Every finding on record at Pineville Rehabilitation and Living Center

Based on record review, review of recorded transcripts, and interviews with staff, Nurse Practitioner, and Medical Director, the facility failed to notify the physician and/or medical provider of all relevant information to ensure the necessary follow up care was provided following a fall with head injury. Resident #116 was receiving antiplatelet medications (an antiplatelet prevents blood clots and increases the risk of bleeding). On [DATE] at approximately 1:07 AM, Resident #116 experienced an unwitnessed fall his room and Nurse #1's assessment identified a quarter-sized hematoma (collection of blood outside of a blood vessel caused by bleeding into surrounding tissue) to the right side of his head. Nurse #1 notified the on-call provider (Physician Assistant) of the fall, head injury, and hematoma; however the Physician Assistant was not notified the resident was on anti-platelet medication and no new orders were provided. Resident #116 was assisted back to his bed, and neurological assessments were completed per protocol. During Nurse Aide (NA) #1's rounding at 4:00 AM, Resident #116 complained of a headache, NA #1 reported this symptom to Nurse #1, but no notification was made to the physician and/or medical provider. At approximately 8:30 AM, Resident #116 was noted to be unresponsive, with labored breathing and wet-sounding lungs (abnormal respiratory finding, breath sounds have a moist, congested or gurgling sound during breathing), and was not responding to verbal stimuli. Emergency Medical Services (EMS) was contacted and found the resident unconscious, with snoring and labored respirations, and unresponsive to pain. He was transitioned to a non-rebreather mask (oxygen mask that provides high concentrations of supplemental oxygen and are used in acute or emergency situations) with 15 liters of supplemental oxygen applied. Resident #116's Glascow Coma Scale (GCS- a tool to assess level of consciousness of patients with acute brain injury) was 3 which is the lowest score and indicates severe neurological impairment. Resident #116 was transported to the hospital. Upon evaluation, Resident #116 was found to have a large subdural hematoma (type of brain bleed in which the blood pools between the skull and the brain) and was intubated (a breathing tube placed through the mouth, into the windpipe to keep the airway open) and mechanically ventilated for airway protection. A CT (computed tomography) scan revealed a very large left subdural hematoma measuring up to 2.4 centimeters (cm) in thickness, resulting in a 2.5 cm rightward midline shift (the accumulated blood was pushing the brain significantly to the right by about 2.5 cm, which indicated strong pressure inside the skull). Neurosurgery was consulted and recommended no surgical intervention due to poor neurological exam. A death certificate dated [DATE] for Resident #116 revealed the cause of death included subdural hematoma with mass effect, blunt force head injury, and ground-level fall from standing height. Additionally, based on record review, review of recorded transcripts, and interviews with staff, Orthopedic Surgeon's Office Receptionist, Mobile Imaging Services Receptionist, Nurse Practitioner (NP), Physiatrist NP, and Former Medical Director, the facility failed to immediately notify the Physician, NP, and family members of significant changes in Resident #117's condition and failed to communicate information including abnormal laboratory test results and x-rays. NP #2 assessed Resident #117 on [DATE] noted crackles and expiratory wheezes (abnormal lung sounds) to bilateral lobes (both lungs) and documented in the progress note a STAT (urgent) chest x-ray would be ordered. The facility failed to notify the Physician or NP when the chest x-ray was not completed that day to obtain guidance for how to proceed. In addition, the facility failed to notify the Orthopedic Surgeon when Resident #117's surgical incision became infected and dehisced (a closed surgical wound reopens, partially or completely) on [DATE]. admission laboratory tests collected and resulted on [DATE] included Resident #117's white blood cell count was 14.6 (normal range 4.1-10.7) and TSH (thyroid-stimulating hormone) was 19.02 (normal range 0.45-5.33). A TSH level above 20 is considered dangerously high and requires immediate medical attention. The Physician and NP were not notified of the abnormal lab results. The Physician or NP were not notified the morning of [DATE] that Resident #117 was not able to eat or drink, and the facility failed to report the results of the chest x-ray completed on [DATE] to the Physician or NP. The failures resulted in the Physician or NP not receiving information regarding significant changes in Resident #117's condition and diagnostic findings necessary to evaluate Resident #117 and determine appropriate medical interventions. Resident #117's condition continued to decline into the evening when Nurse #3 noted Resident #117 sounded moist in her chest like she might have aspirated and did not improve after a nebulizer treatment and then was unresponsive. Emergency Medical Services (EMS) was contacted and documented Resident #117 appeared to have an obstructed airway (potentially life-threatening condition that occurs when the normal flow of air into and out of the lungs is partially or completely blocked). Multiple suction attempts and attempts to clear the airway were unsuccessful and Resident #117 appeared to lose a pulse and stop breathing. Resident #117 had a physician's order for a Do Not Resuscitate (DNR) and no intubation or mechanical ventilation and Resident #117 expired in the facility. Resident #117's death certificate dated [DATE] revealed the causes of death included acute respiratory failure, pneumonia of unknown organism, and chronic obstructive pulmonary disease. Immediate Jeopardy began on [DATE] for Resident # 116 when Nurse #1 failed to notify the physician and/or medical provider that Resident #116 was receiving an antiplatelet medication after the resident sustained an unwitnessed fall with a head injury. Immediate Jeopardy began on [DATE] for Resident # 117 when the Medical Director or NP were not contacted when the chest x-ray had not been completed. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure the monitoring systems put into place are effective and education is completed.The deficient practice affected 2 of 3 residents reviewed for notification of change (Resident #116 and Resident #117). The findings included: 1. Resident #116 was admitted into the facility on [DATE] with diagnosis including cerebrovascular accident (CVA) and coronary artery disease (CAD). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was cognitively intact and was taking an antiplatelet medication during the assessment period. An active physician order dated [DATE] revealed an order for Clopidogrel Bisulfate (Plavix- antiplatelet medication) oral tablet 75 milligram (mg). Give one tablet by mouth daily for CVA. An active physician order dated [DATE] revealed an order for Aspirin (antiplatelet medication) oral tablet chewable 81 mg. Give one tablet by mouth one time daily for heart health. A Medication Administration Record (MAR) dated [DATE] revealed a physician's order for Clopidogrel Bisulfate (Plavix- antiplatelet medication) oral tablet 75 mg. Give 1 tablet by mouth daily for CVA. The medication was documented as administered daily on [DATE] through [DATE]. The MAR also revealed a physician's order for Aspirin oral tablet 81mg. Give one tablet by mouth daily for heart health. The medication was documented as administered daily on [DATE] through [DATE]. A nursing progress note written by Nurse #1 on [DATE] at 2:12 AM revealed at 1:07 AM NA #1 saw the resident's call light on and went into the resident's room and noted him lying on the floor by the window and immediately notified the nurse. Nurse #1 went into the room and noted Resident #116 lying on the floor on his right side. Resident #116 stated, I was trying to fix the air conditioner. NA #1 and Nurse #1 assisted him up off of the floor into a standing position and then seated him onto the bed. Resident #116 was noted with a quarter sized hematoma to the right side of his head, with the skin not broken. He did not voice any complaints at the time of the fall. Resident #116 was placed on neurological monitoring, and his blood sugar was obtained. He denied pain and stated he wanted to eat his snack and watch the television. A nursing progress note written by Nurse #1 dated [DATE] at 2:16 AM revealed at 1:35 AM Nurse #1 spoke with the on-call provider, Physician Assistant (PA), to notify her of Resident #116 being found on the floor and obtaining a quarter size hematoma. The Physician Assistant stated, Ok thank you and have a good night. No new orders were obtained. A recorded transcript dated [DATE], provided by the facility, revealed the following conversation regarding Resident #116 following an unwitnessed fall: At 1:07 AM, Nurse #1 contacted the PA to report that Resident #116 had been found on the floor. Nurse #1 stated that Resident #116 had a quarter-sized hematoma to the right side of his head and was voicing no complaints. Nurse #1 reported the residents' vital signs as blood pressure of 149/72 (normal range 120/80), pulse of 97 (normal range 60-90), respirations of 20 (normal range 12-20), and temperature of 97.9 (normal range 97.0 to 99.0). Nurse #1 further reported that neurological checks conducted up to that time were normal. The PA responded, Okay thank you have a good night. No further assessment, orders, recommendations, or instructions were provided by the PA during the call. The recorded transcript did not include Nurse #1 informing the PA that Resident #116 was receiving daily antiplatelet medication. The PA was no longer employed by the facility and attempts made to conduct a telephone interview with the PA were not successful. A nursing progress note dated [DATE] at 6:49 AM written by Nurse #1 revealed Resident #116 was in bed resting with eyes closed, easily aroused no signs of pain/discomfort noted. The hematoma to right side of the resident's head remained and the skin was intact with no bleeding or tenderness noted. Remained on neurological assessments completed and within normal range. Nurse #1 was no longer employed by the facility, and attempts were made to conduct a telephone interview with Nurse #1 and were not successful. The facility provided Nurse #1's statement from [DATE]. Nurse #1 stated she was notified by Nurse Aide #1 that Resident #116 had experienced an unwitnessed fall around 1:07 AM. She assessed the resident, obtained vital signs and assisted in getting the resident back to bed. The on-call provider was notified with no new orders received. Neurological assessments were initiated with no acute changes identified. She last saw Resident #116 around 7:00 AM and he was resident in bed with no signs of distress. An interview conducted with NA #1 on [DATE] at 3:34 PM revealed she was responsible for Resident #116 on [DATE] during the 11:00 PM to 7:00 AM shift that ended on [DATE]. She stated around 1:15 AM she was in another resident's room when she saw Resident #116's call light come on. She stated she went into the room and observed the resident lying with his bottom on the floor and head/right shoulder on the air conditioning unit. NA #1 indicated Resident #116 was confused, which was a change from how he normally was; she asked him not to move and walked into the doorway of the room and yelled for Nurse #1 to come into the room. Nurse #1 came into the room and assessed Resident #116 for injuries and obtained his vital signs. She explained she and Nurse #1 assisted Resident #116 back into bed. NA #1 stated he initially had no injuries but stated his head was hurting following the unwitnessed fall. NA #1 recalled while she was completing 4:00 AM rounding Resident #116 stated to her that his head was hurting, she immediately notified Nurse #1 and told her she thought he needed to go to the hospital because of his complaints of a headache. She explained she did not know what Nurse #1 did with the information but Resident #116 went back to sleep and during her last rounding at 7:00 AM he was okay and told her goodbye. A review of the medical record revealed no evidence that a medical provider was notified of the headache reported by Resident #116 during NA #1's 4:00 AM rounding. A telehealth note electronically signed by Nurse Practitioner (NP) #1 dated [DATE] at 8:00 AM revealed Nurse #2 called an on-call provider (NP #1) with notification that Resident #116 was sent to the hospital. Resident #116 was status post an unwitnessed fall with a head injury involved that happened at 1:15 AM on [DATE]. Neurological checks were initiated and the on-call provider was called but did not send the resident out to the hospital. Vital signs were stable, however 15 minutes following the last neurological check, the resident was unresponsive with labored breathing, wet sounding lungs and not responding to verbal stimuli. A rapid response was called, as well as 911 emergency services. Vital signs were the following BP 123/58, P 76, oxygen saturation/pulse oximetry 89-90% on room air with respirations 21. He was a dialysis resident, had recently been diagnosed with COVID-19 and had a plurex (a medical drainage system used to manage fluid buildup around the lungs or abdomen). He was placed on oxygen at 2 liters via nasal cannula by Nurse #2 and his oxygen saturation went up to 95%. EMS arrived and he was transported to the hospital for an evaluation. A hospital transfer document dated [DATE] revealed Resident #116 was transported to the hospital for evaluation at 9:07 AM due to unresponsiveness. EMS records dated [DATE] revealed they were contacted at 8:59 AM, arrived on scene at the facility at 9:05 AM and were at Resident #116's bedside at 9:09 AM. Staff reported he was last observed normal at 8:30 AM on [DATE]. Resident #116 was unconscious, with snoring and labored respirations when the medic arrived. He was noted to have a strong regular radial pulse in a semi-Fowlers (lying on his back with the head of the bed raised 30 to 45 degrees in angle) position in bed side. Resident #116 was noted with altered mental status, difficulty breathing, and his right pupil was nonreactive and his left pupil was sluggish. Resident #116 was unresponsive to pain on arrival and throughout transport. It was noted that Resident #116 had a fall at 1:00 AM with a possible head injury and he was not seen at the hospital at the time of the incident. Staff stated resident was found unresponsive with labored breathing a few minutes prior to 9:00 AM. Resident #116 was on supplemental oxygen at 4 liters upon medic arrival, he was transitioned to a non-rebreather mask with 15 liters of supplemental oxygen applied. An oropharyngeal airway was inserted to maintain a patent airway. His Glascow Coma Scale was 3. Intravenous (IV) access (a medical method used to deliver fluids and medications through a vein) was attempted twice but unsuccessful. The primary impression included intracerebral hemorrhage (a type of stroke characterized by sudden bleeding into the brain tissue, which can lead to serious neurological deficits and requires immediate medical attention). Hospital records dated [DATE] revealed Resident #116 was transported to the hospital on [DATE] after being found unresponsive. In the Emergency Department it was noted Resident #116 had experienced a ground level fall but did not seek treatment. Upon assessment he was not responsive to painful stimuli (physical pressure applied to the skin to assess level of consciousness) with his pupils mid-dilated and fixed (are a sign of disrupted pupillary reflex, often due to serious neurological injury). Airway protection was necessary and Resident #116 was intubated and mechanically ventilated. A computed tomography (CT) scan revealed a very large left subdural hematoma measuring up to 2.4 centimeters in thickness, resulting in a 2.5-centimeter rightward midline shift. Neurosurgery was consulted and recommended no surgical intervention due to poor neurological exam and imaging. Resident #116 was placed on comfort care measures and ultimately expired on [DATE]. A death certificate dated [DATE] for Resident #116 revealed the cause of death included subdural hematoma with mass effect, blunt force head injury, and ground-level fall from standing height. On [DATE] at 2:10 PM an interview was conducted with Nurse Practitioner (NP) #1. The interview revealed she worked for an on call company completing telehealth visits during off hours (times the facility Nurse Practitioner or Medical Director were not in the facility). She stated she did not recall Resident #116, nor did she recall receiving the telephone call from Nurse #2. The surveyor read the nursing note from Nurse #2 to NP #1. She stated she always sent residents to the hospital for an evaluation if there was a fall with a hematoma or head injury involved because there was a risk for bleeding especially if the resident had visible injuries and was receiving an antiplatelet medication. NP #1 stated a hematoma to the resident's head would have been a physical disability, and he should have been sent to the hospital following the fall around 1:00 AM by the initial physician contacted. The interview also revealed the on-call physician should have been notified if the resident experienced a change of condition such as a headache. An interview conducted on [DATE] at 11:01 AM with the former Director of Nursing (DON) revealed Resident #116 was sent to the hospital for an evaluation on [DATE] due to unresponsiveness. She stated she did not recall being notified of the resident's fall during the night shift on [DATE] and the nurses would typically call her if there was an injury involved. The DON indicated she became aware of the situation when Resident #116 was sent to the hospital later that morning. The interview revealed the on-call Physician Assistant had only made decisions based on the information Nurse #1 had given her and the DON did not recall the details. The DON stated following the fall Nurse #1 notified the provider on call. Nurse #1 started neurological monitoring which included waking the resident up upon assessment. She explained that Nurse #1 should have notified the provider that the resident was receiving an antiplatelet medication because it would have placed the resident at an increased risk of bleeding. She further explained that if Resident #116 had experienced a headache at 4:00 AM the provider should have been notified of the change of condition. An interview conducted on [DATE] at 9:37 AM with NP #2 revealed she was not contacted on [DATE] following Resident #116's unwitnessed fall because the nurses contacted the on-call providers for assistance during the night shift hours. She learned of the incident after it occurred during a meeting to discuss the situation with the interdisciplinary team. She stated it became the standard to send any resident out to the hospital for an evaluation after the fall with Resident #116. The interview revealed it was up to the provider on call to send the resident to the hospital and she was not aware if Nurse #1 had explained to the provider the resident was receiving an antiplatelet medication. She stated if she was notified, she would want to see the resident and assess the head injury however, if there was a visible hematoma to the resident's head, she would have sent him out to the hospital for an evaluation due to being at an increased risk of bleeding. The interview revealed notifying the provider if a resident was receiving an antiplatelet medication would have been important to identifying an increased risk of bleeding. NP #2 stated if Resident #116 experienced a headache that would have been a change of condition and a provider should have been notified. On [DATE] at 9:46 AM an interview was conducted with the Medical Director who had just started working in the facility during [DATE] but was interviewed regarding his medical opinion. During the interview he stated Resident #116 suffered from a midline shift, explaining that it was a critical and significant condition causing pressure to build up inside of the skull due to bleeding. The Medical Director stated the medication Plavix would be considered anticoagulation (medical treatment using medication often called blood thinners, to slow down the body's process of making clots) and would have put the resident at an increased risk for bleeding. The interview revealed Resident #116 should have been sent to the hospital immediately after the fall for an evaluation due to being at high risk of bleeding and experiencing an unwitnessed fall. The Medical Director indicated he was unable to state whether or not sending the resident to the hospital sooner would have resulted in a different outcome for Resident #116 but stated if he had complaints of a headache during the night that would have been a change of condition and could have indicated the need for further medical attention. The Administrator was notified of the immediate jeopardy on [DATE] at 10:53 AM. The facility provided the following credible allegation of immediate jeopardy removal. 1. Identification of recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On [DATE] at 1:07 AM, Resident #116, who was receiving antiplatelet therapy, experienced an unwitnessed fall in his room and was observed with his head on the air conditioning unit with a hematoma noted to the right side of his head. The licensed nurse assessed Resident #116, initiated neurological checks, which were completed within normal limits, and notified the on-call provider of the fall, head injury, hematoma, and neurological assessment results. Resident #116's antiplatelet medication status was not communicated to the provider during the notification. Emergency response was activated at 8:58 AM upon change in condition, and Resident #116 was transported to the hospital. Resident #116 died on [DATE]. The facility communicated the findings of its review to the contracted telemedicine organization, which placed the provider involved in the [DATE] encounter on suspension pending clinical review on [DATE]. The provider separated from employment with the contracted telemedicine organization on [DATE]. On [DATE], the telemedicine organization communicated its review findings and expectations for post-fall encounters, including completion of a medication review and documentation of the encounter, and provided written confirmation of the completed review. Residents receiving anticoagulant or antiplatelet medications who experience a fall or head injury are the recipients likely to be affected by the identified noncompliance. On [DATE], the Director of Nursing completed a review of all current residents receiving blood thinning medication who experienced a fall within the past thirty days. Fourteen residents were reviewed. Each fall was confirmed to have appropriate post-fall response, including provider notification, and no resident was identified with an adverse outcome or unaddressed clinical concern. The medical provider was updated on [DATE] by the Director of Nursing regarding the fall for each resident reviewed, with notification documented in the clinical record. On [DATE], the Director of Nursing repeated this review with all current residents receiving blood thinning medication who experienced a fall within the past thirty days. Each record was reviewed for any change in condition following the fall, including complaints of pain or headache, with verification that any change in condition was reported to the licensed nurse, assessed, and communicated to the provider, and that appropriate follow-up care was rendered, including transfer to a higher level of care when needed. No resident was identified with an adverse outcome or unaddressed clinical concern. On [DATE], the Director of Nursing also reviewed incident and accident reports for all residents for the past thirty days to identify any change in condition that was not reported to the medical provider. No resident was identified with a change in condition that was not reported to the provider. 2. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the actions were completed On [DATE], the facility implemented a requirement that licensed nurses verify a resident's anticoagulant and antiplatelet status against the medication administration record before provider notification following a fall, so that the medication status communicated to the provider is confirmed rather than recalled. On [DATE], the facility implemented a revised fall checklist requiring notification of the on-call provider after every fall. The checklist includes a reminder to inform the provider when the resident is receiving blood thinning medication. If the on-call provider does not respond or does not act on the clinical information provided, the licensed nurse contacts the attending physician, the medical director, or the Director of Nursing. Revised fall investigation packets containing the checklist were placed at each nursing station on [DATE] by the Director of Nursing. The Director of Nursing or designee is responsible for ensuring that each nursing station maintains copies of the checklist. Beginning [DATE] and completed [DATE], the Director of Nursing and Assistant Director of Nursing provided in-person education to all licensed nurses, including contracted nurses, on provider notification when a resident receiving blood thinning medication experiences a fall or other change in condition. This included verification of the resident's anticoagulant and antiplatelet status against the medication administration record before provider notification, communication of the resident's blood thinning medication status to the provider, documentation of provider and responsible party notification, and escalation through the chain of command, including contacting the attending physician, the medical director, or the Director of Nursing when the on-call provider does not respond or does not act on the clinical information reported. The education addressed the information to be communicated to the provider when reporting a change in condition, including vital signs, clinical findings, high risk medications including anticoagulant and antiplatelet medications, and allergies, and was provided using the facility's training document for provider notification of a change in condition. Education included use of the revised fall packets and checklist and post-fall documentation requirements. Effective [DATE], no licensed nurse works a scheduled shift until the education is completed, as verified by the Director of Nursing. Staff who have not completed the education are removed from the schedule until the education is completed, and newly hired or newly contracted staff receive the education during onboarding before assuming resident care duties, tracked by the Director of Nursing or designee. On [DATE], the Administrator informed the Director of Nursing and Assistant Director of Nursing of this responsibility. On [DATE], an ad hoc Quality Assurance and Performance Improvement committee meeting was held to review the identified noncompliance, the facility's review findings, and the corrective actions and education implemented and in progress. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Services Director, Unit Manager, Human Resources Director, and Business Office Manager. Alleged date of Immediate Jeopardy removal: [DATE] The facility's credible allegation of immediate jeopardy removal was validated on [DATE]. Audits completed by the Director of Nursing (DON) were reviewed of all residents receiving blood thinning medication who experienced a fall within the past thirty days. Fourteen residents were reviewed. Each fall was confirmed to have appropriate post-fall response, including provider notification, and no resident was identified with an adverse outcome or unaddressed clinical concern. Incident and accident reports for all residents for the past thirty days were reviewed to identify any change in condition that was not reported to the medical provider. Interviews conducted with nursing staff revealed they had received education on provider notification when a resident receiving blood thinning medication experiences a fall or other change in condition. This included verification of the resident's anticoagulant and antiplatelet status against the medication administration record before provider notification, communication of the resident's blood thinning medication status to the provider, documentation of provider and responsible party notification, and escalation through the chain of command, including contacting the attending physician, the medical director, or the Director of Nursing when the on-call provider does not respond or does not act on the clinical information reported. Quality Assurance and Performance Improvement committee minutes were reviewed. 2. A review of Resident #117's hospital Discharge summary dated [DATE] revealed she had a follow-up appointment with the Orthopedic Surgeon on [DATE] at 1:00 PM. The discharge summary also indicated Resident #117 had a surgical incision that had absorbable sutures and no drainage or surrounding erythema (redness) was present. Resident #117 was admitted to the facility on [DATE]. Her diagnoses included fracture of the neck of right femur, diabetes mellitus, dysphagia (difficulty swallowing), pneumonia, dementia, chronic obstructive pulmonary disease, and history of thyroid cancer status post thyroidectomy (removal of the thyroid). A Wound Care NP progress note dated [DATE] revealed Resident #117 was a new admission to the facility and was seen for a skin and wound assessment. The note indicated Resident #117 was admitted to the facility on [DATE] after being discharged from the hospital due to a right hip hemiarthroplasty (a surgery that replaces the ball of the hip). Hospital discharge paperwork indicated a vacuum-assisted closure device (a device that uses gentle suction to help complex or slow-healing wounds close faster) was removed and the incision remained open to air. The note revealed recommendations for ongoing pressure reduction and turning and repositioning precautions per protocol, including pressure reduction to Resident #117's heels and all bony prominences. The note indicated there was no evidence of infection during visit and if complications arise, staff were educated to contact the operating surgeon. The Wound Care NP noted to please ensure surgical follow up had been scheduled and to optimize nutritional intake. A review of Resident #117's physician's orders dated [DATE] revealed a treatment for cleansing right hip with wound cleanser, applying glycerin-based wipe and leave open to air, daily on day shift for closed surgical wound. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 was severely cognitively impaired. The MDS revealed Resident #117 was coded for a surgical wound and two unstage

Based on observations, record review, review of recorded transcripts, and interviews with staff, Responsible Party (RP), Nurse Practitioner, and Medical Director, the facility failed to recognize the seriousness of an unwitnessed fall with a head injury for a resident that was prescribed an antiplatelet medication daily which can cause an increased bleeding risk or identify the urgent need for medical attention. On 09/14/25 at 1:07 AM, Resident #116 experienced an unwitnessed fall in his room while attempting to adjust his packaged terminal air conditioner (PTAC) unit (a self-contained heating and cooling system). Resident #116 was observed with his head on the PTAC unit and his bottom on the floor. Resident #116 was assessed by Nurse #1 who noted a quarter-sized hematoma to the right side of his head and the resident reported his head was hurting. Resident #116 complained of a headache to Nurse Aide #1 at 4:00 AM and the NA reported this to Nurse #1. Nurse #1 completed a neurological assessment at 7:15 AM and documented Resident #116's blood pressure was 126/56, pulse 99, respirations 18 and temperature 97.7. Level of consciousness, pupils and hand grasp were checked as normal. Nurse #1 informed Nurse #2 of Resident #116's unwitnessed fall and hematoma during report that morning. Nurse #2 observed the resident was sleeping around 7:00 AM and when she returned to the room at approximately 8:30 AM, Resident #116 was noted to be unresponsive, with labored breathing (difficult) and wet-sounding lungs, and was not responding to verbal stimuli. Emergency Medical Services (EMS) was contacted and found the resident unconscious, with snoring and labored respirations, and unresponsive to pain. He was transitioned to a non-rebreather mask (oxygen mask that provides high concentrations of supplemental oxygen and are used in acute or emergency situations) with 15 liters of supplemental oxygen applied. Resident #116's Glascow Coma Scale (GCS- a tool to assess level of consciousness of patients with acute brain injury) was 3 which is the lowest score and indicates severe neurological impairment. Resident #116 was transported to the hospital. Upon evaluation, Resident #116 was found to have a large subdural hematoma (type of brain bleed in which the blood pools between the skull and the brain) and was intubated (a breathing tube placed through the mouth, into the windpipe to keep the airway open) and mechanically ventilated for airway protection. A CT scan revealed a very large left subdural hematoma measuring up to 2.4 centimeters in thickness, resulting in a 2.5-centimeter rightward midline shift (the accumulated blood was pushing the brain significantly to the right by about 2.5 cm, which indicated strong pressure inside the skull). Neurosurgery was consulted and recommended no surgical intervention due to poor neurological exam. A death certificate dated 09/14/25 for Resident #116 revealed the cause of death included subdural hematoma with mass effect, blunt force head injury, and ground-level fall from standing height. Additionally, based on record review, and interviews with staff, Husband/Responsible Party (RP), Family Member #1, Nurse Practitioner (NP), Wound Care NP, Orthopedic Surgeon's Office Receptionist, Orthopedic Surgeon's Office Nurse, Mobile Imaging Services Receptionist, Laboratory Services Receptionist, Fire Department First Responder, and Former Medical Director, the facility failed to develop and implement an effective and comprehensive plan of care to ensure the health and safety of a resident who had multiple complex medical conditions. Resident #117 was admitted to the facility on [DATE] after hospitalization for a right hip hemiarthroplasty (a surgery that replaces the ball of the hip) with orders for a follow-up with the Orthopedic Surgeon on 11/10/25 which was rescheduled for 11/17/25. Resident #117 was not transported to either follow up appointment with the surgeon and nursing staff did not contact the surgeon's office to consult for recommendations when Resident #117's surgical incision showed signs of infection and dehisced (a closed surgical wound reopens, partially or completely) on 11/19/25. admission laboratory tests ordered on 11/5/25 were not collected until 11/21/25 and included Resident #117's white blood cell count was 14.6 (normal range 4.1-10.7) and TSH (thyroid-stimulating hormone) was 19.02 (normal range 0.45-5.33). A TSH level above 20 is considered dangerously high and requires immediate medical attention. There was no evidence in the medical record that a medical provider was consulted about the results of the laboratory test results. On 11/20/25 a urinalysis and urine culture was ordered due to very turbid thick bladder sludge (urine that is cloudy, murky, or contains visible sediment) in catheter tubing and urine collection bag and the specimen was never collected. NP #2 assessed Resident #117 on 11/21/25 noted crackles and expiratory wheezes (both abnormal lung sounds) to bilateral lobes (both lungs) and documented in the progress note a STAT (urgent) chest x-ray would be ordered. NP #2's progress note indicated Resident #117 had a diagnosis of dysphagia (difficulty swallowing) and noted the crackles and secretions may indicate a component of aspiration (a condition when food, liquid, or saliva slip past vocal cords and could enter the windpipe and lungs). The chest x-ray was not obtained until 11/23/25 and there was no evidence in the medical record NP #2, or a medical provider was contacted for guidance on how to proceed when the x-ray was not obtained on 11/21/25 or 11/22/25. Nursing staff failed to complete or document regular comprehensive assessments of Resident #117's respiratory status and effectively communicate between staff as Resident #117's condition continued to decline. Resident #117 experienced worsening respiratory status on 11/23/25 and beginning at breakfast she could not eat or drink. The facility failed to collaborate with the resident's RP and Family Member #1 when Resident #117's condition continued to decline to determine the course of treatment and/or medical care. Resident #117's condition continued to decline into the evening when Nurse #3 noted Resident #117 sounded moist in her chest like she might have aspirated and did not improve after a nebulizer treatment and then was unresponsive. Emergency Medical Services (EMS) was contacted and documented Resident #117 appeared to have an obstructed airway (potentially life-threatening condition that occurs when the normal flow of air into and out of the lungs is partially or completely blocked). Multiple suction attempts and attempts to clear the airway were unsuccessful and Resident #117 appeared to lose a pulse and stop breathing. Resident #117 had a physician's order for a Do Not Resuscitate (DNR) and no intubation or mechanical ventilation and Resident #117 expired in the facility. Resident #117's death certificate dated 12/1/25 revealed the causes of death included acute respiratory failure, pneumonia of unknown organism, and chronic obstructive pulmonary disease. The deficient practice affected 2 of 3 residents reviewed for quality of care (Resident #117 and Resident #116). Immediate Jeopardy began on 09/14/25 when the facility failed to recognize the seriousness of Resident #116's fall with a head injury and seek medical attention at a higher level of care. Immediate Jeopardy began on 11/21/25 when the facility failed to recognize the seriousness of Resident #117's respiratory status, ensure a chest x-ray was obtained, and review abnormal laboratory test results. A comprehensive plan of care could not be determined due to the lack of collaboration and communication of information with the Physician or NP. Immediate Jeopardy was removed on 8/24/26 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure the monitoring systems put into place are effective and education is completed. This deficient practice affected 2 of 3 residents reviewed for quality of care (Resident #116 and Resident #117). The findings included: 1. Resident #116 was admitted into the facility on [DATE] with diagnosis including pleural effusion, end stage renal disease, dependence on renal dialysis, osteoarthritis, diabetes mellitus, Parkinson's disease, myeloma, cerebrovascular accident (CVA) and muscle weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was cognitively intact. The assessment revealed he required supervision or touch assistance during toilet transfers, chair to bed transfers and walking 10 feet. Mobility devices included use of a wheelchair. Resident #116 was coded as having one fall since admission with no injury. The assessment revealed he was taking an antiplatelet medication during the assessment period. An active physician order dated 08/20/25 revealed an order for Clopidogrel Bisulfate (Plavix- antiplatelet medication) oral tablet 75 milligram (mg). Give one tablet by mouth daily for Cardiovascular accident (CVA). An active physician order dated 08/21/25 revealed an order for Aspirin (antiplatelet medication) oral tablet chewable 81 mg. Give one tablet by mouth one time daily for heart health. A Medication Administration Record (MAR) dated September 2025 revealed a physician's order for Clopidogrel Bisulfate (Plavix- antiplatelet medication) oral tablet 75 mg. Give 1 tablet by mouth daily for CVA. The medication was documented as administered daily on 09/01/25 through 09/13/25. The MAR revealed a physician's order for Aspirin oral tablet 81mg. Give one tablet by mouth daily for heart health. The medication was documented as administered daily on 09/01/25 through 09/13/25. An interview conducted with Nurse Aide (NA) #1 on 08/04/26 at 3:34 PM revealed she was responsible for Resident #116 on 09/13/25 during the 11:00 PM to 7:00 AM shift. She stated around 1:15 AM she was in another resident's room when she saw Resident #116's call light come on. She stated she went into the room and observed the resident lying with his bottom on the floor and head/right shoulder on the PTAC unit. NA #1 indicated Resident #116 was confused, which was a change from how he normally was; she asked him not to move and walked into the doorway of the room and yelled for Nurse #1 to come into the room. Nurse #1 came into the room and assessed Resident #116 for injuries and obtained his vital signs. She explained she and Nurse #1 assisted Resident #116 back into bed, however, could not recall if they lifted him with a mechanical lift or assisted him with a gait belt. She stated he initially had no injuries but stated his head was hurting following the fall. NA #1 recalled while she was completing 4:00 AM rounding Resident #116 again stated to her that his head was hurting, she immediately notified Nurse #1 and told her she thought he needed to go to the hospital because of his complaints of a headache. She explained she did not know what Nurse #1 did with the information but Resident #116 went back to sleep and during her last rounding at 7:00 AM he was okay and told her goodbye. A nursing progress note written by Nurse #1 on 09/14/25 at 2:12 AM revealed at 1:07 AM the Nurse Aide (NA #1) saw the residents call light on and went into the resident's room and noted him lying on the floor by the window and immediately notified the nurse. Nurse #1 went into the room and noted Resident #116 lying on the floor on his right side. Resident #116 stated, I was trying to fix the air conditioner. NA #1 and Nurse #1 assisted him up off of the floor into a standing position and then seated him onto the bed. Resident #116 was noted with a quarter sized hematoma to the right side of his head, with the skin not broken. He did not voice any complaints at the time of the fall. Resident #116 was placed on neurological monitoring, and his blood sugar was obtained. He denied pain and stated he wanted to eat his snack and watch the television. A nursing progress note written by Nurse #1 dated 09/14/25 at 2:16 AM revealed at 1:35 AM Nurse #1 spoke with the on-call Physician Assistant (PA) to notify her of Resident #116 being found on the floor and obtaining a quarter size hematoma. The Physician Assistant stated, Ok thank you and have a good night. No new orders were obtained. A recorded transcript dated 09/14/25, provided by the facility, revealed the following conversation regarding Resident #116 following an unwitnessed fall: At 1:07 AM, Nurse #1 contacted the Physician Assistant (PA) to report that Resident #116 had been found on the floor. Nurse #1 stated that Resident #116 had a quarter-sized hematoma to the right side of his head and was voicing no complaints. Nurse #1 reported the residents' vital signs as blood pressure of 149/72 (normal range 120/80), pulse of 97(normal range 60-90), respirations of 20(normal range 12-20) , and temperature of 97.9 (normal range 97.0 to 99.0). Nurse #1 further reported that neurological checks conducted up to that time were normal. The PA responded, Okay thank you have a good night. No further assessment, orders, recommendations, or instructions were provided by the PA during the call. The recorded transcript did not include Nurse #1 informing the PA that Resident #116 was receiving daily antiplatelet medication. The PA was no longer employed by the facility and attempts made to conduct a telephone interview with the PA were not successful. On 09/14/25 at 2:28 AM a Situation, Background, Assessment and Recommendation (SBAR) Summary for providers completed by Nurse #1 listed the following information: - Blood Pressure: BP 149/72 (normal range 120/80) - Pulse: P 97 (normal range 60-90) - Respirations: 20 (normal range 12-20) - Temperature: T 97.9 (97.0-99.0) - Pulse Oximetry: oxygen saturation of the blood 97 % (normal range >92%) Code Status: Full Code Resident/Patient is on antiplatelet other than warfarin: No Nursing observations, evaluation, and recommendations were: Resident remains at baseline. Denies pain or discomfort. Neuro-checks in progress noted within normal limits. A nursing progress note dated 09/14/25 at 6:49 AM written by Nurse #1 revealed Resident #116 was in bed resting with eyes closed, easily aroused no signs of pain/discomfort noted. Hematoma to right side of head remained, skin intact with no bleeding or tenderness noted. Remained on neurological assessments completed and within normal range. A neurological observation form dated 09/14/25 revealed neurological assessments were initiated at 1:15 AM and completed every 15 minutes until 2:15 AM. At 2:45 AM every 30-minute assessments were completed until 3:15 AM. At 3:15 AM, every one-hour assessments were completed through 7:15 AM. No acute changes were noted within the neurological assessments which assessed level of consciousness, pupils and hand grasp. Resident #116 was noted to be asleep during the 3:15 AM to 7:15 AM assessments completed by Nurse #1. The last documentation on the assessment was by Nurse #1 at 7:15 AM, Resident #116's blood pressure was 126/56, pulse 99, respirations 18 and temperature 97.7. Level of consciousness, pupils and hand grasp were checked as normal. Comments included that the resident was asleep. Following the 7:15 AM assessment, Resident #116 would have received every 4-hour monitoring, it was documented that the resident was hospitalized . Nurse #1 was no longer employed by the facility, and attempts were made to conduct a telephone interview with Nurse #1 and were not successful. The facility provided Nurse #1's statement from 09/14/25. Nurse #1 stated she was notified by Nurse Aide #1 that Resident #116 had experienced an unwitnessed fall around 1:07 AM. She assessed the resident, obtained vital signs and assisted in getting the resident back to bed. The on-call provider was notified with no new orders received. Neurological assessments were initiated with no acute changes identified. She last saw Resident #116 around 7:00 AM and he was resident in bed with no signs of distress. A telehealth note electronically signed by Nurse Practitioner (NP) #1 dated 09/14/25 at 8:00 AM revealed Nurse #2 called an on call (NP #1) with notification that Resident #116 was sent to the hospital. Resident #116 was status post an unwitnessed fall with a head injury involved (happened at 1:15 AM on 9/14, neurological checks were initiated, the on-call provider was called but she did not sent him out). Vital signs were stable, however 15 minutes following the last neurological check, the resident was unresponsive with labored breathing, wet sounding lungs and not responding to verbal stimuli. A rapid response was called, as well as 911 emergency services. Vital signs were the following BP 123/58, P 76, oxygen saturation/pulse oximetry 89-90% on room air with respirations 21. He was a dialysis resident, had recently been diagnosed with COVID-19 and had a plurex (a medical drainage system used to manage fluid buildup around the lungs or abdomen). He was placed on oxygen at 2 liters via nasal cannula by Nurse #2 and his oxygen saturation went up to 95%. Emergency Medical Services (EMS) arrived, and he was transported to the hospital for an evaluation. On 09/14/25 at 2:44 PM Nurse #2 entered a late entry SBAR Summary for providers for 8:00 AM that listed the following information for Resident #116: - Blood Pressure: BP 123/58 - Pulse: P 76 - Respirations: R 21 - Temperature: 98.4 - Pulse Oximetry: oxygen saturation of the blood was 90.0 % Code Status: Full Code Resident/Patient is on Coumadin/warfarin: No Resident/Patient is on antiplatelet other than warfarin: Yes, on an antiplatelet Mental Status Evaluation: Unresponsiveness An interview conducted with Nurse #2 on 08/04/26 at 1:46 PM revealed on 09/14/26 she was responsible for Resident #116 during the 7:00 AM to 3:00 PM shift. Nurse #2 stated it was hard for her to remember what happened with Resident #116 and to rely on her documentation for details. She stated when her shift began Nurse #1 told her Resident #116 had experienced an unwitnessed fall with a hematoma noted to his head. She stated she went into the room around 7:00 AM and he was asleep. Nurse #2 explained that Nurse #1 had started neurological assessments during her shift (11:00 PM to 7:00 AM) and they were to be continued during first shift however Resident #116 was sent to the hospital. Nurse #2 stated she had taken care of Resident #116 in the past and he was alert and responsive, however on the morning of 09/14/25 when she went into the room to administer medication around 8:30 AM and he was unresponsive. She explained Resident #116 still had a pulse, she notified EMS immediately and they arrived shortly after to transfer him to the hospital. Nurse #2 stated she knew he wasn't at his baseline and just wanted to make sure he received assistance as soon as possible. Nurse #2 then notified the on-call Nurse Practitioner to let her know the resident was being sent to the hospital. She explained Resident #116 was impulsive and often would stand up without staff assistance using his wheelchair to ambulate. A hospital transfer document dated 09/14/25 revealed Resident #116 was transported to the hospital for evaluation at 9:07 AM due to unresponsiveness. EMS records dated 09/14/25 revealed they were contacted at 8:59 AM, arrived on scene at the facility at 9:05 AM and were at Resident #116's bedside at 9:09 AM. Staff reported he was last observed normal at 8:30 AM on 09/14/25. Resident #116 was unconscious, with snoring and labored respirations when the medic arrived. He was noted to have a strong regular radial pulse in a semi-Fowlers (lying on his back with the head of the bed raised 30 to 45 degrees in angle) position in bed side. Resident #116 was noted with altered mental status, difficulty breathing, and his right pupil was nonreactive and his left pupil was sluggish. Resident #116 was unresponsive to pain on arrival and throughout transport. It was noted that Resident #116 had a fall at 1:00 AM with a possible head injury and he was not seen at the hospital at the time of the incident. Staff stated resident was found unresponsive with labored breathing a few minutes prior to 9:00 AM. Resident #116 was on supplemental oxygen at 4 liters upon medic arrival, he was transitioned to a non-rebreather mask with 15 liters of supplemental oxygen applied. An oropharyngeal airway was inserted to maintain a patent airway. His Glascow Coma Scale was 3. Intravenous (IV) access (a medical method used to deliver fluids and medications through a vein) was attempted twice but unsuccessful. The primary impression included intracerebral hemorrhage (a type of stroke characterized by sudden bleeding into the brain tissue, which can lead to serious neurological deficits and requires immediate medical attention). Hospital records dated 09/14/25 revealed Resident #116 was transported to the hospital on [DATE] after being found unresponsive. In the Emergency Department it was noted Resident #116 had experienced a ground level fall but did not seek treatment. Upon assessment he was not responsive to painful stimuli (physical pressure applied to the skin to assess level of consciousness) with his pupils mid-dilated and fixed (are a sign of disrupted pupillary reflex, often due to serious neurological injury). Airway protection was necessary and Resident #116 was intubated and mechanically ventilated. A computed tomography (CT) scan revealed a very large left subdural hematoma measuring up to 2.4 centimeters in thickness, resulting in a 2.5-centimeter rightward midline shift. Neurosurgery was consulted and recommended no surgical intervention due to poor neurological exam and imaging. Resident #116 was placed on comfort care measures and ultimately expired on 09/14/25. A death certificate dated 09/14/25 for Resident #116 revealed the cause of death included subdural hematoma with mass effect, blunt force head injury, and ground-level fall from standing height. On 08/04/26 at 2:10 PM an interview was conducted with Nurse Practitioner #1. The interview revealed she worked for an (on call) company completing telehealth visits during off hours (times the facility Nurse Practitioner or Medical Director were not in the facility). She stated she did not recall Resident #116, nor did she recall receiving the telephone call from Nurse #2. The surveyor read the nursing note from Nurse #2 to NP #1. She stated she always sent residents to the hospital for an evaluation if there was a fall with a hematoma or head injury involved because there was a risk for bleeding especially if the resident had visible injuries and was receiving an antiplatelet medication. NP #1 stated a hematoma to the resident's head would have been a physical disability, and he should have been sent to the hospital following the fall around 1:00 AM by the initial physician contacted. An interview conducted with Resident #116's Responsible Party (RP) on 08/04/26 at 9:23 AM revealed she was contacted by the facility on 09/14/25 around 1:00 AM and a voicemail was left stating Resident #116 had hit his head on the air conditioner unit and obtained a hematoma. The Family Member stated Resident #116 was receiving an antiplatelet medication and was at an increased risk of bleeding. She was concerned because the facility did not immediately send him to the hospital for an evaluation. The next call she received was around 8:30 AM from the facility stating Resident #116 was unresponsive, she stated he expired at the hospital due to the hematoma and a fall from standing level. An interview conducted on 08/04/26 at 11:01 AM with the former Director of Nursing (DON) revealed Resident #116 was sent to the hospital for an evaluation on 09/14/25 due to unresponsiveness. She stated she did not recall being notified of the resident's fall during the night shift on 09/14/25 and the nurses would typically call her if there was an injury involved. The DON indicated she became aware of the situation when Resident #116 was sent to the hospital. The interview revealed the on-call Physician Assistant had only made decisions based on the information Nurse #1 had given her and the DON did not recall the details of what Nurse #1 specifically told the on-call provider. Nurse #1 initiated neurological assessments which included waking the resident up upon assessment. She explained Nurse #1 should have notified the provider that the resident was receiving an antiplatelet medication because it would have placed the resident at an increased risk of bleeding. An interview conducted on 08/04/26 at 9:37 AM with Nurse Practitioner #2 revealed she was not contacted during the incident because during the night shift hours the nurses contact the on-call providers for assistance. She learned of the incident after it occurred during a meeting to discuss the situation with the intradisciplinary team. She stated it became the standard to send any resident out to the hospital for an evaluation after the fall with Resident #116. The interview revealed it was up to the provider on call to send the resident to the hospital and was not aware if Nurse #1 had explained to the provider the resident was receiving an antiplatelet medication. She stated if she was notified, she would want to see the resident and assess the head injury however, if there was a visible hematoma to the resident's head, she would have sent him out to the hospital for an evaluation due to being at an increased risk of bleeding. On 08/04/26 at 9:46 AM an interview was conducted with the Medical Director who had just started working in the facility during April 2026 but was interviewed regarding his medical opinion. During the interview he stated Resident #116 suffered from a midline shift, explaining that it was a critical and significant condition causing pressure to build up inside of the skull due to bleeding. The Medical Director stated the medication Plavix would be considered anticoagulation and would have put the resident at an increased risk for bleeding. The interview revealed Resident #116 should have been sent to the hospital immediately after the fall for an evaluation due to being at high risk of bleeding and experiencing an unwitnessed fall. The Medical Director indicated he was unable to state whether or not sending the resident to the hospital sooner would have resulted in a different outcome for Resident #116. The Administrator was notified of the immediate jeopardy on 08/06/26 at 2:40 PM. The facility provided the following credible allegation of immediate jeopardy removal. 1. Identification of recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 09/14/2025 at 1:07 AM, Resident #116, who was receiving antiplatelet therapy, experienced a fall and hit his head on the air conditioning unit. The licensed nurse assessed Resident #116 immediately, initiated neurological checks, which were completed and within normal limits, and notified the on-call provider of the fall and head hematoma within thirty minutes, with vital signs and neurological check results reported. Resident #116 complained of a headache at 4:00 AM to the nurse aide, who stated she reported the complaint to the licensed nurse. Resident #116 was not transferred to a higher level of care until 8:58 AM, when Resident #116 was noted with an acute change in condition, including unresponsiveness to sternal rub, labored breathing, and wet sounding lungs, and emergency response was activated. Resident #116 died on [DATE]. Residents receiving antiplatelet medications who experience a fall or head injury are the recipients likely to be affected by the identified noncompliance. On 09/17/2025, the Director of Nursing completed a review of all current residents receiving blood thinning medication who experienced a fall within the past thirty days. Fourteen residents were reviewed. Each fall was confirmed to have a completed investigation and appropriate post-fall response, and no resident was identified with an adverse outcome or unaddressed clinical concern. The medical provider was updated on 09/17/2025 by the Director of Nursing regarding the fall for each resident reviewed, with notification documented in the clinical record. On 08/06/2026, the Director of Nursing repeated this review with all current residents receiving blood thinning medication who experienced a fall within the past thirty days. Each record was reviewed for a completed investigation, appropriate post-fall response, and any change in condition following the fall, including complaints of pain or headache, with verification that any change in condition was reported to the licensed nurse, assessed, and communicated to the provider, and that appropriate follow-up care was rendered, including transfer to a higher level of care when needed. No resident was identified with an adverse outcome or unaddressed clinical concern. On 09/18/2025, the Director of Nursing completed a review of all current residents receiving anticoagulant or antiplatelet therapy and verified that the medication was accurately reflected on the medication administration record and that a care plan focus with bleeding precaution interventions was in place and current for each resident reviewed. On 08/06/2026, the Director of Nursing repeated this review with all current residents receiving anticoagulant or antiplatelet therapy and verified that the medication was accurately reflected on the medication administration record and that a care plan focus with bleeding precaution interventions was in place and current for each resident reviewed. Care plan interventions are communicated to direct care staff through the Kardex (care guide that provides specific resident information). 2. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the actions were completed On 09/17/2025, the facility implemented a revised fall checklist requiring neurological checks for any fall involving the head or any unwitnessed fall. The checklist specifies that if the on-call provider does not respond or does not act on the clinical information provided, the licensed nurse contacts the attending physician, the medical director, or the Director of Nursing. Revised fall investigation packets containing the checklist were placed at each nursing station on 09/17/2025 by the Director of Nursing. The Director of Nursing or designee is responsible for ensuring that each nursing station maintains copies of the checklist. Beginning 08/06/2026 and completed 08/08/2026, the Director of Nursing and Assistant Director of Nursing provided in-person education to all licensed nurses, including contracted nurses, on the licensed nurse's response when a resident experiences a fall or a post-fall change in condition. This included licensed nurse assessment, initiation and completion of neurological assessments, reassessment and intervention when a resident reports a post-fall complaint, including headache or pain, notification of the provider of any post-fall change in condition or complaint, obtaining and implementing provider orders when indicated, and recognition of the need for evaluation at a higher level of care and activation of emergency medical services when the resident's condition warrants. This also included documentation of provider and responsible party notification, continued post-fall monitoring for change in condition including neurological checks, and escalation through the chain of command, including contacting the attending physician, the medical director, or the Director of Nursing when the on-call provider does not respond or does not act on

Based on observations and staff interviews, the facility failed to maintain the dumpster area in sanitary condition when brown drainage was present around the dumpster and dumpster area for 1 of 1 dumpster reviewed. This practice had the potential to attract pests and rodents. The findings included: An observation and interview were conducted with [NAME] #1 on 8/3/26 at 10:15 AM. The outdoor dumpster area was observed with a wet, cloudy, thick brown liquid drainage with a significant odor all around the dumpster and next to the disposal area for cooking grease. Cloudy, brown watery runoff from the from the dumpster was observed draining onto the front sidewalk and parking area of the facility. [NAME] #1 stated she, along with other kitchen staff, tried to keep the dumpster area clean with the cleaning equipment they had available to them in the kitchen but noted the area around the dumpster needed to be pressure washed and disinfected. A second observation of the dumpster area and interview with the Dietary Manager occurred on 8/3/26 at 3:25 PM. The dumpster had brown, cloudy drainage at the base. The Dietary Manager indicated the kitchen staff attempted to keep the area clean of debris but the ground around the dumpster area needed to be sprayed or pressure washed. A third observation of the dumpster area on 8/7/26 at 2:44 PM revealed cloudy, brown drainage coming out from under dumpster into the parking lot and front sidewalk and there was a very strong foul odor. A telephone interview with the Maintenance Director on 8/7/26 at 4:50 PM revealed he pressure-washed the dumpster area every week. He stated he could not clean and disinfect the inside of the dumpster because by the time he arrived at work in the morning, the facility staff had already put trash in the dumpster, so it was never empty to clean. A follow-up interview with the Maintenance Director occurred on 8/25/26 at 12:02 PM. He stated he pressure-washed the dumpster area early in the morning of 8/3/26 when he first arrived at the facility. The Maintenance Director explained the dumpster compressed what was inside and he stated when staff compressed the garbage, food debris and liquids would leak out to the concrete area around the dumpster. He stated it was likely staff members compressed the garbage on the morning of 8/3/26 after he pressure-washed the dumpster area. An interview with the Administrator on 8/7/26 at 5:10 PM revealed she expected the dumpster area to be maintained by kitchen and maintenance staff.

Based on observations and staff interviews, the facility failed to label and date food items stored for use, failed to discard a wet cardboard box of nutrition shakes covered in frozen condensation- failed to keep the kitchen floor free from standing water and failed to keep the wall behind the three-compartment sink clean without black debris build up. These practices occurred in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, 1 of 1 food preparation area, and 1 of 1 three-compartment sink and had the potential to affect food served to residents. The findings included:An initial tour of the main kitchen occurred on 8/3/26 at 10:00 AM with [NAME] #1 as the Dietary Manager was not available at the time. The observation included the following:a. A large, covered metal preparation pan containing cooked macaroni noodles and shredded chicken with no preparation date or use by date was stored in the walk-in cooler.b. A cardboard box containing approximately 25 individual-use nutrition shakes covered with frozen condensation from the refrigeration unit was observed on a metal shelf in the walk-in freezer.c. An observation of the food preparation area on 8/3/26 at 10:10 AM revealed a puddle of standing water approximately eight inches across, next to main kitchen door. The floor tile sloped toward the wall of the food preparation area and the standing water was approximately one inch deep at the deepest point.d. An observation of the dishwashing area on 8/3/26 at 10:12 AM revealed a black debris build-up on the wall behind the three-compartment sink two to three inches in height above the metal backsplash of the sink and ran along the entire edge above the three-compartment sink. A washable surface was observed on the wall behind the sink but did not cover the two-to-three-inch area directly above the three-compartment sink.An interview with [NAME] #1 on 8/3/26 at 10:13 AM revealed she along with other kitchen staff constantly used a disinfecting cleaner to remove the black debris behind the three-compartment sink but the debris continued to build up. She stated the maintenance department recently completed some work behind the sink and now the wall area was not completely covered with a plastic backsplash, which left the wall exposed above the sink.An interview with the Dietary Manager on 8/6/26 1:01 PM revealed she had been employed at the facility as the Dietary Manager for two weeks. She explained the puddle on the floor near the food preparation area was due to the sloped floor and water would collect next to the wall. The Dietary Manager stated Maintenance was aware of the floor sloping and kitchen staff did their best to keep the water from pooling in that area. She stated the pan of macaroni and chicken not being labeled was an oversight and staff had been educated on labeling all food items in the walk-in cooler. The Dietary Manager stated the cardboard box covered in condensation was the result of water freezing on the fan in the walk-in freezer. She stated the wall behind the three-compartment sink had been an issue since some maintenance was performed on the sink and the kitchen staff cleaned the wall behind the three-compartment sink when build-up occurred.An interview with the Administrator on 8/7/26 at 5:14 PM revealed she had the expectation that prepared food items would be labeled correctly, and the food preparation area, dishwashing area and the walk-in freezer be maintained.

Based on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain a pest free environment in 1 of 1 kitchen, 1 of 1 trash receptacle area, and 1 of 1 resident smoking area observed for maintaining an effective pest control program. The findings included: 1. A review of the facility's electronic maintenance request system since 6/6/25 was conducted. There were no work orders for pest control treatment requests documented for the kitchen area or dumpster area. A review of the monthly pest control service report dated 8/29/25 and signed electronically by the Maintenance Director read in part: Treated drains in kitchen and advised the customer to use white vinegar with a teaspoon of baking soda for drains at night. Advised on some fly traps to deal with fly issues and gave facility some fly light replacement traps. A review of a bi-monthly pest control service report dated 1/13/26 read, in part: would recommend putting a drain cleaner down drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 2/11/26 read, treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 3/24/26 read, in part: treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 4/7/26 read, in part: facility mentioned no pest activity had been observed since last visit (3/24/26) but Pest Control Technician found fungus gnat activity. A review of a bi-monthly pest control service report dated 5/19/26 read, in part: treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 5/5/26 read, in part: treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 6/30/26 read, in part: treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. A review of a bi-monthly pest control service report dated 7/15/26 read, in part: treated kitchen area and around dumpster. Would recommend putting a drain cleaner down the kitchen drains at nighttime when no running or standing water would be present to help with food gunk/debris. a. An observation of the main kitchen on 8/3/36 at 10:10 AM revealed approximately six small black flies and three medium sized, black flies with visible wings flying around the food plating area. An interview with [NAME] #1 on 8/3/26 at 10:10 AM revealed the flies were coming in from outside and the facility put a fly light near the hallway to the outside. [NAME] #1 stated there were a lot of flies near the dumpster outside. An interview with the Dietary Manager and additional observation of the main kitchen occurred on 8/3/26 at 3:20 PM. A medium-sized black fly with visible wings was observed sitting on the top plate of a stack of plates to be used for the dinner meal. The State Surveyor asked the Dietary Manager to remove the plate to have it washed. The Dietary Manager stated the Maintenance Director installed a bug light in the hallway leading from the main kitchen to the outside door near the dumpster area on 7/27/26 because there were so many flies coming in from the outside. b. An observation of the dumpster area on 8/3/26 at 10:15 AM revealed approximately 20-30 medium sized, black flies with visible wings swarming around the base of the dumpster where there was a brown, foul-smelling, cloudy brown sludge. An observation of the dumpster area with the Dietary Manager occurred on 8/3/26 at 3:25 PM There were approximately 20 medium-sized black house flies with visible wings flying around the base of the dumpster and brown, cloudy sludge at the base An additional observation of the dumpster area on 8/7/26 at 2:44 PM revealed approximately 20-30 medium sized, black house flies with visible wings flying around the base of the dumpster. An interview with the Pest Control Technician on 8/3/26 at 12:46 PM revealed the company he worked for was contracted to provide services at the facility bi-monthly and they treated pests that would cross the barrier they placed in the facility. He stated he did not treat the facility specifically for flies as flies would not come into contact with the spray he uses on the ground for other bugs and pests, but he advised the Maintenance Director on what could be beneficial for fly treatment. The Pest Control Technician stated that anytime a food preparation area was near an outside door, flies would get into the building. He stated he advised the Maintenance Director to utilize a drain cleaner for the drains in the kitchen to help combat flies as they were attracted to food and debris in the drains. The Pest Control Technician explained the facility purchased a few fly lights to help combat the flies in bigger areas of the facility including the kitchen. He stated he sprayed around the dumpster, but the cooking oil receptacle was next to the dumpster which caused additional build-up. The Pest Control Technician stated he continued to spray around the dumpster area, but it would not fix the problem of flies attracted to the area. A telephone interview with the Maintenance Director occurred on 8/7/26 at 4:40 PM. He stated the Pest Control Technician comes every other Tuesday to treat areas in the facility for pests and that he was responsible for signing and understanding the Pest Control Technician's reports. The Maintenance Director indicated he recently replaced the window screens in the resident rooms and put new door sweeps on all the doors to the outside. He stated he pressure washes the dumpster area weekly and that the Pest Control Technician sprays around the dumpster. The Maintenance Director stated the facility recently purchased new fly lights which he maintained. He stated he contacted a chemical and material supply company came to the facility on 8/6/26 and he was in the process of adding more fly lights int the kitchen to combat the flies. He stated he continued to treat the kitchen drains with cleaner. An interview on 8/7/26 at 5:10 PM with the Administrator revealed that some flies and gnats in the dumpster area were a seasonal concern. She stated the Pest Control Technician comes every other week to treat the facility and had the expectation that the facility would treat for pests as needed. 2. Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. On 08/03/26 at 11:15 AM an observation was conducted of the resident smoking area. Resident #23 was observed sitting in his wheelchair smoking a cigarette toward the right side of the enclosed smoking area. Behind Resident #23 (approximately 1-2 feet) from his wheelchair was noted to be a large spider web with a black spider observed with a red hourglass shape on the spider's body. On 08/03/26 at 11:31 AM an observation was conducted of an additional deceased black spider with a red hourglass shape on its body beside the resident ash tray in the smoking area. On 08/03/26 at 11:20 AM an interview was conducted with Resident #23. During the interview he stated there were an increased number of flies in the smoking area. He explained that he was, just used to it, because the facility wouldn't do anything about it. Resident #23 stated he hadn't seen the spiders in the smoking area before but that he wasn't afraid of them and they didn't bother him. On 08/03/26 at 11:31 AM an interview and observation were conducted with the Maintenance Director. During the interview he was observed to remove the spider web from the right side of the smoking area. The Maintenance Director confirmed the spider was black in color with a red hourglass shape on its body along with the deceased spider located at the resident ash tray. He stated the facility had a contract with a pest control company that came to the facility every other week to spray all insects. He explained if there were any complaints of spiders, he would have immediately sprayed however there had been no complaints from residents or staff. The Maintenance Director explained that he checked the smoking area daily, and he had never seen the web or any spiders. A review of the facility Pest Control log book revealed no concerns noted regarding spiders in the facility. On 08/03/26 at 12:52 PM an interview was conducted with a representative from the Pest Control Company. During the interview he stated he came to the facility every other Tuesday to treat general rooms, hallways and the outer parameter of the facility. He explained that he would treat the entry ways (doorways) for spiders however they were hard to treat because they were able to, walk over the spray. He stated he had to actually see the spider and spray it in order to kill it. The Pest Control Company representative stated because of the more flies in the area, it would create an environment with an increased number of spiders. On 08/07/26 at 4:31 PM an interview was conducted with the Administrator. During the interview she explained the facility had a contract with the Pest Control Company who came out every other week to spray for all insects. She explained the facility had not had any reports of a spider issue and that was the first time anyone had noticed the spiders in the smoking area.

Based on record review, staff and Resident Representative (RR) interviews, the facility failed to conduct a care plan meeting with the resident and/or resident representative affording them the opportunity to participate in the care planning process for 1 of 3 residents reviewed for care planning (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was severely cognitively impaired.Resident #2's care plan was last revised on 7/27/26.A review of the medical record revealed no documentation that a care plan meeting had been completed for Resident #2 since his admission to the facility on 3/02/26.During a phone interview with the RR on 8/03/26 at 2:23 PM she stated a few days after Resident #2 was admitted to the facility the Social Worker called her to discuss discharge plans, but they did not discuss Resident #2's plan of care. The RR stated she had not received an invitation to participate in a care plan meeting with the interdisciplinary team since Resident #2 was admitted to the facility. The RR indicated she would have attended a care plan meeting if invited, because she had a lot of questions regarding Resident #2's care, medical status and whether his condition was improving.An interview conducted with the Social Services Director on 8/05/26 at 4:15 PM revealed she was responsible for sending out invitations and scheduling care plan meetings with residents and/or resident representatives within 72 hours of admission, quarterly and if there was a significant change. She indicated when she mailed a care plan invitation and there was no response, she usually called the resident representative and attempted to schedule a meeting. The Social Services Director stated she called Resident #2's RR on 3/05/26 to discuss discharge plans but she did not review the care plan because other members of the interdisciplinary team were not on the call. The Social Services Director revealed she thought she mailed a care plan invitation to Resident #2's RR but did not recall if the RR responded or if she called the RR to follow up. The Social Services Director further revealed she was unable to locate or provide any documentation that an invitation was sent to the RR or that a care plan meeting was completed for Resident #2. An interview conducted with the Administrator on 8/07/26 at 4:41 PM revealed the Social Services Director was responsible for scheduling care plan meetings and ensuring the residents and/or resident representatives were invited to attend. She indicated Resident #2's RR should have been invited to attend a care plan meeting with the interdisciplinary team and offered the opportunity to participate in the care planning process.

Based on record review and staff interviews, the facility failed to submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation to North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) for a resident with a new diagnosis of major depressive disorder for 1 of 2 residents reviewed for coordination of PASRR assessments (Resident #87). The findings included:A review of Resident #87's medical record revealed that Resident #87 was deemed by the State of North Carolina to be Level I PASSR. The Level I PASSR was dated 9/2/24 with no expiration date. The notification letter indicated no further PASRR screening was required unless a significant change occurred with the individual's mental status which suggested a diagnosis of mental illness.Resident #87 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder.A review of Resident #87's Electronic Medical Record (EMR) revealed a physician's order dated 7/11/25 for 10 milligrams (mg) of escitalopram oxalate (a medication to reduce anxiety and depression) given once daily. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated active diagnosis of bipolar disorder and use of antidepressant medication. The MDS indicated Resident #87 had not been evaluated by Level II PASRR and determined to have a serious mental illness.An additional review of Resident #87's current physician's order revealed escitalopram oxalate was increased on 9/3/25 to 20 mg, given once daily.Resident #87's EMR revealed a physician's order dated 9/15/25 and discontinued on 9/19/25 for 15 mg of mirtazapine (an anti-depressant) given at bedtime for depression. The mirtazapine was increased on 9/19/25 to 30 mg given at bedtime.A review of a Nurse Practitioner (NP) progress note dated 9/30/25 revealed Resident #87 continued on 30mg of mirtazapine and had improved with the prescribed medication along with 10mg of escitalopram oxalate. The note indicated Resident #87 had a history of bipolar disorder and was working with the Psychiatric NP and would continue to monitor for any symptoms.Major depressive disorder was added to Resident #87's facility diagnoses list on 10/1/25. A review of Resident #87's quarterly MDS 12/13/25 revealed she was coded for depression and bipolar disorder.There was no documentation in Resident #87's medical record that a referral was made for an updated PASRR evaluation when the new mental health diagnosis was identified.An interview with the Social Worker (SW) was conducted on 8/6/26 at 9:02 AM. The SW indicated that assuring the Level II PASSR evaluations were current and accurate was her responsibility. She stated she completed weekly audits to ensure all needed PASSR evaluations were requested in NC MUST. The SW indicted Resident #87's name was not on the audit list, and as of 8/4/26 she was not aware a new diagnosis of major depressive disorder was added to her diagnoses in 2025. An interview with the Administrator was conducted 8/7/26 at 5:15 PM. The Administrator indicated the Social Worker was responsible for submitting requests for PASRR evaluations. She explained all residents should have an evaluation requested as soon as possible for any new mental health diagnosis.

Based on observations, record review, Nurse Practitioner (NP), resident and staff interviews, the facility failed to provide care in a safe manner when bathing a resident which resulted in the resident falling to the floor off the raised bed (Resident #123) and failed to provide supervision and implement safety interventions for a resident with revoked smoking privileges that obtained smoking materials and was found smoking in bed. This occurred for 2 of 10 residents reviewed for accidents (Resident #123 and Resident #14). The findings included: 1. Resident #123 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #123 was severely cognitively impaired. Resident #123 was dependent with all activities of daily living (ADL) and required mechanical lift transfers. Resident #123 was coded as dependent with bed mobility (Helper does all of the effort-resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity). Resident #123's care plan dated 8/7/2019 and revised on 5/20/2026 had a focus area for an ADL self-care performance deficit related to dementia. Resident #123 required staff assistance to complete ADL tasks daily. Goals included Resident #123 would maintain the current level of ADL function through the next review period. Interventions included Resident #123's usual performance with bed mobility was dependent with a two person assist, usual performance with upper and lower body dressing was dependent with a two person assist and usual performance with personal hygiene/oral care was dependent with a two person assist. An interview on 8/6/2026 at 3:38 PM with Nurse Aide (NA) #2 revealed that NA #2 knew Resident #123 well and had provided care to Resident #123 regularly during the morning shift (7:00 AM to 3:00 PM). NA #2 indicated on 7/16/2026 at approximately 9:30 AM, she gave Resident #123 a bed bath which was Resident #123's preference. NA #2 reported the bed was raised to a care height of approximately 4.5 feet. NA #2 stated she rolled Resident #123 toward her to wash his back. NA #2 stated Resident #123 stated he was going to fall. NA #2 indicated Resident #123 frequently said that when being positioned in the bed. NA #2 indicated Resident #123 pushed her hard with both hands at her waist which caused her to stumble back and fall. Resident #123 then fell off the bed and landed on his back. NA #2 revealed the push surprised her as Resident #123 had never been resistant to care or acted aggressively in any way. NA #2 indicated Resident #123's roommate was already up in his wheelchair and rolled to the doorway and called for help. NA #2 stated Resident #123 was alert and stated, get me off the floor. NA #2 recalled Nurse #5 immediately answered the request for assistance from Resident #123's roommate, called a rapid response (an internal protocol used by nurses and staff to quickly evaluate and treat a resident showing early signs of a serious medical decline) and assessed Resident #123. NA #2 reported there were no injuries noted and the mechanical lift pad was placed under Resident #123 and he was returned to bed. NA #2 stated she was aware Resident #123 was a two person assist with bed mobility. NA #2 indicated she performed the bed bath by herself on 7/16/2026 as the morning was very busy and there was not enough help for another person to be present. NA #2 expressed she should have waited for help that morning as there were usually two NAs present for Resident #123's bath. An interview was conducted on 8/7/2026 at 3:41 PM with Resident #123's roommate, Resident #70. A comprehensive MDS assessment dated [DATE] indicated Resident #70 was cognitively intact. Resident #70 stated NA #2 was bathing Resident #123 by herself on the morning of 7/16/2026 and he heard Resident #123 say he was going to fall. Resident #70 recalled the curtain was pulled but he heard the fall and immediately rolled to the doorway to call for help. Resident #70 reported he heard Resident #123 groan and say, Get me off the floor. Resident #70 stated nursing staff arrived quickly and he left the room as he knew staff would need space to care for Resident #123. A nurse progress note created on 7/16/2026 at 12:21 PM by Nurse #5 reported NA #2 stated she was giving morning care when NA #2 rolled Resident #123 and Resident #123 pushed on NA #2 and Resident #123 fell on the floor. A rapid response was initiated immediately and nurses assessed Resident #123. Resident #123 was alert and responsive, noted a small skin tear to his left elbow but Resident #123 denied any pain or discomfort. Resident #123 was lifted back into bed by mechanical lift. Vital signs were stable, pupils were equal, round and reactive to light, and neurological checks were initiated. A review of Resident #123's Neurological Assessment Flowsheet dated 7/16/2026 indicated neurological checks were conducted by Nurse #5. The neurological checks began at 10:30 AM and were conducted every 15 minutes x 4 then every 30 minutes x 2 until 12:15 PM when Resident #123 was found not responding as he usually did. An interview on 8/6/2026 at 4:00 PM with Nurse #5 revealed she was passing medications when Resident #70 called out for help for Resident #123. Nurse #5 stated she immediately ran into Resident #123's room and saw Resident #123 on the floor on his back between the two beds and NA #2 standing in the room beside Resident #123. Nurse #5 stated she called a rapid response which was answered by the Nurse Practitioner (NP) #2, and the former Director of Nursing (DON) #2 as well as other NAs and staff members but did not recall exactly everyone who had arrived in the room. Nurse #5 indicated Resident #123 was alert, talking and had no visible signs of injury except a small skin tear on his left elbow. Nurse #5 reported Resident #123 said, Get me off the floor and he was placed back in bed by mechanical lift. Nurse #5 indicated neurological checks were started. A Nurse Practitioner (NP) progress note created by NP #2 dated 7/16/2026 at 8:00 AM stated a rapid response was called as Resident #123 was reported to be on the floor. The note indicated according to NA #2 she was changing him and turning him towards her. NA #2 reported Resident #123 pushed against her wanting to be let go. NA #2 stated she informed Resident #123 she was rolling him to his back however she needed to get the sheets straightened. NA #2 reported that Resident #123 continued to push against her until she fell backwards. Of note, not to the ground, however, stumbled backwards and Resident #123 fell on the floor. Resident #123 was lying on his back on the floor when the provider arrived in the room. Resident #123 stated he was not in pain however wanted to get up off the ground. Resident #123 was alert and oriented x 1 (when a person is aware of who they are but unaware of their location, the current time or their situation). An interview with NP #2 on 8/7/2026 at 3:05 PM revealed NP #2 had answered the rapid response on the morning of 7/16/2026 around 9:30 AM but could not recall the exact time. NP #2 reported she found Resident #123 on his back on the floor. Nurse #5 and NA #2 were in the room and the former DON #2 arrived shortly after. NP #2 stated Resident #123 was alert, talking and wanted to get off of the floor. NP #2 indicated she assessed Resident #123 and observed a small skin tear to his left elbow but no other injuries. NP #2 stated Resident #123 had no complaints of pain, was returned to bed and neurological checks were initiated. NP #2 explained she had been told NA #2 had been providing care and had rolled Resident #123 toward her when Resident #123 pushed NA #2 which caused her to stumble backwards and Resident #123 fell to the floor. NP #2 stated Resident #123 should have had two staff members providing bathing and bed positioning. Attempts to interview the former Director of Nursing (DON) #2 (employed by the facility from 7/1/2026 to 7/23/2026) by phone on 8/7/2026 and 8/10/2026 were not successful. An interview on 8/7/2026 at 12:58 PM with the Medical Director indicated he did not recall Resident #123 specifically but stated if a resident was care planned for a two person assist with baths and bed mobility then there should always be two staff members present for those activities. An interview on 8/7/2026 at 4:10 PM with the Administrator indicated that residents who were care planned for a two person assist with bathing and bed mobility should always have a second staff person present for safety. The Administrator stated NA #2 should have always had a second staff member help her bathe and position Resident #123. 2. A review of the facility's smoking policy revised October 2023 indicated residents were not permitted to keep cigarettes, lighters or other smoking items in their possession and the facility may impose smoking restrictions on a resident at any time if it was determined they were unable to smoke safely. Resident #14 was admitted to the facility on [DATE] with diagnoses which included intracranial injury without loss of consciousness (mild traumatic brain injury) and tobacco use. A review of the medical record revealed an acknowledgement and understanding of the facility's smoking policy that was signed by Resident #14 on 9/09/25. A smoking safety evaluation dated 9/09/25 indicated Resident #14 was cognitively intact, had consistent decision-making ability but his short-term memory was problematic, and he required supervision when smoking. Resident #14's care plan dated 9/09/25 revealed a focus area related to smoking with interventions that included providing supervision while smoking and educating the resident on the facility's smoking policy and procedure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and coded for current tobacco use. A nurse's note dated 10/30/25 written by the Assistant Director of Nursing (ADON) revealed a lighter was observed in Resident #14's room which violated the facility's smoking policy and Resident #14's smoking privilege was revoked. The care plan revised on 10/30/25 indicated Resident #14 was a supervised smoker but smoking privileges were currently on hold. Resident #14's physician orders revealed an order dated 10/31/25 to apply a nicotine transdermal patch (adhesive patch applied to the skin) 14 milligrams (mg) every 24 hours for 6 weeks for smoking cessation. Resident #14's medication administration record (MAR) indicated the nicotine patch was applied daily from 10/31/25 through 12/12/25 and the order was completed. The NP note dated 11/03/25 written by Nurse Practitioner (NP) #2 revealed a lighter was found in Resident #14's room and his smoking privileges were revoked for not following the facility's smoking policy and a new order was given for nicotine patch 14 milligrams (mg) to be applied once a day for 6 weeks. A safe smoking evaluation dated 3/26/26 indicated Resident #14 required supervision while smoking but his privileges were revoked on 10/30/25 and he was not currently smoking. An interview conducted with the Assistant Director of Nursing (ADON) on 8/06/26 at 1:57 PM revealed the facility permitted residents to smoke, and safety evaluations were completed to determine if a resident required supervision while smoking upon admission and quarterly. She stated she was responsible for updating the list of resident smokers, if they required supervision and ensuring the nurses completed the safe smoking evaluation quarterly. The ADON indicated all smoking materials were locked in a medication cart and residents were not permitted to store any smoking materials in their room. The ADON stated Resident #14 was a smoker when he was admitted to the facility, and a safe smoking evaluation was completed on 09/09/25. She revealed Resident #14 was cognitively intact but did have short term memory loss so it was determined he required supervision while smoking. The ADON stated as documented in the note she had written on 10/30/25, a lighter was found in Resident #14's room and his smoking privileges were revoked because he violated the facility's smoking policy. The ADON revealed Resident #14 was unable to explain how he obtained the lighter that was found in his room. She revealed in April 2026 Resident #14's smoking privileges were still revoked however NP #2 found him smoking in his bed. The ADON indicated when she responded to Resident #14's room after the April 2026 occurrence he was no longer smoking, and she did not recall smelling smoke. She stated a lighter was removed from his room, but she did not recall finding any other smoking materials. The ADON indicated Resident #14 was unable to explain how he obtained the smoking materials and denied that he was smoking in his room. The ADON stated there was not an incident report completed regarding the incident on 4/24/26 however Resident #14 nor his roommate were injured and oxygen was not in use nor were there any oxygen supplies in the room at the time of the incident. An observation was conducted on 8/12/26 at 2:15 PM of the hallway where Resident #14's room was located. The closest room with oxygen in use when the incident occurred on 4/24/26 was approximately 20 feet away from Resident #14's room. An interview was conducted with NP #2 on 8/06/2026 at 9:36 AM. NP #2 stated she did not recall the date but Resident #14's smoking privileges were revoked for violating the facility's smoking policy and she ordered a nicotine patch for 6 weeks. She stated on 4/24/26 during her morning rounds she smelled cigarette smoke in the hallway and observed Resident #14 smoking in his bed. She stated Resident #14 was not injured and there were no burn marks on or around the bed. She revealed the ADON responded to Resident #14's room and was notified of the incident. NP #2 indicated there were no oxygen supplies in the room and Resident #14 nor his roommate required oxygen therapy. NP #2 revealed she was unsure how Resident #14 obtained the smoking materials and that he was cognitively intact but had short term memory loss and denied smoking in his room. NP #2 revealed she had several discussions with Resident #14 offering to continue the nicotine patch after the initial 6-week order was completed, however Resident #14 refused. During a phone interview with the Former Administrator on 8/13/26 at 4:06 PM she revealed she did not recall any incidents involving Resident #14 violating the facility's smoking policy or that he was observed smoking in his room. An observation and interview were conducted with Resident #14 in his room on 8/07/26 at 2:10 PM. Resident #14 revealed he was a smoker, but his smoking privileges were revoked shortly after he was admitted to the facility due to storing smoking materials in his room. Resident #14 stated he was also told by staff he was observed smoking in bed, but denied this ever occurred. Resident #14 indicated he did not require oxygen therapy and there was no oxygen equipment observed in his room. Resident #14 stated he wanted to smoke and recently the facility reinstated his smoking privileges. He revealed staff provided supervision while he smoked and they always maintained possession of his lighter. Resident #14 revealed he was very aware of the facility's smoking rules and followed them so his smoking privileges were not revoked again. During an interview with the Administrator on 8/07/26 at 4:41 PM she revealed she was not working at the facility when the incident involving Resident #14 occurred and she could not speak to what interventions, if any, were put into place. The Administrator revealed Resident #14's smoking privileges were revoked however he wanted to continue smoking. The Administrator indicated she wanted to advocate for Resident #14's right to smoke and implemented additional safety interventions and supervision of Resident #14 prior to reinstating his smoking privileges on 7/15/26.

Based on observations and staff interviews, the facility failed to remove expired medications stored in 1 of 1 medication storage room observed for medication storage. The findings included: An observation of the medication storage room was conducted on 08/07/2026 at 9:49 AM in the presence of Nurse #3. The following medications were found in the medication room: Two 12-fluid ounce bottles of Geri-Mox regular strength antacid and antigas. The expiration date on the bottles was May 2026. One 12-fluid ounce bottle of Geri-Mox regular strength antacid and antigas. The expiration date on the bottle was April 2026. One 12-fluid ounce bottle of Geri-Lanta antacid and antigas. The expiration date on the bottle was June 2026. Nicotine gum 2 milligram 40-piece box. The expiration date was July 2026. An interview with Nurse #3 was completed on 08/07/2026 at 9:50 AM. Nurse #3 stated the medication storage room was checked frequently by the Central Supply staff member. She stated typically if nurses removed a medication from the medication room they would ensure it was not expired prior to administration. An interview with Central Supply Staff Member #1 was completed on 08/07/26 at 10:02 AM. Central Supply Staff Member #1 confirmed that she stocked the medication storage room weekly as well as checked for expiration dates on the medications stored in the room. She stated she checked the room on Monday, 08/03/26 and had overlooked the expired medications by mistake. After speaking with the surveyor regarding where the medications were found (on the back row of the shelf) she explained that she typically only looked at medications toward the front of the shelf. An interview conducted with the Director of Nursing (DON) on 08/07/2026 at 10:08 AM revealed that Central Supply Staff Member #1 was responsible for checking the medication expiration dates weekly in the medication storage room. She also stated the Nurses were also responsible for checking the expiration dates. The DON indicated that any medication that was expired should be removed and over the counter medications could be discarded and prescription medications were sent back to the pharmacy. An interview was completed on 08/07/2026 at 4:33 PM with the Administrator. The Administrator stated the medication storage room should have been checked on a weekly basis for expiration dates. If a medication had expired, it should have been removed from the medication storage room.

Based on record review, staff and resident representative interviews, the facility failed to conduct a care plan conference and offer the resident and resident representative the right to participate in the person-centered care planning process for 1 of 5 residents reviewed for care plans (Resident #346). The findings included: Resident #346 was admitted to the facility on [DATE] and discharged on 4/8/2024. Resident #346's care plan initiated on 3/17/2024 addressed the following areas: the risk for allergic response to fenofibrate, neosporin and gluten, ADL self-care performance deficit and required staff assistance to complete ADL tasks daily, deep vein thrombosis of the left popliteal vein and left posterior tibial vein related to impaired mobility and atrial fibrillation which required anticoagulant therapy, full code status, moderate risk for falls, indwelling foley catheter due to urinary retention, bowel incontinence but was at risk for constipation due to decreased mobility and medication side effects, right hip fracture requiring surgical repair after a fall at home in her bathtub and pain associated with the fracture, nutritional risk factors related to a mechanically altered diet for dysphagia, gluten free restriction, and a history of protein calorie malnutrition, and Stage IV pressure wounds of the left ischium and left elbow, unstageable wounds to both heels, and deep tissue injuries to both the left and right lateral ankles and was at risk for further skin breakdown. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #346 was cognitively intact. As Resident #346 discharged to another skilled nursing facility, an MDS assessment was completed for discharge with return not anticipated. A review of Resident #346's electronic medical record revealed no documentation that a care plan conference had been held during Resident #346's stay at the facility. On 6/3/2025 at 6:00 PM a telephone interview with the Resident Representative revealed on the day of admission, Resident #346 and the Resident Representative were told that a care plan conference would be held on 3/15/2024 at 11:00 AM in Resident #346's room. The resident representative stated she arrived for the conference and waited in the room with Resident #346, but no staff ever came to the room. The Resident Representative stated she inquired about the conference at the nurse's station but was told no one knew about the conference as their system was down. The care plan conference was not rescheduled with the resident or resident representative. The Resident Representative indicated later she asked various staff members if the conference had been held but never received any updates or progress reports. The Resident Representative stated she only discovered there was a care plan document dated 3/17/2024 outlining focus areas, goals and interventions after she requested Resident #346's medical record after Resident #346 discharged on 4/8/2024. On 6/5/2025 at 10:06 AM an interview with Social Worker #1 revealed she was responsible for the care plan conference invitations and meeting schedule based on a list provided to her by the MDS Coordinator. She recalled Resident #346 and thought the conference had been held with the Resident Representative. Social Worker #1 was unable to locate any documentation in the electronic medical record that the care plan conference had been held. She was unable to provide any documentation that discussions regarding care planning had been conducted with Resident #346 or her resident representative. Social Worker #1 indicated that documentation of the completed care plan conference in the electronic medical record was at times completed by nursing and at other times by her. She was not sure why documentation of the care plan conference had not been completed for Resident #346. There was not a clear process in place which determined if nursing or social work would document the completed care plan conference once held. On 6/5/2025 at 2:47 PM an interview with the Director of Nursing (DON) indicated that social services was responsible for arranging the care plan conferences based on a list provided by the MDS Coordinator. The DON stated the care plan process should include a progress note that the conference was held and document who attended. She stated sometimes the Social Worker would document the conference and at other times nursing would document under an Interdisciplinary Team (IDT) note. There was not a clear process to determine if nursing or social work took the responsibility to document in the electronic medical record after a completed care conference. The DON was unable to locate documentation that a care plan conference had been held for Resident #346 or that Resident #346 or the resident representative had participated in the care plan process. She did not know why there was not documentation in the electronic medical record. On 6/6/2025 at 11:34 AM an interview with the Administrator revealed that a resident and the resident representative had the right to participate in the care plan conference if they chose to do so and the care plan conference should be documented in the electronic medical record (EMR). She did not know why Resident #346 had no documentation in the EMR reflecting that a care plan conference had been held and that Resident #346 and the resident representative had participated in the planning.

2. A hospital referral form dated 10/25/24 revealed Resident #147 required continuous supplemental oxygen. Resident #147 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A nursing progress note dated 11/01/24 revealed Resident #147 required 3 liters of supplemental oxygen. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #147 was coded for no oxygen therapy. An interview on 6/5/2025 at 9:38 AM with the MDS Coordinator indicated she reviewed the residents progress notes and referral forms prior to completing the initial admission MDS. The interview revealed based on the referral form and the nursing progress notes Resident #147 had received supplemental oxygen from the time of his admission and should have been coded on his admission MDS. The MDS Coordinator stated she was responsible for completing the assessment and had just miscoded it by mistake. An interview on 6/5/2025 at 2:29 PM with the Director of Nursing (DON) indicated the MDS should be coded accurately. She was not sure why Resident #147's admission MDS had been coded incorrectly. An interview on 6/5/2025 at 10:34 AM with the Administrator revealed that the MDS should be coded accurately. She did not know why Resident #147's admission MDS had been coded incorrectly. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge location (Resident #345) and respiratory treatment (Resident #147) for 2 of 19 residents reviewed for accuracy of assessment. The findings included: 1. Resident #345 was admitted to the facility on [DATE]. A review of a social service progress note dated 4/28/2025 at 4:57 PM stated Resident #345 had a planned discharge to home with home health services on 4/28/2025. A review of the discharge MDS assessment dated [DATE] revealed that the discharge status had been coded as discharge to home/community. An interview on 6/5/2025 at 9:46 AM with the MDS Coordinator indicated she received a resident's discharge information through progress notes, discussions with the Social Worker or weekly utilization review meetings. She stated she routinely coded the discharge status as home/community when a resident discharged home. She was unable to provide an example of when it would be appropriate to use the home under the care of organized home health service organization category. The MDS Coordinator stated she saw the social service progress note documenting the home health services but since Resident #345 discharged home she thought home/community was the correct coding. An interview on 6/5/2025 at 2:47 PM with the Director of Nursing (DON) indicated the MDS should be coded accurately. She was not sure why Resident #345's discharge MDS had been coded incorrectly. An interview on 6/6/2025 at 11:34 AM with the Administrator revealed that the MDS should be coded accurately. She did not know why Resident #345's discharge status had been coded incorrectly.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure Resident #9 swallowed all of her prescribed medications before leaving Resident #9's room for 1 of 1 resident reviewed for medication storage (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, cirrhosis of the liver and end stage renal disease. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was moderately cognitively impaired. A physician order dated 05/27/2025 read; Lactulose 45 milliliters (ml) to be given twice daily by mouth for increased ammonia level due to cirrhosis of the liver. There was not an assessment for medication self- administration documented in Resident #9's electronic medical record. On 6/3/2025 at 8:50 AM, Resident #9 was observed sitting on the edge of her bed eating breakfast with her meal tray on her overbed table positioned next to her bed. A medication cup containing a green liquid was observed sitting next to her breakfast tray. Resident #9 stated she did not know what the liquid was or where it had come from. An interview on 6/3/2025 at 9:10 AM with Nurse #1 revealed she had administered Resident #9's medications that morning and she thought Resident #9 had taken all of the medications while she was in the room. Nurse #1 and this surveyor returned to Resident #9's room and during the interview Nurse #1 explained to Resident #9 that the medication was lactulose, and it reduced her ammonia level. Resident #9 took the medication. Nurse #1 stated she should have been sure Resident #9 had taken all of her medications before she left the room earlier that morning. On 6/4/2025 at 3:05 PM an interview with the Assistant Director of Nursing (ADON) indicated that Nurse #1 should have stayed in the room until Resident #9 had taken all of her medications. No medications should have been left at the bedside. On 6/5/2025 at 2:47 PM an interview with the Director of Nursing (DON) indicated Nurse #1 should have stayed with Resident #9 and watched while she took her medications. The DON said medication should not have been left with Resident #9. She was not sure why Nurse #1 had left Resident # 9's medication at the bedside. On 6/6/2025 at 11:34 AM an interview with the Administrator revealed that Nurse #1 should have stayed with Resident #9 to observe her taking all of the medications administered. The Administrator did not know why Nurse #1 had left medication unattended with the resident.

Based on observation, record review,and resident and staff interview, the facility failed to provide supervision for storage of smoking supplies (cigarettes/lighter) for 1 of 3 residents sampled for supervision to prevent accidents (Resident #31). The findings included: A review of the facility's Resident Smoking policy, dated October 2023, indicated any resident who was deemed safe to smoke independently will have their smoking materials secured by the facility, including lighters, cigarettes and e-cigarettes. Resident #31 was admitted to the facility on [DATE] with diagnoses which included seizure disorder, anxiety and depression. A review of Resident #31's care plan, revised on 02/22/24, revealed he was an unsupervised smoker. The goal was for Resident #31 to not suffer injury from unsafe smoking practices through the review date. Interventions included the residents smoking supplies to be stored with the nurse. A safe smoking assessment dated [DATE] revealed Resident #31 was a safe smoker, and the facility stored his smoking materials. A review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and independent for most activities of daily living (ADL). The MDS indicated Resident #31 utilized a wheelchair for mobility. An observation and interview were conducted with Resident #31 on 06/02/25 at 12:45 PM. Resident #31 was observed with a lighter and one pack of cigarettes in the left pocket of his backpack located on the back of his wheelchair. Resident #31 stated he was an unsupervised smoker and had always kept his smoking supplies because he was trustworthy. He stated no staff member had asked him to keep his supplies at the nurse's station and that he was familiar with the smoking policy because he had signed the smoking agreement when he admitted into the facility. An observation was conducted of Resident #31 on 06/03/25 at 11:31 AM. Resident #31 was observed with a lighter and one pack of cigarettes in the left pocket of his backpack located on the back of his wheelchair. An observation was conducted of Resident #31 on 06/03/25 at 1:38 PM. Resident #31 was observed with a lighter and one pack of cigarettes in the left pocket of his backpack located on the back of his wheelchair. On 06/03/25 at 12:22 PM an interview was conducted with Nurse #1. During the interview she stated she was new to the facility and had just started working in the building that morning at 7:00 AM. Nurse #1 stated residents in the facility that were deemed unsupervised smokers were allowed to go out and smoke at the designated smoking area. She stated typically the cigarettes were kept in the nurse's medication cart however she stated she did not have any cigarettes in the cart on that day. The interview revealed she was not sure who the unsupervised smoker was or where they kept their smoking supplies. On 06/03/25 at 12:27 PM an interview was conducted with Nurse Aide (NA)#1. During the interview she stated she frequently worked with Resident #31 and that he was an unsupervised smoker. NA #1 stated the resident kept his own supplies (cigarette/lighter) so he could go to the smoking area whenever he wanted to. The facility had never had any issues or incident in which his smoking materials would be taken from him. NA #1 stated Resident #31 had kept his cigarettes and lighter in his room for as long as she could remember. On 06/03/25 at 12:39 PM an interview was conducted with NA #2. During the interview she stated she had worked in the facility for one year and typically worked with Resident #31. She stated Resident #31 would go outside to smoke whenever he wanted to, not at certain times. NA #2 stated Resident #31 kept his own cigarettes and lighter in his room. She did not know of any incidents or issues that had resulted from him keeping his own cigarettes. All the other residents had to ask for their supplies. NA #2 stated Resident #31 was the only resident in the facility that kept his own smoking supplies. On 06/04/25 at 10:07 AM an interview was conducted with Nurse #2. During the interview she stated she was responsible for Resident #31 on 06/04/25 and did not have his smoking supplies on the medication cart. She stated Resident #31 was the only resident that was allowed to keep his own smoking materials because he was deemed a safe smoker. On 06/04/25 at 10:31 AM an interview was conducted with the Director of Nursing (DON). During the interview she stated the facility did not have a lot of residents who smoked and only had two residents that were independent smokers. The DON stated the two independent smokers would retrieve their smoking materials from the Nurse on the hall and go in/out of the facility to the smoking area as they wished. All smoking supplies were stored on the medication cart and the resident had to sign the smoking materials out and back in as they reentered the building. She stated it was part of the resident's smoking agreement that they signed at admission. The DON stated she was unaware of any resident in the building that had their own smoking materials on them and was unaware about Resident #31. The DON stated staff received education several months prior for a facility wide education and upon hire regarding the smoking practices/policy of the facility. She stated the nurses along with Resident #31 should be following the facility smoking policy and he should not have been allowed to keep his own smoking supplies in his room. On 06/05/25 at 10:40 AM an interview was conducted with the Administrator. During the interview she stated Resident #31 signed a smoking agreement upon his admission into the facility. However, it was hard to keep up with him because he was known to hide his smoking supplies and curse at staff if they tried to keep them locked in the nurse's cart.

Based on observations and staff interviews, the facility failed to label an open vial of Tuberculin Purified Protein Derivative (PPD) medication observed in 1of 2 medication storage rooms ([NAME] Hall Medication Storage Room) reviewed for medication storage. The findings included: An observation of the [NAME] Hall medication storage room with Nurse #1 on 06/04/25 at 7:40 AM revealed an open multi-use vial of Tuberculin Purified Protein Derivative, Diluted Aplisol Exp: 2026/8, was opened and not labeled with open date. An interview with Nurse #1 on 06/04/25 at 7:40 AM revealed the Tuberculin medication vial should have been labeled with an open date and the expiration date on box should have been circled. Nurse #1 stated the vials were labeled with open date because Tuberculin medication vials were only good for 30 days after they were opened. Nurse #1 stated she was not sure why the vial was not dated; she had not used the vial. An interview with the Assistant Director of Nursing (ADON) on 06/04/25 at 7:50 AM revealed the opened Tuberculin medication vial should have been labeled with an open date and discarded 30 days after the open date. The ADON stated Tuberculin medication vials were used so often and emptied before the 30 days of opening, the nurses probably forgot to label the vial with the open date. The ADON stated that she checked the medications in the refrigerator on day shift and unit manager checked on night shift. The ADON reported she had not completed medication refrigerator checks for the day and discarded the unlabeled open Tuberculin medication vial when it was brought to her attention by Nurse #1.

Based on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #2 did not doff her gloves, perform hand hygiene and don clean gloves prior to applying wound treatment and a clean dressing and before moving to a second wound on Resident #14. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (Nurse #2). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene and dated October 2021 read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: a. Immediately before touching a resident. b. Before performing an aseptic task c. After contact with blood, body fluids, or contaminated surfaces. d. After touching a resident e. After touching the resident's environment f. Before moving from working on a soiled body site to a clean body site on the same resident; and g. Immediately after glove removal. A wound observation was made on 06/03/25 at 3:08 PM on Resident #14 with Nurse #2 and the Infection Preventionist. Nurse #2 and the Infection Preventionist donned a clean gown and clean gloves. The Infection Preventionist stood on the resident's right side and held the resident over in a turned position so Nurse #2 could complete the dressing change. Nurse #2 then removed the old dressings from two wounds located on the residents lower back and sacrum. Nurse #2 placed the two soiled dressings into the trash can. Nurse #2 doffed her gloves, sanitized her hands, donned clean gloves and cleaned the wound to Resident #14's lower back. While wearing the same gloves Nurse #2 applied petroleum and silver alginate to the wound bed and covered the wound with a dry dressing. She then proceeded to move to the next wound located on Resident #14's sacrum without doffing her gloves and sanitizing her hands. Nurse #2 cleaned the wound bed to the sacrum, applied petroleum and silver alginate to the wound bed. A dry dressing was placed on the wound with tape to secure the dressing. She then doffed her gloves and sanitized her hands. An interview conducted on 06/04/25 at 10:24 AM with Nurse #2 revealed she was aware that she had not sanitized her hands and changed her gloves between the dressing changes on Resident #14's lower back and sacrum. She stated the resident had a total of 6 wounds and she had just gotten nervous and missed changing gloves and sanitizing between the first and second wound, however she corrected her mistake on the next dressing change she completed on the same resident. Nurse #2 stated she had received ongoing education on infection control and dressing changes, that it was just a mistake. An interview conducted on 06/04/25 at 2:55 PM with the Infection Preventionist (IP) revealed she had observed the errors made by Nurse #2 during wound care. She stated her expectation was that she would sanitize her hands and change gloves every time she moved from a dirty area to clean area and with any new wound, she was applying a dressing to. She stated the residents lower back was one wound and the sacrum wound was a second wound, she further stated they had to be treated as two separate areas. The IP stated staff received education on infection control annually and multiple times during the year. An interview on 06/04/25 at 11:03 AM with the Director of Nursing (DON) revealed she was aware of Nurse #2's errors during wound care and said she had been provided with additional education 06/03/24 regarding doffing and donning and sanitizing in between wound care. The DON stated it was her expectation for Nurse #2 to follow infection control best practices to avoid introducing microorganisms into the wounds. An interview on 06/05/25 at 10:40 AM with the Administrator revealed she would expect Nurse #2 to follow the Hand Hygiene policy for wound care.

Based on record review, and responsible party (RP), staff, nurse practitioner (NP), and physician assistant (PA) interviews, the facility failed to protect a resident's right to be free of physical restraints for 1 of 3 residents (Resident #1) reviewed for restraints. Resident #1 was found to have his wrists restrained using a pillowcase wrapped in a figure eight [NAME] and then covered with a top sheet. The reasonable person concept was applied as no reasonable person would expect to have their wrists restrained with a pillowcase, restricting their movement, unable to use their call bell for assistance, and making the person feel restricted and/or belittled. Findings included: A review of the facility's Abuse and Neglect Policy and Use of Restraints Policy dated 03/28/2023 stated residents have the right to be free from abuse including physical restraints imposed for purposes of discipline or staff convenience. Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Physical restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included multiple sclerosis (MS), left-side hemiplegia (partial or complete paralysis on the left side of the body), left-side hemiparesis (muscle weakness or partial paralysis on the left side of the body), and cerebral infarction (when blood flow to the brain is blocked, causing the brain tissue to die). Review of the admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #1 had moderate cognitive impairment, required total assistance with all activities of daily living (ADL) and displayed no behaviors during the 7-day assessment period. The MDS revealed Resident #1 had no use of physical restraints. Review of Resident #1's care plan dated 07/30/2024 revealed Resident #1 was care planned for ADL deficits related to disease processes and cognitive deficits with interventions to converse with resident while providing care, be aware of the resident's need for assistance and that additional staff support may fluctuate from day to day and hour to hour. Resident #1's care plan also reflected limited physical mobility related to bilateral upper and lower extremity contractures with interventions to provide gentle range of motion as tolerated with daily care. Resident #1 was also care planned for being resistant to care including personal care, medication, treatments, and lab work with interventions to allow resident to have freedom of choice, and to attempt to determine the reason for non-compliance. Resident #1's care plan also indicated behavioral problems including hitting, kicking, cursing staff and using racial slurs with interventions to explain all procedures to Resident #1 before providing care, approach and speak in a calm manner, divert attention, monitor behavior episodes and attempt to determine the underlying cause and document, and praise any indication of Resident #1's improvement in behavior. Review of the facility's initial abuse investigation report dated 10/02/2024 at 11:30 AM revealed Resident #1 was found to have upper extremity range of motion restricted in linen. The report also indicated that the linen was removed immediately. Resident #1 was assessed by the Director of Nursing (DON) and the Medical Director (MD). The physical assessment revealed discoloration on the top of Resident #1's wrists. Resident #1 denied pain or discomfort and had no mental injury of harm noted upon psychosocial assessment. The report also revealed the incident was reported to local law enforcement and the Department of Social Services on 10/02/2024 at 10:30 AM. The report indicated that Nurse Aide (NA) #1 and NA #2 were suspended pending the conclusion of the investigation. Review of the incident report dated 10/02/2024 at 9:30 AM revealed upon staff rounding, Resident #1 was noted to have upper extremity range of motion restricted in linen. Linen immediately straightened and removed allowing Resident #1 normal range of motion. Resident #1 was assessed by the DON and MD with discoloration noted to top of both wrists. Resident #1 denied pain or discomfort. Review of the MD's acute visit progress note dated 10/2/2024 at 10:50 AM revealed Resident #1 was seen after he was found by nursing staff restrained at the wrists with a pillowcase. Physical examination revealed mild superficial bruising noted on the top of the left and right wrists. No edema was present and Resident #1 had no pain with palpation or movement of the left and right wrists. The MD's plan revealed clinically Resident #1 appeared stable and without fracture but given the mild bruising will obtain STAT (immediate) x-rays of both wrists. Resident #1 elicited no pain with examination. Review of the physician's orders revealed STAT bilateral wrist x-rays were ordered 10/2/224 at 10:45 AM. Review of the bilateral wrist x-ray reports dated 10/02/2024 revealed bilateral wrist x-rays were completed 10/02/2024 at 7:45 PM and results released at 10/03/2024 at 12:51 AM. The results read: 1. Right wrist - minimally displaced fracture of the scaphoid (small bone on the thumb side of the wrist) bone. 2. Left wrist - No obvious acute osseous (bone) or soft tissue abnormality. Further evaluation with Computerized Tomography (CT) (medical imaging procedure that uses x-rays to create 3D cross-sectional pictures) may be considered if clinically indicated. Review of the facility's Nurse Practitioner's (NP) acute visit note dated 10/03/2024 at 8:00 AM. Physical examination revealed Resident #1 was lying bed in no acute distress. Resident #1 endorsed no pain or complaints of pain. Review of bilateral wrist x-rays which showed displaced fracture of the scaphoid bone of right wrist and left wrist showed no acute osseous or soft tissue abnormality however further evaluation with CT may be considered if clinically indicated. NP's plan revealed Resident #1 was to be transferred to the Emergency Department (ED) for further evaluation and treatment and possible CT of left wrist. Resident #1 was sent to the ED on 10/03/2024 at 8:47 AM. Review of the ED physician assistant notes dated 10/03/2024 at 10:15 AM revealed Resident #1 had bilateral wrist x-rays taken at his nursing facility on 10/02/2024 which showed an assumed scaphoid fracture of the right wrist and unclear if there were any fractures of the left wrist. Resident #1 denied pain and when asked if his hands hurt, Resident #1 responded no. Physical examination revealed no traumatic deformity present but contractures of all 4 extremities were present with the left side being the worst. No bruising of the extremities was observed during the examination. The ED note revealed Resident #1 was placed in a thumb spica (device used to immobilize a limb) splint of the right wrist and a CT scan of the left wrist was ordered. Review of the left wrist CT scan results dated 10/03/2024 revealed the examination was degraded by demineralization (bones that have lost minerals that are essential for bone strength which makes bones more likely to fracture). There were findings suspicious for a triquetral fracture (a break in a small wedge-shaped bone in the wrist) and a questionable fracture through the tip of hamate (small bone in the wrist) versus more likely vascular groove (type of indent or [NAME] in bone surfaces). Review of the facility 5-day investigation report dated 10/04/2024 submitted to the state agency indicated staff interviews were conducted with NA #1 who had applied the restricting technique to Resident #1's wrists for combative behavior. The report also revealed NA #1 reported no intent of harm or intent of abuse but identified these techniques as behavioral management which she had learned from NA #2. The facility also conducted an interview with NA #2 who stated that she was not going to lie; she had placed Resident #1's hands inside his shirt when changing him so that Resident #1 would not hit her. NA #2 stated that she did not think she was doing anything wrong by placing Resident #1's hand inside his shirt. NA #1 and NA #2's employment with the facility was terminated effective 10/04/2024. The facility's root cause analysis determined the staff required education on behavioral management during personal care which did not include the use of restrictive devices. Review of statement provide by NA #1 dated 10/02/24 at 4:30 PM read, NA #1 revealed she only tied Resident #1's wrists together with a pillowcase this one time. NA #1 stated that Resident #1 would hit and kick staff during care. NA #1 stated she had seen NA #2 do something like this before; NA #2 would put Resident #1's arms inside his shirt so Resident #1 would not hit her when she changed him. NA #1 stated that NA #2 would take his arms out when she was done with the care. NA #1 was asked if there were other residents these techniques were used on, NA #1 replied no. An attempt to conduct a phone interview with NA #1 on 11/25/2024 at 11:10 AM was unsuccessful. The phone number was no longer in service. A statement provided by NA #2 dated 10/02/24 at 7:00 Pm read, NA #2 stated that she was not going to lie; she had placed Resident #1's hands inside his shirt when changing him so that Resident #1 would not hit her. NA #2 stated that she did not think she was doing anything wrong by placing Resident #1's hand inside his shirt. A telephone interview was conducted with NA #2 on 11/25/2024 at 11:25 AM. NA #2 stated that she had never used linen or anything else to tie a resident down with. She further explained that she had never tied a resident's hands, arms, legs, or body down and she had never seen any staff member tie a resident to the bed or a wheelchair. She further revealed she did not understand why she was involved in this investigation because she had not worked a shift at the facility since 09/29/2024 and was not working when the incident occurred. She also stated that she did not understand how her name got brought up with this investigation. She further stated that she had never shown another NA how to restrain a combative resident so that care could be provided easily, and she had never placed a Resident #1's arms inside his shirt to keep him from hitting her. An interview was conducted with the DON on 11/25/2024 at 11:45 AM. The DON stated that she was coming down the hall on 10/02/2024 and that Nurse #1 and NA #3 asked her to come to Resident #1's room at approximately 9:30 AM. She explained that NA #3 was serving Resident #1's breakfast tray and noticed his linen was tangled and found Resident #1's wrists tied together with linen. Resident #1 was covered with his sheet and when the DON removed the top sheet, she noted Resident #1's wrists were bound together and secured with a pillowcase which was tucked in a figure-8 around both wrists. The DON stated she removed the pillowcase and observed redness to the top of both wrists. The DON further added that Resident #1 denied pain or discomfort. The DON explained she went to the MD who was in the facility and explained to him what happened and ask the MD to see Resident #1. The DON revealed the MD ordered STAT (immediate) x-rays of Resident #1's bilateral wrists which were taken 12/02/2024 at 7:45 PM and resulted on 12/03/2024 at 12:51 AM. The DON stated the x-ray report was placed in the physician's box for review because the report was not flagged as critical and did not indicate an acute fracture. The DON further explained that it was unknown exactly how long Resident #1's wrists were bound by the pillowcase. The DON also revealed that Resident #1 was difficult to care for and he would often resist care. The DON explained Resident #1 would be combative, and he would hit and kick staff. She also stated that when she reviewed the night shift staffing grid, NA #1 was assigned to care for Resident #1. The DON stated that when she interviewed NA #1, NA #1 stated this was the only time she had ever placed a pillowcase around Resident #1's wrists so Resident #1 would not hit her while she provided care. An interview was conducted with NA #3 on 11/25/2024 at 12:25 PM. The NA stated that Resident #1 was tangled up in his linen and when she pulled the top sheet back, she observed Resident #1's wrists tied together with linen. NA #3 called for Resident #1's nurse (Nurse #1) and the DON who came to the room immediately. Multiple attempts to contact Nurse #1 were made and were unsuccessful. Several attempts to contact the MD were made from 11/25/2024 to 11/26/2024. The attempts were unsuccessful and there were no return calls from the MD. An interview was conducted with the facility's Nurse Practitioner (NP) on 11/25/2024 at 2:57 PM. The NP stated that she did not see the pillowcase tied around Resident #1's wrists and further added that a fracture occurring from a pillowcase wrapped around the wrists was unlikely but not impossible. She also explained that it would not be appropriate to restrain any resident because the restraint itself may result in harm and/or injury to the resident. An interview was conducted with Resident #1's responsible party (RP) on 11/25/2024 at 3:05 PM. The RP stated that the facility notified him that a staff member had bound Resident #1's wrists together and Resident #1 had broken wrist. The RP also stated that he was not happy with the care provided to Resident #1 at the facility and did not want him to return to the facility. A telephone interview was conducted on 11/26/2024 at 9:02 AM with the Physician Assistant (PA) who cared for Resident #1 on 10/3/2024 in the ED. The PA stated that they were unable to determine the age of the wrist fractures due to the demineralization of Resident #1's bones. The PA further explained that they could not tell if the fracture(s) were acute or chronic in nature. The PA explained that the fractures could be a chronic condition related to the severity of Resident #1's hand/wrist contractures. A joint interview was conducted with the Administrator and the DON on 11/26/2024 at 1:45 PM. The DON stated Resident #1 was found restrained with his wrists bound together with a pillowcase. The DON explained Resident #1 was assessed by nursing and the MD with x-rays ordered. The Administrator stated the facility reported the incident with the 24-hour initial report and the 5-day investigation report and the facility substantiated the use of the pillowcase as a restraint. The DON also stated that both NAs involved were suspended and ultimately terminated on 10/04/2024. The facility provided the following corrective action plan with a completion date of 10/04/2024. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices: On 10/02/2024, pillowcase was removed from Resident #1's hands by licensed nurse. On 10/02/2024, Resident #1 assessed by licensed nurse for any injury with none noted. On 10/02/2024, Resident #1 was assessed by physician with new orders for x-ray given. On 10/02/2024, Resident #1 assessed for psychosocial harm by licensed nurse with no ill effects noted. On 10/02/2024, Resident #1's responsible party was notified of incident by licensed nurse. On 10/02/2024, NA #1 and NA #2 staff reporting use of restraints were suspended pending investigation by the director of nursing. On 10/02/2024, 1:1 education provided verbally by director of nursing to two staff (NA #1 and NA #2) reporting use if restraints regarding restraint-free facility policy and reporting behaviors to charge nurse. On 10/02/2024, Resident #1's care plan updated by licensed nurse to include two person assist for personal care On 10/03/2024 Resident #1 was transferred to the emergency room . How will the facility identify other residents having the potential to be affected by the same deficient practice: All residents are at risk of this practice. On 10/02/2024, all other residents were assessed by a licensed nurse for use of restraint with no other residents affected. On 10/02/2024, all other residents were assessed by a licensed nurse for any injury or new skin area with no concerns noted On 10/02/2024, all residents with a BIMS score of 10 or greater were interviewed by a nurse unit manager to ensure no other concerns for restraint or other abuse with no additional concerns noted. On 10/02/2024, all facility staff were interviewed by the DON to ensure no other incidents of restraint use were known with no additional concerns noted. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 10/02/2024, all staff were re-educated in person and/or by telephone to the facility's restraint-free policy by director of nursing or other nurse management. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. On 10/02/2024, all staff educated in person and by telephone to abuse policy by facility director of nursing or other member of nurse management including types of abuse, reporting, and response. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing the education. On 10/02/2024, staff were educated in person and/or by telephone to notification & intervention for combative and agitated behaviors by director of nursing or other nurse management. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. How will the facility monitor its corrective actions to ensure the deficient practice will not recur: Beginning on 10/02/2024, the DON, or other nurse manager/leader, administrator or social worker will observe (on alternating shifts to include 3rd shift) five residents per week for four weeks, and then 3 residents per week for four weeks to ensure no restraints, or other restriction of normal movement or range of motion are in place. Beginning on 10/02/2024, the DON, administrator, or other nurse manager/leader, administrator or social worker will interview 5 residents per week for 4 weeks, then 3 residents per week for 4 weeks for any safety, abuse, or restraint concerns. Beginning on 10/02/2024, the DON, administrator, or nurse manager/leader will interview 5 staff members (on alternating shifts to include 3rd) weekly x 4 weeks, then 3 staff weekly x 4 weeks to identify concerns of abuse or restraint use. The Facility Administrator will review the audits to identify patterns/trends and will adjust the plan to maintain compliance. The Facility Administrator will review the plan during the October 3rd, 2024, ad hoc QAPI meeting and the audits will continue at the discretion of the QAPI committee. Date of compliance: 10/04/2024 The facility's corrective action with a correction date of 10/04/2024 was validated onsite by record reviews and interviews with the Administrator, DON, and staff. Facility staff interviews revealed that they had received education on Abuse and Neglect and the Use of Restraints policies. Staff also received education on notification and interventions for combative and agitated resident behaviors. No employees were allowed to return to work until they had completed the training on Abuse and Neglect, Use of Restraints education and Behavior Management. Review of the assessment sheets revealed residents were assessed for the use of restraint devices with no other residents identified or affected. Residents were also assessed for injury and for the presence of new skin impairments with no concerns identified. Residents who were cognitively intact were interviewed to ensure no additional concerns for restraint or other forms of abuse were verbalized. Review of the facility staff interview sheets to ensure no other incidents of restraint use were being utilized by staff and no additional concerns were found. Administrative staff interviews revealed they had completed the education with all staff and interviews with the staff revealed they had been educated on the Abuse and Neglect, Use of Restraints policies, and Behavior Management. The education included the use of any physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Staff were also able to verbalize that restraints were never used for staff convenience. Review of the audit records revealed the Administrative staff observed five residents per week for four weeks, then 3 residents per week for four weeks to ensure no restraints, or other restriction of normal movement or range of motion was in place. Review of the audits also revealed the Administrative staff interviewed 5 residents per week for 4 weeks, then 3 residents per week for 4 weeks for any safety, abuse, or restraint concerns. Review of the audits further revealed the Administrative staff interviewed 5 staff members on alternating shifts weekly for 4 weeks, then 3 staff members weekly for 4 weeks to identify concerns of abuse or restraint use. The Administrator reviewed the audits to identify patterns/trends and reported the auditing results to the monthly QAPI (Quality Assurance and Performance Improvement) committee. The quality improvement monitoring schedule would be modified if needed based on the findings of the audits. Interviews with the Administrator and the DON revealed the facility launched an educational program related to Abuse and Neglect which included the use of restraints immediately after the incident to re-educate all facility staff. The Administrative staff observed residents to ensure no restraints, or other restriction of movement or compromised range of motion was in place, interviewed residents to ensure no safety, abuse, or restraint concerns were present, and interviewed staff to ensure no concerns of abuse or restraint use was in place. The Administrator and the DON stated the interventions were successful as the facility did not have any further incidents of restraint usage. The compliance date of 10/04/2024 was validated.

Based on record reviews, and staff interviews, the facility failed to develop and implement an individualized person-centered care plan that addressed activities of daily living (ADL), psychotropic drug use (Resident #7), and tube feeding (Resident #298) for 2 of 9 residents whose care plans were reviewed. The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included bilateral knee osteoarthritis (type pf arthritis that occurs when flexible tissue at the ends of bones wears down), delusional disorder, and dementia. The modification of admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was cognitively intact, had no behaviors, and required extensive physical assistance with bed mobility, eating, toilet use, and personal hygiene, and was totally dependent on staff assistance with dressing and bathing. She did not have range of motion impairment to either upper or lower extremities. The MDS further indicated that Resident #7 received antipsychotic medications for 6 days and antidepressant medications for 4 days during the assessment period. The Care Area Assessment (CAA) dated 6/15/23 for activities of daily living (ADL) functional/rehabilitation potential indicated Resident #7 required staff assistance with ADL at this time. She was non-ambulatory and required staff assistance with transfers and mobility. She required assistance with feeding. The CAA further indicated that the ADL functional/rehabilitation potential will be addressed in the care plan with the overall objectives of slowing or minimizing decline, avoiding complications, and minimizing risks. There was a note that indicated will proceed to care plan to focus on providing assistance with ADL. The Care Area Assessment (CAA) dated 6/15/23 for psychotropic drug use indicated Resident #7 was at risk for adverse effects related to psychotropic medication usage. She was ordered and received antipsychotic and antidepressant medications daily. She has had no noted adverse effects at this time. The CAA further indicated that the psychotropic drug use will be addressed in the care plan with the overall objectives of avoiding complications and minimizing risks. There was a note that indicated will proceed to care plan to focus on monitoring for adverse effects related to psychotropic medication usage. The most recent quarterly MDS dated [DATE] indicated Resident #7 was cognitively intact, had no range of motion impairment to either upper or lower extremities, and was dependent on staff assistance with toileting hygiene and shower/bathing. She received antipsychotic and antidepressant medications, and a gradual dose reduction was documented as clinically contraindicated on 7/25/23. Resident #7's care plan which was last updated on 1/22/24 did not include a care plan for ADL and psychotropic drug use. An interview with MDS Coordinator #2 on 1/25/24 at 8:27 AM revealed she started in her current position on 11/8/23 and she was responsible for developing and updating the care plans. MDS Coordinator #2 stated she last updated Resident #64's care plan on 1/22/24 when she was asked to go through the residents listed on the matrix and make sure they had a care plan for the medications that they received. MDS Coordinator #2 stated she acknowledged that Resident #7 was listed as receiving antidepressant and antianxiety medications on the matrix, but she did not see a care plan for psychotropic drug use. She also stated that she did not see a care plan for ADL for Resident #7. MDS Coordinator #2 further reviewed Resident #7's care plan and shared that she added a care plan for urinary catheter on 1/22/24. She stated that she was not sure how the care plan for psychotropic drug use and ADL were missed. She further stated that one of the corporate staff completed Resident #7's quarterly MDS and they probably did not update her care plan then. An interview with the Director of Nursing (DON) on 1/25/24 at 3:39 PM revealed that in order for the floor staff to take care of Resident #7, she didn't think there would be specific interventions in her care plan that weren't already reflected in her medical record. The DON stated that behavior monitoring was already in her medication record, and they should have monitoring of behaviors and monitoring of side effects of psychotropic drugs on the medication administration record. The DON stated that it would be ideal if these interventions were included in Resident #7's care plan but she didn't think not having them on the care plan would prevent the staff from monitoring Resident #7. The DON also stated that ADL should be on Resident #7's care plan. The DON shared that they had MDS nurses who monitored and updated the care plans. The MDS nurses referred to the care plans often and they needed to make sure the specific needs were on the residents' care plans and that they were being met. The DON stated that it was not an excuse but that they have had changes in their MDS department related to staff and they had corporate people and outside personnel helping with MDS and care plans. 49000 2. Resident #298 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids). Resident #298's care plan dated 11/20/23 did not include a care plan to address his tube feed and nutrition. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #298 was cognitively intact and used a feeding tube for nutritional intake. An interview with MDS Coordinator #1 on 1/24/24 at 10:30 AM revealed that the feeding tube should be a part of the care plan and the Dietician usually did the dietary and nutritional care plans. An interview with the Dietician on 1/24/24 at 12:05 PM disclosed that she initiated most dietary care plans. If it was a resident who required nutrition through a feeding tube, she would always initiate a care plan. The Dietician stated that Resident #298 had been in and out of the hospital so often that she did not do a care plan for the tube feeding. On 1/25/24 at 3:44 PM an interview with the Director of Nursing (DON) revealed that the MDS Nurses were responsible for making sure care plans were complete. The DON indicated that the remote staff and MDS staff changes were part of the issue with missing care plans. Typically, a feeding tube for nutrition care plan would be initiated by the Dietician. On 1/25/24 at 4:19 PM an interview with the Administrator disclosed that the feeding tube should be a part of the care plan and should have been in place for Resident #298.

Based on observations, record review, resident interviews and staff interviews, the facility failed to provide nail care for 2 of 9 residents dependent on staff for activities of daily living (Resident #44 and #1). The findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses inclusive of Parkinson's disease. The quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #44 had severe cognitive impairment and required setup with eating, oral hygiene, and toileting. The MDS also indicated Resident #44 had not rejected care. A revised care plan dated 12/1/23 revealed Resident #44 had an activities of daily living (ADL) self-care performance deficit related to Parkinson's disease and he required staff assistance to complete ADL tasks daily. An observation and interview conducted on 1/22/24 at 11:10 AM revealed Resident #44's fingernails on both hands were long with jagged edges. Resident #44 stated his fingernails were cleaned the previous week by one staff member then was told a different staff would have to trim his nails and that did not happen. He explained that his fingernails had not been trimmed in a long time and that he wanted them to be cut. He also stated he had never declined to have his nails trimmed. A follow up observation was conducted on 1/23/24 at 9:34 AM and revealed Resident #44's fingernails on both hands remained unchanged (long with jagged edges). A follow up observation was conducted on 1/24/24 at 11:08 AM and revealed Resident #44's fingernails on both hands remained unchanged (long with jagged edges). A review of bathing sheets from 11/2023 through 1/2024 and progress notes from 12/2023 through 1/2024 in the electronic medical record indicated Resident #44 had no refusals of care. During an interview on 1/24/24 at 11:39 AM Nurse Aide (NA) #1 indicated she usually worked with Resident #44 and had provided nail care in the past. She further indicated there was a designated NA (NA#4), who was on light duty, and was assigned to provide nail care to certain residents. However, NA #1 stated she would perform nail care if she recognized the need if NA #4 had not provided nail care. During an interview on 1/24/24 at 3:35 PM the Director of Nursing (DON) expected Resident #44 to receive nail care on shower days. She then explained NA #4 was assigned to provide nail care (clean and file) and although the activities staff provided nail care as an activity, they could only file resident fingernails. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses inclusive of peripheral vascular disease, dementia, and anemia. The quarterly MDS assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and required maximum assistance for toileting, dressing, and personal hygiene and had not refused care. An observation and interview conducted on 1/22/24 at 11:35 AM revealed Resident #1's fingernails on both hands were long with jagged edges and had dark brown matter under both thumbnails. A follow up observation was conducted on 1/23/24 at 9:55 AM and revealed Resident #1's fingernails on both hands remained unchanged (long with jagged edges and dark brown matter under both thumbnails). A follow up observation was conducted on 1/24/24 at 11:19 AM and revealed Resident #1's fingernails on both hands remained as they did on 1/22/24 (long with jagged edges and dark brown matter under both thumbnails). A follow up observation on 1/24/24 at 3:09 PM revealed Resident #1's fingernails had been cleaned and cut. During an interview on 1/24/24 at 12:15 PM NA #3 revealed she was assigned to providing nail care to residents and she cleaned Resident #1's fingernails on 1/19/24. However, when she arrived at work on 1/22/24, she observed brown matter under his fingernails and did not get a chance to clean them again. During an interview on 1/24/24 at 11:55 AM NA #2 indicated she did not cut Resident #1's fingernails during personal care because of the thickness of his fingernails. NA #2 further indicated when she provided personal care to Resident #1, she would give him a wet soapy cloth and he could wash his hands without assistance. She was not sure why his fingernails had not been cut or who was supposed to cut them. During an interview on 1/24/24 at 3:30 PM the DON reported NAs have attempted to file Resident #1's fingernails at times due to the thickness of the nails. The DON stated Resident #1 was hospitalized at the end of December and his fingernails had not been trimmed or filed since he returned from the hospital. The DON stated she expected Resident #1 to receive nail care that included cleaning/ removing debris from his fingernails during personal care and on shower days.

Based on record review and interviews with resident, staff, the Nurse Practitioner and the Mental Health Services Representative, the facility failed to obtain mental health services for 1 of 1 resident reviewed for behavioral and emotional status (Resident #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included depression. A progress note dated 10/2/23 by the Nurse Practitioner indicated Resident #64 was seen for routine medical follow-up. Resident #64 endorsed feelings of depression. He stated that he had not slept well for 5 nights. Resident #64 stated that his Escitalopram (antidepressant used to treat depression and generalized anxiety disorder) was not working. He was currently on 20 milligrams (mg) which was the maximum dose. The NP indicated she would place order for psychiatric consult. Resident #64 was originally prescribed Alprazolam (sedative used to treat anxiety and panic disorder) 0.5 mg twice daily as needed. Resident #64 reported he had tried taking Melatonin (hormone that plays a role in sleep) for sleep in the past and it did not work. Resident #64 denied using Trazodone (antidepressant and sedative) in the past. The NP indicated she would place an order for Trazodone 25 mg every night. There was no order in Resident #64's medical record dated 10/2/23 for a psychiatric consult. A progress note dated 10/6/23 by the NP indicated Resident #64 was seen for follow-up of anxiety and depression. Resident #64 endorsed feelings of depression. He stated he was feeling better since Alprazolam 0.5 mg was scheduled twice daily. He was currently on Escitalopram 20 mg and awaiting psychiatric referral. A nurses' progress note dated 10/17/23 at 11:52 PM by Nurse #1 indicated Resident #64 stated that he had been feeling depressed and the depression had taken over. He denied having any suicidal ideations. The NP was notified and an order for a psychiatrist consultation had been made. Staff had been made aware of the resident's change in mental health and will continue to monitor. An order for psychiatry consultation for depression was scheduled on 10/17/23 in Resident #64's medical record and was marked completed on 10/18/23 by Nurse #1. A phone interview with Nurse #1 on 1/25/24 at 8:09 AM revealed Resident #64 told him on 10/17/23 that his depression had taken over and that he wanted to see a psychiatrist. Nurse #1 stated he felt bad about Resident #64 because he was depressed but he wasn't sure what the process was at the facility. Nurse #1 stated he knew Resident #64 needed to be seen by any provider who could talk to him about his depression, and he was advised by the other nurses who worked on the same shift to leave a note under the door of the medical providers' room. Nurse #1 denied having received any order or having entered any order for psychiatry consultation for Resident #64. Nurse #1 added that he thought Resident #64 had been seen by psychiatry because the next time he worked with him, Resident #64 mentioned to him that he talked to the NP about being depressed. Nurse #1 stated that he assumed the NP had taken care of obtaining psychiatric consultation for Resident #64. A progress note dated 10/18/23 by the NP indicated Resident #64 was seen due to reports from nursing that he was experiencing increased depression. He endorsed feelings of depression. He stated he had a feeling of worthlessness. Last week, Resident #64 was seen and stated he was feeling better since adding Alprazolam 0.5 mg scheduled twice daily. He was currently on Escitalopram 20 mg daily which was the maximum daily dose. He denied suicidal or homicidal ideations. The NP indicated Resident #64 was Awaiting psychiatric referral. Resident #64 stated he had not been eating and had no appetite. He stated this happens when he gets in a depressed state. The NP indicated she would place an order to start Bupropion (antidepressant) 100 mg twice daily. The NP indicated she would increase the Bupropion to three times daily as indicated. A progress note dated 12/11/23 by the NP indicated Resident #64 was seen for depression. Resident #64 reported feeling very depressed, and really wanting to see a psychiatrist. The NP indicated the referral was pending and she would follow up with staff to expedite the referral. Resident #64 is on maximum dose of Bupropion as well as Escitalopram. He is currently taking Alprazolam 0.5 mg scheduled twice daily as well. However, he reported sleeping a lot during the day. (The NP) did not think increasing this would be beneficial. The NP documented she would like to start Resident #64 on Mirtazapine (antidepressant) however, would need the assistance of psychiatry to help with transition, as well as more appropriate medications for this resident. He denied suicidal or homicidal ideations. The NP indicated Resident #64 was awaiting psychiatric referral. The most recent quarterly Minimum Data Set assessment dated [DATE] indicated Resident #64 was cognitively intact, had no depressive symptoms and no behaviors. He received anti-anxiety and antidepressant medications. An order to consult psychiatry related to Resident #64 requesting for a psychiatry consult for depression was scheduled on 1/17/24 in Resident #64's medical record and was marked completed on 1/18/24 by Nurse #2. Attempts were made to contact Nurse #2, but they were unsuccessful. An interview with Resident #64 on 1/22/24 at 10:54 AM revealed he had asked to see a psychiatrist and they had not taken care of it. He stated that he had moods that went up and down, and that he was going through depression. He also stated that sometimes he did not get up out of the bed because of his depression. Resident #64 further stated that since his admission at the facility, he had not been seen by a psychiatrist. Resident #64's care plan last revised on 1/24/24 indicated he received antidepressant medications related to depression and insomnia, and anti-anxiety medications related to anxiety disorder. Interventions included to refer for psychological evaluation as ordered by the doctor. An interview with the Nurse Practitioner (NP) on 1/25/24 at 9:18 AM revealed she knew for sure that she gave a verbal order to a staff member that Resident #64 needed a psychiatric referral, but she couldn't remember who. During the interview, she searched in Resident #64's medical record and stated she couldn't find an order for 10/2/23. She stated that there was an issue with Resident #64's insurance but she didn't know much about it, and he had been waiting to see a psychiatrist. The NP shared that after the first time she saw him at the facility, she wanted him to see a psychiatrist because he had complained of depression. She stated that she was managing him in the meantime, and she didn't think the delay in obtaining a psychiatric consultation for Resident #64 caused a negative outcome. The NP further stated Resident #64's depression had been up and down and would continue to be up and down, and a psychiatrist probably would have ordered the same medications that he was currently on. The NP stated a psychiatrist needed to see Resident #64 first to make sure he was getting the right medications for his depression, and they would be able to refer Resident #64 to a psychotherapist from whom Resident #64 would benefit more. An interview with the Business Office Manager on 1/25/24 at 12:19 PM revealed Resident #64 did not have any issues with his insurance and if he needed to be seen by a psychiatrist, he could have been seen without her checking if it was covered by his insurance. The Business Office Manager stated the staff normally did not need to check with her before a resident was seen for a psychiatric consult unless there was an issue with the insurance. She also stated that the Social Services Director was responsible for arranging the psychiatric consults. An interview with the Social Services Director (SSD) on 1/25/24 at 12:26 PM revealed that if the NP gave an order for a psychiatric consult, the nurses would let her know that it needed to be done. She then would get the resident to sign the consent form or call a family member and obtain a verbal consent. The SSD stated that she initially obtained a verbal consent by phone from Resident #64's responsible party on 10/9/23 and she faxed this consent and referral form to the mental health provider's office on 10/9/23. During the interview, the SSD showed this consent form, and it was signed by the NP on 10/9/23. The SSD stated that Resident #64 was on the caseload to be seen by psychiatry due to his diagnoses and psychiatric medications when he was admitted to the facility. She said she did the referrals by batches which explained why she did the initial referral on 10/9/23. After she had faxed this form, she thought they had included Resident #64 on the list until December when she found out that Resident #64 still had not been seen by the psychiatrist. She The SSD stated she discovered this after Resident #64 was discussed at a utilization review meeting that he was still waiting to be seen by a psychiatrist. The SSD further stated that she called the representative at the mental health services and found out that she needed to send another consent because they changed the form to which two signatures were required if a verbal consent was obtained. The SSD obtained another verbal consent from Resident #64's responsible party on 12/12/23 and faxed it to the mental health services group. The SSD stated that she noticed there were other psychiatric referrals that did not get added to the list of residents to be seen by the mental health provider. So, she sent the representative an e-mail about this concern on 1/24/24 and requested for them to add the new residents to the list and send the new list to her. The SSD reported she had not heard back from the mental health services representative. The interview further revealed that the SSD had not talked to the NP about obtaining a psychiatric consult for Resident #64. The SSD shared that the psychiatrist typically came to the facility on ce a week, but they had requested for them to come more frequently because they had a lot of residents who needed psychiatric services. She also shared that there was a psychotherapist who came to the facility on ce or twice a month. The SSD said she couldn't remember if Nurse #2 notified her about Resident #64's order for psychiatric referral on 1/17/24 and she would need to check if she received an e-mail from Nurse #2 because sometimes the nurses sent her an e-mail if they needed to notify her of orders for psychiatric consults. During a follow-up interview with the SSD on 1/25/24 at 12:57 PM, she shared that the administrative team had a meeting with the psychiatric providers last week and they brought to their attention about the concern that they had been faxing consent forms for new residents, but they did not get added to the list of residents to be seen. They gave them a copy of the consent forms during their visit last week and this included Resident #64's referral. A phone interview with the Mental Health Services Representative (MHSR) on 1/25/24 at 3:57 PM revealed they did recently change the consent form to where two signatures were required for verbal consents and the referral for psychiatric consult was also on the same form. The MHSR stated that she did not see Resident #64 in their system as an active resident, but she would have to refer to the intake department who received the referrals for new residents to get more information. During a follow-up phone interview with the MHSR on 1/25/24 at 4:24 PM, she stated that she confirmed that they did not receive a consent and referral form for Resident #64. The MHSR stated that if the facility faxed a form over to them, it probably didn't go through. The MHSR further stated they always send the schedule for the psychiatric provider's next visit at least 48 hours in advance so if they noted that the new resident was not on the list, they should have called her to make sure they received the consent and referral form. The MHSR disclosed that the provider's assistant normally e-mailed the schedule to a number of administrative staff including the Director of Nursing, the Assistant Director of Nursing, the Social Services Director, and the Administrator to make sure someone was available at the facility to review it prior to the psychiatric provider's visit. An interview with the Director of Nursing (DON) on 1/25/24 at 3:39 PM revealed she met with the psychiatric providers last week and expressed her concern that they had been sending them referrals, but she had not been seeing notes that they were following up with the new residents. The DON shared that the facility's system was that if they received an order for psychiatric referrals, they would send the referral and consent form to the psychiatric provider and then she would receive an e-mail of the list of residents to be seen on the next visit. The DON stated she received an e-mail on either 1/11/24 or 1/12/24 and she noticed that the new residents they had just sent referrals for did not make it on the list, so she spoke with them on 1/16/24. The DON further stated that the psychiatric provider came to the facility every other week and that should have been the maximum wait time for a resident to get seen for a psychiatric consult. The DON shared that she told them that it was not acceptable for a resident to wait longer than two weeks to see a psychiatric provider. An interview with the Administrator on 1/25/24 at 4:18 PM revealed she had just started working at the facility last week and she was part of the meeting with the mental health services group, but she could not remember the details of the meeting and she relied on the DON to lead it. The Administrator stated that whenever they sent referrals to the psychiatric providers, they need to follow through with the order and make sure that they were seen by the psychiatrist as ordered. She shared that she was aware that the DON had been having issues with the psychiatric providers and their referrals not being processed and residents not being seen as they should.

Based on observations and staff interviews the facility failed to remove expired food stored for use from 1 of 3 refrigerators (the walk-in refrigerator) in the kitchen. This had the potential to affect food served to residents. The findings included: On [DATE] at 10:38 AM an observation of the kitchen's walk-in refrigerator with the Dietary Manager (DM) revealed one opened case of lettuce. The box contained approximately 6 heads of lettuce that were brown and black in color, withered on the outside and brown and slimy on the inside. During the observation, the DM stated the lettuce was expired, and it would not have been used. The DM stated she and the cooks checked the refrigerator at the start of each workday for expired food. The DM said the box of lettuce was not checked for freshness earlier in the day. The Administrator stated on [DATE] at 3:40 PM the assigned kitchen staff should have checked the produce and removed all expired produce.

Based on record review and staff, resident, Nurse Practitioner, Medical Director, Home Health Director, Dialysis Center, Clinical Manager and Equipment Company Manager interviews the facility failed to provide a safe and orderly discharge for 2 of 5 residents reviewed for discharge (Resident #1 and #2). Resident #1 was transported to a medical appointment on 3/16/23 and was informed by the Facility Transporter she was being discharged that day. When they returned to the facility, Nurse #6 and the Administrator came out to the van to give Resident #1 her discharge paperwork and she expressed her concern about not being able to get up and down her steps in her wheelchair to the parking lot to access transportation for dialysis services. Resident #1 was discharged to home on 03/16/23 and due to not being able to get to the parking lot from her apartment she missed 2 dialysis treatments. In addition, Resident #1 did not have supplies or daily wound care through home health services set up for a diabetic foot ulcer for 7 days. Resident #1 called Emergency Medical Services (EMS) the evening of 3/24/23 and was evaluated in the emergency room and admitted for hemodialysis and treatment for acute pulmonary edema and diarrhea. Missing dialysis treatments places a person at risk for building up high levels potassium which can lead to heart problems including arrhythmia, heart attack, and death. In addition, Resident #2 was discharged on [DATE] and delivery of a wound vac (used to treat deep wounds) for continued treatment of a surgical wound was not confirmed with the home health agency prior to discharge. Immediate Jeopardy began on 03/16/23 for Resident #1 when she was discharged home without access to dialysis services and wound care. The immediate jeopardy was removed on 03/30/23 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 for Resident #2 was cited at a scope and severity of D. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include end stage renal failure, acquired absence of left leg below knee, dependence on renal dialysis, and type 2 diabetes. Review of quarterly minimum data set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required extensive two+ person assist for mobility and transfers, extensive one person assist for toileting, and physical help one person assist for bathing. Resident #1 was assessed as requiring wound care for a diabetic foot ulcer, being frequently incontinent, requiring use of wheelchair for mobility, and receiving dialysis services. Resident #1 was also assessed for anticipated discharge to community and no referrals made to local contact agencies. Review of the medical record revealed there was not a care plan that addressed discharge or Interdisciplinary Team (IDT) notes about discharge for Resident #1. Review of Nurse Practitioner (NP) discharge summary dated 03/09/23 revealed Resident #1 was being seen for discharge. She stated Resident #1 had a diabetic ulcer located on her right heel that required continued daily treatment and recommended for Resident #1 to receive home health services post-discharge to include physical therapy (PT) and occupational therapy (OT) for evaluation and treatment, nursing services for dressing changes, nursing assistance for bathing, and social work services for support. The NP also recommended durable medical equipment be ordered for Resident #1 home to include a 3-in-1 commode, transfer bench, wheelchair with leg support, and hospital bed. Review of note dated 03/16/23 documented by the Social Worker (SW) revealed the former Administrator had spoken with Resident #1 early last week regarding her pending discharge. She indicated Resident #1 would be returning to her apartment with her grandson. The former Administrator advised that it would be best if Resident #1 went home on a non-dialysis day which she agreed with, and discharge was set for Tuesday 03/14/2023. Several days later Resident #1 told staff that she had a foot doctor appointment on Thursday 03/16/2023 and discharge was then scheduled for today 03/16/2023 after the foot doctor appointment with Resident #1 expressing agreement. This morning, Resident #1 was transported to her foot doctor appointment and then returned to the facility to complete discharge paperwork. Resident #1 was offered to come into the facility and be present for her belongings to be packed but she refused and said her grandson was on his way. Resident #1 was transported and escorted into her home by facility transporter. An interview conducted with Social Worker (SW) on 03/27/23 at 5:09 PM revealed she had begun working at the facility in October 2022 and part of her role as SW was assisting with resident discharge. She stated the interdisciplinary team which included herself, former Administrator, Nursing, Business Office Manager, and Admissions would meet and discuss residents who were ready for discharge and afterwards she was responsible for completing any referrals for post-discharge services such as home health or durable medical equipment for resident that was discussed during the meeting. She revealed home health referrals for post-discharge typically include only PT, OT, and SW services unless she was notified by nursing, or it was discussed during the team meeting the resident would require other services such as nursing care for wounds or nursing assistance for bathing and if that was the case, she would include with the referral any orders provided by nursing. The SW stated the team would also discuss durable medical equipment needs for resident's post-discharge and she would complete those referrals as well. When asked about residents who have transportation needs post-discharge, SW stated the resident or family was responsible for setting up transportation from facility on day of discharge and to any post-discharge appointments. She revealed when a resident was being looked at for discharge, the physician or NP would complete a discharge visit with the resident prior to discharge and reconcile all medications and on the day of discharge it was the nursing staff assigned to resident responsibility to go over discharge paperwork with resident. She stated regarding Resident #1's discharge, the team had been discussing her discharge since November of last year but there had been concerns with her not being able to provide her own care and with her apartment not being handicap accessible since her left leg had been amputated and she required full time use of a wheelchair for mobility. SW revealed she had spoken with the family on-going since November 2022 about a handicap accessible apartment for Resident #1 and they were in the process of completing necessary paperwork for her to be able to obtain one but was not aware of where the family was with the process. She stated at the beginning of this year, Resident #1 refused to discuss with her any plans regarding discharge, so the facility former Administrator took over the discharge responsibilities for Resident #1 and was speaking with her and her family about discharge. She revealed she was informed on 03/07/23 by the former Administrator of Resident #1 being discharged on [DATE] and was asked to notify physician of pending discharge date and complete referrals for home health and durable medical equipment. SW stated she notified the physician of the pending discharge date , completed referral for home health, began completing discharge summary and completed and faxed the referral for durable medical equipment. She revealed she was told by the former Administrator; Resident #1 would be discharged back to her old apartment where she lived prior to coming to the facility and a family member would be living with her. She stated she was informed by the former Administrator on 03/10/23 Resident #1 would be discharged on [DATE] and would be transported home after her morning appointment with her foot doctor. She stated she completed discharge summary and faxed referral to home health for Resident #1 on 03/16/23 for PT, OT, and SW services but did not recall including nursing services for wound treatment or nursing assistance for bathing. She revealed she was not aware Resident #1 required those services post-discharge and had not reviewed the physician discharge summary to make sure all referrals for services needed post-discharge had been completed. The SW stated Resident #1 was brought back to the facility after her appointment on 03/16/23 and the former Administrator and nursing attempted to complete discharge paperwork with her, but she was being non-compliant and refused to sign due to not wanting to go home and wanting her belongings. She revealed transportation took Resident #1 home and her grandson came to the facility later that day to pick up her belongings and speak with the former Administrator. She stated she was not aware of issues with Resident #1's apartment and her having to use steps to get from her apartment to the parking lot to receive transportation to her dialysis appointments or not having family that would be living in her home to help provide her care and if she had known of these issues prior she would have discussed Resident #1 waiting to discharge until she had access to a wheelchair accessible apartment and felt more comfortable providing her own care. An interview conducted with Facility Transporter on 03/28/23 at 3:15 PM revealed on the morning of 03/16/23 he was scheduled to take Resident #1 to her medical appointment and was informed by the former Administrator that morning to take her home after her appointment. He stated he had made a comment to Resident #1 about going home after her appointment and she became upset stating she was not aware she was going home, called her family and then asked to be taken back to the facility so she could discuss her going home and also ask about her belongings. He stated he took Resident #1 back to the facility and she was asked to stay on the van by the former Administrator while a nurse came and spoke with her about her going home. Resident #1 contacted her family and asked if they could come to the facility and gather her belongings. The Transporter stated he took Resident #1 to her home and observed steps leading from the parking lot to her apartment or a grassy hill but no wheelchair ramp, so he turned her wheelchair backwards and took her down the grassy hill with the assistance of her grandson who was there. He revealed he when he returned to the facility, he informed the former Administrator about the issues with the steps at Resident #1 home and her not being able to get to and from her home to the parking lot, and she stated that she knew but Resident #1 family would be there to help. Review of a document titled Bridge to Home Discharge Summary for Resident #1 dated 03/16/23 revealed the seven-page document that had a section for each discipline including patient information, Social Services, Nursing Services, Dietary/Nutrition, Rehab Services, and Discharge instructions were filled out inaccurately or left blank. The sections pertaining to Patient, Caregiver, and Social Services sections had inaccurate information and information left blank. The sections pertaining to Medical Equipment, Dietary/ Nutrition, Activities, Rehab Services, and Discharge Instructions were all left blank. The document did have a set of vital signs taken on 11/04/22 but contained no wound care instructions, no dietary instructions, no medication education, no rehab services or medical equipment instructions, and no contact information regarding the home health agency that would be assisting Resident #1 once she was in her home. The document was signed by Nurse #6. An interview conducted with Nurse #6 on 03/28/23 at 9:35 AM revealed she was familiar with Resident #1 and her discharge from the facility. She stated on the morning of 03/16/23 she was the nurse assigned to Resident #1 and was informed by the former Administrator that she was being discharged and was asked to print off her discharge paperwork and review it with Resident #1 who was sitting out in transportation van. She revealed she printed off Resident #1's discharge paperwork that had previously been completed by SW and went to review with Resident #1 in the facility transportation van. She also revealed she had not been made aware prior of Resident #1 being discharged home after her medical appointment on 03/16/23 and was only given a few minutes notice to get her discharge paperwork ready for review. Nurse #6 stated Resident #1 was being non-compliant with reviewing her discharge paperwork and stating that she did not want to leave and was concerned about how she was going to get to her dialysis treatments and with getting her belongings from the facility specifically her telephone charger and her continuous positive airway pressure (CPAP) machine. She explained she went and got the former Administrator who came onto the van and discussed with Resident #1 her discharge and assured her they would send her all of her belongings. She stated Resident #1 informed the former Administrator that she had spoken with her grandson, and he would be coming later to pick up her belongings. Nurse #6 further revealed she did not review or educate Resident #1 on her wound care for her diabetic ulcer, did not send home any supplies for wound care, did not review medication list only that meds should have been called into pharmacy, and did not review any medical equipment with her due to not knowing what all equipment had been ordered. Nurse #6 stated she did inform Resident #1 home health would be coming to her home but was not aware what services they would be providing. Nurse #6 revealed Resident #1 refused to sign her discharge paperwork and was transported home by facility transportation. She indicated all discharge paperwork was completed beforehand by the Social Worker (SW) and to her knowledge nursing was only responsible for entering vitals if needed. Nurse #6 stated she was not trained to review discharge paperwork or the physician discharge summary to make sure all orders had been followed, all referrals for services had been completed, education had been provided with residents and their families on their care to include wound care and dressing changes or going over their medications. A telephone interview conducted with Resident #1 on 03/28/23 at 10:10 AM revealed she had been sent to the facility in September 2022 for rehab after having her left leg amputated. She stated the facility began talking to her about leaving the facility in November 2022 and tried to give her a discharge notice, but she refused because she did not feel she was ready or able to return to her home and provide her own care. She also stated she needed a wheelchair accessible apartment so she could take herself back and forth to the parking lot for transportation to her dialysis appointments, and she had developed a diabetic ulcer on her right heel while she was at the facility that needed continued daily treatment. She revealed the SW or the former Administrator would come to her every so often after that and speak with her about discharge and she would refuse saying she was not ready to leave, that her family was working with the apartment complex on getting her a wheelchair accessible apartment and she was concerned the diabetic wound on her right heel was not healing and was scared it could lead to her right leg having to be amputated. Resident #1 stated the former Administrator had spoken with her earlier in the month of March 2023 about a possible discharge on 03/20/23 and she had told her again about her concerns with being discharged home, explained about her current apartment being on the first floor with steps leading up and down to the parking lot which would cause issues with her being able to use transportation for her dialysis treatments. Resident #1 explained she even had her neighbor take pictures for her to show the former Administrator of her apartment and the stairs. She revealed she never heard anything further about discharge until Thursday 03/16/23 when she was on the facility transportation van after a medical appointment and was told they would be transporting her home and she asked for them to take her back to the facility so she could discuss her discharge home and gather her belongings. She stated when she arrived back at the facility, she was not allowed off the van and a nurse came onto the van to hand her a paper about discharge for her to sign and she refused to sign the paperwork and told the nurse that she did not want to leave the facility due to concerns with transportation to dialysis appointments and treatment for her wound on her right heel. Resident #1 stated the former Administrator came onto the van to speak with her about discharge and she told the Administrator her concerns with leaving the facility and she was advised she could always rent a portable ramp if she needed to. She revealed she informed the former Administrator that she had contacted her grandson about the situation, and he would be coming by the facility later to speak with the former Administrator and to get her belongings. Resident #1 confirmed neither the nurse nor the former Administrator reviewed or educated her on wound care, provided her with care supplies, discussed her current medications with her, or informed her of what services home health would be providing and she had to call back to the facility later that day to see where her medications were being filled and was told there was an issue with her pharmacy and she would need to choose another pharmacy for her medications to be sent to. When asked if Resident #1's grandson resided with her and if he had told the facility he would be responsible for assisting with her care and transportations, she stated no that her grandson and his wife lived at a different address, and both worked so they would not have agreed to be available to assist with her care or provide her transportation on a regular basis. In addition, her son who was in New York at the time of her discharge lived with her but was in and out and would also not be able to provide assistance with her care or regular transportation. She stated her grandson took her to dialysis appointment on Friday 03/17/23 due to not being able to schedule transportation to her dialysis treatment on short notice. Resident #1 stated she missed her dialysis appointment scheduled for Monday 03/20/23 due to transportation issues and not being able to get up and down stairs from her apartment to the parking lot and the appointment was rescheduled for Tuesday 03/21/23 which she was able to attend with the help of a family member pushing her up a grassy hill to the parking lot so she could meet transportation. She revealed she missed her scheduled dialysis appointment on Wednesday 03/22/23 and Friday 03/24/23 due to same transportation issues and had to call EMS to take her to the emergency roiagnom on that Friday evening so she could receive her dialysis treatments due to not feeling well and having diarrhea and shortness of breath. She stated she was currently still at the hospital receiving her dialysis treatments and treatment for her wound on her right heel. When asked if she had been seen by home health or provided any wound treatment to her right heel while at home, she stated a physical therapist from home health had come to her home on Sunday 03/18/23 and spoke to her about therapy services, social worker came out to her home on Tuesday 03/21/22 and spoke with her about receiving meals on wheels and she told her about her issues with transportation, and they sent a nurse out on Wednesday 03/22/23 who provided wound treatment to her right heel which had not been done since she had left the facility. The interview further revealed the hospital had contacted disability rights who was working with her apartment complex on getting her wheelchair accessible apartment or providing a ramp from her apartment to the parking lot until a wheelchair accessible apartment becomes available but until then she may discharge from the hospital to another facility to continue her dialysis and wound treatment but had no intentions of ever returning to her previous facility. An interview conducted with Assistant Director of Nursing (ADON) on 03/28/23 at 3:01 PM revealed she was not involved with Resident #1 actual discharge on Thursday 03/16/23 but did receive a telephone call later that day from home health asking about Resident #1's diabetic ulcer on her right heel and requiring nursing services for care and treatment and not having received a referral or order for these services. She stated she informed home health Resident #1 would require nursing services for treatment, and she believed her current orders were for daily wound treatment but did not recall telling home health the facility would be responsible for providing treatment and care until Resident #1 was seen by her primary physician. When asked if after the telephone call she provided or faxed home health with a nursing services referral for wound treatment services and a copy of the current treatment order, the ADON stated no she did not fax or provide home health with any orders for wound treatment or referrals for nursing services. An interview conducted with the former Administrator on 03/28/23 at 3:27 PM revealed all resident discharge plans were discussed with resident or their families on day of admission and the facility interdisciplinary team discusses upcoming resident discharges weekly and what referrals for services are needed and the SW was responsible for completing those referrals. She stated the SW was also responsible for speaking with resident or their families about them being able to provide their own transportation home on the day of discharge and any transportation needs post-discharge. The former Administrator revealed regarding Resident #1's discharge, the facility had attempted to schedule her discharge on four different occasions since her admission and she would refuse each time for different reasons. She stated due to Resident #1 refusing to communicate with SW, she took over responsibility of speaking with Resident #1 about her discharge while the SW continued to complete the discharge paperwork and referrals needed for post-discharge services. She revealed Resident #1 had a discharge date for 03/13/23 and she refused stating she had a doctor appointment on 03/16/23 and there was a concern with her not having a wheelchair accessible apartment, which her family was working on, and having to maneuver steps from her apartment to the parking lot to receive transportation for her dialysis treatments. The former Administrator stated she had spoken with the apartment complex earlier in March 2023 and was informed the family was working on paperwork for a wheelchair accessible apartment for Resident #1 and discussed the issues with steps from apartment to the parking lot and no ramp being available for her to be able to receive transportation and that a portable ramp could be used at Resident #1 expense. She revealed she informed Resident #1 of her option of renting a portable ramp that could assist with her getting from her apartment to the parking lot to receive transportation, but it would be at her expense and to her knowledge Resident #1 did not have a ramp to use when she was discharged home on 03/16/23. She stated Resident #1 discharge date was moved to 03/16/23 and she was supposed to be transported home after doctor's appointment, but she requested to come back to the facility so that she could receive her discharge paperwork. When Resident #1 returned to the facility, she refused to sign her discharge paperwork and was upset with her discharge, and she went onto the van and spoke with her about her discharge and that the facility would get her belongings to her and Resident #1 stated her grandson would be coming later that day to pick up her belongings. When asked if Resident #1 was aware she was being discharged on [DATE] and was returning home after her medical appointment, the former Administrator stated she had not spoken with her about the actual date of her discharge or that she would be returning straight home after her medical appointment, but Resident #1 had been spoken to about discharge on different occasions and was aware it was being looked at. When asked about Resident #1's transportation needs for her dialysis treatments and issues with being able to receive that transportation, the former Administrator stated Resident #1 used special transportation for dialysis treatments prior to coming to the facility so she could resume using the same transportation when she returned home. The former Administrator indicated she had provided Resident #1 with information about renting a portable ramp and it was also her understanding that her grandson lived with her and could help assist her with receiving transportation to her dialysis treatment and provide for her care. She revealed she did not speak with Resident #1's grandson herself but was told by the SW that he lived in Resident #1's home and would be able to help with providing her care and assisting her with transportation. When asked about Resident #1 treatment needs post-discharge for the diabetic ulcer on her right heel, the former Administrator stated a nursing service referral should have been completed by the facility to home health to provide treatment and the facility should have discussed treatment with Resident #1 and her family. She revealed residents' discharge summary and paperwork and referrals for necessary services should be completed prior to resident discharge and residents and their families should be educated on all discharge paperwork including medications, services that will be provided post-discharge, and any care issues or treatments. A telephone interview conducted with Home Heath Clinical Manager on 03/27/23 at 3:32 PM revealed she was familiar with Resident #1 and had received a home health referral by fax from the facility Social Worker on 03/16/23 stating she had been discharged on this date and requesting them to provide her with physical therapy (PT), occupational therapy (OT) and social work services. She stated when they reviewed the NP discharge summary dated 03/09/23 they saw Resident #1 had a diabetic ulcer on her right heel that would require wound treatment and had no referral requesting nursing services, no current order for treatment and no description of diabetic ulcer. The Clinical Manager revealed usually the facility would send a referral along with orders for wound treatment so she called back to the facility and spoke with Assistant Director of Nursing (ADON) and clarified Resident #1 still had a diabetic ulcer located on her right heel that required treatment and explained they could not accept Resident #1 for nursing services for treatment without a current order and description of ulcer. She stated the ADON informed her the facility and NP would be assuming responsibility for the diabetic ulcer and treatment until Resident #1 could be seen by her primary care physician. The Clinical Manager stated PT saw Resident #1 at her home on Saturday 03/18/23 and completed an assessment for services and the Social Worker (SW) saw Resident #1 at her home on Tuesday 03/21/23 and discussed referrals for services such as meals on wheels, life alert, and advanced directives. She revealed Resident #1 informed SW that she was having issues with transportation to her dialysis appointments due to being in a wheelchair and not being able to go up and down steps from her apartment to the parking lot. The Clinical Manager stated the SW informed Resident #1 that she would look into issues with transportation. She revealed on Wednesday 03/22/23 she still had not received a referral for nursing services from the facility to include any current treatment orders or a description of diabetic ulcer and was concerned no one had been out to the home to provide treatment, so she sent out a nurse to check on Resident #1. The Clinical Manager stated their nurse contacted Resident #1 primary care physician to see if they could provide an order or give instruction on what treatment could be provided. The primary care physician had not seen Resident #1 for almost a year and had no knowledge of diabetic ulcer and was not able to provide a current order treatment until Resident #1 could be seen at their office. She stated their nurse was able to observe Resident #1's diabetic ulcer and provided treatment based on the dressing that was there. She also revealed Resident #1 was not able to attend her scheduled dialysis on 3/22/23 due to transportation issues and not being able to get herself up the steps to the parking lot and informed their nurse that she was going to call EMS to take her to the hospital so she could receive her dialysis treatment. She stated they called to check on Resident #1 afterwards to see if she had gone to the hospital to receive her dialysis treatment and Resident #1 told them repeatedly that she was going to hospital but was not admitted to hospital until late on Friday 03/24/23 after missing her dialysis earlier that day. The Clinical Manager revealed on days their staff were out at the home there was no family present to assist with Resident #1 care. A telephone interview conducted with Dialysis Center Clinical Manager on 03/27/23 at 12:56 PM revealed Resident #1 was scheduled to receive dialysis treatments at their center every Monday, Wednesday, and Friday with a chair time of 5:20 AM. She stated Resident #1 had been receiving dialysis treatments prior to her stay at nursing home facility and had been able to walk up the stairs from her apartment to the parking lot and meet special transportation who would take her to and from her treatments with no issues. She revealed when Resident #1 was discharged home on 03/16/23, she was now confined to a wheelchair and being able to get up the stairs from her apartment to the parking lot with no ramp and meet special transportation to attend her dialysis treatments had now become an issue. The Clinical Manager stated special transportation was not able to accommodate transportation for Resident #1 for her scheduled dialysis treatment on Friday 03/17/23 due to her not being able to get herself from her apartment to the parking lot, so her grandson brought her in for her dialysis treatment, but he works and was not able to commit to bringing her for treatments three times a week. She revealed Resident #1 missed her scheduled dialysis treatment on Monday 03/20/23 due to special transportation not being able to accommodate her from getting from her apartment to the parking lot, so they rescheduled her appointment for Tuesday 03/21/23 and a family member pushed her up a hill from her apartment to the parking lot so special transportation could take her to her appointment. The Clinical Manager stated Resident #1 was not able to attend her scheduled dialysis treatments on Wednesday 03/22/23 and Friday 03/24/23 due to transportation and to her knowledge Resident #1 was taken to the hospital and admitted on [DATE] so she could receive her dialysis treatments. She revealed herself and the social worker from the dialysis center had begun contacting agencies to look at having a portable ramp put into place for Resident #1 to be able to get from her apartment to the parking lot for transportation needs until her apartment complex moved to a wheelchair accessible apartment or have a permanent ramp put into place where her current apartment was located. A telephone interview conducted with the Manager from Equipment Company on 03/29/23 at 10:22 AM revealed she had received a referral from the facility on 03/10/23 to provide medical equipment for Resident #1 for a discharge date of [DATE]. She stated the medical equipment they were asked to provide for Resident #1 was a

Based on record review, staff, resident, Nurse Practitioner and Medical Director, Home Health Director, Dialysis Center, Clinical Manager and Equipment Company Manager interviews the facility Administration failed to provide leadership and oversight to facility staff to ensure effective systems were in place for a safe and orderly discharge. The Interdisciplinary Team (IDT) failed to communicate effectively, and review preparations made for Resident #1's discharge and ensure referrals for home health services post-discharge to include nursing services for dressing changes and assistance for bathing were confirmed prior to discharge. In addition, the former Administration was aware at the time of discharge that Resident #1 did not have a ramp for the stairs leading to her apartment and continued to proceed with the discharge. In addition, Resident #2 was discharged on [DATE] and Administration did not ensure delivery of a wound vac (used to treat deep wounds) for continued treatment of a surgical wound was not confirmed with the home health agency prior to discharge. Immediate Jeopardy began on 03/16/23 when the facility failed to have systems in place to ensure Resident #1 had a safe and orderly discharge. The immediate jeopardy was removed on 03/30/23 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: This tag is cross referred to F624. F624: Based on record review and staff, resident, Nurse Practitioner, Medical Director, Home Health Director, Dialysis Center, Clinical Manager and Equipment Company Manager interviews the facility failed to provide a safe and orderly discharge for 2 of 5 residents reviewed for discharge (Resident #1 and #2). Resident #1 was transported to a medical appointment on 3/16/23 and was informed by the Facility Transporter she was being discharged that day. When they returned to the facility, Nurse #6 and the Administrator came out to the van to give Resident #1 her discharge paperwork and she expressed her concern about not being able to get up and down her steps in her wheelchair to the parking lot to access transportation for dialysis services. Resident #1 was discharged to home on 03/16/23 and due to not being able to get to the parking lot from her apartment she missed 2 dialysis treatments. In addition, Resident #1 did not have supplies or daily wound care through home health services set up for a diabetic foot ulcer for 7 days. Resident #1 called Emergency Medical Services (EMS) the evening of 3/24/23 and was evaluated in the emergency room and admitted for hemodialysis and treatment for acute pulmonary edema and diarrhea. Missing dialysis treatments places a person at risk for building up high levels potassium which can lead to heart problems including arrhythmia, heart attack, and death. Also, high phosphorus, which can weaken bones over time and increase the risk for heart disease. In addition, Resident #2 was discharged on [DATE] and delivery of a wound vac (used to treat deep wounds) for continued treatment of a surgical wound was not confirmed with the home health agency prior to discharge. A telephone interview conducted with Regional Clinical Director on 03/29/23 at 4:58 PM revealed discharge from the facility should be discussed with residents and their families prior to date of discharge and all necessary referrals and services should be completed and in place to provide post-discharge treatment. Facility administration was notified of immediate jeopardy on 03/29/23 at 5:05 PM. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Administration failed to provide effective leadership and oversight to ensure effective systems were in place for a safe and orderly discharge. The facility did not ensure that resident was able to access her apartment via wheelchair or that she could enter/exit independently. Resident did not have wound supplies or instructed in the care of her wound and adequate home health services regarding the wound. A root cause analysis was completed by the Regional Clinical Director on 03/16/2023 in conjunction with the Administrator and the Director of Nursing, the Assistant Director of Nursing, the Unit Nurse Managers, the MDS Coordinator and the Director of Social Services Director. It was established that resident was removed from the formal Utilization Review Process by MDS Coordinator when she discontinued her skilled services which led to her discharge not being reviewed in the formal weekly meeting which was the facility's previous process. Administrator was involved in informal discussions related to resident discharge plan, however, failed to ensure that supporting documentation was maintained in the resident medical record and provided discharge summary. There was no written documentation to support a safe and orderly discharge. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Administrator and Director of Nursing received one on one education on the new process on 03/29/2023 by the Regional Clinical Director, which includes the new utilization review process, with the assurance of a safe and orderly discharge as well as the additional Regional Oversight Team, consisting of the Regional Director of Operations and Regional Clinical Director who will assist with identifying any potential concerns related to discharge as well as assist in ensuring a safe and orderly discharge to include the assurance of the services necessary for the residents care prior to discharge. Those residents identified without a safe and orderly discharge with all necessary services will not be discharged until they are able to establish necessary services are in place. The Regional Clinical Director completed education on 03/29/2023 for the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Nurse Managers, MDS Coordinator, Admissions Coordinator, Rehab Therapy Director, Business Office Manager and Director of Social Services regarding the new process for safe discharge planning to include discharge planning upon admission to the facility, will review those plans weekly until the resident is discharged home or remains long term care. The revised utilization review process will include all residents in the discharge planning process. No residents will be removed from the utilization review form until they are discharged or transitioned into long term care. The Director of Social Services will ensure the utilization review form is updated with discharge plans of all listed residents. The review includes that the resident will have a safe discharge according to the resident needs. The Interdisciplinary Team, including the Rehab Therapy Director, the Administrator, the Director of Nursing, the Director of Social Services, the Unit Nurse Managers, the Assistant Director of Nursing, the MDS Coordinator, Admissions Coordinator and the Business Office Manager, through our Utilization Review Process will meet weekly to discuss residents planned discharges for care, medical and psychosocial needs for a safe and orderly discharge. The Administrator, Director of Nursing and/or Assistant Director of Nursing will provide oversight of resident discharges daily to assure that the facility discharge protocol is followed, and a safe discharge has been initiated, and information is provided to the resident and/or resident representative. The Regional Director of Operation and/or the Regional Clinical Director will ensure oversight and review discharge planning processes for residents scheduled to discharge to validate that the discharge process is being followed according to facility protocol to ensure a safe and orderly discharge. The Regional Director of Operations and/or the Regional Clinical Director will attend and/or be provided the completed Utilization Review form for any unattended meeting immediately following the meeting to ensure that each resident has a safe and orderly discharge disposition and plan in place as evidenced by written discharge orders and documentation. The Administrator will receive weekly consultation and regular in-person visitation by the Regional Team to ensure effective leadership and monitoring of discharge systems and policies. Alleged Date of IJ Removal: 3/30/2023 On 04/03/23, the facility's corrective action plan for immediate jeopardy removal effective 03/30/23 was validated by the following: Interim Administrator interview revealed she had received education on the discharge policy and process to include discharge beginning at admission and discussing with resident and family about any concerns or barriers to discharge, responsibilities of SW and nursing with completing and educating resident and family on discharge paperwork, referrals for post-discharge services, and educating on medications/ services/care needed for post-discharge. She stated the utilization review team which would include herself, nursing, SW, physician, therapy, admission, and business office manager would meet and discuss resident discharges weekly until the resident had been discharged or moved to long term care status. She revealed she would be reviewing all audits for discharged residents, following up with residents who are ready for discharge or have been discharged for any issues or concerns, monitoring SW and nursing discharge duties and paperwork to make sure has been completed correctly and all services have been referred and contacted.

Based on observation, resident/staff/pharmacist/nurse practitioner interviews and medical record review the facility failed to administer pain medication to 1 of 3 sampled residents reviewed for pain. (Resident #96) The findings included: Resident #96 was admitted to the facility 07/31/16 with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] assessed Resident #96 with mild cognitive impairment and taking scheduled pain medication. The current care plan for Resident #96 included a problem area initiated 06/01/17 noting, Resident #96 has limited physical mobility related to stroke, weakness. Approaches to this problem area included physical therapy, occupational therapy referrals as ordered. Physician/nurse practitioner progress notes in the medical record of Resident #96 included the following: 04/27/17-The physician assessed Resident #96 and noted a history of right shoulder repair. The physician noted Resident #96 reported pain in his right shoulder with discomfort with palpation of the right shoulder as well as decreased range of motion. The physician noted it seemed consistent with impingement syndrome (rotator cuff pinched between the humerus and the scapula.) The physician noted Resident #96 had weakness of his right lower extremity and joint contracture of the right upper extremity. The physician assessed Resident #96 as able to voice/express concerns though there was evidence of cognitive impairment. Due to the right shoulder pain on 04/27/17 the physician ordered [MEDICATION NAME] and an X-ray of the right shoulder. 05/30/17-The nurse practitioner assessed Resident #96 for right shoulder pain. The nurse practitioner noted Resident #96 was seen for evaluation of pain to the right side; noting he had issues with [MEDICAL CONDITION] of the right joint and generalized discomfort to the right side since his stroke. The nurse practitioner assessed Resident #96 as alert and oriented X 2. Review of current physician orders [REDACTED].#96 noted the following medications were ordered: -[MEDICATION NAME] HCL 50 milligrams every 8 hours for moderate to moderately severe pain. [MEDICATION NAME] was scheduled to be given at 12:00 AM, 8:00 AM and 4:00 PM. -[MEDICATION NAME] 5 milligrams as needed twice a day for muscle [DIAGNOSES REDACTED]. -[MEDICATION NAME] right shoulder every day,12 hours on, 12 hours off. In addition, Resident #96 had physician orders [REDACTED]. Review of the X-ray results from 04/28/17 for Resident #96 noted a humeral prosthesis, mild [MEDICAL CONDITION] joint disease of the right shoulder; otherwise, no fracture, separation or dislocation was seen. Review of occupational therapy documentation in the medical record of Resident #96 noted the following: 01/31/17-Resident #96 was screened by the occupational therapist (OT) and noted with complaints of pain in his right shoulder which was rated as an 8 on a scale of 1-10 (with 10 being severe pain). The OT noted Resident #96 stated he had the pain for an extended period of time and the OT felt it was due to impaired strength and range of motion related to the stroke. The OT noted the pain impaired Resident #96's ability to perform mobility tasks and skilled therapy was necessary to improve functional abilities. Goals set by the OT included: -Resident #96 will report decreased pain in right shoulder with a goal for no pain at rest in order to perform transfers. At the end of therapy on 04/05/17 the OT noted progress as follows: -At the start of therapy on 01/31/17 Resident #96 reported his right shoulder pain as severe. At the end of therapy Resident #96 reported his right shoulder pain as a 4 on a scale of 1-10 (with 10 being severe pain.) On 05/31/17 at 9:11 AM Resident #96 was observed laying in bed. Resident #96 stated he was in a lot of pain and stated he had not received his morning dose of [MEDICATION NAME]. In addition, Resident #96 stated he missed his [MEDICATION NAME] the day prior and was told they were out of [MEDICATION NAME]. Review of the May 2017 Medication Administration Record [REDACTED]. The 4:00 PM dose of [MEDICATION NAME] on 05/30/17 was documented as not given by Nurse #5 due to medication not available. The 12:00 AM dose on 05/31/17 was documented as administered to Resident #96 by Nurse # 6. On 05/31/17 at 9:26 AM Nurse #3 (assigned to work with Resident #96 on 05/31/17 from 7:00 AM-3:00 PM) stated she had not given morning medications yet to Resident #96. Nurse #3 was asked specifically about the availability of the [MEDICATION NAME] for Resident #96. Nurse #3 opened the locked narcotic box and stated there was no [MEDICATION NAME] available to give to Resident #96. Nurse #3 stated she would ask another staff nurse to obtain a [MEDICATION NAME] for Resident #96 from the Pyxis MedStation (an automated medication dispensing system). On 05/31/17 at 10:15 AM Nurse #4 (the unit supervisor) stated the Pyxis MedStation was not operating and, as a result, [MEDICATION NAME] was not readily accessible to administer to Resident #96. Nurse #4 stated because [MEDICATION NAME] was a narcotic it required a written prescription for re-ordering. Nurse #4 stated each nurse was responsible for checking when a residents narcotic medication was getting low so the physician or nurse practitioner could be notified and a prescription written. Nurse #4 stated if the medication wasn't available staff should obtain it from the Pyxis MedStation. Nurse #4 stated she did not know how long the Pyxis MedStation had not been working. The Nurse Practitioner (NP) was present at the time of the interview and recalled she had just assessed Resident #96 for continued need of the [MEDICATION NAME] and written a prescription. The NP looked at her notes and verified she had seen Resident #96 on 05/30/17 and wrote the prescription for the [MEDICATION NAME]. The NP stated she would have expected the [MEDICATION NAME] to be delivered from the pharmacy on 05/30/17 for administration to Resident #96. On 05/31/17 at 10:40 AM the Controlled Drug Record for the [MEDICATION NAME] for Resident #96 was requested from Nurse #3. At the time of the request the NP was overheard talking to Nurse #3 about her (the NP's) assessment of Resident #96's pain that morning and the NP recommended giving the [MEDICATION NAME] for muscle spasms until the [MEDICATION NAME] arrived at the facility for administration. Review of the Controlled Drug Record for Resident #96 on 05/31/17 at 10:43 AM noted the last dose of [MEDICATION NAME] was documented and signed as given on 05/30/17 at 9:00 AM. On 05/31/17 at 10:45 AM a phone interview was done with Nurse #6. Nurse #6 reported she had worked with Resident #96 on 05/30/17 from 11:00 PM until 05/31/17 at 7:00 AM. Nurse #6 stated she recalled giving several residents [MEDICATION NAME] during her shift but couldn't recall any specifics regarding Resident #96. Nurse #6 stated if she gave [MEDICATION NAME] to Resident #96 she would have recorded it on the Controlled Drug Record. Nurse #6 stated she would not have borrowed the [MEDICATION NAME] for Resident #96 because they would never borrow a narcotic. Nurse #6 was informed the last dose of [MEDICATION NAME] signed out for Resident #96 was 05/30/17 at 9:00 AM. Nurse #6 reported she was having a lot of computer issues during her shift and stated there was a possibility she signed off for the medication but did not give it. On 05/31/17 at 10:59 AM Resident #96 stated he still had not received the [MEDICATION NAME] and he felt like his arm was pulling and his pain was a 10 on a scale of 1-10 (with 10 being severe pain.) On 05/31/17 at 12:00 PM Resident #96 reported he still had not received his [MEDICATION NAME]. On 05/31/17 at 12:13 PM Nurse #3 stated she had not given Resident #96 the 8:00 AM dose of [MEDICATION NAME] or the [MEDICATION NAME] (as suggested by the NP at 10:40 AM). Nurse #3 stated it was her understanding from the NP that Resident #96 wasn't in pain but had muscle tightness. Nurse #3 offered to go to the room of Resident #96 to verify this. Nurse #3 entered the room of Resident #96 and asked him if he was going to get out of bed to eat lunch. Resident #96 stated he was hurting too much to get out of bed or eat and was waiting for his medication. Nurse #3 stated to Resident #96 that the NP had assessed him that morning and he was having muscle tightness, not pain. Resident #96 responded, no, I am hurting. Nurse #3 asked Resident #96 what his pain level was and Resident #96 replied 10. Nurse #3 returned to her medication cart and produced a paper where she documented the report from the NP (at approximately 10:40 AM) which noted no pain, muscle tightness and given [MEDICATION NAME]. Nurse #3 was asked if she had given the [MEDICATION NAME] to Resident #96 and she reported no, she was planning on doing that. On 05/31/17 at 12:15 PM the interim Director of Nursing was asked if the Pyxis MedStation was operating and she reported it went up at 11:24 AM. The interim Director of Nursing was asked if the [MEDICATION NAME] had been taken out of the Pyxis for administration to Resident #96 and she responded, not yet. On 05/31/17 at approximately 12:20 PM Nurse #3 reported she gave Resident #96 the (8:00 AM scheduled) [MEDICATION NAME]. On 05/31/17 at 12:30 PM the administrator stated she was aware Resident #96 had missed several doses of [MEDICATION NAME] and agreed it was a concern. The administrator stated they were going to audit all narcotics for residents to ensure medication was available to be given to residents as ordered. On 05/31/17 at 12:45 PM a phone interview was done with the NP. The NP stated she assessed Resident #96 on 05/30/17 prior to writing the prescription for the [MEDICATION NAME]. The NP stated she felt the [MEDICATION NAME] was warranted for Resident #96. The NP stated she did assess Resident #96 that morning (around 10:40 AM) and asked him to describe his pain. The NP stated Resident #96 reported his right arm felt tight. The NP stated she felt the right bicep of Resident #96 as well as his right calf and noted his muscles were tight. The NP stated she massaged the right bicep and right calf of Resident #96 and Resident #96 reported a little relief from pain. The NP stated she told Resident #96 she would have Nurse #3 give him the [MEDICATION NAME] until the [MEDICATION NAME] arrived to see if it would relieve his muscle pain. The NP stated she discussed this with Nurse #3 and told her to give the [MEDICATION NAME] while awaiting the [MEDICATION NAME]. The NP stated she would have expected the [MEDICATION NAME] to be given within 30 minutes of their discussion. On 05/31/17 at 2:20 PM in a follow-up interview Nurse #3 stated she got caught up in a lot of things that morning which was why the [MEDICATION NAME] was not given to Resident #96 from 10:40 AM until brought to her attention at 12:13 PM. Nurse #3 stated she later went back and checked on Resident #96 after he received the [MEDICATION NAME] and [MEDICATION NAME] and he reported his pain had gone from a 10 to a 1. On 06/01/17 at 11:35 AM in a phone interview Nurse #5 verified she worked with Resident #96 on 05/30/17 from 3:00 PM-11:00 PM. Nurse #5 stated she recalled the [MEDICATION NAME] was not available to be given to Resident #96. Nurse #5 stated she asked another nurse with access rights to the Pyxis MedStation to obtain a [MEDICATION NAME] for Resident #96. Nurse #5 stated this nurse told her the Pyxis MedStation wasn't working which was why she charted the 4:00 dose of [MEDICATION NAME] wasn't available on the MAR indicated [REDACTED]. On 06/01/17 at 1:25 PM the OT that treated Resident #96 from 01/31/17-04/05/17 was interviewed. The OT reported when she screened Resident #96 on 01/31/17 he complained of right shoulder pain. The OT stated she felt the pain was related to his stroke and immobility of his right side. The OT stated Resident #96 understood the 1-10 pain scale and was able to report his pain using this scale. The OT explained that though Resident #96 could not always give the exact date she felt he answered questions appropriately, including whether he was in pain. The OT stated at the beginning of therapy on 01/31/17 Resident #96 described his pain level as severe. The OT stated various modalities were used to treat the pain of Resident #96 which included heat packs, exercise and electrical stimulation. The OT stated at the end of treatment on 04/05/17 Resident #96 described his pain as a 4 out of 10. The OT stated she knew nursing staff were providing pain medication and there were no OT recommendations for pain management at the end of his therapy on 04/05/17. The OT stated Resident #96 was discharged from therapy on 04/05/17 with the goal for no pain in the right shoulder at rest not met due to Resident's #96's report of a 4 out of 10 pain level. On 06/02/17 at 1:25 PM the consultant pharmacist stated his expectation was for residents to receive medications as ordered by the physician, especially medications for pain management. The consultant pharmacist stated he wasn't aware of any issues with medications not being available to be administered to residents at the facility. When asked specifically about [MEDICATION NAME] the consultant pharmacist stated because it was a narcotic it was a little more involved in the ordering process as well as obtaining from the Pyxis MedStation. On 06/02/17 at 1:33 PM a pharmacist at the dispensing pharmacy pulled up the records of Resident #96 and noted the 05/30/17 prescription for [MEDICATION NAME] for Resident #96 had not been Fax'd to the pharmacy until 05/31/17 at 9:34 AM. The pharmacist stated the prescription had been filled the morning of 05/31/17 and sent to the facility on the 12:30 PM delivery. On 06/02/17 from 3:15 PM-4:00 PM the interim Director of Nursing (DON) was interviewed about the availability of [MEDICATION NAME] for Resident #96. The interim DON stated the facility had a form called the Narcotic Tuesday form which staff utilized to document any residents in need of a prescription for narcotic refill. The interim DON stated all nurses were responsible for looking at the quantity of medications left for residents and either informing the physician or nurse practitioner or documenting on the Narcotic Tuesday sheet any resident needs for narcotic refills. The interim DON stated typically nurses would physically report the need to the physician or nurse practitioner if they were present in the building. The interim DON stated the nurses would document needs on the Narcotic Tuesday sheet if the physician or nurse practitioner were not in the building for them to address when they were present. The interim DON stated there were no set parameters for staff to go by (like a certain number of medications remaining), just when the need was seen. The interim DON explained the name of the sheet (Narcotic Tuesday) had nothing to do when the need for a prescription would be written. The interim DON verified it appeared Resident #96 went from 9:00 AM on 05/30/17 until 12:20 PM on 05/31/17 without [MEDICATION NAME]. The interim DON stated it appeared Resident #96 missed the 4:00 PM dose on 05/30/17, the 12:00 AM dose on 05/31/17 and the 8:00 AM dose on 05/31/17 was over four hours late. The interim DON could not explain why the prescription for [MEDICATION NAME] had not been Fax'd to the pharmacy until it was brought to the facility's attention. The interim DON stated she did not know who Fax'd the prescription to the pharmacy on 05/31/17 at 9:34 AM. The interim DON stated if the medication was not available nursing staff should access the medication from the Pyxis MedStation. The interim DON stated she did not know the Pyxis was down the evening of 05/30/17 and wasn't aware it was down the morning of 05/31/17 until Nurse #4 attempted to access it for the [MEDICATION NAME] for Resident #96. The interim DON stated they currently did not have a second shift nursing supervisor but she was available 24 hours and could have been called on 05/30/17. The interim DON stated the pharmacy was available 24/7 for Pyxis support. The interim DON stated if a medication was not available she expected staff to access the Pyxis MedStation. The interim DON stated if the Pyxis MedStation was down she expected a supervisor or herself to be notified. The interim DON stated the back-up pharmacy was also available until approximately 9:00 PM. The interim DON stated staff should not borrow narcotics. The interim DON was told of the approximate 1 1/2 hour delay in giving [MEDICATION NAME] to Resident #96 on 05/31/17 (while awaiting the [MEDICATION NAME]) and the DON stated she would have expected it to be given sooner. On 06/02/17 at 4:15 PM the administrator stated she expected medications to be available and given as ordered by the physician. The administrator stated there was a system failure that resulted in [MEDICATION NAME] not being given to Resident #96 as ordered.

Based on observation, resident/staff/pharmacist/nurse practitioner interviews and medical record review the facility failed to administer pain medication as ordered by the physician for 1 of 3 sampled residents reviewed for pain management. (Resident #96) The findings included: Resident #96 was admitted to the facility 07/31/16 with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] assessed Resident #96 with mild cognitive impairment and taking scheduled pain medication. Physician/nurse practitioner progress notes in the medical record of Resident #96 included the following: 04/27/17-The physician assessed Resident #96 and noted a history of right shoulder repair. The physician noted Resident #96 reported pain in his right shoulder with discomfort with palpation of the right shoulder as well as decreased range of motion. The physician noted it seemed consistent with impingement syndrome (rotator cuff pinched between the humerus and the scapula.) Due to the right shoulder pain on 04/27/17 the physician ordered [MEDICATION NAME] and an X-ray of the right shoulder. 05/30/17-The nurse practitioner assessed Resident #96 for right shoulder pain. The nurse practitioner noted Resident #96 was seen for evaluation of pain to the right side; noting he had issues with [MEDICAL CONDITION] of the right joint and generalized discomfort to the right side since his stroke. The nurse practitioner assessed Resident #96 as alert and oriented X 2. Review of current physician orders [REDACTED].#96 noted the following medications were ordered: -[MEDICATION NAME] HCL 50 milligrams every 8 hours for moderate to moderately severe pain. [MEDICATION NAME] was scheduled to be given at 12:00 AM, 8:00 AM and 4:00 PM. -[MEDICATION NAME] 5 milligrams as needed twice a day for muscle [DIAGNOSES REDACTED]. -[MEDICATION NAME] right shoulder every day,12 hours on, 12 hours off. Review of the X-ray results from 04/28/17 for Resident #96 noted a humeral prosthesis, mild [MEDICAL CONDITION] joint disease of the right shoulder; otherwise, no fracture, separation or dislocation was seen. On 05/31/17 at 9:11 AM Resident #96 was observed laying in bed. Resident #96 stated he was in a lot of pain and stated he had not received his morning dose of [MEDICATION NAME]. In addition, Resident #96 stated he missed his [MEDICATION NAME] the day prior and was told they were out of [MEDICATION NAME]. Review of the May 2017 Medication Administration Record [REDACTED]. The 4:00 PM dose of [MEDICATION NAME] on 05/30/17 was documented as not given by Nurse #5 due to medication not available. The 12:00 AM dose on 05/31/17 was documented as administered to Resident #96 by Nurse # 6. On 05/31/17 at 9:26 AM Nurse #3 (assigned to work with Resident #96 on 05/31/17 from 7:00 AM-3:00 PM) stated she had not given morning medications yet to Resident #96. Nurse #3 was asked specifically about the availability of the [MEDICATION NAME] for Resident #96. Nurse #3 opened the locked narcotic box and stated there was no [MEDICATION NAME] available to give to Resident #96. Nurse #3 stated she would ask another staff nurse to obtain a [MEDICATION NAME] for Resident #96 from the Pyxis MedStation (an automated medication dispensing system). On 05/31/17 at 10:15 AM Nurse #4 (the unit supervisor) stated the Pyxis MedStation was not operating and, as a result, [MEDICATION NAME] was not readily accessible to administer to Resident #96. Nurse #4 stated because [MEDICATION NAME] was a narcotic it required a written prescription for re-ordering. Nurse #4 stated each nurse was responsible for checking when a residents narcotic medication was getting low so the physician or nurse practitioner could be notified and a prescription written. Nurse #4 stated if the medication wasn't available staff should obtain it from the Pyxis MedStation. Nurse #4 stated she did not know how long the Pyxis MedStation had not been working. The Nurse Practitioner (NP) was present at the time of the interview and recalled she had just assessed Resident #96 for continued need of the [MEDICATION NAME] and written a prescription. The NP looked at her notes and verified she had seen Resident #96 on 05/30/17 and wrote the prescription for the [MEDICATION NAME]. The NP stated she would have expected the [MEDICATION NAME] to be delivered from the pharmacy on 05/30/17 for administration to Resident #96. On 05/31/17 at 10:40 AM the Controlled Drug Record for the [MEDICATION NAME] for Resident #96 was requested from Nurse #3. At the time of the request the NP was overheard talking to Nurse #3 about her (the NP's) assessment of Resident #96's pain that morning and the NP recommended giving the [MEDICATION NAME] for muscle spasms until the [MEDICATION NAME] arrived at the facility for administration. Review of the Controlled Drug Record for Resident #96 on 05/31/17 at 10:43 AM noted the last dose of [MEDICATION NAME] was documented and signed as given on 05/30/17 at 9:00 AM. On 05/31/17 at 10:45 AM a phone interview was done with Nurse #6. Nurse #6 reported she had worked with Resident #96 on 05/30/17 from 11:00 PM until 05/31/17 at 7:00 AM. Nurse #6 stated she recalled giving several residents [MEDICATION NAME] during her shift but couldn't recall any specifics regarding Resident #96. Nurse #6 stated if she gave [MEDICATION NAME] to Resident #96 she would have recorded it on the Controlled Drug Record. Nurse #6 stated she would not have borrowed the [MEDICATION NAME] for Resident #96 because they would never borrow a narcotic. Nurse #6 was informed the last dose of [MEDICATION NAME] signed out for Resident #96 was 05/30/17 at 9:00 AM. Nurse #6 reported she was having a lot of computer issues during her shift and stated there was a possibility she signed off for the medication but did not give it. On 05/31/17 at 10:59 AM Resident #96 stated he still had not received the [MEDICATION NAME] and he felt like his arm was pulling and his pain was a 10 on a scale of 1-10 (with 10 being severe pain.) On 05/31/17 at 12:00 PM Resident #96 reported he still had not received his [MEDICATION NAME]. On 05/31/17 at 12:13 PM Nurse #3 stated she had not given Resident #96 the 8:00 AM dose of [MEDICATION NAME] or the [MEDICATION NAME] (as suggested by the NP at 10:40 AM). Nurse #3 stated it was her understanding from the NP that Resident #96 wasn't in pain but had muscle tightness. Nurse #3 offered to go to the room of Resident #96 to verify this. Nurse #3 entered the room of Resident #96 and asked him if he was going to get out of bed to eat lunch. Resident #96 stated he was hurting too much to get out of bed or eat and was waiting for his medication. Nurse #3 stated to Resident #96 that the NP had assessed him that morning and he was having muscle tightness, not pain. Resident #96 responded, no, I am hurting. Nurse #3 asked Resident #96 what his pain level was and Resident #96 replied 10. Nurse #3 returned to her medication cart and produced a paper where she documented the report from the NP (at approximately 10:40 AM) which noted no pain, muscle tightness and given [MEDICATION NAME]. Nurse #3 was asked if she had given the [MEDICATION NAME] to Resident #96 and she reported no, she was planning on doing that. On 05/31/17 at 12:15 PM the interim Director of Nursing was asked if the Pyxis MedStation was operating and she reported it went up at 11:24 AM. The interim Director of Nursing was asked if the [MEDICATION NAME] had been taken out of the Pyxis for administration to Resident #96 and she responded, not yet. On 05/31/17 at approximately 12:20 PM Nurse #3 reported she gave Resident #96 the (8:00 AM scheduled) [MEDICATION NAME]. On 05/31/17 at 12:30 PM the administrator stated she was aware Resident #96 had missed several doses of [MEDICATION NAME] and agreed it was a concern. The administrator stated they were going to audit all narcotics for residents to ensure medication was available to be given to residents as ordered. On 05/31/17 at 12:45 PM a phone interview was done with the NP. The NP stated she assessed Resident #96 on 05/30/17 prior to writing the prescription for the [MEDICATION NAME] and felt the [MEDICATION NAME] was warranted for Resident #96. The NP stated she did assess Resident #96 that morning (around 10:40 AM) and asked him to describe his pain. The NP stated Resident #96 reported his right arm felt tight and she felt the right bicep of Resident #96 as well as his right calf and noted his muscles were tight. Because of the tightness, the NP reported she massaged the right bicep and right calf of Resident #96 and Resident #96 reported a little relief from pain. The NP stated she told Resident #96 she would have Nurse #3 give him the [MEDICATION NAME] until the [MEDICATION NAME] arrived to see if it would relieve his muscle pain. The NP stated she discussed this with Nurse #3 and told her to give the [MEDICATION NAME] while awaiting the [MEDICATION NAME] and she would have expected the [MEDICATION NAME] to be given within 30 minutes of their discussion. On 05/31/17 at 2:20 PM in a follow-up interview Nurse #3 stated she got caught up in a lot of things that morning which was why the [MEDICATION NAME] was not given to Resident #96 from 10:40 AM until brought to her attention at 12:13 PM. Nurse #3 stated she later went back and checked on Resident #96 after he received the [MEDICATION NAME] and [MEDICATION NAME] and he reported his pain had gone from a 10 to a 1. On 06/01/17 at 11:35 AM in a phone interview Nurse #5 verified she worked with Resident #96 on 05/30/17 from 3:00 PM-11:00 PM. Nurse #5 stated she recalled the [MEDICATION NAME] was not available to be given to Resident #96. Nurse #5 stated she asked another nurse with access rights to the Pyxis MedStation to obtain a [MEDICATION NAME] for Resident #96. Nurse #5 stated this nurse told her the Pyxis MedStation wasn't working which was why she charted the 4:00 dose of [MEDICATION NAME] wasn't available on the MAR indicated [REDACTED]. On 06/02/17 at 1:25 PM the consultant pharmacist stated his expectation was for residents to receive medications as ordered by the physician, especially medications for pain management. The consultant pharmacist stated he wasn't aware of any issues with medications not being available to be administered to residents at the facility. When asked specifically about [MEDICATION NAME] the consultant pharmacist stated because it was a narcotic it was a little more involved in the ordering process as well as obtaining from the Pyxis MedStation. On 06/02/17 at 1:33 PM a pharmacist at the dispensing pharmacy pulled up the records of Resident #96 and noted the 05/30/17 prescription for [MEDICATION NAME] for Resident #96 had not been Fax'd to the pharmacy until 05/31/17 at 9:34 AM. The pharmacist stated the prescription had been filled the morning of 05/31/17 and sent to the facility on the 12:30 PM delivery. On 06/02/17 from 3:15 PM-4:00 PM the interim Director of Nursing (DON) was interviewed about the availability of [MEDICATION NAME] for Resident #96. The interim DON stated the facility had a form called the Narcotic Tuesday form which staff utilized to document any residents in need of a prescription for narcotic refill. The interim DON stated all nurses were responsible for looking at the quantity of medications left for residents and either informing the physician or nurse practitioner or documenting on the Narcotic Tuesday sheet any resident needs for narcotic refills. The interim DON indicated typically nurses would physically report the need to the physician or nurse practitioner if they were present in the building. The interim DON stated the nurses would document needs on the Narcotic Tuesday sheet if the physician or nurse practitioner were not in the building for them to address when they were present. The interim DON reported there were no set parameters for staff to go by (like a certain number of medications remaining), just when the need was seen. The interim DON explained the name of the sheet (Narcotic Tuesday) had nothing to do when the need for a prescription would be written. The interim DON verified it appeared Resident #96 went from 9:00 AM on 05/30/17 until 12:20 PM on 05/31/17 without [MEDICATION NAME]. The interim DON stated it appeared Resident #96 missed the 4:00 PM dose on 05/30/17, the 12:00 AM dose on 05/31/17 and the 8:00 AM dose on 05/31/17 was over four hours late. The interim DON could not explain why the prescription for [MEDICATION NAME] had not been Fax'd to the pharmacy until it was brought to the facility's attention. The interim DON stated she did not know who Fax'd the prescription to the pharmacy on 05/31/17 at 9:34 AM. The interim DON stated if the medication was not available nursing staff should access the medication from the Pyxis MedStation. The interim DON reported she did not know the Pyxis was down the evening of 05/30/17 and wasn't aware it was down the morning of 05/31/17 until Nurse #4 attempted to access it for the [MEDICATION NAME] for Resident #96. The interim DON noted they currently did not have a second shift nursing supervisor but she was available 24 hours and could have been called on 05/30/17. The interim DON stated the pharmacy was available 24/7 for Pyxis support. The interim DON stated if a medication was not available she expected staff to access the Pyxis MedStation. The interim DON stated if the Pyxis MedStation was down she expected a supervisor or herself to be notified. In addition, the interim DON stated the back-up pharmacy was also available until approximately 9:00 PM. The interim DON stated staff should not borrow narcotics. The interim DON was told of the approximate 1 1/2 hour delay in giving [MEDICATION NAME] to Resident #96 on 05/31/17 (while awaiting the [MEDICATION NAME]) and the DON stated she would have expected it to be given sooner. On 06/02/17 at 4:15 PM the administrator stated she expected medications to be available and given as ordered by the physician. The administrator stated there was a system failure that resulted in [MEDICATION NAME] not being given to Resident #96 as ordered.

Based on observations, medical doctor interview, staff interviews and record reviews the facility utilized a device without considering it to be a restraint and without a medical symptom. The Transfer Handle entrapped the resident and when the resident was found, he was dead. This was for 1 of 1 sampled resident with a Transfer Handle (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1 was found lying on his left side on the fall mat beside the low bed with his head entrapped in the Transfer Handle. When found by the staff the resident was dead. The immediate jeopardy is present and on-going. The Findings included: Resident #1 was initially admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #1's diagnoses included [MEDICAL CONDITIONS], right sided [MEDICAL CONDITION]/[MEDICAL CONDITIONS], history of convulsions, heart failure, and major [MEDICAL CONDITION]. Review of Resident #1's most recent comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 had long and short term memory problems and was moderately impaired for daily decision making. No behaviors were identified on the MDS. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member for bed mobility and required extensive assistance of 2 staff members for transfers. The MDS stated that Resident #1 was 72 inches tall and weighed 198 pounds. No falls were identified since the prior MDS. The MDS also revealed that Resident #1 received hospice services and indicated no physical restraint was used while Resident #1 was in the bed. A fall care plan updated on [DATE] specified the resident was to have positioning bars for positioning and fall mats on both sides of the bed while in bed to avoid injury from a fall. Review of the cumulative physician orders [REDACTED]. The facility was unable to locate the original order. Further review of the medical record revealed no [DIAGNOSES REDACTED]. Review of a nurse's note dated [DATE] at 11:32 PM read, Resident #1 was observed not breathing at 5:15 PM. Skin color pale, Resident #1 was lying on his left side. Floor mats were in place, bed was in low position and head of bed was elevated between 45 and 90 degrees. Hospice nurse was notified. Family was notified and physician was notified. The note was signed by Nurse #1. Observations on [DATE] at 10:00 AM and again on [DATE] at 10:00 AM made of Resident #1's bed revealed a bed that was approximately 80 inches long and contained a Transfer Handle on each side of the bed. The transfer handle was approximately 18 inches from the top of the bed making the bottom of a pillow in line with the transfer handles. The transfer handle was a 24 inches by 4 inches wide by 24 inches tall metal rail and was perpendicular to the bed. When attached the vertical bar created 90 degree angle to a flat mattress. The transfer handle was attached to the bed frame per the manufacture instructions. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:50 AM revealed that on [DATE] the Director of Nursing (DON) had been on vacation and she was working late that evening finishing up some paper work in the office. The ADON stated she had gone to get a chart and was walking down the hallway when she noted Nursing Assistant (NA) #2 summoning her to Resident #1's room. The ADON stated she put the chart down and ran to Resident #1's room. The ADON stated that when she entered Resident #1's room Nurse #1 informed her Resident #1 was a hospice patient and had a Do Not Resuscitate order in place and he had expired. The ADON stated when she entered Resident #1's room she saw Resident #1 lying on the floor with his head resting on the mattress and his chin touching the transfer handle. The ADON described the color of Resident #1 as a little yellow. The ADON stated she directed the staff to lower Resident #1's head to the floor and then assist the body back into bed. The ADON stated she was unaware of how long the incident had been going on and she did not think staff knew she was there because she was working in an office with the door closed and had come out to obtain a chart and the staff saw her and summoned her so she just was really not clear on what happened but she had some concerns with the way Resident #1 was positioned. Interview with the Administrator on [DATE] at 12:13 PM revealed that on [DATE] at approximately 5:30PM she got a phone call from the ADON and was informed that Resident #1 had expired. The initial call from the ADON was that the staff stated Resident #1's head was caught in the side rail, so the Administrator told the ADON that she would be on her way back to the facility. The Administrator stated she returned to the facility around 8:00 PM and immediately started interviewing the staff. The Administrator stated that she went into Resident #1' s room and observed that Resident #1 did not have side rails he had assist bars that were 4 inches wide and the assist bars were not considered a side rail or a restraint. The Administrator stated that she observed Resident #1's body and did not see any bruising or discoloration, she stated he did have red bumps on his neck but that he had been shaved earlier in the day but nothing that had indicated he had got hung on the assist bar. The administrator stated that through her interviews she got the same story of what happened and even took it a step further and brought the staff to the desk and used charts to simulate what happened. The staff told her that Resident #1 was sitting on the fall mat with his shoulders leaning on the mattress, his head was lying on the mattress and his forehead and chin were touching the assist bar. The administrator stated she asked the staff what he looked like and they stated he was white as a ghost but did not see bluish color to him. The administrator stated at that time she had no reason to believe the assist bars had anything to do with his death. Interview with NA # 4 on [DATE] at 2:58 PM revealed that she routinely cared for Resident #1. NA #4 stated she had fed him breakfast and lunch on [DATE] and he was his usual self. NA #4 stated that Resident #1 was a wiggler in bed and always leaned to the left side of the bed. NA #4 stated she frequently throughout her shift would have to reposition Resident #1 back to the middle of the bed. Interview with NA #2 on [DATE] at 3:05 PM revealed that she routinely took care of Resident #1 and Resident #1 quite often slid to the left side of the bed and she would have to straighten him back up. NA #2 stated that Resident #1 was a busy body and would scoot from the middle of the bed to that left side of the bed. NA #2 also stated that because Resident #1 had swallowing issues they had been advised to keep the head of his bed elevated. NA #2 stated that on [DATE] at approximately 5:15 PM-5:30 PM they were in the dining room and NA #1 had taken Resident #1's tray to his room to assist him with the meal. NA #2 stated that immediately NA #1 came running back into the dining room and stated he is choking. NA #2 stated that all the staff jumped up and ran to Resident #1's room. NA #2 stated that when she entered Resident #2's rooms she could tell he was dead, there was no movement, he was limp, and his face was completely white. NA #2 stated that Resident #1's bed was in low position and the head of the bed was elevated between 45 and 90 degrees and Resident #1's chin was hooked on the transfers handle with his neck between the mattress and the handle. NA #2 stated that Resident #1's body was lying parallel to the bed except his head which was hooked on the transfer handle. NA #2 stated the bar was tight against Resident #1's neck under his chin (pointed to the larynx area) and stated that they had to lower the head of the bed to remove Resident #1 from the transfer handle. NA #2 stated that after they removed Resident #1 from the transfer handle there was a red area on his neck under his chin (pointed to larynx area) where the transfer handle had been. Interview with Nurse #1 on [DATE] at 3:24 PM revealed that she was the nurse taking care of Resident #1 on [DATE]. Nurse #1 stated she arrived for her shift at 3:00 PM and got report and counted the medication cart and then walked down the hallway to check on her patients. Nurse #1 stated that at that time Resident #1 was in his bed in low position and the head of the bed was elevated and he was his normal self. Nurse #1 she had come up the hall after ending her medication pass at around 4:30 PM and again looked in on Resident #1 and he was he was alive and well. Nurse #1 stated that after she completed her medication pass she had gone into the dining room to wait for the dinner tray so she could assist residents with the meal. Nurse #1 stated that at approximately 5:15 PM NA #1 took Resident #1's tray to his room to assist him with the meal. Nurse #1 stated that immediately NA #1 came running back to the dining room hollering for help. Nurse #1 stated that all the staff jumped up and ran to Resident #1's room. Nurse #1 stated she walked around the side of the bed and Resident #1 was lying on the floor parallel to the bed with his chin firmly between the transfer handles and his neck between the transfer handle and the mattress. Nurse #1 stated that she had summoned for the NA to get some help because she had no idea what to do. Nurse #1 stated that she did confirm that Resident #1 had expired with no respiration and had a Do Not Resuscitate order in place. The ADON advised them to place Resident #1 back in the bed and perform post mortem care. Nurse #1 also stated that they had to lower the head of the bed to remove Resident #1 from the transfer handle. Nurse #1 stated she had notified the hospice provider, the family, and the physician that Resident #1 had expired. Interview with NA #3 on [DATE] at 4:39 PM revealed that she routinely cared for Resident #1 and on [DATE] at approximately 3:45 PM she had provided incontinent care to Resident #1. NA #3 stated that when she entered his room he was lying on his side on the left side of the bed and she had to reposition him near the middle of the bed and after providing care and repositioning Resident #1 she had raised the head of his bed and ensured the bed was in low position and left the room. NA #3 stated that Resident #1 favored the left side of his bed and generally about 3 times during her shift she would have to go in and reposition Resident #1 near the middle of the bed but he would always scoot back to the left side. NA #2 stated that lately he would rest his head on the transfer handle that was attached to his bed and would often time throw his legs off the side of the bed. NA #3 stated that on [DATE] at approximately 5:15 PM the staff was in the dining room and NA #1 had taken Resident #1's tray to his room to assist him with the meal. NA #3 stated that immediately NA #1 came running back to the dining room and stated Resident #1 is choking, so we all jumped up and ran to his room. NA #3 stated that when she entered his room she could tell Resident #1 was dead, she stated he was very pale and white in color. NA #3 stated Resident #1's body was lying on the floor on the fall mat and his chin was between the transfer handles with his neck between the handle and the mattress. NA #3 stated that there was a red line where the bar had been on Resident #1's neck under his chin (pointed to larynx area) and they had to lower the head of the bed to remove Resident #1 from the transfer handle. NA #3 stated that his bed was in the low position and the head of the bed was just as she had left it earlier after rendering care. NA #3 stated that after they removed Resident #1 from the transfers handle they assisted the body back into bed and post mortem care was provided. Interview with the Director of Maintenance on [DATE] at 10:00 AM revealed that on [DATE] he had ordered a new bed for the facility. On [DATE] the new bed arrived to the facility and on or around [DATE] he assembled the new bed which included the Transfer handles. The Director of Maintenance stated that the new bed had come with Transfer handles and he attached them to the bed per the manufacturer instructions and once the bed was assembled the bed was placed in an empty room until someone needed the bed. The Director of Maintenance stated that at some point Resident #1 needed a new bed and someone had grabbed the bed with the Transfer handles on it and assigned it to Resident #1. The Director of Maintenance stated he had no involvement in assigning Resident #1 to the bed with the Transfer Handles. The Director of Maintenance stated to his knowledge the beds were just switched and was not sure that there was anything wrong with the old bed. Interview with the hospice nurse on [DATE] at 11:06 AM revealed that she routinely visited Resident #1 but had no involvement in assigning a bed to Resident #1. The hospice nurse stated that the facility would handle any type of bed or device that was needed for the resident. The hospice nurse stated that when she would visit, Resident #1 was usually found him lying on his left side with his head resting on the top upper rail of the transfer handle. The hospice nurse stated that she would move him closer to the middle of the bed but Resident #1 would wiggle back to the left side of the bed. The hospice nurse stated she had no concerns with Resident #1's preferred position of resting his head on the transfer handle and if she would have had any concerns she would have immediately notified the facility staff. The hospice nurse stated that Resident #1 also seemed to be comfortable and obviously preferred the left side of bed. The hospice nurse stated she had visited with Resident #1 on [DATE] and he was his usual self. Interview with the Central Supply Clerk on [DATE] at 11:22 AM revealed that he had been out of work for medical reason from [DATE] and returned to work at the facility on [DATE]. The central Supply clerk stated that when he left on [DATE] Resident #1 had a different type of rail on his bed and when he returned to work at the facility on [DATE] he had the Transfer handles on his bed. The Central Supply clerk stated that Resident #1 was a fidgety person in bed and would pull himself around to the left side of the bed a lot. Interview with Director of Nursing (DON) on [DATE] at 12:04 PM revealed that she was on vacation when Resident #1 expired and did not participate in any type of investigation associated with his death or the manner in which he was found. The DON stated that Resident #1 was a busy body in the bed and would pull on the other devices that they had in place for him. The DON stated that at one point Resident #1 was able to pull a device called a Halo out of the device that secured them to the bed. The DON stated that they had tried several different types of beds to find what would work best for Resident #1 but we felt like the Transfers Handle that attached to the bed frame was sturdier and better for him. The DON stated that she believed that Resident #1 got the Transfer Handle a couple of months ago but could not recall for sure. Interview with NA #1 on [DATE] at 3:39 PM revealed that she routinely cared for Resident #1 and on [DATE] at approximately 5:10 PM she was in the dining room and when the trays arrived she had taken Resident #1's tray down the hall to his room to assist him with the meal. NA #1 stated that when she entered the room she saw Resident #1's legs were outside of the bed. NA #1 stated when she got to the bedside she saw Resident #1 with his chin between the transfer handles and his neck between the handle and the mattress and it was purple in the area of his chin/neck (pointed to larynx area). NA #1 stated I ran for help but I knew that he was already dead, he was making no noises, he was limp and very pale. NA #1 stated she ran and told Nurse #1 that the rail is choking him come now. When asked to describe the choking NA #1 replied the rail was in his neck, his neck was trapped in the rail, and he could not get out of the rail. NA #1 stated that the head of the bed was elevated and we had to lay the head of his bed flat to remove him from the transfer handle. NA #1 stated that when we removed Resident #1 from the transfer handle there was blueish/purplish bruise still present in the same area (points to larynx area) where the transfer handle had been. NA #1 stated that they were instructed to lower Resident #1 to the floor and then back to bed and perform post mortem care. On [DATE] at 4:20 PM in a follow up interview with the Administrator she stated that the assist rail was 4 inches wide and physically impossible to get your head stuck and the facility did not consider the transfer handle a restraint or a side rail. The Administrator stated she had not re-enacted the scene as Resident #1's body was still present in the facility at the time, however she used charts to simulate the scene. The Administrator failed to provide the written information surrounding the circumstances of the incident. In an interview with the Medical Director (MD) on [DATE] at 4:08 PM revealed that he did not recall writing the order for Resident #1 to have to have the Transfer Handles but could not deny it. The MD stated that he did not assess the need for devices like that the facility would handle that and notify him if they needed anything from him or needed an order. To his knowledge and recollection the MD stated he did not assess Resident #1 for any transfer handle or other device for his bed. The Administrator was notified of the immediate jeopardy on [DATE] at 4:20 PM.

Based on observation, record review and staff interviews, the facility failed to accurately code the quarterly minimum data set assessment to reflect the use of a physical restraint and hospice service for 1 of 3 resident reviewed (Resident #1). Resident #1's chin was restrained between the two bars of a Transfer Handle that was attached to his bedframe and his neck was stuck between the Transfer Handle and the mattress. When the resident was found, he was deceased . Immediate Jeopardy began on [DATE] when the nursing home failed to assess Resident #1 for the use of a device that met the definition of a restraint and had the effect of restraining the resident. On [DATE], Resident #1 was found lying on the left side of his body on a fall mat beside the low bed with his head entrapped in the Transfer Handle. When the resident was found by the staff, the resident was dead. See findings in 1.a. The immediate jeopardy is present and on-going. The findings included: 1a. Resident #1 was initially admitted to the facility on [DATE]. Resident #1's diagnoses included [MEDICAL CONDITION] and heart failure. A fall care plan updated on [DATE] specified the resident was to have positioning bars for positioning and fall mats on both sides of the bed while in bed to avoid injury from a fall. Review of the cumulative physician orders [REDACTED]. Further review of the medical record revealed no [DIAGNOSES REDACTED]. In an interview with the Medical Director (MD) on [DATE] at 4:08 PM the MD revealed that he did not recall writing the order for Resident #1 to have to have the Transfer Handles but could not deny it. The MD stated that he did not assess the need for devices like that. The facility would handle that assessment and notify him if they needed anything from him or needed an order. To his knowledge and recollected the MD stated he did not assess Resident #1 for any Transfer Handle or other device for his bed. Observations on [DATE] at 10:00 AM and again on [DATE] at 10:00 AM made of Resident #1's bed revealed a bed that was approximately 80 inches long and contained a Transfer Handle on each side of the bed. The Transfer Handle was approximately 18 inches from the top of the bed making the bottom of a pillow in line with the Transfer Handles. The Transfer Handle was a tall metal rail that measured 4 inches wide by 24 inches tall and was perpendicular to the bed. When the Transfer Handle was attached to the bedframe, the vertical bar created a 90 degree angle to a flat mattress. The Transfer Handle was attached to the bed frame per the manufacturer's instructions and was not easily removed. Interview with the Central Supply Clerk on [DATE] at 11:22 AM revealed that he had been out of work from [DATE] and returned to work on [DATE]. The Central Supply Clerk stated that when he left on [DATE] Resident #1 had a different type of rail on his bed and when he returned to work at the facility on [DATE] he had the Transfer Handles on his bed. Review of Resident #1's most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #1 had long and short term memory problems and was moderately impaired for daily decision making. The MDS also revealed that Resident #1 required extensive assistance of one person for bed mobility and required extensive assistance of two staff members for Transfer. The MDS further revealed that Resident #1 had no falls since the prior assessment, indicated no physical restraint (defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) was used in bed or chair. Interview with MDS Nurse on [DATE] at 10:30 AM revealed that she had completed the MDS dated [DATE] for Resident #1 and she had not coded any use of restraint because Resident #1 did not have a restraint. The MDS nurse stated he had no side rails, he only had Transfers Handles and those were used for positioning but were not a restraint. Interview with Nurse #1 on [DATE] at 3:24 PM revealed that she was the nurse taking care of Resident #1 on [DATE]. Nurse #1 stated that at approximately 5:15 PM NA #1 requested her assistance. Nurse #1 stated she walked around the side of the bed and Resident #1 was laying on the floor parallel to the bed with his chin firmly between the Transfer Handle vertical rails and his neck was between the Transfer Handle and the mattress. Nurse #1 stated that she confirmed Resident #1 had expired with no respiration and had a Do Not Resuscitate order in place. Nurse #1 also stated that they had to lower the head of the bed to remove Resident #1 from the Transfer Handle. Interview with the Director of Nursing (DON) on [DATE] at 12:04 PM stated that Resident #1 was a busy body in the bed and would pull on the other devices that they had in place for him. The DON stated that at one point Resident #1 was able to pull a device called a Halo Safety Ring out of the post that secured it to the bed. The DON stated that they had tried several different types of beds to find what would work best for Resident #1 but we felt like the Transfer Handle that attached to the bed frame was sturdier and better for him. The DON stated that she believed that Resident #1 got the Transfer Handle a couple of months ago. The DON also stated that residents with side rails were assessed using the side rail assessment located in the electronic medical record and other devices were assessed using the restraint enabler decision tree also located in the medical record. The DON stated that they did not consider the Transfer Handle a restraint for Resident #1. On [DATE] at 4:20 PM in an interview with the Administrator she stated that the Transfer Handle was 4 inches wide and physically impossible to get your head stuck and the facility did not consider the Transfer Handle a restraint or a side rail. The Administrator stated that all residents with side rails were assessed for safety using the side rail assessment document located in the electronic medical record and that other devices were assessed using the restraint enabler decision tree. The Administrator stated that they always try to use the least restrictive device possible and they believed the Transfer Handle was appropriate for Resident #1. The Administrator stated that the Transfer Handle for Resident #1 was used for positioning. The Administrator was notified of immediate jeopardy on [DATE] at 11:39 AM. 1.b. Review of a document titled, Hospice and Palliative care Certification/Recertification Statement that was found in the medical record read in part, I have reviewed the above beneficiary's clinical circumstances and I certify that the beneficiary is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The document was signed by the hospice medical director on [DATE]. The certification period was [DATE] to [DATE]. Review of Resident #1's most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #1 had long and short term memory problems and was moderately impaired for daily decision making. The MDS also revealed that Resident #1 received hospice services, but did not indicate that Resident #1 had a life expectancy of less than 6 months to live (section J1400 of the MDS). Interview with the MDS Nurse on [DATE] at 10:30 AM revealed that she had completed the MDS on Resident #1 dated [DATE] and that he was receiving hospice care during the assessment period. The MDS nurse stated that they never checked the prognosis of less than 6 months to live (section J1400) on the MDS unless the physician wrote a note stating that they have 6 months or less to live. The MDS nurse stated that it was very rare for them to check that on the MDS in section J, because doctors do not time frame how long someone has to live. In a follow up interview on [DATE] at 11:28 AM, the MDS nurse confirmed the assessment should have reflected that Resident #1 had a life expectancy of less than 6 months to live. Interview with Director of Nursing (DON) on [DATE] at 4:31 PM revealed that she expected the MDS to be completed accurately to reflect the resident status.

Based on observations, staff interviews, and record reviews the facility failed to identify a Transfer Handle as an accident hazard for 1 of 1 residents (Resident #1) that resulted in a resident becoming entrapped in a Transfer Handle and when found by staff was dead. Immediate Jeopardy began on [DATE] when Resident #1 become entrapped in the Transfer Handle that was attached to his bed. When Resident #1 was found he was lying on his left side on the fall mat beside the low bed with his head entrapped in the transfer bar and was dead. The immediate jeopardy is present and on-going. The Findings included: Review of facility policy titled Bed Safety revised [DATE] read in part, To try to prevent deaths/injuries from the beds and related equipment (including frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: identify additional safety measure for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) Resident #1 was initially admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's most recent comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 had long and short term memory problems and was moderately impaired for daily decision making. No behaviors were identified on the MDS. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member for bed mobility and required extensive assistance of 2 staff members for transfers. The MDS stated that Resident #1 was 72 inches tall and weighed 198 pounds. No falls were identified since the prior MDS. The MDS also revealed that Resident #1 received hospice services and indicated no physical restraint was used while Resident #1 was in the bed. A fall care plan updated on [DATE] specified the resident was to have positioning bars for positioning and fall mats on both sides of the bed while in bed to avoid injury from a fall. Review of the cumulative physician orders [REDACTED]. The facility was unable to locate the original order. Review of a nurse's note dated [DATE] at 11:32 PM read, Resident #1 was observed not breathing at 5:15 PM. Skin color pale, Resident #1 was lying on his left side. Floor mats were in place, bed was in low position and head of bed was elevated between 45 and 90 degrees. Hospice nurse was notified. Family was notified and physician was notified. The note was signed by Nurse #1. Observations on [DATE] at 10:00 AM and again on [DATE] at 10:00 AM made of Resident #1's bed revealed a bed that was approximately 80 inches long and contained a Transfer Handle on each side of the bed. The transfer handle was approximately 18 inches from the top of the bed making the bottom of a pillow in line with the transfer handles. The transfer handle was a 24 inches by 4 inches wide by 24 inches tall metal rail and was perpendicular to the bed. When attached the vertical bar created 90 degree angle to a flat mattress. The transfer handle was attached to the bed frame per the manufacture instructions. Interview with Nursing Assistant (NA) #2 on [DATE] at 3:05 PM revealed that she routinely took care of Resident #1 and Resident #1 quite often slid to the left side of the bed and she would have to straighten him back up. NA #2 stated that Resident #1 was a busy body and would scoot from the middle of the bed to that left side of the bed. NA #2 also stated that because Resident #1 had swallowing issues they had been advised to keep the head of his bed elevated. NA #2 stated that on [DATE] at approximately 5:15 PM-5:30 PM they were in the dining room and NA #1 had taken Resident #1's tray to his room to assist him with the meal. NA #2 stated that immediately NA #1 came running back into the dining room and stated he is choking. NA #2 stated that all the staff jumped up and ran to Resident #1's room. NA #2 stated that when she entered Resident #1's rooms she could tell he was dead, there was no movement, he was limp, and his face was completely white. NA #2 stated that Resident #1's bed was in low position and the head of the bed was elevated between 45 and 90 degrees and Resident #1's chin was hooked on the transfers handle with his neck between the mattress and the handle. NA #2 stated that Resident #1's body was lying parallel to the bed except his head which was hooked on the transfer handle. NA #2 stated the bar was tight against Resident #1's neck under his chin (pointed to the larynx area) and stated that they had to lower the head of the bed to remove Resident #1 from the transfer handle. NA #2 stated that after they removed Resident #1 from the transfer handle there was a red area on his neck under his chin (pointed to larynx area) where the transfer handle had been. Interview with Nurse #1 on [DATE] at 3:24 PM revealed that she was the nurse taking care of Resident #1 on [DATE]. Nurse #1 stated she arrived for her shift at 3:00 PM and got report and counted the medication cart and then walked down the hallway to check on her patients. Nurse #1 stated that at that time Resident #1 was in his bed in low position and the head of the bed was elevated and was his normal self. Nurse #1 stated she had come up the hall after ending her medication pass at around 4:30 PM and again looked in on Resident #1 and he was he was alive and well. Nurse #1 stated that after she completed her medication pass she had gone into the dining room to wait for the dinner trays so she could assist residents with the meal. Nurse #1 stated that at approximately 5:15 PM NA #1 took Resident #1's tray to his room to assist him with the meal. Nurse #1 stated that immediately NA #1 came running back to the dining room hollering for help. Nurse #1 stated that all the staff jumped up and ran to Resident #1's room. Nurse #1 stated she walked around the side of the bed and Resident #1 was laying on the floor parallel to the bed with his chin firmly between the transfer handles and his neck between the transfer handle and the mattress. Nurse #1 stated that she had summoned the ADON because she had no idea what to do. Nurse #1 stated that she did confirm that Resident #1 had expired with no respiration and had a Do Not Resuscitate order in place. The ADON advised them to place Resident #1 back in the bed and perform post mortem care. Nurse #1 also stated that they had to lower the head of the bed to remove Resident #1 from the transfer handle. Nurse #1 stated she had notified the hospice provider, the family, and the physician that Resident #1 had expired. Interview with NA #3 on [DATE] at 4:39 PM revealed that she routinely cared for Resident #1 and on [DATE] at approximately 3:45 PM she had provided incontinent care to Resident #1. NA #3 stated that when she entered his room he was lying on his side on the left side of the bed and she had to reposition him near the middle of the bed and after providing care and repositioning Resident #1 she had raised the head of his bed and ensured the bed was in low position and left the room. NA #3 stated that Resident #1 favored the left side of his bed and generally about 3 times during her shift she would have to go in and reposition Resident #1 near the middle of the bed but he would always scoot to the left side. NA #2 stated that lately he would rest his head on the transfer handle that was attached to his bed and would often time throw his legs off the side of the bed. NA #3 stated that on [DATE] at approximately 5:15 PM the staff was in the dining room and NA #1 had taken Resident #1's tray to his room to assist him with the meal. NA #3 stated that immediately NA #1 came running back to the dining room and stated Resident #1 is choking, so we all jumped up and ran to his room. NA #3 stated that when she entered his room she could tell Resident #1 was dead, she stated he was very pale and white in color. NA #3 stated Resident #1's body was lying on the floor on the fall mat and his chin was between the transfer handles with his neck between the handle and the mattress. NA #3 stated that there was a red line where the bar had been on Resident #1's neck under his chin (pointed to larynx area) and they had to lower the head of the bed to remove Resident #1 from the transfer handle. NA #3 stated that his bed was in the low position and the head of the bed was just as she had left it earlier after rendering care. Interview with the Director of Maintenance on [DATE] at 10:00 AM revealed that on [DATE] he had ordered a new bed for the facility. On [DATE] the new bed arrived to the facility and on or around [DATE] he assembled the new bed which included the Transfer handle. The Director of Maintenance stated that the new bed had come with Transfer handles and he attached them to the bed per the manufacturer instructions and once the bed was assembled the bed was placed in an empty room until someone needed the bed. The Director of Maintenance stated that at some point Resident #1 needed a new bed and someone has grabbed the bed with the Transfer handles on it and assigned it to Resident #1. The Director of Maintenance stated he had no involvement in assigning Resident #1 to the bed with the Transfer Handles. The Director of Maintenance stated to his knowledge the beds were just switched and was not sure that there was anything wrong with the old bed. Interview with the hospice nurse on [DATE] at 11:06 AM revealed that she routinely visited Resident #1 but had no involvement in assigning a bed to Resident #1. The hospice nurse stated that when she would visit Resident #1 was usually found him lying on his left side with his head resting on the top upper rail of the transfer handle. The hospice nurse stated that she would move him closer to the middle of the bed but Resident #1 would wiggle back to the left side of the bed. The hospice nurse stated she had no concerns with Resident #1's preferred position of resting his head on the transfer handle and if she would have had any concerns she would have immediately notified the facility staff. The hospice nurse stated that Resident #1 also seemed to be comfortable and obviously preferred the left side of bed. The hospice nurse stated she had visited with Resident #1 on [DATE] and he was his usual self. Interview with NA #1 on [DATE] at 3:39 PM revealed that she routinely cared for Resident #1 and on [DATE] at approximately 5:10 PM she was in the dining room and when the trays arrived she had taken Resident #1's tray down the hall to his room to assist him with the meal. NA #1 stated that when she entered the room she saw Resident #1's legs were outside of the bed. Nurse #1 stated when she got to the bedside she saw Resident #1 with his chin between the transfer handle and his neck between the handle and the mattress and it was purple in the area of his neck under his chin (pointed to larynx area). NA #1 stated I ran for help but I knew that he was already dead, he was making no noises, he was limp and very pale. NA #1 stated she ran and told Nurse #1 that the rail is choking him come now. When asked to describe the choking NA #1 replied the rail was in his neck, his neck was trapped in the rail, and he could not get out of the rail. NA #1 stated that the head of the bed was elevated and we had to lay the head of his bed flat to remove him from the transfer handle. Na #1 stated that when we removed him from the transfer handle there was blueish/purplish bruise still present in the same area (points to larynx area) where the transfer handle had been. On [DATE] at 4:20 PM In an interview with the Administrator she stated that the assist rail was 4 inches wide and physically impossible to get your head stuck. The Administrator stated she had not re-enacted the scene as Resident #1's body was still present in the facility at the time, however she used charts to simulate the scene. The Administrator failed to provide the written information surrounding the circumstances of the incident. The Administrator was notified of Immediate Jeopardy on [DATE] at 4:20 PM.