with incontinent care. She added that she was increasing her Hydrocodone to 7.5 mg every 6 hours, but everything was a fine line especially respiratory depression which was a big concern for her. The Wound Nurse Practitioner (NP) was interviewed on 03/20/24 at 8:47 AM. She stated that Resident #35's bottom waxes and wanes, she will have spots that open and then get a little bigger. She stated she generally saw Resident #35 first thing in the morning, and she was usually more irritated from being wet throughout the night. and there were times she would not allow me to look at her bottom because she said it hurt to turn over. The Wound NP stated that when she first started seeing her, she recommend starting some pain medication prior to wound care and after noted an improvement in her participation. The Director of Nursing (DON) was interviewed on 03/21/24 at 10:28 AM, she stated that Resident #35 was verbal when she needed things. She stated the NP had increased Resident #35's pain medication to 7.5 mg on 03/19/24. If Resident #35 was in pain, then the staff should have given her pain medication and would expect the pain medication to be given ahead of the pain.

Based on record review, resident, shelter staff, and facility staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 9/23/2021 Complaint Investigation Survey and the 3/8/2022 Complaint Investigation Survey During the 3/8/2022 Complaint Investigation Survey the facility was cited for Resident Rights (F550) and during the 9/23/2021 Complaint Investigation Survey the facility was cited for Discharge Planning Process (F660). These deficiencies were recited again on the current Recertification Survey and Complaint Investigation Survey of 3/28/2024. The continued failure of the facility to ensure compliance in the two previously deficient areas showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Findings included: This tag is cross referenced to: F660-Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective discharge planning process to ensure discharge needs and goals were identified with the resident and the interdisciplinary team (IDT) as active participants in the discharge plan in order to prepare the resident for an effective transition to post-discharge care for a resident who was a planned discharge. On 2/14/24 Resident #241 was discharged without the facility verifying his discharge location and if his care needs were able to be met. In addition, the resident was discharged without adaptive equipment required for ambulation (rolling walker). Resident #241 indicated he was dropped off at a homeless shelter where he continued to reside and felt unsafe and was fearful. These failures created a high likelihood of harm for Resident #241. This deficient practice affected 1 of 4 residents reviewed for discharge. During a Complaint investigation survey of 9/23/2021 the facility failed to implement and communicate with Emergency Contact #1 or the Resident Representative (RP)/Emergency Contact #2, a discharge plan for a resident's transfer to a locked unit at another Skilled Nursing Facility. F550- Based on record review, resident, roommate, and staff interviews the facility failed to treat a resident in a dignified manner when two Nurse Aides (NAs) were talking about the residents' wounds in front of her but not to her and were rough during incontinent care and when the resident was screaming and crying in pain (Resident #35) and they did not stop the care. The resident stated the interactions with the NAs made her feel angry and upset that they treated her that way for 1 of 1 resident reviewed for pain. During the complaint investigation survey of 3/8/2022 the facility failed to treat a resident in a dignified manner when there was a delay in answering a resident's call light. During an interview with the Administrator on 3/22/2024 at 12:32 pm she stated the facility has a monthly Quality Assessment and Assurance (QAA) meeting with the department managers and the Physician; and the Pharmacist is available for the quarterly QAA meetings. She stated she understood the facility's QAA process had failed since they had repeated the two tags for Resident Rights and Discharge Planning Process and the facility would continue to strive to improve their processes.

Based on record review, observation, staff interviews and resident interviews the facility failed to prevent 2 of 5 cognitively impaired residents from exiting the facility unsupervised (Resident #50 and Resident #114). Findings included: A review of the weather for [DATE] revealed that the temperature was 77 degrees with no rain. 1A: Resident #50 was admitted to the facility on [DATE]. The resident was admitted with multiple [DIAGNOSES REDACTED]. A review of resident #50's Minimum Data Set ((MDS) dated [DATE] revealed that the resident was severely cognitively impaired. The MDS coded the resident as needing extensive assistance with one person for bed mobility, dressing, toileting and personal hygiene, extensive assistance with two people for transfers, supervision with one person for locomotion on the unit in her wheelchair and the resident was coded as a person that would wander out of the building. A review of resident #50's care plan dated [DATE] revealed that the resident had a care plan addressing the residents elopement risk with the following interventions; Staff is to check placement of the wander guard visually every shift, distract the resident from wandering and check the function of the wander guard with electric machine every day. 1B: Resident #114 was admitted to the facility on [DATE]. The resident was admitted with multiple [DIAGNOSES REDACTED]. A review of resident #114's Minimum Data Set ((MDS) dated [DATE] revealed resident #114 had memory problems with moderately impaired decision making abilities. The MDS also revealed the resident needed extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene, supervision with one person for transfers, walking in the corridors, locomotion on and off unit and eating and independent with walking in her room. MDS revealed the resident was not coded for wandering behaviors. A review of the care plan dated [DATE] revealed that there was no plan developed for wandering or exit seeking behaviors. A review of the incident report dated [DATE] revealed that resident #50 was observed outside in the parking lot. A review of the incident report dated [DATE] revealed that resident #114 was observed outside in the parking lot. A review of a written interview by the Rehab Director dated [DATE] revealed that a Physical Therapist Assistant (PTA) saw resident #50 being pushed in her wheel chair by resident #114 outside in the parking lot. The written interview revealed that the PTA went out to the parking lot, checked on the two residents then brought them back inside through the therapy door. An interview with the Rehab Director occurred on [DATE] at 10:20am. The Rehab Director stated that she was informed of resident #50 and resident #114 being outside in the parking lot by her Physical Therapy Assistant (PTA). The staff member stated while her PTA went out to escort the residents back into the building she called the Director of Nursing and the Administrator to come escort the residents back to their respective rooms. The Rehab Director stated she believed the residents went out the front door of the facility. An interview with the Physical Therapy Assistant (PTA) occurred on [DATE] at 10:25am. The PTA stated he was providing therapy for a resident and happen to glance out the window and saw resident #50 and resident #114 outside in the parking lot. The staff member stated resident #114 was pushing resident #50 in her wheel chair and that this occurred around 2:00pm on [DATE]. The PTA walked to where the residents were located outside and attempted to ask where they were going but the PTA stated neither resident could answer him. The PTA stated he escorted both residents back into the building. The area from the therapy door, where the residents were brought back into the building, to where they were found was 100 feet. A review of the Director of Nursing's (DON) investigation dated [DATE] revealed that resident #50 was seen in the dining room eating lunch and then next observed, by a staff member, being pushed in her wheelchair by another resident in the parking lot. The report revealed that staff responded and brought the two residents back inside and that the DON and the maintenance director tested resident #50's wander guard and discovered it was not working. The report also revealed that a head to toe assessment was completed for resident #50. An interview with the Director of Nursing (DON) occurred on [DATE] at 3:50pm. The DON stated after she was made aware of resident #50 being out in the parking lot she immediately tested resident #50's wander guard with the electric machine. The DON stated the wander guard registered as not working and that she then took the resident to one of the doors that had a wander guard alarm and the wander guard did not work. The DON stated she immediately received an order to change the wander guard and placed a new wander guard on the resident. An interview with resident #50 occurred on [DATE] at 9:45am. The resident stated she could not remember the incident. The resident stated she did not go outside. Resident #50's wander guard noted to be present on her right wrist. An interview with resident #114 occurred on [DATE] at 10:00am. Due to residents inability to hear and limited vision it was not possible to ascertain if she remembered being out of the building on [DATE]. A review of resident #50's head to toe assessment dated [DATE] revealed that a complete body check was completed with no abnormal findings. A review of the Medication Administration Record (MAR) revealed that resident #50 received her wander guard bracelet on [DATE]. The MAR further revealed that the wander guard was replaced on [DATE]. A review of the MAR from [DATE] to [DATE] revealed documentation that resident #50's wander guard was working properly. The MAR further revealed that the resident received a new wander guard bracelet [DATE]. A review of the maintenance logs dated [DATE] through [DATE] revealed that all 5 doors that have the wander guard alarm system were operational. A review of the manufacturers guidelines related to the maintenance and replacement of the wander guard revealed that resident #50's wander guard bracelet was to be replaced every 90 days. An interview with the Nursing Assistant (NA #3) occurred on [DATE] at 10:40am. NA #3 stated she remembers she was working on [DATE] but denied knowing anything about resident #50 being outside in the parking lot. The staff member also stated she did not remember rendering any type of care or seeing resident #50 after lunch. An interview with nurse #1 occurred on [DATE] at 10:45am. Nurse #1 stated she remembered working on [DATE] but denied knowing anything about resident #50 being outside in the parking lot till the next day when she came into work. Nurse #1 stated she was told at that time about the resident being outside and that she needed to make sure she checked on resident #50 more often. An interview with maintenance personal occurred on [DATE] at 1:50pm. Maintenance stated that the only way out of the building during the day was through the front door and that all other doors were locked and needed a key or a code to get out. Maintenance measured from the front door, where resident #50 and resident #114 left the building, to where they were located and the measurement was 446 feet. The distance between where the residents were found and the road was 346 feet. Maintenance stated that resident #50's wander guard bracelet did not work but that he did not know why it was not working and guessed it may have been that the battery died . An observation of the nurse testing resident #50's wander guard occurred on [DATE] at 4:10pm. The nurse explained the procedure as she tested the wander guard and found the wander guard to be working properly. An interview with the DON occurred on [DATE] at 9:31am. The DON stated she expected all residents who have wander guards have them checked for placement and functionality daily. An interview with the Nursing Assistant (NA #3) occurred on [DATE] at 1:40pm. NA #3 stated she remembers she was working on [DATE] but denied knowing anything about resident #114 being outside in the parking lot. NA #3 also stated she did not remember rendering any type of care or seeing resident #114 after lunch. An interview with the DON occurred on [DATE] at 9:31am. The DON stated she expected all residents who have wander guards have them checked for placement and functionality daily. The DON also stated she expected resident #114 to be monitored more closely. An observation of the nurse checking placement and functionality of resident #114's wander guard occurred on [DATE] at 2:10pm. The nurse explained the procedure in testing the functionality of the wander guard and that the electric machines light will turn green when the devise is working properly. The result was that resident #114's wander guard was working. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: F323. 1. On [DATE] at approximately 2:00pm a Therapist from the Facility's Rehab staff observed, through the Rehab gym window, Resident #50 and Resident #114 in the Facility parking lot. Resident #114 was pushing Resident #50 seated in a wheelchair. The Rehab staff responded immediately and assisted both Residents back into the facility and proceeded directly to the Charge Nurse and reported the event. Nurse #1 completed a head to toe assessment of Resident #50 and Resident #114, noted no injuries and documented this assessment on a nurse's progress note. On [DATE], immediately following the event, the Director of Nursing validated the placement and function of the Wander guard for Resident #50. The Facility Maintenance Director and Director of Nursing took Resident #50 to the front door to test the function of the resident's bracelet located on her right wrist. As the Resident approached the doors it did not activate the Wander guard System to lock the doors. A new bracelet was placed on Resident #50 by the Director of Nursing and when the resident was taken back toward the front door the alarm activated and the door locked. Resident #50 was assessed as being at risk for elopement and identified at risk on [DATE], a wander guard was placed for intervention and the care plan was updated. Resident #114 was admitted on [DATE], was not assessed a risk for elopement and has no prior history of wandering or exit seeking behaviors and did not use a Wander guard bracelet prior this event. An updated Elopement Assessment was completed for Residents #50 and resident #114 by the Director of Nursing on [DATE]. Residents #50 and resident #114 were assessed at risk for elopement, care plans were reviewed and revised to include exit seeking behaviors, the Wander guard bracelet was continued for Resident #50 and a Wander guard bracelet was added for Resident #114. The Director of Nursing notified the Responsible Party and Physician for both Resident #50 and resident #114 regarding the event, the follow up assessment, and the plan for increased monitoring that began on [DATE]. No new physician's orders [REDACTED]. The Facility Medical Director was notified on of the incident on [DATE] by the Director of Nursing. 2. An Incident report was completed by Director of Nursing on [DATE] and an investigation with root cause analysis was completed by the Director of Nursing on [DATE]. Resident #50 had been identified as possible risk for elopement on [DATE] and a Wander guard bracelet was initiated. Resident #50's medical record revealed that the bracelet was last changed on [DATE] and scheduled to be changed every 90 days, due on [DATE]. The treatment record for July, August and September revealed that the residents bracelet had been checked for placement and function by the Charge Nurse, daily as ordered by the Physician with no discrepancies noted. Staff interviews were conducted to validate the procedure for checking placement and function of the Wander guards. On [DATE] Incident and Accident reports from the last 90 days were reviewed by the Director of Nursing and Administrator and it was determined there were no other unsupervised exits reported for Resident #50. There were no other unsupervised exits reported for other residents assessed at risk for elopement during the last 90 days. To the knowledge of Facility Staff and Leadership, Resident #50 has had no other instances of exiting the facility without supervision prior to [DATE]. The Maintenance Director completed a review of the Wander guard System including validation of properly functioning Wander guard keypads and alarms for all Facility doors on [DATE] and again on [DATE]. This validation is completed by utilizing a functioning Wander guard bracelet to validate that each door locks when the bracelet is within 5 feet and alarms when the bracelet crosses the threshold. The Maintenance Director or Administrator will continue to monitor the Wander guard System for all facility doors daily and document on the Wander guard Log maintained in the Director of Nursing Office. This daily monitoring will continue for 90 days and be re-evaluated for effectiveness by the Administrator and Maintenance Director, this is an ongoing facility process that will continue. The Director of Nursing and Nurse Managers completed an audit of all current residents with Wander guard bracelets and validated placement and function of each device on [DATE] immediately following the event to ensure all other devices were functioning properly. 6 Residents were reviewed and no other discrepancies were identified. On [DATE] the Director of Nursing and Nurse Managers conducted an audit of all current residents at risk for elopement to include a review of current Elopement Assessments for accuracy, validation of Wander guard bracelet placement and operation as required, validation of physician's orders [REDACTED]. Elopement care plans were reviewed and validated on [DATE] by the Nurse Managers. 3. On [DATE] The Director of Nursing and Nurse Managers re-educated all current Facility Staff regarding the resident identified at risk for elopement. The education included monitoring the whereabouts of residents who are at risk for elopement, action to take if a resident exhibits exit seeking behavior, checking function and placement of the Wander guard bracelet and action to take if Wander guard bracelet is not in placement or not properly functioning. No staff shall work after [DATE] before receiving this education. This education has been added to the Facility Orientation program for all new hires and agency staff to be completed prior to beginning work after [DATE]. The Director of Nursing and Nurse Managers will monitor the placement and function of the Wander guard bracelets for 5 random residents with bracelets 3 times per week for 12 weeks, in addition to the daily check of the function and placement conducted by the Charge Nurse. The Director of Nursing and Nurse Managers will validate weekly that Wander guard bracelets are change per orders according to the manufacturer recommendations and this change will be tracked and documented on the MAR. Residents identified at risk for elopement will have their location monitored twice per shift by the Charge Nurse and this will be documented on the MAR. The Director of Nursing and Nurse Managers will validate these location checks for 5 random residents at risk for elopement 3 times per week for 12 weeks. Any opportunities identified will be corrected and reported to the Director of Nursing and Administrator immediately. The Director of Nursing and Nurse Managers will review new admissions and readmission daily and review the 24 hour report during the Clinical Morning Meeting to validate accurate elopement assessments and care plans as required. The Director of Nursing and Nurse Managers will review current residents assessed at risk for elopement monthly to validate accurate assessments and care plans. The Maintenance Director or Administrator will continue to monitor the Wander guard System for all facility doors daily and document on the Wander guard Log maintained in the Director of Nursing Office. This daily monitoring will continue for 90 days and be re-evaluated for effectiveness by the Administrator and Maintenance Director, this is an ongoing facility process that will continue The Administrator is responsible for the implementation of the plan of correction. The facility alleges compliance with F323 on [DATE]. The corrective action plan was validated on [DATE] at 5:00pm Validation included reviewing the educational material and roster for the in-service related to elopement risk behaviors and wander guards. Validation included interviews with randomly chosen staff in different service areas which validated recent education on elopement behaviors, what to do if they notice these behaviors, placement and functionality of the wander guard and who to contact if the wander guards are missing or not working and having staff demonstrate how to test the wander guard on those residents that currently have this devise. On [DATE] the facility began auditing the 6 residents that had wander guards for wandering behaviors and the placement and functionality of their wander guards. No further issues had occurred.

Based on observations, staff, nurse practitioner and physician interviews and record reviews the facility failed to check for incontinence for two of four sampled residents with incontinence. The facility failed to check Resident #5 with worsened incontinence [MEDICAL CONDITION] for five hours and failed to check Resident #3 with a leaking indwelling urinary catheter. The findings included: 1. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #5 had some impairment with short term memory, required extensive assistance of two persons for bed mobility, transfers, and dressing, extensive assistance of one person for toileting and personal hygiene, total dependence of two staff for bathing, was always incontinent of bowel and bladder and had a stage 4 pressure ulcer. The care plan dated 12/7/16 for a problem of requiring extensive assistance with activities of daily living. Approaches included the resident was to participate to her fullest extent as possible, observe for decline and therapy per physician order. The care plan had an update of 1/31/17 for a problem of incontinence of bowel and bladder which had no goal or approaches. Review of the wound physician progress notes [REDACTED]. Entire buttocks and posterior thighs are inflamed. Observations on 1/31/17 at 10:11 AM revealed Resident #5 was in bed lying on her back. The Nursing Assistant (NA) #1, who was assigned to care for Resident #5 was not available. Observations of incontinence care, provided by Nursing Assistant (NA) #2, revealed two cloth pads were positioned under the resident from her mid back to her upper thighs. Cloth pad #2 was on top of the sheet and under the resident's mid back and partially under the top pad (pad #1). The cloth pads were wet from the top of the pads to the bottom. A dried yellow ring was at the outer edges of pad #2. A disposable brief was folded with the pad side next to the resident between her legs. The brief was folded into a small ball. The resident's skin on the inner thighs, perineal area, and buttocks was red and scalded in appearance. There was a strong urine odor, and the resident's gown was wet at the gown tail which was underneath the resident's buttocks and upper thighs. During incontinence care, Resident #5 was turned to side. The dressing that was on the sacral/coccyx area was off and laying under the buttocks. The dressing looked like a piece of wet rolled gauze that was brown in color. On 1/31/17 a 10:15 AM, during observations of incontinence care, Resident #5 explained no one had been in to check her, or clean her that morning. She continued with she was always a clean person, did not like being dirty. During the observation of incontinence care Resident #5 complained of discomfort when cleaned. Interview with Nursing Aide (NA) #1 on 1/31/17 at 11:35 AM revealed she did not put the folded brief between her legs. NA #1 explained Whoever changed her last did that. The NA responded she had not checked the resident for incontinence since coming on duty at 6:20 AM. She further explained she had not checked Resident #5 because she was getting other residents up for breakfast in the dining room. NA #1 explained she had five residents to get up for breakfast. Interview with the Nurse Practitioner on 2/1/17 at 4:25 PM revealed if Resident #5 was left wet for a couple of hours, it could make the [MEDICAL CONDITION] worse. The resident did not want an indwelling catheter, and the staff would need to check her frequently for incontinence and use a protective barrier. Interview with the wound physician on 2/1/17 at 5:29 PM revealed he saw the resident on a weekly basis for wound care. Each visit he found the resident to be wet with urine. The [MEDICAL CONDITION] on her buttocks had worsened during the past two weeks. The staff should check her often and keep the skin free from urine. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect the aides to provide incontinence care at least every three hours. 2. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had no long or short term memory problems, required total assistance of one staff for toileting, was occasionally incontinent of urine and always incontinent of bowel. The MDS indicated an indwelling urinary catheter was in use. Review of the Care Area Assessments (CAAs) indicated the presence of urinary incontinence and an indwelling catheter. The resident required assistance with activities of daily living due to impaired mobility. The care plan dated 1/4/17 for a problem of bowel incontinence and an indwelling urinary catheter included approaches of catheter care as ordered, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode. Observations of Resident #3 on 1/31/17 at 11:00 AM revealed the resident had an indwelling catheter in place. The resident was turned to her right side by the Treatment nurse to do the treatment. The disposable brief the resident was wearing was saturated with urine, as evidenced by the padding in the disposable brief had seperated, the cloth pad under the resident was wet extending up the resident's back, and the resident's gown was wet. There was a strong urine smell at the bedside. Interview with the treatment nurse on 1/31/17 at 11:15 AM revealed the alternating air mattress was wet underneath the resident. The physician was aware the catheter leaked and had tried different sizes without success to prevent leakage of urine. Interview on 1/31/17 at 11:20 AM with Nursing Aide (NA) #1 revealed Resident #3 required total assistance with activities of daily living. NA #1 explained she would check for incontinence every hour for this resident. Further interview revealed she had been in the resident's room to pass the breakfast tray, but had not provided a check for incontinence care as of this time. During the interview NA#1 explained she had not made her way down to Resident #3's room yet, due to getting up five residents for breakfast in the dining room. Interview with Resident #3 on 2/1/17 at 9:30 AM revealed she had been left wet on 1/31/17 due to the catheter leaking. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect staff to check for incontinence at least every three hours.

Based on observations, staff, nurse practitioner and physician interviews and record reviews the facility 1. Failed to check Resident #5 for incontinence in five hours. (Resident #5 had worsening incontinence [MEDICAL CONDITION] per the wound physician.) 2. Failed to check Resident #3 for incontinence for two of four sampled residents with incontinence. The findings included: 1. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/7/16 for a problem of requiring extensive assistance with activities of daily living. Approaches included the resident was to participate to her fullest extent as possible, observe for decline and therapy per physician order. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #5 had some impairment with short term memory, required extensive assistance of two persons for bed mobility, transfers, and dressing, extensive assistance of one person for toileting and personal hygiene, total dependence of two staff for bathing, was always incontinent of bowel and bladder and had a stage 4 pressure ulcer. The care plan had an update of 1/31/17 for a problem of incontinence of bowel and bladder which had no goal or approaches. Review of the wound physician progress notes [REDACTED]. Entire buttocks and posterior thighs are inflamed. Observations on 1/31/17 at 10:11 AM revealed Resident #5 was in bed lying on her back. The Nursing Assistant (NA) #1, who was assigned to care for Resident #5 was not available. Observations of incontinence care, provided by Nursing Assistant (NA) #2, revealed two cloth pads were positioned under the resident from her mid back to her upper thighs. Cloth pad #2 was on top of the sheet and under the resident's mid back and partially under the top pad (pad #1). The cloth pads were wet from the top of the pads to the bottom. A dried yellow ring was at the outer edges of pad #2. A disposable brief was folded with the pad side next to the resident between her legs. The brief was folded into a small ball. The resident's skin on the inner thighs, perineal area, and buttocks was red and scalded in appearance. There was a strong urine odor, and the resident's gown was wet at the gown tail which was underneath the resident's buttocks and upper thighs. During incontinence care, Resident #5 was turned to her side. The dressing that was on the sacral/coccyx area was off and laying under the buttocks. The dressing looked like a piece of wet rolled gauze that was brown in color. On 1/31/17 a 10:15 AM, during observations of incontinence care, Resident #5 explained no one had been in to check her, or clean her that morning. She continued with she was always a clean person, did not like being dirty. During the observation of incontinence care Resident #5 complained of discomfort when cleaned. Interview with Nursing Aide (NA) #1 on 1/31/17 at 11:35 AM revealed she did not put the folded brief between her legs. NA #1 explained Whoever changed her last did that. The NA responded she had not checked the resident for incontinence since coming on duty at 6:20 AM. She further explained she had not checked Resident #5 because she was getting other residents up for breakfast in the dining room. NA #1 explained she had five residents to get up for breakfast. Interview with the Nurse Practitioner on 2/1/17 at 4:25 PM revealed if Resident #5 was left wet for a couple of hours, it could make the [MEDICAL CONDITION] worse. The resident did not want an indwelling catheter, and the staff would need to check her frequently for incontinence and use a protective barrier. Interview with the wound physician on 2/1/17 at 5:29 PM revealed he saw the resident on a weekly basis for wound care. Each visit he found the resident to be wet with urine. The [MEDICAL CONDITION] on her buttocks had worsened during the past two weeks. The staff should check her often and keep the skin free from urine. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect the aides to provide incontinence care at least every three hours. 2. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had no long or short term memory problems, required total assistance of one staff for toileting, was occasionally incontinent of urine and always incontinent of bowel. The MDS indicated an indwelling urinary catheter was in use. Review of the Care Area Assessments (CAAs) indicated the presence of urinary incontinence and an indwelling catheter. The resident required assistance with activities of daily living due to impaired mobility. The care plan dated 1/4/17 for a problem of bowel incontinence and an indwelling urinary catheter included approaches of catheter care as ordered, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode. Observations of Resident #3 on 1/31/17 at 11:00 AM revealed the resident had an indwelling catheter in place. The resident was turned to her right side by the Treatment nurse to do the treatment. The disposable brief the resident was wearing was saturated with urine, as evidenced by the padding in the disposable brief had seperated, the cloth pad under the resident was wet extending up the resident's back, and the resident's gown was wet. There was a strong urine smell at the bedside. Interview with the treatment nurse on 1/31/17 at 11:15 AM revealed the alternating air mattress was wet underneath the resident. The physician was aware the catheter leaked and had tried different sizes without success to prevent leakage of urine. Interview on 1/31/17 at 11:20 AM with Nursing Aide (NA) #1 revealed Resident #3 required total assistance with activities of daily living. NA #1 explained she would check for incontinence every hour for this resident. Further interview revealed she had been in the resident's room to pass the breakfast tray, but had not provided a check for incontinence care as of this time. During the interview NA#1 explained she had not made her way down to Resident #3's room yet, due to getting up five residents for breakfast in the dining room. Interview with Resident #3 on 2/1/17 at 9:30 AM revealed she had been left wet on 1/31/17 due to the catheter leaking. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect staff to check for incontinence at least every three hours.

Based on observations, resident and staff interviews and record reviews the facility failed to promote residents' dignity when incontinence checks were not provided and Residents #5 and were not kept free from excessive urine for two of four sampled residents with incontinence. The findings included: 1. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #5 had some impairment with short term memory, required extensive assistance of two persons for bed mobility, transfers, and dressing, extensive assistance of one person for toileting and personal hygiene, total dependence of two staff for bathing, was always incontinent of bowel and bladder and had a stage 4 pressure ulcer. The care plan dated 12/7/16 for a problem of requiring extensive assistance with activities of daily living. Approaches included the resident was to participate to her fullest extent as possible, observe for decline and therapy per physician order. The care plan had an update of 1/31/17 for a problem of incontinence of bowel and bladder which had no goal or approaches. Observations on 1/31/17 at 10:11 AM revealed Resident #5 was in bed lying on her back. The Nursing Assistant (NA) #1, who was assigned to care for Resident #5 was not available. Observations of incontinence care, provided by Nursing Assistant (NA) #2, revealed two cloth pads were positioned under the resident from her mid back to her upper thighs. Cloth pad #2 was on top of the sheet and under the resident's mid back and partially under the top pad (pad #1). The cloth pads were wet from the top of the pads to the bottom. A dried yellow ring was at the outer edges of pad #2. A disposable brief was folded with the pad side next to the resident between her legs. The brief was folded into a small ball. The resident's skin on the inner thighs, perineal area, and buttocks was red and scalded in appearance. There was a strong urine odor, and the resident's gown was wet at the gown tail which was underneath the resident's buttocks and upper thighs. During incontinence care, Resident #5 was turned to side. The dressing that was on the sacral/coccyx area was off and laying under the buttocks. The dressing looked like a piece of wet rolled gauze that was brown in color. On 1/31/17 a 10:15 AM, during observations of incontinence care, Resident #5 explained no one had been in to check her, or clean her that morning. She continued with she was always a clean person, did not like being dirty. During the observation of incontinence care Resident #5 complained of discomfort when cleaned. Interview with Nursing Aide (NA) #1 on 1/31/17 at 11:35 AM revealed she did not put the folded brief between her legs. NA #1 explained Whoever changed her last did that. The NA responded she had not checked the resident for incontinence since coming on duty at 6:20 AM. She further explained she had not checked Resident #5 because she was getting other residents up for breakfast in the dining room. NA #1 explained she had five residents to get up for breakfast. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect the aides to provide incontinence care at least every three hours. 2. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had no long or short term memory problems, required total assistance of one staff for toileting, was occasionally incontinent of urine and always incontinent of bowel. The MDS indicated an indwelling urinary catheter was in use. Review of the Care Area Assessments (CAAs) indicated the presence of urinary incontinence and an indwelling catheter. The resident required assistance with activities of daily living due to impaired mobility. The care plan dated 1/4/17 for a problem of bowel incontinence and an indwelling urinary catheter included approaches of catheter care as ordered, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode. Observations of Resident #3 on 1/31/17 at 11:00 AM revealed the resident had an indwelling catheter in place. The resident was turned to her right side by the Treatment nurse to do the treatment. The disposable brief the resident was wearing was saturated with urine, as evidenced by the padding in the disposable brief had seperated, the cloth pad under the resident was wet extending up the resident's back, and the resident's gown was wet. There was a strong urine smell at the bedside. Interview with the treatment nurse on 1/31/17 at 11:15 AM revealed the alternating air mattress was wet underneath the resident. The physician was aware the catheter leaked and had tried different sizes without success to prevent leakage of urine. Interview on 1/31/17 at 11:20 AM with Nursing Aide (NA) #1 revealed Resident #3 required total assistance with activities of daily living. NA #1 explained she would check for incontinence every hour for this resident. Further interview revealed she had been in the resident's room to pass the breakfast tray, but had not provided a check for incontinence care as of this time. During the interview NA#1 explained she had not made her way down to Resident #3's room yet, due to getting up five residents for breakfast in the dining room. Interview with Resident #3 on 2/1/17 at 9:30 AM revealed she had been left wet on 1/31/17 due to the catheter leaking. Further interview revealed this had occurred often. Interview with the Director of Nursing on 2/1/17 at 5:50 PM revealed she would expect staff to check for incontinence at least every three hours.

Based on observation, record review and staff interview, the facility failed to provide timely treatment to the pressure ulcer to promote healing for 1 (Resident # 8)of 3 sampled residents with pressure ulcer. The findings include: Resident #8 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had memory and decision making problems, needed extensive assistance with 2 plus persons physical assist with bed mobility, was incontinent of bladder and needed extensive assistance with toilet use. The assessment further revealed that the resident had a stage IV pressure ulcer and had a feeding tube. On 04/16/10, the resident was assessed as moderate risk for developing pressure ulcers. The care plan approaches for the actual pressure ulcer on the sacrum dated 06/10/10 was reviewed. The approaches included apply pressure reduction mattress to bed, turn and reposition during routine care rounds while in bed, complete a full body check weekly and document and measure and stage wound weekly using the pressure ulcer healing assessment form. Review of the weekly pressure ulcer records revealed that on 11/25/09, the resident had developed a pressure ulcer on the sacrum. On 07/08/10, the sacral pressure ulcer was assessed as a stage IV measuring 5.5 x 5.3 centimeter (cm) with undermining. There was no record of a pressure ulcer on the right buttock. On 07/14/10 at 11:14 AM, administrative staff member #1 was observed during the dressing change as the treatment nurse was not available. She (administrative staff member #1) cleansed the sacral pressure ulcer with wound cleanser, packed it with [MEDICATION NAME] rope (antimicrobial silver dressing) and covered with ABD (abdominal) pad. When the resident was turned to the right side during the dressing change, there was an open area observed on the resident's right buttock. The open area had a yellowish wound bed and had no dressing on it. On 07/14/10 at 12:30 PM, the open area on the right buttock was again observed in the presence of Nurse #8 (assigned to the resident). The open area had no dressing on it. When interviewed, Nurse #8 stated that she was aware of the open area on the right buttock since yesterday (07/13/10) and she had informed the acting treatment nurse about it. On 07/15/10 at 8:00 AM, the resident's right buttock was again observed in the presence of Resident Care Specialist (RCS) #5. The open area on the right buttock had no dressing on it. The resident had an incontinent episode (bowel) at this time and NA #1 was observed during the incontinent care. When interviewed, RCS #5 stated that she had not been assigned to the resident for a while and she did not know when the area had first opened. The resident's telephone orders, weekly skin assessments and treatment records were reviewed. There was no treatment ordered for the right buttock open area. The treatment record for July, 2010 revealed that there was no treatment provided to the right buttock open area. There was no assessment on the weekly skin assessment form regarding the open area on the right buttock. On 07/15/10 at 8:10 AM, administrative staff member #1 was interviewed. She stated that she did not notice the open area on the resident's right buttock during the dressing change. She then went to look and assess the open area. The weekly pressure ulcer record dated 07/15/10 revealed " area noted to right lower buttock measuring 2.4 x 1.2 cm with yellowish area measuring 0.5 x 0.7 cm in center of wound. Orders obtained for [MEDICATION NAME]. Resident on Prosource and Multivitamin. Has an appointment at the wound clinic next week. " The open area was assessed as a stage II pressure ulcer. When asked about the staging of wound with a yellow wound bed (slough), the administrative staff member #1 indicated that she had based her staging on the weekly pressure ulcer record form. The form indicated " stage 2 - a partial thickness loss of skin layers that presents clinically as abrasion, blister or shallow crater. " On 07/15/10 at 10:15 AM, administrative staff member #1 provided a copy of the telephone order for the treatment of [REDACTED]. She had verified that Nurse #8 was aware of the pressure ulcer on the right buttock who indicated that she had informed the acting treatment nurse about it. She further stated that according to the acting treatment nurse, she was not informed about the open area on the right buttock but was aware that the resident had an appointment with the wound clinic.

Based on observation, record review and staff interview, the facility failed to notify the attending physician of the new pressure ulcer (Resident #8), the significant weight loss (Resident # 133 ) and to verify the need for [MEDICATION NAME] therapy (Resident # 55) for 3 of 3 sampled residents with significant change in condition. The findings include: 1. Resident #8 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had memory and decision making problems, needed extensive assistance with 2 plus persons physical assist with bed mobility, was incontinent of bladder and needed extensive assistance with toilet use. The assessment further revealed that the resident had a stage IV pressure ulcer and had a feeding tube. The facility's policy on Skin Management dated February, 2010 was reviewed. One of the care interventions for a stage II pressure ulcer was " Resident, family and attending physician are notified of development of a stage II ulcer. " Review of the weekly pressure ulcer records revealed that on 11/25/09, the resident had developed a pressure ulcer on the sacrum. On 07/08/10, the sacral pressure ulcer was assessed as a stage IV measuring 5.5 x 5.3 centimeter (cm) with undermining. There were no records that indicate the presence of pressure ulcer on the right buttock. On 07/14/10 at 11:14 AM, administrative staff member #1 was observed during the dressing change as the treatment nurse was not available. She (administrative staff member #1) cleansed the sacral pressure ulcer with wound cleanser, packed it with [MEDICATION NAME] rope (antimicrobial silver dressing) and covered with ABD (abdominal) pad. When the resident was turned to the right side during the dressing change, there was an open area observed on the resident's right buttock. The area had a yellowish wound bed and had no dressing on it. On 07/14/10 at 12:30 PM and on 07/15/10 at 8:00 AM, the open area on the right buttock was again observed in the presence of Nurse #8 (assigned to the resident) and Resident Care Specialist (RCS) #5. The open area had no dressing on both occasions. On 07/14/10 at 12:30 PM, Nurse #8 was interviewed. She (Nurse #8) stated that she was aware of the open area on the right buttock since yesterday (07/13/10) and she had informed the acting treatment nurse about it. The physician's progress notes, nurse's notes and telephone orders were reviewed. The physician's progress notes did not address the pressure ulcer on the right buttock. There were no telephone orders noted for the treatment of [REDACTED]. The nurse's notes did not address the presence of the pressure ulcer nor was the attending physician informed of the pressure ulcer on the right buttock. On 07/15/10 at 8:10 AM, administrative staff member #1 was interviewed. She stated that she did not notice the open area on the resident's right buttock during the dressing change. She then went to look and assess the open area. The weekly pressure ulcer record dated 07/15/10 revealed " area noted to right lower buttock measuring 2.4 x 1.2 cm with yellowish area measuring 0.5 x 0.7 cm in center of wound. Orders obtained for [MEDICATION NAME]. Resident on Prosource and Multivitamin. Has an appointment at the wound clinic next week. " The open area was assessed as a stage II pressure ulcer. When asked about the staging of wound with a yellow wound bed (slough), the administrative staff member #1 indicated that she had based her staging on the weekly pressure ulcer record form. The form indicated " stage 2 - a partial thickness loss of skin layers that presents clinically as abrasion, blister or shallow crater. " On 07/15/10 at 10:15 AM, administrative staff member #1 stated that she had called the physician and informed him of the stage II pressure ulcer on the right buttock. She also had provided a copy of the telephone order for the treatment of [REDACTED]. She had verified that Nurse #8 was aware of the pressure ulcer on the right buttock who indicated that she had informed the acting treatment nurse about it. She further stated that according to the acting treatment nurse, she was not informed about the open area on the right buttock but was aware that the resident had an appointment with the wound clinic. 2. Resident #55 was last readmitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The hospital Discharge Summary for Resident #55 dated 5/27/10 and the readmission orders [REDACTED]. Review of Resident #55's printed monthly orders for June 2010 and July 2010 revealed an order for [REDACTED]. Review of Resident #55's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. During an interview on 7/19/10 at 3:06 PM, the nurse (Nurse #7) who discontinued the [MEDICATION NAME] on the June MAR indicated [REDACTED]. The nurse indicated that she did not notify the physician. Review of Resident #55's MAR for July 2010 revealed [MEDICATION NAME] 3 milligrams scheduled to be given daily at 20:00. The MAR indicated [REDACTED]. During an interview on 7/19/10 at 3:10 PM, the nurse (Nurse #2) who discontinued the [MEDICATION NAME] on the July MAR indicated [REDACTED]. The nurse indicated that she had intended to notify the physician but did not. During an interview on 7/14/10 at 5:28 PM, the Director of Nursing (DON) stated that in May the facility changed to a new software program for physician orders and MARs. The DON explained that the [MEDICATION NAME] order had not been deleted and so it automatically carried over onto the June and July orders. The DON indicated that she spoke with Resident #55's physician and received an order to restart the [MEDICATION NAME]. Review of Resident #55's orders revealed an order dated 7/14/10 to resume [MEDICATION NAME] 3 milligrams daily and check [MEDICATION NAME] and international normalizing ratio on 7/16/10, 7/17/10 and 7/19/10. During an interview on 7/16/10 at 4:04 PM, the DON said that she would have expected the nurses who discontinued the [MEDICATION NAME] on the June and July MARs to notify the physician of the drug variance at that time. 3. Resident #133 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The resident had no memory problems and no difficulty in making decisions. The resident was an extensive 2 person assist for bed mobility and transfer. The resident had a [DEVICE]. The resident's admission Minimum Data Set ((MDS) dated [DATE] indicated a therapeutic diet, no weight loss of 5% or more in the last 30 days or 10% or more in the last 180 days. Resident #133's comprehensive care plan dated 3/30/10 indicated a nutritional risk due to acute illness and because she was a new admission. review of the resident's medical record revealed [REDACTED]. There was a dietary note on 5/11/10 questioning the admission weight and asking for a re-weigh. It also noted a decreased appetite and indicated that fortified foods would be added at lunch and dinner. No record showed this re-weight as being done. The dietary note on 6/10/10 indicated that fortified foods would be continued. A dietary note on 7/13/10 indicated that fortified foods would be continued and that the resident's appetite had increased. There was nothing in the notes to indicate whether the weights included the [DEVICE]. There was no dietary or nursing note to show that the attending physician had been notified of any weight loss. On review of facility policy dated April 2005 titled, "Changes in Resident Condition," it stated in part,"The resident, attending physician and legal representative or designated family member are notified when there is: a significant change in the resident's physical, mental, or psychosocial status ... " In an interview on 7/14/10 at 5:10 pm, the Director of Nursing (DON) indicated that the resident was admitted with a draining abdominal wound. There was a [DEVICE] in place. The resident's appetite improved and her weight had stabilized since admission. The resident's weight on 7/6/10 was 186.7 pounds. In an interview on 7/14/10 at 5:05 pm, resident #133 and a family member both indicated that the resident had experienced a weight loss of about 25 pounds since admission to the facility, but was doing much better now. The resident's appetite improved and meal consumption was 75-100%. The family member indicated that food was brought in as necessary to encourage weight gain. The resident stated she could stand to lose more than the weight she had already lost. In an interview on 7/15/10 at 3:10 pm, the DON indicated that it was her expectation that the Registered Dietician (RD) would note it in the chart and notify the physician for a significant weight loss. The DON looked through the chart to see if she could find where the physician had been notified, but could not find any record of notification. She stated, "It was just missed."