Every finding on record at Pine Ridge Health and Rehabilitation Center

Based on record review, resident Representative, and staff interviews, the facility failed to conduct quarterly care plan meetings for 3 of 3 residents reviewed for care plan meetings (Resident #28, Resident #71, and Resident #80).The findings included:a. Resident #28 was admitted to the facility 8/16/24.The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #28 was severely cognitively impaired. Review of the medical record revealed no care plan meetings were documented as completed with the interdisciplinary team and the resident Representative from 6/5/25 until 1/22/26.A phone interview was conducted with the Representative on 8/4/26 at 1:34 PM. The Representative reported she did not attend care plan meetings in 2025 and did not recall receiving an invitation for the meetings. b. Resident #71 was admitted to the facility 4/27/23.The annual MDS assessment dated [DATE] documented Resident #71 was cognitively intact.Review of the medical record for Resident #71 revealed a care plan meeting was held 2/20/25 and the next documented care plan meeting was 2/26/26.A phone interview was conducted with Resident #71's Representative and she reported she could not recall the specific dates, but she had not received a care plan invitation after the early part of 2025.c. Resident #80 was admitted to the facility 3/3/25.The quarterly MDS dated [DATE] documented Resident #80 was cognitively intact.Review of the medical record for Resident #80 revealed no documented care plan meeting from 6/5/25 until 4/23/26. A phone interview was conducted with Resident #80's Representative on 8/3/26. The Representative reported she had not received an invitation to a care plan meeting in 2025.Resident #80 was interviewed on 8/3/26 at 3:02 PM. Resident #80 reported that for a time she did not want her Representative to participate in care plan meetings, and that may be why her Representative did not receive invitations. Resident #80 reported she could recall the care plan meeting in April 2026 but did not recall any meetings in 2025.Social Worker (SW) #1 was interviewed on 8/5/26 at 1:53 PM. SW #1 explained she had left the facility in February 2025 and returned in December 2025. SW #1 described reviewing folders and files left by SW #2 in December 2025 and reported she had not found any documentation for care plan meetings.A phone interview was conducted with SW #2 on 8/6/26 at 8:48 AM. SW #2 explained she had worked at the facility from February 2025 until November 2025. SW #2 described sending out letters to residents and/or their Representatives for care plan meetings, and reported she documented the contact as well as the meetings in the resident progress notes. When told there were no documented care plan meetings in the residents' charts, SW #2 reported she had a binder in the SW office with the care plan signature sheets. During an interview with the Director of Nursing (DON) on 8/6/26 at 2:32 PM, the DON reported that while SW #2 was employed by the facility, they had daily morning meetings and the care plan meetings planned for that date were discussed by the interdisciplinary team. The DON reported the former Unit Manager participated in most of the meetings with residents and Representatives.A phone interview was conducted with the former Unit Manager on 8/6/26 at 2:45 PM. The former Unit Manager explained that she participated in care plan meetings with residents, Representatives, and the interdisciplinary team during the time SW #2 was in her position, but the former Unit Manager had not taken notes, nor did she know where the care plan signature sheets would be located.The Administrator was interviewed on 8/6/226 at 3:23 PM. The Administrator reported he was not in his position during the time SW #2 was in her position and he was unable to say why the care plan meetings were not documented. The Administrator reported it was his expectation that the care plan meetings were held within 72 hours of admission to the facility, quarterly, annually, and as needed.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of skin conditions for 1 of 3 residents reviewed for accuracy of assessments for (Resident #75). The findings included:Resident #75 was admitted to the facility on [DATE] with diagnoses of stage 4 pressure ulcer of the sacral region, and unspecified open wound to the lower back and pelvis without penetration (going through) into the retroperitoneum (area behind abdomen).Review of the completed nursing assessment dated [DATE] at 11:14 PM by Nurse #15 indicated Resident #75 had a Stage 4 pressure ulcer to her sacrum with wound vac (a small machine that uses gentle suction to heal a wound by removing extra fluid) in place and there were no new skin issues observed.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 did not have any unhealed pressure ulcers. An interview with the MDS Nurse on 08/06/26 at 2:00 PM revealed she was unaware that Resident #75's MDS assessment was inaccurate and did not show the resident's skin condition. The MDS Nurse stated she was not sure why she coded the assessment that way, as she was aware that Resident #75 had a stage 4 pressure injury since admission. She suggested she may have been working on multiple assessments and switched between them, leading to the omission. She stated she completes corrections when errors are identified and confirmed the MDS assessment should accurately reflect the resident's skin condition.On 08/06/26 at 4:00 PM, an interview was completed with the Director of Nursing (DON). The DON stated it is her expectation that MDS assessments are completed accurately.

Based on observations, record review and staff interviews, the facility failed to have effective systems in place to ensure a resident with a diagnosis of dysphagia (difficulty swallowing) and physician orders for nectar thick liquids and no straws was not provided thin liquids and a straw for 1 of 7 sampled residents with orders for modified diets and no straws (Resident #100).The findings included: Hospital discharge orders dated 7/30/26 included an order for a mechanical soft diet. Resident #100 was admitted to the facility on [DATE] with diagnoses that included dementia, history of aspiration pneumonia (a lung infection occurring when food, liquid, vomit, or saliva enters airways and lungs instead of swallowing it down the throat), and dysphagia. A review of speech therapy notes dated 7/30/26 revealed the Speech Therapist (ST) had observed significant swallowing issues with thin liquids during a bedside swallowing screening of Resident #100 on that date. Based on the evaluation, the ST recommended nectar thick liquids. The ST evaluation on 7/31/26 using the Global Deterioration Scale documented the resident had moderate-severe cognitive impairment. Review of physician orders in Resident #100's record revealed an order for nectar thick liquids dated 7/30/26. The care plan dated 7/31/26 revealed Resident #100 had a problem of nutritional risk and risk for weight changes related to aspiration with interventions for staff to provide all liquids to nectar consistency, provide supervision, touching assistance and verbal cues during meals. The treatment session note dated 8/3/26 revealed the ST documented the resident needed moderate cues to clear oral residue after swallowing and so straws not advised with nectar thick liquids due to decreased intraoral pressure and oral residue amount during liquid intake. Review of physician orders in Resident #100's record revealed an order for no straws dated 8/03/26. The care plan was updated on 8/04/26 to include a problem of potential for potential for ineffective breathing pattern related to dysphagia with interventions of monitoring for difficulty swallowing or clearing airway secretions and signs of infection and no straws. In a phone interview on 8/06/2026 at 3:05 PM with Nurse Aide (NA) #1 she shared that she had worked 11:00 PM to 7:00 AM on 8/4/26. She explained her responsibilities included filling the 20-ounce disposable foam cups for each resident. She further shared this task was completed around 6:00 AM. NA #1 stated she did not know Resident #100 was on nectar thick liquids and did not check the care plan when she left the water in the room on the morning of 8/05/26. She said the soda bottle belonged to her and was placed on the overbed table when she entered Resident #100's room to answer the call light. NA #1 stated the bottle was nearly empty when she set it down and she just forgot to remove it when she left the room after providing care. An observation on 8/05/26 at 11:28 AM of Resident #100's room revealed a 20-ounce covered disposable foam cup with no straw dated 8/5/26 with the resident's room and bed number written on the cup filled with ice and water, a 20-ounce clear plastic bottle of ginger ale with approximately 2 ounces of fluid remaining with the screw lid on, and an empty 8-ounce container of nectar-thickened dairy drink on the resident's overbed table and within her reach. Resident #100 stated those were her drinks, but she did not know how they got there. The resident was not in respiratory distress, and no signs of aspiration were noted. An interview was conducted with NA #2 on 8/05/26 at 11:43 AM. NA #2 stated the full 20-ounce container of water and ice, and the nearly empty soda bottle with screw top on were present on the overbed table when she entered Resident #100's room at 7:10 AM. She stated she had set the breakfast tray up for Resident #100 and brought a straw from the nourishment room and placed it in the dairy drink to make it easier for the resident to drink it but did not stay in the room during the meal. The NA indicated she did not recall if she had looked at the meal ticket when she set up Resident #100's breakfast tray. NA #2 stated it was her first day working with resident, but she had checked the care plan and knew Resident #100 was on nectar thick liquids with no straws. She stated she just wasn't paying attention and should have removed the cup of ice water and the soda bottle and could not explain why she had placed the straw in the dairy drink when she knew the resident had an order for no straws. An interview was conducted on 08/05/2026 at 11:40 AM with Nurse #1 who stated she had been working with Resident #100 since admission and knew there was an order for nectar thick liquids and no straws, but she did not communicate this to NA #2 that morning. Nurse #1 accompanied the surveyor to the resident's room to view the fluids on the overbed table. Nurse #1 confirmed the covered foam cup of ice water was still full. She stated the disposable foam cup filled with ice and water, and the bottle of ginger ale did not match with Resident #100's physician order and the empty 8-ounce container of nectar-thick dairy drink should not have had a straw. She further stated she did not know how the soda got there but the 11:00 PM to 7:00 AM shift nursing assistant (NA) would have put the disposable foam cup of water there per shift routine and the kitchen would have provided the dairy drink. Nurse #1 further explained that the water, soda and the use of a straw placed Resident #100 at risk for aspiration. She indicated she had not observed any difficulty swallowing when she had administered medications to Resident #100 that morning and did not pay attention to the liquids on the overbed table. Nurse #1 removed all the items from the overbed table. Observations on 8/05/26 at 12:46 PM revealed Resident #100 had nectar thick liquids on her tray for lunch. No straws were present on the tray. The tray ticket indicated Resident #100 was to receive nectar thick liquids and no straws. An interview was conducted with the Speech Therapist on 8/05/2026 at 1:00 PM. The Speech Therapist (ST) explained her findings during the initial evaluation of Resident #100 on 7/30/26. She stated the resident exhibited signs of swallowing issues which included immediate coughing, and a wet, gurgly vocal quality after drinking thin liquids. The ST explained the resident required verbal cueing throughout the meal to drink slowly, not to talk while drinking or eating, and to double swallow when drinking. Based on her observations an order for nectar-thick liquids was obtained on 7/30/26 and updated on 8/3/26 to include no straws as Resident #100 continued to require moderate cueing to swallow and clear her mouth. The ST explained that if the resident drank thin liquids or used a straw, it placed her at risk for aspiration. A telephone interview was conducted on 8/6/26 at 9:16 AM with the Medical Director. He confirmed Resident #100's diet orders for nectar-thickened liquids with no straws. The Medical Director further stated that based on the ST evaluation, Resident #100 may even need a swallow study as a diagnosis of dysphagia coupled with the ST findings placed the resident at risk for aspiration. In response to learning the resident had a container of thin liquid on her overbed table and had consumed a drink using a straw, the Medical Director stated, that's certainly not good and in his medical opinion placed resident at risk for aspiration and infection. He further shared his expectations of staff were to follow physician orders. On 8/06/26 at 3:20 PM an interview with Director of Nursing (DON) was conducted. She stated that when a dietary order was initiated or changed it would be updated on the electronic medical record, the care guide section of the care plan, and communicated to the dietary department. She explained that dietary orders can also be found on the care plan, the dietary slip, and the top banner bar on the landing page of the resident's electronic chart. She further explained that dietary orders were shared nurse to nurse and NA to NA during the shift hand off report. The DON stated the NAs were trained to look at the care plan when coming on shift and periodically throughout the shift to monitor for updates. The DON stated she was not sure why the 11:00 PM to 7:00 AM shift NA placed the cup of ice water and left the soda bottle on Resident #100's bedside table and why the 7:00 to 3:00 PM shift NA had placed the straw in the dairy drink. The DON acknowledged direct care staff failing to verify fluid consistencies against the active orders could have placed Resident #100 at risk for aspiration. An interview was conducted on 8/6/26 at 3:21 PM with the Administrator who stated he expected staff to follow physician orders and be familiar with each resident's care plan.

Based on record review, observation and staff interviews, the facility failed to discard expired influenza vaccines and failed to date opened tuberculin skin test (a test used to detect tuberculosis) vials for 1 of 2 medication storage rooms observed (500-hall medication room).The findings included:Review of manufacturer's recommendations for tuberculin skin test multidose vials (multiple doses of medication or testing solution) included instructions to discard the multidose vials 30 days after opening.The 500-hall medication room was observed on 8/6/26 at 9:33 AM with Nurse #3. A box with 4 doses of influenza vaccine with an expiration date of 6/2026 was stored for use in the medication refrigerator. Additionally in the medication refrigerator, 2 multidose vials of tuberculin skin tests were observed to be open without an open date. The multidose vials appeared to be more than half full of tuberculin solution. Nurse #3 reported that the nurses on the 500 hall should have discarded the expired influenza vaccine and all multidose medication should be dated with the date it was opened. Nurse #3 reported she did not know why the vials had not been discarded, or the tuberculin vials were undated.During an interview with the Director of Nursing (DON) on 8/6/26 at 10:00 AM, she revealed that all staff were responsible for checking the medication rooms for expired medications and for assuring all medications were dated when opened. The DON explained all multi-dose medications should be labeled with the open date. The DON did not know why the influenza vials were not discarded when they expired, or why the tuberculin skin tests were not dated.The Administrator was interviewed on 8/6/26 at 3:23 PM and he reported he expected expired medications to be disposed of and open medications to be dated appropriately.

2. Resident #2 was admitted to the facility 10/17/2009 with diagnoses including heart failure and diabetes. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #2 to be moderately cognitively impaired and she received oxygen therapy. A physician order dated 4/3/25 specified for oxygen to be administered at 2 liters per minute by nasal cannula. Resident #2 was observed on 6/2/25 at 1:54 PM. She had oxygen administered by nasal cannula at 2 liters per minute. No oxygen cautionary sign was noted on the door to her room or in her room. Resident #2 was observed with oxygen administered by nasal cannula at 2 liters per minute on 6/3/25 at 8:53 AM. No cautionary oxygen sign was observed. An observation of Resident #2 oxygen administered by nasal cannula at 2 liters per minute was conducted on 6/4/25 at 2:58 PM and no cautionary oxygen sign was observed. Resident #2 was observed with oxygen administered by nasal cannula at 2 liters per minute on 6/5/25 at 8:26 AM with Nurse #3. There was no oxygen cautionary sign observed. Nurse #3 was interviewed at the time of the observation and explained that a sign should be posted outside of the room, and she did not know why there was no oxygen sign for Resident #2. The Director of Nursing (DON) was interviewed on 6/5/25 at 10:14 AM and she reported the facility had completed an audit of all residents using oxygen, and part of the audit was to make certain cautionary signs were posted for oxygen. The DON reported she did not know why there was no sign for Resident #2's oxygen. The Administrator was interviewed on 6/5/25 at 12:52 PM. The Administrator explained the facility had completed a check of residents using oxygen on 6/2/25 and part of the check was ensuring the cautionary signs were in place. The Administrator reported that she did not know why there was no oxygen cautionary sign posted for Resident #2. Based on record reviews, observations, and Medical Director, resident and staff interviews, the facility failed to discontinue an order for the use of supplemental oxygen when a new order was received (Resident #1). In addition, the facility failed to display a cautionary sign indicating the use of oxygen for residents with supplemental oxygen (Residents #2, #18 and #22) and secure a oxygen tank in a Resident's room (Resident #18). This was for 4 of 4 residents reviewed for respiratory care. The findings included: 1. Resident #1 was initially admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). A review of Resident #1's active physician orders included the following orders: - An order dated 8/18/24 for oxygen at 3 liters per minute via nasal cannula. - An order dated 4/3/25 for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact and received oxygen therapy. A review of Resident #1's active care plan, last reviewed 4/21/25, included a focus area for potential for or actual ineffective breathing pattern related to COPD, reflux, dysphagia, asthma, CHF, and hiatal hernia. Interventions included oxygen therapy as ordered. A nursing progress note dated 5/11/25 read that Resident #1 used oxygen at 2 liters per minute via nasal cannula. A review of the May 2025 and June 2025 Medication Administration Records (MARs) revealed an entry for oxygen at 3 liters per minute via nasal cannula. The MARs had a check mark and staff initials for day and night shift. In addition, the MARs had entry for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. The MARs had a check mark and staff initials for day and night shift. On 6/2/25 at 11:40 AM, an observation and interview occurred with Resident #1. She had oxygen flowing at 2 liters per minute via nasal cannula and stated that she used oxygen at 2 liters. Another observation occurred of Resident #1 on 6/4/25 at 9:32 AM who had oxygen flowing at 2 liters. On 6/4/25 at 9:35 AM, an interview occurred with Medication Aide #1 who was familiar with Resident #1 and was assigned to provide medications to her. She stated Resident #1 used oxygen continuously at 2 liters per minute via nasal cannula. After reviewing the June 2025 MAR, MA #1 indicated she checked and initialed both entries for oxygen use but couldn't say why she had not noticed an entry for 2 liters of oxygen and an entry for 3 liters of oxygen. Unit Manager #1 was interviewed on 6/4/25 at 9:43 AM and had been the nurse that created the order for oxygen at 2 liters per minute on 4/3/25. She reviewed Resident #1's active physician orders and verified that there was an order for oxygen at 3 liters and an order for oxygen at 2 liters that were showing as active. She stated when she received the order for oxygen at 2 liters per minute via nasal cannula on 4/3/25 she should have discontinued the order for oxygen at 3 liters per minute via nasal cannula. She felt this was an oversight. The Medical Director was interviewed via phone on 6/5/25 at 9:00 AM and stated that he was aware Resident #1 was using 2 liters of oxygen currently and would have expected the nurse who received the order for oxygen at 2 liters per minute on 4/3/25 to have discontinued the previous order for oxygen at 3 liters per minute. The Administrator and Director of Nursing were interviewed on 6/5/25 at 9:29 AM and stated they would have expected Unit Manager #1 to discontinue the order for oxygen at 3 liters per minute when the new order for oxygen at 2 liters per minute was received on 4/3/25. 3. Resident #18 was admitted to the facility on [DATE] with diagnoses which included hypertension and congestive heart failure. Review of resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. Review of a physician order dated 05/21/25 revealed Resident #18 was ordered to start oxygen at 2 liters per minute per nasal cannula for respiratory distress or when oxygen saturation drops under 92%. An observation on 06/02/25 at 11:50 AM revealed Resident #18 had gone to dialysis, but a free-standing (unsecured) oxygen tank, not in a holster or wheeled rack, was sitting in the corner of the resident's room behind his bed. It was further revealed there was no oxygen signage outside of the room or in the room. An observation was conducted in conjunction with an interview with Resident #18 on 06/03/25 at 10:00 AM. The observation revealed there was still a free-standing oxygen tank in Resident #18's room. Resident #18 stated he sometimes used oxygen if he was having issues breathing. It was further observed there was no signage hanging outside of the room, or inside of the room, for oxygen use. An interview conducted with the Unit Manager (UM) on 06/04/25 at 2:00 PM revealed Resident #18 used oxygen as needed. It was further revealed she was not aware Resident #18 did not have oxygen in use signage outside of his room. UM #1 indicated she and all nursing staff were responsible for posting signage, and all oxygen users were expected to have signage posted. An interview conducted with the Director of Nursing (DON) and Administrator on 06/05/25 at 11:50 AM revealed they were unaware Resident #18 did not have oxygen in use signage posted outside of his room. The DON indicated she was aware Resident #18's tank was stored in the corner of his room. It was further revealed both the DON and the Administrator expected staff to ensure signage was posted when there was oxygen in use, or in resident rooms. 4. Resident #22 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease. Review of Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of a physician order dated 05/22/25 revealed Resident #22 was ordered oxygen at 3 liters per minute via nasal cannula. It further read to keep the oxygen saturation greater than 90% every day and night shift. An observation on 06/02/25 at 11:55 AM revealed Resident #22 had gone to dialysis. An oxygen concentrator was observed in the resident's room. It was further revealed no signage of oxygen was posted outside of, or inside, the resident's room. An observation on 06/03/25 at 9:45 AM revealed Resident #22 in his wheelchair with oxygen on and receiving oxygen via a nasal canula and was in the hall talking to another resident. An interview conducted with the Unit Manager (UM) on 06/04/25 at 2:00 PM revealed Resident #22 used oxygen continuously. It was further revealed she was not aware Resident #22 did not have oxygen in use signage outside of his room. UM #1 indicated she and all nursing staff were responsible for posting signage, and all oxygen users were expected to have signage posted. An interview conducted with the Director of Nursing (DON) and Administrator on 06/05/25 at 11:50 AM revealed they were unaware Resident #22 did not have oxygen in use signage posted outside of his room. It was further revealed both the DON and the Administrator expected staff to ensure signage was posted when there was oxygen in use, or in resident rooms.

Based on record reviews and Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician (Resident #13). This was for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), coronary artery disease (CAD), and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively intact. a. Review of Resident #13's active physician orders included an order dated 4/30/25 for Amlodipine (a blood pressure medication) 5 milligrams (mg). Give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure (SBP) less than 100, diastolic blood pressure (DBP) less than 60 and pulse less than 60. The May 2025 Medication Administration Record (MAR) was reviewed and revealed Resident #13 had received Amlodipine, despite the SBP less than 100 and DBP less than 60. - 5/14/25 SBP was 96 and DBP was 49. - 5/15/25 SBP was 96 and DBP was 49. - 5/28/25 SBP was 97 and DBP was 51. b. Review of Resident #13's active physician orders included an order dated 4/26/25 for Isosorbide Mononitrate Extended Release (a blood pressure medication) 30 mg. Give one tablet by mouth one time a day for CAD. Hold for SBP less than 110 and DBP less than 60. The May 2025 MAR was reviewed and revealed Resident #13 had received Isosorbide Mononitrate Extended Release, despite the SBP less than 110 and DBP less than 60. - 5/7/25 SBP was 102 and DBP was 52 - 5/14/25 SBP was 96 and DBP was 49. - 5/15/25 SBP was 96 and DBP was 49. - 5/16/25 SBP was 96 and DBP was 49. c. Review of Resident #13's active physician orders included an order dated 4/25/25 for Carvedilol (a blood pressure medication) 25 mg. Give one tablet by mouth two times a day for hypertension. Hold for SBP less than 110 and DBP less than 60. The May 2025 MAR was reviewed and revealed Resident #13 had received Carvedilol, despite the SBP less than 110 and DBP less than 60. - 5/7/25 SBP was 102 and DBP was 52 for the 8:30 AM dose. - 5/14/25 SBP was 96 and DBP was 49 for the 4:30 PM dose. - 5/15/25 SBP was 96 and DBP was 49 for the 8:30 AM dose and SBP was 96 and DBP was 49 for the 4:30 PM dose. - 5/16/25 SBP was 96 and DBP was 49 for the 8:30 AM dose. - 5/28/25 SBP was 97 and DBP was 51 for the 4:30 PM dose. On 6/4/25 at 10:49 AM, a phone call was placed to Medication Aide #2. He had provided medications to Resident #13 on 5/14/25 at 8:30 AM and 4:30 PM. A message was left for a return call that was not received during the survey. On 6/4/25 at 10:50 AM, a phone call was placed to Medication Aide #3. She had provided medications to Resident #13 on 5/28/25 at 8:30 AM and 4:30 PM. A message was left for a return call that was not received during the survey. An interview occurred with Medication Aide #4 on 6/4/25 at 2:44 PM. She had provided medications to Resident #13 on 5/7/25 and 5/14/25. She reviewed the May 2025 MAR and verified Isosorbide Mononitrate Extended Release was signed off as given outside the parameter on 5/7/25 and 5/14/25 as well as Carvedilol on 5/7/25. She felt it was an oversight. On 6/4/25 at 5:20 PM, a phone call was placed to Nurse #1. She had provided medications to Resident #13 on 5/15/25 and 5/16/25. A message was left for a return call that was not received. The Medical Director was interviewed by phone on 6/5/25 at 9:00 AM and stated if Resident #13 had received a few dosages of Amlodipine, Isosorbide Mononitrate Extended Release and Carvedilol outside the parameters it should not have caused any serious harm. The Medical Director added he would expect the nurses to follow the orders for the blood pressure medications parameters as written. The Administrator and Director of Nursing were interviewed on 6/5/25 at 9:30 AM, and stated they expected the nursing staff to follow parameters to hold blood pressure medications per physician orders.

Based on record review and Medical Director and staff interviews, the facility failed to prevent Resident #83 from receiving a dose of Lyrica (a medication used to treat nerve and muscle pain) that was prescribed for Resident #13. This affected 1 of 6 residents whose medications were reviewed (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included neuralgia and neuritis (pain and inflammation of the nerves). An admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #83 had severely impaired cognition. Review of Resident #83's May 2025 physician orders included an order dated 2/18/25 for Pregabalin (Lyrica) 25 milligrams (mg) 1 capsule by mouth twice a day for neuropathic pain. Resident #13 was admitted to the facility on [DATE] with diagnoses that included radiculopathy of the cervical region, bursitis of the left shoulder, and chronic pain syndrome. A quarterly MDS assessment dated [DATE] indicated that Resident #13 was cognitively intact. A review of Resident #13's May 2025 physician orders included an order dated 8/22/24 for Lyrica 100 mg one tablet by mouth three times a day for neuropathic pain. A facility investigational summary dated 5/15/25 indicated that Nurse #2 completed a narcotic count on 5/15/25 at 11:00 PM and found a discrepancy with the count for Resident #83 and Resident #13. Both residents received a dose of Lyrica at 8:00 PM, however there had not been a Lyrica 25 mg removed from Resident #83's blister pack for the 8:00 PM dose and two pills had been removed from Resident #13's Lyrica 100 mg blister pack. The incident was reported to the Medical Director and Resident #83's Resident Representative (RR). A review of Resident #83's May 2025 Medication Administration Record (MAR) indicated Lyrica was provided at 8:00 PM. The MAR didn't indicate the medication was not provided to Resident #83. A nursing progress note dated 5/16/25, written by Nurse #2, revealed that a medication count discrepancy was noted with Residents #83 and #13's Lyrica. The note read that both residents received Lyrica at the same time but at different dosages. Nurse #2 indicated he couldn't recall if had given Resident #83 Lyrica 100 mg that was ordered for Resident #13 but immediately notified the former Assistant Director of Nursing (ADON), began evaluations of Resident #83 and notified the Medical Director and RR. A phone interview was completed with Nurse #2 on 6/4/25 at 9:35 PM who recalled the medication error incident. He explained that he had provided medications at 8:00 PM as ordered to Resident #83 and #13. A narcotic count was completed at 11:00 PM and it was noted that Resident #13 had an extra dose of Lyrica 100 mg removed from the medication card while Resident #83's Lyrica 25 mg had the same count as when he started the shift at 7:00 PM. Nurse #2 stated he failed to look at the medication label to ensure the correct medication was pulled for the correct resident. Nurse #2 stated that when he found the discrepancy, he went to assess Resident #83 who was at her baseline, contacted the former ADON, Medical Director and Resident #83's RR. The Medical Director stated to continue monitoring Resident #83 for any side effects. Nurse #2 stated that Resident #83's vital signs remained within normal limits, and she displayed no side effects from receiving the incorrect dosage of Lyrica during the remainder of the night. A review of Resident #83's vital signs from 5/16/25 indicated that at 12:44 AM, 3:04 AM and 6:23 AM they were all within normal limits. On 6/4/25 at 10:57 AM, an interview occurred with the Director of Nursing (DON). She explained that on 5/15/25 Nurse #1 had two residents that received Lyrica at the same time but at different dosages. Resident #83 received 25 mg and Resident #13 received 100 mg at 8:00 PM. Nurse #1 completed his medication pass and completed a narcotic count at 11:00 PM where he found a discrepancy for Lyrica. During the narcotic count he noted that Lyrica 25 mg had not been utilized at 8:00 PM for Resident #83 and two pills had been used out of the Lyrica 100 mg pack for Resident #13. The DON stated that Nurse #2 self-reported the discrepancy, the Medical Director and Resident #83's RR were notified, and Resident #83 was monitored for the rest of the shift. The DON further stated that education was provided to Nurse #2 regarding medication errors and a medication pass observation was completed. A phone interview occurred with the Medical Director on 6/5/25 at 9:00 AM and stated he was notified of the medication error, but didn't feel there would have been any harm caused to Resident #83 from receiving Lyrica 100 mg instead of Lyrica 25 mg one time. He recalled instructing the nurse to monitor Resident #83 throughout the remainder of the shift. Multiple attempts were made to contact the former ADON without success. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 5/15/25 the nurse noted there was a narcotic count discrepancy on two residents' Lyrica with different dosages. The nurse assessed both residents with no noted adverse outcome identified. The residents and/or responsible party as well as the physician were notified. The nurse received one-to-one education on the Rights of Medication Administration on 5/16/25. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 5/16/25 the DON/designee initiated a 100% audit of all current residents who receive Lyrica to ensure the right dosage was administered to the resident as per physician order. The DON/designee will notify the physician of all areas of concern identified during the audit. On 5/17/25 the DON/designee initiated an audit of all incident reports for the past 30 days to identify trends and identify any incidents related to medication administration to ensure appropriate interventions were initiated, physician notified, and resident assessed as indicated. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: All nursing staff to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Medication Aides received education regarding Rights of Medication Administration on 5/16/25 by the former ADON. Education will be provided to any agency nursing staff before taking an assignment and will be incorporated in the new hire process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when correction action will be completed: The DON/designee will complete random audits of medication administration weekly for 12 weeks. The physician will be notified of any identified areas of concern, and the staff will receive re-training of the Rights of Medication Administration. The Administrator or DON will present the findings of the audit tools to the Quality Assurance Performance Improvement (QAPI) committee monthly for two months. The QAPI committee will meet monthly for two months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. This was reviewed in the QAPI meeting on 5/22/25. The plan alleged compliance on 5/22/25. As part of the validation process, the plan of correction was reviewed and verified through review of audit sheets, education records and staff interviews. Education was provided all licensed nursing staff and Medication Aides on the Rights of Medication Administration. A review of the monitoring audits revealed they were completed as stated in the corrective action plan with no concerns identified. Interviews conducted with licensed nurses and Medication Aides revealed they had received education on proper medication administration. Medication Administration was observed as part of the recertification survey and no errors were noted. The compliance date of 5/22/25 for the corrective action plan was validated.

Based on record review, and resident and staff interviews, the facility failed to provide treatments as ordered by the physician for a non-pressure wound for 1 of 4 residents reviewed for non-pressure skin integrity (Resident #292). The findings included: Resident #292 was admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of other part of left foot with unspecified severity, diabetes mellitus with other skin complications, and cellulitis of both right and lower limb. Review of Resident #292's initial nursing assessment dated [DATE] revealed Resident #292 was alert and oriented. Review of Resident #292's care plan initiated 05/27/25 revealed the resident was at risk of skin breakdown related to peripheral vascular disease, chronic venous stasis, changes of lower extremities, diabetic, problems with mobility, and fragile skin. Interventions included observations for changes in skin integrity or skin impairment left great toe ulcer and notify physician as necessary and skin care per facility protocol. Review of physician order dated 05/28/25 revealed Resident #292 was ordered to cleanse left foot second toe with wound cleanser and apply dry gauze daily. A progress note dated 06/04/25 made by Wound Nurse #1 indicated Resident #292's treatment was not completed over the weekend 05/31/25 through 06/01/25. The note further revealed that the Director of Nursing (DON) and the Medical Director (MD) were notified. Review of Resident #292's Treatment Administration Record (TAR) revealed on 05/31/25 and 06/01/25 the resident was checked off for receiving treatment. An interview was conducted with Resident #292 on 06/02/25 at 2:30 PM revealed from 05/31/25 through 06/01/25 the resident did not receive treatment for his toe. It was further revealed he was supposed to have his toe cleaned and new bandage applied daily. Resident #292 stated Wound Nurse #1 was aware because when she changed Resident #292's bandage on 06/02/25 he still had the bandage on that Wound Nurse #1 had applied and dated on 05/30/25. An interview conducted with Wound Nurse #1 on 06/04/25 at 10:15 AM revealed Resident #292 did not receive wound treatment as ordered 5/31/25 through 06/01/25. It was further revealed Resident #292 was supposed to have his ulcer cleaned and bandaged changed over the weekend by the assigned Nurse. Wound Nurse #1 indicated Resident #292 had the same bandage that she had put on 05/30/25. An interview conducted with Nurse #5 on 06/04/25 at 2:30 PM revealed she was assigned to Resident #292 on 05/31/25 and 06/01/25 to complete treatments. It was further revealed she thought she had completed all treatments, but had accidentally overlooked Resident #292 and did not do his. A joint interview conducted with the DON and Administrator on 06/05/25 at 12:00 PM revealed they were made aware that Resident #292 had not received treatment on his toe and they expected orders to be followed.

Based on record review and staff interviews, the facility failed to provide effective supervision for residents with severely impaired cognition that resided on the memory care unit. Resident #91 had a history of wandering and wandered into Resident #92's room and Resident #91 hit Resident #92 in the nose, which caused Resident #92 to sustain a closed fracture of the nasal bone. This was for 1 of 3 residents reviewed for accidents (Resident #92). The findings included: Resident #92 was admitted to the facility on [DATE] and discharged on 07/11/24. Diagnoses included age related osteoporosis, osteoarthritis, dementia, and other behavioral disturbances. Review of Resident #92's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required limited assistance for most activities of daily living (ADL). The MDS further revealed the resident was not coded for behaviors or wandering. Review of Resident #92's care plan initiated 02/23/24 revealed the resident was at risk expressing emotion, sharing information, and decrease and lack of speech related to impaired memory. Also, the resident was at risk of difficulty understanding speech, difficulty forming thoughts, and requiring cues and directions. The goal was for Resident #92's needs to be met through the next review. Resident #91 was admitted to the facility on [DATE] and discharged [DATE]. Diagnoses included abnormalities of gait and mobility, dementia, anxiety, and cognitive communication deficit. Review of Resident #91's care plan initiated on 12/17/24 revealed the resident had a problematic manner in which resident had ineffective coping such as wandering and wandering into other residents' beds. The goal was Resident #91 would have no episodes through the next review. Interventions included document episodes of wandering per facility protocol, approach wandering resident in non-threatening manner, orient to surrounding and room number as frequently as needed, place familiar objects, furniture, pictures in resident surroundings, and provide assistance in locating own room. Review of Resident #91's quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. The MDS further revealed the resident was not coded for behaviors or wandering. Review of progress note dated 07/10/24 created by Nurse #4 revealed Resident #92 was in her doorway to her room yelling for help and stated she had been hit in the nose by another resident. Moderate amounts of blood were observed coming from Resident #92's nose and mouth. A compression (pressure on the nose) was used to stop the bleeding followed by cleansing of mouth to check for further injury. The note indicated the Medical Director (MD) was notified and Resident #92 was sent out to the hospital to be further assessed. The note revealed Resident #92's Responsible Party (RP) was notified. A phone interview conducted with Nurse #4 on 06/05/25 at 9:00 AM revealed she was assigned to both Resident #91 and Resident #92 on 7/10/24 when the incident occurred. Nurse #4 indicated Resident #91 had prior behaviors of wandering but had never been aggressive towards other residents. It was further revealed on 07/10/25 around 3:00 AM she was assisting another staff member and Resident #91 wandered across the hall into Resident #92's room. Nurse #4 indicated she had just checked resident rooms 15 minutes prior and Resident #91, and Resident #92 were both asleep in their bed. Nurse #4 indicated she heard Resident #92 yell and found her standing in her doorway with her nose and mouth bleeding. Nurse #4 revealed Resident #91 was in Resident #92's bed asleep. Nurse #4 stated Resident #92's nose was bleeding, there was some swelling, and it appeared to be disfigured. Nurse #4 indicated she contacted the prior DON, MD, and RP and Resident #92 was sent to the hospital to be further assessed. Nurse #4 revealed Resident #91 was directed back to his bed and was assessed and no injuries were found. The Nurse indicated Resident #91 was put on one-to-one care. An initial facility report dated 07/10/24 indicated Resident #91 hit another resident in the face and was removed immediately. It further revealed Resident #92 was observed yelling out and bleeding from her nose. Review of hospital Discharge summary dated [DATE] revealed Resident #92 was seen in the emergency room for a facial injury and was assessed and diagnosed with a closed fracture to the nasal bone. The summary further revealed Resident #92 was to schedule a follow up appointment with an ear, throat, and nose doctor. Review of progress note dated 07/10/24 revealed later that day Resident #92 returned to the facility and was diagnosed with a fracture to the nasal bone. Review of progress note dated 07/12/24 revealed a psychiatrist referral was completed for Resident #91 date and the RP was notified. A 5-day investigation was completed by the facility dated 07/12/24 and revealed Resident #91 had a history of wandering behaviors and will lay down in whatever bed he finds. It was believed Resident #91 got into Resident #92's bed confused and startled Resident #91 which resulted in Resident #91 hitting Resident #92 and injured Resident #92's nose. The investigation indicated nursing staff had left Resident #92's room [ROOM NUMBER] minutes prior to the incident and did not witness Resident #91 wandering. The investigation concluded that staff did not witness the incident but had Resident #91 on one to one for observations of behaviors. A phone interview conducted with the prior Director of Nursing (DON) dated 06/05/25 at 8:50 AM revealed she was the DON at the time of the incident between Resident #91 and Resident #92. The DON further revealed she was not at the facility when the incident occurred but was notified by Nurse #4. The DON indicated she received a call from Nurse #4 that Resident #91 had wandered into Resident #92's room while nursing staff were giving care to another resident. The DON stated she believed Resident #92 yelled at Resident #91 and Resident #91 got startled and struck out at Resident #92. It was reported to her that Resident #92's nose was bleeding, and the RP and MD were notified, and Resident #92 was sent to the hospital. DON revealed Resident #91 had not had aggressive behaviors prior to the incident but was put on one to one for observations and a psychiatrist referral was made. An interview conducted with the current DON and Administrator on 06/05/25 at 11:50 AM revealed neither one of them worked in the facility at the time of the incident. The interview further revealed they both expected staff to monitor and watch residents in the memory care unit to prevent accidents. The facility provided the following corrective action plan: 1. What corrective action will be accomplished for each resident found to be affected. On 7/10/24 Resident # 91 wandered into Resident # 92's room and was resting on the bed. Resident # 92 came into the room and awakened Resident # 91 startling the resident. Resident # 91 experienced a startle response which resulted in the resident making physical contact with Resident # 92's nose. The facility staff responded immediately by separating Resident # 91 and Resident # 92 and placing Resident # 91 on one-to-one supervision while an investigation of the accident was initiated. A pain and skin assessment on Resident # 92 was completed on 7/10/24. The resident was noted to have a bloody nose and was transferred to the hospital for evaluation. A pain and skin assessment completed on 7/10/24 Resident # 91 revealed the resident had no pain or injury. 2. What corrective action will be accomplished for those residents who have the potential to be affected by the same deficient practice. On 7/10/24 100% of residents progress notes and behavior alerts in the electronic medical record (EMR) were audited by the Quality Assurance Nurse to identify any behavior, to include wandering, that occurred in the last 14 days. The audit was to ensure interventions were in place to address behaviors and interventions were in place on the resident care plan. The audit was completed on 7/10/24. Any identified concerns were addressed during the audit to include updating the care plan and notification of the medical practitioner and resident representative. On 7/10/24 100% skin checks were initiated by the hall nurse for signs and symptoms of injury not previously identified. No signs of injuries were indicated from the assessments. On 7/10/24 the Director or Nursing (DON) reviewed incident reports related to resident-to-resident altercations for the past 30 days to identify patterns and trends. No new areas of concern were identified. 3. What measures are put in place or systemic changes are made to ensure the deficient practice will not re-occur. On 7/10/24 an in-service was initiated, to all staff, by the DON and Staff Development Coordinator (SDC) regarding managing residents with behaviors, utilization of non-pharmacological interventions for behaviors, prevention of resident-to-resident altercations, providing as needed medications/interventions as appropriate to help reduce behavior escalation, and documentation. On 07/10/24 a QAPI meeting was held to discuss resident to resident altercations and residents on the memory care unit with dementia. Multiple people including department heads and the Medical Director participated. The in-service was completed by 7/12/24. After 7/12/24 staff that had not completed the in-service were provided with the in-service on their next scheduled shift. This education is provided to newly hired staff ongoing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. 100% of all progress notes and behaviors alerts were reviewed by the DON, Unit Manager (UM), Unit Coordinator, SDC and Quality Assurance Nurse 5 days a week for 4 weeks during the daily interdisciplinary team meeting utilizing the Behavior Audit Tool. The purpose of the review was to ensure all behaviors were being addressed to include notification of the medical practitioner, responsible party and that care plans were reviewed/revised as appropriate. The Administrator or DON reviewed and initialed the audits weekly x 4 weeks, then monthly x 1 month to ensure all areas of concern were addressed appropriately. The Administrator and DON presented the findings of the Behavior Audit Tool to the Quality Assurance and Process Improvement (QAPI) committee monthly for 2 months. The QAPI committee met monthly for 2 months and reviewed the Behavior Audit Tool to determine trends and/or issues that needed further interventions and the need for additional monitoring. Corrective Action Plan completion date: 07/13/24 As part of the validation process conducted on 06/04/25, the plan of correction was reviewed and verified through review of audit sheets, education records and staff interviews. Education was provided for all nursing staff. A review of the monitoring audits revealed they were completed as stated in the corrective action plan with no concerns identified. Interviews conducted with nursing staff revealed they had received education. The compliance date of 07/13/24 for the corrective action plan was validated.

3. Resident #63 was admitted to the facility 7/30/24 with her most recent readmission on [DATE]. Diagnoses for Resident # 63 included stroke and feeding tube. a. Review of the medical record for Resident # 63 revealed a nursing change of condition note dated 10/30/24 at 11:53 PM. The note documented a change of condition for Resident #63 and a physician order was received to transfer her to the hospital for evaluation and treatment. A nursing progress note dated 11/4/24 documented Resident #63 was readmitted to the facility. Review of the medical record revealed no notice of transfer was in the record for the hospitalization from 10/30/24 to 11/4/24. b. Review of the medical record for Resident #63 revealed a nursing progress note dated 11/11/24 at 9:15 PM documented a change in status for Resident #63 and noted a physician order to send Resident #63 to the hospital for evaluation and treatment. A nursing note dated 12/9/24 documented Resident #63 was readmitted to the facility after hospitalization. Review of the medical record revealed no notice of transfer was in the record for the hospitalization from 11/11/24 to 12/9/24. Resident #63's Responsible Party was interviewed by phone on 6/5/25 at 9:40 AM. The Responsible Party reported she had not received a written notice of transfer anytime Resident #63 has been admitted to the hospital. On 6/4/25 at 9:43 AM, an interview was conducted with Unit Manager #1, who explained that when a resident was transferred to the hospital a copy of the face sheet, medication administration record, any Do Not Resuscitate (DNR) information if present, change in condition form, transfer form and bed hold policy was sent with the resident. She added that the Responsible Party was notified by phone of the reason for the transfer. On 6/4/25 at 12:15 PM, the Director of Nursing and Administrator stated the transfer information for the hospital was sent with the resident when they were discharged to the hospital and they did not have anything in writing that was sent to the Responsible Party. The Director of Nursing was interviewed again on 6/5/25 at 10:14 AM and she reported she did not know that a written notice of transfer was required to be sent to the residents and the Responsible Party. The Administrator was interviewed again on 6/5/25 at 12:52 PM and she reported she did not know why the written notice of transfer was not sent to Resident #63 or her Responsible Party, but she expected a written notice to be sent. 4. Resident #87 was admitted to the facility 4/22/25 with diagnoses including hypertension and dementia. Resident #87 was discharged home on 5/27/25. Review of the medical record revealed no discharge summary including a recapitulation of Resident #87's stay. The Social Worker was interviewed on 6/4/25 at 12:01 PM and she reported she did not know who was responsible for completing the discharge summary for residents leaving the facility. The Social Worker explained she did not think she was responsible for the discharge summary. Resident #87's Responsible Party was interviewed by phone on 6/4/25 at 1:24 PM. The Responsible Party reported she had not received a discharge summary for Resident #87 when she was discharged from the facility. The Director of Nursing was interviewed on 6/5/25 at 10:14 AM and she reported she was not aware the facility was not completing a discharge summary. The Administrator was interviewed on 6/5/25 at 12:52 PM and she reported that any resident and Responsible Party should receive a written discharge summary. Based on record reviews and interviews with Resident Representatives (RR) and staff, the facility failed to provide the resident or RR written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization (Residents #32, #59 and #63). In addition, the facility failed to provide a discharge summary to Resident #87 when they were discharged home or complete a recapitulation of a resident stay after discharge for 1 of 1 resident reviewed for a planned discharge. The findings included: 1. Resident #32 was initially admitted to the facility on [DATE]. Her medical record indicated that a family member was her RR. Resident #32 was transferred to the hospital on 3/23/25 for vomiting and on 5/30/25 for respiratory distress. On 6/4/25 at 9:43 AM, an interview occurred with Unit Manager #1, who explained that when a resident was transferred to the hospital a copy of the face sheet, medication administration record, any Do Not Resuscitate (DNR) information if present, change in condition form, transfer form and bed hold policy was sent with the resident. She added that the RR was notified by phone of the reason for the transfer. On 6/4/25 at 12:15 PM, the Director of Nursing and Administrator stated the transfer notice was sent with the resident when they were discharged to the hospital and they did not have anything in writing that was sent to the RR. A phone call was placed to Resident #32's RR on 6/4/25 at 12:34 PM. He stated that he was called when Resident #32 was discharged to the hospital, but he had never received anything in writing regarding the reason for the hospital transfers. An interview was conducted with the Social Worker (SW) on 6/4/25 at 1:30 PM. She stated she had been employed at the facility since the end of February 2025. The SW stated she was unaware a written reason for hospital transfer was to be provided to the resident or mailed to the RR. On 6/4/25 at 1:48 PM, another interview was completed with the Administrator who had been employed at the facility since March 2025. She verified the RR was notified by phone when a resident was transferred to the hospital and a copy of the transfer form was sent in the packet going to the hospital. She was unaware a written reason for the hospital transfer was required to be provided to the resident or RR. 2. Resident #59 was initially admitted to the facility on [DATE]. Her medical record indicated that she had a guardian for her medical and financial concerns. Resident #59 was transferred to the hospital on 2/28/25 for altered mental status. On 6/4/25 at 9:43 AM, an interview occurred with Unit Manager #1, who explained that when a resident was transferred to the hospital a copy of the face sheet, medication administration record, any Do Not Resuscitate (DNR) information if present, change in condition form, transfer form and bed hold policy was sent with the resident. She added that the RR was notified by phone of the reason for the transfer. On 6/4/25 at 12:15 PM, the Director of Nursing and Administrator stated the transfer notice was sent with the resident when they were discharged to the hospital and they did not have anything in writing that was sent to the RR. A phone call was placed to Resident #59's guardian on 6/4/25 at 12:17 PM. She stated that she was called when Resident #59 was discharged to the hospital, but she had never received anything in writing regarding the reason for the hospital transfer. An interview was conducted with the Social Worker (SW) on 6/4/25 at 1:30 PM. She stated she had been employed at the facility since the end of February 2025. The SW stated she was unaware a written reason for hospital transfer was to be provided to the resident or mailed to the RR. On 6/4/25 at 1:48 PM, another interview was completed with the Administrator who had been employed at the facility since March 2025. She verified the RR was notified by phone when a resident was transferred to the hospital and a copy of the transfer form was sent in the packet going to the hospital. She was unaware a written reason for the hospital transfer was required to be provided to the resident or RR.

2. Resident #1 was initially admitted to the facility on [DATE]. A review of Resident #1's active physician orders included the following orders: - An order dated 8/18/24 for oxygen at 3 liters per minute via nasal cannula. - An order dated 4/3/25 for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. A review of the May 2025 and June 2025 Medication Administration Records (MARs) revealed an entry for oxygen at 3 liters per minute via nasal cannula. The MARs had a check mark and staff initials for day and night shift. In addition, the MARs had entry for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. The MARs had a check mark and staff initials for day and night shift. On 6/4/25 at 9:35 AM, an interview occurred with Medication Aide #1 who was familiar with Resident #1 and was assigned to provide medications to her. She stated Resident #1 used oxygen continuously at 2 liters per minute via nasal cannula. After reviewing the June 2025 MAR, MA #1 indicated she checked and initialed both entries for oxygen use but couldn't say why she had not noticed an entry for 2 liters of oxygen and an entry for 3 liters of oxygen. Unit Manager #1 was interviewed on 6/4/25 at 9:43 AM and had been the nurse that created the order for oxygen at 2 liters per minute on 4/3/25. She reviewed Resident #1's active physician orders and verified that there was an order for oxygen at 3 liters and an order for oxygen at 2 liters that were showing as active. She stated when she received the order for oxygen at 2 liters per minute via nasal cannula on 4/3/25 she should have discontinued the order for oxygen at 3 liters per minute via nasal cannula. She felt this was an oversight. The Administrator and Director of Nursing (DON) were interviewed on 6/5/25 at 9:29 AM and stated they would have expected Resident #1's medical record to be accurate. The DON stated the nursing staff should have asked for clarification when they observed the two active orders for oxygen. Based on record review, and resident and staff interviews, the facility failed to maintain complete and accurate medical records related to a resident's wound when a nurse documented the completion of wound care inaccurately for another nurse (Resident #292) and oxygen administration (Resident #1) for 2 of 4 residents reviewed for complete and accurate medical records. The findings included: 1. Resident #292 was admitted to the facility on [DATE]. Review of Resident #292's initial nursing assessment dated [DATE] revealed Resident 292 was alert and oriented. Review of physician order dated 05/28/25 revealed Resident #292 was ordered was to cleanse left foot second toe with wound cleanser and apply dry gauze daily. Review of Resident #292's Medication Administrator Report dated 05/31/25 and 06/01/25 indicated Unit Manager #1 checked that treatment was completed on Resident #292's toe. Review of progress note dated 06/04/25 revealed Wound Nurse #1 revealed Resident #292 completed the resident's treatment and it was reported that the treatment was not completed on 05/31/25 and 06/01/25. The note further revealed that the Director of Nursing (DON) and the Medical Director (MD) were notified. An interview was conducted with Resident #292 on 06/02/25 at 2:30 PM revealed over the weekend, give dates the resident did not receive treatment for his toe. It was further revealed he was supposed to have it cleaned and new bandage applied daily. Resident #292 stated Wound Nurse #1 was aware because she changed Resident #292's bandage on 06/02/25 and it still had date and the initials on the bandage that she applied on 05/30/25. An interview conducted with Wound Nurse #1 on 06/04/25 at 10:15 AM revealed Resident #292 did not receive wound treatment as ordered. It was further revealed Resident #292 was supposed to have his ulcer cleaned and bandaged changed over the weekend by the assigned Nurse. Wound Nurse #1 indicated Resident #292 had the same bandage that she had put on 05/30/25, but did not see any outcome of it not being changed, but did notify the DON. An interview conducted with Unit Manager (UM) 1 on 06/04/25 at 2:00 PM revealed on 06/02/25 when she checked treatments, she saw that Resident #292 was not checked off on the MAR. It was further revealed she contacted Nurse #5 who indicated that she had completed all treatments. UM #1 stated she checked off the resident for Nurse #5 but should not have done that because she was not aware the residents' treatment was not completed. UM #1 stated she rarely documented for other nursing staff, but would not do it anymore. An interview conducted with Nurse #5 on 06/04/25 at 2:30 PM revealed she was assigned to Resident #292 on 05/31/25-06/01/25 to complete treatments. It was further revealed she thought she had completed all treatments, but had accidentally overlooked Resident #292 and did not do his. Nurse #5 stated she had told UM #1 she had completed the treatment. An interview conducted with the DON and Administrator on 06/05/25 at 12:00 PM revealed they were made aware that Resident #292 had not received treatment on his toe from Wound Nurse #1 on 06/04/25. It was further revealed they expected documentation to be documented correctly and not to document for other staff.

Based on observations and staff interviews, the facility failed to: 1) Discard expired medications stored on 1 of 2 medication (med) carts (200 Hall Med Cart) and in 1 of 1 Med Storeroom (100/200/300 Hall Medication Storeroom); 2) Date injectable medications as to when they were opened to allow for the determination of its shortened expiration date for medications stored on 1 of 2 med carts (200 Hall Med Cart) and in 1 of 1 Med Storeroom (100/200/300 Hall Medication Storeroom); and 3) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (200 Hall Med Cart). The findings included: 1. An observation was conducted on 4/9/24 at 3:15 PM of the 200 Hall Medication (Med) Cart in the presence of Nurse #1. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use vials of Lantus insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Lantus insulin (100 units/ml) dispensed from the pharmacy on 2/10/24 for Resident #19 was dated as opened on 3/1/24 (39 days prior to the date of the observation). A pharmacy auxiliary sticker placed on the medication vial containing the insulin read in part, Expires 28 days after opening. b. According to the manufacturer, in-use vials of Lantus insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Lantus insulin (100 units/ml) dispensed from the pharmacy on 3/1/24 for Resident #30 was dated as opened on 3/1/24 (39 days prior to the date of the observation). A pharmacy auxiliary sticker placed on the medication vial containing the insulin read in part, Expires 28 days after opening. c. According to the manufacturer, in-use vials of Novolog insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Novolog insulin (100 units/ml) dispensed from the pharmacy on 3/1/24 for Resident #30 was dated as opened on 3/2/24 (38 days prior to the date of the observation). d. According to the manufacturer, in-use vials of Lantus insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Lantus insulin (100 units/ml) dispensed from the pharmacy on 2/13/24 for Resident #18 was dated as opened on 3/4/24 (36 days prior to the date of the observation). e. According to the manufacturer, in-use vials of Humalog insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Humalog insulin (100 units/ml) dispensed from the pharmacy on 3/1/24 for Resident #18 was dated as opened on 3/6/24 (34 days prior to the date of the observation). f. According to the manufacturer, in-use vials of Lantus insulin should be stored under refrigeration or at room temperature and used within 28 days. An opened vial of Lantus insulin (100 units/ml) dispensed from the pharmacy on 3/9/24 for Resident #5 was not dated as to when it had been opened to allow for the determination of its shortened expiration date. The insulin vial was dispensed 31 days prior to the date of the observation. g. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when multi-dose vials (MDVs) should be discarded. The Guidelines state, Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose [vial] has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. An opened 20 milliliter (ml) multi-dose vial of 1% lidocaine solution was stored on the med cart. The vial of 1% lidocaine was not dated as to when it had been opened to allow for the determination of its shortened expiration date. h. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when single-dose vials (SDVs) should be discarded. The Guidelines state, Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection . Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient. An opened 10 ml single-dose vial of sterile water for injection dispensed for Resident #26 was stored on the med cart. The vial of sterile water for injection was labeled for single use only. i. According to the manufacturer, intact (unopened) bottles of latanoprost eye drops should be stored under refrigeration at 36 degrees Fahrenheit (o F) to 46 o F. An unopened bottle of latanoprost eye drops dispensed from the pharmacy on 4/7/24 for Resident #19 was stored on the med cart. A blue pharmacy auxiliary sticker placed on the bottle read, Refrigerate until opened. An interview was conducted with Nurse #1 on 4/9/24 at 3:45 PM. During the interview, the nurse reviewed each vial of expired insulin and confirmed the dating of (or failure to date) each of the vials. Upon inquiry, the nurse reported she would need to contact the pharmacy to request replacement vials of insulin for those that were identified as expired. Additionally, the hall nurse reported the multi-dose vial of 1% lidocaine needed to be discarded since she could not determine when it had been opened and the single-dose vial of sterile water for injection should have been discarded after the first use. When asked, Nurse #1 acknowledged the latanoprost eye drops should have been stored in the refrigerator until opened. An interview was conducted with the facility's Director of Nursing (DON) on 4/9/24 at 4:00 PM. At that time, the DON confirmed Nurse #1 had shown her the expired insulin vials and the vials of lidocaine and sterile water for injection. The DON reported she was surprised by the findings of the 200 Hall Med Cart observation because the med carts had been inspected the previous week to ensure proper storage of the medications. A follow-up interview was conducted with the DON on 4/13/24 at 9:43 AM. During the interview, the DON reported she would have expected nursing staff to date the vials of insulin as to when they had been opened, remove any expired medications from the medication carts, and notify the pharmacy of the need to replace these medications so they were available when needed for the resident. Additionally, the DON stated a single-use vial of sterile water for injection should have been discarded immediately after it was used for the first time. She also noted the unopened bottle of latanoprost eye drops should have been refrigerated until needed. 2. Accompanied by Nurse #1, an observation was conducted on 4/9/24 at 3:46 PM of the 100/200/300 Hall Medication Storeroom. The observation revealed the following medications were stored in the Medication Storeroom: a. A manufacturer's box of 650 milligrams (mg) acetaminophen suppositories with 9 suppositories remaining in the box were observed to be stored in the Med Storage Room. The manufacturer's expiration date for the suppositories was June of 2023. b. According to the manufacturer labeling, a vial of PPD solution in use for more than 30 days should be discarded. One (1) opened multi-dose vial of Tuberculin PPD injectable solution (used for skin testing in the diagnosis of tuberculosis) was stored in the med room refrigerator. The PPD solution was labeled as having been opened on 3/7/24 (33 days prior to the date of the observation). c. Three (3) unopened bottles of 80 milligrams (mg) simethicone chew tablets (each containing 100 tablets) were expired with a manufacturer's expiration date of March 2024. Simethicone is an over-the-counter medication used to prevent or reduce excessive intestinal gas. d. One (1) - 8 ounce, unopened bottle of Kaopectate medication was expired with a manufacturer expiration date of March 2024. Kaopectate is an over-the-counter medication used to treat occasional upset stomach, heartburn, and nausea. An interview was conducted with the DON on 4/13/24 at 9:43 AM. During the interview, the DON reported she would expect the nursing staff to date everything as to when it was opened and to discard expired medications in accordance with the manufacturer's instructions. She stated the hall nurses were responsible to check the facility's stock medications in the Med Storeroom to ensure they were not expired.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint surveys completed on 6/17/21 and a complaint investigation completed on 2/24/22. This was for 4 deficiencies that were cited in the areas of: Resident Rights/Exercise of Rights (550) which was cited on 6/17/21, 2/24/22 and recited on the current recertification and complaint survey of 4/13/24; Right to Participate in Planning Care (553) which was cited on 6/17/21 and recited on the current recertification and complaint survey of 4/13/24; Develop/Implement Comprehensive Care Plan (656) which was cited on 6/17/21 and recited on the current recertification and complaint survey of 4/13/24; and Safe/Clean/Comfortable/Homelike Environment (584) which was cited on 2/24/22 and recited on the current recertification and complaint survey of 4/13/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QAA). The findings included: This citation is cross-referenced to: F550: Based on record review, resident, staff interviews and student interviews, the facility failed to treat a resident in a dignified manner for 1 of 23 residents reviewed for dignity (Resident #17). Nurse #2 told Resident #17, in a loud and demeaning tone, to get back in her room and stop stalking her. Resident #17 stated Nurse #2's statement made her feel embarrassed and humiliated to be spoken to as if she were a child. During the recertification and complaint survey on 6/17/21, the facility failed to treat a resident in a respectful and dignified manner for 1 of 1 resident reviewed for dignity when the Speech Therapist and a Nursing Assistant referred to a resident as a feeder. During the complaint investigation survey on 2/24/22, the facility failed to treat residents in a dignified manner when residents did not receive incontinent care for several hours during a period when there was just one Licensed Practical Nurse and two Nursing Assistants in the facility to provide care for 98 residents. 2 of 5 interviewed residents stated the lack of incontinent care for an extended period of time made them feel like they were defeated, not treated with dignity, neglected, dirty, mad, sad, helpless, and abandoned. Emergency personnel reported that residents were observed crying. This deficient practice negatively impacted residents in the facility. F553: Based on record reviews, residents, family and staff interviews the facility failed to offer 3 of 5 residents (Residents #47, #49 and #80) reviewed for care planning, the opportunity to participate in care plan meetings. During the recertification and complaint survey on 6/17/21, the facility failed to invite 2 of 2 residents reviewed for care plan meeting invitations. F584: Based on observations and staff interviews, the facility failed to maintain walls (Rooms 111 B, 114 B, and 115 A) and a door (room [ROOM NUMBER]B) in good repair for 3 of 15 rooms (rooms [ROOM NUMBER]) on the 100-hall reviewed for environment. During a complaint investigation survey on 2/24/22, the facility failed to provide a clean environment for 2 of 2 days investigated for environment. Interviews with first responders who arrived at the facility described and provided photographic evidence bags of garbage in the hallways and an observation on 1/17/22 revealed a room with overflowing garbage, garbage on the floor, garbage under the bed, and spilled fluids. F656: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan which included an area of focus related to nutrition for 2 of 5 residents (Resident #90 and Resident #75) reviewed for nutrition. During a recertification and complaint survey on 6/17/21, the facility failed to develop a care plan for discharge plans for 2 of 4 residents reviewed for discharge planning. During an interview on 4/13/24 at 3:37 p.m., the Administrator stated the QA (Quality Assurance) committee met monthly and consisted of the Administrator, Director of Nursing, Medical Director and the Directors of the facility's departments. When an area of concern was identified during an IDT (Interdisciplinary Team) meeting, a PIP (performance improvement project), including audits with results was submitted to the QA committee every month until the concern was resolved. She further revealed that as oversight, the corporate consultants also have access to this information via SharePoint to audit, submit recommendations, and follow-up to the QA Committee.

Based on record review, resident, staff interviews and student interviews, the facility failed to treat a resident in a dignified manner for 1 of 23 residents reviewed for dignity (Resident #17). Nurse #2 told Resident #17, in a loud and demeaning tone, to get back in her room and stop stalking her. Resident #17 stated Nurse #2's statement made her feel embarrassed and humiliated to be spoken to as if she were a child. Findings included: Resident #17 was admitted to the facility on [DATE] with the most recent readmission on 11/18/22. Her diagnoses included, in part, stroke, hemiplegia, diabetes mellitus and arthritis. An annual Minimum Data Set assessment dated [DATE] revealed Resident #17 cognitively intact and she required substantial to maximal assistance with her activities of daily living. She was independent in her wheelchair for ambulation. On 04/11/24 at 10:20 AM, while preparing to enter room acroos from Resident #17, this surveyor and Nurse #3 overheard Nurse #2 speak to Resident #17 in a demeaning manner. Nurse #2 told Resident #17 to get back in her room and to stop stalking her. Nurse #2 further told Resident #17 she would not attend to her any faster because she was sitting and watching her. Nurse #2 told Resident #17 her priority was the diabetics. The nurse was positioned a few rooms away on the same side of the hall as Resident #17. There was approximately 40 feet of distance between Nurse #2 and the Resident. Resident #17 blushed and backed her wheelchair back into her room. An interview was conducted with Resident #17 on 04/11/24 at 10:50 AM and she stated when Nurse #2 yelled down the hall and told her to go to her room she felt embarrassed and humiliated. She said Nurse #2 spoke to her like a child and she was not a child. She said it was demeaning to be spoken to in that manner. She stated she was not stalking Nurse #17; she was just sitting in the hall waiting for her medications because she did not want to miss getting her as needed pain medication. She stated she had not asked the nurse for anything prior to the nurse telling her to get back in her room. Resident #17 stated she was just watching for Nurse #2 because she had chronic pain and had to stay ahead of her pain, or it was too hard to control. On 04/11/24 at 11:12 AM an interview was conducted with Nurse #3, and she stated she heard Nurse #2 tell Resident #17 loudly, from between room [ROOM NUMBER] and 208, to go back in her room, stop stalking me, I'm not coming to you yet. Nurse #3 stated Nurse #2 talked to Resident#17 in an unprofessional and harsh manner. Nurse #3 stated Nurse #2's tone was too loud and was demeaning. Nurse #3 stated Nurse #2 had been sent home immediately. Nurse #3 added it was not common practice for the facility staff to speak to the residents in that manner. She stated the facility did not tolerate bad customer service. An interview was conducted with Nurse #2 on 04/11/24 at 1:00 PM and she stated she and Resident #17 always spoke to each other in that manner. Nurse #2 stated Resident #17 liked her and knew that was how she talked. She stated Resident #17 was a smoker and wanted her medications before she went to smoke. Nurse #2 stated she told Resident #17 that she had to administer medications to the diabetics and administer blood pressure medications first. She further stated she had to provide for residents going to dialysis and appointments and administer important medications before she could attend to Resident #17. Nurse #2 said Resident #17 was rushing her and she did not want to make a medication error. Nurse #2 stated Resident #17 sat and watched her from her bedroom door. Nurse #2 stated it was not about pain for Resident #17, it was about getting her medications prior to her smoke break. She stated she could not prioritize a cigarette break over diabetics and dialysis residents and other important matters. She further stated That's just how I sound, I don't speak like a Southerner, and I think everyone thinks I am talking harshly and nasty. Nobody is culturally competent in the south about my accent. People don't understand Northerners and now I look like the bad guy. On 04/11/24 at 1:35 PM an interview was conducted with the Director of Nursing (DON) and she stated Nurse #2 received a final written warning due to her unprofessional language with Resident #17. The DON stated Nurse #2 had not had any disciplinary action prior, but the unprofessional behavior necessitated a final level of disciplinary action. She stated the facility did not tolerate staff speaking to residents in such a manner. An interview was conducted with the Administrator on 04/11/24 at 1:49 PM and she stated she wrote the incident between Nurse #2 and Resident #17 up as a grievance and followed up with the Resident. She stated she expected staff to provide good customer service and to treat residents with dignity and respect.

Based on record reviews, residents, family and staff interviews the facility failed to offer 2 residents (Resident #47 and Resident #49) and 1 family member (Resident #80) the opportunity to participate in care plan meetings. This was discovered for 3 of 5 sampled residents reviewed for care planning Findings included: 1. Resident #47 was admitted to the facility on [DATE] with diagnoses which included: hemiplegia affecting her left nondominant side. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #47 was cognitively intact. There was no documentation in the medical record or provided by the social worker indicating Resident #47 attended or refused to attend her care plan meetings. During an interview on 4/9/24 at 1:13 p.m., Resident #47 revealed she was not invited to, or participated in any of her care plan meetings in over a year. On 4/11/24 at 10:05 a.m., during a telephone interview, Resident #47's family member (the resident is her own responsible party) expressed concern that the resident had not had a care plan meeting with the facility in over a year. During an interview on 4/13/24 at 10:16 a.m., the Social Worker (SW) stated she began working at the facility on August 1, 2023, and her responsibilities included scheduling the care plan meetings for all the facility residents. The SW revealed she scheduled the care plan meetings with the residents and/or their Responsible Party (RP) 2-3 days in advance, in person and/or via telephone. When a resident and/or the resident's RP preferred not to attend the upcoming care plan meeting, she would document the refusal in the resident's medical record. The SW also revealed she was responsible for maintaining each resident's care plan meeting participation sign in sheets but was unable to locate any participation sheets for Resident #47. After reviewing her files and the resident's medical records, the SW stated the most recent documentation of Resident #47's participation in her care plan meeting was on 9/14/22. The SW acknowledged Resident #47's most recent MDS was in January 2024, and the resident should have been invited to the care plan meeting. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses which included secondary Parkinsonism. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #49 was cognitively intact. There was no documentation in the medical record or provided by the social worker indicating Resident #49 attended or refused to attend her care plan meetings. On 4/10/24 at 12:02 p.m., during an interview Resident #49 revealed she had not been invited to or attended her care plan meetings. During an interview on 4/13/24 at 10:16 a.m., the Social Worker (SW) stated she began working at the facility on August 1, 2023, and her responsibilities included scheduling the care plan meetings for all the facility residents. The SW revealed she scheduled the care plan meetings with the residents and/or their responsible party (RP) 2-3 days in advance, in person and/or via telephone. When a resident and/or the resident's RP preferred not to attend the upcoming care plan meeting, she would document the refusal in the resident's medical record. The SW also revealed she was responsible for maintaining each resident's care plan meeting participation sign in sheets. The SW confirmed there was a care plan meeting for Resident #49 in March 2024 but she there was no available documentation indicating the resident was invited to or participated in any care plan meetings since her admission to the facility in June 2023. 38904 3. Resident #80 was admitted to the facility on [DATE]. Her cumulative diagnoses included respiratory disease and dementia. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #80 was severely cognitively impaired. During an interview with the Family Member on 4/9/2024 at 1:13 pm she stated she had not been invited to a care plan meeting. During an interview with the Social Worker on 4/11/2024 at 1:19 pm she stated she had worked at the facility for the past 8 months. She stated Resident #80 did not have a care plan meeting since 2/2023. She stated she met with Resident #80's Family Members informally but had not scheduled a formal care plan meeting where other members of the interdisciplinary team met with them. She stated she normally sets a care plan meeting and therapy, dietary, nursing, and activities departments were invited to the care plan for each resident. The Social Worker stated she sends out a mailed invitation to the Family Member and the resident is notified of a scheduled care plan meeting. The Social Worker stated since she meets with Resident #80's Family Member frequently she failed to schedule a formal care plan meeting with other disciplines available. The Administrator was interviewed on 4/11/2024 at 6:37 pm and she stated Resident #80 should have a scheduled care plan meeting every 3 months and the resident and the resident representatives should be invited to the care plan meeting. The Administrator stated the Social Worker was responsible for scheduling the care plan meeting.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan which included an area of focus related to nutrition for 2 of 5 residents (Resident #90 and Resident #75) reviewed for nutrition. The findings included: 1. Resident #90 was admitted to the facility on [DATE] with cumulative diagnoses which included cancer, dementia, and Type 2 diabetes. His admission orders included a diet order for a Cardiac, Consistent Carbohydrate Diet with regular textures. The resident's weight history was reported to include a weight of 151.5 pounds (#) on 2/2/24 and 149.0# on 2/14/24. A progress note authored by the facility's consultant Registered Dietitian (RD) was dated 2/14/24. The RD note reported the resident's meal intake was 50-100 percent (%) meals. She indicated the cardiac dietary restriction was not appropriate at that time and recommended Resident #90's diet be liberalized to a Consistent Carbohydrate Diet with regular textures. A physician's diet order was received in accordance with this recommendation to provide Consistent Carbohydrate Diet with regular textures (initiated 2/14/24) for Resident #90. Further review of the resident's weight history included the following: --On 2/28/24, the resident weighed 146.5#; --His weight was reported to be 141.0# on 3/12/24, which was indicative of a significant weight loss of 5.37% in one month (from 2/14/24 to 3/12/24). An RD progress note dated 3/13/24 reported Resident #90 experienced a significant weight loss of 5% over the previous 30 days. He was noted to have increased nutritional needs related to this significant weight loss. A recommendation was made to initiate 120 milliliters (ml) of Med Pass 2.0 (a high calorie, high protein liquid nutritional supplement) to be given to Resident #90 twice daily. A physician's order was received on 3/13/24 for initiation of 120 ml of Med Pass 2.0 given twice daily in accordance with the RD's recommendation. Review of Resident #90's electronic medical record (EMR) revealed his most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the resident had moderately impaired cognition. He was assessed as being independent with eating. Resident #90 was reported to be 72 inches tall and weighed 141 pounds (#). He received a therapeutic diet. The MDS assessment indicated the resident had a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months but was not on a physician-prescribed weight-loss regimen. Resident #90's current Care Plan (last revised on 2/12/24) was reviewed. The care plan did not include a Nutrition area of focus with dietary orders, goals, and/or interventions to provide for Resident #90's nutritional care. The facility's Dietary Manager was not available for an interview. A telephone interview was conducted on 4/11/24 at 11:55 AM with the facility's consultant RD. During the interview, the RD reported it was the Dietary Manager's responsibility to initiate and revise the nutrition care plans. When asked if she would expect a nutrition care plan to be completed for Resident #90, she stated, Any nutrition intervention should be care planned. An interview was conducted on 4/11/24 at 3:19 PM with the facility's MDS Nurse. Upon inquiry as to who was responsible to complete a Nutrition care plan for a resident with a significant weight loss, she stated, someone from dietary. During a follow-up interview conducted on 4/11/24 at 3:40 PM with the MDS Nurse, the nurse reported the Nutrition care plan had apparently been missed for Resident #90 prior to 4/11/24. An interview was conducted on 4/11/24 at 3:49 PM with the facility's Regional Dietary Consultant. During the interview, the Consultant was informed there wasn't a Nutrition area of focus for Resident #90, who had experienced a significant weight loss. She stated the Dietary Manager was responsible for completing the Nutrition area of focus in the residents' care plans. When asked if she would expect a Nutrition area of focus to be included in a care plan for a resident with a significant weight loss, she nodded her head to indicate she would expect it. An interview was conducted on 4/13/24 at 9:26 AM with the facility's Director of Nursing (DON). During the interview, the DON stated the Dietary Manager may not have been aware that it was her responsibility to complete the Nutrition care plan. 38904 2. Resident #75 was admitted to the facility on [DATE] with diagnoses of a progressive neurological disease, seizure disorder, and dementia. A Significant Change Minimum Data Set assessment was completed 3/21/2024 and indicated Resident #75 was severely cognitively impaired, required extensive assistance with eating, and had a significant weight loss. During a review of Resident #75's Care Plan dated 3/26/2024 no care plan for nutrition was found. Resident #75 had a Dietician's Progress Note dated 3/26/2024 that indicated he had a significant weight loss, received a medication to stimulate his appetite, and had increased nutritional needs related to the weight loss. Nurse #5 was interviewed on 4/9/2024 at 5:39 pm and she stated Resident #75 will only eat a few bites of a meal but will eat snacks. She stated she was not aware he did not have a care plan for nutrition and dietary would be responsible for developing a nutrition care plan. The facility's Dietary Manager was not available for an interview. On 4/11/2024 at 11:48 am the Consultant Registered Dietician was interviewed by phone, and she stated she saw Resident #75 on 3/25/2024 and he presented with significant weight loss. She stated the Dietary Manager is responsible for the nutritional care plans. The Administrator was interviewed by phone on 4/11/2024 at 6:38 pm and she stated Resident #75 should have a care plan for significant weight loss and she thought it must have been overlooked by the Dietary Manager.

Based on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 2 of 7 residents whose medications were reviewed (Resident #71 and Resident #73). The findings included: 1. Resident #71 was admitted to the facility on [DATE] with re-entry from a hospital on 7/2023. His cumulative diagnoses included a history of a stroke and anxiety disorder. A review of the resident's electronic medical record (EMR) revealed a physician's order dated 2/27/23 was received for 0.5 milligram (mg) lorazepam (an antianxiety medication) to be given as one tablet by mouth three times daily for anxiousness. Lorazepam is a psychotropic medication and a controlled substance medication. Further review of Resident #71's EMR revealed a physician's order was received on 9/8/23 for 2 mg / milliliter (ml) lorazepam to be given as 1 mg intramuscularly (IM) every 12 hours as needed (PRN) for agitation until oral lorazepam arrived, then discontinue. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Resident #71 was reported to have severely impaired cognition with no behaviors nor rejection of care. He was dependent on staff for all of his Activities of Daily Living (ADLs), except for requiring only supervision or touching assistance for eating. The Medication section of the MDS revealed Resident #71 received an antianxiety medication during the 7-day look back period. Resident #71's EMR indicated the physician's orders for both the scheduled lorazepam (initially ordered on 2/27/23) and the PRN injectable lorazepam (initially ordered on 9/8/23) continued as active orders up through the date of the review on 4/10/24. A review of Resident #71's Medication Administration Records (MARs) revealed no doses of PRN lorazepam were documented as having been administered to the resident from 9/8/23 through 4/10/24. A telephone interview was conducted on 4/12/24 at 1:47 PM with the facility's consultant pharmacist. During the interview, the pharmacist reported she was addressing the use of PRN psychotropic medications with the facility. Most recently, the pharmacist reported a statement included in the Executive Summary Comments from her April 2024 Consultant Report indicated there were still some psychotropic medications ordered PRN with no stop date. The consultant pharmacist stated she requested the facility please make sure that this was observed for all residents, including Hospice. An interview was conducted on 4/13/24 at 9:26 AM with the facility's Director of Nursing (DON). Upon inquiry, the DON reported nursing staff was aware that PRN psychotropic medications must have a stop date. The DON stated she thought Resident #71's order for the PRN lorazepam had inadvertently been left on the resident's current orders. 2. Resident #73 was admitted to the facility on [DATE]. Her cumulative diagnoses included Alzheimer's disease. She was admitted to Hospice on 3/12/24. A review of the resident's electronic medical record (EMR) revealed a physician's order dated 3/21/24 was received for 1 milligram (mg) lorazepam (an antianxiety medication) to be given as one tablet under the tongue (sublingually) every 4 hours as needed (PRN) for end of life care / anxiety / agitation. The end date for the PRN lorazepam order in Resident #73's EMR was Indefinite. Lorazepam is a psychotropic medication and a controlled substance medication. Resident #73's most recent Minimum Data Set (MDS) was a Significant Change assessment dated [DATE]. The resident was reported to have severely impaired cognition with no behaviors nor rejection of care. She was dependent on staff for all of her Activities of Daily Living (ADLs). The Medication section of the MDS revealed Resident #73 did not receive an antianxiety medication during the 7-day look back period. A review of the controlled substance declining inventory sheets for Resident #73 was conducted on 4/12/24 at 3:00 PM. This review revealed 12 tablets of 1 mg lorazepam were dispensed from the pharmacy on 3/21/24 and stored on the medication cart for this resident. None of the lorazepam tablets were documented as having been removed from the inventory. Documentation on Resident #73's March 2024 and April 2024 Medication Administration Records (MARs) revealed no doses of PRN lorazepam were administered to the resident through the date of the review. A telephone interview was conducted on 4/12/24 at 1:47 PM with the facility's consultant pharmacist. During the interview, the pharmacist reported she was addressing the use of PRN psychotropic medications with the facility. Most recently, the pharmacist reported a statement included in the Executive Summary Comments from her April 2024 Consultant Report indicated there were still some psychotropic medications ordered PRN with no stop date. The consultant pharmacist stated she requested the facility please make sure that this was observed for all residents, including Hospice. An interview was conducted on 4/13/24 at 9:26 AM with the facility's Director of Nursing (DON). Upon inquiry, the DON reported nursing staff was aware that PRN psychotropic medications must have a stop date. She stated these medications were typically limited to 14 days or extended up to 90 days with a stop date designated in the order.

Based on record review and staff interviews the facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for 2 of 5 residents (Resident #64 and Resident #80). Resident #64 did not receive the influenza vaccine at the Responsible Party's request and Resident #80 was not offered the influenza vaccine. Findings included: a. Resident #64 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety and stroke. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #64 was severely cognitively impaired. During a review of Resident #64's medical record a consent with benefits and risks was not found for an influenza vaccine for the last year. The Director of Nursing was interviewed on 4/11/2024 at 4:49 pm and she stated she could not find consents with the benefits and risks of taking the influenza vaccine for 2023 that should have been reviewed with Resident #64's Responsible Party. The Director of Nursing stated before residents were given a vaccine the nursing staff should obtain a signed copy of the consent which included the risks and benefits of the vaccine and if they could not get a signed consent two nurses should witness a verbal consent with the Responsible Party by phone if the resident was cognitively impaired and cannot give consent. The Director of Nursing stated Resident #64 was not given the influenza vaccine at the Responsible Party's request. b. Resident #80 was admitted to the facility on [DATE] with diagnoses of respiratory disease and dementia with agitation. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #80 was severely cognitively impaired. During a review of Resident #80's medical record a consent with benefits and risks was not found for an influenza vaccine for the last year. On 4/11/2024 at 4:53 pm an interview was conducted with the Director of Nursing, and she stated she could not find a consent with the benefits and risks of taking the influenza vaccine for 2023 for Resident #80. The Director of Nursing stated they had issues with getting consent signed by the family members of residents that are cognitively impaired and unable to sign for themselves. The Director of Nursing stated Resident #80 did not receive the influenza vaccine. The Administrator was interviewed by phone on 4/11/2024 at 6:37 pm and stated Resident #64 and Resident #80 should have been provided the benefits and risks of receiving the influenza vaccine and if a resident is not cognitively intact the Family Member should be contacted for consent for the influenza vaccine.

Based on observations and staff interviews, the facility failed to maintain walls (Rooms 111 B, 114 B, and 115 A) and a door (room [ROOM NUMBER]B) in good repair for 3 of 15 rooms (rooms [ROOM NUMBER]) on the 100-hall reviewed for environment. Findings included: 1a. Observations of room [ROOM NUMBER] B on 04/09/24 at 12:32 PM and on 04/10/24 at 12:34 PM revealed areas of gouged drywall to the left of the bathroom door. A 3-to-4-inch triangular section of the bottom corner of the bathroom door was broken completely off from the hinge side of the door. 1b. Observations of room [ROOM NUMBER] B's bathroom on 04/09/24 at 11:30 AM, and on 04/10/24 at 12:30 PM revealed the vinyl baseboard molding had separated from the wall on the right side from the commode in the bathroom. The 12-inch section of baseboard molding was attached to the bottom of the wall but hung loose from the wall at the top. 1c. Observations of room [ROOM NUMBER] A on 04/09/24 at 4:35 PM and on 04/12/24 at 5:20 PM revealed a section of gouged drywall behind the head of the bed. The section of gouged drywall was 3 feet wide and 3 feet long with multiple vertical gouges from top to bottom. During an interview and room observations with the Maintenance Director on 4/12/24 at 3:32 PM he stated he had been the Maintenance Director for a short time. He further stated facility staff notified him of repairs that were needed in residents' rooms. The Maintenance Director shared he was aware that there were many areas in the facility that needed repairs, and they were prioritizing the areas as they identified concerns. He explained he prioritized repairs by working on those which impacted resident safety first. He stated he used a web-based software to manage building tasks and work orders. On 04/13/24 at 3:25 PM an interview was conducted with the Administrator, and she stated she expected the Maintenance Director to complete repairs that impacted patient safety first and then attend to cosmetic repairs.

Based on record review, observations, and staff interviews, the facility failed to have written physician orders for the continued care of the indwelling urinary catheter for 1 of 3 residents reviewed for indwelling urinary catheter care (Resident #8). Findings included: An after-visit summary dated 12/5/2022 documented an emergency room visit on 12/5/2022 with the insertion of an indwelling urinary catheter. Resident #8 was admitted to the facility on [DATE] with diagnosis to include retention of urine. A nursing admission assessment dated [DATE] documented the indwelling urinary catheter. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #8 to be moderately cognitively impaired. The MDS documented the use of an indwelling urinary catheter. The MDS care area assessment dated [DATE] documented Resident #8 was unable to urinate while she was at home and the indwelling urinary catheter was placed during her hospitalization . A physician admission visit note dated 12/8/2022 documented the presence of an indwelling urinary catheter that was inserted due to her inability to urinate. A care plan dated 12/8/2022 addressed Resident #8's potential for a urinary tract infection (UTI) related to the indwelling urinary catheter. Interventions included to change the indwelling urinary catheter per the physician orders. Resident #8's medical record was reviewed and there were no physician orders for indwelling urinary catheter care. A nursing note dated 1/5/2023 written by Nurse #3 documented Resident #8 was seen by the facility physician and a urinalysis with culture and sensitivity (a test to determine infection of the urinary tract) was ordered. A physician order dated 1/6/2023 ordered a urinalysis for pain in the bladder. The urinalysis results on 1/8/2023 showed positive bacteria growth. A physician order dated 1/9/2023 ordered sulfamethoxazole/trimethoprim (an antibiotic) 800/160 milligrams by mouth twice per day for 10 days for UTI. Resident #8 was observed on 1/9/2023 at 10:41 AM. An indwelling urinary catheter was noted to be draining cloudy yellow urine. Resident #8 was interviewed at the time of the observation. Resident #8 reported she had a UTI and was going to start antibiotics. Resident #8 reported she felt generally poor, without specific complaints and hoped the antibiotics helped her. An interview was conducted with Nurse #1 on 1/11/2023 at 2:37 PM. The nurse reported that catheter orders would be entered upon admission to the facility if a resident had a catheter inserted at the hospital. Nurse #1 reported the physician would provide the orders, including the diagnosis for the indwelling urinary catheter use, the frequency of changing the catheter, and the type of catheter to use. Nurse #1 reported she was not aware Resident #8 did not have orders for the catheter. The Unit Manager (UM) was interviewed on 1/11/2023 at 3:08 PM. The UM explained that the nursing staff entered admission orders for new admissions after calling and talking to the physician. The UM reported that she was not aware Resident #8 did not have indwelling urinary catheter orders. The UM reported because the MDS captured the indwelling urinary catheter, a care plan was developed, and a standard of care was implemented. The UM reported Resident #8 started to feel bad a few days ago and a urinalysis was obtained. The UM reported Resident #8 had bacterial growth that showed an infection, and she was started on an oral antibiotic. The physician (MD) was interviewed on 1/11/2023 at 3:56 PM. The MD reported he was not aware Resident #8 did not have orders for the care and management of the catheter. The MD reported that the indwelling urinary catheter should be changed every 30 days. The MD reported that that an indwelling urinary catheter increased the risk of a UTI, but he did not feel that Resident #8 developed the UTI because the catheter was not changed. Nurse #2 was interviewed on 1/12/2023 at 1:10 PM. Nurse #2 reported she completed the admission assessment for Resident #8, but she did not enter the admission orders.

Based on record review, staff, first responders, and resident interviews, the facility neglected to provide basic goods and services, including, but not limited to incontinent care, resident assessments, medications, nourishment, and basic housekeeping to meet the needs of 98 of 98 residents residing in the facility during a winter weather storm on 1/16/22. Neglecting to meet the needs of the residents had the high likelihood of causing severe psychological and physical harm to all 98 residents. Immediate Jeopardy began on 01/16/2022 when the facility neglected to provide basic care and services to meet the needs of the residents during a winter weather storm. The immediate jeopardy was removed on 1/18/22 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal plan. The facility will remain out of compliance at a lower scope and severity of F (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. Findings included: Review of Resident #13 most recent Minimum Data Set (MDS) was coded as an annual assessment with an Assessment Reference Date (ARD) of 1/9/22 revealed the resident was coded as being cognitively intact. An interview at 11:47 AM on 1/17/22 with Resident # 13 was conducted. During the interview she stated that there were only 2 people working on 1/16/22 and she didn't receive lunch or supper yesterday. She explained that she was given a sandwich for each meal and that she didn't consider the sandwich as an actual meal. Additionally, she added that she only saw one nursing assistant going back and forth between 2:00 AM -3:00 AM. Review of Resident #15 most recent MDS was coded as an admission assessment with an ARD of 11/09/21 revealed the resident was coded as being cognitively intact. During an interview at 11:54 AM on 1/17/22, Resident # 15 stated lunch was provided at 2:30 PM yesterday and that she did not get dinner except for a few snacks. She stated she didn't know what was going on, the police, firemen, and EMS was here at the facility. Review of Resident #7's most recent Minimum Data Set (MDS) was coded as an admission assessment with an ARD of 11/4/21 revealed the resident was coded as being cognitively intact. During an interview with Resident #7 on 1/17/22 at 12:19 PM the resident stated on 1/16/22 there was only one nurse and two nursing assistants for the entire facility. She said she had turned her call light on during the day on 1/16/22 because her brief needed to be changed and she needed incontinent care and it wasn't until 11:00 PM the call light was answered, and she received incontinent care. She further explained she did not receive incontinent care again until 3:00 AM. She then stated after 3:00 AM, it wasn't until 10:15 AM on 1/17/22 she had received incontinent care. She said she had put her call light on at 7:15 AM on 1/17/22 and it was not answered until 9:20 AM when breakfast was brought in, and she said the staff who delivered her breakfast were unable to provide incontinent care. She stated she had to eat breakfast while sitting in her incontinent brief and she felt uncomfortable about it. She said they had only received a bag of chips and a sandwich for supper at 9:45 PM on 1/16/22, so she wanted to eat breakfast and did not want to skip breakfast. She explained by 10:15 AM on 1/17/22 the urine had soaked through the brief and soaked through the incontinent pad she was on to the point her bed was wet. She described how she had to sit with her brief full of urine for many hours between 1/16/22 and 1/17/22 and how she felt defeated and was not being treated with dignity due to having to wait so long for receiving basic care. Review of Resident #11's most recent Minimum Data Set (MDS) was coded as an admission assessment with an Assessment Reference Date (ARD) of 12/21/21 revealed the resident was coded as being cognitively intact. During an interview with Resident #11 on 1/17/22 at 12:57 PM the resident spoke about the events that occurred on 1/16/22 and asked if the facility had some type of disaster plan that should have been followed? She stated the facility was short of help, she felt neglected, and expressed no one seemed to care. She further stated there were only two Nursing Assistants (NAs) to cover the whole building from 7:00 AM until 11:00 PM. She said there was only one nurse to cover the whole building. She said NA # 2 had told her she hadn't even had an opportunity to go to the bathroom while she was working. Resident #11 stated she was in pain on 1/16/22 and didn't receive her afternoon meds until 8:00 PM-8:30 PM. She further stated the staff refused to help her out of bed on 1/16/22 and that had upset her because she likes to get out of bed because her leg hurts her, and it feels better to get out of bed and change position. She said when she was wet, she had to wait a very long time for someone to come and change her on 1/16/22 and into the morning of 1/17/22. She said the staff who were there did not even have the opportunity to offer her a bedpan so she would not have to be incontinent. On 1/16/22 she received incontinence care twice, for the whole day she stated. She further stated she had to lay in her own pee or poop for many hours and at the time of the interview her bottom felt uncomfortable. She explained while this was happening, she felt dirty, mad, sad, and helpless. She said she received incontinence care at 10:00 PM on 1/16/22 and did not receive incontinence care again until 6:00 AM on 1/17/22. Review of a quarterly MDS with an ARD of 10/21/21 revealed Resident #1 was coded as being cognitively intact. On 1/17/22 at 12:46 PM an interview was conducted with Resident #1. During the interview, Resident #1 revealed he assisted the facility staff with handing out sandwiches and went on all halls except the COVID hall and the dementia unit between 6:00 PM-7:30 PM. He stated he volunteered to help because there were only 3 people working and didn't believe the 3 could provide care for the facility. He further added he helped at lunch and passed ice. Resident #1 added around 7:30 PM the police and fire department showed up and helped out a whole lot. A phone interview was conducted with Nurse #7 on 1/18/22 at 3:41 PM. She said she worked on 1/16/22 and started at 7:00 AM and worked until 7:00 AM 1/17/22. She explained she had worked from 7:00 AM to 7:00 PM on 1/15/22 and it was a normal day. She explained she was aware of the potential for inclement weather, but there was no one from management who had discussed inclement weather with her, or preparations for inclement weather on 1/15/22. She said the employees of the facility were joking about it and making statements such as pack your bags and be prepared to stay in case it snows on 1/15/22. She said when she left her house on 1/16/22 it was just starting to snow. When she arrived at the facility, she explained she was unable to find the schedule, and she did not know who was supposed to work, or who was supposed to be there without the schedule, and without the schedule, she did not know how to make assignments or who would be assigned to what halls. She said she called DON #1 at around 7:30 AM to let her know she was the only nurse who had arrived for the day shift, she couldn't ' t find the schedule, and the night nurse was going to only stay until 11:00 AM. She further explained there were only 2 Nursing Assistants (NAs) who had arrived to work day shift, and typically there would have been 2 medication aides, 3 nurses, and 8-10 NAs. She said she had talked to the DON and the Administrator #2 multiple times throughout the day, but on one occasion when she talked to her the DON had told her she had just gotten back into her driveway after trying to get to the facility, she didn't ' t know anyone who had a truck who could come get her, and she would try to find some staff to come to the facility to help her. She said when she had talked to Administrator #2 she told her she was sorry, and she was going to call DON #1. The nurse described the residents received a hot breakfast, but at lunch time, bagged lunches were pushed out onto the hallway by the dietary staff, and her and the 2 NAs passed out the bagged lunches, which were actually lunch and dinner combined into one bag. She added there was a medication aide (MA) (NA #3) who had come in at 7:00 AM and left at 2:00 PM and there were 2 NAs who had stayed over to help from night shift, but they had left before lunch time. She explained the NA shifts go from 7:00 AM to 3:00 PM, and no NAs arrived at the facility at 3:00 PM. She further explained the nurses work 12 hour shifts from 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM, and no nurses arrived at the facility at 7:00 PM. The nurse described the day as chaotic, residents were asking for their medications, she was trying to prioritize medications such as antibiotics and insulin to ensure residents received them timely, she and the other staff were unable to answer the facility phone, she was communicating with DON #1 and the Administrator #2 via her personal cell phone which she was carrying with her, she was making periodic rounds on the dementia unit because there was not enough staff to have someone on that unit at all times, at about 4:30 PM one of the NAs was crying, asking if anyone else was going to come to help, and had a panic attack to the point where she felt like she was going to have to call 911 for the NA. The nurse further stated at one point during a conversation with the DON, the DON told her she had too much responsibility in the building and to go lay down for a while and she responded to the DON she was there to take care of the residents and that was her main priority. She said she did not know how long it had been, but at one point there were two police officers behind her, and they had informed her they had received 911 calls regarding the situation at the facility. She said through discussion with the police officers they had asked her who was in charge of the facility, and she responded she was, she was in the only nurse in the facility, there were two NAs, and they were providing care for all of the residents. She explained shortly after that the facility was swarming with police, EMS, and firemen. She said they sat her down and were asking questions, seemed concerned about her and well-being, and she felt relieved to know she was going to get some help for caring for the residents. She further stated at 11:00 PM when the night shift NAs were supposed to arrive, no NAs arrived at the facility and the 2 NAs who had been there since 7:00 AM remained at the facility with her. She explained she did not know who the interim administrator was. During an interview conducted on 1/19/22 at 10:29 AM with Emergency Responder Nurse #1 he stated he and Emergency Responder Nurse #2 administered medications and provided treatments to multiple residents between when he arrived at 11:30 PM on 1/16/22 and then left at 7:00 AM on 1/17/22. He stated amongst the medications he and the other nurse administered included intravenous (IV) [MEDICATION(S)] (a strong antibiotic) to Resident #6. He stated that due to being the only nurse, Nurse #7 was unable to administer all of the prescribed medications for the residents of the facility. He stated there was no supervision for the dementia unit because there were only three staff members for the facility. He further stated the Director of Nursing (DON) did arrive to the facility and she was also assisting in the administration of the backlogged medications which were overdue. He further explained it was not just medications which hadn't been administered but ordered treatments had also not been completed as ordered. He explained there was a resident who had [CONDITION(S)] in her leg and her legs were weeping (a condition in which fluid builds up under the skin and then escapes through the skin and pores). He said the resident wanted to the bandages on her legs changed, but they were unable to get to re-wrapping her legs. Medication Aide (MA) #1 was interviewed via phone on 01/24/2022 at 2:00 PM and she confirmed that she reported to work about 6:45 AM on 01/16/2022 as scheduled by the agency and that she had been assigned to administer medications to the residents on the 200 and 300 halls. MA #1 also reported that while administering medications to her assigned area she had assisted to provide care, answer call lights and to make random checks on the secured dementia unit (also referred to as the SPARKS unit and/or 500 hall). MA #1 reported that she knew that some of the medications were administered late to residents and that the care given was not the best, but they worked as hard as they could. She further stated that she had never experienced a situation like she did on 01/16/2022. MA #1 reported she received permission to leave the facility at 2:00 PM due to the weather. An interview was conducted with NA #2 on 01/19/2022 at 10:28 AM. NA #2 revealed that on 01/16/2022 that only 4 nursing staff members arrived for work at 7:00 AM. The four nursing staff members consisted of 2 nursing assistants, 1 medication aide, and 1 LPN. NA #2 described the entire day as extremely busy and that many residents voiced complaints about not enough staff, not receiving care, call lights not being answered sometimes for 2 or more hours and not adequate food for dinner. NA #2 explained that with only 4 and then 3 staff that there was no staff assigned to the secure dementia unit and that the 3 of them were concerned for the residents on the secured unit. She further stated they gave some care to those residents and tried to check on their safety as they could. NA#2 stated she experienced a panic attack when she realized that no staff came to help them at 3:00 PM. NA #2 explained she overheard some residents talking and they had decided to call 911 because there wasn't enough staff in the facility to take care of them. She further explained the three staff members in the facility (including herself) had to make the residents sandwiches to for dinner which angered the resident's as well. NA #2 stated that the three staff worked with no breaks and that when the police and EMS arrived later that evening, she was very glad to have help to provide care. NA #2 stated that she had never experienced a situation like that and had never been so upset about the lack of resident care. On 01/20/2022 at 1:55 PM an interview was conducted with NA #1, and he revealed that he arrived for work at about 7:15 AM on 01/16/2022. He explained he was a few minutes late due to the snow and having to drive slower. NA #1 revealed in part that he and NA #2 tried as hard as they could to provide care to all the residents at the facility. He stated in the [AGE] years he had been employed, he had never experienced such a lack of staff to give care to the residents and had never heard residents as angry about the lack of care received on 01/16/2022. He said he felt numb and overwhelmed about the experience he had on 1/16/22 while there were just the 2 NAs to care for all of the residents. He said he felt bad for the residents having to wait so long for care and was disappointed because it seemed like no one was making an effort to get other staff in to help the residents. On 01/18/2022 at 12:05 PM an interview was conducted with DON #1. The DON explained that she had received multiple calls from Nurse #7 and the previous NHA on 01/16/2022 and that she had told Nurse #7 that she tried to get to the facility, but the roads were to snowy and icy but that she had been making calls to facility staff and agency and that she did not get any response that staff would going to the facility. The DON stated that she told Nurse #7 to prioritize care and to do the best that they could until more staff arrived to work. An interview was conducted on 1/19/22 at 9:30 PM with Emergency Medical Technician (EMT) #2. He said he and another EMT arrived at the facility at 9:30 PM. He stated he felt like the residents had been neglected due to observing residents who hadn't been fed or received food, residents who hadn't received incontinent care, he had discovered a resident who was lying in her own vomit, and he felt it was all related to the facility on ly having one nurse and 2 NAs to care for all of the residents. He stated when he and the other EMT arrived they had started a mass triage of all of the residents to determine if there were any residents who were in an acute condition through a general assessment and getting vital signs (temperature, pulse, respiration, blood pressure if needed). He said there were residents who said they hadn't received their medications and were genuinely concerned about their health. He said he stayed at the facility until 7:00 AM on 1/17/22. He said he did not see an NA the whole time he was there. He said there was such a lack of staff that there was no one at the facility to help them identify who the residents were and were putting name labels on residents, so they knew who the residents were. He said it was difficult to figure out what had been done for some residents and what hadn't been done for other residents. A phone interview was conducted on 1/20/22 at 12:49 PM with Police Officer #1. She stated she and 2 other police officers arrived at Pine Ridge Nursing Home at about 8:09 PM on 1/16/22. The police officer stated she there were residents out and rolling around in the general facility area when they arrived inside of the building and there were several call lights on throughout the facility. She described when she went back to the dementia unit, there were no staff back there, the residents were observed to have been wandering throughout the unit, in and out of rooms, residents were behind the nurses' station, and there were residents observed behind the nurses' station putting items into their mouths. A phone interview was conducted on 1/20/22 at 3:09 PM with Police Officer #3. He stated he and 2 other police officers arrived at Pine Ridge Nursing Home at about 8:09 PM on 1/16/22. The police officer stated there was a nurse and 2 NAs at the facility and none of them were in the dementia unit when he rounded through the building. He said as he was approaching the dementia unit, which is a locked unit, he could see an elderly woman through the window on the door banging on the door. He then said when he entered the dementia unit, he could see residents wandering throughout the dementia unit with no supervision. He described the residents as wandering behind the nurses' station desk, some of the residents who were behind the nurses ' station desk were going through the drawers. He said he had also observed a resident pushing an empty intravenous (IV) pole around the nurses ' station and dementia unit; there was nothing hanging on it, just an empty IV pole. He described the observation of the dementia unit as shocking. During an interview conducted on 1/17/22 at 11:32 AM with Housekeeper #1 she stated she had worked on 1/16/22 from 5:30 AM to 10:00 AM and she was the only housekeeper at the facility. She said after she left there was no other housekeeping staff at the facility. She said that was not the time she would have normally gone home later in the day, but she said she had to leave at 10:00 AM because it had started sleeting. She stated she was the only housekeeper who was at the facility on 1/16/22 and there were no housekeepers at the facility after she left. She said there were two Nursing Assistants (NAs) at the facility. She further stated there were very few staff members in the facility. She also stated no one had come to the facility to do laundry on 1/16/22. During a phone interview conducted on 1/20/22 at 12:49 PM with Police Officer #1 she stated he arrived at the facility at 8:10 PM. She stated there were rooms where there was a strong smell of urine and feces. She further stated there were some rooms which had garbage on the floor, spilled liquids on the floor, and the rooms just appeared like no one had cleaned them for a while. A phone interview was conducted on 1/20/22 at 1:14 PM with Police Officer #2. He stated he and 2 other officers arrived at Pine Ridge Nursing Home at about 8:09 PM on 1/16/22. The police officer stated there was an odor of feces when he entered into the facility. He explained the smell continued to only get stronger as he went through the building and described the smell as horrible and as pure raw sh*t at one point. A phone interview was conducted on 1/20/22 at 3:09 PM with Police Officer #3. He stated there was garbage laying around everywhere inside of the facility. He also said there was an odor of stool and urine in the hallways, especially on the 200 hall outside of room [ROOM NUMBER] where there was visible feces below the bed. He further stated down another hall there was a line of reddish fluid on the hallway floor. He said the conditions were of concern enough the detective applied for a search warrant to obtain photographs of the unsanitary conditions. Administrator #3 was notified of immediate Jeopardy on 01/21/ 2022 at 12:31 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; At 8:09 PM, after a resident called 911, local law enforcement arrived at the facility for a wellness check. It was determined that there was 1 licensed practical nurse (LPN) and 2 nursing assistants (NAs) on site and there were 97 residents which were in need of care and services. Emergency Management personnel gave the residents sandwiches, assessed residents, and got staff to the building during the night and for the next day to provide care. It was determined that the facility was non-compliant with Tag F600 based on a failure of the Administrator to enact an emergency preparedness plan, resulting in residents not receiving medications or meals in a timely manner, and not receiving other necessary goods and services. As set forth in the immediate jeopardy preliminary findings, all residents were likely to suffer a serious adverse outcome based on the non-compliance with emergency preparedness. 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 1/16/22 at 9:20 PM the Administrator informed the Assistant Regional Vice President (ARVP) that the fire and police personnel were at the facility. On 1/16/22 at 9:52 PM, the ARVP updated the Divisional Vice President (DVP) and the DVP initiated a Quality Assurance and Performance Improvement (QAPI) conference call with corporate support staff verbalize assignments of duties upon arrival to the facility. The AVRP and Corporate staff put in place the Emergency Preparedness Plan to obtain additional staff and address the issues at the facility impacting residents. On 1/16/2022, the DON arrived at the facility approximately 11:30 PM, and provided medications and direct care. At 11:45 PM, a call was held with the Administrator and Corporate support staff to implement Emergency Preparedness Plan. On 1/17/2022 at 1:23 AM, the ARVP arrived at the facility and assumed charge of the facility. At 8:02 AM, the Mobile Certified Dietary Manager arrived in the kitchen, and the dietary department provided breakfast as scheduled, and subsequent meals as scheduled. At 10:47 AM, the Corporate Clinical Director arrived in the facility and provided direct care. At 10:50 AM, the Divisional Vice President arrived at the facility and assisted in securing staff, passing out meal trays. At 11:00 AM, Corporate Employee Experience personnel arrived at the facility, to assist with securing staff on the schedule. At 11:10 AM, the Regional RN MDS Consultant arrived at the facility to provide direct resident care. At 11:30 AM, the supporting RN facility consultant arrived to assist with direct resident care. At 12:00 noon, the assigned RN facility consultant arrived to assist with direct resident care. At 1:00 PM, an additional RN consultant arrived to assist with direct resident care. On 1/17/22, all residents were assessed by clinical staff for acute change of condition and no change in condition were noted. On 1/17/22, the social worker talked with 100% of alert and oriented residents to provide psycho-social support. On 1/17/22, the Interim Administrator and Human Resource Support Staff reviewed the staffing schedule for the upcoming 7 days to ensure sufficient number of staff to provide care for the residents. The Interim Administrator, Divisional Vice President, and Human Resource Support Staff ensured there was enough staff, on each shift, in each department, to provide care to all residents in accordance with the resident plan of care. Date of alleged Immediate Jeopardy removal: 1/18/2022. The facility's credible allegation of compliance was validated through an on-site review process which included record review, observations, interviews with facility staff, corporate staff and residents. Date of IJ removal was validated as 1/18/22

Based on record review, police, Emergency Medical Technicians (EMTs), resident, and staff interviews, the facility failed to provide Activities of Daily Living (ADL) Care, including incontinence care. The failure occurred on 1/16/22 during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. Two interviewed residents (Resident #7 and Resident #11) stated they did not receive incontinent care for an extended period of time and Resident #11 stated she had physical discomfort from having had to wait an extended period of time for incontinent care. Interviews with first responders who arrived at the facility described multiple residents in need of care and a strong smell of urine and feces in the facility. Due to the facility ' s failure to sufficiently staff the facility to provide necessary ADL care on 1/16/22, every resident of the facility was placed at risk of severe harm. During interviews with the three police officers who arrived to the facility at 8:09 PM on 1/16/22 they stated there was a foul odor of urine and feces, there were multiple call lights on, and after interviewing the LPN on site she stated she was the only nurse in the facility and she and the 2 NAs were unable to supply the medical care the residents needed which included timely incontinent care, assisting with toileting, delivery of nutrition and hydration, answering call lights, and other facets of basic care for the residents. The police officers stated it was determined by them, and the LPN, the residents of the facility were in need of immediate ADL care which the three staff members were unable to provide. In order to meet the needs of ADL care to the residents and the police officers reached out to community resources, including Emergency Medical Services (EMS) and firefighters, to immediately assess all residents of the facility, and to provide care to the residents of the facility. Immediate Jeopardy began on 01/16/22 when the facility failed to have adequate nursing staff during a winter storm on 01/16/22 to provide ADL care for the residents. Nurse #7, Nurse Assistant (NA) #1, and NA #2 were the only staff at the facility after 2:00 PM to provide all ADL care for the 98 residents at the facility. The immediate jeopardy was removed on 01/18/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at scope and severity level F (potential for actual harm that is not immediate jeopardy) to ensure systems are put in place are effective. The findings included: 1. Resident #7 was admitted to the facility on [DATE] and the resident ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7 ' s most recent Minimum Data Set (MDS) revealed an admission comprehensive assessment with an Assessment Reference Date (ARD) of 11/4/21. The resident was coded as cognitively intact. The resident was coded as having had no hallucinations or delusions and the resident was coded as requiring extensive assistance of one to two people for bed mobility, transfer (such as transfer from the bed to the wheelchair), dressing, toileting, and personal hygiene. The resident was coded as always continent of both bowel and bladder. The care plan for Resident #7, most recently revised on 12/7/21, specified the resident had Focus areas which included: The resident needed assistance with ADLs/Personal care and the interventions included the resident having been continent of bowel and bladder. Further review revealed a focus area about the resident having the potential for urinary incontinence related to physical immobility and the interventions included encouraging the resident to call for assistance for toileting, praise and encourage attempts to comply with toileting. The resident also had a focus area for her being at risk for skin breakdown, or development of further pressure ulcers related to: Immobility. During an interview with Resident #7 on 1/17/22 at 12:19 PM the resident stated on 1/16/22 there was only one nurse and two nursing assistants for the entire facility. She said she had turned her call light on during the day on 1/16/22 because her brief needed to be changed and she needed incontinent care and it wasn ' t until 11:00 PM the call light was answered, and she received incontinent care. She further explained she did not receive incontinent care again until 3:00 AM. 2. Resident #11 was admitted to the facility on [DATE] and the resident ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11 ' s most recent Minimum Data Set (MDS) revealed an admission comprehensive assessment with an Assessment Reference Date (ARD) of 12/21/21. The resident was coded as cognitively intact. The resident was coded as having had no hallucinations or delusions and the resident was coded as requiring total or extensive assistance of one to two people for bed mobility, transfer (such as transfer from the bed to the wheelchair), dressing, toileting, and personal hygiene. The resident was coded as always continent of both bowel and bladder. The care plan for Resident #11, most recently revised on 12/14/21, specified the resident had Focus areas which included: The resident needed assistance with ADLs/Personal care and the interventions included the resident having occasional incontinence and requiring assistance with toileting. During an interview with Resident #7 on 1/17/22 at 12:19 PM the resident spoke about the events that occurred on 1/16/22 and asked if the facility had some type of disaster plan that should have been followed? She stated the facility was short of help, she felt neglected, and expressed no one seemed to care. She further stated there were only two Nursing Assistants (NAs) to cover the whole building from 7:00 AM until 11:00 PM. She said there was only one nurse to cover the whole building. She said NA # 2 had told her she hadn ' t even had an opportunity to go to the bathroom while she was working. She said the staff refused to help her out of bed on 1/16/22 and that had upset her because she likes to get out of bed because her leg hurts her, and it feels better to get out of bed and change position. She said when she was wet, she had to wait a very long time for someone to come and change her on 1/16/22 and into the morning of 1/17/22. She said the staff who were there did not even have the opportunity to offer her a bedpan so she would not have to be incontinent. On 1/16/22 she received incontinence care twice, for the whole day she stated. She further stated she had to lay in her own pee or poop for many hours and at the time of the interview her bottom felt uncomfortable. During a phone interview conducted on 1/19/22 at 10:28 AM with NA #2 she stated she arrived at 7:00 AM on 1/16/22 and they were unable to find the schedule. She and NA #1 had no idea about who else was supposed to work. She explained her and the only other NA split the halls of the facility to provide care for the residents. She said most of the staff who were assigned to leave at 7:00 AM (the end of night shift) did not wait for someone to take their place and left because it was starting to snow. She said 2 nurses from night shift stayed in the morning to assist with morning care and help with breakfast. She explained the two nurses helped a lot with covering the dementia unit, which was a locked unit. She said after the 2 nurses left, it was just her and the other NA to provide care for 98 residents. She further stated her, and the other NA provided as much care as they could to each resident. She said the residents who were alert and oriented were upset and they knew what was going on and she had a discussion with one resident who informed her she was going to call 911 regarding the situation at the facility, lack of care, and her current state. She said it was after 3:00 PM when she realized the other NAs who were scheduled at 3:00 PM had not arrived, and most likely were not going to arrive, which made her and the nurse very mad and upset. She said the phones were often ringing, they did not have time to answer the phones, and the receptionist who would usually answer the phone at the front desk had also not come to work. She said there was no other staff at the facility at that time, no dietary staff, no receptionist, no housekeeping, and no laundry staff. She explained at one point she became very angry and upset and the nurse was concerned for her health and considered sending her to the hospital, but she said she eventually got moving again and just went back to work. She said it was unreal, she was so busy, and had never had an experience like that before. She said she just kept working and at some point, she didn ' t even remember when, she saw the police officers in the building, then more police officers, then the fire department and Emergency Medical Services. A phone interview was conducted on 1/19/22 at 10:29 AM with Emergency Responder Nurse #1 (male) and Emergency Responder Nurse #2 (female). He explained they arrived at 11:30 PM on 1/16/22 and there were only 2 Nursing Assistants to care for all of the residents at the facility and they had been at the facility for about 16 hours and needed to go home. He said there were no NA ' s who had had arrived for the 11:00 PM to 7:00 AM shift when they had arrived. He explained the nurse and the 2 NAs who were at the facility couldn ' t think beyond the emergency situation. He said the residents expressed frustration over the lack of care, not receiving incontinent care, how they shouldn ' t be treated like that, upset about the condition of the care, and some had informed him they had received candies instead of a meal. She stated a lot of the residents were wet, to the point the urine had gone through the brief the resident was wearing, through an incontinent pad, and on the sheets of the bed. She explained the NAs were doing their best to try and keep up, and keep the patients dry, but it was just not possible for 2 NAs to care for so many residents. She also stated there was no one providing any care or supervision to the residents in the dementia unit. A phone interview was conducted with Emergency Medical Technician (EMT) #1 on 1/19/22 at 8:27 PM. He stated there was only one nurse and two NAs providing care for all of the residents at the facility. He said while they were triaging residents to determine if there were any urgent and acute medical needs of any of the residents one resident had yelled at him that she needed a brief and needed to be changed. He further stated the nurse who was working at the facility told him, the Director of Nursing (DON) told the nurse to find an empty room at midnight, go lie down, and to get some rest, despite her being the only nurse. The conversation between the nurse and the DON had occurred prior to the police arriving at the facility and the subsequent emergency response. The EMT stated the nurse told him she knew that wasn ' t the right thing to do, she was the only nurse there, and the residents were depending on her. A phone interview was conducted with EMT #2 on 1/19/22 at 9:30 PM. He explained he had arrived at the facility at 9:30 PM on 1/16/22. He stated the residents of the facility had been neglected as evidenced by the lack of care they had received. He said many residents were left incontinent and residents were asking how come they were being treated like that. He said he saw multiple residents lying in their own feces. He said the facility had a COVID unit and one resident on the COVID unit told him he had not seen a staff member of the facility since early in the day. He stated he was appalled by the situation he discovered the residents in. During a phone interview conducted on 1/20/22 at 12:49 PM with Police Officer #1 she stated he arrived at the facility at 8:10 PM and the only staff discovered at the facility by himself, and the other two responding officers were one nurse and two Nursing Assistant ' s to care for all of the residents. She stated there were multiple call lights on in each hallway he went down, and she did not see anyone answering the call lights. She stated there were rooms where there was a strong smell of urine and feces, and it was obvious the residents hadn ' t been changed in a long time. The police officer stated Nurse #7 told her this was one of the worst things she had ever seen, and she seemed to be in shock. A phone interview was conducted on 1/20/22 at 1:14 PM with Police Officer #2. He stated he and 2 other officers arrived at Pine Ridge Nursing Home at about 8:09 PM on 1/16/22. The police officer stated there was an odor of feces when he entered into the facility. He explained the smell continued to only get stronger as he went through the building and described the smell as horrible and as pure raw sh*t at one point. He said there were residents who were crying and had told him and the other officers they had not seen a nurse all day. He said he had been in the building many times and had never seen the building in a state like he had found it on 1/16/22. He said the experience was a very sad, disturbing, and emotional ordeal for him. A phone interview was conducted on 1/20/22 at 1:14 PM with Police Officer #3. He stated when he and the other officers arrived at the facility they discovered three staff members, one nurse and two NAs. He said the three of them were doing what they could for the residents, but it was obvious three people could not provide care for all of the residents of the facility. He stated there was a room he had observed which had feces under the bed and there was a strong odor. He said during several interviews with residents they told him they had not seen nurses or NAs for several hours, or since breakfast, and some said they hadn ' t eaten since breakfast. During an interview conducted on 2/2/22 at 1:23 PM with Administrator #3 (Who was the Assistant Regional Vice President prior to assuming the administrator role) he stated it was his expectation to have a level of staffing to provide the needed care for residents. He further stated there needed to be oversight through the Administrator and the Director of Nursing to provide that level of staffing to allow residents to feel like they were getting timely and appropriate care. Administrator #3 was made aware of the Immediate Jeopardy (IJ) on 1/22/22 at 1:23 PM. The facility shared the following plan to address the incident which alleged the facility had put into place measures to lower the scope and severity of the IJ as of 1/18/22. The Removal Plan: F677- Activities of Daily Living (ADLs) The entity ' s removal plan must include the following: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 1/16/22, at 8:09 PM, after a resident called 911, local law enforcement arrived at the facility for a wellness check. It was determined that there was 1 licensed practical nurse (LPN) and 2 nursing assistants (NAs) on site and there were 97 residents which were in need of care and services, including assistance with activities of daily living, (ADL) care. Emergency Management personnel assessed residents, and got staff to the building during the night and for the next day to provide care. It was determined that the facility was non-compliant with Tag F677 based on a failure of the Administrator to enact an emergency preparedness plan, resulting in residents not receiving ADL care. As set forth in the immediate jeopardy preliminary findings, all residents who needed ADL care during the time period where there was only 1 LPN and 2 NAs on site were likely to suffer a serious adverse outcome based on the non-compliance with emergency preparedness. 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 1/16/22 at 9:20 PM the Administrator informed the Assistant Regional Vice President (ARVP) that the fire and police personnel were at the facility and that there was only 1 LPN and 2 NAs at the facility. The ARVP began driving to the facility in order to assist with coordinating care of residents and provision of ADL services to residents while getting additional staff to the facility. The AVRP and Corporate staff put in place the Emergency Preparedness Plan to obtain additional staff and address the issues at the facility impacting residents, including the provision of ADL care. On 1/16/22, the DON arrived at the facility at approximately 11:30 PM, and provided direct activities of daily living (ADL) care, including incontinent care. On 1/16/22, at 11:45 PM, a call was held with the Administrator and Corporate support staff to implement Emergency Preparedness Plan and get sufficient staff to the facility to provide direct ADL care, including incontinent care. On 1/17/22 at 1:23 AM, the ARVP arrived at the facility and assumed charge of the facility, which included coordinating care of residents and provision of direct ADL care, including incontinent care. On 1/17/22 at 10:47 AM, the Corporate Clinical Director arrived in the facility and provided direct resident ADL care, including as needed, incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights. On 1/17/22 at 11:00 AM, Corporate Employee Experience personnel arrived at the facility, to assist with securing staff on the schedule. On 1/17/22 at 11:10 AM, the Regional RN MDS Consultant arrived at the facility to provide direct resident ADL care, including as needed, incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights. On 1/17/22 at 11:30 AM, the supporting RN facility consultant arrived to assist with direct resident ADL care, including as needed, incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights, and assessed residents for acute change in condition, no changes noted. On 1/17/22, at 12:00 noon, the assigned RN facility consultant arrived to assist with direct resident ADL care, including as needed, incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights, and assessed residents for acute change in condition, no changes noted. At 1:00 PM, an additional RN consultant arrived to assist with direct resident ADL care, including as needed, incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights. On 1/17/22, the Interim Administrator and Human Resource Support Staff reviewed the staffing schedule for the upcoming 7 days to ensure sufficient number of staff to provide ADL care for the residents, including timely incontinent care, toileting, bed-mobility, positioning, assisting residents of the dementia unit, and answering call bell lights timely. The Interim Administrator, Divisional Vice President, and Human Resource Support Staff ensured there was enough staff, on each shift, in each department, to provide ADL care to all residents in accordance with the resident plan of care. Date of alleged Immediate Jeopardy removal: 1/18/2022 The facility ' s credible allegation of compliance was validated through an on-site review process which included record review, observations, staff, corporate, and resident interviews. Date of IJ removal was validated as 1/18/22.

Based on record reviews, first responder, staff and interviews, the facility failed to provide adequate staffing to provide care and supervise resident safety during inclement weather (a winter storm) on 01/16/22. Nurse #1, Medication Aide (MA) #1 and two Nursing Assistants (NAs) (NA #1 and NA #2) reported to work on the morning of 01/16/22. MA #1 left the facility at 2:00 PM after she received permission to leave the facility from the Director of Nurses (DON) #1. The nurse and the 2 NAs remained as the only staff to provide resident care and services for 98 residents in the facility. Nurse #7 communicated the staffing situation of the facility to Administrator #2 and her concerns regarding the lack of care and quality of care the three of them could provide for the residents. Administrator #2 told the Nurse #7 that she was sorry about the situation and the staff needed to do the best that they could. Police Officers arrived at the facility at 8:09 PM on 01/16/22 for a wellness check after 911 calls from a resident and after attempted calls to the facility from 911 dispatch went unanswered. This situation affected 98 of 98 residents. Immediate Jeopardy began on 01/16/22 when the facility failed to have adequate nursing staff scheduled during a winter storm on 01/16/22. Nurse #7, Nurse Assistant (NA) #1 and NA #2 were the only staff at the facility after 2:00 PM making all nursing care decisions and providing resident supervision for all 98 residents at the facility. The immediate jeopardy was removed on 01/18/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at scope and severity level F (potential for actual harm that is not immediate jeopardy) to ensure systems are put in place are effective. Findings included: A phone interview conducted with Nurse #9 and Nurse #10 on 01/26/22 at 4:23 PM revealed they were both agency nurses and worked from 7:00 PM on 01/15/22 until 7:00 AM on 01/16/22. Nurse #9 stated at about 6:30 AM on 01/16/22 Nurse #7 reported to work followed by MA #1 and NA #1 and NA #2. Nurse #7 asked where the nurse schedule or assignment sheet was for 01/16/22 and the nurses were not able to find the schedule or the list of nurse staff names and contact information (phone numbers). Nurse #9 and Nurse #10 informed Nurse #7 that no staff had called during the night to report the were not coming to work on 01/16/22. Nurse #9 and Nurse #10 gave a report to Nurse #7 and MA #1 received the medication cart keys for the 200 hall and the 300 hall while Nurse #7 received medication cart keys for the 100 hall, 400 hall and 500 hall. Nurse #9 and Nurse #10 revealed at about 7:30 AM no other staff reported to work, and the night shift staff had left or was about to leave the facility. Nurse #7 called DON #1 and placed the call on speaker for Nurse #9 and Nurse #10 to hear. When Nurse #7 asked if she knew where the schedule was for 01/16/22 or if any staff had called out for work the DON told her she did not know where the schedule was, and she had not received any calls from staff during the night to report they were not able to get to work. Nurse #7 informed the DON that only four staff had reported to work. Nurse #9 and Nurse #10 told the DON that they would stay through breakfast to assist with breakfast and resident care but needed to leave at 12:00 PM because they were tired, but they would leave earlier if more staff arrived. Nurse #9 and Nurse #10 went to the secure dementia unit to give care and assist with breakfast because there was always one staff assigned to remain on that unit at all times. Nurse #9 revealed when she and Nurse #10 left at 12:00 PM no other staff had reported to work and the remaining four nursing staff would only be able to make rounds on the secure dementia unit. A phone interview conducted with Nurse #7 on 01/18/2022 at 3:39 PM revealed in part that on the morning of 01/16/22 when she arrived at work on 01/16/22 at 6:30 AM it had already started to snow. But, she explained, she packed extra clothes in case she was needed to stay at the facility past her shift that ended at 7:00 PM. Nurse #7 revealed she phoned DON #1 at about 7:30 to 8:00 AM and the DON was not aware of any staff not reporting to work and the DON had not received calls from staff about not being able to get to work on 01/16/22. Nurse #7 revealed the DON told her the staff needed to do the best they could and to focus on medication administration making insulin injections the biggest priority because blood sugar changes could cause residents a lot of harm. The DON also told Nurse #7 that she would notify Administrator #2, start to call staff and agencies to get extra help, and she had attempted to drive to the facility, but the ice and snow made the drive impossible which made her return home. Nurse #7 revealed that she had left a message for Administrator #2 but was not certain of the time except it was in the morning of 01/16/22, but when Administrator #2 returned the call to Nurse #7, Administrator # 2 told Nurse #7 that she was sorry about the staffing situation. Nurse #7 revealed Nurse #9 and Nurse #10 left the facility at 12:00 PM. She said MA #1 left at 2:00 PM but had been scheduled until 7:00 PM. Nurse #7 revealed that she called the DON a little after 3:00 PM and reported that no staff arrived at 3:00 PM and the remaining staff was Nurse #7, NA #1 and NA #2. The DON told Nurse #7 to continue to do the best that they could. Nurse #7 explained it was very chaotic and the staff present had all worked together to give care, answer call lights, and Nurse #7 ' s focus was on medication administration. Nurse #7 revealed sometime near 5:00 or 6:00 PM there was no prepared dinner for residents and there was no dietary staff was in the building. Nurse #7 and NA #2 were not able to find and sandwiches or other prepared dinner items for residents and decided to make peanut butter and jelly sandwiches for the resident ' s dinner. Nurse #7 revealed she also had carried her cell phone with her because they were not able to answer the facility phone. Nurse #7 indicated that normally the facility was staffed with at least 3 nurses, 2 to 3 MAs and about 8 - 10 NAs. She further explained at least 1 NA and either 1 MA or 1 nurse was always assigned to the secure dementia unit. Nurse #7 revealed the staff was only able to make walking rounds to the secure unit and provide care at those times. Nurse #7 revealed she was aware some residents were angry about the lack of care and said they were going to call 911 because the care was late, or they did not receive care. Nurse #7 revealed she did not know that the Police Department came to the facility around 8:00 PM on 01/16/22 until one police officer walked up to her and asked her what was going on at the facility. Nurse #7 revealed she almost started to cry when she told the police officer, she was the only nurse at the facility along with NA #1 and NA #2. Nurse #7 explained to the police officer about the lack of care. She said after she explained what had happened to the police officer, he was able to get assistance, and she was so glad to see those Police Officers, Fire Department and Emergency Medical Services (EMS) enter the facility because they had come to help take care of the residents. MA #1 was interviewed via phone on 01/24/22 at 2:00 PM and she confirmed she worked from 7:00 AM until 2:00 PM o 01/16/22. She explained there was only one nurse and two NAs who came to work at 7:00 AM, but when they could not find a schedule to validate who was actually scheduled. MA #1 revealed she began to administer medications the residents on the 200 hall and 300 hall while answering call lights, giving as much resident care as she could, passing breakfast trays, passing bagged lunch meals, and assisting to feed residents. MA #1 revealed she received permission from DON #1 to leave the facility at 2:00 PM because of the winter storm. She explained no other staff came to the facility, so when she left only Nurse #7, NA #1 and NA #2 were the only staff to care for the residents at the facility. MA #1 explained usually there were at least three nurses scheduled, two or three MAs, and at least 10 NAs scheduled to work a typical day shift. MA #1 also explained that she had never experienced such a shortage of staff at the facility prior to that date, and she believed that residents received basic care, but they also lacked a lot of care. An interview was conducted with NA #2 on 01/19/22 at 10:28 AM. NA #2 revealed she was scheduled to work from 7:00 AM until 3:00 PM on 01/16/22 and when she arrived there was no schedule to check what staff was scheduled to work that day. She explained only she, Nurse #7, MA #1 and NA #1 reported to work that morning. NA #1 and NA #2 decided to just split the halls between the two of them and make frequent rounds to the secured dementia unit where normally at least two staff were assigned. She said it never happened before that staff was not able to remain on the on the dementia unit at all times. NA #2 revealed the night shift NAs had already left the facility when she arrived and that was unusual because in the past they had always stayed until they had relief. NA #1 revealed it sometimes took over 2 hours for resident call lights to get answered or for residents to receive care. She said on 01/16/22 the dinner meal was late, and residents were unhappy and complained about the lack of staff and lack of care. NA #2 revealed when no staff came to work at 3:00 PM, the start of the next shift when typically, more staff would arrive, she had a panic attack because she was so tired and felt compelled to stay and keep working, even though had no breaks and no meals. NA #2 explained that she did not leave the facility until after 11:00 PM when Police Officers and EMS were in the facility and assisted with care. On 01/20/22 at 1:55 PM an interview was conducted with NA #1, and he revealed that he arrived for work at about 7:15 AM on 01/16/2022. He explained the snow slowed him down a little bit and that was how come he had not arrived at or prior to 7:00 AM and he was scheduled to work from 7:00 AM until 3:00 PM. NA #1 said that when he arrived at the facility, he did not see many cars in the parking lot and when he entered the facility, he went to the nurse station to find his assignment Nurse #7 told him there was not an assignment because it was just him and NA #1 and she could not find the schedule. He and NA #1 decided to split the halls and start making resident care rounds, answering call lights, delivering breakfast, and eventually passed out lunch. When it came time for supper, NA #1 Revealed he, NA #1, and Nurse #7 had to make sandwiches for the residents because they had not found any prepared meals for dinner on 01/16/22. NA #1 explained he worked as quick as possible and tried to get to each resident timely to provide care but that was not possible, and residents were unhappy. He said the residents were complaining because they had to wait for care and for food, but they thanked him for all that he was able to do for them. NA #1 revealed that he was upset and felt overwhelmed that the facility had no arrangements to get staff to the facility during the storm as they always had for past [NAME]. NA #1 revealed he never heard about any preparations for the pending winter storm on 01/16/22 from anyone at the facility which also disappointed him. NA #1 explained the worst part was that on 01/16/22 he had to make the residents wait for care, and he felt the residents had to suffer for other people ' s decisions and poor planning. During an interview conducted with Administrator #2 at 2:08 PM on 01/17/22 she stated according to the schedules for 01/16/22 the facility to be fully staffed, but the scheduled staff had not shown up for work as scheduled. Administrator #2 revealed she was in constant contact with the (Director of Nursing) DON #1 and Nurse #7 and she attempted to call all of the transport services she knew of to try to get staff, the DON and herself to the facility but had no success. 01/18/2022 at 12:50 PM an interview with DON #1 revealed she had been made aware earlier in the previous week about the possibility of a winter weather storm, she believed Administrator #2 was aware of the pending winter storm, but she had not discussed any of the preparations with the DON. The DON revealed on 01/16/22 she received a phone call from Nurse #7 and was informed of the poor staffing at the facility. The DON added she tried to drive to the facility after Nurse #7 called her, she thought it was shortly after 7:00 AM, but the roads were icy, and she turned around and went home. The DON revealed she had not received calls from any staff about not reporting to work because staff knew they had to call her or a nurse manager at least 2 hours before their scheduled start time. The DON said she called Administrator #2 and made her aware of the staffing; administrator #2 told the DON she had tried to get to work but her car got stuck and she was trying to find a ride to the facility. The DON admitted that she gave permission for MA #1 to leave the facility at 2:00 PM because of the winter weather, even though she was scheduled to stay at work until 7:00 PM. The DON explained she had attempted to call staff to come work at the facility, but no one answered their phone, or told the DON they could not drive to work because of the weather and road conditions. The DON knew that Nurse #7 was very busy and not able to document on all residents. The DON stated they did not have staff assigned to the secure dementia unit as they normally did but that Nurse #7, NA #1 and NA #2 worked very hard and did the best that they could. A phone interview was conducted on 1/20/22 at 12:49 PM with Police Officer #1. He stated he and two other two police officers arrived at the facility on 01/16/22 at 8:09 PM and only 1 nurse (Nurse #7) and two NAs were working at the facility. Police Officer #2 interviewed Nurse #7 and was told she had been in contact with DON #1 and Administrator #2 many times, but no more staff came to the facility. She further explained to the police officer the three staff were exhausted and this was one of the worst things she had ever seen. She said that she was not able to answer the phone because she was busy administering medications. Police Officer #1 described five to six call lights were on in the hallway he was on, multiple residents complained they were hungry, a few rooms had strong smells of urine and feces, and some resident rooms had garbage on the floors. Police Officer #1 revealed he had seen some residents in the secure dementia unit behind the nurse station, putting items in their mouths, and were wandering around the unit. Police Officer #2 was interviewed on 01/20/22 at 1:14 PM via phone. Officer #2 explained he was one of three Police Officers that arrived at the facility at 8:09 PM on 01/16/22 and when he made contact with Nurse #7, she almost started to cry. Nurse #7 explained that only two NAs were at the facility with her. Police Officer #2 stated it was a very emotional ordeal at the facility. Police Officer #2 revealed Nurse #1 reported that some residents had not received lunch or dinner. He observed residents crying that they had not received medications or food that day and the facility smelled horribly of urine and feces. Police Officer #2 revealed that Emergency Medical Services (EMS), the Fire Department, Public Health Director and County Emergency Management were all notified of the status at the facility and responded by sending support staff to the facility. A phone interview conducted with Emergency Medical Technician (EMT) #2 on 01/19/22 at 9:30 PM revealed that he arrived at the facility about 9:30 PM on 01/16/22 and to assist Police Officers and the Fire Department. Emergency Medical Services (EMS) began a mass triage of all residents and he described residents were incontinent, spilled liquids in resident rooms, and spills in the hallway. He revealed they obtained vital signs, provided incontinent care, assisted with meals, and answered call lights. A phone interview conducted on 01/19/22 at 10:29 AM with Emergency Response Team Nurse (ERTN) #1 revealed that he and ERTN #2 were part of the County Emergency Response Team that were dispatched to the facility at 11:30 PM on 01/16/22. He revealed that Nurse #7 provided him with resident information and he and the other ERTN began obtaining resident vital signs, familiarizing themselves with the medication carts and Medication Administration Records (MARs) for medications that needed to be administered. He further stated they reviewed the Treatment Administrations Records (TARS) for treatments that needed to be performed. A phone interview conducted on 01/26/22 with the DON #1 revealed the facility had been short staffed since the summer and Administrator #2 was made aware but never addressed staffing. The DON revealed that the facility never experienced a staffing shortage like they did on 01/16/22 even with staff from agencies. The DON revealed she and Administrator #2 never spoke about plans for staffing or plans for staff transportation prior to the winter storm on 01/16/22. On 02/02/22 at 1:23 PM Administrator #3 was interviewed and stated he expected all vacant positions be posted. He further stated he expected for the facility continue to work with agencies to provide staff and arrangements were to be in place to transport staff to work as scheduled. Administrator #3 was notified of Immediate Jeopardy on 01/21/22 at 12:31PM. The facility shared the following credible allegation of immediate jeopardy removal. Residents who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance Prior to 8:09 PM, the administrator identified there was inadequate staffing in the facility due to the administrator not planning for or making arrangements for adequate staffing prior to inclement weather. At 8:09 PM, after a resident called 911, local law enforcement arrived at the facility for a wellness check. It was determined that there was 1 LPN and 2 Nursing Assistant on site and there were 98 residents which were in need of care and services. It was determined that the facility was non-compliant with Tag 725 based on the staffing at the facility on 1/16/2022. Additional assistance was immediately provided at the facility by a County Emergency Medical Services individuals, including two nurses, directed by the County Emergency Management Director. As set forth in the immediate jeopardy preliminary findings, all residents were likely to suffer a serious adverse outcome based on the non-compliance. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring On 1/16/22 at 9:20 PM the Administrator informed the Assistant Regional Vice President (ARVP) that the fire and police personnel were at the facility. On 1/16/22 at 9:52 PM, the ARVP updated the Divisional Vice President (DVP) about sufficient staffing at the facility. The DVP initiated a conference call with corporate support staff and Corporate staff put in place the Emergency Preparedness Plan to obtain additional staff and address the issues at the facility impacting residents. Action steps taken were as follows: January 16, 2022: (1) 11:30 PM the DON arrived at the facility to provide direct care and medications to the residents. (2) 11:45 PM, a call was held with the Administrator and Corporate support staff to implement Emergency Preparedness - inclement weather staffing plan. January 17, 2022 At 12:35 AM, the corporate RN facility consultants started contacting their local law enforcement to request transportation to the facility during the inclement weather. (1) The ARVP instructed corporate support staff to contact additional staffing agencies to request assistance the facility with staffing needs. The other staffing agency companies were able to provide assistance with the 7 AM-3PM shift on 1/17/22. (2) At 7:00 AM, the nurse unit manager arrived at the facility to assist the DON and other staff nurses with resident care. (3) At 8:02 AM, the Mobile Certified Dietary Manager arrived in the kitchen, to assist in meal preparation and delivery. (4) At 10:47 AM, the Corporate Clinical Director arrived in the facility, to provide direct resident care. (5) 10:50 AM, the Divisional Vice President arrived at the facility to assist in obtaining additional staff and meal delivery. (6) 11:00 AM, Corporate Employee Experience personnel arrived at the facility, to obtain additional staff. (7) 11:30 AM, the supporting RN facility consultant arrived to assist with direct resident care. (8) 12:00 noon, the assigned RN facility consultant arrived to assist with direct resident care. (9) 1:00 PM, an additional RN consultant arrived to assist with direct resident care. (10) By 2:30 PM, the nursing facility staff and agency nursing staff were able to make it to the facility and many came prepared to spend the night, including those who made longer term commitments to stay in the facility until weather cleared up. (11) At approximately 5:30 PM, the Assistant Regional Vice President (ARVP) suspended the Administrator for failure to implement the Emergency Preparedness Plan, sleep pay benefit. The ARVP assigned himself as the Interim Administrator during the investigation. As of 1/17/2022 at 2:30 PM sufficient staff were in the facility providing care for the residents, including but not limited to incontinent care, medications as ordered, treatments as ordered, call lights answered timely, assessment of changes in condition, and supervision of the dementia unit and COVID unit. On 1/17/22, the Interim Administrator and Human Resource Support Staff reviewed the staffing schedule for the upcoming 7 days to ensure sufficient number of staff to provide care for the residents. Over the course of the next 7 days, the Interim Administrator, Divisional Vice President, and Human Resource Support Staff ensured there was enough of staff, on each shift, in each department, to provide care to all residents in accordance with the resident care plans, plans were also made to address who would be spending the night if staff could not get into the facility and possible transportation options to get staff to the facility. After securing staffing for 1/17/22, the facility implemented staffing meetings to review sufficient staffing for shifts going forward. Alleged Immediate jeopardy removal: 1/18/22. The facility ' s credible allegation of compliance was validated through an on-site review process which included record review, observations and interviews with staff and residents. Date of IJ removal was validated as 01/18/22.

Based on staff, resident, police interviews, Emergency Medical Services (EMS) interviews and record reviews, the facility failed to provide dietary staff who were competent to carry out food and nutrition services during a winter weather storm on 01/16/22. Dietary staff made the decision without consultation with the Mobile Certified Dietary Manager (MCDM) or the Consulting Registered Dietitian (RD) to prepare bags of food to be consumed for lunch and dinner and then leave the building at around 1:00 PM in the afternoon. This left no dietary staff in the building after lunch. The decision was authorized by Administrator #2. There was no communication with the nursing staff about the intent of the bagged lunch to last for lunch and dinner, how the potentially hazardous food was to be kept safe between the time of distribution to the residents at lunch until the dinner meal, where additional prepared sandwiches were stored or when dietary staff left the building. When it was dinner time, residents became unhappy that there was no food delivery. Nursing staff responded by preparing sandwiches as they made rounds. Police arrived on the scene and found residents hungry. Emergency Medical Staff (EMS) were alerted and assisted in food preparation and feeding of residents. This situation affected 97 of 98 residents. Immediate Jeopardy began on 01/16/22 when the facility failed to have any dietary staff on duty to prepare and distribute a dinner meal on 01/16/22. Nurse #7, Nurse Aide (NA) #1 and NA #2 had to try and prepare food in addition to provide nursing care to the residents of the facility. The immediate jeopardy was removed on 01/18/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an F (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure systems put in place are effective. Findings included: Timecards were reviewed for Dietary staff for 1/16/22. Cook #1's time was from 5:20 AM - 1:03 PM. Dietary Aide (DA) #1's time was from 6:39 AM - 9:37 AM. Prep Cook #1's time was from 7:54 AM - 11:35 AM and Cook #2's time was from 9:41 AM - 6:20 PM. The ending time stamp did not match the time Cook #2 actually left the building according to Cook #2's interview. An interview was conducted with Cook #1 on 01/20/22 at 10:13 AM. Cook #1 revealed he arrived at the facility at 5:20 AM on 01/16/22 as scheduled and Dietary Aide #1 arrived at 6:30 AM. The scheduled Prep Cook #1 arrived at 8:00 AM or very close to that time. Cook #1 revealed they prepared a hot breakfast meal for the residents and those meals were delivered to the halls as normally scheduled at 8:00 AM. Cook #1 reported he had a phone conversation with Administrator #2 on 01/16/22 and informed her that because of the weather he was allowing both Dietary Aide #1 and Prep Cook #1 to leave the facility earlier than scheduled and he explained that he would like to provide the residents with bagged lunches for the lunch and dinner meals. He said each resident would have their own bag and attached to the outside would be each resident's individual meal tray ticket so that they would be easily identified by the nurse staff. Cook #1 stated that Administrator #2 gave him permission and he did not contact the Registered Dietitian (RD) and did not contact the MCDM to review the plan for the bagged meals. Cook #1 explained Prep Cook #1 began to make a cold bean salad and Prep Cook #1 pureed the salad to place in individual bags for residents that required a mechanically altered or puree meal. Cook #1 also included that he and Prep Cook #1 made chicken salad and that was also pureed for those residents that required a mechanically altered or puree meal and that all the pureed foods were placed in separate bowls and placed in the bags for those residents along with apple sauce, puddings and thickened liquids as ordered. Cook #1 reported he and the other dietary staff also stocked the nourishment rooms on the units with all forms of snacks that included sugar free foods, extra liquid thickener, chips and crackers and they also stocked the nourishment room and dining room refrigerators and freezers with ice cream, pudding, apple sauce, pre thickened liquids and a multiple variety of foods and snacks prior to leaving the facility. Cook #1 stated he then gave permission for Dietary Aide #1 and Prep Cook #1 permission to leave early. Cook #1 contacted Cook #2 to come to the facility to assist with the bagged lunch and dinner meal. When Cook #2 arrived he explained the bagged meal plans to her and both of them prepared a bagged meal for each resident. They placed 2 sandwiches in the bags for the residents who did not require mechanically altered diets. [NAME] #1 stated that he spoke to Nurse #7 and explained to her the plan was for residents to receive meals in bags, that he would bring them to the nurse stations on rolling metal carts at lunch time. He also told Nurse #7 he spoke to Administrator #2 and had received her permission to use the bags on that day. Cook #1 revealed he and Cook #2 made a bagged meal for each resident and took them to the nurse stations along with extra drinks on ice in metal bins. Cook #1 and Cook #2 left the facility at about 1:00 PM. Cook #1 did not notify Nurse #7 nor the two nurse assistants (NAs) that the dietary staff would be gone from the facility at 1:00 and would not return that day. On 01/17/22 at 11:07 AM an interview was conducted with Cook #1. Cook #1 revealed that he did not work the previous night (01/16/22) and that no dietary staff worked after 1:00 PM on 01/16/22. A phone interview with Cook #2 was conducted on 01/21/22 at 9:19 AM. Cook #2 revealed on 01/16/22 she received a call from Cook #1 and was asked to report to the facility as soon as she could that morning prior to her scheduled time which was at 1:00 PM. Cook #2 revealed she arrived at the facility near 9:30 AM and that she observed Dietary Aide #1 leaving the facility at that time. Cook #2 revealed that when she entered the kitchen, she observed Cook #1 and Prep Cook #1 making cold bean salad and chicken salad sandwiches, Prep Cook #1 was mechanically pureeing those items and scooping them into small individual sized bowls. Cook #2 revealed Cook #1 explained he had talked to Administrator #2 and had received the approval to make a bagged meal for all the residents that contained each resident's specific diet. Cook #2 further explained that for residents who required any type of mechanically altered foods, a bagged lunch with bowls in them with each item was placed in a bag for the resident along with the type of drink required for each specific resident. Residents who were able to eat a regular diet were packed two sandwiches along with a drink and a variety of other snacks like cookies, crackers and chips. Cook #2 revealed that they stapled each bag with each tray label on the outside of each bag and there was one bag for each resident. Then Cook #2 rolled the bags along with a bin of ice and extra drinks to the nurse stations at about 12:00 PM which was the scheduled lunch time. Cook #2 revealed she left the facility with Cook #1 at about 1:00 PM and she did not return to the facility on [DATE]. A phone interview with Prep Cook #1 conducted on 01/24/22 at 2:29 PM revealed he arrived at the facility as scheduled the morning of 01/16/22 but he had been later than usual because of the ice and snow. Prep Cook #1 revealed he made the cold bean salad that was scheduled for the dinner meal and he made chicken salad. He pureed both of those items as directed by Cook #1 and the pureed items were scooped into individual serving sized bowls. He assisted to make chicken salad sandwiches and some other sandwiches. Prep Cook #1 assisted wrapping the sandwiches individually. Cook #1 told him to leave the facility early at around 1:30 PM because of the snowstorm. Prep Cook #1 revealed he did not know any details about the bagged meals or what happened after he left for the day. An interview conducted with the Mobile Certified Dietary Manager (MCDM) conducted at 9:54 AM on 01/20/22 revealed she had not been contacted by Cook #1, Cook #2, the Director of Nurses (DON) or Administrator #2 about the emergency meal menu or other dietary concerns at the facility on 01/16/22. The MCDM also revealed she did not know that bagged meals were part of the emergency meal preparations for the facility. On 01/18/22 at 11:45 AM the Registered Dietitian (RD) was interviewed and revealed. The RD revealed she did not have any role in the kitchen staff or their schedules. An interview conducted with Resident #7 on 01/17/22 at 9:20 AM revealed on 01/16/22 her breakfast tray was delivered at 9:20 AM and she did not receive anything but a sandwich for lunch. At about 9:45 PM on 01/16/22 she received another sandwich and a bag of chips for dinner. Resident #7's most recent Minimum Data Set (MDS) with an assessment date of 11/04/21 included that Resident #7 had no cognitive impairment. During an interview with Resident #11 on 01/17/22 at 12:19 PM she revealed she had received her breakfast tray about 9:25 AM on 01/16/22 and the lunch meal was only a sandwich or two delivered in a paper bag. Dinner was also a sandwich that the two Nursing Assistants had to scavenge to make. A review of the most recent MDS for Resident # 11 dated 12/21/21 revealed Resident #11 had no cognitive impairment, had diabetes mellitus and received a therapeutic diet. On 01/19/2022 at 10:28 AM an interview with NA #2 revealed on 01/16/2022 they had been given bagged lunches labeled with meal tickets for each resident and that almost every bag contained 2 sandwiches and a bunch of snack items that the nurse staff delivered to the residents and there were pureed foods in bowls for the residents that required them. NA #2 revealed at the time she was not aware one of the two sandwiches was meant to be saved for dinner and about 5:00 PM NA #2 and Nurse #7 went into the kitchen to look for more bagged items but were not able to find any, so they agreed to make sandwiches for the residents. They were still making sandwiches and passing them out to residents when EMS arrived at the facility. EMS assisted making more sandwiches, passing them out and assisted to feed residents as needed. NA #2 stated she had not seen any dietary staff since about 1:00 PM on 01/16/22 and there had always been dietary staff in the facility through dinner. An interview conducted with NA #1 on 01/20/22 at 1:55 PM revealed on 01/16/22 around the dinner meal he was told by Nurse #7 that there was no prepared dinner meal for the residents. He explained that Nurse #7 and NA #2 went into the kitchen and returned with bread, peanut butter, and jelly and the three of them would need to make sandwiches for the residents as they continued to make rounds. NA #1 also explained he had not seen any dietary staff in the facility after about 1:00 PM. NA #1 revealed the facility had never used paper bags to serve meals to residents before and he was glad when EMS came to the facility with the police and assisted to make sandwiches, serve them and assisted residents to eat. Nurse #7 was interviewed via phone on 01/18/222 at 3:39 PM. Nurse #7 revealed on 01/16/22, Cook #1 approached her and explained that residents would be served bagged meals for both lunch and dinner and that he would bring the bagged meals to the nurse stations in time for lunch. Nurse #7 revealed when the nurse staff began to pass the bagged meals to residents at lunch they discovered the nurse discovered that some of the bags contained two sandwiches along with a drink and other items and that each resident had only one bag. Nurse #7 revealed residents were asking about dinner and she phoned the DON and Administrator #2 to ask about the dinner meal. The DON explained she had no idea about the dinner meal. Administrator #2 said Cook #1 had left more sandwiches in the walk -in cooler in the kitchen and if any residents had received two sandwiches in a bag one of them should have been saved for dinner. Nurse #7 revealed she had not been made aware of that plan. Nurse #7 and NA #2 went into the kitchen. They had no idea where the walk- in cooler was and did not find any made sandwiches. They grabbed some bread, peanut butter and jelly and decided that they would make more sandwiches for residents as they continued to make rounds. Nurse #7 revealed she had never experienced a time when there was no meal prepared by the dietary staff and she had not been aware that there was no kitchen staff at the facility until the DON told her. Nurse #7 also revealed some residents complained of hunger and she said it had been difficult for her and the two NAs to keep up with meals while providing all the care that was needed, but they kept doing as much as they could for the residents. When Emergency Medical Services (EMS) arrived, they assisted her and the two NAs to make and provide meals to the residents. On 01/18/2022 at 12:50 PM (Director of Nursing) DON #1 was interviewed and explained that on 01/16/22 at about 5:20 PM she was informed by Nurse #7 that she and NA #2 went into the kitchen to find resident bagged dinner meals that Nurse #7 believed the dietary staff had prepared. They had not been able to find any prepared bag meals or premade sandwiches. The DON told Nurse #7 she would call Administrator #2 and find out the status of the dinner meal. The DON revealed that she spoke to Administrator #2 and then called Nurse #7 and reported that Cook #1 had left premade sandwiches in the kitchen's walk-in cooler and that Nurse #7 was instructed to go back to the kitchen and look again. Administrator #2 was interviewed on 01/17/22 at 2:08 PM and revealed she had talked to Cook #1 on 01/16/22 around 12:00 PM. She said Cook #1 explained that he had called Cook #2 and asked her to come to the facility earlier than scheduled to assist in the kitchen. Administrator #2 revealed Cook #1 allowed Dietary Aide #1 and the Cook Prep #1 to leave earlier than scheduled because of the weather. Cook #1 also asked her if it was okay to provide the residents with bagged lunch and dinner meals. Administrator #2 agreed with Cook #1's plan for bagged meals and agreed with his plans to leave extra sandwiches in the walk- in cooler in the kitchen. Administrator #2 reported around dinner time she received phone calls from both the DON and Nurse #7. They asked about dinner for the residents. Administrator #2 explained Cook #1 had left extra sandwiches in the walk-in cooler in the kitchen. Administrator #2 revealed she was not aware that there were still concerns about the dinner meal until about 9:00 PM and 10:00 PM when she received calls from some family members of residents that reported dinner had not been served to residents that evening. A phone interview was conducted on 1/20/22 at 1:14 PM with Police Officer #2. He stated he and two other two police officers arrived at the facility on 01/16/22 at 8:09 PM. There was only 1 nurse (Nurse #7) along with two NAs working at the facility. When he interviewed Nurse #7 he asked if the residents had eaten or been fed. Nurse #7 revealed the residents had received breakfast and she believed that all received lunch from a paper bag that had been prepared by the dietary staff. She and the two NAs were trying to give residents sandwiches for dinner that they were making as they went down the hall providing care. Police Officer #2 revealed some of the residents told him they had not received food and they were very hungry. Police Officer #2 revealed EMS arrived shortly after the police arrived and they assisted to provide food and feed residents. A phone interview was conducted on 01/19/22 at 9:30 PM with EMS #1. EMS #1 revealed when he arrived at the facility at 9:30 AM on 01/16/22 multiple residents said they received a bagged lunch but no dinner meal. EMS #1 revealed that the EMS staff and Fire Department looked through the kitchen and nourishment rooms and did find some sandwiches and drinks for the residents, but nothing was labelled and they also found some thickened drinks and applesauce to feed the residents. Administrator #3 was interviewed on 02/02/22 at 1:23 PM and he stated it was expected the facility maintain the appropriate staff to work as scheduled to ensure that the nutritional need of all residents be maintained. Administrator #3 was notified of Immediate Jeopardy on 01/21/22 at 12:31PM. The facility shared the following credible allegation of immediate jeopardy removal. At 8:09 PM, on 1/16/22 local law enforcement arrived at the facility for a wellness check. It was determined that due to a severe ice storm there was 1 LPN and 2 Nursing Assistants on site and there were 97 residents which were in need of care and services. Residents were provided with bagged meals at lunch time that contained a variety of sandwiches, chips, fruit cups, puddings, cakes, and crackers. Pureed consistency was also provided to include meat, bread, three-bean salad, and pudding. The bags provided at lunch included meals for lunch and dinner which included the tray card for each resident attached to each resident's bag. Each tray card includes the resident's name, room number, allergies, diet consistency, and ordered diet type. Additionally, approximately 100 sandwiches were prepared and accessible. The dietary staff notified the administrator that the sandwiches were in the kitchen's walk-in cooler and the kitchen was unlocked. The nourishment room on the dementia unit, and the nourishment room at the main dining room was stocked with snacks and food to include sugar free chocolate ice cream, milk, soda, sandwiches, pudding, applesauce, and thickened liquids. The last two dietary staff members left the facility at 1:03 PM with approval from the Administrator and notified the administrator where the prepared food could be found. The nurse staff were not informed by the dietary staff that they were leaving or where the prepared food could be found. Emergency Management Services personnel that were on site assisted with providing food delivery to the residents. It was determined that the facility was non-compliant with Tag 802 based on the facility failing to have sufficient nutrition staff to provide dinner during inclement weather. The Administrator did not ensure sufficient dietary staff were present at the facility to appropriately deliver the last meal of the day. As set forth in the immediate jeopardy preliminary findings, all residents were likely to suffer a serious adverse outcome based on this identified non-compliance except for one resident who received tube feedings. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring The facility took the following immediate corrective action to ensure that adequate dietary staff is available to ensure that each meal be prepared as ordered for each resident as prescribed. o On 1/17/22, the Mobile Certified Dietary Manager (MCDM) and registered dieticians reviewed residents' electronic health records. The review included diets, weights, and meal intake. Results: no unexpected negative outcomes were identified. o On 1/17/22, the MCDM checked the facility's emergency food supply and ensured disaster menus and plans are in place per the dietary manual. o On 1/17/22, the MCDM educated the dietary staff on the emergency preparedness plan during inclement weather which discussed food supply to the facility. Going forward, the Administrator will ensure the emergency preparedness plan is communicated with the dietary manager and dietary staff to ensure sufficient dietary staff are present to prepare and deliver meals during an emergency. o On 1/17/22, the Interim Administrator and MCDM reviewed the Dietary Staffing Schedule with the Dietary Manager for the next 7 days to ensure sufficient dietary staff were scheduled to provide adequate meals during each meal service. Date of alleged Immediate Jeopardy Removal: 1/18/22. The facility ' s credible allegation of compliance was validated through an on-site review process which included record review, observations, interviews with staff and residents. Date of IJ removal was validated as 01/18/22.

Based on North Carolina State of Emergency press releases, email review, text message review, record review, resident, emergency/disaster relief staff, Emergency Medical Services (EMS), police, and facility staff interviews Administrator #2 failed to enact the facility emergency preparedness plan, failed to utilize resources to provide care for the residents of the facility during inclement weather, failed to communicate the urgency and potential impact of pending inclement weather to administrative staff, key staff, and general staff prior to inclement weather, failed to communicate a potential crisis situation to her administrative and key staff, failed to ensure sufficient dietary staff who left the facility at 1:00 PM, and failed to communicate a dangerously low staffing situation to the Assistant Regional Vice President (Administrator #3) in the midst of inclement weather in a staffing crisis. Furthermore, DON #1 failed to manage the facility nursing staff during the inclement weather event through failure to coordinate with Administrator #2 a plan to house staff at the facility, transport staff, arrange for transport, or utilize community resources to provide transportation to the facility for nurses and Nursing Assistants. The result of the failure impacted all residents during a governor declared state of emergency involving inclement weather. The failure to prepare resulted in a severe shortage of staff which resulted in one Licensed Practical Nurse (LPN) and two Nursing Assistants (NAs) to take care of 98 residents at the facility starting at 2:00 PM on 1/16/22. On 1/16/22 at 8:09 PM three police officers arrived at the facility for a wellness check to investigate a 911 call from a resident at the facility who had called and complained of not having seen staff members for a long period of time. When 911 dispatch attempted to call the facility, the calls went unanswered. The police officers who arrived then contacted the city fire department and county Emergency Medical Services (EMS). Due to the facility administration's (Administrator #2 and DON #1) lack of ability to manage the facility and ensure necessary staffing levels to meet the needs of the residents of the facility, the county Emergency Preparedness Director took over operations of the facility and utilized resources to obtain a combination of skilled individuals to provide care, assess, assist with an evening meal, and other services for the residents of the facility. Immediate Jeopardy began on 1/16/22 when Administrator #2 failed to plan, prepare, and respond for inclement weather (snow/ice). The opportunity to prepare and to involve department heads, key staff, nursing staff, and other facility began on 1/13/22, when the potential for inclement weather was announced by the Governor of the State of North Carolina through his enactment of a state of emergency for the entire state related to the predicted winter storm. Administrator #2 had a sequence of failures which resulted in the immediate jeopardy situation including, but not limited to failure to review, update, and enact the facility emergency preparedness plan, which would have included instituting measures to ensure sufficient staffing, failure to communicate the urgency and potential impact of pending inclement weather to administrative staff, key staff, and general staff prior to inclement weather, failure to communicate a potential crisis situation to her administrative and key staff, failed to ensure sufficient dietary staff who left the facility at 1:00 PM, and failure to communicate a dangerously low staffing situation to the Assistant Regional Vice President (Administrator #3) in the midst of inclement weather. The immediate jeopardy was removed on 1/18/22 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of F (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. Every resident of the facility was placed at risk of severe harm. Findings included: Cross Refer to E0001: Based on North Carolina State of Emergency press releases, email review, text message review, record review, resident, emergency/disaster relief staff, Emergency Medical Services (EMS), police, and facility staff interviews, the facility failed to enact the facility emergency preparedness plan which impacted all residents during a governor declared state of emergency involving inclement weather. The result of the failure to prepare resulted in one Licensed Practical Nurse (LPN) and two Nursing Assistants (NAs) to take care of 98 residents at the facility starting at 2:00 PM on 1/16/22. Cross Refer to F550: Based on record review, police, resident, and staff interviews, the facility failed to treat residents in a dignified manner, when residents did not receive incontinence care for several hours during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. Two of five interviewed residents (Resident #7 and Resident #11) stated the lack of incontinent care for an extended period of time made them feel like they were defeated, not treated with dignity, neglected, dirty, mad, and abandoned. This deficient practice had the high likelihood of negatively impacting many residents in the facility. Cross Refer to F584: Based on record review, observations, photographs, police, Emergency Medical Technicians (EMTs) and staff interviews, the facility failed to provide a clean environment for 2 of 2 days investigated for environment. Interviews with first responders who arrived at the facility described and provided photographic evidence bags of garbage in the hallways and an observation on 1/17/22 revealed a room with overflowing garbage, garbage on the floor, garbage under the bed, and spilled fluids. Cross Refer to F600: Based on record review, staff, first responders, and resident interviews, the facility neglected to provide basic goods and services, including, but not limited to incontinent care, resident assessments, medications, nourishment, and basic housekeeping to meet the needs of 98 of 98 residents residing in the facility during a winter weather storm on 1/16/22. Neglecting to meet the needs of the residents had the high likelihood of causing severe psychological and physical harm to all 98 residents. Cross Refer to F677: Based on record review, police, Emergency Medical Technicians (EMTs), resident, and staff interviews, the facility failed to provide Activities of Daily Living (ADL) Care, including incontinence care. The failure occurred on 1/16/22 during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. Two interviewed residents (Resident #7 and Resident #11) stated they did not receive incontinent care for an extended period of time and Resident #11 stated she had physical discomfort from having had to wait an extended period of time for incontinent care. Interviews with first responders who arrived at the facility described multiple residents in need of care and a strong smell of urine and feces in the facility. Due to the facility ' s failure to sufficiently staff the facility to provide necessary ADL care on 1/16/22, every resident of the facility was placed at risk of severe harm. Cross Refer to F689: Based on record review, first responder, resident, physician, family member, and staff interviews, the facility failed to provide an environment without severe risk of harm through not providing supervision of the residents in the locked dementia unit for several hours. This occurred during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. As reported by Police Officer #2 who went into the dementia unit after arriving to the facility at 8:10 PM on 1/16/22 she discovered no staff supervising the dementia unit, residents wandering throughout the unit, residents behind the nurses' station desk, and residents placing items in their mouths. This deficient practice impacted all residents of the locked dementia unit, 25 of 25 residents. This resulted in the residents on the dementia unit being at severe risk for harm. Based on record review and staff, Physician and Family Member interviews the facility failed to provide the recommended 1 on 1 supervision to prevent falls for 1 of 1 resident reviewed for accidents (Resident #8). Cross Refer to F725: Based on record reviews, first responder, staff and interviews, the facility failed to provide adequate staffing to provide care and supervise resident safety during inclement weather (a winter storm) on 01/16/22. Nurse #1, Medication Aide (MA) #1 and two Nursing Assistants (NAs) (NA #1 and NA #2) reported to work on the morning of 01/16/22. MA #1 left the facility at 2:00 PM after she received permission to leave the facility from the Director of Nurses (DON) #1. The nurse and the 2 NAs remained as the only staff to provide resident care and services for 98 residents in the facility. Nurse #7 communicated the staffing situation of the facility to Administrator #2 and her concerns regarding the lack of care and quality of care the three of them coguld provide for the residents. Administrator #2 told the Nurse #7 that she was sorry about the situation and the staff needed to do the best that they could. Police Officers arrived at the facility at 8:09 PM on 01/16/22 for a wellness check after 911 calls from a resident and after attempted calls to the facility from 911 dispatch went unanswered. This situation affected 98 of 98 residents. Cross Refer to F802: Based on staff, resident, police interviews, Emergency Medical Services (EMS) interviews and record reviews, the facility failed to provide dietary staff who were competent to carry out food and nutrition services during a winter weather storm on 01/16/22. Dietary staff made the decision without consultation with the Mobile Certified Dietary Manager (MCDM) or the Consulting Registered Dietitian (RD) to prepare bags of food to be consumed for lunch and dinner and then leave the building at around 1:00 PM in the afternoon. This left no dietary staff in the building after lunch. The decision was authorized by Administrator #2. There was no communication with the nursing staff about the intent of the bagged lunch to last for lunch and dinner, how the potentially hazardous food was to be kept safe between the time of distribution to the residents at lunch until the dinner meal, where additional prepared sandwiches were stored or when dietary staff left the building. When it was dinner time, residents became unhappy that there was no food delivery. Nursing staff responded by preparing sandwiches as they made rounds. Police arrived on the scene and found residents hungry. Emergency Medical Staff (EMS) were alerted and assisted in food preparation and feeding of residents. This situation affected 97 of 98 residents. Cross Refer to F809: Based on staff interviews, resident interviews, and record reviews that facility failed to provide three meals at regular times during a winter storm on 01/16/22. Ninety-seven of ninety-eight residents were affected by the deficient practice. An interview was conducted with Administrator #2 on 1/17/22 at 2:08 PM. She stated she had been the administrator at the facility since August 2021. She explained for 1/16/22 they were fully staffed on paper, but there were one or two call outs, and the scheduled staff did not come in at 7:00 AM on 1/16/22. She explained a majority of the staff from night shift who worked from 11:00 PM on 1/15/22 to 7:00 AM on 1/16/22 had stayed over to help the 7:00 AM staff who arrived on 1/16/22. She said the staff who stayed over included a majority of the Nursing Assistants (NAs), the medication aides (med aides), and 2 nurses. She said she and the Director of Nursing had tried to come into the building, but they were unable to because of the poor road conditions from the inclement weather. She said she talked with Nurse #7 who arrived at the facility at 7:00 AM on 1/16/22 and was assigned to work until 7:00 PM on 1/16/22 and the nurse told her she had packed a bag and was prepared to stay the night if needed. She then stated the staff who was scheduled at 3:00 PM for the NAs and 7:00 PM for the nurses called and told her they were not able to make it to the facility and would not be coming in. She said she talked to Nurse #7 later in the day and the nurse told her it was just her and 2 NA ' s for the whole facility. She stated she started to call her administrative team for them to come in and help, people were trying to come in, but they were unable to get to the facility. She said she was corresponding with the dietary staff at around noon and was aware the first shift cook was there, and the second shift cook had come in early to help out and she thought the second shift cook stayed until 8:00 PM. She stated Nurse #7 told her the residents had sandwiches for a dinner meal on 1/16/22. She explained at some time between 9:00 PM and 10:00 PM Nurse #7 had called her and informed her Emergency Management was on site, along with the police, fire department, and they had called the state (DHHS). She then stated she had received calls from her supervisors who had informed them they had been contacted by the Nursing Home Section Chief. She said she was also made aware the [NAME] County Emergency Management Coordinator had been trying to contact her and was unable to, but she said she had received no calls from him. She explained she had been talking to Nurse #7 several times through the day and administrative and key staff were to come into the facility to provide help and relief. She stated on 1/16/22 she had reached out to staff who had 4x4s but none of them were able to assist with transportation, including the Central Supply Coordinator (SSC). She said the SSC was able to transport staff on 1/17/22, and that was how they were able to get some staff in. She said she had tried to contact different transport services but the response she received the response the transport agencies were not going to put their drivers on the road. She said she had even tried a mobility service provider through an app and there were no transport options at the time. She further stated part of the challenge was that she did not know the addresses of many staff members so she could not arrange transportation for them to come to the facility and for some which she did have addresses for, lived outside of the county. Administrator #2 stated she was not aware contacting the [NAME] County Emergency Management Coordinator was an option to provide assistance. Administrator #2 further stated she had not reviewed the Emergency Preparedness Plan prior to the inclement weather but it may have had some information which would have been helpful for the situation. Regarding communication with corporate, her supervisor, Assistant Regional Vice President, Administrator #3, she stated she had let him know there were call outs of first (7:00 AM to 3:00 PM) and second (3:00 PM- 11:00 PM) shifts. She said she had a plan with a 4x4 vehicle to pick people up, but she could not get out of her complex and she said staff were trying to get to the facility between 6:00 AM and 7:00 AM. She explained she did not choose to have one nurse, one medication aide, and one NA, there were more staff scheduled than that. A phone interview was conducted on 1/20/22 at 1:14 PM with the Emergency Management Coordinator of [NAME] County. The coordinator stated the facility did not have a very good incident plan regarding the situation with inclement weather. He further stated he had not met, talked to on the phone, or had any type of information exchange with the Administrator #2 of the facility, while he had received communication from other facilities in the area. He explained he felt it was important for the administrators at nursing homes in [NAME] County and him to work with each other. He explained it was especially important to meet and discuss emergency preparedness plans to try work with a facility to make sure the residents receive the care and assistance they need in an emergency situation in order to try and prevent a situation like what happened on 1/16/22. During an interview conducted with the Central Supply Coordinator (SSC) on 1/20/22 at 11:07 AM he stated he had not heard from Administrator #2 about coming into the facility or picking up staff for the facility on 1/16/22. He said if he would have received a call, he would have come to the facility to have helped or even stayed overnight if need be. He further during the week prior to the storm, Administrator #2 had not discussed with anything about coming into the facility in case it stormed or transporting staff members to the facility in the event there was inclement weather over the weekend. During an interview conducted on 1/20/22 at 12:26 PM with the Payroll Bookkeeper she stated as far as she was aware Administrator #2 had not reviewed anything with staff regarding disaster preparedness since she had started in August. She stated it seemed unusual to have not have anyone discuss inclement weather preparations and about her and other staff coming into help out prior to the storm. She said she was very surprised to have heard what happened when she returned to work and would have been willing to try to come in and help and felt guilty about not knowing the residents needed help. Interviews were conducted from 1/17/22 through 2/2/22 with several members of the nursing home administration team and key staff members including the two social workers, central supply coordinator, medical records director, and the Assistant Director of Nursing (ADON). The interviews revealed during the daily department head meetings, including the meetings on Friday. The interviews revealed the staff members found the situation to be odd in that there was a pending potential winter storm and there had been little or no preparation for them to come in and help at the facility. The staff members expressed guilt for not having known the situation the staff members were in at the facility and frustration in knowing they could have come into help but were unaware the residents were not receiving the care they needed. Furthermore, the interviews revealed there was no weekend manager duty or Manager on Duty (MOD) for the weekends, which would have utilized a department head or key staff member to come into the facility on weekends as a means to have presence of an administrative person present. Interviews with conducted from 1/17/22 through 2/2/22 with several members of the nursing home administration team and key staff members including the two social workers, central supply coordinator, medical records director, and the Assistant Director of Nursing (ADON). During the interviews it was discovered there were vacancies or absences in several department head and key vacancy positions including the maintenance assistant, dietary manager, housekeeping director, activities director, staffing development coordinator, and the nursing staff scheduler. It was also discovered the Minimum Data Set (MDS) Coordinator position was occupied by a temporary fill in corporate employee who traveled to stay near the facility during the week and returned home on weekends. During an interview conducted on 2/2/22 at 1:23 PM with the Administrator #3 he stated as the Assistant Regional Vice President he had reviewed the upcoming forecasted inclement weather with Administrator #2 on 1/14/22 while he was at the facility. He stated they had discussed preparations for inclement weather such as transportation, getting to work, being a leader and having the building staffed, and asked to have any issues communicated to him which were to arise and require further intervention. He further explained his expectations in the current role of being the administrator were to instill programs such as the sleep pay benefit which pays an hourly wage to employees who stay at the building and sleep rather than returning home, assure to provision people arrive to work on time for their shift, telephone numbers for key administrative and corporate staff are posted, provide transportation in the event of inclement weather, a supervisor key ring has been supplied which contains keys to reach areas of the facility such as the kitchen, as the administrator, be on-site when needed, and anything which the staff would need regarding service provision to the residents. He stated Administrator #2, who was in place from August, was suspended on 1/17/22 and he was acting as the current administrator. Administrator #3 was made aware of Immediate Jeopardy (IJ) on 1/21/22 at 12:31 PM. The facility shared the credible allegation of immediate jeopardy removal. Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance On 1/16/22 at 8:09 PM, after receiving a call from a resident, local law enforcement arrived at the facility for a wellness check. It was determined that there was 1 LPN and 2 Nursing Assistants on site and there were 97 residents which were in need of care and services. It was determined that the facility was non-compliant with Tag 835 based on the Administrator ' s failure to enact the emergency preparedness plan, ensure key supervisory personnel were in place, communicate with facility staff and did not communicate a problem to her supervisor, Assistant Regional Vice President (ARVP). The Administrator failed to communicate to facility staff, the need to be prepared to travel to the facility during or prior to the inclement weather resulting in a staffing shortage in every Department at the Facility. As set forth in the immediate jeopardy preliminary findings, all residents were likely to suffer a serious adverse outcome based on the non-compliance. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring On 1/16/22 at 9:20 PM the Administrator informed the Assistant Regional Vice President (ARVP) that the fire and police personnel were at the facility. On 1/16/22 at 9:52 PM, the ARVP updated the Divisional Vice President (DVP) and the DVP initiated a Quality Assurance and Performance Improvement (QAPI) conference call with corporate support staff verbalize assignments of duties upon arrival to the facility. The AVRP and Corporate staff put in place the Emergency Preparedness Plan to obtain additional staff and address the issues at the facility impacting residents. The DON arrived at the facility approximately 11:30 PM, and provided medications and direct care. At 11:45 PM, a call was held with the Administrator and Corporate support staff to implement Emergency Preparedness Plan. On 1/17/2022 at 1:23 AM, the ARVP arrived at the facility and assumed leadership of the facility. The corporate staff arriving were directed by the ARVP to work in their assigned areas to ensure care and services were delivered to all residents 8:02 AM, the Mobile Certified Dietary Manager arrived in the kitchen, and the dietary department provided breakfast as scheduled. At 10:47 AM, the Corporate Clinical Director arrived in the facility and provided direct care. At 10:50 AM, the Divisional Vice President arrived at the facility and assisted in securing staff, passing out meal trays. At 11:00 AM, Corporate Employee Experience personnel arrived at the facility, to assist with securing staff on the schedule. After securing staffing for 1/17/22, the facility implemented staffing meetings to review sufficient staffing for shifts going forward. At 11:10 AM, the Regional RN MDS Consultant arrived at the facility to provide direct resident care. At 11:30 AM, the supporting RN facility consultant arrived to assist with direct resident care. At 12:00 noon, the assigned RN facility consultant arrived to assist with direct resident care. At 1:00 PM, an additional RN consultant arrived to assist with direct resident care. At 1/17/22 at 2:30 PM sufficient facility staff were in the facility providing care for the residents. On 1/17/22, all residents were assessed by clinical staff for acute change of condition and no change in condition were noted. On 1/17/22, the social worker talked with 100% of alert and oriented residents to provide psycho-social support. On 1/17/22 at approximately 5:30 PM, the ARVP suspended the Administrator for failure to implement the Emergency Preparedness Plan. Acting as the Governing Body, the ARVP assigned himself as the Interim Administrator during the investigation. Interim Administrator is responsible for implementing credible allegation of compliance, ARVP is committed to ensuring the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain regulatory compliance, until such time the ARVP hires a qualified, licensed Administrator to assume this responsibility. Date of alleged Immediate Jeopardy removal: 1/18/22 The facility's credible allegation of compliance was validated through an on-site review process which included record review, observations, interviews with administrative staff, Administrator #2, and corporate staff. Date of IJ removal was validated as 1/18/22.

Based on North Carolina State of Emergency press releases, email review, text message review, record review, resident, emergency/disaster relief staff, Emergency Medical Services (EMS), police, corporate, and facility staff interviews, the Governing Body (GB) (Principle LTC (Long Term Care)) which manages Pine Ridge Health and Rehabilitation Center of Thomasville, failed to review, and prepare Administrator #2 regarding the facility emergency preparedness plan, how to enact the emergency preparedness plan, and how to manage a facility in the midst of a staffing crisis during inclement weather. Furthermore, the GB failed to instruct Administrator #2 to report urgent situations which may arise in the event of an emergency situations, or how to utilize and communicate with corporate support, such as reporting to her Assistant Regional Vice President (Administrator #3). The result of the failure impacted all residents during a governor declared state of emergency involving inclement weather. The failure of the GB to communicate to Administrator #2 the importance of the Emergency Preparedness Plan and reporting urgent situations resulted in a severe shortage of staff which resulted in one Licensed Practical Nurse (LPN) and two Nursing Assistants (NAs) to take care of 98 residents at the facility starting at 2:00 PM on 1/16/22. On 1/16/22 at 8:09 PM three police officers arrived at the facility for a wellness check to investigate a 911 call from a resident at the facility who had called and complained of not having seen staff members for a long period of time. When 911 dispatch attempted to call the facility, the calls went unanswered. The police officers who arrived then contacted the city fire department and county Emergency Medical Services (EMS). Due to the GB ' s failure to support and communicate with Administrator #2 about the Emergency Preparedness Plan and reporting urgent situations, the county Emergency Preparedness Director took over operations of the facility and utilized resources to obtain a combination of skilled individuals to provide care, assess, assist with an evening meal, and other services for the residents of the facility. Immediate Jeopardy began on 1/16/22 when the GB ' s failure to support and communicate to Administrator #2 about the Emergency Preparedness Plan and reporting urgent situations resulted in the administrator ' s failure to plan, prepare, and respond for inclement weather (snow/ice). The opportunity for the GB to prepare and to involve Administrator #2 began on 1/13/22, when the potential for inclement weather was announced by the Governor of the State of North Carolina through his enactment of a state of emergency for the entire state related to the predicted winter storm. Furthermore, the Assistant Regional Vice President (Administrator #3) was at the facility on 1/14/22 and had met with Administrator #2 but had not reviewed the Emergency Preparedness Plan. The immediate jeopardy was removed on 1/18/22 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of F (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. Every resident of the facility was placed at risk of severe harm. Findings included: Cross Refer to E0001: Based on North Carolina State of Emergency press releases, email review, text message review, record review, resident, emergency/disaster relief staff, Emergency Medical Services (EMS), police, and facility staff interviews, the facility failed to enact the facility emergency preparedness plan which impacted all residents during a governor declared state of emergency involving inclement weather. The result of the failure to prepare resulted in one Licensed Practical Nurse (LPN) and two Nursing Assistants (NAs) to take care of 98 residents at the facility starting at 2:00 PM on 1/16/22. On 1/17/22 at 11:06 AM an interview was conducted with the Divisional Vice President, and she stated the Assistant Regional Vice President (Administrator #3) arrived at the facility at 1:00 AM on 1/17/22. She explained she and several other Regional Support Personnel were either at the facility or on their way to the facility to assist facility operations, resident care, and staffing. An interview was conducted with Administrator #2 on 1/17/22 at 2:08 PM. She stated she had been the administrator at the facility since August 2021. Regarding communication with corporate, her supervisor, Assistant Regional Vice President (Administrator #3), she stated she had let him know there were call outs for first (7:00 AM to 3:00 PM) and second (3:00 PM- 11:00 PM) shifts. During the interview she did not state she had communicated to her Administrator #3 the situation with dietary staffing, that the dietary staff was leaving early, and the dietary staff had prepared bagged lunches to take the place of the scheduled menu meals. She explained she received a call from Nurse #7 about the presence of the police, Emergency Medical Service (EMS), the fire department, and the county emergency management services at the facility at some time between 9:00 and 10:00 PM on 1/16/22. She said it was after that she received a call from Administrator #3, Assistant Regional Vice President (Administrator #3) who informed her he had been notified by the Nursing Home Section Chief of the staffing crisis at the facility. During the interview she was unable to provide information as to how come she had not notified her Administrator #3 about the staffing crisis at the facility which was a result of the inclement weather. She said Administrator #3 was able to make it to the facility before she was able to make it to the facility. Review of the police provided phone records between Administrator #2 and Administrator #3 revealed there was a text on 1/16/22 at 9:53 AM from Administrator #3 stating, OK. Hang in there. You are all a good team. The next communication between the two of them was a phone call at 9:19 PM. A time span of 11 hours and 26 minutes. An interview was conducted on 1/18/22 at 2:30 PM with the Assistant Regional Vice President (Administrator #3). He stated he was the current administrator for the facility and Administrator #2 had been suspended as of 1/17/22. He explained he oversaw, in a regional manager capacity, the operations of three facilities in the central North Carolina area. He said he had not heard from Administrator #2 through the day until around 9:20 PM on 1/16/22 about the presence of the police, Emergency Medical Services (EMS), firefighters, county Emergency Management Services, however, Administrator #2 had not explained how come all of the people were in the building. He did not discuss the texts the text exchange he had with her in the morning. He said he received information from the Nursing Home Section Chief and the Director of Special Projects from his corporate office about concerns regarding staffing levels at the facility. He said he had talked with Administrator #2 after he was made aware of the situation, and he had suggested ways for her to get to the facility through the night, but she was unable to make it to the facility. He said he was able to get to the facility at 1:23 AM on 1/17/22 and Administrator #2 arrived at the facility at 8:20 AM. He said to his knowledge there was something in place at the facility to pick people up and bring them to the facility, but he didn ' t know how people would have been picked up. He said the facility did not have a facility identified vehicle for inclement weather. He said the Maintenance Director may have had a truck, but it would have been his personal vehicle, and he believed Administrator #2 had contacted the Maintenance Director. He said he had talked with Administrator #2 in the morning on 1/16/22, and she said they were dealing with the weather, had been making sure everything was covered, and there were no power outages. He further stated he had been at the facility on Friday and had discussions with Administrator #2 regarding preparations for inclement weather, such as making sure the generator was operational for backup power, sleep pay (a program where staff are paid when they sleep at the facility between shifts), transport for staff, Personal Protective Equipment (PPE), all of the information was reviewed verbally, and she verbally affirmed there was a plan in place, but had not reviewed the Emergency Preparedness Plan. He said prior to suspending Administrator #2 he informed her it was his expectation for her to have called him about the situation. He said he told her he could have assisted in utilizing resources to have avoided the crisis situation. He also stated it was not just the Administrator who could have called him, he explained the Director of Nursing, the nurse, could have reached out to him, or other corporate support personnel who could have provided assistance during the situation. A Video conference was conducted on 1/21/22 at 1:00 PM with the President of Principle LTC. During the conference the president stated it was an abject failure of Administrator #2 not to have notified her supervisor (Administrator #3) regarding the staffing situation. She further stated there was no reason Administrator #2 did not call someone from corporate. During a Video conference was conducted on 1/21/22 at 1:00 PM with the Assistant Regional Vice President (Administrator #3) he stated it was unknown when the last time Administrator #2 had reviewed the Emergency Preparedness Plan. During an interview conducted on 2/2/22 at 1:23 PM with the Administrator #3 he stated as the Assistant Regional Vice President he had reviewed the upcoming forecasted inclement weather with Administrator #2 on 1/14/22 while he was at the facility. He stated they had discussed preparations for inclement weather such as transportation, getting to work, being a leader and having the building staffed, and asked to have any issues communicated to him which were to arise and require further intervention. He further explained his expectations in the current role of being the administrator were to instill programs such as the sleep pay benefit which pays an hourly wage to employees who stay at the building and sleep rather than returning home, assure to provision people arrive to work on time for their shift, telephone numbers for key administrative and corporate staff are posted, provide transportation in the event of inclement weather, a supervisor key ring has been supplied which contains keys to reach areas of the facility such as the kitchen, as the administrator, be on-site when needed, and anything which the staff would need regarding service provision to the residents. Administrator #3 was made aware of Immediate Jeopardy (IJ) on 1/21/22 at 12:31 PM. The facility shared the following credible allegation of immediate jeopardy removal. Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance In August 2021, with oversight of the regional vice president, the previous administrator ensured the oncoming administrator received orientation and training on the facility ' s Emergency Preparedness Plan. The outgoing administrator was a seasoned mobile administrator with approximately [AGE] years nursing home administrator experience. The Mobile Administrator also reviewed, prepared, and updated the emergency preparedness plan for this facility on 5/4/2021. The outgoing administrator overlapped with new administrator during the transition period from 8/9/2021 until 8/18/2021. This mobile administrator has demonstrated history of understanding policies and procedures based on her years of experience. While the assistant regional vice president (ARVP) did not go through the hard copy of the Emergency Prepared Plan with the Administrator, on 1/14/22 the ARVP and the human resources consultant reviewed on-site, with the administrator, the procedures and processes to be put in place in the event of an emergency, including ensuring sufficient staffing and meeting resident ' s needs for medication, nutrition and other services in which the Administrator verbalized understanding of the necessary actions to be taken. The review occurred in advance of the 1/16/22 winter storm and in response to the Governor ' s declaration of a state of emergency. Despite this review, the administrator did not implement the Emergency Preparedness Plan, or the processes and procedures that had been discussed on 1/14/22. On 1/12/22, the corporate dietician sent out a communication to the Administrator at the facility reminding the facility to have a three-day emergency supply of food and water. On 1/13/22, an email communication was sent by the Vice President of Operations Support Services to the facility administrator instructing her to prepare for incoming inclement weather over the weekend. This communication included emergency contact numbers and instructions to the Administrator to use those numbers in case of emergency. On 1/14/22 another e-mail was sent to the facility administrator by the Chief Operating Officer notifying the administrator of inclement weather guidance for review with all staff in anticipation for the weekend of 1/15/22 - 1/16/22. On 1/16/22, the facility was non-compliant with Tag 837 due to the Governing Body ' s failure to ensure the building was prepared for inclement weather staffing and enact the emergency preparedness plan. As a result, State and County Emergency Management and Law Enforcement took over the building on 1/16/22, 3 PM - 11 PM shift. As set forth in the immediate jeopardy preliminary findings, all residents were likely to suffer a serious adverse outcome based on the non-compliance. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring On 1/16/22 at 9:52 PM, the ARVP, acting as part of the Governing Body, updated the Divisional Vice President (DVP). The DVP initiated a conference call with corporate support staff. The ARVP and Corporate staff put in place the Emergency Preparedness Plan to obtain additional staff and address sheltering the residents in place at the facility. The corporate staff utilized a Call Tree to call in corporate and facility staff and provide transportation to the facility. The corporate and facility staff provided direct care to meet the needs of the resident while sheltering in place during the inclement weather. On 1/17/2022 at 1:23 AM, the ARVP arrived at the facility and assumed charge of the facility. On 1/17/22 at approximately 5:30 PM, the ARVP suspended the Administrator for failure to implement the Emergency Preparedness Plan. The ARVP ' s experience and knowledge of the Emergency Preparedness plan implementation was that the facility administrator had been trained and emergency preparedness for the upcoming winter storm was in place. Acting as the Governing Body, the ARVP assigned himself as the Interim Administrator during the investigation. The DVP continues to provide oversight to interim Administrator to ensure responsible management and operation of the facility. The ARVP is involved and overseeing the operations by being on-site from approximately 1:23 AM 1/17/22 through 1/25/22. The DVP is on-site 1/17/22 through 1/25/22. The ARVP and DVP are making rounds, meeting with residents and family members, and continuing with the Emergency Preparedness Plan implementation, including monitoring weather forecasts, and staffing projection levels. Date of alleged removal of Immediate Jeopardy: 1/18/2022 The facility ' s credible allegation of compliance was validated through an on-site review process which included record review, observations, interviews with Administrator #3 (Assistant Regional Vice President) and the Corporate Clinical Director. Date of IJ removal was validated as 1/18/22.

Based on record review, first responder, resident, physician, family member, and staff interviews, the facility failed to provide an environment without severe risk of harm through not providing supervision of the residents in the locked dementia unit for several hours. This occurred during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. As reported by Police Officer #2 who went into the dementia unit after arriving to the facility at 8:10 PM on [DATE] she discovered no staff supervising the dementia unit, residents wandering throughout the unit, residents behind the nurses' station desk, and residents placing items in their mouths. This deficient practice impacted all residents of the locked dementia unit, 25 of 25 residents. This resulted in the residents on the dementia unit being at severe risk for harm. During interviews with the three police officers who arrived at the facility at 8:09 PM on [DATE] they stated there was no staff member within the locked dementia unit. The three staff who were in the building were in the main part of the facility and were unable to supervise the cognitively impaired residents. The police officers stated it was determined the three staff members were in need of immediate assistance to provide appropriate staffing to ensure the safety of the residents of the facility, including the residents of the dementia unit. In order to meet safety needs the residents, the police officers reached out to community resources, including Emergency Medical Services (EMS) and firefighters, to immediately assess all residents of the facility, provide supervision, and assist as need, all residents of the facility. Immediate Jeopardy began on [DATE] when the facility failed to have adequate nursing staff during a winter storm on [DATE] to provide supervision of the dementia care unit to minimize the risk of accidents or severe harm to the 25 residents who were residing in the dementia unit. Nurse #7, Nurse Assistant (NA) #1, and NA #2 were the only staff at the facility after 2:00 PM and were unable to provide a continuous presence on the dementia unit for resident supervision, which many had cognitive loss and required supervision for resident safety. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at scope and severity level H (actual harm that is not immediate jeopardy) for example #2 and to ensure systems put in place are effective. Based on record review and staff, Physician and Family Member interviews the facility failed to provide the recommended 1 on 1 supervision to prevent falls for 1 of 1 resident reviewed for accidents (Resident #8). The findings included: 1. Review of the SPARC Manual, which was dated [DATE], documented dementia unit, or Specialized Programming for Alzheimer ' s and Related Care (SPARC), is a unit which is designed and staff to provide care and services to people living with dementia (PLWD). On page A-10, the section was titled, Safety. The seventh bullet point of the page documented staff assignments had specific responsibilities to assure that residents can be supervised adequately. Further review revealed on page D-1, titled Environment, the first paragraph read in part, the purpose of the environment was to provide a safe and [MEDICATION(S)] space to promote well-being of PLWD, their care partners and families, and staff. Critical to this purpose is shared responsibility of all who work in the space. Additionally, it documented PLWD often have reduced safety awareness. There was a section (G) Behaviors which documented behaviors are understood as communication and approached as efforts to communicate and common unmet needs might include: Physical: hunger, thirst, need for elimination, fatigue, pain, sex; Sensory; too hot/too cold, too loud or noisy, too empty; Emotional: anger, frustration, sadness, enthusiastic; Social: lonely or crowdy; and Cognitive: overwhelmed, confused. During a phone interview conducted on [DATE] at 10:28 AM with NA #2 she stated she arrived at 7:00 AM on [DATE] and they were unable to find the schedule. She and NA #1 had no idea about who else was supposed to work. She explained she and the only other NA split the halls of the facility to provide care for the residents. She said most of the staff who were assigned to leave at 7:00 AM (the end of night shift) did not wait for someone to take their place and left because it was starting to snow. She said 2 nurses from night shift stayed in the morning to assist with morning care and help with breakfast. She explained the two nurses helped a lot with covering the dementia unit, which was a locked unit. She said after the 2 nurses left, it was just her and the other NA to provide care for 98 residents. She explained because there were only 3 staff for the whole facility after 2:00 PM, there was not enough staff for one person to stay in the dementia at all times. She further stated her, and the other NA provided as much care as they could to each resident. She said she went back to the dementia unit from time to time to check on the residents, but she could not stay on the dementia unit because she was covering 2 other halls. She explained there was another resident who was helping to pass the bagged sandwiches, but she did not allow him to go into the dementia unit to pass the bagged sandwiches to the residents. She said there was no one to help her with the residents on the halls she was working on, including the dementia residents, except for the nurse, and she was covering three halls by herself, including the dementia unit. She said it was after 3:00 PM when she realized the other NAs who were scheduled at 3:00 PM had not arrived, and most likely were not going to arrive, which made her and the nurse very mad and upset. She said the phones were often ringing, they did not have time to answer the phones, and the receptionist who would usually answer the phone at the front desk had also not come to work. She said there was no other staff at the facility at that time, no dietary staff, no receptionist, no housekeeping, and no laundry staff. She explained at one point she became very angry and upset and the nurse was concerned for her health and considered sending her to the hospital, but she said she eventually got moving again and just went back to work. She said it was unreal, she was so busy, and had never had an experience like that before. She said she had passed out some food for supper to the residents in the dementia unit, which she and the nurse was able to find in the kitchen, and then after that she saw the police officer in the facility, and then more help arrived with Emergency Medical Services and firefighters. She said she went home at midnight when an agency NA came into help, and she was exhausted. An interview was conducted on [DATE] at 1:55 PM with NA #1. He stated on [DATE] he and NA #2 were the only two NAs at the facility providing care for the residents, and there was only one nurse, after the night shift staff left after lunch time. After lunch he said the nurse and NA #2 made a plan that the 2 NAs would take the 300 hall, the 400 hall, and try to help with the dementia unit. He said there was no one assigned to stay back on the dementia unit and one of them would go back there from time to time. He explained from about 2:00 PM to when the police arrived, he had only gone back there a couple of times. He said NA #2 was going back there and checking on things, maybe every few hours. He further explained at one point when there were only the two of them as NAs in the building a resident had expired, and he and the other NA provided post-mortem care for the resident and during that time neither of them were able to assist other residents or check in the dementia unit. He said he, nor the other two staff members at the facility had time to answer the phone. He said he wasn ' t scared during the period when it was just the three of them, just kind of disappointed, he said it felt like no one was making an effort to get other staff into the facility to help the residents and help them care for the residents. He explained the worst part of it was the residents having to wait such a long time to receive assistance and care. A phone interview was conducted on [DATE] with Nurse #7 on [DATE] at 3:41 PM. She said she worked on [DATE] and started at 7:00 AM and worked until 7:00 AM [DATE]. She explained she had worked from 7:00 AM to 7:00 PM on [DATE] and it was a normal day. She explained she was aware of the potential for inclement weather, but there was no one from management who had discussed inclement weather with her, or preparations for inclement weather on [DATE]. She said the employees of the facility were joking about it and making statements such as pack your bags and be prepared to stay in case it snows on [DATE]. She said when she left her house on [DATE] it was just starting to snow. When she arrived at the facility, she explained she was unable to find the schedule, and she did not know who was supposed to work, or who was supposed to be there without the schedule, and without the schedule, she did not know how to make assignments or who would be assigned to what halls. She said she called DON #1 at around 7:30 AM to let her know she was the only nurse who had arrived for the day shift, she couldn ' t find the schedule, and the night nurse was going to only stay until 11:00 AM. She further explained there were only 2 Nursing Assistants (NAs) who had arrived to work day shift, and typically there would have been 2 medication aides, 3 nurses, and ,d+[DATE] NAs. She said she had talked to the DON and the Administrator #2 multiple times throughout the day, but on one occasion when she talked to her the DON had told her she had just gotten back into her driveway after trying to get to the facility, she didn ' t know anyone who had a truck who could come get her, and she would try to find some staff to come to the facility to help her. She said when she had talked to the former administrator, she told her she was sorry, and she was going to call DON #1. She added there was a medication aide (MA) (NA #3) who had come in at 7:00 AM and left at 2:00 PM and there were 2 NAs who had stayed over to help from night shift, but they had left before lunch time. She explained the NA shifts go from 7:00 AM to 3:00 PM, and no NAs arrived at the facility at 3:00 PM. She further explained the nurses work 12 hour shifts from 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM, and no nurses arrived at the facility at 7:00 PM. The nurse described the day as chaotic, residents were asking for their medications, she was trying to prioritize medications such as antibiotics and insulin to ensure residents received them timely, she and the other staff were unable to answer the facility phone, she was communicating with DON #1 and the former administrator via her personal cell phone which she was carrying with her, she was making periodic rounds on the dementia unit because there was not enough staff to have someone on that unit at all times, at about 4:30 PM one of the NAs was crying, asking if anyone else was going to come to help, and had a panic attack to the point where she felt like she was going to have to call 911 for the NA. The nurse further stated at one point during a conversation with the DON, the DON told her she had too much responsibility in the building and to go lay down for a while and she responded to the DON she was there to take care of the residents and that was her main priority. She said she did not know how long it had been, but at one point there were two police officers behind her, and they had informed her they had received 911 calls regarding the situation at the facility. She said through discussion with the police officers they had asked her who was in charge of the facility, and she responded she was, she was in the only nurse in the facility, there were two NAs, and they were providing care for all of the residents. She explained shortly after that the facility was swarming with police, EMS, and firemen. She said they sat her down and were asking questions, seemed concerned about her and well-being, and she felt relieved to know she was going to get some help for caring for the residents. She further stated at 11:00 PM when the night shift NAs were supposed to arrive, no NAs arrived at the facility and the 2 NAs who had been there since 7:00 AM remained at the facility with her. She explained she did not know who the interim administrator was. A phone interview was conducted on [DATE] at 12:49 PM with Police Officer #1. She stated she and 2 other police officers arrived at Pine Ridge Nursing Home at about 8:09 PM on [DATE]. The police officer stated she there were residents out and rolling around in the general facility area when they arrived inside of the building and there were several call lights on throughout the facility. She described when she went back to the dementia unit, there were no staff back there, the residents were observed to have been wandering throughout the unit, in and out of rooms, residents were behind the nurses ' station, and there were residents observed behind the nurses ' station putting items into their mouths. A phone interview was conducted on [DATE] at 3:09 PM with Police Officer #3. He stated he and 2 other police officers arrived at Pine Ridge Nursing Home at about 8:09 PM on [DATE]. The police officer stated there was a nurse and 2 NAs at the facility and none of them were in the dementia unit when he rounded through the building. He said as he was approaching the dementia unit, which is a locked unit, he could see an elderly woman through the window on the door banging on the door. He then said when he entered the dementia unit, he could see residents wandering throughout the dementia unit with no supervision. He described the residents as wandering behind the nurses ' station desk, some of the residents who were behind the nurses ' station desk were going through the drawers. He said he had also observed a resident pushing an empty intravenous (IV) pole around the nurses ' station and dementia unit; there was nothing hanging on it, just an empty IV pole. He described the observation of the dementia unit as shocking. During a round of the facility conducted on [DATE], which started at 11:07 AM, the dementia, or SPARC, unit was observed to have had two access points, one from the 100 hall and the other from the 200 hall. Both access points had magnetically locked double doors which could only be released by entering a code into a keypad located near the door. A code would have to be entered to either enter or exit the dementia unit. The observation of the unit revealed residents resting in bed, and residents up out of bed wandering about the unit. Several staff members were observed in the unit, some were assisting residents, and some staff members were located behind the desk at the nurses ' station. Attempts to interview residents were unsuccessful due to the cognitive loss of the residents. When questioned even with simple questions such as, how are you doing? Would illicit no response and the resident would look at you, but was unable to speak, or acknowledge an answer. During an interview conducted on [DATE] at 1:23 AM with Administrator #3 (who was the Assistant Regional Vice President prior to assuming the administrator role) he stated it was his expectation to follow the policy for the dementia unit and there should be staff in the dementia unit to supervise the residents, and care for their needs. Administrator #3 was made aware of the Immediate Jeopardy (IJ) on [DATE] at 1:23 PM. The facility shared the following plan to address the incident which alleged the facility had put into place measures to lower the scope and severity of the IJ as of [DATE]. Removal Plan F689-Accidents Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance At 8:09 PM, after a resident called 911, local law enforcement arrived at the facility for a wellness check. It was determined that there was 1 Licensed Practical Nurse (LPN) and 2 Nursing Assistants on site and there were 25 residents on the special care dementia unit. Additional assistance was immediately provided at the facility by a County Emergency Medical Services individuals, including two nurses, directed by the County Emergency Management Director. As set forth in the immediate jeopardy preliminary findings, twenty-five dementia unit residents, were likely to suffer a serious adverse outcome based on the non-compliance. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring On [DATE] at 9:20 PM the Administrator informed the Assistant Regional Vice President (ARVP) that the fire and police personnel were at the facility. Action steps taken were as follows: [DATE]: (1) 11:30 PM the Director of Nursing (DON) arrived at the facility to provide direct care and medications to residents in the special care dementia unit. (2) 11:45 PM, a call was held with the Administrator and Corporate support staff to implement Emergency Preparedness - inclement weather staffing plan. [DATE] At 12:35 AM, the corporate Registered Nurse (RN) facility consultants started contacting their local law enforcement to request transportation to the facility of staff for the special care dementia unit during the inclement weather. (1) The ARVP instructed corporate support staff to contact additional staffing agencies to request assisting the facility with staffing needs, for the special care dementia unit. The other staffing agency companies were able to provide assistance with the 7 AM-3PM shift on [DATE]. (2) At 7:00 AM, the nurse unit manager arrived at the facility to assist the DON and other staff nurses with resident care in the special care dementia unit. (3) At 10:47 AM, the Corporate Clinical Director arrived in the facility, to provide direct resident care, in the special care dementia unit. (4) 11:30 AM, the supporting RN facility consultant arrived to assist with direct resident care in the special care dementia unit. (5) 12:00 noon, the assigned RN facility consultant arrived to assist with direct resident care in the special care dementia unit. (6) 1:00 PM, an additional RN consultant arrived to assist with direct resident care in the special care dementia unit. (7) By 2:30 PM, the nursing facility staff and agency nursing staff were able to make it to the facility and many came prepared to spend the night, including those who made longer term commitments to stay in the facility until weather cleared up. They provided care in the special care dementia unit. (8) At approximately 5:30 PM, the Assistant Regional Vice President (ARVP) suspended the Administrator for failure to implement the Emergency Preparedness Plan, sleep pay benefit. The ARVP assigned himself as the Interim Administrator during the investigation. As of [DATE] at 2:30 PM sufficient staff were in the facility providing care for the residents in the special care dementia unit, including but not limited to incontinent care, medications as ordered, treatments as ordered, call lights answered timely, assessment of changes in condition, and supervision. On [DATE], the Interim Administrator and Human Resource Support Staff reviewed the staffing schedule for the upcoming 7 days to ensure sufficient number of staff to provide care for the residents in the special care dementia unit. Over the course of the next 7 days, the Interim Administrator, Divisional Vice President, and Human Resource Support Staff ensured there was enough of staff, on each shift, in each department, to provide care to residents in the special care dementia unit, in accordance with the resident care plans, plans were also made to address who would be spending the night if staff could not get into the facility and possible transportation options to get staff to the facility. After securing staffing for the special care dementia unit on [DATE], the facility implemented staffing meetings to review sufficient staffing for the special care dementia unit shifts going forward. Alleged Immediate jeopardy removal: [DATE] Date of alleged Immediate Jeopardy removal: [DATE] The facility ' s credible allegation of compliance was validated through an on-site review process which included record review, observations, staff, corporate, and resident interviews. Date of IJ removal was validated as [DATE]. 2. A review of the medical record revealed Resident #8 admitted to the facility on [DATE] and discharged to the hospital on [DATE] after she developed a limp and pain to her right hip and an x-ray obtained in the facility indicated she had a right hip fracture. She returned to the facility on [DATE] after surgical repair of a right hip fracture. Resident #8 had diagnoses of [CONDITION(S)] and dementia. Resident #8's Care Plan initiated [DATE] stated she was at risk for fractures due to [CONDITION(S)] and a Care plan initiated on [DATE] stated she was at risk for falls due to a history of falls and impaired cognition. On [DATE] an intervention to provide supervision as needed was added to Resident #8's Care Plan for Potential for Falls. Interventions of monitor for effectiveness and side effects of [CONDITION(S)] drugs; rehabilitation therapy referral; and observe and interview for factors causing falls was added to Resident #8's Care Plan for Potential for Falls on [DATE]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was severely cognitively impaired and had a history of falls. A Nurse's Progress Note written by Nurse #12 dated [DATE] at 8:03 am stated Resident #8 was found on the floor in the hallway. The Nurse's Progress Note further stated the Nurse was alerted by Resident #8's roommate yelling for help. Attempts were made to contact Nurse #12 without success and the Director of Nursing #1 stated Nurse #12 was out of the country. An intervention of observe and intervene for factors causing falls, ie., bowel and bladder needs and mobility was added to the Potential for Falls Care Plan on [DATE]. On [DATE] at 10:58 am Nurse #4's Nurse's Progress Note stated Resident #8 was noted on the floor in the hallway by staff. The note further stated Resident #8 slid to the floor from her wheelchair. Nurse #4's note stated Resident #8 was assessed and no injuries were noted. During a telephone interview on [DATE] at 4:01 pm with Nurse #4 she stated Resident #8 was found on the floor when she fell on [DATE]. Nurse #4 stated Resident #8 was supposed to be monitored one to one but there was not enough staff. Nurse #4 stated she assessed Resident #8 after the fall on [DATE] and she was not injured. A Nurse's Progress Note written by Nurse #1 and dated [DATE] at 6:12 pm indicated Resident #8 fell at the Nurses Station from a standing position. The note stated staff were not able to get to Resident #8 before she fell . During a telephone interview with Nurse #1 on [DATE] at 8:25 am she stated Resident #8 fell often and an intervention was put into place after she returned from the hospital on [DATE] for her to have a staff member with her one to one to prevent further falls but there was not enough staff to assign a staff member to her. Nurse #1 stated the staff would try to watch Resident #8 as close as they could. Nurse #1 stated on [DATE] when Resident #8 fell at the Nurse's Station she did not have a staff member assigned one to one with her, but the staff were trying to keep a close watch on her and do their assignment, which is why she was at the Nurse's Station when she fell . On [DATE] at 2:40 pm a phone interview was conducted with the Family Member. The Family Member stated Resident #8 had fallen multiple times in the facility and she had been assured a staff member would be always with Resident #8 to prevent her from falling after she returned from the hospital on [DATE]. An interview was conducted with Director of Nursing #1 on [DATE] at 8:16 am . Director of Nursing #1 stated she told the staff before and after Resident #8 was sent to the hospital with a fracture on [DATE] she required one on one monitoring. Director of Nursing #1 further stated the facility was having staffing issues they could not always assign someone to Resident #8. During an interview with the Physician on [DATE] at 11:08 am he stated Resident #8's history of dementia and [CONDITION(S)] made her high risk for an injury, and he felt the facility had done the best they could to prevent an injury.

Based on record review, police, resident, and staff interviews, the facility failed to treat residents in a dignified manner, when residents did not receive incontinence care for several hours during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. Two of five interviewed residents (Resident #7 and Resident #11) stated the lack of incontinent care for an extended period of time made them feel like they were defeated, not treated with dignity, neglected, dirty, mad, sad, helpless, and abandoned. Emergency personnel reported that residents were observed crying. This deficient practice negatively impacted residents in the facility. The findings included: 1. Resident #7 was admitted to the facility on [DATE] and the resident ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's most recent Minimum Data Set (MDS) revealed an admission comprehensive assessment with an Assessment Reference Date (ARD) of 11/4/21. The resident was coded as cognitively intact. The resident was coded as having had no hallucinations or delusions and the resident was coded as requiring extensive assistance of one to two people for bed mobility, transfer (such as transfer from the bed to the wheelchair), dressing, toileting, and personal hygiene. The resident was coded as always continent of both bowel and bladder. The care plan for Resident #7, most recently revised on 12/7/21, specified the resident had Focus areas which included: The resident needed assistance with ADLs/Personal care and the interventions included the resident having been continent of bowel and bladder. Further review revealed a focus area about the resident having the potential for urinary incontinence related to physical immobility and the interventions included encouraging the resident to call for assistance for toileting, praise and encourage attempts to comply with toileting. The resident also had a focus area for her being at risk for skin breakdown, or development of further pressure ulcers related to: Immobility. During an interview with Resident #7 on 1/17/22 at 12:19 PM the resident stated on 1/16/22 there was only one nurse and two nursing assistants for the entire facility. She said she had turned her call light on during the day on 1/16/22 because her brief needed to be changed and she needed incontinent care and it wasn ' t until 11:00 PM the call light was answered, and she received incontinent care. She further explained she did not receive incontinent care again until 3:00 AM. She then stated after 3:00 AM, it wasn ' t until 10:15 AM on 1/17/22 she had received incontinent care. She said she had put her call light on at 7:15 AM on 1/17/22 and it was not answered until 9:20 AM when breakfast was brought in, and she said the staff who delivered her breakfast were unable to provide incontinent care. She stated she had to eat breakfast while sitting in her incontinent brief and she felt uncomfortable about it. She said they had only received a bag of chips and a sandwich for supper at 9:45 PM on 1/16/22, so she wanted to eat breakfast and did not want to skip breakfast. She explained by 10:15 AM on 1/17/22 the urine had soaked through the brief and soaked through the incontinent pad she was on to the point her bed was wet. She described how she had to sit with her brief full of urine for many hours between 1/16/22 and 1/17/22 and how she felt defeated and was not being treated with dignity due to having to wait so long for receiving basic care. 2. Resident #11 was admitted to the facility on [DATE] and the resident ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's most recent Minimum Data Set (MDS) revealed an admission comprehensive assessment with an Assessment Reference Date (ARD) of 12/21/21. The resident was coded as cognitively intact. The resident was coded as having had no hallucinations or delusions and the resident was coded as requiring total or extensive assistance of one to two people for bed mobility, transfer (such as transfer from the bed to the wheelchair), dressing, toileting, and personal hygiene. The resident was coded as always continent of both bowel and bladder. The care plan for Resident #11, most recently revised on 12/14/21, specified the resident had Focus areas which included: The resident needed assistance with ADLs/Personal care and the interventions included the resident having occasional incontinence and requiring assistance with toileting. During an interview with Resident #11 on 1/17/22 at 12:57 PM the resident spoke about the events that occurred on 1/16/22 and asked if the facility had some type of disaster plan that should have been followed? She stated the facility was short of help, she felt neglected, and expressed no one seemed to care. She further stated there were only two Nursing Assistants (NAs) to cover the whole building from 7:00 AM until 11:00 PM. She said there was only one nurse to cover the whole building. She said NA # 2 had told her she hadn ' t even had an opportunity to go to the bathroom while she was working. She said the staff refused to help her out of bed on 1/16/22 and that had upset her because she likes to get out of bed because her leg hurts her, and it feels better to get out of bed and change position. She said when she was wet, she had to wait a very long time for someone to come and change her on 1/16/22 and into the morning of 1/17/22. She said the staff who were there did not even have the opportunity to offer her a bedpan so she would not have to be incontinent. On 1/16/22 she received incontinence care twice, for the whole day she stated. She further stated she had to lay in her own pee or poop for many hours and at the time of the interview her bottom felt uncomfortable. She explained while this was happening, she felt dirty, mad, sad, neglected, abandoned, and helpless. She stated she felt she was not being treated with dignity and respect because she was not able to receive routine incontinence care or be assisted with toileting. She said she received incontinence care at 10:00 PM on 1/16/22 and did not receive incontinence care again until 6:00 AM on 1/17/22. During a phone interview conducted on 1/19/22 at 10:28 AM with NA #2 she stated she arrived at 7:00 AM on 1/16/22 and they were unable to find the schedule. She and NA #1 had no idea about who else was supposed to work. She explained her and the only other NA split the halls of the facility to provide care for the residents. She said most of the staff who were assigned to leave at 7:00 AM (the end of night shift) did not wait for someone to take their place and left because it was starting to snow. She said 2 nurses from night shift stayed in the morning to assist with morning care and help with breakfast. She explained the two nurses helped a lot with covering the dementia unit, which was a locked unit. She said after the 2 nurses left, it was just her and the other NA to provide care for 98 residents. She further stated her, and the other NA provided as much care as they could to each resident. She said the residents who were alert and oriented were upset and they knew what was going on and she had a discussion with one resident who informed her she was going to call 911 regarding the situation at the facility, lack of care, and her current state. She said it was after 3:00 PM when she realized the other NAs who were scheduled at 3:00 PM had not arrived, and most likely were not going to arrive, which made her and the nurse very mad and upset. She said the phones were often ringing, they did not have time to answer the phones, and the receptionist who would usually answer the phone at the front desk had also not come to work. She said there was no other staff at the facility at that time, no dietary staff, no receptionist, no housekeeping, and no laundry staff. She explained at one point she became very angry and upset and the nurse was concerned for her health and considered sending her to the hospital, but she said she eventually got moving again and just went back to work. She said it was unreal, she was so busy, and had never had an experience like that before. She said she just kept working and at some point, she didn ' t even remember when, she saw the police officers in the building, then more police officers, then the fire department and Emergency Medical Services. An interview was conducted on 1/20/22 at 1:55 PM with NA #1. He stated on 1/16/22 he and NA #2 were the only two NAs at the facility providing care for the residents, and there was only one nurse. He said the residents felt there was not enough staff to provide help for the residents. He further stated the residents felt angry because due to the lack of staff they had to wait, but when he and the other NA were able get to them to provide care for them, they were grateful to them. He said he wasn ' t scared during the period when it was just the three of them, just kind of disappointed, he said it felt like no one was making an effort to get other staff into the facility to help the residents and help them care for the residents. He explained the worst part of it was the residents having to wait such a long time to receive assistance and care. A phone interview was conducted on 1/20/22 at 1:14 PM with Police Officer #2. He stated he and 2 other officers arrived at Pine Ridge Nursing Home at about 8:09 PM on 1/16/22. The police officer stated he reached out to community resources which included Emergency Medical Services (EMS) and the fire department to assist in assessing and providing care for the residents of the facility. He explained he and the other police officers remained at the facility and continued to provide support and assistance to the staff at the facility and the residents. The police officer explained several residents were observed to have been crying, stated they had not received food or their medications, and some had said they had not seen a nurse all day. The police officer also described the smell at the facility to be horrible of stool and urine. He said he had not spoken to the NAs who were at the facility because he had not seen them and was not even aware they were there until another police officer made him aware there were 2 NAs. During an interview conducted on 2/2/22 at 1:23 PM with Administrator #3 (who was the Assistant Regional Vice President prior to assuming the administrator role) he stated it was his expectation to preserve the dignity level of the residents through adequate care and staffing which will meet the needs of the residents.

Based on record review and staff interviews and physician interview the facility failed to notify the Physician of signs of infection after completion of an antibiotic for an infection to a surgical site; failed to start an antibiotic when it was ordered; and the facility failed to notify the Physician when a resident was first observed to have developed a limp and pain to her hip for 1 of 1 resident, Resident #8, reviewed for a change in condition. Findings included: 1. Resident #8 admitted to the facility on [DATE] and discharged on [DATE] after an x-ray revealed she had a fracture to her right hip. Resident #8 returned to the facility on [DATE] after having surgical repair of a right hip fracture. Resident #8's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's medical record revealed she had a significant change Minimum Data Set (MDS) assessment dated [DATE] that indicated she was severely cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] a. A Wound Flowsheet dated 12/8/2021 completed by the Wound Care Nurse/Assistant Director of Nursing on 12/8/2021 stated Resident #8 had a right hip incision measuring 11 centimeters by 0.2 centimeters and there was redness and bruising at the incision site. The Flowsheet further stated the current treatment was to monitor for signs of infection. Review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5 due to [CONDITION(S)] of the right hip. Resident #8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Progress Note dated 12/13/2021 written by the Orthopedic Surgeon indicated Resident #8 could begin weight bearing as tolerated to the right lower extremity, daily dressing change to incision, and follow up in one month or sooner if worsening drainage. The Physician's Progress Note written by the Orthopedic Surgeon dated 12/13/2021 did not indicate the condition of Resident #8's incision. A Wound Flowsheet dated 12/22/2021 written by the Assistant Director of Nursing/Wound Care Nurse stated Resident #8 had a right hip surgical incision with a small amount of drainage. A Wound Flowsheet dated 12/29/2021 written by the Assistant Director of Nursing/Wound Care Nurse indicated Resident #8 had a right hip surgical incision with no drainage. A Skin Check dated 1/1/2022 by Nurse #1 indicated Resident #8 had an incision to the right thigh but did not give a description of the incision. Review of the Emergency Department to Hospital Discharge Summary with an admitted d of 1/2/2022 and a discharge date of [DATE] indicated Resident #8 was seen in the Emergency Department for a fall and drainage was noted from her right hip incision. A Computed Tomography (CT) Scan revealed she had an abscess of the right hip incision and right hip joint. The Emergency Department to Hospital Discharge Summary further indicated on 1/3/2022 she was sent to the operating room for irrigation and drainage and hardware removal of the right hip due to the infection. The Assistant Director of Nursing (ADON) was interviewed on 1/25/2022 at 10:38 am and she stated she had been the Wound Care Nurse when Resident #8 returned from the hospital on 11/30/2021 but her position changed to ADON on 12/28/2021. The ADON stated when Resident #8 returned from the hospital on 11/30/2021 she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated when she assessed the incision on 12/29/2021 it did not appear to be infected. The ADON stated Resident #8 was picking at her right hip incision and the order was changed to a dry dressing. The ADON stated there was more drainage from Resident #8's right hip incision when she went back out to the hospital on 1/1/2022. An attempt was made to reinterview the ADON but she did not return my call. On 1/25/2022 at 3:54 pm an interview was conducted with Nurse #3, and she stated she was employed by agency staffing but worked at the facility regularly. She stated the wound dressing changes were completed by the Wound Care Nurse during the weekdays and by the Nurses on the weekend days. Nurse #3 stated she had observed Resident #8's wound after she finished the antibiotics ordered on 12/14/2021 and completed on 12/20/2021 and the incision had a large amount of bloody drainage that would come through the dressing if the dressing had remained on more than 24 hours. Nurse #3 stated Resident #8's right hip incision looked infected when she was taking the antibiotic and when the antibiotic was completed on 12/20/2021. Nurse #3 stated she did not notify the physician of the condition of Resident #8's wound. During an interview with Nurse #1 on 1/26/2022 at 9:32 am she stated she had not cared for Resident #8 until the end of December. Nurse #1 stated the Wound Care Nurse did the dressing changes through the week. She stated she did remember seeing the wound during the week before Resident #8 discharged back to the hospital and it was red and inflamed, there was a staple that had come loose, and there was a lot of drainage. Nurse #1 stated the wound looked infected and she had told the Wound Nurse she should look at the wound. Nurse #1 stated she did not notify the Physician of Resident #8's wound being red and the increased drainage. Resident #8's Physician was interviewed on 1/26/2022 at 11:08 am and stated he remembered Resident #8 had an infection to her right hip incision and he had ordered an antibiotic. The Physician stated he was aware Resident #8's incision was inflamed when the antibiotic was ordered on 12/9/2021 but he had not been notified the incision continued to be red and draining after the antibiotic was completed. The Physician stated the condition of Resident #8's wound should have been reported to either him or the Orthopedic Surgeon if it continued to be inflamed and showed signs of infection. During an interview with the Administrator #3 on 1/31/2022 at 11:00 am he stated he had not been the administrator during Resident #8's stay but nursing should have monitored Resident #8's right hip incision for any signs of infection and reported any signs of infection to the Physician. b. A Nurse's Progress Note dated 11/22/2021 at 3:08 pm written by Nurse #6 stated Resident #8 was walking with a limp and the Physician was notified. On 11/23/2021 at 1:36 pm a Nurse's Progress Note stated Nurse #6 spoke with the Physician regarding the change in Resident #8's gait and an order was received for an x-ray of both hips. Review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was conducted with Nurse #6 on 1/20/2022 at 3:35 pm. Nurse #6 stated she noticed Resident #8 was limping on 11/22/2021 and Resident #8 pointed to her hip when asked if she was hurting. Nurse #6 stated she had attempted to call the Physician on 11/22/2021 but was not able to reach him. Nurse #6 stated she had worked again on the following day, 11/23/2021, but was not assigned to Resident #8, but she spoke with the Nurse who had her that day, Nurse # 12, and asked her to get an x-ray ordered for Resident #8's hips. During the survey attempts were made to call Nurse #12 and the Previous Director of Nursing stated Nurse #12 was out of the country. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Previous Director of Nursing on 1/26/2022 at 8:16 am she stated she was not notified Resident #8 had a limp until the x-ray showing she had a right hip fracture was received on 11/24/2021. The Previous Director of Nursing stated she and Administrator #2 had investigated the hip fracture and had concluded Resident #8 must have fallen and did not tell anyone because of her dementia. The Previous Director of Nursing stated Nurse #6 should have reported Resident #8 developed a limp and had indicated pain to her hip on 11/22/2021. During an interview with the Physician on 1/26/2022 at 11:08 am he stated he had ordered the x-ray of both of Resident #8's hips when Nurse #12 reported Resident #8 was limping. The Physician stated he was not aware Nurse #6 was not able to reach him when she had noticed the limp on 11/22/2021. The Administrator #3 was interviewed on 1/31/2022 at 11:00 am and he stated the staff should have reported Resident #8 was limping immediately. He stated they should have reported the limp and hip pain to the Physician when it was discovered on 11/22/2021.

Based on record review and interviews with the Family Member, staff and Physician the facility failed to provide necessary care and services for a surgical incision; failed to start an antibiotic that was ordered for the right hip incision; and failed to identify signs and symptoms of infection to a right hip incision for 1 of 1 residents, Resident #8, reviewed for an infection. Resident #8 discharged to the hospital on 11/24/2021 with a fractured right hip and she returned to the facility on [DATE] with an incision after surgical repair of a right hip fracture. On 1/1/2022 Resident #8 was sent to the hospital Emergency Department for a fall and an infection was identified to her right hip incision. Findings included: A review of Resident #8's medical record revealed she originally admitted to the facility 11/3/2020 and readmitted after repair of a right hip incision on 11/30/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's Care Plan initiated on 9/21/2021 stated she was at risk for skin breakdown, but no interventions were found for the right hip surgical incision. A review of the Discharge Instruction when Resident #8 was discharged from the hospital with a right hip incision due to surgical repair of a right hip fracture indicated Resident #8 had a dressing to her right hip incision but there were no instructions regarding changing the dressing. The Discharge Instructions stated Resident #8's right hip dressing was a Xeroform (petroleum blend dressing) . A review of the manufacturer's directions for Xeroform dressing indicated the dressing should be changed according to the health provider instructions but is usually changed daily to keep the wound moist and prevent the dressing from sticking to the wound. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident #8's Medication Administration Records (MAR) and Treatment Administration Records (TAR) for 11/2021 no treatments were found for 11/30/2021 when Resident #8 returned from the hospital with surgical repair of her right hip fracture until an order was written for an antibiotic and dressing on 12/14/2021. Review of a Skin Check on 11/30/2021 by Nurse #11 indicated there were no skin integrity issues present and there was no mention of the right hip incision. A Minimum Data Set (MDS) significant change assessment dated [DATE] indicated Resident #8 was severely cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A Skin Check completed by the Wound Care Nurse/Assistant Director of Nursing on 12/7/2021 indicated there was no skin integrity issues present and the right hip incision was not indicated on the skin check. A Wound Flowsheet dated 12/8/2021 completed by the Wound Care Nurse/Assistant Director of Nursing on 12/8/2021 stated Resident #8 had a right hip incision measuring 11 centimeters by 0.2 centimeters and there was redness and bruising at the incision site. The Flowsheet further stated the current treatment was to monitor for signs of infection. Review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5 due to [CONDITION(S)] of the right hip On 1/26/2022 at 4:34 pm an interview was conducted with Nurse #5, and she stated she called the Physician on 12/9/2021 and obtained the order for an antibiotic, [MEDICATION(S)] 500 milligrams twice a day for 7 days, because Resident #8's right hip incision was red, swollen, and draining a pinkish, yellow drainage. Nurse #5 stated there was an area on the incision where a staple had torn loose, and the inside of the wound was protruding. Nurse #5 stated she had questioned the Wound Care Nurse/ADON about how long Resident #8's incision had been infected because the wound looked so bad. A Physician's Progress Note dated 12/13/2021 written by the Orthopedic Surgeon indicated Resident #8 could begin weight bearing as tolerated to the right lower extremity, daily dressing change to incision, and follow up in one month or sooner if worsening drainage. The Physician's Progress Note written by the Orthopedic Surgeon dated 12/13/2021 did not indicate the condition of Resident #8's incision. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Flowsheet dated 12/22/2021 written by the Assistant Director of Nursing/Wound Care Nurse stated Resident #8 had a right hip surgical incision with a small amount of drainage. A Wound Flowsheet dated 12/29/2021 written by the Assistant Director of Nursing/Wound Care Nurse indicated Resident #8 had a right hip surgical incision with no drainage. A Skin Check dated 1/1/2022 by Nurse #1 indicated Resident #8 had an incision to the right thigh but did not give a description of the incision. Review of the Emergency Department to Hospital Discharge Summary with an admitted d of 1/2/2022 indicated Resident #8 was seen in the Emergency Department for a fall and drainage was noted from her right hip incision. A Computed Tomography (CT) Scan revealed she had an abscess of the right hip incision and right hip joint. The Emergency Department to Hospital Discharge Summary further indicated on 1/3/2022 she was sent to the operating room for irrigation and drainage and hardware removal of the right hip due to the infection. An interview was conducted on 1/20/2022 at 2:40 pm with the Family Member who stated Resident #8 returned to the facility on [DATE] after having a surgical repair of a right hip fracture which occurred in the facility. The Family Member stated Resident #8 fell again on 1/1/2022 and was not able to move her leg and she requested the staff send Resident #8 to the hospital. The Family Member stated the emergency room Physician indicated Resident #8's right hip incision was infected, and the infection had spread to the hip joint, and she would require surgery to remove the right hip prosthesis. The Family Member stated she did not understand how Resident #8 had an infection to her right hip incision and the nurses did not know about it if they were changing the dressing daily. The Assistant Director of Nursing (ADON) was interviewed on 1/25/2022 at 10:38 am and she stated she had been the Wound Care Nurse when Resident #8 returned from the hospital on 11/30/2021 but her position changed to ADON on 12/28/2021. The ADON stated when Resident #8 returned from the hospital on 11/30/2021 she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated when she assessed the incision on 12/29 it did not appear to be infected. The ADON stated Resident #8 was picking at her right hip incision and the order was changed to a dry dressing. The ADON stated there was more drainage from Resident #8's right hip incision when she went back out to the hospital on 1/1/2022. An attempt was made to reinterview the ADON but she did not return my call. On 1/25/2022 at 3:54 pm an interview was conducted with Nurse #3, and she stated she was employed by agency staffing but worked at the facility regularly. She stated the wound dressing changes were completed by the Wound Care Nurse during the weekdays and by the Nurses on the weekend days. Nurse #3 stated she had observed Resident #8's wound after she finished the antibiotics ordered on 12/14/2021 and completed on 12/20/2021 and the incision had a large amount of bloody drainage that would come through the dressing if it had remained on more than 24 hours. Nurse #3 stated Resident #8's right hip incision looked infected when she was taking the antibiotic and when the antibiotic was completed on 12/20/2021. Nurse #3 stated she did not notify the physician of the condition of Resident #8's wound. An interview was conducted with Nurse #2 on 1/26/2022 at 9:05 am and she stated when Resident #8 returned to the facility after the hospitalization to repair her right hip fracture on 11/30/2021 she transcribed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #1 on 1/26/2022 at 9:32 am she stated she had not cared for Resident #8 until the end of December. Nurse #1 stated the Wound Care Nurse did the dressing changes through the week. She stated she did remember seeing the wound during the week before Resident #8 discharged back to the hospital and it was red and inflamed, there was a staple that had come loose, and there was a lot of drainage. Nurse #1 stated the wound looked infected and she had told the Wound Nurse she should look at the wound. Resident #8's Physician was interviewed on 1/26/2022 at 11:08 am and stated he remembered Resident #8 had an infection to her right hip incision and he had ordered the antibiotic. The Physician stated he was aware Resident #8's incision was inflamed when the antibiotic was ordered on 12/9/2021 but he had not been notified the incision continued to be red and draining after the antibiotic was completed. The Physician stated the condition of Resident #8's wound should have been reported to either him or the Orthopedic Surgeon if it continued to be inflamed and showed signs of infection. An attempt was made to reach Resident #8's Orthopedic Surgeon on 1/28/2022 at 12:08 pm and the Office Manager stated the Orthopedic Surgeon said the medical records from the hospital would speak to Resident #8's care and he would not be returning my call. During an interview with Administrator #3 on 1/31/2022 at 11:00 am he stated he had not been Administrator #3 during Resident #8's stay but nursing should have monitored Resident #8's right hip incision for any signs of infection and reported any signs of infection to the Physician.

Based on record review, resident, staff and physician interviews, the facility failed to treat a diabetic wound as ordered, resulting in the resident receiving antibiotic treatment, for one of one sampled resident (Resident #32) reviewed for wound care. Findings included: 1. Resident #32 was originally admitted to the facility on [DATE] and was most recently admitted on [DATE] after a hospitalization . The resident ' s cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32's physicians ' orders in his medical record revealed the following order dated 4/14/21 which read, right lateral foot-cleanse with wound cleanser, pat dry with a 4 inch by 4 inch gauze, apply a calcium alginate dressing 4 inch by 4 inch with silver to the wound bed, cover with 4 inch by 4 inch silicone border foam dressing, wrap with rolled gauze to hold in place, and change on Mondays, Wednesdays, Fridays, and as needed until healed. The care plan for Resident #32 had a focus area for at risk for skin breakdown related to diabetes. The focus area was most recently reviewed on 4/16/21. Further review of the care plan revealed a focus area with a created date of 6/6/21 for Actual Infection to the right foot diabetic ulcer. The interventions included an intervention to observer for signs/symptoms of infection to include increased temperature, loss of appetite, nausea, vomiting, diarrhea, myalgia (soreness of the muscles), headache, rash, cough, nasal congestion, change in mental status, increased confusion, etc. and notify physician for evaluation and/or intervention. Resident #32's most recent completed Minimum Data Set (MDS) assessment was a quarterly assessment and had an assessment reference date of 4/16/21. The resident was coded as having moderately impaired cognition and having a diabetic foot ulcer. Review of Resident #32's May Treatment Administration Records (TAR ' s) for the week of 5/24/21 through 5/28/21 revealed the following days with documentation of the prescribed wound care: An order undated treatment order which read, wound cleanser, cleanse right lateral foot, pat dry with a 4 inch by 4 inch gauze, apply a calcium alginate dressing 4 inch by 4 inch with silver to the wound bed, cover with 4 inch by 4 inch silicone border foam dressing, wrap with rolled gauze to hold in place, and change on Mondays, Wednesdays, Fridays, and as needed until healed. Monday, 5/24/21 and Wednesday 5/26/21 had a dash through them. Treatment was documented as provided on Thursday, 5/27/21, and Friday, 5/28/21. The other opportunities on Review of Resident #13's progress notes revealed a note dated Thursday, 5/27/21, and timed 11:40 AM revealed Nurse #4 documented when changing the resident ' s dressing to the right foot, noted that the site had purulent drainage (pus), skin intact, redness around the area was noted and a note was placed in the physician ' s book to evaluate. Further review of Resident #13's progress notes identified a note dated 5/27/21 and timed 2:20 PM indicating the resident ' s physician was aware and had ordered intramuscular one-time antibiotic medication with oral antibiotic medication for 10 days. There were then subsequent orders on the same day for a referral to the local wound clinic and an appointment was made at the local wound clinic on 6/23/21. Resident #13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a clarification physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's Wound Ulcer Flowsheet dated 6/2/21 and timed 1:43 PM documented the resident ' s wound as having been a diabetic wound to the right foot, and measured 0.4 centimeters (cm) long, 0.5 cm long, and less than 0.1 cm deep, a scant amount of serosanguinous (drainage with a mixed fluid of blood and serum (yellow)) drainage, 100% epithelialized (the wound being covered with a base layer of healing tissue), a scant (small) amount of maceration (moisture to the skin), and to continue with the current treatment. Resident #13 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's Wound Ulcer Flowsheet dated 6/9/21 and timed 1:54 PM documented the resident ' s wound as having been a diabetic wound to the right foot, and measured 0.5 cm long, 0.7 cm long, and less than 0.1 cm deep, 100% granulation (healing skin), a scant amount of maceration (moisture to the skin), and to continue with the current treatment. Review of Resident #32's June Treatment Administration Record (TAR) for the day of 6/14/21 revealed the following with documentation of the prescribed wound care: An order undated treatment order which read, wound cleanser, cleanse right lateral foot, pat dry with a 4 inch by 4 inch gauze, apply a calcium alginate dressing 4 inch by 4 inch with silver to the wound bed, cover with 4 inch by 4 inch silicone border foam dressing, wrap with rolled gauze to hold in place, and change on Mondays, Wednesdays, Fridays, and as needed until healed. The opportunity on Monday, 6/14/21 was blank. During an interview conducted on 6/14/21 at 12:34 PM with Resident #32 he stated the dressing on his foot was supposed to have been changed Monday, Wednesday, and Friday, but when the Wound/Treatment Nurse was on vacation back in May it didn ' t get changed when it was supposed to. Review of Resident #32's medical record revealed a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the resident ' s dressing for his right foot wound hadn ' t been changed since Friday, 6/11/21. The note further documented the resident denied fevers/chills, the wound was very macerated (presence of excessive moisture on the skin) with callus, and the dressing would be changed to a soft cast that is to be changed weekly at the wound clinic. An interview was conducted on 6/15/21 at 4:45 PM with the Wound/Treatment Nurse. She said the resident ' s wound was healing and was very small, but the resident was insistent upon going to the wound clinic. She said the resident had been to the wound clinic on the date of the interview and had returned with a dressing which was not to be removed by the facility, but by the wound clinic during the resident ' s next appointment, the following week. She said the resident ' s dressing would often become soiled because the resident was ambulatory, and he would also get his dressings wet somehow. A second interview and a record review were conducted with the Wound/Treatment Nurse on 6/16/21 at 4:25 PM. During the interview she stated she was on vacation from 5/22/21 to 5/29/21 and when she was off, or assigned to a hall, the nurses on the floor were responsible for conducting the treatments on their own for the residents on their hall. She reviewed the May 2021 TAR and stated the dashes for Resident #13 ' s wound treatment on 5/24/21 and 5/26/21 indicate the dressing was not changed or not documented as being changed. She said Nurse #4 had been on Resident #13 ' s hall while she was on vacation and would have been responsible to change the dressing. She further stated there was a medication aide on the cart on 5/24/21 but Nurse #4 would still be responsible to change the treatments on the hall, including the dressing change for Resident #32. Regarding Monday, 6/14/21, she had been assigned to pass medications on another hall and she could not pass the medications and do the treatments. She explained it would have been Nurse #5's responsibility to have completed the dressing change on Resident #32 on 6/14/21. She reviewed the June 2021 TAR for Resident #32 and stated the dressing change for 6/14/21 had not been initialed, which indicated the dressing change had not been completed. She explained all of the nurses on the halls were aware to do their own dressing changes on Monday, because she was on the hall passing medications. The Wound/Treatment Nurse stated the dressings should have been applied as ordered. A phone interview was conducted with Nurse #4 on 6/17/21 at 8:26 AM. During the interview the nurse stated she did not remember if she did or did not do the dressing for Resident #32 on 5/24/21 or 5/26/21. She said she was overseeing a medication aide on one of those days and it was very busy. She further stated she did change the dressing on 5/27/21, had informed the physician of the condition of the wound, and had obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with Nurse #5 conducted on 6/17/21 at 8:45 AM she stated she had not changed the dressing for Resident #32 on Monday, 6/14/21, because she believed there was a treatment nurse that day. A second interview and an observation were conducted with Resident #32 on 6/17/21 at 8:46 AM. The resident was observed to have a bandage wrapped around his right foot, which was covering his whole foot. The resident stated after the dressing on his foot was not changed on 5/24/21 and 5/26/21, it wasn ' t until 5/27/21 the dressing was changed, and the doctor did not look at it that day, but he was started on antibiotics. The resident further stated the dressing had not been changed since 6/11/21 until 6/15/21, and it was at the wound clinic where the dressing change was completed. He explained the dressing change, which was ordered Monday, Wednesday, and Friday, was missed on Monday 6/14/21. During an interview conducted on 6/17/21 at 9:47 AM with the resident's physician he stated he had ordered the dressings for Resident #32 prior to him going to the wound clinic. He stated it was his expectation for his dressing change orders to be followed and had confidence in the Wound/Treatment Nurse providing resident care and dressing changes as ordered. The physician further explained he did not believe there would be a negative outcome related to the dressing having not been changed because the wound was so small. An interview was conducted with the Director of Nursing on 6/17/21 at 12:43 PM. She stated in the event the Wound/Treatment Nurse could not do the treatment, the nurses on the floor are responsible for their treatments. She further stated the ordered dressings and treatments should be completed as ordered. The Administrator stated during an interview conducted on 6/17/21 at 1:20 PM treatments should be provided as ordered regardless of if there is Wound/Treatment Nurse or not.

Based on record review, staff interviews and observation, the facility neglected to document, report, assess and seek medical treatment for [REDACTED].# 11). Resident # 11 experienced a witnessed fall when she tried to sit down in her wheel chair in the small activity room. As a result of this fall Resident # 11 experienced pain and sustained a [MEDICAL CONDITION] diametaphysis (portion of a long bone) of the left ulna and radius (wrist) with tissue swelling and an acute nondisplaced [MEDICAL CONDITION] acetabular (break in the socket portion of the ball-and-socket hip joint). Findings included: Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 06/10/2020 recorded that Resident # 11 was at risk for falls with the goal that she would not have a serious fall related injury through the next review date. The care plan interventions included to maintain her bed in the lowest position, maintain a safe environment, keep the call light in reach and make certain non- skid socks or shoes were worn when she was out of bed and place a fall mat to the side of her bed that was not against the wall. A quarterly Minimum (MDS) data set [DATE] revealed that Resident # 11 had severe cognitive impairment and Resident # 11 usually understood and was able to usually be understood. She required limited assist of one staff for transfers and ambulation in her room. Resident # 11 had unsteady balance. Resident # 11 used a wheel chair for out of room mobility and she sustained one fall without injury since admission to the facility. Review of a written statement dated 10/07/2020 by a floor tech (technician) that worked on the 500 hall on the evening of 10/06/2020 revealed that at about 8:00 PM or 8:30 PM he noticed Resident # 11 walking alone in the small dining area and he thought she should not be walking alone and remembered that he always saw her in a wheel chair. The floor tech told Resident # 11 to sit back down in the wheel chair and that she started to walk backwards toward the chair and reached back to sit down and the chair rolled away, and she fell to the floor onto her buttocks. The floor tech revealed that he stayed with the resident and called for help then 2 or 3 NAs came in the room. The floor tech explained what he saw to the NAs and one of them called code green. A phone interview was conducted on 10/21/2020 at 10:24 AM. The floor tech verified that he worked on the 500 hall the evening of 10/06/2020 and that sometime between 8:00 PM and 8:30 PM he observed Resident # 11 in the small ding or activity room and that she was walking around and there was no staff or other residents present. The floor tech noted Resident # 11 to be unsteady and knew that he always saw her in her wheel chair and that a wheel chair was a few feet behind her. The floor tech then reported that he told Resident # 11 to sit back down so that she would not fall and that Resident # 11 started to walk backward toward the wheel chair and reached behind her to sit down and she ended up missing the wheel chair seat and landed on her buttock, The floor tech described that he did not observe Resident # 11 hitting her head or her arm on anything and that she began to cry that she was in pain. The floor tech went to her and called out to the nurse staff that a resident fell in the little dining room. The floor tech then revealed that the first NA that came to the room called out loudly code green to alert all staff on the unit that a resident had a fall. The floor tech stated that when another NA came into the room that Resident # 11 was not moved and then the nurse came into the room and the floor tech turned to exit the room and heard the nurse say that the NAs should pick Resident # 11 up and take her to bed. The floor tech reported that he did not observe if the nurse assessed Resident # 11 or not. A written statement by NA # 2 on 10/09/2020 revealed that she worked the evening of 10/06/2020 on the 500 hall and that about 8:30 PM or so the floor tech called out to nursing staff that a resident had fallen in the small dining room. NA #2 went to the dining area and saw Resident # 11 lying on her back on the floor and that another NA came in and 1 of them called a code green right away and they did not move Resident # 11. The nurse came to the room and the nurse instructed the NAs to put Resident # 11 to bed. On 10/21/2020 at 4:41 PM an interview was conducted with NA # 2. NA # 2 confirmed that she did work on the 500 hall on 10/06/2020 and that at some point a code green, for a fall was called by another NA and that Resident # 11 was observed lying on her back on the floor of the small dining area. Resident # 11 was heard mumbling, but it made no sense to NA # 2. NA #2 revealed that nurse # 1 came to the dining area after about 5 minutes and examined Resident #11 and told us to pick her up and put her to bed. NA # 2 revealed that a few minutes after that she observed the nurse entering Resident # 11's room and had no further information about any injury. NA # 2 revealed that she did not remember if Resident # 11 had any pain when she was placed into bed. NA # 3 was interviewed at 3:38 PM on 10/21/2020. NA # 3 revealed that she worked on the 500 hall second shift on 10/06/2020. NA # 3 explained that resident # 11 always tried to transfer and ambulate without assistance and needed assist to be safe. NA #3 reported that on 10/06/2020 the floor tech called her to the small dining room about 8:30 PM or so because Resident # 11 fell and as NA #3 went to the resident, she yelled a code green to alert all staff that a resident had a fall. NA #3 revealed that when she entered the room the floor tech was near Resident # 11 and that the resident was lying on her back on the floor and she was awake the floor tech told NA # 3 he did not see her hit her head, but Resident # 11 cried that she was in pain and when the nurse came into the room he told us it was our fault that she fell because we did not monitor her close enough. The nurse instructed the NAs to put her in her wheel chair and take her to her room and put her to bed. NA # 3 revealed that nurse #1 told them he would take care of it and that they should just get back to work. NA # 3 added that she did not know any other details. NA # 3 revealed that the nurse just looked at Resident # 11 and was certain that nurse # 1 did not touch Resident # 11 or take any vital signs. NA # 3 revealed that when the NAs lifted Resident # 11 from the floor and took her in her wheel chair to bed that she did not recall that resident # 11 voiced any complaint of pain. Review of nurse progress note dated 10/06/2020 at 9:35 PM written by nurse #1, revealed that Resident # 11 was alert to self and verbalized needs to staff. Resident # 11 was up in her wheel chair earlier that evening and wore non- skid foot wear to both feet. Resident # 11 propelled self in the wheel chair with no difficulty and was monitored by staff frequently. She had no signs and no complaints of pain. There was no documentation in Resident #11's medical record from 10/06/2020 at 7:00 PM to 10/07/2020 at 7:00 AM that indicated the resident had experienced a fall or incident. A phone interview conducted with Nurse # 1 on 10/21/2020 at 2:05 PM. Nurse #1 explained that he did work 7:00 PM on 10/06/2020 until 7:00 AM on 10/07/2020 and he was assigned to the 500 hall where Resident # 11 resided. Nurse #1 reported that Resident # 11 was able to ambulate but was weak and sometimes wandered and needed redirection. He recalled that 10/06/2020 was hectic but there had been no falls that he was aware of. Nurse #1 also added that Resident # 11 had not had any complaints of pain and that if a code green was called, he would have immediately gone to the area to assess the resident, he would have written a progress note, called the DON, called the MD as well as called the resident RP. Nurse # 1 also revealed that he would complete an incident report, gather staff statements and followed MD (physician) or NP orders. Nurse # 1 denied that he was aware of any fall or injury being observed or reported to him. Nurse #1 reported that he spoke to the DON and told the DON that Resident # 11 did not have a fall or any pain. Nurse # 1 reported that during the conversation with the DON he was informed that he was suspended while an investigation was conducted. Nurse # 1 revealed that he believed it was on 10/12/2020 or 10/13/2020 he met with the DON and administrator and was informed that after a thorough investigation it was determined that Resident # 11 did fall, and he was aware of it and did not follow post fall policy and procedures. Nurse # 1 stated that they terminated his employment. When asked Nurse #1 added that it was NA responsibility to supervise and check on Resident # 11 at least every 20 to 25 minutes and he could not confirm that that happened. An attempt was made to contact NA # 5 on 10/21/2020 at 10:46 AM because she had been scheduled to care for Resident # 11 from 11:00 PM on 10/06/2020 until 7:00 AM on 10/07/2020. The telephone number provided had been disconnected. A written statement by nurse assistant (NA) # 1 dated 10/07/2020 at 11:00 AM revealed that she pulled the bed linens off Resident # 11 to begin daily care and noticed her left wrist was bruised and looked swollen. NA #1 called the nurse # 3 into the room to see the wrist. On 10/20/2020 at 3:43 PM an interview was conducted with NA # 1. NA # 1 revealed that she had checked Resident # 11 earlier in the morning on 10/07/2020 and did not notice any injury or report any pain. The NA went back into Resident # 11's room at about 11:00 AM to give daily care but when she pulled back the bed covers, she noticed swelling and a bruise on the left wrist and hand of Resident # 11. NA # 1 called nurse # 3 to come into the room right away and when she showed the wrist to the nurse the nurse called the NP right away and started to examine Resident # 11. NA # 1 stated when she asked Resident # 11 what happened all Resident # 11 stated was that she fell . NA # 1 had taken care of Resident # 11 on day shift the previous day and her wrist did not look like that when she left at 3:00 PM. NA # 1 explained that if she witnessed a fall or skin tear or anything she reported it to the nurse right away and always called a code green loudly if there was a fall.NA # 1 stated that Resident # 11 was able to ambulate with one staff assist but often needed reminders to ask for assist. A facility incident report dated 10/07/2020 at 12:38 PM revealed that NA # 1 called nurse # 3 to the room of Resident # 11 at 11:00 AM. The nurse observed a discoloration and swelling of the left wrist and some left-hand fingers. Resident # 11 complained of pain when nurse #3 touched the left hip and there was a small bruise on the left hip. Nurse # 3 was told by Resident # 11 that she fell last night. A form titled Incident Checklist attached to the incident report revealed that on 10/07/2020 the following items were marked as completed or initiated: incident report, begin to gather witness statements, complete an investigational summary, begin QAPI (Quality Assurance Performance Improvement). Nurse # 3 wrote in a note dated 10/07/2020 at 12:54 PM that she called the nurse practitioner (NP) into the room to examine Resident # 11. The NP told the nurse to get x-rays as soon as possible of the left wrist and left hip, give Tylenol 650 mg (milligrams) po (orally) every 6 hours for pain, apply ice to the left wrist every 4 hours for 10 to 15 minutes as tolerated and apply an ace wrap to the left wrist to stabilize it. The note specified that nurse # 3 explained to the NP that she was not aware of Resident # 11 having a fall because it was not reported to her during shift change report from the 7:00 PM to 7:00 AM nurse that worked 10/06/2020 until 10/07/2020. The nurse notified the nurse supervisor, administrator and Director of Nurses (DON). The NP phoned the responsible party (RP) for Resident # 11 and explained the situation and pending treatment ordered for Resident # 11. The note specified the NP explained that she would call the RP back once the x- ray results were returned. Resident # 11 had a blood pressure of 168/88, pulse of 92, temperature of 98 degrees and an oxygen saturation of 99% on room air. Resident # 11 was to remain in bed and be log rolled to reposition until further orders received. Nurse # 3 was interviewed on 10/20/2020 at 3:00 PM and revealed that she had not been asked to write a statement for the DON because her documentation was in the medical record and on the incident report dated 10/07/2020. Nurse # 3 explained that all licensed staff nurses worked 12 hour shifts and that she worked from 7: 00 AM to 7:00 PM on 10/06/2020 and again on 10/07/2020. Nurse # 3 recalled that about 11:00 AM on 10/07/2020 she was called to the room of Resident # 11 by NA #1 and that she observed the left wrist and fingers swollen and that a discolored bruise was appearing on the left wrist. Nurse # 3 revealed that on a full body exam she observed some bruising to the left hip and Resident # 11 cried out in pain when those areas were touched or moved. Nurse # 3 called the NP to the room immediately; the NP was in the facility and the NP came and examined Resident # 11. When the NP asked Resident # 11 what happened she replied that she fell last night, but nurse # 3 revealed that she had not been given a report from the nurse that had worked on the 500 hall the previous night and early this morning. Nurse # 3 reported to the nurse manager, DON and administrator that the NP saw Resident # 11 and ordered x- rays, pain medication, ice and an ace wrap for Resident # 11 as she might have sustained a fall. Nurse # 3 revealed that she started to complete an incident report and other documentation as required for an actual or suspected fall or incident. Nurse # 3 stated at that point they were not clear what may have happened and nurse # 4 came to help her carry out the NP orders, a fall risk evaluation, skin check and pain assessment. Nurse # 3 added that when she gave Resident # 11 her morning pills that Resident # 11 did not complain of any pain or report that she had a fall the night before. A written statement by nurse # 2 dated 10/09/2020 revealed that when she came to work on 10/07/2020 about 6:00 AM she made facility rounds and spoke to the night shift nurses and asked if there were any falls or other incidents. Nurse # 2 reported that the night shift nurses did not report any falls or other incidents. Nurse #2 (unit manager) was interviewed on 10/21/202 at 3:52 PM and revealed that the morning of 10/07/2020 when she reported to work that she asked nurse #1 if there had been any falls or other incidents that night and nurse # 1 told her there were no falls or other concerns from 7:00 PM on 10/06/2020 through 7:00 AM on 10/07/2020. Nurse # 2 revealed that later that morning about 11:00 AM nurse # 3 called her to come to the 500 hall to examine Resident # 11 and that the NP was already in with the resident. Nurse # 2 confirmed with nurse # 3 that a fall or unknown injury packet (green folder) had been initiated by nurse # 3. Nurse # 2 revealed that when she went in to see Resident # 11 in her room that she was in bed and told nurse # 2 that she fell into the [MEDICATION NAME] tree last night. On 10/21/2020 at 11:35 AM an interview was conducted with the Assistant Director of Nurses (ADON) who stated that when she came to work the morning of 10/07/2020 she was informed by nurse #2 that Resident # 11 may have had a fall the previous night and that the nurse staff had initiated a green folder incident investigation as soon as Resident # 11 was discovered with pain to the left wrist and left hip. The nurse informed the ADON that the NP had already examined Resident # 11 and ordered x-rays and pain medication. Nurse #2 reported that none of the staff at work the morning of 10/07/2020 were aware of any fall or other incidents and that the DON was trying to contact all staff from the previous evening and night to obtain statements and that it was not until about 11:00 AM that the RP was notified. The ADON explained that any time there was a fall that a code green was called to alert all staff to respond and a green folder initiated to investigate any witnessed or unwitnessed falls or other incidents (skin tears or bruises) and that the DON, MD or NP and RP were to be notified immediately. The ADON revealed that the RP spoke to the NP and had decided not to send Resident # 11 to the emergency room but to only make her an orthopedic appointment. The ADON then spoke to NA #3 and the NA reported that in fact Resident # 11 had fallen around 8: 30 PM on 10/06/2020 that was witnessed by the floor tech. The ADON notified the DON. A phone interview was conducted with the NP on 10/22/2020 at 12:03 PM. The NP explained that on the morning of 10/07/2020 at about 11:00 AM the nurse assigned to the 500 hall called and asked if I would examine Resident # 11 for pain and swelling of the left wrist, hand and fingers as well as a potential bruise to the left hip and hip pain. The NP revealed that on initial observation of the left wrist it appeared broken and the left hip when touched caused pain. NP ordered x- rays to be taken as soon as possible and then called the RP and explained what was observed and immediate treatments ordered. The RP told the NP that Resident # 11 had a mimosa tree ages ago and that might be the reference to a tree. The RP understood that the facility would investigate for a fall and in response to further treatment the RP did not want Resident # 11 sent to the hospital for evaluation and it was agreed that pending x-ray results they would discuss further treatment. The NP revealed that after she received the x - ray reports she spoke again to the RP and it was decided that Resident # 11 would not be sent to the hospital and that an orthopedic appointment would be made, and the RP notified of appointment information. The RP explained to the NP that she would attend all appointments and believed a hospital evaluation might cause duplicate services and also increase anxiety for Resident #11.The NP explained that she tried to allow families to make many care decisions especially with residents that had dementia as the goal was to try to minimize overstimulation which could lead to increased confusion, panic or anxiety for the residents. The Medication Administration Record [REDACTED]. Resident # 11 was not on any scheduled or as needed pain medication prior to 12:00 PM on 10/07/2020. Review of an x- ray report dated 10/07/2020 at 3:15 PM revealed that Resident # 11 had an acute [MEDICAL CONDITION] distal diametaphysis of the radius and ulna with swelling of overlying soft tissue and there was also an acute nondisplaced left acetabular fracture and Resident # 11 had osteopenia and an orthopedic evaluation was recommended. An orthopedic consult note dated 10/09/2020 included in part that Resident # 11 had pain and bruising to the left wrist and left hip and she was to be touch down weight bearing of the left leg, non-weight bearing of the left wrist with a cast in place and that resident # 11 was to remain in bed for 2 to 4 more weeks, maintain pain control and return visit in 4 weeks. A written statement by the DON dated 10/07/2020 at 7:05 PM revealed that she spoke to nurse # 1 via telephone and asked if there were any incidents on 10/06/2020 related to Resident # 11 and nurse # 1 told the DON that there had not been any and when asked if Resident # 11 fell on [DATE] nurse # 1 replied she did not. The DON told nurse #1 to write and sign a statement saying such and to slide the statement under her office door. The DON was interviewed via telephone on 10/22/2020 at 12:43 PM. The DON stated that on 10/07/2020 she was notified at approximately 11:00 AM that the NP ordered x- rays of the left wrist and left hip of Resident # 11. The DON explained that the nurse supervisor and unit nurse had initiated an investigation and used the green folder which nurses use to begin to follow the investigative time line of any fall, skin tear, bruise or other resident incidents or accidents. The DON explained that the green folder included required follow up care and notifications to be made and that each item was to be checked off, dated and timed when the action was completed. The DON revealed that this was a way to track and insure that all required actions after any incident were completed and proper documentation recorded. The DON revealed that she reviewed the medical record for Resident # 11 and there was no documentation of a fall or other incident and that she began to call staff that had been working on the 500 hall on 10/06/2020 and 10/07/2020. The DON stated that she asked staff to meet with her as soon as possible to provide a written statement related to Resident # 11 and any possible injury they might be aware of. The DON also revealed that when she interviewed the floor tech, he described that Resident # 11 had a fall in the small dining room at about 8:00 PM on 10/06/2020 and that the NAs and nurse were aware and that was about all he knew. The DON described that she did contact Nurse #1 the evening of 10/07/2020 and asked him if resident # 11 fell on [DATE] and his response was that no resident had a fall. The DON asked Nurse #1 to leave a hand written statement under her office door that evening and then when she came to work in the morning of 10/08/2020 she could not find a written statement from nurse # 1 and she then called him and was informed that he was not going to write a statement because there had been no fall. The DON explained to Nurse # 1 that witnesses had revealed that Resident # 11 did fall on 10/06/2020 and that the investigation continued and until it was completed Nurse # 1 was suspended from his job. The DON explained that when interviewing staff, she developed a time line of events and determined based on witness statements, NP interview and x-ray and other medical record documentation it was determined that Resident # 11 fell and that the fall was known to Nurse # 1 but was not investigated or reported by that nurse as required. The DON and the administrator determined to terminate nurse #1 from employment effective 10/13/2020. The DON and administrator developed a QAPI and held an ad-hoc meeting on 10/13/2020 and began staff reeducation related to falls and other injuries and required notification and follow up. The DON also initiated audit tools to monitor all resident incidents and related documentation. The DON revealed that she expected all licensed nurses to report any significant changes or incidents/ accidents to the MD, RP, administrator and herself as soon as possible and to follow facility policies and procedures without exception and that failure to follow the correct guidelines would result in disciplinary actions. On 10/20/2020 at 10:04 AM an observation was made of Resident # 11. Resident # 11 was lying in bed and smiled and responded hello to surveyor. When asked if she was in pain or had a recent fall Resident # 11 responded no. Resident # 11 had her call light in reach and was covered up to her shoulders with bed linen and her left wrist or hip was not observed. There was a mat on the floor at the side of the bed that was not against the wall and the bed was in the lowest position. An observation of Resident # 11 on 10/21/2020 8:00 AM revealed Resident # 11 awake and in bed. Her left wrist and lower left arm were covered in a black hard cast. Resident # 11 was not able to remember why she had that thing on her arm but if anyone touched it her arm would hurt. The facility provided a plan of correction with a correction date of 10/13/2020. The plan of correction included: F 600. 1.On 10/07/2020 at approximately 11:00 AM the nurse assigned to the 500 hall contacted the NP and DON to report pain and possible [MEDICAL CONDITION] wrist and left hip. Resident # 11 had complained of pain to both areas and both areas showed [MEDICAL CONDITION] and discolored bruise like areas that were not present on 10/06/2020. The NP notified the RP of injuries identified on examination of Resident # 11. 2.All staff that worked the evening and night shift on the 500 hall on 10/06/2020 and 10/07/2020 were interviewed by the DON and signed a written statement. Nurse #1 refused to write a written statement and on 10/08/2020 he was suspended from employment until the investigation was completed. Nurse # 1 was terminated from employment and not eligible for rehire by the DON and administrator on 10/13/ . Nursing assessments were completed by the unit nurse and facility Unit manager nurse on 10/07/2020 these included a pain assessment, fall assessment and a skin assessment. Resident # 11 complained of pain when the left wrist and left hip were touched, and she remained in bed until an MD order was received for out of bed activities. Resident # 11 was administered pain medication as directed. All licensed nurse staff were reeducated on 10/13/2020 by the DON and SDC (staff development coordinator) for the procedure for notification of change and documentation of incidents by licensed nurses. Educational information also included was to notification to the RP, MD or NP and DON of any falls or other incidents; to fully document all resident incidents as well as any follow up and resident response to any ordered treatments and MD orders. Post fall or other incident the nurse must document the following: an incident report, a skin assessment, pain assessment and a detailed note outlining all notifications, orders received and any other follow up as directed. Nurses not following proper policies and procedures will result in disciplinary action up to and including termination. On 10/07/2020 nurse # 4 completed a form titled Incident/Accident Report review and acknowledged that all investigation requirements had been initiated or were in process as directed by the DON. Eleven members of the interdisciplinary team reviewed and signed that the review was in process. A form titled QAPI (Quality Assurance Performance Improvement) Adverse Event Plan completed by the DON included that resident name, date of admission, current [DIAGNOSES REDACTED]. The form indicated that notification of the event was reported to the MD or NP, DON, RP as soon as identified and that an incident report, witness statements, chart review, timeline of events and monitoring tools had been initiated on 10/07/2020. An ad-hoc QA/PI meeting was held on 10/13/2020 to discuss the investigation outcome for this fall incident. The meeting members discussed implementation of a Performance Improvement Plan for improper notification and documentation. Identification and root cause analysis were reviewed. The system failure was determined to be failure to provide appropriate notification and documentation of an incident that resulted in resident injury. Root cause analysis was that a licensed nurse did not report a fall to anyone and denied the fall occurred. The plan consisted of 5 bullet points that included the nurse is responsible to notify resident RP, MD and DON of all falls and other incidents. The nurse is responsible to document all resident incidents including follow up, resident response to treatment, MD orders. The SDC to provide licensed nurse education related to incident significant change reporting as well as required documentation (incident report, skin assessment, pain assessment and a detailed outline of notification procedures as well as treatment and follow up). Monitoring to be completed by the DON following all resident incidents daily Monday through Friday and weekends (as needed) prn to ensure that proper documentation was completed, all notifications completed to include notification of all appropriate individuals. Facility to monitor on ongoing basis to ensure adherence to this policy and nurse shift supervisors to review incident documentation at the end of each shift to ensure compliance. Resolution date at present 12/31/2020. This meeting was attended to by the DON, administrator and SDC. Audits to be reviewed in scheduled QAPI meetings with interdisciplinary team members. 3. Further investigation revealed that Nurse # 1 began employment at the facility on 01/01/2011. Nurse # 1 received education related to reporting incidents/injuries of unknown origin, notification of MD, DON and RP as soon as possible, incident report documentation on 03/12/2019. On 03/14/2019 Nurse #1 received in - service education related to change of resident condition and notification to MD, DON and RP. On 10/08/2019 Nurse #1 attended an in-service related to calling a code green when a resident fell and all staff available is to respond to the area. On 11/30/2019 Nurse # 1 was educated related to the use of a Green Folder when a resident fell , skin tears, a new wound or bruise. Each folder contains a check list of steps to be taken for each incident type and notification to MD, DON, administrator and RP with date and time of notification. Witness statements to be obtained, assessments to be completed and copies of all documentation to be maintained in the folder and given to the DON. 4. Audit forms dated from 10/13/2020 through 10/20/2020 were completed by the DON and reviewed with the administrator. Audits will be included in upcoming QAPI meetings to be reviewed to maintain compliance. Compliance achieved 10/13/2020. The corrective action plan and compliance date of 10/13/2020 was validated on 10/22/2020. Validation included interviews with 5 randomly chosen nurse staff on 10/21/2020 and 10/22/2020 which included validation of recent in-service education for reporting and documentation required for resident incidents and accidents. On 10/13/2020 the facility-initiated audits of resident incidents and accidents and completion of required documentation.

Based on observations, resident and staff interviews, interview with the pharmacist, interview with the nurse practitioner and record review the facility failed to notify the attending physician or nurse practitioner when [MEDICATION NAME] needed a prescription to refill. The facility failed to notify the attending physician or nurse practitioner when the resident continued to experience unrelieved pain for 2 days. This was evident in 1 of 3 residents reviewed for pain management. (Resident #118) Findings included Resident #118 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 was assessed as noted below: No long term or short-term memory loss. On a scheduled and PRN (when every necessary) pain management. Vocal complaints of pain. Indicators of pain or possible pain observed daily. Review of the pain assessment dated [DATE] and signed on 3/5/18 revealed resident's daily pain level was 7 (seven)and the pain site was front left shoulder and generalized pain. Described the pain as dull, worst at night, interferes with repositioning and transfers. Review of the care plan targeted date of 3/29/18 revealed in part a focus of potential for actual acute and chronic pain. The goal included the resident would voice a minimal level of pain daily through the next review date. The interventions included to notify the physician if pain management was not effective. Record review of the (MONTH) (YEAR) monthly physician orders included: [MEDICATION NAME] 325 mg po daily (QD) and [MEDICATION NAME] 325 mg (2 tablets) by mouth (po) every 4 hours prn for pain or temperature above 100 degrees Fahrenheit. A drug used for the management of mild to moderate pain and fever reducer. [MEDICATION NAME] 10 mg CR 1 tablet twice a day po. [MEDICATION NAME] is a controlled-release opioid [MEDICATION NAME]. [MEDICATION NAME] 10 mg every 6 hours PRN. [MEDICATION NAME] is a semisynthetic opioid used to treat moderate to severe pain. Interview on 4/10/18 at 2:50 PM with Resident #118 who stated that the facility ran out of her [MEDICATION NAME] for several days (unable to state the exact date) and they (referring to the nurse) gave me Tylenol ([MEDICATION NAME]) and it did not help. An inquiry was made about the level of pain the resident experienced when the [MEDICATION NAME] was not available and the Tylenol ([MEDICATION NAME]) was administered. Resident #118 stated the intensity of pain level on a scale of 0 (no pain) to 10 (worst pain imaginable) was an eight before and after the administration of Tylenol ([MEDICATION NAME]). I was still in pain. Continued interview with Resident #118 revealed I get the [MEDICATION NAME] for chronic pain in my left arm and legs and every time I ask them (referring to the staff nurses) they tell me the [MEDICATION NAME] has not come yet from the pharmacy. Resident #118 revealed [MEDICATION NAME] relieved my pain. Review of the Medication Administration Record [REDACTED]. The response to the [MEDICATION NAME] was coded as #3 which indicated slightly effective. The [MEDICATION NAME] was not available to be administered. Review of the progress notes revealed no indication that staff attempted to relieve the resident's pain when [MEDICATION NAME] was not effective. Nurse #5 (who administered the [MEDICATION NAME] at 12 AM, 6 AM on 4/9/18 and 4/10/18 at 12 PM) and documented the [MEDICATION NAME] was slightly effective was not available for interview. Review of the progress notes revealed no indication that the attending physician or nurse practitioner (NP) were notified about the need for the [MEDICATION NAME] refill until 4/9/18 or that the resident had experienced pain without relief. Interview on 4/10/18 at 2:55 PM with Nurse #1 revealed she was unaware of the lack of [MEDICATION NAME], physician or NP notification or the reordering because she just returned to work. Interview via the phone on 4/10/18 at 3:36 PM with the pharmacist from the contracted pharmacy was conducted. The pharmacist stated a new hard copy prescription was required for refills. However, the attending physician could have called the pharmacy for a 3-day supply pending obtaining the hard prescription. Observation on 4/10/18 at 5:30 PM revealed Resident #118 had facial grimacing and moaning suggestive of pain. An inquiry was made about the resident's comfort and pain. The resident stated she was in pain and Tylenol ([MEDICATION NAME]) had been given earlier but I still am in pain at an 8 out of 10 level. Review of the MAR indicated [REDACTED]. Interview on 4/12/18 at 9:15 AM with the Administrator and Director of Nurses was conducted. The Administrator indicated that she expected staff to notify the physician as soon as the narcotic was not available and the resident's pain was not relieved. Interview on 4/13/18 at 7::30 am with Nurse #3 revealed if a control substance was needed for pain relieve I would call the pharmacy to have them call the physician for a script (prescription), use the back-up pharmacy or call the physician for another method of pain relief. Interview on 4/13/18 at 9:18 AM with the NP who stated the facility uses a communication book for non-emergencies located at the nurses' station. The NP stated she was told about needing a hard prescription on 4/9/18 and was available at the facility 5 (five) days a week. Further interview with the NP who stated the facility should have notified me when the hard prescription was needed and the pain could not be managed.

Based on observations, resident and staff interviews, interview with the pharmacist, interview with the nurse practitioner and record review the facility failed to provide pain relief to Resident #118 for 2 (two) days. This was evident in 1 of 3 residents reviewed for pain management. Findings included: Resident #118 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 was assessed as noted below: No long term or short-term memory loss. Modified independence with decision making in new situations. No issues with mood or behaviors. Extensive Activities of Daily Living except for eating. On a scheduled and PRN (when every necessary) pain management. No non-medication intervention. Vocal complaints of pain. Indicators of pain or possible pain observed daily. Review of the pain assessment dated [DATE] and signed on 3/5/18 revealed resident's daily pain level was 7 (seven)and the pain site was front left shoulder and generalized pain. Described the pain as dull, worst at night, interferes with repositioning and transfers. The assessment indicated that repositioning, positioning devices and medication makes the pain better. Continued review of the pain assessment revealed resident had prn medication order and was effective in relieving pain. Review of the care plan targeted date of 3/29/18 revealed in part a focus of potential for actual acute and chronic pain. The goal included the resident would voice a minimal level of pain daily through the next review date. The interventions included acknowledgement of the presence of pain and discomfort, administer pain medication as ordered and note effectiveness and document/report complaints and non-verbal signs of pain. Record review of the (MONTH) (YEAR) monthly physician orders [REDACTED].>[MEDICATION NAME] 325 milligrams (mg) po daily (QD) and [MEDICATION NAME] 325 mg (2 tablets) po every 4 hours prn for pain or temperature above 100 degrees Fahrenheit. A drug used for the management of mild to moderate pain and fever reducer. [MEDICATION NAME] 2.5 mg po QD. Drug used for the treatment of [REDACTED]. [MEDICATION NAME] 0.5 mg po every morning po and 0.25 mg every evening po. Drug used to treat anxiety. [MEDICATION NAME] 10 mg CR 1 tablet twice a day po. [MEDICATION NAME] is a controlled-release opioid [MEDICATION NAME]. [MEDICATION NAME] 10 mg every 6 hours PRN. [MEDICATION NAME] is a semisynthetic opioid used to treat moderate to severe pain. Interview on 4/10/18 at 2:50 PM with Resident #118 who stated that the facility ran out of her [MEDICATION NAME] for several days and they (referring to the nurse) gave me Tylenol ([MEDICATION NAME] and it did not help. An inquiry was made about the level of pain the resident experienced when the [MEDICATION NAME] was not available and the Tylenol ([MEDICATION NAME]) was administered. Resident #118 stated the intensity of pain level on a scale of 0 (no pain) to 10 (worst pain imaginable) was an eight before and after the administration of Tylenol ([MEDICATION NAME]). I was still in pain. Continued interview with Resident #118 revealed I get the [MEDICATION NAME] for chronic pain in my left arm and legs and every time I ask them (referring to the staff) they tell me the [MEDICATION NAME] has not come yet from the pharmacy. Resident #118 stated [MEDICATION NAME] relieved my pain. Review of the Medication Administration Record [REDACTED]. On the front of the MAR for 4/8/18 were the initials of Nurse #5-who documented twice without a time-that [MEDICATION NAME] 10 mg had been administered. The block under Nurse #5 initials was a superimposed marking with an x-mark. Review of the progress notes did not have documentation of the administration times associated with Nurse #5. Continued review of the MAR indicated [REDACTED]. The response to the [MEDICATION NAME] was coded as #3 which indicated slightly effective. Review of the progress notes revealed no indication that staff attempted to relieve the resident's pain when [MEDICATION NAME] was not effective. Nurse #5 (who administered the [MEDICATION NAME] at 12 AM, 6 AM on 4/9/18 and 4/10/18 at 12 PM) was not available for interview. Interview on 4/10/18 at 2:55 PM with Nurse #1 revealed she was unaware of the lack of [MEDICATION NAME] or the reordering because she just returned to work. Observation of the narcotic box on 4/10/18 at 3:05 PM revealed no [MEDICATION NAME] 10 mg po for Resident #118. Interview via the phone on 4/10/18 at 3:36 PM with the pharmacist from the contracted pharmacy was conducted. An inquiry was made regarding the process for reordering control substances. The pharmacist stated a new hard copy prescription was required. Continued interview the pharmacist stated the facility can reorder 3 days before the drug was to run out and a sticker was placed on the medication card to alert staff that the [MEDICATION NAME] was getting low and needed to be reordered. The pharmacist indicated the hard copy prescription dated 4/9/18 was received on 4/9/18 at the pharmacy. Further interview with the pharmacist who stated that the [MEDICATION NAME] was processed and filled on 4/10/18 and would leave the pharmacy around 6:30 PM-7:30 PM and be delivered on 4/10/18 to the facility (unsure of the exact time of delivery to the facility). Additionally, the pharmacist indicated that the attending physician could have called the pharmacy for a 3-day supply pending obtaining the hard prescription. Interview on 4/10/18 at 5:20 PM with Medication Assistant #3 stated she was unaware of [MEDICATION NAME] not being available. Observation on 4/10/18 at 5:30 PM revealed Resident #118 had facial grimacing and moaning suggestive of pain. An inquiry was made about the resident's comfort and pain. The resident stated she was in pain and Tylenol ([MEDICATION NAME]) had been given earlier but I still am in pain at an 8 out of 10 level. Review of the MAR indicated [REDACTED]. On 4/10/18 at 5:40 PM the administrator was made aware of the resident's expressions of pain. Record review of the MAR indicated [REDACTED]. The response and effectiveness of the [MEDICATION NAME] was coded as 1 (one) which represented effective. Observation and interview on 4/11/18 at 3:08 PM with Resident #118 revealed resident was lying in bed awake. Resident #118 stated the facility got her medication and received her [MEDICATION NAME] for pain and felt better. Interview on 4/12/18 at 9:15 AM with the Administrator and Director of Nurses was conducted. The Administrator indicated that she expected staff to re order medications in a timely manner to manage the resident's pain. Interview on 4/13/18 at 7:3:30 am with Nurse #3 revealed if a control substance was needed for pain relief I would call the pharmacy to have them call the physician for a script, use the back-up pharmacy or call the physician for another method of pain relief. Interview on 4/13/18 at 9:18 AM with the Nurse Practitioner (NP) who stated a communication book for non-emergencies was located at the nurses' station. The NP stated she was told about needing a hard script on 4/9/18. Further interview with the NP revealed she was available at the facility 5 (five) days a week.

Based on record reviewed and staff interviews, the facility failed to prevent neglect as evidenced by dressing changes not being completed as ordered for 1 of 3 resident reviewed for wound care (resident #1). Findings included: Resident #1 was admitted the facility on 10/12/17 with the [DIAGNOSES REDACTED]. The resident had a care plan in place for combativeness due to dementia (updated 12/27/17), pressure ulcers dated (updated 12/27/17), state of nutrition is less then body requirements (updated 12/28/17). A physician's wound note from the wound care doctor dated 2/2/18 revealed the resident had a wound to the left foot (the note did not say specifically where), which measured 3 centimeter (cm) x 2 cm x 0.5 cm and this was the initial evaluation. The duration of the wound was 8 days and it had 80% necrotic tissue and 20% granulation tissue present. The wound underwent surgical debridement. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for the left ankle revealed to pack with sterile gauze with [MEDICATION NAME] and wrap with Kerlix everyday starting on 2/2/18. The TAR revealed that it was completed on 2/2/17. The TAR was blank for the following dates of 2/3/18, 2/4/18 and 2/5/18. There was no nursing or progress noted for 2/3/18 through 2/5/18 that indicated wound care was completed for this resident. Nurse #1 (Worked 1st shift with the resident on 2/2/18 and supervisor of facility on 2/3/18, 2/4/18 and 2/5/18 for 1st shift) was interviewed on 2/28/18 at 2:02 PM. She stated that the resident was not alert and oriented and was very confused. The resident had an amputation to one of her legs and a wound to her other leg. The wound physician was seeing the wound. She stated that she didn't know of any new recent wounds that the resident had. The resident had behaviors all the time. She stated that nurses and medication aides on the hall were supposed to do the dressing changes but medication aides could do dressing changes to stage 1 and 2 wounds. Medication Aide #1 was interviewed on 2/28/18 at 2:11 PM. She stated the resident would swat at you. She stated that the resident had a wound on her knee of the amputated leg and a splint in place and would pick at the dressing sometimes. The resident also had another wound on her other foot. She stated that she went one time to help the wound care nurse with dressing change and the resident never refused care. After the wound care nurse stopped working at the facility, the nurses would have to change the dressings for residents. She stated that she never changed the dressing to the resident feet, legs or knees but just went in and assisted the wound care nurse one time. She stated that the Nursing Assistants (NA) would tell the supervising nurse if a bandage needed to be changed after they gave a resident a bath or in between giving medication. She stated if the wound was a stage 1 or 2, it would be documented in the treatment book. Nurse #8 (The supervisor on 2/3/17 and 2/4/17 on second shift) was interviewed on 2/28/18 at 2:42 PM. He stated he did not think he directly took care of the resident in February, (YEAR). The resident needed extensive assistance with care. He thought the resident had a wound on her knee and sacrum. He did not remember any wounds to her feet or ankles or about any dressing changes. The Administrator was interviewed on 2/28/18 at 3:19 PM. The wound doctor was doing the wound assessments every week. The nurses should also be doing the wound assessments. The wound care nurse stopped working at the facility about a month ago. Nurse #7 (rounds with wound care doctor weekly and SDC nurse) was interviewed on 2/28/18 at 3:59 PM. She stated that her job included rounding with the wound care doctor on Fridays. She stated this resident had a wound on her ankle. When she first saw the wound, it was a stage 3 or so. She stated that had called the resident's family on 1/26/18 to get permission to do debridement of the wound. The resident's ankle was wrapped in Kerlix so she thinks the resident was getting dressing changes. On 2/2/17, the resident's family was at the bedside and the family wanted to see the wound. The family agreed to have it debrided. They dressed the wound on 2/2/18 and the family was at the bedside. She stated the ankle wound was white with blackish tissue around it and the black area was preventing it from healing. She thinks that the dressing changes were usually completed on the first shift for this resident. The resident was getting anacept to the ankle wound. Nurse #5 (worked with resident on 2/3/17 and 2/4/17 on 2nd shift) was interviewed on 2/28/18 at 4:19 PM. The resident was very confused but followed simple commands. The resident had wounds and she would do wound care for residents if there was no treatment nurse. The resident had wounds on her toes, knee and sacral area and vulva. She stated she never knew of a wound on the resident's ankle and had never completed a dressing change to her ankle. She stated that her dressing changes could be done at any time during the day. They have a treatment book and that was where they documented wound care. She stated that the Medication aides could only do wound care dressing changes that were simple. She stated 1st shift doesn't do dressing changes often and 2nd shift would try to do them. She stated that they don't have a wound care nurse anymore and they really need one as she was trying to just keep up. Medication Aide # 9 (worked 2nd shift on 2/2/18 and 2/3/18) was interviewed on 2/28/18 at 4:37 PM. She stated that she help the wound care doctor change a dressing a while ago but had never done dressing changes this month for this resident. She stated that the supervising nurse would do the wound care on 1st shift most of the time. The resident was getting dressing change completed in the morning unless something happens. She never knew of a wound to the resident's ankle. Nurse #6 (worked on 2/3/18 and 2/4/18 on third shift and was the supervisor for the facility those days) was interviewed on 3/1/18 at 9:14 AM. She stated that the resident was asleep most of the time and was anxious at times. The resident could be restless at times. The resident had a wound to her inguinal area, left knee and sacral area. The resident was combative sometimes during care. The resident had many contractions and they tried to clean her as much as possible. She stated that she does not remember about a wound to the resident's foot/ankle area and had never completed/attempted a dressing change to a wound on her foot/leg. She only had completed a dressing to the resident's knee occasionally when the resident wound pull off the dressing. Since the treatment nurse left, the even numbered rooms, the 1st shift nurse would complete the dressing changes and the odd numbered rooms, 2nd shift would complete the dressing changes for. She does not recall anything about a wounds on the resident's ankle. She stated she could not even remember if the resident had a dressing on her foot or not before she was discharge. She stated she usually worked 300 and 400 halls and would have to cover when the Nursing Assistant called out. She stated they tried their best to do things for this resident but they have to prioritize their work and she wouldn't necessary wake up this resident to change a dressings and typically another shift should do it. Wound care usually does not fall on her shift so she cannot say if the wound care was being done for residents but if she was told that it was not done then she would typically do it. Nurse #2 (supervising nurse on 2/2/18 on second shift for this resident) was interviewed on 3/1/18 at 9:27 AM. She stated that usually she would work 200 hall and would supervise the 400 hall if there was a medication aide working. She stated that if they dressing changes to do, that 1st shift wound do the even numbered rooms and 2nd shift would do the odd numbered rooms for that hall. For major wounds, the nurses had to do the dressing changes. The medication aides were allowed to do skin preps and creams but not major dressing's changes. The medication aides and nurses are responsible for dressing changes now. She stated that she would typically go through the TAR and do the major dressing changes that needed to be completed for residents. She stated that she had never done dressing changes on this resident and doesn't remember the resident's wounds in particular but does remember the resident. She stated the resident's wound care should have been completed on 1st shift because she was in an even numbered room. Nurse #4 (worked 1st shift on 2/3/18 and on 2/4/18) was interviewed on 3/1/18 at 9:51 AM. He stated the resident was only oriented to person. The resident had behaviors and had intermittent combativeness. However, he never personally witnessed the resident being combative. He knows the resident had a wound on her left knee and coccyx area. He stated he does not recall any wounds to her other leg (non-amputated leg). He stated that he has only completed the dressing changed to the resident's knee and the resident would let him do the dressing change. If a dressing change is completed, it is documented on the TAR or in the nursing notes. Since there was no treatment nurse, the dressing change are not done as regularly. Nurse #3 (worked on 2/2/18 on 3rd shift) was interviewed on 3/1/18 at 10:04 AM. She stated that she worked night shift from 11:00 PM to 7:00 AM. She stated she had never cared for any of the resident's wounds and did not know about them specifically because she had never changed the dressings. The resident would be resistive with care but she usually could provide her with care. At night, if there was a new wound then she wound do the wound care if needed. A nursing note dated 2/5/18 revealed that at 1:30 PM, the resident's family and relative stated there was something wrong with the resident. Vitals were taken and revealed the following: Temperature was 99.7, heart rate was 114 and irregular, respirations were 20 and blood pressure was 110/70. The writer was unable to hear breath sounds and the physician was notified. The resident's family insisted that the resident needed to go to the hospital and Emergency Medical Services (EMS) were called and the resident was transported at 1:45 PM to the hospital. The resident was admitted to the hospital on [DATE]. Hospital records dated 2/5/18 revealed that the resident was admitted to the hospital. Hospital records revealed the resident presented to the hospital with a wound to her left ankle that measured 7 cm x 3 cm and had exposed underlying tendon, black eschar and smelled infected per the Emergency department note. Hospital records also revealed that the resident was diagnosed with [REDACTED]. Antibiotics were started and it was recommended that the resident had an above the knee amputation. However, the risks were spoken with to the family and the resident was placed on hospice care instead and transferred to a skilled nursing facility. Resident's #1 discharge Minimum (MDS) data set [DATE] revealed that the resident was severely cognitively impaired for daily decision making and had short term memory problems. The resident had behaviors of rejection of care 1 to 3 days per week and physical behavioral symptoms that occurred 1 to 3 days. The resident required extensive assistance with bed mobility, locomotion and eating. The resident required total assistance with personal hygiene, toilet use, dressing and transfers. The resident was always incontinent of bowel and of bladder. The resident had a stage 3 pressure ulcer and 1 stage 4 pressure ulcer. The pressure ulcer measured 2.8 cm x 2.1 cm x 00.2 cm. The Wound Care Doctor was interviewed on 3/1/18 at 10:38 AM. The resident had a wound to her foot near the ankle that had occurred at the facility (when asked specifically about where the new left foot wound was in his note). He thought that nursing discovered the wound but wasn't sure. The wound started as a scab and at some point had deteriorated. The last time he saw the wound it was covered in necrotic tissue and it was debrided. He stated he assumed that the dressing changes were being done and had not been told otherwise. It was just a scab earlier on his previous assessment then had formed into a wound. He stated that he didn't know of any concerns with wound care and they used to have a great wound care nurse. Since she was not here anymore, he thought the wound care was still being completed. He did not think that the wound was avoidable. The resident had an above the knee amputation already and had multiple contractures. The resident would always let him do they wound care but had dementia and he thought it may have been difficult for staff at times. The Administrator was interviewed on 3/1/18 at 12:51 PM. She stated that the wounds had gotten worse and the resident was combative with staff and had an above the knee amputation with vascular issues. The family had come back to the facility after the resident was discharged and said they were possibly amputating the resident's other leg. She stated that she read the hospital notes and the hospital said the resident was not doing that bad. The treatments for dressing changed were being completed by the hall nurses and the wound care doctor was seeing the resident. There were no concern of dressing changes that she knew of. Usually the dressing changes were completed daily and documented on the TAR. The medication aide could complete a stage 1 and 2 pressure ulcer but a nurse were the only ones that could stage a wound. She stated that the wound care nurse's last work day was on 1/14/18. She stated she would expect for there to be adequate staffing to provide wound care to residents.

Based on record review and staff interviews, the facility failed to complete dressing changes for a wound for 1 of 3 resident reviewed for wound care (Resident #1). Findings included: Resident #1 was admitted the facility on 10/12/17 with the [DIAGNOSES REDACTED]. The resident had a care plan in place for combativeness due to dementia (updated 12/27/17), pressure ulcers dated (updated 12/27/17), state of nutrition is less then body requirements (updated 12/28/17). A physician's wound note from the wound care doctor dated 2/2/18 revealed the resident had a wound to the left foot (the note did not say specifically where), which measured 3 centimeter (cm) x 2 cm x 0.5 cm and this was the initial evaluation. The duration of the wound was 8 days and it had 80% necrotic tissue and 20% granulation tissue present. The wound underwent surgical debridement. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for the left ankle revealed to pack with sterile gauze with [MEDICATION NAME] and wrap with Kerlix everyday starting on 2/2/18. The TAR revealed that it was completed on 2/2/17. The TAR was blank for the following dates of 2/3/18, 2/4/18 and 2/5/18. There was no nursing or progress noted for 2/3/18 through 2/5/18 that indicated wound care was completed for this resident. Nurse #1 (Worked 1st shift with the resident on 2/2/18 and supervisor of facility on 2/3/18, 2/4/18 and 2/5/18 for 1st shift) was interviewed on 2/28/18 at 2:02 PM. She stated that the resident was not alert and oriented and was very confused. The resident had an amputation to one of her legs and a wound to her other leg. The wound physician was seeing the wound. She stated that she didn't know of any new recent wounds that the resident had. The resident had behaviors all the time. She stated that nurses and medication aides on the hall were supposed to do the dressing changes but medication aides could do dressing changes to stage 1 and 2 wounds. Medication Aide #1 was interviewed on 2/28/18 at 2:11 PM. She stated the resident would swat at you. She stated that the resident had a wound on her knee of the amputated leg and a splint in place and would pick at the dressing sometimes. The resident also had another wound on her other foot. She stated that she went one time to help the wound care nurse with dressing change and the resident never refused care. After the wound care nurse stopped working at the facility, the nurses would have to change the dressings for residents. She stated that she never changed the dressing to the resident feet, legs or knees but just went in and assisted the wound care nurse one time. She stated that the Nursing Assistants (NA) would tell the supervising nurse if a bandage needed to be changed after they gave a resident a bath or in between giving medication. She stated if the wound was a stage 1 or 2, it would be documented in the treatment book. Nurse #8 (The supervisor on 2/3/17 and 2/4/17 on second shift) was interviewed on 2/28/18 at 2:42 PM. He stated he did not think he directly took care of the resident in February, (YEAR). The resident needed extensive assistance with care. He thought the resident had a wound on her knee and sacrum. He did not remember any wounds to her feet or ankles or about any dressing changes. The Administrator was interviewed on 2/28/18 at 3:19 PM. The wound doctor was doing the wound assessments every week. The nurses should also be doing the wound assessments. The wound care nurse stopped working at the facility about a month ago. Nurse #7 (rounds with wound care doctor weekly and SDC nurse) was interviewed on 2/28/18 at 3:59 PM. She stated that her job included rounding with the wound care doctor on Fridays. She stated this resident had a wound on her ankle. When she first saw the wound, it was a stage 3 or so. She stated that had called the resident's family on 1/26/18 to get permission to do debridement of the wound. The resident's ankle was wrapped in Kerlix so she thinks the resident was getting dressing changes. On 2/2/17, the resident's family was at the bedside and the family wanted to see the wound. The family agreed to have it debrided. They dressed the wound on 2/2/18 and the family was at the bedside. She stated the ankle wound was white with blackish tissue around it and the black area was preventing it from healing. She thinks that the dressing changes were usually completed on the first shift for this resident. The resident was getting anacept to the ankle wound. Nurse #5 (worked with resident on 2/3/17 and 2/4/17 on 2nd shift) was interviewed on 2/28/18 at 4:19 PM. The resident was very confused but followed simple commands. The resident had wounds and she would do wound care for residents if there was no treatment nurse. The resident had wounds on her toes, knee and sacral area and vulva. She stated she never knew of a wound on the resident's ankle and had never completed a dressing change to her ankle. She stated that her dressing changes could be done at any time during the day. They have a treatment book and that was where they documented wound care. She stated that the Medication aides could only do wound care dressing changes that were simple. She stated 1st shift doesn't do dressing changes often and 2nd shift would try to do them. She stated that they don't have a wound care nurse anymore and they really need one as she was trying to just keep up. Medication Aide # 9 (worked 2nd shift on 2/2/18 and 2/3/18) was interviewed on 2/28/18 at 4:37 PM. She stated that she help the wound care doctor change a dressing a while ago but had never done dressing changes this month for this resident. She stated that the supervising nurse would do the wound care on 1st shift most of the time. The resident was getting dressing change completed in the morning unless something happens. She never knew of a wound to the resident's ankle. Nurse #6 (worked on 2/3/18 and 2/4/18 on third shift and was the supervisor for the facility those days) was interviewed on 3/1/18 at 9:14 AM. She stated that the resident was asleep most of the time and was anxious at times. The resident could be restless at times. The resident had a wound to her inguinal area, left knee and sacral area. The resident was combative sometimes during care. The resident had many contractions and they tried to clean her as much as possible. She stated that she does not remember about a wound to the resident's foot/ankle area and had never completed/attempted a dressing change to a wound on her foot/leg. She only had completed a dressing to the resident's knee occasionally when the resident wound pull off the dressing. Since the treatment nurse left, the even numbered rooms, the 1st shift nurse would complete the dressing changes and the odd numbered rooms, 2nd shift would complete the dressing changes for. She does not recall anything about a wounds on the resident's ankle. She stated she could not even remember if the resident had a dressing on her foot or not before she was discharge. She stated she usually worked 300 and 400 halls and would have to cover when the Nursing Assistant called out. She stated they tried their best to do things for this resident but they have to prioritize their work and she wouldn't necessary wake up this resident to change a dressings and typically another shift should do it. Wound care usually does not fall on her shift so she cannot say if the wound care was being done for residents but if she was told that it was not done then she would typically do it. Nurse #2 (supervising nurse on 2/2/18 on second shift for this resident) was interviewed on 3/1/18 at 9:27 AM. She stated that usually she would work 200 hall and would supervise the 400 hall if there was a medication aide working. She stated that if they dressing changes to do, that 1st shift wound do the even numbered rooms and 2nd shift would do the odd numbered rooms for that hall. For major wounds, the nurses had to do the dressing changes. The medication aides were allowed to do skin preps and creams but not major dressing's changes. The medication aides and nurses are responsible for dressing changes now. She stated that she would typically go through the TAR and do the major dressing changes that needed to be completed for residents. She stated that she had never done dressing changes on this resident and doesn't remember the resident's wounds in particular but does remember the resident. She stated the resident's wound care should have been completed on 1st shift because she was in an even numbered room. Nurse #4 (worked 1st shift on 2/3/18 and on 2/4/18) was interviewed on 3/1/18 at 9:51 AM. He stated the resident was only oriented to person. The resident had behaviors and had intermittent combativeness. However, he never personally witnessed the resident being combative. He knows the resident had a wound on her left knee and coccyx area. He stated he does not recall any wounds to her other leg (non-amputated leg). He stated that he has only completed the dressing changed to the resident's knee and the resident would let him do the dressing change. If a dressing change is completed, it is documented on the TAR or in the nursing notes. Since there was no treatment nurse, the dressing change are not done as regularly. Nurse #3 (worked on 2/2/18 on 3rd shift) was interviewed on 3/1/18 at 10:04 AM. She stated that she worked night shift from 11:00 PM to 7:00 AM. She stated she had never cared for any of the resident's wounds and did not know about them specifically because she had never changed the dressings. The resident would be resistive with care but she usually could provide her with care. At night, if there was a new wound then she wound do the wound care if needed. A nursing note dated 2/5/18 revealed that at 1:30 PM, the resident's family and relative stated there was something wrong with the resident. Vitals were taken and revealed the following: Temperature was 99.7, heart rate was 114 and irregular, respirations were 20 and blood pressure was 110/70. The writer was unable to hear breath sounds and the physician was notified. The resident's family insisted that the resident needed to go to the hospital and Emergency Medical Services (EMS) were called and the resident was transported at 1:45 PM to the hospital. The resident was admitted to the hospital on [DATE]. Hospital records dated 2/5/18 revealed that the resident was admitted to the hospital. Hospital records revealed the resident presented to the hospital with a wound to her left ankle that measured 7 cm x 3 cm and had exposed underlying tendon, black eschar and smelled infected per the Emergency department note. Hospital records also revealed that the resident was diagnosed with [REDACTED]. Antibiotics were started and it was recommended that the resident had an above the knee amputation. However, the risks were spoken with to the family and the resident was placed on hospice care instead and transferred to a skilled nursing facility. Resident's #1 discharge Minimum (MDS) data set [DATE] revealed that the resident was severely cognitively impaired for daily decision making and had short term memory problems. The resident had behaviors of rejection of care 1 to 3 days per week and physical behavioral symptoms that occurred 1 to 3 days. The resident required extensive assistance with bed mobility, locomotion and eating. The resident required total assistance with personal hygiene, toilet use, dressing and transfers. The resident was always incontinent of bowel and of bladder. The resident had a stage 3 pressure ulcer and 1 stage 4 pressure ulcer. The pressure ulcer measured 2.8 cm x 2.1 cm x 00.2 cm. The Wound Care Doctor was interviewed on 3/1/18 at 10:38 AM. The resident had a wound to her foot near the ankle that had occurred at the facility (when asked specifically about where the new left foot wound was in his note). He thought that nursing discovered the wound but wasn't sure. The wound started as a scab and at some point had deteriorated. The last time he saw the wound it was covered in necrotic tissue and it was debrided. He stated he assumed that the dressing changes were being done and had not been told otherwise. It was just a scab earlier on his previous assessment then had formed into a wound. He stated that he didn't know of any concerns with wound care and they used to have a great wound care nurse. Since she was not here anymore, he thought the wound care was still being completed. He did not think that the wound was avoidable. The resident had an above the knee amputation already and had multiple contractures. The resident would always let him do they wound care but had dementia and he thought it may have been difficult for staff at times. The Administrator was interviewed on 3/1/18 at 12:51 PM. She stated that the wounds had gotten worse and the resident was combative with staff and had an above the knee amputation with vascular issues. The family had come back to the facility after the resident was discharged and said they were possibly amputating the resident's other leg. She stated that she read the hospital notes and the hospital said the resident was not doing that bad. The treatments for dressing changed were being completed by the hall nurses and the wound care doctor was seeing the resident. There were no concern of dressing changes that she knew of. Usually the dressing changes were completed daily and documented on the TAR. The medication aide could complete a stage 1 and 2 pressure ulcer but a nurse were the only ones that could stage a wound. She stated that the wound care nurse's last work day was on 1/14/18. She stated she would expect for there to be adequate staffing to provide wound care to residents.

Based on record review, observations and staff interviews, the facility's administration failed to provide leadership and management to ensure the needs of the resident were met in the areas of wound care and treatments (Resident #1, Resident #2).The failure of administration to address these concerns resulted in one resident's hospitalization [MEDICAL CONDITION] related to an infected ankle wound (Resident #1). Finding Included: This tag is cross referenced to F684: Based on record review and staff interviews, the facility failed to complete dressing changes for a wound for 1 of 3 resident reviewed for wound care (resident #1). F686: Based on record review and staff interviews, the facility failed to assess a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #2). The Administrator (Director of Nursing, Associate Director of Nursing, and corporate consultant were present) was interviewed on 3/1/18 at 12:51 PM. She stated she would expect for there to be adequate staffing to provide wound care to residents. She stated they were interviewing staff and trying to recruit staff. She stated they did just hire an administration nursing team (Director of Nursing and Associate Director of Nursing). She stated they have a quality assurance meeting every two months and she would expect for the quality assurance committee to recognize and address any quality issues/concerns. She stated there were no concerns about wound dressing changes that she knew of.

Based on record review, observations, staff and physician interviews the facility neglected to provide skin assessments and manage skin treatment of [REDACTED].# 2), reviewed for pressure ulcers. The findings included: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission skin assessment was completed by the admitting nurse on 6/26/2016, which noted a reddened area with possible opening on the coccyx. No measurements or staging were noted on this assessment. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] indicated the presence of a stage 2 pressure ulcer, with granulation tissue, present on admission. A review of the care plan dated 7/6/2016 indicated that Resident #2 had a pressure ulcer. Interventions included turning and positioning, incontinent care, wound care as ordered, supplements as ordered, and weekly wound assessments. A review of the treatment record indicated that starting on 7/9/2016 a dressing of [MEDICATION NAME] was to be applied every 7 days and as needed, no area was identified for the application and no staging or measurements were indicated. Another treatment was started on 7/9/2016 to apply a [MEDICATION NAME] dressing daily and as needed to a busted blister on the right buttock. Further review of this treatment record indicated a treatment for [REDACTED]. The previous dressing for [MEDICATION NAME] was discontinued at this time. A referral for the wound care physician to evaluate was also noted at this time. Treatments were documented as completed. A review of the nursing notes revealed a care plan wound note dated 7/26/2016 at 12:16 pm, by the MDS nurse, which identified an unstageable pressure ulcer with measurements of 6 cm x 5 cm, unable to determine depth. A description of the wound was circular with thick dark eschar covering the entire wound bed, surrounding tissue was sensitive to the slightest touch, no purulent drainage. The note indicated that a dressing saturated with serous drainage was removed and the resident was placed on the physician board for a wound care referral. On 7/27/2016 at 1:40 pm the wound care nurse was interviewed. She indicated that she has been scheduled on the floor instead of being assigned to wound care. She explained that she has not been assigned to wound care for the last month. She explained that one nurse had been out on leave and another nurse was gone and she had been taking a hall assignment since then. When asked who is responsible for wound care she explained that the nurses on the halls are supposed to do their own resident ' s wound care. When asked about the assessments, she indicated that the nurses on the hall are supposed to do the weekly assessments as well. First shift is responsible for the even number rooms and second shift does the odd number rooms. On 7/27/2016 at 3:16 pm the MDS nurse was interviewed. She explained that she went in Resident #2 ' s room to do a wound assessment as part of the Change of Therapy assessment that she was doing. She explained that the last documented assessment was on the treatment record, where a nurse had noted a busted blister which would be a stage II ulcer. She verified that the reference to a blister was the last assessment of the wound and that no formal skin assessments with measurements existed. She indicated that she knew the wound care doctor would be here on Thursday and she wanted to make sure Resident #2 was seen. On 7/27/2016 at 4:15 pm the nurse caring for Resident #2 was interviewed. She indicated that she did do the dressing change as expected last night. She explained that the nurse aide came to her and told her that there was no dressing on Resident #2. The nurse indicated that the wound was very black and necrotic with a foul odor. She explained that she had the resident when she was first admitted and the skin was just red, but has turned black. She that she does not do wound assessments and measurements. She explained that the wound nurse would do that. She indicated that she would do the dressings as scheduled on evenings but no one has ever told her that she needed to do measurements. On 7/27/2016 at 4:29 pm the nurse supervisor for evenings was interviewed. She explained that evenings are responsible for the odd number room dressing changes. When asked about wound assessments and measurements, she indicated that the wound nurse would do those and that the nurses on the hall would not be responsible for wound measurements. On 7/28/2016 at 10:09 am wound assessment and care was observed with the consulting wound care physician and the wound care nurse. The resident was seated in an upright position in bed with her knees raised. The physician instructed the wound care nurse to make sure she was never raised higher than 30 degrees due to the pressure that position would put on her back. He also recommended an air mattress to relieve some of the pressure while in bed. The resident was lowered and turned to her side. The dressing was removed. A strong foul odor was noted. The physician explained that the smell was from necrotic tissue. He tapped the eschar and noted that it was firm and thick. He explained that it needed [MEDICATION NAME]. Measurements were completed by the physician and noted to be 7 cm x 5 cm x 1 cm, estimated depth due to eschar. The physician explained that it would probably be stage IV after debridement. Debridement was attempted by the physician with a large amount of black substance removed from the wound bed. The physician explained that he was not able to get it all today so he would come back next Thursday to do the rest. On 7/28/2016 at 11:12 am the wound care nurse was observed applying the dressing to Resident #2 ' s sacral wound. She noted that urine was leaking when the resident was moved. She explained that she may benefit from a urinary catheter. She applied the recommended dressing of Santyl to the wound bed with calcium alginate over that and covered with a dry dressing. After the wound care, on 7/28/2016 at 11:33 am the wound care nurse was interviewed. She indicated that she does not see the wounds like she would like. She explained that she has not been assigned to be the wound care nurse because they do not have enough nurses scheduled. She said, They schedule me to take a hall and I can ' t do two things at once. She explained that the nurses rely on the direct care staff to report changes to them. She indicated that most nurses try to do a good job with dressings but they are assigned 40 plus residents at times. When asked if the lack of wound assessments had impacted the wound for Resident #2, she indicated that it had, explaining further that the interventions that were identified today could have been implemented earlier. She indicated that when Resident #2 came to the facility her wound was small. As a wound care nurse, she indicated that she had been trained to assess wounds for changes and identify interventions. She explained that her priority would have been to change treatments per protocol, ask for wound care referrals, change her positioning, and possible ask for a catheter to keep the urine from soaking the wound. She explained she would have been aware of these interventions and communicated them to the physician to put them into place. Staffing for June and July were reviewed. Beginning in June, the wound care nurse was not assigned to wound treatments about half of the time. In July the wound care nurse was assigned to wound care only 4 days. On 7/28/2016 at 3:42 pm the Director of Nursing was interviewed. She explained that for the last three weeks the wound care nurse was not assigned to wound care. One week she was on vacation and for two weeks she was assigned to take a hall. She explained that it was necessary. She staffed the floor with the wound care nurse so the halls would be covered and expected the floor nurses to do their own wound care. She indicated that would include assessing wounds.

Based on record review, observations, staff interviews and physician interview, the facility failed to follow the care plan and skin protocol by not providing wound assessments and overseeing treatment of [REDACTED].#2) reviewed for pressure ulcers. The findings included: The undated skin care protocol interventions included that the skin should be inspected and appropriate personnel notified of abnormal changes. The protocol indicated skin inspections could be done by Nurse Aides and licensed personnel during daily care and by treatment nurses. The skin care protocol stated, Patients are to be thoroughly assessed prior to selecting a wound dressing. The following treatments were included by wound staging: 1. Stage 2 (Partial thickness skin loss) - If wound has small to moderate amount of drainage apply a [MEDICATION NAME] and change every seven days and as needed. 2. Stage 3 (Full thickness tissue loss) and Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) - Apply a hydrogel to all wound surfaces. Cover with secondary dressing of choice. Frequency of dressing changes per the discretion of the Treatment Nurse. 3. Stage 3 or 4 wounds with necrosis - Santyl dressing recommended for debridement. Resident #2 was admitted on [DATE]. The admission assessment indicated the presence of a reddened are with a possible opening on the coccyx. There was no measurements or wound staging provided on this assessment. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] indicated the presence of a stage 2 pressure ulcer, with granulation tissue, present on admission. A review of the care plan dated 7/6/2016 revealed that weekly wound assessments and treatments as ordered by physician or per protocol to sacrum were listed as interventions. There were no other revisions to this care plan as the condition of the pressure wound progressed to an unstageable wound. The care plan did refer to the skin care protocol which defined interventions at different wound stages. A review of the treatment record showed that [MEDICATION NAME] dressings were applied beginning 7/9/2016, with no reference to wound size or staging, and ordered to be changed every seven days or as needed. Other than the Standing Orders signed at admission, that included wound care protocol, there were no new or different physician orders [REDACTED]. On 7/22/2016 a change in the treatment was noted with a wound assessment documented on the treatment record of Stage 4 with black eschar and measurements of 4 cm x 3 cm x 1 cm. A hydrogel dressing was implemented at this time to be changed every three days or as needed. A review of the nursing notes indicated that there was no wound assessments between the admission assessment and the assessment noted on the treatment record on 7/22/2016. There were no indications that nursing staff were monitoring the skin for changes as outlined in the wound care protocol and the care plan. From the initiation of treatment on 7/9/2016, until the notation on the treatment record on 7/22/2016 there were no measurements documenting the progression of this wound from a stage 2 pressure ulcer to a stage 4. The Treatment Administration Record indicated there were no adjustments made to the treatment of [REDACTED]. On 7/27/2016 at 1:40 pm, the wound care nurse was interviewed. She indicated that she was scheduled on the floor instead of being assigned to wound care for the last month. When asked who was responsible for wound care she explained that the nurses on the halls were responsible for wound care for their residents. On 7/27/2016 at 4:15 pm, the nurse caring for Resident #2 was interviewed. She indicated that she did the dressings as scheduled on evenings but no one had ever told her that she needed to do measurements. On 7/27/2016 at 4:29 pm, the nurse supervisor for evenings was interviewed. When asked about wound assessments and measurements, she indicated that the wound nurse would do those and that the nurses on the hall would not be responsible for wound measurements. On 7/28/2016 at 10:09 am, wound assessment and care was observed with the consulting wound care physician and the wound care nurse. The physician explained that it needed [MEDICATION NAME]. Measurements were completed by the physician and noted to be 7 cm x 5 cm x 1 cm, estimated depth due to eschar. He indicated that it was unstageable, but would probably be a stage 4 after debridement. After the wound care, on 7/28/2016 at 11:33 am, the wound care nurse was interviewed. She explained that she had not been assigned to wound care because she was assigned to a hall of residents most of the last month. When asked if the lack of wound assessments had impacted the wound progression for Resident #2, she indicated that it had, explaining further that the interventions that were identified today could have been implemented earlier. On 7/28/2016 at 3:42 pm the Director of Nursing was interviewed. She explained that for the last three weeks the wound care nurse was not assigned to wound care. She used the wound care nurse for resident care, so the halls would be covered, and she expected the floor nurses to do their own wound care. She indicated that would include assessing wounds.

Based on record review, observation, staff interviews and physician interview the facility failed to accurately assess and oversee treatment of [REDACTED].#2) reviewed for pressure ulcers. The findings included: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission skin assessment was completed by the admitting nurse on 6/26/2016, which noted a reddened area with possible opening on the coccyx. No measurements or staging were noted on this assessment. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] indicated the presence of a stage 2 pressure ulcer, with granulation tissue, present on admission. A review of the care plan dated 7/6/2016 indicated that Resident #2 had a pressure ulcer interventions included turning and positioning, incontinent care, wound care as ordered, supplements as ordered, and weekly wound assessments. A review of the treatment record indicated that starting on 7/9/2016 a dressing of [MEDICATION NAME] was to be applied every 7 days and as needed, no area was identified for the application and no staging or measurements were indicated. Another treatment was started on 7/9/2016 to apply a [MEDICATION NAME] dressing daily and as needed to a busted blister on the right buttock. Further review of this treatment record indicated a treatment for [REDACTED]. The previous dressing for [MEDICATION NAME] was discontinued at this time. A referral for the wound care physician to evaluate was also noted at this time. Treatments were documented as completed. A review of the nursing notes revealed a care plan wound note dated 7/26/2016 at 12:16 pm, by the MDS nurse, which identified an unstageable pressure ulcer with measurements of 6 cm x 5 cm, unable to determine depth. A description of the wound was circular with thick dark eschar covering the entire wound bed, surrounding tissue was sensitive to the slightest touch, no purulent drainage. The note indicated that a dressing saturated with serous drainage was removed and the resident was placed on the physician board for a wound care referral. A review of dietary notes revealed a dietary assessment completed on 7/26/2016. The assessment indicated that the resident consumed 45% of her meals on average with full staff assistance for the last 4 days. Dietary supplements were noted as a frozen dietary supplement served three times a day and a shake supplement between meals and at night. The note also identified the presence of a sacral wound with eschar. On 7/27/2016 at 1:40 pm the wound care nurse was interviewed. She indicated that she has been scheduled on the floor instead of being assigned to wound care. She explained that she has not been assigned to wound care for the last month. She explained that one nurse had been out on leave and another nurse was gone and she had been taking a hall assignment since then. When asked who is responsible for wound care she explained that the nurses on the halls are supposed to do their own resident ' s wound care. When asked about the assessments, she indicated that the nurses on the hall are supposed to do the weekly assessments as well. First shift is responsible for the even number rooms and second shift does the odd number rooms. On 7/27/2016 at 3:16 pm the MDS nurse was interviewed. She explained that she went in Resident #2 ' s room to do a wound assessment as part of the Change of Therapy assessment that she was doing. She explained that the last documented assessment was on the treatment record, where a nurse had noted a busted blister which would be a stage II ulcer. She verified that the reference to a blister was the last assessment of the wound and that no formal skin assessments with measurements existed. She indicated that she knew the wound care doctor would be here on Thursday and she wanted to make sure Resident #2 was seen. On 7/27/2016 at 4:15 pm the nurse caring for Resident #2 was interviewed. She indicated that she did do the dressing change as expected last night. She explained that the nurse aide came to her and told her that there was no dressing on Resident #2. The nurse indicated that the wound was very black and necrotic with a foul odor. She explained that she had the resident when she was first admitted and the skin was just red, but has turned black. She that she does not do wound assessments and measurements. She explained that the wound nurse would do that. She indicated that she would do the dressings as scheduled on evenings but no one has ever told her that she needed to do measurements. On 7/27/2016 at 4:29 pm the nurse supervisor for evenings was interviewed. She explained that evenings are responsible for the odd number room dressing changes. When asked about wound assessments and measurements, she indicated that the wound nurse would do those and that the nurses on the hall would not be responsible for wound measurements. On 7/28/2016 at 10:09 am wound assessment and care was observed with the consulting wound care physician and the wound care nurse. The resident was seated in an upright position in bed with her knees raised. The physician instructed the wound care nurse to make sure she was never raised higher than 30 degrees due to the pressure that position would put on her back. He also recommended an air mattress to relieve some of the pressure while in bed. The resident was lowered and turned to her side. The dressing was removed. A strong foul odor was noted. The physician explained that the smell was from necrotic tissue. He tapped the eschar and noted that it was firm and thick. He explained that it needed [MEDICATION NAME]. Measurements were completed by the physician and noted to be 7 cm x 5 cm x 1 cm, estimated depth due to eschar. The physician explained that it would probably be stage IV after debridement. Debridement was attempted by the physician with a large amount of black substance removed from the wound bed. The physician explained that he was not able to get it all today so he would come back next Thursday to do the rest. On 7/28/2016 at 11:12 am the wound care nurse was observed applying the dressing to Resident #2 ' s sacral wound. She noted that urine was leaking when the resident was moved. She explained that she may benefit from a urinary catheter. She applied the recommended dressing of Santyl to the wound bed with calcium alginate over that and covered with a dry dressing. After the wound care, on 7/28/2016 at 11:33 am the wound care nurse was interviewed. She indicated that she does not see the wounds like she would like. She explained that she has not been assigned to be the wound care nurse because they do not have enough nurses scheduled. She said, They schedule me to take a hall and I can ' t do two things at once. She explained that the nurses rely on the direct care staff to report changes to them. She indicated that most nurses try to do a good job with dressings but they are assigned 40 plus residents at times. When asked if the lack of wound assessments had impacted the wound for Resident #2, she indicated that it had, explaining further that the interventions that were identified today could have been implemented earlier. She indicated that when Resident #2 came to the facility her wound was small. As a wound care nurse, she indicated that she had been trained to assess wounds for changes and identify interventions. She explained that her priority would have been to change treatments per protocol, ask for wound care referrals, change her positioning, and possible ask for a catheter to keep the urine from soaking the wound. She explained she would have been aware of these interventions and communicated them to the physician to put them into place. Staffing for June and July were reviewed. Beginning in June, the wound care nurse was not assigned to wound treatments about half of the time. In July the wound care nurse was assigned to wound care only 4 days. On 7/28/2016 at 3:42 pm the Director of Nursing was interviewed. She explained that for the last three weeks the wound care nurse was not assigned to wound care. One week she was on vacation and for two weeks she was assigned to take a hall. She explained that it was necessary. She staffed the floor with the wound care nurse so the halls would be covered and expected the floor nurses to do their own wound care. She indicated that would include assessing wounds.

Based on record review, observations, staff and physician interviews the facility failed to provide adequate staffing to provide skin assessments and treatment management for 1 of 3 residents (Resident #2) reviewed for pressure ulcers. This tag is cross referenced to F 314. The findings included: F 314 Based on record review, observation, staff interviews and physician interview the facility failed to accurately assess and oversee treatment of [REDACTED].#2) reviewed for pressure ulcers. An interview with the Director of Nursing on 7/28/2016 at 3:42 pm revealed that to cover the resident halls with sufficient nursing staff the wound care nurse had been assigned to care for a hall of residents instead of providing wound care treatments. On many of the days the wound care nurse was assigned to the hall there were only 3 nurses and two med aides to care for all five halls, so the nurses would cover their own hall of about 30 residents and one of the med aide ' s halls for about 30 residents. She indicated that she has open positions for staff development nurse, restorative and rehab nurse and one MDS nurse. The MDS nurse will start next week. She explained that she has hired two registered nurses and two licensed practical nurses. She indicated that when they were trained the floors would be covered. She also explained that the wound care nurse had resigned with her last day to be tomorrow 7/29/2016, and that her position was open as well. She indicated that they had lost two nurses, one sick and one had to be let go. She identified ideal staffing as having a nurse for each hall, plus a supervisor and treatment nurse and that with the new hires that would be possible.

Based on record review, observation and staff interview, the facility failed to maintain an effective infection prevention and control program in order to prevent and control to the extent possible, the spread of scabies to residents and staff. Facility failed to educate all direct care staff immediately after a confirmed case was identified and failed to contain staff members who were exposed or had direct contact with Resident #78. Three (500, 100 and 200 halls) of five halls had residents with suspected scabies and were treated and two staff members ( nurse's aides #4 & # 5) were diagnosed with [REDACTED]. Findings included: The facility's policy on scabies (a parasitic infestation of the skin caused by a mite that burrows in the top layer to the skin where it feeds and lays eggs) dated 9/2014 was reviewed. The policy under education read in part " educate your staff on early detection and reporting of rashes in residents to nurse or for staff to his/her immediate supervisor, active surveillance program to detect infestation as soon as possible and suspect that any undiagnosed pruritic skin condition might be scabies. " The policy under control read in part " consider [MEDICATION NAME] treatment for [REDACTED]. " The dermatology consult reports for Resident #78 (room [ROOM NUMBER]A) were reviewed. The reports indicated that Resident #78 was seen by a dermatologist due to the rashes on her hands, feet and arms on 8/22/14, 8/26/14, 9/26/14, and 12/2/14 and on 1/7/15. She was treated with [MEDICATION NAME] (used for itching) and [MEDICATION NAME] cream with 1% [MEDICATION NAME] for dry skin dermatitis. On 1/7/15, a scraping was done and Resident #78 was diagnosed with [REDACTED]. The facility's infection control report and Medication Administration Records (MARs) for January, 2015 were reviewed. The report/records indicated the following: 500 hall 1/7/15 - residents in rooms 510 B, 511, 512 A and B were observed to have rashes and were treated with [MEDICATION NAME] cream on 1/8/15. 1/14/15 - residents in rooms 503, 506 A and 516 A were observed to have rashes and 516 B was noted to be scratching on chest. Residents in rooms [ROOM NUMBERS] A were treated with [MEDICATION NAME] cream on 1/14/15 while residents in room [ROOM NUMBER] A and B were treated on 1/15/15. 1/15/15 - residents in room [ROOM NUMBER] B and 519 were noted to have a suspected rash and were treated with [MEDICATION NAME] cream on 1/15/15. 1/16/15 - a resident in room [ROOM NUMBER] A had a rash and was treated with [MEDICATION NAME] cream on 1/16/15. Sixteen other residents on the 500 hall were treated with [MEDICATION NAME] cream as a [MEDICATION NAME] measures. 100 hall 1/15/15 - resident in room [ROOM NUMBER] B was noted to have a rash and was treated with [MEDICATION NAME] cream on 1/17/15 1/19/15 - a resident in room [ROOM NUMBER] B was noted to have a rash and was treated with [MEDICATION NAME] cream on 1/21/15 1/20/15 - a resident in room [ROOM NUMBER] A was noted to have a rash and was treated with [MEDICATION NAME] cream on 1/20/15. Three other residents in rooms 109 A, and 112 A and B were treated [MEDICATION NAME]. 200 hall 1/17/15 - residents in room [ROOM NUMBER] A and 208 B were observed to have rashes. Resident in room [ROOM NUMBER] B was treated on 1/17/15 and resident in room [ROOM NUMBER] A was treated on /18/15. The room mates were not treated. The staffing schedule for nursing from January 5 - 9, 2015 was reviewed. NA (nurse aide) #1 was assigned on 500 hall on 1/5/15, 400 and 500 halls on 1/6/15, 400 and 100 halls on 1/7/15 and 200 hall on 1/8/15. NA #2 was assigned on 500 hall on 1/5/15, 100 hall on 1/7/15 and 500 hall on 1/8/15. NA #3 was assigned on 500 hall on 1/5/15, 100 hall on 1/8/15 and 500 hall on 1/9/15. NA #4 was a medication aide and was assigned as a treatment nurse on 1/6/15 and 1/7/15, and as a NA on 100 hall on 1/8/15. Nurse # 1 was assigned on the 200 hall on 1/6/15 and 1/7/15, 500 hall on 1/8/15 and 200 hall on 1/9/15. The in service records were reviewed. The records indicated that 14 nursing staff members on the 500 hall were educated on 1/7/15 regarding scabies and the cleaning of reusable equipments (blood pressure cuffs, thermometers and lifts) with virex (a disinfectant) or alcohol. The rest of the staff members (nursing, housekeeping, dietary, activity, maintenance, administration, laundry, and social services) were educated on 1/15/15. The therapy department staff members were educated on 1/21/15. On 1/20/15 at 10:45 AM, rooms 108, 109, 506, 510, 511, 512 and 516 were observed to have an isolation sign to the doors. Upon interview with administrative staff #1, she indicated that residents in these rooms were on contact isolation due to rashes and had been treated for [REDACTED]. On 1/20/15 at 11:33 AM, administrative staff #1 was interviewed. She stated that the facility had one confirmed case of scabies (Resident #78). Resident #78 went to the dermatology clinic on 1/7/15 due to her rashes and was diagnosed with [REDACTED]. She added that she was out of work and when she came back she heard that other residents had developed rashes. The local health department and the medical director were notified. The medical director had at first ordered to treat only residents with rashes with [MEDICATION NAME] cream and on 1/16/15, he ordered to treat all residents on the 500 hall as a [MEDICATION NAME] measures. Clothing and linens were washed and rooms were deep cleaned including the curtains before and after treatments. Family members and staff were educated regarding scabies. She added that on 1/17/15, two staff members were diagnosed with [REDACTED].# 4. On 1/20/15 at 4:10 PM, NA #1 was interviewed. She stated that she had been in serviced regarding scabies. NA #1 indicated that her normal assignment was on 500 hall but she also had worked on different halls (100 and 200 halls). She also stated that as a nurse's aide, she had always direct contact with all the residents on the hall by answering call lights, delivering trays and assisting with feeding. She added that she was not trained on how to clean the reusable equipments such as blood pressure cuff, thermometers, lifts and belts. On 1/21/15 at 11:45 AM, NA #5 was interviewed. She stated that on 1/16/15 she was assigned to a resident in room [ROOM NUMBER] B who had rashes and on 1/17/15 (Saturday) she had spots all over her body and she was itching. She left the facility and went to the doctor and was diagnosed with [REDACTED]. She added that she was not trained on how to clean the reusable equipments such as blood pressure cuff, thermometers, lifts and belts. On 1/21/15 at 12:27 PM, NA #4 was interviewed. She stated that she worked as a medication aide, treatment nurse or as a nurse's aide. She indicated that as a medication aide, treatment nurse or a nurse's aide, she had a direct contact with the residents on each hall. She added that on 1/16/15, she worked as a medication aide on the 100 hall. On 1/17/15 (Saturday) she started itching and with rashes all over her body. She left the facility and went to a doctor and was diagnosed with [REDACTED]. On 1/22/15 at 9:25 AM, NA # 2 was interviewed. She stated that she was assigned and had worked on a different hall (100 hall). She added that as a nurse's aide, she had direct contact with the residents on the hall. NA #2 further indicated that she had received education on scabies but not on how to clean the reusable equipment. On 1/22/15 at 11:01 AM, administrative staff #1 was interviewed. She indicated that because 500 hall residents were mobile and hard to contain, all residents were treated with [MEDICATION NAME] cream. She stated that 100 and 200 hall residents were not mobile (bed bound), so only residents with rashes were treated. Administrative staff #1 acknowledged that direct care staff had been assigned on different halls. She stated that staff members were informed to see their doctor when they had symptoms of scabies. Administrative staff #1 indicated that on 1/7/15, education regarding scabies was provided to 500 hall staff members only. On 1/15/15, all staff members were educated and on 1/21/15, all therapy staff members were educated. She added that cleaning the reusable equipments with virex and alcohol was added on the education. On 1/23/15 at 8:40 AM, administrative staff #2 was interviewed. He stated that he deep cleaned the room and washed all the soiled clothes and linens twice (initial treatment and after 7 days). He also stated that he had to depend on nursing as to when to clean the room and wash the clothing. He also stated that he didn't keep a record as to when and what room he had deep cleaned and washed the clothing/linens.